OB Exam 1

Combined Spinal-Epidural Analgesia (CSE)

"walking epidural" This technique involves inserting the epidural needle into the epidural space and subsequently inserting a small-gauge spinal needle through the epidural needle into the subarachnoid space. An opioid without a local anesthetic is injected into this space. The spinal needle is then removed and an epidural catheter is inserted for later use. CSE is advantageous because of its rapid onset of pain relief (within 3 to 5 minutes) that can last up to 3 hours. It also allows the woman's motor function to remain active. Her ability to bear down during the second stage of labor is preserved because the pushing reflex is not lost, and her motor power remains intact. The CSE technique provides greater flexibility and reliability for labor than either spinal or epidural analgesia alone (Hemmings & Egan, 2019). When compared with traditional epidural or spinal analgesia, which often keeps the woman lying in bed, CSE allows her to ambulate ("walking epidural"). Ambulating during labor provides several benefits; it may help control pain better, shorten the first stage of labor, increase the intensity of the contractions, and decrease the possibility of an operative vaginal or cesarean birth.

Ultrasound verification of embryo or fetus

(4-6 weeks) -positive sign

apgar scoring

(appearance, pulse, grimace, activity, and respiration) score at 1 and 5 minutes. The Apgar score assesses five parameters—(1) heart rate (absent, slow, or fast), (2) respiratory effort (absent, weak cry, or good strong yell), (3) muscle tone (limp, or lively and active), (4) response to irritation stimulus, and (5) color—that evaluate a newborn's cardiorespiratory adaptation after birth. The parameters are arranged from the most important (heart rate) to the least important (color). The newborn is assigned a score of 0 to 2 in each of the five parameters. The purpose of the Apgar assessment is to evaluate the physiologic status of the newborn

shoulder presentation

(or shoulder dystocia) occurs when the fetal shoulders present first with the head tucked inside. Clinically, signs of shoulder dystocia appear while the woman is pushing as the neonate's head slowly extends and emerges over the perineum but then retracts back into the vagina, commonly referred to as the "turtle sign."

patient controlled epidural analgesia

) involves the use of an indwelling epidural catheter with an infusion of medication and a programmed pump that allows the woman to control the dosing. This method allows the woman to have a sense of control over her pain and reach her own individually acceptable analgesia level. When compared with traditional epidural analgesia, PCEA provides equivalent analgesia with lower anesthetic use, lower rates of supplementation, and higher client satisfaction (Bateman, 2019). With PCEA, the woman uses a handheld device connected to an analgesic agent that is attached to an epidural catheter. When she pushes the button, a bolus dose of agent is administered via the catheter to reduce her pain. This method allows her to manage her pain at will without having to ask a staff member to provide pain relief. Evidence supports the use of PCEA which appears to result in greater maternal satisfaction and lower overall medication use

Risk factors for postpartum hemmorhage

- Precipitous labor (less than 3 hours) • Uterine atony • Placenta previa or abruptio placenta • Labor induction or augmentation • Operative procedures (vacuum extraction, forceps, cesarean birth) • Retained placental fragments • Prolonged third stage of labor (more than 30 minutes) • Multiparity, more than three births closely spaced • Uterine overdistention (large infant, twins, hydramnios)

Third trimester discomforts

- Return of first trimester discomforts - Shortness of breath and dyspnea - heartburn and indigestion - Dependent edema - Braxton hicks contractions

latent phase of labor (first stage)

- dilated 0-3 centimeters - contraction freq every 5-10 mins - contraction duration 30-45 sec - contraction intensity mild to palpation - nullipara=lasts 20 hrs -multipara= lasts 14 hrs - cervical effacement 0-40%

active phase of labor (first stage)

- dilated 6-10 cm - contraction freq every 2-5 mins -contraction duration 45-60 secs -contraction intesensity moderate to palpation -nullipara=lasts 6 hrs -multipara= lasts 4 hrs -cervical effacement 40-100%

normal progressive fetal descent (station)

-5 to +4 moving downward from the negative stations to zero station to the positive stations in a timely manner.

colostrum

-Colostrum (yellowish secretion that precedes mature breast milk) is excreted typically in the third trimester.

progesterone/estrogen role during breastfeeding

-During pregnancy, the breasts increase in size and functional ability in preparation for breastfeeding -Estrogen stimulates growth of the milk collection (ductal) system -progesterone stimulates growth of the milk production system. Within the first month of gestation, the ducts of the mammary glands grow branches, forming more lobules and alveoli. These structural changes make the breasts larger, more tender, and heavy. Each breast gains nearly 1 lb in weight by term, the glandular cells fill with secretions, blood vessels increase in number, and the amounts of connective tissue and fat cells increase

Typical signs of second stage of labor

-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 Other ongoing assessments include the contraction frequency, duration, and intensity; maternal vital signs every 5 to 15 minutes; fetal response to labor as indicated by FHR monitor strips; amniotic fluid for color, odor, and amount when membranes are ruptured; and the coping status of the woman and her partner (Table 14.4). Assessment also focuses on determining the progress of labor. Associated signs include bulging of the perineum, labial separation, advancing and retreating of the newborn's head during and between bearing-down efforts, and crowning (fetal head is visible at vaginal opening; Fig. 14.15). A vaginal examination is completed to determine if it is appropriate for the woman to push. Pushing is appropriate if the cervix has fully dilated to 10 cm and the woman feels the urge to do so.

breast milk summary

-Prolactin levels increase at term with a decrease in estrogen and progesterone levels. -Estrogen and progesterone levels decrease after the placenta is delivered. -Prolactin is released from the anterior pituitary gland and initiates milk production. -Oxytocin is released from the posterior pituitary gland to promote milk let-down. Infant sucking at each feeding provides continuous stimulus for prolactin and oxytocin release aka newborn sucking stimulates pituitary gland, causing the release of prolactin (causing release of breast milk) and oxytocin (causing contraction of smooth muscle in uterus and around breast)

postpartum depression and psychosis

-Symptoms last longer and are more severe and require treatment -May lead to poor bonding, alienation from loved ones, daily dysfunction and violent thoughts/actions (baby blues after 2-3 weeks=postpartum depression) psychosis=voices in head

assessments during each follow up prenatal visit

-Weight and blood pressure, which are compared with baseline values -Urine testing for protein, glucose, ketones, and nitrites -Fundal height measurement to assess fetal growth -Assessment for quickening/fetal movement to determine fetal well-being (use GTAP) -Assessment of fetal heart rate

stomach and digestion in newborn

-cardiac sphinctor and nervous control of the stomach are immature leading to regurgitation and uncoordinated peristaltic activity -physiologic capacity of the newborn stomach is considerably less than anatomic capacity --to gain weight the newborn requires an intake of 109 kcal/day from birth to 6 mnths of age

urinary atony postpartum

-causes excessive bleeding. -caused by urinary retention -a serious condition that can occur after childbirth. It occurs when the uterus fails to contract after the delivery of the baby, and it can lead to a potentially life-threatening condition known as postpartum hemorrhage. Frequent voiding of small amounts (less than 150 mL) suggests urinary retention with overflow, and catheterization may be necessary to empty the bladder to restore tone.

signs of preterm labor

-contractions every 10 minutes or more often -change in vaginal discharge -pelvic pressure -low, dull backache -pelvic cramps -diarrhea -If the woman experiences menstrual-like cramps occurring every 10 minutes accompanied by a low, dull backache, she should stop what she is doing and lie down on her left side for 1 hour and drink two or three glasses of water. If the symptoms worsen or do not subside after 1 hour, she should contact her health care provider.

endocrine system postpartum

-estrogen and progesterone levels drop quickly -placental hormones decline rapidly -prolactin levels decline within 2 weeks if not breast feeding, but remain elevated for a lactating woman (prolactin is a hormone involved with lactation and reproduction) Levels of circulating estrogen and progesterone drop quickly with delivery of the placenta. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy (Blackburn, 2018). Estrogen is at its lowest level a week after birth. For the woman who is not breastfeeding, estrogen levels begin to increase by 2 weeks after birth. For the breastfeeding woman, estrogen levels remain low until breastfeeding frequency decreases.

initiation of labor

-estrogen levels rise, progesterone decreases -uterine contractions begin -increased release of prostaglandins -oxytocin is released by the pituitary -combination of these hormones produces contractions -With the increasing levels of oxytocin in the maternal blood in conjunction with increasing fetal cortisol levels that synthesize prostaglandins, uterine contractions are initiated.

amniocentesis pre op

-explain the procedure and its potential complications -encourage her to empty her bladder just before the procedure to avoid the risk of bladder puncture -Inform her that a 20-minute electronic fetal monitoring strip is usually obtained to evaluate fetal well-being and obtain a baseline to compare after the procedure is completed -Obtain and record maternal vital signs.

breast tenderness

-fat layer of breasts thicken and the number of milk ducts and glands increase during the first trimester (due to increase in progesterone and estrogen) CAUSING breast tenderness -wear a supportive bra, even while sleeping. -As her breasts increase in size, advise her to change her bra size to ensure adequate support.

four types of pelvic shape

-gynecoid -android -anthropoid -platypelloid

vitals during pregnancy

-high HR -high RR; to compensate for increase in tidal volume and oxygen consumption -lower BP (due to vasodilation)

DVT in pregnancy

-if woman has pain in calf when ambulates=indicative of DVT -high levels of estrogen increase risk of DVT

normal changes in pregnancy

-increase in AP chest diameter; bc estrogen promotes relaxation of the ligaments and joints of the ribs -Increases in estrogen and progesterone and blood supply make the breasts feel full and more nodular with increased sensitivity to touch -Blood vessels become more visible and there is an increase in breast size. -Striae gravidarum (stretch marks) may be visible in women with large breasts -Darker pigmentation of the nipple and areola is present, along with enlargement of Montgomery glands -abdomen should be round and nontender -decrease in muscle tone (due to progesterone) -edema in third trimester

Lochia amount postpartum

-it has musky scent, with an odor similar to that of menstrual flow without any large clots (fist size). Foul-smelling lochia suggests an infection, and large clots suggest poor uterine involution, necessitating additional intervention. -Lochia flow will increase when the woman gets out of bed. It tends to pool in the vagina when the woman is lying in bed and when breastfeeding bc of oxytocin. When woman stands she will feel a gush of blood, which is NORMAL Scant: a 1- to 2-in lochia stain on the perineal pad or approximately a 10-mL loss; blood only on tissue when wiped or less than 1 inch stain on peripad Light or small: less than 4 inch stain on peripad Moderate: less than 6 inch stain on pad Large or heavy: saturated pad within 1 hr (on PP flor: 1 pad saturated in 1 hr= hemorrhage) (on L&D floor: 1 pad saturated in 15 mins= hemorrhage) Urge the woman to notify her health care provider if lochia rubra returns after the serosa and alba transitions have taken place Report any abnormal findings, such as heavy, bright red lochia with large tissue fragments or a foul odor. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood.

pelvic exam

-lithotomy position -inspect external genitalia visually; should be no lesions -collect culture for STIs (internal genitalia viewed via speculum) -cervix should be smooth, long, closed -cervix will be softened -uterine isthmus softened -bluish discoloration to cervix and vag mucosa (uterus typically pear shaped and smooth) -uterus now undergoes hypertrophy and hyperplasia -rectal exam also done -pap smear also done

Fundus height

-measured when the uterus arises out of the pelvis to evaluate fetal growth -At 12 weeks' gestation, the fundus can be palpated at the symphysis pubis -At 16 weeks' gestation, the fundus is midway between the symphysis and the umbilicus -At 20 weeks, the fundus can be palpated at the umbilicus and measures approximately 20 cm from the symphysis pubis -By 36 weeks, the fundus is just below the xiphoid process and measures approximately 36 cm. The uterus maintains a globular/ovoid shape throughout pregnancy

GI system postpartum

-quickly returns to normal after birth because the gravid uterus is no longer filling the abdominal cavity and producing pressure on the abdominal organs. -Progesterone levels, which caused relaxation of smooth muscle during pregnancy and diminished bowel tone, are also declining. -decreased bowel tone for several days after birth. -Decreased peristalsis occurs in response to analgesics, surgery, diminished intra-abdominal pressure, a low-fiber diet, insufficient fluid intake, and diminished muscle tone (and decreased progesterone and estrogen) -constipation is common due to fear of straining affecting the perineum -Most women are hungry and thirsty after childbirth, commonly related NPO prior to surgery restrictions

respirations in newborn

-they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). -they should not be labored -chest movements should be symmetric. In some cases, periodic breathing may occur, which is the cessation of breathing that lasts 5 to 10 seconds without changes in color or heart rate. Periodic breathing may be observed in newborns within the first few days of life and requires close monitoring. Apneic periods lasting more than 15 seconds with cyanosis and heart rate changes require further evaluation

respiratory system postpartum

-tidal volume, minute volume, vital capacity, and function residual capacity return to prepregnant values within 1 to 3 weeks of birth -anatomic changes in the thoracic cavity and rib cage caused by increasing uterine growth resolve quickly. As a result, discomforts such as shortness of breath and rib aches are relieved. -Respirations usually remain within the normal adult range of 16 to 24 breaths per minute.

Ways to get EDD

-ultrasound: A second trimester fetal head circumference measurement via ultrasound (most accurate) -Nagele's rule

cervical dilation (starting in 1st stage of labor)

0 cm: external cervical os is closed 5 cm: external cervical os is halfway dilated 10 cm: external os is fully dilated and ready for birth passage -the width of the cervical opening determines diameter

cervical effacement (starting 1st stage of labor)

0%: cervical canal is 2 cm long 50%: cervical canal is 1 cm long 100%: cervical canal is obliterated -the length of the cervix assesses effacement

full dilation of cervix for birth

10 cm (increases from less than 1 cm)

Auscultation of fetal heart tones via Doppler

10 to 12 weeks -positive sign

normal fetal HR

110-160 bpm over a 10 minutes period

Abdominal enlargement

14 weeks -probable sign

fetal movements (quickening) in pregnancy

16 to 20 weeks -presumptive sign

Braxton Hicks contractions

16 to 28 weeks Probable sign -Spontaneous, irregular, and painless contractions (enhanced uterine contractility) -esp noticable the last month of pregnancy -go away when walking or resting or sleeping -These contractions aid in moving the cervix from a posterior position to an anterior position -They also help in ripening and softening the cervix -However, the contractions are irregular and can be decreased by walking, voiding, eating, increasing fluid intake, or changing position. -often felt in abdomen -they are not true labor contractions which are felt in lower back

Ballottement

16 to 28 weeks -probable sign -the examiner pushes against the woman's cervix during a pelvic examination and feels a rebound from the floating fetus

hyperpigmentation in pregnancy

16 weeks -presumptive sign

most sensitive time for fetus risks

17-56 days after conception

Nagele's Rule; calculating EDD

1st day of last period + 7 days - 3 months and then adjust year by adding 1 year (EDD + or - 2 weeks)

early amniocentesis

1st trimester; performed between weeks 11 and 14; is done to detect genetic anomalies. -However, early amniocentesis has been associated with a high risk of spontaneous miscarriage and postprocedural amniotic fluid leakage compared with transabdominal chorionic villus screening

second period of reactivity newborn

2 to 8 hrs newborn awakens and shows an interest in stimuli The second period of reactivity begins as the newborn awakens and shows an interest in environmental stimuli. This period lasts 2 to 8 hours in the normal newborn (King et al., 2019). Heart and respiratory rates increase. Peristalsis also increases. Thus, it is not uncommon for the newborn to pass meconium or void during this period. In addition, motor activity and muscle tone increase in conjunction with an increase in muscular coordination (Fig. 17.7). Interaction between the mother and the newborn during this second period of reactivity is encouraged if the mother has rested and desires it. This period also provides a good opportunity for the parents to examine their newborn and ask questions. Teaching about feeding, positioning for feeding, and diaper-changing techniques can be reinforced during the second period of reactivity.

Fetal movement felt by experienced clinician

20 weeks -positive sign

breast tenderness in pregnancy

3-4 weeks -presumptive sign

Period of decreased responsiveness newborn

30 to 120 minutes old period of sleep or decreased activity At 30 to 120 minutes of age, the newborn enters the second stage of transition—that of the sleep period or a decrease in activity. This phase is referred to as a period of decreased responsiveness. Movements are less jerky and less frequent. Heart and respiratory rates decline as the newborn enters the sleep phase. The muscles become relaxed, and responsiveness to outside stimuli diminishes. During this phase, it is difficult to arouse or interact with the newborn. No interest in sucking is shown. This quiet time can be used for both mother and newborn to remain close and rest together after labor and the birthing experience

Positive pregnancy test

4 to 12 weeks -Probable sign

amenorrhea in pregnancy

4 weeks -presumptive sign

n/v in pregnancy

4-14 weeks -presumptive sign

resting uterine tone (contractions)

5 and 10 mm Hg= in early labor bw 12 and 18 mm Hg= in active labor

Goodell sign

5 weeks -Probable sign -softening of the cervix

normal blood loss during labor

500 mL for vaginal birth 1000 mL for cessarian

Hegar sign

6 to 12 weeks -Probable sign -softening of the lower uterine segment or isthmus

Chadwick sign

6 to 8 weeks -Probable sign -a bluish-purple coloration of the vaginal mucosa and cervix

breast enlargment in pregnancy

6 weeks -presumptive sign

urinary frequency in pregnancy

6-12 weeks -presumptive sign

uterine enlargement in pregnancy

7 to 12 weeks -presumptive sign

blood volume in newborn

A Cochrane Review study on term infants and timing of umbilical cord clamping reported that those with delayed cord clamping had up to a 60% increase in RBCs, high hemoglobin levels, and higher iron levels at 4 to 6 months. Infants whose cords were clamped early were twice as likely to be iron-deficient at 3 to 6 months The blood volume of the newborn depends on the amount of blood transferred from the placenta at birth. It is usually estimated to be 80 to 100 mL/kg of body weight in the term infant (Blackburn, 2018). However, the volume may vary by as much as 25% to 40%, depending on when clamping of the umbilical cord occurs. Early (before 30 to 40 seconds) or late (after 3 minutes) clamping of the umbilical cord changes circulatory dynamics during transition

maternal phenylketonuria

A mother with the genetic disease phenylketonuria (PKU) whose high blood levels of phenylalanine (phe) are dangerous to a developing fetus. High phe is a teratogen. It can damage a baby before birth.

primigravida (gravida I)

A woman pregnant for the first time

Primipara

A woman who has given birth once after a pregnancy of at least 20 weeks, commonly referred to as a "primip" in clinical practice -one birth after a pregnancy of at least 20 weeks ("primip")

Nulligravida

A woman who has never experienced pregnancy

Nullipara

A woman who has not produced a viable offspring; para 0

PROM

AKA prelabor rupture of membranes (PROM):Rupture of membranes with loss of amniotic fluid prior to the onset of labor, It occurs in 8% to 10% of women with term pregnancies, the majority of whom will begin labor spontaneously within 24 hours -risk for high infection

obesity

Adverse perinatal outcomes associated with maternal obesity include neural tube defects, preterm delivery, diabetes, cesarean section, and hypertensive and thromboembolic disease. Appropriate weight loss and nutritional intake before pregnancy reduce these risks.

internal rotation (Cardinal movement of labor)

After engagement, as the head descends, the lower portion of the head (usually the occiput) meets resistance from one side of the pelvic floor. As a result, the head rotates about 45 degrees anteriorly to the midline under the symphysis. This movement is known as internal rotation. Internal rotation brings the anteroposterior diameter of the head in line with the anteroposterior diameter of the pelvic outlet. It aligns the long axis of the fetal head with the long axis of the maternal pelvis. The widest portion of the maternal pelvis is the anteroposterior diameter, and thus the fetus must rotate to accommodate the pelvis.

external rotation (restitution) (cardinal movement of labor)

After the head is born and is free of resistance, it untwists, causing the occiput to move about 45 degrees back to its original left or right position (restitution). The sagittal suture has now resumed its normal right-angle relationship to the transverse (bisacromial) diameter of the shoulders (i.e., the head realigns with the position of the back in the birth canal). External rotation of the fetal head allows the shoulders to rotate internally to fit the maternal pelvis.

amniocentesis post op

After the procedure, assist the woman into a position of comfort and administer RhoGAM intramuscularly if the woman is Rh-negative to prevent potential sensitization to fetal blood. -Assess maternal vital signs and fetal heart rate every 15 minutes for an hour -Observe the puncture site for bleeding or drainage -Instruct the client to rest after returning home and remind her to report fever, leaking amniotic fluid, vaginal bleeding, or uterine contractions or any changes in fetal activity (increased or decreased) to the health care provider. -When the test results come back, be available to offer support, especially if a fetal abnormality is found. Also prepare the woman and her partner for the need for genetic counseling. Trained genetic counselors can provide accurate medical information and help couples interpret the results of the amniocentesis so they can make the decisions that are right for them as a family.

sexuality postpartum

Although couples are reluctant to ask, they often want to know when they can safely resume sexual intercourse after childbirth. Typically, sexual intercourse can be resumed once bright red bleeding has stopped and the perineum is healed from an episiotomy or lacerations. This is usually by the third to the sixth week postpartum. However, there is no set, prescribed time at which to resume sexual intercourse after childbirth. There is no scientific basis for the traditional recommendation to delay sexual activity until the 6-week postpartum check-up. Each couple must set their own time frame when they feel it is appropriate to resume sexual intercourse.

Neutral thermal environment (NTE)

An environment in which body temperature is maintained without an increase in metabolic rate or oxygen use is called a neutral thermal environment. Within a neutral thermal environment, the rates of oxygen consumption and metabolism are minimal, and internal body temperature is maintained because of thermal balance. A neutral thermal environment promotes growth and stability, conserves energy for basic bodily functions, and minimizes heat (energy) and water loss (Chamberlain et al., 2019). Because newborns have difficulty maintaining body heat through shivering or other mechanisms, they need a higher environmental temperature to maintain a neutral thermal environment. If the environmental temperature decreases, the newborn responds by consuming more oxygen. The respiratory rate increases (tachypnea) in response to the increased need for oxygen. As a result, the newborn's metabolic rate increases.

fetal scalp stimulation

An indirect method used to evaluate fetal oxygenation and acid-base balance to identify fetal hypoxia is fetal scalp stimulation or vibroacoustic stimulation. If the fetus does not have adequate oxygen reserves, carbon dioxide builds up, leading to acidemia and hypoxemia. These metabolic states are reflected in abnormal FHR patterns as well as fetal inactivity. Fetal stimulation is performed to promote fetal movement with the hope that FHR accelerations will accompany the movement. Fetal movement can be stimulated with a vibroacoustic stimulator (artificial larynx) applied to the woman's lower abdomen and turned on for 3 to 5 seconds to produce sound and vibration or by placing a gloved finger on the fetal scalp and applying firm pressure. A well-oxygenated fetus will respond when stimulated (tactile or by noise) by moving in conjunction with an acceleration of 15 bpm above the baseline heart rate that lasts at least 15 seconds. This FHR acceleration reflects a pH of more than 7 and a fetus with an intact CNS. Fetal scalp stimulation is not done if the fetus is preterm, or if the woman has an intrauterine infection, a diagnosis of placenta previa (which could lead to hemorrhage), or a fever (which increases the risk of an ascending infection)

uterus assessment postpartum

Assess the fundus (top portion of the uterus) to determine the degree of uterine involution. If possible, have the woman empty her bladder before assessing the fundus and auscultate her bowel sounds prior to uterine palpation. If the client has had a cesarean birth and has a patient-controlled anesthesia (PCA) pump, instruct her to self-medicate prior to fundal assessment to decrease her discomfort. Using a two-handed approach with the woman in the supine position with her knees flexed slightly and the bed in a flat position or as low as possible, palpate the abdomen gently, feeling for the top of the uterus while the other hand is placed on the lower segment of the uterus to stabilize it -fundus should be midline and feel firm. -A boggy or relaxed uterus is a sign of uterine atony (loss of muscle tone in the uterus). This can be the result of bladder distention, which displaces the uterus upward and to the right, or retained placental fragments. Either situation predisposes the woman to hemorrhage. Once the fundus is located, place your index finger on the fundus and count the number of fingerbreadths between the fundus and the umbilicus (one fingerbreadth is approximately equal to 1 cm). One to 2 hours after birth, the fundus is typically between the umbilicus and the symphysis pubis. Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. If the fundal height is above the umbilicus, which would be an abnormal finding, investigate this immediately to prevent excessive bleeding. Frequently, the woman's bladder is full, thus displacing the uterus up and to either side of the midline. Ask the woman to empty her bladder, and reassess the uterus again. Normally, the fundus progresses downward at a rate of 1 cm per day after childbirth and should be nonpalpable by 10 to 14 days postpartum. By day 14, the uterus has descended below the rim of the symphysis pubis and is no longer palpable (Cunningham et al., 2018). On the first postpartum day, the top of the fundus is located 1 cm below the umbilicus and is recorded as u/1. Similarly, on the second postpartum day, the fundus would be 2 cm below the umbilicus and should be recorded as u/2, and so on. Health care agencies differ according to how fundal heights are charted, so follow their protocols for this. If the fundus is not firm, gently massage the uterus using a circular motion until it becomes firm.

fourth stage of labor assessment

Assessments during the fourth stage center on the woman's vital signs, status of the uterine fundus and perineal area, comfort level, lochia amount, and bladder status. During the first hour after birth, vital signs are taken every 15 minutes, then every 30 minutes for the next hour if needed. The woman's blood pressure should remain stable and within normal range after giving birth. A decrease may indicate uterine hemorrhage; an elevation might suggest preeclampsia. The pulse is usually typically slower (60 to 70 bpm) than during labor. This may be associated with a decrease in blood volume following placental separation. An elevated pulse rate may be an early sign of blood loss. The blood pressure usually returns to its prepregnancy level and therefore is not a reliable early indicator of shock. Fever is indicative of dehydration (less than 100.4°F or 38°C) or infection (above 101°F), which may involve the genitourinary tract. Respiratory rate is usually between 16 and 24 breaths per minute and regular. Respirations should be unlabored unless there is an underlying preexisting respiratory condition. Assess fundal height, position, and firmness every 15 minutes during the first hour following birth. The fundus needs to remain firm to prevent excessive postpartum bleeding. The fundus should be firm (feels like the size and consistency of a grapefruit), located in the midline and below the umbilicus. If it is not firm (boggy), gently massage it until it is firm (see Nursing Procedure 22.1 for more information). Once firmness is obtained, stop massaging. The vagina and perineal areas are quite stretched and edematous following a vaginal birth. Assess the perineum including the episiotomy if present for possible hematoma formation. Suspect a hematoma if the woman reports excruciating pain or cannot void or if a mass is noted in the perineal area. Also assess for hemorrhoids, which can cause discomfort. Assess the woman's comfort level frequently to determine the need for analgesia. Ask the woman to rate her pain on a scale of 1 to 10; it should be less than 3. If it is higher, further evaluation is needed to make sure there aren't any deviations contributing to her discomfort. Assess vaginal discharge (lochia) every 15 minutes for the first hour and every 30 minutes for the next hour. Palpate the fundus at the same time to ascertain its firmness and help estimate the amount of vaginal discharge. In addition, palpate the bladder for fullness, since many women receiving an epidural block experience limited sensation in the bladder region. Voiding should produce large amounts of urine (diuresis) each time. Palpating the woman's bladder after each voiding helps in assessing it and ensuring complete emptying. A full bladder will displace the uterus to either side of the midline and potentiate uterine hemorrhage secondary to bogginess.

bloody show

At the onset of labor or before, the mucus plug that fills the cervical canal during pregnancy is expelled as a result of cervical softening and increased pressure of the presenting part. These ruptured cervical capillaries release a small amount of blood that mixes with mucus, resulting in the pink-tinged secretions known as bloody show.

stages of attachment postpartum

Attachment stages include proximity, reciprocity, and commitment. Proximity refers to the physical and psychological experience of the parents being close to their infant. This attribute has three dimensions: Contact: The sensory experiences of touching, holding, and gazing at the infant are part of proximity-seeking behavior. Emotional state: The emotional state emerges from the affective experience of the new parents toward their infant and the parental role. Individualization: Parents are aware of the need to differentiate the infant's needs from themselves and to recognize and respond to them appropriately, making the attachment process also, in a way, one of detachment. Reciprocity is the process by which the infant's abilities and behaviors elicit parental response. Reciprocity is described by two dimensions: complementary behavior and sensitivity. Complementary behavior involves taking turns and stopping when the other is not interested or becomes tired. An infant can coo and stare at the parent to elicit a similar parental response to complement their behavior. Parents who are sensitive and responsive to their infant's cues will promote their development and growth. Parents who become skilled at recognizing the ways their infant communicates will respond appropriately by smiling, vocalizing, touching, and kissing. Commitment refers to the enduring nature of the relationship. The components of this are twofold: centrality and parent role exploration. In centrality, parents place the infant at the center of their lives. They acknowledge and accept their responsibility to promote the infant's safety, growth, and development. Parent role exploration is the parents' ability to find their own way and integrate the parental identity into themselves

Second trimester discomforts

Backache Varicosities of the vulva and legs Hemorrhoids Flatulence with bloating

fundal height measurement continued

Between 12 and 14 weeks' gestation= the fundus can be palpated above the symphysis pubis -The fundus reaches the level of the umbilicus at approximately 20 weeks and measures 20 cm -Fundal measurement should approximately equal the number of weeks of gestation until week 36. For example, a fundal height of 24 cm suggests a fetus at 24 weeks' gestation. -After 36 weeks, the fundal height then drops due to lightening and may no longer correspond with the week of gestation. It is expected that the fundal height will increase progressively throughout the pregnancy, reflecting fetal growth

lightening

Between 38 and 40 weeks, fundal height drops as the fetus begins to descend and engage into the pelvis. Because it pushes against the diaphragm, many women experience shortness of breath. After 36 weeks, the fetal head begins to descend and engage in the pelvis, which is termed lightening. -The client may report increased respiratory capacity, decreased dyspnea, increased pelvic pressure, cramping, and low back pain. She may also note edema of the lower extremities as a result of the increased stasis of blood pooling, an increase in vaginal discharge, and more frequent urination. The nurse would continue to monitor the client as this is a normal progression of pregnancy.

carbohydrate metabolism newborn (liver)

Birth results in the loss of maternal glucose source. Glucose is an essential fuel for brain metabolism. When the placenta is lost at birth, the maternal glucose supply is cut off. Initially, the newborn's serum glucose levels decline. Newborns must learn to regulate their blood glucose concentration and adjust to an intermittent feeding schedule. Usually, a term newborn's blood glucose level is about 80% of the maternal blood glucose level at birth. Hypoglycemia is one of the most frequent problems encountered, and maintaining glucose homeostasis is one of the important physiologic events during the fetal-to-newborn transition. During the first 24 to 48 hours of life, as normal neonates' transition from intrauterine to extrauterine life, their plasma glucose levels are usually lower than later in life (Blackburn, 2018). Glucose is the main source of energy for the first several hours after birth. With the newborn's increased energy needs after birth, the liver releases glucose from glycogen stores for the first 24 hours. Initiating early breastfeeding or bottle-feeding helps stabilize the newborn's blood glucose levels.

First period of reactivity newborn

Birth to 30 minutes to 2 hours after birth Newborn is alert, moving, may appear hungry Neurologic development follows cephalocaudal (head-to-toe) and proximal-distal (center-to-outside) patterns. Myelin develops early on in sensory impulse transmitters. Thus, the newborn has an acute sense of hearing, smell, and taste.

blood volume and cardiac output postpartum

Blood volume, which increases substantially during pregnancy, drops rapidly after birth and returns to normal within 4 weeks postpartum. The decrease in both cardiac output and blood volume reflects the birth-related blood loss (an average of 500 mL with a vaginal birth and 1,000 mL with a cesarean birth). The cardiac output deceases to prelabor values 24 to 72 hours postpartum, rapidly falls over the next 2 weeks and usually returns to nonpregnant levels within 6 to 8 weeks postpartum. Blood plasma volume is further reduced through diuresis, which occurs between days 2 and 5

role of oxytocin

Causes stronger contractions Positive-feedback cycle progressively increases until cervical dilation and delivery are complete -oxy increases towards end of pregnancy

antiepileptic drugs

Certain antiepileptic drugs are known teratogens (e.g., valproic acid). Recommendations suggest that before conception, women who are on a regimen of these drugs and who are contemplating pregnancy should be prescribed lower dosages of these drugs.

STIs

Chlamydia trachomatis and Neisseria gonorrhoeae have been strongly associated with ectopic pregnancy, infertility, and chronic pelvic pain. STIs during pregnancy might result in fetal death or substantial physical and developmental disabilities, including intellectual disability and blindness. Early screening and treatment prevent these adverse outcomes.

Second maneuver of Leopolds

Complete the second maneuver to determine position. 1) While still facing the woman, move hands down the lateral sides of the abdomen to palpate on which side the back is located (feels hard and smooth). 2) Continue to palpate to determine on which side the limbs are located (irregular nodules with kicking and movement).

conduction (newborn)

Conduction involves the transfer of heat from one object to another when the two objects are in direct contact with each other. Conduction refers to heat fluctuation between the newborn's body surface when in contact with other solid surfaces, such as a cold mattress, scale, or circumcision restraining board. Heat loss by conduction can also occur when touching a newborn with cold hands or when the newborn has direct contact with a colder object such as a metal scale or a cool mattress, blanket, or clothing. Using a warmed cloth diaper or blanket to cover any cold surface touching a newborn directly helps prevent heat loss through conduction. Placing the newborn skin-to-skin with the mother also helps prevent heat loss through conduction.

bladder assessment postpartum

Considerable diuresis—as much as 3,000 mL/day—begins within 12 hours after childbirth and continues for several days. A single voiding may be 500 mL or more. By 21 days postpartum, the diuresis is usually complete (Jordan et al., 2019). However, many postpartum women do not sense the need to void even if their bladder is full. In this situation, the bladder can become distended and displace the uterus upward and to the side, which prevents the uterine muscles from contracting properly and can lead to excessive bleeding. -Postpartum urinary retention is defined as the inability to empty the bladder within 6 hours after a vaginal birth. -Urinary retention as a result of decreased bladder tone and emptying can lead to urinary tract infections and postpartum hemorrhage. It is imperative that nurses monitor clients for signs of urinary tract infections, including fever, urinary frequency and/or urgency, difficult or painful urination, and tenderness over the costovertebral angle Palpate the area over the symphysis pubis. If empty, the bladder is not palpable. Palpation of a rounded mass suggests bladder distention. Also percuss the area; a full bladder is dull to percussion. If the bladder is full, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding.

bowel assessment postpartum

Constipation is one of the most common gastrointestinal symptoms in postpartum mothers. -Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. Inspect the woman's abdomen for distention, auscultate for bowel sounds in all four quadrants prior to palpating the uterine fundus, and palpate for tenderness. The abdomen typically is soft, nontender, and nondistended. Bowel sounds are present in all four quadrants. Ask the woman if she has had a bowel movement or has passed gas since giving birth, because constipation is common during the postpartum period, and many women do not offer this information unless asked about it. Normal assessment findings are active bowel sounds, passing gas, and a nondistended abdomen.

convection (newborn)

Convection involves the flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface. Examples of convection-related heat loss would be a cool breeze that flows over the newborn, a cool room, cool corridors, or outside air currents. To prevent heat loss by this mechanism, keep the newborn out of direct cool drafts (open doors, windows, fans, air conditioners) in the environment; work inside an isolette as much as possible and minimize opening portholes that allow cold air to flow inside; and warm any oxygen or humidified air that comes in contact with the newborn. Using clothing and blankets in isolettes is an effective means of reducing the newborn's exposed surface area and providing external insulation. Also, transporting the newborn to the nursery in a warmed isolette rather than carrying them helps maintain warmth and reduce exposure to the cool air

postpartum period

Critical transition period for woman, newborn, and family physiologically and psychologically

folic acid deficiency

Daily use of vitamin supplements containing folic acid (400 mcg) has been demonstrated to reduce the occurrence of neural tube defects by two thirds.

Interventions of third stage of labor

Describing the process of placental separation to the couple Instructing the woman to push when signs of separation are apparent Administering an oxytocic agent if ordered and indicated after placental expulsion Providing support and information about episiotomy and/or laceration if applicable Cleaning and assisting the client into a comfortable position after birth, making sure to lift both legs out of stirrups (if used) simultaneously to prevent strain Assessing the woman's knowledge of breastfeeding to determine educational needs Educating the woman about latching on, positioning, infant sucking and swallowing Repositioning the birthing bed to serve as a recovery bed if applicable Assisting with transfer to the recovery area if applicable Providing warmth by replacing warmed blankets over the woman Applying an ice pack to the perineal area to provide comfort to episiotomy if indicated Explaining what assessments will be carried out over the next hour and offering positive reinforcement for actions

hematocrit level postpartum

Despite the decrease in blood volume, the hematocrit level remains relatively stable and may even increase, reflecting the predominant loss of plasma. Thus, an acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.

fundus positioning postpartum

During the first 12 hours postpartum, the fundus of the uterus is located at the level of the umbilicus. Over the first few days after birth, the uterus typically descends from the level of the umbilicus at a rate of 1 cm (one fingerbreadth) per day. By 3 days, the fundus lies two to three fingerbreadths below the umbilicus (or slightly higher in multiparous women). By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

postpartum assessment times

During the first hour: every 15 minutes During the second hour: every 30 minutes During the first 24 hours: every 4 hours After 24 hours: every 8 hours

nutrition in postpartum

Eat a wide variety of foods with high nutrient density. Eat meals that require little or no preparation. Make sure all foods are well-cooked to prevent bacteria ingestion. Avoid high-fat fast foods. Drink plenty of fluids daily—at least 2,500 mL (approximately 84 oz). Avoid fad weight-reduction diets and harmful substances such as alcohol, tobacco, and drugs. Avoid excessive intake of fat, salt, sugar, and caffeine. Eat the recommended daily servings from each food grou

evaporation (newborn)0

Evaporation involves the loss of heat when a liquid is converted to vapor. Evaporative loss may be insensible (such as from skin and respiration) or sensible (such as from sweating). Insensible loss occurs, but the individual is not aware of it. Sensible loss is objective and can be noticed. It depends on air speed and the absolute humidity of the air. For example, when the baby is born, the body is covered with amniotic fluid. The fluid evaporates into the air, leading to heat loss. Heat loss via evaporation also occurs when bathing a newborn. Drying newborns immediately after birth with warmed blankets and placing a cap on their heads will help prevent heat loss through evaporation. In addition, drying the newborn after bathing will help prevent heat loss through evaporation. Promptly changing wet linens, clothes, or diapers will also reduce heat loss and prevent chilling.

recommended follow up schedule

Every 4 weeks up to 28 weeks (7 months) Every 2 weeks from 29 to 36 weeks Every week from 37 weeks to birth

expulsion (cardinal movement of labor)

Expulsion of the rest of the body occurs more smoothly after the birth of the head and the anterior and posterior shoulders. Manual control of the fetus expulsion and perineal support by the health care provider reduces the risk of perineal injury to the mother (Riethmuller et al., 2018). See Figure 13.3 for an image of a fetal skull.

Internal vs external continuous EFM monitoring

External: can be done without cervical dilation and effacement, is affected by maternal movements Internal: can accurately detect both short-term (moment-to-moment) changes and variability (fluctuations within the baseline) and FHR dysrhythmias. In addition, maternal position changes and movement do not interfere with the quality of the tracing.

function of fetal HR variability

FHR variability is an important clinical indicator that is predictive of fetal acid-base balance and cerebral tissue perfusion. It is influenced by fetal oxygenation status, cardiac output, and drug effects (King et al., 2019). As the CNS is desensitized by hypoxia and acidosis, FHR decreases until a smooth baseline pattern appears. Loss of variability may be associated with a poor outcome.

The ADA recommends targets for women with type 1 or type 2 diabetes as follows:

Fasting: lower than 95 mg/dL 1-hour postprandial: lower than 140 mg/dL 2-hour postprandial: lower than 120 mg/dL Insulin is the preferred medication for treating hyperglycemia in gestational diabetes as it doesn't cross the placenta to a measurable extent. If oral hypoglycemic agents are used, they shouldn't be the first-line therapy since there are no safety data from long-term studies yet.

four categories of baseline variability

Fluctuation range undetectable: absent variability Fluctuation range observed at fewer than 5 bpm: minimal variability Fluctuation range from 6 to 25 bpm: moderate variability (aka CNS of fetus is developed and well oxygenated) Fluctuation range more than 25 bpm: marked variability (could be a sign of fetal anemia)

neurologic system in newborn

Hearing—well developed at birth, responds to noise by turning to sound Taste—ability to distinguish between sweet and sour by 72 hours old Smell—ability to distinguish between mother's breast milk and breast milk from others Touch—sensitivity to pain, responds to tactile stimuli Vision—incomplete at birth; maturation is dependent on nutrition and visual stimulation. Newborns have the ability to focus only on close objects (8 to 10 in away) with a visual acuity of 20/140; they can track objects in midline or beyond (90 in). This is the least mature sense at birth. The ability to fix, follow, and be alert is indicative of an intact CNS Neurologic development follows cephalocaudal (head-to-toe) and proximal-distal (center-to-outside) patterns. Myelin develops early on in sensory impulse transmitters. Thus, the newborn has an acute sense of hearing, smell, and taste. Reflexes: indication of neurological development and function

physiological changes during labor

Heart rate increases by 10 to 20 bpm. Cardiac output increases by 12% to 31% during the first stage of labor and by 50% during the second stage of labor. Blood pressure increases by up to 35 mm Hg during uterine contractions in all labor stages. The white blood cell count increases to 25,000 to 30,000 cells/mm3 perhaps as a result of tissue trauma. Respiratory rate increases and more oxygen is consumed related to the increase in metabolism. Gastric motility and food absorption decrease, which may increase the risk of nausea and vomiting during the transition stage of labor. Gastric emptying and gastric pH decrease, increasing the risk of vomiting with aspiration. Temperature rises slightly, possibly due to an increase in muscle activity. Muscular aches and cramps occur as a result of stress on the musculoskeletal system. Basal metabolic rate increases and blood glucose levels decrease because of the stress of labor

normal newborn blood values

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

nursing management during first stage of labor

Identifying the estimated date of birth from the client and the prenatal chart Validating the client's prenatal history to determine fetal risk status Determining fundal height to validate dates and fetal growth Performing Leopold maneuvers to determine fetal position, lie, and presentation Checking FHR Performing a vaginal examination as appropriate to evaluate effacement and dilation progress Instructing the client and her partner about monitoring techniques and equipment Assessing fetal response and FHR to contractions and recovery time Interpreting fetal monitoring strips Checking FHR baseline for accelerations, variability, and decelerations Repositioning the client to obtain an optimal FHR pattern Recognizing FHR problems and initiating corrective measures Checking amniotic fluid for meconium staining, odor, and amount Comforting the client throughout the testing period and labor Documenting times of notification for team members if problems arise Knowing appropriate interventions when abnormal FHR patterns present Supporting the client's decisions regarding intervention or avoidance of intervention Assessing the client's support system and coping status frequently

HIV/AIDS

If HIV infection is identified before conception, timely antiretroviral treatment can be administered, and women (or couples) can be given additional information that can help prevent mother-to-child transmission.

Episiotomy/perineum assessment postpartum

If the woman has an episiotomy, which is no longer routinely done, to assess the episiotomy and perineal area, position the woman on her side with her top leg flexed upward at the knee and drawn up toward her waist. If necessary, use a penlight to provide adequate lighting during the assessment. Wearing gloves and standing at the woman's side with her back to you, gently lift the upper buttock to expose the perineum and anus (Fig. 16.4). Inspect the episiotomy for irritation, ecchymosis, tenderness, or hematomas. Assess for hemorrhoids and their condition. Lacerations are classified based on severity and tissue involvement: First-degree laceration: involves only skin and superficial structures above muscle Second-degree laceration: extends through perineal muscles Third-degree laceration: extends through the anal sphincter muscle Fourth-degree laceration: continues through anterior rectal wall Large areas of swollen, bluish skin with complaints of severe pain in the perineal area indicate pelvic or vulvar hematomas. Redness, swelling, increasing discomfort, or purulent drainage may indicate infection. A white line running the length of the episiotomy is a sign of infection, as is swelling or discharge. Severe, intractable pain, perineal discoloration, and ecchymosis indicate a perineal hematoma, a potentially dangerous condition. Report any unusual findings. Ice can be applied to relieve discomfort and reduce edema; sitz baths also can promote comfort and perineal healing

Rh status postpartum

If the woman is Rh-negative, check the Rh status of the newborn. Verify that the woman is Rh-negative and has not been sensitized, that her indirect Coombs test (antibody screen) is negative, and that the newborn is Rh-positive. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth to prevent a sensitization reaction in the Rh-negative woman who received Rh-positive blood cells during the birthing process. Administering RhoGAM prevents initial isoimmunization in Rh-negative mothers by destroying fetal erythrocytes in the maternal system before maternal antibodies can develop and maternal memory cells become sensitized. This is a classic passive immunization technique. The usual protocol for the Rh-negative woman is to receive two doses of RhoGAM, one at 28 weeks' gestation and the second dose within 72 hours after childbirth. The standard dose of RhoGAM is 300 mcg given intramuscularly, which prevents the development of antibodies for an exposure of up to 15 mL of fetal red blood cells (King et al., 2019). A signed consent form is needed after a thorough explanation is provided about the procedure, including its purpose, possible adverse effects, and effect on future pregnancies. RhoGAM contains actual Rh antibodies produced by people who have become sensitized. It is therefore, a blood product. Each dose contains enough anti-D to suppress the immune response of 15 mL of Rh-positive red blood cells (Jordan et al., 2019). Jehovah's Witnesses and others who belong to religions prohibiting the use of blood products should decide based on their conscience and possibly ecclesiastical leaders about the use of RhoGAM. Nurses need to respect whatever the mother's decision is.

cervix postpartum

Immediately after a vaginal birth, the cervix extends into the vagina and remains partly dilated, bruised, and edematous. The cervix typically returns to its prepregnant state by week 6 of the postpartum period. -The cervix closes but never regains its prepregnant appearance. The internal cervical os gradually closes and returns to normal by 2 weeks, while the external os widens and never appears the same after childbirth. The external cervical os is no longer shaped like a circle, but instead appears as a jagged slit-like opening, often described as looking like a fish mouth

pelvic shape

In addition to size, the shape of a woman's pelvis is a determining factor for a vaginal birth. Each plane of the pelvis has a shape, which is defined by the anterior-posterior and transverse diameters. The pelvis is divided into four main shapes: gynecoid, anthropoid, android, and platypelloid

leukkorhea

Increased vaginal discharge begins during the first trimester and continues throughout pregnancy. The physiologic changes behind leukorrhea arise from the high levels of estrogen, which cause increased vascularity and hypertrophy of cervical glands as well as vaginal cells (Cunningham et al., 2018). The result is progressively increasing vaginal secretions throughout pregnancy.

postive attachment behaviors

Infant: Smiles; is alert; demonstrates strong grasp reflex to hold parent's finger; sucks well, feeds easily; enjoys being held close; makes eye-to-eye contact; follows parent's face; appears facially appealing; is consolable when crying parent: Makes direct eye contact; assumes en face position when holding infant; claims infant as family member, pointing out common features; expresses pride in infant; assigns meaning to infant's actions; smiles and gazes at infant; touches infant, progressing from fingertips to holding; names infant; requests to be close to infant as much as allowed; speaks positively about infant

engrossment

Infants have a powerful effect on their parents and others, who become intensely involved with them (Fig. 15.7). The partner's developing bond with the newborn—a time of intense absorption, preoccupation, and interest—is called engrossment.

breast assessment postpartum

Inspect the breasts for size, contour, asymmetry, engorgement, or erythema. Check the nipples for cracks, redness, fissures, or bleeding, and note whether they are erect, flat, or inverted. Flat or inverted nipples can make breastfeeding challenging for both mother and infant. Cracked, blistered, fissured, bruised, or bleeding nipples in the breastfeeding woman are generally indications that the baby is improperly positioned on the breast. Palpate the breasts lightly to ascertain if they are soft, filling, or engorged, and document your findings. For women who are not breastfeeding, use a gentle, light touch to avoid breast stimulation, which would exacerbate engorgement. Lactogenesis (the onset of milk secretion) is initially triggered by the delivery of the placenta, which results in falling levels of estrogen and progesterone with the continued presence of prolactin. If the mother is not breastfeeding, the prolactin levels fall and return to normal levels within 2 to 3 weeks. As milk is starting to come in, the breasts become firmer; this is charted as "filling." Engorged breasts are hard, tender, and taut. Ask the woman if she is having any nipple discomfort. Palpate the breasts for any nodules, masses, or areas of warmth, which may indicate a plugged duct that may progress to mastitis if not treated promptly. Any discharge from the nipple should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).

difference bw EFM and intermittent FHR auscultation

Intermittent FHR auscultation can be used to detect FHR baseline and rhythm and changes from baseline. However, it cannot detect variability and types of decelerations, as electronic fetal monitoring (EFM) can.

what to do when absent, minimal variability, or marked

Interventions to improve uteroplacental blood flow and perfusion through the umbilical cord include lateral positioning of the mother, increasing the intravenous (IV) fluid rate to improve maternal circulation, administering oxygen at 8 to 10 L/min by mask, considering internal fetal monitoring, documenting findings, and reporting to the health care provider

ice pack application postpartum

It is applied during the fourth stage of labor and can be used for the first 24 hours to reduce perineal edema and to prevent hematoma formation, thus reducing pain and promoting healing. (20 mins on, 10 mins off)

voiding postpartum

Many women have difficulty feeling the sensation to void after giving birth if they received an anesthetic block during labor (which inhibits neural functioning of the bladder) or if they received oxytocin to induce or augment labor (antidiuretic effect). These women will be at risk for incomplete emptying, bladder distention, difficulty voiding, and urinary retention. In addition, urination may be impeded by: perineal lacerations. generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus. hematomas. decreased bladder tone as a result of regional anesthesia. diminished sensation of bladder pressure as a result of swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor

iron storage newborn

Maturity, birth weight, and hemoglobin level determine the iron status of the newborn. As RBCs are destroyed after birth, their iron is released and stored by the liver until new RBCs need to be produced. If the mother's iron intake was adequate during pregnancy, sufficient iron has been stored in the newborn's liver for use during the first 6 months of age.

analysis of fetal HR

Monitoring of the FHR throughout labor and birth is essential to assure fetal well-being to optimize neonatal outcomes. Analysis of the FHR is one of the primary evaluation tools used to determine fetal oxygen status indirectly. FHR assessment can be done intermittently using a fetoscope (a modified stethoscope attached to a headpiece) or a Doppler (ultrasound) device, or continuously with an electronic fetal monitor applied externally or internally. The object of FHR monitoring is to reduce mortality and morbidity by ensuring that all fetal hypoxic insults are identified in time to allow removal or alteration of the reason for them, or to enable a safe birth of the fetus before irreversible asphyxia damage occurs

Third stage of labor assessment

Monitoring placental separation by looking for the following signs:Firmly contracting uterusChange in uterine shape from discoid to globular ovoidSudden gush of dark blood from vaginal openingLengthening of umbilical cord protruding from vaginaExamining placenta and fetal membranes for intactness the second time (the health care provider assesses the placenta for intactness the first time) (Fig. 14.18) Assessing for any perineal trauma, such as the following, before allowing the birth attendant to leave:Firm fundus with bright red blood trickling: lacerationBoggy fundus with red blood flowing: uterine atonyBoggy fundus with dark blood and clots: retained placentaInspecting the perineum for condition of episiotomy if performedAssessing for perineal lacerations and ensuring repair by birth attendant

musculoskeletal system postpartum

Musculoskeletal changes associated with pregnancy, such as increased ligament laxity, weight gain, change in the center of gravity, and carpal tunnel syndrome, revert back during the postpartum period. During pregnancy, the hormones relaxin, estrogen, and progesterone relax the joints. After birth, levels of these hormones decline, resulting in a return of all joints to their prepregnant state, with the exception of the woman's feet. Parous women may note a permanent increase in shoe size -Women commonly experience fatigue and activity intolerance and have a distorted body image for weeks after birth ( secondary to declining relaxin and progesterone levels, which cause hip and joint pain that interferes with ambulation and exercise. Good body mechanics and correct positioning are important during this time to prevent low back pain and injury to the joints. Within 6 to 8 weeks after delivery, joints are completely stabilized and return to normal) During pregnancy, stretching of the abdominal wall muscles occurs to accommodate the enlarging uterus. This stretching leads to a loss in muscle tone and possibly separation of the longitudinal muscles (rectus abdominis muscles) of the abdomen - After birth, muscle tone is diminished and the abdominal muscles are soft and flabby. (Specific exercises are necessary to help the woman regain muscle tone. Fortunately, diastasis responds well to exercise, and abdominal muscle tone can be improved)

umbilical cord blood analysis

Neonatal and childhood mortality and morbidity, including cerebral palsy, are often attributed to fetal acidosis as indicated by a low cord pH at birth. Umbilical cord blood acid-base analysis drawn at birth provides an objective method of evaluating a newborn's condition, identifying the presence of intrapartum hypoxia and acidemia. This test is considered a good indicator of fetal oxygenation and acid-base condition at birth (Saneh et al., 2020). The normal mean pH value range is 7.2 to 7.3. The pH values are useful for planning interventions for the newborn born with low 5-minute Apgar scores, severe fetal growth restriction (FGR), category II and III patterns during labor, umbilical cord prolapse, uterine rupture, maternal fever, placental abruption, meconium-stained amniotic fluid, and post-term births (Jordan et al., 2019). The interventions needed for the compromised newborn might include providing an optimal extrauterine environment, fluids, oxygen, medications, and other treatments.

Heat loss in newborn

Newborns have several characteristics that predispose them to heat loss: Thin skin with blood vessels close to the surface Increased skin permeability to water Lack of shivering ability to produce heat until 3 months old Limited stores of metabolic substrates (glucose, glycogen, fat) Limited use of voluntary muscle activity or movement to produce heat Large surface area-to-body mass ratio Lack of subcutaneous fat, which provides insulation Little ability to conserve heat by changing posture (fetal position) No ability to adjust their own clothing or blankets to achieve warmth Inability to communicate that they are too cold or too warm

bottle feeding postpartum

Newborns need about 100 to 110 cal/kg or approximately 650 cal/day. Therefore, explain to parents that a newborn will need 2 to 4 oz to feel satisfied at each feeding. Until about age 4 months, most bottle-fed infants need six feedings a day. After this time, the number of feedings declines

alcohol misuse

No time during pregnancy is safe to drink alcohol, and harm can occur early, before a woman has realized that she is or might be pregnant. Fetal alcohol syndrome (a collection of deformities) and other alcohol-related birth defects can be prevented if women cease intake of alcohol before conception.

coagulation postpartum

Normal physiologic changes of pregnancy, including alterations in hemostasis that favor coagulation, reduced fibrinolysis, and pooling and stasis of blood in the lower limbs, place women at risk for blood clots. These changes, which usually return to prepregnant levels after 3 weeks postpartum, are important for minimizing blood loss at childbirth. Smoking, obesity, immobility, and postpartum factors such as infection, bleeding, and emergency surgery (including emergency cesarean section) also increase the risk of coagulation disorders (Resnik et al., 2019). Clotting factors that increased during pregnancy tend to remain elevated during the early postpartum period. Giving birth stimulates this hypercoagulability state further. As a result, these coagulation factors remain elevated for 2 to 3 weeks postpartum (King et al., 2019). This hypercoagulable state, combined with vessel damage during birth and immobility, places the woman at risk for thromboembolism (blood clots) in the lower extremities and the lungs

respiratory system newborn

One of the most crucial adaptations that the newborn makes at birth is adjusting from a fluid-filled intrauterine environment to a gaseous extrauterine environment. During fetal life, the lungs are expanded with an ultrafiltrate of the amniotic fluid. During and after birth, this fluid must be removed and replaced with air. Passage through the birth canal allows intermittent compression of the thorax, which helps eliminate two thirds of the fluid in the lungs. If fluid is removed too slowly or incompletely (e.g., with decreased thoracic squeezing during birth or diminished respiratory effort), transient tachypnea (respiratory rate above 60 bpm) of the newborn occurs. Examples of situations involving decreased thoracic compression and diminished respiratory effort include cesarean birth and sedation in newborns.

topical preparations postpartum

One such treatment is a local anesthetic spray such as benzocaine topical. These agents numb the perineal area and are used after cleansing the area with water via the peribottle and/or a sitz bath. Nonpharmacologic measures to reduce hemorrhoid discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. The pads are placed at the rectal area, between the hemorrhoids and the perineal pad. These pads cool the area, help relieve swelling, and minimize itching Nipple pain is difficult to treat, though a wide variety of topical creams, ointments, and gels are available to do so. This group includes beeswax, glycerin-based products, petrolatum, lanolin, and hydrogel products. Many women find these products comforting. Beeswax, glycerin-based products, and petrolatum all need to be removed before breastfeeding. These products should be avoided in order to limit infant exposure because the process of removal may increase nipple irritation. Applying expressed breast milk to nipples and allowing it to dry has been suggested to reduce nipple pain. Usually the pain is due to an incorrect latch and/or removal of the nursing infant from the breast. Early assistance with breastfeeding to ensure correct positioning can help prevent nipple trauma.

pain meds given during labor

Opioids, such as butorphanol (Stadol), nalbuphine (Nubain), meperidine (Demerol), morphine, or fentanyl (Sublimaze

systemic analgesias during labor

Opioids: Morphine 2-5 mg IV: May be given IV or epidurally, Rapidly crosses the placenta, causes a decrease in FHR variability, Can cause maternal and neonatal CNS depression, Decreases uterine contractions Meperidine (Demerol) 25-75 mg IV: May be given IV, intrathecally, or epidurally with maximal fetal uptake 2-3 hr after administration, Can cause CNS depression, Decreases fetal variability Butorphanol (Stadol) 1-2 mg IV: Is given IV Q 2-4 hr, Is rapidly transferred across the placenta, Causes neonatal respiratory depression Nalbuphine (Nubain) 10-20 mg IV: Is given IV, Causes less maternal nausea and vomiting, Causes decreased, FHR variability, fetal bradycardia, and respiratory depression Fentanyl (Sublimaze) 50-100 mcg IV: Is given IV or epidurally, Can cause maternal hypotension, maternal and fetal respiratory depression, Rapidly crosses placenta, Antiemetics Hydroxyzine (Vistaril) 50-100 mg IM: Does not relieve pain but reduces anxiety and potentiates opioid analgesic effects; cannot be given IV, Is used to decrease nausea and vomiting Promethazine (Phenergan) 25-50 mg IV or IM: Is used for antiemetic effect when combined with opioids, Causes sedation and reduces apprehension, May contribute to maternal hypotension and neonatal depression Prochlorperazine (Compazine) 5-10 mg IV or IM: Frequently given with morphine sulfate for sleep during prolonged latent phase; counteracts the nausea that opioids can produce Benzodiazepines: Diazepam (Valium) 2-5 mg IV: Is given to enhance pain relief of opioid and cause sedation, May be used to stop eclamptic seizures, Decreases nausea and vomiting, Can cause newborn depression; therefore, lowest possible dose should be used Midazolam (Versed) 1-5 mg IV: Is not used for analgesic but amnesia effect, Is used as adjunct for anesthesia, Is excreted in breast milk

oxytocin in breastfeeding

Oxytocin acts so that milk can be ejected from the alveoli to the nipple. Therefore, sucking by the newborn will release milk. A decrease in the quality of stimulation causes a decrease in prolactin surges and thus a decrease in milk production. Prolactin levels increase in response to nipple stimulation during feedings. Prolactin and oxytocin result in milk production if stimulated by sucking (Blackburn, 2018) (Fig. 15.3). If the stimulus (sucking) is not present, as with a woman who is not breastfeeding, breast engorgement and milk production will subside within days postpartum.

afterpains

Part of the involution process involves uterine contractions. Immediately after birth and delivery of the placenta, the uterus begins to contract constricting the intramyometrial vessels and impeding blood flow; this is the primary mechanism preventing hemorrhage from the placental site. Inadequate myometrial contractions will result in atony which will result in an early postpartum hemorrhage (Berens, 2020). These painful uterine contractions are often called afterpains. All women experience afterpains, but they are more acute in multiparous and breastfeeding women secondary to repeated stretching of the uterine muscles from multiple pregnancies or stimulation during breastfeeding with oxytocin released from the pituitary gland. Primiparous women typically experience mild afterpains because the uterus is able to maintain a contracted state. Breastfeeding and administration of exogenous oxytocin both cause powerful and painful uterine contractions. Afterpains are usually stronger during breastfeeding because oxytocin released by the sucking reflex strengthens the contractions. Mild analgesics can reduce this discomfort.

the 5 Ps

Passageway (birth canal) Passenger (fetus and placenta) Powers (contractions) Position (maternal) Psychological response These critical factors are commonly accepted and discussed by health care providers. However, five additional "P's" can also affect the labor process: Philosophy (low-tech, high-touch) Partners (support caregivers) Patience (natural timing) Patient (client) preparation (childbirth knowledge base) Pain management (comfort measures)

Fourth maneuver of Leopolds

Perform the fourth maneuver to determine attitude. 1)Turn to face the client's feet and use the tips of the first three fingers of each hand to palpate the abdomen. 2) Move fingers toward each other while applying downward pressure in the direction of the symphysis pubis. If you palpate a hard area on the side opposite the fetal back, the fetus is in flexion, because you have palpated the chin. If the hard area is on the same side as the back, the fetus is in extension, because the area palpated is the occiput. Also, note how your hands move. If the hands move together easily, the fetal head is not descended into the woman's pelvic inlet. If the hands do not move together and stop because of resistance, the fetal head is engaged into the woman's pelvic inlet

Third maneuver of Leopolds

Perform the third maneuver to confirm presentation. 1) Move hands down the sides of the abdomen to grasp the lower uterine segment and palpate the area just above the symphysis pubis. 2)Place thumb and fingers of one hand apart and grasp the presenting part by bringing fingers together. 3)Feel for the presenting part. If the presenting part is the head, it will be round, firm, and ballottable; if it is the buttocks, it will feel soft and irregular.

physiologic changes in labor for FETUS

Periodic fetal heart rate accelerations and slight decelerations related to fetal movement, fundal pressure, and uterine contractions Decrease in circulation and perfusion to the fetus secondary to uterine contractions (a healthy fetus is able to compensate for this drop) Increase in arterial carbon dioxide pressure (PCO2) Decrease in fetal breathing movements throughout labor Decrease in fetal oxygen pressure with a decrease in the partial pressure of oxygen (PO2)

First Maneuver of Leopold's

Place the woman in the supine position and stand beside her. Perform the first maneuver to determine presentation. 1) Facing the woman's head, place both hands on the abdomen to determine fetal position in the uterine fundus 2) Feel for the buttocks, which will feel soft and irregular (indicates vertex presentation); feel for the head, which will feel hard, smooth, and round (indicates a breech presentation).

Smoking

Preterm birth, low birth weight, and other adverse perinatal outcomes associated with maternal smoking in pregnancy can be prevented if women stop smoking before or during early pregnancy. Because only 20% of women successfully control tobacco dependency during pregnancy, cessation of smoking is recommended before pregnancy. -nicotine in the cigarettes causes vasoconstriction in the mother, leading to reduced placental perfusion; results in small baby for gestational age

A woman's ability to adapt to the stress of labor is influenced by her psychological and physical state. Among the many factors that affect her coping ability are:

Previous birth experiences and their outcomes (complications and previous birth outcomes) Current pregnancy experience (planned versus unplanned, discomforts experienced, age, risk status of pregnancy, chronic illness, weight gain) Cultural considerations (values and beliefs about health status) Support system (presence and support of a valued partner during labor) Childbirth preparation (attended childbirth classes and has practiced paced breathing techniques) Exercise during pregnancy (muscles toned; ability to assist with intra-abdominal pushing) Expectations of the birthing experience (viewed as a meaningful or stressful event) Anxiety level (excessive anxiety may interfere with labor progress) Fear of labor and loss of control (fear may enhance pain perception, augmenting fear) Fatigue and weariness (not feeling adequately energized for the challenge and duration of labor)

immunizations postpartum

Prior to discharge, check the immunity status for rubella for all mothers and give a subcutaneous injection of rubella vaccine if they are not serologically immune (titer less than 1:8). Be sure that the client signs a consent form to receive the vaccine. The rubella vaccine should not be given to any woman who is immunocompromised, and the immune status of her close contacts needs to be determined before any vaccine is administered to her to prevent a more virulent case of the vaccine-preventable illness or potential death. With the recent increase in the number of cases of pertussis in infants younger than 3 months of age, the Centers for Disease Control and Prevention (CDC) is also recommending vaccination with (Tdap) (combination of diphtheria, pertussis, and tetanus vaccines) for the mother during her postpartum stay (CDC, 2019c). If it is flu season, the inactivated influenza vaccines are recommended to be administered. Nursing mothers can be vaccinated because the live, attenuated rubella virus is not communicable. Inform all mothers receiving immunization about adverse effects (rash, joint symptoms, and a low-grade fever 5 to 21 days later) and the need to avoid pregnancy for at least 28 days after being vaccinated because of the risk of teratogenic effect

prolactin in breastfeeding

Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the glandular cells to secrete milk instead of colostrum. ******This takes place within 4 to 5 days after giving birth.

Interventions during fourth stage of labor

Providing support and information to the woman regarding episiotomy repair and related pain relief and self-care measures Applying an ice pack to the perineum to promote comfort and reduce swelling Assisting with hygiene and perineal care; teaching the woman how to use the perineal bottle after each pad change and voiding; helping the woman into a new gown Monitoring for return of sensation and ability to void (if regional anesthesia was used) Encouraging the woman to void by ambulating to the bathroom, listening to running water, or pouring warm water over the perineal area with the peribottle Monitoring vital signs and fundal and lochia status every 15 minutes and documenting them Assessing for postpartum hemorrhage and urinary retention via uterine palpation Promoting comfort by offering analgesia for afterpains and warm blankets to reduce chilling Offering fluids and nourishment if desired Encouraging parent-infant attachment by providing privacy for the family Being knowledgeable about and sensitive to typical cultural practices after birth Assisting and encouraging the mother to nurse, if she chooses, during the recovery period to promote uterine firmness (the release of oxytocin from the posterior pituitary gland stimulates uterine contractions) Teaching the woman how to assess her fundus for firmness periodically and to massage it if it is boggy Describing the lochia flow and normal parameters to observe for postpartum Teaching safety techniques to prevent newborn abduction Demonstrating the use of the portable sitz bath as a comfort measure for her perineum if she had a laceration or an episiotomy repair Explaining comfort and hygiene measures and when to use them Assisting with ambulation when getting out of bed for the first time Providing information about the routine on the mother-baby unit or nursery during the stay Observing for signs of early parent-infant attachment: fingertip touch to palm touch to enfolding of the infant

Leopold Maneuvers (Abdominal Palpation)

Purpose: To Determine Fetal Presentation, Position, and Lie a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation. The flat palmar surfaces of the nurse's hands with the fingers together palpate the uterus. A longitudinal lie is expected, and the presentation can be cephalic, breech, or shoulder. Each maneuver answers a question: Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) Maneuver 3: What is the presenting part? Maneuver 4: Is the fetal head flexed and engaged in the pelvis?

radiation (newborn)

Radiation involves the loss of body heat to cooler, solid surfaces that are in proximity but not in direct contact with the newborn. The amount of heat loss depends on the size of the cold surface area, the surface temperature of the newborn's body, and the temperature of the receiving surface area. For example, when a newborn is placed in a single-wall isolette next to a cold window, heat loss from radiation occurs. A newborn will become cold even though they are in a heated isolette. To reduce heat loss by radiation, keep cribs and isolettes away from outside walls, cold windows, and air conditioners. Also, using radiant warmers for transporting newborns and when performing procedures that may expose the newborn to the cooler environment will help reduce heat loss.

RBC production postpartum

Red blood cell production ceases early in the puerperium, causing mean hemoglobin and hematocrit levels to decrease slightly in the first 24 hours. During the next 2 weeks, both levels rise slowly. The white blood count, which increases in labor, remains elevated for first 4 to 6 days after birth but then falls to 6,000 to 10,000/mm3. This white blood cell elevation can complicate a diagnosis of infection in the immediate postpartum period.

rubella seronegativity

Rubella vaccination provides protective seropositivity and prevents congenital rubella syndrome.

scapula (acromion process (A)): Fetal position

Shoulder presentation

what helps determine fetal head position?

Sutures play a role in helping to identify the position of the fetal head during a vaginal examination. - During a pelvic examination, palpation of these sutures by the examiner reveals the position of the fetal head and the degree of rotation that has occurred.

vital signs assessment postpartum

Temperature: slight elevation during first 24 hours; normal afterward Pulse: 40 to 80 bpm during first week after birth; puerperal bradycardia (After giving birth, there is an increase in intravascular volume. The cardiac output is most likely caused by an increased stroke volume from the venous return now. The elevated stroke volume leads to a decreased heart rate; tachycardia postpartum is abnormal) Respirations: 16 to 20 breaths per minute (Pulmonary function typically returns to the prepregnant state after childbirth when the diaphragm descends and the organs revert to their normal positions) Blood pressure: within usual range (Immediately after childbirth, the blood pressure should remain the same as during labor. An increase in blood pressure could indicate gestational hypertension, while a decrease could indicate shock or orthostatic hypotension or dehydration, a side effect of epidural anesthesia. Blood pressure readings should not be higher than 140/90 mm Hg or lower than 85/60 mm Hg) Pain: goal between 0 and 2 on pain scale

breastfeeding

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for 6 months followed by the introduction of appropriate complementary foods and continued breastfeeding to 1 year and beyond

Positions of FHR

The FHR is heard most clearly at the fetal back. -cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen -breech presentation, it is heard at or above the level of the maternal umbilicus -For low-risk women, the FHR=assessed every 15 to 30 minutes in active labor -every 5 to 15 minutes while pushing, as well as before and after any digital vaginal examinations, membrane rupture, medication administered, and ambulation to the restroom

molding

The cartilage between the bones allows the bones to overlap during labor, a process called molding that elongates the fetal skull, thereby reducing the diameter of the head. Along with molding, fluid can also collect in the scalp (caput succedaneum) or blood can collect beneath the scalp (cephalohematoma), further distorting the shape and appearance of the fetal head. -oblong shape is normal and will reside (reassure parents; oblong=longer in one direction than the other)

bilirubin in newborn

The causes of newborn jaundice can be classified into three groups based on the mechanism of accumulation: Bilirubin overproduction, such as from blood incompatibility (Rh or ABO), drugs, trauma at birth, polycythemia, delayed cord clamping, and breast milk jaundice Decreased bilirubin conjugation, as seen in physiologic jaundice, hypothyroidism, and breastfeeding Impaired bilirubin excretion, as seen in biliary obstruction (biliary atresia, gallstones, neoplasm), sepsis, hepatitis, chromosomal abnormality (Turner syndrome, trisomies 18 and 21), and drugs (aspirin, acetaminophen, sulfa, alcohol, steroids, antibiotics)

Integumentary system newborn

The epidermal barrier begins to develop during midgestation and is fully formed by about 32 weeks' gestation. Although the neonatal epidermis is similar to the adult epidermis in thickness and lipid composition, skin development is not complete at birth -protective barrier between the body and environment -Functions: limits loss of water, prevents absorption of harmful agents, protects against physical trauma, and protects thermoregulation and fat storage -accelerated epidermal development with exposure to air for all newborns

pain during labor

The etiology of pain during the first stage of labor is associated with ischemia of the uterus during contractions. In the second stage, pain is caused by the stretching of the vagina and perineum and compression of the pelvic structures.

passanger

The fetus (with placenta) is the passenger.

cardiovascular system in newborn

The fetus depends on the placenta to provide oxygen and nutrients and to remove waste products. Once placenta is withdrawn and umbillical cord is cut, fetus takes first breath and lungs are now activated -increase in pulmonary blood flow (change from placental to pulmonary gas exchange) -The ductus venosus shunted blood from the left umbilical vein to the inferior vena cava during intrauterine life. It closes within a few days after birth because this shunting is no longer needed as a result of activation of the liver. The activated liver now takes over the functions of the placenta (which was expelled at birth). The ductus venosus becomes a ligament in extrauterine life.

Three-letter abbreviation for fetal position identification

The first letter defines whether the presenting part is tilted toward the left (L) or the right (R) side of the maternal pelvis. The second letter represents the particular presenting part of the fetus: O for occiput, S for sacrum, M for mentum, A for acromion process, and D for dorsal (refers to the fetal back) when denoting the fetal position in shoulder presentations (King et al., 2019). The third letter defines the location of the presenting part in relation to the anterior (A) portion of the maternal pelvis or the posterior (P) portion of the maternal pelvis. If the presenting part is directed to the side of the maternal pelvis, the fetal presentation is designated as transverse (T). For example, if the occiput is facing the left anterior quadrant of the pelvis, then the position is termed left occiput anterior and is recorded as LOA. (FIG 13.9) -LOA most favorable position for birthing

renal system changes newborn

The glomeruli and nephrons are functionally immature at birth, resulting in a reduced glomerular filtration rate (GFR) and limited concentrating ability. A limited ability to concentrate urine and the reduced GFR make the newborn susceptible to both dehydration and fluid overload The majority of term newborns void immediately after birth, indicating adequate renal function. Although the newborn's kidneys can produce urine, they are limited in their ability to concentrate it until about 3 months of age, when the kidneys mature more. Until that time, a newborn voids frequently and the urine has a low specific gravity -6-8 voidings daily is normal for newborn The renal cortex is relatively underdeveloped at birth and does not reach maturity until 12 to 18 months of age. The GFR is the amount of fluid filtered each minute by all the glomeruli of both kidneys and is one index of kidney function. At birth, the newborn's GFR is approximately 30% of normal adult values, reaching approximately 50% of normal adult values by the 10th day of life and full adult values by the first year of life (Oh et al., 2019). The low GFR and the limited excretion and conservation capability of the kidney affect the newborn's ability to excrete salt, water loads, and drugs.

amniocentesis procedure

The health care provider inserts a long pudendal or spinal needle, a 22-gauge, 5-in needle, into the amniotic cavity and aspirates amniotic fluid, which is placed in an amber or foil-covered test tube to protect it from light. When the desired amount of fluid has been withdrawn (about 20 mL), the needle is removed and slight pressure is applied to the site. If there is no evidence of bleeding, a sterile bandage is applied to the needle site. The specimens are then sent to the laboratory immediately for the cytologist to evaluate.

HR and BP postpartum

The increase in cardiac output and stroke volume during pregnancy begins to diminish after birth once the placenta has been delivered. This decrease in cardiac output is reflected in bradycardia (40 to 60 bpm) for up to the first 2 weeks postpartum. This slowing of the heart rate is related to the increased blood that flows back to the heart and to central circulation after it is no longer perfusing the placenta. This increase in central circulation brings about an increased stroke volume and allows a slower heart rate to provide ample maternal circulation. Gradually, cardiac output returns to prepregnant levels by 3 months after childbirth (Cunningham et al., 2019). Tachycardia (heart rate above 100 bpm) in the postpartum woman warrants further investigation. It may indicate hypovolemia, dehydration, or hemorrhage. However, because of the increased blood volume during pregnancy, a considerable loss of blood may be well tolerated and not cause a compensatory cardiovascular response such as tachycardia. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of the compensatory increase in heart rate. Thus, a decrease in blood pressure and cardiac output are not expected changes during the postpartum period. Early identification is essential to ensure prompt intervention. Blood pressure falls mostly in the first 2 days, then increases 3 to 7 days after childbirth, and returns to prepregnancy levels by 6 weeks (Jordan et al., 2019). A significant increase accompanied by headache might indicate preeclampsia and requires further investigation. Decreased blood pressure may suggest an infection or a uterine hemorrhage.

mucous barrier protection newborn

The intestinal mucosal barrier remains immature for 4 to 6 months following birth. An important adaptation of the gastrointestinal system is the development of this mucosal barrier to prevent the penetration of harmful substances (bacteria, toxins, and antigens) present within the intestinal lumen. At birth, the newborn must be prepared to deal with bacterial colonization of the gut. Colonization is dependent on oral intake. Nutrition, be it via breast milk or formula, plays a major role in early colonization patterns in the neonatal gut. It usually occurs within 24 hours of age and is required for the production of vitamin K GI: The full-term newborn has the capacity to swallow, digest, metabolize, and absorb food taken in soon after birth. At birth, the pH of the stomach contents is mildly acidic, reflecting the pH of the amniotic fluid. The once-sterile gut changes rapidly, depending on what feeding is received. Bowel sounds are normally heard shortly after birth but may be hypoactive on the first day.

let down reflex

The let-down reflex is what makes breastmilk flow. When your baby sucks at the breast, tiny nerves are stimulated. This causes two hormones - prolactin and oxytocin - to be released into your bloodstream. Prolactin helps make the milk, while oxytocin causes the breast to push out the milk.

pushing

The maternal urge to push is generally felt when there is direct contact of the fetus to the pelvic floor. Stretch receptors in the wall of the vagina, rectum, and perineum communicate the pressure of the fetus descending in the birth canal that, along with increased abdominal pressure, causes the overwhelming urge to push described by laboring women -If the mother has an epidural in place, this sensation to push is dulled -the perineum bulges, and there is an increase in bloody show. The fetal head becomes apparent at the vaginal opening but disappears between contractions. When the top of the head no longer regresses between contractions, it is said to have crowned. The fetus rotates as it maneuvers out. Evidence now shows that labor actually progresses slower than was previously thought

overheating

The newborn is also prone to overheating. Limited insulation and limited sweating ability can predispose any newborn to overheating. Control of body temperature is achieved via a complex negative feedback system that creates a balance between heat production, heat gain, and heat loss. The primary heat regulator is located in the hypothalamus and the central nervous system (CNS). The immaturity of the newborn's CNS makes it difficult to create and maintain this balance. Therefore, the newborn can become overheated easily. For example, an isolette that is too warm or one that is left too close to a sunny window may lead to hyperthermia. Although heat production can substantially increase in response to a cool environment, basal metabolic rate and the resultant heat produced cannot be reduced. Overheating increases fluid loss, the respiratory rate, and the metabolic rate considerably. -large body surface area -limited insulation -limited sweating ability

para

The number of times a woman has given birth to a fetus of at least 20 gestational weeks (viable or not), counting multiple births as one birth event -aka a woman who has produced one or more viable offspring carrying a pregnancy 20 weeks or more

perineum postpartum

The perineum stretches during childbirth to allow passage of the newborn, but the majority of women sustain some degree of perineal trauma during childbirth, which can be painful postpartum. The perineum is often edematous and bruised for the first day or two after birth. If the birth involved an episiotomy or laceration, complete healing may take as long as 4 to 6 months in the absence of complications at the site, such as hematoma or infection. The muscle tone may or may not return to normal, depending on the extent of injury to muscle, nerve, and connecting tissues (Begley et al., 2019). Perineal lacerations may extend into the anus and cause considerable discomfort for the mother when she is attempting to defecate or ambulate. The presence of swollen hemorrhoids may also heighten discomfort. Local comfort measures such as ice packs, pouring warm water over the area via a peribottle, witch hazel pads, anesthetic sprays, and sitz baths can relieve pain. Supportive tissues of the pelvic floor are stretched during the childbirth process, and restoring their tone may take up to 6 months. Pelvic relaxation can occur in any woman experiencing a vaginal birth. Pelvic floor dysfunction is one of the most common complications of childbirth following a vaginal birth, and it can have a significant impact on the woman's quality of life as she ages. Nurses should encourage all women to practice pelvic floor muscle training exercises (PFMT) to improve pelvic floor tone, strengthen the perineal muscles, and promote healing

lochia

The process of involution and restoration of the endometrium is reflected in the characteristics of the lochia. Lochia is the vaginal discharge that occurs after birth and continues for approximately 4 to 8 weeks. It results from involution, during which the superficial layer of the decidua basalis becomes necrotic and is sloughed off. Immediately after childbirth, lochia is bright red and consists mainly of blood, fibrinous products, decidual cells, and red and white blood cells. The lochia from the uterus is alkaline but becomes acidic as it passes through the vagina. Patterns of lochia flow vary in amount and duration among women and pregnancies. Each day, the amount of bleeding should be less and the color lighter. The color changes result from the changing composition of the tissue that is sloughed and expelled during the endometrial restoration process (Berens, 2020). Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta by the physician. Lochia is present after a surgical birth with most women experiencing it up to 6 weeks. It occurs from days 10 to 14 but can last 3 to 6 weeks postpartum in some women and still be considered normal. Lochia at any stage should have a fleshy smell; an offensive odor usually indicates an infection, such as endometritis.

reproductive system postpartum

The reproductive system goes through tremendous adaptations to return to the prepregnancy state. All organs and tissues of the reproductive system are involved. The female reproductive system is unique in its capacity to remodel itself throughout the woman's reproductive life. The events after birth, with the shedding of the placenta and subsequent uterine involution, involve substantial tissue destruction and subsequent repair and remodeling. For example, the woman's menstrual cycle, interrupted during pregnancy, will begin to return several weeks after childbirth if the woman is not breastfeeding. Ovulation can return any time, so breastfeeding should not be considered a safe contraceptive and other methods should be used to prevent pregnancy. The uterus, which has undergone tremendous expansion during pregnancy to accommodate progressive fetal growth, will return to its prepregnant size over several weeks. The mother's breasts have grown to prepare for lactation and do not return to their prepregnant size as the uterus does.

what does lightening cause?

The shape of the abdomen changes as a result of the change in the uterus. With this descent, the woman usually notes that her breathing is much easier and that there is a decrease in gastric reflux. However, she may complain of increased pelvic pressure, leg cramping, dependent edema in the lower legs, and low back discomfort. She may notice an increase in vaginal discharge and more frequent urination. In primiparas, lightening can occur 2 weeks or more before labor begins; among multiparas, it may not occur until labor starts

Gravid

The state of being pregnant

gate control theory of pain

The theory that pain is a product of both physiological and psychological factors that cause spinal gates to open and relay patterns of intense stimulation to the brain, which perceives them as pain. -methods promoting this method include continuous labor support, hydrotherapy, hypnosis, ambulation and maternal position changes, transcutaneous electrical nerve stimulation (TENS), acupuncture and acupressure, attention focusing and imagery, therapeutic touch and massage, breathing techniques, and effleurage. (avoid supine positioning always)

diabetes (preconception)

The threefold increase in the prevalence of birth defects among infants of women with type 1 and type 2 diabetes is substantially reduced through proper management of diabetes. -Uncontrolled diabetes in pregnancy raises the risks for spontaneous abortion, fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal hypoglycemia, and hyperbilirubinemia. -A1C should be kept under 6.5% (A1c is a blood test that measures the average blood glucose level over the previous 3 months to determine glucose control and management) -Due to increased red blood cell turnover, A1c is slightly lower during pregnancy. The target A1c should be lower than 6% to 7% to prevent hypoglycemia.

Gravida

The total number of times a woman has been pregnant, regardless of whether the pregnancy resulted in a termination or if multiple infants were born from a pregnancy (aka a pregnant woman)

how to perform a vaginal assessment

The woman is typically on her back during the vaginal examination. The vaginal examination is performed gently with concern for the woman's comfort. If it is the initial vaginal examination to check for membrane status, water is used as a lubricant. After donning sterile gloves, the examiner inserts their index and middle fingers into the vaginal introitus. Next, the cervix is palpated to assess dilation, effacement, and position (e.g., posterior or anterior). If the cervix is open to any degree, the presenting fetal part, fetal position, station, and presence of molding can be assessed. In addition, the membranes can be evaluated and described as intact, bulging, or ruptured.

oral anticoagulants

They are best avoided in pregnancy due to their association with adverse pregnancy outcomes including miscarriage, prematurity, lower birth weight, neurodevelopmental problems and fetal bleeding, as well as a risk of major birth defects with first trimester exposure

Guidelines to assessing FHR

They recommend the following guidelines for assessing FHR: -Initial 10- to 20-minute continuous FHR assessment upon entry into labor and birth area -Completion of a prenatal and labor risk assessment on all clients -Intermittent auscultation every 30 minutes during active labor for a low-risk woman and every 15 minutes for a high-risk woman -During the second stage of labor, every 15 minutes for the low-risk woman and every 5 minutes for the high-risk woman and during the pushing stage

the breast crawl

This instinct occurs when a newborn, left undisturbed and skin-to-skin on the mother's trunk following birth, moves toward the mother's breast for the purpose of locating and self-attaching for the first feeding.From there, the newborn uses leg and arm movements to propel toward the breast. Upon reaching the sternum, the newborn will bounce the head up and down and side to side. As the newborn approaches the nipple, the mouth opens and after several attempts, latch-on and suckling take place. Newborns have senses and skills that enable early initiation of feeding at the breast. Nurses can help facilitate the breast crawl as a continuation of the birthing process. Nurses have a responsibility to promote the health of their childbearing families and provide evidence-based care. Encouraging use of the breast crawl can be the first step in health promotion for every newborn.

Extremities assessment postpartum

Three factors predispose women to thromboembolic disorders during pregnancy: stasis (compression of the large veins because of the gravid uterus); altered coagulation (state of pregnancy); and localized vascular damage (may occur during the birthing process). All of these factors increase the risk of clot formation and having it travel to the lungs.While inspecting the woman's extremities, also determine the degree of sensory and motor function return (recovery from anesthesia) by asking the woman if she feels sensation at various areas the nurse touches and also by observing her ambulation stability. When DVT progresses to PE, it may do so without any signs or symptoms until the woman presents with hypotension or syncope. Dyspnea and chest pain are the most common symptoms that should prompt further evaluation.

First trimester discomforts

Urinary frequency or incontinence Fatigue Nausea and vomiting Breast tenderness Constipation Nasal stuffiness, bleeding gums, epistaxis Cravings Leukorrhea

assessment during 1st stage of labor

Vital signs (BP, pulse, respirations) Every 30-60 min: latent phase Every 15-30 minutes: active phase Contractions (frequency, duration, intensity) Every 30-60 minutes by palpation or continuously if EFM: latent phase Every 15-30 minutes by palpation or continuously if EFM: active phase Fetal heart rate Every hour by Doppler or continuously by EFM: latent phase Every 15-30 minutes by Doppler or continuously by EFM: active phase

how to suppress lactation

Wear a supportive, snugly fitting bra 24 hours daily, but not one that binds the breasts too tightly or interferes with breathing. Suppression may take 5 to 7 days to accomplish. Take mild analgesics to reduce breast discomfort. Let shower water flow over your back rather than your breasts. Avoid any breast stimulation in the form of sucking or massage. Drink to quench your thirst. Restricting your fluid intake will not dry up your milk. Reduce your salt intake to decrease fluid retention. Use ice packs or cool compresses inside the bra to decrease local pain and swelling; change them every 30 minutes

extension (cardinal movement of labor)

With further descent and full flexion of the head, the nucha (the base of the occiput) becomes impinged under the symphysis. Resistance from the pelvic floor causes the fetal head to extend so that it can pass under the pubic arch. Extension occurs after internal rotation is complete. The head emerges through extension under the symphysis pubis along with the shoulders. The anterior fontanlle, brow, nose, mouth, and chin are born successively.

epidural analgesia

Women requesting epidural analgesia in labor will do so when they feel they need pain relief, and for some, it might be quite early in their labor. Epidural analgesia for labor and birth involves the injection of a local anesthetic agent (e.g., lidocaine or bupivacaine) and an opioid analgesic agent (e.g., morphine or fentanyl) into the lumbar epidural space. A small catheter is then passed through the epidural needle to provide continuous access to the epidural space for maintenance of analgesia throughout labor and birth (Fig. 14.11). Epidural analgesia does increase the duration of the second stage of labor and may increase the rate of instrument-assisted vaginal deliveries as well as that of oxytocin administration -An epidural is contraindicated for women with a previous history of spinal surgery or spinal abnormalities, coagulation defects, cardiac disease, obesity, infections, and hypovolemia -Ensuring that the woman avoids a supine position after an epidural catheter has been placed will help minimize hypotension.

breast fed newborn stool

Yellow-gold, loose, stringy to pasty, sour-smelling

lochia rubra

a deep-red mixture of mucus, tissue debris, and blood that occurs for the first 3 to 4 days after birth. As uterine bleeding subsides, it becomes paler and more serous.

effleurage

a light, stroking, superficial touch of the abdomen in rhythm with breathing during contractions, It is used as a relaxation and distraction technique during labor and contractions

peribottle (postpartum)

a plastic squeeze bottle filled with warm tap water that is sprayed over the perineal area after each voiding and before applying a new perineal pad. Usually the peribottle is introduced to the woman when she is assisted to the bathroom to freshen up and void for the first time

engorgement

a postnatal physiologic painful condition in which distention and swelling of the breast tissue occurs as a result of an increase in blood and lymph supply as a precursor to lactation -peaks in 3 to 5 days postpartum and usually subsides within the following 24 to 36 hours. - If milk is not removed as it is formed, the alveolar space can become overdistended, causing tender, swollen, and painful breasts -Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. -If engorged, the breasts will be hard and tender to touch. They are temporarily full, tender, and uncomfortable until the milk supply is ready. - Relieved by frequent emptying of the breasts, warm showers and compresses before feeding, and cold compress between feedings, if breast feeding. -tight supportive bra, ice, avoidance of breast stimulation if not breast feeding A nonprescription antiinflammatory medication can also be taken for the breast discomfort and swelling resulting from engorgement. These measures will also enhance the let-down reflex. Between feedings, applying cold compresses to the breasts helps reduce swelling. To maintain milk supply, the breasts need to be stimulated by a nursing infant, a breast pump, or manual expression of the milk

intermittent FHR monitoring

a primary method of fetal surveillance in labor. It is the practice of using a handheld Doppler or fetoscope for periodic assessment of the FHR. The handheld Doppler device uses ultrasound waves that bounce off the fetal heart, producing echoes or clicks that reflect the rate of the fetal heart -Intermittent FHR monitoring allows the woman to be mobile during the first stage of labor. She is free to move around and change position at will since she is not attached to a stationary electronic fetal monitor. However, intermittent monitoring does not provide a continuous FHR recording and does not document how the fetus responds to the stress of labor (unless listening is done during the contraction). The best way to assess fetal well-being would be to start listening to the FHR at the end of the contraction (not after one) so that late decelerations could be detected. However, the pressure of the device during a contraction is uncomfortable and can distract the woman from using her paced-breathing patterns.

how to confirm ruptured membranes

a sample of fluid is taken from the vagina via a nitrazine yellow dye swab to determine the fluid's pH. Vaginal fluid is acidic, while amniotic fluid is alkaline and turns a nitrazine swab blue. Sometimes, however, false-positive results can occur, especially in women experiencing a large amount of bloody show because blood is alkaline. The membranes are most likely intact if the nitrazine swab remains yellow to olive green with pH between 5 and 6. The membranes are probably ruptured if the nitrazine swab turns a blue-green to deep blue with pH ranging from 6.5 to 7.5

Ballottment sign

a sharp upward pushing against the uterine wall with a finger inserted into the vagina for diagnosing pregnancy by feeling the return impact of the displaced fetus

surfactant

a surface tension-reducing lipoprotein found in the newborn's lungs that prevents alveolar collapse at the end of expiration and loss of lung volume. It lines the alveoli to enhance aeration of gas-free lungs, thus reducing surface tension and lowering the pressure required to open the alveoli. Normal lung function depends on surfactant, which permits a decrease in surface tension at end expiration (to prevent atelectasis) and an increase in surface tension during lung expansion (to facilitate elastic recoil on inspiration). Surfactant provides the lung stability needed for gas exchange. The newborn's first breath, in conjunction with surfactant, overcomes the surface forces to permit aeration of the lungs. The chest wall of the newborn is floppy because of the high cartilage content and poorly developed musculature. Thus, accessory muscles that help in breathing are ineffective.

episiotomy

a surgical cut made at the opening of the vagina during childbirth, to aid a difficult delivery and prevent rupture of tissues.

linea nigra

a thin brownish black pigmented line running from the umbilicus to the symphysis pubis

amniocentesis

a transabdominal puncture of the amniotic sac to obtain a sample of amniotic fluid for analysis -The fluid contains fetal cells that are examined to detect chromosomal abnormalities and several hereditary metabolic defects in the fetus before birth. In addition, amniocentesis is used to confirm a fetal abnormality when other screening tests detect a possible problem. -second trimester: bw 15-20 weeks gestation to check for chromosomal abnormalities

fetal decerlations

a transient fall in FHR caused by stimulation of the parasympathetic nervous system. Decelerations are described by their shape and association to a uterine contraction. They are classified as early, late, and variable only -early, late, and variable

Secundyigravida (Gravida II)

a woman pregnant for the second time

prolonged decelerations

abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes (Carvalho, 2019). The rate usually drops to less than 90 bpm. Many factors are associated with this pattern, including prolonged cord compression, abruptio placenta, cord prolapse, supine maternal position, vaginal examination, fetal blood sampling, maternal seizures, regional anesthesia, or uterine rupture (AWHONN, 2018). Prolonged decelerations can be remedied by identifying the underlying cause and correcting it.

when is an amniocentesis performed?

after an ultrasound examination identifies an adequate pocket of amniotic fluid free of fetal parts, the umbilical cord, or the placenta

category III: fetal heart rate pattern

aka abnormal Predictive of abnormal fetus acid-base status and require intervention • Fetal bradycardia (<110 bpm) • Recurrent late decelerations • Recurrent variable decelerations—declining or absent • Sinusoidal pattern (smooth, undulating baseline) Possible interventions: giving maternal oxygen, changing maternal position, discontinuing labor augmentation medication, and/or treating maternal hypotension

Placenta expulsion

aka coming outside vaginal opening -After separation of the placenta from the uterine wall, continued uterine contractions cause the placenta to be expelled within 2 to 30 minutes unless there is gentle external traction to assist. After the placenta is expelled, the uterus is massaged briefly by the attending physician or midwife until it is firm so that uterine blood vessels constrict, minimizing the possibility of hemorrhage. -If any piece is still attached to the uterine wall, it places the woman at risk for postpartum hemorrhage because it becomes a space-occupying object that interferes with the ability of the uterus to contract fully and effectively.

Placental separation

aka detaching from uterine wall After the infant is born, the uterus continues to contract strongly and can now retract, decreasing markedly in size. These contractions cause the placenta to pull away from the uterine wall. Spontaneous birth of the placenta occurs in one of two ways: the fetal side (shiny gray side) presenting first (called Schultz mechanism or more commonly called "shiny Schultz") or the maternal side (red raw side) presenting first (termed Duncan mechanism or "dirty Duncan").

Category II: fetal heart rate pattern

aka indeterminate Not predictive of abnormal fetal acid-base status, but require evaluation and continued surveillance • Fetal tachycardia (>160 bpm) present • Bradycardia (<110 bpm) not accompanied by absent baseline variability • Absent baseline variability not accompanied by recurrent decelerations • Minimal or marked variability • Recurrent late decelerations with moderate baseline variability • Recurrent variable decelerations accompanied by minimal or moderate baseline variability; overshoots, or shoulders • Prolonged decelerations >2 minutes but <10 minutes

skin to skin contact

aka kangaroo care gold standard to initiate breastfeeding within 1st hour after birth This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents.

category 1: fetal heart rate patterns

aka normal Predictive of normal fetal acid-base status and do not require intervention • Baseline rate (110-160 bpm) • Baseline variability moderate • Present or absent accelerations • Present or absent early decelerations • No late or variable decelerations • Can be monitored with intermittent auscultation during labor

perineal phase (second stage of labor)

aka period of active pushing -nullipara lasts up to 3 hrs -multipara lasts up to 2 hrs -contraction freq every 2-3 mins -contraction duration 60-90 sec -contraction intensity strong to palpation -strong urge to push during later perineal phase

third stage of labor

aka placental expulsion begins with the birth of the newborn and ends with the separation and birth of the placenta -The ideal placement for the newborn immediately following the birth is on the mother's abdomen, in skin-to-skin contact which promotes a positive transition from intrauterine to extrauterine life. The third stage of labor consists of two phases: placental separation and placental expulsion (READ 13.14 FIG) -usually takes 5-10 mins but may take 30 mins

Signs of placental separation

aka signs that they are ready to deliver -The uterus rises upward. -The umbilical cord lengthens. -A sudden trickle of blood is released from the vaginal opening. -The uterus changes its shape to globular.

second stage of labor

aka the expulsive stage begins with complete cervical dilation (10 cm) and effacement and ends with the birth of the newborn -contractions occur every 2-3 mins, last 60-90 secs, and strong to palpation -Although the previous stage of labor primarily involved the thinning and opening of the cervix, this stage involves moving the fetus through the birth canal and out of the body. The cardinal movements of labor occur during the early phase of passive descent in the second stage of labor. -primarily involves PUSHING and ends with birth

fourth stage of labor

aka the restorative stage or immediate postpartum period the first 1-4 hrs after delivery of placenta -begins with completion of the expulsion of the placenta and membranes and ends with the initial physiologic adjustment and stabilization of the mother (1 to 4 hours after birth). This stage initiates the postpartum period. -The mother's fundus should be firm and well contracted. Typically it is located at the midline between the umbilicus and the symphysis, but it then slowly rises to the level of the umbilicus during the first hour after birth (Jordan et al., 2019). If the uterus becomes boggy, it is massaged to keep it firm. The lochia (vaginal discharge) is red, mixed with small clots, and of moderate flow. If the woman has had an episiotomy during the second stage of labor, it should be intact with the edges approximated and clean and no redness or edema present. -main focus: monitor to prevent hemorrhage, bladder distention, and venous thrombosis. Her bladder is hypotonic, and thus she has limited sensation to acknowledge a full bladder or to void. Vital signs, the amount and consistency of the lochia, and the uterine fundus are usually monitored every 15 minutes for at least 1 hour. The woman will be feeling cramp-like discomfort during this time due to the contracting uterus.

true conjugate

also called the obstetric conjugate, is the measurement from the anterior surface of the sacral prominence to the posterior surface of the inferior margin of the symphysis pubis. This diameter cannot be measured directly; rather, it is estimated by subtracting 1 to 2 cm from the diagonal conjugate measurement. The average true conjugate diameter is at least 11.5 cm (Cunningham et al., 2018). This measurement is important because it is the smallest front-to-back diameter through which the fetal head must pass when moving through the pelvic inlet.

episiotomy

an incision made in the perineum to enlarge the vaginal outlet and theoretically to shorten the second stage of labor. Alternative measures such as warm compresses and continual massage with oil have been successful in stretching the perineal area to prevent cutting it. Certified nurse midwives can cut and repair episiotomies, but they frequently use alternative measures if possible. The midline episiotomy has been the most commonly used one in the United States because it can be easily repaired and causes the least amount of pain. The application of warmed compresses and/or intrapartum perineal massage is associated with a decrease in trauma to the perineal area and reduced need for an episiotomy (Waldman, 2019). Routine episiotomy has declined since liberal usage has been discouraged by ACOG except to avoid several maternal lacerations or to expedite difficult births. Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds with a sharp increase in cesarean births, which may indicate that health care providers are favoring cesarean births for difficult births

nesting

an increase in energy before labor -caused by an increase in epinephrine and decrease in progesterone -usually occurs 24-48 hrs before labor

Chorionic villus sampling (CVS)

an invasive procedure involving an 18-gauge needlestick through the abdomen or passage of a suction catheter through the cervix under ultrasound guidance -used to obtain a sample of the chorionic villi from the placenta for prenatal evaluation of chromosomal disorders such as Down syndrome or cystic fibrosis, enzyme deficiencies, and fetal gender determination and to identify sex-linked disorders such as hemophilia, sickle cell anemia, and Tay-Sachs disease (detects many genetic disorders with the exception of neural tube defects)

colostrum

antibody rich yellow fluid expressed after 12th week gestation -can

buttocks (sacrum (S)) landmark: Fetal position

breech presentation

isotretinoin's (accutane)

can result in serious birth defects such as cleft palate, congenital heart defects, hearing loss, and microcephaly.

postpartum diuresis

caused by -large amounts of IV fluids given during labor -decreasing antidiuretic effect of oxytocin as its level declines -buildup and retention of extra fluids during pregnancy -decreased production of aldosterone; the hormone that decreases sodium retention and increases urine production All of these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum. Normal function returns within a month after birth

what is assessed during vaginal assessment?

cervical dilation and effacement, ruptured membranes, and fetal descent and presenting part

active labor

cervix dilationg starts at 6 cm

fatigue

common in 1st and 3rd trimester (most energy in 2nd trimester)

urinary frequency and incontinence

common in 1st and third trimester (subsides in second trimester)

baby blues (or maternal blues)

considered normal -mild depressive symptoms, anxiety, irritability,crying, mood swings, loss of appetite, trouble sleeping, tearfulness (often for no discernible reason), increased sensitivity, and fatigue. These symptoms usually begin 2 to 4 or 5 days after childbirth and resolve by day 10 (or 8).**** -they usually resolve with restorative sleep Although these symptoms may be distressing, they do not reflect psychopathology, and they typically do not affect the mother's ability to function and care for her child

android pelvic shape

considered the male shaped pelvis, not favorable; funnel shaped

epidural block

continuous infusion or intermittent injection; usually started when dilation >5 cm -well hydrate before epidural (IV fluids 500-700 dextrose) major side effect of epidural: maternal hypotension

baseline variability

defined as irregular fluctuations in the baseline FHR, which is measured as the amplitude of the peak to trough in beats per minute -Because variability is in essence the combined result of autonomic nervous system branch function, its presence implies that both branches are working and receiving adequate oxygen

sinusoidal pattern of FHR

described as having a visually apparent smooth, sinewave-like undulating pattern in the FHR baseline with a cycle frequency of 3 to 5 bpm that persists for more than 20 minutes. A true sinusoidal FHR pattern is rare. It is attributed to a derangement of CNS control of FHR and occurs when a severe degree of hypoxia secondary to fetal anemia and hypovolemia is present. It is always considered a category III pattern, and to correct it, a fetal intrauterine transfusion would be needed. It indicates the fetus is in marked jeopardy

fetal position

describes the relationship of a given point on the presenting part of the fetus to the different sides of the maternal pelvis. Fetal position is determined first by identifying the presenting part and then the maternal quadrant the presenting part is facing

occipital bone (O)landmark: Fetal position

designates a vertex presentation

Continuous electronic fetal monitoring (EFM)

detects the fetal pulse by sensing and analyzing tissue movements via Doppler ultrasound. The machine uses a transducer that is capable of both sending and receiving ultrasound waves. The waves travel through the ultrasound gel, then body tissues, and are eventually reflected by any tissue. The fast reflections are analyzed and software in the machine determines the FHR. -EFM uses a machine to produce a continuous tracing of the FHR. When the monitoring device is in place, a sound is produced with each heartbeat. In addition, a graphic record of the FHR pattern is produced. MAIN purpose of EFM: The primary objective of EFM is to provide information about fetal oxygenation and prevent fetal injury that could result from impaired fetal oxygenation during labor. -Fetal hypoxia is demonstrated in a heart rate pattern change and is by far the most common etiology of fetal injury and death that can be prevented with optimal fetal surveillance during labor and early interventions

what is primarily assessed in fetal assessment?

determining the FHR pattern A fetal assessment identifies well-being or signs that indicate compromise. -Aside from FHR, additional assessments include amniotic fluid assessment, and Umbilical cord blood analysis and fetal scalp stimulation are additional assessments performed as necessary in the case of questionable FHR patterns.

fundus displaced to the right after birth

due to a full bladder

uterine contraction intensity bw 50 and 80 mm hg

during active labor

Spinal (intrathecal) analgesia/anesthesia

during labor and cesarean birth pain management technique involves injection of an anesthetic "caine" agent with or without opioids into the subarachnoid space to provide pain relief during labor or cesarean birth. The subarachnoid space is a fluid-filled area located between the dura mater and the spinal cord. Spinal anesthesia is frequently used for elective and emergent cesarean births. The contraindications are similar to those for an epidural block. Adverse reactions for the woman include hypotension and spinal headache. The subarachnoid injection of opioids alone or in combination, a technique termed "intrathecal narcotics," has been used for laboring women successfully for decades. A narcotic is injected into the subarachnoid space, providing rapid pain relief while still maintaining motor function and sensation (Layera et al., 2019). An intrathecal narcotic is given during the active phase (more than 5 cm of dilation) of labor. Compared with epidural blocks, intrathecal narcotics are easy to administer, require a smaller volume of medication, produce excellent muscular relaxation, provide rapid-onset pain relief, are less likely to cause newborn respiratory depression, and do not cause motor blockade (Hemmings & Egan, 2019). Although pain relief is rapid with this technique, it is limited by the narcotic's duration of action, which may be only a few hours and not last through the labo

BPP scoringq

each worth two points if present. A total score of 10 is possible if the NST is used. Thirty minutes are allotted for testing, though less than 10 minutes are usually needed. The following criteria must be met to obtain a score of 2; anything less is scored as 0 Body movements: three or more discrete limb or trunk movements Fetal tone: one or more instances of full extension and flexion of a limb or trunk Fetal breathing: one or more fetal breathing movements of more than 30 seconds Amniotic fluid volume: one or more pockets of fluid measuring 2 cm NST: normal NST = 2 points; abnormal NST = 0 points

regional anesthesia types

epidural block, combined spinal-epidural, local infiltration, pudendal block, and intrathecal (spinal) analgesia/anesthesia.

Fern test

estrogens in amniotic fluid cause crystallization of the salts ; crystals appear as a blade of fern

Ptyalism

excessive salivation -which may be caused by the decrease in unconscious swallowing by the woman when nauseated.

chine (mentum (M)) landmark: Fetal position

face presentation

cephalic fetal presentation (vertex)

fetal head first (most favorable) -consists of military, brow, face

quickening

fetal movements (16-20 weeks)

amniotic fluid

fluid within the amniotic sac that surrounds and protects the fetus -amniotic fluid should be clear when membranes rupture -cloudy or foul smelling indicates infection -green fluid indicates meconium passed in utero

palpating the fundus

for contraction intensity*** -place the pads of your fingers on the fundus and describe how it feels: -like the tip of the nose (mild) -like the chin (moderate) -like the forehead (strong)

Three parameters of uterine contractions

frequency, duration, intensity

assessment of uterine contractions

frequency, intensity, duration, resting tone

Lochia alba

he final stage. The discharge is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content. It occurs from days 10 to 14 but can last 3 to 6 weeks postpartum in some women and still be considered normal.

fontanelles (anterior and posterior)

help identify position of fetal head and help in molding

pelvic floor muscles

help the fetus rotate anteriorly as it passes through the birth canal. The soft tissues of the vagina expand to accommodate the fetus during birth.

human chorionic gonadotropin (hCG)

hormone produced by the placenta to sustain pregnancy by stimulating the ovaries to produce estrogen and progesterone -hormone produced when pregnant

naegeles rule

how to calculate EDD -first day of last menstrual period minus 3 months plus 7 days plus 1 year Best EDD dating= ultrasound prior to 20 weeks GA

gums in pregnancy

hyperemic, swollen, and friable and tend to bleed easily -This change is influenced by estrogen and increased proliferation of blood vessels and circulation to the mouth

how to assess intensity of contraction

if it can be dented with the nurse's fingers. The ability to indent the fundus at the peak of the contraction would typically indicate a mild contraction.

HR during pregnancy

increase of 10 to 15 beats per minute (bpm) (starting between 14 and 20 weeks of pregnancy) -due to increase in cardiac output and blood volume -The body adapts to the increase in blood volume with peripheral dilation to maintain blood pressure. Progesterone causes peripheral dilation.

edema in early pregnancy

indicative of gestational HTN

gingival tissue in mouth

indicative of high estrogen levels

negative attachment behaviors

infant: Feeds poorly, regurgitates often; cries for long periods, colicky and inconsolable; shows flat affect, rarely smiles even when prompted; resists holding and closeness; sleeps with eyes closed most of time; stiffens body when held; is unresponsive to parents; doesn't pay attention to parents' faces parent: Expresses disappointment or displeasure in infant; fails to "explore" infant visually or physically; fails to claim infant as part of family; avoids caring for infant; finds excuses not to hold infant close; has negative self-concept; appears uninterested in having infant in room; frequently asks to have infant taken back to nursery to be cared for; assigns negative attributes to infant and calls infant inappropriate, negative names

uterine contraction intensity 30 mm hg ++++

initiate cervical dilation

rupturing membranes

intact membranes= felt as a soft bulge that is more prominent during a contraction. Ruptured membranes= the woman may have reported a sudden gush of fluid. Membrane rupture may also occur as a slow trickle of fluid. When membranes rupture, the priority focus should be on assessing fetal heart rate (FHR) first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. - Prolonged ruptured membranes increase the risk of infection as a result of ascending vaginal pathologic organisms for both mother and fetus. Signs of intrauterine infection to be alert for include maternal fever, fetal and maternal tachycardia, foul odor of vaginal discharge, and an increase in white blood cell count. -fetal membranes usually rupture during first stage of labor

Ovulation and Return of Menstruation- lactating women

interplay of hormones: estrogen, progesterone, prolactin, and oxy -nonlactating woman: return of menstruation 7-9 weeks after birth -lactating woman: return dependent on breast feeding frequency and duration; anywhere from 2-18 mths Estrogen plays a major role during pregnancy, but levels drop profoundly at birth and reach their lowest level a week into the postpartum period. Progesterone quiets the uterus to prevent a preterm birth during pregnancy, and its increasing levels during pregnancy prevent lactation from starting before birth takes place. As with estrogen, progesterone levels decrease dramatically after birth and are undetectable 72 hours after birth. Progesterone levels are reestablished with the first menstrual cycle During the postpartum period, oxytocin stimulates the uterus to contract during the breastfeeding session and for as long as 20 minutes after each feeding. Oxytocin also acts on the breast by eliciting the milk let-down reflex during breastfeeding. Prolactin is also associated with the breastfeeding process by stimulating milk production. In women who breastfeed, prolactin levels remain elevated into the 6th week after birth. The levels of prolactin fluctuate in proportion to nipple stimulation. Prolactin levels decrease in nonlactating women, reaching prepregnant levels by the third postpartum week. High levels of prolactin have been found to delay ovulation by inhibiting ovarian response to follicle-stimulating hormone (Blackburn, 2018). The timing of first menses and ovulation after birth differs between women who are breastfeeding and women who are not breastfeeding. For nonlactating women, menstruation may resume as early as 7 to 9 weeks after giving birth, but the majority take up to 3 months, with the first cycle being anovulatory (Jordan et al., 2019). The return of menses in the lactating woman depends on breastfeeding frequency and duration. It can return any time after childbirth, depending on whether the woman is exclusively breastfeeding or supplementing with formula. -Ovulation may occur before menstruation. Therefore, breastfeeding is not a totally reliable method of contraception unless the mother exclusively breastfeeds, has had no menstrual period since giving birth, and has an infant younger than 6 months

secondary power stimulus

intra-abdominal pressure from mother pushing and bearing down during the second stage of labor (voluntary muscle contractions)

centering (prenatal care)

involves groups of up to a dozen women in similar gestational ages meeting with their health care provider for 10 sessions of approximately 1.5 to 2 hours each.

artifact

irregular variations or absence of the FHR on the fetal monitor record that result from mechanical limitations of the monitor or electrical interference. For instance, the monitor may pick up transmissions from radios used by drivers on nearby roads and translate them into a signal.

posterior fontanelle

is located at the back of the fetal head; it is triangular. This one closes within 8 to 12 weeks after birth and on average, measures 1 to 2 cm at its widest diameter

mild contractions

last 30 sec occuring every 5-7 mins -early labor

moderate to high contractions

last 60 sec occuring every 2-3 mins

LMP

last normal menstrual period

postpartum period

lasts about six weeks or until the mother's body has completed its adjustment and has returned to a nearly pre-pregnant state (can be 9-12 weeks)

platypelliod pelvic shape

least favorable; FLAT -The pelvic cavity is shallow but widens at the pelvic outlet, making it difficult for the fetus to descend through the mid-pelvis

fetal bradycardia

less than 110 bpm lasting 10 mins or longer -Bradycardia may be benign if it is an isolated event, but it is considered an ominous sign when accompanied by a decrease in baseline variability and late decelerations.

complications of amniocentesis

lower abdominal discomfort and cramping that may last up to 48 hours after the procedure, spontaneous abortion (one in 300 to 500), maternal or fetal infection, postamniocentesis chorioamnionitis that has an insidious onset, fetal-maternal hemorrhage, leakage of amniotic fluid in 2% to 3% of women after the procedure, and higher rates of fetal loss in earlier amniocentesis procedures (before 15 weeks) vs later ones

true pelvis

made up of three plates: the inlet, mid pelvis, and outlet -it lies below the linea terminalis (which is an imaginary line diving the false and true pelvis) -the bony passageway where the fetus must travel

suboccipitobregmatic diameter

measured from the base of the occiput to the center of the anterior fontanelle, identifies the smallest anteroposterior diameter of the fetal skull. -approximately 9.5 cm at term

biparietal diameter

measures the largest transverse diameter of the fetal skull—the distance between the two parietal bones -approximately 9.25 cm at term

gynecoid pelvic shape

most favorable for vaginal delivery -the inlet is round and the outlet is roomy.

Flexion (Cardinal Movements of Labor)

occurs as the vertex meets resistance from the cervix, the walls of the pelvis, or the pelvic floor. As a result, the chin is brought into contact with the fetal thorax and the presenting diameter is changed from occipitofrontal to suboccipitobregmatic (9.5 cm), which achieves the smallest fetal skull diameter presenting to the maternal pelvic dimensions.

Engagement (Cardinal Movements of Labor)

occurs when the greatest transverse diameter of the head in vertex (biparietal diameter) passes through the pelvic inlet (usually 0 station). The head usually enters the pelvis with the sagittal suture aligned in the transverse diameter.

longtitudinal lie

occurs when the long axis of the fetus is parallel to that of the mother (fetal spine to maternal spine side-by-side). -most common

transverse lie

occurs when the long axis of the fetus is perpendicular to the long axis of the mother (fetal spine lies across the maternal abdomen and crosses her spine)

footling or incomplete breech position

one or both legs are presenting -may result a c section

pelvic inlet

or upper pelvic narrow, is the entrance toward the birth canal. It allows entrance to the true pelvis. It is bounded by the sacral prominence in the back, the ilium on the sides, and the superior aspect of the symphysis pubis in the front (Decherney et al., 2019). The pelvic inlet is wider in the transverse aspect (sideways) than it is from front to back

uterine contractions

palpate fundus for pain -mild contractions: feels like tip of nose -moderate contractions: feels like chin -strong contractions: forehead (nonindentable=strong)

pelvic outlet

pelvic measurements -If the diagonal conjugate measures at least 11.5 cm and the true or obstetric conjugate measures 10 cm or more (1.5 cm less than the diagonal conjugate, or about 10 cm), then the pelvis is large enough for a vaginal birth of what would be considered a normal-sized newborn.

breech fetal presentation

pelvis first -Breech presentation occurs when the fetal buttocks or feet enter the maternal pelvis first and the fetal skull enters last. -Primarily, the largest part of the fetus (skull) is born last and may become stuck in the pelvis. In addition, the umbilical cord can become compressed between the fetal skull and the maternal pelvis after the fetal chest is born because the head is the last to exit. Moreover, unlike the hard fetal skull, the buttocks are soft and are not as effective as a cervical dilator during labor compared with a cephalic presentation. Finally, there is the possibility of trauma to the head as a result of the lack of opportunity for molding.

bimanual exam (during pelvic exam)

performed to estimate the size of the uterus to confirm dates and to palpate the ovaries -The ovaries should be small and nontender without masses. -At the conclusion of the bimanual examination, the health care provider reinserts the index finger into the vagina and the middle finger into the rectum to assess the strength and regularity of the posterior vaginal wall.

cardinal movements of labor

positional changes that the fetus goes through as it travels through the passageway -allow the smallest diameter of the fetal head to pass through a corresponding diameter of the mother's pelvic structure. Although cardinal movements are conceptualized as separate and sequential, the movements are typically concurrent

BUBBLE LEE

postpartum assessment acronym breasts, uterus, bladder, bowels, lochia, episiotomy/perineum/epidural site, extremities, and emotional status —can be used as a guide for this head-to-toe review

puerperium

postpartum period that begins after the delivery of the placenta and lasts approximately 6 weeks. It is frequently called the "fourth trimester." During this period, the woman's body begins to return to its prepregnant state, and these changes generally resolve by the 6th week after giving birth. Aka changes in all aspects of mothers life that occur during the first year following birth of child

breast feeding postpartum

recommended breastfeeding for all full-term newborns. Exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first 6 months of life. Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child

Uterine contraction parameter: Duration

refers to how long a contraction lasts and is measured from the beginning of one contraction to the end of that same contraction.

Uterine contraction parameter: Frequency

refers to how often the contractions occur and is measured from the beginning of one contraction to the beginning of the next contraction

fetal attitude

refers to the posturing (flexion or extension) of the joints and the relationship of different fetal parts to one another AKA fetal attitude= FULL flexion The most common fetal attitude when labor begins is with all joints flexed—the fetal back is rounded, the chin is on the chest, the thighs are flexed on the abdomen, and the legs are flexed at the knees -This normal fetal position is most favorable for vaginal birth, presenting the smallest fetal skull diameters to the pelvis!!! (attitude of extension presents larger fetal skull diameters which make it difficult to pass for birth)

Uterine contraction parameter: Intensity

refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine pressure catheter. The catheter is positioned in the uterine cavity through the cervix after the membranes have ruptured. It reports intensity by measuring the pressure of the amniotic fluid inside the uterus in millimeters of mercury. It is not recommended for routine use in low-risk laboring women due to the potential risk of infection and injury to the placenta or fetus. In a recent study using noninvasive technology, it was found that using a multichannel electromyogram that acquires a uterine signal and maternal and fetal electrocardiograms was more accurate than that of an external Doppler and fetal scalp electrode monitor

Danger signs in pregnancy 2nd trimester

regular uterine contractions (preterm labor); pain in calf, often increased with foot flexion (indicative of DVT); sudden gush or leakage of fluid from vagina (prelabor rupture of membranes); and absence of fetal movement for more than 12 hours (indicative of possible fetal distress or demise).

ruptured membranes

rupture of the amniotic sac, usually at labor onset -use nitrozine paper: blue colored if ruptured

shoulder fetal presentation

scapula first

what is "binding in"

seeking acceptance to self as mother of infant

fetal engagement

signifies the entrance of the largest diameter of the fetal presenting part (usually the fetal head) into the smallest diameter of the maternal pelvis (Deering, 2018). The fetus is said to be engaged in the pelvis when the presenting part reaches 0 station. Engagement is determined by pelvic examination. -The largest diameter of the fetal head is the biparietal diameter. It extends from one parietal prominence to the other. It is an important factor in the navigation through the maternal pelvis. Engagement typically occurs in primigravidas 2 weeks before term, while multiparas may experience engagement several weeks before the onset of labor or not until labor begins.

Danger signs in pregnancy 1st trimester

spotting or bleeding (miscarriage), painful urination (infection), severe persistent vomiting (hyperemesis gravidarum), fever higher than 100°F (37.7°C; indicative of infection), and lower abdominal pain with dizziness and accompanied by shoulder pain (indicative of ruptured ectopic pregnancy).

Danger signs of pregnancy 3rd trimester

sudden weight gain; periorbital or facial edema, severe upper abdominal pain, or headache with visual changes (indicative of gestational hypertension and/or preeclampsia); and a decrease in fetal daily movement for more than 24 hours (indicative of possible demise).

baseline periodic changes

temporary, recurrent changes made in response to a stimulus such as a contraction. The FHR can demonstrate patterns of acceleration or deceleration in response to most stimuli.

establishing a baseline FHR with intermittent FHR auscultation

the FHR is assessed for a full minute after a contraction. From then on, unless there is a problem, listening for 30 seconds and multiplying the value by two is sufficient.

effaces

the THINNING of the cervix to allow the presenting fetal part to descend into the vagina -The soft tissues of the passageway consist of the cervix, the pelvic floor muscles, and the vagina

neuraxial analgesia/anesthesia

the administration of analgesic (opioids) or anesthetic (capable of producing a loss of sensation in an area of the body) agents, either continuously or intermittently, into the epidural or intrathecal space to relieve pain. This includes low-dose and ultra-low-dose epidural analgesia, spinal analgesia, and combined spinal-epidural analgesia

baseline fetal HR

the average FHR that occurs during a 10-minute segment that excludes periodic or episodic rate changes, such as tachycardia or bradycardia. It is assessed when the woman has no contractions and the fetus is not experiencing episodic FHR changes (110-160 over 10 mins)

fetal presentation

the body part of the fetus that enters the pelvic inlet first (the "presenting part"). This is the fetal part that lies over the inlet of the pelvis or the cervical os. Knowing which fetal part is coming first at birth is critical for planning and initiating appropriate interventions.

frank breech position

the buttocks present first with both legs extended up toward the face. -results a vaginal birth

bonding

the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth. Bonding is a continuation of the relationship that began during pregnancy (Sears & Sears, 2020a). It is affected by a multitude of factors, including the parents' socioeconomic status, family history, role models, support systems, cultural factors, and birth experiences. The mother initiates bonding when she caresses her infant and exhibits certain behaviors typical of a mother tending her child. The infant's responses to this, such as body and eye movements, are a necessary part of the process.

attachment

the development of strong affection between an infant and a significant other (mother, father, sibling, and caregiver). This attachment is reciprocal; both the significant other and the newborn exhibit attachment behaviors. The attachment relationship formed between the infant and primary caregiver influences the child's view of the world and future relationships The newborn responds to the significant other by cooing, grasping, smiling, and crying. Nurses can assess for attachment behaviors by observing the interaction between the newborn and the person holding them. It occurs through mutually satisfying experiences. Maternal attachment begins during pregnancy as the result of fetal movement and maternal fantasies about the infant and continues through the birth and postpartum periods. Attachment behaviors include seeking; physical caregiving behaviors; emotional attentiveness to the infant's needs; staying close to, touching, kissing, cuddling, and choosing the en face position (face-to-face) while holding or feeding the newborn; expressing pride in the newborn; and exchanging gratifying experiences with the infant. In a high-risk pregnancy, the attachment process may be complicated by premature birth (lack of time to develop a relationship with the unborn baby) and by parental stress due to fetal and/or maternal vulnerability.

fundal height measurement

the distance (in cm) measured from the top of the pubic bone to the top of the uterus (fundus) with the client lying on her back with her knees slightly flexed AKA; the McDonald method -Fundal height typically increases as the pregnancy progresses; it reflects fetal growth and provides a gross estimate of the duration of the pregnancy.

diagonal conjugate

the distance between the anterior surface of the sacral prominence and the anterior surface of the inferior margin of the symphysis pubis -This measurement, usually 12.5 cm or greater, represents the anteroposterior diameter of the pelvic inlet through which the fetal head passes first. The diagonal conjugate is the most useful measurement for estimating pelvic size because a misfit with the fetal head occurs if it is too small.

Descent (Cardinal Movement of Labor)

the downward movement of the fetal head until it is within the pelvic inlet. Descent occurs intermittently with contractions and is brought about by one or more of the following forces: Pressure of the amniotic fluid Direct pressure of the fundus on the fetus's buttocks or head (depending on which part is located in the top of the uterus) Contractions of the abdominal muscles (second stage) Extension and straightening of the fetal body Descent occurs throughout labor, ending with birth. During this time, the mother experiences discomfort, but she is unable to isolate this particular fetal movement from her overall discomfort.

anterior fontanelle

the famous "soft spot" of the newborn's head. It is a diamond-shaped space that measures from 1 to 4 cm. It remains open for 12 to 18 months after birth to allow for growth of the brain

oblique lie

the fetal long axis is at an angle to the bony inlet, and no palpable fetal part is presenting. This lie is usually transitory and occurs during fetal conversion between other lies. A fetus in a transverse or oblique lie position cannot be delivered vaginally

full or complete breech position

the fetus sits cross-legged above the cervix -may result a c section

neonatal period

the first 28 days of life. It is a period of the most dramatic and rapid physiologic changes in humans. After birth, the newborn is exposed to a whole new world of sounds, colors, smells, and sensations. The newborn, previously confined to the warm, dark, wet intrauterine environment, is now thrust into an environment that is much brighter and cooler.

attachment

the formation of a relationship between a parent and a newborn through a process of physical and emotional interactions. Attachment between a woman and her newborn has lifelong implications. Maternal attachment has the potential to affect both child development and parenting. The bond between a parent and the newborn is one of strength, power, and potential. Attachment begins before birth, during the prenatal period when acceptance and nurturing of the growing fetus takes place. It continues after giving birth as parents learn to recognize the newborn's cues, adapt to the newborn's behaviors and responses, and meet the newborn's needs. Oxytocin plays an essential role in the chemistry aspect of bonding, and its effects can be enhanced by skin-to-skin contact; breastfeeding; eye contact; social vocalizations; maternal and milk odors, which are soothing for the newborn; and newborn massage during the first postpartum hour (Jordan et al., 2019; Sultan, 2019). Early and sustained contact between newborns and their parents is vital for initiating this relationship.

gFR and renal flow postpartum

the glomerular filtration rate and renal plasma flow increase significantly. Both usually return to normal by 6 weeks after birth. There is a gradual return of bladder tone and normal size and function of the bladder, ureters, and renal pelvis, all of which were dilated during pregnancy

First stage of labor

the longest stage; it begins with the first true contraction and ends with full dilation (opening) of the cervix. Because this stage lasts so long, it is divided into two phases, latent and active, each corresponding to the progressive dilation of the cervix. -this stage primarily involves the thinning (effacement) and opening (dilation) of the cervix Cervical dilation is gauged subjectively by vaginal examination and is expressed in centimeters. -It ends when the cervix is dilated to 10 cm (!!!) in diameter and is large enough to permit the passage of a fetal head of average size. -this stage involves cervical dilation AND effacement !!!

non stress test (NST)

the most common form of prenatal testing used in practice today. The NST provides an indirect measurement of uteroplacental function. Unlike the fetal movement counting done by the mother alone, this procedure requires specialized equipment and trained personnel. The basis for the NST is that the normal fetus produces characteristic fetal heart rate patterns in response to fetal movements. In the healthy fetus, there is an acceleration of the fetal heart rate with fetal movement. Currently, an NST is recommended twice weekly (after 28 weeks' gestation) for clients with diabetes and other high-risk conditions, such as intrauterine growth restriction (IUGR), preeclampsia, post-term pregnancy, renal disease, and multifetal pregnancies (Cunningham et al., 2018). NST is a noninvasive test that requires no initiation of contractions. It is quick to perform and there are no known side effects.

vagina postpartum

the mucosa thickens and rugae return in approximately 3 weeks. The vagina gapes at the opening and is generally lax. It returns to its approximate prepregnant size by 6 to 8 weeks postpartum but will always remain a bit larger than it had been before pregnancy. Normal mucus production and thickening of the vaginal mucosa usually return with ovulation. The vagina gradually decreases in size and regains tone over several weeks. By 3 to 4 weeks, the edema and vascularity have decreased. The vaginal epithelium is generally restored by 6 to 8 weeks postpartum (Blackburn, 2018). Localized dryness and coital discomfort (dyspareunia) plague many women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse.

cervical dilation

the opening or enlargement of the external cervical os

thermoregulation

the process of maintaining the balance between heat loss and heat production in order to maintain the body's core internal temperature. It is a critical physiologic function that is closely related to the transition and survival of the newborn. -Newborns have a decreased ability to regulate body temperature, producing heat through nonshivering thermogenesis. Thermoregulation, the balance between heat loss and heat production, is related to the newborn's rate of metabolism and oxygen consumption. Skin-to-skin contact should be the first line of treatment for hypothermia and as a measure to establish successful breastfeeding immediately after birth.

preconception care

the promotion of the health and well-being of a woman and her partner before pregnancy. The goal of preconception care is to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management interventions.

fetal lie

the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother. There are three possible lies: longitudinal (the most common), transverse (Fig. 13.6), and oblique. -When the fetal long axis is longitudinal to the maternal long axis, the lie is said to be longitudinal.

fetal station (aka fetal descent)

the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and is referred to as a minus or plus, depending on its location above or below the ischial spines. Typically, the ischial spines are the narrowest part of the pelvis and are the natural measuring point for the birth progress. -Zero (0) station is designated when the presenting part is at the level of the maternal ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spines, the distance is recorded as plus stations. For instance, if the presenting part is above the ischial spines by 1 cm, it is documented as being a −1 station; if the presenting part is below the ischial spines by 1 cm, it is documented as being a +1 station. -An easy way to understand this concept is to think in terms of meeting the goal, which is birth. If the fetus is descending downward (past the ischial spines) and moving toward meeting the goal of birth, then the station is positive and the centimeter numbers grow bigger from +1 to +4. If the fetus is not descending past the ischial spines, then the station is negative and the centimeter numbers grow from −1 to −4. The farther away the presenting part from the outside, the larger the negative number (−4 cm). The closer the presenting part of the fetus is to the outside, the larger the positive number (+4 cm). Figure 13.10 shows stations of the presenting part

passageway

the route through which the fetus must travel to be born vaginally. Compared to other primates, childbirth is remarkably difficult in humans because the head of the neonate is large relative to the birth-relevant dimensions of the maternal pelvis. The passageway consists of the maternal pelvis and soft tissues.

Taking hold phase (reva rubin)

the second phase of maternal adaptation, is characterized by dependent and independent maternal behavior. This phase typically starts on the second to third day postpartum and may last several weeks. As the client regains control over her bodily functions during the next few days, she will be taking hold and becoming preoccupied with the present. She will be particularly concerned about her health, the infant's condition, and her ability to care for them. She demonstrates increased autonomy and mastery of her own body's functioning, and a desire to take charge with support and help from others. She will show independence by caring for herself and learning to care for her newborn, but she still requires assurance that she is doing well as a mother. She expresses a strong interest in caring for the infant by herself.

lochia serosa

the second stage. It is pinkish brown and is expelled 3 to 10 days postpartum. Lochia serosa primarily contains leukocytes, decidual tissue, red blood cells, and serous fluid.

letting go phase

the third phase of maternal adaptation, the woman reestablishes relationships with other people. She adapts to parenthood in her new role as a mother. She assumes the responsibility and care of the newborn with a bit more confidence (Jordan et al., 2019). The focus of this phase is to move forward by assuming the parental role and to separate herself from the symbiotic relationship that she and her newborn had during pregnancy. She establishes a lifestyle that includes the infant. The mother relinquishes the fantasy infant and accepts the real one.

interconception care

the time between pregnancies when a woman can improve her health status, especially if the prior pregnancy experience had a poor outcome or adverse events occurred.

taking in phase (reva rubin)

the time immediately after birth when the client needs sleep, depends on others to meet her needs, and relives the events surrounding the birth process. This phase is characterized by dependent behavior. During the first 24 to 48 hours after giving birth, mothers often assume a passive role in meeting their own basic needs for food, fluids, and rest, allowing the nurse to make decisions for them concerning activities and care. They spend time recounting their labor experience to others. Such actions help the mother integrate the birth experience into reality; the pregnancy is over and the newborn is now a unique individual, separate from herself. When interacting with the newborn, new mothers spend time claiming the newborn and touching them, commonly identifying specific features in the newborn, such as "he has my nose" or "his fingers are long like his father's"

ischial tuberosity

the transverse diameter of the pelvic outlet. This measurement is made outside the pelvis at the lowest aspect of the ischial tuberosities. A diameter of 10.5 cm or more is considered adequate for passage of the fetal head

involution (of uterus during postpartum)

the uterus returns to its normal size through a gradual process of involution: which involves retrogressive changes that return it to its nonpregnant size and condition. Involution involves three retrogressive processes: -Contraction of muscle fibers to reduce those previously stretched during pregnancy -Catabolism, which shrinks enlarged individual myometrial cells -Regeneration of uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed during lochial discharge

sutures

they allow the cranial bones to overlap and allows changes in shape (elongation) when pressure is exerted on it by uterine contractions or the maternal bony pelvis; this helps identify position of fetal head and degree of rotation that has occurred

effacement

thinning of the cervix during labor

late amniocentesis

third trimester; to determine fetal lung maturity after the 35th week of gestation via analysis of lecithin-to-sphingomyelin ratios and to evaluate the fetal condition with Rh isoimmunization.

mid pelvis

this occupies the space between the inlet and outlet. It is through this snug, curved space that the fetus must travel to reach the outside. As the fetus passes through this small area, their chest is compressed, causing lung fluid and mucus to be expelled. This expulsion removes the space-occupying fluid so that air can enter the lungs with the newborn's first breath.

how are uterine contractions monitored?

through palpation of the uterine fundus and electronic monitoring

main goal of first prenatal visit

to collect baseline data about the woman and her partner and to detect any risk factors that need to be addressed to facilitate a healthy pregnancy

two main functions of uterine contractions

to dilate the cervix and to push the fetus through the birth canal

fetal accelerations

transitory abrupt increases in the FHR above the baseline that last less than 30 seconds from onset to peak. They are associated with sympathetic nervous stimulation. They are visually apparent, with elevations of FHR of more than 15 bpm above the baseline, and their duration is longer than 15 seconds but less than 2 minutes. They are generally considered reassuring and require no interventions. Accelerations denote fetal movement and fetal well-being and are the basis for nonstress testing.

continuous external FHR monitoring

two ultrasound transducers, each of which is attached to a belt, are applied around the woman's abdomen. They are similar to the handheld Doppler device. One transducer is called a tocotransducer, a pressure-sensitive device that is applied against the uterine fundus. It detects changes in uterine pressure and converts the pressure registered into an electronic signal that is recorded on graph paper (Lindsay et al., 2018). The tocotransducer is placed over the uterine fundus in the area of greatest contractility to monitor uterine contractions. The other ultrasound transducer records the baseline FHR, long-term variability, accelerations, and decelerations. It is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. The diaphragm of the ultrasound transducer is moved to either side of the abdomen to obtain a stronger sound and is then attached to the second elastic belt. This transducer converts the fetal heart movements into beeping sounds and records them on graph pape

general anesthesia

used for c sections!! (esp emergency ones when epidurals take too long) major complication: fetal depression All anesthetic agents cross the placenta and affect the fetus. The primary complication with general anesthesia is fetal depression, along with uterine relaxation and potential maternal vomiting and aspiration. General anesthesia complications are usually due to maternal aspiration or the inability to intubate the woman. -Ensure that the woman is not taking anything by mouth (NPO) and has a patent IV line. In addition, administer a nonparticulate (clear) oral antacid (e.g., Bicitra or sodium citrate) or a proton pump inhibitor (Protonix) as ordered to reduce gastric acidity. Assist with placement of a wedge under the woman's right hip to displace the gravid uterus and prevent vena cava compression in the supine position.

acupuncture and acupressure

used to relieve pain during labor

Biophysical Profile (BPP)

uses a real-time ultrasound and NST to allow assessment of various parameters of fetal well-being that are sensitive to hypoxia. A BPP includes ultrasound monitoring of fetal movements, fetal tone, and fetal breathing as well as ultrasound assessment of amniotic fluid volume with or without assessment of the fetal heart rate. A BPP is performed in an effort to identify infants who may be at risk of poor pregnancy outcome, so that additional assessments of well-being may be performed or labor may be induced or a cesarean section performed to expedite birth. -main reasons for test: to reduce stillbirth and detect hypoxia

anthropoid pelvic shape

usually adequate -The pelvic inlet is oval and the sacrum is long, producing a deep pelvis (wider front to back [anterior to posterior] than side to side [transverse]).

local infiltration anesthesia

usually for episiotomy or laceration repair involves the injection of a local anesthetic, such as lidocaine, into the superficial perineal nerves to numb the perineal area. This technique is done by the physician or midwife just before performing an episiotomy or before suturing a laceration. Local infiltration does not alter the pain of uterine contractions, but it does numb the immediate area of the episiotomy or laceration. Local infiltration does not cause side effects for the woman or her newborn.

pudendal nerve block

usually for second stage labor, episiotomy, or operative vaginal birth provides long-lasting perineal analgesia. A pudendal nerve block refers to the injection of a local anesthetic agent (e.g., bupivacaine, ropivacaine) into the pudendal nerves near each ischial spine. It provides pain relief in the lower vagina, vulva, and perineum (Fig. 14.12). A pudendal block is used for the second stage of labor, an episiotomy, or an operative vaginal birth with outlet forceps or vacuum extractor. It must be administered about 15 minutes before it would be needed to ensure its full effect. A transvaginal approach is generally used to inject an anesthetic agent at or near the pudendal nerve branch. Neither maternal nor fetal complications are common.

continuous internal FHR monitoring

usually indicated for women or fetuses considered to be at high risk. Possible conditions might include multiple gestation, decreased fetal movement, abnormal FHR on auscultation, IUGR, maternal fever, preeclampsia, dysfunctional labor, preterm birth, or medical conditions such as diabetes or hypertension. It involves the placement of a spiral electrode into the fetal presenting part, usually the parietal bone on the head, to assess FHR, and a pressure transducer placed internally within the uterus to record uterine contractions (Fig. 14.6). The fetal spiral electrode is considered the most accurate method of detecting fetal heart characteristics and patterns because it involves receiving a signal directly from the fetus Both the FHR and the duration and interval of uterine contractions are recorded on the graph paper. This method permits evaluation of baseline heart rate and changes in rate and pattern Four specific criteria must be met for this type of monitoring to be used: -Ruptured membranes -Cervical dilation of at least 2 cm -Presenting fetal part low enough to allow placement of the scalp electrode -Skilled practitioner available to insert spiral electrode

braxton hicks contractions time frame

usually last about 30 seconds but can persist for as long as 2 minutes. As birth draws near and the uterus becomes more sensitive to oxytocin, the frequency and intensity of these contractions increase. However, if the contractions last longer than 30 seconds and occur more often than four to six times an hour, advise the woman to contact her health care provider so that she can be evaluated for possible preterm labor, especially if she is less than 38 weeks pregnant.

breast engorgment

usually occurs during the first week postpartum. It is a common response of the breasts to the sudden change in hormones and the presence of an increased amount of milk. Reassure the woman that this condition is temporary and usually resolves within 72 hours. To alleviate breast engorgement: If the mother is breastfeeding, encourage frequent feedings at least every 2 to 3 hours, using manual expression just before feeding to soften the breast so the newborn can latch on more effectively. Advise the mother to allow the newborn to feed on the first breast until it softens before switching to the other side Avoiding engorgement in bottle feeding women: Encourage the woman to use ice packs, to wear a snug, supportive bra 24 hours a day, and to take mild analgesics such as acetaminophen. Encourage her to avoid any stimulation to the breasts that might foster milk production, such as warm showers or pumping or massaging the breasts. Medications no longer used for lactation suppression

Powers in labor

uterine contractions and intra-abdominal pressure

primary power stimulus

uterine contractions: -cause complete dilation and effacement of the cervix during the first stage of labor. -involuntary; uterine contractions are responsible for thinning and dilating cervix

blood loss

vaginal delivery: 250-500 mL lost= use epidural c section: 500-750 mL lost= use spinal anesthesia vaginal birth: 500 mL C/S: 1000 mL

variable decelerations

visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be of a U, V, or W, or they may not resemble other patterns (Norwitz et al., 2019). Variable decelerations usually occur abruptly with quick deceleration. They are the most common deceleration pattern found in the laboring woman and are usually transient and correctable (Cunningham et al., 2018). Variable decelerations are associated with cord compression. However, they are classified either as category II or III depending on the accompanying change in baseline variability (Murray et al., 2019). The pattern of variable deceleration consistently related to the contractions with a slow return to FHR baseline warrants further monitoring and evaluation.

early deceleration

visually apparent, usually symmetrical, and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. They rarely decrease more than 30 to 40 bpm below the baseline. Typically, the onset, nadir, and recovery of the deceleration occur at the same time as the onset, peak, and recovery of the contraction. They are most often seen during the active stage of any normal labor, during pushing, crowning, or vacuum extraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions. Early decelerations are not indicative of fetal distress and do not require intervention.

late decelerations

visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. They have a gradual waveform and can be recurrent, occurring with each contraction over a period of time. The FHR does not return to baseline levels until well after the contraction has ended. Delayed timing of the deceleration occurs with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency, which occurs when blood flow within the intervillous space is decreased to the extent that fetal hypoxia or myocardial depression exists (Blackburn, 2018). Conditions that may decrease uteroplacental perfusion with resultant decelerations include maternal hypotension, gestational hypertension, placental aging secondary to diabetes and postmaturity, hyperstimulation via oxytocin infusion, maternal smoking, anemia, and cardiac disease. They imply some degree of fetal hypoxia. Recurrent or intermittent late decelerations are always category II (indeterminate) or category III (abnormal) regardless of depth of deceleration. Acute episodes with moderate variability are more likely to be correctable, while chronic episodes with loss of variability are less likely to be correctable (SOGC, 2018). Box 14.1 highlights interventions for category III decelerations.

floating

when engagement has not occurred because the presenting part is freely movable above the pelvic inlet. -no engagement, presenting part freely movable about pelvic inlet

presenting

when the presenting part (usually the fetal head) reaches 0 station (the smallest diameter of maternal pelvis)

formula fed newborn stool

yellow, yellow-green, loose, pasty, or formed, unpleasant odor

summary of fetal to neonatal circulation

• Clamping the umbilical cord after birth eliminates the placenta as a reservoir for blood. • Onset of respirations causes a rise in PO2 in the lungs and a decrease in pulmonary vascular resistance, which... • Increases pulmonary blood flow and increases pressure in the left atrium, which... • Decreases pressure in the right atrium of the heart, which causes closure of the foramen ovale (closes within minutes after birth secondary to a decreased pulmonary vascular resistance and increased left heart pressure). • With an increase in oxygen levels after the first breath, an increase in systemic vascular resistance occurs, which... • Decreases vena cava return, which reduces blood flow in the umbilical vein (constricts, becomes a ligament with functional closing). • Closure of the ductus venosus (becomes a ligament) causes an increase in pressure in the aorta, which forces closure of the ductus arteriosus within 10 to 15 hours after birth.

Postpartum danger signs

• Fever >100.4°F (38°C) • Foul-smelling lochia or an unexpected change in color or amount • Large blood clots or bleeding that saturates a peripad in an hour • Severe headaches or blurred vision • Visual changes, such as blurred vision or spots, or headaches • Calf pain with dorsiflexion of the foot • Swelling, redness, or discharge at the episiotomy, epidural, or abdominal sites • Dysuria, burning, or incomplete emptying of the bladder • Shortness of breath or difficulty breathing without exertion • Depression or extreme mood swings

Obstetric History: GTPAL

• G(gravida)—the current pregnancy to be included in count • T(term birth)—the number of term gestations delivering between 38 and 42 weeks • P(preterm birth)—the number of preterm pregnancies ending >20 weeks or viability but before completion of 37 weeks • A(abortions)—the number of pregnancies ending before 20 weeks or viability • L(living children)—the number of children currently living

phases of contractions

• Increment - buildup of contraction (increasing strength) • acme - peak or highest intensity • Decrement - decreasing intensity; descent or relaxation of uterine muscle fibers

challenges facing families after discharge postpartum

• Lack of role models for breastfeeding and infant care. • Lack of support from the new mother's own mother if she did not breastfeed. • Increased mobility of society, which means that extended family may live far away and cannot help care for the newborn and support the new family. • Nonsupportive, overwhelmed, and fatigued partner. • Feelings of isolation and limited community ties for women who work full-time. • Shortened hospital stays; parents may be overwhelmed by all the information they are given in the brief hospital stay. • Prenatal classes usually focus on the birth itself rather than on skills needed to care for themselves and the newborn during the postpartum period. • Limited access to education and support systems for families from diverse cultures.

Interventions for Category III Patterns

• Notify the health care provider about the pattern and obtain further orders, making sure to document all interventions and their effects on the FHR pattern. • Discontinue oxytocin or other uterotonic agent as dictated by the facility's protocol if it is being administered. • Turn the client on her left or right lateral, knee-chest, or hands and knees to increase placental perfusion or relieve cord compression. • Administer oxygen via nonrebreather face mask to increase fetal oxygenation. • Increase the IV fluid rate to improve intravascular volume and correct maternal hypotension. • Assess the client for any underlying contributing causes. • Provide reassurance that interventions are to effect pattern change. • Modify pushing in the second stage of labor to improve fetal oxygenation. • Document any and all interventions and any changes in FHR patterns. • Prepare for an expeditious surgical birth if the pattern is not corrected in 30 minutes.

Risk factors for Postpartum Infection

• Operative procedure (forceps, cesarean birth, vacuum extraction) • History of diabetes, including gestational-onset diabetes • Prolonged labor (more than 24 hours) • Use of indwelling urinary catheter • Anemia (hemoglobin <10.5 mg/dL) • Multiple vaginal examinations during labor • Prolonged rupture of membranes (>24 hours) • Manual extraction of placenta • Compromised immune system (HIV-positive)