OB Exam 2

conjugated bilirubin

water soluble, Excreted into the bile and cleared from the body.

Indications for C-section

"You should know this list" Dystocia, Malpresentation Cephalopelvic disproportion (CPD) Fetal distress Cord prolapse Placenta abruption Complete placenta previa positive HIV active genital herpes previous cesarean section or (maternal request)

Jaundice

A benign yellowing of the skin do you to increased bilirubin production and breakdown of fetal red blood cells and immaturity of red blood cells. Unconjugated Billy Rubin levels 72 to 120 hours after birth. Rapid decline of levels to 3 mg/dL 5-10 days After birth. pathologic: could be the result of an underlying disease. Appears before 24 hours of life. Or is persistent after day 14. Bilirubin levels increase to greater than 0.5 mg/dL/hour. Bilirubin levels peak at greater than 12.9 mg/dL. Is associated with anemia and hepatosplenomegaly Usually caused by blood group incompatibility, infection, or red blood cell disorder.

fetal macrosomia

A cause of labor dystocia, one of the "passenger" problems in the 5 P factors. The macrosomic infant weighs more than 8 pounds at birth (8.8 pounds or 4,000 g in lecture). The head or shoulders may not be able to adapt to the pelvis if they are too large. In addition, distention of the uterus reduces strength of contractions. Size however is relative. Use of different maternal positions that open the pelvis may promote vaginal delivery. Positions that promote the sea curve of the spine, in which the patient leans the shoulders forward and causes the spine to curve forward, direct the fetal pressure toward the back of the pelvis rather than the front, and more narrow part of the pelvis. Use of labor balls, a firm foundation to sit on, side lying position's with a peanut ball between the knees, can all help the infant to pass through.

Breast abscess

A collection of pus in an area of the breast. They will have to go in and surgically drain the pus. They will receive antibiotics.

respiratory distress syndrome (RDS)

A condition caused by insufficient production of surfactant in the lungs. It occurs most often in preterm infants under 28 weeks of gestation, And increases as gestational age decreases. Other risk factors for RTS include birth asphyxia, cesarean birth, multiple births, male gender, called stress, and maternal diabetes because these conditions interfere with surfactant production. It is less frequent when antenatal corticosteroids or chronic fetal stress, such as in heroin addiction, maternal hypertension, or prolonged rupture of membranes because his lungs to mature more quickly. RDS typically worsens over the first 48 to 72 hours, then improves with treatment. When two little surfactant is present, the alveolar collapse each time the infant exhales. The lungs become noncompliant and resist expansion. Manifestations: Signs begin during the first hours after birth. They include tachypnea, tachycardia, nasal flaring, cyanosis, shallow breathing, grunting, chest wall retractions, seesaw respirations, general cyanosis, crackles, acidosis, CXR will show "ground glass" appearance. Interventions: surfactant is instilled into the infants trachea shortly after birth or as soon as signs of RDS become apparent. Other treatment is supportive including oxygen, continuous CPAP, inhaled nitric oxide, correction of acidosis, IV fluids, thermal regulation, nutritional support, cardiovascular support, normal glucose level maintenance, infection prevention.

Musculoskeletal clubfoot

A deformity of the bone structure that turns the feet in an inward position like a club. The cause is unknown and it is usually an isolated anomaly. Treatment requires surgery or serial casting depending on how bad the clubfoot is.

Developmental dysplasia of the hip

A musculoskeletal congenital anomaly where the ball of the acetabulum is not properly seated in the socket of the pelvis. When you swaddle an infant swaddle with their legs in the flexed position not straightened out to prevent it. It is more common in first born, girls, breech birth infants, Family history, Low amniotic fluid (oligohydramnios)

narrow pelvis

A passageway problem. Variations in the maternal bony pelvis Can inhibit fetal descent. The woman may experience poor contractions, slow dilation, slow fetal dissent, and a long labor. The way you can tell that the ischial spines are too narrow for the infants head to pass is that the infant stays at station -1 and doesn't move past it. Cesarean section will need to be done

Fetal malposition/presentation

A passenger problem. Persistence of the fetus in the occiput posterior OP or occiput transverse OT position can contribute to dysfunctional labor. These positions prevent the cardinal movements from occurring normally. Most fetuses that begin in the OP position rotate spontaneously to the occiput interior 08 position, promoting normal extension and expulsion of the head. Many women cannot readily deliver a fetus in the OP position, although some can. Labor is usually longer and more uncomfortable when the fetus remains in the OP or OT position. Intense back or leg pain that may be poorly relieved with analgesia makes coping with labor difficult for the woman. "Back labor" apple describes the sensations a woman feels when her fetus is in the OP position. Maternal position changes promote fetal head rotation to the OA position. Hands and knees, rocking the pelvis back-and-forth while on hands and knees promotes rotation the woman's knees should be slightly behind her hips in this position. A peanut bar may aid in helping a patient feel supported. A dense epidural may interfere with the use of this position. Side lying on the opposite side of the fetal occiput. Squatting (For second stage labor) Sitting on a slightly under inflated birth ball gives a similar effect. Sitting, kneeling, or standing while leaning forward. Upright maternal positions promote descent.

Soft tissue obstructions

A problem with the passageway. A full bladder is the most common soft tissue obstruction. The woman should be assessed for bladder distention regularly and encouraged to avoid every 1 to 2 hours. Catheterization may be needed if she cannot urinate or if epidural analgesia depresses her urge to void. There are mixed opinions in the literature as to whether intermittent catheterization or Foley placement is more appropriate

Anesthesia: pudendal block

A pudendal block anesthetizes the lower vagina and part of the perineum. It is often used to provide anesthesia for an episiotomy and vaginal birth, especially one that requires using low forceps. It does not block pain from uterine contractions, and the mother feels pressure. The physician or nurse midwife injects the pudendal nerves near each ischial spine with a local anesthetic the perineum is infiltrated with local anesthetic because the pudendal block does not fully anesthetize this area. Possible maternal complications include a toxic reaction to the anesthetic, rectal puncture, hematoma, and sciatic nerve block. If maternal toxicity is avoided, the fetus usually is not affected..

Spinal block (SAB)

A subarachnoid spinal block is a simpler procedure than the epidural block and may be performed when I quick cesarean birth is necessary and an epidural catheter is not in place. Performed just before birth. The physician or nurse anesthetist injects local anesthetic such as lidocaine into the subarachnoid space in a single dose. It is never used just for the pain of labor. It is always used for procedures Contraindications: the woman's refusal, coagulation defects, low platelet count, uncorrected hypovolemia, infection in the area of insertion, systemic infection, and allergy. Adverse effects: three adverse effects of an SAB are maternal hypotension, bladder distention, post dural puncture headache. The patient becomes movement dependent because she won't be able to move her legs. Spinal block cannot be redone

HELLP syndrome

A variant of gestational hypertension where hematologic conditions coexist with severe preeclampsia and hepatic dysfunction. It is a life-threatening occurrence That is a risk for mothers in severe preeclampsia or eclampsia. It stands for: Hemolysis, Elevated Liver enzymes, and Low Platelets. Hemolysis is believed to occur as a result of the fragmentation and distortion of erythrocytes during passage through small damaged blood vessels. Liver enzyme levels increase when hepatic blood flow is obstructed by fibrin deposits.

HELLP syndrome

A variant of gestational hypertension where hematologic conditions coexist with severe preeclampsia and hepatic dysfunction. It's a life threatening occurrence And can occur with eclampsia and severe preeclampsia. It stands for: Hemolysis, ELevated liver enzymes, Low Platelets The prominent symptom of HELLP is URQ pain. Concern for liver function, and a drop in platelet count, because it can increase bleeding.

Psyche

A woman's psychological response to labor and birth are influenced by anxiety, culture, expectations, life experiences, and support. Maternal catecholamine secreted in response to anxiety and fear can inhibit uterine contractility and placental blood flow. In contrast, relaxation augments the natural process of labor. Much of the nurses care during labor involves reducing anxiety and fear and assisting with coping strategies.

ABO incompatibility

ABO incompatibility occurs when the mother is blood type O, and the fetus has blood type A, B, or AB. Types A, B, and AB blood contain an antigen that is not present in type O blood. People with type O blood develop anti-A, or anti-B antibodies naturally. The antibodies may be either IgG or IGM. When the woman becomes pregnant, the IgG antibodies cross the placenta and cause hemolysis of fetal RBCs (why there is jaundice). Although the first fetus can be affected, ABO incompatibility is less severe then Rh incompatibility because the primary antibodies of the ABO system are IGM, which do not readily cross the placenta. No specific prenatal care is needed; however the nurse should be aware of the possibility of ABO incompatibility. During delivery, the cord blood is taken to determine the blood type of the newborn and the antibody Titer (direct Coombes test). ABO incompatibility can cause hyperbilirubinemia.

Incompetent cervix

Abnormality that is associated with second trimester bleeding. The client gets pregnant and progresses well through first trimester with no problems at all, but as The uterus stretches, it puts pressure on the cervix, and the cervix cannot hold up to it and it effaces and dilates too early. So the woman goes into labor and delivers between 16 to 18 weeks and loses the pregnancy. The next time she gets pregnant she'll have to come in and get her cervix sutured to hold it and that's called a Cerclage.

Gestational trophoblastic disease (hydatidiform mole)

Abnormality that's associated with second trimester bleeding. Occurs when trophoblasts Develop abnormally. The fluid filled villiform grape like clusters of tissue that can rapidly grow large enough to fill the uterus to the size of an advanced pregnancy. The mold may be complete with no fetus present or partial in which fetal tissue or membranes are present. The incidence is higher among Asian women and women who have had one molar pregnancy have a greater risk to have another. Clinical manifestations: routine use of ultrasound allows earlier diagnosis. Possible signs and symptoms include: Higher levels of beta hCG than expected for gestation. Characteristic "snowstorm" ultrasound pattern that shows the vesicles and the absence of fetal sac or fetal heart activity. A uterus that is larger than expected for gestational age. Vaginal bleeding which varies from dark brown spotting to profuse hemorrhage. Excessive nausea and vomiting or hyper emesis gravidarum. early development of preeclampsia before 24 weeks gestation. Diagnostics: measurement of beta hCG levels to text the abnormally high levels of the hormone before treatment. After treatment, beta hCG levels are measured to determine whether they fall and then disappear. Management: includes two phases: (1) evacuation of the trophoblastic tissue and the mole and (2) continuous follow up of the woman to detect malignant changes. Before evacuation CT scan, MRI may be performed, CBC, and blood type screening Because this can cause hemorrhaging. The mole usually is removed by vacuum aspiration followed by curettage. After removal oxytocin is given to contract uterus. Pregnancy must be avoided during the follow up Because the normal rise of beta hCG would obscure evidence of choriocarcinoma.

Nursing interventions with oxytocin adverse outcomes

Adverse reactions include excessive uterine activity, impaired uterine blood flow, uterine rupture, and placental abruption. Uterine hypertonicity may result in fetal bradycardia fetal tachycardia, reduce FHR variability, and light or prolonged decelerations. Discontinue oxytocin administration, oxytocin has a short half-life, about a minute and a half. Increase IV fluids in position client to the left lateral side for better oxygenation. Administer oxygen via mask at 10 L per minute. Administered tocolytic - Terbutaline 0.25 mg SC. This medication helps to reduce uterine muscle contraction.

Post partum: endocrine system

After expulsion of the placenta, placental hormones such as estrogen, progesterone, and human placental lactogen decline fairly rapidly. This allows High prolactin levels trigger the body to make milk for breast-feeding. And women who are not breast-feeding, prolactin levels return to normal and help regulate the menstrual cycle. Ovulation in 27 days after birth for non-lactating women. In 70 to 75 days for lactating women (mean time is 6 months)

fetal alcohol syndrome (FAS)

Alcohol is a teratogen known to have the potential to cause both mental delays and birth defects in the developing fetus. Alcohol intake during the first trimester appears to have the largest negative impact on cell growth and division, alcohol use during any point however in a pregnancy can have harmful effects on the fetus. Compared with other harmful substances in pregnancy, alcohol causes the most significant harm in long-term impact. It increases the risk for miscarriage and preterm labor. Alcohol crosses the placenta and reaches the fetal liver however the fetal liver is unable to metabolize alcohol. Fetal alcohol syndrome is characterized by three distinct features: prenatal and postnatal growth restriction, central nervous system impairment, and identifiable grouping of facial features. Growth restriction is evident in length, weight, and head circumference.

Support system

An anxious partner is less able to provide the support and reassurance the woman needs during labor. In addition, anxiety in others can be contagious, increasing the woman's anxiety. She may assume that if others are worried, something is wrong. The birth experiences Of a woman's family and friends have a large impact as those individuals can be an important source of support if they express realistic information about labor pain and control. If they describe labor as intolerable, however, she May experience needless distress.

Mastitis

An infection of the breast, occurs most often 2 to 4 weeks after childbirth, although it may develop at any time during breast-feeding. It usually affects only one breast. Mastitis is often caused by staph, MRSA, E. coli and streptococci. The organism may enter through an injured area of the nipple such as a crack or blister. Engorgement and stasis of milk may proceed mastitis. This may occur when a feeding is skipped. Constriction of the breast by a bra that is too tight may interfere with emptying of all the ducts and may lead to infection. Initial signs and symptoms may be flu like with fatigue, aching muscles, chills, fever, headache, malaise. She may feel a lump in her breast and it is red may have a streak, warm to the touch she may notice an enlarged lymph nodes. Needs to be treated with antibiotics and continued emptying of breasts by breast-feeding or breast pump. With anabiotic's and emptying of breasts it should resolve within 24 to 48 hours. It will be important to continue and finish antibiotics because if not this problem can become a breast abscess. Breast-feeding is still encouraged with mastitis.

breech presentation

Another fetal malposition/presentation. Cervical dilation and effacement often are slower when the fetus is in breech presentation because the buttocks or feet do not form a smooth, round dilating wedge like the head. The greatest fetal risk is that the head is the last to be born. By the time the lower body is born the umbilical cord is well into the pelvis and may be compressed. The shoulders, arms, and head should be delivered quickly so that the infant can breathe. Reasons for breech presentation may include the following: low birth weight, fetal anomalies contributing to breech presentation such as hydrocephalus, complications secondary to placenta previa or previous cesarean birth.

Shoulder dystocia

Another passenger problem that is an urgent situation because the umbilical cord can be compressed between the fetal body and the maternal pelvis. One of the initial signs of shoulder dystocia is known as the "turtle sign." Shoulder dystocia is more likely to occur when the fetus is large or the mother has diabetes, but many cases occur in pregnancies with no identifiable risk factors. When turtle sign is identified the delivery team should make preparations for surgical delivery while at the same time taking immediate steps to deliver the baby vaginally. Although the head is on the outside, the chest is still on the inside preventing respirations. McRoberts maneuver is a nursing action that should be taken immediately, pulling the mothers knees up as far toward the shoulders as possible. This can widen the passage just enough for the shoulders to pass through. Another intervention is suprapubic pressure, where the nurse pushes the fetal anterior shoulder downward to displace it from the mothers symphysis pubis. Fundal pressure should be avoided so that the shoulders are not pushed even harder against the synthesis. The provider after delivery should check clavicle's to be checked for crepitus, deformity, and bruising which all suggests fracture.

Multifetal pregnancy

Another passenger problem. may result in dysfunctional labor because of uterine over distention which contributes to labor dystocia, And abnormal presentation of one or both fetuses. The over distended uterine muscle does not contract evenly or with great force. In addition, the potential for fetal hypoxia during labor is greater because the mother must supply oxygen and nutrients to more than one fetus. She is greater risk for postpartum hemorrhage resulting from uterine atony because of uterine over distention. Because of risk for cord prolapse, placental shearing, and potential bleeding problems, many women opt for cesarean birth. If three or more fetuses are involved, the birth is almost always cesarean. Each twins fetal heart rate is monitored during labor. When in bed the woman should remain in the lateral position to promote adequate placental blood flow. One or more neonatal nurse Or above per fetus should be available to care for each infant. One nurse should be dedicated to caring for the mother.

Neonatal sepsis: treatment

Antibiotics, Use of sterile and aseptic technique's during delivery, the application of a erythromycin To the eyes. Have to take care of the umbilical cord in a certain way.

gestational diabetes

Any degree of carbohydrate intolerance first diagnosed during pregnancy is classified as GDM. GDM is an added risk factor that a woman will develop type two diabetes later in life. Factors such as obesity, inactivity, abnormal cholesterol levels, vascular disease, or family members with type two diabetes further increase a woman's risk for developing type two diabetes. Risk factors: -Overweight -maternal age older than 25 years -previous birth outcome often associated with GDM (neonatal macrosomia, maternal hypertension, infant with unexplained congenital anomalies, previous fetal death) -gestational diabetes in previous pregnancy -history of abnormal glucose tolerance -history of diabetes in a close relative -member of a high-risk ethnic group (African-American, Hispanic or Latino, American Indian, Asian American, or Pacific Islander) -history of pre-diabetes -history of polycystic ovary syndrome Screening: a woman without any risk factors may be screened by history alone. Women with one or more risk factors may have a glucose challenge test done usually administered between 24 and 28 weeks of gestation. Fasting is not necessary. the woman ingests 50 g of oral glucose solution, a blood sample is taken one hour later. If the blood glucose concentration is 140 or greater, a three hour oral glucose tolerance test is recommended Oral glucose tolerance test OGTT: The gold standard diagnostic. The woman was fast from midnight on the day of the test. After a fasting plasma glucose level is determined, the woman should ingest 100 g of oral glucose solution. Plasma glucose levels are than determined at one, two, and three hours. A diagnosis of GDM is made of two or more of the values Meet, or exceed the threshold - fasting 95 - 1 hr 180 - 2 hr. 155 - 3 hr. 140 (Don't have to memorize these numbers)

Postpartum blues

Any depression That takes place after childbirth and last longer than two weeks. Blues: mom cries easily for no apparent reason, becomes tearful, restless, a little bit of anger maybe, having trouble coping. This happens frequently and is postpartum blues. Most frequently seen in the first 10 days after delivery and is frequently limited to crying bouts. Short fuse. Postpartum depression: is more significant. Feelings of depression worsen over time and lasts longer than postpartum blues. They will start to feel like they're not able to care for themselves or the baby. They don't interact with the baby, they don't take showers and this is significant And they need to realize that these won't go away on their own. They will need medication. Women that are at increased risk or women who previously had depression, previous pregnancy, sexual abuse, unexpected pregnancy, smoking women have higher incidence.

Cervical ripening and bloody show

As full-term nears, the cervix softens because of the effects of the hormone relaxin. As the fetal head descends with lightning, it puts pressure on the cervix, starting the process of effacement and dilation. This causes expulsion of the mucous plug that sealed the cervix during pregnancy, rupturing small cervical capillaries in the process. May begin several days to a few weeks before the onset of labor, especially in the nulliparous woman. Ask if the blood is brown or bright red, Because bright red bleeding is never normal, but mucousy brown bloody show is normal

Asphyxia

Asphyxia is insufficient oxygen and excess carbon dioxide in the blood and tissues. It may occur in utero, at birth, or later and results in ischemia to major organs. It can be the result of preterm lungs within sufficient surfactant to function adequately. Maternal, placental, or fetal factors may be involved. Maternal factors include complications such as hypertension, infection, and drug use. Asphyxia in utero may be caused by placental conditions such as placenta previa, placental abruption, or postmaturity. Cord problems, infection, premature birth, and multifetal gestation are among the fetal causes of asphyxia. Asphyxia results in respiratory acidosis Manifestations: When asphyxia occurs after birth, rapid respirations are followed by cessation of respirations (primary apnea) And a rapid fall in heart rate. If asphyxia continues without intervention, gasping respirations may resume weakly Until the infant enters a period of secondary apnea. And secondary apnea, the oxygen levels in the blood continue to decrease, the infant loses consciousness, and stimulation is ineffective. Resuscitative efforts should be initiated immediately. Risk factors: complications that occur during pregnancy, labor Such as cord compression, or birth, increase the infants risk for asphyxia. In addition, if the expectant mother receives narcotics for analgesia shortly before birth, the infants central nervous system may be too depressed at birth to allow adequate spontaneous breathing. Sepsis and birth trauma are also causes.

Nursing management of care with cervical ripening agents

Assess contraindications: Vaginal bleeding, fetal distress, previous cesarean birth, major uterine surgery Monitor VS: evaluate That maternal vital signs are within normal limits and monitor fetal heart rate and contraction tracing. Assess for vaginal bleeding. Bloody show and mucous plug is normal but vaginal bleeding is not normal. Assess rupture of membranes (ROM):

Nursing assessment: hyperbilirubinemia

Assess the level of jaundice at least every eight hours by blanching the skin (Pressing the skin over a bony prominence) To see the color in the area before blood returns. Evaluate the skin color in good light with phototherapy lights turned off because they distort the skin color. In infants with dark skin, assess the color of the pallet and mucous membranes of the mouth and the conjunctivae. Determine areas of the body affected by jaundice. Jaundice begins at the head and moves down the body as the Bilirubin level rises.

Nursing care for clients receiving a C-section

Assess the time of last oral intake and what was eaten (GI slows so aspiration risk)(Administer Bicitra to neutralize stomach acid in case of aspiration). Have the woman sign informed consents for surgery, anesthesia, and usually blood transfusion. Obtain the ordered lab work (CBC, blood type screen). Do preoperative teaching: what the woman can expect in the operating and recovery rooms, infant care, and who will be present, recovery routine. Start the ordered intravenous infusion (# 18 Angiocath), and begin a fluid bolus for the regional anesthetic at the appropriate time. Clip body hair from the skin area needed for planned incision. Administer the ordered medication to control gastric secretions. Insert an indwelling urinary catheter. Assist the woman to use the operating table, positioning her with a wedge under her hip to displace the uterus if the table is flat (prevent supine hypotension syndrome). Apply the grounding pad for electrocautery and sequential compression devices (SCDs) Notify the nursery care team. Instrument/needle/sponge/lab counts

Postpartum pain management

Assess where the pain is coming from. For peroneal pain give ice packs for the first 24 hours. Ice causes vasoconstriction and is most effective if applied soon after birth to prevent Adema and numb the area. Chemical ice packs in plastic bags or non-latex gloves filled with ice maybe used after a vaginal birth. The ice pack is wrapped in a washcloth or paper before it is applied to the perineum. It should be left in place until the ice melts. It is removed for 10 minutes before a fresh pack is applied. After 24 hours give heat, like sitz bath or warm shower. Pain medications also can be used such as Tylenol and codeine. The nurse should be careful that the woman receives no more than 4 g of acetaminophen in a 24 hour period. Drugs like ibuprofen are often prescribed because of their anti-inflammatory effects. Local anesthetic is also available to decrease surface discomfort. Usually lidocaine It is available as a spray or foam.

Latent phase

Beginning of real contractions. 0 to 3 cm dilated. Latent labor may be quite long and much of it may pass unnoticed by the pregnant woman as latent labor gradually merges into active labor. Cervical effacement and fetal position change occur preparing for the more rapid changes of active labor. The interval between contractions shortens to about five minutes apart and duration increases to 30 to 40 seconds by the end of latent phase. Contractions gradually build to their peak intensity and remain briefly Before diminishing. Woman may notice discomfort in her back and in circles to the lower abdomen with each contraction. Many women describe the discomfort as like menstrual cramps.

Phototherapy

Bilirubin in the skin absorbs light and changes into water soluble products, the most important of which is lumirubin. These products do not require conjugation by the liver and can be excreted in bile and urine. Phototherapy can be delivered in several ways. A bank of fluorescent lamps can be placed over the infant who is in an incubator or under a radiant warmer to maintain heat or in an open crib. The infant wears only a diaper to ensure maximum exposure of the skin to the lights. The diaper is removed if the TSB is becoming dangerously high. The eyes are covered. Nursing care: Feed infant early in frequently, every 3 to 4 hours. This promotes excretion of bilirubin In the stools. Encourage continued breast-feeding. Formula may be needed. Monitor I&O and daily weight. Maintain adequate fluid intake to prevent dehydration. Newborn stool that contains bail will be loose and green. Bilirubin should start to decrease within 4-6 hours after starting treatment. do not apply lotion or ointment to newborn skin. Remove newborn from phototherapy every four hours, remove mask and inspect for injuries. Reposition newborn every two hours to expose all body surfaces to light and to prevent pressure sores. Turn off phototherapy lights before drawing blood. Encourage parents to hold and interact with infant when lights are off.

Acute Bilirubin Encephalopathy (ABE)

Billy Rubin is deposited into the brain. May lead to permanent damage: dystonia, athetosis (Slow, involuntary, convoluted, rising movements of fingers, hands, toes, and feet and in some cases, arms, legs, neck and tongue) Upward gaze, hearing loss, cognitive impairments.

Gastroschisis and Omphalocele

Both of these anomalies are caused by congenital defects in the abdominal wall. In omphalocele, The intestines protrude into the base of the umbilical cord. Other anomalies often cooccur. Gastroschesis Is a defect to the right side of the abdomen, it is a result of compromise from the right umbilical vein, through which the intestines protrude. They are not covered by peritoneum or skin and float freely in the amniotic fluid. Assessment: diagnosis is made by prenatal measurement of elevated alpha-fetoprotein level and by prenatal ultrasound and is obvious at birth. Therapeutic management: gastric tube is placed to decrease air in the stomach. Gastric section, parenteral nutrition, and antibiotics are necessary. Surgery is performed as soon as the infant is stable. A Silastic silo (pouch) Maybe used to replace the intestines gradually over a period of days to prevent pressure on the other organs. The abdomen is closed when the contents have been replaced in the abdominal cavity. Nursing considerations: placed the infants torso into a sterile plastic bag or cover the intestines with Silastic or warm sterile saline dressings wrapped with plastic immediately after birth to reduce heat and water loss. Observe for respiratory distress from increased intra-abdominal pressure. Prevent infection and trauma. Position to avoid pressure on the intestines.

Non-pharmacological techniques: breathing techniques

Breathing techniques give a woman a different focus during contractions, interfering with pain sensory transmission. It also helps to prevent hyperventilation. They begin with simple patterns and progress to more complex ones as greater distraction is needed. Complex patterns however can be fatiguing if used for a long time. For best results, the woman and her partner should practice the techniques frequently. If patterns are too complicated or if the woman has not practiced, they may not be helpful during labor. Breathing techniques should only be used when needed, usually when the woman can no longer walk or talk during a contraction. The woman should not change from a simple technique to the next more complex technique until necessary, so that the use of the most complex techniques is limited to the shortest time possible. Start with slow breathing, do a cleansing breath. Review different ones on pg. 327

First stage of labor

Cervical effacement and dilation occur in the first stage or the stage of dilation. It begins with the onset of true labor contractions and ends with complete dilation of 10 cm and effacement of 100% of the cervix. The first stage of labor is the longest for both Nullaparous and Parous women. Three phases within the first stage are latent, active, and transition.

Emergency childbirth

Call EMS. Wash hands and don gloves. As head crowns, instruct woman to pant-blow. Place flat side of your hand on fetal head and apply gentle pressure down toward the vagina. After birth of head, check for cord around neck. Move cord over baby's head from being around the neck. Deliver shoulders by applying pressure downward until anterior shoulder is out and then push upwards and posterior shoulder is delivered. Suction baby's mouth and nose. If no suction is available tap the baby's back. Keep Baby at level of umbilicus until cord stops pulsating. Dry baby with warm towels. Place baby against Mom skin and keep covered with blankets. Wait for placenta to separate, never tug on cord. Do not cut the cord, wait for EMS to arrive.

Non-pharmacological techniques: positioning

Can be effective for contractions And should not be underestimated that you can get her into different positions. She can be sitting upright, Standing, walking, up on all fours, up on a ball, it all makes a difference in getting the baby to move and rotate easily through the cardinal movements.

Cleft lip and palate

Cleft lip and palate is among the most common congenital anomalies. They occur together or separately, on one or both sides. There can be a minor notching of the lip or a complete separation through the lip and into the floor of the nose. With the pallet, there can be a division of only the soft palate, or of the entire hard and soft palate. Severe clefts are obvious at birth. Palpate the hard and soft palate of all neonate during initial assessment. Management: Lip surgery is usually performed by three months to enhance appearance and parental bonding. Further surgery may be needed at 4 to 5 years. Palate surgery is usually done by one year to minimize speech problems. Long-term follow up should be done for orthodontist, speech therapy, and possible hearing problems. The degree of the cleft determines the approach to feeding: Breast-feeding, nipples with large hole, compressible bottles, special longer nipples, and special assistive devices can be employed. Feed the infant in the upright position because of increased tendency to aspirate. Feed slowly with frequent stops to burp because of tendency to swallow excessive air. Teaching: help the parents deal with their disappointment over the infant with an obvious anomaly. Show them before and after pictures of plastic surgery. Reinforce the physicians explanation of plans for surgery. Teach feeding techniques, let them observe it first then allow them to take over gradually. Prevent infections. Emphasize the need for long-term follow up.

Effects of cocaine (and other stimulants) on the newborn

Cocaine alters major neurotransmitters. It rapidly crosses the placenta. You'll see neuro behavioral changes 2-3 days after birth. The infant will present with hyperactive Moro reflex, jitteriness, excessive sucking. Methylxanthine is found in caffeine and it accumulates in breast-fed infants. Nicotine is transferred through the placenta and may reach concentrations 15% higher than maternal levels. Affects infants ability to be comforted. Exaggerated startle reflex and tremor. Marijuana: no neonatal withdrawal problems. They do have problems however with hypoglycemia, hypocalcemia, sepsis, hypoxic encephalopathy, intracranial hemorrhage, jitteriness. There's also growth inhibition pronounced at birth.

Evaluation/care for a client receiving oxytocin

Contraction pattern every 2 to 3 minutes with 60 second durations. Fetal monitor pattern average variability, no late decelerations. Normal vital signs. Progressive dilation 1 cm/h. Adverse outcomes, assess for tachysystole (Too many contractions) Uterine resting tone greater than 20 mmHg or peak greater than 80mghg (IUPC). Continuous late decelerations.pl

Grandparents

Grandparents contribute to family continuity. Involvement depends on cultural and familial factors. Intergenerational relationships shift. Grandparents may not be educated on latest best practice such as reducing the chances of the incidence of SIDS. Grandparents may also want to supplement the child with formula if the mother is breast-feeding which is not good practice in those initial days it is best For the mother to continue exclusively breast-feeding.

Disseminated Intravascular Coagulation (DIC)

DIC is a life-threatening defect in coagulation that may occur with several complications of pregnancy such as placental abruption or hypertension. At the same time anticoagulation is occurring, inappropriate coagulation is also taking place in the micro circulation. The results of DIC are excessive bleeding and the formation of tiny clots in tiny blood vessels, blocking blood flow to organs and causing ischemia. It is always a secondary diagnosis Predisposing factors are placental abruption, pregnancy induced hypertension, embolism, placental retention, fetal demise, pulmonary embolism. So one of these takes place first, and then DIC becomes a risk. You will see the patient bleeding from every orface. Eye, ear, IV site, gums. Once you see that you know she is developing DIC which is a medical emergency. PT and PTT will be prolonged Tx is delivery, D&C, then a blood transfusion. Apply 10 L per minute oxygen per face mask. Be sure to weigh all bloodsoaked materials to obtain an accurate output

Ectopic pregnancy management

Dependent on whether the tube is intact or ruptured. Medical management with methotrexate may be an option to surgery in the woman with an early ectopic pregnancy if the tube is unruptured. The goal of medical management is to preserve the tube and improve the chance of future fertility. Methotrexate, a chemotherapeutic agent, is a folic acid antagonist that inhibits cell replication and therefore targets rapidly dividing cells such as the trophoblastic cells in early pregnancy. It is approximately 90% effective in treating ectopic pregnancy. Surgical management of a tubal pregnancy that is unruptured may involve a linear salpingostomy or a salpingectomy When ectopic pregnancy results in rupture of the fallopian tube, the goal of therapeutic management is to control the bleeding and prevent hypovolemic shock. If the woman is Rho D Negative, then the nurse administers RhoGAM. If the plan of care includes methotrexate, remember that is a chemotherapeutic agent and protocols for chemotherapy should be followed (Double glove, appropriate PPE, air should not be expelled from syringe because it could aerosolize the medication, Her urine is considered toxic for 72 hours, avoid getting urine on the toilet seat, the toilet should be flush twice and close the lid)

Pharmacological cervical ripening methods

Dinoprostone (Cervidil) Is a time release vaginal insert left in place for up to 12 hours. Remove with onset of active labor, membrane rupture, or uterine tachysystole. Remove insert if hypertonic contractions occur. Risks are hyperstimulation (tachysystole) and fetal distress. It has a string on it so that it can be removed, oxytocin can begin 30 to 60 minutes after removal of insert. Misoprostol (Cytotec) Is a prostaglandin tablet cut into a quarter and inserted every 4 hours. It should not be given to a woman who has had a previous cesarean birth or major uterine surgery. It is inserted vaginally to the cervix. Oxytocin induction can begin at least four hours after last dose. Risk can be the same as for Cervidil.

Magnesium sulfate

Drug of choice for severe preeclampsia. Loading doses is 4-6g bolus over 20 to 30 minutes to get serum levels higher. Maintenance dose is 2-4g/hr IVPB. Always runners IV piggyback. Monitor for respiratory depression or decrease CNS, lethargy, And shut off the magnesium. Magnesium sulfate usually continued until 12 to 24 hours postpartum. Keep calcium gluconate available because it is the antagonist.

Ecclampsia

Eclampsia is preeclampsia with seizures. Most of the treatments during preeclampsia are to prevent eclampsia because the seizures can have a bad outcome for both the mother and the fetus.

ectopic pregnancy

Ectopic pregnancy is a significant cause of maternal death from hemorrhage and is a true medical emergency. In addition, damaged fallopian tubes can decrease chances of subsequent successful pregnancies and can increase chances of another ectopic pregnancy. Common factors of ectopic pregnancy development is scarring of the fallopian tubes because of pelvic infection, inflammation or surgery. Pelvic infection often is caused by chlamydia or gonorrhea. Regardless of the cause of tubal pregnancy the effect is that transport of the fertilized ova through the Fallopian tube is hampered. Classic signs of ectopic pregnancy include: missed menstrual period positive pregnancy test abdominal pain vaginal spotting If implantation occurs in the distal end of the fallopian tube, which can contain the growing embryo longer, the woman made at first exhibit the usual early signs of pregnancy and consider herself to be normally pregnant. Several weeks into the pregnancy intermittent abdominal pain in small amounts of vaginal bleeding occur, and initially this could be mistaken for threatened abortion. Because routine ultrasound examination in early pregnancy is common, however, it is not unusual to diagnose an egg topic pregnancy before onset of symptoms. If implantation has occurred in the proximal end of the fallopian tube, rupture of the tube may occur within 2 to 3 weeks of the mist. Because the tube is narrow in this area. Symptoms include sudden severe pain in one of the lower quadrants of the abdomen as the tube tears open in the embryo is expelled into the pelvic cavity often with profuse abdominal hemorrhage. Radiating pain under the scapula may indicate bleeding into the abdomen caused by phrenic nerve irritation. Diagnosis is achieved if beta-hCG Is present but at lower levels than expected. If gestational sac cannot be visualize when beta hCG is present, a diagnosis can be made with great accuracy. Visualization of an intrauterine pregnancy does not absolutely rule out an ectopic pregnancy. Other method is direct visualization of a bluish swelling within the tube via laparoscopy.

Gestational hypertension

Gestational hypertension is the onset of hypertension after 20 weeks of pregnancy without protein urea. Just stational hypertension should be considered a working diagnosis because it may progress to preeclampsia. If gestational hypertension persists after 12 weeks postpartum, chronic hypertension is diagnosed.

Maternal, fetal, and neonatal effects of GDM

Effects of GDM are similar to those associated with pre-existing diabetes. Poorly controlled GDM, characterized by maternal hyperglycemia during the third trimester, is associated with increased Neonatal morbidity and mortality. The major fetal complications: are macrosomia, leading to birth injuries or cesarean birth, and neonatal hypoglycemia. Other problems such as hypocalcemia, hyperbilirubinemia, and respiratory distress also may occur. It can also cause preterm labor, premature rupture of membranes and congenital anomalies. Maternal risks: hypertension, preeclampsia, UTI, ketoacidosis, labor dystocia, birth injury to maternal tissues, large amounts of amniotic fluid

Nursing interventions with dystocia

Encourage regular voiding. Repositioning/ambulation. Oxytocin augmentation per protocol. Assist with amniotomy (AROM)(releases prostaglandins and causes her to have stronger contractions). Promote relaxation-hydrotherapy. Continuous EFM (electronic fetal monitoring).

Fathers

Encourage the father to engage in as much of the child's care as possible to help grow and establish confidence. Fathers can lack confidence in demonstrations of infant care.

Environment

Environment can play a significant role in helping her deal and cope with labor contractions. A low stimulating environment such as darkened room, quiet room, Comfortable temperature, the changing of soiled underpads, extra pillows, encouraging the use of music, have her focus on the focal point, being a supportive nurse and encouraging the partners in the room to be a supportive person can help how she copes with labor. Encourage the partner to have an active role and help get to the partner the materials that the woman might need.

Postpartum care management

Evaluate clients H&H 24 hours after delivery. Continue to evaluate the fundus every four hours. She should feel abdominal cramping, that's a good sign it means the uterus is contracting, which means it has minimal bleeding. Should evaluate breast-feeding and make sure that the infant is properly latching on and teach that it reduces postpartum hemorrhage also because of natural release of oxytocin. It's important for the nurse to assess who is a high risk factor for postpartum hemorrhage, and that is a client with a large uterus (Mothers of twins, gestational diabetics, Polyhydramnios). Another cause of bleeding is cervical lacerations. If you see that her fundus is midline and firm, but she is bleeding anyway, it might be a cervical laceration. If that is found it is an urgent call to the provider. Encourage her to get up and urinate frequently because a distended bladder can off center of the uterus and promote uterine bleeding. Prevent infection: When she is breast or bottlefeeding, she should wash her hands, Or use hand sanitizer before handling the infant. She should be taught to prevent any type of breast infection or an abscess, that she should be frequently breast-feeding and emptying her breasts and any type of plugged ducts should be massaged. She should keep her nipple and Areola area open to air so that moisture does not collect and bacteria form. Frequently use peri bottle after urination, and frequently change pad to prevent infection of stitches. She should ambulate as soon as she can if she's had an epidural or spinal. Educate her on the signs of DVT and PE.

fatigue

Fatigue reduces a woman's ability to tolerate pain and use coping skills she has learned. A extremely fatigued woman may have an exaggerated response to contractions or she may be unable to respond to sensations of labor such as the urge to push. Her energy reserves are also likely to be depleted in a long labor. Many women also may have a sleep deficit because the last weeks of pregnancy make it difficult for a woman to sleep.

Long term complications of Neonatal abstinence syndrome (NAS)

Feeding problems, CNS dysfunction (cognitive impairment, cerebral palsy), attention deficit disorder, language abnormalities, microcephaly, delayed growth and development, poor maternal newborn bonding. Prognosis: Widely varies. Depends on the family, Socioeconomic variables, and whether either or both parents continue to use illicit drugs. A home environment within addicted mother is a compromising variable. Long-term mortality rates are low. Risk for SIDS is significantly higher among infants who are exposed to opiates.

Position

Fetal position describes the location of a fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvis. The four quadrants are the right and left anterior, and right and left posterior. Fetal position is not fixed but changes during labor as the fetus Moves downward. Abbreviations correlate with: right or left. occiput, mentum, or sacrum. Anterior, posterior, or transverse. Lecture includes fetal lie as being the position. See passenger card for fetal lie. Cephalic position is head down, it is broken up into three cephalic positions: vertex, brow, face. Both brow and face positions are not favorable because they increase the diameter coming through the canal. Brow can become a C-section. Face presentation however can still be delivered vaginally.

Taking in phase

First of the three phases of maternal role attainment: in this phase the mother is focused primarily on her own need for fluid, food, and sleep. And experienced nurses may be puzzled by the mothers passive, dependent behavior as he takes in or receives attention and physical care. She also takes in every detail of the neonate but seems content to allow others to make decisions. The major task for the mother during this time is to integrate her birth experience into reality. She attempts to integrate All the details. This helps the mother to realize that the pregnancy is over and the newborn is now a separate individual. It usually lasts a day or less. This phase may be prolonged with a cesarean birth especially if it was an emergency.

Foods rich in folic acid

Folic acid fortified cereals, Dark green leafy vegetables, beans/legumes. asparagus, okra, brussels sprouts, broccoli, chili peppers, orange juice, yeast and enriched whole grains, organ meats, lean beef, fish, fresh fruits and vegetables, eggs, cheese and milk

Sources of labor pain

Four sources of labor pain exist in most labors: In the first stage of labor, pain can come from cervical dilation. Dilation and stretching of the cervix and lower uterus are a major source of pain. In the first stage pain can also come from pressure in pulling on pelvic structures such as ligaments, fallopian tubes, ovaries, bladder, and peritoneum. The pain is a visceral pain; a woman may feel it as referred pain in her back and legs. In the second stage of labor, pain can come from distention of the Vagina and perineum. This occurs with fetal descent. The woman may describe a sensation of burning, tearing, or splitting (somatic pain)

General anesthesia

General anesthesia is is systemic pain control that involves loss of consciousness. It is rarely used for vaginal births because of fetal and maternal respiratory depression, and risk of maternal aspiration. but it still has a place in cesarean birth. General anesthesia may be needed unexpectedly and quickly for emergency procedures at any stage of pregnancy, such as to repair injury that results from an accident or domestic violence or to perform an appendectomy. It is the very last thing done just before making any surgical incision. Minimize adverse effects: administer Bictra, oral antacid to reduce stomach acid. Restricting take to clear fluids or maintain NPO status. Apply cricoid pressure during intubation. Reduce time of intubation to clamping of the cord to two minutes.

defects that can be present at birth

Heart: Defective vessels, leaky valves, Ventricular septal defect (VSD), Atrial septal defect (ASD). When doing a physical assessment it's always important to listen to the heart Neurological: There can be neural tube defects Such as spina bifida. Look and inspect at the area of the top of the buttocks for any abnormality. Encephalopathy Where the brain does not completely form Environmental factors can be a lack of folic acid, maternal insulin dependent diabetes, and anti-convulsant medications in the mother.

Cardiovascular system

Hypervolemia, which produces an average 30% to 45% increase in blood volume at term, allows the woman to tolerate a substantial blood loss during childbirth without ill affect. Up to 500 mL of blood is lost in vaginal deliveries, and up to 1000 mL is lost in cesarean births. Despite the blood loss a transient increase in maternal cardiac output occurs. The rising cardiac output returns to pre-labor values within an hour after delivery, and gradually cardiac output returns to Pre-pregnancy levels in most women by 6 to 8 weeks after birth. If her blood pressure is decreasing and her heart rate is rising that is abnormal and could be a sign of hemorrhage. Check her temperature to make sure there's not an infection. Anytime the temperature is above 100.4°F that is abnormal and indicates a possible infection. After delivery a CBC will be drawn and will look at the H&H. It will drop because she lost blood. It is typically only taken on day one unless there's a drastic drop in her H&H. It will typically drop a little bit more in the first three or four days and then will gradually return back to normal. White blood cell count will be high and that is normal because of the process of labor and delivery. A white blood cell count of 20,000 to 25,000 is Normal. Coagulation factors stay elevated for several weeks As a preventative measure for any type of bleeding. This however can increase the possibility of a DVT or Pulmonary embolism. She should always be aware that any kind of chest pain or shortness of air is abnormal. Best prevention is getting up and ambulating as much as possible. Varicosities can often be seen and they have a genetic predisposition. They will regress it may take 6 to 8 weeks. They may come back at the next pregnancy and at getting older in age around menopause.

Hypospadias and Epispadias

Hypospadias: defect occurs on the ventral (underside) aspect of the penis (corpus spongiosum) Hypospadias may be associated with inguinal hernias and undescended testes Epispadias: defect occurs on the dorsal (top part) aspect of the penis urethra opens as a groove on the dorsum of the penis. These infants will not be circumcised.

Forcep assisted birth

If mother has been pushing for more than two hours and shows signs of exhaustion, or signs of fetal distress. Nursing interventions: make sure her bladder is empty. If she has an epidural you don't have to worry about it. The fetus has to be engaged and that is a provider assessment. Position client in lithotomy position. Explain procedure to client. Risks: There's always the possibility of cephalohematoma, Extensive episiotomy, fourth-degree tear.

Health promotion for a future pregnancies

If she is not immune to rubella then she needs a vaccination subcutaneously while in hospital prior to discharge. She should be told to avoid a pregnancy in the first month Because there is risk for teratogen. If she's not immune to varicella she should also have a varicella vaccination prior to discharge. If she has not had a T Dap vaccine within the last 10 years, she should have this done too RH negative mothers who give birth to RH positive infants Should have RhoGAM administered within 72 hours after delivery.

Placenta previa

Implantation of the placenta in the lower uterus. As a result the placenta is closer to the internal cervical os Then to the presenting part of the fetus. The three classifications of placenta previa are total, partial, and marginal. Depending on how much of the internal cervical os is covered by the placenta. The classic sign of placenta previa is the sudden onset of painless uterine bleeding in the last half of pregnancy. Bleeding results from the tearing of the placental villi from the uterine wall as a lower uterine segment thins and the internal os begins to dilate near term. Digital examination of the cervical os or stimulation of contractions when placenta previa is present can cause additional placental separation or tear of the placenta itself, causing severe hemorrhage and fetal distress. Therefore until confirmation there is no manual vaginal examinations. The mother for the pregnancy will be put on restrictions of activities, just getting up to go to the bathroom permitted, she won't be allowed to go to work, no intercourse, And will frequently be monitored. The patient will get steroids to mature the babies lungs and will be delivered by C-section.

other premonitory signs of labor

Increased vaginal mucus secretions: An increase in clear non-irritating vaginal secretions occurs as fetal pressure causes congestion of the vaginal mucosa. A lot of the times the woman may think that she has broken her bag of waters but a pH test that does not turn blue indicates that it is not. Energy spurt: Some women have a sudden increase in energy, which is called nesting. They should be cautioned to conserve their energy so that they are not exhausted when labor begins. Weight loss: a small weight loss of 1 to 3 pounds may occur because of the altered estrogen to progesterone ratio causes excretion of some of the extra fluid that accumulates during pregnancy.

vaccum-assisted birth

Indications: ineffective pushing, exhaustion, fetal distress. The provider pulls a little bit during a contraction. Nursing interventions: Empty bladder, fetus is engaged, position client in lithotomy, explain procedure to client

Transient tachypnea of the newborn (TTN) (Retained lung fluid)

Infants who experience TTN Develop rapid respirations soon after birth from inadequate absorption of fetal lung fluid. The condition usually resolves within 24 to 48 hours, it is the most common respiratory causes of admission to a NICU. Risk factors: cesarean birth with or without labor, macrosomia, multiple gestation, excessive maternal sedation, prolonged or precipitous labor, male gender, and maternal diabetes or asthma. Mailed immaturity of surfactant production also may be a factor. Infants are usually term or late preterm, although some may be preterm. Because: although the cause of TTN is unknown it is thought to result from a delay in absorption of fetal lung fluid by the pulmonary capillaries and lymph vessels. Manifestations: NTTN, tachypnea develops within six hours of birth. Grunting, retractions, nasal flaring, and mild cyanosis also are present. Chest radiography demonstrates hyper inflation, perihilar Streaking that shows in gorged lymphatics, in the presence of fluid in the fishers between the lobes and in the plural space. TTN may be the cause of wheezing later in life. Treatment: treatment is supportive and may include oxygen for cyanosis. Gavage feeding may be given when respiratory rate is high to prevent aspiration and conserve energy. The infant is observed for RDS and sepsis because signs are similar. Anabiotic's may be given until sepsis is ruled out. CPAP is rarely needed.

Anesthesia: local infiltration

Infiltration of the perineum with a local anesthetic is done by the physician or nurse midwife before an episiotomy or perineal repair. Local infiltration does not alter pain from uterine contractions or distention of the vagina. Local infiltration rarely has adverse effects on either mother or infant.

Postpartum: after pains

Intermittent uterine contractions known as after pains are a source of discomfort for many women. The discomfort is more acute for multipair is because repeated stretching of muscle fibers leads to loss of muscle tone that causes repeated contraction and relaxation of the uterus. Some women (4th time moms) even think that it's more painful than labor itself. After pains are particularly severe during breast-feeding. Oxytocin released from the posterior pituitary to stimulate the milk ejection reflex causes strong contractions of uterine muscles. Nursing considerations: analgesics are frequently used to lessen the discomfort of after pains. Some others are apprehensive for fear of analgesics getting to breastmilk but that is not the case. NSAIDS are also good.

Braxton Hicks contractions

Irregular, mild uterine contractions that occur throughout pregnancy and become stronger in the last trimester. Parous women often describe more uterine activity preceding labor than do nulliparous women. This makes sleep difficult at the end of pregnancy. The contractions may become regular at times, only to decrease spontaneously. They are often uncomfortable and cause Women to be confused about whether labor has begun.

Parent infant contact

It's important to have early skin to skin contact. Bonding is unidirectional from parent to child and is enhanced one parent and infants are permitted to touch and interact during the first 30 to 60 minutes after birth. Infants should be placed skin to skin on the mothers chest or abdomen for bonding time immediately after delivery if possible. Also it's important to try to get the infant to latch early because it helps with the bonding process also. It's important to try to keep the infant with the mother instead of taking the infant straight to the nursery.

Hyperbilirubinemia (Pathologic jaundice)

Jaundice is considered abnormal or non-physiologic when the TSB rises more rapidly to a higher level than is expected or stays elevated for longer than normal. Non-physiologic jaundice may be seen in the first 24 hours of life. It is a concern because it may lead to Bilirubin encephalopathy. The acute manifestation of bilirubin toxicity. This may lead to kernicterus, The chronic and Permanent result of bilirubin toxicity. In this condition, bilirubin deposits caused yellowish staining of the brain. It is more likely to occur in infants who have suffered hypoxemia, respiratory acidosis, infection, dehydration, or other injury that impairs the blood brain barrier and allows unconjugated Bilirubin to enter the brain. Causes: The most common cause of pathologic jaundice is hemolytic disease of the newborn from incompatibility between the blood of the mother and that of the fetus. The best known cause is Rh incompatibility in which the RH negative mother forms antibodies when blood from an RH positive fetus enters her circulation. Antibodies may have developed during a previous pregnancy or after injury, abortion, amniocentesis, or a transfusion of RH positive blood. The antibodies cross the placenta, attached a fetal red blood cells and destroy them. ABO incompatibility also causes pathologic jaundice. Mothers with type O blood have natural antibodies to type A and B blood. The antibodies cross the placenta and cause hemolysis of fetal RBCs. Bilirubin levels above 25 mg/dL Place the newborn at risk for acute Bilirubin encephalopathy.

Complications related to forceps and vacuum extraction

Lacerations of cervix, vagina, or perineum. Urinary retention, facial nerve palsy of the neonate (temporary), facial bruising on the neonate, cephalohematoma

Previous experiences with pain

Learning about the normal sensations of labor, including pain, helps a woman suppress her natural reactions of fear and withdrawal, allowing her body to do the work of birth. A woman who has given birth previously has a different perspective. If she has had a vaginal delivery, she is probably more aware of the labors sensations and is less likely to associate them with injury or abnormality. Also Time has a way of blunting the memory of painful experiences. A woman who had a previous long and difficult labor may be anxious about the outcome of the present one. She may be surprised that her second labor moves more quickly than her first. The woman having a second vaginal birth may find late first stage and second stage labor to be more painful because the fetus descends faster.

Effect of opiates on the newborn

Low birth weight, prematurity, IUGR With drawl symptoms, 24 hours after delivery, peaks within 48 to 72 hours. Methadone, acceptable form of therapy for opiate dependent pregnant women. When properly use, it is relatively safe for the fetus. It decreases illicit behaviors, improves prenatal care, and OB outcomes and prevents acute eternal withdrawal. Maternal methadone use is associated with NAS. Maternal methadone is better at keeping patients in treatment. Suboxone is a semi synthetic opioid. Infants exposed to this require: significantly less morphine for the treatment of NAS. Shorter period of treatment. Significantly shorter hospital stay.

Lochia

Lochia I will stay rubra for a good week or so. Rubra is red. Lochia amount is also important. If she is saturating a pad in an hour, that is abnormal needs to be evaluated. Assess lochia color, odor, consistency, amount. Postpartum hemorrhage is usually obvious, but if she is bleeding heavily for a long period that needs to be addressed also or she will have to come in for blood transfusions. Lochia color changes from rubra (1-3 days) to Serosa (brownish) (3-10 days) to alba (whitish discharge after about 8 weeks) C-section patients will usually have less lochia than vaginal delivery patients

Meconium aspiration syndrome

MAS is a condition in which there is obstruction, chemical pneumonitis, and air trapping caused by meconium in the lungs. The condition occurs most often in infants who are post term, small for gestational age, and compromised before birth by placental insufficiency with decreased amniotic fluid and cord compression. MAS occurs most often when hypoxia causes increase peristalsis of the intestines and relaxation of the anal sphincter before or during labor. MAS Develops when meconium enters the lungs during fetal life or at birth. It may be drawn into the lungs if gasping movements occur in utero as a result of asphyxia and acidosis. Manifestations: signs of mild to severe respiratory distress or present at birth, with tachypnea, cyanosis, retractions, nasal flaring, grunting, crackles, and in severe cases a barrel shaped chest from hyper inflation (So the chest to axillary width ratio would be 1:1 instead of 2:1). Radiography shows patchy infiltrates, atelectasis, consolidation, and hyperexpansion from air trapping. The infants nails, skin, and umbilical cord may be stained yellow-green. Management: Cluster newborn care so you are not constantly irritating them. Maintain optimal thermal environment.. Administer broad-spectrum antibiotics. Sedation for agitation. Continuous monitoring and parental reassurance. Cluster newborn care so you are not constantly irritating them. Maintain optimal thermal environment.. Administer broad-spectrum antibiotics. Sedation for agitation. Continuous monitoring and parental reassurance. suctioning the infants secretions as soon as the head is born has not been found to reduce the incidence of MAS. Infants with depressed respirations and muscle tone should be moved to the radiant warmer and suction with a bulb syringe. If the infant is not breathing or has a heart rate below 100 after opening the airway, suctioning, and being dried and stimulated, positive pressure ventilation is required. Infants may need only warmed, humidified oxygen, or extensive respiratory support with mechanical ventilation may be required. Surfactant lavage has been used in severe cases but is controversial.

The addicted newborn

Maternal substance-abuse may be identified before an infant is born, but some infants are born to women who substance use is not known to the healthcare professionals. A history of minimal or no prenatal care or the mothers behavior during labor may cause the nurse to suspect substance abuse. Women who use heroin are generally switched to methadone or bupreorphene during pregnancy to decrease the incidence of wide variations in the drug dosage, which is harmful to the fetus. Methamphetamine exposure results in lethargy, irritability, high-pitched cry, and hypertonicity and infants. SSR I and other antidepressants taking during pregnancy also result in NAS behaviors. Signs of drug exposure usually begin during the first 24 to 72 hours after birth but may not occur for up to two weeks depending on the specific drug. Dependence is due to the passage of the drug across the placental barrier. Once drugs cross the placenta, they tend to accumulate in the infant. This is due to the immaturity of the renal function and enzymes use for metabolism in the infant.

Non-pharmacological techniques: mental stimulation

Mental techniques occupy the woman's mind and compete with pain stimuli. The nurse can help her create a relaxing mental scene. Most women find images of warmth, softness, security, and total relaxation most comforting. Imagery can help the woman disassociate herself from the painful aspects of labor. For example, the nurse can help her visualize the work of labor, the cervix opening, The fetus moving down with each push. This gives her a visualization of success or movement toward a goal. Or a woman may prefer to close riser may want to concentrate on an external focal point. She can use any point in her room as a focal point.

Drugs commonly used for intrapartum pain management

Meperidine (Demerol) Fentanyl (Sublimaze) The above narcotics can cause respiratory depression primarily in the neonate as a main side effect. Onset is quick but duration of action is short. Not as commonly used as the following two: Butorphanol (Stadol) nalbuphine (Nubain) These have some narcotic antagonist effects; should not be given to the opiate dependent woman (may precipitate withdrawal) or after other narcotics such as Merepidine (May reverse their analgesic effects); also a respiratory depressant. These drugs will have less effects on fetal circulation. If the baby is born within an hour of administering some of these analgesics, you have to monitor the baby for respiratory depression, sucking reflex may be delayed and so cannot breast-feed, may have a lethargic appearance. A critical nursing intervention that must be remembered prior to administering one of these analgesics is to check cervical dilation, Because if she's 9 cm, and this is her second baby, you would not want to give her Nubain or stadol she's probably going to deliver within the hour And you do not want to have an infant with respiratory depression. You could instead use non-pharmacological measures. If a narcotic is used, you must have Narcan and neonatal Narcan available. Nitrous Oxide: Is used for labor pain management in several western countries and was used briefly in the United States in the early to mid-1900s. It's use is returning to this country. Nausea, vomiting, and dizziness or some of the possible side effects to consider, So the client should always be in bed when using, same with any narcotics also. For labor pain, the gas is delivered as 50% nitrous oxide. It is self administered and the woman controls when she takes breaths.

Anxiety and fear

Mild or moderate anxiety can enhance attention and learning. However, high anxiety and fear magnify sensitivity to pain and impair a woman's ability to tolerate pain. Anxiety and fear consume energy the woman needs to cope with the birth process, including its painful aspects. Anxiety and fear increase muscle tension, diverting oxygenated blood to the brain and skeletal muscles. Tension in the pelvic muscles counters the explosive forces of uterine contractions. Also, If a previous pregnancy had a poor outcome, the woman is probably going to be more anxious during labor and for a time after. The best nursing tool for decreasing anxiety in the mother is education. Let her know what's going on every step of the way of what to expect and what's going on.

Nursing interventions for GDM

Monitor blood glucose, high blood pressure, weight gain, diabetic diet, More frequent stress tests, more ultrasounds, check amniotic fluid volume There is concern for the baby after delivery to have hypoglycemia, because once the baby is born, within an hour they are not getting that glucose from the mom, So the blood glucose can drop quickly and become hypoglycemic.

spontaneous abortion (miscarriage)

Most miscarriages take place in the first trimester under 12 weeks. Many may occur before implantation or during the first month after the last menstrual period. The incidence increases with parental age. The most common cause of spontaneous abortion is severe congenital abnormalities that are often incompatible with life. Chromosomal abnormalities account for approximately 50 to 60%. Additional causes include maternal infections; such as syphilis, listeriosis, toxoplasmosis, brucellosis, rubella, cytomegalovirus, and periodontal disease. And also maternal endocrine disorders such as hypothyroidism, diabetes and decreased progesterone. Finally heavy alcohol consumption and heavy smoking may play a role. There are seven types of abortions Mostly different and classified by contents of the uterus during the time of the abortion. In an incomplete abortion, some but not all of the products of conception are expelled from the uterus. The major manifestations are active uterine bleeding and severe abdominal cramping. The cervix is open and some fetal and or placental tissues are passed. A blood Specimen is drawn for blood type and screen or crossmatch, and an IV line is inserted for fluid replacement and drug administration. When the woman's condition is stable, a D&C usually is performed to remove remaining tissue. Rh immune globulin (RhoGAM) is given to the unsensitized Rho D negative woman to prevent development of anti-Rh antibodies. In fact it is given to all Rho D Negative women Who are pregnant and present with possible bleeding. It is also given at 28 weeks anyway for preventative measure.

Special considerations in medicating a pregnant woman

Narcotics can cause maternal respiratory depression and fetal CNS depression. It can also affect the course and length of labor. Continuous fetal monitoring should be done. A drug also can cause maternal hypotension, which would reduce blood flow to placenta in fetal hypoxia and acidosis could result. In a healthy fetus, pain medications may not cause harm, but in a sick fetus it may cause harm.

Neonatal sepsis

Neonatal sepsis is caused by transmission of infection. It is the presence of organisms or toxins in the blood during 1st month after birth. Vertical infection is acquired before ordering birth from the mother. Horizontal infection occurs after birth, acquired from hospital staff members or from contaminated equipment, or from family members or visitors. Newborns are particularly susceptible to sepsis Because there immune system's are immature and they react more slowly to invasion by organisms. Newborns and especially preterm infants have fewer antibodies and are unable to localized infection as well as older children. In addition, the blood brain barrier is less effective in preventing the entrance of organisms and CNS infection may result. Common organisms: The most common is staph aureus, staph epidermis, E. coli, H influenza, Strep B hemolytic Group B. Organisms such as those causing rubella, cytomegalovirus, syphilis, HIV may pass across the placenta and cause infection during pregnancy. During labor and birth, organisms in the vagina such as Group B streptococcus (GBS), Herpes, and hepatitis may enter the uterus after the rupture of membranes. Early onset sepsis is acquired during birth, often from complications of labor such as prolonged rupture of membranes, prolonged labor, or chorioamnionitis (triple I)

Preeclampsia

Occurring after 20 weeks of pregnancy, In addition to hypertension, renal involvement may cause proteinuria. Many women also experience general edema. Pedal edema is normal, but it is abnormal for it to be in the hands AND face. Preeclampsia is defined as onset of high blood pressure after 20 weeks of pregnancy that is greater than or equal to 140 mmHg systolic, or greater than equal to 90 mmHg diastolic or higher. Proteinurea 0.3 g protein or higher in a 24 hour urine specimen, OR Greater than equal to +1 per dipstick. Risk factors: first pregnancy, men who fathered preeclamptic pregnancies are more likely to father further preeclamptic pregnancies. Age older than 35, or a very young teen. African-American. History of thrombophilia. Obesity. Diabetes. Family history of preeclampsia. Metabolic syndrome. Multifetal pregnancy. Etiology: The primary pathology process of hypertension is vasoconstriction Which causes poor organ perfusion to liver and kidneys. It can cause a decrease in the GFR, And an increase in the urine protein and BUN The only known cure for preeclampsia is birth of the fetus and delivery of the placenta. Nursing interventions are that the woman should rest, lay often on her left side, more often prenatal visits, limit activities, she should monitor her blood pressure several times daily, Daily weight At the same time every day, assessment of fetal kick. It should take about 10 to 15 minutes to get about 10 kicks. Promote healthy nutrition, do not restrict her salts, but do not add salt either. And maintain adequate hydration.

Breasts

Once placenta delivery takes place, The progesterone and estrogen levels decline and that causes an increase in prolactin. Prolactin initiates milk production. The mother produces colostrum in the first 24 hours. It transitions to milk in 72 to 96 hours. The other important hormone related to breast-feeding is oxytocin, it is important for the milk let down. Oxytocin allows the milk that's in the alveoli to travel down through the ducts. The clostrum comes in it's a small amount, about a tablespoon or so and is yellow and sticky. It is adequate, the baby does not need water or any supplement. Engorgement Is always a problem for lactating moms, and the best treatment for preventing engorgement is frequent breast-feeding. Expressing some milk helps the baby to latch on. Taking a warm shower also helps with let down. Engorgement can be a problem for the first week. For non-lactating moms they will have the same problem they will deal with engorgement after the first 24 to 48 hours. For these moms the nurse should encourage her to use a very good supportive bra or breast binder. Ice packs are helpful and Tylenol for pain, but she should avoid nipple stimulation, so if she's in the shower she should have her back to the flow of water so it does not stimulate her nipples, and she should not try to express milk. Within three days typically she's feeling better and engorgement has lessened.

Nursing assessment for neonatal abstinence syndrome (NAS)

Ongoing assessment is important. Use a scoring system, behaviors are generally scored every 2 to 4 hours until low scores are obtained consistently. assess the babies reflexes, monitor their ability to feed such as their sucking ability and coordination, Offer small frequent feedings. Swaddle with the legs flexed, not straight, Swaddling with legs straight out can cause hip problems. Offer non-nutritive sucking such as a pacifier. Monitor fluid and electrolytes, skin turgor, anterior Fontanelle should be Soft and non-sunken. Monitor daily weights, intake and output, Reduce environmental stimuli such as reduce lighting. I likely serious complication is seizures.

Postpartum: Contractions

Oxytocin causes contractions. After delivery the mothers natural oxytocin Provides to keep the uterus contracted, especially with breast-feeding mothers because when the newborn sucks the oxytocin is released from the mom's maternal system and that allows for the letdown of milk

Medications for postpartum hemorrhage

Oxytocin: A uterine stimulant, is first line thx for bleeding. is given in 20-40 units/liter IV, 10 units IM. Never give undiluted as an IVP. May be given IM. Methylergonvine (methergine): Uterine stimulant. Given 0.2 mg IM injection; may repeat in five minutes and then every 2-4 hrs. Contraindicated in clients with hypertension. Carbopost trometgamine (hemabate): Uterine stimulant. 0.25 mg IM injection; repeat every 15-90 minutes (max 2 milligrams). Contra indicated in active cardiac, pulmonary, renal or hepatic disease. More potent than Methergine, Won't be used unless Methergine and Pitocin is not working. It's a vasoconstrictor. Cytotec: used for cervical ripening, But can also be used for postpartum hemorrhage. It is inserted rectally. It will work quickly to contract uterus . Misoprosol:

Premature rupture of the membranes

PPROM, refers to rupture of membranes earlier than 37 weeks. It is associated with preterm labor and birth. The greatest risk to the newborn Occur with birth before completion of 32 to 34 weeks. Risk factors include triple I May be associated with GBS. Infections. Amniotic sac with a weak structure. Previous preterm birth especially if preceded by PPROM. Fetal abnormalities or malpresentation. Incompetent cervix or a short cervical length of 30 mm or less. Overdistention of uterus such as multiple gestation or polyhydramnios. Maternal hormonal changes. Maternal stress or low socioeconomic Status. Maternal nutritional deficiencies and diabetes. Both mother and newborn are at risk for infection during the intrapartum and postpartum periods. Infection can be both a cause and a result of PROM. Organisms that cause triple I weaken the amniotic membrane. Membranes that rupture before term may form a seal stopping the fluid leak and allowing the amniotic fluid to become reestablished. However, membranes may continue to leak, resulting in oligohydramnios. This results in less fluid cushion for the fetus and umbilical cord Compression, reduce lung volume, and deformities resulting from compression may occur. If the fetus is less than 36 weeks, therapeutic management is more complex and may involve short term tocolytic medications to delay delivery until steroids can be administered to enhance fetal lung maturity, and antibiotics can be started to reduce transmission of bacteria including GBS. For a woman near term, PROM may herald the eminent onset of true labor. The first step is to verify ruptured membranes. Urinary incontinence, increased vaginal discharge, or loss of the mucous plug can be mistaken for ruptured membranes. A digital examination is avoided, particularly if gestation is preterm and no evidence of labor exists. Instead, a sterile speculum exam is performed to look for a pool of fluid near the cervix and estimate cervical dilation and effacement. A PH test, or fern test may be done on the fluid to verify that the liquid is amniotic fluid.

Pain management taught in childbirth classes

Positioning: Ambulation, sitting on exercise ball, rocking and rocking chair, squatting, kneeling, all fours, side lying. Upright position makes contractions more efficient and less painful. Frequent position changes promotes labor progress. Position should be changed at least every 30 to 60 minutes during labor. Hydrotherapy: submersion in water or shower. Shower with or without handheld spray; tub, whirlpool. Buoyancy supports the body spray provides cutaneous stimulation. Check with provider and facility protocol before submersion if membranes are ruptured. Relaxation: There are several different techniques for relaxation such as contracting and releasing muscle groups until all voluntary muscles are relaxed. Contracting In areas such as arm or leg, then concentrate on releasing tension from the rest of her body. There is touch relaxation from the partner to loosen tight muscles. A more broad description of relaxation techniques on page 150

Vaginal birth after cesarean section (VBAC)

Possible upon maternal request only if uterine incision in previous C-section was low transverse and not vertical.

Transfer from the recovery area

Post anesthesia recovery. If she had a vaginal delivery she will recover in the room she labored in. The nurse will be evaluating her in that room. If she had a C-section once she leaves the OR she will go to a recovery room. The nurse should evaluate what kind of anesthesia she's had, does she have an epidural or a spine block? It's important to document and evaluate return of movement and sensation. She will probably be numb for the first hour after delivery, especially after a spinal, but she should gradually start to have return of feeling usually starting with her foot and toes. You don't want her to attempt to stand if she cannot lift her leg. If they've had general anesthesia, The best position for anyone is on their side in case they get sick and vomit. In that first hour they should gradually becoming awake and alert. Do you evaluate vital signs every 15 minutes for the first hour on every patient no matter what kind of delivery. So it may be difficult because of the environment it's imperative to get vital signs every 15 minutes and assess lochia every 15 minutes because it is the most crucial time. Change pad every time you assess. It's always concerning if there's large clots. You should always assess the fundus every time you assess lochia Trend heart rate, temperature, and blood pressure. Be wary about increasing heart rate and lowering blood pressures. Assess urinary output, she may not void much in the first hour but when she does she should void at least 150 mL with each void. Ideally it should be about 250 mL. A method to help initiate urination When you've gotten her to the bathroom and you know she has a full bladder because of a deviated uterus, you can run water in the bathroom and get the perry bottle and spray water over perineum.It should help to initiate urination.

Components of the birth process: the five "P's"

Powers (contractions), passage (birth canal), passenger (Fetus and placenta), position (of mother), psyche

Precipitous labor

Precipitous labor is one in which birth occurs within three hours or less of its onset. Sudden, Intense contractions often begin abruptly rather than gradually increasing in frequency, duration, and intensity. Precipitous labor is not the same as precipitous birth. A precipitous birth occurs after labor of any length, in which a trained attendant is not present to assist. However, a woman in precipitous labor may also have a precipitous birth. The nurse should wear gloves and simply support the infants body as it emerges if the physician or midwife has not arrived yet. Several conditions associated with precipitous labor include Placental abruption, fetal meconium, infection like STI or uterine infection, maternal cocaine use, postpartum hemorrhage, and low Apgar scores for the infant. This type of labor can cause trauma to the mother from the stretching. Vaginal wall lacerations, cervical lacerations, genital tract lacerations etc. there's also increased risk for postpartum hemorrhage because the uterus does not contract well after birth. It can also be a very frightening experience for the mother and produce anxiety. Because of the rapid nature of it the infants lungs are still filled with fluid

Stopping preterm labor

Preterm delivery may be inevitable, but steroid therapy promotes earlier fetal lung maturation. Even one more day of fetal maturation may make a great difference in the outcome for the very premature infant. The physician initially determines whether any maternal or fetal problems exist that contraindicate continuing the pregnancy. Some examples are maternal complications Such as hypertension or hypotension, hypokalemia, hypoxemia, Cardiac disease, and pyelonephritis. Next is the Prompt treatment of infections. Next is limiting activity usually by relaxing in the side lying or semi sitting position, this increases placental blood flow and reduce fetal pressure on the cervix. Patient is not put on complete bed rest. Hydration to stop preterm contractions has not been shown to be beneficial for all women. High volume IV infusions may cause maternal respiratory distress if taco lytic medications are also administered, especially in combination with steroids. However, dehydration may contribute to uterine irritability for some women.

premature onset of labor (POL)

Preterm labor begins after the 20th week but before the start of the 37th week of pregnancy. It may result in the birth of an infant who is ill-equipped for extrauterine life particularly if earlier than 32 weeks. Adverse effects may include cerebral palsy, developmental delay, vision and hearing impairment. Risk factors for preterm labor include: low weight for height, obesity, chronic illness, smoking, infection, history of preterm labor and birth, previous first trimester spontaneous abortion (more than 2), Abdominal surgery during pregnancy, uterine bleeding, anemia, preeclampsia, PPROM, poor nutrition, substance abuse Signs and symptoms: uterine contractions that may or may not be painful. I sensation that the baby is "balling up." Cramps, constant low back ache, sensation with the baby is pushing down, pain, discomfort, or pressure in the vagina or thighs, change or increase in vaginal discharge, A sense of "just feeling bad." Once she is diagnosed with preterm labor, she will be on restrictive activity. She'll be encouraged to lay on her left side to improve fetal circulation, she can get up to go to the bathroom but not walk around the halls, make sure she's not dehydrated and make sure she does not have a fever as all these things can cause contractions. Preventing preterm birth topics: role of early and regular prenatal care including dental care. Duration of normal pregnancy, consequences of preterm birth, Conditions that increase the risk for preterm birth, symptoms of preterm labor. Promote the cessation of the use of tobacco and recreational drugs.

Nonpharmacologic techniques: relaxation

Promoting relaxation is a basis for all other methods, for both nonpharmacologic and pharmacologic. It achieves the promotion of uterine blood flow, improved fetal oxygenation. It promotes efficient uterine contractions, reduce his tension that increase his pain perception and decreases pain tolerance. Reduces tension that can inhibit fetal dissent. Can be achieved through the aforementioned environmental comfort measures, general comfort measures, reducing anxiety and fear, and contracting specific muscle groups and then relaxing them.

Rh Incompatibility

RH factor incompatibility during pregnancy is possible only when two specific circumstances coexist: the mother is RH negative, and the fetus is Rh positive. For such a circumstance to occur, the father of the fetus must be RH positive. Rh incompatibility is a problem that affects the fetus; it causes no harm to the mother. When blood from a person who is Rh positive enters the bloodstream of a person who is RH negative, the body reacts as it would any foreign substance. It develops antibodies to destroy the invading antigen. In this case the entire red blood cell must be destroyed. The antibodies do not affect the RH negative red blood cells because they do not have the Rh antigen. Most exposure of maternal blood to fetal blood occurs during the third stage of labor, From damage to placental vessels. In this case the woman's first child is not usually affected because antibodies are formed after the birth of the infant. However, since the antibodies remain in the woman's body and cross and intact placenta, subsequent Rh positive fetus is may be affected unless the mother receives RhoGAM. This must be done within 72 hours of giving birth. It is also done for any miscarriage, ectopic pregnancy, any procedure like amniocentesis or chorionic villi sampling, trauma, abruptio placentae, Any situation where the fetal blood cells could have moved to maternal system.

respiratory distress

Respiration rate less than 30 or greater than 60. Apnea

Psyche

Responses to excessive or prolonged stress interfere with labor in the following several ways: increase glucose consumption reduces energy supply. Secretion of catecholamines epinephrine and norepinephrine stimulates uterine beta receptors which inhibit uterine contractions. Adrenaline secretion of catecholamines diverts blood supply from uterus and placenta to maternal skeletal muscles. Labor contractions and maternal pushing efforts are less effective because these powers are working against the resistance of tints abdominal and pelvic muscles. Pain perception is increased and pain tolerance is decreased. Nursing measures involve the following: the most important thing is establishing a trusting relationship with the woman and her significant other. Making the environment comfortable, identifying coping measures the patient find useful, promoting physical comfort, providing accurate information, implementing nonpharmacologic and pharmacologic pain management

Kernicterus (bilirubin encephalopathy)

Results from untreated hyperbilirubinemia w/bilirubin levels 25 or higher; *SIGNS*: lethargy, tonic motions such as backward arching of the neck and trunk, hypotonia

Abdomen

Returns to pre-pregnancy state six weeks after birth. Strike may persist return of muscle tone will return and process can be sped up with gradual abdominal exercises, modified sit ups. Diastasis recti: is a vertical pair of muscles that goes right down the middle of the abdomen that may separate a pregnancy to accommodate the growing fetus and muscle tone is diminished. The separation is usually 2 to 4 cm. It usually returns to normal position by six weeks after birth.

Finnegan Neonatal Abstinence Scoring System

See hand out

Finnegan Neonatal Abstinence Scoring System

See handout for scoring sheet. Record first score 2 hours after delivery to obtain the baseline. Continue scoring every four hours unless the score is high (Greater than or equal to 8). Then complete every two hours; continue every two hour assessments for 24 hours. Training on how to use the scale is important as scoring is subjective.

Lightening

The fetus descends toward the pelvic inlet, "dropping." the Woman notices that she breathes more easily because upward pressure on her diaphragm is reduced. However increase pressure on bladder causes urinary frequency pressure of the fetal head in the pelvis may also cause leg cramps and edema. The woman may notice her pants do not fit as well anymore Because of the dropping of the fetal head.

Abruptio placentae

Separation of a normally implanted placenta before the fetus is born. Occurs in cases of bleeding and formation of a hematoma on the maternal side of the placenta concealing bleeding. It is dangerous for both the pregnant woman and the fetus. The major dangers for the woman are hemorrhage and the major dangers for the fetus are asphyxia, excessive blood loss, and prematurity. The cause is not known but several factors show to increase the risk have been identified. Maternal use of cocaine, maternal hypertension, maternal Cigarette smoking, multigravida status, short umbilical cord, abdominal trauma, PROM, In previous history of abruptio placentae. Clinical manifestations: bleeding, uterine tenderness, uterine irritability, dull abdominal or low back pain, Board like abdomen, "port wine" colored amniotic fluid, Nonreassuring FHR patterns or fetal death, signs of hypovolemic shock. And a partial abruption the hemorrhage may be concealed, and a partial abruption you may see hemorrhage because only one side of the placenta is detached and it allows blood to freely move into the amniotic fluid. With complete abruption it is a dire emergency because the fetus is not getting any oxygen at all, and the hemorrhage may be concealed or heavy. The One symptom that differs abruption from previa Is that with abruption the mother will be in a lot of pain. Management: delivery by c section.

Elimination patterns

She will have reduced bladder tone/sensation From all the pain meds and if she has an epidural. It is very important for her to have a empty bladder because it can impede the birth process. Lower G.I. motility speeds up just before labor So that the bowels will be empty when she goes to push. It may not be completely empty and often times it is not, but it helps. Then once she is in active labor the G.I. motility slows down.

Siblings

Siblings response to the birth of a new brother or sister depends on their age and development level. Toddlers usually are not completely aware of the impending birth. When the baby arrives they may be in the infant has competition in fear they will be replaced in the parents affection. They may have feelings of jealousy and resentment when they must share time and attention with a baby. Some toddlers exhibit hostile behaviors toward the mother, particularly when she holds or feeds the newborn. Sleep problems, an increase in attention seeking efforts, and regression to more infantile behavior such as renewed bedwetting and thumbsucking are common. These behaviors show the jealousy and frustration Young children feel as they observe the mothers attention being given to another. These findings are normal in toddler behavior. It may help to allow the toddler to try to hold the baby, or allow the toddler to interact with the baby to feel included. But only if the child wants to, if the child is not ready it may work counterproductive.

Neonatal sepsis: findings

Signs and symptoms are very subtle. If the infant has a temperature of 100.5 they need to be evaluated. Temperature instability as a common sign. They may have a high temperature or a low temperature. Newborn should be kept home for the first two months because there immune systems are weak. Any suspicious drainage coming from the court would be concerning, not feeding well, Hyper/hypoglycemia, Domino distention, apnea, grunting, nasal flaring, decreased O2 stat, color changes, increased or decreased heart rate, tachypnea, irritability, poor muscle tone, Lethargy. If the infant has a low-grade fever then the provider Will order tests to identify the cause: They will draw blood, blood cultures, check urine and check for UTI, do a chest x-ray looking for infiltrates, they will do a spinal tap to be sure that CSF is not infected

Culture

Sociocultural roots influence how she perceives, interpret, in responds to pain during childbirth. Some cultures encourage loud and vigorous expression of pain whereas others value self control. The experience of pain is personal and caregivers should not make assumptions about how a woman will behave during labor. The nurse should avoid praising behaviors such as stoicism, and belittling others such as those who have more noisy expression.

Cervical ripening techniques

Sometimes the cervix just won't open. That is because it is not ripened. One way they will assist the opening of the cervix is through a transcervical balloon catheter That will help to stimulate dilation of the cervix. Stripping of membranes: they try to separate the cervix from the outer membrane. Amniotomy: The insertion of a hook through the cervix and snag the amniotic bag and ruptures it.

Gastrointestinal system

Soon after childbirth, digestion begins to be active. The new mother is usually hungry because of the energy expended in labor. She is thirsty because of decreased oral intake during labor and fluid loss from exertion, mouth breathing, and early diaphoresis. Constipation is a common problem mostly because the bowel tone and motility have been diminished as a result of progesterone, and remain sluggish for several days. She may have small hard stools. Perineal trauma and 3rd and 4th degree episiotomy and hemorrhoids cause discomfort and interfere with the effective bowel elimination. Women anticipate pain when they attempt To defecate and are unwilling to exert pressure on the perineum. Women who are taking iron have an added cause of constipation. The first stool usually occurs within 2 to 3 days postpartum. Normal patterns of bowel illumination generally resume by 8 to 14 days after birth.

Labor augmentation

Stimulation of uterine contractions after labor has started spontaneously but progress is unsatisfactory. Methods include oxytocin administration and amniotomy.

Treatment for neonatal abstinence syndrome (NAS)

Swaddling, need extra calories due to increased activity, may need IV fluids if becomes dehydrated because of severe vomiting and diarrhea (GI impact with drug withdraw). Medications: methadone for heroin an opiate withdrawal, benzodiazepines for alcohol withdrawal, drug of same classification that Baby is withdrawing from. Goal is to control the signs of withdrawal and then wean from the drug.

Placental site

Takes about six weeks to heal. Some of the lochia is a result from the site.

Neonatal sepsis: discharge teaching

Teach good handwashing techniques, protecting who the infant comes in contact with, keep the infant indoors for the first two months of their life, teach good handwashing techniques and to always wash hands before handling the infant, And teach about any medications that the infant is on. There is a longer list in the ATI book.

Passage

The birth passage consists of maternal pelvis and soft tissues. The bony pelvis is usually more important to the outcome of labor than the soft tissue because the bones and joints do not readily yield to the forces of labor. However the hormone relaxin near term softens the Cartlidge linking the pelvic bones. The linea terminalis (Pelvic brim) Divides the bony pelvis into the false pelvis (top) the true pelvis (bottom). The true pelvis is the most important in childbirth. The true pelvis has three divisions (1) the inlet, or upper pelvic opening, (2) the mid pelvis or pelvic cavity, and (3) the outlet or lower pelvic opening. During birth, the true pelvis functions such as a curved cylinder with different dimensions at different levels. Ischial spine: The most narrow part of the true pelvis are two little prominences called the ischial spine. The ischial spine are the reference point for the fetus' station. If the fetus is at the level of the ischial spine, it is at "Station zero" if it is 1 cm above the ischial spine it is at "station negative one." If the baby comes down and is below the ischial spine 1 cm, that is "station plus one" and so on.

Transition phase

The cervix dilates 8 to 10 cm in this phase of the first stage. The fetus descends further into the pelvis. Bloody show often increases with completion of cervical dilation. Transition is a short (shortest) but intense phase within the first stage. Contractions are very strong and may be as frequent as one and a half to two minutes apart, and their duration is 60 to 90 seconds. The woman may have an urge to push and bear down during contractions. Leg tremors, nausea and vomiting are common. The woman who does not choose epidural analgesia often finds the transition phase to be the most difficult part. Hyperventilation is a concern. Make sure the mother is in the best position. If the fetus is in the OP position, then mother on all fours is ideal for that. Make sure mother is hydrated through IV or giving ice chips. Evaluate urinary frequency. Make sure she has a empty bladder Because it can impede passage of infant. If she has a epidural, then a Foley will be in and you don't have to worry about it.

Esophageal atresia (EA)

The esophagus is most commonly divided into two unconnected segments with a blind pouch at the proximal end. If the distal end is connected to the trachea, it causes tracheoesophageal fistula (TEF). Usually infants that have esophageal atresia have other birth defects such as Down syndrome. Watch for EA when polyhydramnios occurs because the excessive fluid may be caused by fetal inability to swallow amniotic fluid. Suspect EA in infants with excessive frothy drooling and needing suction more often than usual, when regurgitation occurs from secretions that pool and a blind pouch, and when a catheter will not pass into the stomach. Diagnosis is confirmed by Symptoms and radiography. Esophageal suctioning should be used for the upper pouch, and a gastrostomy tube is placed. Surgery involves ligation of the fistula and anastomosis of the esophageal segments. If the separation is large, surgery may be done in stages to allow growth. Long-term follow-up is needed for a Soffa Gille reflux and dilation of structures that may form at the surgical site. Nursing considerations: observe all infants carefully during the first feeding for respiratory difficulty or other signs. Prevent aspiration by maintaining the infant in a semi upright position to prevent reflux of gastric fluid. Maintain suction equipment. Care after surgery involves low pressure ventilation, chest tubes, parenteral nutrition, and gastrostomy feedings.

Theories of onset of labor

The exact mechanisms remain unknown. Labor normally starts when the fetus is mature enough to adjust easily to extrauterine life but before it grows so large that vaginal birth is impossible. This stage term gestation occurs between 37 and 42 weeks after the first day of the last menstrual period. Factors that appear to have a role in starting labor: changes in the ratio of maternal estrogen to progesterone so that estrogen levels are higher than progesterone levels. Progesterone promotes smooth muscle relaxation of the uterus during most of pregnancy. Prostaglandins produced by the deciduous and membranes may have a role in preparing the uterus for oxytocin stimulation at term. Increased secretion of natural oxytocin appears to maintain labor once it has begun. Oxytocin does not start labor alone. A fetal role in the initiation of labor appears likely. The fetal membranes release prostaglandin in high concentrations during labor.

Presentation

The fetal part that enters the pelvis is termed the presenting part. Presentation falls into three categories: cephalic, breech, and shoulder. The cephalic presentation is more favorable than others for the following reasons: the fetal head is the largest single fetal part and can gradually change shape, the fetal head is smooth round and hard, making it a more effective part to dilate the cervix for the rest of the fetus. Vertex is the most common type of cephalic presentation in which the fetal head is fully flexed. Breech presentation is more common in preterm birth's, hydrocephaly, multiple gestation's, abnormalities of the maternal uterus and pelvis, and with placenta previa. Breech presentation can result in C-section because it's dangerous for the fetus whose head is still stuck in the birth canal and it can compress the umbilical cord and Suffocate the infant. There are three variations of breech presentation: Frank breach which is the most common when the feet or legs are extended across the abdomen towards the shoulders. Complete breach, which is a reversal of usual cephalic presentation, The fetus is in a flexed fetal position, but the buttocks are presenting. Footling breach,when one or both feet are presenting.

engagement/station

The fetus is at zero station. Whatever part is presenting at the level of the ischial spines. The station scale ranges from -4 (floating) to +4 (at outlet).

Urinary system

The kidneys return to normal function by four weeks after delivery. Both protein and acetone may be present in the urine for the first few postpartum days secondary to the catabolic process involved in uterine involution and dehydration that often occurs during exertion of labor. Postpartum bladder may have increased capacity and decreased muscle tone. The urethra, bladder, and tissue around urinary meatus may become edematous and traumatized. The result is often diminished sensitivity to fluid pressure and decreased, or no sensation of needing to void even when bladder is distended. The bladder fills rapidly because of diuresis that follows childbirth. The woman is at risk for over distention of the bladder. This can cause UTI and increase postpartum bleeding. The displacement of uterus by bladder results in decreased contraction of the uterine muscles, a primary cause of excessive bleeding. So it will be important to ask the mother if she's having any problems initiating urination, Can she completely empty her bladder, is she having painful urination? One good technique for evaluating if she has a full bladder is to assess the location of the fundus. It should be midline. If it's deviated to the right, she may not be emptying her bladder. Also, measure what she avoids with a hat. If each void is 200 or 300 ML's then that is adequate. But if she is frequently voiding and it's only 50 ML's than that is concerning. She probably has symptoms of urinary retention. A postpartum woman may have stress incontinence for 8 weeks.

Epidural block

The lumbar epidural block is a popular regional block that provides analgesia and anesthesia for labor and birth without sedation of the woman. The epidural space is outside the Dura matter, between the Dura and the spinal canal. An epidural block is performed by injecting a local anesthetic agent, often combined with an opioid into the tiny epidural space. The level of the epidural block can be extended upward for a cesarean birth. The epidural space is Internet about the L3-L4 interspace. The infusion of epidural medication also may be regulated by a patient controlled PCEA pump. A test dose may be given at first to Make sure the epidural catheter has not punctured a blood vessel or the Dura. If a large dose of anesthetic reaches the subarachnoid space instead of the epidural space, the woman experiences rapid intense motor and sensory block, Numbness of the tongue and lips, lightheadedness, dizziness, and tinnitus. Epidural opioids include fentanyl, sufentanil, ropivacain and morphine. All drugs injected into the epidural or subarachnoid space is should be preservative free. Leakage of CSF can occur which may result in a "spinal" headache. Contraindications include coagulation defects, low platelet count, uncorrected hypervolemia, and infection in the area of insertion or a severe systemic infection, allergy, or a fetal condition that demands immediate birth. Adverse effects may include hypotension, Client should be given a 500 to 1000 mL bolus of fluids prior to to prevent.

Effects of SSRI's on the newborn

The most frequently use drugs to treat depression both in general population and in pregnant women are SSRI's. Infants exposed in last trimester may exhibit neonatal adaptation syndrome. CNS signs: irritability, seizure, agitation, tremors, hypertonia, increased respiratory rate, nasal congestion, emesis, diarrhea, feeding difficulty, fever, hypoglycemia

Passenger

The passenger is the fetus, membranes, and placenta. Several fetal in atomic and positional variables influence the course of labor: Fetal head: the fetus enters the birth canal in the cephalic presentation 96% of the time. The five major bones are not fused but are connected by sutures which allows the head to adapt to the size and shape of the pelvis by molding and overlapping each other. The by parietal diameter average is 9.5 cm in a term fetus. Vertex (flexed) is best position for labor. "Caput" Is the cone head shape and usually resolves in 24 hours. Fetal lie: the orientation of the long axis of the fetus to the long axis of the woman is called fetal lie. In most pregnancies the lie is longitudinal and parallel to the long axis of the woman. In the longitudinal lie, either the head or the buttocks of the fetus enters the pelvis first. A transverse lie exists when the long axis of the fetus is at a right angle to the woman's long axis. This is rare. Attitude: the relation of fetal body parts to one another is the attitude of the fetus. The normal fetal attitude is when a flexion with the head flexed forward in the arms and legs flexed over the thorax in the back is curved in a convex C shape.

Taking hold phase

The second of three phases of maternal role attainment: the mother becomes more independent during this phase. She exhibits concern about managing her own body functions and assumes responsibility for her own care. And she feels more comfortable and in control of her body, she shifts her attention to the behaviors of the infant. She compares her infant with other infants to validate wellness and wholeness. The mother may verbalize anxiety about her competence as a mother. She may compare her caretaking skills and favorably with those of the nurse. Nurses should be careful not to assume the mothering role in caring for the infant. They should encourage the mother to perform as much of the caretaking as possible. Fathers also should be Encouraged to participate. It is important at the nurse not only encourage, but give praise and attempts that the mother and father makes that caring for the infant to build confidence. The taking hold phase extends over several days and has been called the teachable, reachable, preferable moment.

second stage of labor

The second stage (Expulsion) begins with complete 10 cm dilation and for 100% effacement of the cervix and ends with the birth of the baby. Duration of the second stage for the nullapara with no epidural average is 2.8 hours whereas the average duration is 3.6 hours with an epidural. Contractions may diminish slightly or even pause briefly as the second stage begins. They are still strong about 2 to 3 minutes apart, with a duration of 40 to 60 seconds. As the fetus descends pressure of the presenting part on the rectum and pelvic floor causes an involuntary pushing response in the mother. She may say that she needs to have a bowel movement or say "the baby is coming" or "I have to push." Her voluntary pushing efforts augment involuntary uterine contractions. The vulva distends and the crowning of the fetal head takes place. she may feel like sensation of stretching or splitting even if no trauma occurs. The woman regains a feeling of control during the second stage of labor. It will be important to instruct the mother to take a few breaths and then push to assist with the process. It will be important for the mother to relax and oxygenate also because when she's pushing she deoxygenate and so also does the fetus.

fourth stage of labor

The stage of physical recovery for the mother and infant. It lasts from the delivery of the placenta through the first one to four hours after birth.

Letting go phase

The third of three phases of maternal role attainment: this is a time of relinquishment for the mother and often for the father. If this is their first child, the couple must give up their previous role as a childless couple and acknowledge the loss of their more carefree lifestyle. Many mothers must also give up idealized expectations of the birth experience. For example they may have plan to have a vaginal birth with minimal to no anesthesia but instead required a cesarean birth. In addition some mothers and fathers are disappointed in the size, gender, or characteristics of the infant who does not match up with the fantasy baby of pregnancy. They must relinquish the infant of their fantasies and accept the real infant. These losses often provoke feelings of grief that are so subtle they may not be examined or acknowledged. Both parents may benefit however, if given the opportunity to discuss unexpected feelings and realize that they are common. During this phase the mother refocus is on her relationship with her partner. She also may return to work at this time. This requires relinquishing part of the care of the infant to a caretaker.

third stage of labor

The third stage or placental stage begins with the birth of the baby and ends with the expulsion of the placenta. The stage is the shortest with average length of six minutes.

Non-pharmacological techniques: Cutaneous stimulation

The woman may rub her abdomen, legs, or back during labor to counteract discomfort. Some women find abdominal touch irritating, especially near the umbilicus. Women in labor may find firm stroking more helpful than light stroking. Some women benefit from firm palm or sole stimulation during labor. They may like someone to rub their palms vigorously; independently to rub their hands or feet together; or to bang their palms on or grip a cool surface. Massage by others increases circulation and reduces muscle tension. Sacral pressure may help when the woman has back pain. Sacral pressure may be applied using the palm of the hand, the fist or fists, or a firm object such as two tennis balls in a sock. It can be very helpful And you apply quite a bit of pressure. Non-clinical touched by the nurse is a powerful tool of the woman does not object to it. Holding her hand, stroking her hair, or similar actions convey caring, comfort, affirmation, and reassurance. Thermal stimulation applied to the back, abdomen, or perineum during labor is therapeutic. A warm shower, tub bath, or whirlpool bath is relaxing and provides thermal stimulation. A sock filled with dry rice and microwaved provides gentle warmth and can be used to apply warm pressure to the sacral area.

Postpartum: Involution of the uterus

To return to the non-pregnant size and condition. Uterine involution involves three processes: (1) contraction of muscle fibers, (2) catabolism the process of converting cells into simpler compounds, and (3) regeneration of the uterine epithelium. Involution begins immediately after delivery of the placenta, when uterine muscle fibers contract firmly around maternal blood vessels at the area where the placenta was attached. This contraction controls bleeding from the area left denuded when the placenta separated. The uterus decreases in size as Muscle fibers, which have been stretched for many months contract and gradually regain their former contour and size. Regeneration of the uterine epithelial lining begins soon after childbirth. After childbirth the fundus can be felt at about the area of the umbilicus and then goes down about 1 cm per day. At about day number 7-9 The funds cannot be felt any longer (Book says by the 14th day). She should be taught to feel her fungus to make sure it is firm to control bleeding.

Pharmacological interventions to stop preterm labor

Use of magnesium sulfate (preferred treatment) as a tocolytic. Magnesium decreases muscle excitability and activity. Pt needs to be monitored. Side and adverse effects are dose related, occurring at higher maternal serum levels. Depression of DTRs Which should be present, although less active. Respiratory or cardiac depression if serum levels are high, So the main adverse effect is that at a high enough level the mother could stop breathing. Less serious side effects or lethargy, weakness, visual blurring, headache, sensation of heat, nausea and vomiting, constipation. Ideally you want to get serum magnesium levels between 5-7. Nifedipine (Procardia) Is a calcium channel blocker for Tocolysis. It's usually use for hypertension but it also can be used to decrease uterine activity by blocking the calcium channels. Indocin Is a prostaglandin inhibitor. Going back to looking at medications used to soften the cervix; prostaglandins, Indocin has the opposite effect and slows preterm labor By keeping the cervix non "ripened" Terbutaline Is a beta adrenergic for tocolysis. It is given subcutaneous. It is not used as much as it use to be, but it is used to knock out hyper contractions while the labor and delivery team can get IVs and other medications going. It has a quick action but short half-life and only last about 20 minutes. Betamethasone and dexamethasone are steroids that are used to promote and accelerate fetal lung maturity. She gets two injections 12 hours apart. Pg 444

Powers

Uterine contractions: during the first stage of labor uterine contractions are primary force that moves the fetus through the maternal pelvis. During the second stage of labor (Full cervical dilation) Uterine contractions continue and in addition the woman feels an urge to push and bears down as the fetus puts pressure on her rectum. True labor: regular contractions, intervals gradually shorten, duration and severity increases, pain starts in back in moves towards front, walking increases intensity, cervical changes (The true test of actual labor), sedation won't stop them. False labor: irregular, no change in frequency, no change in strength and duration, pain in front, no cervical changes, sedation will stop the contractions.

Prolapsed cord

When a loop of cord lies below, or beside the presenting part. The cord slipped downward after the membranes ruptured, subjecting it to compression between the fetus and the pelvis. Prolapse of the umbilical cord is more likely when the fit is poor between the fetal presenting part in the maternal pelvis. When the fit is good, the fetus fills the pelvis, leaving a little room for the cord to slip down. Though it is possible during any labor, it is more likely if the following conditions are present: a fetus that remains at high station. A very small Or preterm fetus. Breach presentations. Transverse lie. hydraminos. Long cord. Occult prolapse of the cord is one in which the cord slips along the fetal head or shoulders and cannot be palpated or seen but is suspected because of changes in the FHR such as sustained bradycardia, variable decelerations, or prolonged decelerations.

C-section incisions

Vertical: not done as often because it's so visible, are usually only done in emergencies, can be done for placenta previa because the placenta is low lying. Advantages are that it's quicker to perform, better visualization of the uterus, I can quickly extend upward for greater visualization if needed. Often more appropriate for obese women. Disadvantages: easily visible when healed, greater chance of dehiscence and hernia formation. Pfannenstiel: Advantages: less visibility when healed, and the pubic hair grows back. Less chance of dehiscence or formation of hernia. Disadvantages: less visualization of the uterus. Cannot be done as quickly. Which may be important in an emergency cesarean birth. Cannot easily be extended to give greater operative exposure. Reentry at a subsequent cesarean birth may require more time. They cut through the skin tissue and muscle and then get to the uterus. Once they get to the uterus the incision in the uterus is always transverse. But sometimes it might be vertical, and once it is vertical, It puts her at greater risk for uterine rupture in future pregnancies so she will not ever be allowed to have a vag birth (VBAC), She will always need C-sections. Just because she has a vertical skin incision does not mean she did not have a low horizontal (transverse) uterine incision.

Non-pharmacological techniques: hydrotherapy

Water therapy can supplement any relaxation technique, the buoyancy afforded by immersion supports the body, equalizes pressure on the body, and aids muscle relaxation. In addition, fluid shifts from the extravascular space to the intravascular space reducing Edema as the excess fluid is excreted by the kidneys. A shower, tub bath, or whirlpool bath is relaxing and several studies have shown benefits of using water therapy during labor. Jacuzzi Jets hitting abdomen and back can be very helpful and have reportedly been just as effective as IV medication. The only major concern has been that it could cause infections, however several studies have failed to find a significant association.

Management of prolapsed cord

When cord prolapse occurs the priority is to relieve pressure on the cord to improve umbilical blood flow until delivery. Interventions should not delay the prompt delivery of a living fetus. Have someone push the call light to summon help. Others should call the physician and prepare for birth while the nurse caring for the woman relieves pressure on the cord vaginally. Prompt actions reduce cord compression and increase fetal oxygenation: Position the woman's hips higher than her head to shift the fetal presenting part toward the diaphragm. Any of these methods may be used: knee chest position (rarely done). Trendelenburg position. Hips elevated with pillows, with side lying position maintained. Maintain vaginal elevation of the presenting part using a sterile gloved hand while the woman is transferred to the operating room or until the physician orders cessation of vaginal elevation usually just before cesarean birth. It is important to know that once you apply manual pressure with the gloved hand you never move until the c section is done. While preparing for surgery, give the woman oxygen at 8 to 10 L per minute by facemask to increase maternal blood oxygen saturation making more available for the fetus. A tocolytic drug such as terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent pressure.

integumentary system

When estrogen, progesterone, and melanocyte stimulating hormone decline after childbirth, the skin gradually reverts to the non-pregnant state. This changes particularly noticeable when melasma, the "mask of pregnancy," and linea Nigra Fade and disappear for many women. In addition, spider Nevi and Palmar erythema, which may develop during pregnancy as a result of increased estrogen levels, gradually disappear. Stretch marks gradually fades a silvery lines but do not disappear. Loss of hair may especially concerned the woman. This is a normal response to the hormonal changes that caused decreased hair loss during pregnancy. Hair loss begins at 4 to 20 weeks after delivery and is re-grown in about 4 to 6 months for 2/3 of women and by 15 months for the remainder. C-section incision are always close with staples. It is left open to air is the best way for it to heal. She can get that wet in a shower but she should avoid soap, so it be best if she put her back to the shower and make sure the incision is thoroughly dried with a towel after she gets out of the shower.

Active phase

When the rate of cervical change accelerates, the woman has progressed to active phase. The fetus descends in the pelvis and internal rotation begins. Active in transition phases are linked as one phase interesting next, and references may not distinguish the two. Contractions are about 2 to 5 minutes apart with duration of approximately 40 to 60 seconds and an intensity that ranges from Moderate to strong. Discomfort increases, the woman's behavior changes. She becomes more anxious and may feel helpless as contractions intensify. The sociability that characterized early labor is gone and replaced by a serious inward focus. Women who choose to take pain meds usually do in this phase. Active phase goes from 4 to 7 cm dilated.

Promotion of nutrition

Women who are breast-feeding need an additional 500 cal. Postpartum women in general need about 1800 to 2400 cal per day. She has a needs adequate protein for tissues and adequate fiber and fluid intake for bowel movements.

Down Syndrome

a condition of intellectual disability and associated physical disorders caused by an extra copy of chromosome 21.

imperforate anus

a congenital defect in which the rectal opening is missing or blocked. Requires surgery.

Severe preeclampsia

a systolic blood pressure of 160 or greater, Or a diastolic blood pressure of 110 or greater. She's also experiencing decreased urine output of less than 500 mL in 24 hours. She will notice severe headaches and visual problems. Another sign is epigastric pain and pain in the upper right quadrant.

Oxytocin (Pitocin)

administered as a piggyback IV. Initiates contractions to stimulate labor. It's always run secondary because there are many reasons why it would have to be shut off, such as too many contractions, or fetal distress. Indicated for prolonged labor, and for a mother that has a history of precipitous labor and wants an induction in a more controlled way. Contraindicated for any woman that does not want a vaginal birth for reasons such as unknown vaginal bleeding, if the fetus is not in a favorable position, If the baby is very large. Complications are that the dose can be too high because Pitocin is titrated. Uterine rupture. Nursing management: administered piggyback via infusion pump with lactated ringers. Increase dosage every 30 to 60 minutes until contractions are every 2 to 3 minutes/60 second durations. Continuous maternal/fetal assessment every 30 minutes. Assess tolerance, progress and pattern of labor. Record intake and output.

Perineum assessment

episiotomy, tear, or c-section incision(REEDA). hematomoa or hemorrhoids. done in Sim's position. Pelvic muscular support: pelvic relaxation, kegel exercises (100 a day throughout day) Although the episiotomy is relatively small, the muscles of the perineum are involved in many activities such as walking, sitting, stooping, squatting, bending, urinating, and defecating. So an incision in this area can cause a great deal of comfort. Relief of perineal discomfort is a nursing priority. It includes teaching self-care measures such as applying ice, taking sitz baths, performing perineal care, using topical anesthetics and cooling astringent pads, and taking ordered analgesics.

Prenatal admission data

gather basic data, like Gravada para, EDC, Because a normal delivery is between 37 and 40 weeks, if it's past 40 weeks it's termed "post term" and it may be because of a problem and increases risk of meconium and placenta function decreases. Gather Information about previous pregnancy, gather vital signs, check labs for anemia, current infection, STI, ultrasound results. All patients have a CBC done. Blood typed, Risk is high for blood transfusion during labor and postpartum. Urinalysis, Spilling of proteins could indicate a blood pressure problem, Spelling of glucose could indicate gestational diabetes. GBS (group b strep) Swab, If she's positive for GBS she will need anabiotic's during labor. Will gather information about the position the infant is in aka "station." Find out about if the water has been broken because there is an increase of infection with ROM early.

Unconjugated bilirubin

indirect bilirubin. The waste product of the breakdown of hemoglobin. It is taken up by the liver and converted into conjugated bilirubin.

Parental attachment, bonding, and acquaintance

you want to see that the mom and dad are gazing at the infant with iContact face-to-face. Do you want to see them in close proximity, holding the baby, identifying the baby, naming the baby, seeing the baby has a son or daughter, Expressing pride in this baby, observing behavior of the baby in a positive light. Do you also want to make sure the baby has correct reflexes rooting and sucking. Concerning behaviors: the infant is crying and being left in the crib with no attempt to pick the infant up. Whenever you walk in the room someone else is always holding the baby never the mother, or she refuses to hold the baby when given the opportunity. Or she identifies a feature of the baby to somebody she does not like or if she's not on good terms with the father. If she does not name the baby. If she handles the baby kind-of roughly. Showing impatience with feeding. Showing disappointment with the baby. Document in hand off to the next nurse to see if any changes take place because sometimes they can, sometimes the mother is just fatigued.