Maternal Newborn

Primary dysmenorrhea

-A condition associated with increased uterine activity -Due to myometrial contractions induced by prostaglandins in the second half of the menstrual cycle -Systemic responses include backache, weakness, sweating, GI symptoms, CNS symptoms -Pain begins at the onset of menstrual flow and lasts from 8-48 hours -Not caused by underlying pathology; symptoms are definitely related to ovulation and do not occur when ovulation is suppressed -Most common in women in their late teens and early 20's with incidence declining with age -Management includes heat, massage, exercise, yoga, nutrition, increasing water and other natural diuretics, decreasing red meat, salt and sugar; NSAIDs

HELLP syndrome

-A lab diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction H= hemolysis E L= elevated liver enzymes L P= low platelets <100,000 -Advanced form of gestational hypertension -High infant and maternal mortality -Women with severe preeclampsia are at high risk for developing HELLP -Patients complain of worsening signs and symptoms of severe preeclampsia: worsening headache, epigastric pain, nausea and vomiting and severe edema (especially facial) -Treatment includes: mag sulfate; transfusion of fresh frozen plasma or platelets; delivery of fetus -Be alert of s/s of hemorrhage, hypoglycemia and liver failure; avoid palpating the abdomen-this could lead to a subscapular liver hematoma; administer blood and meds as ordered; prepare for delivery; be aware that pt. cannot have epidural with very low platelets

Couvade syndrome

-A phenomenon in which some men experience pregnancy-like symptoms -In older societies, the man enacted the ritual couvade; that is, he behaved in specific ways and respected taboos associated with pregnancy and giving birth so his new status was recognized and endorsed

Trimesters

-A pregnancy can be counted in terms of trimesters roughly divided into 3-month segments -First trimester: last day of LMP through 12 weeks -Second trimester: 13 weeks through 27 weeks -Third trimester: 28 weeks through 40 weeks -40 completed weeks is the desired term date

Preeclampsia

-A pregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks of gestation in a previously normotensive woman -Preeclampsia is a vasospastic, systemic disorder and is usually categorized as mild or severe for purposes of management -Vasospasms decrease the diameter of the blood vessels causing endothelial cell damage, impeded blood flow, and increased blood pressure; circulation to all body organs, including placenta is decreased -Other symptoms include relative hypovolemia/edema; hepatic edema; elevated liver enzymes and increased BUN and creatinine; increased ICP; blurred vision, "seeing stars"; hyperreflexia Treatment includes: rest for 1 1/2 hours/day on left side; normal diet with no fluid or salt restriction; pt. should be taught to take daily weights and bp at home and to recognize s&s of worsening condition -Treatment for severe preeclampsia includes: hospitalization and bed rest; anticonvulsants (mag sulfate); antihypertensives; continuous fetal monitoring; frequent vital signs; monitor I&O and deep tendon reflexes (DTR)

Male infertility

-Can be caused by structural and hormonal disorders such as undescended testes, hypospadias, varicocele (varicose veins of the scrotum), low testosterone levels, previous vasectomy, or mumps -Spermatogenesis, sperm antibodies, and sperm transport may be to blame -May also be caused by some of the same health issues that affect women: nutrition, endocrine, genetic and psychologic disorders and STIs -Male obesity, exposure to hazards, cancer treatments, substance abuse, alcohol consumption and cigarette smoking can be major factors -Male fertility declines slowly after age 40 even though no cessation of sperm production occurs

Placenta previa

-Abnormal implantation of the placenta in the lower uterine segment- over or near the cervical os -The placenta is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces -Complete placenta previa covers the entire internal cervical os -Marginal placenta previa is near the edge of the cervix and the edge of the placenta can be seen -Partial placenta previa only partially covers the cervix -Classic manifestation is painless, bright red bleeding -Vital signs may be normal- clinical presentation and decreasing urinary output may be better indicators of blood loss -All women with painless vaginal bleeding after 20 weeks of gestation should be assumed to have a placenta previa until proven otherwise -Treatment includes: External fetal monitoring (priority); No vaginal exams; evaluate bleeding; labs; meds (terbutraline to control contractions; betamethasone to increase fetal lung maturity); bed rest; pelvic rest; delivery at 36 weeks (c section if partial or complete/ may be able to deliver vaginally with marginal)

Secondary dysmenorrhea

-Acquired menstrual pain that develops later in life, typically after 25 years -Associated with pelvic pathologies such as adenomyosis, endometriosis, pelvic inflammatory disease, endometrial polyps or fibroids -Women with secondary dysmenorrhea often have other symptoms that suggest an underlying cause (ex. heavy menstrual flow, bloating, pelvic fullness, dull, lower abdominal aching that radiates to back or thighs) -Diagnosis is pelvic exam, ultrasound, d&c, biopsy or laparoscopy -Treatment is directed at removal of the underlying condition -Many of the measures for pain relief used for primary dysmenorrhea are the same for secondary

Nutritional risk factors

-Adolescent pregnancy (underweight; fad diets) -Bizarre or faddish food habits; eating disorders -Abuse of nicotine, alcohol (interferes with absorption/ metabolism) or drugs (interferes with nutrition) -Vegetarian diet -N/V during pregnancy -Pica -Excessive weight gain -Financially unable to buy food -Low BMI; low height for weight -Frequent pregnancies -Preexisting or gestational illness

Amniotic fluid

-Amnion develops from the interior cells of the blastocyst; as it grows larger, the amnion forms on the side opposite the blastocyst; the developing embryo draws the amnion around itself, forming a fluid filled sac -As the embryo grows larger, the amnion enlarges to accommodate the embryo and amniotic fluid -Fluid is initially derived from maternal blood (amniotic membrane) and fluid secreted by the respiratory and GI tracts of the fetus also enter the amniotic cavity; in the second and third trimesters, the fluid is produced by the fetal kidneys -The amount of fluid increases weekly -At term 500-1000 ml of fluid is normal; it increases during pregnancy and peaks at 34 weeks (800-1,000ml) and decreases at term -The amniotic fluid volume changes constantly; the fetus swallows fluid and it flows out of the fetal lungs; beginning week 11, the fetus urinates into the fluid, increasing its volume -Amniotic fluid is clear and mostly composed of water. It also contains proteins, carbohydrates, lipids, electrolytes, fetal cells, lanugo -Amniotic fluid acts as a cushion for the embryo against injury; helps control the embryo's temperature; serves as a source of oral fluid and repository for waste; allows freedom of movement and permits growth and development; assists in fluid and electrolyte maintenance; prevents adherence of the fetus to the amnion and permits position changes; allows umbilical cord to be free of compression; acts as a wedge during labor; provides fluid for analysis to determine fetal health and maturity

Pregnancy complications related to nutrition

-Anemia -Macrosomia -Gestational diabetes -Intrauterine growth restriction

Teratogens

-Any drugs, viruses, infections, or other exposures that can cause embryonic/fetal/developmental abnormality -Most vulnerable up to the first 8 weeks of gestation when the embryo is developing organ systems and main eternal features and areas of rapid cell division are most vulnerable to malformation -The degree of malformation varies based on length and amount of exposure and when it occurs in development

Weight gain during pregnancy

-Assessing weight gain during pregnancy identifies potential nutritional problems or complications of pregnancy: preterm labor; newborn mortality/morbidity; macrosomia; prolonged labor; birth trauma; asphyxia; cesarean birth -Normal weight gain: normal weight- 25 to 35 lbs; underweight- 28-40 lbs; overweight- 26-29 lbs; obese- 11-20 lbs -The pattern of weight gain is as important as the total increase in weight -The average weight gain should be 1-2 kg (2.2-4.4 lbs) during the first trimester -The average weight gain in the second and third trimesters should be 0.4 kg (0.88 lbs) per week; increase caloric intake 340/day for second trimester and 452/day for third trimester

Calendar Based Methods

-Based on the number of days in each cycle, counting from the first day of menses -The fertile period is determined after accurately recording the lengths of menstrual cycles for at least 6 months -The beginning of the fertile period is estimated by subtracting 18 days from the length of the shortest cycle; The end of the fertile period is determined by subtracting 11 days from the length of the longest cycle; the days between the two would be the fertile period - To avoid conception, the couple would abstain during the fertile period (subtraction of difference between short and long cycles or abstaining on days 8-19 which is the standard days method) -The calendar method is most useful as an adjunct to the basal body temp or the cervical mucus methods

Signs and symptoms of ovulation

-Before ovulation, the basal body temp (BBT) is often less than 37 C; after ovulation, with increasing progesterone levels, her BBT increases -Changes in the cervix and cervical mucus follow a predictable pattern; preovulatory and postovulatory mucus is thick, so that sperm penetration is discouraged -At the time of ovulation, cervical mucus is thin and clear; it looks, feels, and stretches like egg white (spinnbarkeit) -Some women have abdominal pain (mittelschmerz) that coincides with ovulation -Some spotting may occur

Autosomal Recessive disorder

-Both genes of a pair are forms associated with the disorder to be expressed -The recurrence risk for autosomal recessive disorders is 25%, or one in four, if both parents are carriers (they each have one recessive gene, and one normal gene) -If two individuals affected by an autosomal recessive disorder mate, all of their children will be affected -Most inborns errors of metabolism are autosomal recessive disorders -Ex: PKU, galactosemia, maple syrup urine disease, Tay-Sachs disease, sickle cell anemia, and Cystic fibrosis

Toxoplasmosis

-Can cause fetal demise, mental retardation, and blindness when the embryo is exposed to Toxoplasma during pregnancy -Toxoplasma is as parasite found in cat feces, uncooked or rare beef and lamb -Pregnant women or women who are attempting pregnancy need to avoid contact (ex. no changing litter box; wear gloves when gardening; avoid eating rare beef or lamb)

Maternal assessment of fetal movement

-Count to ten method= woman perceives at least 10 fetal movements in a 12 hour period or the woman counts two to three times a day to identify at least three fetal movements in 60 minutes -No movement in a 12 hour period is cause for investigation and possibly intervention

PMS

-Cyclic symptoms occurring in luteal phase of menstrual cycle -Cluster of physical, psychological, and behavioral symptoms -Symptoms include fluid retention, behavioral or emotional changes, irritability, panic attacks, and impaired ability to concentrate; premenstrual cravings; headache, backache, and fatigue -Ovarian function is necessary for the condition to occur because it doesn't occur before puberty, after menopause, or during pregnancy

Fetal presentation

-Determined by the part of the pole of the fetus that first enters the pelvic inlet -3 main presentations: cephalic (head first) breech (pelvis first) shoulder (shoulder first) -The "presenting part" is the specific fetal structure lying closest to the cervix. It is determined by fetal attitude or posture

Ovarian factors for infertility

-Developmental anomalies -Anovulation, primary and secondary -Pituitary or hypothalamic hormone disorder -Adrenal gland disorder -Congenital adrenal hyperplasia -Disruption of hypothalamic-pituitary-ovarian axis -Amenorrhea after discontinuing OCPs -Premature ovarian failure -Increased prolactin levels

Uterine and tubal factors for infertility

-Developmental anomalies -Tubal motility reduced -Inflammation within the tube -Tubal adhesions -Endometrial and myometrial tumors -Asherman syndrome (uterine adhesions or scar tissue) -Endometriosis -Chronic cervicitis -Hostile or inadequate cervical mucus

PMS management

-Don't smoke -Limit consumption of sugar, salt, red meat, caffeine, and alcohol -Eat whole grains, legumes, seeds, nuts, fruits and veggies, and vegetable oil -Eat 3 small to moderate sized meals and 3 small snacks a day rich in complex carbs and fiber -Use natural diuretics to help reduce fluid retention -Daily vitamins -Regular exercise, especially in the luteal phase is recommended -Yoga, acupuncture, hypnosis, light therapy, chiropractic therapy, and massage therapy have reported benefits -Meds (NSAIDs, SSRIs, diuretics, progesterone, etc.)

Fertilization

-Fertilization takes place in the outer third of the uterine tube -When a sperm successfully penetrates the ovum, both sperm and ovum are enclosed within a membrane and the membrane becomes impenetrable to other sperm -The nuclei fuse, and chromosomes combine, and conception (formation of the zygote) has been achieved -Cleavage (mitotic replication) begins as the zygote travels the length of the uterine tube to the uterus- a 3-4 day process -3 days after fertilization, the zygote has formed a 16 cell, solid sphere called a morula -Mitosis continues, and around day 5, the developing human is a blastocyst and enters the uterus -The blastocyst has an inner cell mass called an embryoblast (which develops into the embryo) and an outer cell mass called a trophoblast which assists in implantation and becomes part of the placenta

Five digit system

-GTPAL -Gravidity (G)- the total number of pregnancies (without reference to the number of fetuses) the woman has had (including current) -Term (T)- the number of pregnancies carried to term, not the number of deliveries at term -Preterm (P)- number of pregnancies that resulted in a preterm birth -Abortions (A)- signifies whether the woman has had any abortions or miscarriages before the period of viability (20 weeks) -Living Children (L)- number of children born that are currently living -The five digit system utilizes these 5 letters to summarize a woman's obstetric history -Ex. If a woman is pregnant for the fourth time and her previous pregnancies yielded one full term neonate, premature twins, and one abortion at 19 weeks, and now has three living children, she is designated as 4-1-1-1-3

Dominant and Recessive genes

-Genes are either dominant or recessive -When there is both a dominant and a recessive gene in the pair, the traits of the dominant gene are present -When both genes of a pair are recessive, the traits of the recessive gene are present

Magnesium Sulfate

-Given to patients with severe preeclampsia as an anticonvulsant; goal is to prevent patient from having a seizure or for Pre-term labor (#1 drug for pre-term labor) -Excreted by kidneys, therefore kidney function should be assessed; if urine output is less than 30 ml/ hr, mag toxicity could occur -Adverse reactions include: CNS depression, hypotension, depressed DTRs, depressed respirations, flushing, sweating -Signs of toxicity: Serum mag >8mg/dl; decreased LOC; decreased respirations (<12/min); absent DTRs; confusion; postpartum- high serum levels of mg sulfate can cause relaxation of the uterus resulting in a boggy uterus -Nursing care: monitor DRTs; check for clonus; monitor respirations; check for LOC; draw mag levels q6-8 hrs; have calcium gluconate or calcium chloride available (antidotes for mag sulfate); administer oxygen as needed

HIV in pregnancy

-HIV infected women should be treated with highly active antiretroviral therapy (HAART) during pregnancy -Usually started after the first trimester and continued throughout pregnancy -Major side effect is bone marrow suppression -Schedule cesarean at 38 weeks -Every effort should be made to decrease neonate's exposure to blood and secretions -Immediately after birth, infants should be wiped free of all body fluids and then bathed -Avoid breastfeeding -Infants may test positive for up to 18 months after birth d/t passive maternal immunity and then convert to HIV negative -All staff working with mother or infant must adhere strictly to infection control techniques -Observe standard precautions for blood and other body fluids

Autosomal dominant disorder

-In an autosomal dominant disorder, both the occurrence and recurrence risk is 50%, or one in two, when one parent is affected and the other is not -Autosomal dominant disorders are not always expressed with the same severity of symptoms -Predicting whether an offspring will have a minor or severe abnormality is not possible -Ex: Huntington's Disease, Marfan syndrome, neruofibromastosis, myotonic dystrophy, stickler syndrome, treacher Collins syndrome, and achondroplasia (dwarfism)

Nursing interventions for infertility

-Individuals experiencing infertility are at risk for distress, anxiety, anger, lowered self-esteem, isolation, marital dysfunction, and grief -Nurses can help couples express and discuss their feelings as honestly as possible -The nurse needs to provide support to the couple in their decision making process and during therapy -Some actions the nurse can take: point out the resemblance to a normal grieving process- refer to support group such as RESOLVE; encourage and allow time for talking; do not feed into denial; explain that the reaction to loss of control is often anger and that anger is a natural feeling; accept bargaining statements without comment; develop role playing situations to practice interactions with others- this helps increase ability to cope and increases self confidence

Infertility

-Infertility is the involuntary ability to conceive when desired -Primary infertility applies to a woman who has never been pregnant -Secondary infertility applies to a woman who has been pregnant -It is a serious medical concern that is a problem for 10-15% of reproductive-age couples -Infertility implies "subfertility" which is a prolonged time to conceive, as opposed to "sterility" which means inability to conceive -Infertility increases with age, particularly in women older than 40 -Most infertility cases are treated with conventional medical and surgical therapies; less than 3% are treated with in vitro fertilization -Categories for infertility include: ovulatory dysfunction; uterine, tubal, and pelvic pathology; cervical mucus or other factors

Frank breech

-Longitudinal or vertical lie -Breech presentation -Presenting part= sacrum -Attitude: flexion, except for legs at knees

Single footling breech

-Longitudinal or vertical lie -Breech presentation -Presenting part= sacrum -Attitude: flexion, except for one leg extended at hip and knee

Complete breech

-Longitudinal or vertical lie -Breech presentation -Presenting part=sacrum with feet -Attitude: general flexion

Role of nurse in genetics

-Make referrals to genetic specialists and/or support groups -Construct family pedigrees of three or more generations -Provide genetics info before, during, and after initial counseling session -Clarify info and help families manage challenges -Provide emotional support -If family decides to terminate: explain stages of grief they may experience; inform couple that grief is a normal process; encourage communication between couple; refer to support group -If family decides to continue: provide additional info about disorder; refer to support groups for specific disorder; provide list of web sites with accurate info; explain grief over loss of "dream child" and that these are normal feelings; encourage communication between couple

Nonstress test

-Method for evaluating fetal status during antepartum period by observing for accelerations of the FHR. -Most widely used technique for antepartum evaluation of fetal well-being performed during third trimester -Noninvasive; monitors placed on client's abdomen and client instructed to press button each time she feels fetus move -Results are either reactive or nonreactive -Reactive (reassuring)= two FHR accelerations with/without fetal movement in a 20 minute period and peaking at least 15 bpm above baseline for 15 seconds (15 by 15) from baseline to baseline -Nonreactive (non-reassuring)= no accelerations in FHR within a 40 minute period

Chlamydia

-Most common and fastest spreading bacterial STI -Infections often silent and highly destructive -Difficult to diagnose -Screening includes cervical cultures done initially at first prenatal visit (asymptomatic and pregnant women) and comparisons of diagnostic procedures -Treated with doxycycline and azithromycin -If the woman is pregnant, erythromycin or amoxicillin is used

Other factors for infertility

-Nutritional deficiencies (ex. anemeia) -Obesity -Thyroid dysfunction -Idiopathic conditions

Nutritional requirements during pregnancy

-Nutritional needs increase during pregnancy to meet the demands of the mother and fetus -Pregnant adolescents are at higher risk for LBW babies (due to fad diets and low BMI) -Complex carbohydrates for energy should make up large portion of diet -Protein needed for metabolism and growth; especially needed for rapid growth of fetus -Vitamin A in excess can cause birth defects -Folic acid supplement important preconceptionally and during pregnancy; deficiencies can cause neural tube defect (spina bifida) -Water soluble vitamins (niacin, vitamin c &b's, folic acid) -Iron (best taken at bedtime and should take vitamin c to help with absorption; may cause constipation-encourage fiber and fluid) -Zinc -Water

Sex-linked or X-linked inheritance

-Only located on the X chromosome -These genes are either recessive or dominant -The Y chromosome does not have the corresponding genes for some of the X chromosome's genes -A male child who receives an X chromosome with a disorder of one or more of its genes presents the disorder when the Y chromosome doesn't carry that gene; even if the gene is recessive, it becomes dominant -Female children who have one X chromosome with a sex-linked trait disorder do not present with the trait, but are carriers of the trait

Dysmenorrhea

-Pain during or shortly before menstruation -One of the most common gynecologic problems in women of all ages -Young adult women 17-24 are most likely to report painful menses -Severe dysmenorrhea is also associated with early menarche, null parity, and stress -Differentiated as primary and secondary -Range and severity of symptoms are different from woman to woman and from cycle to cycle in the same woman

PMDD

-Premenstrual dysphoric disorder -A more severe variant of PMS in which 3%-8% of women have marked irritability, dysphoria, mood lability, anxiety, fatigue, appetite changes, and a sense of feeling overwhelmed -The most common symptoms are those associated with mood disturbances -Diagnosis is dependent on the following criteria for at least two menstrual cycles: five or more affective and physical symptoms are present in the week before menses and absent in the follicular phase of the menstrual cycle at least one of the symptoms is irritiability, depressed mood, anxiety or emotional lability symptoms interfere markedly with work or interpersonal relationships symptoms are not caused by an exacerbation of another condition or disorder

Nursing actions for Eclampsia

-Primary duty is to stay with client -Have another staff member notify the physician -Maintain a patent airway by attempting to turn the patient to her side -Note the time and length of seizure -Suction the mouth as needed after the seizure -Provide O2 (8-10 L min) via face mask -Monitor fetal heart tones -Administer meds as directed

Placental hormones

-Progesterone: facilitates implantation and decreases uterine contractility -Estrogen stimulates the enlargement of the breasts and uterus -hCG stimulates the corpus luteum to continue to secrete estrogen and progesterone until the placenta is mature enough to secrete them. this is the hormone assessed in pregnancy tests because hCG rises rapidly during the first trimester (then has a rapid decline). -hPL promotes fetal growth by regulating glucose available to fetus; stimulates breast development in preparation for lactation

Probability

-Refers to the likelihood of something occurring, rather than whether or not it definitely occurs -It is very important that nurses communicate to parents that every time the woman is pregnant, she has the possibility of carrying a baby with the defect

Fetal lie

-Refers to the long axis (spine) of the fetus in relationship to the long axis (spine) of the woman -Two primary lies and one abnormal lie -Longitudinal lie= the long axis of the fetus and the mother are parallel (most common) -Transverse lie= the long axis of the fetus is perpendicular to the long axis of the mother (the fetus cannot be delivered this way) -Oblique lie= one angle between the longitudinal and transverse lie

Hypogonadotropic amenorrhea

-Reflects a problem in the central hypothalamic-pituitary axis -Most commonly, it results from hypothalamic suppression as a result of two principal influences: stress or a body fat to lean ratio that is inappropriate for an individual woman, especially during a normal growth period -Amenorrhea is one of the classic signs of anorexia nervosa and can also be r/t excessive exercise, sports participation, and low body weight

Oral contraceptives

-Regular ingestion of combined oral contraceptive pills suppresses the action of the hypothalamus and anterior pituitary, leading to insufficient secretion of FSH and LH which keeps follicles from maturing and thus, preventing ovulation -Advantages include: acceptability, sexual response, regular menstrual flow, decreased blood loss and iron deficiency anemia, reduced dysmenorrhea and PMS, protection against certain gynecologic cancers, improvement of acne, protection against cysts and etopic pregnancy -Oral contraceptives are considered a safe option for nonsmoking women until menopause -Pills that contain estrogen and progesterone are inappropriate for breastfeeding mothers b/c estrogen inhibits milk production; must use progesterone only pills -Not a contraindication for mothers who bottle feed

Alpha-fetoprotein screening

-Screening occurs between 15-22 weeks of gestation -Used to rule out Down Syndrome (low level) and neural tube defects (high level) -Recommended for all pregnant women

Diaphragms

-Shallow, dome shaped latex or silicone device with a flexible rim that covers the cervix -The diaphragm should be the largest size a woman can wear without her being aware of its presence -The anterior lip must be pushed snugly under the symphsis -The woman must have an annual exam to assess fit and it should be replaced every 2 years or for weight fluctuations, surgery or pregnancy -It is ineffective without spermicide and the action of the spermicide is only effective for 4 hours -The diaphragm must stay in place for at least 6 hours after intercourse -If the urethra is pinched upon insertion, it can increase risk of UTI -Women must regularly check for holes or breaks -Typical failure rate is 16% in first year of use -Disadvantages: reluctance to insert or remove, cold gel and diaphragm can temporarily reduce vaginal response, messiness of spermicide -Toxic shock syndrome can occur. S&S include: sunburn type rash, diarrhea, dizziness, faintness, weakness, sore throat, aching muscles or joints, sudden high fever, vomiting. If symptoms occur, remove immediately and do not use again

Positive signs of pregnancy

-Signs attributable only to the presence of a fetus -Establishes a diagnosis of pregnancy -Auscultation of fetal heart (by 10-12 weeks) -Observation and palpation of fetal movement by the examiner -Sonographic visualization of the fetus (cardiac movement noted at 4-8 weeks) -Ultrasound visualization of a pregnancy (routine and expected part of prenatal care) -Gestational sac (can be seen at 5 weeks) -Fetal cardiac activity (observed between 6-7 weeks)

Documenting abuse

-Take photos of injuries -Write clearly -Write women's words in quotes -Avoid legalistic phrases ("woman claims or alleges") -Don't summarize a client's report in conclusive terms (the client is a battered woman"); this will be inadmissible in court -Describe the woman's demeanor (crying, shaking, angry, calm, laughing or sad) -Record the time of day of the examination and indicate how much time has passed since the abuse

Cycle of violence

-Tension building= caused by anything from a bad day at work to a mid life crisis -Acute battering= the battering incident occurs, which may or may not include physical contact (may be verbal) -Honeymoon phase= the batterer tries to make up with the partner (he may feel guilt but still wont admit fault)

Amenorrhea

-The absence of menstrual flow and a clinical symptoms of a variety of disorders -These circumstances should be evaluated: the absence of both menarche and secondary sexual characteristics by 14 years; absence of menses by 16 years, regardless of growth and development *(primary amenorrhea)*; 3-6 month absence of menses after a period of menstruation *(secondary amenorrhea)* -Although amenorrhea itself is not a disease, it is often the sign of one -Most commonly and benignly, it is a result of pregnancy -It can be the result of anatomic abnormalities, endocrine or anterior pituitary disorders, chronic diseases (type 1 diabetes), medications, hysterectomy, medications, drug abuse, or oral contraceptive use -Assessment of amenorrhea begins with H&P, labs (first to rule out pregnancy, then diagnostic tests of FSH, TSH, ect.) -Counseling and education are primary interventions and appropriate nursing roles

Size of fetal head

-The bones of the fetal head are united by membrane filled spaces (fontanels) -During labor, after rupture of membranes, palpation of fontanels and sutures during vaginal exam reveals fetal position, presentation, and attitude -Anterior fontanel= diamond shaped and closes at 18 months of birth -Posterior fontanel= triangle shaped and closes 6-8 weeks after birth -Sutures and fontanels make the skull flexible to accommodate the infant brain

Eclampsia

-The onset of seizure activity or coma in a woman with preeclampsia, with no history of preexisting pathology, which can result in seizure activity -Usually preceded by premonitory signs and symptoms, including persistent headache, blurred vision, severe abdominal pain and altered LOC -Starts with facial twitching and progresses to full body rigidity, is equivalent to grand mal seizure -Tonic-clonic movements last about a minute -Breathing stops during seizure -Pt. may experience postictal confusion combativeness as well as loud breathing, snoring, drooling, and unable to wake up for a period of time -Transient fetal heart tones may be non-reassuring -Seizures can occur before/after delivery -During the seizure, the pt. can experience: poor placental perfusion; fluid shift to the interstitial spaces; pulmonary edema; reduced blood flow to kidneys that may cause them to fail; possible cerebral hemorrhage

Placenta

-The placenta is formed from both fetal and maternal tissue -The chorionic membrane that develops from the trophoblast along with the chorionic villi form the fetal side of the placenta- the chorionic villi are projections that later form the fetal blood vessels of the placenta -The endometrial layer- decidua basalis- forms the maternal portion of the placenta -The maternal side of the placenta is divided into lobes known as cotyledons -The placental membrane separates the maternal and fetal blood and prevents fetal blood mixing with maternal blood, but allows for exchange of gases, nutrients and electrolytes -Fetal waste products and CO2 are transferred from the fetal blood into the maternal blood sinuses -Nutrients such as amino acids and O2 are transferred from the maternal blood to the fetal blood -The placenta produces progesterone, estrogen, hCG, and human placental lactogen (hPL) -Certain viruses and drugs can cross the placental membrane and cause fetal defects or death -The placenta becomes fully functional between the 8th and 10th week of gestation -By the 9th month, the placenta is between 15-25 cm in diameter, 3 cm thick, and weighs 600g

Endometriosis

-The presence and growth of endometrial glands and stroma outside of the uterus -Endometrial tissue contains glands and responds to cyclic hormonal stimulation the same way that the uterine endometrium does -During the proliferative and secretory phases of the cycle, the endometrial tissue grows; during or immediately after menstruation, the tissue bleeds, resulting in an inflammatory response with subsequent fibrosis and adhesion to adjacent organs -Endometriosis may worsen with repeated cycles or it may remain asymptomatic and undiagnosed, eventually disappearing after menopause -Symptoms vary from nonexistent to incapacitating -Major symptoms are pelvic pain, dysmenorrhea, dyspareunia (painful intercourse), abnormal menstrual bleeding, and infertility; chronic noncyclic pelvic pain, pelvic heaviness, or pain radiating to the thighs; bowel symptoms (diarrhea, pain with defecation, constipation); abnormal bleeding and pain during exercise -Women with endometriosis can also have fibromyalgia, chronic fatigue syndrome, endocrine and autoimmune disorders -Treatment is based on the severity of symptoms- NSAIDs, hormonal antagonists, and steroids; continuous contraception for menstrual suppression; surgical intervention for severe symptoms; hysterectomy if no children are desired

Probable signs of pregnancy

-The signs and symptoms of pregnancy observed by an examiner -Chadwick's sign (increased vascularity leads to bluish vaginal mucosa and cervix-evident at 8th week) -Goodell's sign (softening of the cervical tip observed at beginning of sixth week) -Hegar's sign (softening of lower uterine segment observed at six weeks) -Uterine growth -Skin hyperpigmentation (melisma/chloasma; linea negra; darkening of nipples, underarms and vulva; striae gravidarum) -Ballottement (passive movement of the unengaged fetus- done by palpating a floating structure and feeling it rebound) -Leukorrhea (white or gray mucoid discharge with faint musty odor- occurs in response to cervical stimulation by hormones and results in a operculum or plug) -Positive pregnancy test results

Presumptive signs of pregnancy

-The signs and symptoms of pregnancy which are changes noticed by the woman and are not considered diagnostic -Amenorrhea -Nausea and vomiting -Breast changes (fullness, sensitivity, tingling, heaviness) -Fatigue -Urination frequency -Quickening (maternal perception of fetal movement- difficult to distinguish from peristalsis)

Symptoms based methods

-The two day method is based on the monitoring and recording of cervical secretions; on the two days which a woman notes cervical secretions, she should avoid coitus or use back up birth control; after two days without secretions, the woman may resume unprotected sex; the typical failure rate is 14% -Ovulation method requires that the woman recognize and interpret the cyclic changes in the amount and consistency of cervical mucus that characterize her own unique pattern of changes; right before ovulation, the watery, thin mucus becomes more abundant and thick, and alkaline- it feels similar to lubricant and can be stretched 5+ cm between thumb and forefinger (this is called spinnbarkeit) and its presence indicates maximum fertility because sperm deposited in the is type of mucus can survive until ovulation occurs -Basal body temp (BBT) method is based on the fertile period being defined as the day of first temperature drop or first elevation through 3 consecutive days of elevated temperature; abstinence begins on the first day of menstrual bleeding and lasts through 3 consecutive days of sustained temperature rise; many circumstances can alter the BBT, therefore BBT alone is not a reliable method of predicting ovulation -Symptothermal method combines BBT and the ovulation method as well as secondary symptoms (increased libido, midcycle spotting, pelvic and vulvar fullness) and cervix palpation to determine fertile periods

Condoms

-Thin, stretchable sheath that covers the penis -Used correctly, an excellent means of infection control as well as prevention of unwanted pregnancy -Failure rate for correct and consistent users is 2% (typical users- 15%) -Advantages include: Safe, no side effects, readily available, premalignant changes in cervix can be prevented; method of male nonsurgical contraception -Disadvantages: interruption of lovemaking, sensation alteration, spillage resulting in pregnancy if not used properly, condoms may tear during intercourse, STI protection -Do not use petroleum based lubricants -Uncircumcised male must pull back foreskin before application

Shoulder presentation

-Transverse or horizontal lie -Shoulder presentation -Presenting part= scapula -Attitude: flexion

Ultrasonography

-Used to visualize deep structures of the body by recording reflections (echoes) of sound waves directed into the tissue -Non invasive -First trimester usually done transvaginally; used to determine presence and location of pregnancy, gestational age, fetal viability and anomalies, fibroids, cysts, bicornuate uterus -Second and third trimester performed to confirm viability and anatomy, gestational age, amniotic fluid volume, determine placental location, fetal presentation, and to guide needle placement for procedures such as amniocentesis or PUBS (percutaneous umbilical blood sampling)

ACHES

-Warning signs of potential complications from Oral contraceptives A= Abdominal pain (severe) may indicate a problem with liver or gallbladder C= Chest pain or shortness of breath; hemoptysis; may indicate possible clot within lungs or heart H= Headaches (sudden or persistent) may be caused by cardiovascular accident or hypertension; weakness or numbness of extremities E= Eye problems (visual changes such as blurred or double vision or visual loss, speech disturbance) may indicate vascular accident or hypertension S= Severe leg pain may indicate a thromboembolic process *Teach patient to stop taking the pill and report symptoms or go to ED immediately*

Contraction stress test

-Woman lightly brushes palm against nipple for 2 min which causes oxytocin release -Nipple stimulation is stopped when contraction begins; process is repeated after a 5 min rest period -Analysis of FHR response determines how the fetus will tolerate the stress of labor -A pattern of at least three contractions within a 10 min period with duration of 40-60 seconds each must be obtained for assessment data -Negative CST: no late or significant decelerations noted in a 10 minute period (baby handling contractions) -Positive CST: late decelerations follow 50% or more of contraction in a 10 minute period (baby not handling contractions)

Alterations in cyclic bleeding

-Women often experience changes in amount, duration, interval, or regularity of menstrual cycle bleeding -Oligomenorrhea is decreased menstruation in amount, time, or both -Hypomenorrhea refers to scanty bleeding at normal intervals (usually caused by OCPs) -Metorrhagia refers to intermenstrual bleeding or bleeding where spotting, menses, or hemorrhage occur at any time other than normal menses (caused by OCPs, infection, foreign bodies, or polyps) -Menorrhagia refers to excessive menstrual bleeding in either duration or amount (can be caused by disease, infection, medications, contraception or early pregnancy loss)

Genetic counseling

A communication process that deals with the human problems associated with the occurrence or risk of genetic disorder in the family. Trained individuals help the family to understand facts including diagnosis and course of disorder and management; explain how heredity contributes to the disorder; understand alternatives; choose a course of action; make adjustments -Reasons for referral to genetic counseling include: advanced maternal age >35; fathers >40 years; known genetic disorders; family history of birth defects or mental retardation; history of unexplained stillbirth; women who experience multiple spontaneous abortions; pregnant women with abnormal prenatal screening results

Laborists

AKA Hospitalists The chief role of the laborist is to manage the inpatient care of pregnant women. Their other responsibilities include education of the residents and medical students, participating in the multidisciplinary team for patient care, participating in clinical research, and working within the hospital infrastructure so that optimal patient care can be provided for the least cost and maximal patient satisfaction.

BRAIDED

Acronym for Informed Consent with contraception B= benefits; information about advantages and success rates R= Risks; information about disadvantages and failure rates A=Alternatives; information about other available methods I= Inquiries; opportunity to ask questions D= Decisions; opportunity to decide or change her mind E= Explanations; information about method and how it is used D= Documentation; information given and client's understanding

Amniocentesis

Aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client's uterus and amniotic sac under direct ultrasound guidance -May be done after 14 weeks of gestation -Indications for use include: genetic disorders; fetal lung maturity assessment; fetal hemolytic disease; meconium in amniotic fluid -Indications for 2nd trimester: Maternal age >35; chromosomal abnormality in close family member; sex determination for maternal carrier of x-linked disorder; birth of previous infant with chromosomal abnormalities or neural tube defect; pregnancy after multiple spontaneous abortions; elevated levels of alpha-fetoprotein that remain unexplained Complications include: Maternal or fetal hemorrhage; maternal or fetal infection; miscarriage or premature labor; abruptio placentae; damage to intestines or bladder; amniotic fluid embolism; leakage of amniotic fluid; needle injury to fetus; fetal death

Maternal death

Death of a woman during pregnancy or within 42 days of termination of a pregnancy Types: Direct- resulting from complications; Indirect- resulting from preexisting disease; Late maternal- from direct or indirect cause; Pregnancy related- regardless of cause

Injectable hormones

Depo-provera -150 mg given IM during first 5 days of a menstrual cycle and administered every 11-13 weeks thereafter -Advantages include: long lasting effects, required only 4x/year, lactation is not impaired -Disadvantages include: prolonged amenorrhea, irregular spotting, increased risk of thromboembolism, decreased bone density, long term (more than 2 years), fertility delayed for up to 18 months after discontinuation, weight gain, lipid changes, decreased libido -Breastfeeding women should start 6th week postpartum; non-breastfeeding should begin within 5 days following delivery -Instruct women to always keep follow up appointments and to increase intake of Ca and Vitamin D

Caution for Oral Contraceptives

Do not use oral contraceptives with history of: -Thrombophlebitis and thromboembolic disorders -Cerebrovascular or cardiovascular disorders -Estrogen-dependent cancers or breast cancer -Hypertension (unless controlled by medication) -Migraines with focal aura -Diabetes with vascular involvement

FAMs

Fertility Awareness Methods of contraception -Also known as periodic abstinence or natural family planning and depends on identifying the beginning and end of the fertile period of the menstrual cycle -These methods provide contraception by relying on avoidance of intercourse during fertile periods -Phases of fertility include: infertile- before ovulation fertile- about 5-7 days around the middle of the cycle, including several days before and during ovulation, and the day afterward infertile- after ovulation -The human ovum can be fertilized no later than 12-24 hours after ovulation -One problem with FAMs is that the exact time of ovulation cannot be predicted accurately -Women with irregular periods have the greatest risk of failure with FAMs -Couple should wait 6 weeks after delivery to try for another child to reduce risk of infection -Type of FAMs include: calendar-based methods (calendar rhythm and standard days methods) and symptoms-based methods (two day method, ovulation method, bbt method, symptothermal method)

Passenger

Fetus and its relationship to the passageway is the major factor in the birthing process This includes: Size of fetal head and fontanels Fetal presentation Presenting part Fetal lie Fetal attitude or posture Fetal position

GIFT

Gamete Intrafallopian Transfer -GIFT requires women to have at least one normal uterine tube -Ovulation is induced, as in IVF, and the oocytes are retrieved from the ovary and washed with motile sperm (collected before laparoscopy) and immediately transferred into the uterine tube, permitting natural fertilization and cleavage -Sperm and oocytes are mixed outside of the woman's body and then placed into the fallopian tube via laparoscopy -Less than 1% of all ARTs use this technique -Indications for GIFT include: A history of failed infertility treatment for anovulation; unexplained infertility; low sperm count; same indications as IVF except woman must have at least one uterine tube with normal anatomy and patency and no history of disease in that tube

Two digit system

Gravidity (G)- the total number of pregnancies (without reference to the number of fetuses) the woman has had (including current) Parity (P)- refers to any birth that occurred after 20 weeks gestation, regardless of whether or not the baby was born alive and also without reference to number of fetuses -The two digit system utilizes these two letters to summarize a woman's obstetric history -Ex. If a woman's second pregnancy ends in abortion at 18 weeks and she has a living child from a previous pregnancy, born at term, she is designated as G2P1

IVF

In Vitro Fertilization -A common procedure for women with blocked or absent uterine tubes or with unexplained infertility and for men with low sperm counts -A woman's eggs are colleted from her ovaries, fertilized in the lab with sperm (in vitro-in a dish) for 6 days, and transferred to the uterus using ultrasound guidance -If sperm are not available via ejaculation, they can be retrieved via needle from the testes or the epididymis -Indications for IVF include: tubal disease or blockage, severe male infertility, endometriosis, unexplained infertility, cervical factor, immunologic infertility

Preconception screening

Includes history, lab tests, exams, DNA analysis -Occurrence risk is given to couples who are known to be at risk of having children with a genetic disease -Recurrence risk is given to a couple with one or more children with a genetic disease -Both occurrence and recurrence risk are determined by the mode of inheritance for the genetic disease in question

Health risks in Childbearing Obesity

Mother: Gestational hypertension; Gestational diabetes; Thromboembolism; Caesarean section; Shoulder dystocia Baby: Spina bifida; Heart defects; Intrauterine fetal death; Birth injuries r/t macrosomia (LGA); Childhood obesity and diabetes

Low birth weight

Newborns weighing less than 2500 grams (5 lb, 8 oz) AKA: Small for gestational age (SGA) -Weight of neonates at birth is an important predictor of future morbidity and mortality -Smoking is main cause -Higher rates among African Americans

Maternal mortality rate

Number of maternal deaths per 100,000 live births -Leading causes: gestational hypertension, hemorrhage; pulmonary embolism, age (<20 and >35), lack of prenatal care, low education, unmarried, and non-Caucasian -Highest rate are Af Am women

Nursing care for the battered woman

Nursing diagnoses: loss of trust; hopelessness; fear; ineffective family coping; situational low self-esteem; risk for self-directed violence; social isolation -ABCDES of caring for abused women: Alone (reassuring her she is not alone) Belief (express belief that violence against women is unacceptable and it is not her fault) Confidentiality (the information being shared will remain confidential) Documentation (descriptive documentation: quotes, accurate description of injuries, evidence such as photos) Education (educate about options including shelters and community resources) Safety (the most dangerous time for a woman is when she's about to leave- tell woman to call 911 if she's in danger) -Prevention and evaluation= educate woman that abuse if a violation and facilitate access to legal and protective services; evaluation should be based on expected outcomes and in harmony with the choices the woman has made

Neonatologist

Physician that provides medical care of newborn infants, especially the ill or premature newborn infant. It is a hospital-based specialty, and is usually practiced in neonatal intensive care units (NICUs).

Perinatologist

Physician who specializes in fetal and neonatal care

Diagnosis of fetal abnormalities

Pre-natal diagnosis : Includes screening tests, ultrasounds, amniocentesis, and chorionic villus sampling -In amniocentesis, a needle is placed through the abdominal and uterine walls and amniotic fluid is removed for testing -In chorionic villus sampling, fetal tissue is removed via vaginal catheter and removed for testing Post-natal diagnosis: Includes physical exam, blood tests, DNA analysis, and imaging procedures

Abruptio placentae

Premature separation of the placenta from the uterine wall after 20 weeks of gestation and before the birth of the infant -Serious complication that accounts for significant maternal and fetal morbidity and mortality -Maternal hypertension is the most common risk factor -Cocaine, smoking, multigravida status, short umbilical cord, abdominal trauma, history of previous abruption, advanced maternal age, fibroids, or autoimmune blood disorders are risk factors -The hemorrhage is apparent when bleeding separates or dissects the membranes from the endometrium and blood flows out through the vagina -Symptoms include: sharp, persistent abdominal pain with sudden onset and with or without blood; hard, board-like abdomen; "port wine" blood; abnormal FHR; elevated uterine resting tone; uterine tenderness; watch for early systemic signs of hemorrhage Treatment: depends on maternal and fetal status; emergent C-section for severe hemorrhage coagulopathy, poor labor progress, or increasing uterine resting tone; if fetus is immature and no signs of distress, conservative measures initiated and steroids (betamethasone) given to accelerate fetal lung maturity; monitor maternal and fetal vitals, uterine contractions and vaginal bleeding; fluid and electrolyte replacement therapy; blood transfusion; assess and measure bleeding (weigh chux); I&Os

Prenatal care

Prenatal care can promote better pregnancy outcomes by providing early risk assessment and promoting healthy behaviors (ex. improved nutrition and smoking cessation) -Prenatal care ideally begins before pregnancy -African Americans and Hispanics receive less prenatal care than whites -Infant mortality rate is 45% higher in babies with mothers who don't seek prenatal care during the first trimester or at all.

Basic care

Provided by obstetricians, family physicians, certified nurse midwives, and other advanced practice clinicians approved by local governance -Routine risk oriented prenatal care, education, and support are provided -Specialty care is provided by obstetricians who must provide fetal diagnostic testing and management of obstetric and medical complications in addition to basic care. -Subspecialty care is provided by maternal-fetal medicine specialists and includes specialty care in addition to genetic testing, advanced fetal therapies, and management of severe maternal and fetal complications

Certified nurse-midwives

Registered nurses with education in the two disciplines of nursing and midwifery -Women can choose physicians or nurse-midwives as primary care providers -Women who choose nurse- midwives as their primary providers participate more actively in childbirth decisions and receive fewer interventions during labor -Certified Midwives are educated only in midwifery -Doulas are trained and experienced female labor attendants and provide a continuous, one on one caring presence throughout labor and birth

Prevention of STIs

Risk reduction measures= -knowledge of partner -reduction in number of partners -condom use (male compliance, negotiation of use) -female condom -vaccinations (hep b, hpv, etc.) -abstinence of activities with fluid exchange -Avoid: unprotected anal-oral, anal-genital intercourse; practices that increase tissue damage; direct contact with lesions; fellatio (unprotected oral sex); multiple sex partners

5 P's

The essential components in the outcome of labor 1)Passenger- fetus and placenta 2)Passageway- pelvis and birth canal 3)Powers- contractions 4)Position- maternal postures and physical positions to facilitate labor 5)Psyche- response of the woman

Infant mortality rate

The number of deaths of infants younger than 1 year of age per 1000 live births; Death before first birthday -50% occur in first week of life/ 50% occur on first day of life -A common indicator of the adequacy of prenatal care and the health of a nation as a whole -Associated with limited education, young or advanced maternal age, unmarried status, poverty, lack of prenatal care, and smoking -Highest for mothers 16 and younger/ older than 44; vulnerable populations -Poor nutrition, alcohol and substance abuse, and maternal conditions such as poor health or hypertension can also contribute -The leading cause of death in the neonatal period is congenital anomalies -Decreases in infant mortality rates in the U.S. do not keep pace with other industrialized countries- a reason for this is the high rate of LBW babies in contrast with other countries.

Genetic Transmission

The patterns by which genetic material is transmitted to the next generation are affected by the number of genes involved in the expression of the trait -Multifactoral inheritance includes two or more genes on different chromosomes acting together- it is the most common cause of congenital malformations (ex. cleft palate, congenital heart disease, neural tube defects- spina bifida, and pyloric stenosis) -Unifactorial inheritance includes a single gene which controls a particular trait or disorder- single gene disorders far exceed chromosomal abnormalities in numbers- they include autosomal dominant, autosomal recessive, and x-linked inheritance

Karyotype

The pictorial analysis of the number, form, and size of an individual's chromosomes -Cells from any nucleated, replicating body tissue can be used -The most commonly used are white blood cells and fetal cells in amniotic fluid -The chromosomes are numbered from largest to smallest (1-22) and sex chromosomes (23) are designated x and y -This determines gender and chromosomal abnormalities -Trisomy 21= down syndrome; trisomy on sex chromosome= kleinfelter's syndrome (extra x and one y) -Monosomy on sex chromosome= Turner syndrome (only one x)

Monosomy

The product of the union between a normal gamete and a gamete that is missing a chromosome -Monosomic individuals only have 45 chromosomes in each of their cells Ex. Turner syndrome- a female with only one x sex chromosome (monosomy 45)

Trisomy

The product of the union of a normal gamete with a gamete containing an extra chromosome -Trisomic individuals have 47 chromosomes in almost all of their cells -The vast majority of trisomies occur during oogenesis and the incidence of these types of chromosomal errors increases exponentially with advancing maternal age -The most common trisomal abnormality is Down Syndrome (21) -Kleinfelter (trisomy xxy) is the most common sex chromosome abnormality. The affected male has one extra x chromosome

Fetal attitude

The relationship of fetal parts to one another -Noted by flexion or extension of the fetal joints -Proper fetal attitude: the head is in complete flexion in a vertex presentation and passes more easily through the true pelvis -The complete flexion of the head is the best way for the baby to come through the pelvis because the smallest diameter is leading out

Preterm Birth

Very premature- less than 32 weeks Moderately premature- between 32-33 weeks Late premature- between 34-37 weeks *Despite widespread advances in perinatal care, preterm birthrate continues to rise* Highest among AA, AI, Hispanic