OB Module 5 Exam NP3

Rubella Vaccine & Hepatitis B vaccine

-Rubella: German measles; generally mild for mom, but can cross placenta & effect baby, in 1stT poses greatest risk. Transferred by contact or droplets. Congenital Rubella Syndrome: hearing-loss, intellectual disability, cataracts, cardiac defects, microcephaly, & IUGR. Infected child can infect other children. ID immune status of all women of childbearing age (immune if >1:8), if not immune get MMR vaccine BEFORE pregnancy & don't become pregnant for 4wks (live virus vax). If pregnant & not immune, admin vax in early PP period. -Hepatitis B: incidence decreased w/ screening; infection during pregnancy associated w/ increased incidence of premature birth, low birth weight, & neonatal death. Vaccine recommended for newborns, admin before D/C from hospital or at 1st PEDS visit. 2nd dose at 2mo old. 3rd dose at 6-18mo old. Pregnant women w/ risk factors offered vaccine. Positive mom admin vaccine to newborn w/in 12hrs of delivery. Test baby 1-3mo after 3 doses to see if they have chronic infection.

Uterine Atony, Subinvolution, Early and Late Postpartum Hemorrhage

-Uterine Atony: decreased uterine muscle contraction (tone), primary cause of excessive bleeding bc uterus does not contract firmly around BVs when placenta separates. . · Subinvolution: uterus does NOT achieve involution (daily contraction & return to original size). At first seems like involution is occurring, then it does not continue the process. Causes retained placenta fragments & infection. o Early Postpartum Hemorrhage: usually occurs in 1st hr PP, often from uterine atony. Also trauma, hematoma, retained placental fragments, abnormal coagulation, placenta previa/acreta, uterine inversion. o Late Postpartum Hemorrhage: occurs between 24hrs & 6wks (up to 12wks). Usually due to subinvolution in some regard. o Delayed return of the uterus to its nonpregnant size and consistency caused by: Retention of placental fragments or Infection o Nurses should teach the family signs and symptoms that may need to be reported to the health care provider. Teach mom how to locate/palpate the fundus & how to determine the fundal height, assess lochia & its progressive changes, ID when pain increases to a level more than previous—s/s that indicate she needs to call the HCP. -Ex. D/C after 24hrs she had started involution, then notices her uterus is starting to get higher again even though she has voided & massaged—contact the HCP right away. -Risk Factors: multiple cervical exams, overdistension of uterus, multiparity, precipitate labor or birth, prolonged labor or ROM, forceps or vacuum, CS, manual removal of placenta, uterine inversion, placenta previa/acreta or low implantation, Drugs (oxytocin, prostaglandins, tocolytics, Mg), general anesthesia, chorioamnionitis, clotting ds, Hx PP hemorrhage or uterine surgery, DIC, uterine leiomyomas (fibroids).

Abruptio placenta

Abruptio Placentae: placenta comes off the lining of the uterus. Blood may be visible or concealed, darker (w/ possible clots) bc its higher in the uterus, increases time to move into vaginal canal so it oxidizes. Almost always w/ severe pain, uterine tenderness & hyperactivity. Normal uterine resting tone is 20 or less, abruption will be higher than this. Can contribute to bleeding disorders like DIC—when the clotting factor thromboplastin is released into the maternal blood stream bc of placental bleeding & clot formation. Can be a complication of preeclampsia. -S/S: Abdominal pain with no palpable relaxation between contractions. Placental separation often begins at the top of the uterus, allowing some blood to seep into the uterine wall. This causes abdominal rigidity & pain; also manifested in a uterus that does not seem to relax between contractions. · S/S of Concealed Hemorrhage in Abruptio Placentae: placental margins still intact so it starts bleeding behind the placenta. o Fundus gets very hard & increase in height bc blood accumulates w/in uterus & doesn't come out. o Hard, board-like abdomen o High uterine baseline tone on monitor. o Persistent abdominal pain o Systemic signs of early hemorrhage—increased HR o Persistent late decelerations on monitor, why we don't wait, call for help ASAP. o Vaginal bleeding that may be slight or absent

Afterpains

Afterpains: intermittent contractions, source of discomfort; decrease to mild by 3rd day. More acute for multiparas, severe for primiparas w/ multifetal, large infant, polyhydramnios, or retained blood clots. Oxytocin released from breastfeeding can also cause strong contractions. -RN: Tx w/ analgesics; short term relief w/o harm to infant. Benefits of relaxation & comfort, facilitate milk ejection reflex (letdown reflex)—outweigh the risks. Lie in prone w/ pillow or blanket under ABD to contract the uterus & relieve pain. Pain is self-limiting & decreases after 48hrs. o "Afterpains" Uterine Contractions: Afterpains are caused by intermittent uterine contractions -Common in multiparas bc loss of tone causes alternate contraction & relaxation. -Marked distention of the uterus- multiple gestation pregnancy--twins, polyhydramnios--increased amniotic fluid stretches uterus, or w/ retained placental fragments. Distension may cause increased contractions in an effort to return it to its normal size. -Duration of afterpains w/ severe discomfort for 2-3 days after birth. -Oxytocic agents admin to stimulate uterine contraction increases uterine pain. Admin 10-20u after delivery of placenta. Helps contraction & prevents hemorrhaging. -Breastfeeding increases frequency & severity of afterpains bc of oxytocin release from suckling. -Admin a mild analgesic 1hr before breastfeeding can help mom relax & lessen the pain from contractions. She can also lay prone w/ small pillow under ABD—applies pressure to uterus & stimulated contractions. When the uterus maintains constant contractions the afterpains will usually stop.

Lochia rubra, serosa and Alba

Assess Lochia: color & amount provides info about involution. · Lochia Rubra—days 1- 3; red-brown color, bloody, small clots, earthy odor. Made of decidua & mucus. Abnormal: large clots, saturated pad, foul odor. · Lochia Serosa—days 4-10, decreased amount; serosanguinous, pink or brown tinged. Made of erythrocytes, leukocytes, serous exudate, cervical mucus. Abnormal: excessive amount, foul smell, continued or recurrent red color. · Lochia Alba: days 11-21 (42), decreased further; white, cream, light yellow. Made of leukocytes, decidual cells, epithelial cells, fat, cervical mucus, bacteria. Abnormal: persistent serosa, return to rubra, foul odor, continued discharge. · Amount: seen on the pad, must determine time it's been in place (1hr). CS may have less; increases when mom stands for 1st time. o Scant: <2.5cm (1in) o Light: 2.5-10cm (1-4in) o Moderate: 10-15cm (4-6in) o Heavy: saturated pad o Excessive: saturated pad in 15min

Pregnant mother with asthma

Asthma: obstructive lung dz, caused by airway inflammation. S/S: dyspnea, cough, wheezing. Course in pregnancy is variable. -Maternal & Fetal Effects: good Px if effective Tx allows avoidance of attacks. Meds used are well tolerated & appear safe for fetus. Breastfeeding is safe & can reduce risk of allergies. -RN: early use of anti-inflammatory agents (ex. INH corticosteroids- Beclomethasone) can prevent severe attacks. Cromolyn sodium & nedocromil sodium are effective, but take longer than INH corticosteroids. Bronchodilators (ex. theophylline or INH beta-agonists) may be required.

BUBBLE EE: Bladder/Urinary Tract

BUBBLE EE: Bladder/Urinary Tract o Increased bladder capacity: baby was pushing on bladder & now its not. o Decreased bladder tone o Decreased sensitivity to fluid pressure o Decreased sensation of bladder filling o Swelling & bruising—of tissue around the urethra causes reduced sensation. o Puerperal diuresis—causes rapid filling of the bladder, where mom sweats excessively & there is increased bladder filling. Teach her that there will be frequent bladder emptying after delivery. o Urinary stasis—increases risk of UTI. o Encourage her to void every 4-6hrs, & assess the bladder till there is complete emptying w/ each void. If there are issues, assess w/ bladder scanner to see if it's been emptied. Risk for overdistension of the bladder, incomplete emptying, & buildup of residual urine. HCP may order cath when bladder is distended & pt can't void, or if she hasn't been able to void in past 8hrs—esp. after epidural or spinal. o Full bladder may increase uterine relaxation by displacing uterus & interfering w/ contractility—can lead to hemorrhage. Full bladder won't allow uterus to contract, if there is loss of tone, she can bleed from where the placenta was. S/S bladder distension: uterus high & displaced from midline--can cause PP hemorrhage & UTI. o Teach s/s of urinary retention, overflow voiding, & UTI w/ patient.

BUBBLE EE: Bowel/GI/Elimination

BUBBLE EE: Bowel/GI/Elimination o GI: Hunger & thirst—expected after birth, long/hard workout. Drink lots of fluids to replace what was lost during labor, diuresis, perspiration. o Sluggish intestines: from lingering effects of progesterone & decreased muscle tone. --Spontaneous bowel movements: may not occur for 2-3 days after delivery. Can cause discomfort. --Anticipated discomfort: from pushing, perineal tenderness, hemorrhoids, or fear to have BM bc of episiotomy or laceration. May resist passing stool, so give a stool softener to increase bulk & moisture in feces. o Elimination returns to normal: after 1wk; encourage ambulation & increase fluid intake. Up to 2000mL/day or more. Add fresh fruit & roughage in the diet. o Bowel tone & flatulence after C-section: may take a few days to return to normal. Promote ambulation & stool softeners to help. Flatulence can cause ABD discomfort & pain in addition to the pain of contraction. May need to give anti-flatulent meds if causing problems. Listen to bowel sounds so diet can be advanced to solid food. Bowels stop bc ABD has been cut into for CS, listen & evaluate if BS have returned to normal before she can eat solid food.

BUBBLE EE: Episiotomy/Perineal Changes

BUBBLE EE: Episiotomy/Perineal Changes o Episiotomy: vacuum or forceps assisted birth w/ episiotomy for a faster delivery. May cut midline or mediolateral, to allow more room for baby. Now only in an emergency. o Inspecting the perineum: Depending on how far the incision is & if there was additional tearing, inspect the perineum for episiotomy or lacerations. Position mom in sims, w/ gloves, may need to lift buttocks to expose perineum. Must check even if mom doesn't want the assessment. o Edema & Bruising: of vaginal area. Bruising is from pelvic congestion & usually disappears quickly. Hematoma: eccymotic area w/ outline of swollen area visible, extreemly painful--Tx drain. o Lacerations: superficial ones may be seen. Baby pulls the skin too tightly resulting in lacerations, or the baby can cause by scraping against skin. o Perineum returns to normal: non-lactating women in 6wks; lactating women's hyper estrogenic state from ovarian suppression can cause dyspareunia o Improving tone & contractility: w/ perineal exercises, Kegels. Teach her to stop flow of urine midstream w/ Kegel muscles by tightening them, count to 10, release. Repeat 10x. o Labial changes: more flaccid in women who have given birth. Check for bruising in this area—stretching can burst a BV & fill labia w/ blood. · Evaluating & Providing Care for the Perineum: o Ask her if she thinks any measures may relieve edema & offer choices when possible. Good hand hygiene before & after Tx, & use gloves. o Teach to clean from front to back to avoid contamination of urethral/vaginal & anal area. Give her a peri-bottle, used to squirt warm tap water over perineum after voiding & BM. Can also used it while voiding to dilute urine, urine causes pain when it touches the laceration.

BUBBLE EE: Extremities

BUBBLE EE: Extremities: Increased risk for thrombophlebitis, thrombus formation & inflammation involving a vein. Usually a vein in the legs. Keep legs straight, relaxed, w/ knees flexed. Do NOT cross legs bc it puts pressure behind the knee. Encourage ambulation to promote circulation. o Risk Factors: o Homans sign: screening tool; grasp around mom's foot & sharply dorsiflex it—should be NO pain. If there is calf pain it's a "positive Homans sign", notify the HCP. Dx of thrombophlebitis may be made w/ US, do NOT rub it. o Observe for: Pain is cause by inflammation of the BVs; Edema, Redness, Tenderness, Increased skin temperature. o Low dose heparin Tx (or other blood thinners) is used to treat a DVT after delivery. Encourage leg exercises every 2hrs until mom starts ambulating. Exercise increases circulation & helps prevent thrombophlebitis, & aids in intestinal motility by tightening the ABD muscles. Teach her w/ blood thinners she is at risk for bleeding, hypotension, & needs follow-ups. o Woman w/ CS: give ted hoes & compression stockings if staying in bed. Encourage her to get up, move around, or at least sit up—to prevent DVT.

BUBBLE EE: Focused Assessment of PP Mom

BUBBLE EE: Focused Assessment of PP Mom · B = Breast · U = Uterus · B = Bladder · B = Bowel · L = Lochia · E = Episiotomy/Perineum · E = Extremities · E = Emotional · Puerperium- postpartum period, 6wks after birth. AKA 4th trimester.

BUBBLE EE: Breasts

BUBBLE EE: Focused Assessment of PP Mom · B = Breast: Std. precautions; note if mom plans to breastfeed or not, to guide education & interventions. -Assess for discomfort: 1-2 days after birth, should be soft & nontender. -Assess fit and support of the bra: proper fit/support maintains breast shape & limits stretching of supporting ligaments & connective tissue. Purchasing a bra 1 size to large during pregnancy will result in good fit, bc size increases w/ milk production. -After bra removal, assess: -Size and shape of breasts: & symmetry. -Abnormalities: skin dimpling or thickening, may be tumor (rare). Nipple shape/size flat or inverted—baby can't latch on. -Reddened areas: w/ masses indicate mastitis—inflammation or infection of mammary glands/ducts. s/s streak, reddened area, warm. May need to pull back glove & feel w/ back of hand. -Engorgement: Assess if breastfeeding or not bc engorgement can occur—so full that baby can't latch, can flatten nipple. Very painful for mom bc all glands have filled up, have her pump to allow for breastfeeding. -Lightly palpate: -Softness: normal; Slight firmness associated with filling: normal; Firmness associated with engorgement: flat nipple, breast very firm, painful; Warmth: engorgement or mastitis; Tenderness: engorgement or mastitis. -Assess nipples for: -Fissures, cracks, soreness & inversion: indicate problems w/ breast feeding & need to assist baby to latch properly. Cracks can lead to mastitis. Inversion of nipple can be corrected by shield, so baby can suckle; or pump a little to help the nipple become erect. o Normal: breasts feel soft, no evidence of nipple tenderness or cracking. o Not Breastfeeding: use ice, & wear a good fitting bra.

BUBBLE EE: Lochia

BUBBLE EE: Lochia: The discharge seen when the uterus rids itself of debris remaining after birth o Classified according to its appearance & contents: -Lochia rubra: dark red; 2-3 days after delivery. Contains erythrocytes, epithelial cells, decidua, meconium, vernix from baby. -Lochia serosa: pink; 3-10 days after delivery. Contains serous exudate, shreds of degenerating decidua, erythrocytes, leukocytes, cervical mucus, & microbes. -Lochia alba: creamy-yellow; persists for additional 1-2wks. Contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, cholesterol crystals, bacteria. o Also classified by how/when the lochia flow stops: cervix is closed, decreases chance of infection ascending from vagina to uterus. o What to check: wear gloves! Discard after checking lochia, & apply new ones to assess another area. Teach & demonstrate good hygiene. -Odor: after delivery its non-offensive, musty-stale odor. Foul indicates infection, report to HCP. Check WBCs & differential, fever, & uterus for tenderness on palpation. -Amount: no more than 225mL of total lochia. Should never exceed a moderate amount—4-8 partially saturated pads per day. Amount should decrease every day. -Hemorrhage/Heavy: saturate pad in 1hr. -Character: rubra to serosa, then alba. -Presence of clots: rubra—a few clots are normal from blood pooling in vagina, esp. if standing after laying for a long time. Massage her uterus, clean out the clots, & monitor if clotting continues. -Document: amount then character—"lochia moderate rubra" or "lochia small rubra-serosa". o Increased lochia: -Clots & heavy bleeding: caused by uterine relaxation or no tone, inadequate uterine contractions allow bleeding at BV at placental site, retained placental fragments, or unknown cervical/vaginal laceration. Assess for lacerations if clots & heavy bleeding continue. Assess location & firmness of fundus, massage if boggy, & express the clots. -Increase after sleep: lochia has been pooling in vagina, standing drains it. -Increase after exertion: may also be normal. -Assess how long pad has been there, needs to be changes after each void, apply new pad & provide peri-care. If concerned about amount, weight the pad & compare to a empty pad—1g = 1mL of blood. o Decreased lochia: in women who had CS; after placenta was removed, HCP can suction out the lining of the uterus. Evacuation & suction is done of the uterine cavity, so less lochia may be present. o Persistent lochia rubra: may be from inadequate uterine contractions, retained placental fragments, or infection. Assess location & firmness of fundus, massage if boggy. Assess activity pattern & for s/s of infection.

New parent considering a circumcision

Circumcision: parents of male babies may choose circumcision; this is an out-of-pocket expense for them (not covered by insurance unless medically necessary). In the event of hypospadias or epispadias, OP will be necessary to correct & will be covered by insurance—foreskin is left intact. · Reasons parents choose: prevent certain conditions (ex. infections)—teach parents how to clean the penis. People believe circumcision makes the penis "cleaner"—EBP suggests that this is not the case w/ all patients, & if proper hygiene is taught, infections can be prevented. Also parental preferences, ex. dad wants son to look [or not look] like him. May be worried about son being different, when changing in a locker room. Could be a religious choice. · Reasons parents reject: parental preferences, beliefs that uncommon conditions don't necessitate OP. OP is painful, sometimes lidocaine is used but the injection may also be painful, but it's still pain/stress to the newborn. o RN: must teach proper hygiene of penis to all parents. Educate on OP process: clamp down 3-5min, then incise all the way around. Can use a plastic bell or a metal clamp. Baby is put in a restraint-like bed for the OP. Help parents make informed decisions, let them know it hurts the baby, explain the SE of the OP. Honor their request, but provide education. · Risks: Hemorrhage, Infection, Unsatisfactory cosmetic effect, Urinary retention—from scaring, Urethral stenosis or fistula, Adhesions, Necrosis, Injury to the glans, Pain during and after surgery. · S/S of complications: Bleeding more than a few drops—just a small amount on the diaper is normal, failure to urinate—assess diapers, s/s of infection—temp increase, increased or foul/purulent drainage, displacement from the plastic bell.

Eclampsia

Eclampsia: progression of eclampsia to generalized seizures after 20wks gestation, can't be attributed to other causes. BP >160/>110. Proteinuria >5g/24hrs. o Magnesium sulfate is used to prevent seizures in preeclampsia. Assess every 30-60min, check DTRs. Hyporeflexia precedes respiratory depression. o RN monitor the patient to determine the effectiveness of medical therapy. Ex. After admin of Mg, reflexes should go from +3 to +1. Keep O2 & suction equipment in her room in case of a seizure. o Control external stimuli and initiate measures to protect the woman in case preeclampsia proceeds to eclamptic seizures. Bed in lowest position, pad bedside rails, press emergency button to call for help. o Nursing care during and after seizure—protect mom & baby. Remain w/ her the whole time, during tonic phase turn her to her side, note the time & sequence of the convulsions to determine duration. After seizure maintain airway & suction mouth/nose if needed, admin O2 8-10L/min, observe FHR monitor for patterns that indicate hypoxia (brady, tachy, decreased variability may resolve after 2 min). Notify HCP, admin meds, prep for additional Tx. Seizures are detrimental to pregnancy, one can lead to abruption of placenta. Typically, if seizures are present, we need to get the baby out—vaginal preferred bc of clotting deficiency. -Late decelerations reflect placental insufficiency; fetus at risk & requires immediate intervention. Pt w/ preeclampsia is likely to have a small placenta and be prone to placental insufficiency.

Ectopic pregnancy

Ectopic Pregnancy: Implantation of the fertilized ovum in an area outside of the uterine cavity; 95% in fallopian tubes, usually the ampulla site. Sites: fimbrial, ampullar, isthmic, interstitial. o Increased Incidence: in the US; from pelvic inflammation—STIs that are untreated cause PID. Other causes: use of IUD, A&P defects in the tubes (failed tubal litigation), tobacco use, vaginal douching (fluid pushes ovum up). Anything that slows movement of fertilized ovum through the tube or causes it to implant early increases the risk. Also >35yrs, assisted reproductive techniques (GIFT), multiple induced abortions, Hx of ectopic pregnancy. o Dx: transvaginal US, hCG levels abnormal based on dates, severe lower right ABD pain 2-3wks passed missed period—why pregnancy test done for appendectomy pt. o Therapeutic management: prevent severe hemorrhaging in the mom, preserve fallopian tubes for future fertility. Less than 3.5cm, use metheltrexate, a folic acid antagonist that interferes w/ cell production & it's a chemo drug. It stops growth of fertilized ovum. Greater than 3.5cm, try to save tube if it's not ruptured, do a linear salpingostomy, where they clear out the pregnancy. If it has been ruptured control bleeding & prevent hypovolemic shock, once CV status stable then do a salpingectomy, where they remove the ruptured tube—can still get pregnant w/ 1 tube. · RN: monitor VS, s/s of shock, provide emotional support—tragic for mom. Watch for sudden, sharp ABD pain.

Erythromycin ophthalmic ointment (Ilotycin)

Erythromycin ophthalmic ointment (Ilotycin): antibiotic; inhibits protein synthesis in bacteria; bacteriostatic or bactericidal depending on organism. -Prophylaxis against Neisseria Gonorrhoeae; required by law regardless of mom being +/-. Prevents ophthalmia neonatorum in infants w/ mom's who have gonorrhea. -Dose: ribbon of 0.5% Erythromycin ointment, 1cm (0.4in) long, applied to lower conjunctival sac of each eye w/in 1hr after birth. -Adverse Rx: burning, itching, irritation may result in chemical conjunctivitis, lasting 24-48hrs. May cause temporary blurred vision. -RN: clean baby's eyes PRN before admin. Hold in horizontal position to avoid injuring the eye from sudden movement. Admin from inner to outer canthus w/o touching the tip to the eye bc it will spread the infection to the other eye. Do NOT rinse, may wipe away excess after 1 min. Observe for irritation. New tube used for each baby to avoid spreading infection.

Hemabate (carboprost tromethamine)

Hemabate (carboprost tromethamine, Prostin/15M): prostaglandin, oxytocic; stimulates contraction of the uterus. Used to Tx PP hemorrhage caused by uterine atony, also for abortion. -Dose: PP hemorrhage 250mcg IM, may repeat at 15-90min intervals. Max dose 2mg. -NEVER give to women w/ hypersensitivity to carboprost or other prostaglandins, acute PID; pulmonary, renal, hepatic dz. CAUTION if Hx of asthma, hypotension or HTN, anemia, jaundice, DM, epilepsy, or previous uterine OP. -Adverse & Side Effects: excessive dose may cause tetanic contraction & laceration or uterine rupture. Can cause uterine hypertonus if admin w/ oxytocin. N/V, diarrhea (frequent), fever, chills, facial flushing, headache, hypotension or HTN, tachycardia, pulmonary edema. -RN: keep refrigerated. Admin via deep IM, rotate sites if repeated. Monitor VS. Admin antiemetics & antidiarrheals if ordered.

Hypovolemic shock

Hypovolemic Shock: During and after birth, women can tolerate a blood loss approaching that of blood added during pregnancy. 1500 to 2000 mL total. o Compensatory mechanisms maintain the blood pressure so that vital organs are perfused. o Hypovolemia occurs with excessive blood loss. -Pad saturated w/in 1 hr indicates excessive blood loss & postpartum hemorrhage. -Any loss >500mL is considered impactful to the patient. >500mL for vaginal, >1000mL for CS—get H&H values sooner following delivery. If delivery went well then the redraw can be after 12hrs to assess status. H&H tells us if they are truly in hypovolemic shock & need to receive blood or not. · Monitoring for Signs of Hypovolemic Shock: o When mom comes in bleeding: get her HR & FHR/tones right away. o Increased pulse rate, falling blood pressure, increased respiratory rate o Weak, diminished, or "thready" peripheral pulses o Cool, moist skin; pallor; or cyanosis (late sign) o Decreased urine output (<30mL/hr) o Decreased hemoglobin and hematocrit o Change in mental status (restless, agitated, reduced concentration)

Infections during pregnancy: Chicken pox

Infections During Pregnancy: o TORCH: Toxoplasmosis, Other infections (hepatitis), Rubella, Cytomegalovirus, & Herpes simplex. These infections negatively affect pregnant women. -STIs: affect fertility & pregnancy. Chlamydia, Gonorrhea, Syphilis can be Tx w/ antibiotics, but viral infections pose a great risk. -Varicella-zoster (chickenpox): herpes group; transmitted by direct contact or via respiratory tract. Results are similar to Rubella + risk for limb hypoplasia, cutaneous scaring, & contact/airborne precautions must be maintained on mom & baby & only cared for by immune staff. Pregnant w/ shingles, on contact precautions. -Congenital Varicella Synd.: small risk in 1st T, greatest if 13-20wks. Limb hypoplasia, cutaneous scars, chorioretinitis, cataracts, microcephaly, FGR. -Later pregnancy: baby protected from mom's ABs crossing placenta. -Mom infected 2wk before birth: newborn varicella may occur bc mom didn't have time to make ABs. Admin Varicella-Zoster Immunoglobulin (VZIG). -Also give VZIG to baby's <28wks or <1,000g bc mom's ABs from early in pregnancy have not crossed placenta, reducing natural passive immunity. Admin w/in 96hrs to give passive/temporary immunity to exposed/susceptible pregnant woman. -Varivax: live, attenuated vaccine for children & susceptible adults who live in house w/ susceptible pregnant women -Non-immune PP woman: get 1st dose before D/C & 2nd at 4wks PP. AVOID pregnancy for 1mo. -Pregnant: report pulmonary s/s--SOB & cough. If Dx varicella pneumonia: hospitalization, fetal surveillance, full resp. support, & hemodynamic monitoring.

Interventions for PP hemorrhage: Bimanual Compression & Balloon Tamponade

Interventions for PP hemorrhage: Bimanual Compression & Balloon Tamponade o When concerned about postpartum hemorrhage, immediately following delivery the HCP can do certain interventions. o Mom has trickling blood after deliver, or pad saturated w/in 1 hr after delivery—must consider possibility of hemorrhage. RN: assess for risk factors before it occurs. Hold uterus down at bottom, & massage w/ other hand, increase fluids. Notify HCP, may do bimanual compression. o Bimanual compression: done by HCP to stop hemorrhage; 1 hand in the vagina, other hand compresses the uterus through the ABD wall. o Balloon tamponade: done by HCP to stop hemorrhage; like a large foley catheter, balloon filled w/ fluid (NS) to provide pressure on inside of uterus to stop the hemorrhage from occurring.

Laceration of Perineum: Degrees

Laceration of Perineum: · 1st degree: superficial vaginal mucosa or perineal skin · 2nd degree: vaginal mucosa, perineal skin, deeper tissues (fascia/muscles perineum). · 3rd degree: 2nd degree + anal sphincter. · 4th degree: extends through anal sphincter into rectal mucosa. -Laceration of periurethral area: can cause difficulty urinating, indwelling cath may be necessary for 1-2days. -Laceration of vaginal wall: mucosa of vaginal wall -Laceration of cervix: tears may be source of significant bleeding.

Mastitis

Mastitis: big problem w/ breastfeeding moms—infection of the breasts; breasts feel tender, warm, pie-shaped redness or trailing up the breast, w/ possible fever & flu-like s/s. · Early mastitis: enlarged tender axillary node, flush w/o sweating. · Acute Mastitis: enlarged, tender · Prevent mastitis in breastfeeding mom: early/frequent feedings, heat.

Methergine (methylergonovine)

Methergine (methylergonovine): ergot alkaloid, uterine stimulant. Stimulates sustained uterine contraction & causes arterial vasoconstriction. Used to prevent & Tx PP or post-abortion hemorrhage caused by uterine atony or subinvolution. -Dose: 0.2mg IM every 2-4hrs, max of 5 doses. Change to PO 0.2mg every 6-8hrs, max of 7 days. IV not recommended, in life threatening emergency give over 60s+ & closely monitor BP & HR, can cause severe HTN. -NEVER use in pregnancy or to induce labor, or if mom is hypersensitive to ergot, has HTN, severe hepatic or renal dz, thrombophlebitis, CAD, PVD, hypocalcemia, sepsis, or before the 4th stage of labor. -Adverse Rx: n/v, cramping, HTN, dizziness, headache, dyspnea, chest pain, palpitations, peripheral ischemia, seizure, & uterine & GI cramping. -RN: before admin, assess BP. Follow policy on what BP indicates med should be withheld. Tell mom to AVOID smoking (vasoconstrictor). Tell her to report any adverse effects.

Misoprostol (cytotec)

Misoprostol (cytotec): vaginal insert; used for pre-induction cervical ripening & labor induction (off label use). It's a synthetic prostaglandin tablet normally used to prevent gastric ulcers. -Dose: For ripening 1/4 of a 100mcg tab (25mcg) inserted vaginally. For induction repeat 25mcg dose ever 3-6hrs. 50mcg dose associated w/ hypertonic contractions.

Nutritional Needs of the Newborn & Recommendations of AAP on infant nutrition

Nutritional Needs of the Newborn: -Full term newborn needs about 100 kcal/kg of weight each day, formula & breastmilk have about 20kcal/oz (breastmilk may be a little bit +/-). Formula fed babies have increased risk of developing allergies. -Full-term breastfed infants: 85-100 kcal per kg (39-45 kcal per lb) daily -Formula-fed infants: 100-110 kcal per kg (45-50 kcal per lb) daily -Weight loss: During the early days the newborn may lose up to 10% of body weight as a result of insufficient intake and normal loss of ECF (was being provided by mom in utero). >10% weight loss is concerning. Term infant usually regains wt by 2wks old, evaluate further if: wt loss >7-8%, loss continues beyond 3 days old, or if wt not regained by 2wks old. -Newborns stomach size is small & may fall asleep before adequately feeding—stomach size increases rapidly, by the end of the 1st wk may take 60-90mL (2-3oz). Simple CHO & protein digested well, Complex CHO & fats not well digested bc lack pancreatic amylase & lipase. Fluids in first 3-5 days 60-100mL/kg needed (normal term baby), gradually increases to 150-175mL/kg--formula or breastmilk supplies this, no H20 necessary. -AAP recommends infants receive ONLY breastmilk for first 6mo, continue to breast feed till 12mo old w/ addition of complementary foods.

Placental Previa

Placenta previa: implantation of placenta in the lower uterus & near the fetal presenting part. 1:200-300 pregnancies. S/S: painless vaginal bleeding during last ½ of pregnancy, usually bright-red bc from lower segment of uterus. Dilation at location of placenta causes bleeding into vaginal canal. Not painful bc it's just the small dilatation of the cervix, most moms don't feel this right away. CS must be performed bc we don't want her to dilate (start labor), dilation causes bleeding so mom & baby will lose blood. CS planned right at 37wks or completion of 37wks. Types: marginal—low lying, right up to cervix but may not cover- can later be drawn upward, partial—at least 3cm from internal cervical os, total—completely covers the os, causes more bleeding.

Preeclampsia: Mild vs Severe

Preeclampsia: BP elevation after 20wks w/ proteinuria; Systolic >140 or Diastolic >90. Presence of protein in urine indicates need to do a 24hr urine collection >0.3g in 24hrs; or a Urine dipstick >1+ protein Dx proteinuria. o Mild: Systolic >140 but <160. Diastolic >90 but <110. Protein 24hr collection >0.3 but <2g; >1+ random dipstick. May have minimal increase in liver enzymes ALT/AST, absent-mild visual disturbances. o Severe: Systolic >160 (2 readings, 6hrs apart, on bedrest); Diastolic >110. Proteinuria 24hr collection >5g; >3+ random dipstick. Serum creatine elevated >1.2mg/dL, decreased platelets <100,000, Liver enzymes ALT/AST elevated, oliguria <500mL/day, severe headache common, confusion from cerebral edema, persistent URQ or epigastric pain may radiate to back from distension of liver capsule (w/ n/v) may be present & precipitates seizure, visual disturbances (spots, sparkles, temporary blindness, photophobia) are common & retinal detachment can occur, pulmonary edema/HF & cyanosis may be present, fetal growth restriction & reduced amniotic fluid. ABD pain may also indicated abruptio placentae. Changes in LOC, mood, alertness can precipitate a seizure.

Pregnancy Hypertension

Pregnancy Hypertension: · BP range: must consider pt baseline. · Gestational HTN: no BP problems before pregnancy, BP elevates after 20wks w/o proteinuria, returns to normal w/in 6wks PP. Systolic >140 or Diastolic >90. · Chronic HTN: Dx when known to exist before pregnancy or developed before 20wks gestation. Also Dx if HTN persists after 6wks postpartum. Sometimes moms don't know they have BP problems, so we don't know if its gestational or chronic HTN, but if it persists 6wk after delivery then it is chronic. Preexisting HTN or occurring prior to 20wks gestation. If not assessed before 20wks, it can't be Dx until 6wks after birth in postpartum visit. Systolic >140 or Diastolic >90.

Preterm labor signs

Preterm labor signs: -US or exam reveals changes in cervix occurring over several wks in 2nd & 3rd T. Only when it is in its active phase, will the typical s/s of labor occur: -Uterine contractions, may or may not be painful, may not be felt at all. -Sensation of the baby frequently "balling up". -Cramps (period-like) -Constant low backache; intermittent or regular low back pain. -Pelvic pressure, baby is pushing down or is heavier. -Pain, discomfort, or pressure in the vulva or thighs. -Change or increase in vaginal discharge (watery, bloody). -ABD cramp, w/ or w/o diarrhea. -Feeling "bad" or "coming down w/ something".

Puerperal infections

Puerperal Infection: postpartum infection; s/s fever, chills, pain or redness of wounds, purulent drainage, edges not approximated, tachycardia, uterine subinvolution (uterus not contracting the way it should), abnormal duration of lochia—rubra for too long, foul odor of lochia, elevated WBC count, frequency or urgency of urination, dysuria or hematuria (not associated w/ lochia), suprapubic pain, localized areas of warmth/redness or tenderness (includes breasts), body aches, or general malaise. o Endometritis: inflammation of uterus lining; occurs 36hrs PP. Usually caused by normal flora. Leukocytosis that doesn't decrease after early PP 30,000+. o Wound infection: incision not well approx. w/ seropurulent drainage, UnTx general infection S/S of malaise, fever occur. o Urinary tract infection: bladder & urethral trauma during birth, in PP hypotonic & stasis present/reflux. Cath may cause UTI. o Mastitis: infection of breast, 2-4wk PP or anytime during breastfeeding. Local lump or wedge-shape area of pain, redness, heat, inflammation, & enlarged axillary nodes. UnTx can cause breast abscess. o Tx postpartum infection: antibiotics, depends on location & type of organism—must do a C&S of the site we think is infected. May start w/ broad-spectrum AB & as culture comes back change to a specific AB.

Rh Incompatibility: Rhogam

Rh Incompatibility: Rhesus (Rh) incompatibility during pregnancy; 2 events must occur—mom is Rh- & baby is Rh+, so dad must be Rh+. This dz only affects the fetus, not the mom. Rh- is a recessive trait, so much inherit the gene from both parents. More common in Caucasians (15% of pop.), less common in African-Americans & Asians. -Rh antibodies cross placenta & destroy fetal RBCs, causing reduced fetal O2. RBC destruction causes bilirubin to rise (icterus gravis), can cause severe neuro-dz (bilirubin encephalopathy or kernicterus) w/ staining of brain tissue. Hemolysis causes rapid production of erythroblasts (immature RBCs) that cant carry O2—called erythroblastosis fetalis. Severe anemia leads to hydrops fetalis (general edema) & fetal CHF. o Dx: all pregnant women need to have blood test for type/factor at initial prenatal visit. Rh- mom will have antibody titer (indirect coombs test) to see if they are sensitized. If negative, then repeat at 28wks. Continued negative tests accurately determine risk for hemolytic dz of newborn. Positive coombs indicates that mom is sensitized & is forming antibodies to Rh+ RBCs. Test repeated throughout pregnancy to determine if antibody titer is rising. -Amniocentesis performed to evaluate optic density of fluid, measures bilirubin/hemolysis—low OD = baby Rh- or no jeopardy if Rh+; high OD = fetus in jeopardy. US & Doppler also used to evaluate cardiac function, BF in vessels. General edema, enlarged heart, & hydramnios—occurs w/ severe anemia. -PUBS or cordocentesis: invasive procedure; ID degree of RBC destruction. Reserved for baby that's significantly affected. -Rho(D) Immune Globulin (RhoGAM): prevents Rh incompatibility by admin passive antibodies against Rh factor—prevents antibody formation by destroying fetal cells in mom's circulation, IM injection. Give after every birth of Rh+ baby. Dose 300mcg (higher dose for hemorrhaging) at 26-28wks as prophylactic, again after delivery w/in 72hrs—fetal Rh antigens in maternal blood are destroyed preventing antibody formation. Hospitals starting to draw titers & don't administer unless negative for antibodies, & mom is Rh-, baby Rh+. At birth, if mom Rh- & umbilical cord blood test to ID baby's type/factor & antibody titer (direct coombs). RhoGAM also given for amniocentesis or chorionic villus sampling, ABD trauma, ectopic pregnancy, abortion or threatened abortion where pregnancy continues—abortion very early in pregnancy, admin a micro-dose of 50mcg after abortion <12wks. -Preventative: baby considered Rh+ & RhoGAM admin to unsensitized Rh- mom at 28wks. Repeat after birth if baby is Rh+.

Shoulder dystocia

Shoulder dystocia: head delivers but shoulders stuck under symphysis pubis; "turtle sign" or failure of complete external rotation of the shoulders. -McRoberts Maneuver: bring moms knees up to her ears, as close as possible—helps open the pelvic opening & deliver the baby by straightening the pelvic curve. A supported squat will have a similar effect w/ benefit of gravity. -Suprapubic Pressure: done after McRoberts; press down on suprapubic area to apply pressure to the anterior shoulder to push it down from above the symphysis pubis & assist in pelvic opening. Frequently breaks or flexes the baby's clavicle. After delivery, baby's arm will be immobilized w/ a shirt that is pinned. Pressure is right above symphysis pubis, do NOT press on fundus at all bc that will push shoulder back into symphysis pubis.

Sickle Cell Anemia & Anemia (iron, folic acid) in Pregnancy

Sickle Cell Disease: autosomal recessive genetic ds; causes anemia bc abnormal Hgb, resulting in distortion & destruction of RBCs. SCD is worsened by pregnancy changes, pt may need to stay in the hospital for most of the pregnancy. -Management: avoid SC Crisis; provide prenatal teaching on prevention of crisis, keep all prenatal appts, stay hydrated, adequate nutrition & folic acid supplements for RBC production, good hygiene, avoid people w/ infections, promptly Tx self for illness & fever. -Monitor Frequently: CBC, Hgb, & serum iron. When home, Tx infections & monitor fetus. May have prophylactic transfusions done to keep higher number of good RBCs in their body to transport O2 & nutrients to the baby. -Anemias: decline in the circulating RBC mass, reduced the ability to carry O2 to vital organs of mom & baby. Associated w/ preterm birth & low birth weight infants. Anemia Dx if moms Hgb <11g/dL in 1st/3rdT or <10.5g/dL in 2ndT. o Iron deficiency: 75% of anemias in pregnancy; difficult to meet iron needs during pregnancy through diet alone, so ferrous sulphate 325mg 1-3x/day is frequently ordered. Take w/ meals to decrease discomfort & take w/ 500mg Vit C to enhance absorption. Iron can change color of BM & increase constipation, so educate pt about the SE & to increase fluids & fiber. o Folic acid deficiency (megaloblastic): associated w/ increased risk of neural tube defects. Folic supplementation is necessary, even if woman is considering pregnancy, she should get blood tests to determine nutritional status & begin taking prenatal vitamins. If she has folic acid deficiency, she will need higher supplemental doses than what is in a prenatal vitamin.

Assessing the skin of a newborn

Skin: checked right after birth w/ ABCs/APGAR o Color: Pink or tan is normal; indicates good O2. Red/thin skin in premature baby is normal, red skin in a term baby may be polycythemia. -Acrocyanotic: normal, expected when they go from fetal to neonatal circulation; hands are blue in first 24-48hrs of life, s/s of acclimation—most of the blood is shunted to the brain & vital organs centrally, so they have poor peripheral perfusion. Educate parents, they often think it's a s/s of being cold & they need to cover up the baby. -Pallor: paleness of skin, indicates anemia or poor perfusion. -Mottling (cutis marmorata): lacy/patchy red or blue marbling/discoloration of the skin, indicates baby being cold, stressed, overstimulated, or possible chromosomal abnormality. -Cyanotic: blue color all over, NEVER a good s/s in a newborn. -Harlequin: 1 side of baby is pale/blue, other side is pink/red—can indicate an underlying problem, needs to be investigated further. Often temporary, transient condition in low birth weight babies, it's benign. o Vernix: thick-white substance (cheese-like), protective covering of fetal skin in utero. Thin covering on term baby, thick on preterm, yellow if high bilirubin, green if meconium stained. Ex. large baby, more vernix, meconium stained—may be a baby of a DM mom bc large size w/ s/s of prematurity & complications w/ delivery. o Lanugo: fine hair that covers the baby in utero, used in gestational age assessment—more prevalent if premature. o Milia: 1mm white cyst, caused by sebaceous gland secretions. On forehead, nose, cheeks--disappear in 1st few wks w/o Tx. o Meconium stained: green, indicates 1st stool has passed. o Assess for Edema, Peeling, Rash, Petechiae—may indicate an underlying problem. Petechia not expected in a newborn. o Ecchymosis: bruising o Mongolian Spots: blue/gray spots that look like bruises, seen in African & Asian babies (babies w/ darker skin); usually on backside & disappear after 1st yr of life, some continue into adulthood. Teach parents that this isn't a bruise. o Café Au Lait Spots: looks like a coffee-stain on the skin; can get darker w/ time. They do NOT indicate any problem or ongoing issue—it's just a birthmark. o Stork Bite: indicates baby may have been laying on a bony prominence in utero & had capillary beds form. Usually on the back of the head (could be elsewhere like nose) bc this is normal position in utero—typically don't go away & if head shaved when older, you can see it when they are overheated.

Heat loss by: Evaporation, conduction, radiation and convection

Thermoregulation: cold temp. is needed to stimulate respirations, but we don't want baby to get cold after birth. Dry them off to stop them from losing heat. o Newborn characteristics leading to heat loss: Skin with little subcutaneous (white) fat; BVs close to the surface--& are constricted after birth to push the vital blood supply to the lungs, brain, heart; Large skin surface area for their body size. o Methods of heat loss: -Evaporation: air drying of skin that causes cooling, insensible loss from skin & respiratory tract increases heat loss from evaporation; present at birth, wet when they come out & heat is lost through the moisture on their skin—ex. when not dried right away at birth or when bathing. Keep them relatively warm & covered. Teach mom how to keep them covered at home bc they don't have a radiant warmer. -Conduction: movement of heat away from the body when baby comes in contact w/ cold objects, ex. bed. We want the bed to be warm, in hospital use the radiant warmer, skin to skin, at home teach mom to lay baby on warm towel. Contact w/ warm objects increases body heat by conduction. -Convection: transfer of heat from baby to the cooler surrounding air; from drafts & open doors, air conditioning or air currents; occurs when we remove them from heat. Teach mom when bathing or laying baby in bed at night, ensure there aren't drafts coming through. -Radiation: transfer of heat to cooler objects that are not in direct contact w/ skin; when baby is near a cold surface, not touching, ex. near a window when it's cold outside. Baby will lose heat bc of proximity to the cold surface. Keep baby away from cold windows & walls, use a radiant warmer. --RN: dry the baby when wet, keep on a warm surface, away from drafts or air currents, & away from cold areas.

Parent teaching formula feeding their newborn

Types of formulas: all should be iron-fortified. -Ready to use: in bottles that you need to add nipple to, or in cans that can be poured into a bottle. Do NOT dilute; its more expensive, but convenient for travel (H20 supply is questionable, or mixing is difficult). Open can should be refrigerated & used w/in 48hrs. -Concentrated liquid: add equal parts H2O to liquid & mix in a bottle. Open can should be refrigerated & used w/in 48hrs. Careful w/ concentrated & Powdered: before multiple languages printed on packaging, people in different cultures were giving baby concentrated formula w/o diluting it—lead to dehydration in these babies. Companies now provide multi-language labeling. Educate to ensure they are mixing formula correctly, do NOT microwave bc it creates hot spots that could burn the baby. -Powdered: mix powder & H2O. More economical & good for breastfeeding moms who want to do an occasional formula feed. Usually, 1 level scoop is added to 2oz H2O, mix well to dissolve. New formula used for each feeding; it's not sterile, so may not be appropriate for preterm or immunocompromised baby. -Preparation: Should be diluted exactly according to directions, improper dilution can cause undernutrition, dehydration, or Na imbalances. Should not be heated in the microwave. Proper hand hygiene before preparation, clean top of can & can opener before prep. Contaminated milk or H2O can cause an infection. Prepared bottles should be used w/in 24hrs. -Feeding techniques: Teach to feed in semi-upright position like the cradle hold, hold the nipple so that it fills w/ formula (prevent excessive air intake). Alternate arms for each feeding to provide varied visual stimulation. Burping (Bubbling) takes place after every 1/2 oz of formula intake for the 1st few days, gradually the time will increase & will only need to be done ½ way through the feeding. To burp place the baby over your shoulder or in a sitting position w/ head supported, while you pat & rub the babies back. Feed every 3-4hrs, only ½ -1oz for each feeding the 1st day, increases to 2-3oz/feeding w/in 1 wk. Sleep = satisfied baby. Heat in a bowl of hot water for 15min, test temp by dropping formula on you inner arm. -Gagging, choking, sputtering, drooling, biting indicates the flow is too fast. If infant sucks too quickly, provide a rest period by tipping the baby forward, so there is no milk in the nipple. -Do NOT prop the bottle or let the baby sleep w/ the bottle—could lead to aspiration, you're also eliminating the bonding that should accompany feeding. Pooled milk can lead to cavities. Sleeping w/ bottle or having it propped can lead to Otis media. Don't coax the baby to finish the bottle bc could cause regurgitation & excessive weight gain. Discard unused milk w/in 1hr to prevent infection. -Formula can be admin at room temp, but some babies like it hot or cold. Use same techniques for stimulation that are used w/ breastfeeding, when the baby is sleep. Angle tip of nipple so that it rubs the palate should trigger the suck reflex.

Uterine rupture

Uterine Rupture: muscle of the uterus ruptures. Ex. in mom w/ previous CS where they did a vertical incision, previous uterine surgery, or unDx uterine deformity (thin muscle layer of uterus—pressure of baby & contractions leads to rupture). -Complete: direct communication between uterine & peritoneal cavities. -Incomplete: rupture into the peritoneum covering the uterus or into broad ligament, but NOT into peritoneal cavity. -Dehiscence: partial separation of old uterine scar (from CS w/ classic/vertical into upper uterus incision, or removal of fibroids). May be little to no bleeding, or any s/s--found during CS birth or ABD OP. o Clinical manifestations: -Signs of shock. Extreme ABD pain. A sense of tearing—mom will report this. Chest pain or pain in the shoulders. Abnormal FHR patterns. Cessation of contractions—seen on the monitor. Palpation of the fetus outside of the uterus—done by the HCP. -Tx: get this baby delivered ASAP. Risk of rupture decreases after birth.

Vitamin K injection

Vitamin K injection (K1, phytonadione, AquaMEPHYTON, Konakion, Mephyton): an anti-hemorrhagic, fat soluble vitamin. Promotes formation of factor II (prothrombin), VII, IX, X by the liver for clotting. Provides vit-K, not synthesized in GI until the flora is established. Prevents or Tx of vit-K deficiency bleeding (hemorrhagic dz of the newborn). -Dose: 0.5-1mg (0.25-0.5mL containing 1mg/0.5mL) given IM w/in 1hr of birth for prophylaxis. May be delayed until after 1st breastfeeding in the delivery rm. May be repeated or higher dose used if mom used anticonvulsants in pregnancy or if baby shows bleeding tendencies. Effective w/in 1-2hrs. -Adverse Rx: erythema, pain, edema at IM site. Hemolysis or hyperbilirubinemia, esp. in preterm or if large dose used. -RN: protect med from light, until just before admin bc it causes decomposition & loss of potency. Observe all infants for s/s of Vit-K deficiency: ecchymosis or bleeding from any site. Ensure baby had Vit-K before circumcision is performed.

Care for Preeclampsia: home vs hospital

o Care for Preeclampsia: -Home Management: · Activity restrictions—but not full bedrest, have periods of rest in left-lateral, then normal ADLs. · Monitoring of fetal activity w/ kick counts · Blood pressure monitoring 2-4x/day same position & arm · Weight measurement- daily, same time & scale, w/ similar clothing. Edema means worsening, s/s rapid weight gain—ex. 3-5lbs in 2-3 days. Progressive wt gain is expected w/ pregnancy. · Urinalysis for protein · book says regular diet w/o salt or fluid RESTRICTIONS · Fetal surveillance: kick-counts at home, frequent US to assess fetal growth. BPP (5): NST, US lung movements, US gross movements, US fine movements, US FHR. Can be given corticosteroids (beta-methylzel) if <34wks to accelerate fetal lung maturity, done when BP is getting worse bc induction is indicated. · Report to HCP: reduced fetal activity, protein >1+, pain in URQ (liver hemorrhage precedes seizure), visual disturbances. -Hospital Management: · Bedrest w/ bathroom privileges (lay on left side), excessively salty food is avoided, high protein encouraged, admin IV fluids, visitors in moderation allowed. · Bedrest/Seizure precautions: reduce stimuli. Monitor reflexes to see if worsening condition. · Antihypertensive Medications o hydralazine hydrochloride: IV push, 5-10mg doses every 20min for max of 20mg. o methyldopa: 250mg BID; drug of choice for safe use in pregnancy. But Procardia used more often. These 2 are PL DOC. o labetalol (Trandate): 20-40-80mg, every 10min, max of 220mg. · Anticonvulsant Medications: reflexes +1 to +4, at +4 they will have a seizure. o magnesium sulfate: drug of choice; its an anticonvulsant, not an anti-HTN, but it does end up lowering BP. 40g/500mL- 1L, lower fluid vL used when edematous. Give 6g/20min, then 2-3g/hr by IV piggyback—closest to port of entry bc if needs to be stopped, can prevent more from going into BVs. SE: respiratory depression, reduced/absent reflexes—monitor closely. Always on a pump, if giving bolus watch mom/baby very closely. It's a CNS depression that prevents or Tx seizures, secondarily it increases peripheral BF, so decreases BP initially—but BP isn't the purpose of use. Can be used for preterm labor bc increase BF to the uterus, which inhibits contraction. Delivering on Mg can cause uterus to not contract after delivery, "boggy uterus", risk of hemorrhage at placental site—monitor more closely after delivery. Hold Mg if RR <12 & UO <25mL/hr. Antidote: Calcium Gluconate, kept in a labeled syringe at pt bedside. o Continuous Fetal Monitoring: the entire time while on Mg-sulphate. Mg can cause decreased FHR variability, unlikely to cause late decelerations. o Induction of Labor: likely used in preeclampsia to delivery baby quicker. Mg inhibits contraction (risk of hemorrhage), so higher levels of Pitocin may be needed. Risk of high BP present for a few days PP, Mg is continued. -Baby: Reduced BF to the placenta in preeclampsia limits nutrients, fluids, and oxygen available to the fetus and often results in a low-birth-weight infant (SGA infant). SGA: hypoglycemia <40mg/dL, temp. instability, polycythemia, & bleeding tendency.

Classification of Heart Disease & PP Care

o Classification of Heart Disease: maternal & fetal risks are low w/ I & II, greatly increased w/ III & IV. -Functional Classification of Heart Disease (NY Heart Association): -Class I: not compromised; no activity limits. -Class II: slightly compromised; requires slight limitations of activity. Pt is comfortable at rest, but normal activity causes fatigue, dyspnea, palpitations, or anginal pain. -Class III: markedly compromised; marked imitations of activity. Pt is comfortable at rest, but less than normal activity causes excessive fatigue, dyspnea, palpitations, or anginal pain. -Class IV: compromised; unable to perform activity w/o discomfort, s/s of cardiac insufficiency present at rest. --Focus of Management: for I & II, limit activities so cardiac demand does NOT exceed the functional capacity of the heart; keep free from s/s of cardiac stress. For III & IV, prevent cardiac decompensation & development of CHF. -RN: while hospitalized or during pregnancy; assess for changes in VS, ID factors that can increase mom's cardiac workload—cleaning/child-care, help pt/family understand these factors & assess for adherence to restrictions when home, teach modifications that allow mom to live w/in her cardiac reserve—ex. rest periods & sitting when able, avoid temp. extremes, & stress management.

Other Changes in the PP period: ABD, Blood vL & components, Weight loss, Chills/Diaphoresis, Urinary Tract

o Diastasis recti (separation of longitudinal muscles) may have occurred, minimal-severe. Improved w/ gentle exercise, diastasis resolves in 6wks. More often in fit moms. o VS and Blood Values: VS return back to normal, esp. if mom had any changes/issues during pregnancy. Blood vL—during pregnancy hemodilution to account for bleeding after delivery. Extra vL excreted in urine (3,000mL day, esp. day 2-5) & sweat, Hct 4-6wks to return to normal (unless hemorrhage). Take additional labs (12hrs postpartum) to check H&H. If mom has been bleeding, take sooner than 12hrs. Fibrinolysis decreased during pregnancy, increases after birth to several days—increased risk of thrombus. 4-6wks for hemostasis to return to normal. Thrombophlebitis increased w/ prior Hx, varicose veins, CS. Monitor, compression devices applied or ordered. o WBC is 25,000 2nd PP day, marked leukocytosis w/ WBCs as high as 30,000 normal during labor & immediate PP period. Returns to normal by 6th PP day. o Weight Loss: sudden from delivery of baby, amniotic fluid, placenta, blood loss. 5.5kg (12lbs) lost during birth. Additional 4kg (9lbs) over next 2wks, 2.5kg (5.5lbs) by 6mo. Loss of fat is slow, average wt gain of 1kg (2.2lbs) per pregnancy. RN: provide info on proper diet/exercise that wont deplete energy or impair health. o Chills & Diaphoresis: extra fluid of pregnancy, when not used to accommodate for blood loss, will need to be removed from circulatory system. Moms will find themselves saturated from head to toe (hormones & extra fluid)—and think something is wrong bc chills usually indicate fever/illness. Educate her that this is normal following delivery, assess lab values, provide showers & dry clothing. o Urinary Tract: sensation of need to void may not return immediately postpartum—could have incontinence bc she doesn't feel bladder filling up. This should return to normal after a few days-wks. Increased risk of UTIs, bleeding (distended bladder causes uterine atony), stress incontinence. Kidney & ureter dilation improves by 1st wk, normal by 2-8wks. Protein (catabolism) & acetone (dehydration) in UO for few days.

Gestational Diabetes

o Gestational Diabetes: CHO intolerance of variable severity that develops, or is 1st recognized during pregnancy. It may be unDx DM2, but if it occurs/Dx during pregnancy than it is gestational diabetes. Placenta produces estrogen & cortisol, they inhibit insulin, BS level is increased. Counterintuitive to role of the placenta, should help the baby grow, not block its growth. -Gestational diabetes is responsible for 2 major complications in the fetus: · Macrosomia: at birth baby is 4,000g+, may cause birth injury & complications getting out of birth canal (shoulder dystocia). Bigger baby, born too soon has immature lungs. · Hypoglycemia: result of increased BS levels in mom, baby's BS increases & it responds w/ diuresis & increased panaceas production of insulin. At birth, the pancreas is still producing high insulin, fetal glucose stores are used up, resulting in hypoglycemia. Low BS & hypoglycemia can cause brain damage in the baby. -Maternal effects of GDM: · UTI: from increased voiding. [Poly]hydramnios: from fetal hyperglycemia & diuresis—can lead to premature ROM. Preeclampsia: increased risk w/ GDM. -Risk factors: mom is overweight or obese (BMI >25), maternal age >25yrs, previous birth outcome associated w/ GDM (macrosomia, maternal HTN, unexplained fetal congenital anomalies, previous fetal death), GDM in previous pregnancy, Hx of abnormal glucose tolerance level, Hx of DM in a 1st degree relative, member of high-risk ethnic group (Hispanic, African, Native American, South or East Asian, Pacific Islander). · Therapeutic Management of GDM: o Diet: will be restrictions; meet w/ DM educator or nutritionist. 30 kcal/kg/day for a DM woman w/ normal weight. Adjusted for over & underweight pts. CHO/Protein/Fat: 40-45% of kcal should be from CHO, for energy & G&D of baby. 10-12% of kcal from protein, approx. 60g. 40% of kcal from fat. Diet 3 meals/3 snacks—spread out throughout the day, eat regular meals w/ snacks & protein. Depending on GI issues, content of the food intake will vary. o Exercise: helps manage BS levels. o Glucose level monitoring: helps guide the diet & insulin Tx. o Fetal surveillance: "kick counts" at home. She will have increased US assessments of fetal growth & amniotic fluid levels, serial NSTs & BPP (NST, US of FHR, breathing, movement, tone, amniotic fluid vL).

Hepatic system - Hyperbilirubinemia

o Hepatic system - Hyperbilirubinemia: excessive bilirubin in the blood, can lead to accumulation in the brain (bilirubin encephalopathy). If long term can cause permanent injury (kernicterus); liver is one of the last things to mature. Physiologic & pathologic causes of bilirubinemia. o Physiologic jaundice: premature or immature liver is normal. Increase in bilirubin is gradual over first 24hrs of life—result of hemolysis of RBCs & immature liver. Gradual yellowing of skin usually starts on ABD & moves to face, once in face can move to the eyes. Eyes are an ominous s/s of it moving to the brain. Watch these gradual physiologic processes closely. o Breast milk jaundice: another physiological process; when breast feeding & there's not the fluid vL needed to push the bilirubin into the GI for removal. Not caused by breastfeeding, it's a lack of vL needed to clear out the bilirubin. Baby may have small amounts of jaundice; we still need to monitor & see if increasing—if increasing may need to admin fluids. Tx increased formula or breastfeeding, other fluid admin, Bili-lights (phototherapy breaks bilirubin down through the skin). o Pathologic jaundice: disease process; blood incompatibility for mom & baby. Rapid development of jaundice. Also mom & baby could have had hepatitis, or there may be another patho problem of the liver/body that causes excessive RBC loss o Factors that increase hyperbilirubinemia: hemolysis of erythrocytes (or underlying RBC problem), short RBC life in newborn, lack of albumin binding sites (sites help clear bilirubin from body through the liver), liver immaturity, preterm & late preterm infants, lack of GI flora, feeding was delayed, trauma that causes bruising (cephalohematoma), fatty acids from cold/stress/asphyxia. o Bili lights: for pathologic or physiologic jaundice. But physiologic is common, so all babies won't be put on photo Tx—watch/monitor, when level becomes higher, put on photo Tx.

Feeding cues for hungry infant

o Hunger Cues in the Infant: RN will ID cues & teach the mom. o Early Cues: stirring, mouth opening, bringing hands towards face, sucking on hands, lip-smacking, seeking/rooting around—indicates they are getting a little hungry, why we don't want to wrap hands down around body, so they cant bring them to their face. o Mid Cues: increased sucking/hand-to-mouth, increased movement, yawning/stretching, activity increases. o Late Cues: crying, agitated movements, color turning red—calm them down FIRST, then feed.

What are signs that the baby breast fed well?

o Is the baby getting enough? Assess wt gain & I&Os. o 1st Assess latch and suck: is the latch/suck appropriate & can you hear swallowing. o Then ask if her breast softens after feeding—in early PP, breasts aren't going to be filling, so this may not be a good determinant for proper feeding. o Is the baby feeding 8-12 times a day, every 1.5-3hrs? Preterm sleep more, term will wake up every 2-3hrs to feed. o Does the baby have wet diapers: 2 on day 1; 3 by day 3; 6 by day 4. o Assess for passing of stools: By day 3 - passing at least three bowel movements. 1st stool is meconium (black, sticky-tary), transitions to the green stool, then yellow-seedy, then yellow-mushy. Breastfed babies stool is usually yellow-mushy for a long time. -HCP: baby will have follow-up in 1st wk., or less 2-3 days if problems are present. -If mom wants to breast & bottle feed, tell her to breastfeed for 1mo, once milk is established can bottle. Freeze for 6mo or refrigerate for 48hrs--dont reuse milk baby has drank off of.

Newborn Reflexes- Moro, suck, rooting, palmar, plantar, Babinski, tonic neck, stepping, crawl.

o Moro: startle reflex; lift up baby & drop head/trunk by 30 degrees, both arms go out & hands open up (done 1x/day). Indicates the NS is intact, when you move them or make a loud noise they should startle. o Suck: baby should be able to latch on and suck when a finger or nipple is put in their mouth; assess for presence & strength to determine feeding effectiveness. o Rooting: important in feeding, usually shown when hungry; touch the cheek near the mouth & the baby will turn head toward side that has been touched. Helps baby find the nipple, occurs on both sides; doing it on both sides at same time confuses the baby. o Palmar Grasp: when you put a finger in the baby's palm near the base of their fingers, their fingers will close around your finger. Weak or absent indicates injury to the nerves. o Plantar Grasp: push your finger right below the toes, toes will curl. o Babinski: abnormal in an adult; normal in an infant. Stroke the lateral side of the sole of the baby's foot, from the heel forward & across the ball of the foot—toes will flare outward & the big toe will dorsiflex. o Tonic neck: infants extends the arm & leg on the side the head is turned to, the extremities on the opposite side will flex. (AKA "fencing reflex") o Stepping: when you hold the baby up w/ their feet touching a solid surface, they will lift one foot then the other—looks like walking. On ABD can push themselves up w/ legs to their moms breast. o Crawl: put baby on ABD & they will lift their head up & put arms down. Important to put baby on ABD daily while awake for "belly time"—allows them to build up their neck tone bc while sleeping they are always on their back.

Assessing the tone & activity of a newborn

o Normal Tone: baby should be very active, w/ flexion & extension. Sharp flexion & resistance of extension during exams is normal. o Hypotonic: decreased muscle tone (limp or floppy); move somewhat, but just not interested in in moving—ex. don't want to lift up head when pulled or dangled, or lay flat on bed w/o trying to move. When tone is diminished, we often see respiratory effects as well—so monitor for respiratory problems. Infants w/ previously good tone may show decreased flexion when hypoglycemic or w/ respiratory difficulty (inadequate O2). o Hypertonic: extreme flexion & movement; may indicate neurological or BS problems, so monitor. o Normal Activity: crying, when being assessed (put on scale) they should be pulling inward. o Lethargic: tired, exhausted; unable to elicit a cry-response. Can elicit reflexes, but unable to show us normal activity. RN assess what mom was given in labor, is this drug still active. o Jittery: hands will shake, stop for a moment, then continue; from low BS or CNS stimulant—RN check BS right away. · Cry: moms can differentiate between cry types pretty quickly, but the baby's nervous system is still developing & they sometimes elicit incongruent cries—ex. crying may be from neuro-problems, drug addiction, or just overstimulation—teach mom how to differentiate the cries & RN needs to ID/assess the different cries. o Normal Cry: this is a good sign, helps lungs/O2 & allows us to assess for proper functioning; crying when cold, hungry, uncomfortable, upset, etc. o No Cry: indicates a problem—crying is needed for lung expansion. Meds [narcotics] may depress the lungs & respiratory function, resulting in poor expansion & poor O2. o Excessive: must assess as to why—pain after delivery, clavicles not intact. o Shrill: indicates a problem w/ the baby like drug addiction; unable to console them w/ any measures.

Assessing the genitalia & anus of a newborn

o Normal female Genitalia: assess labia, in term baby the labia majora should be large & completely cover the minora & clitoris. Labia may be darker, edema of the labia & white vaginal discharge are normal. Pseudo-menstruation: small amount of vaginal bleeding, from sudden withdrawal of maternal hormones. Can see the clitoris & urethral opening. Hymenal/vaginal tags are normal & usually disappear in a few wks (from the book), but Smith said they are abnormal (not on test). o Normal male Genitalia: can see the urethral opening at tip of penis. Scrotum should be pendulous & may be dark color, could have edema from pressure in breech delivery. Rugae are deep & cover the scrotum in a term baby. Feel to see if testes have moved down into the scrotal sac, on both sides. If testes are still in ABD, could become sterile from body heat—monitor for a time, esp. if premature, but US may be indicated to ID location/presence & fix if needed. o Ambiguous: cant differentiate between male & female; associated w/ chromosomal abnormality. -Abnormal Female, Hymenal or Vaginal Tag: small piece of tissue at vaginal orifice; indicates an internal problem, investigate further w/ US—can sometimes just be removed & a suture will be left in place. -Abnormal Male: parents may be concerned about genital abnormalities, explain the condition & why foreskin should not be removed for circumcision bc it may be needed for future plastic surgery to repair the defect. · Hydrocele: fluid from ABD enters into the scrotal sac & surrounds 1 or both testes, enlarging the sac—can make the penis look smaller (relative size difference). · Cryptorchidism: undescended testes, located in the ABD where they may become sterilized. Usually descend by 6mo old, if still haven't descended by 1yr old, OP is considered. · Hypospadias: urethral opening (meatus) is on the underside portion of the penile shaft or perineum. · Epispadias: urethral opening on upper side of the penile shaft. · Chordee: may accompany hypospadias; the fibrotic tissue causes the penis to curve downward—may be corrected by OP later in life. Teach parents why foreskin needs to be kept. · Anus, Normal: can see the anal opening. Assess by taking first temp. w/ anal probe thermometer, ID temp. + patency. o Imperforate: when the anus is NOT patent; no opening for feces to come out. Must be ID & corrected ASAP to prevent further problems for this baby.

PROM & PPROM

o PROM: Premature Rupture of Membranes; rupture of the sac before the onset of true labor, regardless of length of gestation. Can be normal if before a term birth at 38wks+, even if induction is needed. o PPROM: Preterm premature rupture of membranes; rupture occurs before the end of 37 weeks of gestation, can be w/ or w/o contractions. Associated with preterm labor (PTL) & can lead to chorioamnionitis. -Avoid vag-exams if preterm & no s/s of labor, HCP does a sterile speculum exam to look for fluid & est. dilation & effacement. Fern test ID fluid (blood, semen, infection can alter). Assess fetal lung maturity, TV US to ID cervical length (short = <25mm). -If at/near term w/ good cervix, then induce. Cervix not favorable & no infection, delay induction 24hrs+ to allow softening & admin prophylactic anti-infective drugs. If induction unsuccessful, or if there is an infection/complication--CS indicated. But CS increases risk of infection. o Chorioamnionitis: inflammatory reaction in the amniotic membranes caused by bacteria or viruses in the amniotic fluid. Can be the cause and a result of PROM, can cause premature labor as well; ROM before term & we try to continue to get the baby to grow & admin betamethyzone to increase maturity of lungs, baby can get infection of ROM continuing for a prolonged period. o Teach: difference between urine & spontaneous ROM—pH test on amniotic fluid, or a fern test (amniotic fluid under microscope looks like fern or snowflake crystals). o Signs Associated with Intrapartum Infection: From PROM or infection present w/ ROM: fetal tachycardia bc mom/baby temp. >100.4, foul or strong-smelling amniotic fluid, & cloudy or yellow amniotic fluid.

Postpartum Blues, Postpartum Depression, Postpartum psychosis, PTSD, RN responsibilities

o Postpartum Blues: caused from hormones trying to get back to prepregnancy norm. Mom is overly emotional, cries out of happiness. This is NOT postpartum depression/problems bc <2wks. "Baby Blues", transient & self-limiting condition. o Postpartum Depression: hormones go up & down, but now stuck in down. Mom doesn't want to care for herself or her baby. Occurs a few days-weeks after delivery, so we wont be able to assess her—do postpartum depression screen before D/C to evaluate risk. Assess during followup at HCP office, & educate mom & partner about s/s to look for—goes beyond worrying about care of baby, or feelings of being overwhelmed. It's when she is not caring for herself, acting like herself. Dx if >2wks in PP; w/ >4 present: changes in appetite or weight, sleep & psychomotor activity, decreased energy or feelings of worthlessness or guilt, difficulty thinking/concentrating or making decisions. Tx: admin hormones or antidepressant meds. o Postpartum psychosis: much more rare condition; mental state in which her ability to recognize reality, communicate, & relate to others is impaired. Classified as depressed or manic types. She may do harm to herself or her baby. o PTSD: women perceive childbirth as a traumatic event—ex. Emergency OP, anything that causes trauma to body or mind. She didn't anticipate what happened during L&D, its painful, or there was a bad outcome w/ the baby. o RN: must monitor for these s/s, on all moms before D/C use a postpartum depression assessment tool—to see if mom is at risk for postpartum depression or may harm themselves or their baby.

-Psychosocial Adaptation: First period of reactivity, Period of sleep or decreased activity, Second period of reactivity. -Behavior: Deeper quiet sleep, Light or active sleep, Drowsy, Quiet alert, Active alert, Crying

o Psychosocial Adaptation: how the baby is reacting after birth. o First period of reactivity: wide awake, alert, interested in surroundings. Temp. may be decreased & HR elevated. Priority to get baby to mom & allow bonding/feeding in this 1st period of reactivity. o Period of sleep or decreased activity: after being awake/alert & burning kcals, may fall into deep sleep. Not the time for breastfeeding & bonding. o Second period of reactivity: interested in surroundings & feeding again. o Deeper quiet sleep: no eye movements. Respirations quiet, regular & slower. RN: good time to evaluate respirations, but don't disturb them. When checking VS, warm the stethoscope & listen to lungs & heart, bc they aren't active or crying it helps us evaluate—then take the temp after. o Light or active sleep: begin to move, change facial expressions, or fuss. o Drowsy: transitional period between sleep & waking. Or waking & going to sleep. o Quiet alert: best time for bonding; baby is focusing on objects & people. Happens after they eat, if they are able to stay awake. o Active alert: often fussy & more aware of feelings & discomforts—ex. wet diaper, uncomfortable position. Intervene to prevent crying state, crying too long may make the infant not respond to care at first--rock & hold the baby close to settle. o Crying: may quickly follow active alert phase; seem okay, then start fussing. May take a period of comforting to get into a state where feeding or other activities can be accomplished. Don't just put them straight to the breast when crying, calm them down—crying can increase air intake into the stomach & discomfort, rather than an increase in nutrition. Important for the baby to be relaxed when feeding. -Other interventions: swaddling, play music, pacifier, talk to the baby, white noise or water noises, change diaper, feed, etc.

Perineum-REEDA

o REEDA Scale: -R = redness; E = edema (swelling); E = ecchymosis (bruising); D = drainage; A = approximation (episiotomy/laceration) o Cleansing/ Ice packs/ Sitz Baths: -Ice reduces edema & numbs tissue, reduces pain. Wrap ice in cloth to avoid ice burns, or diaper to absorb fluid & lochia. Apply ice for 20min & remove for 10min for 1st 24hrs, after use warmth to assist in healing by increasing blood flow. -Sitz bath: warm water for comfort & reduces pain. Promotes tissue circulation for healing of an episiotomy, ordered 3x/day & PRN. Sit in bath for 20min & pad dry perineum w/ clean towel & apply clean pad. Warm/moist heat can cause fainting after delivery, so monitor. -Witch hazel compresses, numbing ointment or spray. Teach her to wash hands before/after topical Tx to reduce risk of infection. · Vaginal/Perineal Changes Episiotomy: o Episiotomy: 2-4th degree laceration will need suturing. -Assess: Edges approximated; Initial healing occurs 2-3wks after birth. Assess wound & evaluate state of healing. Complete healing can take 4-6mo, perineum stretches w/o discomfort. Observe for ecchymosis & approximation; warmth, tenderness, edema—may separate the incision. After 24 hours edema may be present, but edges should be approximated so that gentle pressure doesn't separate them. Gentle palpation may cause mild tenderness, esp. if laceration, episiotomy, or suture line present -Infection—no hard areas should be present. Look for redness, edema, ecchymosis, discharge, gaping stitches. Encourage sitz bath, review peri-care, wipe from front to back to avoid infection. -Teaching: sutures are dissolvable slowly over next few wks. Don't remove, they are absorbed y the body. When they dissolve, tissue is strong enough to prevent separation. o Hemorrhoids: around the anus, if full, tender & inflamed—encourage sitz bath or laying in side lying position, avoid prolonged sitting. Meds like tux-pads or topical anesthetics, stool softeners may help. AVOID rectal suppositories. Manual replacement of hemorrhoid into anal sphincter may be done by HCP. o Chart what you see: "midline episiotomy w/ no edema, tenderness, or ecchymosis present. Skin edges are approximated & pt reports that sitz baths & tux-pads are controlling discomfort".

Signs and symptoms of hypothermia in a newborn

o Thermogenesis: heat production, how the baby produces heat when cold. o Methods of heat production when cold: -Increase activity: when cold babies are restless & cry; crying & being awake increases heat. -Flexion: movement increases heat. -Metabolism: rises, increasing need for O2 & glucose. -Vasoconstriction: reduces heat loss, may cause acrocyanosis (bluish color of hands & feet). -Non-shivering thermogenesis (brown fat stored on front & between shoulder blades): shivering seen in cold adults, not often in babies unless exposure to cold is prolonged. Not an important method of heat production. Babies use NST as primary method to increase heat, metabolism of brown fat increases heat by 100%. Premature babies have little white & brown fat, extreme difficulties producing heat. o These factors increase oxygen and glucose consumption and may cause respiratory distress, hypoglycemia, and jaundice. -S/S hypothermia: Moving, crying, utilizing heat—uses up energy causing resp. distress, use up glucose causes hypoglycemia, & may cause jaundice. o Cold Stress: increases the need for O2, decreased production of surfactant—leads to resp. distress, metabolic acidosis, & hypoglycemia.

Thrombus, Thrombophlebitis, Embolus, Pulmonary embolism: 3 common in pregnancy, Tx, risk factors

oThrombus: collection of blood factors (fibrin & platelets) on a vessel wall. Causes: Venous stasis usual cause of thrombus formation. Increased levels of coagulation factors is another common cause of thrombus formation. Also Decreased levels of thrombolytic factors, Blood vessel injury, Hx of Deep vein thrombosis. o Thrombophlebitis: BV wall develops an inflammatory response to a thrombus; further occludes the BV. o Embolus: a mass that is released into the blood stream & obstructs a capillary bed in another part of the body (lungs); possibly composed of a thrombus or amniotic fluid. o Pulmonary embolism: Pulmonary artery is obstructed by an embolism, can result from a thrombus; potentially fatal. o 3 most common in pregnancy: 1) superficial venous thrombophlebitis (SVT: saphenous sys.; confined to lower leg). 2) Deep vein thrombosis (DVT: veins of the foot to the iliofemoral region, predispose to PE). 3) Pulmonary embolism (PE). o Major causes: venous stasis & hyper-coagulable blood (in all pregnancies), & BV injury (endothelial/innermost--occurs during birth). o Anticoagulant therapy: indicated if thrombus present. o Increase Risk: inactivity or bedrest, obesity, CS birth, sepsis, smoking, Hx of thrombosis, varicose veins during pregnancy, DM, trauma, prolonged labor, prolonged time in stirrups in 2nd stage of labor (pushing for prolonged time), maternal age 30+yrs, increased parity (multiple deliveries), dehydration (sweating), close relative w/ thrombosis, use of forceps, inherited thrombophilia's (factor 9 impacts pregnancy & clotting after delivery), antiphospholipid antibody syndrome.

Pregnant with cardiac disease

· Cardiac Disease: CV changes that occur in normal pregnancy impose additional burdens that may result in cardiac decompensation & CHF if the mother has preexisting heart disease. -During Pregnancy: increased plasma vL, venous return, & CO occur in pregnancy—SV & HR increase, which increases the CO. Maternal HR rises above baseline in 3rdT, increased SV responsible for the rise in CO in early pregnancy. If a heart condition is unDx, mom can be impacted negatively by the normal changes in cardiac function that occur in pregnancy. o Primary goal of pregnancy management of heart disease is to prevent the development of CHF. o Intrapartum and postpartum management focuses on preventing fluid overload. o S/S of CHF: failure of the heart to maintain adequate circulation. Usually caused by enlargement of the left ventricle due to dilated cardiomyopathy or dilated BVs in pregnancy. -Cough: frequent, & productive or nonproductive. Blood may be seen in productive (hemoptysis). -Progressive dyspnea: worse w/ exertion. Worsening dz if at rest. -Orthopnea: discomfort when breathing when laying flat. -Pitting edema: pitting of legs & feet, or generalized edema of the face, hands, or sacral area. -Heart palpitations: felt by the pt. -Progressive fatigue: or syncope w/ exertion. -Moist rales: in lower lobes, indicates pulmonary edema. -Antepartum Assessment: must be thorough, listen to heart sounds & respiratory sounds to ID underlying cardiac problems.

Assessing the cardiac system of a newborn

· Cardiac: ABC assessment right after delivery; check heart for rate, rhythm, & murmurs or abnormal sounds. When baby is asleep, listen to heart/lung sounds before taking the apical pulse or temp—bc these assessments may upset them & make auscultation difficult. If crying, use a pacifier (some hospitals don't allow pacifiers) or gloved pinkie finger & let them suck on it, while you try to get a HR. Point of maximal impulse: 3rd or 4th intercostal space, midclavicular line—pneumothorax or dextrocardia (reversed heart position) change the position. Know the position of the infant heart structures/valves—ex. patent DA, remains open & causes a murmur—frequent in first 24hrs of life—Tx increased pressure from crying & breathing to close the shunt. o Apical pulse should be regular, strong, & HR [110] 120-160 (100 if sleeping, 180 if crying). HR 120+ BPM may be difficult to listen to, so take opportunities to practice & close your eyes to focus. Apical should be assessed for 1min, at least every 30min until baby is stable for 2hrs—more frequent if there are abnormalities. Once stable, check once every 8-12hrs. o Irregular beats between S1-S2 are abnormal. S1-S2 should be heard clearly. o Murmur: sound of irregular BF through the heart; may indicate opening in the septum or problem w/ BF through the valves. Murmurs are usually temporary, caused by incomplete transition from fetal to neonatal life; common until the DA is functionally closed in 72hrs (permanent in 1-2wks). Any abnormal sound needs to be investigated, could indicate a heart defect—assess, notify HCP, may order cardiac test w/ US or further Dx tests.

Effects of Pregnancy and Fuel Metabolism

· Effects of Pregnancy and Fuel Metabolism o Episodes of hypoglycemia may occur during 1-20wks of pregnancy, from increased insulin levels released in response to serum glucose levels—mom is growing a baby & energy is used up, favors fat storage in the body. Significant hypoglycemia in mom's w/ n/v & anorexia. o Levels of placental hormones rise sharply after 20wks when fetal growth accelerates—creates resistance to insulin in maternal cells. Estrogen, Progesterone, & Placental Lactogen produce a diabetogenic effect—the effects of DM. For most women the pancreas responds by making more insulin. As the placenta grows, resistance in mom's cells results in all pregnancies, esp. in preexisting DM pt, hyperglycemia results. o Maternal insulin needs will change throughout pregnancy—if mom has DM, insulin amounts needed in beginning of pregnancy, won't stabilize BS in middle & end of the pregnancy. Monitor her BS very closely. o Late pregnancy: earlier switch to gluconeogenesis (form glycogen from fat/protein)—high levels of free fatty acids inhibit uptake & oxidization of glucose bc body is saving it for the CNS & baby. Similar process to "accelerated starvation", fat metabolized to meet body needs.

HELLP

· HELLP Syndrome: Hemolysis Elevated Liver Enzymes & Low Platelets. Occurs in 10% of pregnancies w/ severe HTN; its a severe complication of preeclampsia after delivery. HELLP can lead to DIC. o Hemolysis: result of fragmentation & distortion of erythrocytes when they pass through small, damaged BVs (vasoconstriction causes damage, resulting in clots). Hemolysis occurs to breakdown the clots. Thrombocytopenia, elevated ALT/AST, RUQ pain, decreased Hgb, & increased bilirubin. o Liver enzymes: elevate when hepatic BF is blocked by fibrin deposits, liver impairment leads to hyperbilirubinemia & jaundice. ALT, AST, ALP, GGT: liver releases enz. when damage occurs. --Liver Function Tests: evaluate AST/ALT, albumin/total protein, bilirubin, PT. Albumin is a protein made by the liver; total protein test measures total amount of protein in blood. Bilirubin is a waste-product made by the liver; PT is a protein involved in blood clotting & ID clotting time. o Low Platelets: caused by BVs damage from vasospasm; platelets aggregate at site of damage, causing systemic thrombocytopenia. o Basically, vasoconstriction damages RBCs, which damages the platelets. o S/S: Pain in RUQ, lower chest, or epigastric area. ABD tenderness from liver distension. N/V, severe edema. Avoid damaging liver when palpating the ABD, be careful during patient transportation. Sudden increase in intra-ABD pressure (ex. Seizure) can rupture the subcapsular hematoma—leading to internal bleeding & hypovolemic shock. o Tx: manage in setting w/ ICU available. Tx is the same as preeclampsia & eclampsia. Usually after delivery recovery begins w/in 72hrs.

Assessing the Neck/Chest, ABD & cord of a newborn

· Neck/Chest: inspect & palpate. o Check that it is symmetrical, if not 1 lung may not be inflated & appear sunken-in. Barreled—not indicative of COPD in infant, it correlates to the size of the heart or lungs, presence of fluid w/in the lungs, injury from birth. Extra Nipples—typically it's just colored tissue w/ no mammary glands, rare if mammary glands are present. Check for masses in the neck/chest area, ex. tumors. · Abdomen: listen to bowel sounds after cardiac & respiratory assessment. o Normal ABD is soft, round & non-distended (slight protrusion normal), w/o masses & scaphoid. o Distended: w/ stretched/shiny skin indicates an obstruction. Visible loops may be air & meconium not passing through the GI normally. o Masses: tumors of the kidneys. o Scaphoid: sunken ABD; occurs in diaphragmatic hernia—intestines in the chest cavity rather than the ABD, bowel sounds are heard in the chest (appear 1hr after birth). · Cord: normal is 2 arteries/1 vein. Should be thick w/ Wharton's jelly (clear substance around the cord)—thicker = healthier cord, jelly protects the BVs in utero. Thin/depleted = malnourished; problem seen in IUGR, premature babies. o Abnormal if 1 artery/1 vein; indicates chromosomal problem (Trisomy 21 w/ associated cardiac anomalies). o Meconium Stained: cord looks yellow-brown or green, color also seen in amniotic fluid. Indicates meconium was released before birth & has been in place long enough to stain the cord.

Preeclampsia: patho, S/S

· Preeclampsia: o Patho: generalized vasospasm decreases circulation to all organs of the body including the placenta, liver, kidneys, and brain. Can lead to HELLP or DIC. o S/S: Uric acid is often elevated prior to the onset of s/s of preeclampsia. Increased BP w/ pt seated, arm supported, & proper cuff size used. Proteinuria—Dx by clean catch 24hr collection & no UTI present. Headache (frontal) from vasoconstriction & increased pressure w/ poor cerebral perfusion. Visual disturbances from vasoconstriction & increased pressure, HCP can see retinal constriction—spots caused by retinal constriction of BF. Very brisk reflexes in the lower extremities (hyperreflexia), but if she had an epidural test in the upper extremities. Reflexes increase in briskness until she has a seizure—so assess reflexes often, caused by cerebral irritability secondary to decreased circulation & edema (0 to +4, +2 is normal). Elevated liver enzymes from decreased perfusion to the liver, impairing its function—leads to hepatic edema & subcapsular hemorrhage, may result in hepatic necrosis. Liver distension, edema & vasoconstriction manifests as epigastric pain, pushes into stomach—can lead to HELLP syndrome. -Edema: result of reduced BF to kidneys, causes Na/H20 retention & excessive weight gain (greater than 2 pounds/week). Edema of LE is normal in pregnancy bc of increased bvL, but then may be seen as rapid wt gain caused by fluid retention—can be generalized, but most specific in hands & face, or she could NOT have edema at all. Can lead to pulmonary edema, assess breath sounds. · Facial Edema: when massive, distorts her appearance. · Pitting Edema: +1 = minimal edema of LE. +2 = marked edema of LE, +3 = edema of LE, face, hands, & sacral area. +4 = generalized massive edema w/ ascites -Treatment: chronic HTN is a risk factor, monitor closely for proteinuria & edema. Initiate anti-HTN meds if diastolic BP >100. Bed rest, reducing environmental stimuli (to reduce seizure risk), admin anticonvulsants. -Untreated: mom is at risk for seizures, intracranial hemorrhage, CHF, pulmonary edema, RF, and possibly coma and death. Baby is at risk for placental insufficiency or abruption.

Diabetes Mellitus

· Preexisting Diabetes Mellitus o DM1: polydipsia, polyuria (glucosuria), polyphagia. Lack/absence of insulin secretion from pancreas Beta-cells. Hyperglycemia occurs, body increases thirst, fluid is pulled from the ICF into the BVs. Dehydration at cellular level, but increased fluid in BVs. Kidneys excrete water/glucose through osmotic diuresis. Cells stave, weight is lost in presence of increased food intake. Body breaks down fat (ketones) & protein (lipolysis- negative N balance) for fuel. Hypoglycemia & hyperglycemia damage BVs, impair organs—esp. kidneys, eyes, heart. -Women with DM1 have a greater risk for: Preeclampsia, Infections, Ketosis, Polyhydramnios o Polyhydramnios: excess amniotic fluid; result of maternal hyperglycemia (reduced insulin control) that causes fetal hyperglycemia & diuresis. Excess fluid can distend the uterus, leading to premature ROM/labor, prolapsed cord, abnormal labor, & PP hemorrhage. o Goal of management is to establish normal blood glucose levels before conception. Prevent hyperglycemia & ketosis. o Fetal Growth: depends on maternal BVs & BS levels. Maternal insulin doesn't cross the placenta, but by 10thwk baby makes its own. High BS causes increase of fetal insulin (acts as GH), causing macrosomia (4,000+g at term). -Infant of DM mom: risk for hypoglycemia, hypocalcemia, hyperbilirubinemia, & respiratory distress syndrome. Because w/ high BS, the baby grows larger, is delivered earlier, & lungs aren't mature. -Maternal hyperglycemia during the 1stT increases the risk for congenital anomalies in the fetus. Abnormal metabolic conditions of the mom can cause fetal hyperglycemia, hypoglycemia, & ketosis—leading to spontaneous abortion & major malformations.

Assessing the respiratory system of a newborn

· Respirations: Should be regular; identify if they are irregular. If the baby is crying & trying to settle itself, may do a quick breath in & a shaky breath sound—may sound like a problem w/ breathing, but its normal. If it happens frequently, then it may be an irregular respiratory pattern. RR: 30-60 BPM. Babies pattern & depth are irregular, so assess for a full 1min. o Breathing should be unlabored (low effort); if they are having difficulties breathing, as soon as O2sat changes we will see flaring of the nares bc they are trying to get as much O2 as possible (s/s of respiratory distress). Will then move into the thorax & will use their rib cage muscles, manifested as retractions (accessory muscle use), done to assist w/ breathing by expanding/retracting lungs as much as possible. Grunting is a s/s that they are trying hard to breath. o Flaring, Retractions, & grunting are s/s of respiratory distress. Seesaw/paradoxical breathing, chest & ABD rise/fall at different times—severe respiratory difficulty. o Periodic breathing: pause for 5-10s w/o s/s, then rapid RR for 10-15s; sometimes babies, esp. premature, become so relaxed they stop breathing, but if it occurs regularly, they may be put on an apnea monitor. Tx: stimulation; rub baby on their back, or commonly self-regulated (fixed). o Apnea: pause for 20s+ w/ cyanosis, pallor, bradycardia, or decreased muscle tone—requires immediate intervention. · Breath Sounds: Should be equal & clear, but we may hear some moist sounds bc of fluid—provide suctioning to Tx. Assess to see if the sounds are diminished in the lower lobes, to ensure the entire lung field is being used by the newborn—if not we will see color changes & a decrease in O2sat. o Coarse: fluid; may be present in CS babies bc fluid is still in lungs, present for short time—continued abnormal/diminished sounds are reported to HCP. o Crackles: fluid; normal for a few hrs, fluid is still being absorbed by the tissue.

Assessing the spine & skeletal system of a newborn

· Spine: RN palpates the vertebral column to ID vertebral defects. o Normal: spinal column is straight w/ no curvature or deformity present. Look at the skin, there should NOT be a dimple. o Sacral Dimple: an indentation near the vertebra; pilonidal dimple—present at the base of the spine, examine for a sinus & note the depth. When the indentation has a tuft of hair over it—s/s of spina bifida occulta (failure of the vertebra to close completely). Do an US to ID how far in it goes & what is occurring. When assessing extremities & their movement, findings may also indicate a spinal problem. --Dimple can also just be skin covering an opening in the spine. Rare instance when there is spinal column, spinal fluid, or sac on the outside of the spine—clear s/s of spina bifida. o Spina Bifida: indicated w/ dimple and/or sinus/opening o Sacral Sinus: opening in the spinal column. o Meningocele: a more obvious neural tube defect; protrusion of spinal fluid & meninges through the defect in the vertebrae. Appears as a sack on the back, sometimes covered by skin or only the meninges. o Myelomeningocele: protrusion of spinal fluid, meninges, & spinal cord through the defect in the vertebrae. Appears as a sack on the back, sometimes covered by skin or only the meninges. · Skeletal: o Clavicles Intact: during delivery, if shoulder dystocia present & suprapubic pressure was applied to mom—may result in fractured clavicle on the baby. Assess the clavicles: see if the movement in both arms are equal. o Crepitus R/L: assess by running fingers over R/L clavicles to check for crepitus (air-bubble feeling under the skin)—indicates a broken bone.

BUBBLE EE: Emotional/Psychological

BUBBLE EE: Emotional/Psychological o Postpartum: time of readjustment as woman experiences a variety of responsibilities related to baby & adjustment of new family member. Can experience postpartum discomfort, changes in body image, & reality that she is no longer pregnant. Women are usually D/C w/in 24hrs. -Taking In Period: (1-2 days) focus remains on herself; afterpains, bleeding, hunger/thirst. She also talks about L&D experience to integrate it into her reality; baby is now a separate being. CS moms (esp. emergency) may have difficulty integrating the OP, may have negative perception of experience. Maslow: make sure her basic needs are met so she can begin her maternal role attainment, so she can then focus on baby. D/C after 24hrs limits our ability to do this, why followups are important w/ homecare & making sure mom can care for herself & baby. -Taking Hold Period: (2-3 days) focus turns toward baby. She becomes more independent, responsible for her own care, & managing her bodily functions. When she feels in control of her body, her focus shifts toward the baby. RN: don't do all infant care, let parents participate, praise each attempt. -Letting Go Phase: role adaptation as parents, give up idealized expectations of birth, relinquish fantasies of what they wanted the baby to be/look like & accept the baby. Feelings of loss or grief, allow open discussion. -Maternal Role Attainment: adjusting to motherhood; anticipatory stage during pregnancy, formal stage w/ birth to 4-6wks. Informal stage may overlap formal, begin once mom has learned appropriate responses to infants cues, not just responses from a book. Personal stage attained when mom feels sense of harmony in her role, infant is central part of life, has internalized the parental role. -Age: Feelings of loss or grief, more acute in the young mother--allow them to express feelings. -Culture: communication when pt speaks another language--verify understanding, nodding or saying "yes", may be a sign of politeness, not agreement. Use teach back to verify, use interpreter. Hot/Cold--PP is cold, family may bring in hot foods--encourage the practice, but discuss diet restrictions. Ask her what the significance of the food is, she can have it unless its harmful to the baby. Some believe mom should be confined to indoors in PP, or discourage bathing--use sensitivity to find a compromise, but its the mom's choice. -Psych Assessment: Postpartum Blues, Postpartum Depression, Postpartum psychosis, PTSD.

BUBBLE EE: Uterus

BUBBLE EE: U = Uterus -Involution: rapid reduction in size of uterus & return to pre-pregnancy state. After placenta separates, the uterus lining is irregular/jagged w/ varied thickness. Part of the lining is discarded by the body as lochia. The basal layer (not discarded) forms a new endometrium. Changes take 3 wks . The placental site takes 6-7wks for complete healing. -Lochia: bleeding after delivery, includes part of the lining of the uterus. -Exfoliation: process by which the placental site heals; important part of involution. The superficial placental site tissue becomes necrotic & sloughs off; lower decidua regenerates the site. If process doesn't occur properly, uterus heals w/ a scar—may cause future pregnancies to not implant in this area, may limit future pregnancies. -Exfoliation is enhanced by uncomplicated labor and birth—includes complete expulsion of placental fragments, breast feeding, & early ambulation of mother. -Involution is slowed by prolonged labor, anesthesia or excessive analgesia (increased time w/ med-Tx), difficult birth, grand multiparity, a full bladder, and retention of placental fragments · Specifics about the Uterus: -Fundus: top of the uterus; located midway between the symphysis pubis & umbilicus. -Assessment: while in L&D check every 5min for 1st 15min, to ensure bleeding is okay, then every 15min. Every 15min after 1st hr PP. Every 30min for next hr. Every hr for 2hrs, while in postpartum unit. Then every 8hrs (or every shift, based on clinical s/s). Typical recovery is 2hrs. -Location of the uterus: at level of umbilicus w/in 6-12hrs after birth. Descends by 1cm per day. Assess the fundus for location & consistency, we want it to be at or near the umbilicus & midline. -Slightly normal for fundus to be 1-2 finger breadths above the umbilicus right after delivery, but w/in 6-12hrs it should be at the level of the umbilicus or below. -1st day: fundus located 1cm (1 finger) below the umbilicus; 10th day: fundus descends into the pelvis; 14th day: deep in pelvis & can't be palpated on ABD. -Height of fundus: recorded in finger breadths. At umbilicus = 0; Above umbilicus = +1/+2; Below umbilicus = -1/-2. -If located above the umbilicus - the fundus is "boggy": soft/spongy fundus, not firm or well contracted. Associated w/ excessive uterine bleeding. We want the uterus to be firmly contracted. -Boggy uterus (atony): fundus above umbilicus & not firm; boggy means there is no tone. Occurs as blood collects & forms clots in uterus, causing the fundus to rise & it interrupts firm uterine contractions. Chart as, "uterus boggy", & if it becomes firm w/ light massage. -Monitor uterine status: · RN lightly massage the ABD until the fundus becomes firm. Support bottom of uterus during massage—hand at symphysis pubis while other hand massages & palpates, so it doesn't prolapse. Teach her to massage her uterus to check position & determine firmness. Monitor uterine status more than every 8hr if it is boggy, not midline, w/ heavy flow of lochia or clots are present. · When uterus is firmly contracted the uterine BVs are compressed by the myometrium & bleeding is controlled. Why we want mom to have contractions, manifest as after-pains. -Checking the uterus after C-section—palpate carefully bc incision is very tender. Inspect it for approximation, bleeding, s/s of infection (edema, foul odor, drainage, redness). Check suture line, staples, steri-strips for intactness. Teach the patient about normal healing, s/s infection, incision care while you're assessing. -If fundus is higher and not midline—usually deviated to the right; bladder distension is suspected. Tell her to void, then remeasure the uterus. If unable to void after delivery, an in & out cath may be indicated, esp. if she had an epidural & still can feel the need to void. ALWAYS have her void before an ABD or fundal exam. -If breastfeeding, oxytocin is released by the posterior pituitary in response to suckling, helps with uterine contraction & involution. Getting the baby to breastfeed right after delivery is vital in helping uterus contact & assist w/ involution.

Dysfunctional Labor

Dysfunctional Labor: does not result in normal progress of effacement, dilation, & decent; usually caused by problems w/ powers or passenger. Dystocia—general term for any difficulty w/ labor or birth. o Powers: Ineffective contractions: hypotonic (more common)—coordinated, but too weak to be effective--from F&E imbalance, hypoglycemia, excessive analgesia/anesthesia, uterine overdistension, catecholamines from fear/pain, fatigue, disproportion; or hypertonic contractions—uncoordinated & erratic in frequency, duration, intensity. Leads to labor disfunction & ineffective pushing. Ineffective pushing: incorrect techniques or position, fear of injury, minimal/absent urge, exhaustion, regional block anesthesia, psychological unreadiness. o Passenger: Macrosomia: baby >4,000g (8lbs 13oz) at birth; cephalopelvic (fetopelvic) disproportion (CPD)—head or shoulders can't adapt to pelvic opening. Shoulder dystocia: head delivers but shoulders stuck under symphysis pubis; "turtle sign" or failure of complete external rotation of the shoulders. Abnormal presentation: LOP (OP, OT), transverse, breeched, or poorly flexed. Change mom's position to Tx—if occiput posterior turn to side-lying on side opposite of the baby is facing, hands & knees while rocking pelvis, or a lunge position w/ 1 foot on chair lunge to the side for 5s w/ contraction, squatting (2nd stage). Sitting, kneeling, standing while leaning forward. -Multifetal pregnancy: overdistension of uterus causes hypotonic contractions & abnormal presentation for 1 or both babies. CS may be indicated. -Fetal anomalies: hydrocephalus & large tumors may prevent passage. Abnormal presentations are also associated w/ anomalies. CS may be indicated. o Passage: Pelvis small/contracted or abnormally shaped pelvis can slow labor & obstruct fetal passage. May experience poor contractions, slow dilation, slow fetal decent, & long labor. Risk of uterine rupture (tear in uterine wall) if there is thinning of the lower uterus, esp. if contractions remain strong. -4 pelvis shapes: most women have mixed characteristics of 2+ types; Gynecoid—round/cylindrical shape & wide arch 90+ degrees, good Px. Anthropoid—long/narrow oval & anteroposterior diameter > transverse diameter, narrow pubic arch, baby can be born OP, good Px. Android—heart/triangle shape inlet, narrow diameters & pubic arch, poor Px. Platypelloid—flattened, wide/short oval, transverse diameter wide, anteroposterior diameter short, wide pubic arch, poor Px. o Soft-tissue abnormalities: full bladder is a common soft tissue obstruction—reduces space in the pelvis & increases discomfort. Assess mom for distension frequently & remind her to void every 1-2hrs. Cath may be needed if she can't void or had a regional block anesthesia. o Psyche: Prolonged labor when problems w/ any factors in birthing process. Precipitous labor: rapid birth w/in 3hrs of labor. Could happen when mom doesn't believe she is pregnant, baby comes & she didn't ID s/s of labor. RN: support fetal O2 & maternal comfort, keep side lying, adin O2 & non-additive IV fluids if needed, stop oxytocin if running, admin tocolytic. Precipitous Birth: occurs after labor of any length, in or out of hospital, when a trained attendant is not present to assist. Can follow a precipitous labor. Dysfunctional labor: does not result in normal progress of effacement, dilation, & decent. Maternal exhaustion: can cause dysfunctional labor, result of induction or prolonged labor.

Newborn assessment of the head

Initial Newborn Assessment: at birth follow ABCs; bulb syringe for airway clearance, cord is clamped & their circulation has taken over (fetal to extrauterine circulation)—ensure these are all normal & baby is stable before moving on to the initial assessment. APGAR score w/in 1 min of life. -Head: Round—only round if had a CS. Vaginal w/ vacuum extractor or forceps can cause bruising. -Caput [succedaneum]: ("baseball cap") area of localized edema, often over the vertex of the head, result of pressure against cervix during labor. Fluid has gone over both sides of the head, ex. hematoma. -Crosses the cranial suture lines, why it is ID as caput—can see molding, but on top of the molding is swelling at the backside. -Molding: normal, generally all babies born vaginally will have molding; changes in the shape of the head from overriding of cranial bones at the sutures. In order for the baby to come through the canal (passenger/powers), the suture lines will cross over each other & allow for molding of the head to allow baby to pass through. Usually not present w/ CS baby—CS will have round head. -Cephalohematoma: bleeding between the periosteum & skull caused by pressure during birth; bruising/swelling on 1 side of the head (suture line), usually caused by vacuum extractor assisted delivery. Can occur on both sides of the head, usually over parietal bones. When the fluid crosses the suture line, deviation in the middle will be absent—this is caput. -Forceps Marks: when we feel for the suture lines, we should also feel for ears when placing the forceps—in emergency we may not be able to do this bc need to get baby out ASAP—can lead to forceps marks on baby. Ideally place forceps over each ear to assist w/ the delivery. -Fontanels: Anterior & Posterior; slightly elevate head w/ 1 hand & run fingers of other hand over the fontanel. Anterior is diamond shaped where the frontal & parietal bones meet, measures 4-5cm from bone to bone—should be soft & flat, even w/ surrounding bone. Posterior is toward the back, triangle shaped, where occipital & parietal bones meet—smaller & measures 0.5-1cm. Posterior closes by 2-4mo old, Anterior closes by 18mo old. Assesses dehydration, fluid status—babies have higher amount of fluid as total weight—dehydration can occur quickly, & anterior fontanels may appear sunken. Bulging of the fontanel may indicate increased ICP. -Face: we want to see symmetry. Asymmetry of the facial expression may indicate bels palsy, injury in delivery, use of forceps, could be temporary from the way the baby pushed through the pelvis—ID & monitor. -Eyes: will be puffy initially after delivery. Assess to see if they are clear, w/o discharge. Admin erythromycin, assess right away before admin bc you don't want to have to assess through the ointment. -Sclera: should be white; hyperbilirubinemia will make it yellow (jaundice). Daily assessments will include monitoring of the eyes/sclera. -Mouth: normal mouth palate is intact; Assess by taking gloved finger (pinkie) & feel the roof of the mouth to check for intactness—an open palate if in w/ trachea can lead to aspiration. Abnormal is a cleft palate/lip—requires special feeding (ex. feeding tube for severe, longer bottle nipple for mild to reach past deformity to allow for swallowing w/o aspiration), facial deformities also impede bonding—reassure parents that the deformity can be fixed w/ OP. Check gums, lift up the tongue (tongue tied-frenulum goes to the teeth reduces proper sucking), pearls (look like teeth), or may have an actual tooth coming through (rare). -Ears: ears involved in gestational age assessment; pina intact w/o deformity, presence of opening to allow for hearing, good cartilage around the ear to aid in hearing, ears should NOT be low set (inspect outside line of the eye, across the head)—top part of ear should cross-secting w/ the eye line, if lower may have a congenital anomaly (usually genetic) & requires further assessment.

Newborn vitals & measurements

Newborn Vital Signs: -Temperature: newborn taken axillary 36.5-37.5C (97.7-99.5F); some hospitals do 1st temp rectally (temp check & patency of anus & presence of meconium). Take temp. ASAP & keep baby warm. -Pulses: 120-160 BPM; range changes based on condition—low as 100 if asleep, 180 when crying. Sustained high HR is tachycardia, not Dx if crying or if there is another reason. Apical Pulse: always done on a baby; taken at the 4th intercostal space—use a small stethoscope if different/abnormal sound (ex. murmur), smaller scope can differentiate between the landmarks (aortic, pulmonic, etc.). Can take brachial, pedal, femoral pulses to check for equal distribution—but normally we focus on apical in initial assessment. -Respirations: 30-60 BPM; faster than adult RR, so their lungs are working harder. Should be regular (no irregular movements), symmetric chest expansion, clear sounds (some fluids normal after birth—suction). -BP: varies w/ age & weight; average systolic 65-95/ diastolic 30-60. BP not normally taken on newborn if other VS are normal. If problems, esp. if baby in NICU, BP taken. o Measurements: after [or during] we have taken VS & listened to the cardiac & respiratory systems to ensure they are normal, can move onto measurements. -Weight: 2,500-4,000g (5lbs 8oz-8lbs 13oz); cover scale w/ blankets & 0-out before putting baby on. -Length: 48-53cm (19-21in); start at top of head, pull the legs straight/extend to get an accurate measurement, note the side measured for consistency of follow-ups. -Head Circumference: 32-38cm (12.5-15in); all the way around head to the occiput, & right across eyebrows in the front. Head & neck are approx. ¼ of body SA (baby SA is large for their compact size). -Chest Circumference: 30-36cm (12-14in), just 2cm less than head circumference; around the back & at the nipple line. Standard/consistent measurements needed for accuracy. PEDS growth tables are used to assess G&D for 1st yr, then 2yrs, all the way up to 18yrs of life.

Terbutaline (Brethine)

Terbutaline (Brethine): Beta-adrenergic tocolytic; stops contractions during pregnancy (PTL). Now carries "Black Box" warning for use as a tocolytic, rather than its intended use as a bronchodilator. -Side effects = tachypanea, tachycardia, MI, chest pain, palpetations, hypoptention. Can cause cardiorespiratory SE, have propranolol on hand to Tx. -Assess apical HR, lung sounds before admin dose, reassess moms VS & FHR.

Postpartum Assessment of Mom & risk factors

o Postpartum: CS stay in hospital for 72-96hrs; vaginal stay in hospital for 24-48hrs. Some leave earlier by choice. o High risk of contact w/ bodily fluids, RN uses std. blood & fluid precautions. o PP assessment begins in 4th stage of labor—1-2hrs after delivery. Purpose is to determine if mom is physically stable. -Initial assessments: VS (orthostatic hypotension BP falls 15-20mmHg), skin color, location/firmness of fundus, amount/color of lochia, perineum condition, pain location/degree, IV infusion type/rate; site condition, UO time/amount; catheter, status of ABD incision/dressing, level of feeling & ability to move if regional anesthesia was admin. -Chart Review: when initial assessment confirms stability, RN reviews the chart to assess for risk factors of complications. · Gravida/Para, time/type of delivery (vacuum, forceps), presence/degree of episiotomy or laceration, anesthesia/meds admin, medical/surgical Hx (DM, HTN, CVD), meds admin during L&D, meds routinely taken/purpose, allergies, chosen method of infant feeding, condition of baby. · Labs: prenatal H&H, ABO type/Rh, Hep-B ag, rubella immune status, syphilis screen, group b streptococcus status. · RN care after CS: Assessment is the same as vaginal, maybe PCA used. Pain management, PCA, duromorph. Assess Respiratory, pulseOx for 18-24hrs. Prevent ABD distension w/ activity & walking; after 6hrs PP get out of bed, 8-10hrs walk in room, 12hrs walk in the hall. -Postpartum Risk Factors: · Hemorrhage: grand multiparity (5+), overdistension of uterus (large baby, twins, hydramnios), rapid or prolonged labor, retained placenta, placenta previa or previous placenta accrete or abruptio placentae, drugs (tocolytics, Mg sulphate, general anesthesia, prolonged oxytocin), OP procedures (CS, vacuum, forceps), uterine fibroids, Hx postpartum hemorrhage, preeclampsia, coagulation defects. · Infection: OP procedures (CS, vacuum, forceps), multiple cervical exams, prolonged labor, prolonged ROM, manual extraction of placenta or retained fragments, DM/GDM, catheterization, bacterial colonization of lower GU. -Be alert for possible complications associated with identified risk factors; Preeclampsia, diabetes, cardiac disease, c-section, problems with labor, distended uterus.

Preterm Labor: fetal fibronectin, late preterm, RN care/Tx

o Preterm Labor: labor that begins after completion of 20wks & prior to the end of 37wks. Can predict this in pt w/ short cervical length, more prone to infection, fetal fibronectin. Higher risk to baby if <32wks. o Fetal Fibronectin: protein from fetal tissue found in cervical & vaginal secretions. Present at 16-20wks & again near term. Early appearance before term suggests labor may start early. o Early indications: complaints are often vague, Labor signs. Prompt ID enables the most effective therapy to delay preterm birth. o Late preterm is not term: -Term: after 37wks to 41wks. -Late Preterm: infant born between 34 (0/7) and 36 (completed--6/7 weeks of gestation). May appear full term, but it's deceiving bc mortality is 3x higher than term. o Nursing Care: -Initial measures: prevent or stop preterm labor; ID & Tx infections, ID causes for preterm contractions (ex. polyhydramnios), limit activity, hydrate mom, & tocolytics (anti-contraction drugs). -Tocolytics: · Magnesium sulfate: anti-seizure med; also stops labor bc effect on uterine contractions. Monitor VS closely, reflexes—if diminished reflexes or RR, discontinue Mg & notify HCP. · Calcium antagonists: ex. Procardia; Ca-channel blockers normally admin for HTN, its also a smooth muscle relaxant. Relax uterus = stop labor. · Prostaglandin synthesis inhibitors: prostaglandins start labor; inhibitors stop prostaglandins from starting labor. · Beta-adrenergic drugs: ex. ritodrine (Yutopar) or Terbutaline; terbutaline is for bronchospasm, off-label for tocolytic & stops PTL. Can cause cardiorespiratory SE, have propranolol on hand to Tx. Assess apical HR, lung sounds before admin dose, reassess moms VS & FHR. · Betamethasone(Dexamethasone): corticosteroid used for fetal lung maturity, reduces severity of RDS 24-34wks. Betamethasone 12mg given IM, 2 doses, 24hrs apart. Dexamethasone 6mg IM every 12hrs for 4 doses. Mom comes in w/ preterm labor, we need to stop labor for at least the amount of time it takes to admin both doses of betamethasone. --Preterm Labor: perform amniocentesis to ID if lungs are mature, admin betamethasone to help fetal lungs G&D.

Assessing the extremities & hips of a newborn

· Extremities: ability to actively move arms/legs, equally & in a random manner—flexion/extension present. Term baby will have sharp flexion & resist extension during exam. When crying they usually pull arms up to flexion. Everything should be intact, 10 fingers & 10 toes. o Syndactylism: webbing between the digits, can be incomplete or complete fusion of the digits; Tx w/ OP. o Extra digit: called polydactyl; extra digits are usually small & may not have bones. Assess for presence of bones & blood flow. Tx: if no bone (skin tag) tie w/ sutures, this causes them to fall off; if bone & BF present it's left in place, will need OP to remove. o Skin tag: may look like an extra digit. Inspect carefully for these, may indicate internal problems. o Simian Crease: 2 broken creases are normal; seen on the palm side of the hand. Abnormal (chromosomal- Trisomy 21) if 1 solid line (Simian Crease = single palmar crease). o Positional Foot: foot is bent, when you push, it will easily correct to the proper position; could be result of laying transverse in utero. RN must ID & differentiate from a club foot. o Club Foot: bent & will NOT correct w/ manual pushing; indicates future problems w/ crawling & walking. Tx: casting & fix the joints to allow for proper crawling & walking. · Hips: should be even, if not could cause problems walking later in life. Check for hip dysplasia. · Hip Click R/L: assess by lifting the baby up, forward, & then out. If hand is on hip we may feel/hear a "hip click"—when we move baby from a bent-knee position, outward. Could indicate hip dysplasia. · Gluteal folds: folds underneath gluteus. -Equal: both legs folds look the same—same area as you look across; normal finding & means the hips are in the same area, no hip dysplasia present. -Unequal: asymmetry of the folds, or the height of both feet are different when the knees are bent ("apparent thigh length").

Hyperemesis gravidarum

· Hyperemesis Gravidarum: n/v is normal, but this is when she cant eat or drink & its persistent & uncontrollable beginning in first wks of pregnancy & continues. Loss of 5%+ of prepregnancy weight, dehydration, acidosis from starvation, elevated ketones, alkalosis from loss of HCl, & hypokalemia. o Cause unknown, possible increase in hormones (estrogen, beta-hCG), maternal thyroid dysfunction, H. pylori. More common in 1st pregnancy, unmarried white women, multifetal pregnancies. Results in reduced pregnancy weight, low birth weight baby. o Dx: exclude all other causes, ex. PUD, cholecystitis. Labs: Hgb/Hct- dehydration; electrolytes- low Na, K, Cl. Elevated creatine- kidney dysfunction. o Management: Tx w/ methods used for morning sickness—Vit B6/pyridoxine, Vit B6 + doxylamine, ginger, promethazine/Phenergan (ST), methyl prednisone, CNS drugs- Zofran, Reglan. If unsuccessful IV F&E, TPN, or NGT. monitor I&Os/daily weights & urine ketones, normal UO—1mL/kg/hr, BM (hard/decreased = dehydration). Dehydration: decreased intake <2,000mL/day, decreased UO, increased SG >1.025, dry skin & mucus membranes, & nonelastic turgor. -Prevent F&E imbalance: w/ NGT or TPN, gradually discontinued when there is no n/v & PO fluids are tolerated. Small PO of clear liquids started when no n/v. Report continued n/v & intolerance to PO feedings. -Prevent malnutrition: eat every 2-3hrs, add salt to food to replace Cl that is lost. K/Mg-rich foods are encouraged bc of depletion, low Mg worsens n/v. -Reduce n/v: small portions of bland food w/o strong odor, low fat & easily digested CHO (fruit, bread, cereal, rice, pasta). Prevent low blood sugar, liquids only between meals, sit upright after meals. -Emotional support: these women are often met w/ a lack of sympathy bc people assume the n/v is psychological. Allow her to express her feelings, observe her & her family to ID family dynamics contributing to her response, evaluate your own personal biases/beliefs. o Medical management: meds, deyhdration- IV F&E, feeding tubes for severe, IV TPN.