ADN 205- OB Test 2

False Labor

- Contractions but no changes in cervix - Activity doesn't change pattern - Hydration or sedation slows/stops contractions

Go to hospital immediately if...

- Membranes ruptured or water broke- 24 hrs to deliver; increased risk of infection - Experiencing intense pain - Blood show increases- dark bleeding-- abruptio placenta

Difficulties with Leopald's Maneuver

- Obesity - Excessive amniotic fluid-- polyhydramnios

True Labor

- Regular contractions increase in frequency, intensity, and duration - Changes in cervix- progressive dilation and effacement

Contraindications to Leopald's Manuever

- Unexplained vaginal bleeding - Pre-term labor

Secondary Contractions

- use of abdominal muscles to push during second stage of labor

Interventions PPH

-1st palpate uterus - 2nd Massage if boggy but not deviated-- methergine or oxytocine or - 2nd Void if boggy and deviated to right or left

Diaphragm

-Woman must be fitted by healthcare provider -Not recommended for women with history of UTI, yeast infection, increase risk of toxic shock syndrome -Leave in place 6 hours after intercourse

Taking Hold Phase

-begins on day 2-3 until the next few weeks -mom focused on baby care and mastering skills

INR

0.8-1.1

7 NORMAL Maternal Adaptations Following Birth

1. Blood Pressure- Returns to pre-labor level 2. Pulse- Slightly lower than in labor 3. Uterine Fundus- In the midline, at the umbilicus, or 1-2 fingerbreadths below the umbilicus 4. Lochia- Rubra (red); small to moderate amount 5. Bladder- non-palpable 6. Perineum- smooth, pink, without bruising or edema 7. Emotional State- Wide variation; includes excited, exhilarated, smiling, crying, fatigued, pensive, and sleepy

7 cardinal movements (Positional)

1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External Rotation 7. Expulsion

5 Interacting Factors of Passenger (Fetus)

1. Fetal Skull 2. Fetal Attitude or posture- ex.) flexed, knee to chest 3. Fetal Lie 4. Presentation 5. Presenting Part

5 Types of Mechanical Cervical Ripening

1. Hygroscopic Dilators 2. Balloon Catheter 3. Sweeping or Stripping of Membranes 4. Amniotomy 5. External Cephalic Version

3 Lochia Types (What order should it decrease?)

1.) Lochia Rubra- red, 2-3 days postpartum. few small clots are common. 2.) Lochia serosa - pinkish color. 3-10 days postpartum. 3.) Lochia alba - white color. ●Increased by exertion or breastfeeding Cesarean birth has less lochia than vaginal delivery. ●Monitored frequently, as should go from dark (rubra) to light (alba). Increase or reverse could indicate postpartum hemorrhage.

5 P's of labor

1.) Powers (contractions) 2.) Passageway ( birth canal)- ex.) baby turns and repositions due to changes in natural anatomy 3.) Passenger (Fetus) 4.) Psychological Response 5.) Position- ex.) head first (normal), breech *Progress of labor is depending on complementary relationship of all 5

3 types of breech presentation

1.) frank breech- feet first, baby curled up, butt heads out first 2.) complete breech- baby fully curled up and arms wrapped around 3.) footling breech- one foot sticking out and coming out first

5 Methods of Contraceptives

1.)Natural Methods- abstinence, pulling out 2.)Barrier Methods- condoms, vaginal sponges, cervical caps, diaphragms, sperimicidal gels, creams, suppository or foam 3.) Hormonal- birth control, injectable, implant, vaginal ring, or skin patch 4.) Long Acting Reversible Contraceptives- long acting injectable progesterone 5.)Sterilization- vasectomy, tubal ligation, sterilization implant

Advantages of Amniotomy

1.No risk of hypertonus or rupture of uterus as with oxytocin 2.Does not require same intensive monitoring (oxytocin) 3.EFM via scalp electrode may be applied 4.Color and composition of amniotic fluid can be evaluated 5.Amniotomy is less costly

Disadvantages of Amniotomy

1.Risk of infection (labor proceeds beyond 24 hours) 2.Danger of prolapsed cord is increased 3.Compression and molding of fetal head increased 4.Fetal injury from amnihook 5.Bleeding from undiagnosed vasa previa 6.Severe variable decelerations can occur - increasing likelihood of c-section 7.Can cause an increase in pain making labor more difficult to manage

PT

11-12.5 seconds

Hbg

12 to 16 g/dL female; 14 to 18 g/dL male

Platelets

150,000-400,000/mm3

●Warm IV fluids before infusion ●Do not use formula at room Temperature

2 important nursing interventions for cold stress?

INR (therapeutic)

2-3

Breastfeed or formula feed IV infusion of dextrose solution or buccal 40% dextrose gel Maintain neutral temperature environment

3 Treatments for neonatal hypoglycemia?

●Press on skin - ●yellow coloring icterus ●caudal progression - face then trunk

3 ways to assess for jaundice?

Hct

37-47% Female 42-52% Male

1. neonates of gestational diabetic moms 2. >4,000g or LGA 3. post/pre term 4. Hypothermia, neonatal infections 5. RDS, neonatal resucitation

5 Risk factors for hypoglycemia in neonates?

Jitteriness Hypotonia Grunting respiration Irritability, lethargy Apnea, temperature instability

5 s/s hypothermia?

WBC

5,000-10,000/uL

c.) initiate IV access

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action? a.) Witness the signature for informed consent for surgery. b.) Prepare the abdominal and perineal areas c.) initiate IV access d.) insert an indwelling foley catheter

d.) Continuous contraction lasting 2 min

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first? a.) Expulsion of clear fluid from the vagina b.) Expulsion of a blood-tinged mucous plug c.) Pressure on the perineum causing the client to bear down d.) Continuous contraction lasting 2 min

b.) The lowermost portion of the fetus is at the level of the ischial spines

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding? a.) The posterior fontanel is palpable b.) The lowermost portion of the fetus is at the level of the ischial spines c.) The largest fetal diameter has passed through the pelvic outlet d.)The fetal head is in the left occiput posterior position

a.) shortly after giving birth

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? a.) shortly after giving birth b.) during her next attempt to get pregnant c.) immediately d.) in the third trimester

b.) Changes in the cervix

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor? a.) Station of the presenting part b.) Changes in the cervix c.) Rupture of the membranes d.) Pattern of contractions

b.) Frank breech

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions? a.) Cephalic b.) Frank breech c.) Posterior d.) Transverse

d.) Change the client's position

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first? a.) Administer oxygen at 10 L/min via a nonrebreather mask b.) Apply a fetal scalp electrode c.) Increase the rate of the IV infusion d.)Change the client's position

d.) Uteroplacental insufficiency

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following? a.) Maternal bradycardia b.) Fetal head compression c.) Umbilical cord compression d.) Uteroplacental insufficiency

A.Assist the client into the left-lateral position

A nurse is caring for a client who is in labor and observes late deceleration on the electronic fetal monitor. Which of the following is the first action the nurse should take? A.Assist the client into the left-lateral position B.Apply a fetal scalp electrode C.Insert an IV catheter D. Perform a vaginal exam

d.) Variable decelerations are due to umbilical cord compression

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding? a.) Variable decelerations are a result of the administration of IV narcotic analgesics. b.) Variable decelerations are related to fetal head compression. c.) Variable decelerations are caused by uteroplacental insufficiency d.) Variable decelerations are due to umbilical cord compression

b.) Fundus firm to palpation

A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective? a.) Report of absent breast pain b.) Fundus firm to palpation c.) Increase in lochia d.) Increase in blood pressure

6

A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn's Apgar score. Answer the number only.

a.) Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take? a.) Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction b.) Have the client stand at the bedside with her arms at her side. c.) Administer a 500 mL bolus of 5% dextrose in water prior to induction d.) Inform the client the anesthetic effect will last for approximately 6 h

a.) Postpartum hemorrhage

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions? a.) Postpartum hemorrhage b.) Hypertension c.) Thromboembolic events d.) Postpartum infection

d.) "Your contractions will become stronger and more frequent."

A nurse is providing education to a client who is in labor and has a prescription for a continuous IV infusion of oxytocin. Which of the information should the nurse include? a.) "I will remove the electronic fetal monitor once contractions are regular." b.) "This medication will help prevent nausea and vomiting." c.) "You can push the button on the control device to administer more medication." d.) "Your contractions will become stronger and more frequent."

a.) Position the client with one hip elevated

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take? a.) Position the client with one hip elevated b.) Ask the client if she needs pain medication c.) Have the client void d.) Notify the provider of the findings.

4 Facts on the Fundus Postpartum

A.Immediately after delivery of placenta. Top of fundus is midline between symphysis pubis and umbilicus B.6-12 hours after birth - at level or 1 fingerbreadths below the umbilicus.*** C. Decreases about 1 fingerbreadth or 1 cm. each day.*** D. Pre-pregnancy state in about 5-6 weeks

Where you listen to heart if baby is in Frank breech position

Above umbilicus of mom

b. 25

According to Bharti and colleagues, the needle gauge associated with fewer febrile reactions to vaccinations of infants is a. 23. b. 25. c. 27

c. sucking on sucrose solutions

According to Taddio and colleagues, which of the following activities during injections is an effective method of reducing injection pain in newborns? a. nonnutritive sucking b. snug swaddling c. sucking on sucrose solutions

a. is unnecessary.

According to the CDC, aspirating for a blood return before IM injections of vaccines a. is unnecessary. b. confirms needle placement. c. is only necessary for older children.

b. only when they are contaminated or damaged

According to the Centers for Disease Control and Prevention (CDC), nurses should replace needles they use to draw up vaccines from vials a. every time they use them. b. only when they are contaminated or damaged. c. only when there is a needlestick injury.

b. reduces the risks of wasting a medication.

According to the Immunization Action Coalition, not aspirating for a blood return a. is risky. b. reduces the risks of wasting a medication. c. prevents contamination.

a. does not expose the community to dangerous waste

According to the World Health Organization, a safe injection does not cause harm to the patient, does not expose the nurse to injury, and a. does not expose the community to dangerous waste. b. does not implant fearful recollections of the event. c. achieves the intended therapeutic effect

on the day of birth to combat potential bleeding problems

An injection of AquaMEPHYTON (VITAMIN K) is given prophylactically is given when and why?

Timing of Newborn Asessment

Assessment of Physical Maturity Characteristics Critical during 1st 24-hours of life ●Three major times: ●1st assessment - birthing area immediately after birth ●2nd assessment - nursery nurse part of routine admission ●estimate gestation age & evaluate adaptation to extrauterine life 3rd assessment - before discharge - physician, NP or certified midwife

nonshivering thermogenesis (NST)

At birth, the neonate rapidly cools in response to the relatively cold extrauterine environment. Thus, the neonatal temperature rapidly drops soon after birth. In order to survive, the neonate must accelerate heat production via nonshivering thermogenesis (NST), which is coupled to lypolysis in brown adipose tissue.

Precipitous Labor and Birth

Birth/delivery with less than 3 HOURS OF LABOR ●Fear/Pain ●Risk of PPH increased ●Fetus at risk for hypoxia, CNS depression and respiratory distress

Blood Administration

Blood typing and cross matching Signed consent form Check blood according to policy 2 RN bedside check Vital signs before infusion Vital signs when blood hits patient VS 15 minutes & 30 mins

Emotional State BUBBLEHE-P

Bonding, postpartum depression Observation by nurse

Characteristics of Fetal Skull

Bones are soft and overlap (molding) so baby can get through narrow birth canal- misshapen bones

False signs of labor

Braxton Hicks contractions Weights loss no change in duration discomfort begins in abdomen no change when walking no change in cervix

Bloody Show

Breaking of mucus plug. Doesn't mean true sign of labor.

BUBBLEHE- P (Postpartum Assessment)

Breast Uterus Bladder Bowels Lochia Episiotomy/ Incision Homan's Sign Emotional State Pain

Homan's Sign BUBBLHE-P

Bring feet towards knees and assess pain, especially in calves. Not used commonly anymore. (not valid)-- Test for DVTs Leg or chest pain Lung Sounds

Mini-pill

Can be used during lactation.

Contraindications for Prostaglandins

Cardiovascular problems, HTN, preeclampsia

Transitional Milk

Changes from yellow to white. 5 days- 2 weeks.

Braxton Hicks Contractions

Described as strong-like; dysmenorrhea. Second trimester. False sign of labor. Irregular, strengthen with labor contraction.

13 mg/dL

During the 1st week of life; bilirubin should not exceed?

Stepping Reflex

Elicit by holding newborn upright with feet touching a flat surface. The newborn responds with stepping movements. Birth to 4 weeks.

Babinski reflex

Elicit by stroking outer edge of sole of the foot, moving up toward toes. Toes will fan out Expected: Birth to one year -a positive Babinski sign happens when the big toe bends up and back to the top of the foot and the other toes fan out.

Sucking reflex

Elicited when an object is placed in the newborn's mouth or anything touches the lips. Newborns suck even while sleeping; this is called non nutritive sucking

Rooting

Elicited when the side of the newborn's mouth or cheek is touched. In response the newborn turns toward that side and opens the lips to suck -Like pigs, turn neck and try to put finger in mouth in direction that you touch cheeck

Pneumonic for Cardinal positions

Every Day Fine Infants Enter Eager and Excited

bleeding that soaks more than one pad per hour

Excessive bleeding PPH is described as:

Nursing Actions for Oxytocin Induction of Labor

Explain induction (informed consent) ●Apply fetal monitor and obtain 15 to 20 minute tracings and NST to assess FHR before starting IV oxytocin ●Maximum rate is 40 milliunits/min ●Assess FHR, maternal vitals, UCs ●Assess cervical dilation as needed ●** May be used after expulsion of placenta

❖Decreased subcutaneous fat ❖Decreased BAT (premature) ❖Large body surface area Loss of body heat (evaporation, conduction, convection, or radiation)

Factors negatively affecting thermoregulation?

Flexion

Fetal chin flexes downward onto chest

Engagement

Greatest diameter of the fetal head passes through the pelvic inlet

2 on APGAR

HR- ABOVE 100 Respiratory Effort- GOOD CRYING Muscle tone- ACTIVE MOTION Reflex irritability-VIGOROUS CRYING Color- COMPLETELY PINK

0 on Apgar

HR- ABSENT Respiratory Effort- ABSENT Muscle tone- FLACCID Reflex irritability- NONE Color- PALE BLUE

1 on APGAR

HR- SLOW-- BELOW 100 Respiratory Effort- SLOW-- IRREGULAR Muscle tone- SOME FLEXION OF EXTREMITIES Reflex irritability- GRIMACE Color- BODY PINK, BLUE EXTREMITIES

Mini-Pills

Have higher failure rate than combo with estrogen

Mature Milk ( 2 types)

Hindmilk- white or cream-colored Foremilk- clear or blue

Start of midline then go down 1 fingerbreadth a day

How do measure the fundus postpartum?

6 weeks

How long does it take for the fundus to go back to pre-labor state?

Within 72 hours

How soon should RhoGam be given?

2 Maternal side effects of oxytocin

Hyperstimulation and hypercontractility

glucose <40mg/dL

Hypoglycemia in newborns? This is when you treat it.

What to report postpartum?

Hypotension and HTN Tachycardia Uterine atony- "boggy uterus"-- words interchangeable Excessive bleeding temperature over 100F

Iron storage and RBC production

If mother's iron has been adequate; newborn has enough to last until 5 mos. of age. 6 mos. foods containing iron or supplements must be given to prevent anemia.

Pudendal Block

Injected into pudendal nerve (close to ischial spines) ✱Perineal anesthesia ✱Second stage of labor, birth, episiotomy repair ✱Advantages and disadvantages ✱Ease of administration ✱Absence of maternal hypotension ✱Disadvantage ✱Urge to bear down may be decreased.

2 positions of Lumbar Epidural Block

Lateral or sitting

Ischial spines

Line from right to left; imaginary line. When baby's head reaches this part of pelvis it is called " Zero station". Below line numbers become + numbers.

Mongolian spots

Macular areas of bluish black or gray-blue pigmentation on the dorsal area and the buttocks that are common in newborns of Asian, Hispanic, and African descent and other dark-skin races. They gradually fade during the first or second year of life.

Spontaneous rupture of membranes (SROM)

May occur before onset of labor. Takes away barrier and forces mother to deliver in 24 hours to prevent infection for mom and fetus. Just because membranes rupture does not mean true sign of labor.

Bearing down

Mom can't do this until cervix is completely dilated. ✱After cervix is completely dilated, the maternal abdominal musculature contracts as the woman pushes

●Hypoxemia ●Intracranial hemorrhage ●Hypoglycemia (less than 40 mg/dl)

NST (nonshivering thermogenesis) impaired in?

What you need by 1st stage of Labor of latent stage

Need to get IV antibiotics

Sudden Burst of Energy

Nesting. May start cleaning the house; instinct.

Carbohydrate metabolism

Newborn glucose is 15 mg/dL lower than maternal Fuel sources are consumed at a faster rate because of work of breathing, heat loss, and activation of muscle tone. Glucose levels steady about 3 hours after birth.

Brown Adipose Tissue (BAT)

Non-shivering thermogenesis. AKA: BROWN FAT Skin sensors perceive a drop in temperature and transmit sensations to stimulate Sympathetic nervous system. Use newborn's store of brown adipose tissue (BAT) to provide heat. Appears 26-30 weeks gestation - 2-5 weeks after birth

Baseline FHR

Normal baseline 110 to 160 bpm

110-160 bpm

Normal pulse newborn?

30-60/ Minute

Normal respiration newborn?

Examples of when RhoGam is needed

Occurs WHEN Rh- (negative) Mom: ●carries an Rh + positive fetus to term or to termination (miscarriage or induced abortion). ●receives Rh + positive blood ●Experiences an Rh positive tubal pregnancy (ectopic) ●Has an amniocentesis ●Traumatic event allow Rh+ fetal cells to enter circulation of Rh- woman

Placement of Cervidil

Packages in an intravaginal insert. Placed in posterior vagina and left in place to provide a slow release of 10 mg at a rate of 0.3 mg/hr over 24 hours.

Pain BUBBLHE-P

Pain scale Where is your pain? What medication requested? What medication taken last? Pain Assessment

Physiologic Jaundice

Peak bilirubin levels are reached between days 3 and 5 in full-term & 5-7 in preterm Nursery and post-partum environment (lighting) can hinder early detection of jaundice Assess for jaundice: ●Press on skin - ●yellow coloring icterus ●caudal progression - face then trunk

Episiotomy/ Incision BUBBLHE-P

Peri-care Cold pack Care of Incision

Erythema toxicum (newborn rash)

Pink popular rash with an unknown cause with vesicles appear 24-48 hours after birth and resolve 2-3 days

Placement of Prepidil

Placed intracervical

1st-- breastfeeding 2nd-- Sugar water or dextrose

Priority interventions for hypoglycemic newborn?

c. subsequent painful events

Procedural pain in newborns can lead to hyperalgesia, which is a heightened sensitivity to a. pain medication. b. non-painful stimuli. c. subsequent painful events

Cervical Ripening

Process of physical softening, thinning, and dilating the cervix in preparation for labor and birth Prior to the onset of labor contractions

Initial Steps of Resuscitation

Provide warmth under radiant heat source- CHANGE IN TEMP AFFECTS BREATHING!!! Position head in a sniffing position A.Airway Perform initial steps to open airway (reposition, open mouth, clear secretions) B.Breathing Apnea or bradycardia may need PPV (Positive Pressure Ventilation) C.Circulation - severe and persistent bradycardia perform coordinated chest compressions with PPV D.Drugs If unsuccessful epinephrine or reversal (narcan) if drug related

REEDA- Acronym for Episiotomy

R- Redness E- Edema E- Ecchymosis D- Discharge A- Approximation of Edges of Episiotomy/ Laceration

a. decrease injection pain.

Rapid injection of vaccines has been found to a. decrease injection pain. b. increase injection pain. c. have no effect on injection pain

Involution

Return of the uterus to a pre-pregnant state after birth

Belly during contraction

Rises up and becomes firm

IM

Route Carboprost (Hemabate)?

IM, IV only in emergency cases

Route methylergonovine?

PO, Rectally, vaginal tablet

Route misoprostol (Cytotec)?

Lochia BUBBLEHE-P

Rubra (red), Serous (pink), Alba (clear) Large (saturate full pad in less than an hour), Moderate (<6 inches), Small (<4 inches), Scant (< 1 inch)

c. no difference in bruising or systemic reactions between the two.

Salomon and colleagues compared the one- and two-needle techniques for administering DPT vaccines to children and found a. more bruising with one needle. b. more systemic reactions with two needles. c. no difference in bruising or systemic reactions between the two.

Hearing

Screening done universally in all 50 states for newborn.

Edinburgh Postnatal Depression Scale (EPDS)

Screening test used to identify depression in the postpartum period

Trunk Incurvation (Galant reflex)

Seen when the newborn is prone. Stroking the spine causes the pelvis to turn to the stimulated side -Lieing prone; draw curve to left and baby will move left

Complementary/ Alternative Therapies to Labor Induction

Sexual intercourse- female orgasm stimulates UCs; male ejaculate contains rich source of natural prostaglandins Nipple stimulation - stimulates the release of endogenous oxytocin, stimulates uterus to contract Herbal: blue/black cohosh, evening primrose oil, raspberry leaves castor oil, enemas, acupressure/acupuncture

External Rotation/Restitution

Shoulders of infant enter pelvis turning head to one side Restitution- shoulder and body quickly follows

Surgical Techniques in C-Section

Skin Incision- transverse or vertical. Determined by time factor, patient preference, cosmetic reasons, or physician preference. Transverse - made across lowest and narrowest part of abdomen Vertical - made between navel and symphysis pubis, quicker, preferred in emergency situations. Uterine Incision - choice of incision affects woman's opportunity for subsequent vaginal birth & risk of ruptured uterine scar with subsequent pregnancy

Late Decelerations

Slowing of FHR AFTER contraction has started with return of FHR to baseline well after contraction has ended ✱Uteroplacental insufficiency - fetus not getting enough nutrients or oxygen ✱Maternal hypotension, placenta previa, abruptio placentae, uterine hyperstimulation with oxytocin ✱preeclampsia ✱late or post term pregnancy ✱Maternal diabetes mellitus

Taking in phase

Soon after delivery, the mother may appear primarily concerned with herself. This is known as the _______________________.

Moro reflex

Startle reflex Elicited when newborn is startled by a loud noise, or lifted slightly above crib and then suddenly lowered Arms extend while knees flex fingers spread forming a C May persist until about 6 mos. of age

Tx Afterpains

TREATMENT: use of Warm water bottle, mild analgesic 1 hour prior to feeding, ibuprofen prior to bedtime helpful or even prior to assessment

Axillary (97.5-99 F)

Temp for newborns? Route and normal temp range

Early Decelerations - Fetal Heart Rate

Term is deceiving Slowing of FHR with start of contraction with return of FHR to baseline at end of contraction ●Compression of fetal head from uterine contractions, vaginal exam, fundal pressure ●No intervention required

a. in all clinical settings.

The Needlestick Safety and Prevention Act requires that nurses use safety-engineered injection devices for injectables a. in all clinical settings. b. that are irritating to tissues. c. that are injected into patients, not into IV bags or tubing.

4

The immediate postpartum period or the fourth stage of labor and lasts from the delivery of the placenta to the 1st ___________ hours after labor.

4. Latent

The laboring client in the first stage of labor is talking and laughing with her husband. The nurse should conclude that the client is probably in what phase? 1. Transition 2. Active 3. Active pushing 4. Latent

1. Turn the client onto her left side.

The laboring client is experiencing dyspnea, diaphoresis, tachycardia, and hypotension while lying on her back. Which intervention should the nurse implement immediately? 1. Turn the client onto her left side. 2. Turn the client onto her right side. 3. Notify the attending obstetrician. 4. Apply oxygen by nasal cannula.

palpating the uterus

The most crucial assessment (Postpartum) is ____________________________

4. More frequent contractions, Globular-shaped,rise in abdomen

The nurse is caring for the client in labor. Which assessment finding would help the nurse determine whether the client is in the third stage of labor? 1. Lengthening of fetal cord 2. Increased bloody show 3. A strong urge to push 4. More frequent contractions

4.Begin immediate positive pressure ventilation on the newborn

The nurse is completing the 1-minute Apgar assessment on the full-term newborn. the newborn's HR is 80 bpm. What should the nurse do next? 1.Assign a 2 for the Apgar score that pertains to the heart rate 2.Suction the excess secretions from the newborn's oral cavity 3.Wrap in warm blankets and place on the mother's abdomen 4.Begin immediate positive pressure ventilation on the newborn

b. 5/8

The recommended needle length for IM injections for term neonates is a. 1/2 inch. b. 5/8 inch. c. 1 inch

untracted uterus injury to the birth canal large infant/twins excessive amniotic fluid prolonged/precipitous labor

There are several causes of postpartum hemorrhage, list them.

Frequency

Time between the beginning of one contraction and the beginning of the next contraction

Milia

Tiny white papules appearing on the face of a newborn as a result of unopened sebaceous glands; they disappear spontaneously within a few weeks.

Goal of Oxytocin Induction/ Augmentation

To obtain an adequate UC pattern without tachysystole- more than 5 contractions in 10 minutes (averaged over a 30 minute window)

4 T's of PPH

Tone: uterine agony-- firm or boggy? Trauma: retained placental fragments-- asess amniotic sac Tissue: Lower genital tract laceration Thrombin disorder: DIC

Variable Decelerations

Transitory, abrupt slowing of FHR less than 110/min, variable in duration, intensity, and timing in relation to uterine contraction ❖Umbilical cord compression - most common ❖short or prolapsed cord ❖nuchal cord (around fetal neck)

Methergine

Unrelieved vaginal bleeding that is not resolved by fundal massage will require:

Uterotonics

Use of uterotonics for the prevention of PPH during the 3rd stage of labor is recommended for ALL births!

Bishop Score (Know what it is)

Used to determine maternal readiness for labor by evaluating whether the cervix is favorable by rating the following ●Cervical Dilation ●Cervical Effacement ●Cervical Consistency (firm, medium, or soft) ●Cervical Position (posterior, mid position, or anterior) ●Station of presenting part *** Five Factors are assigned a numerical value of 0 to 3, and the total score is calculated

Hepatitis B

Vaccine given before newborn sent home?

VEAL CHOP

Variable Cord Compression Early Head Compression Acceleration OK Late Deceleration Placenta Insufficiency

Globular-shaped abdomen Lengthening of the cord

What are signs that the placenta is about to be delivered? NAME 2

postpartum hemorrhage, infection (related to retained placental parts), preeclampsia/eclampsia

What are some risks/concerns for the mother in the postpartum period? NAME 3

Bladder is full; Have them void (then get bladder scanner)

What does it mean if you assess the fundus and it's deviated to the right/left? What would you do?

DIC, sepsis, hemorrhage

What happens if placental parts are left inside?

Progesterone

What hormone is safe to use during lactation?

Dystocia

What is it? Difficult labor or failure to progress Primary Causes? ●Malpresentations ●Uterine abnormalities (remember pelvic differences) ●Tachysystole of uterus ●Maternal fatigue/dehydration ●Admin of analgesia or anesthesia early in labor ●Fear, exhaustion

Fundal Massage

What is the initial first step in PPH protocol?

1. Infection 2. DVT 3. PPH- Postpartum Hemorrhage

What three complications should you prevent postpartum?

3rd day postpartum

When does breast engorgement occur?

Within 1st 24 hours of delivery

When is infection greatest risk after delivery?

b. breastfeeding

Which of the following is considered a combined pain management intervention for newborns receiving injections? a. pressure b. breastfeeding c. skin-to-skin contact

a. upright

Which position is most effective for reducing newborns' pain at the time of injection? a. upright b. supine c. lateral

Change

_____________ is initiated by compression of the thorax, which forces amniotic fluid from the lungs

Vaginal Birth after Cesarean (VBAC)

a woman who had previous cesarean birth(s) and opting for a vaginal delivery

20-24 weeks

alveolar ducts begin to appear

Forceps

are designed to assist the birth of a fetus by providing traction or by providing means to rotate the fetal head

Amniotomy

artificial rupture of membranes

Labor Augmentation

artificial stimulation of UCs when spontaneous contractions have failed to result in progressive cervical dilation or descent of the fetus ex.) Breaking water

Intrapartum period

begins with the onset of UC and lasts until the expulsion of the placenta AKA .... LABOR CAUSE IS UNKNOWN - Many speculations

Acrocyanosis

blueness of the extremities

Physiologic Jaundice Def.

caused by accelerated destruction fetal RBCs, impaired conjugation, increased bilirubin reabsorption. Normal biologic response of newborn.

Advantages of Prostaglandins

cervidil can be removed easily if uterine hyperstimulation occurs ●Demonstrated cause cervical ripening, shorter labor, and lower requirements for oxytocin during labor induction ●Vaginal birth achieved within 24 hours for most women

Sweeping or Stripping of membranes

digital separation of the chorionic membrane from wall of cervix

Condom

example of barrier method

Internal Rotation

fetal head rotates to fit diameter of pelvic cavity

. External cephalic version

fetus is rotated from breech to cephalic presentation

Uterus BUBBLEHE-P

firm fundus if good, midline good displaced left or right-- full bladder-- increase risk of hemorrhaging if "boggy" then hemorrhaging-- palpate fundus and massage-- giver uterotonics like methylgovorine (Methergine) or oxytocin (Pitocin) to stimulate contraction and firm fundus

Meconium

first stool of the newborn

Light amount of lochia

less than 4-inch stain on peripad

Moderate amount of lochia

less than 6 inch stain on peripad

0.5% erythromycin ophthalmic ointment

medication instilled into the lower conjunctival sac of each eye ●Nurse massages the eyelid gently to distribute the ointment ●Instillation may be delayed for 1 hour to allow eye contact during parent-newborn bonding

Bath Time Newborns

newborns experience cold stress. Bathe in warm room, have all supplies available, Dry with warmed towels and dress immediately

Extension

occiput, brow and face, emerge from vagina

Intensity

refer to the strength of the uterine contractions ✱Estimated by palpating the contraction ✱Directly with an intrauterine catheter attached to an electronic fetal monitor ✱Intensity by palpation - mild, moderate or strong- PALPATE abdomen during contraction ✱Uterine wall indented easily - mild ✱Uterine wall cannot indent - strong As labor progresses the frequency of contractions every 2-3 minutes

Maternal Factors that cause labor

release of prostaglandin & oxytocin & increase of estrogen; increased pressure

Breast BUBBLEHE-P

soft filling, engorged Colostrum, breast milk Bottlefeeding- no nipple stimulation, wear supportive bra (one size smaller), ice packs, tylenol, cabbage leaves Breastfeeding- assess nipples (inverted, flat, everted, cracked, bleeding?), well- fitting bra, lanolin cream, air dry

Labor Induction

stimulation of UCs before the spontaneous onset of labor, with or without ruptured membranes, for the purpose of accomplishing birth

28-32 weeks

surfactant is produced & peaks at 35 weeks

Duration

time from the beginning of the contraction to the completion of the contraction ✱In beginning - 30-40 seconds ✱Labor continues - 30-90 seconds

Fundus

top portion of the uterus

Hindmilk

white or cream-colored

Vision Screening

within 1 mos., confirm within 3 mos., and treat before 6 mos.

Topical Contraceptive Patch

•Applied to clean, dry skin •A new patch is applied same day of week, each week for 3 weeks in a row •4th week no patch is applied •Menstruation should begin during this time •Highly effective in women who weigh less than 198 lbs. Side Effects: weight gain, mood changes, skin reaction at site ***Not effective with higher BMI

Spermicide

•Available OTC •Minimally effective alone •Use with barrier method increases effectiveness •Not effective against sexually transmitted infections (STIs)

Combination Estrogen/ Progesterone Oral (Contra.?)

•Contain both estrogen and progestin •Low failure rate (9%) •Does not provide protection against STIs •Contraindicated: •Hx DVT/PE, HBP, Age 35+, smoker, active cancer, clotting disorders

Long-Acting Reversible Contraception (LARC)

•Do not require user compliance •Reversible upon discontinuation •Cost-effective •Suited for adolescents

Hormonal Contraception

•Forms such as pill, injectable, implant, vaginal ring, or skin patch •Combination of estrogen and a progestin or progestin-only hormones -Synthetic form of progesterone

Intrauterine Contraception

•Inserted at office/immediate postpartum period •May be used with lactation •Good for 1-10 years •Copper IUC can be used as emergency contraceptive must be inserted within 7 days of intercourse •Failure rate 0.2%

Progesterone Only Pills

•Mini-pills (progesterone only) ●Can be used during lactation •Use: -Daily every day -Started on any day, no pill free days -Higher failure rate due to no estrogen -Take pill same time daily for greatest effectiveness

Emergency Hormone Contraception

•Not used as regular form of contraceptive •Indicated when woman is worried about pregnancy because of unprotected intercourse -Sexual assault -Possible contraceptive failure (broken condom, slipped diaphragm, missed oral contraceptives) Take within 72-120 hours of incident

Contraindications to use of oral contraceptives

•Pregnancy •Previous hx of thrombophlebitis/thromboembolitic disease •Acute or chronic liver disease •Estrogen-dependent carcinomas •Undiagnosed uterine bleeding •Smoking •Gallbladder •Hypertension •Diabetes •Hypercoagulable disorders •hyperlipidemia

Barrier Methods of Contraception

•Require couple to use prior to every act of coitus •Few side effects •Safe •Some level of protection against STIs, HPV •Condoms (male/female), vaginal sponges, cervical caps, diaphragms, spermicidal gels, creams, suppository or foam

Operative Sterilization

•Vasectomy -Involves surgically severing the vas deferens in both sides of the scrotum - basically pathway for sperm is "surgically severed." -Can be reversed -Spontaneous reanastomosis can occur. •Tubal ligation -surgical procedure under general anesthesia •Sterilization implant -Office procedure -Implants placed in fallopian tubes, which cause scar tissue, eventually blocks tubes -Alternative contraceptive method used until blockage confirmed, usually 3 months

Gastrointestinal Sytem

●36-38 weeks gestation; GI tract is adequately mature ●Full term infant has adequate intestinal and pancreatic enzymes ●Newborns have trouble digesting starches - not eat complex carbohydrates until after a few months of life ●Regurgitation avoided by avoiding over feeding and burping Continuous vomiting or regurgitation should be reported

Amniotomy

●Artificial rupture of amniotic membranes (AROM) ●Most common procedure in obstetrics ●Amniotomy requires an instrument (amnihook) at least 2 cm. Of cervical dilation must be present. ●May be a method of induction ●Performed during labor to allow access to fetus for internal fetal monitoring

Vitals Post Delivery

●Assess blood pressure and pulse ●Every 15 minutes for first hour after delivery ●Every 30 minutes for the second hour ●Every 4 hours for the next 22 hours ●Every shift after the 1st 24 hours or as stated by hospital protocol

Breastfeeding Jaundice (milk jaundice)

●Associated with poor feeding practices ●inadequate fluid intake - dehydration ●encourage frequent feedings (every 2-3 hours) ●During the 1st week of life; bilirubin should not exceed 13 mg/dl ●Peak at 3-5 days

Signs of cold stress

●Axillary temperature at or below 36.5 ℃ (97.7 ℉) ●Cool Skin ●lethargy ●Pallor ●Tachypnea ●Grunting ●Hypoglycemia ●Jitteriness ●Weak Suck

Fetal Lung Development

●Before birth, fetus practice breathing movements - allowing him/her to breathe immediately after birth ●20-24 weeks - alveolar ducts begin to appear ●Surfactant - composed of surface active phospholipids (lecithin and sphingomyelin) which are critical for alveolar expansion and stability ●28-32 weeks - surfactant is produced & peaks at 35 weeks

Cesarean Birth

●Birth of infant through BOTH an abdominal (skin) and uterine incision Indicated: ●Complete placenta previa, cephalopelvic disproportion, placental abruption, umbilical cord prolapse, failure to progress in labor, breech, previous c-sections (VBAC attempted more), severe Rh isoimmunization

Cardiovascular System postpartum

●Blood loss estimated 200 - 500 mL ○Risk of orthostatic hypotension ●Transient anemia - resolves by 8 weeks after delivery ●WBCs may increase to 30,000/mm within a few hours after birth (stress of labor) and return to normal within 7 days ●Risk for thromboembolism - r/t increase circulating clotting factors during pregnancy ○Life threatening pulmonary emboli

Contraindications for Breastfeeding

●Breast augmentation (cosmetic, breast cancer, etc). ●HIV or other health conditions not ideal ●Taking medications (chemotherapy, antipsychotics, seizure) that can pass through the milk ●Patient is using marijuana, cocaine or other drugs, drinking alcohol, or smoking cigarettes while breastfeeding. ○Using these substances while breastfeeding can harm the baby.

Maternal Contraindications to Oxytocin Induction

●Contraindications for vaginal birth ●Previous vertical (classic) uterine scar ●Placental abnormalities (placenta previa) ●Cephalopelvic disproportion or malpresentation ●Umbilical cord prolapse

Immune System

●Defense (fighting microorganisms) ●homeostasis (disposition of worn out cells) ●surveillance (recognize and destroy) ●Not fully activated until sometime after birth ●S&S of infection - subtle Hepatitis B - given at birth

Oxytocin Induction/ Augmentation

●Effective method of initiating UCs ●Goal obtain an adequate UC pattern without tachysystole - more than 5 contractions in 10 minutes (averaged over a 30 minute window) ●Assessment of maternal pelvis, fetal station and position performed before oxytocin infusion ●Primary IV fluid started and infused first - prevent large dose of oxy and hydration

Cold stress (hypothermia)

●Excessive heat loss resulting in use of compensatory mechanisms (increased respirations, thermogenesis - use of brown fat stores) ●Heat loss at birth --- cold stress --- RDS ●Preterm and SGA - increased risk **Can be fatal

Vaginal Ring

●Flexible hormone-filled ring inserted and left in the vagina for 3 weeks, then removed for 1 week ●Can be left in place for 28 days, with immediate placement of new ring

Physical Assessment

●General Appearance ●Weight and Measurements ●Skin Characteristics - see terms ●Head- caput succedaneum - localized swelling of soft tissues of scalp caused by pressure on the head during labor. Resolves 3-4 days ●Hair, Face, Eyes, Nose ●Mouth, Ears, Neck, Chest, Cry, Respiration ●Heart, Abdomen, Umbilical Cord ●Genitals, Extremities

Signs of Postpartum that need to be reported

●Heavy lochia (saturating 1 pad in 1 hour) ●Increased temperature (> 100.4) ●Frequency/burning on urination ●blurry vision, severe headaches, epigastric abdominal pain, fluid retention assoc. with preeclampsia ●leg pain, swelling or chest pain (DVT/PE)

GI Tract Postpartum

●Hunger returns postpartum ●Assess bowel sounds ●Quite thirsty - will drink a lot - especially if breastfeeding ●Bowels are sluggish. Pain medications can make this worse ●Constipation interventions: stool softener, increase fluids, early ambulation, high fiber foods.

Guidelines for Cytotec

●Initial dosage 25 mcg (3-6 hours apart) ●Pitocin should not be administered less than 4 hours after last Cytotec dose ●Used only where Uterine activity and FHR can be monitored continuously

Depo-provera

●Injectable every three months ●Can be used during lactation

Perineum Asessment

●Inspected for edema and hematoma formation ●ice pack often used to reduce swelling and alleviate discomfort ●to fully assess episiotomy or laceration, the nurse has the woman lie on her side and lifts her anterior butock to visualize the suture line ●Healing of episiotomy or laceration occurs in 2-3 weeks after birth

Maintenance of Neutral Thermal Environment

●Keep newborn's clothing & bedding dry ●Double-wrap the newborn and put a stocking cap on him/her ●Use the radiant warmer during procedures ●Warm objects that will come in contact (e.g. stethoscope) ●Encourage mother to snuggle with newborn under blankets or to breastfeed with hat and light cover

Coagulation

●Liver plays an important role in coagulation during fetal life and continues following birth ●Coagulation factors II, VII, IX, and X are activated under the influence of Vit. K - considered Vit. K dependent ●Absence of normal flora in newborn's gut results in low levels of Vitamin K ●Do not reach adult levels until 9 mos. ●** An injection of AquaMEPHYTON (VITAMIN K) is given prophylactically on the day of birth to combat potential bleeding problems ●Vitamin K given intramuscularly in the vastus lateralis muscle. Uses a 25-gauge, ⅝" needle ●IM 0.5 to 1 mg within 1 hour of birth

Primary Causes of Dystocia (Name 6)

●Malpresentations ●Uterine abnormalities (remember pelvic differences) ●Tachysystole of uterus ●Maternal fatigue/dehydration ●Admin of analgesia or anesthesia early in labor ●Fear, exhaustion

Contraindications to Misoprostol

●Nonreassuring FHR tracing ●Frequent uterine contractions of moderate intensity ●Prior cesarean or uterine scar ●Placenta previa ●Undiagnosed vaginal bleeding

Prevention of Eye Infection

●Nurse is responsible for giving the legally required prophylactic eye treatment for Neisseria gonorrhoeae ●0.5% erythromycin ophthalmic ointment ●medication instilled into the lower conjunctival sac of each eye ●Nurse massages the eyelid gently to distribute the ointment ●Instillation may be delayed for 1 hour to allow eye contact during parent-newborn bonding ●Can cause: ●eye conjunctivitis, interfere with baby's ability to focus, edema, inflammation and discharge - inform parents this will clear 24-48 hours & eye ointment is necessary for baby's well being

Afterpains

●Occur more commonly in multiparas ●caused by intermittent uterine contractions ●Discomfort 2-3 days postpartum ●IV oxytocic agent - (pitocin or methergine) increases ●Endogenous oxytocin released when infant suckles

Assessing the Uterine Fundus

●Palpate ●Determine whether it's firm. It is it not, massage the abdomen lightly. *A firm fundus indicates the uterine muscles are contracting and bleeding will not occur. ●Measure the top of the fundus, in fingerbreadth. *Fundal height gives information about involution. ●Determine location in relation to mid-line; *if not midline assess for bladder distention. ●Assess lochia******

Nursing Care of Vacuum Assisted Delivery

●Parents educated that caput (chignon) on the baby's head will disappear within 2-3 days Nurse continues to monitor for: ●Bruising ●Newborn jaundice ●Cephalohematomas ●Intracranial hemorrhage ●Retinal hemorrhages

indications for Oxytocin Induction of Labor (Name 6)

●Post term pregnancy ●PIH ●Preeclampsia/eclampsia ●Maternal Medical conditions ●PROM Fetal demise

Prostaglandin Agents (Cervidil)

●Prepidil and Cervidil ●Prepidil - placed intracervical ●Cervidil - packages in an intravaginal insert. Placed is posterior vagina and left in place to provide a slow release of 10 mg at a rate of 0.3 mg/hr over 24 hours

Amniotomy Procedure

●Prior: Fetus is assessed for presentation, position, station, and FHR ●While performing a sterile vaginal exam the physician or certified nurse midwife introduces amnihook into vagina, through cervix, and against amniotic membrane. ●Small tear is made. ●Following rupture, amniotic fluid is allowed to escape slowly. ●Amniotic fluid is inspected for amount, color, odor, presence of meconium or blood. ●Woman's temperature monitored every 2 hours ●Bedrest is maintained

Vacuum Extraction

●Procedure used by physicians and certified midwives to assist the birth of fetus by applying suction to the fetal head ●Soft suction cup placed against occiput of the fetal head ●Longer the duration, more likely scalp injuries result ●ACOG advises 30-minute time limit ●Failure to descend with multiple attempts indicates c-section Used: Prolonged second stage, relieve woman of pushing effort or when analgesia or fatigue interferes with ability to push

Urinary Tracts postpartum

●Risk for overdistention ●Incomplete bladder emptying ●Buildup of residual urine ●Worsened by medications: anesthetic block ●Report any S&S of UTIs, hematuria, stasis of urine

Hormone Implants

●Rod implanted in the arm ●office procedure ●lasts for several years ●can be used during lactation

Immune System rules post pregnancy

●Rubella: A client who has a titer of less than 1:8 is administered a subcutaneous injection of rubella vaccine or MMR during postpartum period to protect subsequent fetus from malformation. The client should NOT get pregnant for 1 month following immunization. ●Rh: All rh-negative mothers who have newborns who are Rh-positive must be given Rho(D) immune globulin to suppress antibody formation in the mother. ●*Test in 3 mos for immunity.

Vacuum Extraction Complications

●Scalp lacerations ●Bruising ●Hematomas ●Intracranial hemorrhages ●Fractured clavicle ●Damage to 6th & 7th cranial nerves ●Retinal hemorrhage and fetal death

Safety with Newborns

●Security: (HUGS) ●Identification bracelets ●Checking that identification bands are in place; if missing replace immediately ●allow only people with proper birthing unit identification to remove baby from room ●report presence of suspicious people on birthing unit ●Safety: ●Never leave infant alone. Never lift infant if parent feels weak or faint or unsteady ask for help. Keeping an eye and hand on newborn when out of crib. ●Protect from infection - hand washing, those will illnesses to avoid visiting.

Misoprostol (Cytotec) - Know what it is, routes, what it increases, how quickly it should be delivered, what is it used with

●Synthetic Prostaglandin ●Used to soften and ripen the cervix ●Available as a tablet inserted into the vagina - orally or sublingually ●** evidence shows an increase rate of uterine rupture ●More effective than oxytocin ●Delivery within 24-hours

Elimination

●Term newborns - pass meconium within 8-24 hours of life ●Meconium - formed in utero from amniotic fluid and its constituents ●Thick, tarry, black (or dark green) appearance. ●Transitional (thinner brown to green) ●Breastfed - pale yellow (may be pasty green) ●more liquid and more frequent than formula-fed newborns ●Frequency varies - one every 2-3 days; to as many as 10x/day

Reflexes

●Tonic neck ●grasping ●moro ●rooting ●sucking ●trunk incurvation (galant reflex) ●Babinski Stepping

Shoulder Dystocia

●Unpredictable obstetric emergency ●Risk Factors: ●Fetal macrosomia (weight greater than 4,500 grams) ●Maternal diabetes ●History of shoulder dystocia ●Prolonged second stage Excessive weight gain

umbilical care

●Use of sterile water or air drying results in umbilical cords separating more quickly than those treated with alcohol- leave open to air ●Fold diaper down to prevent coverage of stump ●Teach S&S of infection (to parents): foul smell, redness and greenish yellow drainage, localized heat and tenderness, bright red bleeding, if area remains unhealed 2 to 3 days after cord has sloughed off

Disadvantages of Prostaglandins

●Uterine hyperstimulation, nonreassuring fetal status, higher incidence of postpartum hemorrhage, uterine rupture ●Prostaglandin should be used in caution in women with compromised cardiovascular, hepatic, or renal function and women with asthma or glaucoma

Contraindications to Labor Induction or Augmentation

●Vasa previa or complete placenta previa ●Transverse fetal lie ●Umbilical cord prolapse ●Previous classical cesarean delivery ●Previous myomectomy entering the endometrial cavity ●Myomectomy (surgical procedure to remove fibroids)

Route-- intramuscularly in the vastus lateralis muscle Gauge size-- a 25-gauge, Needle size-- ⅝" needle Time frame-- within 1 hour of birth

●Vitamin K given what route? gauge size? needle size? what time frame?

Breast Care for non-lactating women

●Wear a well-fitting supportive bra continuously for the first 72 hours ●Suppression of lactation is necessary for clients not breastfeeding. Avoid breast stimulation or running warm water over the breasts for prolonged periods until no longer lactating ●For breast engorgement, occur on 3rd or 5th day postpartum, apply cold compresses 15 min on and 45 min off. ●Fresh, cold cabbage leaves can be placed inside the bra ●Mild analgesics or anti-inflammatory medication can be taken for pain and discomfort of breast engorgement

Fetal breathing movements (FBM)

●ability to breathe after birth results from intrauterine FBM - 17th to 20th week ●lungs convert from fluid-filled organ to air-filled organ capable of gas exchange ●development of chest wall muscles & diaphragm ●Change is initiated by compression of the thorax, which forces amniotic fluid from the lungs

0.5% erythromycin ophthalmic ointment can cause:

●eye conjunctivitis, interfere with baby's ability to focus, edema, inflammation and discharge - inform parents this will clear 24-48 hours & eye ointment is necessary for baby's well being

Characteristics affecting thermal stability in newborn:

●less subcutaneous fat than an adult and thin epidermis ●Blood vessels are closer to the skin than adult ●flexed posture of the term infant decreases the surface area exposed to the environment, thereby reducing heat loss ●smaller infant; need for higher temperatures

Decrease Jaundice

●maintain skin temperature at 97.8 or above - prevent cold stress ●Monitor stool - bilirubin is eliminated in feces; inadequate stooling may result in reabsorption and recycling of bilirubin ●encourage early breastfeeding; laxative effect of colostrum increases excretion of meconium and transitional stool ●if baby is treated with phototherapy a few additional days of hospitalization may be needed

Cervical Caps

●provider determines fit ●spermicide must be added before each insertion ●Must be left in place for 6 hours after coitus ●Does not protect against STIs

Primary Contractions

✱- uterine contractions ✱Complete effacement and dilatation

Fourth Stage of Labor

✱1-4 hours after birth ✱Physiologic readjustment of mother's body ✱Hemodynamic changes occur ✱EBL 250-500 mL ✱Drop in BP and tachycardia- fluid loss or PPH ✱Uterus remains contracted ✱Midline of abdomen ✱Fundus usually midway between symphysis pubis and umbilicus

When to go to hospital when pregenant

✱1st time Mom's - ✱wait until contractions are 5 minutes apart ✱last 60 seconds ✱regular for at least an hour

Amnisure testing

✱99% accurate. detects PAM-G biomarker in vaginal secretions present when ROM occured

First Stage (Active Stage)

✱Anxiety increases - Increased intensity of contractions ✱Some exhibit a decreased ability to cope (energy); and a sense of helplessness ✱Cervix dilates from 4-7 cm. ✱averages 3-6 hours ✱Fetal descent is progressive ✱Contractions intense every 3-5 minutes with duration of 30-45 seconds * Mother is scared, worried not relaxed

Nursing Actions for SROM

✱Assess FHR- cord wrapped around baby? ✱Increased risk of prolapsed cord with ROM & presenting part not engaged ✱Assess amniotic fluid: color, amount, and order ✱Normal amniotic fluid - clear or cloudy with normal odor ✱Fluid - can be meconium-stained; reported immediately may indicate fetal compromise ✱Document - date, time of ROM, characteric of fluid & FHR

Tachycardia FHR

✱Baseline FHR over 160 bpm over 10 minutes ✱Nonreassuring with other FHR patterns ✱Late or severe variable decelerations Decreased or absent variability

Bradycardia FHR

✱Baseline under 110 bpm for at least a 10-minute period ✱Causes can include: ✱Vagus nerve stimulation ✱Drugs ✱Maternal hypotension ✱Fetal hypoxemia or dysrhythmia

Third Stage of Labor

✱Birth of infant to completed delivery of placenta ✱5 minutes to 30 minutes after birth ✱S&S ✱Globular-shaped uterus ✱Rise of fundus in abdomen ✱Sudden gush or trickle of blood ✱Further protrusion of the umbilical cord out of the vagina Placental Delivery: ✱Expelled with fetal (shiny) side known as Schultze mechanism or shiny Schultze ✱Expelled with maternal (rough) side known as Duncan mechanism or Dirty Duncan

GBS Positive (GBS+)

✱Can cause perinatal morbidity & mortality ✱Penicillin drug of choice ✱Screen for allergies: Clindamycin or vancomycin drug of choice

Second Stage of Labor

✱Cervix is completely dilated (10 cm.) and ends with the birth of the infant ✱Typically completed within 2 hours ✱Contractions continue with frequency and intensity as in transition phase (1-2 minutes; 50-90 seconds duration) ✱Crowning occurs when the fetal head is encircled by the external opening of the vagina ✱Positioning changes of fetus (Cardinal movements) occurs

Carboprost (Hemabate)

✱Classification - Prostaglandin ✱Route/Dosage: IM 250 mcg injected into a large muscle ✱Actions - Contraction of uterine muscle ✱Indications - Uterine atony *Additonal doses may be given at 15 to 90 minute intervals (PPH)

Misoprostol (Cytotec)

✱Classification - anti-ulcer/Prostaglandins ✱Route/Dosage - PO/Rectally 200-1,000 mcg ✱Actions: Causes uterine contractions ✱Indications - Control PP Hemorrhage. Used off label and not FDA approved- NOT USED OFTEN

Methylergonovine (Methergine)

✱Classification: Oxytocic/ ergot alkaloid ✱Route: PO 200-400 mcg (0.4-0.6 mg) every 6 to 12 hours for 2-7 days. IM 200 mcg (0.2 mg) every 2 to 4 hours up to 5 doses. IV - emergency ✱Actions: Directly stimulates smooth and vascular muscle causing sustained uterine contractions ✱Indications: Prevent or treat PP hemorrhage/uterine atony/subinvolution. Contraindicated in hypertensive patients.

Characteristics of Transition Phase

✱Contractions have a frequency of 1 - 2 minutes, duration of 40-60 seconds & STRONG in intensity ✱As dilation approaches 10 cm. - increased rectal pressure and uncontrollable urge to bear down ✱Woman may become apprehensive and irritable ✱Hyperventilation, Restless, Increased sensitivity to touch, Increased need for partner/nurse's presence ✱Request for medication ✱"Can't take it anymore." ✱Crying, yelling

Presentation

✱Determined by the lie and refers to the body part of the fetus that enters the birth canal first. ✱Cephalic, breech, or shoulder. ✱Breech or Shoulder considered malpresentations - With a frank breech presentation, the fetal heart is generally above the level of the client's umbilicus. ✱Cephalic (head first) most common

Nursing Actions during Latent Stage (1st Stage of Labor)

✱Diet & Hydration ✱Activity & rest ✱Elimination- make sure she voids ✱Comfort- tone it down Support & family involvement

4 Stages of Labor and Childbirth

✱FIRST STAGE - latent, active and transition ✱SECOND STAGE - cervix completely dilated (10 cm.) and ends with birth of infant ✱THIRD STAGE - birth of infant - completely delivery of placenta ✱FOURTH STAGE - 1 to 4 hours after birth; physiologic readjustment of the mother's body begins

Oxytocin (Pitocin)

✱IM or IV (as an infusion NOT bolus) ✱Common: 20 u in 1 L NSS or LR ✱Actions: Stimulates uterine smooth muscle producing contractions ✱Has vasopressor and antidiuretic properties ✱Indications: Control of PP bleeding after ✱placental expulsuion *SEE pg 312 fro critical component

Advantages of Spinal Block

✱Immediate onset of anesthesia ✱Relative ease of administration ✱Smaller drug volume ✱Maternal compartmentalization of the drug Low failure rate

Lumbar Epidural Block

✱Injection of local anesthetic into epidural space ✱Continuous block ✱Complete pain relief ✱Common during labor and birth *Sitting up and bearing over table

First Stage ( Transition Phase)

✱Last part of the 1st Stage ✱Restless/inner-directed; fearful of being alone ✱Cervical dilation slows as it progresses from 8 cm to 10 cm ✱Phase should be no longer than 3 hours (nullipara) 1 hour (multipara) ✱Epidural may increase the duration of 1st stage by 1 hour ✱Perform amniotomy if not previously done- If membranes are not ruptured

Signs if Imoending Labor

✱Lightening ✱Braxton Hicks Contractions ✱Cervical Changes ✱Bloody Show ✱Sudden Burst of Energy ✱Other Signs - weight loss, backache, GI ✱Weight loss is due to water loss and increased basal metabolic rate

First Stage (Latent)

✱Onset of regular contractions ✱Cervix dilation (0 to 4 cm) and effacement 0-40% ✱Mild contractions every 5 to 15 min lasting 10-30 sec ✱Nullipara - average 12 hours - not > 20 hours ✱Uterine contractions increase in frequency, duration and intensity ✱Woman often talkative and smiling ✱Excitement is high- Nesting Bag of waters USUALLY ruptures at this time

Accelerations

✱Periodic ✱Associated with uterine contractions ✱Generally associated with stimulation of autonomic nervous system No intervention required

Advantages of Lumbar Epidural Block

✱Produces good analgesia ✱Woman fully awake during labor and birth ✱Continuous technique allows different blocking for each stage of labor. ✱Dose of anesthetic agent can be adjusted Can be used for Vaginal and Cesarean births

Station

✱Relation of presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis. Ischial spines marked as Zero Station

3 Phases of Contractions

✱Rhythmic tightenings and shortenings of the uterine muscles during labor First Phase: Increment or building up (longest phase) Second Phase: Acme or peak Third Phase: Decrement "letting up" of contraction Between contractions is a period of relaxation Describing Terms: Frequency, Duration & Intensity

Episiotomies/Tears

✱Surgical incision of the perineal body ✱Midline may extend through the anal sphincter and rectum ✱Pain ✱INFECTION !!!! Inspect, inspect, inspect... ✱Urinary Retention (tear anteriorly) ✱Constipation - stool softeners ✱INTERVENTIONS: Analgesics, Topical ointment of spray such as: Tucks Medicated Pads, ICE PACKS, Warm Sitz (after 24-hrs).

Neonatal Resuscitation

✱TERM GESTATIONAL? ✱CRYING OR BREATHING? ✱GOOD MUSCLE TONE? *If answer is "yes" to at least 2 of these-- Resuscitate

Signs of Fetal Respiratory Distress

❖Cyanosis ❖abnormal respiratory pattern such as apnea and tachypnea ❖retractions of the chest wall ❖grunting ❖flaring of nostrils hypotonia

Management Protocols PPH (Initial)

❖Fundal massage ❖Ensure 16 G or 18 G IV access ❖Increase IV fluids (crystalloid without oxytocin) ❖Insert indwelling urinary catheter

Interventions for Late Decelerations

❖Insert IV, increase IV fluid (fluid resuscitation) ❖Discontinue oxytocin if being infused ❖Administer oxygen 8 to 10 L/min via nonrebreather face mask ❖Elevate client's legs ❖Notify provider ❖Prepare for an assisted vaginal birth or cesarean birth

Interventions for Variable Decelerations

❖Reposition client from side to side or into knee-chest. WHY ???- work with gravity cord to go behind baby ❖Discontinue oxytocin if being infused ❖Administer oxygen at 8 to 10 L/min via non rebreather mask ❖Perform or assist with a vaginal examination ❖Assist with amnioinfusion if prescribed. Let's talk about this.

Rh alloimmunization is only a concern...

❖Subsequent exposure to Rh + blood cause a serious reaction of hemolysis of RBCs in future newborns !!!!

Circulatory System

❖Transition from fetal circulation to neonatal circulation begins rapidly within seconds ❖Influenced by changes in respiratory system ❖Three major fetal circulatory structures undergo changes are: ➢ductus venosus ➢foramen ovale ➢ductus arteriosus

6-8 wet diapers a day indicates?

effective breastfeeding; baby getting enough nutrients

Grasping reflex

elicited by stimulating the newborn's palm with a finger or object. Newborn will grasp the object or finger firmly

tonic neck reflex

elicited when newborn is supine and head turned to one side. In response, extremities of same side straighten, opposite side they flex. Persists until about 3rd month **Turning the neck

Lightening

engagement - ease of breathing - increased urinary freq., vaginal secretions, leg cramps, pelvic pressure, edema lower extremities

1. Multiple gestation 2. Previous C-section 3. High Parity- multipara 4. Prior PPH 5. Augmented or induced Labor 6. Precipitous Labor--not whole lot of contraction

6 Risk Factors of PPH

Balloon Catheter

Foley Catheter placed in uterus and balloon filled. Stimulate prostaglandin release

Cervical Changes

"ripening" - softening of cervix. Most positive, true sign of labor. Dilation, true sign of labor.

Vaginal deliver and PPH

- Blood loss greater than 500 mL (vaginal) and 1,000 mL (cesarean) - Vaginal-- uterine contractions decrease risk of hemorrhage

Leopald's Maneuver

-Palpation used to assess fetal adaptation btw mother and fetus - Can be prepared after 24 weeks of pregnancy and during labor - Methods of palpating maternal abdomen - Maneuvers reveal: general location of fetal heart, whether engagement has taken place, approximate size of infant, and whether size is appropriate for length of pregnancy

Abstinence

0% failure rate

PT therapeutic

1.5 x 2.5 x normal range

Taking In Phase

24-48 hours after birth: dependent, passive; focuses on own needs; excited, talkative

D. Relaxation between uterine contractions

A nurse is reviewing the electronic monitor tracing of a client who is in active labor. The nurse should know that a fetus receives more oxygen when which of the following appears on the tracing? A.Peak of the uterine contraction B.Moderate variability C.FHR acceleration D. Relaxation between uterine contractions

300-500 mL/voiding

A postpartum patient should void between approximately ______-_________ ml/voiding.

c. fewer systemic and fewer local reactions

According to Cook and Murtagh, administering immunizations by inserting the needle into the preferred site at 90° with the skin stretched flat between the thumb and index finger results in a. more systemic but fewer local reactions. b. more local but fewer systemic reactions. c. fewer systemic and fewer local reactions

Test most commonly used when assessing status of membranes

Amnisure testing

c. vastis lateralis

For newborns and infants up to the age of 18 months, the recommended site for IM injections is the thickest part of which muscle area? a. deltoid b. ventrogluteal c. vastis lateralis

Conjugation of Bilirubin

At birth, newborn's liver must begin to conjugate bilirubin. Produces a rise in serum bilirubin (1st few days)

Warm water

Avoid this so breastmilk can reproduce?

Bowels BUBBLEHE-P

BM? Bowel sounds? Hemmorhoids?

Postpartum Hemmorhage (PPH)

Blood loss greater than 500 mL (vaginal) and 1,000 mL (cesarean) 10% drop in hemoglobin and/or hematocrit Two part approach 1.Treatment of obstetric hemorrhage/potential hypovolemic shock 2.Identification/management of underlying cause

48hrs

By ________ hours newborn should be voiding?

Administration of Phytonadione (Vit K)

Cleanse the area thoroughly with alcohol swab Use a 23-25-gauge, ⅝" needle With the skin stretched flat between thumb and index finger insert the needle at a 90° to the long axis of the femur on the anterior lateral aspect of thigh (vastus lateralis) Remove the needle, massage the site with an alcohol swab ** Oral Vit K. not absorbed well by the GI tract

Foremilk

Clear or blue

Colostrum

Clear yellowish fluid, precedes milk production. Higher in protein and lower in carbohydrates than breast milk and contains immunoglobulins G & A, provide protection for the early weeks of life.

Medications or blood in breast milk

Dark colored milk results from?

Bladder BUBBLHE-P

Empty completely with each voiding burning, pain upon urination-- bad Measure first voiding after delivery

Warm surfaces Don't place near window

Interventions negative thermoregulation?

Metabolic System

Large quantities of glycogen are stored by the fetus during pregnancy in preparation for energy requirements when transitioning from intrauterine to extrauterine life. Glucose values generally decrease about 1 hour post birth, and rise and stabilize 2 to 3 hours post birth Normal range glucose 70-100 mg/dL ** Neonates of gestational diabetics HYPOGLYCEMIA (glucose < 40 mg/dL) ... Treat

●Neck ●Thorax ●Axilla ●Intrascapular areas ●Around adrenal glands/kidneys

Location of Brown Adipose Tissue (BAT)?

Diaphragm

Must be fitted by a healthcare provider.

IM or IV (not as a bolus)

Oxytocin route?

Circumcision Care

Post-op: Assess S&S infection and hemorrhage every 30 min. for 2 hrs. Observe 1st voiding. ●Petroleum and gauze are applied to site; prevent bleeding and protect the healing tissue -Bleeding and infection risk -Make sure site is clean and dry

Epstein's Pearls

Small, white blebs found along the gum margins and at the junction of the hard and soft palates; commonly seen in the newborn as a normal manifestation.

Fetal Factors that cause labor

aging placenta, prostaglandin synthesis by fetus, fetal cortisol rises - in turn quiets the progesterone in maternal allow increase prostaglandins

Surfactant

composed of surface active phospholipids (lecithin and sphingomyelin) which are critical for alveolar expansion and stability

Normal position of baby

head down, or in cephalic position

Letting Go Phase

interdependent phase after birth in which the mother and family move forward as a system with interacting members

scant amount of lochia

less than 1 inch

Descent

movement of fetus through birth canal - 1st & 2nd stage

70-100mg/dL

normal blood glucose for nondiabetic?

Hygroscopic dilators (Laminaria, Lamicel, or Dilapan)

produced from dried seaweed. Inserted into cervix, expand over 12 to 24 hours as they absorb water. This absorption of water leads to expansion which releases local prostaglandin. Used primarily during pregnancy termination

Fetal lie

refers to the relationship of the long, or cephalocaudal, axis (spinal column) of the fetus to the long, or cephalocaudal, axis of the mother

Heavy amount of lochia

saturated pad within 1 hour

Cervical Ripening

softening & effacing of the cervix

Long-Acting injectable Progesterone Only

•1st dose given within 5 days following onset of menstruation •After that, an injection is needed every 11-13 weeks Side Effects: •Amenorrhea •Delay return to fertility after stopping drug •Weight gain and depression

Natural Methods

•Abstinence •Natural family planning •Coitus Interruptus (withdrawal) •Lactational amenorrhea (LAM) - considered postnatal infertility when woman is amenorrheic and fully breastfeeding. •Basal Body Temperature Method

Management Protocols PPH (Medications)

❖Increase oxytocin, additional uterotonics ❖Oxytocin (Pitocin) 10-40 units per 500-1000 mL solution ❖Methylergonovine (Methergine), 0.2 mg IM (may repeat) ❖Hermabate (Carboprost) 250 mcg IM (may repeat in q 15 minutes, max dose 8) ❖Misoprostol (Cytotec), 800-1000 mcg PR or 600 mcg PO ❖Blood Type & Crossmatch 2 units PRBCs (revisit blood administration) OR stat! If no interventions are effective!

Newborn APGAR

❖Purpose: Evaluate physical condition of newborn at birth ❖Rated at 1 minute and 5 minutes ❖Score 0-10 based on the criteria