ob final

Menstruation returns in nonbreastfeeding women by:

12 wks -in breastfeeding women, menstruation occurs in 2-18 months -*elevated serum prolactin levels in breastfeeding women appears to be responsible for suppressing ovulation*

Insulin requirements normally peak at ______ weeks of gestation and drop significantly after that

36

Gestational diabetes (GDM) is more likely to occur among:

Hispanic, African American, Native American, Asian, Pacific Islander women than Caucasions -likely to recur in future pregnancies -risk for development of overt diabetes later in life is also increased

Infection in pregnant women with diabetes is serious because it causes increased ________________ and may result in ___________________

Insulin resistance; ketoacidosis

If conjugated bili is not excreted in the feces, intestinal enzymes (ß-glucuronidase) convert conjugated into unconjugated bili then it is:

*reabsorbed* by the gut to *return to the liver* Must have *protein albumin* to conjugate & excrete!

Nursing priorities - meconium stained amniotic fluid

-Indicates that the fetus has passed meconium (first stool) before birth -Major risk associated with meconium- stained amniotic fluid is the *development of meconium aspiration syndrome (MAS) in the newborn.* Before birth: 1. Assess amniotic fluid for meconium after ROM 2. If meconium stained, gather equipment and supplies that might be necessary for neonatal resuscitation 3. Have at least one person capable of performing endotracheal intubation on the baby present at the birth Immediately after birth 1. Assess the baby's respiratory efforts, HR, and muscle tone 2. Suction only the baby's mouth and nose, using either a bulb syringe or a large bore suction cath if the baby has: -Strong respiratory efforts -Good muscle tone -Heart rate > 100 beats/ minute 3. Suction the trachea using an endotracheal tube connected to a meconium aspiration device and suction source to remove any meconium present if the baby has: -Depressed respirations -Decreased muscle tone -Heart rate < 100 beats/ minute

How is perinatal loss different?

-Suddenness and unexpected nature of loss -The way infant death is socially defined in our culture -Loss of dreams and future with the child -In some situations, anticipatory grief is experienced. Two major types: 1. death of fetus or newborn 2. birth of less than perfect child

Nutritional assessment - determining adequate intake

1. *1-3 wet/ dirty diapers during the first day* 2. *By day 5, baby should have 6-8 wet diapers and 3 dirty diapers a day* 3. Watch for signs of milk transfer -Audible swallowing -Pause during sucking -Occasional milk pooling around baby's lips -Mothers breast become softer 4. Infant weight in pounds or kilograms

8 impending neurological problems

1. Absence of newborn reflexes 2. Facial asymmetry 3. Facial paralysis 4. CNS depression 5. Abnormal respiration 6. Hypoglycemia 7. Low or high pitched cry 8. Stridor or weak cry

5 components to FHR interpretation

1. Baseline FHR 2. Variability 3. Accelerations 4. Decelerations 5. Trends over time

Fertilization & implantation (5)

1. Sperm: 5 ml/200-500 million sperm. 2. Some reach site of fertilization within 5 min. *Avg transit time 4-6 hrs* 3. Sperm *remain viable 2-3 days.* 4. Fertilized ovum (zygote) takes *3-4 days to enter uterus.* 5. *7-10 days to complete implantation* in uterus.

Patent Ductus Arteriosus (PDA)

1. ductus arteriosus *opens and blood shunts across the PDA avoiding the lung* 2. management is medical or surgical -- ventilation, fluid restriction, diuretics, indomethacin (constricts ductus arteriosus); surgical ligation when PDA is clinically significant and medical management fails.

FAS craniofacial abnormalities

1. small palpebral fissures of the eyes 2. flat maxillary area 3. thin upper lip 4. flat or absent philtrum 5. short, upturned nose

Ovulation occurs ____ days before the next cycle

14

Conception occurs approximately ____ weeks after first day of last menstrual period (LMP)

2

Preterm birth is any birth that occurs between:

20-36 6/7 weeks of gestation

Developmental milestones: weeks 3-8

3 weeks: *heart starts beating & blood circulates* 4 weeks: *2 chamber forms a 4 chamber heart* -respiratory system begins 5 weeks: umbilical cord developed 8 weeks: gender distinguishable

Passageway - bony pelvis (4) & soft tissue (4)

4 types of bony pelvis: 1. *gynecoid is the most common*; classic female type -*round* shape -*IDEAL FOR BIRTH* 2. android: resembles the *male pelvis* -*heart* shaped 3. anthropoid: resembles the *ape pelvis* -*oval* shaped 4. platypelloid: *flat* pelvis -rare -*NOT conducive to vaginal delivery* Soft tissues 1. lower uterine segment: *distends* to accommodate intrauterine contents 2. cervix: *thins and opens to allow descent* into the vagina 3. pelvic floor muscles: *help rotate the fetus* as it passes through the birth canal 4. vagina & introitus: *dilate* to accommodate the fetus and permit passage to the external world

Fertile period is ____ to ____ days before ovulation and ____ hours after ovulation

4-5 days before; 48 hours after

Risk factors for GDM

A family history of diabetes and previous pregnancy that resulted in unexplained stillbirth or birth of malformed or macrosomic fetus Other risk factors include obesity, HTN, glycosuria, & maternal age older than 25 years However, more than half of all women diagnosed with GDM do not have these risk factors

When should women be screened for GDM?

Between 24-28 weeks of gestation -those with strong risk factors should be screened earlier in pregnancy; if results are normal, they should be rescreened at 24-28 weeks

Hyperbilirubinemia is a condition in which the:

Bilirubin level 1 in the blood is increased 1. Characterized by a yellow discoloration of the skin, mucous membranes, sclera, and various organs -- known as jaundice or iceterus 2. Jaundice *occurs when unconjugated bilirubin accumulates in the skin and other tissues* -When it crosses the blood barrier it is called kernicterus. -*Our goal in the management of hyperbilirubinemia is to prevent kernicterus (bilirubin encephalopathy)*

____________ & _____________ facilitate involution

Breastfeeding & fundal massage Breastfeeding immediately after birth & in the early days pp *increases the release of oxytocin, which decreases blood loss & reduces the risk for pp hemorrhage*

Oral glucose tolerance test is a gestational diabetes test that measures: A. How insulin is processed in the mother's body B. Baby's glucose levels C. How a mother's body processes sugar D. Hormone levels in the placenta

C. How a mother's body processes sugar In the oral glucose tolerance test, glucose is administered to the mother, and blood sugar levels are measured at regular intervals. This test is done after overnight fasting. It measures how the body processes the sugar administered orally.

Montevideo units (MVUs)

Calculated by subtracting the baseline uterine pressure for each contraction that occurs in a 10 min window, & then adding together the pressures generated by each contraction that occurs during that period of time -*Spontaneous labor usually begins when MVUs are between 80 and 120* -Uterine activity during normal labor rarely exceeds 250 MVUs

Insulin requirements in breastfeeding women may be half of prepregnancy levels because of the:

Carbs used in human milk production 1. Bc glucose levels are lower than normal, *BF women are at increased risk for hypoglycemia, especially in the early PP period & after BF sessions*, particularly after late night nursing 2. BF mothers with diabetes may be at increased risk for mastitis & yeast infections of the breast 3. *The insulin dose, which is DECREASED during lactation, must be recalculated at weaning*

Most frequent reason for hospital readmission during the first week of life:

Hyperbilirubinemia

APGAR scoring

If NB is less than 37 weeks -- *worried about respirations*

During the 2nd and 3rd trimesters, because of insulin resistance, the insulin dose must be:

Increased significantly to maintain target glucose levels

________________ is a laboratory diagnosis for a variant of *severe preeclampsia* that *involves hepatic dysfunction*

HELLP syndrome Characterized by: H - *hemolysis* (*↑ Bilirubin level or presence of Burr cells* on peripheral smear) EL - *elevated liver enzymes* (*↑ AST, ALT*) LP - *low platelet count* (*↓ Platelets <100,000/mm³*)

Ketoacidosis occurring at any time during pregnancy can lead to:

Intrauterine fetal death

Neonatal Abstinence Syndrome (NAS)

Infants of substance abusing mothers will experience withdrawal if the drug has been used regularly during the pregnancy and was used just prior to birth *Symptoms: WITHDRAWALS* *W*akefulness *I*rritability *T*remulousness *H*yperactive, high pitched cry *D*isorganized *R*egurgitation *A*pneic *W*eight loss *A*lkalosis *L*acrimation and nasal congestion *S*eizures

Primary vs secondary powers

Involuntary & voluntary powers combine to expel the fetus & placenta from the uterus 1. Primary -*uterine contractions (involuntary)*; signals the beginning of labor -*responsible for effacement and dilation* of cervix and fetal descent -*Ferguson reflex: maternal urge to push* 2. Secondary -*pushing (voluntary)*; *increase force of the involuntary ctxs* -NO effect on dilation or effacement

____________, the yellowish color of the skin & sclera, is caused by elevated serum levels of:

Jaundice; unconjugated (indirect) bilirubin. 1. *When levels of unconjugated bilirubin exceed the ability of the liver to conjugate it, plasma levels of bilirubin increase, and jaundice appears* 2. Jaundice is generally noticeable *first in the head, especially in the sclera and mucous membranes*, and progresses gradually to the thorax, abdomen, and extremities 3. The liver is responsible for conjugation of bilirubin, which *results from the breakdown of RBCs.*

_________________ and __________________ are commonly prescribed rapid-acting insulins with a shorter duration of action than regular insulin and are preferred for use during pregnancy

Lispro (Humalog) and aspart (Novolog) -Advantages: *convenient bc injected immediately before meals, produce less hyperglycemia after meals, cause fewer hypoglycemic episodes* in some people -*Effects only last 3-5 hours* so most clients also require longer-acting insulin

What happens when the corpus luteum stops functioning before the placenta produces enough progesterone and estrogen?

MISCARRIAGE

Distended, small, white sebaceous glands noticeable on the newborn face are known as:

Milia

Poor glycemic control around time of conception and in early weeks is associated with:

Miscarriage & preeclampsia Metabolic control is instrumental in decreasing the risk of congenital abnormalities & miscarriages

Cranial size & shape can be distorted by _____________

Molding -overlapping of the cranial bones to facilitate movement through the birth canal during labor

Bluish black areas of pigmentation most commonly found on back and buttocks

Mongolian spots -most frequently observed on infants whose ethnic origins are mediterranean, latin american, asian, or african

Respiratory distress syndrome (RDS) in infants of mothers with diabetes

Much less common than in the past bc of improved protocol to manage maternal blood glucose levels & enhanced antepartum fetal surveillance techniques to assess lung maturity -*maternal hyperglycemia can affect fetal lung maturity* -in the fetus exposed to high levels of maternal glucose, *synthesis of surfactant can be delayed*

Newborns produce heat though __________ thermogenesis

Nonshivering thermogenesis -adults are able to produce heat through shivering; however, *the shivering mechanism is NOT operable in the newborn*

Baseline FHR

Normal: 110 - 160 bpm Tachycardia: > 160 bpm > 10 min Bradycardia: < 110 bpm > 10 min 1. Average rate during a 10-minute segment that excludes periodic or episodic changes, periods of marked variability, and segments of the baseline that differ by more than 25 bpm 2. There *must be at least 2 minutes of interpretable baseline data in a 10 minute seg of tracing in order to determine the baseline FHR*; if not its considered indeterminate 3. The approximate mean rate is *rounded to the closest 5 bpm interval* -Example: if the FHR ranges from 130 to 140 in a 10-minute segment, the baseline is recorded as 135 bpm

Hemolytic disease results in the destruction of RBCs & is the most common cause of:

Pathologic hyperbilirubinemia & jaundice *Most severe hemolytic disease that causes hyperbilirubinemia is fetal hydrops* (when fetus compensates for anemia by producing large numbers of immature erythrocytes, resulting in hypoxia)

Premature separation of the placenta from site of implantation is called:

Placental abruption Etiology: 1. *Maternal hypertension (most prominent)* 2. Cocaine -causes vascular disruption in the placental bed 3. Trauma: MVA, domestic abuse 4. Smoking & poor nutrition 5. Multiple gestation

When the placenta has separated, it triggers the production of _____

Prolactin -hormone responsible for milk production

Fetal position (3)

Relationship of a *reference point on the presenting part to the four quadrants of the mother's pelvis* Noted in a 3 part abbreviation: R or L -- O, S, or M -- A, P, or T 1. first letter: location of the presenting part in the right or left side of pelvis 2. second letter: presenting part of the fetus - O for occiput, S for sacrum, M for mentum (chin), Sc for scapula (shoulder) 3. third letter: location in relation to anterior (A), posterior (P), or transverse (T) portion of the pelvis

An extremely important point to understand is that women with HELLP syndrome may not have:

Signs or symptoms of severe features of preeclampsia. -although most women have HTN, BP may be only mildly elevated in 15-50% of cases -proteinuria may be absent -as a result, *women with HELLP syndrome are often misdiagnosed*

Any pregnancy that ends prior to 20 weeks gestation is defined as:

Spontaneous abortion -Fetal weight less than 500 grams may also be used to classify as spontaneous abortion

Tachycardia & bradycardia causes

Tachycardia 1. maternal fever- Infection, amnionitis 2. *early sign of fetal hypoxia* 3. beta-sympathomimetic drugs (terbutaline, ritodrine) 4. maternal hyperthyroidism Bradycardia 1. *late sign of fetal hypoxia* 2. occurs before fetal demise 3. perfusion problems -- prolonged cord compression, maternal hypotension 4. anesthetics

What is the only disposable organ?

The placenta -*adequate blood supply is dependent on the maternal blood pressure supplying circulation* -pumps 1 pint (almost 500 mL) of blood a minute -the *sperm is responsible for creating the placenta & umbilical cord* -the placenta is made up of *50% cells from the mother & 50% cells from the baby* -a baby can send stem cells through the placenta to heal its mother's organs if they are struggling -placenta also creates cells to protect the mother's heart & fend off breast cancer -some cultures bury the placenta, some eat the placenta (placentophagy) & some cultures use the placenta in meds

Many times women confuse the signs of preterm labor with:

The usual discomforts of pregnancy. They need to be educated that if any symptoms occur *it is best to be evaluated and sent back home than to let them continue unchecked* and therefore arrive to labor and delivery too late for successful intervention.

Glycosuria (excess sugar in urine) puts a diabetic expectant women at a higher risk for:

UTI

After 35 weeks of gestation, the skin is covered by ________ that is fused with the epidermis & serves as a protective covering

Vernix caseosa (a cheeselike, whitish substance) -covers the skin but decreases with age & sheds in the amniotic fluid -*product of the sebaceous glands* -*lanugo* (face, shoulders, & back) lessens with maturity & *helps hold vernix* -*term newborns have vernix in the creases of the neck, axilla, & the groin* -post-term will have little vernix

Any breastfed infant who develops jaundice should be evaluated carefully for:

Weight loss greater than 7%, decreased milk intake, infrequent stooling (fewer than 3 stools per day), and decreased urine output (fewer than 4-6 wet diapers per day) Bilirubin levels should be assessed by serum testing or transcutaneous monitoring

What to say & what not to say to bereaved parents

What to say: "I'm sad for you" "how are you doing with all of this?" "this must be hard for you" 'What can I do for you?" "I'm sorry" "I'm here, and I want to listen" What not to say: "God had a purpose for her" "Be thankful you have another child" "The living must go on" "I know how you feel" "It's God's will" "You have to keep on going on for her sake" 'We'll see you back here next year, and you'll be happier" "Now you have an angel in heaven" "This happened for the best" "Better for this to happen now, before you knew the baby" "There was something wrong with this baby anyway"

After birth, a decrease in hormones occurs that stimulated breast development during pregnancy. The time required for hormones to return to prepregnancy levels is determined by:

Whether or not the mother breastfeeds her infant

Episiotomy 4 interventions

Will have *pain for 24-48 hrs* 1. *Apply a covered ice pack to perineum from front to back during 1st 24 hours* to decrease edema formation & increase comfort 2. *After 1st 24 hrs, use heat (sitz bath)* 3. Analgesics, systemic/topical 4. Good perineal care to prevent infection -educate pt to wipe from front to back, squeeze bottle with warm water or antiseptic solution used after voiding to cleanse perineal area, pt should change perineal pad from front to back each time she voids & wash hands thoroughly before & after *Same interventions are used for hemorrhoids*

Infant morbidity and mortality rates associated with diabetic pregnancy are significantly reduced how?

With strict control of maternal glucose levels before and during pregnancy

Retinopathy of prematurity

affects developing retina vessels of preterm infants. *Oxygen levels closely monitored as too high of levels can result in vasoconstriction*

A fetal scalp electrode (FSE) has been applied. The nurse repositions the patient when noting repeated variable decelerations. The nurse knows this pattern is consistent with: a. uteroplacental insufficiency b. cord compression c. head compression d. prolapsed cord

b. cord compression

The nurse knows that sub-involution is most often the result of: a. premature separation of placenta b. retained placental fragments & infection c. self-destruction of excess hypertrophied tissue d. velamentous insertion of the umbilical cord.

b. retained placental fragments & infection

A woman who's 36 weeks pregnant comes into the labor & delivery unit with mild contractions. Which of the following complications should the nurse watch out for when the client informs her that she has placenta previa? a. sudden rupture of membranes b. vaginal bleeding c. emesis d. fever

b. vaginal bleeding

The nurse is caring for a patient in active labor and documents a baseline fetal heart rate of 155, fetal heart rate acceleration, moderate variability with occasional mild variable decelerations. The nurse should consider this pattern as: a. Category I - reassuring b. Category I - non-reassuring c. Category II - indeterminate d. Category III - non-reassuring

c. Category II - indeterminate

The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy? a. Painless vaginal bleeding b. Abdominal cramping c. Throbbing pain in the upper quadrant d. Sudden, stabbing pain in the lower quadrant

d. Sudden, stabbing pain in the lower quadrant

During the 2nd and 3rd trimesters, pregnancy exerts a ________ effect on the maternal metabolic status

"Diabetogenic" Because of the major hormonal changes, *decreased tolerance to glucose, increased insulin resistance, decreased hepatic glycogen stores, & increased hepatic production of glucose occur*. Rising levels of human chorionic somatomammotropin, estrogen, progesterone, prolactin, cortisol, & insulinase *INCREASE insulin resistance through their actions as insulin antagonists* *Insulin resistance is a glucose-sparing mechanism that ensures an abundant amount of glucose for the fetus* Maternal insulin requirements gradually increase from 18-24 weeks to about 36 weeks Insulin requirements double or quadruple by end of pregnancy

7 Cardinal movements of labor

"Every darn fool in Egypt eats raw eggs" 1. every= Engagement 2. darn= descent 3. fool= flexion 4. in= internal rotation 5. egypt= extension 6. eats raw= external rotation (restitution) 7. eggs= expulsion

APGAR

*A-ppearance*: (generalized skin color- pallid, cyanotic, or pink) *P-ulse* (heart rate) *G-rimace (reflex irritability)*: response to suctioning nares or nasopharynx *A-ctivity (muscle tone)*: degree of flexion and movement of extremities *R-espiration*: observed movement of chest wall

RDS complication - retinopathy of prematurity

*High oxygen tensions* affect the developing retinal vessels resulting in vasoconstriction, formation of new vessels in the retina and vitreous, capillary hemorrhage, retinal detachment, scarring *----> visual impairment to blindness* *All premies who received oxygen should be examined by an ophthalmologist before discharge with scheduled f/u exams.*

Pregnancy & IPV

-Abuse can be physical, mental, emotional, verbal -IPV has negative effects on mom & baby Signs of abuse: 1. Delay in seeking care 2. Missed appointments 3. Social isolation 4. Lack of eye contact 5. Substance abuse 6. Partner does not want to leave woman alone 7. Vague explanations of injuries/Vague somatic complaints Screening + assessment + intervention = improved outcomes

5 complications of prematurity

1. Bronchopulmonary Dysplasia (BPD) 2. Germinal Matrix Hemorhage-Intraventricular Hemorrhage (GMH-IVH) 3. Necrotizing Enterocolitis 4. Patent Ductus Arteriosus (PDA) 5. Retinopathy of prematurity

Postpartum nursing care

1. Assist with rest & recovery 2. Assess physiologic/ psychologic adaptation 3. Prevent complications 4. Self-management/infant care education 5. Support during initial adaptation

Leopold maneuvers help determine what? (4)

1. # of fetuses 2. presenting part, fetal lie, & fetal attitude 3. Degree of descent (presenting part into the pelvis) 4. point of maximum intensity (PMI - apical impulse felt most strongly)

You note on your patient's chart that she had a previous c-section delivery and you also have the previous records including her operative report. In order for her to be eligible to attempt VBAC, the previous uterine incision must have been: 1. vertical 2. low transverse 3. it does not matter the type of uterine incision 4. classical

2. low transverse

A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication. (Select all that apply.) A. Acute fetal distress B. Preterm labor C. Vaginal bleeding D. Cervical dilation greater than 6 cm E. Severe gestational hypertension

A. Acute fetal distress C. Vaginal bleeding D. Cervical dilation greater than 6 cm

A nurse is providing care for a client who is at 32 weeks of gestation and who has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following types of medications should the nurse anticipate the provider will prescribe? A. Betamethasone (Celestone) B. Indomethacin (Indocin) C. Nifedipine (Adalat) D. Methylergonovine (Methergine)

A. Betamethasone (Celestone)

When does the placenta begin to form?

At implantation -The maternal-placental-embryonic circulation is *in place by day 17 (when the embryonic heart starts beating).* -Pancake-shaped 6-10" diameter, 1" thick

Which of the following laboratory test must be monitored for pregnant patients receiving dexamethasone? A. RBC count B. Serum calcium C. Blood sugar D. Uric acid

C. Blood sugar *Blood glucose levels may INCREASE while taking steroids*

In addition to hyperglycemia, other causes of stillbirth include:

Congenital abnormalities, placental insufficiency or fetal growth restriction, macrosomia or polyhydramnios, or obstructed labor (intrapartum stillbirth)

_________________ is defined as elevated blood pressure *prior to pregnancy or is diagnosed prior to 20 weeks* gestation

Chronic hypertension -HTN initially diagnosed during pregnancy that *persists longer than 12 weeks postpartum is also classified as chronic HTN*

Reserves of brown fat, usually present for several weeks after birth, are rapidly depleted with __________

Cold stress -when neonates temp drops, *vasoconstriction occurs as a mechanism to conserve heat* -infant can appear pale & mottled (patchy); skin feels cold, especially on the extremities -*if hypothermia is not corrected, it will progress to cyanosis & cold stress*, which imposes metabolic & physiologic demands on ALL infants, regardless of gestational age & condition

_________________ is the *onset of seizure activity or coma* in a woman with preeclampsia who has no history of preexisting pathology that can result in seizure activity.

Eclampsia -onset after 20 weeks of gestation -although eclamptic seizures can occur before, during, or after birth, *approximately 50% of cases occur during the antepartum period*

The ______ stage is the most critical time in the development of the organ systems & the main external features

Embryonic (day 15 to 8 weeks)

High blood sugar level in the mother does not affect the fetus' sugar level. True or false?

False. They do affect the fetus' sugar level As maternal glucose levels rise → so do fetal glucose levels resulting in increased fetal insulin production.

When to increase feedings & newborn stomach capacities

Increase feedings at: -10 days -3 weeks -6 weeks -3 months -6 months Newborn stomach capacities: -Day 1: 5-7 mL -Day 3: 22-27 mL -Day 10: 45-60 mL

____________ is the only factor KNOWN to be associated with preterm labor

Infection -cervical, bacterial, or urinary tract infection

C-section surgical techniques, complications, & care

Surgical techniques: 1. Skin: horizontal or vertical 2. Uterine incision: Low transverse, low vertical, classic Complications: 1. aspiration 2. hemorrhage 3. atelectasis 4. wound dehiscence/ infection 5. injury to bladder & bowel Anesthesia: spinal, epidural, general Intraop care: Nurse acts as circulator or scrub nurse, Nurse present for newborn Immediate postop care: Women will go to PACU (Vital signs, maintenance of airway, incisional dressing, fundus, and lochia)

Sucking & rooting reflex

Touch infant's lip, cheek, or corner or mouth with nipple or finger Infant turns head toward stimulus & opens mouth *Response is difficult if not impossible to elicit after infant has been fed*, if response is weak or absent, consider preterm birth or neurologic defects

The hormone oxytocin, released from the pituitary gland, strengthens & coordinates what?

Uterine contractions, which *compress blood vessels & promote hemostasis.* During the first 1-2 pp hours, uterine contractions can decrease in intensity & become uncoordinated. Bc it's vital that the uterus remains firm & well contracted, exogenous oxytocin (Pitocin) is administered immediately after expulsion of the placenta

Birth trauma or birth injury refers to:

*Physical injury sustained by neonate during labor & birth* Risk factors: 1. Maternal age <16 2. Primigravida 3. Prolonged labor 4. Cephalopelvic disproportion 5. large for gestational age (LGA) 6. small for gestational age (SGA) 7. Abnormal presentation 8. Forceps 9. Vacuum- assisted births 10. Version and extraction 11. C section

Fetal presentation (3)

*Part of the fetus that enters the pelvic inlet first* and part of the fetal body first felt during a vaginal exam 1. cephalic: head first;* presenting part = occiput.* *NOTED AS VERTEX* 2. breech: butt first; *presenting part = sacrum* 3. shoulder: *presenting part = scapula*

Premature preterm rupture of membranes (PPROM) occurs when a patients amniotic sac ruptures when?

*Prior to 37 weeks gestation* 1. The cause of PPROM is unknown, however *infection is thought to be a major contributor* 2. *Chorioamnionitis is a major complication of PPROM* -Chorioamnionitis is an infection of the chorion and amnion: it can be life-threatening for both fetus and mother 3. Other risk factors associated with PPROM -*Cord prolapse* -*Cord compression* -*Placental abruption* 4. Treatment -*Antenatal glucocorticoids if no sign of infection* -*Prophylactic antibiotics to prevent infections* - unknown effectiveness

HTN disorders in pregnancy

-Common -Medical complications (5-10%) of pregnancy. -Major cause of: 1. Perinatal Mortality & Morbidity -Uteroplacental Insufficiency -Premature Birth 2. Maternal Mortality & Morbidity -Renal Failure -Coagulopathy -Cardiac or Liver Failure -Placental abruption -Seizure -Stroke

Why are mothers with diabetes encouraged to breastfeed?

1. Breastfeeding has an antidiabetogenic effect for the baby 2. Breastfed infants of women with diabetes are also *less likely to become obese* -important bc a child born to a mom with DM2 has a 70% chance of also developing DM2 later in life

DIC 8 nursing interventions

1. Assessment for signs of bleeding 2. Signs of complications 3. Protect from injury 4. *Administer blood products* 5. Monitor VS, urinary output 6. Patient remains in *side-lying position* 7. *O2 with face mask @ 8 - 10 L/min* 8. Support to woman and family

Why are preterm infants susceptible to temperature instability?

1. *Bc of their large body surface in relation to their weight*, they are at high risk for heat loss 2. minimal insulating subcutaneous fat 3. limited stores of brown fat 4. fragile capillaries/decreased control of capillaries 5. inadequate muscle mass activity 6. *poor muscle tone resulting in more body surface area being exposed* to cooling effects of environment

Pregnancy length & conception

1. Healthcare providers refer to gestational age using the concept of lunar months (28 days/4 weeks) 28 days X 10 lunar months = 40 weeks (280 days) 2. Postconception age: 28 days X 9 calendar months = 38 weeks (266 days)

Etiology of accelerations (7)

1. Partial cord compression 2. Uterine contractions 3. Fetal scalp stimulation 4. Breech presentation 5. Vaginal exam 6. ISE application 7. Fetal movement No nursing interventions required

Etiology of late decels (9)

1. Uterine tachysystole 2. Intraamniotic infection 3. Epidural/Spinal 4. Placenta previa 5. Placental abruption 6. HTN/DM 7. Postmaturity 8. Intrauterine growth restriction 9. Maternal supine hypotension

Preeclampsia fetal complications

1. Uteroplacental insufficiency -*causes hypoxia/acidosis & placental abruption* 2. IUGR 3. Premature birth 4. Intrauterine fetal death (IUFD)

The major goal of caring for a laboring pt with preeclampsia is: (select all that apply) 1). Rapid delivery 2). Maintain uteroplacental perfusion 3). Prevent seizures 4). Prevent IUGR

2). Maintain uteroplacental perfusion 3). Prevent seizures

A spontaneous bowel evacuation may not occur for _____ to ____ days after birth

2-3 days This delay can be explained by *decreased muscle tone in the intestines, prelabor diarrhea, lack of food, or dehydration* Also mom *may resist the urge to defecate bc of the anticipation of pain from hemorrhoids, epis, or lacerations* Regular bowel habits need to be reestablished when bowel tone returns. Medications may be given to assist -- stool softeners, laxatives, etc. *Teach importance of high fiber diet, plenty of fluids, & exercise*

Respiratory distress syndrome (RDS) refers to a lung disorder usually affecting preterm infants & is caused by:

A *lack of pulmonary surfactant* which leads to progressive atelectasis, loss of functional residual capacity, & a ventilation-perfusion imbalance with an uneven distribution of ventilation The weak respiratory muscles & an overly compliant chest wall, common among preterm infants, contribute to the sequence of events that occurs Clinical symptoms usually *appear immediately after or within 6 hrs* of birth

Signs of healthy psychosocial maternal-fetal bonding Include (select all that apply) A. Fantasizing what the baby will look like B. Frequently talks to the unborn child C. Uses a nickname during pregnancy when referring to baby D. Speculate about the sex of the baby if unknown E. Considers how the baby will fit into the family's life

A. Fantasizing what the baby will look like B. Frequently talks to the unborn child C. Uses a nickname during pregnancy when referring to baby D. Speculate about the sex of the baby if unknown E. Considers how the baby will fit into the family's life

A woman with a adherent retained placenta is at risk for: (select all that apply) A. Hemorrhage B. Hysterectomy C. Perforation of the uterine wall D. Preterm labor E. PP infection

A. Hemorrhage B. Hysterectomy C. Perforation of the uterine wall E. PP infection

The _________ permits a rapid assessment of the newborn's transition to extrauterine life based on 5 signs that indicate the physiologic state of the neonate

APGAR score -*universal description of well-being* -rapid need assessment for resuscitation -*typical score is 8 & 9* -performed 1 min & 5 mins after birth

A nurse is caring for a client who has a diagnosis of ruptured ectopic pregnancy. Which of the following is an expected finding? A. No alteration in menses. B. Transvaginal ultrasound indicating a fetus in the uterus. C. Serum progesterone greater than the expected reference range. D. Report of severe shoulder pain.

D. Report of severe shoulder pain.

A woman, 8 weeks pregnant, is admitted to the obstetric unit with a diagnosis of threatened abortion/miscarriage. Which of the following tests would help to determine whether the woman is carrying a viable or a nonviable pregnancy? A. Luteinizing hormone level. B. Endometrial biopsy. C. Hysterosalpinogram. D. Serum progesterone level

D. Serum progesterone level

____________________ frequently develops during the 3rd trimester of pregnancy in women with diabetes.

Hydramnios (*poly*hydramnios) -*amniotic fluid level >2000 ml* -*caused by an increased glucose concentration* in amniotic fluid resulting from maternal & fetal hyperglycemia which *induces fetal polyuria*

The risk of________________, a less than normal amount of glucose in the blood, is also increased during pregnancy

Hypoglycemia -*early in pregnancy, when hepatic production of glucose is diminished & peripheral use of glucose is enhanced, hypoglycemia occurs frequently, often during sleep* -women with a prepregnancy history of severe hypoglycemia are at increased risk for severe hypoglycemia during gestation -*hypoglycemic episodes do NOT appear to have significant damaging effects on fetal well-being*

Clotting factors & fibrinogen are normally _________ during pregnancy

Increased & *remain elevated in the immediate puerperium* -*Factors 1,2,8,9, and 10 will decrease* to nonpregnant levels *within a few days* When combined with vessel damage & immobility, this hypercoagulable state causes an *increased risk for venous thromboembolism (VTE), especially after c-section* Assessment: observe for redness, swelling, pain, or thrombophlebitis (clot formation) Hemorrhoids (anal varicosities) are common. Internal can evert during pushing. *If present, hemorrhoids appear soft & pink*

GDM - fetal risks

No increase in defects if GDM is developed after first trimester since organ formation is complete Still at risk for macrosomia and birth trauma and electrolyte imbalances including neonatal hypoglycemia

Maternal psychosocial changes

Prior to the onset of labor: 1. surge of energy 2. nesting instinct First stage of labor 1. Latent phase -Alert & mildly anxious -Happy & excited -follows directions well 2. Active phase -labor oriented -May not want to be left alone -alert/eager -more demanding -- wants encouragement -concentrating and focusing energy on contractions -some difficulty following directions 3. Transition -irritable -- fears loss of control -fatigued -frustrated -intense concentration -symptoms of transition -- nausea, vomiting Fourth stage of labor: 4. Recovery -excited -exhausted -emotionally labile -- bonding

Newborn bathing

Provides opportunities for: cleansing the skin, (*best to use cleanser with neutral pH* & without preservatives), observing infants condition, promoting comfort, & parent-child interaction 1. Sponge baths are usually given until umbilical cord falls off & umbilicus is healed 2. Immersion bathing has been found to allow less heat loss & provoke less crying; swaddling is a type of immersion in which NB is swaddled in a towel & immersed in a tub of water, one body part is unwrapped and washed 3. Ideally, *bath is delayed at least 2 hrs after birth until NB has reached thermal & cardiorespiratory stability* 4. should last *between 5-10 mins* 5. Following the bath, the infant should be dried immediately, diapered, & wrapped in warm blanket; a cap is placed on the head 6. 10 mins later, the NB is dressed, wrapped in warm blanket, & cap is changed 7. Daily bath is NOT necessary & can do harm by disrupting the integrity of the NB's skin 8. *Should not be bathed more than every other day and hair shouldn't be washed more than 1-2 times a week*

Vital signs of a postpartum client who delivered vaginally 10 hours earlier indicate a temperature of 100º, pulse 76 beats/minute, respirations 18/min, and blood pressure 124/70 mmHg. The client reports feeling sweaty and having to urinate frequently but is otherwise comfortable. How should the nurse interpret these findings? a. The client is demonstrating signs and symptoms of hypovolemic shock indicated by her slow pulse and diaphoresis. b. The client's elevated temperature and diaphoresis are an indication of puerperal infection and need to be addressed. c. The client is bradycardic and the primary care provider should be notified for further assessment. d. The client's vital signs and reports of feeling sweaty are normal and there is no need for intervention at this time

d. The client's vital signs and reports of feeling sweaty are normal and there is no need for intervention at this time

Management of placenta previa is based on:

*Gestational age, amount of bleeding, fetal conditions* 1. Active Management: -If a patient is *> 37 weeks' gestation, in labor, or bleeding persistently then deliver by C/S* -C-Section is *always performed in the presence of complete previa* regardless of status -*Vaginal birth may be an option for those with a partial or marginal previa with minimal bleeding* 2. Deliver regardless of gestational age if: -Heavy bleeding -Fetal distress 3. Following delivery -Monitor for postpartum hemorrhage: fundal portion of the uterus exerts the strongest contractions therefore would control bleeding in a normally implanted placenta. -The lower portion of the uterus does not exert as much contraction force therefore *leaving a patient prone to postpartum hemorrhage due to possible retained placental fragments* following delivery

Post-loss follow up

*Important times for follow up are: 1 week, 3 weeks- 4 months, due date * Initial session 4-6 weeks after loss: 1. Flag chart so that personnel that interact with patient are aware there has been a loss 2. Minimize time in waiting room, instruct front desk staff to take family back to room immediately 3. Designate a RN in the practice as the resource for information on local resources for families experiencing loss 4. Follow up with phone call or note to patient—above nurse should coordinate follow up. 5. *HIGHER risk for postpartum depression* 6. Assessment of the grieving process 7. Additional genetic services, if indicated 8. Review preliminary autopsy data -Of the parents who suffer a perinatal loss, at least 80% become pregnant again within 18 months -*Anxiety and depression are common maternal responses during subsequent pregnancies after a loss*. -During subsequent pregnancies, it's *important for previous loss to be acknowledged and for the mother to have the opportunity to contact the health care team as often as needed*.

Common causes of iatrogenic/indicated preterm birth

*intentionally delivered due to maternal or fetal health reasons:* 1. Preeclampsia/Eclampsia 2. OB disorders or risk factors in the current or a previous pregnancy 3. Previous C/S via a classic uterine incision 4. Placental disorders 5. Medical disorders 6. Seizures 7. Thromboembolism 8. Maternal HIV or active herpes infection 9. Obesity 10. Advanced maternal age 11. Fetal disorders 12. Chronic (IUGR) or acute (abnormal NST or BPP) fetal compromise 13. Excessive or inadequate amount of amniotic fluid (oligo/polyhydramnios​) 14. Congenital fetal abnormalities

Discharge teaching for the woman after early miscarriage

1. *Clean the perineum* after each voiding or bowel movement & change perineal pads often 2. Shower *(avoid tub baths) for 2 weeks* 3. *Avoid tampon use, douching, & vaginal intercourse for 2 weeks* 4. Notify your physician if an *elevated temperature or a foul-smelling vaginal discharge* develops 5. Eat foods high in iron & protein to promote tissue repair & RBC replacement 6. Seek assistance from support groups 7. Allow yourself (and your partner) to *grieve the loss before becoming pregnant again*

Incomplete miscarriage

1. *Heavy, profuse* bleeding 2. *Severe* uterine cramping 3. *Passage of tissue* 4. Cervical dilation *WITH tissue in cervix* 5. Management: -*May or may not require additional cervical dilation before curettage* -Suction curettage may be performed -*D&C, D&E, or induction of labor depending on gestational age*

Inevitable miscarriage

1. *Moderate* bleeding 2. *Mild to severe* uterine cramping 3. *NO passage* of tissue 4. Cervical dilation 5. Management: -Bed rest if no pain, bleeding, or infection -*If ROM, pain, bleeding, or infection is present then prompt termination of pregnancy* is accomplished usually by *dilation and curettage (D&C)* -can also be terminated by *dilation & evacuation (D&E) or induction of labor depending on gestational age*

Placenta previa is typically characterized by:

1. *Painless bright red vaginal bleeding* -bleeding is associated with the *disruption of placental blood vessels that occurs with stretching & thinning* of the lower uterine segment 2. Vital signs may be normal, even with heavy blood loss (pregnant woman can lose up to 40% of her blood volume without showing signs of shock) 3. FHR is normal unless major detachment of placenta occurs 4. *Uterus is soft, non-tender, with normal tone* 5. *Presenting part of fetus remains high* bc placenta occupies the lower uterine segment; fundal height is greater than expected 6. Bc of the abnormally located placenta, *fetal malpresentation is common*

Complete miscarriage

1. *Slight* bleeding 2. *Mild* uterine cramping 3. *Passage of tissue* 4. NO cervical dilation; *cervix has already closed after tissue passage* 5. Management: -*No further interventions* may be needed *if uterine contractions are adequate to prevent hemorrhage and no infection* is present. -*Suction curettage* may be performed to *ensure no retained fetal or maternal tissue* -*Monitor for bleeding*

Threatened miscarriage

1. *Slight* bleeding, *spotting* 2. *Mild* uterine cramps 3. NO passage of tissue 4. NO cervical dilation 5. Management: -*Bed rest often ordered* but has not been proven to be effective in preventing progression to actual miscarriage -*Sedation* -*Repetitive transvaginal ultrasounds and assessment of hCG and progesterone levels* may be done to *determine if the fetus is still alive and in the uterus* -Further treatment depends on whether progression to actual miscarriage occurs

Indomethacin (Indocin) 5 nursing considerations

1. *Used ONLY if gestational age is less than 32 weeks.* 2. *Only administer for 48 hours* 3. Do no use if presence of renal/hepatic disease, active PUD, poorly controlled HTN, asthma, or coagulation disorders 4. *Administer with food* to decrease GI distress 5. Monitor for *signs of postpartum hemorrhage*

Causes of preterm birth

1. 25% of preterm births are classified as "iatrogenic" -fetus was *intentionally delivered prematurely due to maternal or fetal health reasons* 2. 25% of preterm births are a result of PPROM 3. *50% are "idiopathic" which means it occurs spontaneously and may be preventable* 4. At least 50% of all women who deliver prematurely have no identifiable cause or risk factor

Ectopic pregnancy management

1. B-hCG level & progesterone level -*if lower than expected, have patient return in 2 days for a follow up* 2. Transvaginal ultrasound to confirm intrauterine or tubal pregnancy 3. Assess for signs of rupture -*vertigo, shoulder pain, hypotension, & tachycardia* Treatment: 4. *Removal by salpingostomy is possible before rupture* with residual tissue *dissolved by methotrexate* 5. *Methotrexate can be used to treat an ectopic pregnancy if it is not ruptured and < 4cm* -done on an outpatient basis with single injection 6. Patient has follow up *beta-hCG levels drawn until titers decrease* 7. Patient education while waiting for beta-hCG levels return to normal includes: -*Vaginal rest* -*Avoid sun exposure* -*Avoid alcohol and vitamins containing folic acid*

In rare instances there is abnormal adherence of the placenta to the myometrium. Why does this occur?

1. Cause is unknown; thought to be due to *implantation into an area of defective endometrium* 2. Placenta cannot be removed in the usual manner -If attempted, can cause laceration or perforation of the uterine wall -Places the woman *at risk for postpartum hemorrhage and infection* 3. Extensive involvement *may require a hysterectomy and the infusion of blood components*

Molar pregnancy - 2 types

1. Complete mole -Results from *fertilization of an egg with an inactivated or lost nucleus* -*The mole resembles a bunch of white grapes* -Contains *no fetus, placenta, amniotic membranes, or fluid.* -Maternal blood has *no placenta to receive it*; therefore, *hemorrhage into the uterine cavity and vaginal bleeding occur* 2. Partial mole -*One apparently normal ovum is fertilized by two or more sperms* -Often have *embryonic or fetal parts and an amniotic sac* -*Congenital anomalies* are usually present -*Less risk of persistent GTD* than a complete mole -If GTD does occur, it is *usually not a choriocarcinoma*

9 adverse effects of bedrest

1. Decreased muscle tone 2. Weight loss 3. Calcium loss 4. Glucose intolerance 5. Constipation 6. Thrombophlebitis 7. Fatigue 8. Depression 9. Anxiety

Self-management - what to do if symptoms of preterm labor occur

1. Empty your bladder 2. Drink 2-3 glasses of water or juice 3. Lie down on your side for 1 hour 4. Palpate for contractions 5. If symptoms continue, call your HCP or go to the birthing facility 6. If symptoms go away, resume light activity, but not what you were doing when the symptoms began 7. If symptoms return, call your HCP or go to the birth faciltiy 8. If any of the following symptoms occur, call your HCP or go to the birth facility immediately: -*uterine contractions every 10 min or less for 1 hour or more* -*vaginal bleeding* -*smelly vaginal discharge* -*fluid leaking from the vagina*

Nursing care for the woman receiving tocolytic therapy (9)

1. Explain the purpose and side effects of the tocolytic medications to the woman and family 2. *Position the woman on her side to enhance placental perfusion and reduce pressure on the cervix* 3. Monitor maternal vital signs including lung sounds and respiratory effort, FHR and pattern, and labor status 4. Assess the mother and fetus for signs of adverse reactions related to the tocolytic medications being administered 5. Determine maternal fluid balance by measuring the daily weight and intake and output. 6. *Limit fluid intake to 2500 to 3000 mL/ day, especially if beta adrenergic agonist or magnesium sulfate is being administered* 7. Provide psychosocial support and opportunities for the woman and family to express feelings and concerns 8. Offer comfort measures as needed 9. Encourage diversional activities and relaxation techniques

With placental abruption, deliver if:

1. Fetus is term 2. Moderate to severe bleeding 3. Maternal or fetal jeopardy -Deliver by c-section -Start large bore IV (16 gauge) -Frequent monitoring of maternal vital signs *(increased HR & decreased BP = signs of shock)* -Foley catheter placement to monitor urinary output *(monitor shock and organ perfusion)* -Continuous fetal monitoring is mandatory -Serial laboratory studies: H&H and clotting studies -*Blood and fluid replacement with the goal of maintaining urinary output at 30ml/hr & Hct at 30% or more* -Fresh frozen plasma or cryoprecipitate may be given to maintain fibrinogen level at a minimum of 100-150mg/dl -Cryoprecipitate: derived from whole blood - consists of fibrinogen, factor VIII, von Willebrand factor, factor XIII, and fibronectin

Placental abruption assessment

1. History and physical -Gravidity and parity -EDC -Bleeding: quantity, precipitating event, associated pain present 80% of the time 2. Uterine and fetal assessment -abdominal *pain and uterine tenderness* are usually present -*Boardlike abdomen to palpation* -*Contractions present with uterine tetany* (incomplete relaxation) -*Fetal distress* may or may not be present depending on the amount of placental separation 3. Laboratory Studies -Clotting studies *(due to many women demonstrating coagulopathy or excessive bleeding with uterine abruption)* -Fibrinogen, platelet count, prothrombin time, partial thromboplastin time, fibrin split products 4. Ultrasound performed to rule out placenta previa -Not always diagnostic for placenta abruption

PPROM 13 risk factors

1. History of prior preterm birth, especially if associated with preterm PROM 2. History of cervical cerclage 3. Urinary or genital tract infection 4. Short cervical length in the 2nd trimester 5. Preterm labor in the current pregnancy 6. Uterine overdistention 7. 2nd & 3rd trimester bleeding 8. Pulmonary disease 9. Connective tissue disorders 10. Low socioeconomic status 11. Low BMI 12. Nutritional deficiences 13. Smoking

Placenta previa etiology

1. Hx of previous cesarean birth 2. Advanced maternal age 3. Multiple gestation 4. Hx of prior suction curettage 5. Smoking 6. Occurs more frequently in women carrying male fetuses (placental sizes are larger in pregnancies with males) 7. Hx of placenta previa

Antenatal glucocorticoids

1. Indications -To prevent or *reduce the severity of neonatal respiratory distress syndrome* by *accelerating lung maturity in fetuses between 24 and 34 weeks of gestation* -also less likely to experience *intraventricular hemorrhage, necrotizing enterocolitis, or neonatal death* 2. Dosage & route -Betamethasone: 12 mg intramuscular for 2 doses 24 hours apart -Dexamethasone: 6 mg IM for 4 doses 12 hours apart 3. Effects -Maternal: *Transient (lasting 72 hours) increase in WBCs & hyperglycemia* -Fetal: *Transient (lasting 72 hours) decrease in fetal breathing and body movements* 4. Nursing considerations -Give deep IM in ventral gluteal or vastus lateralis muscle -*MUST BE GIVEN IM* -Injection is painful -Med should NOT affect maternal BP -*Assess blood glucose levels*. Women with DM whose blood sugars have previously been well controlled *may require increased insulin doses for several days* -*fetus is at risk for hypoglycemia*

Preterm labor prevention interventions

1. Lifestyle modifications -The nurse caring for a woman with preterm labor should help her identify activities that precipitate the symptoms of preterm labor and then assist the woman in lifestyle modifications to avoid these activities. 2. Bedrest -*used to decrease pressure on the cervix and to promote blood flow to the uterus* -prescribed in & out of hospital -commonly used, but no evidence to support its effectiveness 3. Home uterine activity monitoring -ordered by the physician to aid in the detection of contractions

Induction for demise

1. Pain relief 2. Plan of care: what is different from previous deliveries, i.e. monitoring of contractions only 3. Keep them informed of labor progress 4. *Explain what to expect based on gestational age, i.e. size of baby, may have shorter pushing stage, etc* 5. Most patients do well when *informed about possible appearance of baby, ie: peeling skin, bruising, etc.*

Miscarriage diagnosis is based on:

1. Signs & symptoms present 2. Laboratory findings 3. Ultrasound 4. *The further in gestation, typically more bleeding & pain* -miscarriage that occurs between weeks 6 & 12 of pregnancy causes moderate discomfort & blood loss -*after week 12, miscarriage is typified by severe pain, similar to that of labor, because the fetus must be expelled*

Signs & symptoms of preterm labor

1. Uterine activity -Uterine contractions *occurring more frequently than every 10 minutes persisting for 1 hour or more.* -Uterine contractions may be painful or painless 2. Discomfort -Lower abdominal cramping similar to gas pains; may be accompanied by diarrhea -Dull, intermittent low back pain (below the waist) -Painful, menstrual-like cramps -Suprapubic pain or pressure -Pelvic pressure or heaviness; feeling that "baby is pushing down" -Urinary frequency 3. Vaginal discharge -Change in character or amount of usual discharge: thicker (mucoid) or thinner (watery), bloody, brown or colorless, increased amount, color -Rupture of amniotic membranes

A client with an incompetent cervix with a previous pregnancy had a cerclage procedure done at 18 wks in the current pregnancy. The client calls the clinic at 37 wks gestation bc of irregular contractions occurring every 5-7 minutes. Which response by the nurse is most appropriate? A. "go to the hospital to have the cerclage removed so your cervix isn't injured & to allow the birth to progress" B. "wait & come in when contractions are closer & harder" C. "you sound like you are worried about this baby. It must be frightening for you"

A. "go to the hospital to have the cerclage removed so your cervix isn't injured & to allow the birth to progress"

The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the clients pulse to be 144. The nurse's priority action should be to A. withhold the medication B. Decrease the dose by half C. Administer the medication D. Wait 15 minutes, then recheck the rate

A. withhold the medication not administered if HR > 130

Who needs to be educated early in their pregnancy on signs & symptoms of preterm labor & what to do if they occur?

All women, not just those who have identifiable risk factors.

Which drug would the nurse choose to utilize as an antagonist for magnesium sulfate? A. Oxytocin B. Terbutaline C. Calcium Gluconate D. Narcan

C. Calcium Gluconate

_________________ is defined as *passive and painless dilation* of the cervix leading to recurrent preterm births

Cervical insufficiency/incompetent cervix 1. Cervical cerclage (cervical stitch) is a *prophylactic measure to prevent preterm delivery*. Usually *placed between 10 and 14 weeks when a patient has a history of previous losses* as a result of passive, painless dilation. 2. Can also be *placed before 25 weeks if found to have a shortened or dilated cervix* 3. *Rarely used after 25 weeks* gestation *due to the risk of infection and PPROM.* -In this case, tocolytics + bedrest = best treatment option 4. Most common procedure is the McDonald cerclage used to constrict the internal os of the cervix

Etiology of early & late miscarriage

Early 1. The majority - *80% of miscarriages - are early pregnancy losses, occurring before 12 weeks* 2. *Result from chromosomal abnormalities* 3. Other possible causes include endocrine disorders, autoimmune disorders, STDs, immunologic factors (antiphospholipid antibodies), systemic disorders, genetic factors -*infection is NOT a common cause of early miscarriage* -however, there's an *increased risk for spontaneous abortion with varicella infection in the 1st trimester* Late 1. Sometimes called a *2nd trimester loss, occurs between 12-20 weeks of gestation* 2. Risk factors include *advanced maternal age and parity, chronic infections, premature dilation, anomalies of the reproductive tract*

_______________ is a pregnancy that occurs outside of the uterus.

Ectopic pregnancy 1. Fallopian tube is the most common site of occurrence 2. *Leading cause of infertility* 3. Contributing factors: *tubal sterilization, STDs, pelvic inflammatory disease* 4. Clinical manifestations: -Abdominal pain that *may refer to the shoulder if a rupture of the ectopic pregnancy occurs* -*Dark red or brown vaginal bleeding*: 50-80% of patients -*An ecchymotic blueness around the umbilicus (Cullen sign)* indicating blood in the abdominal cavity, may develop in an undiagnosed, ruptured intraabdominal ectopic pregnancy

Plan of care for expectant management of placenta previa

Expectant management is *implemented if <36 weeks of gestation, woman is not in labor, & bleeding is either mild or has stopped* 1. Bedrest 2. Pad count 3. Fetal surveillance - BPP & NST 4. Laboratory studies for H&H and changes in coagulation studies 5. IV access 6. *Administration of antenatal glucocorticoids if less than 34 weeks of gestation* 7. *NO VAGINAL EXAMS* 8. Possible transfer to tertiary center 9. Emotional support for patient & family

Classification of placental abruption

Grade 1: small amount of vaginal bleeding and some uterine contractions, no signs of fetal distress or low blood pressure in the mother. Grade 2: mild to moderate amount of bleeding, uterine contractions, the *FHR may show signs of distress.* Grade 3: moderate to severe bleeding or concealed (hidden) bleeding, *uterine contractions that do not relax (called tetany), abdominal pain, low blood pressure, fetal death*

The first step in preventing preterm labor & birth is:

Identifying who is at-risk. This is done by obtaining a complete history and physical starting at the first prenatal visit.

___________________, a NSAID, has been shown to suppress preterm labor by blocking the production of prostaglandins.

Indomethacin (Indocin) 1. Prostaglandin synthetase inhibitors 2. Relaxes uterine smooth muscle by inhibiting prostaglandins 3. Dosage & route: *50 mg PO then 25-50 mg every 6 hours for 48 hours* 4. Adverse effects -Maternal (common): NV, heartburn -less common, but more serious: *GI bleeding, prolonged bleeding time, thrombocytopenia* -Fetal: *Constriction of ductus arteriosus, oligohydramnios (caused by reduced fetal urine production), neonatal pulmonary hypertension*

Low birth weight does not necessarily mean a preterm birth has occurred. An infant can be born with a low birth weight at term. This is called:

Intrauterine growth restriction (IUGR) & occurs when there has been *complications of pregnancy that interferes with uteroplacental perfusion*

______________ is the most commonly used tocolytic agent because maternal and fetal or neonatal adverse reactions are less common than with the beta-adrenergic agonists.

Magnesium sulfate 1. CNS depressant 2. relaxes smooth muscles, including uterus 3. Dosage & Route: -*IV* -*loading dose 4-6 gms/30 min* -*maintenance dose 1-4 gms/hr*

Complications of placental abruption

Maternal complications are associated with the abruption or its treatment: 1. hemorrhage, hypovolemic shock, hypofibrinogenemia, and thrombocytopenia 2. DIC 3. Infection 4. Renal failure and pituitary necrosis may result from ischemia 5. Rh sensitization -Fetal mortality occurs as a result of fetal hypoxia, preterm birth -increased risk of neurological defects

Magnesium sulfate adverse effects

Maternal: -hot flashes, NV, HA, lethargy, dyspnea, *hypocalcemia*, blurred vision, transient hypotension Fetal: -decreased breathing movement, reduced FHR variability, nonreactive NST, *respiratory depression*, hypotonia, lethargy

Because using a calcium channel blocker can result in orthostatic hypotension & dizziness, it's essential to instruct women to:

Slowly change position from supine to upright and then sit until any dizziness disappears before standing. It is important to maintain adequate fluid balance to reduce the drop in BP that can occur with the drug-related vasodilation

______________ is the most commonly administered beta2-adrenergic agonist. It relaxes smooth muscles, inhibiting uterine activity by stimulating beta2-receptors

Terbutaline (Brethine) 1. Dosage & route: *subcutaneous injection of 0.25 mg every 4 hours* 2. Has many maternal & fetal adverse reactions, including *beta1-stimulated cardiopulmonary (tachycardia) effects & beta2-stimulated metabolic (hyperglycemia) effects* -maternal: *tachycardia*, palpitations, tremors, dizziness, nervousness, HA, nasal congestion, NV, *hypokalemia, hyperglycemia, hypotension* -fetal: *Mild tachycardia, fetal hyperglycemia, & neonatal hypoglycemia* 3. Contraindications: -*HR greater than 130 bpm* -Heart dx -Severe preeclampsia/eclampsia -Gestational diabetes -Hyperthyroidism

______________ are medications used to arrest labor.

Tocolytics -*No medication is approved for use as a tocolytic in the US.* -No medication has been shown to reduce the rate of preterm birth -The rationale for giving these meds is to *delay birth long enough (at least 48 hours) to allow time for maternal transport and for corticosteroids to reach maximum benefit* to reduce neonatal morbidity & mortality -Most common: Magnesium Sulfate, Terbutaline (Brethine), Nifedapine (Procardia), Indomethacin (Indocin)

Spontaneous preterm labor is caused by multiple pathologic processes that eventually result in:

Uterine contractions, cervical changes, & rupture of membranes -*preventable* 1. Placental implantation bleeding (1st or 2nd trimester) 3. *Maternal & fetal stress (#1 major cause of preterm labor)* 4. Uterine overdistention 5. Allergic reaction 6. Decrease in progesterone level

Classic symptoms of placental abruption include:

Vaginal bleeding, abdominal pain, and uterine tenderness and contractions

Postpartum assessment - "BUBBLE-HE"

*B-Breasts* -Inspect: size, symmetry, shape of breast and nipples taking notes of erection, flatness, redness, bruising, open wounds, presence of mastitis and colostrum -Palpate: fullness, soft or engorged, firmness and lumps -Pain assessment *U-Uterus* -Palpate: firmness/ bogginess, location of the fundus in relation to the abdomen, determine the location of the fundus in relation to the belly button to determine amount of fundal involution -*Palpate fundus at frequent intervals for position and firmness (ALWAYS support with two hands)* -Inspect incision site *B-Bladder* -Void amount -Assess for distention, incontinence, urinary retention, urinary infection especially if pt had a foley *B-Bowel* -Last BM, Flatus -Assess for distention and abdominal pain -Listen to the bowel sounds *L-Lochia* -Amount, color, odor -Assess for postpartum hemorrhage *E-Episiotomy* -level of laceration -number of stitches, redness, edema, discharge, approx. of wound edges, assess perineal area *H-Hemorrhoids* -observe for discolored hemorrhoidal tissue, severe pain, itching, bleeding with defecation, thrombosed hemorrhoid *E-Emotional status* -assess for signs & symptoms of pp depression & infant mother bonding While performing pp assessment, *opportune time for pt teaching. Explain your findings, what is normal and address any discomforts* with nursing interventions.

Hyperbilirubinemia & jaundice treatment (3)

*Best treatment is prevention* 1. Early & frequent feeding to stimulate the gastrocolic reflex and the passage of meconium in which bilirubin is excreted 2. Phototherapy -High intensity flurescent light source which *oxidizes the unconjugated bili in the skin* -The unconjugated bili then *becomes water soluble and is excreted in both the bile and the urine* without going through the usual conjugated process in the liver 3. Exchange transfusion -Goal is to remove unconjugated bile, sensitized RBCs, circulating immune antibodies; *replace with non-sensitized compatible RBCs; restore blood volume, correct anemia* -Accomplished by alternately *removing a small amount* of the infant's blood and *replacing it with an equal amount* of donor blood -Exchange 75%-85% of total blood volume 4. Correction of underlying problem

Obstetric history - GTPAL

*Birth information* G--ravidity: # of pregnancies *(including present one)* T—erm births: pregnancy from *38 - 42 weeks* P—reterm births: pregnancy from *20 ending prior to 38 weeks* A--bortion: (spontaneous or elective) termination of pregnancy before fetus is viable (< 20 weeks or < 500 g) L--iving: # currently alive Ex: mother carries pregnancy to term & neonate survives: G1, T1, P0, A0, L1

Hypoglycemia in newborn

*Blood glucose less than 40 mg/dl in term infant occurring within first 3 days of life; 25 mg/dl in a preterm infant* Symptoms: 1. Tachypnea 2. Apnea 3. Cyanosis 4. Tremors: jitteriness; floppy posture 5. Convulsions: significant hypoglycemia 6. Abrupt pallor: diaphoresis 7. Weak cry 8. Lethargy: poor feeding *Asymptomatic or abrupt onset of symptoms in the first 1-3 hours after birth* *Best management is prevention* - early identification of risk factors, early feeding, minimize stress/prevent cold stress

Intact vs. ruptured membranes

*Confirm ROM with nitrazine test for pH or test for ferning* Nitrazine test (detects amniotic fluid - slightly alkaline vs urine and pus - acidic) 1. *Intact (negative): body fluids mostly ACIDIC* -yellow: pH 5.0 -olive yellow: pH 5.5 -olive green: pH 6.0 2. *Ruptured (positive): amniotic fluid is alkaline* BUT so are bloody show, insufficient amniotic fluid, & semen -blue green: pH 6.5 -blue gray: pH 7.0 -deep blue: pH 7.5 3. Ferning: microscopic appearance of a *fernlike crystalline pattern*

What is the function of the umbilical cord?

*Connects fetus to the placenta* -*has 3 vessels (2 arteries, 1 vein)* which supply nutrients & O2 from mom -*arteries carry deoxygenated blood from the embryo*; blood collected at delivery from arteries provides objective measure of respiratory status -*vein carries oxygenated blood to the embryo* -approximately 1% of umbilical cords have 1 artery & 1 vein (sometimes associated with congenital malformations) -at term, the cord is 2 cm in diameter & 30-90 cm in length (avg is 55 cm) -It spirals on itself & loops around the embryo/fetus -A true knot is rare, but false knots occur as folds or kinks in the cord & can jeopardize circulation to the fetus -Connective tissue called *Wharton's jelly prevents compression of the blood vessels & ensures continued nourishment* of the embryo or fetus -compression can occur if the cord lies between the fetal head & maternal pelvis or is twisted around the fetal body -*Cord is located centrally but if located toward the edge, it's called battledore placenta.*

In women with pregestational diabetes, the goals of fetal surveillance are to:

*Detect fetal compromise as early as possible & prevent IUFD or unnecessary preterm birth* 1. ultrasounds to monitor fetal growth and size 2. *maternal serum alpha-fetoprotein performed between 15-20 weeks bc fetus is at increased risk for neural tube defects* (spina bifida, anencephaly, or microcephaly) and then *ultrasound at 18-20 weeks to check* 3. *ultrasound measurement of fetal nuchal translucency (NT)* with maternal serum screening late in first trimester (11-14 weeks) has been *found to increase detection of heart defects* and other anomalies 4. *fetal echo between 20-22 weeks* to detect cardiac anomalies 5. *doppler studies of umbilical artery* if mom has vascular disease to detect placental compromise 6. *daily fetal movement counts beginning at 28 weeks* 7. NST to evaluate fetal well-being -*Usually start at 32 weeks then twice weekly* -If nonreactive, BPP or contraction stress test -*Testing earlier (28-32 weeks) if woman has vascular disease or poor glucose control*

Rubella status/vaccination

*For women who have not had rubella or who are serologically non-immune (titer of 1:8 or enzyme immunoassay level less than 0.8), a rubella vaccine is recommended* in the pp period *PRIOR to hospital discharge* to prevent the possibility of contracting rubella in future pregnancies -given as MMR vaccine Women are cautioned to *AVOID becoming pregnant for 28 days after receiving the rubella vaccine* bc of teratogenic risk to the fetus The live attenuated virus is NOT COMMUNICABLE in breastmilk; therefore, *breastfeeding mothers CAN be vaccinated* *Should not be given if household members are immunocompromised* bc virus is shed in urine & other body fluids Vaccine is *made from duck eggs* -- allergic reaction may require adrenaline

Insulin acts as a growth hormone, causing the fetus to produce excess stores of:

*Glycogen, protein, and adipose tissue and leading to increased fetal size, or macrosomia* Birth injuries are more common in infants born to moms with diabetes compared to moms who do not, and macrosomic fetuses have the highest risk for this complication

Hyperglycemia occurs as a result of increased:

*Hepatic glucose production & decreased peripheral glucose use* Stress hormones released > fatty acid mobilized into circulation > ketone bodies released into peripheral circulation > buffering system unable to compensate > metabolic acidosis develops > osmotic diuresis with fluid loss *MEDICAL EMERGENCY NEEDING PROMPT TREATMENT*

Direct vs. Indirect Coombs

*Indirect: tests mothers serum for antibodies to Rh antigen* -*at first PNV and again at 28 weeks* will determine presence of antibodies. -In this test, the maternal blood serum is mixed with Rh-positive RBCs -if the Rh-positive RBCs agglutinate or clump when mixed with Rh positive RBCs, this indicates that maternal antibodies are present or that the mother has been sensitized -The *dilution of the specimen of blood at which clumping occurs determines the level of maternal antibodies*; determines the degree of maternal sensitization -A level of 1.8, RARELY results in fetal jeopardy -*Repeated at 28 weeks if remains negative & woman is given RhoGAM* -*If test is positive*, showing sensitization has occurred, *it is then repeated every 4-6 weeks* to monitor the maternal antibody titer Direct: tests *infant's cord blood* for antibodies to Rh antigen

Position of mother (4)

*Lithotomy, semirecumbent, squatting, lateral* 1. Affects adaptation to labor 2. Frequent changes in position relieve fatigue, increase comfort, & improve circulation 3. Positioning promotes descent of fetus & increases effectiveness of contractions = shorter labor 4. Increase in cardiac output = increase in blood flow 5. Correctly aligns abdomen for increased pushing efforts

Maternal nutritional recommendations (9)

*Maternal nutritional status is directly related to growth & development of fetus* 1. Weight Gain *(total = 25-35lbs)* -*2 to 4 lbs (1st trimester)* -*1 lb/week (2nd & 3rd trimester)* 2. Adequate fluid intake *(3L/day)* -8-10 glasses/day -*4-6 glasses should be water* 3. *Increase caloric intake by 300 calories per day* -*Breastfeeding = 450-500 calories per day* 4. Increase Vitamin A, C, & calcium 5. Take prenatal vitamins & supplemental iron as prescribed. 6. Avoid constipation by eating raw fruits, vegetables, cereals, and bran 7. Avoid heartburn by eating small, frequent meals, avoiding fatty foods, avoid lying down after meals, & carbonated soda 8. Avoid alcohol/tobacco 9. Limit caffeine

Newborn respiratory adaptations (8)

*Most CRITICAL adaptation* 1. Clamping of the umbilical cord *causes BP to rise and increases circulation in lungs for perfusion* 2. *First breath of air initiates change from fetal to neonatal circulation* 3. Emptying the lungs of fluid -retention of fluid interferes with ability to maintain adequate oxygenation -*infants born by c/s in which labor didn't occur before birth can experience some lung fluid retention & are also more likely to develop transient tachypnea of the newborn* 4. Establishing pulmonary function -*Diaphragm descends* creating *negative intrathoracic pressure* -Alveoli are *lined with surfactant which lowers surface tension so alveoli stay open with less pressure* -decreased surface tension *results in increased lung compliance, helping to establish functional residual capacity of the lungs* -Chest and abdomen *rise simultaneously* with inspiration of air (seesaw respirations are not normal) 5. *30-60 breaths per min* 6. *Shallow, irregular* breaths 7. Short periods of apnea <15 secs 8. Symmetrical chest movement

Variability

*Most reliable indicator of fetal well-being & most important FHR characteristic* 1. Can be described as *irregular waves or fluctuations in the baseline FHR* of two cycles per minute or greater 2. It is a characteristic of the baseline FHR and does NOT include accelerations or decelerations of the FHR 3. Is quantified in bpm and is *measured from the peak to the trough of a single cycle* 4. indicates *ability of fetus to neurologically modulate FHR* in response to oxygen needs absent: undetected minimal: 0-5 bpm (peak to trough) moderate: *6 - 25 bpm considered normal* marked: > 25 bpm

Physiologic jaundice

*Normal in 50% of newborns* -*Higher rate of bilirubin production* -Shorter life span of fetal RBC (90 days compared to 120) -Reabsorption of bilirubin from small intestine—need early feeds to increase passage of meconium and stool 1. Onset *after 24 hours of birth (term) 48 hours (preterm)* 2. Bilirubin levels of <12 mg/dl (term) or <15 mg/dl (preterm) 3. Serum bili (unconjugated- indirect) level does not rise more than 5 mg/dl in 24 hours 4. Serum bili (conjugated- direct) is <1-1.5 mg/dl 5. *Disappears by the end of the 7th day (term) 9-10th day (preterm)* 6. *Results from an increased bilirubin* that if left untreated *can result in acute bilirubin encephalopathy or kernicetus* 7. Acute bilirubin encephalopathy describes the acute central nervous system manifestations seen in the first week of life 8. *Kernicterus describes the chronic and permanent results of bilirubin toxicity*

Obstetric history - GP

*Number of pregnancies that have reached 20 wks of gestation* G—ravidity: # of pregnancies (including present one) P—arity: # of pregnancies carried 20+ weeks (alive or stillborn) ex: G1P0 means that a woman is pregnant for the first time & has not carried a pregnancy to 20 weeks -twins: 1 birth, 2 living

Postpartum blues (baby blues)

*PEAK: day 5-10, GONE: day 10* 1. Experienced by most women as a *period of emotional lability -- crying easily for no apparent reason.* 2. Etiology is unknown but a *let-down feeling, restlessness, fatigue, insomnia, and anxiety contribute to feelings of depression*. May be overwhelmed by parental responsibilities, deprived of supportive care experienced during pregnancy, fatigued from the round-the clock demands of the new baby. 3. Teach: *"blues" are normal.* Rest, go to bed early, control visits from family and friends, relaxation techniques, talk to your partner about how you feel. 4. Call provider if *symptoms of depression intensify or persist past the baby's first few weeks.* May be a sign of postpartum depression that rarely disappears without outside help and pharmacologic intervention. May develop into postpartum psychosis -- a syndrome of depression, delusions, and suicide/infanticide ideation.

Breastfeeding - positioning

*Positioning is key* For initial feedings, encourage & assist mom to breastfeed in semi-reclining position with the NB lying prone, skin to skin on moms bare chest 4 traditional positions: 1. ball or clutch hold (under the arm) -*Often recommended for early feeding* bc the mother can see the baby's mouth easily as she guides the infant onto the nipple -*mothers who gave birth by c/s also prefer this* 2. cross cradle or across the lap (modified cradle) 3. cradle 4. side lying

Postpartum changes in cardiac output

*Pulse rate, stroke volume, & cardiac output* increase throughout pregnancy & *remains increased for first 48 hrs pp* -the immediate blood loss reduces plasma volume WITHOUT reducing cardiac output *CO decreases by 30% by 2 weeks* after childbirth and then gradually *decreases to nonpregnant values by 6-12 weeks* in most women.

DIC is often triggered by:

*Release of large amounts of thromboplastin* 1. *placental abruption (most common cause of DIC)* 2. retained dead fetal syndrome 3. anaphylactoid syndrome 4. Severe preeclampsia 5. HELLP syndrome 6. Gram-negative sepsis 7. Amniotic fluid embolism (usually not able to be determined until autopsy) 8. Hemorrhagic shock 9. Transfusion reaction

EFM - Internal Monitoring (2)

*Requires dilated cervix, ruptured membranes, & fetal descent (-1 station)* 1. Spiral Electrode -small spiral electrode attached to the presenting part -*converts fetal ECG to the FHR via a cardiotachometer* 2. Intrauterine Pressure Catheter (IUPC) -*objectively measures the frequency, duration, and intensity of UC as well as resting tone.* -cath with pressure sensitive tip measures changes in intrauterine pressure during contractions. The pressure is read in millimeters of mercury (mm Hg). -Evaluating UA for adequate progression of labor: (MVUs 80 - 120 mmHg) over 10 mins

IPV nursing care

*Teens are at higher risk* Assessment: 1. Regular screening of ALL women for history/risk of IPV 2. *Most important - validate that they have been heard* 3. Establish safety (at the moment and future) 4. Observe for injuries - old/new 5. Associated health conditions warranting further assessment: HA, GI probs, chronic pain, arthritis, STIs, pelvic pain, substance abuse, depression, PTSD, suicide Education: 1. Abuse is a violation of rights 2. Facilitation of access to protective and legal services is first step

Why are narcotics usually not given in transition?

*To reduce the risk of neonatal respiratory depression* -Give IV for faster onset and shorter duration -Give IV slowly at beginning of contraction: *when giving IV meds at the beginning of the contraction, the uterine blood vessels are constricted, therefore less analgesia reaches the fetus* -Notify nursery staff if delivery occurs during peak drug absorption time -Monitor maternal vital signs and observe for respiratory depression. -*Pain relief from a narcotic is temporary and limited*

RDS treatment (6)

*Treatment is supportive* 1. Adequate ventilation and oxygenation must be established and maintained in an attempt to prevent ventilation-perfusion mismatch and atelectasis 2. ventilation and oxygenation: hood, CPAP, positive pressure ventilation 3. *Surfanta: synthetic exogenous surfactant* -improves ability of lungs to exchange O2 & CO2 4. maintaining a normal thermal environment: hypoxemia can't increase metabolic rate when cold stressed. 5. Fluid and nutrition: parenteral nutrition (IV fluids, TPN, lipids) and tube feedings to *reduce the work of sucking.* 6. Monitor ABGs [umbilical artery catheter], electrolytes, urinary output, specific gravity, weight

Tonic neck or fencing reflex

*With infant in supine neutral position, turn head quickly to one side* With infant facing left side, arm and leg on that side extend; opposite arm and leg flex (turn head to right, and extremities assume opposite postures) Responses in leg are more consistent -Complete response disappears by 3-4 months; incomplete response may be seen until 3rd or 4th yr -*After 6 weeks' persistent response is sign of possible cerebral palsy*

Pregestational diabetes

*Woman already has type 1 or type 2 diabetes at the time she becomes pregnant* -almost all women with this are *insulin dependent during pregnancy* -normal hormonal adaptations of pregnancy affect glycemic control and pregnancy *may accelerate progress of vascular complications* -*first trimester: insulin may have to be reduced to prevent hypoglycemia* -*NV and cravings typically result in dietary fluctuations* that influence maternal glucose levels and *may necessitate reduction in insulin dose as well* -*Then insulin requirements steadily increase so insulin dose adjusted to prevent hyperglycemia* -Insulin resistance begins as early as 14- 16 weeks and continues to rise until stabilizes during last few weeks of pregnancy

Lactogenesis

-After mom gives birth, a *fall in progesterone triggers the release of prolactin* -during pregnancy, prolactin prepares the breasts to secrete milk & during lactation to synthesize & secrete milk -prolactin levels are highest 10 days after birth, gradually declining but remaining about baseline for duration of lactation -*prolactin is produced in response to infant suckling & emptying of the breasts* -milk production is a *supply meets demand system (milk is removed from breast, more is produced)* -incomplete removal can lead to decreased supply -oxytocin essential to lactation is responsible for the milk ejection reflex (MER). Cells surrounding alveoli respond to oxytocin by contracting & sending milk forward through ducts to the nipple. MER is triggered multiple times during a feeding session (by thoughts, sights, sounds, odors) -reflex can be inhibited by fear, stress, & alcohol

Breast milk

-Anitbodies, hormones, anti-vruses, anti-allergies, anti-parasites, growth factors, enzymes, minerals, vitamins, fat, DHA/ARA, carbs, protein, water -Species specific -*Uniquely designed to meet human needs* High complex: 1. Anti-infective 2. Nutritional components 3. Growth factors 4. Enzymes 5. Fatty acids 6. Colostrum=Immunoglobulin A (IgA). *IgA is the major immunoglobulin* but others are present as well. BF contains immunoglobulins, T & B lymphocytes. *Composition of milk changes over time to meet the infants needs* 7. *Reduces the risk of baby developing DM*, eczema, asthma and other allergic disorders 8. Enhances baby's brain development 9. Reduces baby's exposure to sugar and decreases the rate of cavities later on 10. Reduces mom's risk of ovarian, uterine and breast cancer as well as osteoporosis 11. Reduces post delivery bleeding and the chance of mom developing anemia 12. *provides 67 kcal/kg/day or 20 kcal/oz.* 13. Fat portion provides greatest amount of energy

Nursing care to ethically diverse women

-Avoid generalizations -Knowledgeable and sensitive actions toward cultural factors -Immigrants from poorer countries *choose artificial milk because they believe "it''s better, more modern" or desire to adapt to culture* 1. Hispanic women *born in US are less likely to breastfeed;* whereas women immigrating choose methods common to their homeland (BF) -*Hot (chicken and broccoli) and cold (fruits and veggies)* foods are best 2. Muslims: -*Support Bf for 24 months*, may elect to *pump in hospital or feed artificial milk due to privacy and modesty* -Prior to the first feeding, they may want to *rub a small piece of softened date on the NBs palate* 3. Southern Asia, Pacific Islands, sub Saharan Africans -*May restrict BF first few days, colostrum is harmful or inadequate and use "prelacteal" food;* honey or clarified butter until milk comes in and to help clear out meconium 4. Mexicans -*"Los Dos" (breast milk and formula)* common.. this gives infant additional vitamins -Unfortunately this *promotes decreased milk supply and early weening* 5. Koreans -Often *eat seaweed soup and rice to increase milk supply* -Hmong --> *boiled chicken, rice, and hot water* are the only food appropriate during first month PP -Believe the *balance of energy forces (hot/cold, yin/yang) is critical* to the diet of lactating woman 6. Westerns -*favor schedule feeding*

Maternal caloric requirements during breastfeeding

1. *500 calories above pre-pregnant diet* 2. Adequate fluid intake -*Drink a glass of water every time you nurse/pump* -It can be helpful for the mother to know that *if her urine appears light yellow (like lemonade), she probably is consuming enough fluids* 3. Rest -The mother should rest as much as possible, especially in the first 1-2 weeks -*Fatigue, stress, and worry can negatively affect milk production and ejection* (let-down) -Breastfeeding in a side-lying position promotes rest for the mother 4. Breast care -Soap can have a drying effect on nipples; therefore the *mother should avoid washing the nipples with soap* 5. Avoid smoking, alcohol and excessive caffeine intake 6. Adequate calcium intake

Preparation of artificial milk

1. *Artificial milk left in bottle after feeding should be discarded* (infant's saliva mixed) 2. Teach *never to warm up in microwave* due to uneven heating and potential for harm to baby with too hot of formula 3. Commercial iron artificial milk adequate nutrients for infants for 1st 6 months of life 4. *After 6 months, fluoride supplementation of 0.25 mg/day is required if local water not fluoridated*

5 nursing interventions for preterm labor

1. *Bedrest in side-lying position* -*promotes uteroplacental perfusion* 2. Hydration -*Dehydration can contribute to uterine contractions*; therefore, *hydration may be the first intervention used* to suppress contractions. -CAUTION should be used when hydrating a patient currently being treated with tocolytics *due to the increased risk of pulmonary edema* (magnesium sulfate and the beta-adrenergic agonists) -Total PO and IV fluid intake should be kept between *1500-2400ml/24 hours* -Monitor respiratory status & breath sounds, accurate I&O, daily weights 3. Tocolytics to suppress uterine activity 4. Antenatal glucocorticosteroids -*promote fetal lung maturity & reduce complications of prematurity such as necrotizing enterocolitis and cerebral hemorrhage* 5. Antibiotic therapy -*if beta strep status is unknown, prophylactic treatment with antibiotics is used to prevent neonatal sepsis* in event of delivery

Immediate care of a patient experiencing eclampsia

1. *Call for help & stay with patient* *Ensure airway* 2. Turn onto side: Done first to avoid aspiration and supine hypotension 3. Suction: AFTER seizure activity stops to clear food and fluid from the airway 4. *O2 via face mask @ 10L/min* 5. IV Magnesium Sulfate: if no IV, place one with a large bore needle 6. Monitor fetus: *Transient fetal bradycardia and decreased FHR variability are common* 7. Uterine & Cervical Assessment during a seizure: -membranes may have ruptured -cervix may have dilated -birth may be imminent 8. Following a seizure, a decision must be made regarding delivery. May try to postpone delivery until antenatal glucocorticoids can be given and benefit received 9. Document: Time, duration, and any urinary or fecal incontinence

Variable deceleration (9)

1. *Due to umbilical cord compression* 2. *Most commonly occurring deceleration * 3. Abrupt and dramatic decrease in FHR below the baseline 4. Onset to beginning of lowest point (nadir) is < 30 sec 5. Decrease is > 15 or more bpm below baseline lasting > 15 or more sec., and < 2 minutes 6. Often decelerates below 100 bpm 7. Shape is variable -- V-shaped, U-shaped, or W-shaped 8. Sometimes with transitory acceleration (shouldering) or overshoot. This is a good sign -- indicates some compensation. 9. Recovery -- rapid (returns to baseline in less than 2 minutes)

Pregestational diabetes - postpartum interventions

1. *First 24 hours: insulin requirements DECREASE* a lot bc major source of insulin resistance (the placenta) has been removed 2. *Type 1 diabetic patient may require 1/3 - 1/4th of the prenatal insulin dose the first postpartum day. Some will require no insulin for 24 - 72 hours* 3. C section usually on IV dextrose and insulin until egular diet is resumed; subq dose of insulin one hour before discontinuing IV insulin 4. Blood glucose frequently assessed and insulin dose adjusted 5. Insulin-dependent diabetic woman needs to realize importance of eating on time even if the baby needs feeding or other pressing demands exists 6. Type 2 often require no insulin and can be managed by diet of oral hypoglycemic agents 7. Possible PP complications: preeclampsia, eclampsia, hemorrhage, infection (increased risk for endometritis)

Breast changes during pregnancy (6)

1. *Fullness, heightened sensitivity, tingling, & heaviness* begins in early weeks *in response to increased estrogen & progesterone* 2. Nipples and areolae become more *pigmented & erect* 3. *Hypertrophy of the oil glands embedded in the primary areolae, called Montgomery tubercles*, may be seen around the nipples 4. Around the tubercles, *oil & sweat glands secrete lubrication and anti-infective substances* for protection during breastfeeding 5. Vessels beneath the skin will be dilated 6. *Lactation is inhibited until the progesterone levels decrease after birth*

9 impending liver problems

1. *Jaundice= total bilirubin > 2.5 mg/dL* 2. Restlessness 3. *Blood glucose < 40* 4. Jitteriness 5. Lethargy 6. Apnea 7. Feeding Problems 8. Seizures 9. Bleeding

Respiratory changes during pregnancy (7)

1. *Maternal oxygen requirements increase* in response to the acceleration in metabolic rate and need to add to the tissue mass in the uterus and breast 2. Elevated levels of *estrogen cause the ligaments of the ribcage to relax*, permitting *increase in chest expansion* 3. Tidal volume increase by 33% 4. Inspiratory capacity increases by 6% 5. Expiratory reserve volume decreases by 20% 6. Minute ventilation increase up to 50% 7. *Oxygen consumption increases by 20 to 40%*

Nursing priorities during obstetrical hemorrhage (3)

1. *Need to have a venous access,* preferably with a large bore IV cath. 2. To restore circulating blood volume, a *rapid IV infusion of crystalloid solution is given at a rate of 3 mL* infused for every 1 mL of estimated blood loss 3. MONITOR -- Evaluate the skin temperature, color, and turgor and mucous membrane. Breath sounds should be assessed before to know a base line; may need to administer oxygen

Risk factors for spontaneous preterm labor

1. *Previous history of preterm labor and birth* 2. Nonwhite race - *black & hispanics have a higher incidence of preterm birth* 3. *Genital tract colonization & infection* 4. Multifetal gestation 5. Second-trimester bleeding 6. Low prepregnancy weight 7. Poverty, lack of education, living in a disadvantaged neighborhood, state, or region, & lack of access to prenatal care are also risk factors 8. Risk also appears to be genetically related - women whose sisters gave birth prematurely are also more likely to do so

Preeclampsia risk factors

1. *Primip in age extremes (< 19/> 40 yo)* 2. *First pregnancy/new partner* 3. *Pt/family hx of preeclampsia* 4. ↑ trophoblastic tissue -Twins or more -Hydatidiform mole 5. Poor outcome pregnancy -Intrauterine growth restriction (IUGR) -Placental abruption -Fetal death 6. Periodontal disease 7. Obesity 8. Preexisting medical or genetic conditions -Chronic HTN, Renal Dx, Type 1 DM, Collagen Dx 9. Thrombophilias -Antiphospholipid antibody syndrome -Protein C, protein S, antithrombin deficiency -Factor V Leiden mutation

6 effects of cold stress

1. *RR increases* in response to increased need for oxygen 2. In the cold stressed infant, *oxygen consumption & energy are diverted from maintaining normal function & growth to thermogenesis* for survival 3. *Vasoconstriction* to insure blood flow to vital organs *jeopardizes pulmonary perfusion - may reopen shunt across the ductus arteriosus* 4. Basal *metabolic rate (BMR) increases & may result in anaerobic glycolysis (increased acid production)* 5. PO2 & pH *decrease* 6. Excess fatty acids *displace the bilirubin from albumin-binding sites --> increased level of circulating unbound bilirubin that increases the risk of kernicterus*

Postpartum vital sign changes (4)

1. *Temp first ↓ then ↑* -During 1st 24 hrs, temp can increase to 38 C (100.4 F) as a result of dehydrating effects of labor. After 24 hrs, woman should be afebrile 2. *P -- ↓* -Pulse, along with stroke volume & CO, remains elevated for the 1st hour or so after birth. *It gradually decreases over the 1st 48 hrs* -puerperal bradycardia (40-50 bpm) is common 3. *R -- ↓* -RR should be *within the woman's normal prepregnancy range soon after birth* 4. *BP first ↑ then ↓* -BP shows an *increase of 5% over 1st few days after birth*, returning to prepregnancy levels over weeks or months -BP ↑ during uterine massage or pain -Splanchnic Engorgement: rapid ↓ in intraabdominal pressure after birth results in a dilation of blood vessels supplying the intestines & causes blood to pool in the viscera -*contributes to the development of orthostatic hypotension* -may occur when woman who recently gave birth sit or stands up, first ambulates, or takes a warm shower or sitz bath.

EFM - External Monitoring (2)

1. *Ultrasound transducer (FHR)* -works by reflecting high-frequency sound waves off a moving interface which in this case is the fetal heart and valves. -Identify PMI, apply conductive gel to the surface of the USG transducer, position over the area, and held securely in place using elastic belts. 2. *Tocotransducer (contractions)* -works by means of a pressure-sensing device applied to the abdomen. -Placed over the fundus above the umbilicus and held securely in place by elastic belts. -UC or fetal movements depress a pressure sensitive surface on the side next to the abdomen. -*Measures and records the frequency and duration of UCs but not their intensity.* -Accuracy of strength affected by placement location, amount of maternal adipose tissue, belt tightness, maternal and fetal position.

GDM - intrapartum interventions

1. *monitor blood glucose to keep at 80-110* 2. avoiding dextrose will usually keep levels at right place 3. c section if preeclampsia or macrosomia

GDM - postpartum interventions

1. *most return to normal levels after birth* 2. some will develop type 2 DM 3. *monitor glucose 6-12 weeks PP and every 3 years* 4. encourage lifestyle changes 5. oral contraception is fine with these 6. if overweight or HTN or high lipid levels, use contraceptive w/o potential for causing cardiovascular side effects (IUD is good option)

Fetal circulatory system after birth

1. *the ductus arteriosus constricts*, allowing all blood leaving the right ventricle to travel to the lungs via the pulmonary arteries 2. *the foramen ovale closes, leaving a small depression called the fossa ovalis*. This isolates deoxygenated & oxygenated blood within the heart. 3. *ductus venosus degenerates & becomes the ligamentum venosum*. The inferior vena cava now carries only deoxygenated blood back to the heart.

Screening for GDM - 1 step method

1. 75- g OGTT 2. Between 24-28 weeks 3. Requires *fasting blood glucose levels drawn before giving glucose load then drawn 1 and 2 hours later* 4. *If one value is exceeded = positive* -*fasting: 92 mg/dl* -*1 hr: 180 mg/dl* -*2 hr: 153 mg/dl*

10 Signs of potential complications

1. > 80 mm Hg intrauterine pressure/> 20 mm Hg resting tone 2. Ctxs > 90 secs 3. > 5 ctxs in 10 mins 4. < 30 secs of relaxation between ctxs 5. Non-reassuring FHR 6. Meconium stained fluid 7. Arrest of labor- dilation/effacement/descent 8. Maternal temp > 100.4○ F 9. Foul-smelling vaginal discharge 10. Persistent bright/dark red vaginal bleeding

Goals of maternity & prenatal care

1. A healthy pregnancy with a physically safe and emotionally satisfying outcome for mother, infant, and family 2. Improvement in birth outcomes by reducing maternal and infant complications *Pregnant women should be told that the first prenatal visit is longer & more detailed than future visits* Elements to initial visit: interview, physical exam, lab testing -ongoing screening, assessment, & intervention throughout pregnancy

Infant feeding recommendations

1. AAP recommends *exclusive breastfeeding for the first 6 months* of life and that breastfeeding *continues as complementary foods are introduced*. 2. WHO: infants should be exclusively breastfed for 6 months, receive safe and nutritionally adequate complementary foods beginning at 6 months, and continue breastfeeding until age 2 or beyond 3. *8-12 feedings in 24 hour period* 4. Cluster feeds are normal 5. Length of feeding may vary depending on baby's schedule and time of day 6. *Newborns will take just one breast at each feeding*

Newborn sleeping safety

1. AAP recommends placing the infant in the *supine position* for sleeping during the first year of life to prevent sudden infant syndrome (SIDS) 2. Infants should *lie on a firm surface*, specifically on a firm crib mattress *covered by a fitted sheet* 3. Soft material such as bumper pads, comforters, quilts, and pillows *should not be placed in the crib* 4. Room sharing but not bed sharing, *bed sharing can increase the risk of suffocation and falls* 5. *"I sleep safest Alone, on my Back, in my Crib" (ABCs)* 6. Side lying and back lying place the infant at less risk for SIDS. -*Back lying has the lowest risk for the healthy newborn.* -Right after a feeding placing the infant on his or her right side will prevent aspiration. -When sleeping, place infant on back or side to prevent suffocation.

6 warning signs of magnesium toxicity

1. Absent DTR 2. Respiratory Depression 3. Blurred Vision 4. Slurred Speech 5. Severe Muscle Weakness 6. Cardiac Arrest

Erythromycin ophthalmic ointment

1. Action: -These antibiotic ointments are *both bacteriostatic and bactericidal* caused by *Neisseria gonorrhea* 2. Indication: -Applied to *prevent ophthalmic neonatorum or neonatal conjuctivitis* in NB of mothers who are infected with Neiseria Gonorrhea. -Eye prophylaxis for ophthalmic neonatorum is required by law in all US states and in some Canadian provinces 3. Adverse: -Can cause *chemical conjunctivitis that lasts 24-48 hours; vision can be blurred temporarily* 4. Nursing Considerations: -Administer within 1-2 hours after birth. Wear gloves. Cleanse the eyes if necessary before administration. Open the eyes by putting a thumb and finger at the corner of each lid and gently pressing on the periorbital ridge. Squeeze the tube and spread the ointment from the inner canthus of the eye to the outer canthus. Do not touch the tube to the eye. After 1-minute excess ointment may be wiped off. Observe eyes for irritation. Explain the treatment to the parents.

Phytonadione (AquaMEPHYTON)

1. Action: -This intervention provides vit K because the newborn *does not have the intestinal flora to produce this vitamin* in the first week after birth. It also *promotes formation of clotting factors* (II, IV, IX, X) in the liver 2. Indication: -Vitamin K is *used for preventing and treating hemorrhagic disease* in the NB 3. Adverse: -Edema, erythema, and pain at the injection site occur rarely; hemolysis, jaundice, and hyperbilirubinemia 4. Nursing considerations: -Follow IM injection

What constitutes a high-risk pregnancy? (13)

1. Age: < 17/> 34 y.o. 2. High parity (> 5) 3. Child spacing (< 3 mo) 4. HTN/preeclampsia 5. Anemia or hx of hemorrhage 6. Multiple gestation 7. Rh incompatibility 8. Hx of dystocia/operative birth 9. IPV hx/lack of social support 10. Height (< 5 feet) 11. Malnutrition (< 15% ideal wt)/extreme obesity (> 20% ideal wt) 12. Medical dx during pregnancy -diabetes, hyperthyroidism, hyperemesis, clotting disorders (thrombocytopenia) 13. infection -toxoplasmosis, rubella, Cytomegalovirus, Herpes simplex (TORCH), influenza, HIV, chlamydia, HPV

Examples of teratogens that cause abnormal development

1. Androgens 2. ACE inhibitors 3. Cigarette smoking 4. Cocaine 5. Coumarin 6. Cytomegalovirus 7. Diethylstilbestrol 8. Ethanol (>1 drink/day) 9. Hyperthermia 10. Iodides 11. Lead 12. Lithium 13. Mercury 14. Parvovirus 15. Phenytoin 16. Rubella 17. Syphilis 18. Tetracycline 19. Thalidomide 20. Toxoplasmosis 21. Valproic acid 22. Varicella 23. Zika

8 Nursing diagnoses common in intrapartum

1. Anxiety -- labor and birthing process; negative experience with previous childbirth 2. Knowledge deficit -- factors and processes of labor and birth; unfamiliar setting and procedures 3. Pain -- increasing frequency and intensity of contractions 4. Risk for fluid volume deficit -- altered intake during labor 5. Potential for infection/mother -- ROM before or during labor 6. Risk for altered urinary elimination --sensory impairment secondary to labor 7. Impaired gas exchange (fetal) -- maternal position, maternal hypotension, intense contractions, cord compression 8. Situational low self-esteem (maternal) -- loss of control during labor, difficulty in meeting self-expectations

Hydralazine (Apresoline)

1. Arteriolar vasodilator 2. Targets *peripheral arterioles to decrease muscle tone, decrease peripheral resistance*; hypothalamus and medullary vasomotor center for minor decrease in sympathetic tone 3. Maternal effects: *H/A, flushing, palpitations, tachycardia, some decrease in uteroplacental flow, increase in HR and cardiac output* 4. Fetal effects: *tachycardia, late decels and bradycardia if maternal diastolic pressure <90*

Bedrest - nursing interventions

1. Assess for adverse effects of bedrest & initiate/administer appropriate interventions 2. Psychological support for both patient and support system with referral to appropriate resources -referrals to chaplain, nutritionist, social worker -refer to support groups 3. Assist the patient in planning activities to aid in self-care and decrease boredom (journaling, scrapbook, passive exercise, knitting etc.) 4. Nurses caring for patients that have been on prolonged bedrest should be aware that the *adverse effects can carry over into the postpartum period.* -*have a longer recovery time* due to the decreased endurance and muscle wasting -*at a higher risk for postpartum depression* and other psychological issues like feelings of guilt for not being able to carry their baby to term. *All of which can effect infant bonding.*

Antihypertensive agents 4 nursing actions

1. Assess for effects of medication; alert woman to expected effects of medication 2. *Assess BP frequently because a quick drop can lead to shock and perhaps placental abruption* 3. If multiple doses, *wait 20 minutes after the first dose is given to administer an additional dose* to allow time to assess the effects of the initial dose 4. Maintain bed rest in *lateral position with side rails up*

Epidural/spinal nursing care - after (4)

1. Assess return of sensory & motor function 2. Monitor VS & bladder distention 3. Ensure safety- side rails up, call light in reach 4. Instruct woman not to get out of bed without help

Magnesium sulfate 8 nursing considerations

1. Assess woman and fetus to obtain baseline before beginning therapy and then before and after each incremental change 2. *Drug almost always given IV* 3. Monitor serum Mag levels, *therapeutic range between 4- 7.5 mEq/L or 5.8 mg/dl* 4. Be prepared to *D/C if intolerable adverse effects* occur *(respiratory rate <12, pulmonary edema, ABSENT DTRs, chest pain, severe hypotension, altered LOC, urine output less than 25-30 mL/hr., serum levels of 10 or higher)* 5. Strict I&O 6. Total IV intake should be *limited to 125 mL/ hr.* 7. *Calcium gluconate*/calcium chloride readily available *to reverse mag toxicity* 8. *Should NOT be given if woman has a hx with myasthenia gravis*

Epidural/spinal nursing care - during (7)

1. Assist with positioning during procedure 2. Monitor VS, FHT, level of pain & bladder distention 3. O2 & Suction accessible 4. Monitor for SE during test dose 5. *Reposition every hour* 6. Ensure safety- side rails up, call light in reach 7. Keep catheter site clean & dry

Newborn renal adaptations

1. At term, the kidneys occupy a large portion of the posterior abdominal wall. 2. In the NB almost all palpable masses in the abdomen are renal in origin 3. *At birth* a small quantity *(~40 mL) of urine is present* in the bladder of a full term infant 4. 98% of NB *void within the first 30 hrs.* -*1st-2nd day: 2-6 voids* -*3-4 days: 5-25 voids* -*>4: 6-8 voids* 5. After first voiding the infants *urine can appear cloudy (bc of mucus content)* 6. Normal urine during early infancy is usually *straw colored & almost odorless* 7. 75% of body weight is water

Severe preeclampsia

1. BP *> 160/110* -4-6 hours apart x2 2. MAP: >105 3. Proteinuria *> 3+ dipstick* 4. 24 hours *urine protein > 500 mg* 5. Irritability 6. Visual changes 7. Headache 8. Maybe: impaired liver function, pulmonary edema, epigastric pain, thrombocytopenia

Pregestational diabetes - postpartum contraception

1. Barriers and IUD safe 2. *Oral meds controversial bc possible increased risk of thromboembolic and vascular complications and effect on carb metabolism* 3. Long acting implants debated 4. Patches and vaginal ring (fine unless obese then high failure rates) 5. Since pregnancy puts at risk for vascular changes and risks get worse with age, sterilization recommended if done with family, who has poor metabolic control, or who has significant vascular problems 6. Vasectomy safer than woman sterilization

What laboratory tests would be expected for a pregnant woman with pregestational diabetes?

1. Baseline renal function with 24hr urine protein and creatinine clearance 2. Urinalysis & culture to assess for presence of UTI (common in diabetic pregnancy) 3. Urine glucose and ketones 4. Thyroid function (risk of coexisting thyroid disease) 5. *Glycosylated hemoglobin A1c - Provides measurement of glycemic control over time* -with prolonged hyperglycemia some of the hemoglobin remains saturated with glucose for the life of the RBC - *Good diabetic control 2.5% to 5.9%* - *Fair control 6% to 8%* - *Poor control >8%* 6. Review of patient's self-monitoring results (should be reviewed at every prenatal visit)

Self-management treatment for hypoglycemia

1. Be familiar with S/S 2. Check blood glucose with symptoms 3. If BG <70: -Eat 2-4 glucose tablets/gel (8-16 g carbs) -½ cup (4 oz.) unsweetened orange juice or soda *(regular soda, not diet)* -5 or 6 hard candies/lifesavers -1 cup (8 oz.) skim milk 4. Rest 15 minutes and recheck BG 5. If BG still <70, eat 2-4 additional glucose tabs 6. If BG >70, eat a meal to stabilize the sugar level 7. Recheck in 15 minutes. If BG is still <70, notify HCP immediately 8. If nausea r/t hypoglycemia prevents ingestion of carb, inject 0.15 mg glucagon IM. This will elevate the BG enough to allow eating

Pharmacologic comfort measures - sedatives (2)

1. Benzodiazepine -side effect is *maternal amnesia; avoided during labor* -*disrupts fetal thermoregulation in newborns*, making them less able to maintain body temp -Diazepam (valium) -Lorazepam (ativan) 2. Benzodiazepine antagonist -*reverses sedation & resp depression* -Flumazenil (Romazicon)

A pt with DIC is at risk for ischemia to major organs due to:

1. Blood loss 2. Loss of intracellular volume 3. Activation of intrinsic clotting factors 4. Hypotension

Essential data in the postpartum period includes:

1. Blood type -ABO incompatibility *occurs if fetal blood type is A, B, or AB, & maternal type is O* -incompatibility arises bc *naturally occurring anti-A & anti-B antibodies are transferred across placenta to fetus* -unlike Rh incompatibility, *1st born infants CAN be affected bc mother already has anti-A and anti-B antibodies* in the blood 2. Rh Status 3. Rubella status 4. Infant feeding method 5. Support system

Teaching for a breastfeeding mother who wants to do all night feedings by bottle

1. Breast feeding and bottle feeding require different skills so it is *best to avoid a bottle until the infant is proficient at breast feeding.* -Some infants develop nipple confusion and have difficulty latching on after taking a bottle. *Best to wait 4 to 6 weeks before offering a bottle* 2. Your milk production responds to the baby's suckling. The more the baby nurses, the more milk you will produce. -Pumping or hand expression is NOT as efficient -best to initiate pumping after the milk supply is well established and the infant is latching on and breastfeeding well.

Breastfeeding related jaundice

1. Breastfeeding associated (early onset) -*onset 2-4 days* -*lack of effective breastfeeding* (less caloric & fluid intake --> dehydration) 2. Breast milk (late onset) -*onset 4-6 days* -*related to factors in breast milk* (pregnanediol, fatty acids, and B-glucuronidase) inhibiting conjugation or ↓ excretion of bili 3. *Both last up to 3-12 wks* 4. *Lack of breastfeeding* is the cause

Postpartum breast changes - nonbreastfeeding mother

1. Breasts feel nodular; *nodularity is bilateral & diffuse* 2. Prolactin levels drop rapidly 3. Colostrum is present for the first few days after birth 4. Palpation of the breasts on the *2nd or 3rd day as milk production begins can reveal tissue tenderness* 5. *On 3rd or 4th pp day, engorgement can occur* 6. Breasts are distended, firm, tender, & warm to the touch 7. Breast distention is *caused by the temporary congestion of veins & lymphatics rather than by an accumulation of milk* 8. Teach mother not to stimulate breasts in any way: *AVOID warm water in shower, nipple stimulation, manual expression, suckling* -if suckling or milk expression is never begun (or is discontinued), *lactation ceases within a few days to a week* 9. Engorgement *resolves spontaneously & decreases within 24-36 hrs* 10. *Teach comfort measures: breast binder or tight bra, ice packs, mild analgesics.*

Nifedipine (procardia)

1. Calcium channel blocker 2. Targets arterioles: to reduce systemic vascular resistance by relaxation of arterial smooth muscle 3. Maternal effects -*H/A, flushing; may interfere with labor* 4. Fetal effects -Minimal 5. *Avoid concurrent use with magnesium sulfate* because skeletal muscle blockage can result 6. *Do not administer sublingually*

Nursing priorities during prolapsed umbilical cord (10)

1. Call for assistance. Do not leave the woman alone. 2. Have someone notify the HCP immediately 3. Glove the examining hand quickly and insert two fingers into the vagina to the cervix. With one finger on either side of the cord or both fingers to one side, *exert upward pressure against the presenting part to relieve compression of the cord. DO NOT move your hand!* Another person may place a rolled towel under the woman's right or left hip 4. Place woman in the *extreme Trendelenburg or a modified Sims position or a knee chest compression* 5. If cord is protruding from vagina, wrap loosely in a sterile towel saturated with warm sterile normal saline solution. *Do not attempt to replace cord into the cervix* 6. Administer oxygen to the woman by *nonbreather mask at 8-10 L/minute* until birth is accomplished 7. Start IV fluids or increase existing drip rate 8. Continue to monitor FHR continuously, by internal fetal scalp electrode, if possible. 9. Explain to woman and support person what is happening and the way it is being managed 10. Prepare for immediate vaginal birth if cervix is fully dilated or c section if it is not

Caput succedaneum vs. Cephalohematoma

1. Caput succedaneum: *edematous area of the scalp* found on the occiput -present at birth & *extends across suture lines of the skull* -usually *disappears spontaneously within 3-4 days* -infants born with assistance of vacuum extraction usually have a caput in the area where the cup was applied -bruising of the scalp is often seen 2. Cephalohematoma: *collection of blood* between a skull bone & its periosteum -*does NOT cross a cranial suture line* -firmer & more well defined than a caput -these two often occur simultaneously -usually *resolves in 2-8 wks* -as hematoma resolves, *hemolysis of RBCs occurs, & hyperbilirubinemian can result*

Soft-tissue injuries

1. Cephalohematoma 2. Sub conjunctival and retinal hemorrhages—*rupture of capillaries from increased intracranial pressure* during birth. *Clear up within 5 days; benign.* 3. *Bruising over presenting or dependent parts* with petechiae that *resolves spontaneously in 2 days.* If not, notify physical (thrombocytopenic purpura) 4. To differentiate hemorrhagic areas from skin rashes and discoloration, the nurse blanches the skin with two fingers. Because extravasated blood remains within the tissue, *petechiae and ecchymosis do not blanch*

Postpartum CV changes in blood volume

1. Changes in blood volume depends on: *blood loss during childbirth & the amount of extravascular water mobilized & excreted* 2. Pregnancy-induced hypervolemia (an *increase in blood volume of at least 35% more* than prepregnancy values near term) *allows most women to tolerate considerable blood loss during childbirth.* 3. Average *blood loss for vaginal delivery ranges from 300 to 500ml* (10% blood volume) 4. *C-section delivery is 500-1000ml* (15%-30% blood volume) 5. During the first few days after childbirth the *plasma volume decreases further as a result of diuresis.*

Nursing interventions for hypoglycemia

1. Check BG level when symptoms 1st appear 2. If BG less than 70, eat 2-4 glucose tablets or gel (8-16 g carb) immediately 3. Recheck BG level in 15 min. If glucose level is still less than 70, eat 2-4 additional glucose tabs. 4. Recheck BG in 15 min. If still less than 70, notify HCP immediately 5. *If woman is unconscious, administer 50% dextrose IV push, 5-10% dextrose in water IV drip, or 1 mg glucagon IM* 6. Obtain blood & urine specimens for lab testing

Circumcision care (5)

1. Check for bleeding -If it occurs, *apply gentle pressure with a folded sterile gauze square* 2. Observe urination -Check to see that the infant urinates after the circumcision -Infant should have *2-6 wet diapers per 24 hours the first 1-2 days and then 6-8 per 24 hours after 3-4 days* 3. Keep area clean -Change and inspect *at least every 4 hours* -Wash the penis gently with *warm water* to remove urine and feces. *Apply petrolatum* to the glans with each diaper change. *Do not use diaper wipes because they can contain alcohol* -*Do not wash the penis with soap until healed (5-6 days)* -Apply diaper *loosely* to prevent pressure 4. Check for infection -Glan penis is dark red after circumcision and then becomes covered with yellow exudate in 24 hours, which is normal & will persist for 2-3 days. *Do not remove it* -*Redness, swelling, discharge, odor indicate infection* 5. Provide comfort -Circumcision is painful. Handle with care and be gentle -Comfort measure: skin to skin, cuddling, swaddling, or rocking

Heat loss in the newborn occurs by 4 modes:

1. Convection: body surface *to cooler ambient air* -wrap newborn, keep nursery warm 2. Radiation: body surface to cooler solid surface *not in direct contact but in relative proximity* -keep cribs away from windows 3. Evaporation: loss of heat when *liquid is converted to a vapor* -dry infant directly after birth and bathing 4. Conduction: body surface to cooler surface *in direct contact* -warm crib when admitted to nursery, skin to skin contact with mother *Goal of care is to provide a neutral thermal environment for the neonate in which heat balance is maintained*

6 signs of effective feeding - mother

1. Copious milk production (milk is "in" by day 3-4) 2. Firm tugging sensation on nipple but no pain 3. Uterine cramping and increased vaginal bleeding (within 1st week) 4. Thirsty 5. Breast soften while feeding 6. Warm, tingling with milk ejection or leaking from opposite breast

DIC treatment involves:

1. Correction of the underlying cause (removal of the dead fetus, treatment of existing infection or of preeclampsia or eclampsia, or removal of an abrupted placenta) 2. Volume expansion 3. *Rapid replacement of blood products and clotting factors* 4. Optimization of O2 & perfusion 5. Achievement of normal body temperature 6. Continued reassessment of labs -*priority labs = hct & hgb* 7. Vitamin K 8. Recombinant activated factor VII

RDS physical exam (8)

1. Crackles 2. poor air exchange 3. pallor 4. the use of accessory muscles (retractions) 5. occasionally apnea 6. respiratory or mixed acidosis 7. hypotension and shock 8. hypotonic and inactivity RDS is a *self-limiting disease* that usually abates *after 72 hrs.* -This *disappearance of respiratory signs coincides with the production of surfactant in the type 2 cells of alveoli*

Early deceleration (5)

1. Decrease in FHR simultaneously with the contraction - mirror image 2. Rarely decelerates <110 bmp or 20-30 bpm below baseline 3. Repetitive with each contraction 4. Gradual decrease from baseline to nadir (>30 sec) 5. *Vagal stimulation --> head compression*

Postpartal diuresis is caused by:

1. Decreased estrogen levels 2. removal of increased venous pressure in lower extremities 3. loss of remaining pregnancy-induced increase in blood volume

3 phases of maternal postpartum adjustment

1. Dependent: taking-in phase -*First 24-48 hours* -*Mother's needs dominate* (focused on self) -Nurturing and protective care are required by the new mother -Decision making difficult -*Dependent on others* to help in care -Comfort-rest- food needs paramount -*Re-lives delivery experiences*: parents need to verbalize their experiences of pregnancy and birth. Focusing on, analyzing and accepting these experiences help the parent to move on to the next phase. 2. Dependent-independent: taking-hold phase -*2nd- 3rd day and last till ~ day 10* -Desire for independence arise -*Mother fluctuates between need for nurturing and the desire to "take charge"* once again -*Enthusiastic response to learning or carrying out baby care* -Taking hold behaviors are enhanced by current OB practice—childbirth prep classes, OB pain management, early contact with newborn, rooming- in -*Mothers are discharged during this phase* -Mom's concern is fatigue, weight loss or figure, pain from episiotomy or c section, sexual relations, hemorrhoids. -*Baby blues* are a recurring emotional concern but feelings of depression are transient -*Responds to instruction, praise* 3. Interdependent: letting-go phase -Mom and her family *move forward as a unit with interacting members* -May be a time when new father feels alienated and jealous of the infant -A *stressful period as the parental pair resolve issues* of divergent interests and needs. -See self as separate from infant -*Give up fantasy* delivery and baby -*Depression and grief* -*Readjustment*- giving up previous role

How do we assess for jaundice?

1. Depress and quickly release skin on tip of nose -- *observe for yellow color* 2. Examine *sclera* 3. *There is no relationship between the observed degree of yellow discoloration and the severity of jaundice. Therefore, serum bilirubin levels are necessary to validate clinical findings in all cases.* Serial serum bilirubin levels are key to determining the severity of progressing jaundice and will indicate what treatment to use.

What should be obtained in the initial interview of a pregnant woman with pregestational diabetes?

1. Detailed history of disease: onset, duration, management, degree of control 2. The woman and her partner's understanding of the disease and management with teaching -needs identified and followed up on at every subsequent visit 3. Emotional response to pregnancy (concerns and fears should be addressed) 4. Assessment of support system 5. Socioeconomic factors

Postpartum breast changes - breastfeeding mother

1. During 1st 24 hrs after birth, there is little to no change in breast tissue 2. Colostrum (secreted from 3rd tri), or early milk, a clear yellow fluid can be expressed from the breasts. Colostrum is *rich in antibodies & protein* 3. Breasts gradually *become fuller & heavier as colostrum transitions to mature milk by about 72-96 hrs after birth* 4. Breasts can feel warm, firm, & somewhat tender 5. As milk glands & milk ducts fill with milk, *breast tissue can feel nodular or lumpy* 6. Some women experience engorgement at this time *due to an increase in blood & lymphatic fluid as milk production increases* 7. Engorged breasts are hard & uncomfortable; fullness of the nipple can make it difficult for infant to latch on & feed 8. *With frequent breastfeeding & proper care, engorgement is temporary & lasts only 24-48 hrs*

Antepartum interventions for pregestational diabetes

1. During 1st-2nd trimester, routine prenatal visits every 1-2 weeks 2. During 3rd trimester, 1-2 times per week 3. *Blood glucose levels should be in range of 60-99 before meals and 100-129 when measured 1 hour after meal; after 2 hours, should be no higher than 120* 4. Need to get up and go to bed, eat, exercise, and take insulin *at same time each day* 5. Daily bath that includes thorough perineal and foot care is important 6. Avoid tight clothing 7. Shoes should fit properly 8. Avoid extreme temps

Estimating gestational age

1. EDC (estimated date of confinement), EDD (estimated date of delivery), & EDB (estimated date of birth) -*implications for EDC include: Timing of specific prenatal screening tests, assessing fetal growth, and making critical decisions* for managing pregnancy complications 2. *Naegele's rule: 1st day of LMP - 3 months + 7 days* 3. McDonald's rule (18-30 wks) -ht of fundus in cm = # of weeks gestation (± 2 wks) 4. Ultrasound: standard procedure for determining gestational age 5. Quickening: first recognition of fetal movements (16-22 weeks)

Important hunger cues to recognize & teach to mom

1. Early cues: "I'm hungry" -Stirring -Mouth opening -Turning head -Seeking/ rooting 2. Mid cues: "I'm really hungry" -Stretching -Increased physical movement -Hand in mouth 3. Late cues: "Calm me, then feed me" -Crying -Agitated body movement -Color turning red

Preeclampsia maternal complications

1. Eclampsia 2. Pulmonary edema 3. Stroke 4. Hepatic failure 5. ARDS 6. DIC 7. Placental abruption 8. Cerebral hemorrhage 9. Acute renal failure -*Complications most commonly occur in 2nd trimester* -Majority of deaths result from complications of *hepatic rupture, placental abruption, or eclampsia*

Mild preeclampsia

1. Elevated BP often 1st sign of preeclampsia - *>140/90 @ 4-6 hrs apart x 2* -MAP >105 2. *Proteinuria > 1+ dipstick* -dipstick measurement on *2 random samples at least 6 hrs apart* with no sign of UTI 3. 24 hr urine *protein > 300 mg* 4. *> 25-30 ml/hr urine output* 5. No epigastric pain 6. No visual changes 7. Maybe a headache or irritability

4 common concerns of the breastfeeding mother

1. Engorgement -Common response of the breasts to the sudden change in hormones and the onset of significant increased milk volume -*Breastfeeding often and effectively prevents engorgement* -Warm showers may help, use cold packs after BF, chilled cabbage, breast massaging, antiinflammation meds, and pumping 2. Sore nipples -Proper positioning is key 3. Mastitis -Inflammation of the breast, it is most often used to refer to *infection of the breast* -Sudden onset of fever, chills, body aches, and H/A -Localized breast pain, and tenderness, a hot, reddened area on the breast -*Most common in the upper outer quadrant* -*Factor: inadequate emptying of the breast* 4. Plugged milk ducts can become plugged or clogged causing an area of the breast to become swollen & tender -most often the *result of inadequate removal of milk from breast, which can be caused by clothing that is too tight, poorly fitted bra, or always using the same feeding position* -frequent feeding is recommended, with baby beginning feeding on affected side to foster more complete emptying

Pharmacologic comfort measures - anesthesia (3)

1. Epidural/spinal -*high incidence of postbirth HA is seen with spinal blocks* 2. nitrous oxide 3. general -Reserved for emergency c/sections -Used if regional anesthesia is contraindicated -*Most common cause of maternal death is aspiration of gastric contents* into the lung -*At higher risk for uterine atony* (uterus fails to contract after delivery)

9 impending GI problems

1. Failure to pass meconium 2. Inactive rectal "wink" 3. Abdominal fullness above the umbilicus 4. Abdominal distention 5. Scaphoid (sunken abdomen) 6. Abdominal fullness below the umbilicus 7. Diarrhea- forceful ejection 8. Meconium from vagina or urinary meatus 9. Vomiting

5 early signs of respiratory distress

1. Flaring of the nares and an expiratory grunt 2. Retraction can be seen in the subcostal, suprasternal, or intercostal with stridor or gasping 3. *If the infant shows increasing respiratory effort* (seesaw breathing patterns, retractions, flaring of the nares, expiratory grunting, and/or apneic spells) *this indicates deepening distress* -RR <30 or >60 bpm, apneic episodes, tachypnea 4. A compromised infant's color progresses from pink to circumoral cyanosis (mouth only) and then generalized cyanosis 5. Acrocyanosis is a normal finding in the neonates, but *central cyanosis indicates an underlying problem that requires immediate attention*

2 types of operative vaginal birth

1. Forceps 2. Vacuum assisted

Uterine contractions (5)

1. Frequency: 2-5 ctxs per 10 min 2. Duration: normal 45-80 seconds (not >90 sec) 3. Strength -External: mild = <50 mmHg; moderate >50 mmHg -Internal: 40-70 mmHg (1st stage); 80 mmHg (2nd stage) 4. Resting tone -external: soft -internal: 10 mmHg 5. Relaxation time - > 60 sec (1st stage) - > 45 sec (2nd stage)

Assessment of contractions

1. Frequency: time from beginning of one contraction to beginning of the next contraction; also measured peak to peak - *in minutes* -Number of contractions in a 10-minute window, averaged over 30 minutes -Normal: < 5 ctx in 10 minutes, averaged over a 30-minute window* -*Tachysystole: > 5 ctx in 10 minutes, averaged over a 30-minute window; stressor for baby* 2. duration: time from onset of contraction to end of same contraction; *measured in seconds* 3. intensity: strength of contraction at its peak *[can't measure with external monitoring]* -Mild: feels like pressing finger on the nose -Mod: feels like pressing finger to chin -Severe: feels like pressing finger to forehead 4. resting tone: *tension in uterine muscle between contractions [can't measure with external monitoring]*

Preeclampsia postpartum

1. Frequent VS, I&Os, DTRs, & LOC 2. *Magnesium sulfate is administered 12-24 hours post delivery to prevent the development of eclampsia* 3. Uterine tone & lochia -Magnesium sulfate can interfere with the uterus clamping down thus causing a *boggy uterus and heavy lochia flow, placing the woman at risk for postpartum hemorrhage* -*Oxytocin should be administered to treat the boggy uterus and control bleeding* -*Methergine and Ergotrate are contraindicated* because they cause an increase in BP 4. Family support & bonding -encourage breastfeeding. Breastfeeding is the best form of nutrition for premature infant. *Magnesium sulfate is NOT a contraindication for breast feeding* 5. Preeclampsia *S/S typically resolve ≤ 48 hrs* 6. Caution: *NSAIDs ↑ BP* 7. Teach when to call HCP 8. *BP monitoring for 72 hrs & recheck (7-10 days)* -*BP should be monitored every 4 hours for 48 hours* 9. Assess for HA, visual disturbances, epigastric pain, diuresis, & decreased edema

Leopold Maneuvers (4)

1. Fundal grip (pushing down from under breast) -determines *fetal part* in the fundus -Determines *fetal lie* (longitudinal vs. transverse) and *presentation* (cephalic or breech) 2. Umbilical grip (gripping belly laterally) -Identify *location of fetal back* -Determines *presentation* 3. Pawlik's grip (gripping head under bikini line) -Determines *presenting part over the true pelvis* -If the head is presenting and not engaged, Determine the *attitude of the head (flexed or extended)* 4. Pelvic grip (grip below the bikini & above feeling the back of head & chin) -Determine the *attitude of the head by palpating the cephalic prominence.* -If the cephalic prominence is noted to be on the same side as the small parts, the head must be flexed meaning a VERTEX presenting.

During normal pregnancy, adjustments in maternal ______________, ________________, & _______________ occur

1. Glucose metabolism, insulin production, and metabolic homeostasis. *Adjustments in maternal metabolism allow for adequate nutrition for both mother and fetus.* 2. *Glucose, the primary fuel for the fetus*, is transported across the placenta through the process of carrier-mediated facilitated diffusion *(glucose levels in fetus are directly proportional to mom glucose levels)* 3. *Although glucose crosses the placenta, insulin does NOT.* 4. 10th week of pregnancy infant secretes their own insulin at levels adequate to use the glucose from mom (significant for the management of IDM) 5. *As maternal glucose levels rise → so do fetal glucose levels resulting in increased fetal insulin production.*

Late deceleration (6)

1. Gradual decrease (>30 sec) and return to baseline FHR associated with a uterine contraction 2. Begins after the contraction -- nadir (lowest point) of the deceleration occurs after the peak of the contraction 3. U-shaped, repetitive 4. Rarely decelerates below 100 bpm 5. Persistent, uncorrected of any magnitude are nonreassuring 6. fetal hypoxia due to *uteroplacental insufficiency*

Postpartum CV changes in blood components (5)

1. Hct & hgb: after childbirth, the *total blood volume decreases approximately 16%* from its prebirth value, *resulting in transient anemia* -*After 8 weeks number of RBCs has increased* and the majority of women *have a normal hematocrit* 2. WBC (leukocytes): during first 10-12 days after birth, *WBC values can be between 20,000-25,000* -this can obscure a diagnosis of acute infection 3. ↓ Lymphocytes 4. ↑ Fibrinogen--*risk of thrombophlebitis* 5. ↑ Erythrocyte Sedimentation Rate (ESR)

Cardiovascular changes during pregnancy (6)

1. Heart- *displaced left and upward* 2. Output-* increases 50% by 32 weeks* (increases to provide adequate perfusion of the placenta) 3. HR- *increase 10-15 bpm* 4. *Clotting factors increase* 5. *WBC increases* 6. Volume increase to around *45%*

PPH 5 signs & symptoms

1. Heavy vaginal bleeding -*Bleeding more than 500 mL in a vaginal and more than 1000 mL in a C-section* 2. Tense and rigid uterus -May indicate internal bleeding and possible external bleeding 3. Hematomas -Pain is the most common symptom -Vaginal hematoma: a collection of blood in connective tissue; occurs more commonly in association with forceps assisted birth, an episiotomy, or primagravidity -Retroperitoneal hematoma: reports *persistent perineal or rectal pain or feeling of pressure in the vagina* -subperitoneal hematoma: may cause *minimal pain. Initial symptoms may be signs of shock* 4. Inversion of the uterus -Sudden and includes hemorrhage, shock, and pain -*Uterus is not palpable abdominally* 5. Sub-involution of the uterus -Prolonged lochia discharge -Irregular or excessive bleeding -*Larger than normal uterus that can be boggy*

Common laboratory changes in preeclampsia

1. Hgb (12-16)/hct (37-47%): may increase 2. Platelets (150,000-400,000): decreases; <100,000 3. PT (12-14 sec), PTT (60-70 sec): unchanged 4. Fibrinogen (200-400): increases; 300-600 5. FSPs (normal = absent): absent or present 6. BUN (10-20): increases 7. Creatinine (0.5-1.1): increases; >1.1 8. Creatinine clearance (80-125): increases; 130-180 9. LDH (45-90): increases 10. AST (4-20): elevated 11. ALT (3-21): elevated 12. Uric acid (2-6.6): increases; >5.9 13. Bilirubin (0.1-1): unchanged or increased

HELLP syndrome lab values

1. Hgb, hct decreases 2. Platelets <100,000 3. PT, PTT unchanged 4. Fibrinogen decreases 5. FSPs present 6. BUN increases 7. Creatinine increases 8. LDH increases (>600) 9. AST increases (>70) 10. ALT increases 11. Creatinine clearance decreases 12. Burr cells present 13. Uric acid >10 14. Bilirubin increases (>1.2)

Preeclampsia assessment

1. History & S/S -1st Prenatal Visit: thorough history to identify risk factors for the development of preeclampsia -Assess for S/S of preeclampsia at each subsequent prenatal visit 2. Vitals: BP measured in a standardized manner 3. Breath sounds are auscultated to assess for crackles, which may indicate pulmonary edema. *Pulmonary edema is associated with severe preeclampsia* 4. Edema: assess for distribution, degree, & pitting -*NO LONGER A DIAGNOSTIC MEASURE*; occurs in too many normal pregnancies -pathological edema: generalized fluid accumulation of face, hands, or abdomen that does not respond to 12 hours of bedrest -*Diuretics are only used in preeclampsia when there is evidence of CHF or pulmonary edema* -Daily weights: *weight gain of >2 kg (4.4 lbs) in 1 week* 5. DTRs -Assess biceps & patellar reflexes as well as ankle clonus (hyperactive reflexes) -Negative clonus: No rhythmic oscillations (negative beats of clonus) -Positive clonus: Presence of rhythmic oscillations (positive # of beats of clonus) -*Hyperreflexia is a sign of CNS irritability (sign of impending eclampsia)* -*Absence of reflexes when a patient is being treated with magnesium sulfate is a sign of toxicity* 6. Fetal status 7. Uterine tonicity 8. Laboratory results

Management of severe preeclampsia

1. Hospital bedrest -*Management of severe preeclampsia is best achieved in a tertiary care center* 2. Maternal monitoring -Baseline labs and frequent laboratory monitoring *observing for an increase in liver enzymes, decrease in platelets, changes in coagulation studies and electrolytes*. Assess for HELLP and DIC -Daily weights, I&O, foley catheter placement to assess for renal function 3. Close fetal surveillance is warranted; *observing for signs of uteroplacental insufficiency* through daily NST, biophysical profile, umbilical artery doppler flow studies 4. May require an ICU setting and/or hemodynamic monitoring -Invasive monitoring should be considered for women with severe cardiac disease and/or renal failure, and in some instances pulmonary edema 5. Environment should be *quiet and non-stimulating due to CNS irritability* 6. Seizure precautions -*emergency medications and equipment close by and readily available (suction and oxygen)* 7. Safety precautions 8. Pharmacological interventions 9. Delivery -If immediate delivery is indicated then *c-section would most likely be the delivery mode of choice*, especially if the cervix is unfavorable. A *prolonged labor could increase risk of maternal morbidity*

4 placental hormones

1. Human chorionic gonadotropin (hCG): detected in maternal serum by 8-10 days -*preserves function of corpus luteum* -*ensures supply of estrogen and progesterone* needed to maintain pregnancy 2. Human Chorionic Somatomammotropin (hCS): -stimulates maternal metabolism (supplies nutrients needed for fetal growth) -*increases insulin resistance* -facilitates *glucose transport across the placenta* -stimulates *breast development* to prepare *for lactation* 3. Progesterone: stimulates maternal metabolism (supplies nutrients needed for fetal growth) -*maintains endometrium* -*decreases contractility of the uterus* -stimulates development of *breast alveoli* 4. Estrogen -stimulates *uterine growth* -Stimulates *uteroplacental blood flow* -proliferates *breast glandular tissue* -stimulates *myometrial contractility*

4 antihypertensive agents

1. Hydralazine (Apresoline) 2. Labetalol Hydrochloride (Normodyne) 3. Methyldopa (Aldomet) 4. Nifedipine (Procardia)

17 Side effects of epidural & spinal

1. Hypotension 2. Convulsions 3. Fever 4. Dizziness 5. Lightheadedness 6. Ringing in the ears 7. Metallic taste 8. Slurred speech 9. Urinary retention 10. Pruritus (itching) 11. Limited movement 12. Loss of consciousness 13. *Longer second stage labor* 14. ↑ use of oxytocin 15. ↑ forceps/vacuum birth 16. High or total spinal anesthesia 17. Numbness of the tongue/mouth

Pregestational diabetes - intrapartum interventions

1. IV hydration: *Lactated Ringers with 5% Dextrose or Lactated Ringers* 2. Insulin administration: *Continuous infusion or intermittent injection based on blood glucose monitoring. Only regular insulin is used during the intrapartum period* 3. Blood glucose monitoring: monitored hourly with adjustments made in fluids and insulin to *maintain a capillary blood glucose level between 80-120 mg/dl* 4. Continuous fetal monitoring for fetal tolerance to labor 5. Monitoring of labor progression: Possibility of failure to progress 6. During second stage the nurse should be alert to the *possibility of shoulder dystocia* 7. *If scheduled C/S, scheduled first thing in the am.* -Pt. NPO prior to surgery. -MD may have patient hold am insulin -*Epidural anesthesia recommended because hypoglycemia can be detected earlier if the woman is awake.*

Newborn GI adaptations

1. In the intestines, conjugated bili becomes unconjugated and recirculates through the enterohepatic system & increases serum bili level 2. Sucking behavior is influenced by neuromuscular activity, maternal meds received during labor & birth, & the type of initial feeding. Peristaltic activity is uncoordinated at first but quickly learned 3. *Stomach capacity is small (<30 mL) on day 1 and relaxes to accommodate larger (>90 mL) on day 3.* 4. Meconium is first stool. Progressive changes in stooling pattern is expected

8 impending renal problems

1. Inadequate fluid intake 2. Restlessness 3. Bladder distention 4. Pain 5. Pink or orange stains on diaper "brick dust" 6. Lack of steady stream 7. Gross anomalies -hypospadias and exstrophy of the bladder 8. Enlarged or cystic kidneys

Acceleration

1. Increase in FHR with response to contractions or fetal activity -episodic -onset to peak in <30 sec -acme is >15 bpm above baseline -lasts more than 15 sec but less than 2 min from onset to return to baseline - > 2 min but < 10 min = prolonged accel - > 10 min or more = change in baseline 2. *NORMAL & desirable* 3. *Sign of fetal well being*

Renal changes during pregnancy (4)

1. Increased *urinary frequency & nocturia (uterine pressure on bladder, progesterone relaxes smooth muscle)* 2. *Dilation* of ureters and renal pelves allows for *bacterial ascension* 3. Stasis: *urine provides medium for bacterial growth, increased pH from added glucose* 4. Bladder capacity *increased to 1500 mL*

Integumentary changes during pregnancy (4)

1. Increased pigmentation 2. linea nigra (dark vertical line that appears on abdomen) 3. striae gravidarum (stretch marks) 4. hair thickens

Amnioinfusion

1. Infusion of room-temperature isotonic (normal saline, lactated Ringer's solution) fluid into the uterine cavity to relieve intermittent umbilical cord compression resulting in variable decelerations and transient fetal hypoxemia. 2. Purpose: *treatment of variable decels & low amniotic fluid* -for variable decels, purpose is to *treat oligohydramnios & provide cushion* for the umbilical cord -can be performed to dilute meconium-stained fluid to avoid aspiration syndrome

Screening for GDM - 2 step method

1. Initial 50-g oral glucose load: positive if plasma level 130-140 mg/dl or greater (fasting not necessary) 2. If positive, follow with a 3 hour glucose tolerance test (OGTT) with a 100 g oral glucose load (fasting required) 3. Pt should be on an *unrestricted diet 3 days prior* to 3 hour GTT. *12 hours prior to the exam the patient should maintain NPO and avoid caffeine and smoking* 4. If *2 or more values are met or exceeded*, woman is diagnosed with GDM -*fasting: 95 mg/dl or greater* -*1 hour: 180 mg/dl or greater* -*2 hour: 155 mg/dl or greater* -*3 hour: 140 mg/dl or greater*

Amniotic fluid structure (4)

1. Initially fluid comes from maternal blood by diffusion 2. Fluid is also secreted by the respiratory and GI tracts of the fetus. 3. *Volume serves as indicator of fetal well-being* 4. Amount of fluid increases weekly; *700ml-1000ml is normal at birth* - <300 (oligohydramnios) is associated with *absence of kidneys or obstruction of urethra [fetus can't excrete urine]* - > 2000ml (polyhydramnios) is associated with *congenital anomalies of the GI tract [fetus can't drink fluid]; GDM*

Assessment of amniotic membranes & fluid

1. Intact/ruptured 2. FHR: umbilical cord may prolapse when the membranes rupture. *Nursing responsibility to monitor the FHR for several minutes following ROM to ascertain fetal well-being* 3. Color: *normally pale and straw colored with white flecks of vernix caseosa.* -Greenish-brown: meconium stained due to recent hypoxic episode that caused relaxation of anal sphincter -Yellow: fetal hypoxia > 36 hours prior; fetal hemolytic disease [bilirubin]; infection -Port wine: bleeding associated with premature separation of placenta [abruptio] 4. Viscosity & odor: normally lacks strong odor. *Suspect infection if thick, cloudy, or foul smelling.* 5. Amount: expected amount is 700-1000 ml 6. Infection: after ROM microorganisms from the vagina can ascend into the amniotic sac causing chorioamnionitis and placentitis. -*Assess maternal temperature and vaginal discharge q 1-2 hrs so developing infection can be identified early.*

Perinatal loss - what parents appreciate

1. Involvement in decision making 2. Being treated like parents 3. Time to grieve - not being rushed 4. Positive memories/mementos 5. Sense of empathy and being cared for 6. Time with supportive family & friends 7. Continuity in care of caregivers 8. Unlimited time with infant 9. Seeing, holding, touching the baby 10. Direct communication

What foods would you encourage if a mother needs to increase her iron? Calcium? Protein?

1. Iron: liver, meats, whole grain or enriched breads & cereals, dark green leafy vegetables, legumes, dried fruits 2. Calcium: milk, cheese, yogurt, sardines or other fish eaten with bones left in, dark green leafy vegetables except spinach or swiss chard, calcium-set tofu, baked beans, tortillas 3. Protein: meats, eggs, cheese, yogurt, legumes (dry beans and peas, peanuts), nuts, grains

False labor

1. Irregular contractions -stop with walking or repositioning -in back or upper abdomen -stop with comfort measures 2. No cervical change -no effacement, dilation -no bloody show -remains posterior 3. No movement of fetus -no engagement in pelvis

Rationale for FHR monitoring (4)

1. Labor is a period of physiologic stress to the fetus 2. Maintain fetal O2 supply during labor -Prevent fetal compromise -Promote newborn health after birth 3. Contraction: -Mechanical force impedes intervillous space blood flow -Exert pressure directly on the fetus -Occlude blood flow in both directions (umbilical cord) 4. Provides evidence of stress or distress so we can intervene early and a visual record for documentation

6 signs of effective feeding - infant

1. Latches without difficulty 2. Burst of *15 to 20 sucks/swallows* at a time 3. Audible swallowing 4. Releases breast at the end 5. Appears content after feeding 6. *3 bowel movements & 6 - 8 wet diapers/day after day 4*

3 phases of labor

1. Latent (0-3 cm) -*effacement, little descent* -primipara 7-8 hrs; multipara 4-5 hrs -ctxs 3-30 minutes lasting 30-40 sec 2. Active (4-7 cm) -*dilation & descent* -primipara 4 hrs; multipara 2 hrs -ctxs 2-5 minutes lasting 40-60 sec 3. Transition (8-10 cm) -*rapid dilation & increased rate of descent* -primipara 3 hrs; multipara varies -ctxs 1.5-2 minutes lasting 60-90 seconds

Musculoskeletal changes during pregnancy (3)

1. Ligament laxity (ligaments loosen) 2. Symphysis pubis widens "waddling" 3. Uterus enlarges moving upward and outward causing *lumbar lordosis* (curving inward of the lower back - *helps maintain balance*)

Newborn hepatic adaptations

1. Liver is enlarged and occupies 40% of abdominal cavity at birth 2. Liver began storing iron in utero. -If mother had adequate iron intake: iron stores will last until 4-6 months of life -If preterm: iron stores will last 2-3 months. -The bioavailability in breastmilk is superior to formula. *Breastfeeding newborns DO NOT need supplemental iron but formula fed do need iron.* 3. Liver is site for production of hemoglobin after birth. 4. In utero, the glucose concentration in the umbilical vein is approx. 80% of the maternal levels -at birth the newborn is *cut off from maternal glucose supply* & as a result *experiences an initial decrease in serum levels* 5. Blood glucose *stabilizes within first several hours @ 50-60 mg/dL*. -*less than 40 is considered abnormal & warrants intervention* 6. By day 3, BG should be *approx. 60-70 mg/dL.* 5. *Coagulation factors* which are synthesized in the liver *are activated by vitamin K.* Injection of vit K shortly after birth *helps prevent clotting problems.*

Lochia color & characteristics

1. Lochia rubra: dark red -consists mainly of blood & decidual & trophoblastic debris -*Lasts 3 days* 2. Lochia serosa: pink or brown in color -consists of old blood, serum, leukocytes, & tissue debris -*lasts 4-10 days* 3. Lochia alba: color is yellow/white -consists of leukocytes, decidua, epithelial cells, mucus, serum, & bacteria -*lasts up to day 10 to 6 weeks pp*

Phase of intense grief

1. Loneliness, emptiness, yearning 2. Guilt 3. Anger, resentment, bitterness, irritability 4. Fear and anxiety 5. Disorganization 6. Difficulty with cognitive processing 7. Sadness and depression 8. Physical symptoms Nursing considerations: -difficulty processing: explain & repeat information. -Hard for them to follow even simple instructions sometimes. -Don't take the anger personally. -Guilt very common: reassure them they did nothing to cause this loss.

Assessment of FHR (4)

1. Looking for PMI of FHR -- *location where FHR is heard the loudest -- usually over fetal back* 2. Perform Leopold Maneuvers 3. *Auscultate the FHR based on fetal presentation identified with Leopold Maneuvers* 4. Chart PMI of FHR using a two-line figure to indicate the 4 quadrants of the maternal abdomen: RUQ LUQ RLQ LLQ X/140

2 most important interventions to prevent PPH:

1. Maintain good uterine tone 2. Prevent bladder distention

Amniotic fluid 7 functions

1. Maintains body temperature 2. Barrier to infection 3. Allows fetal lung development 4. Provides freedom of movement for musculoskeletal development 5. Cushions the fetus from trauma by blunting & dispersing outside forces 6. Keeps the embryo from tangling with the membranes, facilitating symmetric growth 7. Source of oral fluids & repository (storage) for waste = balancing electrolytes -the baby swallows & inhales amniotic fluid while in utero & *replaces the volume in the amniotic sac by urinating & exhaling the liquid* -amniotic fluid *completely replaces itself every 3 hours*, even after ROM

Eclampsia - after care

1. Maternal and infant stabilization, timing and method of delivery may be necessary 2. *Regional anesthesia is avoided for eclamptic women with coagulopathy or platelet count less than 50,000*

Magnesium sulfate nursing care

1. Maternal monitoring: *hr 1-3 monitor every 15-30 min; hr 4-7 monitor every hour* 2. Continuous fetal monitoring 3. Blood pressure per hospital protocol. *Report SBP > 160mm Hg and DBP > 110mm Hg* 4. Pulse 5. Respirations: *Report < 12/min* 6. Monitor for pulmonary edema 7. DTRs: *Report loss of DTRs or increased DTRs* 8. LOC 9. I&O -Restrict hourly intake 100-125cc/hr -Urinary output (indwelling cath): If renal dysfunction (low urinary output), at risk for Magnesium toxicity (level >8mg/dl) -Report urinary output < 25-30ml/hr 10. *Headache, visual disturbances, epigastric or right quadrant pain* 11. Labor progression 12. Laboratory values: Report any abnormal values

Etiology of variable decels (5)

1. Maternal position with cord compressed 2. Cord wrapped around neck, arm, leg, or other body part 3. Short cord 4. Knot in cord 5. Prolapsed cord

Nursing care for stage 2 (10 cm - delivery of baby)

1. Maternal positioning 2. Open-glottis pushing: Encourage women to push as they feel like pushing which is instinctive, spontaneous pushing

Changes in stooling patterns of newborns

1. Meconium = *first stool* -The infant's first stool is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood (ingested maternal blood or minor bleeding of alimentary tract vessels) -Passage of meconium *should occur within the first 24- 48 hours, although it can be delayed up to 7 days in very low birth weight.* The passage of meconium can occur in utero and can be a sign of fetal distress 2. Transitional stools -Usually appear by *third day after initiation of feeding* -*Greenish brown to yellowish brown*; thin and less sticky than meconium; *can contain some milk curds* 3. Milk stool -Usually appears by the 4th day -Breastfed infants: stools *yellow to golden*, pasty in consistency; resemble a *mixture of mustard and cottage cheese,* with an odor similar to sour milk -Formula: stools pale yellow to light brown, firmer consistency, with more offensive odor

Placenta 2 functions

1. Metabolic exchange -respiration: *oxygen diffuses from the maternal blood across the placental membrane into the fetal blood, & CO2 diffuses in the opposite direction* -nutrition: carbs, proteins, calcium, & iron are *stored in the placenta for ready access to meet fetal needs*. Water, inorganic salts, carbs, proteins, fats, & vitamins pass from the maternal blood supply across the placental membrane into the fetal blood, supplying nutrition. -excretion: *metabolic waste products of the fetus cross the placental membrane from the fetal blood into the maternal blood. The maternal kidneys then excrete them* -storage 2. Endocrine gland -hCG, hCS, progesterone, estrogen

3 Factors increasing variability

1. Mild hypoxia 2. Fetal stimulation: external uterine palpation, uterine contractions, fetal activity, application of ISE, SVE, acoustic stimulation, maternal activity -- will stimulate fetal autonomic nervous system resulting in increase in variability 3. Street drugs

Formula

1. Minerals, vitamins, fat, DHA/ARA, carbs, proteins, water 2. *Standard- 20 kcal/oz.* 3. Infant formulas *simulate caloric content of human milk*

Perinatal loss

1. Miscarriage -any in utero death *prior to 20 weeks of gestation* 2. Ectopic pregnancy 3. Stillborn -5-12% per 1000 live births in US -occurs at *20 weeks or later* 4. Neonatal loss 5. Loss of "healthy child"- delivery of preterm infant or baby with anomalies

Bleeding in early pregnancy

1. Miscarriage (spontaneous abortion) 2. Ectopic pregnancy 3. Molar pregnancy

Miscarriage - nursing responsibilities

1. Monitor bleeding & vital signs 2. Administer medications as ordered: -*10 to 20 Units of oxytocin in 1000ml of fluids to prevent hemorrhage* -*Ergot products to control bleeding (methergine)* -Antibiotics as indicated -Analgesics for cramping -Transfusion if shock or anemia 3. *Administer Rhogam within 72 hours if Rh negative & no isoimmunization* 4. Psychological support & referral to support group -Includes patient and family -Explanations are provided regarding the nature of the miscarriage, expected procedures, possible future implications for pregnancy

Nursing care - exchange transfusion

1. Monitor heart rate and rhythm, respirations, blood pressure, temperature, pedal pulses, presence of edema 2. Monitor infusion site for hemorrhage 3. *Administer calcium gluconate prn for symptoms of hypocalemia* triggered by preservation in donor blood that lower serum calcium, magnesium and glucose.

Nursing care - phototherapy (8)

1. Monitor lamp energy output routinely during treatment 2. Protect infant's eyes with opaque mask--- *completely cover eyes but not nares* -*Before applying, gently close eyes* to prevent excoriation of cornea—some nurseries use artificial tears and have a protocol for changing the mask 3. Remove mask during feedings 4. Maintain a regular feeding schedule—infant may sleep longer during this 5. *Monitor number and consistency of stools* 6. Maintain good skin care—loose stools 7. Temp at least every 4 hours—may become elevated 8. Adequate hydration--- *accelerates insensible water loss*

Management of mild preeclampsia

1. Monitoring of BP: report elevations 2. Home Bedrest -*if proteinuria <.3 gm on a 24 hr urine specimen, without subjective complaints, & home situation & support system conducive* 3. Daily weights: report abnormal weight gain 4. Fetal surveillance -Home: *fetal kick counts daily* and if available home NST 1-2 times weekly -Hospital: NSTs; biophysical profiles as indicated -*Ultrasound for fetal growth at diagnosis and every 3 weeks* 5. Monitor urine protein: *dip urine daily & report any increase in value* 6. Educate on warning signs 7. Healthy diet & adequate hydration 8. Emotional support

Pregestational diabetes - antepartum diet

1. Must be educated to incorporate changes of pregnancy into diet 2. Diet individualized to allow for increased fetal and metabolic requirements 3. Dietary goals: *to provide weight gain consistent with normal pregnancy, prevent ketoacidosis, and minimize wide fluctuation of blood glucose levels* 4. *2200-2500 cal ADA divided among 3 meals and 2 or 3 snacks* -Large bedtime snack of at least 25 g of complex carb with some protein or fat is recommended to help prevent hypogylcemia and starvation ketosis during night 5. Woman must follow a *consistent eating schedule* - meals should be eaten on time and never skipped 6. Going more than 4 hours w/o food intake increases risk for episodes of hypoglycemia

GI changes during pregnancy (6)

1. N/V (hCG) 2. Gums: hyperemic, spongy, swollen causing them to bleed easily 3. Cravings: PICA 4. Ptyalism: excessive salivation 5. *Decreased tone and motility*: reflux, slower emptying of the stomach, reverse peristalsis (vomiting) 6. Pyrosis: acid indigestion, heartburn

8 impending respiratory problems

1. Nasal flaring, grunting, retractions *(should go away within the 1st hour)* 2. Crying 3. Respiratory rate ˂ 30 or ˃ 60 breaths per min 4. Suprasternal/ subclavicular retractions + stridor or gasping 5. Acrocyanosis 6. Seesaw or paradoxical respirations 7. Skin flushing or pale 8. Extended posture

Teaching - wake baby to feed on a schedule

1. Newborn infant should be fed *at least every 3 to 4 hours*, even if it requires waking the baby for feedings. 2. The infant showing an adequate weight gain can be allowed to sleep at night and fed only on awakening. 3. Most newborns *need 6 to 8 feedings every 24 hours*. This will decrease as infant matures. 4. A fairly predictable feeding pattern has usually *developed by 3 to 4 weeks.*

Breastfeeding 5 contraindications

1. Newborns *who have galactosemia should not receive human milk* 2. For mothers who are *positive for human T-cell lymphotropic virus type 1 or 2 and those with untreated brucellosis* 3. Should not breastfeed if they *have active TB or if they have active herpes simplex lesions* on the breast -Women with active TB *can breastfed when they have been treated for at least 2 weeks and deemed noninfectious* 4. *Varicella that occurs 5 days before or 2 days after birth* and *acute H1N1 infection* require separation of mother and infant -Safe for infants to receive expressed milk 5. In US, *HIV infection is considered a contraindication for breastfeeding*

Missed miscarriage

1. No bleeding 2. No uterine cramping 3. No passage of tissue 4. No cervical dilation 5. Management: -*If spontaneous evacuation of the uterus does not occur within 1 month, pregnancy is terminated by method appropriate* to duration of pregnancy -*Blood clotting factors are monitored* until uterus is empty -*DIC & incoagulability of blood with uncontrolled hemorrhage may develop in cases of fetal death after the 12th week, if products of conception are retained for longer than 5 weeks* -may be treated with *D&C or misoprostol (cytotec) given orally or vaginally*

Hypovolemic shock - 11 nursing interventions

1. Notify HCP 2. if uterus is atonic, *massage gently & expel clots to cause it to contract*; compress uterus manually, as needed, using 2 hands. Add oxytocic agent to IV drip as ordered 3. *give O2 by nonrebreather* face mask at 10 L/min 4. *tilt woman on her side or elevate the right hip; elevate legs to at least a 30 degree angle* 5. provide IV fluids (LR or NS) to restore circulatory volume 6. admin blood products as ordered 7. monitor vitals 8. insert indwelling urinary catheter *to monitor kidney perfusion* 9. admin emergency drugs as ordered 10. prepare for possible surgery/procedure 11. document the incident

Hyperglycemia (DKA) nursing interventions

1. Notify HCP immediately 2. Administer insulin in accordance with BG levels 3. Give IV fluids such as NS solution or 1/2 NS solution; potassium when urinary output is adequate; bicarb for pH <7 4. Monitor lab testing of blood & urine

PPROM expectant management

1. Observe for infection: *fever, abdominal tenderness, vaginal discharge with foul odor or change in color, elevated WBC's* 2. Frequent biophysical profiles to monitor fetal status and amniotic fluid volume 3. Frequent nonstress tests: this can be done with home monitoring if patient is discharged 4. Instructions on signs and symptoms that warrant immediate medical attention (Infection, decreased fetal movement, signs of labor, vaginal bleeding) 5. Instructions on self-care: -Ways to decrease risk of infection: *no tub baths, nothing in vagina, proper hygiene after BM, frequent pad changes, monitoring of temperature* -*Fetal kick counts* (movement chart, keeps track of baby's well-being) 6. *Delivery if Chorioamnionitis* -*ACOG recommends delivery at 34 weeks if PPROM*

Placenta previa assessment

1. Obtain History & Physical -Gravidity and Parity -Estimated date of confinement (EDC) -General status -Bleeding: quantity, precipitating event, associated pain 2. Uterine & Fetal Assessment -*Assess for fetal distress (uteroplacental insufficiency)* 3. Laboratory Studies -CBC, type & screen, coagulation profile, possible type & cross match 4. Ultrasound -Transabdominal -Transvaginal used if placenta location not clearly seen with transabdominal 5. *NO VAGINAL EXAMS* -*Nurses are not to perform vaginal exams in the presence of vaginal bleeding* -Usually *not done by physician if <34 weeks* and then done by sterile speculum -If the physician feels that a vaginal exam is necessary then it should be done under a *DOUBLE SET UP* -Double Set Up is when the *woman is placed in an OR set up for a cesarean birth because profound hemorrhage may occur* and the medical team must be prepared for an emergency C-section

Pathologic jaundice

1. Onset *within 24 hours of birth* 2. Bili > 4 mg/dL in cord blood 3. *Bilirubin levels of >15 mg/dL in a term or >10 mg/dl preterm infants* 4. Serum bili level rises >5 mg/dl in 24 hours or are increased at a rate of 0.5 mg/dl or > over 4-8 hours 5. Conjugated bili is more than 2 mg/dl 6. *Persists beyond 10 days (term)/ 21 days (preterm)*

Pharmacologic comfort measures - analgesia (3)

1. Opioid agonist -Meperidine hydrochloride (demerol) -Fentanyl citrate (sublimaze) 2. Opioid agonist-antagonists -butorphanol tartrate (stadol) -nalbuphine (nubain) 3. Opioid antagonist -*reverses CNS depression* -Naloxone (Narcan)

Perinatal loss in the office

1. Parents have a urgent need for information and to receive attention during the initial phase of shock. 2. Value sympathetic staff and feeling cared for 3. Freedom of choice to see the USG monitor 4. Support from care givers is an important factor regarding how well parents handle the acute situation and later move on 5. If not an urgent need to be admitted to hospital, *most patients appreciate being given a choice* 6. If office is located within the delivery hospital, *inquire if hospital chaplains or social workers are available* to patients prior to hospital admission If expectant mother has come alone to office, *offer to call a family member/friend so she is not alone*. In recognition that the family is in the shock phase, they may need instructions repeated and written down as well. Continuity in HCPs is valued by the expectant mother.

5 P's of labor

1. Passenger 2. Passageway 3. Powers 4. Position of Mother 5. Psychological Response

3 types of jaundice

1. Pathologic jaundice 2. Breastfeeding related jaundice 3. Physiologic jaundice

Periodic vs. non-periodic changes

1. Periodic changes in fetal heart rate are *transient changes* (accels or decels) from baseline *occurring in response to uterine contractions.* 2. Episodic changes: accelerations or decelerations that occur *without any specific relationship to uterine activity.*

7 signs & symptoms of hypovolemic shock resulting from PPH

1. Persistent significant bleeding occurs - perineal pad is *soaked within 15 min*; may not be accompanied by a change in vital signs or maternal color or behavior 2. woman states she feels weak, lightheaded, "funny," nauseated, or that she "sees stars" 3. woman begins to act anxious or exhibits air hunger 4. skin color turns ashen or grayish 5. skin feels cool & clammy 6. *Pulse increases* 7. *BP decreases*

6 impending cardiac problems

1. Persistent tachycardia 2. Dyspnea 3. Hypoxia 4. Persistent bradycardia 5. Skin pallor or cyanosis 6. Jaundice

Nursing actions - memory making

1. Photographs, foot prints, armband, lock of hair 2. Naming of baby 3. Involve family in rituals and memory making 4. Offer the family the option of bathing and dressing infant 5. Each delivery hospital will have bereavement supplies - donated smoked gowns, blankets, hats, educational materials 6. Offer baptism/blessing - Hospital Chaplain usually immediately available. They can also assist in calling in a rabbi or priest

Adherent retained placenta - 3 degrees of attachment

1. Placenta Accreta- *Slight penetration* of myometrium by placenta trophoblast 2. Placenta Increta- *Deep penetration* of myometrium by placenta 3. Placenta Percreta - *Perforation* of uterus by placenta

Bleeding in late pregnancy

1. Placenta previa 2. Placenta abruption 3. Adherent Retained Placenta

Effects of preeclampsia

1. Placental -*uteroplacental spasm results in IUGR, decreased amniotic fluid volume, abnormal fetal oxygenation, low birth weight, & preterm birth* 2. Renal -reduced kidney perfusion decreases GFR & can lead to degenerative glomerular changes & oliguria -*protein (primarily albumin) is lost in the urine* -uric acid clearance is decreased; serum uric acid levels increase -sodium & water are retained 3. Hepatic -*decreased liver perfusion can lead to impaired function & elevated liver enzymes* -if hepatic edema & subcapsular hemorrhage develop, woman may complain of *epigastric pain* 4. Neurological -cerebral edema & hemorrhage and increased CNS irritability *(HA, hyperreflexia, positive ankle clonus, & seizures)* -arteriolar vasospasms and decreased blood flow to the retina can lead to *visual disturbances* (scotoma & blurred/double vision)

DIC - laboratory coagulation screening test results

1. Platelets—decreased 2. Fibrinogen—decreased 3. Factor V (proaccelerin)—decreased 4. Factor VII (antihemolytic factor)—decreased 5. Prothrombin time—prolonged 6. Activated partial thromboplastin time—prolonged

3 stages of development

1. Pre-embryonic (ovum) -conception to day 14 -cellular *replication*, *blastocyst formation*, embryonic membrane development, primary germ layers 2. Embryonic (embryo) -day 15 to 8 weeks -rapid cell *division*, *major organ systems, main external features* -embryo is unmistakably human at the end of 8th week -*MOST susceptible to teratogens (substances or exposure that causes abnormal development)* 3. Fetal (fetus) -9 weeks to end of preg -refinement of structure & function -*less susceptible to teratogens* -*viability (ability to live outside the uterus, 22-25 weeks, based on: CNS & lung maturity)*

14 indicators for prolonged hypoxia

1. Prematurity/post maturity 2. Epidural 3. Congenital anomalies 4. Fetal anemia 5. Maternal hypotension/hypertension 6. Maternal hypothermia/hyperthermia 7. Uterine tachysystole 8. Uterine rupture 9. Extreme placental insufficiency 10. Prolonged cord compression 11. Cord prolapse 12. Placental abruption/ Previa 13. Diabetes mellitus 14. Inraamniotic infection

3 signs of pregnancy

1. Presumptive: those changes *felt by the woman* (amenorrhea, fatigue, breast changes) 2. Probable: *those changes observed by an examiner/HCP* -goodell sign (5 wk) -chadwick sign (6-8 wk) -hegar sign (6-12 wk) -postive serum (4-12 wk) & urine (6-12 wk) pregnancy test -braxton hicks contractions (16 wk; regular & painless, continue throughout pregnancy) -ballottement (16-28; technique used to palpate fetus) 3. Positive: those signs *attributed only to the presence of the fetus* (hearing fetal heart tones, visualizing the fetus, palpating fetal movements)

Those at risk for cold stress (5)

1. Preterm 2. small for gestational age (SGA) -*preterm & SGA don't have much brown fat* 3. intrauterine growth restriction (IUGR - doesn't grow at normal rate inside womb) 4. Post Date 5. Infection -*brown fat is wasted with infection*

Gestational age classification

1. Preterm or premature: *born before completion of 37 weeks of gestation, regardless of birth weight* 2. Late preterm: 34-36 6/7 weeks 3. Early term: 37-38 6/7 weeks 4. Full term: 39-40 6/7 weeks 5. Late term: 41-41 6/7 weeks 6. Postterm: 42 weeks & beyond 7. Postmature: born after completion of week 42 of gestation & showing the effects of progressive placental insufficiency

Newborn neurological adaptations

1. Primitive reflexes present at birth *reflect maturity and intactness of CNS* 2. Responsive and reactive with capacity for social interaction and self-organization 3. Brain growth requires glucose for energy and large supply of O2 for metabolism 4. Transient tremors of the mouth, chin (during crying episodes) and extremities -These tremors *should not be present when the infant is quiet and should not persist beyond 1 month of age* -Persistent tremors or tremors involving the total body can indicate pathologic conditions. -Normal tremors, tremors (jitteriness) of hypoglycemia, and seizure activity *must be differentiated* so corrective care can be instituted as necessary 5. The posture of the term newborn demonstrates *flexion of the arms at the elbows & the legs at the knees. Hips are abducted & partially flexed. Intermittent fisting of the hands is common*

Nursing care for labor & birth pain (11)

1. Provide companionship and reassurance 2. Offer positive reinforcements and praise her for her efforts 3. Encourage participation in distracting activities and no pharmacologic measures for comfort 4. Give nourishment (if allowed) 5. Assist with personal hygiene 6. Offer information and advice 7. Involve the woman in decision making regardless of care 8. Interpret the woman's wishes to other health care providers and to her support group 9. Create a relaxing environment 10. Use calm and confident approach 11. Support and encourage the woman's support people by role-modeling labor support measures and providing time for breaks.

3 forms of artificial milk

1. Ready to feed -*Most expensive* -*Easiest to use* -Pour desired amount into bottle -Opened can be refrigerated for 48 hours -*Individual disposable bottles* for most convenient feeding 2. Concentrated -*Less expensive* -*Dilute equal parts with water* -Stored in refrigerator for 48 hours after opening 3. Powdered -*Least expensive* -Easily mixed using *one scoop for every 60 mL water*

What causes fetal oxygen supply to decrease? (4)

1. Reduction of blood flow through the maternal vessels as a result of HTN, hypotension, or hypovolemia 2. Reduction of oxygen content in the maternal blood as a result of hemorrhage or severe anemia 3. Alterations in fetal circulation, occurring with compression of the umbilical cord, placenta previa or abruption, head compression *(head compression causes increased ICP and vagal nerve stimulation with accompanying decrease in the FHR)* 4. Reduction in blood flow to the intervillious space in the placenta secondary to uterine hypertonus (caused by excessive exogenous oxytocin) or secondary to deterioration of the placental vasculature associated with maternal disorders such as HTN or DM

Nutrition - nurses' role in counseling

1. Reflect positive images about breastfeeding in office/ clinic—*avoid free advertising for breast milk substitutes* 2. Discuss breastfeeding among expectant mothers with their old children 3. Inform mothers about risk of not breastfeeding 4. Encourage prenatal breast assessment by the obstetrician 5. Assist parents with selection 6. Rooming in; lacation consultants, assisting mothers to BF in 1st half hour, no pacifiers 7. How to get it started? -Initial APGAR and drying should be done when placed on the mother -Delaying procedures enhances early interactions -*AAP recommends newborn to breast within 1 hour of birth*

True labor

1. Regular contractions -increased intensity, frequency, & duration -increased intensity with walking -lower back & radiating to lower abdomen -continue despite comfort measures 2. *Cervical change* -softens, effaces (thins), & dilates - + bloody show (passage of small amount of blood or blood tinged mucus through the vagina near the end of pregnancy) -moves posterior to anterior 3. Movement of fetus -engagement in pelvis

Preterm labor is generally diagnosed clinically as:

1. Regular contractions along with a change in cervical effacement, dilation, or both OR 2. Presentation with regular uterine contractions and cervical dilation of at least 2cm (because of their small size, preterm fetuses can be delivered through a partially dilated cervix)

Pregestational diabetes - antepartum exercise

1. Regular exercise may be contraindicated in women with diabetes who also have uncontrolled HTN, advanced retinopathy, or severe autonomic or peripheral neuropathy 2. Exercise monitored by PCP 3. Best type: aerobic exercise with resistance training for at least 30 min most days of week 4. Other exercises: non-weight bearing activities 5. Best time: after meals, when blood glucose level is rising 6. Monitor blood glucose and should be with someone else in case something happens 7. *Avoid if: have positive urine ketones or blood glucose greater than 250 mg/ dl bc hyperglycemia and ketosis can worsen with physical activity* 8. Uterine contractions may occur; *stop immediately if felt, drink 2-3 glasses of water, lie down on side for hour; if continues, call doctor*

6 R's for managing abnormal FHR patterns

1. Reposition (Opposite lateral, Knee-chest, Trendelenberg) 2. Relax 3. Remove Pitocin 4. Rehydrate (fluid bolus) 5. Reoxygenate (8-10 Liters via face mask) 6. Report to MD *classic nursing interventions for any ominous sign*

Infection in the neonate - signs of sepsis

1. Respiratory -- Apnea, bradycardia, tachypnea, grunting, nasal flaring, retractions, decreased oxygen saturation, acidosis 2. Cardiovascular -- decreased cardiac output, tachycardia, hypotension, decreased perfusion 3. Central nervous system -- *temperature instability* [difficulty maintaining temp, requires more output on warmer to maintain same temp], lethargy, hypotonia, irritability, seizures 4. Gastrointestinal -- feeding intolerance, abdominal distention, vomiting, diarrhea 5. Integument -- jaundice, pallor, petechiae

Amnioinfusion procedure (7)

1. Review MD order 2. Membranes must be ruptured 3. Infused through an IUPC 4. Use either Lactated Ringers or Normal Saline 5. Warm fluid if ordered 6. Continuously monitor contraction intensity, duration, and resting tone, as well as FHTs 7. Document

Hyperbilirubinemia/pathologic jaundice etiology (6)

1. Rh sensitization 2. ABO incompatibility: doesn't result in significant anemia from hemolysis of RBCs. -*Easily treated with phototherapy.* 3. Preterm: has immature liver, ineffective glucuronyl transferase enzyme system, *decreased survival rate of RBCs* 4. Cold stress: *reduces availability of binding sites.* -Other causes of inadequate binding sites are asphyxia, hypoglycemia, maternal ingestion of drugs (aspirin, sulfa) near birth, oxytocin administration. 5. Sequestered blood: hemolysis of sequestered blood in cephalohematoma or ecchymosis 6. Intestinal obstruction: meconium ileus

APGAR interventions

1. Scores of 0-3 indicate *severe distress* -CPR -Drug tx: resuscitation drugs -Intubation 2. 4-6 indicate *moderate difficulty* -Vigorous stimulation -Oxygen -Narcan 3. 7-10 indicate *minimal or no difficulty* adjusting to extrauterine life -Dry -Provide warmth -Clear airway -Ongoing evaluation -If resuscitation is required, it should be initiated before the 1 minute APGAR -Change in score from 1 to 5 minutes is a *useful index of the effectiveness of resuscitation efforts*. There is poor correlation between the 1 and 5 minute Apgar score and future neurologic outcome. *Correlation increases when the score is 0 - 3 at 10, 15, and 20 minutes.*

Opioid side effects (7)

1. Sedation 2. N/V 3. Dizziness 4. Euphoria 5. Decreased GI motility 6. Decreased bladder/bowel elimination 7. *Decreased HR, RR, BP --> fetus not getting enough O2* *Readily crosses the placenta* & has profound fetal effects: -*decreased variability* -*decreased neonatal respiration*

10 barriers to breastfeeding

1. Separation 2. breast surgery 3. type of delivery 4. insufficient milk 5. pain 6. family 7. combined feedings 8. formula samples 9. maternity care practices 10. lack of support

Physiologic jaundice is diagnosed by:

1. Serum bilirubin concentration of greater than 5 in cord blood 2. Any case of visible jaundice that *persists for more than 14 days of life in term baby*

Some activities associated with symptoms of preterm labor are:

1. Sexual activity *(not contraindicated in pregnancy unless symptoms of preterm labor occur)* 2. Riding or standing for long periods of time 3. Lifting and carrying heavy loads such as small children or laundry 4. Strenuous physical work 5. Infrequent rest periods

Passenger (5)

1. Size of fetal head -6 bones: 2 parietal, 2 temporal, 1 frontal, 1 occipital -biparietal diameter: about 9.25 cm, largest transverse diameter -suboccipitobregmatic: 9.5 cm, *smallest & most critical bc when the head is in complete flexion, it allows the head to pass through true pelvis easily* 2. Presentation 3. Lie 4. Attitude 5. Position -Station & Engagement

DIC possible examination findings

1. Spontaneous bleeding from gums, nose 2. Oozing, excessive bleeding from venipuncture site, intravenous access site, or site of insertion of urinary catheter 3. Petechiae (e.g., on the arm where BP cuff was placed) 4. Other signs of bruising 5. Hematuria 6. GI bleeding 7. Tachycardia 8. Diaphoresis

Fetal position - station & engagement

1. Station: relationship of the *presenting part to an imaginary line drawn between the maternal ischial spine*, measured in cm above or below the line -line = 0 station; *above the line (-); below the line is (+)* -*birth imminent at +4-+5* -station determined when labor begins as baseline against which we measure the rate of fetal descent 2. Engagement: term used to indicate that the *presenting part has passed through the maternal pelvic brim or inlet* into the true pelvis -*usually corresponds with 0 station*

Etiology of absent/minimal variability (9)

1. Tachycardia 2. Prematurity 3. Sleep state 4. Fetal hypoxemia 5. Metabolic acidemia 6. Congenital anomalies 7. CNS depressant meds 8. General anesthetics 9. Preexisting neurologic injury IF INDETERMINATE - CON'T OBSERVATION & EVALUATION

Gestational diabetes patho

1. The stomach converts food to glucose & glucose enters the mother's bloodstream. Mother's pancreas produces sufficient insulin, but the insulin is resistant. Glucose can't get into body's cells causing high glucose levels in bloodstream 2. High glucose levels in the mother's blood enter the baby through the placenta. The baby's pancreas makes more insulin to handle the excess glucose 3. Gestational diabetes affects the mother in late pregnancy, after the baby's body is fully formed, but while the baby is still growing 4. Since the baby is getting more energy than it needs to grow, the extra energy is stored as fat causing the baby to weigh much more than normal 5. Gestational diabetes can causes problems for the mom & baby during delivery. The baby may need to be delivered by c-section & may have breathing problems. As adults they may develop diabetes or obesity

What should be included in the physical exam of a pregnant woman with pregestational diabetes?

1. Thorough physical assessment 2. Baseline EKG 3. Evaluation for *retinopathy (changes in kidneys) (microvascular changes)* 4. Blood pressure - *should be followed closely during pregnancy to observe for preeclampsia* 5. Weight gain 6. *Fundal height - hydramnios*

5 types of miscarriage

1. Threatened 2. Inevitable 3. Incomplete 4. Complete 5. Missed

Why should a diabetic woman obtain preconception counseling?

1. To plan the optimal time for pregnancy 2. Establish euglycemia control before conception 3. Diagnose vascular complications 4. Associated with decreased infant mortality & decrease in congenital anomalies 5. *HbA1c < 7 is goal for those with DM*

3 types of placenta previa

1. Total/complete: internal os is *completely covered* by the placenta 2. Partial: *incomplete covering* of the internal os 3. Marginal: *only an edge of the placenta extends to the internal os* but *may extend onto the os during dilation* of the cervix

GDM - antepartum interventions

1. Treatment as soon as diagnosed 2. Educate a lot since this is new 3. Diet: -*Mainstay of treatment is diet modification* -Placed on standard diet for diabetes -30 kcal/ kg/ day unless obese then 25 -Carb intake restricted to about 50% of caloric intake -Meet with dietician 4. Exercise: moderate exercise if overweight to improve blood sugar control and facilitate weight loss 5. Self-monitoring blood glucose: on rising, 1 or 2 hours after breakfast, before and after lunch, before dinner, at bedtime 6. Pharm therapy: -¼ require insulin during pregnancy to maintain satisfactory levels, despite diet change -If fasting plasma continually more than 95, 1 hour postmeal more than 140, 2 hour postmeal more than 120 -Try oral meds before injections -*Glyburide most commonly used; only small amounts cross to placenta* -Take 30 min- 1 hour before meals -*Metformin crosses placenta more but doesn't appear teratogenic* 7. Fetal surveillance: -if levels well controlled, low risk for IUFD so antepartum fetal testing not done routinely unless also have HTN, hx of stillbirth, or suspected macrosomia -begin fetal testing at 40 weeks

Molar pregnancy treatment

1. Usually *spontaneous delivery* - if not, suction curettage -*induction with oxytocic agents or prostaglandin = not recommended* bc of increased risk of embolization of trophoblastic tissue 2. *Administer Rhogam if patient is Rh negative* 3. Educate on follow up management -serial beta-hCG levels are drawn watching for increased levels; *increasing levels & enlarging uterus may indicate choriocarcinoma* -*pregnancy should be avoided for 1 year*; any contraceptive measure is appropriate *EXCEPT for an IUD* -oral contraceptives preferred bc they are highly effective

17 risk factors & causes of PPH

1. Uterine Atony - *loss of tone resulting from an overdistended uterus:* -Large fetus -Multiple fetuses -Hydramnios -Distention with clots 2. Anesthesia and analgesia (conduction anesthesia) 3. Previous history of uterine atony 4. High parity 5. Prolonged labor, oxytocin-induced labor 6. Trauma during labor and birth -Forceps or vacuum assisted birth, c-section 7. Unrepaired lacerations of the birth canal -*Should be suspected if bleeding continues despite a firm, contracted uterine fundus* -This bleeding can be a slow trickle, an oozing, or frank hemorrhage 8. Retained placental fragments -*When the placenta hasn't been delivered within 30 minutes after birth* despite gentle traction on the umbilical cord and uterine massage 9. Ruptured uterus 10. Inversion of the uterus 11. placenta accreta, increta, percreta 12. Coagulation disorder 13. Placental abruption 14. Placenta previa 15. Manual removal of a retained placenta 16. Magnesium sulfate administration during labor or the PP period 17. Uterine sub-involution

Reproductive changes during pregnancy (2)

1. Uterus- predictable growth pattern, increase blood flow, *lower segment of uterus softens*; more pressure on the bladder *(Hegar's)* 2. *Cervix- softens (Goodell's)* turns *deep blue violet in color (Chadwick's)*, forms operculum (mucous plug - protects against bacterial invasion)

Molar pregnancy clinical manifestations

1. Vaginal bleeding -*May be dark brown to bright red - scant to heavy* (resembles prune juice) 2. Excessive nausea & vomiting *(hyperemesis gravidarum)* 3. Anemia from blood loss 4. Abdominal cramps caused by uterine distention are common 5. Excessively enlarged uterus or smaller than expected 6. *Preeclampsia* occurs in 70% of women with large hydatidiform moles & occurs earlier than usual -*if diagnosed before 24 weeks, hydatidiform should be suspected & ruled out* 7. hyperthyroidism

Maternal & fetal assessment

1. Vital signs 2. Medical & Ob history 3. Gestational age 4. Fundal height 5. Fetal Heart Rate (Doppler, EFM) 6. Fetal movement 7. Uterine activity (contractions) 8. Nutrition (diet, weight gain) 9. Fetal movement 10. Signs of bonding 11. Signs of IPV 12. Ultrasonography 13. Biophysical profile (BPP) 14. Laboratory testing 15. Non-stress Test (NST) Screening tests offered to all pregnant women. *If positive or a women is at higher risk for fetal anomalies, they may opt for amniocentesis or chorionic villi sampling* to obtain further information about the fetus

8 Non-pharmacologic comfort measures

1. Walking/rocking/changing positions 2. Childbirth Preparation 3. Relaxation Techniques 4. Counterpressure -*pressure to the sacral area of the back during contractions*; helps woman cope with the sensations of internal pressure & pain in the lower back 5. Touch & Massage - Hand and foot massage may be especially relaxing in advanced labor, when a woman's tolerance for touch is limited. 6. Aromatherapy 7. Breathing techniques 8. Music

Conjugation of bilirubin

1. When RBCs reach the end of their life, their *membranes rupture & hgb is released.* When hgb is phagocytosed by macrophages, it *splits into heme & globin* 2. The *heme is broken down and converted to bilirubin in unconjugated form* (indirect bilirubin) which *mostly binds to plasma proteins.* 3. Adequate protein binding sites are available in the newborn *unless the infant is asphyxiated, has cold stress, or hypoglycemia.* 4. Maternal ingestion of drugs *(aspirin, sulfa) prebirth can reduce binding sites.* 5. Unconjugated bili can leave the vascular system and permeate other tissues but *if it crosses the blood brain barrier, it can cause neurotoxicity which is called kernicterus*. 6. *Unconjugated MUST be conjugated before it can be excreted.* 7. In the liver, the unconjugated bili is conjugated with glucuronic acid in the presence of enzyme glucuronyl transferase. 8. The *conjugated form of bilirubin is excreted as a constituent of bile (direct bilirubin).* 9. *Direct bilirubin* is converted to urobilinogen and stercobilin which is *excreted in urine and feces.* 10. Total bili is the *sum of direct and indirect bili.*

Nursing care immediately after cervical cerclage placement

1. Woman will likely be on bedrest for at least a few days -also will probably be advised to *avoid sexual intercourse until after a post-op check* -after, decisions about physical activity & lifestyle changes are *individualized based on the status of the woman's cervix* 2. Woman must understand the need for close observation & supervision for the remainder of pregnancy -*home uterine contraction monitoring* 3. Preterm labor precautions & instructions on when to return to the hospital: *strong contractions less than 5 min apart, PPROM, severe perineal pressure, & an urge to push* 4. *Stich removal for vaginal delivery* -active labor with dilation, ROM < infection, term pregnancy (37 wks) 5. *If c-section then the stitch can be left in place*

Methyldopa (aldomet)

1. a2-receptor agonist 2. Targets postganglionic nerve endings: interferes with chemical neurotransmission to reduce peripheral vascular resistance; *causes CNS sedation* 3. Maternal effects -*Sleepiness, postural hypotension, constipation; rare, drug induced fever and positive coomb's test* 4. Fetal effects -*After 4 months of maternal therapy, positive coomb's test result in infant*

Labetalol Hydrochloride (Normodyne)

1. alpha & beta blocker 2. Targets peripheral arterioles 3. Maternal effects -Minimal: flushing, tremulousness, orthostatic hypotension; *minimal changes in pulse rate 4. *Fetal effects minimal*, if any 5. *Less likely to cause excessive hypotension and tachycardia; less rebound hypotension than hydralazine* 6. *DO NOT use in women with asthma or HF* 7. *Do NOT exceed 80 mg in a single dose*

12 signs of hyperthermia in newborn

1. apnea 2. CNS depression 3. dehydration (increased insensible water loss) 4. flushed/red skin 5. hypernatremia 6. irritability 7. lethargy 8. poor feeding 9. seizures 10. sweating 11. warm to touch 12. weak or absent cry -*overheating produces an increase in o2 & calorie consumption* -preterm infant is not able to sweat

16 signs of hypothermia in newborn (cold stress)

1. apnea 2. bradycardia 3. *central cyanosis* 4. coagulation defects 5. *hypoglycemia* 6. *hypotonia* 7. *hypoxia* 8. feeding intolerance 9. *increased* metabolic rate 10. irritability 11. lethargy 12. *metabolic acidosis* 13. *peripheral vasoconstriction* (persistent pulmonary hypertension of the newborn) 14. poor weight gain (chronic hypothermia) 15. shivering (mature infants in presence of severe hypothermia) 16. *weak cry or suck*

16 Common discomforts & recommendations

1. breast changes: wear supportive maternity bras with pads to absorb discharge; *wash with warm water & keep dry*; discomfort temporary 2. urinary frequency: empty bladder regularly; perform kegel exercises; limit fluids at bedtime; report pain/burning to HCP 3. N&V: avoid empty or overloaded stomach; maintain good posture; *stop smoking; eat dry carbs on awakening*; remain in bed until feeling subsides; *alternate dry carbs with fluids such as decaf herbal tea; eat 5-6 small meals* 4. ptyalism (excessive saliva): use mouth wash, chew gum, eat hard candy 5. nasal stuffiness: use humidifier, avoid trauma; normal saline drops or spray may be used 6. leukorrhea: *not preventable (from increased estrogen* - white or yellow vaginal discharge); do not douche, wear pads; wipe front to back; report if foul odored 7. heartburn: limit/avoid gas producing or fatty foods & large meals; maintain good posture; *sip milk for temp. relief* 8. constipation: drink 2L (8-10 glasses) of water; engage in mod. exercise; maintain regular schedule for BM; use relaxation techniques 9. HA: conscious relaxation; OTC analgesics 10. varicose veins: avoid lengthy standing/sitting, constrictive clothing, & constipation/bearing down; *rest with legs & hips elevated*; wear support stockings; relieve with warm sitz bath 11. round ligament pain: *not preventable;* rest, maintain good body mechanics to avoid 12. SOB: good posture; *sleep with extra pillows*; stop smoking 13. leg cramps: check for homans sign, if negative use massage & heat; *dorsiflex until spasm relaxes*; stand on cold surface; calcium supplement removes phosphorus 14. ankle edema: *ample fluid intake for diuretic effect*; rest periodically; support stockings 15. acne 16. pica: report abnormal cravings to HCP; *may indicate anemia*

The initiation of respirations in the neonate is the result of a combination of which 4 factors?

1. chemical factors -with each labor contraction, there's a decrease in uterine blood flow & transplacental gas exchange, resulting in fetal hypoxia & hypercarbia -*results in progressive ↓in Po2, ↑Pco2, & ↓blood pH → initiate breathing by stimulating the respiratory center in medulla* 2. mechanical factors -as infant passes through birth canal, chest is compressed, causing ↑ intrathoracic pressure -with birth, *pressure on chest is released & negative intrathoracic pressure helps draw air into lungs* -*crying distributes air & promotes expansion of alveoli* -positive pressure created by crying keeps alveoli open 3. thermal factors -newborn enters extrauterine environment which has a significantly lower temp --> *change in temp stimulates skin receptors --> which stimulates resp. center in medulla* 4. sensory factors -handling, mouth THEN nose suctioning, & drying

Fetal circulation

1. ductus arteriosus: shunt of blood from *pulmonary artery to descending aorta bypassing the lungs* -Fetal PO2 will increase from 27 mmHg (intrauterine) to 50 mmHg (extrauterine) 2. foramen ovale: valve allowing blood flow directly *from right to left atrium* 3. ductus venosus: connection of *umbilical vein to inferior vena cava* -Shunt redirecting oxygen-rich blood into inferior vena cava *bypassing liver*

Fetal circulation

1. ductus arteriosus: shunt of blood from *pulmonary artery to descending aorta* 2. foramen ovale: valve allowing blood flow directly *from right to left atrium* 3. ductus venosus: connection of *umbilical vein to inferior vena cava*

Postpartum bladder changes

1. edema, hyperemia (excess blood in vessels), & marked diuresis 2. increased capacity & decreased sensitivity 3. overdistention --> incomplete emptying 4. urethral trauma may cause dysuria (painful urination) 5. *transient glycosuria, proteinuria, & ketonuria are normal in immediate pp*

3 postpartum physiologic changes that protect the woman by increasing circulating blood volume:

1. elimination of uteroplacental circulation reduces blood volume 2. loss of placental endocrine function that *removes the stimulus for vasodilation* 3. mobilization of extravascular water stored during pregnancy *By the 3rd pp day, the plasma volume has been replenished as extravascular fluid returns to the intravascular space*

Epidural/spinal nursing care - before (4)

1. ensure informed consent 2. assess VS, hydration, labor progress, FHR, & pain 3. Start & maintain IV -bolus (500-1000 ml 15-30 min prior) 4. monitor lab results (hct, hgb)

2 predictive diagnostic measures for preterm labor

1. fFN 2. endocervical length *more powerful when used together in predicting spontaneous preterm birth*

9 Factors affecting pain

1. fatigue 2. anxiety 3. culture 4. experience 5. comfort 6. support 7. environment 8. maternal positioning & mobility 9. rapid fetal descent

Self-monitoring of blood glucose

1. fingersticks recommended for site 2. *routinely assessed before meals; 1-2 hours after meals; at bedtime; in middle of night* if nighttime insulin is being adjusted 3. if NVD, monitor more frequently 4. acceptable pregnancy levels: -fasting: 60-99 -peak (1 hour) postmeal: 100-129 -2 hour postmeal: < 120 5. Report recurrent episodes of hypoglycemia (less than 70) and hyperglycemia (more than 200) 6. *Hypoglycemia treated with 15 g of carb if mild; if severe need IV* 7. *Hyperglycemia less likely but rapidly progresses to DKA and associated with increased risk of fetal death*

8 Hormones during pregnancy

1. hCG: *maintains corpus luteum production of estrogen & progesterone* until placenta takes over 2. progesterone: Decreases secretion of FSH/LH -*essential for maintaining pregnancy*; it does so by *relaxing smooth muscles*, which reduces uterine activity and prevents miscarriage. -increase fat deposits -Decreases ability to use insulin 3. estrogen: decreases FSH/LH -increases fat deposits -*increases size of genitals, uterus, & breasts* -increases vascularity -interferes with folic acid metabolism 4. prolactin: prepares breasts for lactation 5. oxytocin: *stimulates contractions & milk ejection* from breasts 6. hCS: *acts as growth hormone* -contributes to *breast development* -*decreases metabolism of glucose* -*increases fatty acids* for metabolic needs 7. insulin: *production increased* to compensate for insulin antagonists caused by placental hormones -antagonists decrease tissue sensitivity to insulin or ability to use it 8. cortisol: *increase insulin production* -increase peripheral resistance to insulin

15 Prenatal labs

1. hgb, hct, WBC, differential: detects *anemia & infection* 2. hgb electrophoresis: identifies women with *hemoglobinopathies* (sickle cell anemia, thalassemia) 3. blood type, Rh, & irregular antibody: Identifies those fetuses at risk for developing *erythroblastosis fetalis or hyperbilirubinemia* in neonatal period 4. rubella titer: determines immunity to rubella 5. TB skin test; chest film after 20 wks of gestation in women with reactive TB tests 6. Urinalysis, including microscopic examination of urinary sediment; pH, specific gravity, color, glucose, albumin, protein, RBCs, WBCs, casts, acetone; hCG: Identifies women with *glycosuria, renal disease, hypertensive disease* of pregnancy; *infection; occult hematuria* 7. urine culture: identifies women with *asymptomatic bacteriuria* 8. renal function tests (BUN, creatinine, electrolytes, creatinine clearance, total protein excretion): Evaluates *level of possible renal compromise* in women with a *history of diabetes, hypertension, or renal disease* 9. PAP test: Screens for *cervical intraepithelial neoplasia*; if a liquid-based test is used, may also screen for *HPV* 10. cervical cultures: Screens for asymptomatic infection at first visit *(gonorrhea, chlamydia)* 11. vaginal/anal culture: *GBS test done at 35-37 weeks for infection* 12. RPR, VDRL, or FTA-ABS: Identifies women with *untreated syphilis, done at first visit* 13. HIV antibody, hepatitis B surface antigen, toxoplasmosis: *screens for specific infections* 14. MSAFP: Maternal Serum Alpha-Fetoprotein 15. Cardiac evaluation - ECG, chest x-ray, and echocardiogram: Evaluates *cardiac function* in women with a *history of hypertension or cardiac disease*

Hypoxemia, hypoxia, asphyxia

1. hypoxemia: deficiency of oxygen in the *blood* 2. hypoxia: inadequate supply of oxygen to *tissues* that can cause metabolic acidosis 3. asphyxia: when fetal hypoxia results in metabolic acidosis

Anticipatory grief may be experienced when the following occurs:

1. in threatened miscarriage 2. when there is a diagnosis of a fetal condition incompatible with life 3. as a result of selective pregnancy termination 4. when a newborn is born prematurely or becomes critically ill 5. voluntary termination

8 impending thermoregulatory problems

1. increased muscle activity 2. crying 3. restlessness 4. cold skin 5. acrocyanosis 6. hypoglycemia 7. skin flushing or pale 8. extended posture

Liver plays an important role in: (4)

1. iron storage 2. carbohydrate metabolism 3. conjugation of bilirubin 4. coagulation

FAE - Fetal Alcohol Effects

1. lesser manifestation of the problem 2. ADHD 3. Fine motor impairment, clumsiness 4. delays in speech development 5. over past several years this term has been replaced with more precise phrases -- alcohol related neurodevelopmental disorder (ARND) and alcohol related birth defects (ARBDs)

An infant's weight is classified as:

1. low birth weight if they are born weighing *less than 2500 grams (about 5.5 pounds)* 2. very low birth weight if they weigh *less than 1500 grams (about 3.3 pounds).* 3. extremely low birth weight (ELBW) if they weigh *less than 1000 grams (2.2 pounds).*

Pregestational diabetes - determination of birth date & mode of birth

1. optimal time for birth is 39-40 weeks as long as good metabolic control maintained and parameters of antepartum fetal surveillance remain within normal limits 2. reasons to proceed with birth: poor metabolic control, coexisting HTN, nonreassuring FHR 3. many plan for elective labor induction between 38-40 weeks 4. to confirm fetal lung maturity, amniocentesis if birth before 38 weeks 5. c section when fetal weight expected to be over 4500 g

Maternal sensitization can occur as the result of: (6)

1. previous pregnancy with an Rh-pos fetus 2. transfusion with Rh-pos blood 3. spontaneous or elective abortion after the eighth week of gestation [hematopoiesis begins in 8th week] 4. amniocentesis 5. premature separation of the placenta 6. trauma The nurse takes a history to determine if any of these events have occurred. Then checks records to determine if RhoGAM was administered.

Lochia amount

1. scant (< 2.5 cm) 2. light (< 10 cm ) 3. moderate (> 10 cm) 4. heavy (saturated in 2 hours) *If woman receives an oxytocic med, the flow of lochia is often scant* until the effects of the med wear off *Amount of lochia is usually less after cesarean birth* bc the surgeon suctions the blood & fluids from the uterus Flow of lochia usually *INCREASES with ambulation & breastfeeding* - lochia tends to pool in vagina when woman is lying in bed then gushes upon standing

Treatment of infection in the neonate

1. septic work-up -- CBC [low white cell count an ominous sign], oropharyngeal or nasopharyngeal swabs, blood cultures, urine culture [suprapubic], spinal tap 2. followed by regimen of *broad spectrum antibiotics for 7 - 10 days. May change antibiotic based on results of blood cultures. If cultures are negative stop antibiotics in 3 days.* 3. *Keep warm to reduce cold stress*

Assessment of adequate nutritional intake

1. steady weight gain -- *infant loses 10% of birth weight or less but regains it in first 10 to 14 days of life. Doubles birthweight in first 5 to 6 months, triples by end of first year. Length increases by 50% in first year*. 2. regular sleep pattern 3. normal elimination pattern -- regular stooling *( 10 times a day or several days without), voiding 6 to 10 times in a 24 hour period* (may void up to 20 times per day) 4. Active with happy disposition 5. Firm muscles and appropriate fat 6. *Teething by 5 - 6 months* 7. Want mom to know the baby is going through a growth spurt when they are hungry

NAS nursing care

1. supportive therapy for fluid and electrolyte balance, nutrition, infection control, respiratory care 2. swaddling, holding, *reducing stimuli may ease withdrawal* 3. pharmacologic treatment in severe withdrawal -- phenobarbital or paregoric

Extrauterine adaptation - physical characteristics

1. vital signs: HR = 110 - 160 (first 30 minutes- HR ↑ 160-180 then ↓ 110-120) R = 30 - 60 (first 30-60 mins- Resp ↑ 60-80 then ↓ 60 breaths per minute) T = 97.5 - 99 2. weight: >2500 grams but <4000 grams (5.5 lbs - 8.5 lbs) 3. head circumference: 33 - 35 cm 4. chest circumference: 2-3 cm < head 5. length: 50 cm (20 in)

Nursing care for stage 1 - active phase (4-7 cm)

1. vital signs: initial VS used as baseline for comparison, take BP when pt is relaxed, monitor temp to identify infection or fluid deficit 2. hydration: pts are only allowed ice chips & sips of clear liquid bc of risk of anesthesia -IV fluids for the laboring woman to maintain hydration 3. elimination: *encourage voiding q 2h.* 4. ambulation & positioning: encourage ambulation if possible. *Position should be changed every 30-60 min; side lying preferred* 5. general hygiene: offer the use of showers or warm water baths if available; encourage women to wash hands after voiding & to perform self hygiene measures. *Change linens as it gets wet or stained* with fluids 6. leopold maneuvers 7. *amniotic membrane status q. 2* 8. vaginal exam 9. neuro exam (LOC, DTR, clonus) 10. lab data (urine specimen, CBC, type & screen)

The fetal pancreas begins to secrete insulin at ________ to _______ weeks of gestation

10 to 14 weeks The fetus responds to maternal hyperglycemia by secreting large amounts of insulin (hyperinsulinemia)

Characteristics of labor & birth pain

1st stage: *Visceral pain* (pain in lower abdomen) -*discomfort during ctx & free of pain between ctxs* -women whose *fetus is posterior will have lower back pain* -as labor progresses, pain becomes more intense & persistent. Woman becomes fatigued & discouraged, often experiencing difficulty coping with ctxs -women often experience *referred pain* through labor progression: pain *originates in uterus & radiates* to abdominal wall, back, gluteal area, & thighs 2nd stage: *Somatic pain (skin/tissues)* -intense, sharp, burning, & well localized -results from: pressure against bladder & rectum; stretching & distention of perineal tissues & the pelvic floor to allow passage of fetus 3rd stage: Uterine pain -*similar to pain experienced earlier in first stage*

Developmental milestones: weeks 28-40

28 weeks: eyes open & close -process sights & sounds -taste buds developing -hair on the head 32 weeks: fingernails, toenails, fingerprints present -subcutaneous fat develops -vigorous fetal movement -*fetus viable* -*L/S ration = 1.2:1 (lung maturity = 2:1)* 36 weeks: *lanugo disappearing* -amniotic fluid decreases -*L/S ration >2:1* 40 weeks: fetal development complete

Developmental milestones: weeks 9-24

9 weeks: fingers, toes, eyelids, nose, & jaw evident 11 weeks: *urine secreted in amniotic fluid* 12 weeks: *placenta complete* -*organ systems complete* -thumb sucking -turn somersaults 16 weeks: *meconium in bowel* 20 weeks: hearing developing -*quickening (mom feels movement)* -*lanugo covers the body* -wake/sleep cycles evident 24 weeks: circulation visible -rapid brain growth -hiccups -*vernix caseosa is thick* -*lecithin (L) present*

Placental abruption - expectant management

< 36 weeks gestation with mild abruption: 1. *Hospital Bedrest* 2. Observe for Bleeding and Labor 3. Close Fetal Surveillance (BPP & NST) 4. *Antenatal Glucocorticoids* 5. *Rhogam* if Rh negative mother 6. Emotional Support

With HELLP syndrome, RBCs are damaged as they pass through narrowed blood vessels & become hemolyzed, resulting in:

A *decreased RBC & platelet count*, as well as *hyperbilirubinemia.* Endothelial damage & fibrin deposits in the liver lead to *impaired liver function* & can cause hemorrhagic necrosis. *Liver enzymes are elevated when hepatic tissue is damaged*

Hydatidiform mole (molar pregnancy) is what type of disease?

A gestational trophoblastic disease (GTD) 1. GTD is a group of pregnancy-related *trophoblastic proliferative disorders WITHOUT a viable fetus that are caused by abnormal fertilization* 2. Women are at *higher risk if they have been treated with Clomid* (infertility drug) 3. Etiology is unknown, *may be r/t an ovular defect or nutritional deficiency* 4. Women who had a prior molar pregnancy & those who are in their *early teens or older than 40* are also at risk

If gestational diabetes is left untreated in the mother, what are potential outcomes for the baby? (Select all that apply.) A. High Birth Weight B. Respiratory Distress Syndrome (RDS) C. Hypoglycemia D. Shoulder Dystocia

A. High Birth Weight - caused by mothers increased sugar level that triggers the fetus' pancreas to produce more insulin, causing the baby to grow larger than normal B. Respiratory Distress Syndrome (RDS) - caused from underdeveloped lungs which occurs if baby is born preterm; high blood sugar levels in the newborn can impede lung development thus contributing to breathing problems C. Hypoglycemia - due to high insulin production D. Shoulder Dystocia - due to large baby

A nurse is providing care for a client who is diagnosed with a marginal abruptio placenta. The nurse is aware that which of the following findings are risk factors for developing the condition? (Select all that apply.) A. Maternal hypertension B. Blunt abdominal trauma C. Cocaine use D. Maternal age E. Cigarette smoking

A. Maternal hypertension B. Blunt abdominal trauma C. Cocaine use E. Cigarette smoking

A nurse is caring for a client at 14 weeks gestation who has hyperemesis gravidarum. The nurse is aware that which of the following are risk factors for the client? (Select all that apply.) A. Obesity B. Multifetal pregnancy C. Maternal age greater than 40 D. Migrane headache E. Oligohydramnios

A. Obesity B. Multifetal pregnancy D. Migrane headache

A nurse is reviewing the physician's orders for a client admitted for premature rupture of membranes. Gestational age of the fetus is determined to be 37 weeks. Which physician's order should the nurse question? A. Perform a vaginal examination every shift B. Monitor maternal vital signs every 4 hours C. Monitor fetal heart rate (FHR) continuously D. Administer ampicillin 1 gm as an intravenous piggyback (IVPB) every 6 hours

A. Perform a vaginal examination every shift

A client, 34 weeks pregnant, arrives at the ER with SEVERE abdominal pain, uterine tenderness and an increased uterine tone. The client denies vaginal bleeding. The external fetal monitor shows fetal distress with severe, variable decels. The client most likely has which of the following? A. Placental Abruption B. Placenta Previa C. Molar pregnancy D. Ectopic pregnancy

A. Placental Abruption

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (Select all that apply.) A. Respirations fewer than 12/min. B. Urinary output less than 30 mL/hr. C. Hyperreflexic deep-tendon reflexes. D. Decreased level of consciousness. E. Flushing and sweating

A. Respirations fewer than 12/min. B. Urinary output less than 30 mL/hr. D. Decreased level of consciousness.

Ketoacidosis

Accumulation of ketones in the blood *resulting from hyperglycemia* & leading to metabolic acidosis Occurs most often during the *2nd & 3rd trimesters, when the diabetogenic effect of pregnancy is greatest*

Rh disease

Affects *mothers with a negative Rh Factor when the baby is Rh positive* Fetal blood crosses the placental barrier and the *mother develops antibodies to the Rh antigen. This is referred to as maternal sensitization.* *The first pregnancy in which sensitization occurs is NOT affected.* In subsequent pregnancies the maternal antibodies will attack and lyse fetal red blood cells resulting in a severe fetal hemolytic anemia -- erythroblastosis fetalis or hydrops fetalis.

Amniotic fluid contains what?

Albumin, urea, uric acid, creatinine, lecithin, sphingomyelin, bilirubin, fructose, fat, leukocytes, proteins, epithelial cells, enzymes, & lanugo hair. Study of fetal cells in amniotic fluid through amniocentesis yields much info about the fetus -genetic studies (karotyping) provide knowledge about the sex & number/structure of chromosomes -*L/S ratio determines health or maturity of fetus*

Central nervous system injuries

All types of intracranial hemorrhage 1. *Subdural hematoma—life threatening*; can't be aspirated by subdural tap (inaccessible) -Blood subdural space of cerebellum -Nulliparous mom; total labor and birth <2-3 hours; difficult forceps birth; LGA 2. *Subarachniod hemorrhage—most common*, occurs in newborn from trauma; preterm from asphyxia (venous bleeding) 3. Spinal cord injuries (breech) -Extraction

Perinatal loss - active listening

Allow them to tell their story 1. Start with a sincere acknowledgement of the loss 2. Ask if they would like to tell you what happened 3. Allow for silence - don't rush them 4. Assess whether touch should be used as a therapeutic technique

Maternal serum ______________ levels are used as a screening tool for neural tube defects in pregnancy

Alpha-fetoprotein -through this technique, 80-85% of all open NTDs and open abdominal wall defects can be detected early. *Screening is recommended for all pregnant women* -AFP is produced in the fetal GI tract & liver, & increasing levels are detectable in the serum of pregnant women from 14-34 weeks gestation -maternal serum AFP (MSAFP) is a screening tool ONLY -*can be performed any time between 15-20 weeks gestation (16-18 weeks being ideal)*

The initial assessment of the neonate is performed immediately after birth using the:

Apgar score & a brief physical exam -initial exam can occur while nurse is drying & wrapping the infant, or observations can be made while infant is lying with mother -if infant is breathing effectively, is pink, & has no apparent life-threatening anomalies or risk factors requiring immediate attention, further exam can be delayed until parents have had an opportunity to interact with the infant

VBAC

Approximately 70%-80% success rate Vaginal delivery after cesarean criteria: 1. *One previous low-transverse cesarean birth* 2. Clinically adequate pelvis 3. No hx of uterine rupture or uterine scars 4. MD immediately available 5. Anesthesia available Concerns: 1. uterine rupture 2. operative injury 3. blood transfusion 4. one or two previous low transverse C sections

Supine hypotension

As pregnancy advances, the *weight of the uterus presses on abdominal vessels (vena cava & aorta) causing low BP* -Pallor, dizziness, faintness, breathlessness, tachycardia, nausea, clammy (damp cool) skin; sweating -*encourage a side-lying position to relieve symptoms & increase perfusion to uterus, placenta, & fetus*

Assessment of bowel function

Assess for: 1. (+/-) flatus 2. hemorrhoids 3. constipation (from pain meds) 4. ↑ roughage & fluids 5. laxative & stool softeners 6. *no enemas/rectal suppositories (3rd/4th degree perineal lacerations)*

Assessment of bladder & teaching to stimulate voiding

Assess for: 1. dysuria 2. fullness 3. tone (ability to empty) 4. placement 5. amount 6. frequency Teach: 1. early ambulation 2. listening to running water 3. placing hands in warm water 4. warm water poured over perineum Catheterization may be necessary if efforts to stimulate voiding are unsuccessful

A client's admitting medical diagnosis is third-trimester bleeding: rule out placenta previa. Each time the nurse enters the client's room, the woman asks: "Please tell me, do you think the baby will be all right?" Which of the following is an best nursing diagnosis for this client? A. Hopelessness related to possible fetal loss. B. Anxiety related to unidentified diagnosis. C. Situational low self-esteem related to blood loss. D. Potential for altered parenting related to inexperience.

B. Anxiety related to unidentified diagnosis.

A mother is newly diagnosed with gestational diabetes. The nurse anticipates the doctor to first suggest: A. Insulin Therapy B. Diet & Exercise C. Oral Hypoglycemic Agents D. Delivery of baby

B. Diet and exercise Start out with the least invasive measure

A nurse is caring for a client who is receiving nifedipine (Procardia) for prevention of preterm labor. The nurse should monitor the client for which of the following clinical manifestations? A. Blood-tinged sputum B. Dizziness C. Pallor D. Somnolence

B. Dizziness

A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states she missed one menstrual cycle and cannot be pregnant because she has an intrauterine device. The nurse should suspect which of the following? A. Missed abortion B. Ectopic pregnancy C. Severe preeclampsia D. Hydatidiform mole

B. Ectopic pregnancy

A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a clinical manifestation of this condition? A. Hgb 12.2 g/dL B. Urine ketones present C. Alanine aminotransferase (ALT) 20 IU/L D. Serum glucose 114 mg/dL

B. Urine ketones present

The nurse is reviewing a food log from a mother with gestational diabetes. Which of these foods would the nurse tell the mother to avoid? A. Liver B. White Rice C. Eggs D. Kiwi

B. White Rice -*Avoid foods white in color: bread, pasta, crackers, bagels, rolls, rice, tortillas* Liver & Eggs are high in Protein Fresh fruits are okay with gestational diabetes in moderation

A client at 33 weeks gestation and leaking amniotic fluid is placed on EFM. The monitor indicates uterine irritability and contractions occurring every 4-6 min. The doctor orders terbutaline. Which of the following teaching statements is appropriate for this client? A. This medicine will make you breathe better B. You may feel fluttering or tight sensation in your chest C. This will dry your mouth and make you thirsty D. You'll need to replace potassium lost by this drug

B. You may feel fluttering or tight sensation in your chest Tachycardia is a SE of terbutaline

Chronic hypertension with superimposed preeclampsia

BP increases *> 30 mmHg systolic or > 15 mmHg diastolic from baseline with onset of significant proteinuria* 1. Hypertension before 20 weeks: new onset proteinuria (> 5g protein in 24 hour urine) 2. Hypertension before 20 weeks AND proteinuria = an exacerbation of hypertension plus one of the following: thrombocytopenia, or increase in hepatocellular enzymes (liver enzymes)

Blood pressure is NOT a reliable indicator of impending shock from early PPH. Why?

Because compensatory mechanisms (volume expansion during pregnancy) *prevent a significant drop in BP until the woman has lost 30-40% of her blood volume.* Respirations, pulse, skin condition, urinary output, LOC are more sensitive means of identifying hypovolemic shock

____________, ______________, & _____________ can result in a decreased urge to void.

Birth induced trauma, increased bladder capacity after birth, & effects of conduction anesthesia Decreased voiding combined with postpartal diuresis (increased production of urine) can result in bladder distention *WANT TO AVOID BLADDER DISTENTION* - immediately, *excessive bleeding can occur* if bladder becomes distended bc it *pushes the uterus up & to the side & prevents it from contracting firmly* -later, a distended bladder *increases the risk for infection* With adequate bladder emptying, *bladder tone is usually restored by 5-7 days after birth*

Vacuum assisted

Birth method involving the *attachment of a vacuum cup to the fetal head* using negative pressure to assist in the birth of the head. 1. Indications are the same for a forceps delivery 2. *Used more often than forceps because easier to apply and the need for less anesthesia.* 3. Risk for newborn include *cephalhematoma, scalp lacerations, and subdural hematoma.* 4. Maternal risk include *perineal, vaginal, or cervical lacerations and soft tissue hematoma.* 5. Nurse should educate and provide support to the woman to remain active during labor, documentation, and make sure newborn and postpartum caregiver are informed of vacuum delivery.

Cesarean birth

Birth of the fetus through trans abdominal incision of the uterus. May be planned, unplanned, or elective 1. Maternal: Specific cardiac disease, respiratory distress, mechanical obstruction to the lower uterine segment, hx of previous c-section 2. Fetal: abnormal FHR or pattern, malpresentattion, active maternal HSV, maternal HIV, congenital abnormities -*c-section is performed primarily for the benefit of the fetus* 3. Maternal-fetal: dysfunction labor, placenta abruption, placenta previa, elective c-section.

Common birth injuries associated with diabetic pregnancies include:

Brachial plexus palsy, facial nerve injury, humerus or clavicle fracture, and cephalhematoma Most of the injuries are associated with difficult vaginal birth & shoulder dystocia *Hypoglycemia at birth is also a risk for infants born to mothers with diabetes*

Chronic pulmonary condition *resulting from prolonged periods of high oxygen* concentrations under high tension:

Bronchopulmonary Dysplasia (BPD) Signs: 1. Tachypnea, retractions, nasal flaring, increased work of breathing, activity intolerance to handling and feeding, tachycardia 2. Auscultation of the lungs typically reveal crackles, decreased air movement, and occasionally expiratory wheezing 3. Hypoxia, hypercapnia, and respiratory acidosis are common Treatment: 1. Oxygen therapy, nutrition, fluid restrictions, and medications 2. Difficult to wean these kids off of a ventilator or oxygen 3. Management is supportive but key is prevention of prematurity and RDS

Nonshivering thermogenesis is accomplished primarily by metabolism of:

Brown fat, which is unique to the newborn; & secondarily by increased metabolic activity in the brain, heart, & liver -brown fat is located in superficial deposits in the intrascapular region & axillae & in deep deposits at the thoracic inlet, along the vertebral column, & around the kidneys -brown fat has a *richer vascular & nerve supply than ordinary fat* -*heat produced by intense lipid metabolic activity* in brown fat *can warm the newborn* by *increasing heat production as much as 100%* -amount of brown fat reserve *increases with the weeks of gestation* -a full-term newborn has GREATER stores than a preterm infant

Oral glucose tolerance test for gestational diabetes is usually done during: A. 12 to 14 weeks of pregnancy B. 32 to 36 weeks of pregnancy C. 24 to 28 weeks of pregnancy

C. 24 to 28 weeks of pregnancy

A client in preterm labor (32 weeks) who is dilated to 5cm has been given magnesium sulfate and the contractions have stopped. If the labor can be delayed for the next 2 days, which of the following medications does the nurse expect that will be prescribed? A. Fentanyl (Sublimaze) B. Sufentanil (Sufenta) C. Betamethasone (Celestone) D. Butorphanol tartrate (Stadol)

C. Betamethasone (Celestone)

A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea and vomiting and scant, prune-colored discharge. She has experienced no weight loss and has a fundal height larger than expected. Which of the following should the nurse suspect? A. Hyperemesis gravidarum B. Threatened abortion C. Hydatidiform mole D. Preterm labor

C. Hydatidiform mole

A pregnant client is receiving magnesium sulfate therapy for the control of preterm labor. A nurse discovers that the client is encountering toxicity from the medication in which of the following assessment? A. Urine output of 25 ml/hr B. The presence of deep tendon reflex C. Respirations of 10 breaths per minute

C. Respirations of 10 breaths per minute

After reviewing the client's maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? A. Hypoglycemia B. Jitteriness C. Respiratory depression D. Tachycardia

C. Respiratory depression

The nurse is preparing to administer methotrexate to a client. This hazardous drug is most often used for which obstetric complication? A. Complete hydratidiform mole B. Missed Abortion C. Unruptured ectopic pregnancy D. Placental Abruption

C. Unruptured ectopic pregnancy

3-tier FHR interpretation system

Category I -*NORMAL; NO ACTION REQUIRED* -baseline 110-160 bpm -moderate variability -no late or variable decels -accels & early decels Category II -Not predictive of abnormal fetal acid base status but can't categorize I or III -*everything not categorized as I or III* -ex: tachy, brady with normal variability; absent, minimal, or marked variability. lates + mod variability, unusual variables -re-evaluate, intra-utero tx & continue surveillance Category III -*ABNORMAL FETAL ACID-BASE STATUS* -absent variability, plus either recurrent late/variable decels, bradycardia -sinusoidal pattern -*ACTION REQUIRED*

Hypoglycemia (insulin shock) - causes, onset, & symptoms

Causes: excess insulin, insufficient food (delayed or missed meals), excessive exercise or work, indigestion, diarrhea, vomiting Onset: rapid (regular insulin), gradual (modified insulin or oral hypoglycemic agents) Symptoms: irritability, hunger, sweating, nervousness, personality change, weakness, fatigue, blurred/double vision, HA, pallor/clammy skin, shallow respirations, rapid pulse -urine negative for sugar & acetone -BG less than 70

Hyperglycemia (DKA) - causes, onset, & symptoms

Causes: insufficient insulin, excess or wrong kind of food, infection, injuries, illness, emotional stress, insufficient exercise Onset: slow (hours-days) Symptoms: thirst, N/V, abdominal pain, constipation, drowsiness, dim vision, increased urination, HA, flushed/dry skin, rapid breathing, weak/rapid pulse, acetone (fruity) breath order -urine positive for sugar & acetone -BG >200

Changes in ______________ occur BEFORE uterine activity, so cervical measurement can identify women in whom the labor process has begun

Cervical length -however, because *preterm cervical shortening occurs over a period of weeks,* neither digital nor ultrasound cervical examination is very sensitive at predicting imminent preterm birth -women whose cervical length is *greater than 30 mm are UNLIKELY to give birth prematurely* even if they have symptoms of preterm labor *(<30 mm in a singleton pregnancy = predicts some instances of preterm labor)*

Nursing care for cocaine dependent neonates

Cocaine dependent neonates don't experience withdrawal like narcotic exposed infants -- *have neurotoxic effects instead* 1. Reduce environmental stimuli 2. *Organize to provide "clustered" care* 3. Provide anticipatory guidance to parents 4. Careful positioning

What is the number 1 cause of infant mortality in the U.S?

Congenital anomalies 1. Occur through influence of a single gene; combination action of many genes (down syndrome, cardiac defects); action of the intrauterine environment (IDM, sacral angenesis, congenital heart lesions); or through interaction of multiple genes with environmental factors that affect embryonic development (cleft lip palate, CHD) 2. Many congenital anomalies are detected prenatally through ultrasounds however there are still surprise findings at birth. Still encounter mothers who have had no prenatal care or multiple missed appointments and even with good prenatal care, ultrasound cannot detect all anomalies. 3. *Mothers with pregestational diabetes have a 2-5X higher incidence of anomalies.* Risk tied to higher fasting blood glucose levels and A1C levels. Most of these defects occur before the 8th week of pregnancy. Underscores the importance of controlling blood glucose levels BEFORE conception 4. *Mothers may learn of congenital anomalies early in 2nd trimester*

Major causes of perinatal mortality associated with maternal diabetes are:

Congenital malformations, respiratory distress syndrome, & extreme prematurity IUFD (sometimes called stillbirth) remains a major concern; *poor glycemic control is the most consistent finding in women who had a stillbirth*

Many women report feeling the baby "balling up". They should be educated that this could be:

Contractions & warrants closer attention

PPH 9 priority nursing interventions

Critical for the survival of the pt 1. *Administration of Pitocin* -If the uterus is unable to contract, the physician might prescribe Pitocin to maintain the tone of the uterus 2. Administration of Carboprost tromethamine -This is a *prostaglandin derivative that could help in promoting sustained uterine contractions* 3. Blood transfusion -Cross matching and blood typing is necessary to replace blood loss 4. Administration of oxygen -If the woman is experiencing respiratory distress, administration of oxygen can be prescribed 5. Must be alert to the symptoms of hemorrhage and be prepared to act quickly to minimize blood loss 6. *Save all perineal pads used during bleeding and weigh them to determine the amount of blood* 7. Place the woman in a *side lying position* to make sure that no bleeding is pooling underneath her 8. Assess lochia frequently to determine the amount discharged is still within normal limits 9. Assess vital signs

A nurse in labor and delivery is providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? A. Calcium gluconate B. Indomethacin (Indocin) C. Nifedipine (Procardia) D. Betamethasone (Celestone)

D. Betamethasone (Celestone)

A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? A. Nifedipine (Adalat) B. Pyridoxine (vitamin B6) C. Ferrous sulfate D. Calcium gluconate

D. Calcium gluconate

Which of the following foods/drinks would NOT be appropriate to give a mother experiencing hypoglycemia? A.1/2 cup of Orange juice B. 5 hard Lifesavers C. 1 cup of skim milk D. ½ cup of Diet Coke

D. Diet Coke We would want to give this mother regular soda and not diet.

A 25-year-old client is admitted with the following history: 12 weeks pregnant, vaginal bleeding, no fetal heart beat seen on ultrasound. The nurse would expect the doctor to write an order to prepare the client for which of the following? A. Cervical cerclage. B. Amniocentesis. C. Nonstress testing. D. Dilation and curettage

D. Dilation and curettage

A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following should be included in the teaching? A. Use a condom with sexual intercourse. B. Avoid bubble bath solution when taking a tub bath. C. Wipe from the back to front when performing perineal hygiene. D. Keep a daily record of fetal kick counts.

D. Keep a daily record of fetal kick counts.

Placenta previa - home care

Decided on case-by-case basis; woman's condition *should be stable, and she should have experienced no vaginal bleeding for at least 48 hours* before discharge 1. Can she be compliant with bedrest at home 2. Will she always have someone with her incase she starts bleeding 3. How far does she live from the hospital 4. Would she have to care for other children 5. Transportation to physician office and hospital 6. Is there a phone in the house to call an ambulance

Uteroplacental insufficiency

Decline in placental function (exchange of gases, nutrients, & wastes) leading to fetal hypoxia & acidosis; evidenced by late decels in response to contractions

Because the plasma increase is greater than the increase in RBC production, there's a decrease in what values in pregnant women?

Decrease in normal hgb values (12 to 16 g/dL blood) and hct values (37%- 47%) -This state of *hemodilution* is referred to as *physiologic anemia (common in 2nd trimester)* -Anemic if: *Hgb drops to ≤11 g/dL in 1st or 3rd trimester OR Hgb drops < 10 g/dL in 2nd OR Hct ↓ ≤ 32%* -a *hgb level less than 6-8 mg/dl is considered SEVERE anemia*, NOT physiologic

In preeclampsia, vascular remodeling does NOT occur or only PARTIALLY develops, resulting in:

Decreased placental perfusion & hypoxia *(vessels of uterus are too thick & can't handle increased blood volume)*

Hyperglycemia during the 1st trimester of pregnancy, when organs and organ systems are forming, is the main cause of:

Diabetes-associated birth defects Anomalies commonly seen in infants born to women with diabetes affect primarily the *CV system & the CNS*

When the maternal metabolism is stressed by illness or infection, the woman is at increased risk for:

Diabetic ketoacidosis -DKA can also be caused by poor compliance with treatment or use of beta-mimetic drugs such as *terbutaline (Brethine) for tocolysis to treat preterm labor or corticosteroids for fetal lung maturation* -*May occur with blood glucose levels barely exceeding 200* (in nonpregnant it would be 300 or more)

________________ is a pathological form of clotting

Disseminated intravascular coagulation (DIC) 1. diffuse & consumes large amounts of clotting factors, causing *widespread external bleeding, internal bleeding, or both & clotting* 2. *NEVER a primary diagnosis*. Instead it results from some event that triggered the clotting cascade

The fetal lungs do not function for respiratory gas exchange, so a special circulatory pathway, the _______, bypasses the lungs

Ductus arteriosus

GDM is usually diagnosed when?

During the 2nd half of pregnancy -As nutrient demands rise, maternal nutrient ingestion induces greater and more sustained levels of blood glucose -Maternal insulin resistance is also increasing so maternal insulin demands rise greatly -Most pregnant women are capable of increasing insulin production to compensate for insulin resistance and maintain euglycemia but when pancreas is unable to produce sufficient insulin or insulin is not used effectively, GDM can result

Insulin, produced by the beta cells in the islets of Langerhans in the pancreas, regulates blood glucose levels by:

Enabling glucose to enter adipose and muscle cells, where it is used for energy. *When insulin is insufficient or ineffective in promoting glucose uptake by the muscle and adipose cells, glucose accumulates in the bloodstream*, and hyperglycemia results.

_________ is an incision in the perineum used to enlarge the vaginal outlet

Episiotomy -*Midline is the most common* 1st degree: laceration that extends through the skin & structure superficial to muscles *(vaginal membranes)* 2nd degree: extends through the fascia & muscles of the perineal body *(vaginal membranes + fascia)* 3rd degree: extends through the anal sphincter muscle *(membranes + fascia + anal sphincter)* 4th degree: involves anterior rectal wall *(membranes + fascia + anal sphincter + anal canal)*

Innocuous pink papular neonatal rash of unknown cause, with superimposed vesicles appearing within 24-48 hours after birth & resolving spontaneously within a few days is called:

Erythema toxicum -also called erythema neonatorum, newborn rash, or flea bite dermatitis

The primary goal of care in the first moments after birth is to assist the newly born infant to transition to extrauterine life by:

Establishing effective respirations 1. *if NB is term, is crying or breathing, & has good muscle tone, routine care can begin* -Continue monitoring, skin to skin contact, keep airway patent -Drying infant with *vigorous rubbing removes moisture to prevent evaporative heat loss* & provides tactile stimulation to *stimulate respiratory effort* 2. Normal: breathing spontaneously, trunk & lips are pink, acrocyanosis (hands & feet appear cyanotic up to 10 days) -Continue monitoring 3. Abnormal: apneic, gasping -*Positive pressure ventilation (PPV)* 4. Assess HR (grasping the base of the cord or auscultating) -*Count for 6 seconds, multiple x 10* 5. NORMAL: -HR > 100 beats/min. ACTION: Continue Care 6. *ABNORMAL: listen for full minute* -HR < 100 beats/min. *ACTION: Get more help, begin AHA algorithm for resuscitation* 7. Place identifying security bands on mom & infant 8. Footprint with ink or scanning device *within 2 hrs*

In a pregnant woman, the upper respiratory becomes more vascular in response to elevated levels of what?

Estrogen -As the capillaries become engorged, edema, and hyperemia (excess blood in vessels) develop within the nose, pharynx, larynx, trachea, and bronchi. -This congestion within the tissues of the respiratory tract gives rise to several conditions commonly seen during pregnancy, including *nasal and sinus stuffiness, epistaxis (nosebleed), changes in the voice, and marked inflammatory response* to even a mild URI

During the first trimester of pregnancy (1-13 weeks) the pregnant woman's metabolic status is significantly influenced by the rising levels of:

Estrogen & progesterone These hormones *stimulate the beta cells in the pancreas to increase insulin production, which promotes increased peripheral use of glucose and decreased blood glucose*, with fasting levels being reduced by 10% At the same time, an *increase in tissue glycogen stores & a decrease in hepatic glucose production occur*, which further encourage lower fasting glucose levels As a result of these normal metabolic changes of pregnancy, *women with insulin-dependent diabetes are prone to hypoglycemia during the first trimester* -NV & decreased food intake contribute to hypoglycemia

Achieving and maintaining constant ___________ is the primary goal of medical therapy for GDM

Euglycemia (normal blood glucose level; normoglycemia) fasting: <95 preprandial: 65-95 1 hr postprandial: <130-140 2 hr postprandial: <120 2-4 am: 60-120

IA pros & cons

FHTs assessed with: Pinard stethoscope, Doppler ultrasound, Ultrasound stethoscope, or DeLee- Hillis fetoscope FHTs is a *high-touch, low-technology, non-invasive, inexpensive method of assessing* fetal status during labor. 1. Allows for maternal freedom of movement. 2. FHR is heard at periodic intervals but can be time consuming. 3. May be difficult in obese women 4. Significant events occur when FHR is not being auscultated 5. No permanent documented visual record of the FHR 6. No visual patterns of FHR variability or periodic changes Ctxs: traditional method of monitoring contractions is palpation 1. Measures frequency, duration, and relative strength. 2. Use of fingertips to feel the rise upward as the contraction develops 3. Described as mild, moderate, or strong -mild: fundus easy to indent (tip of nose) -moderate: firm fundus, difficult to indent (chin) -strong: rigid, board-like, can't indent (forehead)

Swallowing reflex

Feed infant; swallowing usually follows sucking and obtaining fluids Swallowing is usually coordinated with sucking and breathing and usually occurs without gagging, coughing, apnea, or vomiting If response is weak or absent, this can indicate *preterm birth, effect of maternal analgesics, or illness that needs investigation*

_____________ is important in reducing serum bilirubin levels because it *stimulates peristalsis & produces more rapid passage of meconium*, thus *diminishing* the *amount of reabsorption* of *uncojugated bilirubin.*

Feeding -Feeding also introduces bacteria to aid in the reduction of bilirubin to urobilinogen -Colostrum, a natural laxative, facilitates passage of meconium

The leading known cause of mental disability, surpassing both Spina Bifida and Down Syndrome:

Fetal alcohol syndrome Diagnostic Criteria for FAS: Prenatal and postnatal growth retardation 1. damage to the central nervous system: microcephaly (small head) & mental retardation 2. other problems: -poor coordination, hypotonia, ADHD -cardiac anomalies, hemangiomas, eye and ear anomalies -weak suck, irritability, developmental delays -dysfunctional family environment

_________ is a glycoprotein "glue" found in plasma & produced during fetal life & is a diagnostic test for preterm labor

Fetal fibronectin (fFN) -*normally* appears in cervical & vaginal secretions *early in pregnancy & then again in late pregnancy* -test is performed by collecting fluid from the woman's vagina using a swab during a speculum exam -*presence of fFN during the late 2nd & early 3rd trimesters of pregnancy may be r/t placental inflammation*, which is thought to be one cause of spontaneous preterm labor *(not normally found between 24-34 weeks)* -*presence of fFN alone is NOT very sensitive as a predictor of preterm birth* -often the test is *used to predict who will NOT go into preterm labor, because preterm labor is very unlikely to occur with a negative result* -negative result indicates a <95% chance of delivering prematurely

Newborn circulatory system

First breaths + increased capillary distention = lung inflation & decreased pulmonary vascular resistance to blood flow from pulmonary arteries 1. *the ductus arteriosus constricts*, allowing all blood leaving the right ventricle to travel to the lungs via the pulmonary arteries -Fetal PO2 increases from 27 mmHg (intrauterine) to 50 mmHg (extrauterine) --> -ductus arteriosus constricts as a result of increased O2 & prostaglandin E2 (PGE2) --> -closes the ductus arteriosus (can reopen in response to hypoxia, asphyxia, or prematurity) 2. *the foramen ovale closes, leaving a small depression called the fossa ovalis*. This isolates deoxygenated & oxygenated blood within the heart. -pulmonary pressure drops causing an increase in pressure of right atrium --> -increased pulmonary blood flow from the left side of the heart increases pressure in the left atrium --> -closure of foramen ovale (for a few days, crying can reverse closure --> mild cyanosis) 3. *ductus venosus degenerates & becomes the ligamentum venosum*. The inferior vena cava now carries only deoxygenated blood back to the heart. -umbilical vein & arteries constrict in response to cooler room temps + increase in O2 from infant respirations --> -clamping & cutting cord --> -closure of ductus venosus (within 2 hours)

Warning signs during pregnancy

First trimester: 1. Severe vomiting 2. Chills, fever 3. Dysuria 4. Diarrhea 5. Abdominal cramping 6. Vaginal bleeding Second & third trimesters: 1. Persistent, severe vomiting 2. Sudden discharge of fluid from vagina < 37wks 3. Vaginal bleeding, severe abdominal pain 4. Severe backache/flank pain 5. Change in fetal movements 6. Contractions; pressure; cramping < 37 wks 7. Visual disturbances: blurring/double vision/spots 8. Face/fingers/sacrum swelling 9. Headaches; severe/frequent or continuous 10. Muscular irritability or convulsions 11. Epigastric/abd pain (heartburn/severe stomachache) 12. Glycosuria, + GTT reaction

White's classification of diabetes in pregnancy

GDM Class A: *Any degree of glucose intolerance with the onset or first recognition during pregnancy* -Mom and baby have same reactions: Big Mom → Big Baby Class A - C generally have good pregnancy outcomes. Class D - T *usually have poorer pregnancy outcomes because of pre-existing vascular change*

Placental ischemia causes endothelial cell dysfunction by stimulating the release of a toxic substance to endothelial cells. This dysfunction causes:

Generalized vasospasm, which results in poor tissue perfusion in all organ systems, increased peripheral resistance & BP, increased endothelial cell permeability, leading to intravascular protein loss and ultimately to less plasma volume

One of the *most common types of blood injuries in neonates* & is among the most severe from stand point of both short & long term outcomes:

Germinal Matrix Hemorhage-Intraventricular Hemorrhage (GMH-IVH) 1. Risk is being premature 2. *fragile blood vessels* in the germinal matrix of premature infant; lies beneath the lateral ventricles 3. fluctuating or increasing cerebral blood flow or increases in cerebral venous pressures *can cause blood vessels to rupture.* 4. If it occurs, *care is focused on maintaining oxygenation and perfusion, an NTE, and normoglycemia* 5. Severity of bleed is classified using a grading system I - IV

_________________ is the onset of hypertension WITHOUT proteinuria or other systemic findings diagnostic for preeclampsia after week 20 of pregnancy.

Gestational HTN 1. defined as systolic BP greater than 140 or a diastolic BP greater than 90. *Only one pressure (either systolic or diastolic) needs to be elevated to meet the definition of HTN* 2. the HTN should be recorded on *two occasions at least 4 hours* apart after 20 weeks of gestation in a woman with a previously normal BP. 3. *Does NOT persist longer than 12 weeks postpartum* & usually *resolves during the first postpartum week*

Management of HELLP syndrome

Gestational age <32 weeks: 1. Administer a corticosteroid 2. Manage the patient based on the clinical response during period of observation 3. Patients conditions worsen -Delivery 4. Patient is stable -Monitor the patient in a tertiary care facility Gestational age 32-34 weeks 1. Administer a corticosteroid 2. Is the patient eligible for conservative management? -If no, deliver -if yes, counsel the pt about the potential benefit of continuing the pregnancy for 2 more weeks to allow more time for fetal lung maturity -Transfer the patient to a tertiary care facility that has neonatal intensive care unit 3. Patient's condition worsens -Delivery 4. Patient is stable -Monitor the pt. in a tertiary care facility *Gestational age >34 weeks = Deliver*

_________________ is a long-acting insulin lasting approximately 24 hours and is not approved for use in pregnancy but appears to be safe

Glargine (Lantus) -No peak since slowly released -when administered with rapid or short-acting insulin, *unpredictable spikes in insulin levels & resulting hypoglycemia appear to occur less often*

Newborn cardiovascular adaptations - HR & BP

HR 1. 100 - 160 (resting) beats/min 2. 85 - 100 (deep sleep), 180 (crying) beats/min 3. Cardiac output (per unit of body weight) higher than that of the adult 4. 50% more Hgb than mom 5. Hgb carries 20 - 30% more O2 than mom BP 1. 60 - 80 mm Hg Systolic 2. 40 - 50 mm Hg Diastolic 3. *↓ systolic by 15 mm Hg in first hour is common*

Women with preexisting diabetes are at risk for several obstetric and medical complications, including:

HTN, preeclampsia, c section, preterm birth, & maternal mortality

Etiology of early decels

Head compression: -Contractions -Vaginal Exam -Fundal pressure -Placement of internal monitor

Fetal circulation supplies the highest levels of oxygen & nutrients to the ____, ______, & ______ which enhances the cephalocaudal (head-to-rump) development of the embryo/fetus

Head, neck, & arms

Fetal circulation supplies the highest levels of oxygen & nutrients to the:

Head, neck, and arms which enhances the cephalocaudal (head-to-rump) development of the embryo/fetus

Next to establishing respirations & adequate circulation, __________ is most critical to the newborn's survival.

Heat regulation During the first 12 hrs after birth the neonate attempts to achieve thermal balance in adjusting to the extrauterine environmental temperature

Moro reflex

Hold infant in semi sitting position, allow head and trunk to fall backward to angle of at least 30 degrees (with support) -Place infant supine on flat surface; perform sharp hand clap *Symmetric abduction and extension of arms are seen; fingers fan out and form a C with thumb and forefinger*; slight tremor may be noted; arms are adducted in embracing motion and return to relaxed flexion and movement. A cry may accompany or follow motor movement -Legs may follow similar pattern of response -*Preterm infant does not complete "embrace"; instead arms fall backward because of weakness* Response is present at birth; complete response may be seen until 8 weeks; body jerking is seen between 8 and 18 weeks -*Asymmetric response can connote injury to brachial plexus, clavicle, or humerus* -*Persistent response after 6 months indicates possible neurologic abnormality.*

Stepping or "walking" reflex

Hold infant vertically under arms or on trunk, allowing one foot to touch table surface Infant will simulate walking, alternating flexion and extension of feet, *term infants walk on soles of their feet, and preterm infants walk on their toes* *Response is normally present for 3-4 weeks*

The uterus involutes because of what?

Hormone withdrawal (estrogen & progesterone) Increased estrogen & progesterone levels are responsible for stimulating the massive growth of the uterus during pregnancy After birth the *decrease in these hormones causes autolysis - the self-destruction of excess hypertrophied tissue.* The additional cells laid down during pregnancy remain & *account for the slight increase in uterine size after each pregnancy*

________ is the earliest biologic sign of pregnancy

Human chorionic gonadotropin (hCG) -pregnancy tests are based on the presence of hCG -detected through urine (3 to 4 weeks - accuracy depends on following instructions; otc test uses ELISA for results) -serum (8 to 10 days) -*higher than normal* hCG may *indicate down's or multiples* -*lower than normal* hCG may *indicate ectopic or impending miscarriage*

Women are 5 to 6 times more at risk during pregnancy for thromboembolic disease therefore considered a ______ state

Hypercoagulable -There is a greater tendency for blood to clot during pregnancy bc of *increases in various clotting factors (Factor VII, VIII, IX, X, and fibrinogen) & decreases in factors that inhibit coagulation* -This tendency combined with the fact that fibrinolytic activity (the splitting up or dissolving of a clot) is depressed, *provides a protective function to decrease the chance of bleeding* but also *makes the woman more vulnerable to thrombosis, especially after cesarean birth*

When vomiting during pregnancy becomes excessive enough to cause weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria, the disorder is termed:

Hyperemesis gravidarum Risk factors: hyperthyroid disorders, prepregnancy psych diagnosis, previous pregnancy complicated by hyperemesis gravidarum, molar pregnancy, multiple gestation with a male & female fetus, diabetes, & GI disorders. Women carrying a female fetus are more at risk CM: weight loss, dehydration, dry mucous membranes, decreased BP, increased HR, & poor skin turgor Most important lab test is determination of ketonuria Tx: IV therapy for correction of fluid & electrolyte imbalances

Intermittent Auscultation (IA) vs Electronic Fetal Monitoring (EFM)

IA: -q 15-30 min (stage 1-active phase) -q 5-15 min (stage 2) EFM: continuous

Afterpains (afterbirth pains)

In first time mothers uterine tone is good, the fundus remains firm, & woman usually perceives only mild uterine cramping. Periodic relaxation & vigorous contractions are *more common in subsequent pregnancies & can cause uncomfortable cramping* called afterpains, which *typically resolve in 3-7 days.* Afterpains are *more noticeable after births in which the uterus was overdistended* (multifetal gestation, polyhydramnios) *Breastfeeding & Pitocin usually intensify these afterpains* bc both stimulate uterine contractions

Genetic testing - metabolic diseases (PKU, galactosemia, hypothyroidism)

Inborn error of metabolism is the term applied to a large group of disorders caused by a metabolic defect *that results from the absence of or change in a protein, usually an enzyme.* -*Blood sample is taken by a heelstick* 1. PKU: deficiency of phenylalanine dehydrogenase -*Requires a diet low in phenylalanine or infant will develop severe mental retardation* -Test performed *24 hrs after ingestion of first milk* 2. Galactosemia: deficiency of galactose 1-phosphate uridyl transferase. -*Can't convert galactose to glucose* -Galactose levels rise and infant will show *failure to thrive, mental retardation, jaundice, hepatomegaly, and cirrhosis of the liver, with death in first month of life*. -Therapy consists of *galactose free diet.* 3. Hypothyroidism: measurement of thyroxine *(T4) in blood from heel stick at 2 to 5 days of age.* -Cretinism develops in untreated affected people. -Same blood sample used to test all 3 metabolic disorders.

In the 1st trimester, from weeks 3 to 7 of gestation, insulin requirements are:

Increased, followed by a decrease between weeks 7 and 15 of gestation

Transient tachypnea of the newborn (TTNB)

Infants who experience mild TTNB often have *signs of respiratory distress during the first 1-2 hrs after birth* as they transition to extrauterine life. Tachypnea with rates up to 100 breaths/min can be present along with *intermittent grunting, nasal flaring, & mild retractions* *TTNB usually resolves in 24-48 hrs* In neonates with more serious respiratory problems, symptoms of distress are more pronounced & tend to last beyond the 1st 2 hours after birth

Complications of pregestational diabetes requiring hospitalization

Infection, which can lead to hyperglycemia & DKA, is an indication for hospitalization, regardless of gestational age Hospitalization during the 3rd trimester for close maternal & fetal observation may be indicated for women whose diabetes is poorly controlled Women with diabetes are more likely to have preexisting HTN or develop preeclampsia, which may necessitate hospitalization

__________________ are more common & more serious in pregnant women with diabetes than in those without the disease

Infections -*disorders of carb metabolism alter the normal resistance of the body to infection* -the inflammatory response, leukocyte function, & vaginal pH are all affected -vaginal infections (monilial vaginitis) are more common -UTIs are also more prevalent -*women who are insulin dependent are more likely to have postpartum infection*

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in:

Insulin secretion, insulin action, or both

What is the *most accurate means of evaluating fetal well-being* during labor?

Internal monitoring -*not interrupted by fetal movement or maternal size.*

The return of the uterus to a nonpregnant state after birth is called:

Involution This process *begins immediately after expulsion of the placenta* with contraction of the uterine smooth muscle At the end of the 3rd stage of labor, the uterus is midline, *approximately 2 cm BELOW the level of the umbilicus* Rises to *1 cm ABOVE the umbilicus at 12 hrs* *halfway between umbilicus & pubic symphysis at 6 days pp* The fundus descends *1-2 cm every 24 hrs* *Unable to palpate fundus after 9th pp day*

LATCH

L: latch A: audible swallowing T: type of nipple C: comfort level of mother H: hold (positioning) In preparation for early feeding, the mother should *manually express a few drops of colostrum or milk and spread it over the nipple; this action lubricates the nipple and entices the baby to open the mouth* as the milk is tasted

Postbirth uterine discharge is called:

Lochia -Lochia is initially bright red (lochia rubra) & may contain small clots -For the first 2 hrs after birth the *amount of uterine discharge should be about that of a heavy menstrual period*. After that time the lochial flow should steadily decrease

____________ placenta is the term used when the placenta is implanted in the lower uterine segment *but does NOT reach the os*

Low-lying

Maintaining airway... suctioning _______ then ______

MOUTH then NOSE

Poor glycemic control later in pregnancy increases the rate of fetal _______________

Macrosomia (birth weight more than 4000-4500 g or greater than 90th percentile) -Tend to have *disproportionate increase in shoulder, trunk, & chest size* -Risk for *shoulder dystocia is high* -Women with diabetes face an *increased likelihood of c section because of failure of fetal descent or labor progress or of operative vaginal birth* (birth involving use of episiotomy, forceps or vacuum)

________________ is the drug of choice for preventing and treating seizure activity (eclampsia).

Magnesium sulfate Indications: 1. Severe preeclampsia 2. HELLP syndrome 3. Eclampsia prevention/treatment Administer: 1. IVPB 2. Loading dose: 4-6 grams (over 15-30 min) 3. Maintenance dose: 1 to 2 g/hr (40 g in 1000 ml of LR; 1 g= 25 ml) and administered by an infusion pump at 2-3 g/hr -*this dose should maintain a therapeutic serum magnesium level of 4-7 mEq/L*

Contraindications to Tocolytics

Maternal 1. Severe Preeclampsia 2. Ecclampsia 3. Bleeding with hemodynamic instability 4. Contraindications to specific medications Fetal 1. Intrauterine fetal demise 2. Lethal fetal anomaly 3. Non-reassuring fetal status 4. Chorioamnionitis (inflammation of membranes) 5. PPROM

Maternity blues vs. postpartum depression (PPD)

Maternity blues: 1. *50% - 80%* 2. *first few days - 2 wks.* 3. mood swings 4. feeling sad, anxious, or overwhelmed 5. crying spells 6. loss of appetite 7. trouble sleeping PPD: 1. *13 - 20%* 2. little interest in doing things 3. feeling down/depressed or hopeless 4. disturbed sleep patterns 5. not wanting to socialize or "join in"

Acute inflammatory disease of GI mucosa complicated by perforation:

Necrotizing Enterocolitis (NEC) 1. *caused by preferential shunting of blood to heart and brain in an asphyxiated infant away from the GI tract*. Bacterial colonization resulting in an ileus. 2. Symptoms -- abdominal distention, bile-stained gastric aspirate, vomiting, bloody stools, abdominal tenderness 3. management -- supportive: *rest the GI tract by stopping feedings*; gastric decompression; TPN; antibiotics for treatment of infection; surgical resection if perforation. 4. *lower risk of NEC by breastfeeding.* -Breast milk enhances the maturation of the GI tract

______________, a calcium channel blocker, is a tocolytic agent that can suppress contractions. It works by preventing calcium from entering smooth muscle cells, thus reducing uterine contractions.

Nifedapine (Procardia) 1. Dosage & route: *Initial 10-20 mg PO, then q 3-6 hours until contractions are rare* 2. Adverse effects -Maternal (most effects are mild): hypotension, *HA*, flushing, dizziness, nausea -fetal: hypotension (questionable) 3. Contraindications: -*Should NOT be given concurrently with magnesium sulfate* because skeletal muscle blockade can result -*Should NOT be given simultaneously or immediately after terbutaline* because of effects on heart rate and blood pressure.

Magnesium sulfate nursing responsibilities & patient safety

Nursing responsibilities: 1. Educate patient and family on use and side effects 2. *Assist patient into side lying position* Patient safety: 1. Seizure Precautions 2. Discontinue infusion if toxicity is suspected (to prevent respiratory/cardiac arrest) 3. Have Calcium Gluconate and intubation equipment close by 4. *Siderails ↑ x 4* 5. Call button within reach 6. Delivery pack accessible 7. Maintain *quiet environment with lights dimmed* 8. Therapeutic Magnesium Sulfate level - 4 to 7 mg/dl 9. *NEVER Abbreviate Magnesium Sulfate as MgSO4*

Babinski's (plantar) reflex

On sole of foot, beginning at heel, stroke upward along lateral aspect of sole, then move finger across ball of foot. *All toes hyperextend, with dorsiflexion of big toe—recorded as a positive sign* Absence requires neurologic evaluation; *should disappear after 1 year of age*

Who should be included in preconception counseling & why?

Partner should be included 1. Assess their understanding of the effects of pregnancy on diabetes mellitus and potential complications 2. Educate on the need for a multidisciplinary approach (perinatologist, nutritionist, ophthamologist) 3. Discuss financial implications related to frequent maternal & fetal surveillance (cost of missed work, possible bedrest) 4. Review contraception to plan ideal time for pregnancy (need for strict metabolic control) 5. Educate on the possible need of changing medication prior to pregnancy -*oral hypoglycemic agents are contraindicated during pregnancy, however, glyburide is being used experimentally. Metformin also being used*. -*need to be taking folic acid 0.4mg/ day (4mg a day if previous birth with a neural tube defect [NTD])* to decrease the risk of NTD.

In a newborn, the urinary system is structurally complete but is:

Physiologically immature 1. *unable to concentrate* urine 2. *water losses are greater* -Loss of fluid through urine, feces, lungs, increased metabolic rate, and limited fluid intake result in 5-10% of birth weight 3. water requirements per kilogram of body weight are greater (125 -150 mL/KG per day will produce 100 mL of urine per 24 hours) 4. *decreased ability to remove waste* products from the blood (GFR 30% compared to 50%) 5. decreased ability to handle high osmolarity 6. 40% of body weight is extracellular (adult = 20%) 7. *bladder capacity is ~30 mL -- May not void for 12 - 24 hours.* -It is important to note and record first voiding -*If not voided by 24 hours, should be assessed* for adequacy of fluid intake, bladder distention, restlessness, and symptoms of pain

Grasp plantar reflex

Place fingers at base of toes Toes curl downward Plantar response *lessens by 8 months*

Grasp palmar reflex

Place fingers in palm of hand Infant's fingers curl around examiner's fingers Palmer response *lessens by 3-4 months;* parents enjoy this contact with infants

Trunchal incurvation (galant) reflex

Place infant prone on flat surface; run fingers down back about 4-5 cm lateral to spine; first on one side and then down the other *Trunk is flexed, and pelvis is swung toward stimulated side* Response *disappears by 4th week.* Response varies but should be *obtainable in all infants, including preterm.* -Absence suggests *general depression of nervous system*

In _______________ the placenta is implanted in the lower uterine segment

Placenta previa -the placenta *completely or partially covers the cervix* or is close enough to the cervix *to cause bleeding when the cervix dilates or the lower uterine segment effaces* -If placenta previa occurs early in pregnancy, there is a *chance that as the uterus grows the placenta will migrate up* thus resolving the placenta previa. -*The placenta NEVER migrates down*

The complications most frequently associated with hydramnios are:

Placental abruption, uterine dysfunction, & postpartum hemorrhage PPROM as a result of hydramnios leading to premature labor

At birth, expulsion of placenta prompts an abrupt drop in levels of circulating:

Placental hormones, cortisol, and insulinase Maternal tissues quickly regain prepregnancy sensitivity to insulin *Nonbreastfeeding: insulin-carb balance usually returns in 7-10 days* *Lactation uses maternal glucose* so breastfeeding mom's *insulin requirements remain LOWER DURING LACTATION* (prepregnancy requirement reestablished after weaning)

DIC is an overactivation of the clotting cascade and the fibrinolytic system, resulting in depletion of:

Platelets and clotting factors, which causes the formation of fibrin clots -*blood cells are destroyed as they pass through these fibrin choked vessels* -thus, *DIC results in clotting, bleeding, & ischemia*

What effect does poor metabolic control have on lactogenesis?

Poor metabolic control may DELAY lactogenesis & contribute to decreased milk production

The main pathogenic factor of preeclampsia is not an increase in BP but:

Poor perfusion as a result of vasospasm and reduced plasma volume

All women who give birth are at risk for:

Postpartum hemorrhage (PPH) -*defined as loss of 500 ml or more after vaginal birth & 1000 ml or more after cesarean birth* Bleeding is controlled by the contraction of smooth muscle in the uterus. *If the uterus is flaccid after detachment of the placenta, brisk venous bleeding occurs, & normal coagulation of the open vasculature is impaired & continues until the uterine muscle is contracted.* This marked hypotonia of the uterus is called uterine atony *The most frequent cause of hemorrhage is uterine atony*

__________________ is a pregnancy-specific condition that occurs after 20 weeks of gestation or early postpartum and is determined by *hypertension and proteinuria in a woman who previously had neither condition*.

Preeclampsia -ranges from mild to severe & then may progress into HELLP syndrome or eclampsia -*occurs prior to 20 weeks in the case of trophoblastic disease (hydatidiform mole)*

8 problems that can affect the respiratory system of preterm infants

Preterm infants are likely to have *difficulty making pulmonary transition from intrauterine to extrauterine life* 1. Decreased number of functional alveoli 2. Deficient surfactant levels 3. Smaller lumen in the respiratory system 4. Greater collapsibility or obstruction of respiratory passages 5. Insufficient calcification of the bony thorax 6. Weak or absent gag reflex 7. Immature and friable capillaries in the lungs 8. Greater distance between functional alveoli and the capillary beds

Episiotomy assessment - REEDA

R-redness E-edema E-ecchymosis D-drainage A-approximation

Fetal attitude - flexion vs. extension (4)

Relationship of the *fetal body parts to each other - posture* 1. vertex: chin tucked to chest 2. military: moderate extension 3. brow: chin up (to large to enter pelvis) 4. face: looking up as far as it can; *fully extended* *Deviations can cause difficulties in maneuvering the maternal pelvis - prolonged labor, forceps or vacuum-assisted birth, c-section*

Fetal lie (3)

Relationship of the *long axis (spine) of the fetus to the long axis of the mother* 2 primary: 1. longitudinal (parallel axes) 2. transverse (perpendicular axes) -*vaginal birth cannot occur when the fetus is in transverse lie* Rare: 3. oblique (usually converts to longitudinal or transverse during labor)

Because magnesium sulfate depresses the function of the CNS, it is essential that the nurse frequently assesses the woman's:

Respiratory status, DTR, & LOC to identify signs that the serum level of magnesium sulfate is reaching toxic levels

Administration of RhoGAM

Rhogam is a preparation of passive antibodies that *bind with fetal RBC antigens* causing the cells to phagocytose *before the woman's immune system is activated to produce antibodies.* Administered at *28 weeks and within 72 hours of birth* 1 vial (300 ug) is usually sufficient -- handles 15 mL of fetal blood in maternal circulation. If large fetomaternal transfusion is suspected, *perform a Kleihauer-Betke (KB) test to detect the amount of fetal blood in maternal circulation and adjust the Rhogam dose* accordingly. *Treat Rhogam as a blood product* -- identification, lot number, expiration date, religious beliefs.

Diuresis aids the body in what?

Ridding itself of excess fluid *Urine output of 3000 ml or more each day during the first 2-3 days is common* *Profuse diaphoresis occurs, especially at night, for the first 2-3 days after birth* -causes increased odor -postpartum chills can also occur; shaking chill due to vasomotor instability *Fluid loss through perspiration & increased urinary output accounts for a weight loss of approximately 2.25 kg (5 lb) during early puerperium*

4 stages of labor

Stage 1: Labor -from start of regular contractions or ROM to 10 cm dilated, 100% effacement -*longer than 2nd & 3rd stage combined* Stage 2: Baby -from 10 cm dilated to delivery of the baby -pushing stage: normal up to 2 hrs -primipara 50-60 min; multipara 20-30 min -prolonged 2nd stage not related to adverse outcome as long as there is progress & fetal status is reassuring Stage 3: Placenta -from delivery of baby to delivery of placenta -placenta separates in 3-4 ctxs, delivered on 5th ctx -duration: short as 3-5 min; up to 1 hr is normal -*risk of hemorrhage increases with length of 3rd stage* Stage 4: Recovery -period of immediate recovery -2 hrs after delivery of placenta (arbitrary timing) -*homeostasis reestablished* -observation period for complications

_______________ is the failure of the uterus to return to nonpregnant state

Sub-involution The most common causes of sub-involution are *retained placental fragments & infection*

Prolapse of the umbilical cord occurs when:

The cord lies below the presenting part of the fetus Cord prolapse may be occult (hidden, rather than visible) at any time during labor whether or not the membranes are ruptured Pressure on the cord may be relieved by the examiner putting a sterile gloved hand into the vagina & holding the presenting part off the umbilical cord The woman may also be assisted into a position such as modified sims, Trendelenburg, or knee-chest position, in which gravity keeps the pressure of presenting part off the cord

In response to cold the neonate attempts to generate heat, or ___________, by:

Thermogenesis; *increasing muscle activity* -cold infants *may cry & appear restless* -bc of vasoconstriction the skin can feel cool to touch & acrocyanosis (blue color of hands & feet) can be present -there is an *increase in cellular metabolic activity, primarily in the brain, heart, & liver; this also increases O2 & glucose consumption --> hypoglycemia*

__________ is the ability to maintain balance between heat loss & heat production

Thermoregulation -newborns & adults are homiotherms: can maintain a constant core body temperature regardless of environmental temperature. -Newborns have a *much narrower range to which they can adapt without being stressed* than adults. -newborns attempt to stabilize their core body temps *within a normal range of 97.7 to 98.9* Hypothermia from excessive heat loss is a common & dangerous problem

Normally in pregnancy the spiral arteries in the uterus widen to:

Thinner, saclike vessels with much larger diameters. This change *increases the capacity of the vessels, allowing them to handle the increased blood volume* (40%) during pregnancy

A molar pregnancy is diagnosed by:

Transvaginal ultrasound & serum hCG 1. Transvaginal ultrasound is the most accurate tool -A characteristic *pattern of multiple diffuse intrauterine masses*, often called snowstorm pattern, is *seen in place of, or along with, an embryo or a fetus* 2. hCG levels are *persistently high or rising beyond 10-12 weeks of gestation*, the time they would begin to decline in a normal pregnancy

DM classification

Type 1: caused by *pancreatic islet beta cell destruction and prone to ketoacidosis* -usually *abrupt onset at young age and absolute insulin deficiency* Type 2: *insulin resistance and usually relative insulin deficiency* -risk factors: obese, aging, sedentary lifestyle, family history and genetics, puberty, HTN, prior gestational diabetes GDM: diabetes *diagnosed during pregnancy* that is clearly not overt (preexisting) diabetes

Nutritional factors affecting pregnancy outcomes

Underweight - at risk for: 1. Preterm labor 2. Low Birth Weight (LBW) 3. Intrauterine Growth Restriction (IUGR) Overweight - at risk for: 1. Macrosomia & Cephalopelvic Disproportion (CPD) 2. Operative Vaginal Birth & Emergency Cesarean Section 3. Postpartum Hemorrhage 4. Infection (wound, genital tract, urinary tract) 5. Birth Trauma 6. Late Fetal Death 7. Preeclampsia 8. Gestational Diabetes

Forceps birth

When an instrument with two curved blades is used to assist in the birth of the fetal head. Indications for use include a *prolonged second stage of labor and the need to shorten the second stage of labor due to maternal and fetal complications.* Nursing care: 1. obtain the type of forceps for the MD, the nurse may explain to the mother that the forceps will fit the same way two tablespoons fit around an egg. 2. After birth the nurse should assess the woman for *vaginal or cervical lacerations, urinary retention, and hematoma* formation in the pelvis soft tissues, which may result from blood vessel damage. 3. The infant should be assessed for *bruising or abrasions at the site of blade application, facial palsy.* 4. Newborn and postpartum caregivers should be told that a forceps delivery was performed

The nurse caring for a patient in the active stage of labor notes the fetal heart tone baseline is fluctuating between 1-5 beats for a 20 minute period. The nurse knows that this could be caused by the: (Select all that apply). a. patient's use of cocaine prior to admission b. application of an internal scalp electrode c. administration of 1mg Stadol IV d. fetus being in a state of sleep

c. administration of 1mg Stadol IV d. fetus being in a state of sleep

The ______ system is the first organ system to function in the developing human

cardiovascular