OB final

Naegle's rule

- After the diagnosis of pregnancy, the woman's first question is usually when she will give birth. The estimated date of birth (EDB) is determined based on the date of the woman's last normal menstrual period (LMP) and the first accurate ultrasound examination. Accurate dating of pregnancy is vital to promoting a healthy outcome for the woman and fetus. The EDB is important for planning prenatal care, scheduling specific prenatal screening tests, assessing fetal growth, and making critical decisions for managing complications of pregnancy. - The Naegele rule is a common method for calculating the EDB. It is based on the woman's accurate recall of her LMP. It assumes that the woman has a 28-day cycle and that fertilization occurred on the 14th day - Only about 5% of women give birth spontaneously on the EDB as determined by the Naegele rule; most births occur 7 days before to 7 days after the EDB.

Fetal position

relationship of a presenting part (part that comes into the pelvis 1st) to the 4 quadrants of pelvis 3 parts: 1. location of presenting part in R or L side of pelvis 2. specific presenting part of the fetus (O= occiput, S= sacrum, M= mentum/ chin, Sc= scapula/ shoulder): --O: after feeling for fontanels (if can't confirm--> US) --S: breech 3. location of presenting part R/T anterior (A), posterior (P), or transverse (T) portion of pelvis

Alterations in Cyclic Bleeding

1. infrequent menstruation (40-45 days or longer): oligomenorrhea --causes: ---abnormalities of hypothalamic, pituitary, or ovarian function ---physiologic ---part of normal pattern for 1st few yrs. after menarche or for several yrs. before menopause 2. scanty at normal intervals: hypomenorrhea --causes: structural abnormalities of endometrium--> partial disintegration of endometrium (e.g., Asherman syndrome (adhesions from curettage or infection obliterate endometrial cavity), congenital partial obstruction of vagina) 3. excessive: menorrhagia 4. menstruation occurs between periods: metrorrhagia - Metrorrhagia, or intermenstrual bleeding, refers to any episode of bleeding—whether spotting, menses, or hemorrhage—that occurs at a time other than the normal menses. In mittelstaining, also referred to as mittelschmerz, a small amount of bleeding or spotting occurs at the time of ovulation (14 days before onset of the next menses); this is considered normal. The cause of mittelstaining is not known; however, its common occurrence can be documented by its repetition in the menstrual cycle. - Menorrhagia (hypermenorrhea) is defined as excessive menstrual bleeding, in either duration or amount. The causes of heavy menstrual bleeding are many, including hormonal disturbances, systemic disease, benign and malignant neoplasms, infection, and contraception (IUDs). A single episode of heavy bleeding may occur, or a woman may have regular flooding as a pattern in which she changes tampons or pads every few hours for several days. Hgb and Htc are objective indicators of actual blood loss and should always be assessed

Fetal attitude, figure 16.5

A. suboccipitobregmatic diameter: complete flexion of head on chest so that smallest diameter enters B. occipitofrontal diameter: moderate extension (military attitude) so that large diameter enters C. occipitomental diameter: marked extension (deflection)--> largest diameter (too large to permit head to enter pelvis) is presenting

Categorizing fetal heart tracings, box 18.1

Category I: best/ normal strip -baseline rate 110-160 bpm -baseline FHR variability: mod. -late or variable decels: absent -early decels: present or absent -accelerations: present or absent Category II: everything inb/w -baseline rate: bradycardia not accompanied by absent baseline variability or tachycardia -baseline FHR variability: minimal, absent not accompanied by recurrent decels, or marked -accelerations: none -decels: periodic or episodic, recurrent variable decels + minimal or mod. variability, prolonged (≥2 mins but <10 mins.), recurrent late decels + mod. variability, variable decels + other characteristics (e.g., slow return to baseline, "overshoots," or "shoulders") Category III: Worst -absent baseline variability + recurrent late or variable decels, bradycardia, or sinusoidal pattern

Assessment of amniotic membranes and fluid

During the triage process, the nurse must determine the status of the woman's amniotic membranes. If the woman has noticed a gush or leakage of fluid, the membranes may have ruptured (spontaneous rupture of membranes [SROM] → happens in 25% of preg women). If there has been a discharge that may be amniotic fluid, in many instances a sterile speculum examination and Nitrazine (pH) and fern tests can determine whether the membranes have ruptured Membrane rupture can also occur at any time during labor but most commonly in the active phase of the first stage of labor. If the membranes do not rupture spontaneously, artificial rupture of membranes (AROM), called an amniotomy, may be attempted by the physician or nurse-midwife using a plastic AmniHook or a surgical clamp during labor. However, this practice is discouraged if there is no medical reason for it because it can increase the laboring woman's sensation of pressure and pain and is not necessary for a normal birth to occur. Whether the membranes rupture spontaneously or artificially, the time of rupture should be recorded. Other necessary documentation includes information regarding the FHR immediately before and after rupture, the color (clear or meconium-stained), estimated amount, and odor of the fluid.

Gestational Diabetes testing and nursing care

Early pregnancy testing - All pregnant women not known to have pregestational diabetes should be screened for GDM by history, clinical risk factors, and laboratory screening of blood glucose levels - Although most women are screened for GDM between 24-28 wks. gestation, those with strong risk factors should be screened earlier in pregnancy. Increasing rates of obesity and diabetes have resulted in more women of childbearing age with type 2 diabetes, many of whom are undiagnosed when they become pregnant. Both the ADA and ACOG recommend that women with high-risk factors for type 2 diabetes (i.e., severe obesity, a strong family history of type 2 diabetes, and a history of GDM in a previous pregnancy) be tested for preexisting diabetes at their initial prenatal visit by one of the methods used to diagnose diabetes in the nonpregnant population - Screening early in pregnancy diagnoses women with preexisting diabetes so that appropriate treatment and postpartum follow-up are possible. If early screening indicates that these women do not have preexisting diabetes, they should be rescreened at 24-28 wks. gestation for GDM Screening at 24-28 wks. Gestation - 2 diff. blood glucose screening methods for GDM are used in the United States. ACOG recommends the two-step screening method that has been used for many years. The first step is a screen consisting of a 50-g. PO glucose--> plasma glucose measurement 1 hr. later. The woman need not be fasting when the screen is done - A glucose value of 130-140 mg./dL, or higher, is considered a positive screen. An initial positive screening result is followed by step 2, a 3-hrs. (100-g.) PO glucose tolerance test (OGTT) on another day. ACOG recommends use of the 2-step screening procedure because there is no evidence that the one-step method leads to clinically significant improvement in

Indicators of effective breastfeeding

One of the most common concerns of breastfeeding mothers is how to determine if the baby is getting enough milk. In the newborn period, when breastfeeding is becoming established, parents should be taught about the signs that breastfeeding is going well. Awareness of these signs helps them recognize when problems arise so they can seek appropriate assistance During the early days of breastfeeding, keeping a feeding diary can be helpful. This involves recording the time and length of feedings and infant urine output and bowel movements. The data from the diary provide evidence of the effectiveness of breastfeeding and are useful to health care providers in assessing adequacy of feeding. Parents are instructed to take this feeding diary to the follow-up visit with the infant's health care provider. There are smartphone apps that parents can use to track infant feedings and urine/stool output. The infant's output is highly indicative of feeding adequacy. It is important that parents are aware of the expected changes in the characteristics of urine output and bowel movements during the early newborn period. As the volume of breast milk increases, urine becomes more dilute and should be light yellow; dark, concentrated urine can be associated with inadequate intake and possible dehydration. (Note: Infants with jaundice often have darker urine as bilirubin is excreted.) Infants should have at least six to eight sufficiently wet diapers (light yellow urine) every 24 hours after day 4. The first 1 to 2 days after birth, newborns pass meconium stools, which are greenish black, thick, and sticky. By day 2 or 3, the stools become greener, thinner, and less sticky. If the mother's milk has transitioned by day 3 or 4, the stools start to appear greenish yellow and are looser. By the end of the first week, breast milk stools a

Lochia

The characteristics of postbirth uterine discharge, known as lochia, correlate with uterine involution and changes in the endometrium. Most women experience lochia for 4 to 6 weeks after birth. For the 1st 2 hrs. after birth, the amount of uterine discharge should be about that of a heavy menstrual period. After that time, the lochial flow will steadily decrease in amount and the characteristic appearance of the lochia will change If the woman receives an oxytocic medication, regardless of the route of administration, the flow of lochia is often scant until the effects of the medication wear off. The amount of lochia is usually less after a cesarean birth because the surgeon suctions the blood and fluids from the uterus or wipes the uterine lining before closing the incision. Flow of lochia usually increases with ambulation and breastfeeding. Lochia tends to pool in the vagina when the woman is lying in bed; the woman then can experience a gush of blood when she stands. This gush should not be confused with hemorrhage. Persistence of lochia rubra in the postpartum period suggests continued bleeding as a result of retained fragments of the placenta or membranes. It is not uncommon for women to experience a sudden, but brief, increase in bleeding 7-14 days after birth when sloughing of eschar over the placental site occurs. If this increase in bleeding does not subside within 1 to 2 hours, the woman needs to be evaluated for possible retained placental fragments About 10%-15% of women still have normal lochia serosa discharge at their 6-wk. postpartum examination. However, the continued flow of lochia serosa or lochia alba by 3-4 wks. after birth can indicate endometritis, particularly if the woman has fever, pain, or abdominal tenderness. Lochia should smell like normal menstrual flow; an offensive odor usually indicate

Initiating breastfeeding

The mother needs to understand infant behaviors in relation to breastfeeding and recognize signs that the baby is ready to feed. Infants exhibit feeding-readiness cues or early signs of hunger. Instead of waiting to feed until the infant is crying in a distraught manner or withdrawing into sleep, the mother should attempt to breastfeed when the baby exhibits feeding cues: -Sucking or mouthing motions • Hand-to-mouth or hand-to-hand movements • Rooting reflex—infant moves toward whatever touches the area around the mouth and attempts to suck Babies normally consume small amounts of milk with feedings during the first 3 days of life. As the baby adjusts to extrauterine life and the digestive tract is cleared of meconium, milk intake increases from 5 to 15 mL per feeding in the first 24 hours to 60 to 90 mL by the end of the first week In the postpartum period, interventions focus on helping the mother and the newborn initiate successful breastfeeding. An important goal is to build maternal confidence in breastfeeding. Interventions to promote successful breastfeeding include educating and assisting mothers and their partners with basics such as latch and positioning, signs of adequate feeding, and self-care measures such as prevention of engorgement. It is important to provide the parents with a list of resources that they can contact after discharge from the birthing facility. The ideal time to begin breastfeeding is within the first hour after birth. Newborns without complications should be allowed to remain in direct skin-to-skin contact with the mother until the baby is able to breastfeed for the first time. This is true both for mothers who gave birth by cesarean and for those who gave birth vaginally. Routine procedures such as vitamin K injection, eye prophylaxis, weighing, and bathing should be delayed unti

Nonstress test and interpretation

The nonstress test (NST) is the most widely applied technique for antepartum evaluation of the fetus. The basis for the NST is that the normal fetus produces characteristic heart rate patterns in response to fetal movement, uterine contractions, or stimulation. In the term fetus, accelerations are associated with movement more than 85% of the time. The most common reason for the absence of FHR accelerations is the quiet fetal sleep state. However, CNS depressant medications, chronic smoking, and the presence of fetal malformations can also adversely affect the test results. The NST can be performed easily and quickly in an outpatient setting because it is noninvasive, easy to perform and interpret, relatively inexpensive, and has no known contraindications. Disadvantages include the requirement for twice-weekly testing, a high false-positive rate, and a higher false-negative rate than is achieved with most other methods. The test also is slightly less sensitive in detecting fetal compromise than the CST or the BPP Procedure The woman is seated in a reclining chair (or in the semi-Fowler position) with a slight lateral tilt to optimize uterine perfusion and prevent supine hypotension. The FHR is recorded with a Doppler transducer, and a tocodynamometer is applied to detect uterine contractions or fetal movements. The tracing is observed for signs of fetal activity and a concurrent acceleration of FHR. If evidence of fetal movement is not apparent on the tracing, the woman may be asked to depress a button on a handheld event marker connected to the monitor when she feels fetal movement. The movement is then noted on the tracing. Because almost all accelerations are accompanied by fetal movement, the movements need not be recorded for the test to be considered reactive. The test is usually completed within 20 to 30 minute

Dysmenorrhea (risk factors, s/s, types)

risk factors: -1st 3 yrs. after menarche -17-24 y/o -severe: early menarche, nulliparity, and lack of physical exercise -smoking -obese s/s: -pain during or shortly before menstruation usually located in suprapubic area or lower abs.: sharp, cramping, gripping, or a steady dull ache that may radiate to the lower back or upper thighs (2ary) types: 1. primary: associated with the ovulatory cycle (usually 6-24 mths. after menarche) since both estrogen and progesterone are necessary to occur 2. 2ary: develops later in life (typically after 25 y/o) due to pelvic pathology (e.g., adenomyosis, endometriosis, PID, endometrial polyps, or submucous or interstitial myomas (fibroids)) --often have other s/s that may suggest underlying cause

Vaginal exam

The vaginal examination reveals whether the woman is in true labor and enables the examiner to determine whether the membranes have ruptured. Because this examination is often stressful and uncomfortable for the woman and may introduce microorganisms into the vagina if the membranes are ruptured, it is performed only when indicated by the status of the woman and her fetus. For example, a vaginal examination is performed on admission, prior to administering medications (e.g., analgesics, oxytocin infusion), when significant change has occurred in uterine activity, on maternal request or perception of perineal pressure or the urge to bear down, when membranes rupture, or when variable decelerations of the FHR are noted. A full explanation of the examination and support of the woman are important in reducing the stress and discomfort associated with the examination

Box 18.5 Late Decelerations

abnormal pattern Causes: disruption of O2 transfer from environment to fetus -uterine tachysystole -maternal supine hypotension -epidural or spinal anesthesia -placenta previa or abruption -HTN disorders -postterm -IUGR -DM -chorioamnionitis Periodic Episodic Interventions: 1. D/C oxytocin if infusing 2. lateral (side-lying) position 3. admin. O2 @ 10 L/ min. via nonrebreather 4. correct maternal hypotension by elevating legs 5. increase maintenance IV rate 6. palpate uterus to assess for tachysystole 7. notify HCP 8. consider internal monitoring for more accurate fetal and uterine assessment 9. assist with birth (vaginal-assisted or c-section) if unTx complications: -fetal hypoxemia -acidemia -low Apgar

Medication guide: Oxytocin (Pitocin)

action: hormone produced in the posterior pituitary gland that stimulates uterine contractions and aids in milk ejection (let-down) (Pitocin is a synthetic form of this hormone) indications: primarily for labor induction and augmentation; it is also used to control postpartum bleeding. dose: • The IV solution containing oxytocin should be mixed in a standard concentration. Concentrations often used are 10 U in 1000 mL of fluid, 20 U in 1000 mL of fluid, or 30 U in 500 mL of fluid.• Oxytocin is administered intravenously through a secondary line connected to the main line at the proximal port (connection closest to the IV insertion site). Oxytocin is always administered by an infusion pump. • Begin oxytocin administration at 1 milliunit/min. Increase the rate by 1-2 mu./min., no more frequently than every 30-60 mins. based on the response of the woman and fetus and the progress of labor. • The goal of oxytocin administration is to produce acceptable uterine contractions as evidenced by: • Consistent achievement of 200-220 MVUs or • A consistent pattern of one contraction every 2-3 mins., lasting 80-90 secs., and strong to palpation adverse: -uterine tachysystole, placental abruption, uterine rupture, unplanned cesarean birth caused by abnormal FHR and pattern, postpartum hemorrhage, infection, and death from H2O intoxication (e.g., severe hyponatremia). • Possible fetal adverse effects include hypoxemia and acidosis, eventually resulting in abnormal FHR and pattern. Nursing Considerations • Client and partner teaching and support: • Reasons for use of oxytocin (e.g., start or improve labor) • Reactions to expect concerning the nature of contractions: the intensity of the contraction increases more rapidly, holds the peak longer, and ends more quickly; contractions come regularly and more often Mon

probable Signs of Pregnancy

objective: changes observed/ perceived by an examiner (e.g., positive pregnancy test, Hegar sign, Chadwick sign), strongly suggest pregnancy

positive Signs of Pregnancy

objective: changes observed/ perceived by examiner (e.g., fetal heart tones, US), indicate proof of pregnancy

presumptive Signs of Pregnancy

subjective: changes experienced by the woman (e.g., fatigue, breast changes, quickening); these suggest the possibility of pregnancy but can also be caused by conditions other than pregnancy

why might a pt. with placental abruption not have vaginal bleeding?

the bleeding behind the placenta might be concealed

GTPAL, GP

- 2 digit system: GP (counts pregnancies reaching viability) - Gravidity- # of pregnancies the woman has had including the present one - null gravidity=never pregnant - primigravidity= 1 pregnancy - multigravidity= 2 or more pregnancies - Parity- # or pregnancies that have reached 20 weeks of gestation (viability). Not = the # of fetus(es) born (ex: twins). Includes live or stillborn. Examples: G1P1; G1P0 (woman is pregnant for the first time (primigravida) has not carried a pregnancy to 20 weeks (P0-nullipara), G4P0; G6P5 - 5 digit system: GTPAL - G- gravidity (# of pregnancies woman has had including the present one)- twins and triplets still count as one - T- term pregnancies (full term- 37 weeks >) - Pre-term (36 weeks and 6 days is still considered pre-term, 20-36.6 weeks) - Abortions/miscarriages (6 weeks to 19.5 weeks) - Living children

Assessment of uterine contractions

- A general characteristic of effective labor is regular uterine activity (i.e., contractions becoming more frequent with increased duration and intensity), but uterine activity is not directly related to labor progress. Uterine contractions represent the primary force that acts involuntarily to expel the fetus and placenta from the uterus. Several methods can be used to evaluate uterine contractions, including the woman's subjective description, palpation and timing of contractions by the nurse or another health care professional, and electronic monitoring. - Each contraction exhibits a wave-like pattern. It begins with a slow increment (the increasing intensity of a contraction from its onset), gradually reaches a peak, and then diminishes rapidly (decrement, the decreasing intensity of the contraction). An interval of rest ends when the next contraction begins. A uterine contraction is described in terms of the following characteristics: • Frequency: How often uterine contractions occur; the time that passes from the beginning of one contraction to the beginning of the next contraction • Intensity: The strength of a contraction at its peak • Duration: The time that passes between the onset and the end of a contraction • Resting tone: The tension in the uterine muscle between contractions; relaxation of the uterus Uterine contractions are assessed by palpation or by using external or internal electronic monitors. Frequency and duration can be measured by all three methods of uterine activity monitoring. The accuracy of determining intensity and resting tone varies by the method used. The woman's description and examiner's palpation are more subjective and less precise ways of determining the intensity of uterine contractions and resting tone than are the external or internal electronic monitors. The following

Post Op care for breast cancer surgery

- After recovery from anesthesia, the woman is returned to her room. Special precautions must be observed to prevent or to minimize lymphedema of the affected arm. - The affected arm is elevated with pillows above the level of the right atrium. Blood is not drawn from this arm, and this arm is not used for IV therapy or any injections. Early arm movement is encouraged. Any increase in the circumference of that arm is reported immediately. - Nursing care of the wound involves observing for signs of hemorrhage: (dressing, drainage tubes, drainage reservoirs), shock, and infection. Dressings are reinforced as necessary and drainage reservoirs (e.g., Hemovac, Jackson-Pratt) are emptied at least every 8 hrs. The woman is asked to turn (alternating between unaffected side and back), cough (while the nurse or the woman applies support to the chest), and deep breathe every 2 hrs. Breath sounds are auscultated every 4 hours. Active range-of-motion (ROM) exercise of legs is encouraged. Parenteral fluids are given until adequate oral intake is possible. Emotional support is continued. - Care given during the immediate postoperative period is continued as necessary. Most women who undergo lumpectomy have surgery in outpatient facilities and return home a few hours after surgery. Women are discharged 24 hours or less after mastectomy without reconstruction. Women having a mastectomy with tissue expander placement will be in the hospital for 24 hours. Those having flap reconstruction at the same time will be hospitalized for 3 to 5 days. Because of the generally short time spent in the hospital, thorough teaching is important. It is best to do as much teaching as possible before surgery if the outcome is known. If this is not possible, discharge teaching should be done with the woman's caregiver present. This is to acknowledgethe po

Nursing care for preeclampsia

- Assess edema - Auscultate lungs, monitor HR and RR, assess for SOB, chest tightness/discomfort, cough, O2 Sat <95%, apprehension, anxiety - RUQ pain/epigastric pain. Do not palpate liver - Presence of proteinuria - Assess for severe features and CNS changes, headache, visual disturbances, DTRs and clonus - Labs: elevated creatinine >1.1 mg/dl, HCT >35% with preeclampsia, platelets <100,000, elevated liver enzymes 2x upper limits - Fetal evaluations: daily kick counts, NST/BPP once or twice weekly, fetal growth evaluation, doppler studies elevated S/D ratio <3.4. Assess if disease progression necessitates hospitalization. Deliver if severe - I&O, restrict fluids to 2,000 ml/24 hr - Quiet environment, keep client informed of disease process and plan of care, report maternal/fetal deterioration Interventions - Diet with increased protein, calcium, folic acid, zinc, sodium, adequate fluid intake 6-8 glasses of water - Activity restrictions - With severe features as managed inpatient - Magnesium sulfate (CNS depressant) is given for seizure prophylaxis. More effective than anticonvulsants - Administer antihypertensive as ordered for BP >160/110 - Goals: to promote safety, assess degree of maternal and fetal risk, delivery plans, prevent complications, control BP, prevent seizures and cerebral hemorrhage - Magnesium sulfate loading dose 4-6 g in 100 ml solution over 15-20 min, maintenance 40 g in 1 liter RL 2-3 g/hr (1 g=25 ml). If no IV access, can be given IM 10 g loading dose 2 separate injections, maintenance 5g q4h alternating buttocks, unpredictable absorption rates. - Therapeutic range 5-7 mg/dl - Monitor BP, RR, report if > or equal to 160/110, <12 breaths/min - Monitor FHR and contractions, report abnormal changes - Monitor urine output, report 25-30 ml/hr - Monitor I&O hourly. Report oliguria <30 ml/hr for more t

Preterm labor Self-care management

- Bedrest, hydration, and limited work are often recommended to reduce the risk for preterm birth in women at risk for giving birth prematurely. There is no evidence, however, to support the effectiveness of these interventions, and they should not be routinely recommended. - Both bed rest and excessive hydration can cause potentially harmful maternal complications. Research indicates that bed rest causes adverse physical effects, including risk for thrombus formation, muscle atrophy, bone loss, cardiovascular deconditioning, and endocrine system changes Teaching: -s/s preterm labor -What to Do If s/s of Preterm Labor Occur: stop any activity, • Lie down on your side. • Drink 2-3 glasses H2O or juice • Wait 1 hr. • If s/s get worse, call HCP or go to birthing facility • If s/s go away, tell HCP what happened at next prenatal visit • If symptoms come back, call your healthcare provider. Restriction of sexual activity, sometimes referred to as pelvic rest, is frequently recommended for women at risk for preterm birth. Evidence is lacking that this is an effective intervention for preventing preterm birth - The woman's environment can be modified for convenience by using tables and storage units around her bed or daytime resting place to keep essential items within reach (e.g., cell or smartphone, television, radio, MP3 player, CD player, computer with Internet access, snacks, books, magazines, newspapers, and items for hobbies) - Ensuring that the bed or couch is near a window and the bathroom is also helpful. Covering the bed with an egg crate mattress can relieve discomfort. Women often find that a daily schedule of smaller, more frequent meals, activities (e.g., paying bills, planning and helping with meal preparation, hobbies), limited naps, and hygiene and grooming (e.g., shower, dressing in street c

Gestational Diabetes nursing care

- Client probs. and expected outcomes of care for women with GDM are basically the same as those for women with pregestational diabetes. However, the time frame for planning may be shortened with GDM because the Dx is made later in pregnancy - When the Dx of GDM is made, treatment begins immediately, allowing little or no time for the woman and her family to adjust to the diagnosis before they are expected to participate in the treatment plan. With each step of the treatment plan, the nurse and other health care providers educate the woman and her family, providing detailed and comprehensive explanations to ensure understanding, participation, and adherence to the necessary interventions. Potential complications are discussed and the need for maintaining euglycemia throughout the remainder of the pregnancy reinforced. Knowing that GDM typically disappears when the pregnancy is over may be reassuring for the woman and her family - As with pregestational diabetes, the aim of therapy in women with GDM is strict blood glucose control. Fasting blood glucose levels less than 95 mg./dL, 1-hr. post meal blood glucose levels less than 140 mg./dL, and 2-hrs. post meal glucose levels less than 120 mg./dL are recommended - These levels are very similar to but not exactly the same as those recommended for women with preexisting diabetes - Dietary modification is the mainstay of treatment for GDM. The woman with GDM is placed on a standard diabetic diet. The usual prescription is 2000 2500 kcal./day, which represents approximately 35 kcal./kg./day of present pregnancy weight. For overweight or obese women, a reduction to 25 kcal/kg/day and 15 kcal/kg/day (present pregnancy weight), respectively, may be advised. The usual carbohydrate intake is restricted to approximately 50% to 60% of caloric intake. However, some authorities believ

Urinary system renal function

- In normal pregnancy renal function is altered considerably. Renal plasma flow (RPF) rises significantly from early in pregnancy, peaking by the end of the first trimester. RPF remains elevated above nonpregnant levels throughout pregnancy, although it begins to decrease after 34 wks. of gestation. The glomerular filtration rate (GFR) increases by 50% during the 1st trimester and remains elevated throughout pregnancy. These changes are caused by pregnancy hormones; an increase in blood volume; and the woman's posture, physical activity, and nutritional intake. The woman's kidneys must manage the increased metabolic and circulatory demands of the maternal body, as well as the excretion of fetal waste products. The increase in GFR results in increased creatinine clearance and a reduction in serum creat., blood urea nitrogen (BUN), and uric acid levels. - Renal function is most efficient when the woman lies in the lateral recumbent position and least efficient when the woman assumes a supine position. A side-lying position increases renal perfusion, which increases urine output and decreases edema. When the pregnant woman is lying supine, the heavy uterus compresses the vena cava and the aorta and CO decreases. As a result, blood flow to the brain and heart is continued at the expense of other organs, including the kidneys and uterus

Changes R/T the fetus

- Passive movement of the unengaged fetus is called ballottement and can be identified by the examiner generally between the 16th and 18th weeks. Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. To palpate the fetus, the examiner places a finger within the vagina and taps gently upward on the cervix, causing the fetus to rise. The fetus then sinks, and a gentle tap is felt on the finger - Quickening is the first recognition of fetal movements, or "feeling life." It can be detected by the multiparous woman as early as 14 to 16 weeks of gestation. The nulliparous woman may not notice these sensations until the 18th week or later. Quickening is commonly described as a flutter and is difficult to distinguish from peristalsis. Fetal movements gradually increase in intensity and frequency as pregnancy progresses. The week in which quickening occurs provides a tentative clue in dating the duration of gestation.

Second stage of labor

- The second stage of labor is the stage at which the infant is born. It begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth - The force exerted by uterine contractions, gravity, and maternal bearing-down efforts facilitates the achievement of a spontaneous, uncomplicated vaginal birth. The length of second-stage labor varies considerably among women and is affected by parity and the use of epidural anesthesia, age, body mass index (BMI), emotional state and adequacy of support, and level of fatigue; fetal size, position, and sometimes presentation also play a role. As is true for first-stage labor, researchers have discovered that second-stage labor lasts longer than had been believed in the past - ·The latent phase, sometimes referred to as delayed pushing, laboring down, or passive descent, is a period of rest and relative calm. During this phase the fetus continues to descend passively through the birth canal and rotate to an anterior position as a result of ongoing uterine contractions. The woman is quiet and often relaxes with her eyes closed between contractions. The urge to bear down is not strong, and some women do not experience it at all or only during the acme (peak) of a contraction. Delayed pushing has been shown to result in significant increases in the duration of second-stage labor but significant decreases in pushing time and a reduction in the number of operative vaginal births. - During the active pushing (descent) phase the woman has strong urges to bear down, as the Ferguson reflex is activated when the presenting part presses on the stretch receptors of the pelvic floor. The urge to bear down intensifies as descent progresses and the presenting part reaches the perineum. The woman may be more verbal about the pain she is experiencing. The - nu

Respiratory pulmonary function

- Tidal volume (the amount of air exchanged during normal inspiration and expiration) increases by 40% during pregnancy. Respiratory rate does not change during pregnancy, although minute ventilation (volume of gas expelled from the lungs per minute) increases by 30%-50%. This is likely related to increased progesterone and increased basal metabolic rate - Pregnancy is a state of chronic mild hyperventilation with reduced arterial carbon dioxide (PaCO2) and increased oxygen (PaO2) over nonpregnant levels. - Progesterone may be responsible for increasing the sensitivity of the respiratory center receptors so that PaCO2 decreases, the base excess (HCO3, or bicarbonate) decreases, and pH increases slightly. These alterations in acid-base balance create a state of respiratory alkalosis. - These changes also facilitate the transport of CO2 from the fetus to the mother and O2 release from the mother to the fetus.

Magnesium Sulfate

- When preterm birth appears inevitable (i.e., is expected to occur within the next 24 hours), magnesium sulfate may be administered to reduce or prevent neonatal neurologic morbidity (e.g., cerebral palsy). The current recommendation is that magnesium sulfate for neuroprotection be given to women who are at least 24 but <32 wks. of gestation at the time birth is expected to occur. The magnesium sulfate infusion should not be continued longer than 24 hrs. if birth has not occurred. How magnesium sulfate works to provide neuroprotection is not well understood. Although it is likely that the neuroprotective effects are the result of residual concentrations of the medication in the neonate's system, data are insufficient to determine the precise maternal dose necessary to achieve the benefit - The recommended dose of magnesium sulfate for neuroprotection is a loading dose of 4 g. given intravenously over 30 mins., followed by a maintenance dose of 1 g./hr. - Labor that has progressed to a cervical dilation of 4 cm. or more is likely to lead to inevitable preterm birth. If birth appears imminent, members of the interprofessional healthcare team will make preparations to care for a small, immature neonate. Women in preterm labor can rapidly progress to birth, and a very small fetus can be born through a partially dilated cervix. Also malpresentation (e.g., breech presentation) occurs much more frequently in preterm than in term fetuses. - Therefore nurses must be prepared to handle the emergency birth of a preterm infant, from either cephalic or breech presentation, without the woman's obstetric health care provider being present. Personnel skilled at neonatal resuscitation should be present at the time of birth. Equipment, supplies, and medications used for neonatal resuscitation should be gathered in advance and prepa

Third stage of labor

- lasts from the birth of the baby until the placenta is expelled. It is generally by far the shortest stage of labor .Longer than 30 min for placenta to be delivered call the provider to manually remove but this increases her risk for infection. - Retained placental fragments- increase risk for bleeding so it needs to be completely peeled off. - Placental separation s/s: Uterus changes from discoid to globular shape, Placenta descends into the vagina (as it removes itself from wall), Lengthening of the cord (as it descends), Gush of blood and placental expulsion, - Uterus must remain firm to compress the vessels and prevent hemorrhage. → After placental delivery, fundus is massaged, and oxytocin is administered to ensure uterus is firm and contracting to compress vessels - Breastfeeding is a natural way to release oxytocin and keep uterus firm; if baby is stable after delivery give to mom to breastfeed. (You can give 20U of Pitocin in 1L (up to 80U) or 10U IM) - At this time the nurse will obtain a sample of blood from the umbilical cord to be used for determining the baby's blood type and Rh status. Some parents will also have arranged to have blood from the cord collected for storage and possible future use. Signs That Suggest the Onset of the Third Stage • A firmly contracting fundus • A change in the uterus from a discoid to a globular ovoid shape as the placenta moves into the lower uterine segment • A sudden gush of dark blood from the introitus • Apparent lengthening of the umbilical cord as the placenta descends to the introitus • The finding of vaginal fullness (the placenta) on vaginal or rectal examination or of fetal membranes at the introitus interventions: • Perform Q15mins.: maternal BP, pulse, respirations • Assess for signs of placental separation and amount of• bleeding. • Assist

Corticosteroids

-Antenatal glucocorticoids, given as IM injections to the mother to accelerate fetal lung maturity by stimulating fetal surfactant production, are now considered one of the most effective and cost-efficient interventions for preventing morbidity and mortality associated with preterm birth. Antenatal glucocorticoids have been shown to significantly reduce the incidence of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and death in neonates, without increasing the risk of infection in either mothers or newborns - ACOG recommends that all women b/w 24-34 wks. gestation be given a single course of antenatal glucocorticoids when preterm birth is threatened. Because recent data indicate that betamethasone decreases neonatal respiratory morbidity when given to women b/w 34 0/7- 36 6/7 wks. who are at risk for giving birth within the next 7 days and who have not previously received glucocorticoids during the current pregnancy - ACOG also recommends that a course of betamethasone be given to these women. A single course of steroids may also be considered for women at 23 wks. of gestation if it seems likely that they will give birth within the next 7 days - A single repeat (rescue) course of antenatal steroids may be given to women who received their initial course more than 2 weeks previously if their gestational age remains less than 32 6/7 wks. and they are still considered likely to give birth within the next week. More than two courses of antenatal glucocorticoids, however, are not recommended Antenatal Glucocorticoid Therapy With Betamethasone or Dexamethasone Action Stimulates fetal lung maturation by promoting release of enzymes that induce production or release of lung surfactant. Glucocorticoids have similar maturational effects on other organs, including the brain, kidneys, and

Urinary system structural adaptations

-Changes in renal structure result from hormonal activity (estrogen and progesterone), pressure from an enlarging uterus, and an increase in blood volume. Kidneys enlarge during pregnancy. As early as the 10th week of pregnancy, the renal pelvis and the ureters dilate. Dilation of the ureters is more pronounced above the pelvic brim, in part because they are compressed between the uterus and the pelvic brim. In most women, the ureters below the pelvic brim are normal size. The smooth-muscle walls of the ureters undergo hyperplasia and hypertrophy and muscle tone relaxation. The ureters elongate, become tortuous, and form single or double curves. In the latter part of pregnancy, the renal pelvis and ureter dilate more on the right side than on the left because the heavy uterus is displaced to the right by the sigmoid colon - Because of these changes, a larger volume of urine is held in the pelves and ureters and urine flow rate is slowed, causing urinary stasis. Consequently, a lag occurs between the time urine is formed and when it reaches the bladder. Therefore clearance test results may reflect substances contained in glomerular filtrate several hours before. Because of the urinary stasis and potential stagnation, pregnant women are more susceptible to urinary tract infection. - Bladder irritability, nocturia, and urinary frequency and urgency (without dysuria) are commonly reported in early pregnancy and during the third trimester. Urinary frequency results initially from increased bladder sensitivity and later from compression of the bladder. In the second trimester, the bladder is pulled up out of the true pelvis into the abdomen. The urethra lengthens to 7.5 cm. as the bladder is displaced upward. The pelvic congestion that occurs in pregnancy is reflected in hyperemia of the bladder and urethra. This increased v

Uterus size, shape, and position

-High levels of estrogen and progesterone stimulate significant uterine growth in the first trimester. Early uterine enlargement results from increased vascularity and dilation of blood vessels, hyperplasia (production of new muscle fibers and fibroelastic tissue) and hypertrophy (enlargement of preexisting muscle fibers and fibroelastic tissue), and development of the decidua. Uterine weight increases dramatically from 4 g to 70 g in the nonpregnant state to 1200 g. at term gestation. Volume increases from 10 mL before pregnancy to 5 L at term. By 7 wks. of gestation, the uterus is the size of a large hen's egg; by 10 wks., it is the size of an orange (twice its nonpregnant size); and by 12 wks., it is the size of a grapefruit. After the 3rd month, uterine enlargement is primarily the result of mechanical pressure of the growing fetus. - As the uterus enlarges, it also changes in shape and position. By 12 wks. the uterus changes from its nonpregnant pear shape to a more spherical or globular shape. Later, as the fetus grows, the uterus becomes larger and more ovoid. During the first trimester the uterus is a pelvic organ; by 12 weeks it rises out of the pelvis into the abdominal cavity. - The pregnancy may "show" after the 14th week, although this depends to some degree on the woman's height and weight. Abdominal enlargement may be less apparent in the nullipara with good abdominal muscle tone. Posture also influences the type and degree of abdominal enlargement that occurs. In normal pregnancies, the uterus enlarges at a predictable rate. - As the uterus grows, it can be palpated above the symphysis pubis sometime between the 12th and 14th weeks of pregnancy. The uterus rises gradually to the level of the umbilicus by 20 to 22 weeks of gestation and nearly reaches the xiphoid process at term. Between weeks 38 and 40,

Systemic analgesics: opioids

-IV, IM, or PCA -provide sedation and euphoria, but their analgesic effect in labor is limited. The pain relief they provide is incomplete, temporary, and more effective in the early part of active labor. All opioids cause side effects, the most serious of which is respiratory depression. Other undesirable opioid side effects include sedation, nausea and vomiting, dizziness, altered mental status, euphoria, decreased gastric motility, delayed gastric emptying, and urinary retention - Prolonged gastric emptying time increases the risk for aspiration if general anesthesia becomes necessary in a woman who has received opioids (Hawkins & Bucklin). Bladder and bowel elimination can be inhibited. Because heart rate (e.g., bradycardia), blood pressure (e.g., hypotension), and respiratory effort (e.g., depression) can be adversely affected, opioid analgesics should be used cautiously in women with respiratory and cardiovascular disorders. Safety precautions should be taken after opioid administration, because several opioid side effects increase the risk for injury due to falls. - Opioids readily cross the placenta. Effects on the fetus and newborn can be profound, including absent or minimal FHR variability during labor and significant neonatal respiratory depression requiring treatment after birth - Classifications of analgesic drugs used to relieve the pain of childbirth include opioid (narcotic) agonists and opioid (narcotic) agonist-antagonists. Choice of which medication to use often depends on the obstetric health care provider's preferences and the situation of the laboring woman, including factors such as her preferences, physical condition, and current medications. The type of systemic analgesics used therefore often varies among obstetric units. There is insufficient evidence to recommend the use of one opioid over

primary powers

-Involuntary uterine contractions to expel fetus and placenta -signal beginning of labor -originate @ pacemaker points in thickened muscles of upper uterine segment--> move downward over uterus in waves with short rest periods -responsible for effacement (shortening and thinning) and dilation of cervix and descent of fetus during 1st stage of labor --helps by uterus pulling upward over baby's head (effacement) + pushing baby down against cervix (dilation and descent) ilation of the cervix occurs by the drawing upward of the musculofibrous components of the cervix, caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part can promote cervical dilation. Scarring of the cervix as a result of prior infection or surgery may slow cervical dilation. - In the 1st and 2nd stages of labor, increased intrauterine pressure caused by contractions exerts pressure on the descending fetus and the cervix. When the presenting part of the fetus reaches the perineal floor, mechanical stretching of the cervix occurs. Stretch receptors in the posterior vagina cause release of endogenous oxytocin that triggers the maternal urge to bear down, or the Ferguson reflex. -usually independent of external forces (e.g., laboring women who are paralyzed because of spinal cord lesions above 12th thoracic vertebra have normal but painless uterine contractions) -epidural doesn't decrease frequency or intensity of contractions

Prenatal interview historical data

-The therapeutic relationship between the nurse and the woman is ideally established during the initial assessment interview. During this interview the nurse makes an effort to gain the woman's trust - The pregnant woman and family members who are present should be told that the first prenatal visit is longer and more detailed than future visits. The initial evaluation includes a comprehensive health history emphasizing the current pregnancy, previous pregnancies, the family, a psychosocial profile, a physical assessment, diagnostic testing, and an overall risk assessment. - 1 or more fam. often accompany the pregnant woman. With the woman's permission, the nurse includes those accompanying the woman in the initial prenatal interview. Observations and information about the woman's family is then included in the database. For example, if the woman has small children with her, the nurse can ask about plans for child care during the time of labor and birth. The nurse notes any special needs that are identified during this first interview (e.g., wheelchair access, assistance in getting on and off the examining table, difficulty speaking and/ or understanding English, and cog. deficits)

Nursing management of abnormal fetal heart tracings

-admin. O2 by nonrebreather face mask at a rate of 10 L/min for approximately 15-30 min. • Assist woman to a side-lying (lateral) position. • Increase maternal blood volume by increasing the rate of primary IV infusion. Interventions for Specific Problems • Maternal hypotension • Increase rate of primary IV infusion. • Change to lateral or Trendelenburg positioning. • Administer ephedrine or phenylephrine if other measures are unsuccessful in increasing blood pressure. • Uterine tachysystole • Reduce or discontinue dose of any uterine stimulants in use (e.g., oxytocin [Pitocin]). • Administer uterine relaxant (tocolytic) (e.g., terbutaline [Brethine]). • Abnormal FHR pattern during 2nd stage of labor • Use open-glottis pushing. • Use fewer pushing efforts during each contraction. • Make individual pushing efforts shorter. • Push only with every other or every third contraction. • Push only with a perceived urge to push (in women with regional anesthesia). IV, Intravenous. The five essential components of the FHR tracing that must be evaluated regularly are baseline rate, baseline variability, accelerations, decelerations, and changes or trends over time. Whenever one of these five essential components is assessed as abnormal, corrective measures must be taken immediately. The purpose of these actions is to improve fetal oxygenation The term intrauterine resuscitation is sometimes used to refer to specific interventions initiated when an abnormal FHR pattern is noted. Basic corrective measures include providing supplemental oxygen, instituting maternal position changes, and increasing intravenous (IV) fluid administration. These interventions are implemented to improve uterine and intervillous space blood flow and increase maternal O2 and CO Depending on underlying cause of the abnormal FHR

Fourth stage of labor

-begins with expulsion of placenta--> pt. is stable in immediate postpartum period (usually within 1st hr. after birth) -crucial recovery time for mom & baby: recovering from physical process of birth + becoming acquainted with each other and additional fam. -maternal organs undergo initial readjustment to nonpregnant state, and the functions of body systems begin to stabilize. - Repairs(from lacerations or episiotomy), chills(from shift of fluids-usually last about 20 mins.), edema, cramping pain/after pains happen in this stage - If the woman received epidural or spinal anesthesia, she should be able to raise her legs, extended at the knees, off the bed, or flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed. The numb or tingling, prickly sensation should be entirely gone from her legs. The length of time required to recover from regional anesthesia varies greatly. Often it takes several hrs. for these anesthetic effects to disappear completely. She can't be discharged from recovery unless she can move her legs assessment: -BP: Q15mins. for 1st 2 hrs. -pulse rate and regularity: Q15mins. for 1st 2 hrs. -temp.: right after birth--> Q4h for 1st 8 hrs.--> Q8h -fundus: position pt. with knees flexed and head flat--> cup hand just below umbilicus and press firmly while stabilizing uterus @ symphysis with opp. handIf the fundus is firm (and bladder is empty), with uterus in midline, measure its position relative to the woman's umbilicus. Lay your fingers flat on the woman's abdomen under the fumbilicus; measure how many fingerbreadths (fb) or centimeters (cm) fit between the umbilicus and the top of the fundus. Fundal height is documented according to agency guidelines. For example, if the fundus is 1 fo or 1 cm above the umbilicus, fundal height may be recorded as either +1, u+1, or 1/

Molar Pregnancy

-bleeding condition -nonviable pregnancy -trophoblast (cells that eventually form into placenta by 10 wks. and nourish baby) tumor Molar pregnancy is one of a group of pregnancy-related cancers without a viable fetus known as gestational trophoblastic neoplasia (GTN) that are caused by abnormal fertilization. GTN have the potential for local invasion, distant metastasis, and death from disease. In addition to partial and complete molar pregnancies, gestational choriocarcinoma and placental site trophoblastic tumors are also GTNs causes: unknown, although it may be related to an ovular defect or a nutritional deficiency. Women at increased risk for hydatidiform mole formation are those who have had a prior molar pregnancy and those who are at the extremes of age for reproduction risk factors: -Asian, Hispanic, and Native American -increased age -hyperthyroidism causes: sperm fertilizes empty egg cell or 2 sperm cells fertilize normal egg cell types: 1. gestational trophoblastic neoplasia (GTN): carcinogenic type --causes: abnormal chromosomes with fertilization --s/s: local tumors that can metastasize--> death 2. hydatiform mole: benign proliferative growth of trophoblast --s/s: chorionic villi--> edematous, cystic, avascular transparent vesicles that hang in grape-like cluster --types: --1. complete: no fetus, placenta, or amniotic fluid present ----complications: hyperthyroidism ----Tx: restore thyroid function to normal --2. partial: contains some fetal tissue and amniotic sac ----less risk of persistent GTN ----s/s: may be mistaken for incomplete or missed miscarriage - Molar pregnancies typically result from chromosomally abnormal fertilization. They are further categorized as a complete or partial mole. - The complete mole results from fertilization of an egg in which the nucleus has been lost or inactivated

Intermittent auscultation (IA)

-listening to fetal heart sounds at periodic intervals to assess FHR with Doppler, US stethoscope, or DeLee-Hillis fetoscope. Doppler ultrasound and ultrasound stethoscopes transmit ultra-high-frequency sound waves, reflecting movement of the fetal heart, and convert these sounds into an electronic signal that can be counted. -easy to use, not $, and less invasive than EFM -often more comfortable for pt. and gives her more freedom of movement -other care measures (e.g., ambulation and use of baths or showers) are easier to carry out when IA is used -may be difficult to perform transabdominally in obese pt. A transvaginal fetal Doppler probe is available that provides closer proximity to the uterus, making it easier to auscultate the FHR when the woman is obese or early in gestation. Because IA is intermittent, significant events may occur during a time when the FHR is not being auscultated. In addition, IA does not provide a permanent documented visual record of the FHR and cannot be used to assess visual patterns of the FHR variability or periodic changes. When using IA the nurse can assess the baseline FHR, rhythm, and increases and decreases from baseline There is a lack of literature to recommend the optimal intervals for FHR auscultation during latent- and active-phase labor. Therefore, several professional organizations have provided general guidelines for frequency of assessment for low- and high-risk clients during the intrapartum period. These organizations include the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), the American Academy of Pediatrics (AAP), ACOG, the National Institute for Health and Care Excellence (NICE), and the Society of Obstetricians and Gynaecologists of Canada (SOGC). The suggested frequencies are generally based on protocols reported in research clinical trials

Tocolytics

-meds. given to arrest labor after uterine contractions and cervical change have occurred. No medications are currently approved for use as tocolytics by the FDA Drugs marketed for other purposes, such as treatment of asthma or hypertension or as anti-inflammatory or analgesic agents, are used on an "off-label" basis (i.e., drugs known to be effective for a specific purpose, although not specifically developed and tested for this purpose) to suppress preterm labor - No tocolytic has been shown to reduce the rate of preterm birth. Rather, the rationale for giving these medications is to delay birth long enough to allow time for maternal transport to a Level III or Level IV neonatal care center and for corticosteroids to reach maximum benefit to reduce neonatal morbidity and mortality. Studies of individual drugs used for tocolysis rarely contain information about whether delaying birth improved infant outcomes Selecting the appropriate tocolytic medication requires consideration of each drug's effectiveness, risks, and adverse -contra: -most common tocolytic since maternal and fetal or neonatal adverse reactions are less severe and less common than with the β-adrenergic agonists. Clinicians are familiar with its use as a treatment for preeclampsia and believe it is safer to use when compared with the β-adrenergic agonists. However, although magnesium sulfate is still frequently used, its effectiveness as a tocolytic is not supported by the literature - β2-adrenergic agonists (e.g., ritodrine and terbutaline [Brethine]) have been widely used as tocolytics. They have many maternal and fetal adverse reactions, however, including β1-stimulated cardiopulmonary (e.g., tachycardia) effects and β2-stimulated metabolic (e.g., hyperglycemia) effects. Therefore β2-adrenergic agonists are increasingly being replaced by

Opioid agonist analgesics

-meperidine, fentanyl, remifentanil: stimulate major opioid receptors (μ and κ), no amnesic effect but create a feeling of well-being or euphoria and enhance a woman's ability to rest between contractions. Because opioids can inhibit uterine contractions, they should not be administered until labor is well established unless they are being used to enhance therapeutic rest during a prolonged early phase of labor Meperidine (Demerol) is a synthetic opioid that has frequently been used worldwide as a systemic medication for labor pain. widespread use is probably related to its low cost, the fact that care providers are quite familiar with the drug, and studies (done many years ago) which found that it caused less respiratory depression than morphine (see the Meperidine Hydrochloride [Demerol] Medication Guide). However, its use during labor is becoming more controversial because of undesirable side effects, particularly in the neonate. Both meperidine and normeperidine, an active metabolite of meperidine, cross the placenta and cause prolonged neonatal sedation and neurobehavioral changes. These metabolite-related effects cannot be reversed with naloxone. Because meperidine and normeperidine have long half-lives, the neonatal effects can persist for the first 2 to 3 days of life Fentanyl (Sublimaze) is a potent short-acting synthetic opioid agonist analgesic (see the Fentanyl Citrate [Sublimaze] Medication Guide). It rapidly crosses the placenta so is present in fetal blood within 1 minute after intravenous maternal administration. As compared with meperidine, fentanyl provides equivalent analgesia with fewer neonatal effects and less maternal sedation and nausea. Fentanyl is used as a labor analgesic because of its rapid onset of action, short half-life, and lack of a metabolite. A disadvantage of fentanyl is that more

Birth plan

-must be viewed as tentative (may change as labor and birth unfold) -preference list based on best-case scenario - It is useful for the nurse in a prenatal practice setting to initiate a discussion of choices related to birth planning. Some maternity practices provide printed material describing available options and giving answers to commonly asked questions, and tours of the birth setting are offered by almost all birthing facilities. The nurse can provide couples with pertinent information and make them aware of the various options for care and the advantages and consequences of each, so that they can begin making informed decisions. Early plans can be modified as the couple learns more details in their childbirth classes. -RN can direct pt. to websites with info. about creating birth plan - can serve as open communication between pt. and partner and between the couple and the HCPs. An early introduction to the idea of a birth plan allows the couple time to think about events or situations that could make their childbearing experience more meaningful and those they would prefer to avoid. -created prenatally and implemented on admission to the labor and birth unit. However, when women without predesigned birth plans are admitted, nurses can use a template with simple questions about preferences for care to help them develop a simple birth plan. This is in accordance with the AWHONN position statement on nursing support of laboring women, specifically creating individualized care plans for laboring women based on their needs, desires, and expectations

Medication administration: IM route

-not the preferred route for pt. in labor -quick admin. -no need to start IV line -higher doses req. -med. released @ unpredictable rate from muscle tissue and available for transfer across placenta to fetus -maternal med. levels after admin. unequal because of uneven distribution (maternal uptake) and metabolism -if neuraxial anesthesia is planned later in labor: deltoid preferred . The autonomic blockade from the neuraxial anesthesia increases blood flow to the gluteal region and accelerates absorption of medication that may be sequestered there. Administration of opioids subcutaneously in the upper arm avoids this risk and, as a result, is often used as an alternative to IM injection.

Nonpharmacologic methods

-sense of control -pt. should explore variety of measures in prenatal period Techniques she usually finds helpful in relieving stress and enhancing relaxation (e.g., music, meditation, massage, warm baths) may be very effective as components of a plan for managing labor pain. The woman should be encouraged to communicate to her health care providers her preferences for relaxation and pain relief measures and for active participation in their implementation. -many req. practice for best results (e.g., hypnosis, patterned breathing and controlled relaxation techniques, focal point, distraction) -don't req. practice: slow-paced breathing, massage and touch, effleurage, counter-pressure, relaxation, music, hot or cold packs, movement or positioning -encourage pt. to try variety of methods and seek alternatives (including pharm. methods) when measure being used is no longer effective -may be viewed as more complex and time consuming than monitoring pt. receiving an epidural -effect comparable to or even superior to opioids -Cutaneous stimulation strategies: Counter-pressure, Effleurage (light massage), therapeutic touch and massage, walking, Rocking, changing positions, application of heat or cold, transcutaneous electrical nerve stimulation (TENS), acupressure, H2O therapy (showers, baths, whirlpool baths), intradermal H2O block -Sensory stimulation strategies: aromatherapy, breathing techniques, music, Imagery, use of focal points -cog. strategies: Childbirth education, Hypnosis

Placenta previa

-placenta implants low in uterus close to cervical os (marginal)--> bleeding when cervix dilates or lower uterine segment effaces, partially covers it, or completely covers it -marginal/ low-lying: can resolve as uterus grows and it moves away (req. frequent US to verify)--> can have vaginal birth -partial or complete: req. c-section - When transvaginal ultrasound is used, the placenta is classified as a complete placenta previa if it totally covers the internal cervical os. In a marginal placenta previa the edge of the placenta is seen on transvaginal US to be 2.5 cm. or closer to the internal cervical os. When the exact relationship of the placenta to the internal cervical os has not been determined or in the case of apparent placenta previa in the second trimester, the term low-lying placenta is used Some evidence suggests that the incidence of placenta previa is increasing, perhaps as a result of more cesarean births. In addition to a history of previous cesarean birth risk factors: all increase risk for postpartum hemorrhage -Multiple gestation (larger placental area) -short interval pregnancies (10-12 mths. apart) -asian -advanced maternal age (>35-40 y/o) -live in high altitudes, smoking: -->decrease in uteroplacental O2--> need for increased placental SA -invasive placentation (how deep it implants in uterine wall (e.g., bladder): accreta, increta, percreta -prior Hx (genetic predisposition) -prev. c-section or suction curettage for miscarriage or induced abortion: endometrial damage and uterine scarring (placenta tries to implant on healthy area) -male fetuses: placental sizes are larger -utertine anomalies: fibroids, tumors -DM -HTN -large placenta Dx: repeated US (vs. abruption which is clinical presentation) to see where placenta is and make sure no gushes of blood

Assessment of the fetal heart rate

-point of maximal intensity (PMI) of FHR: usually directly over the fetal back. In a vertex presentation the FHR can usually be heard below the mother's umbilicus in either the right or the left lower quadrant of the abdomen. In a breech presentation the FHR is most easily heard above the mother's umbilicus. The PMI is where the nurse places the ultrasound transducer when the electronic fetal monitor is used to assess the FHR. It is essential to assess the FHR after ROM during the first stage of labor because this is the most common time for the umbilical cord to prolapse, after any change in the contraction pattern or maternal status, and before and after the woman receives medication or a procedure is performed

Medication administration: IV route

-preferred route of admin. of meperidine, fentanyl, remifentanil, or nalbuphine -admin. into port nearest point of insertion of the infusion (proximal port) slowly, in small amounts, during a contraction over a period of 3-5 consecutive contractions if needed to complete dose (given during contractions to decrease fetal exposure to med. since uterine blood vessels are constricted during contractions and the med. stays within maternal vascular sys. for several seconds before uterine blood vessels reopen)--> infusion is then restarted slowly to prevent bolus -pain relief obtained with small doses -duration of effect more predictable

Endometriosis

-presence and growth of endometrial tissue outside of uterus (implanted on ovaries; anterior and posterior cul-de-sac; broad, uterosacral, and round ligaments; rectovaginal septum; sigmoid colon; appendix; pelvic peritoneum; cervix; and inguinal area) - Endometrial lesions have been found in the vagina and surgical scars and on the vulva, perineum, and bladder. They have also been found on sites far from the pelvic area, such as the thoracic cavity, gallbladder, and heart. A cystic lesion of endometriosis found in the ovary is sometimes described as a chocolate cyst because of the dark coloring of the contents of the cyst, which is caused by the presence of old blood. - Endometrial tissue contains uterine glands and stroma (connective tissue) and responds to cyclic hormone stimulation in the same way that the uterine endometrium does but often out of phase with it. The tissue grows during the proliferative and secretory phases of the cycle. During or immediately after menstruation the tissue bleeds, resulting in an inflammatory response with subsequent fibrosis and adhesions to adjacent organs. - The overall incidence of endometriosis is 5%-15% in reproductive-age women, 30%-45% in infertile women, and 33% in women with chronic pelvic pain - Although the condition usually develops in the third or fourth decade of life, endometriosis has been found in adolescents with disabling pelvic pain or abnormal vaginal bleeding. Endometriosis may worsen with repeated cycles, or it may remain asymptomatic and undiagnosed, eventually disappearing after menopause. However, it has been reported to occur in about 5% of postmenopausal women receiving menopausal hormone therapy. Endometriosis was previously considered to be a rare occurrence in adolescents, but - currently it is estimated that approximately 50% of teens with pelvic pain

preterm labor nursing care

-review prenatal record for risk factors + US date for gestational age (1st trimester most accurate) -sterile vaginal exam. (SVE): assess cervix dilation and effacement --contra: ROM (risk for infection) (can do initial vaginal exam. but no more unless abnormal FHR, increasing pain, feeling urge to push), s/s bleeding -assess FHR: persistent fetal tachycardia if maternal infection, variables if ROM due to fluid loss -assess contractions frequency and duration -urine and vaginal cultures: UTI or STI -fetal fibronectin test (FFN): contra= recent intercourse, bleeding, or ROM -transvaginal US for cervical length -monitor I&O's especially if admin. mag. sulfate -admin. antibiotics: prevents neonatal GBS -admin. antenatal glucocorticoids (e.g., betamethasone, dexamethasone): improve fetal lung maturity by helping produce surfactant, prevents or reduces neonatal and infant morbidity and mortality from probs. (e.g., respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis) -admin. mag. sulfate if <32 wks. gestation: reduces incidence of CP --auscultate lungs during due to risk of pulm. edema

Cerclage

-sutures (Mersilene tape) placed around cervix to reinforce strength of cervix and avoid dilation -vaginal cerclages removed @ 36-37 wks. if no complications (no ROM, bleeding, painful contractions, cervical change) indications: Tx cervical insufficiency due to cervical weakness 1. prophylactic due to poor OB Hx (1 or more prev. early preterm birth R/T cervical insufficiency w/o going into labor, prior cerclage in prev. pregnancy): usually placed @ 12-14 wks. 2. therapeutic due to short (<25 mm.) cervical length on transvaginal US and Hx preterm birth with short cervix: placed @ 14-23 wks. in singleton pregnancy (contra: multiple gestation due to increasing risk of preterm birth) 3. rescue (>1 cm. dilated or prolapsed membranes on digital or speculum exam.): placed @ 16-23 wks. --risk of accidentally rupturing membranes--> preterm labor types: 1. McDonald sutures: often procedure of choice due to effectiveness and ease of placement and removal --suture placed beneath mucosa to constrict internal os--> close like a drawstring purse 2. shirodkar: suture near internal cervical os 3. abs.: around lower neck of uterus @ junction of lower uterine segment and the cervix --stays in place for subsequent pregnancies --for failure of prior Hx-indicated transvaginal cerclage where spontaneous preterm birth occurred <33 wks. gestation --usually done @ 11-12 wks. or before conception via laparotomy -c-section necessary after -risk of chorioamnionitis if ROM management: -bed rest -progesterone Tx IM or vaginal to maintain pregnancy -assess FHR -after cerclage: no intercourse, pelvic rest for 1 wk. (nothing in vagina), showers, educate s/s preterm labor (ROM, infection, contractions Q5mins., pelvic or perianal pressure, urge to push)

secondary powers

-voluntary bearing-down efforts once cervix has dilated to augment force of involuntary contractions and expel fetus and placenta from the uterus -mom feels urge to push - As soon as the presenting part reaches the pelvic floor, the contractions change in character and become expulsive. The laboring woman experiences an involuntary urge to push. She uses secondary powers (bearing-down efforts) to aid in expulsion of the fetus as she contracts her diaphragm and abdominal muscles and pushes. These bearing-down efforts result in increased intraabdominal pressure that compresses the uterus on all sides and adds to the power of the expulsive forces -no effect on cervical dilation but effective once fully dilated -pushing techniques vary -may feel urge to have BM but don't assist to bathroom due to risk of baby coming out

Hyperemesis gravidarum

-vomiting becomes excessive enough to cause weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria, the disorder is termed hyperemesis gravidarum -usually begins during the 1st trimester, but approximately 10% of women with the disorder continue to have symptoms throughout the pregnancy -2nd most common reason for hospitalization during pregnancy in US - There are a number of maternal characteristics associated with an increased risk for the development of hyperemesis gravidarum, including younger maternal age, nulliparity, a BMI less than 18.5 or greater than 25, and low socioeconomic status. Women with asthma, migraines, preexisting diabetes, psychiatric illness, hyperthyroid disorders, gastrointestinal disorders, or a prev. pregnancy complicated by hyperemesis gravidarum are also more likely to develop hyperemesis. Factors related to the current pregnancy that make a woman more likely to develop hyperemesis gravidarum are carrying a female fetus, multifetal gestation, and gestational trophoblastic disease. In addition, a maternal family history of hyperemesis is associated with the disorder - Hyperemesis gravidarum can cause complications for both women and infants. Severe but rare maternal complications of hyperemesis gravidarum include esophageal rupture, pneumomediastinum, and deficiencies of vit. K and thiamine with resulting Wernicke encephalopathy (CNS involvement) - Infants born to women who had poor pregnancy weight gain because of hyperemesis may be SGA, have a low birthwt., or be born prematurely - The woman with hyperemesis gravidarum usually has significant weight loss and dehydration. She may have dry mucous membranes, decreased BP, increased pulse rate, and poor skin turgor. Frequently she is unable to keep down even clear liquids taken by mouth. Laboratory tests may reveal electro

Bowel function

After birth, women can be at risk for constipation related to side effects of medications (opioid analgesics, iron supplements, magnesium sulfate), dehydration, immobility, or the presence of episiotomy, perineal lacerations, or hemorrhoids. The woman can be fearful of pain with the first bowel movement. Nursing interventions to promote normal bowel elimination include educating the woman about measures to prevent constipation, such as ambulation and increasing the intake of fluids and fiber. Alerting the woman to side effects of medications such as opioid analgesics (e.g., decreased gastrointestinal tract motility) can encourage her to implement measures to reduce the risk for constipation. Stool softeners or laxatives may be necessary during the early postpartum period. These are used only at the direction of the health care provider. Some mothers experience gas pains; this is more common following cesarean birth. Ambulation or rocking in a rocking chair can stimulate passage of flatus and provide relief. Antiflatulent medications may be ordered. The mother can avoid foods (e.g., legumes, beans, broccoli) that tend to produce gas.

Lactogenesis

After the mother gives birth, a precipitous fall in progesterone triggers the release of prolactin from the anterior pituitary gland. During pregnancy, prolactin prepares the breasts to secrete milk and during lactation to synthesize and secrete milk. Prolactin levels are highest during the first 10 days after birth, gradually declining over time but remaining above baseline levels for the duration of lactation. Prolactin is produced in response to infant suckling and emptying of the breasts. Milk production is a supply-meets-demand system (i.e., as milk is removed from the breast, more is produced). Incomplete removal of milk from the breasts can lead to decreased milk supply. Oxytocin is essential to lactation. As the nipple is stimulated by the suckling infant, the posterior pituitary gland is prompted by the hypothalamus to produce oxytocin. This hormone is responsible for the milk ejection reflex (MER), or let-down reflex The myoepithelial cells surrounding the alveoli respond to oxytocin by contracting and sending the milk forward through the ducts to the nipple. The MER is triggered multiple times during a feeding session. Thoughts, sights, sounds, or odors that the mother associates with her baby (or other babies), such as hearing the baby cry, can trigger the MER. Many women report a tingling "pins and needles" sensation in the breasts as milk ejection occurs, although some mothers can detect milk ejection only by observing the sucking and swallowing of the infant. The MER also can occur during sexual activity because oxytocin is released during orgasm. The reflex can be inhibited by fear, stress, and alcohol consumption. Oxytocin is the same hormone that stimulates uterine contractions during labor. Consequently, the MER can be triggered during labor, as evidenced by leakage of colostrum. This reflex read

Integumentary system

All skin structures are present at birth. The epidermis and dermis are loosely bound and extremely thin. After 35 weeks of gestation, the skin is covered by vernix caseosa (a cheeselike, whitish substance) that is fused with the epidermis and serves as a protective covering. Vernix caseosa is a complex substance that contains sebaceous gland secretions. It has emollient and antimicrobial properties and prevents fluid loss through the skin; it also has antioxidant properties. Removal of the vernix is followed by desquamation of the epidermis in most infants. There is evidence that leaving residual vernix intact after birth has positive benefits for neonatal skin such as decreasing the skin pH, decreasing skin erythema, and improving skin hydration The skin of a term infant is erythematous (red) for a few hours after birth, and then it fades to its normal color. The skin often appears blotchy or mottled, especially over the extremities. The hands and feet appear slightly cyanotic (acrocyanosis); this is caused by vasomotor instability and capillary stasis. Acrocyanosis is common during the first 48 hours and appears intermittently over the first 7 to 10 days, especially with exposure to cold The healthy term infant usually has a plump appearance because of large amounts of subcutaneous tissue and extracellular water content. Subcutaneous fat accumulated during the last trimester acts as insulation. Fine lanugo hair may be noted over the face, shoulders, and back. Edema of the face and ecchymosis (bruising) or petechiae may be noted as a result of face presentation, forceps-assisted birth, or vacuum extraction. Creases are located on the palms of the hands and the soles of the feet. The simian line, a single palmar crease, is often seen in Asian infants and infants with Down syndrome. The soles of the feet should be inspe

Opioid (narcotic) agonist-antagonist analgesics

An agonist is an agent that activates or stimulates a receptor to act; an antagonist is an agent that blocks a receptor or a medication designed to activate a receptor. Nalbuphine (Nubain) is a commonly used opioid (narcotic) agonist-antagonist analgesic Opioid agonist-antagonist analgesics are agonists at κ opioid receptors and either antagonists or weak agonists at μ opioid receptors. In the doses used during labor, these mixed opioids provide adequate analgesia without causing significant respiratory depression in the mother or neonate. Their major advantage is their ceiling effect for respiratory depression; higher doses do not produce additional respiratory depression. They are less likely to cause nausea and vomiting, but sedation may be as great or greater when compared with pure opioid agonists Nalbuphine use also has some disadvantages. Its antagonist activity may limit the amount of analgesia it can produce. Also, it is not suitable for use in women with an opioid dependence, because the antagonist activity could precipitate withdrawal symptoms (abstinence syndrome) in both the mother and her newborn

Gestational age assessment

Assessment of gestational age is important because perinatal morbidity and mortality rates are related to gestational age and birth weight. A frequently used method of determining gestational age is the New Ballard Score, which can be used to measure gestational ages of infants as young as 20 weeks The New Ballard Score assesses six external physical and six neuromuscular signs. To ensure accuracy, experts recommend that the initial examination is performed within the first 48 hours of life. When gestational age is determined according to the New Ballard Score, the newborn will fall into one of the following nine possible categories for birth weight and gestational age: Preterm, or premature—born before 37 0/7 weeks of gestation, regardless of birth weight Late preterm—34 0/7 through 36 6/7 weeks Early term—37 0/7 through 38 6/7 weeks Full term—39 0/7 through 40 6/7 weeks Late term—41 0/7 through 41 6/7 weeks Postterm—42 0/7 weeks and beyond Postmature—born after completion of week 42 of gestation and showing the effects of progressive placental insufficiency Posture- With infant quiet and in supine position, observe degree of flexion in arms and legs. Muscle tone and degree of flexion increase with maturity. Full flexion of the arms and legs = score 4. a Square Window- With thumb supporting back of arm below wrist, apply gentle pressure with index and third fingers on dorsum of hand without rotating infant's wrist. Measure angle between base of thumb and forearm. Full flexion (hand lies flat on ventral surface of forearm) = score 4. a Arm Recoil- With infant supine, fully flex both forearms on upper arms and hold for 5 s; pull down on hands to extend fully, and rapidly release arms. Observe rapidity and intensity of recoil to a state of flexion. A brisk return to full flexion = score 4. a Popliteal Ang

Afterpains & Fundal assessment

In primiparous women, uterine tone is good, the fundus generally remains firm, and the woman usually perceives only mild uterine cramping. Periodic relaxation and vigorous contractions are more common in subsequent pregnancies and can cause uncomfortable cramping called afterpains (afterbirth pains), which typically resolve in 3 to 7 days. Afterpains are more noticeable after births in which the uterus was overdistended (e.g., large infant, multifetal gestation, polyhydramnios). Breastfeeding and exogenous oxytocin medication usually intensify afterpains because both stimulate uterine contractions. At the end of the third stage of labor, the uterus is in the midline, approximately 2 cm. below the level of the umbilicus, with the fundus resting on the sacral promontory. At this time, the uterus weighs approximately 1000 g. Within 12 hours, the fundus can rise to approx. 1 cm. above umbilicus. By 24 hrs. after birth, the uterus is about the same size as it was at 20 weeks of gestation. Involution progresses rapidly during the next few days. The fundus descends 1-2 cm. QD. By postpartum day 6, the fundus is normally located halfway between the umbilicus and the symphysis pubis. The uterus should not be palpable abdominally after 2 weeks and should have returned to its nonpregnant location by 6 weeks after birth The uterus, which at full term weighs approximately 11 times its prepregnancy weight, involutes to approximately 500 g by 1 week after birth and to 300 g. by 2 wks. after birth. By 4 wks, postpartum, it weighs approx. 100 g., which is the nonpregnant size

Ovaries

Lactating and nonlactating women differ in the timing of their first ovulation and resumption of menstruation. Ovulation occurs as early as 27 days after birth in nonlactating women, with a mean time of about 7-9 wks. About 70% of nonlactating women resume menstruating by 12 wks. after birth. The mean time to ovulation in women who breastfeed is about 6 months. The persistence of elevated serum prolactin levels in lactating women appears to be responsible for suppressing ovulation; the resumption of ovulation and the return of menses are determined in large part by breastfeeding patterns. (e.g., ovulation is delayed longer in women who breastfeed exclusively compared with women who breastfeed and offer supplemental infant formula to their infants. Because of the uncertainty about the return of ovulation and menstruation, discussion of contraceptive options early in the postpartum period is necessary. The first menstrual flow after birth is usually heavier than normal. Within 3-4 cycles: amount of menstrual flow returns to the pre-pregnancy vol.

Lactation suppression

Lactation suppression is necessary when a woman has decided not to breastfeed or in the case of neonatal death. The woman wears a well-fitted support bra continuously for at least the first 72 hours after giving birth. She should avoid breast stimulation, including running warm water over the breasts, newborn suckling, or expressing milk. Some non breastfeeding mothers experience severe breast engorgement (swelling of breast tissue caused by increased blood and lymph supply to the breasts as the body produces milk, occurring about 72 to 96 hours after birth). Breast engorgement can usually be managed satisfactorily with nonpharmacologic interventions. Periodic application of ice packs to the breasts can help to decrease the discomfort associated with engorgement. Although there is lack of scientific evidence to support effectiveness, cabbage leaves are often recommended to help relieve engorgement; formula-feeding mothers may be told to place fresh green cabbage leaves over their breasts and to replace the leaves when they are wilted (Fig. 25.17). A mild analgesic or antiinflammatory medication can reduce discomfort associated with engorgement. Medications that were once prescribed for lactation suppression (e.g., estrogen, estrogen and testosterone, and bromocriptine) are no longer used.

Stools

Meconium fills the lower intestine at birth. It is formed during fetal life from the amniotic fluid and its constituents, intestinal secretions (including bilirubin), and cells (shed from the mucosa). Meconium is greenish black and viscous and contains occult blood. Most healthy term infants pass meconium within the first 12 to 24 hours of life, and almost all do so by 48 hours. The number of stools passed varies during the first week, being most numerous between the third and sixth days. Newborns fed early pass stools sooner. The colostrum consumed by breastfed neonates during the first 2 to 3 days after birth promotes stooling. Progressive changes in the stooling pattern indicate a properly functioning GI tract

Box 18.4 Early decelerations

Normal Causes: Head compression -Uterine contractions -vaginal exam. -Fundal pressure -internal monitoring Periodic Episodic

Box 18.3 Accelerations

Normal: signifies fetal well-being due to fetal alertness or arousal states Causes: • Spontaneous fetal movement • Vaginal exam. • Electrode application • Fetal scalp stimulation • Fetal reaction to external sounds • Breech • Occiput posterior position • Uterine contractions • Fundal pressure • abs. palpation Periodic Episodic

Doppler studies

One of the major advances in perinatal medicine is the ability to study blood flow in the woman, fetus, and placenta noninvasively using ultrasound. Doppler blood flow analysis uses systolic/diastolic flow ratios and resistance indices to estimate blood flow in various arteries. Thus, it provides an indication of fetal adaptation and reserve. The vessels most often studied are the fetal umbilical and middle cerebral arteries and the maternal uterine arteries. Severe restriction of umbilical artery blood flow as indicated by absent or reversed flow during diastole has been associated with IUGR Doppler ultrasound has been demonstrated to be of value in reducing perinatal mortality and unnecessary obstetric interventions in fetuses with IUGR. Significantly increased peak systolic velocity in the middle cerebral artery has been found to predict moderate to severe fetal anemia. Abnormal maternal uterine artery Doppler waveforms have been used to predict fetal growth restriction

Vagina and perineum

Postpartum estrogen deprivation is responsible for the thinness of the vaginal mucosa and the absence of rugae. The smooth-walled vagina that was greatly distended during birth gradually decreases in size and regains tone, although it does not completely return to its prepregnancy state. Rugae reappear within 3 wks., but they are never as prominent as in the nulliparous woman. Most rugae are permanently flattened. The mucosa remains atrophic in the lactating woman, at least until menstruation resumes. Thickening of the vaginal mucosa occurs with the return of ovarian function. Estrogen deficiency is responsible for a decreased amount of vaginal lubrication; vaginal dryness is more prevalent among breastfeeding mothers. Localized dryness and coital discomfort (dyspareunia) can persist until ovarian function returns and menstruation resumes. The use of a H2O-soluble lubricant during sexual intercourse is usually recommended Immediately after vaginal birth, the introitus is erythematous and edematous, especially in the area of an episiotomy or laceration repair. It is barely distinguishable from that of a nulliparous woman if lacerations or an episiotomy have been carefully repaired, hematomas are prevented or treated early, and the woman practices good hygiene during the 1st 2 wks. after birth. Most episiotomies and laceration repairs are visible only if the woman is lying on her side with her upper buttock raised or if she is placed in the lithotomy position. A good light source is essential for visualization of some repairs. Healing of an episiotomy or laceration is the same as any surgical incision. Signs of infection (pain, redness, warmth, swelling, or discharge) or lack of approximation (separation of the edges of the incision) can occur. Initial healing occurs within 2-3 wks., but 4-6 mths. can be required for the

Placental abruption

Premature separation of placenta from uterine wall grades: based on separation 1. mild: minimal dark red bleeding (<500 mL), rare hemodynamically unstable s/s (shock, DIC), normal relaxed uterine tone, may not have any uterine tenderness 2. no bleeding- mod. dark red bleeding (1000-1500 mL), mild s/s of shock and may go into DIC, uterine tone increases, uterus doesn't relax well b/w contractions 3. absent- mod. dark red bleeding >1500 mL, shock and DIC, board-like persistent hard uterus even after contractions Cocaine use is also a risk factor because it causes vascular disruption in the placental bed. Blunt external abdominal trauma, most often the result of motor vehicle accidents (MVAs) or maternal battering, is another frequent cause of placental abruption risk factors: -cigs. -maternal HTN, preeclampsia: vasoconstriction--> separates placenta from wall -coke -blunt force trauma to abs. (partner violence, fall) -Hx abruption in prev. pregnancy -PROM -uterine anomalies/ probs. -thrombophilia: increased risk of clotting (hyper-coagulable) -twin gestations -2 prev. abruptions: recurrence risk of 25% in next pregnancy s/s: -vaginal bleeding--> maternal hypovolemia (i.e., shock, oliguria, anuria) and coagulopathy -Mild-severe uterine hypertonicity -abs. pain: mild-severe, localized over 1 region of uterus or diffused over uterus with board-like abs. -uterine tenderness -contractions -increased fundal ht. -abnormal FHR: late decels, bradycardia -DIC s/s - Extensive myometrial bleeding damages the uterine muscle. If blood accumulates between the separated placenta and the uterine wall, it may produce a Couvelaire uterus. The uterus appears purple or blue, rather than its usual "bubble-gum pink" color, and contractility is lost. Shock may occur and is out of proportion to blood loss. Laboratory findings include

Epidural: nursing interventions for maternal hypotension, Box 17.6

Prior: -explain procedure and obtain informed consent -Assess maternal VS, level of hydration, labor progress, and FHR pattern. -start IV with bolus of fluid (LR or NS) as ordered (e.g., 500-1000 mL 15-30 mins. before induction of anesthesia) -obtain lab. results (e.g., Htc, Hgb) -assess pain -assist pt. to void. During: Assist the woman to assume and maintain the proper position. • Verbally guide the woman through the procedure, explaining sounds and sensations as she experiences them. • Assist the anesthesia care provider with documentation of vital signs, time and amount of medications given, etc. • Monitor maternal vital signs (especially blood pressure) and FHR as ordered. • Have oxygen and suction readily available. • Monitor for signs of local anesthetic toxicity as the test dose of medication is administered. While in Effect: -continue to monitor maternal VS and FHR as ordered (continuous monitoring of maternal HR [electrocardiogram] and BP may be ordered to monitor for accidental IV injection of med.) -continue to assess pain Q VS check -monitor for bladder distention: • Assist with spontaneous voiding on bedpan or toilet. -insert urinary cath. if necessary Encourage or assist the woman to change positions from side to side Qh Promote safety: • Keep the side rails up on the bed.• Place the telephone and call light within easy reach.• Instruct the woman not to get out of bed without help.• Make sure there is no prolonged pressure on anesthetized body parts. - keep the insertion site for the epidural catheter clean and dry.• Continue to monitor for anesthetic side effects While the Block Is Wearing Off After Birth• Assess regularly for the return of sensory and motor function.• Continue to monitor maternal vital signs as ordered.• Monitor for bladder distention:• Assist with spo

Biophysical Profile

The biophysical profile is a noninvasive dynamic assessment of a fetus that is based on acute and chronic markers of fetal disease. The BPP includes AFV, FBMs, fetal movements, and fetal tone determined by ultrasound and FHR reactivity determined by means of the NST. Therefore, the BPP can be considered a physical examination of the fetus, including determination of vital signs. FHR reactivity, FBMs, fetal movement, and fetal tone reflect current CNS status, whereas the AFV demonstrates the adequacy of placental function over a longer period of time The BPP is used frequently in the late second and the third trimester for antepartum fetal testing because it is a reliable predictor of fetal well-being. A BPP of 8 or 10 with a normal AFV is considered normal. Advantages of the test include excellent sensitivity and a low false-negative rate One limitation of the test is that if the fetus is in a quiet sleep state, the BPP can require a long period of observation. Also, unless the ultrasound examination is videotaped, it cannot be reviewed The modified BPP (mBPP) is being used increasingly as a way to shorten the testing time required for the complete BPP by assessing the components that are most predictive of perinatal outcome. The mBPP combines the NST, which assesses the current fetal condition, with measurement of the quantity of amniotic fluid, an indicator of placental function over a longer period of time. It is recommended that the AFV be determined by measuring a single deepest pocket of fluid instead of using the AFI. Desired test results are a reactive NST and a single deepest vertical pocket of amniotic fluid that is more than 2 cm

Contraction stress test and interpretation

The contraction stress test or oxytocin challenge test (OCT) was the first widely used electronic fetal assessment test. It was devised as a graded stress test of the fetus, and its purpose was to identify the jeopardized fetus that was stable at rest but showed evidence of compromise after stress. Uterine contractions decrease uterine blood flow and placental perfusion. If this decrease is sufficient to produce hypoxia in the fetus, a deceleration in FHR results. In a healthy fetoplacental unit, uterine contractions do not usually produce late decelerations, whereas if interrupted oxygenation is present, contractions produce late decelerations. The CST provides an earlier warning of fetal compromise than the NST and produces fewer false-positive results. Like most methods of antepartum fetal surveillance, however, it cannot predict acute fetal compromise (e.g., umbilical cord accidents, placental abruption, or rapid deterioration of glucose control in a woman with diabetes). The CST is more time consuming and expensive than the NST. It is also an invasive procedure if oxytocin stimulation is required. In general, the CST cannot be performed on women who should not give birth vaginally at the time the test is done. Absolute contraindications for the CST are the following: preterm labor, placenta previa, vasa previa, cervical insufficiency, multiple gestation, and previous classical incision for cesarean birth. Because of these disadvantages, the CST is generally used as a backup, rather than a primary method of antepartum testing. Procedure The woman is placed in the semi-Fowler position or sits in a reclining chair with a slight lateral tilt to optimize uterine perfusion and avoid supine hypotension. She is monitored electronically with a fetal ultrasound transducer and a uterine tocodynamometer. The tracing is observ

Jaundice

The presence of jaundice can indicate ABO or Rh factor incompatibility problems After birth, the liver can conjugate and excrete ⅔ of the circulating bilirubin. fewer binding sites because newborns have less serum albumin. Bilirubin Synthesis: When levels of unconjugated bilirubin exceed the ability of the liver to conjugate it, plasma levels of bilirubin increase and jaundice appears. Jaundice, the visible yellowish color of the skin and sclera, is likely to appear when the total serum bilirubin (TSB) level exceeds 6-7 mg./dL. Jaundice is generally noticeable first in the head, especially in the sclera and mucous membranes, and progresses gradually to the thorax, abdomen, and extremities. (for dark skin babies check their scelera and oral mucosa). To assess for jaundice you blanch the skin on the nose or chest there will be a yellow tint. The degree of jaundice is determined by serum total bilirubin measurements Newborn jaundice has been categorized as either physiologic or pathologic (nonphysiologic), depending primarily on the time it appears and on serum bilirubin levels. Physiologic or nonpathologic jaundice (unconjugated hyperbilirubinemia) occurs in approximately 60% of term newborns. It appears after 24 hours of age and usually resolves w/o Tx -Occurs after the first 24 hours of birth. -occurs in 60% of term infants - Total bilinubin generally peak 72 to 96 hours of life and decrease to 2-3 mg/d by day 5 in term neonates, bilirubin peaks days 5-6 in preterm infants. Bilirubin gradually decreases between days 5-10, reaching normal levels (2mg/di) by day 14. Gradual decrease in preterm infants over 2-4 weeks. Jaundice is usually considered pathologic or nonphysiologic if it appears within 24 hours after birth, TSB levels increase by more than 0.2 mg/dL per hour, TSB is greater than the 95th percentile for age i

Promoting comfort

The woman's description of the location, type, and severity of her pain is the best guide in choosing appropriate interventions. To confirm the location and extent of discomfort, the nurse inspects and palpates areas of pain as appropriate for redness, swelling, discharge, and heat and observes for body tension, guarded movements, and facial tension. Blood pressure, pulse, and respirations can be elevated in response to acute pain. Diaphoresis can accompany severe pain. A lack of objective signs does not necessarily mean there is no pain because there can be a cultural component to the expression of pain. Nursing interventions are intended to eliminate the pain entirely or reduce it to a tolerable level that allows the woman to care for herself and her newborn. Nurses may use nonpharmacologic and pharmacologic interventions to promote comfort. Pain relief is enhanced by using more than one method or route. Nonpharmacologic interventions Various nonpharmacologic measures are used to reduce postpartum discomfort. These include distraction, imagery, touch, relaxation, acupressure, aromatherapy, hydrotherapy, massage therapy, music therapy, and transcutaneous electrical nerve stimulation (TENS). For women who are experiencing discomfort associated with uterine contractions, application of warmth (e.g., heating pad) or lying prone can be helpful. Interaction with the infant can also provide distraction and decrease this discomfort. Because afterpains are more severe during and after breastfeeding, interventions are planned to provide the most timely and effective relief. A simple intervention that can decrease the discomfort associated with an episiotomy or perineal lacerations is to encourage the woman to lie on her side whenever possible. Other interventions include application of an ice pack; topical application (if or

first stage of labor

begins with onset of reg. contractions--> complete cervical effacement and dilation phases: 1. latent phase (0-5cm.): multi & nullipara woman progress @ same rate, more open to teaching since pt. more focused and not in a lot of pain 2. active phase (6-1o cm.): cervical dilation occurs more rapidly, multipara progress faster, bloody show is normal, more serious apprehensive, difficulty focusing due to more pain, expresses doubt, N/V, thigh shaking, lots of rectal pressure Contractions Strength Mild to moderate by palpation Moderate to strong by palpation Frequency' 2-30 min apart; may be irregular 1.5-5 min apart Duration" 30-40 sec 40-90 sec Descent Station of presenting part* Nulliparous women 0 by 6 cm Multiparous women -1 by 6 cm Show Color Brownish discharge, mucus plug, or pale pink mucus Pink-to-bloody mucus Amount Scant Moderate to coplous Behavior and appearance Excited; thoughts center on self, labor, and baby; able to walk or talk through most contractions; may be talkative or silent, calm or tense; some apprehension; pain controlled fairly well; álert, follows directions readily; open to instructions Becomes more serious, doubtful of pain control, more apprehensive; desires companionship and encouragement; attention more inwardly directed; has some difficulty following directions As active labor continues: Pain may be described as severe; backache is common; frustration, fear of loss of control, and irritability may be voiced; expresses doubt about ability to continue; nausea and vomiting, especially if hyperventilating: perspiration of forehead and upper lip; shaking tremor of thighs; feeling of need to defecate, pressure on anus

Promoting ambulation

free movement is encouraged once anesthesia wears off unless an opioid analgesic has been administered. After the initial recovery period, the mother is encouraged to ambulate frequently. In the early postpartum period, some women feel lightheaded or dizzy when standing. The rapid decrease in intra abdominal pressure after birth results in a dilation of blood vessels supplying the intestines (splanchnic engorgement) and causes blood to pool in the viscera. This condition contributes to the development of orthostatic hypotension when the woman who has recently given birth sits or stands up, first ambulates, or takes a warm shower or sitz bath. When assisting a woman to ambulate, the nurse needs to consider the baseline blood pressure; amount of blood loss; and type, amount, and timing of analgesic or anesthetic medications administered. Women who have had regional (epidural or spinal) anesthesia can experience slow return of sensory and motor function in their lower extremities, increasing the risk for falls with early ambulation. Careful assessment by the postpartum nurse can prevent falls. Factors that the nurse should consider are the time lapse since epidural or spinal medication was given; the woman's ability to bend both knees, place both feet flat on the bed, and lift buttocks off the bed without assistance; medications since birth; vital signs; and estimated blood loss with birth. Before allowing the woman to ambulate, the nurse assesses the ability of the woman to stand unassisted beside her bed, simultaneously bending both knees slightly, and then standing with knees locked. If the woman is unable to balance herself, she can be safely eased back into bed without injury Preventing VTE is important. Blood is hypercoagulable in the postpartum period, especially during the first 48 hours after birth Women who mu

Leopold maneuver

help to answer three important questions: (1) Which fetal part is in the uterine fundus? (2) Where is the fetal back located? (3) What is the presenting fetal part? Leopold maneuvers can also be used to estimate fetal size. If you cant distinguish the position of the baby do an ultrasound But is softer than head Back curved and smooth Head is hard Limbs boney

Apgar score

routine rapid assessment of the newborn's overall status and response to resuscitation This assessment is based on five signs that indicate the physiologic state of the neonate: (1) heart rate, based on auscultation with a stethoscope or palpation of the umbilical cord; (2) respiratory effort, based on observed movement of the chest wall; (3) muscle tone, based on degree of flexion and movement of the extremities; (4) reflex irritability, based on presence of a grimace, crying, or active withdrawal; and (5) generalized skin color, described as pallid, cyanotic, or pink Evaluations can be completed by the nurse or birth attendant, depending on facility policy. Apgar scores of 0 to 3 indicate severe distress, scores of 4 to 6 indicate moderate difficulty, and scores of 7 to 10 indicate that the newborn is having minimal or no difficulty adjusting to extrauterine life. An Apgar score is assigned at 1 and 5 minutes after birth. For scores less than 7 at 5 minutes, the assessment should be repeated every 5 minutes for up to 20 minutes. Apgar scores do not predict future neurologic outcome for the newborn but are useful in describing the newborn's transition to the extrauterine environment and response to resuscitative efforts, if needed. If resuscitation is required, it should be initiated before the 1-minute Apgar score is determined Scores determine how the baby is adjusting to extrauterine life Minimal 7-10 Moderate 4-6 Severe 0-3 Severe or moderate score (0-6) require interventions.

Thermoregulation

maintenance of balance between heat loss and heat production. Hypothermia from excessive heat loss is a common and potentially serious problem. Changes in environmental temperature alter the temperature of the blood, thereby influencing temperature regulation centers in the hypothalamus The body temperature of newborn infants depends on the heat transfer between the infant and the external environment. Factors that influence heat loss to the environment include the temperature and humidity of the air, the flow and velocity of the air, and the temperature of surfaces in contact with and around the infant. The goal of care is to provide a neutral thermal environment for the newborn in which heat balance is maintained. The neutral thermal environment is the ideal environmental temperature that allows the newborn to maintain a normal body temperature to minimize oxygen and glucose consumption. Heat loss in the newborn occurs by four modes:***need to know*** 1. Convection is the flow of heat from the body surface to cooler ambient air. Because of heat loss by convection, the ambient temperature in newborn care areas should range between 22°C and 26°C (72°F to 78°F) and the humidity between 30% and 60% (exposure to drafts and circulating air) 2. Radiation is the loss of heat from the body surface to a cooler solid surface not in direct contact but in relative proximity. To prevent this type of loss, bassinets and examining tables are placed away from outside windows, and care is taken to avoid direct air drafts.(transfer of heat from body to cooler surface not in direct contact ex. Open window,cool wall, bassinet/incubator placed near vents) 3. Evaporation is the loss of heat that occurs when a liquid is converted to a vapor. In the newborn, heat loss by evaporation occurs as a result of moisture vaporization from the sk

Preterm labor definition

reg. contractions (power) + change in cervical effacement and/or dilation (2 cm. or more)

Mechanism of Labor

the turns and other adjustments req. for vaginal birth 7 cardinal movements of labor in vertex presentation: a combo. of these movements occur simultaneously 1. engagement: both descent and flexion 2. descent 3. flexion 4. internal rotation 5. extension 6. external rotation (restitution) 7. birth by expulsion

Box 18.6 Variable Decelerations

usually transient and correctable Causes: umbilical cord compression -maternal position with cord b/w fetus and maternal pelvis -cord around fetal neck, arm, leg, or other body part -short cord -knot in cord -prolapsed cord Episodic Interventions: 1. D/C oxytocin if infusing 2. change position (side to side, knee chest) 3. admin O2 @ 10 L/ min. via nonrebreather 4. notify HCP 5. assist with vaginal or speculum exam. to assess for cord prolapse 6. assist with amnioinfusion if ordered 7. assist with birth (vaginal-assisted or c-section) if unTx