Special Pops II Exam I CSN

Restrictions on Abortion

In Louisiana, the following restrictions on abortion were in effect as of May 1, 2018: • Abortion would be banned if Roe v. Wade were to be overturned • A woman must receive state-directed counseling that includes information designed to discourage her from having an abortion, and then wait 24 hours before the procedure is provided - Counseling must be provided in person and must take place before the waiting period begins, thereby necessitating two trips to the facility • Health plans offered in the state's health exchange under the Affordable Care Act may not provide coverage of abortion • The use of telemedicine to administer medication abortion is prohibited • The parent of a minor must consent before an abortion is provided • Public funding is available for abortion only in cases of life endangerment, rape or incest • A woman must undergo an ultrasound at least 24 hours before obtaining an abortion; the provider must show and describe the image to the woman • Update May 2019 - Louisiana Gov John Bel Edwards has signed a ban on abortion as early as 6 wks of pregnancy - New law will outlaw abortion when a fetal heartbeat is detected, which can come before a woman knows she's pregnant; law doesnt contain exceptions for pregnancy from rape or incest

Genetic Testing

• 11-14 weeks - Multiple marker screen done that incorporates the US for nuclear transparency and biochemical markers • 15-20 weeks - Maternal serum: AFP (alfa fetal protein) done w/ a quad screen, looks at 4 diff components for chromosomal abnormalities that would give an indication of possible neural tube defects • 18-24 weeks - US for fetal anatomy, diagnostic US • 24-28 weeks - Rh typing screen (if she has an Rh- factor and unsensitized she will get Rhogam at 28 wks gestation and again w/in 72 hrs of delivery - Glucose tolerance test (GTT) for gestational diabetes mellitus (GDM) • 35-37 weeks - H&H check for anemia, is pt at risk for anemia or hemorrhage - At 36 wks group B beta strep or group b strep culture, depending on the results we may need to give antibiotics during labor (ie. +) • Provides the tools to determine the hereditary component of many diseases - Improves the ability to predict susceptibility to diseases, the onset, progression of the diseases, and response to treatment/meds - Biggest problem is financial issues like not covered w/ insurance and cost ramifications • Genetic diseases affect individuals, families, communities, and society - Regards to financial aspects, lifestyle alterations, cost of long-term care, physical health problems, social isolation • Genetics-related nursing activities - Develop a plan of care that incorporates genetic assessment - Collecting, reporting, and recording genetics information - Offering genetics information and resources to clients and families - Make sure that pts are fully informed about their rights, risks for potential harm, and if the benefits outweigh the risk - Participating in informed consent process and facilitating informed decision making - Care of families who have lost a child to a genetic condition

Stages of Labor****

• 1st stage (pic) - Latent: start of contractions (0 cm) to 6 cm - Lasts < 20 hrs for nullipara - Lasts < 14 hrs for a multipara - Active: 6 cm-8 cm (acceleration phase) - Lasts < 1.1-3.8 hrs for nullipara - Lasts < 0.9 - 3.2 hrs for multipara - Transition: 8-10 cm (deceleration phase) - Lasts < 1-3.2 hrs for nullipara - Lasts < 0.6 - 2 hrs for multipara • 2nd stage - Lasts 30 mins - 3hrs for nullipara - 5 - 30 mins for multipara - Full dilation through delivery of the baby; 10 cm dilation and 100% effaced • 3rd stage - Up to 30 mins considered normal - Delivery of the baby through delivery of placenta - Dont want to pull it out; if it rips out of uterus can have fragments stuck in there; mom could hemorrhage to death • 4th stage - Lasts 1-4 hrs afterbirth - Delivery of the placenta through the first four postpartum hrs - Mom may have swelling, we need to apply ice to perineum, the sooner the better, ie. glove or ice 20 min intervals; apply it 20-30 mins and remove it fir 20 mins - Assess q 15 mins in 1st hr after birth for VS, perineum (intact), lochia and feeling fundus want it to firm up, q 30 mins the second hr - Emptying bladder constantly (uterus can't effectively contract)

Presumptive Signs

• Amenorrhea: women has missed her cycle - Other things: athlete w/ little fat content, irregular cycles • N&V (morning sickness) - Virus, things we ate, flu • Excessive fatigue (esp in 1st trimester) - Tired or stress • Urinary frequency (as baby grows, uterus can sit on bladder) - UTI • Breast changes (due to hormones) - Cycle • Quickening: felt btwn 18-20 wks gestation for a primagravida and 16 wks gestation for a multigravida (movement in stomach, fluttering) - Gas • Side note: pregnancy is 40 wks, broken up into 3 trimesters - 1st trimester: week 1-13 - 2nd trimester: 14-26 wks - 3rd trimester: 26-40 wks

Lacerations (Episiotomy)

• Assess their bottom if they have any lacerations or an episiotomy - May be edematous, bruised, are the stitches attached, is there a foul smelling odor pic - top left: 1st degree laceration, superficial vaginal mucosa and perineal skin; top right 2nd degree: vaginal mucosa, perineal skin and deeper tissue and muscles, 3rd degree all the above and goes to anal sphincter; 4th degree: all the above and lacerates through the anal sphincter • Are pt will be in pain, afraid to urinate or they will have a bowel movement • NI - Control pain: ice packs, dermophast spray ie. lidocaine spray, give a stool softener

Breastfeeding vs. Bottle

• Benefits - Breastfeeding: has immunoglobulins, nutritional aspects, vitamins and minerals, does wonders for psychosocial bonding of mom and baby, free and do it everywhere - Bottle: anyone can buy it and feed the baby, easy, trying to make is nutritional as the breast milk • Pros vs Cons - Con: family cant help with breastfeeding, mom would still have to pump in a bottle and then allow the family to help - Cons: formula is expensive, not the same bonding • When pt's ask say - Tell them about both, the benefits and pros and cons • Allow them to make an informed decision

Factors Important to Labor and Birth

• Birth passage: birth canal; mom pelvis has to be adequate • Fetus: size of fetus makes the biggest difference • Relationship btwn the passage and the fetus: size of passage and fetus • Physiological forces of labor: contractions and mom pushing • Psychosocial considerations: mom first time doing this, is she fearful, mom doing vaginal birth after c-section

Care of Breasts

• Bra - Correct bra to breastfeed • Pads - Moms will leak milk at the most inoppurtune time • Wash - Milk in dry moist pads the breasts will form funk, need to wash • Air - Air them out at home • Lanolin - Cares for breasts and prevents dry, cracking chaffing of breasts (colostrum has this same effect)

Malpresentation

• CPD (cephalopelvic disproportion)/fetopelvic disproportion - Baby is not proportional to fit through the pelvis; baby is too large - Frequently associated w/ labor dystocia (difficult) ends up in c-section • Transverse lie - Fetus assumes horizontal position in utero • Face presentation (mentum) - Fetal face becomes presenting part • Breech - Presenting part is buttock, feet or both - Flootling: one foot down coming out - Double footling: both feet coming down - Frank: butt is coming down and like they are touching their toes

Maternal Response to Labor

• Cardiovascular - Increase (slight) in BP w/ contractions; maternal position can affect CO (never on back and tilted to either side) • Respiratory - Oxygen demand and consumption increased with labor; increased depth and rate of respirations - Teach to take slow deep breaths, breath with contractions and not hold their breath otherwise they are cutting off O2 to their baby during this stressful time • GI - Decreased motility; gastric emptying time is prolonged and gastric vol remains increased regardless of when pt has last meal (can vomit) - Doesn't get digested so they are NPO; nothing heavy • Urinary - Reduced sensation of a full bladder; may have edema from the pressure of the presenting part of the bladder - Make sure bladder is empty and kept empty; baby can't come down the birth canal if bladder is full • Hematological - WBC count will slightly increase which is a physiological response to stress on the body from labor; increased risk for venous thrombosis during pregnancy and postpartum period

Uterine Rupture

• Causes - Uterine hyper stimulation (uterus needs to refill with oxygenated blood, needs a 60 sec interval to rest) - Tearing of old scar (watch VBACs) • Symptoms - Fetal distress - Loss of palpable contractions (moms uterus is ruptured and bleeding out, wont feel contractions) and bleeding and • Nursing interventions - Monitor maternal/fetal status - Prepare pt for emergency cesarean birth (baby can die)

Other Changes

• Cervical changes - After delivery its flabby, formless, may still be 2 cm dilated for 1st couple of days; after 1st childbearing the cervical os is permanently changed • Vaginal changes - Vagina is demitous, bruised, the size decreases and the rugae inside the vagina will eventually return around 3-4 wks postpartum, the tone and contractility is slow, may improve with kegel exercise - Upon discharge teach mom about kegel exercises at red lights or commercials (these are the muscles that stop the flow of urine

Biophysical Profile (BPP)

• Comprehensive assessment of 5 variables (not invasive, dynamic assessment based on acute and chronic markers of fetal disease; gives us an idea of baby's CNS) - Fetal breathing - Fetal movements - Fetal tone - Amniotic fluid volume - FHR accelerations with activity (reactive NST) <- desired effect - Each scored 2 for normal, 0 abnormal (no in btwn); total score of 8 is normal anything less than that you will have to look at 5th component - Indications

Monitoring Maternal Wellbeing

• Coping skills - Hard for mom to get monitored and stay still until she can get breathing techniques, or pain meds if she doesn't want epidural - First time moms are fearful and dont know what to expect • Support - Support person, who is there to help them get through this - They need our support if there is no one w/ them • Knowledge - The more mom knows the better prepared and the less anxiety (literature, pamphlets, and prenatal classes that we can give them info to sign up) - Assess their level of knowledge • Physical comfort - Position: have to stay still on either side; change positions frequently (q 1hr) (esp w/ epidural anesthesia) - Supine hypotension: dont want them on back, vena cava is compressed by heavy uterus and fetus

Maternal Assessment of Fetal Activity

• Daily Fetal Movement Count (Kick count); how active is fetus - Counting amount of movement the baby is doing (mom can do it at home, time how many times you feel baby moving or kicking) - What is a fetal kick count? - What is its purpose? - This is frequently used in pregnancies complicated by conditions that may affect fetal oxygenation - May be ordered one time a day for 60 mins or until 10 fetal movements are counted; Or 2-3 times a day for 2 hrs until 10 fetal movements are counted - Fewer than 10 movements in a 2-3 hr period would be less than usual; a count <3 in 1 hr need further eval and other testing ie. NST (non-stress test), CST contraction stress test, US - Note: movements aren't typically present during sleep cycles that can last about 20 mins (30-40 mins); if their on antidepressants, drink alcohol, smoke or take a narcotic including methadone, heroin; Also their movement doesnt increase nearing term (not a lot of room due to growth); obesity decreases perception of fetal movement - Provides reassurance of fetal well being

Shoulder Dystocia

• Delayed or difficult delivery of the anterior shoulder due to impingement on the symphysis pubis • Symptoms - Delay in delivery of head; regression of head into vagina (turtle sign; mom is pushing and baby's head comes down and as soon as the contraction is over the baby's head goes back in vagina) • Nursing Interventions - Assist w/ maneuvers to effective delivery of infant - Assessment of infant for injury (assess clavicles for fractures and lift both arms up for startle reflex) (pic) Positioning for anticipated or expected shoulder dystocia, put the in Mc'Roberts to open pelvis as wide as possible - Suprapubic pressure is only ok; fundal pressure is not ok, dont put elbows over breast bone (cause broken bones and cranial issues)

Cesarean Birth

• Delivery of infant through an abdominal incision; uterine incision may differ from skin incision • Skin incision types - Pfannenstiel/ low transverse: bikini cut - Vertical incision into uterine body: big incision • Uterine incision types - Low transverse: bikini cut - Low vertical - Classical: incision is made in the upper uterine segment, all the way down; was done mainly in emergency cases and not used as much anymore • Indications - Fetal distress/maternal distress or compromise - Abnormal placental implantation/abruption (placenta not were it needs to be, previa, covering the cervix; uterus has the placenta glued to the uterine wall, and starts to pull off) - Cervical/vaginal abnormalities (moms has tumors on cervix or cervix doest dilate) - Fetal mal presentation - Cord prolapse (cord falls out before baby) - True CPD (cephalopelvic disproportion; moms pelvis is too small for baby) - Prior classical/undocumented cesarean birth - STI (HIV, Herpes) can deliver vaginally, for herpes as long as their is no outbreak of lesions because baby can become infected

Umbilical Cord Prolapse

• Descent of umbilical cord into birth canal ahead of presenting part (cord is out, presenting part like a head causing cord compression) - ie. mom calls, not ready to deliver but says something fell out my vagina, cervix wasnt that dilated just left the room • Symptoms - Pulsating cord noted outside of vagina or noted in vagina on vaginal exam • NI - Maternal positioning (reposition to all fours, knee to chest) - Elevation of presenting part (lift presenting part off of the cord until they bring mom to OR, would see variable decels) - Preparation for cesarean birth - Pt cannot ambulate around the room, unless baby is 0 station or more in the positive plane; cant even get up to go to the bathroom, put a bed pan - ie. Moms membranes are broken, her cervix is dilated 5 cms, 90% effaced and baby is at a -1, cannot get her to ambulate around the room because the baby is not engaged and the cord can slip down; babies that are breech are more prone to have a prolapsed cord because the babies head isnt blocking - ie. If mom is dilated, not ruptured, she can ambulate around in the - plane (pic)

Nutritional Care of Formula-Feeding Mothers

• Dietary requirements to prepregnancy levels - Go back to normal diet; but include nutritional foods like green leafy vegetables and lots of fluids • Nutrition teaching is necessary • Referral to dietician if excessive weight gain - Also if they have excessive waking, can refer to a dietician • Teach about infants nutritional needs

Fetal Breathing Movements

• Done w/ US • Normal: Score of 2 - ≥ 1 episode of rhythmic breathing lasting ≥ 30 seconds within 30 minutes • Abnormal: Score of 0 - Absence of a ≤ 30 second breathing episode in 30 minutes

Breast and Breastfeeding

• During pregnancy - Breasts have increased, start making colostrum - Increased levels of estrogen, progesterone stimulate breast duct proliferation, development • Once placenta expelled - Progesterone levels fall -> triggers milk production • When assessing moms breasts, assess her nipples, are they dry, cracking or healthy, look at the size, shape and engorgement (may put a warm compress or ice)

Assessing Fetal Heart Tracings

• Early Decelerations: decline in FHR, lowest part HR drop correlates w/ peak of contraction, produces mirror image; or the lowest part of the decel can also occur prior to contraction peak - Least worry some, tells us that there is head compression and the baby is coming down, good thing - Interventions checking pt to see where baby is, how far down is it, its it almost coming out; prepare for delivery, call the doc, check the cervix, pull those covers out and maybe baby is coming out • Late Decelerations: lowest part of decel occurs after or later than peak of contraction - Most worry-some, interruption in O2 and perfusion btwn mom's uterus to placenta, cord and fetus; baby is getting hypoxic - Interventions: reposition mom, make sure she is not on back, face mask on mom w/ 7-10 L of O2 (start w/ 7-8 L), IV fluids (raise BP due to hypotension*; if not going up fast enough can get nurse anesthetist and give pt IV push vasoconstrictor, ephedrine), turn off pitocin, call doc - ie. See them in moms w/ epidural • Variable Decelerations: abrupt drop and abrupt return to baseline that looks like a u, v, or w; doesnt correlate w/ contractions, can occur at anytime on the strip even when there are no contractions - Related to cord compression, baby is rolling on cord - Interventions: if mom has a koala monitor can instill fluids, reposition, give O2 through face mask 7-10 L (O2, turn pitocin off, turn her over) - ie. Could be cord hanging out which is an emergency cesarean, can cover w/ some saline gauze to keep it clean, hold presenting part off umbilical cord (dont let them walk around of they are 0 station and water broken, cord can fall out) • VEAL CHOP (pic) (extra study practice 41:26 YouTube intrap. 2)

Nutritional Care of Breastfeeding Moms

• Eating healthy and meeting daily requirements - Take 500 additional calories of food • Needs increased during breastfeeding • Inadequate intake can reduce milk vol • Liquids important during lactation (water) • Discussion of specific foods, breastfeeding - ie. eating gassy foods like broccoli or cabbage will make the baby gassy too, hot spicy food will be passed on and alcohol will be passed on

Contraction Stress Test (CST)

• Evaluating function of placenta (placental sufficiency or insufficiency) - Means of (inducing or natural contractions to) evaluating the oxygen and carbon dioxide exchange of the placenta, an indicator of if the fetus is at risk for intrauterine asphyxia by observing the response of the FHR to the stress of the contractions • Critical component of CST • Electronic fetal monitor (requires) • CST classification: negative, positive, equivocal, unsatisfactory (pics) (35:00)

Eval (Antepartum)

• Expected outcomes may include: - Client, partner are knowledgeable about pregnancy - Expectant couple and children, if any, are able to cope with pregnancy, future implications - Client receives effective health care throughout pregnancy, birth, postpartum - Client, partner develop skills in child care and parenting

Urinary System

• Extensive diuresis (production of urine) occurs almost immediately after birth • Urethral edema: from fetal head coming down and placing pressure on ureters - Status increases risk for UTIs (make sure water pitchers and filled and they urinate) - Decrease sensation to void • Bladder - Assessing if it distended, if she had an epidural and c-section will have a foley, make sure she urinates - What does the urine look like, is it clear, cloudy, dark, 30 ml/hr • Bowel movement - As long as she is passing gas thats good; may not have a bowel movement if she was NPO or on ice chips - If she is swollen, has a laceration or episiotomy will be afraid, provide lots of water, may give a stool softener

Any Problems?

• Falling asleep after feeding less than 5 mins - Is baby all warm and swaddled they will fall asleep; get the baby mad, naked and do skin to skin (baby will be warmed by moms temp of body) • Refusal to breastfeed - Baby a c-section baby, has a belly full of amniotic fluid, their full and dont wanna eat • Tongue thrusting • Smacking or clicking sound • Dimpling of cheeks - (^ all three) Baby is not latched on correctly • Failure to open mouth wide enough to latch-on - Help baby open mouth • Lower lip turned in • Short, choppy motions of the jaw • No audible swallowing - (^) baby not latched on correctly • Use of formula - Only give formula in an exclusively breastfed baby if there's any hypoglycemic problems and the baby needs sugar now (breastmilk isnt raising BS enough) - If mom wants to exclusively breastfeed, we discourage the use of formula, the baby who drinks out of the bottle doesn't have to work for the milk (nipple confusion: get used to bottle nipple rather than moms breasts)

Positive Signs

• Fetal visualization (see the fetus by like 16 wks; using vaginal US or trans abdominal <- 17-18 wks to see something) - Ultrasound (or very early using a vaginal probe US; early as 5 wks can "see" fetus heartbeat) - X-ray (not recommended, can cause fetal abnormalities) • Fetal heart sounds - Fetoscope (like a stethoscope) - Doppler (10 wks gestation; "heard" esp in lower in suprapubic area in early pregnancy) - Uterine Souffle: mom's pulse from aorta, bruit type swish slower pulse (doppler over that umbilical artery) - Funic Souffle: fetus's pluse, fast pace (normal 110-160) • Palpable Fetal Movement: can feel the movement of the baby over abd - Quickening (more obvious)

Maternal Teaching

• First movement felt around 18 weeks • Explain procedure for counting (how) - Take a daily record, count at the same time each day - ie. if they will do it after work or in the evening, try to get it as close by the same time each day - Usually it's approximately 1 hr after a meal (baby getting enough sugar or not eating) - At least 1 hr after each meal, you want them to lie quietly in the side lying position (either side) and do the kick count • When to contact provider

Genetic Key Points

• Genetic disease affects people of socioeconomic levels and racial and ethnic backgrounds • Genetic disorders span every clinical specialty • Expensive • Decisions based on results (ie. mom or fam getting an abortion based on findings)

Gravida & Para**

• Gravida is how many times a women is pregnant no matter what the outcome is • P stands for para which refers to live births (births that occur after 20 wks gestation) • TPAL - Abbreviation gives a more descriptive meaning of P - Term (after 37 wks), Preterm (20 wks to end of 37 wks beginning 38 wks), Abortion (prior to 20 wks if a women loss a baby/pregnancy, a miscarriage), Living - Side note: still born baby is one who is loss after 20 wks and baby isn't viable, not moving around, no HR (ie. 22 wks) - Twins, triplets, and other multiples are counted one one pregnancy and one birth

Nurses Role in Admission to L&D Unit

• Greet pt and establish a rapport w/ pt and support person • Obtain prenatal record of available (last time seeing doc, any changes) • Obtain VS and perform admission assessment per institution protocol (last time they ate or drank) • Contraction monitoring for frequency and intensity • FHR monitoring*** (1st thing to do after mom in gown in bed) - ie. in terms of priority, if mom says i think im leaking fluid, before you check and make sure its amniotic fluid, get on monitor and check babies HR and check if its amniotic fluid is - ie. if baby is coming out vagina we will take care of baby and not FHR • Urine and blood samples (as ordered) - ie. CBC: WBC, H&H and PLTs (enables them to get an epidural - ie. Cardiac pt, renal or preeclampsia may have to do chemistry, STI testing at end • IV fluids line may be started (if ordered) to prevent dehydration and give meds if necessary; pt may be allowed ice chips, popsicles, or sips of oral fluids (NPO) • Comfort measures and pain relief options will be discussed if desired • Documentation of admission

Physical Assessment (PP)

• Head to toe • VS - BP should return back to baseline, pulse may be around 50-90 bpm, RR 16-24 breaths per min, temp should be afebrile (anything over 100.4 she has a fever) • Abdomen - C-section incision - Musculature - Abd soft, doughy texture (due to diastasis recti) (57:29 practice Qs)

Fetal Response to Labor

• Hemodynamic Changes (Placental Circulation) - Decrease in maternal fetal transfer of oxygen and nutrients during contractions (cessation if blood flow); usually a healthy fetus can withstand the anoxic periods during the contraction and has enough oxygen reserves • Cardiovascular - HR is rapid and changes based on fetal response to stress of contractions; if it doesn't return to baseline than something else going on, ie. head getting squeezed • Pulmonary System - Increased absorption of lung fluid; additional fluid is expelled as baby passes through birth canal (an still have extra fluid seeping out, all that fluid will come out w/ baby; c-section babies dont get that squeeze so its normal to hear wet lungs) • Fetal Sensation - Beginning at 37-38 wks, the fetus is able to experience sensations of light, sound, and touch; can hear the maternal voice and can also feel the practitioner doing vaginal exams during labor (their HR jumps; good thing)

GI System (Bladder and Bowel)

• Hunger and thirst is common - Babies aren't in the way anymore and they are hungry, plus was NPO or on ice chips • Hemorrhoids common - Can get it during antepartum period or through actual labor from pushing, need to assess to make sure they dont have any • Relaxin still present decreases bowel activity - Need to assess and listen to our pt's bowel sounds before advancing their diet as tolerated • Painful stool evacuation - Esp if they are on pain meds that cause constipation, teach to eat lots of fiber, green leafy vegetables and keep water by bedside full • Cesarean birth - Clear liquids

Placenta Previa

• Implantation of placenta close to or over cervical os • Symptoms: - Painless vaginal bleeding (bright red blood coming down; from irritation of vessels in the placenta) - May be noted on US examination • Nursing interventions - Teaching - Do not put anything in the vagina can perforate the placenta and cause a huge issue, no digital exams (tell residents) - Monitoring fetus - Monitoring of maternal hemodynamic status (mom can hemorrhage to death, watching it for shock, her VS)

Premonitory Signs

• Increased Braxton-Hicks contractions: annoying, tightening and relaxation of uterus that can be painful, if you exercise they go away, wont get stronger and closer together during labor (not the type) • Lightening: baby drops down preparing for delivery • Rupture of membranes: amniotic fluid breaks and starts leaky amniotic fluid (needs to come in both mom and fetus can get an infection) • Bloody show: blood tinged mucus discharge from contractions, the cervix dilating and effacing, causing trauma and bleeding; perineum or inside thighs slightly bloody means their is cervical change and its getting bigger (normal and want to see this) • Increase in energy level: mom gets burst of energy at the end of pregnancy "nesting ready"; get sure nursery is ready, calender • Cervical changes: starts to soften, loosen up, dilate and efface • Weight loss: may loose appetite, diarrhea, nausea (ie. pound or half a pound) • Mucus plug isnt a monitory sign, they can loose this wks before

Phases of Contractions (3 phases) pic

• Increment - Contraction is starting to build, starting to feel the abd get harder and harder and harder • Acme (peak) - Hardest, forehead feel • Decrement - Decline of contraction to baseline • Remember the interval needs to be at least 60 secs of rest

Monitoring Fetal Well Being

• Intermittent auscultation (doppler)/continuous monitoring (big monitor in the hospital) - Fetoscope: facilitates auscultation if FHR (like a stethoscope) - Doppler/external monitor: after 10 wks, done at q doctor visit, helps to listen to FHR, put it on moms abd - Internal monitoring/spiral electrode aka FSE (fetal scalp electrode) Describing FHR - Baseline established first; normal 110-160 - Accelerations: HR thats increases in bpm - Decelerations: HR that decreases or slows down - Variability: how variant/active is the FHR; want it all over the place, lets us know fetus has an intact CNS (how much up and down is it going) - ie. flat or minimal means the baby is either in a sleep cycle or mom has a narcotic thats affecting baby, or baby not getting enough O2 • External monitors - Transabdominal US: measures HR (disk on monitor is flat, put conduction jelly and apply to moms abd) and this is heard best over babies back - Tocodynamometer (TOCO): measures contractions (button gets pressed when abd gets hard like a rock w/ contractions) Do Leopold's maneuver to determine babies position • Internal Monitor - FSE: electrode attached to the babies head, a corkscrew thats screwed into babies scalp to trace the FHR; done if baby is continuously not staying on the monitor but we can auditorily hear on external monitor a drop in HR but cant see it on monitor we want to know whats going on - For this to be down moms cervix needs to be dilated, her membranes or water needs to be broken, and baby needs to be at least a -1 station to get it on babies scalp - A nurse or practitioner can insert these (push it ip against baby's scalp and twist it in the babies scalp) - Intrauterine Pressure Catheter (IUPC) Koala: long stiff catheter thats threaded into moms vagina and rests against uterine wall and measures the pressure during a contraction (most accurate way to measure contractions) - Used if can't trace the contractions or keep contraction pattern going - ie. Pt running a high-dose pitocin - Can cause uterine rupture, can perforate the uterine wall (nurses don't insert; physician) - Anyone w/ a uterine scar from a surgery/GYN thing or uterine scar from a previous c-section thats doing a VBAC (vaginal birth after cesarean) the IUPC is contraindicated; can perforate the uterine wall and cause a uterine rupture - Has a port that enables us to put IV fluids, filling uterine cavity; fluids hung on blood warmer - ie. baby has meconium (thick pea soup; greenish clear fluid that can have chunks of particulate) easier to suck out meconium on baby if we can thin it in utero; dont want baby to aspirate thick meconium coming down the birth canal, prones for bacterial pneumonia in their lungs - ie. baby not tracing real well and having variable decels due to cord compression, we can add fluid in uterine cavity to keep cord floating and save mom a c-section • Fetal Heart Tones Landmarks - On external monitors FHR best heard on babies back over the sacral area - If hearing fetal heart tones above umbilicus on either quadrant of the abd, this baby is foot down and breech - Close to the bottom quadrants the occiput (back of head is the landmark), when its posterior and baby is head down and leaning more to the right will hear it on the right side ROA (anterior), if leaning on the left will hear heart tones more to the left • Leopold's Maneuver (pic) - Feeling for baby • Fetal Positioning (pic) - Moms pelvis is divided into 4 quadrants: RA, RP, LA, LP (viewing/looking moms pelvis like looking down at our own) - Determine which quadrant presenting part (occiput) is pointing towards

Uterus Involution

• Involution: - Uterus returns back to its prepregnancy state, after delivery fo placenta it starts to shrink down (doesn't go back completely to prepregnancy state but starts to try) - Rapid contraction of uterus • Placental sealing - Placenta site heals and seals over 6 wks to control the bleeding through rapid contraction; stops itself from hemorrhaging • Uterine shrinking - Fundus should feel firm; if it feels boggy (soft and flabby) its not contracted as really wanted - If uterine atony occurs during the 1st hr of postpartum, the woman can loose blood very quickly and go into postpartum hemorrhage • Within 6-12 hrs after delivery the fundus rises to the level of the belly button, one finger-breadth above the umbilicus and then it descends about 1 to 2 cm a day by day 10 you cant feel it anymore - pic : day of delivery is at the umbilicus, day 1 is -1 and one finger breadth below the umbilicus, day 2 is -2, 2 finger breadths below and so on - If moms uterus is shrinking faster, like day one postpartum and she is 3 fingerbreadths below the umbilicus thats okay - Remind pts to continue to void so their uterus can contract

Preterm Labor/Preterm Birth**

• Labor/ Delivery after 20th wk of pregnancy, but before completion of the 37th wk of pregnancy (beginning of 38th wk) - Can be due to infection, multiple gestation (more than one baby), cervix is real soften, wants to dilate and has contractions - Magnesium sulfate is given to delay labor, relaxes smooth muscles, uterus but also lungs and heart; constantly assess resp status, rate and quality (can go into resp depression), deep tendon reflexes, urine output 30 ml/hr (to prevent toxic blood levels; q 2hrs checking and they have a urometer on the catheter) and Mg2+ levels (q 6 hrs) - antidote: calcium gluconate; available - can use terbutaline, Brethine can get it go home

Monitoring Labor Progress

• Maternal Behaviors - First stage of labor - Latent (talk on phone, not really feeling pain)/Active/ Transition (beginning) - Second stage of labor - Transition (toward the end) completely dilated to delivery of baby - Third stage of labor - Delivery of baby to placenta • Cervical Exams (pic) - Assessing dilation, station and effacement • Friedman Curve: not responsible, avg labor curve with normal time span of labor

Uterine Involution

• May be delayed due to (not be firm) - Birth of multiples: twins, triplets; uterus was stretched doubly, triply and its going to take more effort to go back to prepregnancy size - Hydramnios: more fluid; extra fluid extra stretches uterus and going to take more effort to contract - Exhaustion: if mom was in labor for hrs and hrs, uterus muscle is tired, going to take a lot of effort - Grand multiparity: 2nd, 3rd, 4th kid, the uterus has stretched and released that many times - Retained placenta or membranes: if pieces are left (no matter how small) in the uterus, it wont firm up like we want it to; need to massage the fundus - Full bladder: if bladdr is full and pushing the uterus to the side, not gonna firm up; make sure pt pees

Speculum Exam (SSE)

• May be performed if pt is preterm, uncertain about rupture of membranes or to obtain specimens - ie. Pt comes in at 34 wks gestation, their contracting every 5-10 mins and we want to check the cervix but not aggregate it by touching and pulling, put sterile speculum in to see how open the cervix is - Also done when pt comes to L&D with no prenatal care, no cultures, have nothing • Sterile speculum used to visualize vagina and cervix • Dilation, presence of fluid, blood or indicators of infection can be observed - Have mom do valsalva maneuver, where she will cough or bears-down w/ speculum in there if their is a ruptured membrane, the membrane fluid will pool in the vagina for us to check to see if its amniotic fluid • Fetal fibronectin testing (protein, that if its present then its possible that its ruptured membranes), PG testing (take amniotic fluid to test for a ratio that correlates w/ surfactant and development of the lungs)

Operative Vaginal Delivery

• Mom is pushing and having a hard time getting baby out • Use of instruments to facilitate and hasten delivery of infant when vaginal birth is anticipated • Vacuum extractor (no more than 3 "pop offs") aka kiwi - Suction cup that goes over babies head (cant be over fontanels), when mom is pushing and contraction is occur the doc will pump it up and pull it - Sometimes the suction gives up and pops off, when it pops off its sucking of the babies scalp, only allow 3, baby can get a serious hematoma on their scalp (use as necessary; mom is exhausted or had a really good epidural and pushing well enough) • Forceps - Used now just to get baby down far enough through the birth canal to deliver the baby - Can be used if baby's head is turned sideways, and we just rotate the baby's head w/ the forceps to the position we like so it can fit under the pubic bone - Can cause cranial damage, cephalic issues, neuro damage/neuromuscular issues • Indications - To expedite delivery due to - Fetal distress (hear babies HR is going down (decels) w/ every contraction, and mom cant push effectively) - Maternal exhaustion - Inability to push due to profound anesthesia - To decrease maternal exertion

Effacement and Dilation

• Multigravida: - Effacement & dilation take place concurrently • Primagravida - Effacement: 50% before labor starts - Dilation: takes longer because the cervical tissue has not be stretched before (Fig 33-47 pg 2277) • Documentation - 5/90/+1 - Cervix is 5 cm dilated - Cervix is 90% effaced - Station is at +1

Determining Due Date

• Nagle's Rule - Take the first day of the LMP and subtract 3 months and add 7 days - ie. 1st day of last menses was June 10th so if I subtract 3 months and 3 days, the due date is March 17th • Due date is expressed as EDB (estimated date of birth) or EDC (estimated date of confinement) - Also can use a EDB wheel (usually used by practitioners) and is esp helpful to determine wks gestation for a pt that presents w/ preterm labor

Management of Discomforts of Labor

• Nonpharmacological - Support - Position changes - Massage - Hot/cold compresses - If have back labor, might roll up a warm blanket out of warmer and stick it back there or microwave rice sock - Hydrotherapy - Rhythmic breathing/Lamaze - Hypnotism (hypnobirth) - Visualization - ie. Your on the beach, do you smell the pinapple, pina colada, you'll be there just after you deliver this baby - Acupressure/acupuncture • Pharmacological Comfort Measures - IV meds: sedatives, hypnotics, analgesics (usually given in early labor and have very limited times for admin) still feel pain, grimacing, just eases the pain; most commonly given is Stadol/Phenergan IVP) max of 2 doses - ie. If someone gets this and delivers their baby soon, need narcan because the baby will come out floppy, maybe having a hard time to breath - Local anesthetics: paracervical block, infiltration of perineum (commonly used to suture lacerations/episiotomies at the time of the delivery) - Regional anesthetics: epidural (takes longer to work but lasts longer than a spinal), spinal (work very quickly but doesn't provide pain relief for long periods of time; can get a spinal HA due to blood mix w/ CSF so dont sit up real fast, keep room quiet and dark, can do a blood patch, lay flat, no walking), CSE (combination spinal and epidural; begin w/ spinal for quick relief of pain then administer the epidural to provide longer pain relief throughout labor) - After admin monitor BP q 5 mins w/ spinal then when epidural kick in monitor BP for at least 1st 30 mins - ie. If mom becomes hypotensive, roll her on her side, give O2, give fluids, if fluids not raising it admin ephedrine

Lochia Documentation

• Normal vs. abnormal amounts - After we massage the fundus we need to assess what came out - If they saturate a pad in less than an hr its abnormal and were going to be concerned for postpartum hemorrhage - Lochia shouldn't contain large clots, if pt says they are passing clots we need to ask what size, can refer them as size of coins penny size, dime size, quarter size; one or two is ok; passing large egg clots concerned - Should never have an absence of lochia, a c-section pt may have very minimal lochia for the 1st couple of hrs • Document amounts per hr - Scant: 1" stain - Light: 1"-4" stain - Moderate: 4"-6" stain - Heavy: saturated - ie. if we come in pts room and assess their pad and see thats its heavy and saturated, were going to ask them when was the last time they changed their pad, if it was an hr again were concerned, if she fell asleep and got a decent's night sleep and didnt change her pad the night before then ok were gonna keep and eye on their pad

Amniotic Fluid Vol (23:54)

• Normal: Score of 2 - At least one pocket of fluid that measures at least 2 cm. in two planes perpendicular to each other • Abnormal: Score of 0 - Either fluid is absent in most areas of uterine cavity or the largest pocket measures ‹ 2 cm • Amniotic fluid index (AFI): measures the amount of fluid around the uterus

Fetal Muscle Tone

• Normal: Score of 2 - ≥ 1 episode of extension of a fetal extremity with return to flexion, or opening or closing of the hand within 30 minutes • Abnormal: Score of 0 - Extension with return to partial flexion; absence of flexion

Fetal Body Movements

• Normal: Score of 2 - ≥ 3 trunk movements in 30 minutes; limb and trunk movement is considered one movement • Abnormal: Score of 0 - ≤ 2 episodes of trunk movement in 30 minutes

Implementation (Antepartum)

• Nursing care of parents over 35 more likely to have chronic medical conditions • Risks: - Risk if death has declines dramatically - Birth rate for women 35-39, 40-44 - Highest in more than 3 decades - Women over 35 more likely to have chronic medical conditions - Cesarean birth rate increased - Risk of conceiving child w/ Down syndrome • Identify concerns and promote strengths Nurse needs to: - Discuss risks - Identify concerns - Promote strengths amniocentesis or Chorionic villi sampling - Provide information, answer questions (explain all plan testing procedures including any special pretesting directions and obtain informed consents; answer all client questions including why the tests are needed, what the test entails, when will results be available, and significance of test results - Provide comfort, emotional support in decisions (demonstrate nonjudgmental attitudes and do not project our beliefs and feelings to the patient just because we feel a certain way) - Protect privacy during testing

Nutritional Aspects During Pregnancy

• Nutritional Needs (make sure mom is eating properly and getting enough) - Folic acid and prenatal vitamins should be taken even when contemplating getting pregnant - Extra: nutritional aspects: weight gain, avg is 25 lbs (includes baby, breast, uterus, placenta, amniotic fluid); majority of weight gained in 3rd trim. • Nutritional risk factors - Make sure they have access, like WIC so they can eat properly - Teen moms are worried about body image and they dont want to gain weight, • Patient teaching - Edu about eating healthy and get them the resources they need • Prenatal vitamins w/ iron • Folic Acid is important - Foods like meat, legumes, beans, spinach, green leafy vegetables

Assessment (Antepartum)

• Ongoing assessment - General guidelines for prenatal visits - Every 4 weeks -> first 28 weeks - Every 2 weeks -> until 36 weeks - After week 36 -> every week until birth • If at high risk may come in more often or come in for NST • Pregnancy - Understanding of pregnancy, changes - Attitudes, expectations - Health teaching needs - Support available - Knowledge of infant care, nutrition

Fundal Check

• Palpate the fundus after delivery, q 15 mins for the 1st hr PP (want firm - Support the fundus with one hand at the bottom, and use your dominant hand to feel and massage the fundus with the side of your hand (pic) - Tell the pt what we are doing and why we massage the fundus because sometimes it can be painful esp if they have a c-section; normal for them to say they feel like something is coming out, its blood and thats normal; when breastfeeding she may feel blood come and thats ok due to oxytocin contracting that uterus • Document as - U-1, U-2, U-3, U-4 - Firm - Boggy - Midline, right, to the left • If fundus is off midline, our first action is to have mom pee, bladder may be in the way

Monitoring Contraction Patterns (Methods)

• Palpation (bell shaped curve on strip, it accelerates, peaks up and goes back down to baseline) - Strength: feel moms abd and feel the "nose" softest part of abd, as contraction starts to build the abd will feel like a "chin", when contraction peaks you feel the "forehead" hardest part and then it goes down the chin, nose, and resting tone - Frequency: time period from the beginning of one contraction to the beginning of the next contraction (ie. q 2 mins) - Duration: time period from the start of the contraction to end of the contraction (ie. counting the 10 sec squares, have one that 50 secs, next one 40 secs, next one 70 secs, range is 40-70 secs in duration) • External monitoring - Palpation (palpate abd) - Toco (when putting Toco, palpate abd to see where it's balling up the hardest) • Internal monitoring - Intrauterine pressure catheter (come out during labor)

Meconium Staining

• Passage of fetal intestinal contents into amniotic fluid usually occurs when there is some kind of distress going on w/ fetus (hypoxia at some point) • S+S - Green or brown colored amniotic fluid (has a bowel movement); may be particulate - Want to see whiteish clear color (vernix on babies skin) • NI - Assessment of fetal status (make sure they dont aspirate it by thinning fluid out, suction out babies air way) - Procedures as ordered (amnioinfusion; hook some warm fluids up and flush out uterus w/ IUPC)

Assessment (Postpartum)

• Physical assessment - Thorough and a great opportunity for teaching • Psychological assessment - How is she adjusting, is she coping ok because this is a happy time but a big adjustment -ie. first child and now she is a mom who has to take care of another human - ie. She has 4 little ones running around and this is her 5th child • Postpartum psychological adaptations - Psychological assessment high risk factors - Unplanned pregnancy - Just her jib due to Covid and thinking how am I going to pay for this child and myself - In an abusive relationship - Is she excessively fatigued - Does she have a hx of depression prior to delivery; look out for postpartum depression - Is there evidence of lack of self esteem or lack of support - ie. she is constantly in the room alone or she delivered alone, does she have marital problems; have an open eye and really listen to whats going on w/ our pts - Does she have the ability to care for and nurture her newborn when she goes home

Perineal Changes

• Portions of the perineum may show ecchymosis, edematous • Laceration? Episiotomy? - Extended if a laceration was involved - Usually they are 1-2 cm long - Incision is generally fused by 24 hrs PP (want to make sure the edges are well approximated) • NI - Provide pain relief by using ice packs, dermoplast spray - Teach pt how to clean their bottom, provide a water bottle, spray their perineum from front to back with the warm water - They may do sitz baths

Psychological Adaptations

• Postpartum period - Readjustment, adaptation for family, mother - Went from husband and wife to husband, wife and child or was husband and wife with 3 kids now their 6 - How are the siblings reacting, are they adjusting or jealous • Mother experiences variety of responses - Adjustments in body, family life - Many women expect for their body to go right back to prepregnancy shape but for the majority it doesn't happen • Assess, facilitate maternal-infant bond - Look how is mom bonding with her baby - ie. is she lovingly holding her baby, making eye contact, constantly checking out the baby, changing the baby - ie. come in the room and see baby crying in bassinet in the corner and mom is sitting and texting on her phone, that would bring a cause for concern

Prolonged Pregnancy

• Pregnancy over 42 wks of gestation • Risks - Uteroplacental insuff (placenta ages and disintegrates, not as vascular and starts to calcify; hypoxia sets in, see late decels on the monitor) - Macrosomia (gets nutrients that are not as good but continues to grow) • Monitoring - NST - CST - BPP (Done on pts at high risk, DM pts, vascular issues pts (hypertensives and preeclamptic)

Placental Abruption (38 mins show jess)

• Premature tearing away of placenta from uterine wall • Symptoms - Vaginal bleeding - Intense abd pain (board-like, very hard abd); guarding • Nursing interventions - Management of hypovolemia/shock - Monitor hemodynamics (can have outward hemorrhaging coming out the vagina or internal, concealed bleeding inside the uterine cavity - Monitoring of fetal status - Assistance w/ cesarean birth

Contraindication for CST

• Preterm labor or who are risk for preterm labor (not a good candidate) • Extensive hx of uterine surgeries or a classic uterine incision from a prior cesarean birth (dont want to create contractions and put them at risk for a uterine rupture) • Diagnosed pf placenta previa (placenta is at the opening of the cervical os and doesn't move up w/ the pregnancy • Premature rupture of membranes (prematurely broke their water; membranes: amniotic membranes)

Contractions

• Primary force - Def: uterine wall contracts and balls up and there is temporary cessation of blood flow and relaxes - Purpose: squeeze baby down the birth canal - Phases of contractions (3 phases) - ***Imperative that there is at least 60 secs resting interval btwn ctx. - Note: the resting period becomes shorter w/ the progression of labor - ie. give terbutaline to space out contractions

Alternations High Risk

• Prolonged labor (lasts hrs) - Exhaustion - Increased risk of hemorrhage - Nutritional, fluid depletion (NPO) - Bladder atony, trauma (concerned about voiding) • Difficult birth (ie. shoulder dystocia, baby gets stuck) - Exhaustion - Risk of lacerations, hepatomas, hemorrhage • Extended period of time in stirrups (blood flow is interrupted in lithotomy position) - Increased risk of thrombophlebitis • Retained placenta - Increased risk of hemorrhage - Increased risk of infections

Pregnancy's at Risk

• Prolonged pregnancy, past 42 weeks - 42 wks is a long pregnancy that can cause high risk issues, placenta starts to breakdown (doesn't give perfusion and oxygenation needed) • Multiple gestation - More than one fetus • Prior preterm birth - Delivered a premie before, at risk • Previous pregnancy losses before 20 weeks gestation or diagnosed cervical insufficiency - Competent cervix, is it able to hold pregnancy Think about • Maternal Age - If younger than 16 yrs or greater than 35 yrs • Chronic maternal conditions • Rh iso immunization • Maternal hx of still birth • Suspected intrauterine growth retardation/restriction (IUGR)

Assessing Rupture of Membranes

• SROM vs. AROM - Spontaneous or artificial (amnihook inserted and snag at fluid) • Time - What time is it (dont want to go past 24 hrs and risk chorioamnionitis) - ie. Mom comes in my water broke at 4 am now its 7 am - ie. Doc breaks water at 8 am • Color - Brown, green, amber green yellow (meconium present?), clear, specks of blood • Consistency - Pea soup or thin watery • Odor - Pungent infectious odor or reg odor • How to Tell - Nitrazine paper: a q-tip collect fluid, rub this on paper, if it turns dark blue, the patient is ruptured or lost her water bag; if it doesnt change color than might be urine or vaginal secretions - Ferning: take swab and put on a slide, look under a microscope and see a ferning pattern, its positive for amniotic fluid - Valsalva: get fluid to pool in vagina to have enough to collect for these (pic)

Non-Stress Test FHR Activity

• Score less than 8 do this; purpose is to identify whether the fetus is well oxygenated or at risk of injury or death because fetal movement is associated w/ HR increasing, showing an intact CNS - Put pt in reclining chair or bed and on electronic fetal monitor, and instructed to push a button thats hooked up to the monitor when they feel any type of fetal movement, should see accelerations or an increase in fetal heartbeat w/ each movement - 1st 10 mins is to establish FHR baseline, begin the test that lasts 20 mins • Reactive: > 2 accelerations peaking at least 15 beats/min. above baseline for 15 sec. in 20 min. period - ie. Baseline is 135 and increased to 150 and lasts at least 15 secs on monitor • Nonreactive: Absence of required characteristics for reactive test after a 40 min. period - Would give it a little longer than 40 mins remembering that babies go into sleep cycles (pic)

Breasts and Lactogenesis

• Stages of human milk - Colostrum: immediately available to baby at birth - Some women can express colostrum during the last trimester, the breast remains soft and non tender and then boom comes the milk - Baby's stomach is the size of a cherry so if they are wetting 6-8 diapers a day (need like 5 ml) - Transitional milk: days 2-5 (primary engorgement; women feel like their breast is fuller, tingly, become bigger) - Mature milk: present by 2 wks - The fat in the milk provides the most caloric intake * Continued milk production depends on whether nipple stimulation occurs - ie. If we have a pt and she wants to bottle feed, she should not stimulate her nipples whatsoever • If mom doesnt want to breastfeed, she should wear a tight fitting bra (sports bra), shouldn't go braless, shirt rubbing against the nipple will stimulate milk production, husband needs to keep his hands off her breasts, if she is in the shower she needs to have her back to the shower • If a mom says she cant breast feed because she has flat nipples, we can teach her that nipples retract when they are compressed, nipples shields can be used to pull that nipple out when baby latches on • Teach mom how to massage the breasts: press, compress, release (start on the outside and squeeze towards areola) and this helps express the milk (want baby to smell the breast milk and they will latch on better, realizing they may be hungry) - Do this for our premie babies, they are in the NICU and moms sometimes aren't able to breastfeed, if they want to breastfeed we can tell them to start storing their milk it expressing it so their breasts keep making milk - Even if moms can only get one drop out, (it counts) will put on a sterile swab and put that in babies mouth

Induction of Labor

• Starts from ground 0, no contractions nothing going on with the uterus and we give meds to start them up - With augmentation, the pt may have come in contracting, in labor, maybe her cervix has effaced at some point and give meds to get everything going • Indications for induction (pg 2288)*** - ***The pt must be at least 39 wks to be induced, w/o a medical reason (ie. cant say will induce at 38 wks because she is tired of being pregnant) - Mom w/ gestational DM to avoid her giving birth to a macrosomia baby we may have to induce them like 38 wks - ie. induced a 37 wk because baby had a heart defect and IUGR intrauterine growth restriction - SN if we know were gonna have a compromised premie we can give mom 2 doses of betamethasone aids w/ development of surfactant prior to birth • Fetal Concerns - Because of risk to fetus and mom, if we induce too early it can cause fetal concern like are lungs fully developed, are they at risk for TTN transient tachypnea of newborn • Maternal Concerns - If we induce mom too early, if cervix is "green" (like an unready fruit) its not ready to be induced, dilate and give favorable results to birth, can set mom to an unwanted c-section • Induction of labor - Natural induction - Stripping of membranes: pt goes in to see her doc towards the end of the pregnancy and they do a vigorous vaginal exam; riles things up in there (might leak fluid the next day - Nipple stimulation: causes oxytocin to be released in the body - Intercourse: sperm contains prostaglandin and the vigorous act of it all can start things up - Mechanical Induction - Foley balloon catheter: foley would go in the vagina, puts tension and pressure to soften open and dilate - Medical induction - Use of misoprostol (cytotec 25 mcg): pill put in the cervix that causes contractions, some cramping; not usually used by itself, put pitocin; if pt is hemorrhaging can be put in rectum; cervical softening agent, ripens the cervix and make it more inducible - Use of oxytocin: in milliunits/min on a pump; can cause uterine rupture, hypoxia and fetal distress - Use of prostaglandins (Cervidil and Prepidil Gel): shoot the gel up into the vagina into the cervix to help soften and ripen • Bishop score: diff criteria that need to be met before the pt is assumed to be induced ***

Psychological Adaptation (Hormone & Emotion)

• Taking in phase - Lasts a day or 2 (~24hr), mom is very passive and dependent; she wants people to do things for her - A time of reflection, she wants to talk about her pregnancy, her delivery, may have a little care in her infant, because she is still dependent - She's in pain and tired, ie. pls go get me some food, as wash rag • Taking hold - After that 24 hrs or so she begins to initiate more action towards her baby, she's eager to learn, stronger interest in infant, maybe a little insecure and needs reassurance (let her know she is doing a good job) - Moving from being dependent to becoming independent w/ caring for her baby; accepting her responsibility • Letting go - 10 days after delivery, refines her role as a mom, assumes responsibility for newborn care and new role and relationship w/ her partner • Emotion - Teach mom and partner the signs of postpartum depression, so she is alert and aware to get help (not taking care of self, doesnt want to get out of bed, not taking care of baby)

Chorionic Villi Sampling (CVS)

• Test that uses a small of the chorionic villi from thw placenta using abd US trasducer to guide the needle (taking tissue from the fetal side of the placenta for testing purposes) • Performed btwn 10-12 wks gestation • Can also be utilized for genetic, metabolic or DNA studies; this in particular doesnt detect neural tube defects • Background: Embryonic membranes begin to form at the time of implantation and protect and support the embryo, the outermost membrane is the chorion and that becomes the fetal portion of the placenta - Chorionic villi can be sampled for early genetic testing of the embryo

Infants Position

Baby needs to have the lower 2/3rds of the areola in the baby's mouth, lips flare outward, over the areola

Physiologic Discomforts and Interventions:

• 1st trimester - n+v: soda crackers (by bedside), sprite, ginger ale & ginger - Urinary frequency: dont want them to hold their bladder and teach to urinate as needed (prevent UTIs) - Breast tenderness: wear a good fitting bra that will provide support - Vaginal discharge: pantyliners, cotton panties - Nasal stuffiness and epistaxis: ocean spray or ayr (ointment to keep things lubricated - Pytalism: gum or hard candy - Fatigue: teach them to take care of themselves, lay down, take power naps • 2nd and 3rd trimester (pic)(think non pharmacological 1st) - Pyrosis: dont lay down after eating, small frequent meals, nothing spicy (Tabasco) or greasy - Constipation: change diet by drink plenty of water and eating high fiber (not safe to take laxatives, wont really encourage) - Hemorrhoids: witch hazel, tux pads, sitz baths - Ankle edema: elevate legs at end of the day - Varicose veins: supportive hose - Leg cramps: supportive hose, exercises -Backache: pregnancy gurdle - Round ligament pain: maternity girdle - Braxton hicks: start walking and exercises, maternity girdle - Insomnia: lots of pillows, back rubs, warm milk, avoid caffeine after 1 pm, ie. if ok by HCP avoid drinking their one coke a day after a certain time (beginning of day) - HA: teach to have snacks, eat small frequent meals (can be related to low BS) - Mood changes: they cry easily, emotional but temporary - Faintness and dizziness: try to avoid crowded rooms, prolonged standing; always hot - Dyspnea: wear clothes that dont decompress the diaphragm, proper posture when sitting and standing - Altered body image: comes with it and will get back to normal or do exercises - Pica: cant make them not eat it but teach them to follow up with something of nutritional value - Carpal tunnel syndrome: wrist braces to wear esp to sleep w/ • Interventions: (pics) - Raise legs high against the wall (or recliner, pillows) to decrease edema - Proper posture while standing for backache - Back rubs - Flex foot up towards knee or use chair to lunge

Pattern of Contractions

• 1. Resting tone • 2. Frequency • 3. Duration • 4. Intensity (how strong is it, mild mod, strong) • Contractions are painful because of hypoxia of compressing muscle cells, compression of nerve ganglia in the lower uterine segment, cervical stretching & stretching of the perineum

Physical Assessment BUBBLEHE

• B: breast • U: uterus • B: bladder • B: bowel • L: lochia • Episiotomy • H: hormones • Emotions/bonding

4 P's of L&D

• The Powers - Uterine contractions: tightening of the uterine muscle which results in expulsion of the fetus; contractions are coordinated, involuntary, intermittent - Maternal pushing efforts: after full dilation occurs, pressure of the presenting part of the pelvic floor causes voluntary (and involuntary) bearing down or pushing by the mother - Unless mom is 10 cm she shouldn't be bearing down and pushing - SN: catheter removed prior to pushing • The Passage - Bony Pelvis - Pelvis Types: gynecoid (favorable/postive response), anthropoid (oval up and down), andropoid (heart shaped), platypoid (oval) (pic) - Soft tissues: made of soft tissue, pelvis can open and accommodate as baby comes down; but baby has to fit - Clinical pelvimetry: measures the dimensions of the pelvis to estimate pelvic size and adequacy for birth (closer to end of pregnancy when baby drops down) • The Passenger - Positon - Lie: vertical, transverse - Attitude: flexion (extremities brought in and chin to chest), extension (extremities out and head flexed back) - the relationship of fetal parts to one another (position in relation to the trunk & head if the body) - Presentation: cephalic (head down/first), shoulder (protruding and leading the way), breech (butt 1st jacknife - frank breech or footling breech 1 or 2 feet first) - Gestational age: the longer the pregnancy the bigger the baby grows; diabetic mom tends to have bugger babies - Muscle tone: goes w/ position, flexion, attitudes - Size: a big baby < than 4,000 G (8 lbs); macrosomia baby - Mechanism of Labor: relationship btwn fetus and passage - Engagement (descent): movement of fetal presenting part into true pelvis - Station: refers to the relationship of the presenting part to an imaginary line drawn btwn the ischial spines of the maternal pelvis; if the presenting part is above the ischial spine - plane and if its below considered to be a + plane - ie. 2 cm above ischial spine neg plane, as baby comes down and hits ischial spine they are at 0, if baby is 1 cm below ischial spine its a +1 station; baby our after +3 - Fetal position: refers to the relationship btwn a designated landmark on the presenting fetal part, and front sides and back of the maternal pelvis - Vertical: occupit (head down), Face: mentum (face presenting part looking out at cervix, neck flexed back), Breech: sacrum, shoulder: acromian process - Cardinal Movements: Leopoles maneuvers - Descent/engagement: movement of fetal presenting part into pelvis - Flexion: fetus assumes chin to chest position to aid in descent - Internal rotation: fetus turns to place largest diameter of head in line with the largest diameter of the pelvis - Extension: rotation of head below symphysis pubis - External rotation/restitution: shoulders rotate into largest diameter of maternal pelvis - Expulsion: fetus expelled from body - Membranes - Amnion: amniotic fluid made up of waste products from baby - Chorion - Placenta: - Implantation site: attached to wall of uterus; starts out low and as baby grows and uterus expands it slides up uterine wall till it reaches too • The Psyche - Maternal readiness for labor: is she ready, has she done this before, is this the 1st time - Fear - Tension - Pain Cycle: can have fear, tension, and know they will experience pain - Past trauma: even if they had a baby before - ie. 11 lbs baby and needed sutures; remembers what happens and dont wanna go through it again - Social support: who is w/ mom, does she have a coach, significant other, mom, cousin, best friend, or no one (frightening)

Physiologic Adaptations

• Uterus - Increases in length, weight, and vol - Supine hypotensive syndrome (vena caval syndrome); never want a pregnant women to sleep on their back, the uterus sits on her vena cava and causes this and placenta insufficiency (blood and O2) to the baby; they get clammy, diaphoretic, feel sick from that drastic drop in BP - Braxton-Hicks contractions (contractions; contracting and relaxation of uterus) - ****Fundal height: method used to assess gestational age; measure from under breast bone/diaphragm to pubic bone, measure in centimeters; by 36 wks (not accurate) the baby drops from abdomen to pelvis to get ready for birth - ie. Mom is 22 wks gestation, fundal height will be 22 cm; at 20 wks gestation fundal height should be at the umbilicus - pic and pg 2194 - Cervix - Competent (can hold products of conception or withstand pregnancy) - Chadwick sign: cervix turns blue - Mucus plug that protect baby from bacteria (can loose it at the end of pregnancy) • Ovaries - Stop producing ova, but continue to produce hormones until the 11th week of pregnancy - Progesterone is secreted until about 7th week of pregnancy then the placenta assumes the task (if ppl have low progesterone they tend to spot at the beginning and have a chance of loosing the pregnancy, may give progesterone injections to help sustain the pregnancy by that 7th wk) • Vagina - Thicken, pliable, distensible - Increase secretions (thin watery, acidic in nature) to protect fetus from ie. bacteria - Prone to getting candida (yeast inf) • Breast - Increase size, nodularity, sensitivity (increase in vascularity) - Nipples enlarge & darken (preparing for lactation) - Prepare for lactation (comes in 3-4 days after delivery) - Colostrum (1st breastmilk that may leak at the end esp when breasts are heavy; yellowish thick, rich with immune properties; good for baby) • Cardiovascular - Heart displaced up and rotated forward - Increase plasma volume, leads to an increase in RBC's leads to physiologic anemia of pregnancy which leads to a slight decrease in the Hct count (not enough to say the pt is anemic) - Slight increase in HR from mom's normal (10-15 bpm @ term) - Slight decrease in BP - Increase CO - Increase tendency for coagulation (get swelling after walking, recommend to raise legs at the end of the day) - Risk of venous thrombosis • Respiratory - Increase O2 requirements (uterus pushes up on diaphragm) - C/o SOB (on exertion) - Breathing changes from abdominal to thoracic - Increase vascularity of upper resp tract (can have epistaxis and stuffy noses) • Renal - 50% increase in GFR - Decrease renal threshold for glucose - Decrease smooth muscle tone in bladder - Urinary frequency during the 1st (baby is sitting low in the abd and sitting on the bladder) and 3rd trimester from the enlarged uterus (sitting on the bladder) - Increased risk of UTIs (since glucose build up in urine) • Integumentary - Striae gravidarum (stretch marks at the bottom of their stomach (breast, hips, but, thighs); dont go away) - Linea nigra (dark like on abd, due to hormones and very prevalent in hispanic or AA women) - Chloasma (mask of pregnancy, skin gets blotchy (discolored patches) on face, exacerbated if in direct sunlight) - Vascular Spider Nevi (broken vessels in legs from increase pressure from weight they're carrying) - Palmar erythema (lacy looking rash/mottling pattern over the hands, discolored and reddened areas, related to hormones) - Sweat and sebaceous glands are hyperactive (acne, night sweats) • Musculoskeletal - Center of gravity shifts forward -> lordosis, backache, waddling gait - Diastasis recti abdominis (abs or recti abdominis seperate after pregnancy); to fix could do a tummy tuck and stitch them back together - Influence of relaxin on joints (causes things to relax, ie. shoe size, feet grows half a size - Round ligament pain (groin area, will feel a soreness/pain or bruising, muscle tissue on uterus that pulls and expands with growth of fetus) - Carpal Tunnel Syndrome (exacerbated w/ pregnancy, swelling and edema in wrists and hands) • GI - Displacement of stomach & intestines by uterus - Elevated levels of progesterone causes delayed emptying - Decreased production of HCL & pepsin, decrease peristalsis -> indigestion - Increase saliva production = pystalism - Pica (crave strange things of no nutritional value, ie. crushed ice, red clay (American Indian), starch) - Increase risk of gallstones (emptying time of the gallbladder is prolonged/levels of cholesterol increase; mom can get cholecystectomy) - Morning sickness (n+v during 1st trimester from increase hCG (human corianic gonadotropin) levels, can occur the whole pregnancy) - Pyrosis (from relaxation of the cardiac sphincter; part of indigestion) - Hemorrhoids (edema, swelling and straining cause swollen, inflamed veins in rectum and anus) • Endocrine - Estrogen (stimulates uterine development and assists w/ ductal system of breasts) - Progesterone (prevents early spontaneous abortion) & helps with breasts and lactation - hCG: pregnancy hormone - Relaxin: inhibits uterine activity, softens the cervix - Oxytocin: causes uterine contractions

Fetal Acoustic Stimulation

Used if baby isn't moving a sound or vibration is given off to stimulate the fetus, usually put it up against mom's abd, press button and vibrates and arouses the baby or awakens them from a sleep cycle

Prenatal Labs

• CBC • Rubella • Pap Smear • Group Beta Strep (GBS): done at 36 wks gestational age • Glucose Tolerance Test (GTT) • Type and Screen • Urinalysis • GC, Chlamydia (cultures done w/ pap smears after confirmation of pregnancy test) • HIV • 2 major goals of Antenatal Testing • 1: Identifying fetuses at risk - Can have issues caused by acute or chronic interruption of oxygenation so permanent injury or death may be prevented • 2: Identifying appropriately oxygenated fetuses - Done so unnecessary intervention can be avoided (table pic) • Monitoring usually begins by 32-34 wks gestation and continue until birth

Probable Signs

• Abdominal enlargement: gaining weight, abdomen is getting bigger - bloating • Goodell's sign: softening of cervix felt on exam • Chadwick's sign: blueish color/hue around the cervix with blood pooling to the area due to hormones • Hegar's Signs: softening of isthmus of uterus (flexing) • Positive pregnancy test (urine test) • Braxton Hicks contractions: tightening and relaxation of uterus, not real/severe contractions; goes away with walking and exercise • Ballottement: cervix is more bouncy, cervix is ballottable; physician feels a fullness or bouncing off gloved fingertip (usually around 16 wks)

True vs. False Labor

• True Labor - Contractions become progressively closer together - Contractions dilate and efface the cervix • False Labor (Prodromal Labor) - Contractions don't result in observable dilation and effacement of the cervix • First time moms will have trouble differentiating them - If mom comes in unsure, if safe to do so, will have mom walk around for a bit (1hr 1/2 or 2), if contractions get strong, get closer together and check her cervix, it changes then probably in true labor

Abdomen/Integumentary

• Uterine ligaments stretched • Striae • The changes in pigment and elasticity present during pregnancy false - Pt may experience hair loss because of hormone changes begin 4-20 wks postpartum but reverses by 4-6 mons PP

Labor

• The process by which the fetus is expelled from the uterus by systematic contractions (muscle tightening) that open (dilate) the cervix (mouth of uterus) and thin (efface) the cervix which pushes the baby through the birth canal to be born • Aka parturition - SN: dilation goes from 0 (closed) - 10 cm (fully open); effacement expressed in % the higher the % the thinner the cervix becomes

Amniocentesis

• Uses a transducer of the abd US to guide and see where to insert the needle and not puncture the placenta • Indicators for testing are prenatal diagnosis of congenital abnormalities (ie. downs, neural tube defects like spina bifida), high alpha fetal protein, pulmonary maturity (ie. w/ pts at risk for preterm labor) • Complications: - Maternal: amniotic fluid leakage, possible hemorrhage, infection, can go into labor, damage to the intestines or bladder, amniotic fluid embolism, placenta abruption (placenta tears off the wall of the uterus), fetal maternal hemorrhage w/ possible Rh iso immunization - Fetal risk: hemorrhage, infection, direct injury to fetus from needle, preterm delivery, and even death

Lochia

• Uterine flow consists of "blood", fragments of decidua, WBCs, mucus and some bacteria - Lochia rubia: bright red moderate flow of blood with some clots, lasts 3 days (may look like a heavy period); need to make note of the amount and how many clots - Lochia serosa: decrease in blood flow that consists of serous exudate or erythrocytes mucus, pink to brown color (should not be heavy) day 4-10 - Lochia alba: creamy yellowish color (contains leukocytes, epithelial cells, deciduous cells and cervical mucus cells and some bacteria) after 10 days (can last 6 wks of the whole PP time)

Assessment of Attachment

• En face position (looking at each other face to face), holds baby close, cuddles • May express initial disappointment and or abandonment (normal) - Might express disappointment if she has 4 girls at home, last chance of having a girl and has a boy, let her know that its normal - May feel a self of abandonment when everyone is fanning over baby and mom is just sitting their like hey • Problems may exist if... - Continued expressions of disappointment (calling baby ugly), and lack of binding behaviors • As many as 70-80% of women experience some feelings of unexplained sadness - why? - Called baby blues, due to hormones, as soon as placenta is delivered all the hormones are all over the place they are trying to balance, tell mom its normal, lets it all out, exhaustion may play a part; important to let mom verbalize her feelings and to let her know that this is perfectly normal

Premature Rupture of Membranes

• Testing and treatments - Ferning - Nitrazine paper - AFI (US to see pockets of fluid around baby and how much fluid is around the baby) - Monitoring fetus (if baby gets infected and premies) - GBS status (done at 36 wks gestation, if we get someone prior to 36 wks we wont know what their status is; want to know if their positive to admin antibiotics) - Induction of labor (dont want them to get infected, sometimes they can put the in trendelenburg and the membranes will seal off, but overall they induce) - Temperature monitoring (q 2 hrs get a temp on a pt to make sure they dont get an infection)

Ultrasound

• Transabdominal ultrasound (passes over abd) - Full bladder (pt must have a full bladder that will push the uterus up and forwards for better viewing; might use pillows under her head and knees - Usually done after 1st trimester • Transvaginal ultrasound (transducer that goes intravaginally; done early) - Prepped as for pelvic exam (in lithotomy position or pelvis; pelvis elevated w/ towels or pillows) - Benefits are early identification of pregnancy, observation of fetal heartbeat (5-6 wks gestational age), breathing movements of fetus, can identify more embryo or fetus, assess growth patterns, detect ectopic pregnancies, view the nucal cord or nuclear translucency of vessels, fetal cardiac structures, length of the fetal nasal bone, identify AFI • US can assess number, size, and location of the gestational sacs, the gestational age of the fetus, presence of fetal cardiac and body movements, their growth pattern, any uterine abnormalities (fibroids, bicornuate uterus; double uterus), fetal abnormalities and viability (can it survive outside the uterus), placenta condition (intact, vascularity) & location, fetal position, how long is the cervix • US can provide critical info about fetal activity, placenta anatomy, gestational age and well being, normal vs. abnormal growth of fetus and can assist invasive tests like a CVS

VBAC

• Vaginal birth after cesarean aka TOLAC (trial of labor after cesarean) - Mom has delivered by c-section w/ a previous pregnancy and now trying to attempt to deliver vaginally • Candidates for VBAC/TOLAC - Previous cesarean and a LTCS (low transverse c-section) incision (if there is any weakened area or scaring over the uterus it can perforate and open) - Adequate pelvis - ie. small pelvis w/ 8 lbs baby needed c-section and now they have an 8 1/2 baby not gonna be very successful - No other uterine scars or uterine rupture (at any moment the uterus could dehis and open and rupture) - MD needs to be near during induction - Anesthesia near for emergency C/S • Nursing Assessments and Interventions - Watching them esp of they have pitocin running, put external monitors, remember that IUPC is contraindicated

Prolactin, Oxytocin and Milk Production

• When baby latches on, its going to send nerve impulses to the hypothalamus of the brain which causes the anterior pituitary to secrete prolactin to increase breast milk production - Sucking causes posterior pituitary to secrete oxytocin, which produces the let down reflex that releases milk from the breasts; at the same time the oxytocin contracts the uterus