MATERNITY ATI
Contraception
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Depo Provera: IM injection every 11-13 weeks
Vaginal Ring: insert for 3 weeks, take out for 1 week
Patch: change 1 x week
Arm Implant: good for 3 years. Can be used while breastfeeding
IUD: 1-10 yrs. Can be used while breastfeeding. Risk for PID, perforation, ectopic preg.
Minipill: progesterone only. Fewer s/e. safe to take while breastfeeding
Infertility
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1 year w/o ability to conceive
Semen analysis: first test done b/c least expenisive test to perform
Presumptive signs of pregnancy
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Woman things she is pregnant. Symptoms only.
o Quickening – fluttering movements of fetus at 16-20 weeks
o Uterine enlargement
Probably signs of pregnancy
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Signs & medical conditions
o Hegars Sign: softening and compressibility of lower uterus
o Chadwicks’s Sign: blue color cervix
o Goodells sign: softening of cervical tip
o Callottement: rebound of unengaged fetus
o Braxton Hicks
o Positive pregnancy test
o Fetal outline felf by examiner
Positive signs of pregnancy
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Signs only related to pregnancy.
o Fetal heart sounds
o Fetus in ultrasound
o Fetal movement felt by experienced examiner
hCG
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7-10 days after conception
Peaks at 60-70 days
Higher levels if mulitples, ectopic, molar pregnancy, down syndrome
Do a pee-stick test on first-void morning sample
GTPAL
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Gravidity
Term birth: 38 weeks or more
Preterm: 37 weeks or less
Abortion/miscarriages
Living
Pregnant Vital Signs
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Blood pressure degreases 5-10 mmHG during 2nd trimester then returns to normal at 20 weeks
Pulse increases 10-15 around 20 weeks and stays elevated
Respirations increase by 1-2 breaths (due to elevated diaphragm)
Prenatal Check-ups
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Monthly for the first 7 months
Every 2 weeks during 8th month
Weekly during 9th month
Initial Check up
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EDD, medical hx, baseline physical assessment, lab tests (Blood type, Rh, CBC, H/H, Rubella, Hep, GBS, Glucose,
TB, UTI, STD, HIV, TORCH)
Ongoing Check ups
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FHR at 10-12 weeks via ultrasound, 16-20 weeks w/ stethoscope
Fundal height at 12 weeks
Fetal movement at 16-20 weeks
RhoGAM 28 weeks if mom is Rh Neg.
Discomforts of pregnancy
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1st Trimester: N/V, breast tenderness, Urinary frequency, Fatigue, Braxton hicks
2nd Trimester: Heart burn, Constipation, hemorrhoids, backaches, Varicose veins, Braxton hicks
3rd Trimester: urinary frequency, fatigue, heartburn, constipation, hemorrhoids, backaches, SOB, Leg cramps,
varicose veins, Braxton hicks, supine hypotension
Danger signs: ROM <37 weeks, vaginal bleeding, ab pain, decrease fetal movement, hyperemesis gravidarum,
severe headaches (gestianiton HTN) dysuria (UTI), blurred vision (gest HTN) edema face and hands (Gest. HTN),
epigastric pain, fruity breath & rapid breathing & increased urination (hyperglycemia), hypoglycemia
Nutrition
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2Nd trimester: increase calories by 340. 3rd trimester: increase calories by 452
Breastfeeding: increase calories by 330 for first 6 month, then 400 for second 6 months
High protein, High folic acid, calcium & iron supplements
2-3 L fluid per day
Limit caffeine to 300mg/day
Nausea: eat dry crackers or toast. Do not eat fats, spices. Avoid drinking fluids with solid meals
PKU: where high levels of phenylalanie cause danger to fetus. Avoid foods high in protein (fish, poultry, meat,
eggs nuts, dairy)
Ultrasound
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Confirms pregnancy, gestational age, site of implanation, growth, abnormatlities, amniotic fluid volume,
heartbeat, activity
Make mother drink 1-2 quarts of fluid prior to fill bladder, lift utuers and displace bowel to get better image
BBP
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Biophysical profile: visual fetus and fetal response to stimuli
Includes: reactive FHR, fetal breathing, body ovements, fetal tone, amniotic fluid
Score 8-10 = normal, 4-6= abnormal
<4= fetal asphyxia
NST
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Nonstress test: done during 3rd trimester to assess for intact CNS. Mom pushes button when she feels fetal
movement
Reactive: FHR normal baseline w/ moderate variability accellearates 15 beats/min lasting 15 seconds. Must
occur 2 + times during 20 mins.
Nonreactive: after 40 mins the criteria of 15/15 hasn’t been met
Do this test for: GDM, GHTN, hx of fetal demise, advanced maternal age, postmaturity, decrease fetal
movement, IUGR
CST
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Contraction stress test: Nipple stimulation or Pitocin to create contractions
Accurate data needs to have 3 contractions 40-60 sec duration during a 10 min time frame to get idea of how
FHR responds
Negative CST: Normal. Shows no LATE decels
Positive CST: Abnormal: shows LATE decels. (That is bad).
Amniocentesis
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Aspirate amniotic fluid with needle into uterus and amniotic sac
Diagnosis: chromosomal anomaly, neural tube defects, genetic disorders, lung maturity, meconium, hemolytic
disease, Alpha -fetoprotein (high = for neural tube defects, low = downs syndrome, molar preg.)
Fetal Lung test: Lecithin/sphingomyelin (L/S) ratio= a 2:1 ratio indicates maturity
Phosphatidyglycerol (PG): if Absent = respiratory distress. We want PG!!!
Decels
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Early Decels: fetal head compression = not serious
Late Decels: uteroplacental insufficiency = serious
Variable Decels: cord compression = depends on amount and duration
Umbilical Blood Sample
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Most common method for fetal blood sampling and transfusion
Chronic Villi Sampling (CVS)
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1st trimester to check for abnormalities at 10-12 weeks
Risk for miscarriage, SAB, ROM, fetal limb loss
Quad Marker Screening
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A blood test that includes hCG, AFP, Estriol, Inhibin - done at 16-18 weeks
Low Estriol- down syndrome.
Alpha Fetal Proteins (AFP)
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16-18 weeks
Protein produced by fetus
High levels = nueral tube defect
Low levels = down syndrome
Sponteanous Abortion
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1st trimester- bleeding, cramping, partial or complete expulsion of products of conception
Terminated before 20 weeks gestation or less than 500 g
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Caused by: High maternal age, substance abuse, chromosomal abnormalities (most common), maternal illness,
cervical dilation, trauma, antiphospholipid syndrome
Don’t have bath, sex, for 2 weeks. Finish abx. Discharge will occur for 2 weeks. Wait 2 months to try again
Ectopic Pregnanancy
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Implanted outside uterine cavity usually in fallopian tubes which can cause a fatal hemmorahge if ruputured.
Risks: STD, IUD, tubal surgery
S/S: stabbing pain in lower ab. On one side. Delayed or irregular pregnancy, Dark red/brown spotting or RED if
Ruptured. Shoulder pain!!, dizzy from bleeding into ab cavity
Gestational Trophoblastic Disease (GTD)
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Proliferation & degeneration of trophoblastic villi in placenta that looks like GRAPE CLUSTERS!
No embryo develops instead a metastasizing malignancy (Choriocarcinoma) forms.
COMPLETE MOLE: No genetic material or any placenta, fluids
PARTIAL MOLE: Has genetic material plus some baby parts
Risks: young and old mothers
S/S: Excessive vomiting, High levels hCG, Rapid uterine growth that is way too big for age, prune-juice looking
blood
Placenta Previa
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Placenta abnormally implants in lower utuerus resulting in bleeding in 3rd trimester
Complete: cervical os is covered by placenta
Incomplete: partially covered cervical os
Low-lying: doesn’t reach cervical os
Risks: Previous placenta previa, scarring, older mother, multiples, smoking
S/S: PAINLESS. Bright red bleeding 2nd-3rd trimester
Abruptio Placenta
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Premature separation of placenta from utuerus AFTER 20 weeks.
Causes baby and mother mortality. Leading cause of maternal death
Risks: maternal HTN, trauma, previous incident of abruption, smoking, multiples,
S/S: Sudden DARK RED bleeding, shock, fetal distress
TORCH
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Toxoplasmosos: Raw or undercooked meat & handling cat feces. Flu symtoms
Rubella: joint & muscle pain
Cytomeglovirus: droplet infection- can cause damage to baby during birth. Asymptomatic
Herpes Simplex: Oral or genital lesions
Group B Strep (GBS)
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Bacterial infection passed to fetus during L&D
Risks: <20y, black or Hispanic, prolonged ROM, low birth weight, preterm baby, fever
Treat with PCN
Chlamydia
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Bacterial infection. Most common STD.
S/S: ITCHING! Watery vaginal discharge
Give erythro eye ointment to babies, treat with abx
Gonorrhea
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Urethral discharge, painful urination & frequency, Yellow/green vag discharge can lead to PID.
Candida Albicans
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Fungal infection
S/S: thick, creamy white discharge, itching, grey-white patches on vag wall
Patches in neonate mouth
Premature dilation of cervix
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Incompetent cervix: feel urge to push. Expulsion of products
Risks: cervical trauma, defects
Give Tocolytics to inhibit contraction, mom on bedrest, no sex
Hyperemsis Gravidarum
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Excessive n/v. past 12 weeks.
Risk for IUGR or preterm birth if not treated
Risks: <20 yo, migraines, obese, 1st pregnancy, multiples (high hCG), emotional stress, hyperthyroidism
S/S: n/v, ketones in urine from protein breakdown, electrolyte imbalances, high hCG
GDM
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Can cause: SAB, infections, hydyramnios, ROM, preterm, hemorrhage, macrosomia
Glucose test at 24-28 weeks, county daily kicks
GHTN
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20 weeks. BP >140/90 at least twice 4-6 hours apart in a 1 week period. No proteinuria
Mild Preeclampsia
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Same as GHTN but with proteinuria 1+
Severe Preeclampsia
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BP 160/100, proteinuria 3+, headache, blurred vision, hyperrfelxia, edema, hepatic issue, RUQ pain,
thrombocytopenia
Eclampsia
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Seizure activity following severe preeclampsia
HEELP Syndrome
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H- hemolysis resulting in anemia & jaundice
EL- elevated liver enxymes (ALT, AST), Epigastric pain, n/v
LP- low platelet (<100,000), causing thrombocytopenia, bleeding, cant clot, DIC (intravascular coagupathy)
RISK FOR GHTN & elevated BP
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<20y or >40, Obesiety, muliltple babies, DM, molar pregnancy, hx of preivious HTN
S/S: non-stop headache, blurred vision, flashes of light, n/v
Treat: give HTN meds (NO ACE Inhibitors), give Mag
Preterm Labor
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20-37 weeks
Risks: infections, previous preterm labors, hydramnios, young age, smoking, drugs, violence, hx or SAB, DM,
HTN, remature dilation, placenta previa, abrputio placentae, preceding labor pregnant quickly after giving birth,
Treatment: can give meds to slow, stop labor. Nifedipine, mag
Signs of preceding labor (Labor is coming)
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Backache, weight loss 1-3lb, leightning where fetal head descends down into pelvis 2 weeks prior, bloody show,
energy burst, n/v, ROM (labor occurs 24 after this),
5 P’s
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Passenger: size of head, presentation (head/occiput, chin/mentum, shoulder/scapula, breech/sacrum or feet
Lie: transvers, longitudinal
Attitude: fetal flexion (chin to chest), fetal extension
Passageway: birth canal
Powers: uterine contractions, dilation, urge to push
Position: how mom is positioned in labor
Psychological: stress, anxiety can impair labor
Meachanism of Labor
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Engagement: head passes into pelvic – 0 station
Descent: head through pelvis
Flexion: head flexes chin to chest
Internal rotation: rotates laterally to pass through pelvis
Extension: Head is born
External rotation: head roates to allow body to roate
Expulsion: rest of baby born
Variability
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Absent
Minimal: <5/min
Moderate: 6-25/min
Marked: >25/min
Category I
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FHR baseline 110-160 – normal
Moderate variability
Accel present or absent
Early decels present or absent
Variable or late decels are absent
Category II
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Baseline tachy or brady
Variability minmal, absent, marked
Decels b/t 2-10 mins
No accels after stimulation
Category III
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Absent FHR
Recrrent variable decls, late decles, brady
First Stage of Labor
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Latent (0-3cm), Active (4-7cm), Transition (8-10cm)
Lepold maneuver to determine where baby is
Vag exam for dilation and effacement & station
Blood Pressure: Latent phase (30-60min), Active phase (30 min), Transiation Phase (15-30min)
Temp: q4h or q1-2h for ROM
Contraction Monitor: Latent phase (30-60min), Active Phase (15-30 min) Transition (10-15min)
FHR Monitor: Latent (30-60min), Active (15-30), Transition (15-30)
Encourage voiding q2h
Second stage of labor
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Dilation to birth – can take 30mins – 2 hrs for first time moms
FHR q15 min.
1st degree lac – does not involve muscle
2nd degree lac- extends through skin & muscle to peri
3rd degree lac- extends through skin muscle peri and anal sphincter
4th degree- through skin, mucle, anal sphincter and anterior rectal wall. (WTF, seriously?)
Third Stage of Labor
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Delivery of baby to delivery of placenta
Monitor vitals q15min
Firm fundus
Fourth Stage of labor
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Placenta is out, recovery
Vitals q15 for 1 hour
Fundal and lochia check q15min for 1hour
Massage fundus, encourage voiding
Amniotomy
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Rupture or membrane with amnihook
Amniofusion
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Supplement the amout of amniotic fluid and decrease cord compression or oligohyramnios
Induction of Labor
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39 weeks
Bishop score greater than 8 for multip, 10 for nullip
A prolonged ROM that has risk of infection
DM, HTN, Fetal demise
Precipitous Labor
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3 hours or less. High risk for hemmroharge
Panting will control urge to push
Side lying position optimizes perfusion and fetal oxygenation
Never stop delievery
Amniotic fluid embolism
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Ruprture in amniotic sac plus high pressure causes PE, resp distress and collapse
S/S: respiratory distress, tachy, shock, cardiac arrest
Postpartum
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Vitals q15 mins for first hour, q30min for second hour, q1hour then q4-8hr
BUBBLE : breast, uterus, bowel, bladder, lochia, episotomy/edema
Fundus descend 1-2cm per day. Day 10, non palpabale uterus
Lochia: Rubria (1-3 day), Serosa (4-10 days), Alba (11day – 6 weeks)
Lochia amount: Scant, light, moderate (10 cm), heavy ( pad saturated in 2 hours) , excessive (one pad saturated
in 15 mins)
Blood loss: Vag deliever = 500 mL C-sect.= 1,000 mL
WBC increase to 20-25 for 10-14 days w/o infection present
Bladder empty q2-3h. Bowel movement 2-3 days
Dependent- taking in phase
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24-48 hr
Focus on personal needs
Rely on others
Excited, talkative, wants to share story
Dependent-independent – taking-hold phase
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2-3 days-weeks
Baby care and improving care-giving competency
Needs acceptance from others
Learn and practice
Inderdependent – letting-go phase
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Focus on family as unit
Resumption of role- wife
Discharge teaching
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Menses returns 4-10 weeks if not breastfeeding
Contraception ASAP
Fluids, rest, limit activity
Infant feeding 8-12 x a day
ABGAR Score
Score
Heart Rate
Respiratory Rate
Muscle Tone
Reflex Irritability
Color
0
Absent
Absent
Flaccid
None
Blue, Pale
0-3 = severe distress
4-6= Moderate distress
1
<100
Slow, weak cry
Some flexion
Grimace
Pink body, acrocyanosis
7-10= no distress
Initial Assessment
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External Assessment: skin color, peeling, birthmarks, meconium, nasal patency
Chest: breathing, heart rate, any crackles, wheezes, point of maximum impulse
Ab: round, umbilical cord with 1 vein, 2 arteries
Neuro: muscle tone, reflex reaction, fontanels and sutures
Abnormalities
Gestational Age
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Done 2-12 hours of birth
Weight: 2500 – 4000g
Length: 45-55 cm
Head circumference: 32-36.8cm
Chest circumference: 30-33cm
Preterm: <37 weeks
Term: 38 weeks
Postterm: 42 weeks
Postmature: 42+ weeks
2
>100
Good Cry
Well-flexed
Cry
Completely pink
Newborn Vitals
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Resp: 30-60/ min
Heart rate: 100-160 bpm
BP: 60/40 – 80/50
Temp: 36.5-37.2 (97.7 – 98.9)
Head
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2-3 cm larger than chest circumference
If 4 cm or larger than chest circumference it can be hydrocephalus.
Head less than 32 – microcephaly
Anterior fontanel: 5cm & dimanond shape. Posterior fontanel: smaller & triangle shaped
Fontanels: soft, flat, may bulge when newborn cries/vomits/coughs. Abnromal bulge= hemorrhage, infection,
pressure increase
Sutures: palpable, separated, overlapping from molding
Eyes & ears
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Eyes should be equal 1/3 distance b/t outer canthus
Ears should line up with outer canthus of eyes. Rule out down syndrome or kidney disorder
Chest & Ab
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Breast nodules 6 cm
Bowel sounds present 1-2 hours after birth
GI & GU
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Anus should not be covered by membrane
Meconium should be passed w/in 24 hours
Rugae should be on scrtoum, testes in scrotum
Vaginal blood-tinged discharge may occur in female newborns
Hymenal take should be present
Urine w/in 24 hours after birth.
Chapter 24-27… read on your own and take notes on the important stuff 