Newborn Transitioning
The newborn must begin the work of physiologically and behaviorally adapting to the
new environment
● Neonatal period: the first 28 days of life
● Transitioning usually occurs within the first 6 to 10 hours of life, but many adaptations
take weeks to attain full maturity.
● Cardiovascular system adaptations
○ Switch from fetal to newborn circulation
■ One of biggest challenges
○ Change from placental to pulmonary gas exchange
○ Physical forces leading to increased release of catecholamines critical for changes
involved in transition to extrauterine life
○ Changes in fetal structures: foramen ovale, ductus arteriosus, ductus venosus,
umbilical arteries (2) and vein
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●
○ Foramen ovale closes as the pulmonary artery in order to have adult circulation
○ Premature infants have much higher risk of PDA (patent ductus arteriosus)
○ PFO: patent foramen ovale; may not notice b/c there may not be s/s and can have
it as an adult
○ PDA: do not go straight to surgery to close it off so you give ibuprofen and
indomethacin to close it off instead of going to surgery
■ Give these meds in a week or 2 and then will move onto surgery if that
does not work
○ Fetal circulation (umbilical cord): vein has oxygenated blood, artery has
unoxygenated
○ Heart rate
■ 120 to 180 bpm; after decreases to an average of 120 to 130 bpm
○ Blood pressure
Highest after birth and reaches a plateau within a week after birth
○ Blood volume
■ Depends on the amount of blood transfer from the placenta at birth;
usually is 80-85 ml/kg
○ Blood components
■ Red blood cells: lifespan 80 to 100 days, compared to 120 days in adults
● 4.6 to 5.2 million/mm3
● RBCs lyce after birth - affects jaundice
■ Hemoglobin: initially declines (physiologic anemia of infancy)
■ Leukocytosis: present as result of birth trauma
● During the newborn period is around 12,000 mm3
● (elevated from normal value of 10,000)
■
○
■ Know hemoglobin and hematocrit
■ Know WBCs will be elevated
● Respiratory system adaptations
○ Initiation of respirations: adjusting from a fluid-filled intrauterine environment to
gaseous extrauterine environment
○ Role of surfactant: ​surface tension-reducing lipoprotein that prevents alveolar
collapse.
■ If don’t have enough - lung collapse -> ventilator
■ Pre term infants get synthetic form of surfactant through ET tube of
ventilator (does not work as well as real surfactant)
○ Respirations: 30-60 breaths/minute; irregular, shallow, unlabored; short periods of
apnea (<15 sec); symmetrical chest movements
■ If fluid is removed too slowly or incompletely, transient tachypnea (>60
breaths/minute) occurs.
● Vaginal vs C sections
■ Apea - stimulate to remind them to breathe or give caffeine
○ Events leading to maintenance of respiratory function
■ Initiation of respiratory movement
Expansion of lungs
■ Establishment of functional residual capacity (ability to retain some air in
the lungs on expiration)
■ Increased pulmonary blood flow
■ Redistribution of cardiac output
○ Respiratory distress syndrome (short term)
■ Signs and Symptoms Indicating a Problem
● Nasal Flaring
● Chest Retractions
● Grunting on Exhalation
● Labored Breathing
● Generalized Cyanosis
● Flaccid Body Posture
■ Not super severe; get over it in 72 hours, don’t need ventilator
● Body Temperature Regulation
○ Newborns tolerate a narrower range of environmental temperatures.
○ It is crucial for the newborn’s survival to obtain a stable body temperature to
promote optimal transitioning to extrauterine life.
■ Also important to conserve fat - small amounts of fat at their age, mainly
brown fat
○ Normal temperature: 97.9 to 99.7 F (36.5 to 37.5 C)
○ Thermoregulation​: process of maintaining the balance between heat loss and
heat production.
○ Thermoregulation
■ Heat production: primarily through nonshivering thermogenesis ​(brown
fat)
■ Heat loss via 4 mechanisms leading to cold stress
○ Need for a neutral thermal environment (NTE): environment in which body
temperature is maintained without an increase in metabolic rate or oxygen use.
■ High humidity, weaned off very slowly
○ Brown fat - very first fat you have, goes away
■ Main role to protect organs (not a whole lot, even less as a preme)
■
■
○ Characteristics predisposing newborn to heat loss
■ Thin skin; blood vessels close to the surface
■ Lack of shivering ability; limited stores of metabolic substrates (glucose,
glycogen, fat)
■ Limited use of voluntary muscle activity
■ Large body surface area relative to body weight (head largest surface area)
■ Lack of subcutaneous fat; little ability to conserve heat by changing
posture
■ No ability to adjust own clothing or blankets to achieve warmth
■ Infants cannot communicate that they are too cold or too warm
○ Mechanism of heat exchange**
■ Conduction​: ​transfer of heat from object to object when the two objects
are in direct contact with each other
■ Convection​: ​flow of heat from body surface to cooler surrounding air or to
air circulating over a body surface
■ Evaporation​: ​loss of heat when a liquid is converted to a vapor
■ Radiation​: ​loss of body heat to cooler, solid surfaces in close proximity
but not in direct contact
■
○ Thermoregulation of the newborn
■ Overheating
● Large body surface area
● Limited sweating ability
● Increases fluid loss, increases respiratory rate and increases
metabolic rate
■ Cold stress
● Newborn lethargic, hypotonic, weaker
● Preterm newborns are at higher risk
Can deplete brown fat stores, increase oxygen needs, respiratory
distress, hypoglycemia, hypoxia
● Hepatic system function
○ Iron storage (destruction of red blood cells)
○ Carbohydrate metabolism
○ Bilirubin conjugation
■ Causes of jaundice
● Overproduction (8 to 10 mg/kg/day, more than twice the
production rate in adults), declines 10 to 14 days after birth
● Decreased conjugation (unconjugated bilirubin which is fat soluble
to conjugated bilirubin, water soluble, is decreased)
● Impaired excretion because of the liver’s immaturity and thus
cannot conjugate bilirubin as quickly as needed (jaundice) in first
couple of days
■ Bilirubin is eliminated in feces and urine
● Decrease jaundice - feed them as much as possible
● Photherapy, sunlight
■ Assess
● Blanche over bony prominences (by eyebrows, clavicle)
● Orangey looking
● Gastrointestinal system adaptations
○ Does not mature until 6 months
■ Colick, gas issues until 6 months
○ Newborn must be prepared to deal with bacterial colonization of the gut
○ Physiologic capacity of the newborn stomach is considerably less than anatomic
capacity
○ Cardiac sphincter and nervous control of stomach is immature leading to
regurgitation and uncoordinated peristaltic activity
■ Decreased peristalsis
○ Limited ability to digest complex carbs and fats
○ Normally term newborns lose 5% to 10% of their birth weight
■ Retained water from trauma from labor
○ To gain weight the newborn requires an intake of 108 kcal/kg/day from birth to 6
months of age
○ Small, frequent meals are recommended
■ Keep baby upright, otherwise will get gas
● Symethicone - only thing you can give infant for gas pain
■ Every 3 hours/on demand
○ Stimulate frequent burping to minimize regurgitation
●
○ Characteristics of Newborn Stools
■ Stools: meconium, then transitional stool, then milk stool*
● Breast-fed newborns: Yellow-gold, loose, stringy to pasty,
sour-smelling
● Formula-fed newborns: yellow, yellow-green, loose, pasty, or
formed, unpleasant odor
■
Meconium
● Extremely sticky - getting rid of stuff from in utero
● Need to get rid of it because they cannot go onto ventilator with it
■ Tan color: issue with gallbladder
■ Red color: bleed
● Renal system changes
○ Limited ability to concentrate urine until about 3 months of age (urine has a low
specific gravity)
○ 6 to 8 voidings/day considered normal
○ Low glomerular filtration rate and limited excretion and conservation capability
■ Affects newborn’s ability to excrete salt, water loads, and drugs
■ Important to check dosages - vancomycin worst drug for newborn
● Immune system adaptations
○ Natural immunity: physical barriers, chemical barriers (enzymes, gastric acids),
and resident nonpathologic organisms
○ Acquired immunity
■ Absent until after 1​st​ invasion by foreign organism or toxin
■ Development of circulating antibodies or immunoglobulins and formation
of activated lymphocytes
■ Newborn primarily dependent on 3 immunoglobulins: ​IgG (cross the
placenta)​, IgA, and IgM
● Integumentary system adaptations
○ Protective barrier between body and environment
○ Functions: Limits loss of water, prevents absorption of harmful agents, protects
thermoregulation and fat storage, and protects against physical trauma.
○ Accelerated epidermal development with exposure to air for all newborns
○ Skin variations
■
A, telangiectatic nevus or “stork bite”.
■ B is milia or small papules or sebaceous cysts on the infants face
resembling pimples. *
■ C is Mongolian spots or blue or purple hyperpigmented areas*
■ D is erythema toxicum or newborn rash.
■ E is called nevus flammeus or port wine stain.
■ F is nevus vasculosus or strawberry hemangioma.
○ Acrocyanosis
■ Extremities a bit blue
■ Normal; part of APGAR score when first born
■ After around 3 minutes - pick up more color
○ Lanugo
■ Fine downy hair
■ Seen in preterm infants
■ Also seen in among certain ethnic groups (Hispanic children)
○ Vernix Caseosa
■ Protective covering, protects the skin
■ Preterm infants have more
■
Found in creases and hair
● Neurologic System Adaptations
○ Development follows cephalocaudal and proximal–distal patterns
○ Acute senses of hearing, smell, and taste
○ Vision: incomplete at birth, ability to focus only on close objects
■ 2 months: can see 18 in away from them
■ 5-6 months: full color vision
○ Adaptations of respiratory, circulatory, thermoregulatory, and musculoskeletal
systems indirectly indicating central nervous system transition
○ Reflexes: indication of neurologic development and function
● Reproductive system
○ Female - labia normally swollen
○ Male
○ Swelling of breast tissue: because of hormones from mom and this is normal
○ Sexual organs developed in utero
● Behavioral patterns of newborns
○ First period of reactivity
■ Birth to 30 minutes to 2 hours after birth
■ Newborn is alert, moving, may appear hungry
○ Period of decreased responsiveness
■ 30 minutes to 120 minutes old
■ Period of sleep or decreased activity
○ Second period of reactivity
■ 2 to 8 hours
■ Newborn awakens and shows an interest in stimuli
○ Orientation: response to stimuli
○ Habituation: ability to process and respond to auditory and visual stimuli; ability
to block out external stimuli after newborn has become used to activity
■ Nurses block out stimuli (responding to stimuli takes up metabolic
processes)
○ Motor maturity: ability to control movements
○ Self-quieting ability: consolability
○ Social behaviors: cuddling and snuggling
■
○
Newborn Assessment
● Early newborn period
○ Maternal History
■ Newborn infant does not have a past medical history
■ Maternal history will affect fetus and newborn
■ Mother’s age
● Teen pregnancy
● Advanced maternal age pregnancy
■ Prenatal care
■ Socio-economic status
■ Education
■ Prenatal infection(s)
○ Prenatal history
○ Physical examination
■ APGAR score
● A: activity
● P: pulse
● G: grimace
● R: Respiratory effort
○ After 1 minute the infant has a RR of 110
○ Slow, weak cry
○ The infants body is pink/blue in extremities
■ Vital signs
■ Anthropometric measures: weight, length, head/chest circumference
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■ Skin: condition and color, common skin variations
■ Head: size, fontanels, variations in head size, and appearance of
abnormalities in head or fontanel size
■ Face: nose, mouth, eyes, ears
■ Neck and chest
■ Abdomen
■ Genitalia
■ Extremities and back
■ Neurologic status
○ Initial newborn Assessment
■ APGAR scoring
■ Length, weight, vital signs
■ Gestational age assessment
● Physical maturity: skin texture, lanugo, plantar creases, breast
tissue, eyes and ears, genitals
● Neuromuscular maturity: posture, square window, arm recoil,
popliteal angle, scarf sign, heel to ear
■ APGAR scoring* be able to calculate
● A = Activity (muscle tone)
● P = Pulse (heart rate)
● G = Grimace (reflex irritability)
● A = Appearance (color)
● R = Respiratory effort
○ After 1 minute the infant has a RR of 110
○ Slow, weak cry
○ The infants body is pink/blue in extremities
○ 7 and above = good
○ Typically want 9
○ Usually never have perfect 10
■ All babies born with a little acrocyanosis
●
■ Anthropometric measurements
● Weight
○ Average weight = 3400g or 7.5 lbs.
○ Weight range: 2500 – 4000g (5lbs 8oz to 8lbs 14oz)
○ Newborn’s will usually loose 10% of their birth weight
within first few days of life.
○ Should regain weight within approximately 10 days of life.
● Length
○ Average length = 50cm (20in)
○ Length range: 44-55cm (17-22in)
○ Measure from head to the soles of the feet
○ Hold the knees in an extended position when measuring
● Head circumference
○ Average Head circumference = 32-38cm
○ Measured at the widest diameter or occipitofrontal
circumference
● Chest circumference
○ Chest size of an infant is 2-3cm less than the head
circumference
○ Measure the chest at the nipple line with newborn
unclothed
○ Average chest circumference = 30-36cm (12-14in)
● Abdominal girth
○ Should be approximately the same size as the chest
○ Encircle newborn’s body with the paper tape measure
directly above the umbilicus
■ Head size and shape variations in the newborn
● Molding - changing of head shape (overlapping of sutures) to get
to birth canal
● Cephalohematoma: retaining blood
○ Often due to vacuum
● Caput succedaneum: inflammation; swelling underneath the head
○ Does cross suture lines
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■ Moro Clavicle
● Moro Reflex may be asymmetrical in an infant with birth trauma
that causes a fracture of the clavicle
● May be the only sign that the clavicle is fractured
● An absent Moro reflex could mean bilateral clavicle fracture
● Also, asymmetrical positive Moro reflex may be caused by another
form of birth trauma called brachial palsy.
○ The newborn will have an absent Moro reflex on affected
side, but will often have a grasp reflex on affected side
○ Often resolves spontaneously in about 3 months
○ If not resolved, surgical intervention may resolve it
■ Brachial Palsy
● When nerves in the brachial plexus get damaged, signals cannot
travel like usual from the brain to the arm muscles. So some or all
of your child's arm muscles may no longer work. When this affects
only the shoulder and elbow muscles, it is called an Erb's palsy.
● Mouth assessment
○ Some babies form with teeth
■ Take them out - risk for aspiration
■ Dont breastfeed
○ Thrush, cleft lip/palate
● Trunk and back
○ The nurse is inspecting for unequal skins folds (child hip dysplasia) as well as
normal curvature of the back and spine. Also note if dimpling is present (spin
abnormalities).
■ Asymmetrical legs - sign of fractured/dislocated hip
○ Rarely, sacral dimples are associated with a serious underlying abnormality of the
spine or spinal cord. Examples include:
■ Spina bifida.​ A very mild form of this condition, called spina bifida
occulta, occurs when the spine doesn't close properly around the spinal
cord but the cord remains within the spinal canal. In most cases, spina
bifida occulta causes no symptoms.
■ Tethered cord syndrome.​ The spinal cord normally hangs freely within
the spinal canal. Tethered cord syndrome is a disorder that occurs when
tissue attached to the spinal cord limits its movements. Signs and
symptoms may include weakness or numbness in the legs and bladder or
bowel incontinence.
■ The risks of these spinal problems increase if the sacral dimple is
accompanied by a nearby tuft of hair, skin tag or certain types of skin
discoloration.
○ Thigh ​folds​ (seperate from gluteal ​folds​) that are asymmetrical rarely indicate hip
dysplasia unless they are associated with ​uneven​ gluteal ​creases​. ... When a
baby's​ hip dislocation is present for several months, the hips gradually lose range
of motion and the leg appears shorter because the hip has migrated upward.
● Hip assessment
○ Congenital hip dysplasia is a common defect with infants in the breech position.
Barlow-Ortolani maneuver assesses for presence of clicking or crepitus indicating
joint instability.*
○ Happens a lot with breech babies
● Umbilical hernia
○ An umbilical hernia is an abnormal bulge that can be seen or felt at the umbilicus
(belly button). This hernia develops when a portion of the lining of the abdomen,
part of the intestine, and / or fluid from the abdomen, comes through the muscle
of the abdominal wall.
■ Common - 10-20%
■ They are, however, more common in African-Americans.
■ Low birth weight and premature infants are also more likely to have an
umbilical hernia. If a physician gently pushes on the bulge when a child is
lying down and calm, it will usually get smaller or go back into the
abdomen.
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○ Sometimes the intestines get trapped within the umbilical hernia. This is referred
to as an incarcerated hernia. When this occurs, the child usually has severe pain
and the bulge may be firm and red. Urgent medical evaluation to exclude an
incarcerated hernia is required in order to prevent possible damage to the
intestines. It is uncommon for this to occur.
Checking for patency of anus
○ Temperature rectally of infant
○ Imperforate anus: An imperforate anus is a birth defect that happens while your
baby is still growing in the womb. This defect means that your baby has an
improperly developed anus, and therefore can’t pass stool normally from their
rectum out of their body.
○ Need surgery, colostomy
Circumcision
○ If a baby is going to have the surgery, it’s usually done before he leaves the
hospital, 2 or 3 days after birth.
○ Biggest indicator: whether father has one
○ “Cleaner” - less infections; but other than that not a difference
■ Only during newborn periods
○ Teach parents to put petroleum jelly on penile area so diaper doesnt get stuck
■ Change diaper frequently, not too tight, wash area with soap and water,
keep dry
Nursing interventions: immediate newborn period
○ Maintain airway patency
○ Ensure proper identifiecation
■ One on foot and one on arm with mother’s info
○ Administer prescribed meds
■ Vitamin K
■ Eye prophylaxis
● Gentamycin - prevent gonnorrhea and chalmydia from getting into
baby’s eye
○ Maintain thermoregulation
Common concerns of newborn transition
○ Transient Tachypnea of the newborn
■ Provide Oxygen
■ Ensure warmth
■ Observe respiratory status frequently
■ Allow time for pulmonary capillaries and lymphatic to remove the
remaining fluid
○ Physiologic jaundice
Hypoglycemia
■ Diabetic mothers
● Transient tachypnea: nursing interventions
○ Provide oxygen
○ Ensure warmth
○ Observe respiratory status frequency
○ Allow time for pulmonary capillaries and lymphatics to remove the remaining
fluid
● Hypoglycemia in (IDM)
○ S/S
■ Jitteriness
■ Lethargy
■ Cyanosis
■ Apnea
■ Seizures
■ High-pitched or weak xcry
■ Hypothermia
■ Poor feeding
○ Nursing management/interventions
■ Monitor for s/s
■ Identify newborns at high risk
■ Glucose screening on at-risk infatns and those with symptoms
○ Prevention
■ Start early feedings
■ Notify HCP if hypoglycemia persists
■ Assess at risk infants early
○ Treatment
■ Rapid acting glucose orally and breast milk/formula
■ IV administration of glucose
■ Continuous monitoring of glucose level
○ Side effects
■ Neurologic sequelae
■ Learning disabilities
■ Intellectual disabilities
● Common newborn screenings
○ PKU
○ Congenital hypothyroidism
○ Galactosemia
○ Sickle cell anemia
○
Each state mandates a list of congenital diseases that each newborn born in that
state are screened for
○ Test is done via heel stick before discharge home
● Heel-stick procedure
○ Materials
■ Gloves
■ Antiseptic solution
■ Heel-lancing deviced sized appropriately
■ A towel or pad to cover bed linens
■ The blood collecting medium (filter paper, hematology tube, etc.)
■ Bandage or gauze
○ positioning/site selection
■ Easiest when infant is supine
■ Posterior pole of heel shouldn’t be used
■ Avoid contact with calcaneus
■ Use outer edge of heel (minimizes pain)
○ Technique
■ Don gloves
■ Prepare automated heel-lancing device
■ Clean area with antiseptic solution
■ Position heel between thumb & forefinger with the fingers underneath the
calf & ankle
■ Thumb over the ball of foot
■ Place a minimal pressure to place the foot in dorsiflexion
■ Place the lancing device on the site and activate it
■ Use mild pressure with thumb and fingers
■ Wipe away first drop of blood
■ Collect the sample
■ When sufficient blood is collected, apply pressure to the puncture site with
gauze until bleeding stops
■ Cover with new gauze or bandage
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■
● Early newborn period: nursing interventions and management
○ General Newborn care
○ Bathing and hygiene
○ Elimination and diaper area care
■ Urine characteristics
■ Stool pattern - very important to look at
■ Diaper area care
○ No need to give newborn bath every day (until 6 months and have actual food)
■ 3x a week or every other day
■ Bathing too much dries out skin
■ Before your baby's umbilical cord stump falls off (between ​10​ days and
three weeks after birth), it's best to sponge-bathe her to avoid getting the
cord stump wet.
○ Cord Care - keep area dry and clean
■ Will fall off within 7-10 days
○ Circumcision care
○ Safety
■ Prevention of abduction
■ Car safety (Rear facing car seat until 2 years)
○ Infection Prevention
○ Sleep Promotion (Back to sleep)
■ Apnic babies - better on stomach in hospitals (where there are monitors)
○ Bonding
○ Nutrition
○ Fluid requirements
○ Feeding method choice
○ Discharge education
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Follow-up care
■ When they should make appointment with pediatrician
● Follow up usually 2 days later (check bilirubin levels)
● Then 1 month follow up
● Then 2 months
■ Warning signs and symptoms
■ Immunization information
Fetal Assessment During Labor
● Amniotic fluid analysis
○ Amniotic sac
■ Integrity of membranes
■ Spontaneous rupture of membranes (SROM)
■ Artificial rupture of membranes (AROM)
● Plastic hook, amnihook
■ SROM
● Sudden gush of fluid
○ Color
■ Cloudy or foul smelling amniotic fluid indicates infection
■ Green: fetus has passed meconium
● Poor fetal outcomes
● Could mean baby is stressed out
○ Rupture of membranes
■ Assess FHR to identify declerations: cord compression and cord prolapse
■ Make sure no cord prolapse
● Umbilical cord is not coming out of the uterus because it indicates
an emergency
● Never want cord to come out before baby
■ Risk of infection
● Assess maternal fever, maternal tachycardia, foul odor of vaginal
discharge, and increase in WBC
■ Should smell fleshy; infection: putrid
■ Confirmation that membranes have rupture: sample of fluid from the
vagina via a nitrazine swab to determine fluid’s pH
● Vaginal fluid: acidic (yellow to olive green)
● Amniotic fluid: alcaline (nitrazine swab turns deep blue)
○ Not diagnostic this is a screening test
● pH should be alkaline
● Leopold’s Maneuvers
○ Done by physician
○ Method for determining the presentation, position, and lie of the fetus through the
use of 4 specific steps
○ Inspection and palpation of the maternal abdomen as a screening assessment for
malpresentation
○ Each maneuver answers a question
1. what fetal part is located in the fundus?
a. Fetal presentation
2. On which maternal side is the fetal back located?
a. Fetal position
3. What is the presenting part?
a. Confirm presentation (head first, feet first, etc.)
4. Is the fetal head flexed and engaged in the pelvis?
a. attitude
○
● Fetal adaptations to labor
○ Changes in FHR
○ Decrease in circulation and perfusion
■ Oxygen coming through placenta
■ Contraction: less perfusion coming through umbilical cord
● Every contraction creates less perfusion coming through umbilical
cord and less oxygen coming through to baby from placenta
● Quicker the contractions come the harder is it for baby to
recuperate
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○ Increase in arterial CO2 pressure
○ Decrease in fetal oxygen pressure; decrease in partial pressure of oxygen
○ Decrease in fetal breathing movements
■ Fetus does not breathe in utero, they get oxygen from placenta
Basis for monitoring
○ Fetal response
■ Labor is a period of physiologic stress for fetus
■ Frequent monitoring of fetal status is part of nursing care during labor
■ Fetal oxygen supply must be maintained during labor to prevent fetal
compromise
○ Fetal oxygen supply can decrease:
■ Reduction of blood flow through maternal vessels as result of:
● Maternal hypertension: chronic or pregnancy-induced hypertension
● Hypotension caused by supine maternal position, hemorrhage,
epidural analgesia, or anesthesia
● Hypovolemia caused by hemorrhage
Fetal heart rate monitoring
○ Handheld vs electronic
■ Handheld: intermittent
● Doppler and pinard stethoscope (this is black tube, not used
anymore but was used to amplify sound)
■ continuous : electronic
○ Intermittent vs continuous
○ External vs internal
■ External
● FHR: ultrasound transducer
● UCs: tocotransducer
■ Internal: on baby’s scalp (electrodes)
● Spiral electrode
● Several requirements needed: high risk pregnancy more likely to
do this; needs to be done by skilled practitioner (more accurate)
Fetal heart rate patterns (electronic monitoring)
○ FHR (variability, accelerations, decelerations)
○ Contractions (frequency and intensity)
Guidelines for Assessing Fetal Heart Rate
○ Initial:
■ 10 to 20 minute continuous FHR assessment on entry into labor/birth area
■ Low risk: 10-20 min
○ Intermittent auscultation
● every 30 minutes during active labor for low-risk women
● every 15 minutes for high-risk women
● During second stage of labor
● intermittent auscultation every 15 minutes for low-risk women
● every 5 minutes for high-risk women
● Further along in labor it is more important to look at FHR
● Continuous Electronic Fetal Monitoring
○ Uses a machine to produce a continuous tracing of the FHR
○ Produce a graphic record of the FHR pattern
○ Primary objective
■ To provide information about fetal oxygenation and prevent fetal injury
from impaired oxygenation
■ To detect fetal heart rate changes early before they are prolonged and
profound
○ Bottom: 3 Contractions
○ Top: FHR
■ 130-140 HR within normal range
■ The number will tell you roughly where it falls (where majority of line lies
tells you)
○ Basics of Reading Strip
■ Each tiny box is 10 seconds
■ Should be 60 tiny boxes with big red vertical lines (indicate 1 minute)
○ All accelerates are good: Seen with fetal movemen
● Electronic monitoring tracing
○
○ Baseline FHR: 130-140
● External monitoring
Bottom in heart, could be on right or left depending on babies position
○ Have to put gel so first time mother puts on tonometers warn her about
temperature or use gel warmer
○ Have to move it around to get accurate reading since baby moves so much
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Criteria for Using Continuous Internal Monitoring of FHR
○ Only for high risk pregnanct
○ Electrodes on baby’s head
○ Ruptured membranes
○ Cervical dilation of at least 2 cm
■ Need room to put electrodes on
○ Present fetal part low enough to allow placement of the scalp electrode
○ Skilled practitioner available to insert spiral electrode
External vs internal monitoring
○ Internal: Determines variability (heart changes) more accurately
○ Both look at baseline FHR
Baseline FHR
○ Baseline FHR
■ Baseline rate is average during 10-minute
○ Normal = 110-160 bpm
■ Healthy term infant
Fetal Heath Rate (FHR) patterns essential to interpretation of monitor strips
○ Changes in FHR
■ Bradycardia < 110 bpm
■ Tachycardia =/> 160 bpm
○ Variability (irregularities in FHR)
■ Absent
■ Minimal
■ Moderate (normal)
■ Marked fluctuation rante
○ FHR patterns
■ Accelerations
■ Decelerations
● Causes of Bradycardia
○ Congenital heart block
○ Maternal hypotension
○ Maternal hypothermia
○ Severe hypoxia (long labor)
○ Prolonged hypoglycemia
○ Post dates pregnancy
○ Second stage labor
○ Anesthetics
■ Mother’s BP drops
○ Beta-adrenergics
○ Fetal cardiac dysrhythmias
○ Maternal heart rate
● FHR Tachycardia causes
○ Prematurity
○ Maternal fever
○ Chorioamnionitis*
■ Infection d/t very prolonged labor
■ Membranes ruptured for more than 24 hours - high risk
○ Fetal anemia
○ Cardiac arrhythmias
○ Maternal hyperthyroidism
○ Fetal hypoxia
○ Drugs
● Variability
○ Variability of FHR - “normal” irregularity of cardiac rhythm, resulting form a
continuous balance of the sympathetic and parasympathetic branches of the
autonomic nervous system
○ Irregularity fluctuations in the baseline FHR, which is measured as the amplitude
of the peak trough in bpm
■ Amplitude: how high the peak from the trough
○ Important because:
■ Reflects an intact neurological system
■ Optimal fetal oxygenation
■ Measure of fetal oxygenation reserve
■ Single ​MOST​ important characteristic of FHR
○ Absent: fluctuation undetectable
○ Minimal: fluctuation range < 5bpm
○ Moderate (normal): fluctuation range between 6-25 bpm
○ Marked: fluctuation rate > 25 bpm
○
● Causes of decreased variability
○ Hypoxia/acidosis
○ Drugs (narcotics, magnesium sulfate)
○ Fetal Sleep (fetal sleep cycles last approximately 20-40min)
○ Congenital Abnormalities
○ Extreme prematurity
○ Fetal Tachycardia and other dysrhythmias
● Accelerations
○ Response to the environment by a transient sympathetic stimulation
○ Transitory abrupt Increase in the FHR above the baseline
○ Increase baseline:
■ More than 15 bpm above the baseline, and
■ Duration is > 15 seconds but less than 2 minutes
○ Seen with Fetal movement; response to environment through stimulus
○ Contractions
■ Typically accelerate before contraction
■ Decelerate with a contraction
○ HR Increases by 15-18 bpm
○ Longer than 15 seconds and increased by 15
○ Vaginal exam
○ Good sign of fetal well-being
○
● Decelerations
○ Early decelerations​: response to fetal head compression
■ Good
■ We want these because its the babies response to head compression
● Head compression: As they come down and they are in
effacement/dilation the head is being compressed through cervical
oz, crowning
○ Late decelerations: ​caused by utero-placenta insufficiency
■ bad
○ Variable umbilical: ​cord compression
■ Bad - at some point oxygen dropped for baby
● Early decelerations
○ Characteristics
■ Uniform in shape
■ “mirrors” the contraction
■ Rarely below 110 bpm, or 20-30 bpm below baseline FHR
■ Repetitive
○ Treatment -- No intervention required
○
● Late decelerations
○ Baby is having contraction but is not being adequately perfused
○ bad
○ Characteristics
■ Uniform shape
■ Repetitive
■ Deceleration begins ​AFTER​ the peak of the contraction and returns to
baseline FHR ​AFTER​ the end of the contraction
○
Management/Interventions
■ Notify health care provider
■ Decrease or discontinue (d/c) pitocin*
■ Reposition (first)*
● Always on left side
■ Provide oxygen (8-10L/min)*
■ IV Fluid bolus
■ Perform vaginal exam-- check for positive fetal scalp stimulation
● Variable decelerations
○ Umbilical cord compression
○ Cord is wrapped around head or foot and it is being compressed
○ Oxygen drops for baby because of the compression
○ Most frequently observed FHR deceleration pattern
○ Characteristics
■ Shaped like “V”, “U”, or “W”
■ Shape, depth, duration, and timing varies
■ Usually abrupt in onset
■ Frequency preceded and followed by an acceleration
■ Often falls below 100 bpm
○ Mechanism---> cord compression
○ Treatment/Interventions
■ Reposition
■ Increase intravenous fluids (IVF)
■ Provide oxygen
■ Vaginal exam
○
○
● Head compressions which go with early decelerations
● Arrow pointed at umbilical cord wrapped around babies leg “cord compression” so this is
a variable deceleration
● Placentas vessels constricted during contraction which means less O2 perfusion for baby
resulting in late contractions
●
● Key points
○ Fetal well-being during labor is gauged by response of FHR to UCs
○ Five essential components of FHR tracings are:
■ Baseline rate
■ Baseline variability
■ Accelerations
■ Decelerations
■ Changes or trends over time
●
○
○
○
○
○
FHR: 110
Moderate: Greater than 5, less than 25
No pattern
Variability
-NO pattern probably because the contractions are absent so not in labor
●
○ FHR: 180
○ Variability: Minimal-Moderate, gets more moderate towards end
○ Not deceleration (only 10 bpm drop)
○ Contractions: 4 in 6 minutes so in labor
●
○ FHR: 150
○ 5.5 minute long an 3 contractions
○ Deceleration goes after the peak of the contraction - Good example for test
●
○ FHR: 150
○ Acceleration: Over 15 seconds and HR has increased by 15 bpm (2 accelerations)
●
○
○
○
○
○
FHR: 130
7 contractions: Pitocin
Accelerations: With peak, increases 60 beats
Variability: Marked
Not normal here; shut off pitocin
●
○ FHR: 150
○ Minimal to Moderate Variablitiy
○ Pattern: Variable (Because shape) or Early Decelerations (because decels
happening same time as peak)
●
○ Case 7: Variable because declarations slightly mirrors the contractions
●
○ Case 8: Early decelerations
○ Variability: Moderate
Postpartum Adaptations
● Postpartum period
○ Puerperium: period after delivery of placenta, lasting for 6 weeks
○ Maternal physiologic and psychological changes
Mother and family adjustment to new family member
● Reproductive system adaptations
○ Uterus
■ Involution: contraction of muscle fibers; catabolism; regeneration of
uterine epithelium
● Fundus descends 1 cm every 24 hours
● By the end of 10 days, the fundus usually cannot be palpated
because it has descended into the true pelvis.
■ Afterpains (uterine contraction when the woman is breastfeeding) why??
○ Cervix: returns to its prepregnant state by week 6. It never regains its prepregnant
appearance.
■ C Section Woman: Does not occur if schedule C Section but if she
dilated/effaced she will
○
■
A= No pregnancy and B=Pregnancy
● Assessment of the uterine involution
○ After delivery: ​midline, halfway between the umbilicus and the symphysis pubis
○ 12 hours after birth: ​At the level of the umbilicus
○ 24 hours after birth (day one): ​1 cm or fingerbreadths below the umbilicus
(u/1)
○ Day 2 after birth: ​2 cms below the umbilicus
○ Day 3: 3 cms below the umbilicus
○ Day 4….
○ Day 5….
○ Day 10 uterus should not be palpable abdominally
● Palpating fundus
○ Two hands
○ Idea is to use dominant hand goes at top of fundus and non dominant hand goes at
bottom of uterus
○ Supposed to be able to feel entire uterus
○ 1 finger is a cm
■ Each cm is 1 day
■ How many days postpartum is woman in first picture? 2 cm (2 fingers) so
2 days postpartum
■ If uterus goes beyond belly button there is a complication
●
● Reproductive system adaptations
○ Uterus
■ Lochia: Postbirth uterine discharge
■ Lochia: rubra, serosa, alba
● Lochia rubra ​(3-4 days after birth)
○ Blood, mucus, tissue, and blood
○ Blood clots mainly with vaginal. C section they clean them
out!
● Lochia serosa ​(3 to 10 days after birth but it can last until 22 to 27
days postpartum)
○ Pinkish brown
○ Old blood, serum, leukocytes, and debris
● Lochia alba ​(10 to 14 days, but it can last until 3-6 weeks
postpartum)
○ Creamy, white or light brown
○ Leukocytes, decidua, epithelial cells, mucus, serum, and
bacteria
■ Decidua: type of leukocyte
○ Uterus
■ Lochia: Amount
● Scant: 1-2 inch (10ml loss)
● Light or small: 4 inch (10-25ml loss)
● Moderate: 4 to 6 inch (25-50ml loss)
● Large or heavy: pad saturated in within 1 hour
○ Vagina: eventual thickening and return of rugae.
○ Perineum:
■ Pelvic muscular support
■ Supportive tissues of pelvic floor torn or stretched during childbirth
■ Require up to 6 months to regain tone
■ Kegel exercises encourage healing
■ Later in life women can experience pelvic relaxation
● Once older, especially after menopause it gets soft toned and
subsequent issues voiding can occur
● Endocrine system adaptations
○ Placental hormones
■ Expulsion of placenta results in dramatic decreases of placental-produced
hormones
● Estrogen and progesterone levels drop markedly
■ Prolactin levels increase
Decreases hCG, human placental lactogen [hPL], cortisol
● Cardiovascular system adaptations
○ Vaginal : 500ml
○ Void large outputs
○ Blood volume and cardiac output
■ Blood volume which increased during the pregnancy drops rapidly after
birth and return to normal within 4 weeks postpartum
■ Volume plasma is reduced because the blood loss during the pregnancy,
diuresis, and diaphoresis
● Night sweats: Body getting rid of extra plasma and blood volume
○ Red blood production return to normal after the second week of the delivery
○ White cells are elevated the first 4 to 6 days and then return to normal levels
○ Catheter in because of bladder retention
■ Anesthesia/Epidural: don’t feel need to void so need catheter
○ Cardiac output: remains high for the first few days postpartum and then
gradually to non pregnant values within 3 months of birth
○ Pulse: bradycardia (40-to 60 bpm) first two week after delivery
○ Blood pressure: the same as during the one during labor and return to normal one
week after the delivery
○ Coagulation factors
■ Clothing factors that increased during pregnancy tend to remain elevated
during early postpartum (2 to 3 weeks post partum)
■ DVT risk
■ This hypercoagulable stated plus vessel damage and immobility put
the mother at increase risk for thromboembolism in the lower
extremities and lung (assessment using Homan sign)
● PE: SOB
● Homans: Redness, swelling, foot flexed will cause pain
● Urinary System Adaptations
○ GFR and renal plasma flow return to normal by 6 weeks.
○ Pain assessment is very important postpartum (want it 0-2)
○ With pain they cannot walk, breastfeed properly
○ Voiding sensation affected by:
■ Perineal lacerations
■ Generalized swelling and bruising of the perineum and tissues surrounding
the urinary meatus
■ Hematomas
● Not normal
● If you see a hematoma in perineal area you must notify physician
■
Decreased bladder tone due to regional anesthesia
■ Diminished sensation of bladder pressure due to swelling, poor bladder
tone, and numbing effects of regional anesthesia used during labor
○ Within 12 hours women must urinate
○ Profuse diaphoresis often occurs at night for first 2 to 3 days
○ Urinary retention is a mayor cause of UTERINE ATONY which allows
excessive bleeding (DISPLACEMENT OF THE UTERUS: UPWARD AND
TO THE SIDE).
■ Atony: loss of tone in uterine musculature
○ Palpate the fundus and it feels boggy: Massage then contact the physician
○ Palpate the fundus and it’s boggy but displaced to the right: If they can void they
need to go to bathroom, or if they cannot feel need to void you need to put
catheter in
■ If uterus is displaced it is bladder retension!
● GI System Adaptations
○ The GI system quickly returns to normal
■ Relief of pressure on organs
○ Decreased bowel tone for several days
○ Decreased peristalsis occurs
○ Hunger and thirst
○ Constipation is common due to fear of straining affecting the perineum
■ Give colase
○ If they pas gas and you hear bowel sounds= okay to let them leave if they have
not had stool defecation
○ Trapped air: Will travel to shoulder after C Section
■ Happens after surgery
■ Release through ambulation
○ Spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth
● Musculoskeletal system adaptations
○ Joints return to prepregnant state
○ Women commonly experience fatigue and activity intolerance for weeks after
giving birth
○ Abdominal muscle tone is diminished after birth and special exercises are needed
to return to normal - ab workouts
■ Side weight
■ Sway back and lordosis naturally relieve since decrease in pressure
● Integumentary system adaptations
○ Pigmentation disappears or diminishes
■ Chloasma will go away (hormone related color)
■
Stretch marks change to silvery lines
○ Linea nigra fades; chloasma fades
Respiratory system adaptations
○ Anatomic changes reside quickly
Immune system
○ No significant changes in maternal immune system occur during postpartum
period
○ If woman is not immune, vaccination during postpartum is recommended:
■ Rubella vaccination
● Cannot get while pregnant if she does not have it
■ Tetanus-Diphtheria-Acellular-Pertussis vaccine
■ Rho (D) immune globulin or also called RhoGAM for prevention of Rh
isoimmunization.
● Rh immune globulin should be given within 72 hours for
Rh-negative women who deliver an Rh-positive infant
● If she was Rh negative she gets it at 28 weeks and within 72 hours
of delivery
Ovulation and Return of Menstruation
○ Breastfeeding or not determines if they get period back
○ Interplay of hormones: estrogen, progesterone, prolactin, and oxytocin
○ Nonlactating women: return of menstruation 7 to 9 weeks after birth
○ Lactating women: return dependent on breast-feeding frequency and duration;
anywhere from 2 to 18 months. Women who breastfeed may not ovulate for long
periods
■ May ovulate before first menstrual cycle
■ Women who breastfed may not ovulate for long periods of time
■ If you supplement aside from breastfeeding it will come back sooner
■ Ovulation does not occur because the breastfeeding is inducing oxytocin
and delays menstrual cycle
■ DO NOT tell them not to take birth control if breastfeeding. They can get
pregnant
Maternal Psychological Adaptations
○ Attachment: formation of a relationship between a parent and his or her newborn
through a process of physical and emotional interactions
■ Attachment
● Bilateral between child and mother
■ Bonding
● Unilateral: mom bonds with child, the child does not bond with
mother
○
●
●
●
●
Early and sustained contact between newborns and parents is vital
○ Nurses play a crucial role is assisting with this process of attachment
■ If mom says “I haven’t named the baby and it’s been 5 days”
● Sign mother is not attached
■ Mother is not wanting to hold the baby or make eye contact or change the
baby
● Sign mother is not attached
○ Factors influencing attachment include environmental circumstances, newborn
health, and quality of nursing care
● Engrossment: Partner Psychological Adaptation
○ Visual awareness of the newborn
○ Tactile awareness of the newborn
○ Perception of the newborn as perfect
○ Strong attraction to the newborn
○ Awareness of distinct features of the newborn
○ Extreme elation by the father
○ Increased sense of self-esteem
● Assessment in postpartum period
○ During the first hours: every 15 minutes
○ During the second hour: every 30 minutes
○ During the first 24 hours: every 4 hours
○ After 24 hours: every 8 hours
○
○
○ Temp: immediately after delivery slightly elevated
○ Saturated pad: means heavy
○ HA/Blurred Vision: Hypotension, Hypovolemia
○ Epidural or Spinal Block: Assess back!
■ Leakage could cause blurred vision or H/A
■ Will patch with blood
○ DVT: Calf plain with dorsiflection
○ UTI: Dysuria, burning, incomplete emptying
○ SOB: Pulmonary Embolism
○ Depression/Mood Swings; PP Depression
○ Baby blues is 1-2 days. PPD is 2 weeks but happens later like 1 month in
● Vital signs assessment
○ Temperature: slight elevation during 1​st​ 24 hours; normal afterwards
○ Pulse: Puerperal bradycardia
○ Respirations: 16 to 20 breaths/minute
○ Blood pressure: within usual range
■ Initially you have a drop
○ Pain: goal between 0 and 2 on pain scale
● Physical assessment
○ Breasts
■ Size, contour, asymmetry, engorgement
■ Check nipples for cracks, redness, fissures or bleeding and note whether
they are erect, flat or inverted
■ Presence of colostrum or foremilk and discharge (report)
○ Uterus:
■ Degree of uterine involution (height of fundus)
■ Assess uterus: boggy or relaxed uterus:
● Bladder distention or retained placental fragments, risk of
hemorrhage
● Uterine massage
● Bladder distention: relieve this
● Hemmorhage: Only know through pad or heavy bleeding
○ Bladder
■ Increase in diuresis (3,000 ml)
■ Assess bladder emptying
■ Bladder distention
○ Bowels
■ Bowel sounds present in 4 quadrants, nondistented abdomen and passing
gas are normal findings
○ Lochia
■ Assess amount, color, odor
○ Episiotomy and perineum
■ Inspect episiotomy (irritation, ecchymosis, tenderness or hematoma)
■ Hemorrhoids: may have especially with vaginal delivery
■ Lacerations
○ Extremities
■ Risk of thromboembolic disorders and pulmonary embolism
● Compression socks
● Ambulation teaching
● Incentive spirometer to avoid PE
■ Assess the degree of sensory and motor function return
● Nursing interventions
○ Providing optimal cultural care
○ Promoting comfort (relieve the underlying problem)
■ Cold and heat applications (ice packs, peribottle and sitz bath)
■ Topical preparations (local anesthetics)
■ Analgesics (tylenol, NSAIDs, narcotics)
○ Assisting with elimination
■ Promoting voiding (warm water, running tap water, privacy, basin of
warm water)
■ Promoting bowel elimination (ambulate, increase fluid and fiber intake,
diet changes increasing fruits and vegetables, stool softener such as
docusate, laxative)
○ Promoting activity, rest, and exercise
■ Early ambulation
■ Rest periods (naps, limit number of visitors, shared household tasks to
conserve energy)
■ Exercise program; recommended exercises; Kegel exercises
○ Assisting with self-care measures
■ Ways to prevent infection (change perineal pads, avoid tampons, sitz bath
or peribottle, avoid tub baths)
○ Ensuring safety
■ Newborn care
○ Counseling about sexuality and contraception
■ Sexual activity 3​rd​ to the 6​th​ week postpartum
■ Fluctuations in sexual interest are normal
■ Contraception should be discussed with the couple so they can take an
informed decision (LAM, diaphragm, oral pills, condoms)
● Should avoid postpartum pregnancy
● Teaching about postpartum blues
○ Transient emotional disturbances
Characterized by anxiety, irritability, insomnia, crying, loss of appetite, and
sadness (Hanley, 2010)
○ Symptoms usually begin 2 to 4 days after childbirth and resolve by day 8
○ Blues typically resolve with restorative sleep
○ Postpartum depression and psychosis are more serious and require professional
referral
● Preparing for discharge (criteria)
○ Vital signs normal
○ Lochia appropriate amount and color
○ Hemoglobin and hematocrit normal
○ Uterine fundus firm
○ ABO and RhD status known and RhoGAm has been indicated if necessary
○ Mother ambulates
○ Care of infant demonstrated
○ Family and support system available
○ Food and fluids taken without difficulty
○ Mother aware of possible complications
○ Provide immunizations
○ Ensuring follow-up care
■ Telephone follow-up (first week)
■ Outpatient follow up (4-6 weeks later)
■ Home visit follow up (first week)
● Teaching topics for postpartum period
○ Pain and discomfort
○ Immunizations
○ Nutrition
○ Activity and exercise
○ Lactation
○ Discharge teaching
○ Sexuality and contraception
○ Follow-up
○ Local Anesthetics for suture or laceration
○ Analgesics: usually want you off real pain meds after 1st day
○ Promoting comfort:
■ Cold/heat applications (sitz bath)
■ Topical preparations
○ Match babies itinerary for sleep
○ Limit visitors
○
○
Do kegals
Gestational Diabetes
● Diabetes Mellitus
○ Affects 3% to 5% of all pregnancies
○ 2% to 3% develop the condition during pregnancy (gestational diabetes)
○ Risk of develop type 2 DM later in life may be as high as 50% to 60%
○ The most common seen medical condition in pregnancy
■ As well as preeclampsia
○ New challenges:
■ How to manage type 1 and type 2 diabetes during pregnancy
■ How to protect an infant in utero from the adverse effects of increased
glucose levels?
● Fetus can have birth defects
● If diabetic woman says she wants to have a baby, make sure she
controls her glycemic levels even before they conceive
○ As baby develops, before they know their pregnant, high
glucose can affect baby
○ Increase physical activity, change diet before conception
■ How to care for the infant in the first 24 hours after birth
● Monitor for hypoglycemia
● Type 1
○ Autoimmune process
○ Absolute insulin deficiency
● Type 2
○ Insulin resistance or deficiency
○ Multifactorial cause
● Glucose intolerance
○ Fasting glucose between 100 and 125 mg/dL
○ Risk of LGA infants
○ No diabetic symptoms
● Gestational diabetes
○ Any degree of glucose intolerance first detected in pregnancy
○ Onset during pregnancy
○ Usually resolves 6 weeks after birth
○ Bigger risk for developing type 2
● Risk factors for gestational diabetes
○ Maternal obesity
○ Age over 25
○ Excessive gestational weight gain
○ Glucose intolerance pre pregnancy
○ Diabetes pre pregnancy
○ Sedentary lifestyle
○ Familial link
○ Higher prevalence among minorities
● Maternal complications from diabetes in pregnancy
○ Dystocia or difficult labor
○ Stillbirth
○ Preterm labor
○ C-section
○ Increased risk of developing preeclampsia
○ More frequent UTIs
○ Hydramnios
○ Chronic monilial vaginitis (chronic yeast infection)
○ Ketoacidosis
○ Macrocomeia (large birth weight); difficult labor, C section
○ Yeast infections
○ Higher lifetime risk of obesity and glucose intolerance
● fetal/newborn complications from diabetes
○ Birth Defects
■ Usually cardiac
○ Large for Gestational Age (LGA) infants / Macrosomia (25 to 42%)
○ Stillborn
○ Fetal birth trauma (if baby’s large)
■ Hypoxia; etc.
○ Hypoglycemia
○ Fetal asphyxia
○ SGA and IUGR
○ Respiratory distress syndrome
○ Polycythemia
○ Jaundice
○ Higher lifetime risk of obesity and glucose intolerance
○
● Signs of hypoglycemia in the newborn
○ Hypoglycemia: glucose < 40 (50) mg/dl
○ Signs
■ Poor feedings - first sign
■ Jitteriness
■ Lethargy
■ High pitched or weak cry
■ Apnea
■ Cyanosis and seizures (lower than 20 or 30) - late sign
○ To bring up glucose level:
■ Give breastmilk (least invasive to most invasive)
■ If not going up or can’t drink anything -> IV glucose (drastically goes up,
then have to get it down, etc. give insulin)
■ Best way is to orally feed them if they can handle it
● Insulin requirements during pregnancy
○ First trimester: Decrease in the need for insulin
■ Fetal needs are minimal
■ Women consume less food because of nausea and vomiting
■ Placental hormones are low (hPL low)
■ Risk of hypoglycemia (secondary to nausea and vomiting)
2​nd​ and 3​rd​ trimesters: Insulin requirements increase
■ Increase in glucose use and storage by the woman and the fetus
■ Insulin requirements may double or quadruple by the end of pregnancy as
a result of the placental maturation and hPL production
○ Labor: increased energy needs during labor may require increased insulin to
balance intravenous glucose
○ Post-partum: abrupt decrease in insulin requirements
○
○
○
● Gestational diabetes: Pathophysiology
○ Inability to meet the demand of pregnancy induced insulin resistance
○ Not enough beta-cell production
○ Insulin secretion not enough to respond to increase in insulin resistance by
placental hormones
○ Glucose levels increase
○ Hyperglycemia results; fetal and maternal complications arise
● Screening in pregnancy
○ ACOG and ADA recommend:
■ All women at first prenatal visit undergo a risk assessment
High Risk Women reassessed between 24 – 28 weeks
● Generally all women, not just high risk
○ First visit:
■ Fasting (>125 mg/dl)
■ HbA1C > 7 %
■ Random (>200 md/dl)
○ 24-28 weeks:
■ Fasting (>92 mg/dl)
■ 75 g OTTG- 1hr (> 180 mg/dl)
■ 75 g OTTG- 2hr (> 153 mg/dl)
○ * Using HbA1c and plasma glucose measurements beneficial
○ AbA1C typically for high risk women
○ Only test that confirms if gestational diabetes - Oral Glucose Tolerance Test
(OTTG)
■ All women get 1 hour
■ Give sugary liquid and stay around for 1 hour, take blood glucose again
■ If greater than 180, then have risk for gestational diabetes
■ If positive, do 2 hour or 3 hour to diagnose gestational diabetes
○ GDM can only be diagnosed upon an abnormal result on the Oral Glucose
Tolerance Test (at 24-28 weeks)
● Care management
○ Goals:
■ To maintain a physiologic equilibrium of insulin availability and glucose
during pregnancy
■ To ensure an optimally healthy mother and newborn
○ Therepeutic management
■ Preconception Counseling
■ Blood Glucose level Control
■ Glycemic control
■ Nutrition, exercise, and lifestyle changes
■ Insulin usage in pregnancy
■ Maternal and fetal surveillance
■ High risk labor and delivery management
■ Fetal monitoring postpartum
○ Want to do least invasive to most
○ But many practitioners start with insulin (safer for fetus)
○ Considered high risk pregnancy (see doctor more often)
○ Maternal monitoring
■ Thorough health history
■
Physical exam
■ Urine test
● Ketones
● Proteins (sign of preeclampsia)
● Glucose if not controlled
■ Renal function each trimester
● Diabetes affects kidneys
■ Eye exam in first trimester
■ HbA1c every 4-6 weeks
○ Fetal monitoring
■ Ultrasound
■ Biophysical profile
● Non-stress tests (monitoring movements of child:
accelerations/decelerations)
■ Genetic screenings like alpha-fetoprotein
■ Amniocentesis - if found high risk for genetic disorder
○ Gestational diabetes correlates a lot with preeclampsia (HTN)
○ Gestational diabetes mellitus
■ Fetal risks
■ Screening for gestational diabetes mellitus
● Antepartum care
○ Diet and exercise
○ Monitoring blood glucose levels
○ Medications for controlling blood sugar levels
○ Fetal surveillance
● Intrapartum and postpartum care
● Postpartum management
○ Breastfeeding aids in blood glucose homeostasis
■ Transfer of mother’s glucose to breast milk to feed the baby
■ Colostrum helps balance baby’s blood sugar level
○ Insulin needs will reduce after delivery
○ Glucose challenge test at the 6 week postpartum exam
○ If result normal, screened every 3 years
■
Hypertensive Disorders
● Vast array of types: chronic HTN, preeclampsia, eclampsia, etc.
● Most common medical condition in pregnant women, up to 15% of all pregnancies
● Associated with higher rates of maternal, fetal and infant mortality and severe morbidity
● Include different disorders
Gestational hypertension
○ Preeclampsia
○ Eclampsia
○ Chronic hypertension
○ Chronic hypertension with superimposed preeclampsia
● Gestational hypertension
○ Onset of hypertension without proteinuria after the 20​th​ week of pregnancy
■ Systolic BP > 140 mm Hg
■ Diastolic BP >90 mm Hg
○ Diagnosis of onset during pregnancy based on two measurements that meet
criteria for gestational BP elevation within a 1-week period
■ Have to have repeated BP readings
○ No proteinuria, typically starts after 20 weeks
● Preeclampsia
○ Pregnancy-specific syndrome
○ Hypertension develops after 20 weeks of gestation in previously normotensive
woman
○ Disease of reduced organ perfusion with presence of hypertension and proteinuria
○ Complicates 1% to 2% of all pregnancies
○ Proteinuria ​is present
○ Classified by mild and severe with potential progression to eclampsia
○
■
○ Etiology
■ Multisystem, vasoppresive disorder
■ Unique to human pregnancies, etiology still not completely clear
■ Signs and symptoms develop only during pregnancy and disappear after
birth
■ Primarily effects kidneys, brain, and liver
■ Associated high risk factors
● Primigravidity (first pregnancy)
● Multifetal pregnancy
● Obesity
● Preexisting medical condition
● Preeclampsia in a prior pregnancy
○ Pathophysiology
■ May be caused by disruptions in placental perfusion and ​endothelial cell
dysfunction
● Main pathogenic factor is not an increase in BP, but poor perfusion
resulting from vasospasm*
○ Main reason it is effecting the organs
● Arteriolar vasospasm diminishes diameter of blood vessels, which
impedes blood flow to all organs and increases BP
● Significant decreases in placental, kidney, liver, and brain function
■
■ Disseminated Intravascular Coagulation (DIC)
● Clotting system is abnormally activated, resulting in a widespread
clot formation in small vessels
■ Proteinuria
● Presence of an excess of serum proteins in the urine
● Increased capillary permeability in the kidney allows albumin to
escape
● Eclampsia
○ Seizure activity or coma in woman diagnosed with preeclampsia
○ No history of previous seizure disorder
○ Presentation varies
■ One third in labor
■ One third during delivery
■ One third within 72 hours postpartum
Chronic hypertension
● Present before the pregnancy or diagnosed before week 20 of gestation
Chronic hypertension with superimposed preeclampsia
● Women with chronic hypertension may acquire preeclampsia or eclampsia
● Increases morbidity for mother and fetus
○
○ HELLP syndrome
■ Laboratory diagnostic variant of severe preeclampsia/ eclampsia syndrome
involves hepatic dysfunction, characterized by:
● Hemolysis (H)
○ RBCs become fragmented as they pass through small,
damaged blood vessels
● Elevated liver enzymes (EL)
○ Reduced blood flow to the liver
● Low platelets/ thrombocytopenia (LP)
○ From vascular damage, vasospasm, platelets aggregates at
site of damage
■ It is a life threatening obstetric complication
■ Is a clinically progressive condition
■ 20% of women diagnosed with severe preeclampsia
■ Associated with increased risk for:
● Pulmonary edema
● Acute renal failure
● Disseminated intravascular coagulation (DIC)
● Placental abruption
● Liver hemorrhage or failure
● Adult respiratory distress syndrome
Sepsis
● Stroke
●
○
High risk for maternal death
● Caremanagement
○ Nursing Assessment:
■ Risk factors, physical exam, laboratory test
■ Physical examination
● Assess nutritional intake and weight
○ Reduce sodium
● Consistency in taking BP readings and recording them in a
standardized manner
● Edema
○ Dependent edema
■
○ Pitting edema
● Deep tendon reflexes
○ If she has severe preeclampsia or eclampsia she will have
hyperreflexia
■ Laboratory Test for Proteinuria:
● Dipstick: ​Qualitative measure, positive is defined as 1+ or more
on dipstick analysis. It is a colorimetric test, the filter paper on the
dipstick changes its color.
○ Not diagnostic, but good way to screen urine for protein
● 24 hours urine collection ​(gold standard): preeclampsia if protein
excretion is greater than 300mg/24hrs
○ Diagnostic gold standard
● Ratio of protein to creatinine: ​usually correlates with the value
obtained in a 24 hr collection
○ Mild gestational hypertension and mild preeclampsia
■ Goal is to ensure maternal safety and deliver a healthy newborn
■ May be safely managed at home
● Maternal and fetal assessment: Daily BP monitoring (every
4-6hrs), Fetal movement counts, Non stress test if necessary,
Weight gain and urine test (dipstick)
Activity restriction (bed rest)
● Diet (balanced, no sodium restriction is advised, drink water)
● In some cases, hospitalization may be needed
● IV magnesium sulfate during labor
■ Maternal education:
● If she can, assess BP; tell her what level it should be at
● Teach her to use same arm, same machine (consistency)
● Teach her to check her weight
○ Drastic increase in weight could be water retention
■ Organs affected, declining with her disorder
● With the baby,
○ Do the fetal counts (how often is the baby moving within
each hour)
○ May have to do nonstress test every week or every 2 weeks
● Educate patient on how to void, where to put dipstick, when to call
HCP (+1/+2)
● May have to go on activity restriction especially if eclampsia
(seizures)
○ Priority: maintain patient safety
● Gestational HTN and mild preeclamspia can be managed at home
○ Once going into severe and eclampsia - will be hospitalized
○ Severe gestational hypertension or severe preeclampsia ​(BP >160/110)
■ At greater risk for pregnancy complications
■ Should be hospitalized for at least 24 hours for observation and treatment
if necessary
● Control of blood pressure
● Magnesium sulfate - to prevent seizures
● Prevent seizures: Quiet environment, sedatives, seizure precautions
● Seizure precautions:
○ Padded bedrails (not usually seen in clinical practice)
○ Bed in lowest position
○ Put on her side
○ Make sure you have oxygen and suction set up
○ Eclampsia
■ Premonitory signs and symptoms
● Headache
● Blurred vision
● Severe epigastric pain
● Altered mental status
●
Tonic- clonic convulsions
■ Hypotension
■ Coma
■ Immediate care
● Ensure a patent airway
● Administer oxygen
● Patient safety a major concern
● Post-seizure decision regarding timing and method of birth
● Other care management: magnesium sulfate, uterine contractions
monitoring, fetal monitoring
○ HELLP syndrome: ​Management similar to severe pre-eclampsia and also it
needs:
■ Lab evaluation (liver enzymes, chemistry panel, CBC, coagulation test,
platelet count,)
● Specifically if you see low platelet count, may need to transfuse
blood products
■ Infusion of blood products
● Magnesium sulfate
○ Severe Preclampsia to prevent Eclampsia (convulsions)
○ Magnesium Sulfate (MS): Severe Pre Eclampsia, HELLP, eclampsia
■ * Secondary infusion (piggyback) to the main IV line
■ * Using a volumetric infusion pump
■ * Initial loading dose of 4- 6 g of MS infused over 15 -20 minutes
■ * This dose is followed by a maintenance SM dose diluted in 1000 ml of
Lactated Ringer’s solution administer by pump 2 g/hour. This maintain a
therapeutic magnesium level of 4-7 mEq/L
○ Anything above 8 considered toxicity
○ Toxicity
■ More than 8 mEq/L
■ Antidote: Calcium gluconate (Ig IV)
■ Different s/s
● Hyporeflexia
● Respiratory depression (<12)
● Decreased urinary output (<30 ml/hr)
● Hypotension
● CNS depression
● Cardiac arrest
● Chronic Hypertension
○ Chronic hypertension associated with increased incidence of:
■
Abruptio placentae - high risk for fetal death
■ Superimposed preeclampsia
■ Increased perinatal mortality
■ Fetal effects
● Fetal growth restriction
○ Don’t have enough room to grow any more - restricted by
body
● Small for gestational age
○ Means that they’re small for their gestational age
Can occur before/after pregnancy
About 25% of the women with chronic hypertension develops preeclamsia
Ideally management begins before conception
Lifestyle changes may be necessary
In postpartum, high risk women monitored closely for complications
May safely breastfeed even though low levels of antihypertensive medications
will be in breast milk
■
○
○
○
○
○
○
Placenta Previa and Abruptio Placenta
● Hemorrhage
○ Death from hemorrhage still remains a leading cause of maternal mortality
○ Is one of the leading causes of antepartum hospitalization and operative
intervention
○ It is a medical emergency
○ If mother has postpartum hemorrhage
■ Give pitocin (contracts uterus)
■ If hemorrhage resulted from placental abrupto; do not run pitocin
● Placenta Previa
○ Definition
■ Placenta implanted in lower uterine segment near or over internal cervical
■ Placenta attached itself in a location that is not ideal
○ Not as bad as abrupto previa
○ 0.5% of births
○ Clinical manifestations
■ Vaginal bleeding occurs in 70% of women
○ Maternal and fetal outcomes
■ 5% morbidity rate
■ 1% mortality rate
○ Pathophysiology
■ Unknown
■ Implantation of the embryo in the lower uterus perhaps due tor scarring or
damage in upper uterine segment
● Can have scarring due to previous C section
■ Uteroplacental underperfusion, increasing the surface area required for
placental attachment
■ Placental vascularization is defective, can cause problems with the
implantation of the placenta
○ Risk factors
■ Advancing maternal age
■ Multiparity
■ Multifetal gestations
● Due to several placentas (twins, etc.)
■ Prior cesarean delivery
■ Smoking
■ Prior placenta previa
■ Abortion
■ Diabetes or hypertension
■ Uterine anomalies/fibroids/endometritis
○ Classification based on degree to which internal cervical is covered by placenta
■ Complete placenta previa
■ Partial placenta previa
■ Marginal placenta previa
■ Low-lying placenta*
● Lower uterine segment, but not on cusp of cervical os
○ At 18 weeks 5 to 10% of placentas are low lying . Most “migrate” with
development of the lower uterine segment
■ Usually don’t diagnose women with pacenta previa until after 20 weeks
○
○ ****
○
○
○
○
○
1 = complete
2 = partial
3 = on the cusp (marginal)
4 = low hanging
○
○ Signs and symptoms
■ Bright red vaginal bleeding *** (differentiates from abrupto)
● Since it is lower in the body, the blood is much brigher
■ Painless
■ Spontaneous cessation then recurrence
■ Rarely to profuse as to prove fatal
■ Usually ceases spontaneously
■ Coagulopathy is rare with placenta previa
○ Risks for women and the fetus
■ Maternal morbidity and mortality (LOW)
■ Complications (hemorrhage, hypovolemic shock)
■ Fetal risks include mal presentation and fetal anemia
● Mal presentation d/t not being able to put its head in the pelvis if
there’s a placenta in the way
● Fetal anemia can happen due to the hemorrhage
■ Preterm birth
■ Low fetal mortality
■ Potential RH sensitization
○ Diagnosis
■ Standard diagnosis is transabdominal ultrasound examination
● Any woman with ​painless vaginal bleeding after 20 weeks
gestation should be evaluated for a placenta previa
● Examination of the cervix is ​never​ permissible unless the woman
is in an operating room with all the preparation for immediate
cesarean, because vaginal examination can cause torrential
hemorrhage
● Do not do vaginal examination
● If she’s having very bad symptoms, prepare for C section
○ Management
■ Emergency Management (mother or fetus unstable):
● C-section when either maternal or fetal status is compromised as a
result of extensive hemorrage.
Vaginal delivery maybe attempted with low lying placenta
● Blood transfusion
■ Therapeutic Management (mother and fetus stable):
● Expectant management
● At home or in the hospital
■ Therapeutic Management (mother/fetus stable): when bleeding is minimal
(<250ml), prolonging pregnancy and delaying delivery may be possible.
● Nursing assessment (bleeding, vital signs, uterine contractions)
● Close observation and hospitalization
● Bed rest with bathroom privileges
● No vaginal examination
● Evaluate HCT and HGB
● Fetal assessment: monitoring and give corticoids if necessary
● IV fluids
● Oxygen
● Home care: Bed rest (no active bleeding)
● Cesarean birth
●
○
■ Do not need to memorize
● Abruptio Placentae
○ Much worse
○ Detatchment issue (placenta has detatched)
○ Premature separation of the implanted placenta after the 20​th​ week of gestation
and prior to birth of the fetus leading to compromised fetal blood supply
○ Significant cause of third trimester bleeding with a high mortality rate
○
○
○
○
○
○
○
■ This bleeding is dark red
Etiology unknown
Pathophysiology
■ Unknown
■ Degenerative changes in the small maternal arterioles ->
■ thrombosis, degeneration of the decidua, and possible rupture of the
vessel ->
■ Bleeding of the vessels forms a retroplacental clot ->
■ Bleeding causes increases pressure behind the placenta and results in
separation
Occurs in 1- 2% or all pregnancies
Accounts for significant maternal and fetal morbidity and mortality Maternal
■ 1% mortality rate
Perinatal
■ 20% to 40% mortality rate
■ IUGR and preterm birth
10 to 20 times greater risk of reoccurrence in subsequent pregnancy
Big cause of premature labor
○
■ Trauma typically #1 reason (blunt trauma)
○ Classification
■ Degree of separation
● Partial separation
● Complete separation
■ Type of bleeding
● Concealed
● Apparent
■ Extent of separation and amount of blood loss
Grade 1 mild
● Grade 2 moderate
● Grade 3 severe
●
○
○ **** know difference between B and C
○
○ Signs and symptoms
■ Can vary considerably. They will depend of the extension of the placenta
detachment
● Dark ​Vaginal bleeding (present in 80% of the cases)*
● Persistent or intense abdominal pain ​knife-like
● Hypertonic uterus
● Uterine tenderness or back pain
● Uterine contractions
● Change of the fetal heart rate
● Fetal movement and activity (decreased)
● Fetal death
● Mother shock and renal failure
○
■ Mild, moderate, severe
○ Risks for the woman and the fetus
■ Hemorrhagic shock
■ DIC
● No way to perfuse organs to the fetus if the placenta is detatched
■ Hypoxic damage to organs
■ Preterm birth
■ Hypoxia, neurologic injury, fetal death
○ Management
● Depends upon severity of blood loss and fetal status
● Delivery is the treatment of choice (c-section); expectant
management only if the mother is stable and fetus is immature.
■ Therapeutic Management: assessment, control, and restoration of blood
loss;
■ Prevention of Disseminate Intravascular Coagulation (loss of balance
between the clot forming activity or thrombin and the clot lysing activity
of plasmin)
■ Left lateral position, strict bed rest, oxygen therapy, vital signs, fundal
height, continuous fetal monitoring
● Look at fundal height b/c if big drop in fundal height, she might be
dilating and effacing
■ Monitor labs CBC, platelets and clotting studies
■ NST, biophysical profile
■ Support and education: empathy, understanding, explanations, possible
loss of fetus
Ultrasonography: differential diagnosis with placenta previa (CT is more
reliable)
■ Administer Rogham if mother is RH negative
■
■
● Key points
○ Placenta previa and abruptio placenta are differentiated by:
■ Type of bleeding
■ Uterine tonicity
■ Presence or absence of pain
■ Fetus condition
Premature Labor
● Greater than 20 weeks, less than 37 weeks
● Preterm labor and birth
○ Preterm labor: cervical changes and uterine contractions occurring between 20
and 37 weeks of pregnancy
○ Preterm birth: any birth that occurs before completion of 37 weeks of pregnancy
○ Approximately 12% of all live births
○ Many complications d/t the lack of maturity of their organs
○ The more premature, the more at risk they are
○ Preterm birth and prematurity describes length of gestation, regardless of birth
weight
○ Preterm birth is more dangerous to the infant
■ Decreased length of time in utero correlates with immaturity of body
systems
Low birth weight describes only birth weight:
■ 2500 g or less
● Easier to measure than preterm birth
○ Preterm labor does not correlate with birth weight
○ Predicting spontaneous preterm labor and birth
■ Known risk factors
■ Biochemical markers
● Fetal fibronectin (“biologic glue”)
○ Cells of uterus wall and cells of amniotic sac have to be
attached - test how much these two walls are attached
○ Can tell by swabbing vagina
○ If they find cells of uterus in vaginal secretions, have
higher chance for premature labor
● Salivary estriol
● Cost of determining biochemical markers is high
■ Endocervical length (ultrasound)
○
■
■ Fetal fibronectin
●
● Risk factors for preterm birth
Non white race
○ Age (<16, > 40)
○ Low socioeconomic status, single, <HS education
○ Smoking, Substance abuse, lifestyle stressors
○ Poor nutrition
○ Maternal periodontal disease
■ Gingivitus is a contributor d/t infection could travel to heart
○ Previous preterm labor or birth
○ Short interpregnancy intervals: less than 1 year
○ Uterine anomalies
○ Cervical incompetence
■ Has to due with environment for attachment
■ Related to fertility, and how well environment is for implantation
○ Small stature
○ Multifetal pregnancy
○ Hydramnios
○ Bleeding Placental problems
○ Infections (typically STIs), UTI
○ PROM
○ Fetal anomalies (genetic abnormality, spinal bifida, etc.)
○ Maternal Anemia
○ Domestic violence
○ Medical diseases (DM, hypertension, anemia)
● Care management
○ Prevention
■ Preventive strategies to address risk factors
■ Education about early symptoms of preterm labor
● Dilating, effacing, having contractions early
● Educate difference between Braxton Hicks and true contractions
■ Teach what to do if symptoms occur
■ Women may ignore symptoms because of:
● Ignorance regarding significance
● Belief that symptoms are expected during pregnancy
○ Early recognition and diagnosis
■ Gestational age between 20 and 37 weeks
■ Uterine activity (contractions)
■ Progressive cervical change - “being in labor”
● Effacement of 80%
● Cervical dilation of 2 cm or greater
○
Lifestyle modifications
■ Activity restrictions
● Bed rest
● Limited work
■ Restriction of sexual activity - sex can induce labor
■ Home care
● Environmental modification
● Home uterine monitoring
○ Suppression of uterine activity - if already having true contractions
■ Tocolytics – goal is to delay birth long enough to institute interventions
that delay neonatal morbidity and mortality
● Magnesium sulfate most commonly used
● Beta adrenergics
● Terbutaline
● Nifedipine
● Indomethacin
● Research has demonstrated that a gain of 48 hours to several days
is best outcome that can be expected with the use of tocolytics
● Best reason to use tocolytic therapy is to achieve sufficient time to
administer Steroids (glucocorticoids) in an effort to accelerate fetal
lung maturity and reduce severity of respiratory complications in
preterm infants
● Medications with tocolytic properties
○ Ritodrine
○ Terbutaline
○ Magnesium sulfate
○ Nifedipine
○ Indomethacin
○
●
○ Promotion of fetal lung maturity
■ Antenatal glucocorticoids
● NIH recommends for all women at risk for preterm
● Reduces incidence of:
○ Respiratory distress syndrome
○ Necrotizing enterocolitis
○ Intraventricular hemorrhage
○ Death
● Fetal lung maturity: steroids
○ The most common steroid, betamethasone (Celestone), is given in two doses, 12
mg each, 12 or 24 hours apart.
○ The medications are most effective from two to seven days after the first dose.
○ Multiple studies have shown that prenatal corticosteroids are very safe for
mothers and babies (Roberts and Dalziel, 2010).
● Management of inevitable preterm birth
○ Labor progressed to cervical dilation of 4 cm likely to lead to inevitable preterm
birth
○ May rapidly progress through labor
○ A very small fetus can deliver through a cervix not fully dilated
○ Nurses must be able to handle emergency deliveries
Nursing Management of Labor and Birth
● Dystocia
○ Abnormal or difficult labor
○ Progress of labor deviates from normal
○ 8 to 11% of all labors and leading cause of C-sections
■ “Failure to progress”
Influenced by several maternal/fetal factors
○ Usually is apparent in active phase
○ Risk factors
■ Epidural analgesia/excessive analgesia
■ Multiple gestation
■ Ineffective maternal pushing technique
■ Occiput posterior position - how baby is coming out of vaginal canal (best
is occiput anterior)
■ Fetal birth weight over 8.8 lb.
■ Ineffective uterine contractions
■ Abnormal fetal presentation or position
● Face presentation
■ Fetal anomalies
○ Causes
■ Problems with powers (contractions)
● Hypertonic uterine dysfunction (side effect of pitocin) - too many
contractions - not supposed to have more than 5 within 10 min
● Hypotonic uterine dysfunction (not enough/strong enough
contractions)
○ Augment labor with meds
● Protracted disorders: slower cervical dilation and/or descent of the
fetal head
● Arrest disorders: no progress in cervical dilation and/or failure to
descend
● Precipitate labor (labor complete in less than 3 hours)
○ Too fast, usually had several deliveries before
■ Problems with the passageway (birth canal)
● Pelvic contraction
● Obstructions in maternal birth canal (swelling of the soft tissues)
● Placental location
■ Problems with passenger (presentation, lie)
● Occiput posterior position (back of head toward’s womans butt)
● Breech presentation and shoulder dystocia
● Multifetal pregnancy
● Macrosomia (large gestational baby)
○ High risk for shoulder dystocia and genital lacerations
■ McRobert’s maneuver to rotate child if they don’t
rotate - shoulder dystocia
● Structural abnormalities
○
Problems with psyche (mother’s coping)
● Surge in epinephrine will delay labor
○ Nursing management
■ Assessment: vital signs, contractions, fetal position and presentation,
SROM
■ Management
● Patience
● Evaluate labor progress
● Provide emotional and physical support
● Back massage in case of occiput posterior position
● Promote relaxation and reduce stress
● Intrauterine fetal demise
○ Numerous causes
○ Devastating effects on family and staff
○ Nursing Assessment
■ Inability to obtain fetal heart sounds
■ Ultrasound to confirm absence of fetal activity
■ Labor induction
○ Nursing Management
■ Assistance with grieving process
■ Referrals
○ Fetus dying within uterus - HTN, blood trauma, etc. Have to be beyond 20 weeks,
pass away before birth
■ Extremely devestating - have to be there to console, have to deliver child
(if don’t, will get septic shock)
■ Many parents need to be with the stillborn, support groups
● Labor induction and augmentation
○ Many women need help to initiate or sustain the labor process
■ Intrauterine fetal demise
■ Post term women (42 weeks, usually in US 41 weeks), etc.
○ Induction: ​stimulating contractions via medical or surgical means before the
onset of spontaneous labor - usually pharmacological
○ Augmentation: ​enhancing ineffective contractions after labor has begun
■ Stimulation of uterine contractions after labor has started but progress is
unsatisfactory
■ Implemented for management of hypotonic uterine dysfunction
■ Pitocin
○ Indications
■ Prlonged gestation
■
○
○
○
○
○
○
■ Prolonged premature
■ ROM
■ Gestational hypertension
■ Chorioamnionitis
■ Intrauterine fetal demise
Contraindications
■ Complete placenta previa
■ Abruptio placentae
■ Transverse fetal lie
■ Prolapsed umbilical cord
■ Prior classical uterine incision or uterine surgery
● Ex. prior ovarian cyst surgery (scared of uterine perforation)
Therapeutic management
■ Common induction methods
■ Nonpharmacologic agents (nipple stimulation, sexual intercourse) oxytocin
● Don’t have intercourse if at risk for preterm labor
■ Pharmacologic agents
● Prostaglandins: Labor induction (cervical ripening agents) - ripen
cervix before inducing - shortens uterine canal and opens up the os
(not considered dilation), makes tissue thinner
○ Dinoprostone gel (prepidil), dinoprostol inserts (cervidil)
and misoprostol (Cytotec)
● Oxytocin: Labor Induction and Augmentation
Nursing assessment
■ Gestational age
■ Fetal status; maternal status
■ Indication/contraindications
Nursing management
■ Explanations
■ Medication administration
■ Pain relief and support
Misoprostol (cytotec)
■ Most common labor inducers
■ Synthetic PGE1 analog
■ It can administered intravaginally or orally to induce the labor.
■ Tablets: 100 to 200 mcg
■ Adverse effect: hyperestimulation of the uterus
Pitocin
Prepare the infusion: 10 U in 1000 ml LR
■ Use an infusion pump on a secondary line connected to the primary
infusion
■ Label Oxytocin; Begin at .05 to 2 mu/min
■ Monitor contraction pattern every 15 minutes
■ Monitor FHR every 15 minutes
■ Monitor BP, pulse and respirations every 30-60 minutes
■ Monitor input and output
■ Monitor for nausea , vomiting, headache hypotension
■ Perform vaginal examination as indicated
○ induction/augmentation risks
■ Water intoxication
■ Tumultuous labor with tetanic contractions
■ Premature separation of the placenta
■ Rupture of the uterus - contraindication, high risk for both fetus and
mother
■ Lacerations of cervix - if baby comes too quickly
■ Postpartum hemorrhage
■ Uterine hyperstimulation
● Reduces blood flow resulting in
● Bradycardia
● Diminished variability
● Late deceleration
● Fetal asphyxia
○ Emergency measures
■ Discontinue use of oxytocin per hospital protocol
■ Turn woman on her side
■ Increase primary IV rate
■ Give oxygen by face mask at 8-10 L/min per protocol
■ Notification to medical provider
■ Prepare to administer terbutaline .25 mg sq
■ Documentation
■ Oxygen to baby
● Oxygen mask to mom
● Turn her on her side
● Increase IV
● Do these interventions first, don’t leave her alone - prepare
terbutaline (stops contractions)
○ Nursing safety
■
Conflict exist between nursing and medical providers
■ “Push the pit”
■ “Keep it going”
■ Nurse is responsible for oxytocin administration and avoiding excessive
uterine activity
● Monitor reaction to contractions and how they’re coming along
Forceps or Vacuum Assisted Birth
○ Application of traction to fetal head
○ Indications: Prolonged second stage of labor, failure of presenting part to fully
rotate and descend, limited sensation or inability to push effectively, maternal
fatigue
○ Risk of tissue trauma to mother and newborn and increase in ICP
■ Increases risk of genital laceration
■ Baby has markings that go away, may have laceration
○ Prevention as key
Cesarean birth
○ Classic or low transverse incision
○ Major surgical procedure with accompanying risks
○ Nursing Assessment: history and physical examination for maternal and fetal
indications
○ Nursing Management
■ Preoperative care
● If in OR; clean surgical site, clean woman, needs IV, give meds
(ex. antibiotics) if she’s group B streptoccus positive - give
antibiotics, sometimes prophylaxis
■ Postoperative care
● Make sure incision doesn’t have drainage - no infection, do regular
postpartum care, push incentive spirometer more, avoid having
pulmonary embolism, any thrombotic event
Vaginal birth after cesarian (VBAC)
○ Controversy related to risk of uterine rupture* and hemorrhage
■ 90% of women who have had a C section will have a repeat one
○ Contraindications
○ Special areas of focus: consent, documentation, surveillance, and readiness for
emergency
○ Nurses as advocates for clients; expertise in reading fetal monitoring tracings to
identify nonreassuring pattern and instituting measures for emergency delivery
Posterm pregnancy, labor, and birth
○ Maternal Risk
■
●
●
●
●
Related to excessively large infant
● Dysfunctional labor
● Birth canal trauma
■ Fatigue and psychological reactions
■ Fetal risks
■ Prolonged labor, shoulder dystocia, birth trauma, and asphyxia (no
oxygen, d/t umbilical cord wrapped, etc, stuck in birth canal) from
macrosomia
■ Compromising effects on fetus of an “aging” placenta
○ Management
■ Increased morbidity and mortality after 42 weeks
■ Most physicians induce at 41 to 42 weeks
■ Others allow pregnancy past 41 weeks
● With assessment tests of fetal well-being normal
● Nonstress test and biophysical profile twice a week
■
Nursing Management of the Postpatum Woman at Risk
● Factors increasing a woman’s risk for postpartum complications
○ Risk factors for postpartum infection
■ Operative procedure (forceps, c section, vacuum extraction)
■ Premature ROM* (>24 hours)
■ Hx of diabetes, including gestational onset
■ Prolonged labor (>24 hours)
■ Use of indwelling urinary catheter
● Always for C section, always in for at least 24 hours
○ Helps prevent overdistended bladder - prevents postpartum
hemorrhage
■ Anemia (hmg < 10.5 mg/dL)
■ Multiple vaginal examinations during labor
■ Manual extraction of placenta
● Happens a lot in C sections (trying to get you out of OR asap)
● If you don’t let placenta naturally come down and expel, much
higher chance of tearing it and leaving parts inside
■ Compromised immune system (HIV positive)
○ Risk factors for postpartum hemorhage
■ Precipitous labor (less than 3 hours)
■ Uterine atony*
● Any reason why uterus won’t contract after giving birth
● “Boggy uterus”
■
■
■
■
Placenta previa or abrupto placenta
Labor induction or augmentation
Operative procedures (vacuum extraction, forceps, C section)
Retained placental fragments
● Taking up space in uterus, can’t contract like it’s supposed to
■ Prolonged 3rd stage of labor (more than 30 min)
■ Multiparity, more than 3 birhts spaced closely
■ Uterine overdistention (large infant, twins, hydramnios)
● Common postpartum disorders
○ Hemorrhage
○ Thromboembolic disease
○ Infection
○ Sequelae of Childbirth Trauma
○ Postpartum Psychologic/affective disorder
● Postpartum hemorrhage
○ Definition and incidence
■ PPH traditionally defined as loss of more than:
● >500 ml of blood after vaginal birth
● >1000 ml after cesarean birth
● 10% drop in hematocrit*
○ Problematic part of hemorrhage
● Any amount of bleeding that places the mother in hemodynamic
jeopardy
○ Definition and incidence
■ Leading cause of maternal morbidity and mortality: 1 maternal death
every 4 minutes
■ Life-threatening with little warning
■ Often unrecognized until profound symptoms
● Because of large plasma volume, not recognized as early
● Assess woman well - peripads (if only going off of VS, you’re
going to be too late
■ 5% of all births, the majority within 4 hours of childbirth
○ Causes
■ Uterine atony
■ Lacerations of the genital tract and episiotomy
● Won’t be as much blood - brigher blood
■ Hematomas
■ Retained placental fragments
■ Retained placenta
Uterine inversion (inside out)
■ Subinvolution of the uterus
■ Coagulation disorders
● Hemorrhage much slower, petechiae
○ Etiology and risk factors
■ Uterine atony: Most common
● Marked hypotonia of uterus “boggy uterus”
● Overdistention is the major risk factor for uterine atony (e.g.
multifetal gestation, macrosomia, distented bladder)
■ Lacerations of genital tract and episiotomy
■ Hematomas, typically around vulva
● Have to excise and drain blood out
■ Retained placental fragments
● Nonadherent retained placenta (manually taken out)
● Adherent retained placenta
○ Acreda - not as imbedded into muscles
○ Intacreda
○ Percreda - takes whole muscles, have to have histerectomy
■ Uterine inversion
● Turning inside out of uterus
● Potentially life threatening
● 1 in 2500 births
● Due to them pulling too forcefully on umbilical cord
■ Subinvolution of uterus
● Incomplete involution of uterus after birth
● Late postpartum bleeding
● Prolonged lochial discharge and excessive bleeding
○ Coagulopathies
■ Disorders that interfere with the clot formation can lead to postpartum
hemorrhage
■ Should be suspected when postpartum bleeding persist without any
identifiable cause
■ Idiopathic thrombocytopenic purpura
● Autoimmune disorder
● Control of platelet stability
■ Von Willebrand’s disease - type of hemophilia
● Factor VIII deficiency and platelet dysfunction
● Treatment of choice is Desmopressin
● Aids in the release of vWF and factor VIII
■
● Autosomal dominant
■ Disseminated Intravascular Coagulation
● Clotting system is abnormally activated, resulting in a widespread
clot formation in small vessels
● Risk for PE and other thrombolytic diseases
○ Assessment
■ Risk Factors; family history
■ Early recognition is critical
■ First step is evaluation of contractility of uterus
■ Assess the amount of bleeding (count pads)
■ Inspect the skin and mucous membranes: assess for hematoma, lacerations
■ Vital signs
■ Urinary output
○ Management
■ Improve uterine tone:
● fundal massage (page 753)
● Administration of intravenous fluids and medication to manage
bleeding
● Administration of medications to contract the uterus
○ Pitocin (20-40 units in 1000ml IV)
○ Methergine, Herbamate, protaglandins (IM injections),
Prostin 2
○ Prostin E2 (suppository)
■ Massage the uterus
● Vital signs
● Empty the bladder
● Monitoring for signs and symptoms of shock
● Notify the health care provider if the fundus does not become firm
with massage
■ Plan of care and implementation
● Hypotonic uterus
● Bleeding with a contracted uterus
● Uterine inversion
● Subinvolution
● Herbal remedies
○ Hemorrhagic (hypovolemic) shock
■ Emergency situation
■ Perfusion of organs severely compromised
■ Death may occur
Physiologic compensatory mechanisms are activated
■ Signs of shock may not appear until 30% to 40% of blood volume is lost
■ The worse that it gets, the more severe the symptoms
● Mild:
○ diaphoresis (first 1-2 days this is normal)
○ Increased cap refill
○ Cool extremities
○ Maternal anxiety
● Moderate
○ Tachycardia
○ Postural hypotension
○ Oliguria
● Severe
○ Hypotension
○ agitation/confusion
○ Hemodynamic instability
■ Management
● Medical management
○ Restore circulating blood volume
○ Treat the cause of the hemorrhage
● Nursing interventions
○ Frequent assessment
○ Monitoring of vital signs
○ Accurate intake and output
○ Fluid or blood replacement therapy (rapid IV infusion of
crystalloid solution)
○ Pathophysiology of postpartum hemorrhage: “5 T’s”
■ Tone: uterine atony, distended bladder
■ Tissue: retained placenta and clots
■ Trauma: vaginal, cervical, or uterine injury
■ Thrombin: coagulopathy (preexisting or acquired)
■ Traction: causing uterine inversion
● Thromboembolic Disease
○ Results from blood clot caused by inflammation or partial obstruction of vessel
○ Risk for DVTs and PEs
○ Incidence and etiology
■ 1 in 1000 to 1 in 2000
■ Venous stasis
■ Hypercoagulation
■
● Both natural things that occur whether you have it or not
○ Clinical manifestations
■ Positive Homans’ sign
■ Affected leg red, swollen, warm
○ Most common types
■ Superficial thrombosis
● Usually confined to the saphinous vein in lower leg
■ Deep vein thrombosis
● May cause pulmonary embolism
○ SOB, chest pain
○ Medical Management
■ Analgesia, rest with elevation of the leg and elastic stockings (elevate
above the heart)
■ DVT is treated with anticoagulant therapy (IV heparin)
○ Nursing Interventions
■ Inspection and palpation of the affected leg
■ Laboratory studies
■ Administration of oral anticoagulants and discharge teaching (safe to use
with breastfeeding)
● Postpartum infections
○ 8% in all births
○ Fever >38° C or 100.4° F after 1st 24 hours
○ Puerperal sepsis: any infection of genital canal within 28 days after abortion or
birth
○ Most common infecting agents are numerous streptococcal and anaerobic
organisms
○ Endometritis: most common cause
■ Infection in muscle of endometrium, can go further into myometrium
■ Metritis: infection of endometrium, decidua, and adjacent myometrium
○ Wound infections
■ From C section or epistiotomy
○ Urinary tract infections
○ Mastitis
■ Inflammation of the breast
■ 2 to 33% of breastfeeding women, frequent reason for women to stop
breastfeeding
● Improper latch - unable to empty out breast properly
■ A breast abscess may develop if not treated
■ Symptoms
Flu like symptoms
● Breast are red, tender and hot to the touch
■ Treatment: effective milk removal, pain medications and antibiotic
therapy, ice or warm packs (warm good if you’re going to continue to
breastfeed). Lactation should not be suppressed.
○ Nursing management infection
■ Aseptic technique while performing invasive procedures
■ Good handwashing technique
■ Administer antibiotics
■ Teaching about hygiene
● Sequeiae of Childbirth Trauma
○ Disorders of uterus and vagina related to pelvic relaxation and urinary
incontinence; are often result of childbearing
■ Most if not all is due to vaginal delivery
○ Uterine displacement and prolapse
■ Posterior displacement, or retroversion
■ Retroflexion and anteflexion
■ Prolapse a more serious displacement
■ Changes in bowel movement and voiding
○ Cystocele and rectocele
■ Cystocele: protrusion of bladder downward into vagina when support
structures in vesicovaginal septum are injured
■ Rectocele is herniation of anterior rectal wall through relaxed or ruptured
vaginal fascia and rectovaginal septum
○ Urinary incontinence
○ Genital fistulas
■ May result from congenital anomaly, gynecologic surgery, obstetric
trauma, cancer, radiation therapy, gynecologic trauma, or infection
● Vesicovaginal: between bladder and genital tract
● Urethrovaginal: between urethra and vagina
● Rectovaginal: between rectum or sigmoid colon and vagina
● Presence of urine, flatus, or feces in the vagina
○ Urine - cystocele
○ Feces - fectocele
○ Care management
■ Assessment for problems related to structural disorders of the uterus and
vagina
■ Pessaries for a limited time
■ Estrogen therapy (improves tissue tone) - done a lot for older women
●
Surgical repair
■ Kegel exercises
■ Hygiene practices
● Postpartum psychologic complications
○ Mental health disorders in postpartum period have implications for mother,
newborn, and entire family
■ Interfere with attachment to newborn and family integration
● Natural drop in hormones 3rd-4th day - postpartum blues, natural
● Down for 2 weeks within first month - postpartum depression
■ May threaten safety and well-being of mother, newborn, and other
children
○ Mood disorders
■ Many women experience a mild depression or “baby blues” 80%
■ 13%-20% of women develop more serious depression
■ Can eventually incapacitate them to point of being unable to care for
themselves and their babies
○ Postpartum depression without psychotic features
■ Postpartum depression: an intense and pervasive sadness with severe and
labile mood swings
■ Hard to diagnose - people don’t want to admit, most physicians don’t
screen for it; often goes undetected
■ Treatment options
● Antidepressants, anxiolytic agents, and electroconvulsive therapy
(not common)
● Psychotherapy focuses on fears and concerns related to new
responsibilities and roles; monitoring for suicidal or homicidal
thoughts
○ Postpartum depression with psychotic features
■ Postpartum psychosis: syndrome characterized by depression, delusions,
and thoughts of harming either infant or herself
■ Psychiatric emergency; may require psychiatric hospitalization
■ Antipsychotics and mood stabilizers such as lithium are treatments of
choice
○ Nursing care
■ On postpartum unit
■ In home and community
■ Referrals
■ Providing safety
■ Psychiatric hospitalization
■
Psychotropic medications
■ Other treatments for postpartum depression
● Nursing care in postpartum
○ Combs test (mother RH-, child RH+) = positive comb’s test
■ To prevent mother’s sensitization.
■ RhoGAM so next time she gets pregnant, doesn’t have a reaction
○ Rubella Titer
■ Most useful as a screening tool to determine who is susceptible to Rubella
and who is not
■ Those found to have no immunity can be immunized following delivery to
protect them during any future pregnancy.
■ Cannot get a rubella vaccine during pregnancy
○ Cultural soup
■ Know cultural beliefs and be open to that
■ Hard - Jehova’s Witness (ethical decision)
■
HIV (Exam 3)
● HIV still increasing in the US (Florida very prevalent)
● Incidence
○ Increasing rates among women
○ Minorities are severely affected
○ If she didn’t know she had HIV and is pregnant (found out during pregnancy always tested during first visit and again later on)
■ Has to have her meds, started during first 16 weeks until births
■ Antiretrovirals - goal: to make viral load undetectable
■ Babies automatically get AZT for first 6 weeks, tested
● HIV transmission
○ Unprotected sexual intercourse (Horizontal transmission)
○ Contact with infected blood or blood products (Horizontal transmission)
○ Perinatal transmission/ mother-to-child transmission: Pregnancy, birth and
breastfeeding (Vertical transmission)
● Women who are HIV positive
○ All pregnant women should be screened for HIV as early as possible during each
pregnancy.
○ Impact of pregnancy and HIV: threats to self, fetus, and newborn
○ Therapeutic Management:
■ Mother: oral antiretroviral drugs twice daily from 14 weeks until birth; IV
administration during labor
Newborn: liquid AZT (Retrovir) for1​st​ 6 weeks of life; decision for
birthing method
○ Nursing Assessment: history and physical examination; HIV antibody testing;
testing for STIs
○ Can have vaginal birth if viral load is undetectable (up to physician)
○ Cannot breastfeed
■
Exam 2
● Test for ROM - nitrozene swab (pH turns blue, positive for amniotic fluid)
● Differences between internal vs external electronic monitoring
○ If internal, what are the categories that need to occur?
■ ROM, skilled practitioner needs to put those in, how many cm dilated?etc.
■ What has to be met
● Early vs late decelerations
○ Late - bad, what causes
○ What causes decelerations
○ Early - just document
○ Late and variable - if pitocin is running, stop, put mother on left side, put O2 on
mom, increase IV fluids, call physicians
● Accelerations - good
● Know normal FHR and variability
● How to set up fetal monitoring
● How to increase O2 to baby - positioning, O2, IV increase
● Causes of fetal tachycardia
○ Maternal temperature
● Postpartum assessment
○ Check breast for cholostrum
○ Fundal height
○ Progression of lochia and days
○ VS postpartum
■ BP increase or decrease? Usually goes back to normal
■ RR
■ Bonding - S/S
● Uterine fundal assessment
○ Use dominant hand to trap on top, use bottom (trap uterus in between) - can feel if
it is boggy or firm
■ If boggy - massage in a circular motion downward
● Bladder distension actions
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○ If have bladder that’s distended, uterus will be displaced from midline (usually to
the right, can be left) - tell her to void, then massage fundus afterwards
Postpartum blues
○ Know when
Lochia - amount, color, classification, days
Clotting factors
○ Risk for thromboembolism and nursing assessment
○ Risks and S/S for DVT and PE, what to do (give heparin), patient eduction to
prevent
■ Compression socks, incentive spirometer, walk around if they can, etc.
VS and WBC count (will be elevated for 3 days postpartum)
Rhogam - administer for 72 hours postpartum
Diaphoresis in the postpartum - normal especially at night
Help syndrome - labs (lots to do with liver - ALT, AST)
Preeclampsia - lots of questions
○ Proteinurea (usually above 300)
○ BP, edema, weight changes
■ Types, education
○ Eclapsia - with seizures
■ Open airway, side rails up
○ Magnesium - therapeutic level, antidote, what level is toxicity (S/s)
○ Definition and difference between chronic vs gestational HTN
■ Gestational starts with pregnancy, should reside after
Insulin requirements with gestational diabetes
○ Used because easier to control, safe for baby
■ 1st trimester- requirements lower
■ 2nd and 3rd - requirements higher
■ Once have baby - insulin requirements drop again
■ A1C levels
Screening and pregnancy for gestational diabetes
○ Oral glucose test process, when
Diet and exercise for gestational diabetes
○ Can try to control in beginning with diet and exercise
Risk factors for dystochia
○ Shoulder dystochia and occiput posterior position (know concepts)
○ Mcrobert’s nursing intervention
○ What can happen to baby with shoulder dystochia
○ What you as a nurse can do for occiput posterior position - back massage (painful)
● Hypotonic uterine dysfunction (definition and meds for induction and augmentation) and
adverse reaction (typically hyperstimulation)
● Nursing actions for late decelerations
○ Know what early, late, and variable look like
■ Early - round, happen with contraction peak
■ Late - round, happen after contraction peak
■ Variable - ugly, messy
● Uterine hyperstimulation - what to give to stop
● Fetal demise - nursing actions for parents (grieving process); know they will induce
● Pitocin side effects
● Cytotec indications and side effects
● Thermoregulation in the newborn - heat loss mechanisms (cold stress) - look at pictures
○ Brown fat - locations and why they have it
○ What is normal weight loss in newborn
○ Nursing interventions for cold stress
○ Acrocyanosis vs central cyanosis
○ Know skin variations (mongolians, etc.)
● May be question about bilirubin?
● APGAR score
● Know difference between cephalohematoma etc. and caput
○ Cephalohematoma - high risk for jaundice
○ Know heel stick procedure - how to take blood from newborn
● Circumcision care
● Know reflexes
● Postpartum hemorrhage - know causes
○ Main cause of late postpartum hemorrhage? Involution
● Nursing interventions for atony
● Lacerations - look like, what you’re gonna do
● What you do for DVT
● Teaching about anticoagulants (no apsirin, bleeding precautsions)
● Postpartum depression what it looks like with and without psychosis
● Postpartum infection (after 24 hours)
● Recommendations and risks for uterine prolapse - peceries too