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Student Nurse Guides
Family Planning
- Family planning involves both trying to get pregnant or trying to prevent pregnancy
- Thus, family planning is goal-oriented in selection of methodg prevention versus planning
- Factors that may influence contraceptive selection or method of family planning selection:
• Religious, cultural, personal influences
• Ageg if young, any surgical intervention is typically not done incase they want a children later g if older,
maybe they would want to consider a vasectomy/hysterectomy/tubal ligation
• Smoker or nonsmokerg smoking is a risk factor for increased likelihood of adverse effects for many oral
contraceptives
• Goals for family planning (do they want kids in the future? If so, do not do a tubal ligation or vasectomy; if
patient needs a procedure that will compromise reproductive abilities, patient may want to do sperm banking
or freeze eggs ahead of time)
• Level of compliance (will patient an oral contraceptive every day?)
• Frequency of intercourse (if someone is frequently having intercourse, will they use a condom every time? Or
would an oral contraceptive or IUD be more appropriate?)
• Currently breastfeedingg hormones caused by pregnancy can affect this
** Important note: If planning on getting pregnant, start taking a folic acid supplement while trying to get pregnant g
since 50% of pregnancies are unplanned, every woman of child bearing age is recommended to take folic acidg folic acid
plays huge role in neural tube developmentg neural tube develops early, and deficiencies before finding out you’re
pregnant can potentially cause defects or neural tube issues
- Common methods for contraception:
• Pregnancy prevention
§ Mechanical barriers – diaphragm, condoms, cervical caps, use of spermicides
§ Hormonal contraceptives—oral contraceptives (birth control pill g progestin or estrogen/progestin),
IUDs, Injection (“the shot”), implant (goes in arm usually)
§ Plan B/ Morning after pill— taken up to 120 hrs after sex for progestin (2 pills) gshould not be
primary means of contraception
§ Combined oral pills g 2 pillsg 1 taken 72 to 120 after sex then 1 taken again 12 hrs later
• Pregnancy and STI prevention
§ Condoms
§ Abstinenceg the only method that is 100% proven to prevent pregnancy or STI’s L
- Trying to get pregnant
• Three common methods for fertility g revolve around tracking ovulation
§ Calendar method
§ Basal body temperature charting
§ Cervical mucous method
Options for Overcoming Infertility
§ Medsg to increase hormones needed for pregnancy to occur
§ Surgical proceduresg fix whatever the problem is (ie: blockage in the tubes carrying the sperm)
§ In vitro fertilization
§ Intrauterine insemination
§ Surrogacy
§ Embryo hosts
§ Adoption
- If finished having children and want to permanently prevent future pregnancy:
• Tubal ligation (female) or Vasectomy (male)
Notes on Family Planning
- Oral contraceptives (birth control pills) should be taken at the same time every day
- Antibiotics and other meds may decrease the effectiveness of contraceptives – use other form of protection
- It is important to take a prenatal vitamin when trying to conceive – should include folic acid
•
Contraception
- Types of Contraception:
• Behavior Methods
• Barrier Methods
• Hormonal Methods
• Permanent Methods
- Ideal Contraceptive for Women
- Easy to use
- Safe and effective
- Immediately reversible **
- “Naturalness”
- Non-hormonal **
- Minimal side effects
- Behavioral
• Abstinenceg only sure way to prevent pregnancy; decreases risk of STIs and HIV
• Coitus interruptus (withdrawal)
• Fertility awarenessg helps if woman has regular menstrual cycle
r The ovum is released by ovary 14 days prior to next menstrual cycle
- The fertile time is the 14 days before + or – a few days
r Use physical signs that change with menstrual cycle to predict fertility
- Changes in cervical mucus and placement of cervixg copious slippery mucous that lets sperm enter cervix
and move up
- Basal body temperature elevations with ovulationg temperature is lowest before arising in the morning
Ø Temperature dips slightly at midpoint of
menstrual cycle then rises sharply to indicate
ovulation
Ø Take oral temperature prior to getting out of
bed in the morning
Ø Remind women that illness also increases
temperature
Ø Women use BBT to either get pregnant or
prevent it
r Individual standard days methodg use calendar to track menstrual cycle and therefore be able to predict
ovulationg refrain from sex during those days
- Cycle beadsg help women by using color of bead to visually represent fertility days; avoid unprotected
sex on those days; often used with limited resource access
r Lactation amenorrhea methodg not good; requires breast feeding on demand and is only good for 6 months
r and not for everyone
- Prolactin h during breast feeding inhibits the release of gonadotropin, which is necessary to start cycle
again to get pregnant
- Barrier
• Condom (Male and Female) g not all condoms are latex because some people have latex allergies
• Diaphragm and cervical cap are prescription only
r Diaphragm is latex; cervical cap is latex or silicone
r Require the addition of spermicides to them; some have spermicide in it, other’s require woman to do it
r Requires refitting and must be placed correctlyg after a pregnancy or weight gain or loss of 20+ lbs they must
be refitted
• Contraceptive sponge is non-prescription
r Requires action on the part of the woman
- Non-hormonal
- Used in conjunction with a spermicide (already in it)
- Specific insertion and leave in time periods
- Sponge more spontaneous; contains spermicide within it
- Hormonal (OCP’s)
• Fewer health risks with changes in hormone combinations
• Need to be taken at same time every day for hormone stabilityg can be used long-term, is non-permanent, & reliable
• Alter the women's hormonal cycleg combination of estrogen and progestin but some are progestin only
r Progestin only pills are used if woman cannot take estrogeng but more bleeding associated with it though and
less effective at cervical mucus response
NOTE: Progestin is the name of
• BC works by:
the manmade synthetic
r Suppressing ovulation by adding these hormones to the body to stifle FSH and LH
hormone that mimics what the
r Cause cervical mucus thickening so its difficult for sperm to get through
body’s natural hormone,
progesterone, does.
r Prevents the endometrium from being ready for implantation due to the change of
- Progesterone = natural
hormones
- Progestin = synthetic
• Note: Mimics pregnancy so body is in hypercoagulable stateg risk for DVT
•
Patient Teaching Pointg If on antibiotics BC is NOT effective
r Need alternative method during use of antibiotics; usually by next month patient is okay
•
Advantages and disadvantages
Advantages of OCPs
-
Regulate & shorten menstrual cycle
i severe cramping/bleeding g reduces anemia
Improve acne & reduce incidence of menstrual HA
i incidence of rheumatoid arthritis (RA)
Protect against loss of bone density and i risk of
osteoporosis
i risk of benign breast disease
i risk of endometrial cancer, colorectal cancer, and
ovarian cancer
Minimize perimenopausal symptoms
Improve PMS symptoms
Disadvantages of OCPs
- Offer no protection against STI’s
- Mimic pregnancy so hypercoagulable stateg RF DVT
- Modest risk for venous thrombosis and pulmonary
emboli
- h risk for migraine headaches
- h risk for MI, stroke, and HTN for women who smoke
- High cost for some women
- Pose slightly h risk of breast cancer
- May h risk of depression
- User must remember to take pill
•
Health history
r Do NOT require pap smear to obtain prescription
r Risk Factors:
- DVTs; Hypertension; Smoking
- Use with caution with women who smoke **
r Antibiotic use requires alternate method of birth control
•
Early Signs of Complications r/t Oral Contraceptive Use: A-C-H-E-S
r A= Abdominal paing may indicate liver or gallbladder problems
r C= Chest pain or SOBg may indicate a PE
r H= Headachesg may indicate HTN or impending stroke
r E= Eye problemsg may indicate HTN or related attack
r S= Severe calf paing could be related to DVT
- Other Hormonal
• Injectable
r Works 12 weeks, but has more menstrual cycle irregularities
r Progestin only, so possibility for bone density loss
• Transdermal patch
r 3 weeks on/1 week off, allows for more spontaneity than some other methods
•
•
r More risk for venous thrombosis and embolism
Vaginal rings
r 3 weeks in/1 week out
r Absorbs hormones through the vaginal mucosa
Implantableg 3 years!
- Intrauterine Device (IUD)
• T-shaped hormonal object inserted in the uterus
r 2 Types: Hormonal (progestin) or non-hormonal (copper)
r Causes inflammationg this makes the lining of the uterus non conducive to implantation
r Also causes changes to cervical mucous to immobilize sperm; inhibits sperm and ova from meeting
r Long term useg 5-7 years for hormonal and 10 years for non-hormonal
• Possible complications
r If women is exposed to STI the IUD might have to come out in order for it to be treated
r The string of IUD: women need to check the string periodically
- If shorterg the IUD might be up higher than it should be
- If longerg the IUD is misplaced to the bottom of the uterus
•
Warning signs of potential IUD Complications: PAINS
r P= Period late, pregnancy, abnormal spotting, or bleeding
r A= Abdominal pain, pain with intercourse
r I= Infection exposure, abnormal vaginal discharge
r N= Not feeling well, fever, chills
r S= String length shorter or longer or missing
- Emergency Contraception
• Depending on the brand:
r Most effective the earlier it is usedg ideally used within 72 hrs
r Hormonal and can be used 3, 5, or 7 days after unprotected intercourse depending on brand
• Copper releasing IUD can be inserted up to 7 days post unprotected intercourse
r Can be left in for long term contraception
• Sold OTC only if 18 or older, by Rx for those younger (or have someone old enough buy it for them)
r Most of these pills use levonorgestrel, a form of progesterone
r Essentially works like an oral contraceptive given at a higher dose to prevent ovulation or fertilization
• Do NOT cause abortion
• Should not be used in place of regular contraceptive usage
- Permanent Methods
• Tubal ligation (Women)g surgical or non-surgical
r Laparoscopicg surgical
- Involves, tying, cutting or sealing the tubes
- Sometimes will be done postpartum, especially if a woman has a c-section and is sure she doesn’t want to
have anymore children
r Trans-cervicalg non-surgical
- Coils are inserted through cervix into fallopian tubes, which promotes tissue growth and closes off the
tubes within 3 monthsg is not effective immediately
• Vasectomy (Men)
r Outpatientg Cutting the vas deferens so semen no longer contains sperms
r Takes 8-16 weeks after procedure to be effectiveg male will have to submit a sample afterwards to make sure
it worked
Family Planning Method Effectiveness:
-
Fertility awareness ones are very poor at preventing pregnancy
Spermicide alone is very poor
As we get higher the device becomes more reliable
Birth control is where it is due to women forgetting to take it, not taking at the same time every day, etc.
- Important factors to consider:
• Age
• Health status
• Frequency of sexual intercourse
• Number of partners
• Desire to have children in the future
• Side effects
• Effectiveness rate
• Comfort
• Personal preference
- It is the woman’s choice.
Student Nurse Guides
Getting Pregnant & Fetal Development
□ Phases of Pregnancy
- Antepartum – Before birth
- Intrapartum – During labor and birth
- Postpartum – After birth
Note: the terms oocyte, ovum, and egg
may be used interchangeably, but all
are referring to the same thing
□ Overview of the Menstrual Cycle
- 28 day cycle overall that consists of 2 cycles divided midcycle by ovulation
• Ovarian cycle—during which ovulation occurs
• Endometrial cycle—during which menstruation occurs
• Menstruation (shedding of the endometrium) marks the beginning and end of the monthly cycle.
□ Hormones for Pregnancy—FSH, LH, estrogen, progesterone
- Hypothalamusg releases gonadotropin releasing hormone (Gn-RH)g stimulates anterior pituitary glandg to release
FSH and LH
• FSH g signals ovaries to produce follicles and the egg to ripen
§ Each follicle contains one oocyte (also referred to as an “ovum” or “egg”)
• LH g stimulates the maturing follicle to release estrogen g LH also responsible for final development and
rupture of the mature follicle
§ As estrogen levels ↑, the output of LH is inhibited
• This happens 14 days prior to the next cycle
- The surge in the demand for LH damages the estrogen-producing cellsg results in a decline in estrogen g ovulation
- Ovulation-when the mature oocyte is released or “bursts” from its follicleg starts traveling towards the uterus via the
fallopian tube to potentially become fertilized by a sperm
• Note: if ovary releases multiple maturing follicles at the same time, that is how you end up with fraternal
twins, triplets, etc.
• Symptoms of ovulation:
§ vaginal wetness g due to cervical mucous becoming thinner and more alkalineg does this to help
accept sperm more readily and move up uterus thru fallopian tubes to fertilize egg
§ cramping
§ increased libidog natural occurrence because best chance to get pregnant
§ slight increase in body temperature
- Meanwhile, the ovaries are secreting estrogen and the empty follicle (the corpus luteum) secretes progesterone
• Estrogeng secreted by the ovaries g thickens the endometrium (uterine lining) and myometrium (muscle
itself) for implantation in the upper 1/3 of the uterus
• Progesteroneg secreted by the corpus luteum (the site of ruptured follicle that the ovum was released from
g thickens endometrium for implantation
• The thickening is important because must be very vascular to have pregnancy occur
- If fertilization doesn’t occur, the rise in estrogen and progesterone levels lead to a suppression of LH
• Lack of LH g degeneration of the corpus luteumg decrease in estrogen and progesterone output
• Drop in these estrogen and progesterone does the following:
§ Causes uterine lining to shed because it’s not needed to support a pregnancyg blood, tissue, and the
ovum are shed and leave the body via the vagina period or menses) g can take up to 7 days
§ Ends their suppression of LHg LH is secreted again
- If an oocyte does get fertilized, it implants itself into the thickened wall of the uterus.
• Conception g Pregnancy
• Fertilization occurs when with the sperm and oocyte (egg) unite g usually occurs in upper 1/3 of uterus
because it is very vascular there and the muscle is very strong so it can contract when placenta is released g
muscle contraction decreases bleeding caused by the expulsion of the placenta
§ Fertilized oocyte (egg) is called a zygote
§ Zygote matures into a blastocyte and implants ≈ 6-8 days after ovulation
- Blastocyte is the term it is referred to when it implants into the endometrium of the uterus
• Blastocyst causes the body to produce human chorionic gonadotropin (hCG)
§
hCG g tells the corpus luteum to continue secreting progesteroneg maintains the pregnancy until
the placenta takes over production, 2-3 months later
- After fertilizationg many cell divisions become differentiated structures
• Inner layer of the divisiong becomes the embryo and amnion (sac that holds embryo and eventual fetus in
the amniotic fluid)
• Outer layerg becomes the chorion (second protective layer) and helps form the placenta
□ Amniotic Fluid
- How amniotic fluid is made:
• In the beginning, it is produced by the amniotic membranes
• Later in the pregnancy (16 weeks), it is the swallowed fluid urinated by the fetus
§ Swallowed fluid creates urine in the fetus, which the fetus excretes out as long as it has normal renal
system and fxng this is how GI tract is formed in fetus
- Functions
• Symmetrical growthg because fetus can move arms/legs without restriction
• Provision of unrestricted movement (again, allowing for symmetrical growth)
• Allows cord to be free from compressiongcompressed cord iblood flow, oxygen, and nutrients to fetus
• Cushions the fetusg physical protection of fetus for muscle development
• Temperature regulation
- Amniotic Fluid Balances fluctuate throughout the Pregnancy
• Fluid increases as pregnancy progresses, with minor fluctuation on a day to day basis
• Normal pregnancy has about 1,000 mL at term
• Complications related to amniotic fluid imbalances: oligohydramnios and hydraminos
•
Oligohydramnios (< 500 mL at term) is associated with:
§ Fetal renal abnormalities g not urinating the fluid swallowed out, then the fetus body will use the
fluid but amniotic fluid will be lower than it should be
§ Uteroplacental insufficiencyg not enough blood flow getting there or a problem with the placenta
§ Increased risk of surgical birthg because often an issue with placenta and uterus
§ Low birth weight infants
•
Hydramnios (> 2,000 mL at term) is associated with:
§ Maternal diabetesg (think 3 Ps: polydipsia, polyuria, etc)
§ Neural tube defects
§ Malformations of the CNS and/or gastrointestinal tract that prevents swallowing of the amniotic fluid
by the fetus esophageal problems/impaired swallowing g fluid not getting into fetus, but mother still
produces fluid so there will be too much in uterusg problem of increased pressure as a result g can
cause premature rupture of membranes
§ Premature rupture of membranes
□ Umbilical Cord
- The umbilical cord consists of 3 vessels (AVA) g artery, vein, artery
• Length determined by genetics, space and fetal activity
Student Nurse Guides
Mother’s uterine arteries and veins supply blood, O2 and take away waste, BUT the maternal and fetal blood
does not circulate together. ***
• Maternal & fetal blood do not circulate together, but maternal blood CAN leak into fetal blood in small
amounts. (due to things like trauma, amniocentesis)
• Mother and fetus can have 2 different blood types
- The umbilical cord is covered in Wharton’s jelly
• It is a connective tissue, gelatinous
• Protects against cord compression (such as form fetus laying on it) which would cut off circulation to the fetus
•
□ Placenta
- Placenta is formed in part from the chorionic villa
- How well the placenta works depends on how much blood gets to it which is determined by BP g so function depends
on the mother’s BP supplying blood circulationg low BP = less blood getting to placenta = functions less well
• Acts as a barrier against certain harmful things
§ Chickenpox, measles, etc can still cross placenta
• Protects the fetus from attack by the mother’s immune system-things that would be seen as a foreign body
• Nourishes the fetus with oxygen and nutrients thru the umbilical cord to baby
• Removes fetal wastes g waste comes back thru cord, and is excreted out thru mother
• Produces hormones
- Nutrient/Waste Exchange **
• Maternal uterine arteries bring oxygenated blood and nutrients to the placenta
• The blood is diffused over the placenta by the maternal uterine arteries g Umbilical vein takes the oxygen
and nutrients to the fetus after diffusion over the placental barrier
• Umbilical arteries remove deoxygenated blood and wastes from fetus and take it to the placenta, where it is
diffused over the placental barrier
• Maternal uterine veins remove deoxygenated blood and waste from
the placenta, where it then goes to the mother’s kidneys for
excretion
Ø In summary- AVA (artery, vein, artery)
1. Maternal uterine arteries take blood/nutrients g to the placenta and diffuses
it over the placental barrier
2. Umbilical vein takes that diffused blood and nutrients g to the fetus
3. Maternal uterine veins g remove deox blood and waste from placenta
- Placental Hormones
• Estrogen g enlarges breasts and uterus g stimulates contractility of the uterus when it’s time for woman to
go into
labor
• Progesterone g maintains endometrium g decreases contractility to avoid pre-term labor
• Relaxing works with progesterone to maintain pregnancyg to soften cervix and pelvic ligaments for delivery
□ In Summary: Role of Estrogen and Progesterone before and after Implantation
Before Implantation
After Implantation
- Estrogen
- Estrogen
• From the developing follicle
• Enlarges breasts
• Endometrial and myometrial thickening
• Stimulates contractions
- Progesterone
• Secreted by the corpus luteum
• Endometrial and myometrial thickening &
increased vascularity of the uterus
- Progesterone
• Maintains the endometrium
• Decreases contractility of the uterus
□ Overview of Fetal Development Timeline
Student Nurse Guides
- Three Stagesg Pre-embryonic, Embryonic, and Fetal
- A developing human is referred to as an embryo from weeks 2-8 and is considered a fetus from 8 weeks – birth
- By end of the embryonic phase, most organs are formed (but may not be necessarily functional; think of premature
babies g i.e. lungs are formed but not functioning yet)
• The head takes up half the body
• The heart is pumping
- Pre-embryonic g first 2 weeks after fertilization
• Free floating cells making its way to the uterus
• Ends with implantation
- Embryonic g 2 weeks – 8 weeks after conception
• Heartbeat is present g circulation begins
• Heartbeat seen on transvaginal ultrasound around 6 weeks
• All major brain structures are in place
• Bone begins to replace cartilage
• Embryo is ≈ 1.2 inches long
- Fetal g 8 weeks to birth
• Circulatory system and all organs are present
• Heartbeat is able to be heard on external ultrasound at ≈ 12 weeks
• Fetus able to hear at 18 weeks
• Able to open and close eyes at 28 weeks
• Lungs continue to develop and more alveoli form g completed around ≈ 35 weeks
§ Fetus does practice breaths
§ Placenta does gas exchange
- Fetal Development by week
Week
Fetal Development
8
Heart completely developed
12
Gender may be able to determined; FHTs can be heard by doppler
16
Quickening may be felt
18
Fetus is able to hear
20
Quickening felt
24
Surfactant begins to be produced by lungs
28
Able to open and close eyes
38
Full term (38-42 weeks)
Student Nurse Guides
Maternal Adaptation During Pregnancy
□ Signs of Pregnancy: 3 categories
- Presumptive (Subjective)- indications of pregnancy but no definite diagnosis of pregnancy can be made
• + home pregnancy testg could be false positive
• amenorrheag could be due to anorexia, an athlete
• nausea and vomiting
• frequent urinationg possibly due to UTI, increased fluids
• fatigueg basically anything can cause this
• quickeningg fetal movement (?) felt by patientgcould be gas
• breast changesg could be due to hormonal issues
- Probable (Objective)- strong evidence of pregnancy but no definite diagnosis of pregnancy can be made
(Note—almost all uterine changes)
• + bood pregnancy test
• Hager’s signg softening of lower part of uterus just above cervix (softening of the uterus)
• Chadwick signg blueish color of vagina and cervical tissue due to increased vascularization
(Chadwick = Cyanotic Cervical color)
• Goodell’s sign- softening of vaginal portion of cervix (softening of the cervixg due to increased vascularization)
• Ballottement of head—the examiner pushes against the woman’s cervix during a pelvic examination and feels a
rebound from the fetus due to fetus coming down and hitting top of cervix
Hager = softening of upper
part of cervix
Uterus Side
Goodell = softening of lower
(Hager’s)
part of cervix
Cervix
Vaginal Side
(Goodells)
- Positive- signs only evident in a developing fetus
• Confirmation of fetus via ultrasound
• Fetal heartbeat on ultrasound (6-8 weeks) or doppler (12 weeks)
Probable and positive signs and symptoms of pregnancy. These signs indicate a likely pregnancy. Positive signs involve the
presence of a heartbeat on ultrasound
□ Physiologic Changes in Pregnancy
- Uterus
• Braxton Hick’s contractionsg contraction’s that don’t really do anything, spontaneous, irregular, contractions.
• Hager’s signg softening of lower part of uterus just above cervix (softening of the uterus)
• Uterus increases in strength and elasticity g grows graduallyg fundus of the uterus (the top of the uterus) enters
the abdomen at about 13 weeks (before then, it was in the lower part of women’s peritoneal cavity) g reaches the
xyphoid process at term g makes it hard to breathe
- Cervix
• Cervix softens to allow for expulsion of fetus and vascularization is increased
• Goodell’s and Chadwick’s signs
§ Goodell’s signg softening of vaginal portion of cervix (softening of the cervixg due to increased
vascularization)
§ Chadwick’s signg blueish color of vagina and cervical tissue due to increased vascularization (Chadwick =
Cyanotic Cervical color)
• Forms a mucus plug that prevents entry of pathogens
- Gastrointestinal
• Appetite increases g due to increased metabolic demands
Relaxation and slower emptying of stomach and intestinesg causes increase in issues with reflux and
constipation (decreased peristalsis leading to heartburn, N/V, etc)
Gums are hyperemic; increased dental plaque; gums bleed
•
•
- Cardiovascular
• 50% increase in blood volume over pre-pregnancy blood volumeg due to the need for getting fluid and
oxygen to fetus
• Physiologic anemia of pregnancyg anemia caused by increased blood volume (Hemodilu*on anemia!!)
§ Ex: Start with 4 oz fluid, 1 Tbsp of salt
§ (Fluid represents blood, and salt represents Hbg and is more dense than the fluid)
§ Add 50% more fluidg so now 6 oz fluid and still the same 1 Tbsp of salt (Hbg)
§ Increased fluid but no increase in Hbg makes it appear as anemia
• Orthostatic hypotensiong uterus sits on vena cava when lying down so when sit up it drops your BP
• Increased clotting factorsg this is to help with bleeding when placenta is delivered/expelled, thus preventing
woman from bleeding outg in the mean time it causes an increased RF DVT
• Increase in blood volume also causes nose bleeds (epistaxis) and gums to bleed more
- Respiratory
• Pressure on diaphragm increases with growing uterus
• History of asthma, other respiratory problems can decompensate more quickly
• Increased cardiovascular congestion (due to increased blood volume) g causes nasal congestion-epistaxis
(aka nose bleeds) and gums to bleed
- Urinary system (increased urinary frequency, especially early in pregnancy and last trimester)
• Increased Glomerular Filtration Rate (GFR) g Due to vasodilation effect of increased progesteroneg more blood
flow and volume g more wastes to excrete (maternal and fetal) g more glucose and protein excretion
• Increased risk for UTIs
- Musculoskeletal
• Lordosis g caused by release of relaxin from the placenta
• Puts pressure on ligaments that support uterus
- Skin Changes
• Everything as far as skin changes go eventually go away except for stretch marks
• “Mask of pregnancy” g aka chloasma or melasma g brownish spots on skin due to hormonal changes
• Acne that becomes worse due to hormones
• Linea nigra g line from navel to bottom of abdomen
• Stretch marks
Melasma/Cholasma
Linea nigra
Worsening acne
Stretch marks
□ Nutrition while Pregnant
- Nutrition deals with promoting healthy food and healthy weight gain
- Expected weight gain is 25-30 lbs for women with a normal pre-pregnancy weight
• Note: this number varies depending on the source; some sources say 25-30, others say 25-35
- Expected weight gain **
• 1st Trimester g 5 pounds total g usually less weight gain in 1st trimester than in later trimesters due to
vomiting
• Then, 1 pound per week
- Based on BMI
• Underweight individualsg should gain 28-40 pounds
• Normal weight individualsg should gain 25-30 pounds
• Overweight individualsg should gain 15-25 pounds
Student Nurse Guides
- Mother is NOT “eating for two”
• Increase of approximately 300 additional calories/day
Increase intake
iron by 30%
• Protein:
h 30%of>protein
than notand
pregnant
Increase intake
by 25%
• Iron:
h 30%of> folic
than acid
not pregnant
• Folic acid: h 25% > than not pregnant
• Vitamins A and C have smaller required increases
- Take a Prenatal vitamin daily to help meet these daily requirements
- If planning on getting pregnant, start taking a folic acid supplement while trying to get pregnant g since 50% of
pregnancies are unplanned, every woman of child bearing age is recommended to take folic acidg folic acid plays huge
role in neural tube developmentg neural tube develops early, and deficiencies before finding out you’re pregnant can
potentially cause defects or neural tube issues
- Sodium restriction not necessary during pregnancy unless underlying problem
- Monitor for picag eating non-food substances (clay, ice, starch)
- Limit caffeineg to about 1 cup of coffee or so per day of
- No alcohol
- Need adequate calcium for fetal bone/teeth development
- Toxoplasmosisg parasite found in some animals including cats g can be found in cat feces can cause eye and neural
damage to fetusg don’t empty cat litter boxes while pregnant
- Mercury and Listeria Risks**
• Mercury can cause CNS problems, hearing/vision problems in developing fetus
§ Avoid seafood high in Mercury (i.e. swordfish, tuna, king mackerel)
§ It is okay to eat fish, just ones with small amounts of mercury and limit servings to a few meals a week
(i.e. shrimp, salmon, anchovies, sardines, trout, catfish, and pacific mackerel)
§ No raw fish
• Listeria is bacteria found in some animals in water and in some soil g cause flu like symptoms that can occur
up to 2 months after eating something with listeria in it g can cause spontaneous abortion or still birth
§ Avoid uncooked hot dogs, unpasteurized milk, unwashed fruits and vegetables, cold lunchmeats,
undercooked meats, eggs, and poultry
□ Some prenatal discomforts can be remedied with dietary changes
- Eliminate chocolate or caffeine for heartburn
- Increase carb intake for nausea
- Small frequent meals to help with nausea
Student Nurse Guides
Student Nurse Guides
Listeria is bacteria found in animals in water and in some soilg causes flu like symptoms that can occur up to 2
months after eating something with listeria in itg can cause spontaneous abortion or stillbirth
* Note: Some prenatal discomforts can be remedied with dietary changes:
§ Avoid uncooked hot dogs, unpasteurized milk, unwashed fruits and vegetables, cold lunchmeats,
- Eliminate chocolate or caffeine for heartburn
undercooked meats, eggs, and poultry
- Increase carb intake for nausea
- - Small
Toxoplasmosisg
parasite
found
in some
animals including cats g can be found in cat feces can cause eye and neural damage
frequent meals
to help
with
nausea
to fetusg don’t empty cat litter boxes while pregnant
•
PsychosocialAdaptation
Adapta/ons
□ Psychosocial
- 1st Trimesterg tend to focus on self, not baby (may be ambivalent)
- 2nd Trimester gfeel/look pregnant, vomiting usually subsides, so usually more acceptance of self (sees fetus as separate en,ty inside her)
- 3rd Trimesterg women ready to deliver, tired of being pregnant and their body changes, usually more body discomfort,
usually making preparations for baby (room, buying things, etc).
(she may ques+on her ability to be a good mother, demonstra+ng “giving of oneself”)
Nursing Management During Pregnancy
□ Purpose of Preconception care:
- To identify risks (physical, behavioral, social) and to develop interventions
- For healthier pregnancy outcomes
- To address specific areas of concerng i.e. immunization status, pre existing illnesses, reproductive health, safe sex practices,
nutrition, weight, exercise patterns, do they work somewhere where they’re at risk of contracting diseases, what meds are
they taking, the possible need for genetic counseling
• 32% of women having children are obese and 70% don’t take folic acid
• First 2 weeks to few months are most important time for developing fetus, often when many women don’t even
know they’re pregnant
- If no pre conception care then they should see OB as soon as learn they’re pregnant
□ The Initial Visit
• Comprehensive health historyg physical and psychosocial healthg gynecological history including pregnancies
• Date of last menstrual periodg will determine EDC/EDD/EDB (estimated date of confinement, delivery or birth)
• Weightg vital signsg attempt to hear fetal heart tones (FHTs) g urinalysis
• Glucose screening for high risk women (age > 25 y/o)
• Cervical smears for STIs including chlamydia, gonorrhea and Group B streptococcus (GBS) g HIV test is optional
- Initial Visit: Baseline lab work
• CBC g looks at Hbg/Hct especially
•
Rubella titerg checks for immunity to rubellag rubella aka “three day measles” will cross placenta (transplacental
transmission) and cause severe damage to fetus if contracted during pregnancy (Rubella Syndrome)
§ If not immune, needs vaccination in the postpartum periodg cannot vaccinate during pregnancy because
it is a live vaccine and fetus could get infected if vaccinated during pregnancy
•
Hepatitis B Surface Antigen (HbsAg)g if mother is HbsAg positive for active infection, the newborn needs hepatitis
B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birthg this helps reduce risk of newborn
contracting it from mothergonce immunized, baby can breastfeed
•
Group B Streptococcus (GBS) g carried in about 25% of women in their stool and vagina naturallyg only
consequence is if fetus contracts it during deliveryg requires treatment of mother during pregnancy with
Penicilling Get penicillin Q4h during laborgif untreated, baby can become infected and be seriously ill
•
Blood typing and Rh factorg ABO incompatibility and Rh incompatibility
- Blood Typing and Rh Factor
• ABO Incompatibility g occurs when a pregnant woman’s blood type is Og her type O blood contains naturally
occurring antibodies against type A and B blood (anti-A and anti-B)
§ If pregnant with a fetus with non-O blood (A, B or AB)g her anti-A or anti-B antibodies can cross the
placenta andg cause hemolysis of fetal red blood cellsg milder than Rh incompatibility
§ Look for early onset jaundice in newborn
• Blood Type Inheritanceg A and B are dominant, O is recessive
Student Nurse Guides
§
§
§
•
•
•
•
Type A and B are dominant over O
- AO = Type A
- BO = Type B
- OO = Type O
Type A and B are considered co-dominantg AB together = Type AB
Type O is recessiveg Must have 2 ‘O’ s to have blood type O
Rh Incompatibilityg more severeg pregnant woman with Rh (-) factor becomes pregnant with a fetus that has Rh
(+) factor g don’t know fetus Rh type until it’s born
§ Normally maternal and fetal blood don’t mixg if there is a surgery or something though, blood can leak
§ Erythrocytes (RBCs) from fetal circulation leak into maternal circulationg caues maternal antibodies to be
made against the fetus’ Rh (-) anti-D antigen
§ These antibodies cross the placenta and destroy fetal RBCs g results in hemolytic disease of the newborn
§ Mother has no symptoms of Rh incompatibility but Rh antibodies adversely affect fetal health
Risks for Isoimmunization (Rh incompatibility)
§ Being pregnant
§ Invasive proceduresg abortion, amniocentesis, chorionic villa sampling
§ Traumag rupture of placenta, delivery itself
Prevention of Isoimmunization with Rhogam (blood product)
§ Rh-negative mothers must all receive Rhogam to prevent sensitization to the D antigen of a potentially Rhpositive fetusg Rhogam binds fetal RBCs with the D antigen before the mother is able to produce an
immune response and form anti-D antibodies.
§ Rhogam is given:
- at 28 weeks
- within 72 hours post partum, IF the newborn is Rh positiveg this is to protect FUTURE babies, not
this babyg must be given post partum due to risk of mixing any blood during delivery
- after spontaneous or induced abortion
- after amniocentesis or chorionic villi sampling
Rh Factor Heritability g Autosomal Recessive g so both parent’s need an Rh (-) allele to have any chance of an
Rh (-) fetus
□ Subsequent Visits
• Weight, vital signs g new onset hypertension especially important later in last trimester
• Urine dip stickg protein, ketones, glucose
• Fetal heart tones
• Fundal height g measured in cmg measure of fetal growth and rough estimation of duration of pregnancyg at 20
weeks the fundus is at the levels of the umbilicus and the measurement from the symphysis pubis to the fundus is
20 cmg Fundal measurement should approximately = the # of weeks of gestation until week 36 (so 24 cm = 24
weeks) ***
§ If fundus height is lower than expected (i.e. 20 cm and 26 weeks) or plateaus, possibly an issue with baby
(FGR) or amniotic fluid (oligohydraminos)
§ If fundus height more than normal, (i.e. 30 weeks measuring 40 weeks) an issue of hydramnios possibly
• Fetal movement assessment g # of times baby kicks after mother has eateng mother on left side because best
nutrient load to fetus in this positiong baby more active after meals
• Edema as the pregnancy progresses
• 24-28 weeksg glucose challenge test (done earlier with risk factors like diabetic) g if abnormal, 3-hour glucose
challenge testg if normal 3 hr test then not considered gestational diabetes
• At 37 weeksg screening for Group B Streptococcus, chlamydia and gonorrhea
Student Nurse Guides
If GBS + at 37 weeks, wait until labor to treat
- Because + in past, she may be + during labor/delivery toog give penicillin q4 hrs and at least 2
doses prior to delivery protects fetusg baby will not need treatment
- If she goes into labor earlier than 37 weeks with a hx of GBS+ but no recent screenings, OR if she
goes into labor very quickly and she does not get the 2 doses, then you automatically treat it
Always question about early contractions, preterm labor, leaking
§
•
□ Obstetric History
• Gravida (pregnancies) g any pregnancy the woman has had including current one regardless of the outcome
• Para (deliveries) g any delivery > 20 weeks
• Abortiong any delivery <20 weeksg includes spontaneous abortion (SAB) and induced abortion (EAB)
- Short Notationg Includes gravida and para
• Written as G/P
§ Gg all pregnancies including the current one
§ Pg all deliveries > 20 weeks g this P does not mean preterm
- Long Notationg describes what happened in each pregnancy (gravida, term, preterm, abortion, living children)
• Written as GTPAL
§ Gg all pregnancies including the current one
§ Tg number of term gestations delivered (38-42 weeks)
§ Pg number of preterm deliveries >20 weeks to 37 weeks, 6 days
§ Ag number of pregnancies ending before 20 weeks
§ Lg number of currently living children
v Obstetric History Example:
A woman is pregnant, had two previous deliveries at 37 weeks, and one pregnancy loss at 16 weeks.
2) What is her history using the short notation?
G/P
4/2
2) What is her history using the long notation?
G 4
T 0
P 2
A 1
L 2
□ Things to be Concerned About During Pregnancy
- 1st Trimester
• Bleedingg sign of spontaneous abortion (miscarriage)
• Signs of infectiong fever, etc.
• Vomiting that leads to dehydration, electrolyte imbalances, etc
• Low abdominal paing possible ectopic pregnancy
nd
- 2 Trimester (14-20 weeks)
• Regular contractionsg at 20 a fetus is viable, but newborns born at 23 weeks or less are very difficult to keep alive
• Leaking vaginal fluidg possibly water breaking
• Calf paing possible DVT due to hypercoagulable state
• Decreased fetal movementg possible death of fetus
- 3rd Trimester
• Any listed in 1st + 2nd
• Sudden weight gain
• Periorbital edema
Possible s/s of Preeclampsia
• Severe upper gastric pain
• Headaches with visual disturbances
• Decreased fetal movementg fetal death possibly
□ Screening Tests to Determine Genetic Risk
- Quad screeng blood testg AFP, Estriol, beta hCG + inhibin A **
• Abnormal results may indicate neural tube defect, multiple gestation, certain heart conditions, or physical
abnormalities
Student Nurse Guides
•
•
Low inhibin A increases identification of Down syndrome if < 35 years of age
Abnormal hCG, low estriol and low AFP mean possible chromosomal abnormality
□ Diagnostic Tests to Determine Genetic Risk
- Chorionic Villus Sampling g done at 10-13 weeksg sample taken from the chorionic villi
from the placentag this tissue shares DNA from the fetusg can be used to assess for down
syndrome, trisomy 13, trisomy 18g detects > 98% of chromosomal abnormalitiesg also can
be used as proof for paternity
- Amniocentesisg done at 15-18 weeks done to confirm findings from a screening testg ultrasound
guided needle inserted into amniotic sacg Amniotic fluid aspirated from amniotic sac to perform
chromosomal analysis, DNA, AFP, inborn errors of metabolismg no special prep for either procedure
except emptying the bladder minor pain, may numb the skin, outpatient procedureg risk for mixing
of bloods during this procedure so mother needs Rhogam afterwards
• Timing of amniocentesisg 2nd semester most common for diagnosesg 3rd semester for
evaluation of fetal lung maturity
- For chorionic sampling and aminocentesis the risk for complications, infection, or fetal harm is very very minimalg more
important to do test than to not do itg allows couple to decide if they want to continue pregnancy or notg if they decide to
keep the baby it allows them to have time to prepare for life with a special needs child g no special
prep for these tests aside from emptying bladder
- Ultrasoundg only diagnostic if it is more advanced and finds structural abnormalitiesg diagnostic for those findings
□ Who Should be Tested:
- Quad Screen g offered to all pregnant women so they know if they’re having a healthy baby, but especially women who:
• Have diabetes
• Are of advanced maternal age (age ³ 35)
• With a family history of birth defects
• Taking or have taken medication/drugs while pregnant
- Abnormal hcG, low estriol and low AFP mean possible chromosomal abnormality
- Trans-vaginal Ultrasoundg done during early pregnancy, such as around 6 weeks
- Ultrasounds (normal abdominal U/S) g very common and safe
□ Assessment of Fetal Well-Being
- Non-Stress Test (NST) g Indirect measure of utero-placental functiong measures fetal heart rate while baby is at rest and
while baby is moving g looking for fetal heart rate acceleration
• Done twice weekly for high risk pregnanciesg done for 20-40 minutes
§ Reactive g if the fetus accelerates its heart rate for 15 bpm above the baseline for 15 seconds (15 x 15) in
a 20-minute periodg indicates good interplay between uterus and placenta/fetus getting what it needs
§ Non-reactive if the fetus does not meet this criteria
- non-reactive NST correlates with fetal distress in labor, fetal mortality and intrauterine growth
restriction (IUGR) (when fetus not growing as it should be)
- NNN- Non reactive Non-stress test is Not good
- Biophysical Profile (BPP) g real time ultrasoundg done when NST is non-reactive (watch 4 fetal characteristics) or when
pregnancy is high risk (watch 4 fetal characteristics + do the NST)g each characteristic is rated from 0-2
• Not always done at the same time as non stress test (NST); if it IS done at same time, a reactive NST would be
measured as a 2
§ Movement (2)
Mnemonic:
Scoring:
4 characteris0cs looked at §
Tone (2)
- 8/10 or 10/10 normal
The - Tone
§ Breathing (2)
- 6/10 is equivocal
Baby - Breathing
§ Amniotic fluid volume assessment (2)
Always - Amnio5c fluid
- 4/10 abnormal and immediate delivery usually
§ NST (reactive would give score of 2)
Moves- Movement
indicated
□ Promotion of Self-Care
- Stay out of hot tubs and saunasg bacteria can ascend into cervix and cause infection of placenta or amniotic sacg also if
mom is hot fetus will get hot and fetus will become tachycardic
- Dental careg more cleanings/dental care is needed due to high BV and more plaque
Student Nurse Guides
-
Clothingg comfy, non restrictiveg no knee high socks because can decrease return circulation from heart to veins
Exerciseg as long as exercised before pregnancy can do same types during
Employmentg only risk is if hazardous occupation may need modifications
Travelg plane travel may be contraindicated if abnormal pregnancyg seatbelts should be worn with lap belt under abdomen
- Immunizations Contraindicated In pregnant womeng due to being live viruses
• Measles, mumps rubella (MMR)
• Influenza (Nasal) g need the inactivated one which is an injection
• Varicellag need done in post partum
□ Causes of Bleeding During Pregnancy:
• Abortion
• Ectopic Pregnancy
• Cervical Insufficiency
• Placenta Previa
• Abruptio Placentae
Contraindicated Vaccina-ons in Pregnancy:
Mother
Is Not
Vaccinated
MMR
Influenza (Nasal)
Varicella
Antepartum Complications
- Abortiong spontaneous or induced
• Nursing assessment
§ Description and duration of bleedingg clots, how much bleeding
§ Evaluate intensity of abdominal paing may be due to placenta detaching
§ Vital signs and level of paing s/s shock?
§ Support in the grieving process with reassurance even if it’s just the ER nurse
• Spontaneous abortionsg if it occurs at home she is asked to bring in whatever was expelled to see if full fetus
expelled or if there is a need for dilation and evacuation
§ Spontaneous abortions in 1st trimesterg due to abnormal fetusg something makes it incompatible with
life
§ Spontaneous abortions in later trimestersg issue with reproductive system specifically cervix
• Possible medications
§ misoprostol g causes uterine contractionsg used to expel rest of contents of uterus if evacuation was not
completeg often administered vaginally
- Note: original indication is as a prostaglandin analogue that decreases gastric acid secretion
and increases protective mucosa due to it causing uterine contractionsg if given to a pregnant
woman it could cause an abortion
- Off label use for cervical ripening and pregnancy termination
§ If woman is Rh (-) she needs RhoGAM
- Ectopic Pregnancy g fertilized ovum that implants outside the uterine cavity (i.e. fallopian tube, ovary, abdomen, intestine)
• As it grows, it draws blood supply from site g no site other than the uterus can support placental implantation or
growth of the embryo
• Often occurs in fallopian tubes
• Causes include:
§ STIsg damage cilia of tubes
§ Surgery on the tubeg from previous ectopic pregnancy forming scar tissue
§ Infection of the tube
§ abnormally shaped tube a woman is born with
• Nursing Assessment
§ Health historyg Are risk factors present? (surgeries, STIs, etc.)
§ Classic Triad S/S: 6-8 weeks after missed periodg abdominal paing spotting
- Other s/s: symptoms typical of early pregnancy, such as breast tenderness, nausea, fatigue,
shoulder pain, and low back pain.
§ Signs and symptoms of internal bleeding if rupturedg dizziness when standingg low BPg confusiong if
in fallopian tube, pain on one side confusion
§ Diagnostic testing
-
•
beta-hCG levels are too low/lower than they should be for length of pregnancy if it is implanted in
the tubes
- Visualization of a mass outside the uterus
Ectopic Pregnancy Treatment
§ Unruptured fallopian tubeg one dose of methotrexate IM based on body surface areag methotrexate is a
cancer drug g to preserve tube, need a salpingostomy (still will develop scar tissue)
§
Ruptured fallopian tubeg surgery by laparoscopy or laparotomyg both methods require weekly
bloodwork until beta-hCG levels are un-detectable
- Cervical Insufficiency (CI) g structurally defective cervix gcervix can’t handle the weight of the amniotic fluid and fetus
• Results in a spontaneous abortion in the 2nd or 3rd trimester of pregnancyg non-painful, rapid dilation and
effacement, with minimal bleeding
• Management
§ Bed rest and/or pelvic restg pelvic rest is no sexual activity
§ Avoidance of heavy lifting
§ Placement of a cerclage as late as 28-weeksg ties cervix shut to maintain pregnancy
- Transvaginal Cerclage- surgical procedure that is done through the
vagina. Stitches are used to close the cervix during pregnancy to
help prevent a premature birthg need to have a C-section in order
to keep stitches in place for future pregnancies
• Nursing Assessment for CIg woman may have a history of:
§ Cervical trauma or surgery
§ Lack of muscle tone in the cervix
§ Short cervix
§ Preterm laborg fetal loss in the second trimester, often ~ 20 weeks g can be due to contractions + CI
• May have complaints of pelvic pressure or pink tinged discharge to bleedingg loss of amniotic fluid
- Placenta Previag Implantation of placenta in the lower uterus (remember that implantation in upper 1/3 of uterus is best)
• “Afterbirth first”
• Can be total, partial, marginal, low lying
• Bleeding in 2nd or 3rd trimesterg painless, bright red bleeding that comes
and goesg secondary to thinning of the lower uterus for laborg lower
uterus cannot contract well to stop bleeding
• Nursing assessment and management
§ Health historyg myomas and uterine fibroidsg surgical removal of
uterine fibroids in pastgIf she has had placenta previa before
§ Risk factorsg hx of placenta previa g being > 35 y/o g having multiple fetuses in uterus g smoking g
HTN g diabetes
§ May be diagnosed with a transvaginal US early on, then regular ultrasound later
§ May be treated with bed rest
§ If Actively bleeding
- Pad count, V/S, FHTs, abdomen palpation
- No vaginal examsg can disrupt placenta and cause hemorrhageg delivery by c-section
- Oxygen at the bedside
- Abruptio Placentaeg separation of normally located placenta (upper 1/3 of uterus) > 20 weeks
• There is a bleeding from an old clot formed behind placenta that causes
separation of itg fetal blood supply compromisedg leads to fetal distress
• RFs include: smokingg cocaine useg trauma to abdomeng hx of abruptio
placentaeg chorioamnioitis (infection of chorion) preceded by
membrane rupture for > 16-18 hrs g preeclampsia
• Most often due to chronic or severe interruption of perfusion to the
placenta ***
• Manifestations:
§ Hallmark sign is pain
Student Nurse Guides
Dark red vaginal bleeding (port-wine color) g 80% of casesg dark red color due to the blood being old
bloodg no overt signs of bleeding in 20% of cases
§ “Knife-like” abdominal pain that can be rigid
§ Uterine tenderness g contractions g decreased fetal movement
Nursing assessment and management
§ Bed restg left lateral position
§ Immediate c-section delivery g straight to OR
§ Frequent V/Sg fundal height checksg peri pad count
§ Foley and large bore IV insertion
§ Fetal and contraction monitoring g fetal heart tones
§ Watch for unusual bleedingg report bleeding gums, oozing from IV siteg clotting problem
§
•
Comparison Summary:
***if having trouble
understanding the
pathophysiology of
these, please see the
handout “The
Placenta” in the other
file. Some?mes
visualizing it can help!
Manifestation
Onset
Type of bleeding
Abruptio Placentae
Sudden
Can be concealed or visible
Blood description
Placenta Previa
Insidious
Always visible;
slight, then more profuse
Bright red
Discomfort pain
None (painless)
Uterine tone
Fetal heart rate
Fetal presentation
Soft and relaxed
Usually normal range
Maybe breach or transverse lie;
engagement is absent
Constant, uterine tenderness on
palpation
Firm to rigid
Feral distress or absent
No relationship
Dark red
- Hyperemesis Gravidarumg persistent, uncontrollable nausea and vomiting in 1st trimester lasting into the 2nd trimester
• Leads to 5% loss of body weight gdehydrationg electrolyte imbalanceg hospitalization
• If untreatedg can lead to infant deathg electrolyte imbalances cause cardiac arrythmiasg mothers death
§ IV fluids may be required for rehydration, but the priority is to stop all intake of food and fluid for a period
of time until vomiting has stopped ***
• History and Physical for H.G.
§ History of risk factorsg young mothersg had it beforeg obesityg h. pylori g first pregnancy
§ Physical examg most women it resolves by 20 weeks
• Lab and diagnostic testing
§ Liver enzymesg CBCg TSH/T4g Urine specific gravityg Electrolytes
§ Ultrasoundg multiple fetuses/2 placentas increase risk
• Management of H.G.
§ NPO 24 to 36 hours
§ IV fluids with normal saline with electrolytes and vitamins added
§ IV or IM anti-emetics until able to eat
§ G-tube if oral intake is unsuccessful
§
Student Nurse Guides
□ Hypertensive Disorders of Pregnancy
• Chronic HTN
• Gestational HTN
• Pre-eclampsia
• Eclampsia
Note: >140/90 means
- Chronic HTNg HTN (> 140/90) that exists or develops prior to 20th week of pregnancy
> 140 systolic and/or
• No proteinuria
> 90 diastolic
• Increased risk for development of preeclampsia
- Gestational HTNg HTN (> 140/90 mm Hg) identified after 20 weeks of pregnancy
• BP (> 140/90) at least least twice, taken at least 6 hours apart after 20th week in a woman known to be
normotensive prior to thatg take BP multiple times to make sure she is truly hypertensive nowg gestational
hypertension women had normal BP before pregnancy g need the same device and same positions when taking
blood pressures
• No proteinuria
• Increased risk for development of preeclampsia
• Blood pressure returns to normal by 12 weeks’ postpartum.
Chronic Hypertension
Gestational Hypertension
th
• > 140/90 prior to 20 week of pregnancy
• Systolic >140 mm Hg and/or diastolic >90 mm Hg
• No proteinuria
• At least twice, taken at least 6 hours apart after 20th
• Increased risk for development of preeclampsia
week in a woman known to be normotensive prior to that
• No proteinuria
• Increased risk for development of preeclampsia
- Preeclampsiag multi system vasoppressive disorder
• Nursing assessment
! Can involve cardiovascular system, liver, renal, and CNS
! Can develop very quicklyg can also develop in the post-partum period
! RFsg chronic or gestational HTN, being adolescent when giving birth, abruptio placentae or
chorioamniotis, PROM for > 16-18 hrs
! S/S include: elevated BPg proteinuria g edema g bleeding or bruising g worsening headaches g vision
changes g epigastric pain
- Accurate measurement of maternal blood pressureg same device and same position = most
accurate readings
- Frequent weightsg can help assess for edema
- Edemag swelling of the hands and faceg generalized edema above the waist
o This differs from the dependent edema from standing a lot which is normally often
seen later in pregnancies
- Subjective complaintsg visual changes, worsening headaches, epigastric pain, may complain of
rings feeling small (this is due to edema)
- Hyperreflexia is also a component of preeclampsiagassess DTRs and check ankle clonusg if
patient was a 2+ reflex before pregnancy and now is a 3+, this needs to be addressed
- Ankle clonus is when you hold the woman’s leg and pullback on the toesg if they beat back at
you for a period of time it is clonus (marked hyperreflexia)
o Grading DTRs: (2+ to 3+ is considered normal)
! Reflex absent, none solicited = 0
! Hypoactive response sluggish = 1
! Reflex in lower half of normal range = 2
! Reflex in upper half of normal range = 3
! Hyperactive, brisk, clonus present = 4
Normal urine output is 30 mL per hour in adults g in pre-eclampsia it can become very scant g
leading to renal failure in eclamptic period
Key problems not to dismissg visual disturbances is #1 **
-
!
Symptoms
Blood pressure
Proteinuria
Seizures/coma
Hyper-reflexia
Edema
Headache
Urine output
Vision
Cerebral
Epigastric Pain
-
Mild Pre
>140/90mm Hg
1+
No
No
Mild-hands/face
No
Normal (30 mL/hr)
—
—
—
-
Severe Pre
>160/100 mm Hg
>3+
No
Yes
Can worsen
Yes
Oliguria
Blurred/blind spots
Disturbances
Yes
-
Eclampsia
>160/110 mm Hg
Marked
Yes
Yes
Generalized/above waist
Severe
Renal failure
Disturbances
Hemorrhage
Yes
** Note: how as you progress towards eclampsia, blood pressure increases and urine starts to have proteins
•
HELLP Syndromeg signs of severe preeclampsia
! a diagnosis of help syndrome is the most severe diagnosis of preeclampsia
- Hemolysisg the breakdown of red blood cells
- Elevated
- Liver function tests
- Low
- Platelet count (< 150,000)
•
Magnesium Sulfateg used to treat Preeclampsia
!
!
Blocks neuromuscular transmission, vasodilatorg used to prevent seizures in preeclampsia
Nursing actions:
Monitor magnesium levels closely g with any patient on medication requiring blood levels the
nurses responsibility is to monitor the blood levels closely
o Example: For a patient on 3 g, if patient still experiencing hyperreflexia may need to
h to 4 g.
o Example: If patient is on 4 g, if RR levels drop below normal adult RR (12-20
breaths/min), or if the DTRs are decreased too much, then you need to reduce the
dose
! Magnesium Sulfate Nursing Considerations
- Loading dose of Magnesium Sulfate is 4-6 g, then 1-4 g/hour
- Continuous monitoring of fetal heart tones
- Monitor and report:
o Hypotension and/or depressed DTRs
o LOC, blurred vision, headache
o U/O less than 30 mL/hour, I/O hourly
o Respiratory rate < 12 breaths per minute
- Calcium gluconate should be available for reversal of Magnesium Sulfate toxicity g S/S are CNS
depression, hypotension, decreased DTRs and decreased RR, etc. (see above)
Cardiovascular Drugs used in treatment of Preeclampsia
! Diuretics g furosemide (Lasix)g given for fluid accumulation/hydramnios
! Inotropicg digitalis (Lanoxin)
! Antihypertensivesg usually used in postpartum
-
•
-
•
labetalol (Trandate) g usually used first to try to bring BP downg if doesn’t bring it down enough
move onto nifedipine
FDA Drug Risk Categories:
- nifedipine (Procardia)
- Category A: Controlled human studies show no risk
! Anticoagulantg not antihypertensives but still used to help
- Category B: No controlled human studies, but no
with BP and clotting issues due to hypercoagulability
evidence of risk
experienced in pregnancy
- Category C: Risk to humans has not been excluded
- warfarin (Coumadin) is Category X, so can’t use it
- Category D: Positive risk to humans proven by
human or animal studies
- used insteadg enoxaparin sodium injection or
Category X: Contraindicated in pregnancy
acetylsalicylic acid (apirin)
The only cure for pre-eclampsia is delivery of the fetus ***
! So, Example: you can have a mother that is 35 weeks (which is preterm) with severe preeclampsia but has
not had a seizure yet (because that would take her into the eclampsia stage). If she is on too high a dose of
magnesium (i.e. 4 g/hr but having side effects like respiratory depression) but you cannot lower her dose
without preeclampsia being an issue, then you need to deliver the babyg have calcium gluconate at the
bedside if she does have low DTR, but you still may have to deliver the baby preterm
- Eclampsiag having a seizureg onset of seizure activity in a woman with preeclampsia
• Generalized seizureg(looks like any type of generalized seizure) g begins with facial twitchingg involves
alternating contraction and then relaxation of muscles
•
•
Nursing Interventionsg turn to side lying positiong stay with herg call for help (do not leave her)g raised bed
rails with padding
! Valium may be given at bedside to stop seizure
After a seizureg continue patient on magnesium sulfateg rationale: t is supposed to prevent the seizure so you do
not want to discontinue it g continue monitoring fetus/FHTsg put oxygen on herg dim lights and maintain quiet
environmentg document time of seizure g prepare for delivery (patient will be sent to delivery room ASAP
Summary Points:
• Both Chronic and Gestational HTN put a woman at risk for pre-eclampsia
• No proteinuria for chronic or gestational HTN
• Proteinuria present in severe pre-eclampsia and eclampsia
□ Amniotic Fluid Imbalance
• Amniotic Fluid Balances fluctuate throughout the Pregnancy
• Fluid increases as pregnancy progresses, with minor fluctuation on a day to day basis
• Normal pregnancy has about 1,000 mL at term
• Complications related to amniotic fluid imbalances:
! Oligohydramnios
! Hydramnios
- Oligohydramnios ( < 500 mL amniotic fluid between 32 - 36 weeks)
•
Causes of it:
! Conditions that do not allow fetus to make or excrete urineg fetal renal abnormalitiesg not urinating the
fluid swallowed out, then the fetus body will use the fluid but amniotic fluid will be lower than it should
! Post-date pregnancy
! Uteroplacental insufficiencyg not enough blood flow getting there or a problem with the placenta
• Risks associated with it :
! Increased risk of surgical birthg because often an issue with placenta and uterus
! Low birth weight infants
• Signs
! Fundal height < dates
! May be unaware membranes have ruptured
- Hydramnios aka polyhydramnios (> 2,000 mL amniotic fluid between 32- 36 weeks)
• Causes of it:
! Maternal diseaseg i.e. gestational diabetes (Type II)
! Fetal anomaliesg neural tube defects
! Upper gastrointestinal problems of the fetusg malformations of the CNS and/or gastrointestinal tract that
prevents swallowing of the amniotic fluid by the fetus esophageal problems/impaired swallowing g fluid
not getting into fetus, but mother still produces fluid so there will be too much in uterusg problem of
increased pressure as a result g can cause premature rupture of membranes
! Idiopathic
• Risks associated with it:
! PROMg preterm deliveryg prolapsed cord
• Signs: dyspneag fundal height > dates
□ Premature Rupture of Membranes: PROM or PPROM
- Premature rupture of membranesg means the amniotic fluid sac ruptures before any contractions
•
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PROMg rupture of membranes before labor begins in term pregnancy ( > 38 weeks)
PPROMg rupture of membranes before labor begins in preterm pregnancy ( < 38 weeks )
! Diagnosis of PROM or PPROM: 3 methods
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•
•
Nitrazine paperg turns blue in presence of alkaline fluid such as amniotic fluidg if it is
inconclusive, you put a drop of fluid on a microscope slidegfern appearance on microscope slide
- Microscope slideg fern appearance
- Speculum visualizationg look for pooling of amniotic fluid around vagina
RFsg hydramnios, pregnant with multiples, trauma,
! Concerns
- Infectiong if membrane ruptured for 18 hours it puts woman at high risk for infectiong she will
be started on antibioticsginfection would be the inside of the uterus or the placenta itselfg
infection of the placenta is called chorioamnionitis
- Cord compression or prolapseg can occur if mother has hydramnios
- Closely observed in the hospital but some women are managed at home
- Fetal lung maturityg if fetus is less than 34 weeks the lungs are not usually developed well
enough to do well in the outside environmentg give betamethasone to mother of babies less
than 34 weeksg this promotes good lung developmentg after 34 weeks do not need to give it
because the fetus could theoretically be OK without it
o betamethasoneg promotes fetal lung maturity by increasing surfactantg 2 doses
IM 24 hours apartg repeat in 7 days until lungs are mature or deliveryg
improvement in lung maturity can be seen after 24 hours
! Nursing Considerationsg monitor mother for infection, especially lung
Key Assessments with Premature Rupture of Membranes
! Determining the date, time, and duration of membrane rupture by client interview ***
- Rationaleg should be clear amniotic fluid
o if it is yellow tingedg it could indicate infection
o if it is green tingedg it means that the fetus has had a bowel movement in uterog
this is called meconium
! Ascertaining gestational age of the fetus based on date of mother’s last menstrual period, fundal height,
and ultrasound dating
! Questioning the woman about possible history of or recent UTI or vaginal infection that might have
contributed to PROM
! Assessing for any associated labor symptoms, such as back pain or pelvic pressure
! Assisting with or performing diagnostic tests to validate leakage of fluid, such as Nitrazine test, “ferning”
on slide, and ultrasound.
! Contamination of Nitrazine tape with lubricant or insufficient fluid will render the assessment unreliable.
! Continually assessing for signs of infection including:
- Elevation of maternal temperature and pulse rate
- Abdominal/uterine tenderness
- Fetal tachycardia more > 160 bpm
- Elevated white blood cell count and C-reactive protein
- Cloudy, foul-smelling amniotic fluids
□ Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations
• Diabetic
• HIV positive
• teen pregnancy
• Pregnancy in women of AMA ( > 35 y/o)
- Gestational Diabetesg women who at some point in pregnancy develop Type II Diabetes
• It is glucose intolerance (form of Type II diabetes) that develops during pregnancy—usually around 24 weeks—or is
first detected in pregnancy.
• Importance of preconception counselingg insulin resistance due to placental hormonesg the placental hormones
have an effect of insulin resistanceg so even a woman who is not gestationally diabetic would need increased
•
•
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insulin during her second half of pregnancy because of this insulin resistance caused by the placenta
Checking blood glucose
! Blood glucose done at first prenatal visit if at risk
- Normal = fasting glucose < 126 mg/dL
! Blood glucose challenge at 24-28 weeks if no risk factors
- 1 hour testg abnormal if > 140 mg/dL
o If abnormal, do a 3 hour challenge done at a later time to dx gestational diabetes
Risk Factors for Gestational Diabetesg these are people you would do a BG test on at first prenatal visit
- Pre-gestational diabetes
- recurrent candida infections
- previous infant > 4,000 grams
or 9 lbs
- 1st degree relative with diabetes - obesity / BMI > 30
- previous infant with congenital
anomaly
- hypertension
- physical inactivity
- unexplained previous fetal
demise or neonatal death
- hypercholesterolemia
- smoker
- PCOS
- age > 25
- Hispanic, African American,
- family hx of diabetes
Native American, Pacific Islander
Surveillance of the Woman with Diabetes
! Maternal
- Urinary protein, ketones, nitratesg nitrates in urine are indicative of infection
- Kidney function- creatinine clearance/protein levels
- Eye exams and HbA1c
! Fetal
- Frequent ultrasounds for growth, activity and amniotic fluid levels
- Quad screen for congenital anomaliesg AFP, estriol, beta hCG , + inhibin A
- Weekly NSTs, BPP as needed
- Amniocentesis for fetal lung maturityg done at 34 weeks if the need to deliver feels imminent
- Human Immunodeficiency Virus
• Pregnant women may not know they are HIV+
• Disproportionate affect on services for people living with HIVg HIV medical care providers often don’t take care of
pregnant women
• Care for the HIV + pregnant patient:
! Antiretroviral medications (ART)g before/during pregnancy reduces risk to fetus greatly (28% to <2%)
- Must take at same time, every dayg missing doses can be very detrimental
- Infant must be treated for 4-6 weeks after birth to reduce risk
! Other measuresg NO breastfeeding or pre-chewing infant’s food if HIV+
- Adolescents g 11-19 years of age
• Complicated by:
! Limited financesg less work experienceg if they’re in school, then they usually don’t have a full time job
to pay for expenses of a child or pregnancy
! Immature psychosocial developmentg many don’t have a high level of education on child developmentg
lack skills in conflict resolutiong lack knowledge about health
! Unfinished physical development of ageg can cause fetal complicationsg at higher risk of preeclampsia
! Lack of supportg many will drop out of school as a result
• Teach about high risk behaviors
• Empower good decision makingg offer resources for support
- Woman of AMAg > 35 years of age
• Complicated by:
!
!
!
Chronic health conditionsg pre-gestational hypertension, heart disease
Increased risk for obstetric complicationsg infertility, spontaneous abortion, GDM, gestational
hypertension, placenta pervia, surgical birth, HTN, etc.
AMA predisposes fetus to a higher risk for abnormalitiesg large birth weights (fetal macrosomia)g
depressiong childhood obesity
- Should do screening testsg goal is promotion of a healthy pregnancy
- Substance Abuse
• Smokingg heart, cleft & placental problems, preterm births, LBW
• Alcoholg fetal alcohol syndrome
• Caffeineg LBW, irritability in large amounts
• Tobacco, marijuana, stimulantsg can double or triple the rate of stillborn
Summary Points
- Genetic issuesg risk of heredity
- Substance abuseg Cross the placenta
• Smokingg heart, cleft & placental problems, preterm births, LBW
• Alcoholg fetal alcohol syndrome
• Caffeineg LBW, irritability in large amounts
• Tobacco, marijuana, stimulantsg can double or triple the rate of stillborn
- Sexually transmitted infectiong can be passed to infant
• Herpes, Syphilis, HIV, AIDS, Hepatitis B
- Cardiac conditions
• The heart is a pump
• Increased blood volume needs to be pumped during pregnancy
• Increased weight during pregnancy is more work on the heart
- Diabetes
• High blood sugars = increased insulin → growth hormone = bigger baby
• Hormones in pregnancy raise blood sugar
• Placental hormones increase insulin resistance
- Obesity
• At increased risk for diabetes and other concerns
• Gain more weight in pregnancy
• Poor nutrition → not good for fetal development
• Grow a larger fetus
- Hypertension
• High blood pressure→ grows a smaller fetus → doesn’t get proper nutrients
- Young (under 11- 19)
• Lack of maturity for situation and understanding
• Poor nutrition
• More at risk for preeclampsia
- Advanced maternal age
• Older eggs
• Body doesn’t provide for the fetus as well as younger age
• Increased risk for fetal abnormalities and issues
• Mother at risk for more pregnancy complications
• Fetus at risk for more issues in life including childhood obesity
Student Nurse Guides
Labor & Birth Process + Associated Nursing Management
- Labor g uterine contractions resulting in cervical change (dilation and/or effacement) **
• Full-term labor is 38-42 weeks
• Preterm labor is < 30
37 weeks
weeks (Note: some define it as < 30 weeks, some define it as < 37)
- Premonitory Signs of Labor—Signs that Labor is Coming Soon
• Cervical changesg during most of pregnancy it is fairly hardg when it's close to the end of the pregnancy the cervix
shortens and softens for dilation and effacementg this is sometimes caused by contractions
• Lighteningg the fetal head descending into the pelvis; this causes pressure on the cervix (but it’s a good thing) g
will cause her to have increased urinary frequency and vaginal discharge though
! May also be called engagement or dropping ***
• Increased energy levelg burst of energy can happen around 24 – 48 hrs before labor
• Possible weight lossg estrogen and progesterone levels fluctuate, causing a fluid shift and subsequent weight loss
of 2.2-6.6 kg approximately 24-48 hrs prior to labor
• Bloody showg when the mucus plug comes outg it has a little bit of blood from the dilating cervix
• Braxton Hicks contractions g “practice contractions” g occur on the outside of the uterus rather than the top of
the fundus; they don't do a lot in terms of helping to dilate/efface the cervix
• Spontaneous rupture of membranesg aka a woman’s “water breaking” g can be anywhere from 50-300 mL
membranes may have ruptured spontaneously at homeg if that were to happen, the woman should be told to come
in and to make note of the date and time it happened, as well as the color of the fluid/whether it was clear, yellow,
green tinted, etc.
! Note: membranes MUST rupture or be ruptured for labor to occur! g Rationale: the absence of the
amniotic fluid acting as a buffer in the uterus means that the fetal head will now be sitting on the cervix. g
this stimulates contractions and thus labor occurs
- PPROM: Preterm premature rupture of membraneg greatest risk to baby occurs when this occurs
before 37 weekgHigh risk for infection (bacteria gets in because prolonged rupture)
- PROM: premature rupture of membranesg rupture prior to laborg can be gush of fluid or steady
leak
- ROM: spontaneous rupture of membranes at full term
- AROM: artificial rupture of membranesg done with a tool or hand of physician
! Can perform Nitrazine test to determine if mother it is truly amniotic fluid or just urination
- Nitrazineg paper that tests pH of fluidg amniotic fluid Is alkaline with a pH of 7-7.5.
- Alkaline liquids will turn test strip blue
- True vs False Labor
Parameters
True Labor
False Labor
Contraction timing
Regular
Irregular
Progressiveg become closer together
Not becoming closer together
4-6 min. apart lasting 30-60 sec.
Contraction strength
Become stronger over time
Weak; not getting stronger
Vaginal pressure usually felt
Contraction discomfort Starts in back and radiates to front
Usually felt in front of abdomen
Change in activity
Stay or Go?
Contractions continue no matter what
positional change is made
Stay home until contractions are 5 min apart
and 45-60 seconds, if she cannot talk through
them, or if continuous bleeding present
- Initial Maternal Assessment
Contractions stop or slow with walking or
positional change
Drink fluids and walk. If contractions diminish,
stay home
Student Nurse Guides
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Review of prenatal recordsg usually sent electronically to hospital she should be delivering at
Current labor and amniotic fluid statusg has her water broken or not
Personal medical/surgical and social history
Plans and desires for labor and birthg who does she want in the room, what is her birth plan, does she want an
episiotomy if one needs to be done, does she want pain management/epidural
Plans and desires for care of her newborng most hospitals do roaming
! Roamingg newborn stays with mother 24 hrs a day except if there is complications (i.e. issue with
thermoregulation)g if child is having a circumcision it would go to the nurseyg baby can also be watched
by a nurse if mom wants a break
Cultural preferencesg some women don't want men in the room including their partner for the delivery
- Lab Studiesg drawn if they were not available in prenatal screening
Hbg/Hct and blood typing
HbsAg
VDRL (syphilis)
Drug screening if history
supports use
HIV (with consent)
GBS
- Group B Strep Treatment
• Who get’s treated:
! Labor at less than 37 weeks gestationg who have not had a recent GBS test (we assume she is +)
! Intrapartum temperature of > 100.4 F
! Rupture of membranes for 18 hours or longer
! GBS + bacteriuria in the current pregnancy
! Previous infant with GBS disease
• Tx: Penicilling after a loading dose, give 1 g q4h until delivery
- Assessing FHR
• Intermittent monitoringg uses a specialized doppler, stethoscope, fetoscope, or by putting the mother on the
monitor
! Allow freedom of movement for the womang she is not hooked up to monitor the whole timeg she can
walk around etc.g bring her back every 30-60 min to check the heart tones.
! May miss concerning FHR
• Continuous monitoring
! Restricts movement to a bed or a chair
! Identifies concerning changes in FHR
• External or internal monitoring
! Normally do external monitoring
! Internal monitoringg Fetal scalp electrode used in high risk pregnancies or if fetal
heart tracings are abnormalg electrode screws into the baby’s scalpg if mother
has any type of uterine infection or HSV it can enter the baby through the hole
• Artifactg like chicken scratch on the monitor tracingg you're not really picking up what you need to and you need
to move the transducer or the tow around so that you can get a better tracing
- Current Labor and Amniotic Fluid Status
• Analysis of amniotic fluid status (nitrazine test) g analysis of FHRg uterine contraction patterng vaginal exam/fetal
descentg Leopold’s maneuvers
- Leopold’s Maneuvers (see vocab sheet)
• ACOG recommendation when woman is admitted for labor
• To determine the position of the fetus in utero
• To determine the expected presentation for labor and delivery
- Cardinal Movements of Laborg the positional changes a fetus goes through as it travels thru passageway
Student Nurse Guides
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•
•
•
•
•
•
Engagementg when presenting part passes through the pelvic inlet (usually 0 station) g may also be called
lightening or dropping
Descentg downward movement of the fetal head until it is within the pelvic inletg measured by stationg
continuous process until delivery
Flexiong when the vertex meets resistance from the cervix, the walls of the pelvis, or the pelvic floorg baby flexes
head downg occurs simultaneously with descent
Internal rotationgrotation of the baby within the birth canalg after engagement, as the head descends, the lower
portion of the head meets resistance from one side of the pelvic floor, causing the head to rotates about 45 degrees
anteriorly to the midline under the symphysisg aka, baby’s face should be in line with mom’s rectum
Extensiong occurs after internal rotation is complete and crowning has begung head emerges through extension
under the symphysis pubis along with the shouldersg completed when baby’s chin is out of the perineum
External rotationg after head is born and is free of resistance, it untwists, causing the occiput to move about 45
degrees back to its original left or right position (restitution) g external rotation of fetal head allows the shoulders to
rotate internally to fit the mom’s pelvis
Expulsiong the rest of the body coming outg easier after birth of head and anterior and posterior shoulders
- Factors Affecting the Labor Processg the 5 Ps
• The Mom
! Passageway (birth canal)
! Powers (contractions)
! Position (maternal)
! Psychological response or Psyche
• The Baby (Passenger- the 5th P)g includes the fetus and placenta
! HALPPS
! H- Headg size and presence of molding
! A-Attitudeg degree of body flexion
! L-Lieg relationship of body parts
! P-Presentation (Presenting part) g first body part coming out
- Occiput (what we want)
- Scapula
- Mentum
- Fetal butt
- Leg, hand
! P-Positiong Right or left, Presenting part, Anterior or posterior
! S-Stationg Where the presenting part is located
1. Passageway (birth canal)
- Passagewayg the tunnel/route through which the fetus must travel down to be born vaginally
• It is a misconception that because someone is very petite that they are unlikely to be able to deliver vaginally. Pelvic
shape is more important.
- Pelvic shape
• Gynecoid pelvisg most favorable pelvis for vaginal birthg round inlet and
roomy outlet; optimal diameters in all 3 pelvic planeg occurs in » 40% of
womeng allows for early/complete fetal internal rotation during labor
•
Arthropoid pelvisg occurs in » 25% of women, most of which are non-white
womeng oval pelvic inlet and long sacrumg result is a deep pelvis (wider
front to back than side to side; in other words, pelvic anterior to posterior
measurement is > transverse measurement) g vaginal birth more favorable
than with android or platypelloid pelvises
Student Nurse Guides
•
Android pelvisg considered the male-shaped pelvis; characterized by a funnel shape g occurs in a» 20% of
women. Heart-shaped pelvic inlet and reduced posterior segments g Slow descent of fetal head into pelvis; failure
of fetus to rotate is commong poor prognosis for laborgleads to cesarean birth
•
Platypelloid (Flat) pelvisg least common type of pelvic structure g shallow pelvic cavity that widens at pelvic
outletg this makes it difficult for fetus to descend through the mid-pelvisg Labor prognosis is poor with arrest at
the inlet occurring frequentlyg Vaginal birth is NOT favorable unless fetal head can pass through inletg C section
usually required
- Soft tissues (cervix, vagina, pelvic floor muscles)
• Vaginal tissuesgexpand to accommodate the fetus during birth.
Pelvic floor m.g help fetus rotate anteriorly
Gradual progression from 0g100% effacement and 1g10 cm dilation
! Effacementg cervix effaces (thins) to allow the presenting fetal part to
descend into the vagina
! Dilationg the gradual opening of the cervixg measured in cm (0-10 cm)
- Ideally we want 1 cm dilation per hour in active labor
! Process of dilation and effacementg think of pulling turtleneck sweater over head
- Determining Cervical Dilation and Effacement
• Full term, non ruptured or ruptured membranesg do a vaginal exam
! Use a sterile-gloved hand and insert two fingers into vagina up to cervix.
Separate fingers to feel how far dilated the cervix is.
• Pretermg limit the number of vaginal exams if membranes are rupturedg but if in active
labor her dilation status must be checked as a baseline
•
•
2. Passengerg (fetus with the placenta)
- Head (size and presence of molding)
• Head has an open fontanelle and sutures that are not completely fusedg this allows for the cranial bones to overlap
a littleg this helps make the head a little narrower so it is easier for it to pass through the birth canal during delivery
! The changed (elongated) shape of the fetal skull at birth as a result of overlapping of the cranial bones is
known as molding
- Attitude
Student Nurse Guides
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•
- Lie
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The posturing (flexion or extension) of the joints and the relationship of fetal parts to one another.
Most common fetal attitude when labor beginsg all joints flexedg fetal back is rounded, chin is on the
chest, thighs are flexed on the abdomen, and legs are flexed at the knee g this fetal position is most
favorable for vaginal birth
(relationship of body parts)
Has to do with how the fetus is laying in the uterus
Fetal lie refers to the relationship of the long axis (spine) of the fetus to the long axis (spine) of the
mother
3 Types of fetal lies:
! Cephalic (aka vertex or longitudinal)g most commong baby’s spine is parallel to mother’s
! Breech (aka oblique)g fetal long axis is at an angle to the bony inlet; no palpable fetal part is presentingg
usually transitory and occurs during fetal conversion between other lies.
- Frank breech is the only type of breech where a vaginal delivery would be attemptedg otherwise
have to do C-section as well **
! Transverseg fetus spine is perpendicular to the mother’s (so fetus spine lies across the
mother’s abdomen and crosses the spine
A fetus in transverse lie cannot be delivered vaginally g C-section required **
! Some physicians will take mother to OR and try to manually move fetus into cephalic
positiong some risks with thisg need to measure fetal heart tones carefullyg if an emergency C-section
is needed, they would already be in OR ready to do it
- Fetal Presentation (first body part)
• Vertex (Cephalic)
! Head firstg Most often
! Moldingg overlapping of the cranial bones during delivery resulting in an (elongated) shape of the fetal
skull at birthg can make them look like a conehead
• Breech
! Frankg could possibly deliver vaginally
! Full or complete
! Footling
- Fetal Position (relationship to maternal pelvis)
• Described in 3 letters
• Have to imagine like we’re looking inside the mother through the cervix
! 1st letterg is presenting part tilted toward left or right side of woman’s pelvis
! 2nd letterg refers to what the presenting part is
! 3rd letterg is the presenting part in the anterior, posterior, or transverse part of
the woman’s pelvis
• Note: Maternal pelvis divided into 4 quadrantsg L/R anterior and L/R posterior
• Most common and favorable fetal position for birthingg left occiput anterior (LOA); second best is ROA
• Posterior occiput is more painful than anterior
! Causes a lot of back pain in the woman
! Babies born in posterior occiput are born facing the ceiling (aka Sunny Side Up)
• If the baby's head is transverse then it's going to rotate around to the anterior position and be delivered with face
looking down at the floor
First letter
Presenting part on
Left or Right side
of the woman’s
pelvis
Second Letter
Presenting part
Occiput,
Mentum (chin), or
Sacrum
(can also have Back,
Leg, or Hand)
Third Letter
Front or back of
the woman’s
pelvis
Anterior, Posterior,
or Transverse
Student Nurse Guides
Look at where the anterior fontanelle is in the different onesg notice how completely in different positions
- Fetal Station
• Relationship of the presenting part to the level of the maternal pelvic ischial spines.
• Measured in +/- cm
• Starts in negatives and moves toward the positive as the fetal head (or presenting
part) descends further into the pelvisg the larger the positive number, the closer
the presenting part of the fetus is to the outside
• Zero (0) stationg when presenting part is at the level of the maternal ischial spines.
! Zero (0) station is engagement ***
- When the presenting part is above the ischial spines, the distance
is recorded as minus (-) stations
- When the presenting part is below the ischial spines, the distance
is recorded as plus (+) stations
- Documentation: Cervical Dilation, Effacement, and Station
• How we document this:
! Always cervical dilation first cm dilated)
! Always cervical effacement second (% effaced)
! Always fetal station third
• Example: halfway dilated, halfway effaced, and 3 cm above ischial spineg document as: 5/50/-3
3. Powersg Uterine Contractions
- Uterine contractionsg involuntary, rhythmic, and intermittentg blood flow to uterus and placenta is temporarily paused
during each contractiongperiod of relaxation between them to allow uterine muscles to rest and to restore blood flow to
uterus and placentagcause thinning of the cervix (effacement) and dilation
- Each contraction has 3 phases: increment( build up), acme (peak), and decrement (relaxation period)
• Frequencyg how often the contractions occurg measured from beginning of one contraction to the beginning of
the next one
• Durationg how long a contraction lastsg measured from beginning of one contraction to the end of same oneg
measured in seconds
• Intensityg strength of contractiong most often on the floor it is assessed by the look on the woman’s face
• Intervalg time between contractionsg measured from end of one to the beginning of the next in seconds
• Maternal pushingg secondary powers in laborg woman using intra-abdominal muscles/pressure to push and
bear down during labor (aka when she is “pushing”)
- Assessing Uterine Contractions
• Intensityg can be determined by manual palpation or measured by an electronic device
• Intermittent or continuous
! External (toco-transducer)g placed at top of fundus of uterusg non-invasiveg limited data about
external monitor use for determining strength/intensity of contractions
! Internal (IUPCg intrauterine pressure catheter)g catheter positioned in
the uterine cavity through the cervix after the membranes have rupturedg
woman must have her membranes ruptured and be at least 2 cm dilatedg
fetal head must be low enough to be reachedg fetal scalp electrode put on
the baby’s headg intensity is measured in mmHg by determining the
pressure of the amniotic fluid in the uterusg need a skilled practitionerg
not recommended for low-risk pregnancies because RF infection/placental
Injury
Student Nurse Guides
4. Position (Maternal)
- Encourage movementg allow her to stand next to bed if she is on external monitoringg let her sit on big exercise balls
- Squatting enlarges the pelvisg in a lot of underdeveloped countries it is common for women to deliver while squatting in a
fieldg easier to deliver this way because it helps with fetal descent due to gravity ***
- Kneeling helps rotate the fetus
- Any position other than supine or upright may: ***
• Give mother control
• Reduce the length of labor and incidence of assisted deliveriesg less use of forceps or vacuum extractors
• Reduce tears and use of episiotomies
• Assist gravity for fetal descent
- When supine, mother is laying on vena cavag reduces blood flow back to heart and placenta
5. Psychological Response
- Trust in the staff and partner to help and support
- Clear information of the process and proceduresg if an emergency occurs need to talk her through it as you’re in the
process of it
- Control over decisions being made
- Control over breathingg when in pain we often hyperventilateg need to help patient control her breathingg Lamaze
classes
Stages of Labor
- 4 stages of Labor (See summary page at end)
I. First Stage of Laborg onset of labor until completely dilated
- Latent
• Cervical change 1-3 cm, effacement 0-40%
• Mild contraction q 5-10 mins for 30-45 seconds
- Active
• Cervical change 4-6 cm, effacement 40-80%
• Moderate contractions q 2-5 mins for 45-60 seconds
- Transition
• Cervical change 8-10 cm, effacement 80-100%
• Strong contractions q 2 mins for 60-90 seconds
- Nursing Care for 1st Stageg 0-10 cm
• Close attention to FHR and contraction patterns
• Rupture of Membranesg if haven’t ruptured membranes before she came in, you will do it artificially at some
pointg you take a little plastic tool that looks like a crochet hook to snag the membrane
! If doing artificial rupture of membranes, it is nurse’s responsibility to make sure the FHR stays stableg
need to listen to FHR for at least 1 minute **
Student Nurse Guides
! If head not engaged at 0 and membrane ruptures either spontaneously or artificially the cord could come
down ahead of the presenting partg if this happens and cord comes down first, when presenting part hits
it then you could have compression of the cord, resulting in decreased fetal heart rate tones
• Somewhat independent role
! Knowledge and performance of interventions
! Document of all communication in timely manner
- Before and after calls to provider
- Before and after interventions
- Detailed documentation of progress and changesg document every time patient is checked, any
interventions, etc.
- Pain Management During Labor
• First stage, labor itself, pain management
• Nonpharmacologicg walking and position changes, hydrotherapy, therapeutic touch, imagery, acupuncture,
breathing techniques
•
Systemic Analgesia
! Synthetic opioids
- Butorphanolg takes the edge off, but doesn’t take pain away
- Merperidine
-
Problems with opioidsg RF maternal respiratory depression, newborn respiratory depression,
decreased alertness, decrease sucking, delay of or ineffective feeding
- Opioid timingg want to time giving an opioid either within 1 hour of delivery or 4 hrs before
deliveryg if deliver within 1 hour of getting opioid it doesn’t have time to get into the baby's
system for the baby to have respiratory depressiong when it' ³ 4 hrs since last dose of opioid the
drug does get through the baby's system, but it wears off and is excreted so it still wont’ have
respiratory depression.
It’s when baby is born between 1 and 3 hours after opioid where risk for respiratory depression
in newborn occurs.
"
Can give Narcan to the mother if it looks like she's going to deliver in that time period
! Antiemeticsg sometimes potentiate opioids, so given together
- Promethazine
- Hydroxyzine
! Tranquilizers
! Diazepine
•
Regional Analgesia
! When a woman is going to have an epidural, going to have a c-section, and it isn’t an emergencyg 60-90%
of women have them
! Local anesthetic and opioid into lumbar epidural space (i.e. fentanyl or morphine)
- Catheter remains inserted for continuing analgesiag taped to mother’s backg PCA pump
- If having a C-section, epidural often left in for 24 hrs for pain relief
- As long as she has epidural though, she won’t be able to get up and go to bathroom (unlike with
IV opioids where you can still get up)
Student Nurse Guides
!
!
!
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- Prolongs second stage of labor (pushing stage) and increases risk for use of assisted devices
Left lateral position after placement
Local anesthetic, then injection of epidural anestheticg
sterile procedureg can be done sitting or laying on side
Prior to putting epidural in woman needs to have fluids ↑
increased g need at least 1 L IV fluid running to compensate
incase she develops hypotension after epidural meds
Check pain to make sure it’s working
Put in Foley catheterg won’t feel need to urinate
Epidural
Complications
- Hypotension that can lead to fetal distressg check
BP for hypotension (possible complication)g not
as much blood getting to placenta and can cause
fetal distress
- Respiratory depressiong from medication itself
- Allergic reaction
- Intravascular injection
- Fever/infectiong from procedure complications
Contraindications (relative and absolute)
- Refusal (absolute)
- Previous spinal surgery (relative)g might be able
to
with a proficient anesthesiologist
- Spinal abnormalities (relative)g might be able to
with a proficient anesthesiologist
- Coagulation defects (absolute)g RF bleeding
- Anticoagulation therapy (absolute)g RF bleeding
- Infection (absolute)g if infection of skin where
needle needs to go, won’t do epidural because
don’t
want to introduce bacteria into epidural space
NOTE: some will still do an epidural with a
systemic
infection though
- Obesity (relative) g only reason you wouldn’t is if
you cant find epidural space
II. Second Stage of Laborg expulsion of the fetus, pushing (30 mins to 3 hours)
- Direct pushingg older method
• Instructed by the caregiverg Valsalva maneuver for 10 seconds, breathe, 10 seconds again
• Problem is that not breathing during pushg decreases oxygen delivery to fetus and increases risk to perineum
- Spontaneous pushing (laboring down) g preferred method to use
• Patient centeredg doesn’t push until she feels a strong urge to do so
• Better outcomes for mother and baby
- Nursing Care for 2nd Stage
• Allow rest prior to the onset of pushing
• Allow woman to push as needed and not “directed”
• Encouragement, watch the baby descendg after pushing for 2-3 hours it can be very discouragingg you can give
her a mirror to look and show the baby getting lower and lowerg seeing more and more of baby’s head can be
encouraging and make her feel accomplished
• Push 6-7 times with each contraction, not one long push
• Alert for complications
• Get the provider there in time
• Preparing the bed and set up instruments
• Immediate care of the newborng dry baby and head, put blanket on baby, allow mother skin-to-skin
- Second Stage: Needing Extra Room
Student Nurse Guides
Sometimes massaging around the perineum as mother is pushing can help make more room
If still need more room can do an episiotomyg anesthetic to the pudendal nerve on both sides and use scissors to
cut diagonallyg allows the skin to give moreg once baby is born it is stitched back up
• Lacerations to perineum are described by depth
! 1st degreeg through skin
! 2nd degreeg through muscle
! 3rd degreeg through the anal sphincter muscle
! 4th degreeg through the anterior rectal wall
Pudendal Nerve Block
Episiotomy
- Administration of Oxytocin Post Delivery
• Oxytocing usually given between delivery of the anterior shoulder and the placenta
• h uterine contraction to help i the risk of PPHg contractions cause uterine wall blood vessels to contract and
decrease bleeding
• Oxytocin dosingg 10 units IM or 20-40 units in 1 liter of NS or LR
•
•
III. Nursing Care 3rd Stageg Delivery of the Placenta
- Unhurried, uninterrupted bonding of mother and baby
- Assessments during and after delivery of placenta
• Delivery of placenta takes a few minutes up to 30 ming once you get to 30 min need to manually remove it
• Gush of dark red blood once placenta separates
• Umbilical cord lengtheningg happens because once placenta detaches cord will be getting closer to you
• Firm fundusg if not firm, then you need to massage it
• Examination of the placenta and membranes a 2nd timeg make sure it all came out intactg if
some is left behind
it poses a risk for PPHg if placenta stays adhered to uterine lining it acts as a foreign body and
can cause infectiong can also cause uterus to not contract as well
- Assess the Perineum and Fundus
• With a firm fundus
! Bright, red, continuously trickling blood is NOT normalg indicates internal laceration
- Normal bleeding postpartum is intermittent like with a period
• If the fundus is “boggy”
! Bright red flowing blood is not normal
! Dark blood and clots are not normal
IV. Fourth Stageg restoration stage (right after delivery for 1-4 hours)
- Initial attachment to the newborng bondingg mother is usually excited and awake
- Critical to watch for postpartum hemorrhage, bladder distentiong tell mother “if you feel like you’re wet you need to tell
me so I can check your bleeding”
- Nurse needs to check fundus during first few hours to make sure it remains firm
Student Nurse Guides
Labor Summary
Fist Stage
Second Stage
Third Stage
Fourth Stage
Effacement and dilation of
cervix
(onset of labor until
completely dilated)
Three stages - latent, active,
and transition
Expulsion of fetus
(30 min to 3 hrs)
Separation of placenta
(takes a few min- 30 min)
Physical recovery
(right after delivery for 1-4
hours)
Pushing stage
Expulsion of placenta
1-4 hr after expulsion of
placenta
Mother is talkative and eager
in latent phase,
becoming tired, restless,
anxious as labor intensifies
and contractions become
stronger
Mother has intense
concentration on pushing
with contractions; may fall
asleep between contractions
Mother is relieved after birth
of newborn; mother is
usually very tired
Mother is tired, but is eager
to become acquainted with
her newborn
Fetal Positions
Vertex Positions
Face Positions
Breech Positions
Other
ROA (right occipitoanterior)
RMA (right mentoanterior)
LSA (left sacroanterior)
Brow
LOA (left occipitoanterior)
LMA (left mentoanterior)
LSP (left sacroposterior)
Shoulder
ROP (right occipitoposterior)
RMP (right mentoposterior)
LOP (left occipitoposterior)
ROT (right occipitotransverse)
LOT (left occipitotransverse)
Fetal Heart Monitoring Changes- VEAL CHOP TO A STOP
Fetal Heart Observation
Related To
g
g
Intervention
V
Variable decelerations
C
Cord compression
T
E
Early decelerations
H
Head compression
O
Turn patient on side to relieve
pressure on cord
OK-no intervention needed
A
Accelerations
O
Okay! (normal)
A
Acceptable- no intervention
L
Late decelerations
P
Placental insufficiency
S
T
O
P
Stop Pitocin
Turn pt. on side
O2 via facemask
↑ Plain IV fluid
Contraction & Fetal Heart Rate Monitoring
Evaluating Initial Labor Strip:
- Contractions
• Frequency, duration, intensity
Upper pane is
- Fetal Heart Rate
FHR tracing
• What is the baseline FHR?
r Normalg 110 –160 bpm
r Bradycardia (< 110 for 10+ min)
r Tachycardia (> 160 for 10+ min)
Lower pane
shows uterine
• Are there periodic changes?
activity
• Accelerations or decelerations?
• Is this a reassuring strip?
r Reassuring– good, healthy fetal response
r Non- reassuring – not okay, needs intervention and notify MD
Contractions:
-
Involuntary, rhythmic, and intermittent contractions of uterus cause effacement and dilation
Caused by release of oxytocin
Blood flow to uterus and placenta is temporarily paused during each contraction
Period of relaxation between them to allow uterine muscles to rest and to restore blood flow to uterus and placenta
Each contraction has a build up, peak, and relaxation period
•
•
•
Frequencyg how often the contractions occurg measured from beginning of one contraction to the beginning of
the next one (in minutes)
r If contractions are too frequent, the relaxation
period i and the lack of blood flow can cause
baby to become hypoxic
Durationg how long a contraction lastsgmeasured
from beginning of one contraction to end of same one
(in seconds)
Intensityg strength of contraction
r Can feel top of fundus during contraction;
fundus during a mild one feels like if you press the tip of your nose
Contraction Types:
- Dystociag abnormal or difficult laborg progress of labor deviates from normal
• Normal— contractions are 4-6 min. apart lasting 30-60 sec.
• Hypertonic (aka Tachysystole)— means ³ 5 contractions in 10 mingno relaxation or
Normal
rest interval between contractions
• Hypotonic— £ 3 contractions in 10 ming usually happens during dilation part of
labor, around 4 cm
Hypertonic
r Possible Causes: overstretching of the uterus (possibly from a macrosomnia
baby, or multiple fetuses in uterus)
r lack of contractions puts woman at risk for PPH (no contractions to stop the
Hypotonic
bleeding)
Practice: Counting Contractions
- Frequency = From the beginning of one contraction to the beginning of the next one in minutes
• # of seconds from beginning of one contraction to beginning of next ÷ 60
10s 10s
These black lines are
start of contraction
These boxes between the
thicker red lines each
represent 10 seconds
- Duration = from the start of one contraction to the end of that
contraction in seconds (denoted as the black lines)
- Rest interval = from the end of one contraction to the start of the
next contraction in seconds (denoted as the black lines)
The Fetal Heart Rate:
- Fetal Heartg forms at 8 weeks g FHR (FHT) can be heard via doppler at 12 weeks
- Purpose of Assessing the FHRg determine fetal well being
• Baseline FHRg measured in a 10-minute periodg so any change in a baseline would have to be for at least 10 min
r Normalg 110 –160 bpm
r Bradycardia (< 110 for 10+ min)
- Possible Causes: hypoglycemia in mother, medications (i.e. after epidural), or drop in mother BP
r Tachycardia (> 160 for 10+ min)
- Usually due to infection (of mother or fetus)
• Both Bradycardia and Tachycardia can be very serious if FHR variability and late FHR decelerations are present
The
FHR
Normal fetal heart rate
•
Fetal Tachycardia
For the fetal tachycardia example, need to see where FHR comes down to a baseline the most
r Do interventions as needed
Variability:
- FHR Variabilityg beat to beat changes in fetal heart rate
- FHR Variability is NOT the same as Variable Decelerations!!!(will talk about later)
•
Moderate variabilityg good thing, indicates
baby doing well
•
Minimal variabilityg concerning, change in baby
status from moderate g could be simply baby
went to sleep, so just need to monitor it
Periodic Changes:
- Accelerations (Increased FHR)g increases in FHR by 15 bpm+ for 15 seconds (15 x 15) rule
• This is goodg denotes healthy fetus
• Accelerations often due to fetal movement
r Example: Reactive NST (15x15 in 20 min)
- Decelerations
• Both Early and Late decelerations are shaped like a “U”
r Early decelerationsg occur with start of contractiong
deceleration begins at the start of the contraction
and returns to baseline at the end of the contraction
r Late decelerationsg deceleration occurs after the
start of the contraction, caused by fall in O2 to the
fetusg Late decelerations are MOST concerning! ***
Late = Lethal (potentially)
•
Variable decelerations are shaped like a “V”
r Variable decelerationsg abrupt decreasesg have a
“variable” onset which means they occur at any point
before, during or after a contractiong go down quickly
and come back up quickly
- Fetal Heart Monitoring Changes- VEAL CHOP TO A STOP
Fetal Heart Observation
Related To
g
g
Intervention
V
Variable decelerations
C
Cord compression
T
E
Early decelerations
H
Head compression
O
Turn patient on side to relieve
pressure on cord
OK-no intervention needed
A
Accelerations
O
Okay! (normal)
A
Acceptable- no intervention
L
Late decelerations
P
Placental insufficiency
S
T
O
P
Stop Pitocin
Turn pt. on side
O2 via facemask 8-10 L
↑ Plain IV fluid
Can also refer to it as VEAL CHOP TOAST (ST being the first letters of STOP and corresponding to the L and P in
the mnemonic)
Examples of FHR Variability
Normal
Hypertonic
Hypotonic
Assessing Fetal Well-being with FHR:
- Non-Stress Test (NST) g Indirect measure of utero-placental functiong measures fetal heart rate while baby is at rest
and while baby is moving g looking for fetal heart rate acceleration
• Done twice weekly for high risk pregnanciesg done for 20-40 minutes
r Reactive g if the fetus accelerates its heart rate for 15 bpm above the baseline for 15 seconds (15 x 15) in
a 20-minute periodg indicates good interplay between uterus and placenta/fetus getting what it needs
r Non-reactive if the fetus does not meet this criteria
- non-reactive NST correlates with fetal distress in labor, fetal mortality and intrauterine growth
restriction (IUGR) (when fetus not growing as it should be)
- NNN- Non reactive Non-stress test is Not good
- Biophysical Profile (BPP) g real time ultrasoundg done when NST is non-reactive (watch 4 fetal characteristics) or when
pregnancy is high risk (watch 4 fetal characteristics + do the NST)g each characteristic is rated from 0-2
• Not always done at the same time as non stress test (NST); if it IS done at same time, a reactive NST would be
measured as a 2
Scoring:
r Movement (2)
- 8/10 or 10/10 normal
r Tone (2)
- 6/10 is equivocal
r Breathing (2)
- 4/10 abnormal and immediate delivery
r Amniotic fluid volume assessment (2)
usually indicated
r NST (reactive would give score of 2)
Mnemonic of 4 characterstics:
The g Tone
Baby g Breathing
Always gAmniotic fluid
Moves g Movement
How We Monitor FHR
•
•
Internal vs External
r External g noninvasive
- Monitor placed on mother’s abdomen over the fetal back
r Internal g invasive
- Requires rupture of membranes and mother to be dilated 2-3 cm
- Electrode is placed under the fetal scalp g used in high risk pregnancies or if fetal
heart tracings are abnormalg electrode screws into the baby’s scalp g if mother
has any type of uterine infection or HSV it can enter the baby through the hole
Continuous vs Intermittent
r Intermittent monitoringg uses a specialized doppler, stethoscope, fetoscope, or by
putting the mother on the monitor
- Allow freedom of movement for the womang she is not hooked up to monitor the whole timeg she can
walk around etc.g bring her back every 30-60 min to check the heart tones.
- May miss concerning FHR
r Continuous monitoring
- Restricts movement to a bed or a chair
- Identifies concerning changes in FHR
Nursing Management of Labor & Birth at Risk
- Nurse’s Role in Promoting Labor Progress
• Evaluate regularly
r Contractions, fetal heart rate, fetal descent
r Cervical dilationg 1 cm/hour in active labor is desired
r Intake and Outputg full bladder can impede laborg the use of oxytocin to augment labor can lead to
fluid intoxication
• Provide support
r Relaxation and stress reductiong blankets, back rubs, low light, music she likes, clustering care to
provide privacy, warm shower if not contraindicated, repositioned q 30 min, extra pillows for support,
offer her something to eat or drink if permissible
• Promote empowerment
r Allow expression of fears and concerns
r Provide encouragement
- Problems with the Powersg Contractions
• Preterm laborg contractions start too early (preterm is < 37 weeks)
• Prolonged pregnancyg contractions won’t start (full term is 38 – 42 weeks)
- Preterm Labor (PTL)g < 37 weeks
• Pretermg prior to the start of the 37th week of gestation (so up to 36 weeks and 6 days aka 36/6)
r Regular contractions with dilation and effacement
• Common Symptoms:
r Uterine contractions, cramping or low back pain, pelvic pressure or “fullness”, h in vaginal discharge over
normal, N/V/D, unusual leaking fluid from vagina (could be amniotic fluid)
- PTL Risk Factors
Maternal age
< 18 or ³ 35 y/o
African American
Low socioeconomic statusg
less access to prenatal care,
Alcohool, drugs, smoking
Hx of preterm labor or birth
Diabetes and/or chronic HTN
Pregnancy with multiples
PROM and late/no prenatal
care
- Is it Really Preterm Labor?
• How do the contractions feel to her?
• Do these things help to stop or decrease contractions? g resting on side, emptying bladder, increasing h fluids
r If they do, and contractions go away, it is probably not real pre-term labor
r Need to contact HCP either way
- Management of PTL
• Tocolytic therapyg medication to stop the contractions
r Magnesium Sulfateg relaxes uterine muscle to stop and prevent contractions
r Terabutalineg don’t give before 20 weeks, monitor FHR (don’t need to know this one)
• Corticosteroids
r betamethasoneg helps mature the fetus’ lungs
• Home monitoringg if stable and patient can be relied on to get back to hospital if needed
• Diagnostic testing
r Fetal fibronecting produced by the fetus and found in the cervixgif test is positive (+) it means that the
woman will probably rupture her membranes in the next two weeks
Medication
Tocolytic Therapy
Reason patient Receiving
(** = also a sign of pre-eclampsia)
Nursing Considerations
Adverse Effects
Magnesium
Sulfate
(MgSO4)
• For preterm laborg relaxes
uterine muscle to stop and
prevent contractions
• Loading does, then 1-4
gm/hour
• continuous monitoring of
fetal heart tones
• For preeclampsiag i cerebral
excitability and thus i risk of
seizures in women with
preeclampsia
Corticosteroid
betamethasone
• Calcium gluconate is
reversal agent
Promotes fetal lung maturity by
h surfactant
• 2 doses IM 24 hours apart
• May repeat in 7 days if has
not delivered
• Improvement in lung
maturity can be seen after
24 hours
Monitor and Report:
• Hypotension and/or
depressed DTRs
• LOC, blurred vision, HA **
• U/O < 30 mL/hour **
• RR < 12 breaths per minute
• monitor mother for
infection
- Prolonged Pregnancyg past the end of the 42nd week
• Can go past due date as long as NSTs are okay and US shows adequate amniotic fluid
• The longer a pregnancy goes past due date, though, the likelihood of fetal complications h
• Risks caused by being “post term”:
r Placental insufficiencyg r/t the aging placentag placenta becomes less functional in gas exchangeg may
also start to decrease in size
r Fetal macrosomiag means large babyg babies grow ½ lb per week in the last 4 weeks and continue that
growthg if past 42 weeks, risk for having a large baby increases and may be hard to deliver
- Shoulder dystociag r/t fetal macrosomiag anterior shoulder is not able to be delivered g can lead
to Brachial plexus injuries
- Brachial plexus injuries
r Cephalopelvic disproportion (CPD)g head is larger than the amount of room in the pelvis
•
Prolonged Pregnancy Management
r Non-stress tests (NST) twice a week
r Daily fetal movement countsg baby moves more if getting adequate blood supply from placenta
- at least 10 in 2 hoursg if < 10 in 2 hrs she needs to be seen by HCP to make sure baby not in distress
- Best position to do thisg laying on her left side after having eaten a meal
r Possible cervical ripening and induction of labor
r Biophysical Profileg performed if NST is abnormal or nonreactive
- Score of 6g need retesting in 12-24 hrs
- Score of £ 4g want to deliver baby soon
S. no.
1.
2.
3.
4.
Parameters
Non stress test (NST)
Fetal breathing movement
Gross body movement
Fetal muscle tone
5.
Amniotic fluid
Minimal normal criteria
Reactive pattern
1 episode lasting > 30 s
3 discrete body/limb movements
1 episode of extension (limb or trunk) with
return of flexion
1 pocket measuring 2 cm in
- Contra-indications for Induction of Labor
- any type of abruption
- previous C-section
- transverse lie
- prolapsed cord
- genital herpes of mother
Score
2
2
2
2
2
- Indications for Induction of Labor
- Being post term
- Uncontrolled or worsening
gestational HTN
- Gestational diabetes
- PROM or PPROM
- Uterine infection
- Maternal or fetal medical
conditions
- Placental insufficiency
- Non-reassuring non-stress
test
- Induction of Labor
• Cervical ripening based on Bishop score
r £ to a 6 g means cervical ripening agents should be used
r ³ to an 8g can skip cervical ripening and the woman would have a successful vaginal delivery
r Lower the score, Longer the Labor
r Higher the score, shorter the labor and less need for induction
POINTS
CERVICAL EXAM
Dilation (cm)
Effacement (%)
Station
Consistency
Position
•
•
•
0
Closed
0 – 30%
-3
Firm
Posterior
1
1-2 cm
40-50%
-2
Medium
Mid
2
3
SUBSCORE
3-4 cm
5-6 cm
60-70%
80%
-1. 0
+1, +2
Soft
Anterior
BISHOPS SCORE =
Stability
Possible amniotomyg artificially rupturing the membrane encasing the amniotic fluid
Oxytocin and misoprostol
r Nursing responsibilitiesg contraction and fetal heart rate monitoring
- misoprostol g prostaglandin used to “ripen” cervix to help begin contractionsg aka makes cervix soften
• Inserted into cervix every 6 hoursg bring her in night before induction and do this throughout the night
• Monitor FHR and contraction pattern closely
• May cause hypertonicity of uterus or FHR changes
r Hypertonicityg meaning too many contractions in a row too close together or one contraction that doesn't
go awayg leads to FHR changes
• Induction cannot be done for 4 hours after last doseg can’t give the oxytocin any sooner or RF hypertonicity
- oxytocing uterotonic agent used for induction or augmentation of labor
• Intravenously, on medication pump per protocol
• Baseline and ongoing vital signs and FHR assessments
• Contraction pattern may become hypertonicg causing decreased FHR variability
• Rapid dilation of cervix may occurg leading to precipitous delivery, cervical laceration
or rupture of uterus
- Oxytocin for Induction of Labor
• 10 units oxytocin (Pitocin) in 1000 mL Lactated Ringers
• IVPBg Infusion pump piggybacked into main IV line
• Start at 1-2 mU/hour
• Assess contraction and fetal heart rate patterns:
r q. 15 minutes in first stage (think Gucci Mane song 15 and the First)
r q. 5 minutes in second stage
• Monitor I/O and voiding, vital signs and pain
• Provide emotional support
Uterotonic— the term for a
drug used to induce labor or
augment labor
Induction—starting from
scratch with no contractions
Augmentation— means she's
had contractions, just need
to help her to have stronger
or more frequent
contractions
- Oxytocin for Augmentation of Labor
• Same oxytocin, dosing, administration, nursing management, and complications as for induction of laborg simply
called “augmentation” and not “induction”
- Dystociag abnormal or difficult laborg termed “Failure to Progress” of dilation or descent of the head
• Progress of labor deviates from normal
r Characterized by slow, abnormal progression of labor
r Primary reason for a first cesarean section ***
r Becomes apparent during “active phase of labor” (4 cm) (second stage)
•
Contraction Types
r Normalg 4-6 min. apart lasting 30-60 sec.
r Hypertonicg no relaxation between contractionsg Tachysystole is part of
hypertonic uterusg means ³ 5 contractions in 10 min OR one contraction
lasting 2 minutes or more
r Hypotonicg £ 3 contractions in 10 ming may have very little paing lack of
contractions puts woman at risk for PPH (because no contractions to
stop the bleeding)
- Dystocia: Hypertonic Contractions & Tachysystole
• Risks associated with hypertonicity
- Precipitous birthg Labor and delivery in < 3 hours
- Fetal hypoxiag no break between contractions means
blood supply to placenta is cut offg leads to hypoxia
•
Normal
Hypertonic
Hypotonic
- Trauma to the woman and/or fetusg i.e. cervical
lacerationsg also an h risk for fetal intracranial
bleeding (from skull compression by contractions)
- Uterine Rupture
Interventions
-
D/C oxytocin
-
Left lateral position g
helps h blood supply
-
Oxygen
-
Increase plain IV fluidsg IV
rate h to as fast as possible
-
Closely monitor FHR
-
Contact provider
- Dystocia: Abnormalities in Length of Labor
• Arrested dilationg when woman stops dilating
r Usually caused by fetal head not engaging in the pelvis (so still in the minus part, not at zero yet)
r Characterized by lack of dilation for 2 or more hours
• Arrested descent of the head
r Fetal head doesn’t make any descent in station for 1 or more hours
• Protracted disordersg means rate of L&D is drawn-out
r Slower than normal rate of labor and delivery
r Lasts more than 18-24 hours
• Precipitous
r Starts and ends in 3 or less hours
- Problems with the Passenger
• Positiong breech or transverseg need C-section
• Presentationg posterior presentation (i.e. occiput posterior) may lead to dystocia
r occiput anterior is best chance for normal progress of labor
r shoulder presentation can lead to shoulder dystocia
•
•
Numberg more babies stretch out uterus/makes it over-distendedg most common postpartum complication
associated is hemorrhage
Sizeg macrosomia babies can cause shoulder dystocia
•
Shoulder Dystociag anterior shoulder can't get past symphysis pubis
r Head slowly emerges but then retracts back into vagina as you try to pull baby out
(this is called the “turtle sign”) trying to pull on the baby's head
r Diagnosed when the shoulder fails to deliver shortly after the head, which
normally should happen smoothly
•
Brachial Plexus Injury
r Caused by excessive lateral traction on the head away from the shoulder
r Results in varying degrees of injury to the nervesg usually not permanent and can
heal, but sometimes can lead to total loss of fxn of affected nerves
r Can occur during a delivery involving shoulder dystocia and macrosomia
r Signs/Symptoms of it:
- Affected arm hangs limp alongside the body
- Affected shoulder and arm are adducted, extended, and internally rotated
with a pronated wrist
- Moro reflex absent on affected side
- Weak or absent grasp reflex on affected side
•
McRobert’s Maneuverg procedure done in instances of shoulder dystocia
r Pull mother’s legs back toward her abdomeng forces the pelvis to move
backward and more horizontally so the shoulder can get past
r This is an emergency situation!!
r Can’t push the baby's head back into the uterus and do a C-section at this point
so McRobert’s maneuver is how we try to get baby out
•
Suprapubic pressureg used along with McRobert’s maneuver
r Trying to force shoulder to come out by applying pressure
r How to do itg use hands to put pressure on the external super pubic area
r Possible that you would have to break infant’s shoulder to get baby out
- Problems with Passageway (see previous intrapartum lecture)
• Gynecoid is best pelvic shape for vaginal delivery
• Placenta previag do C-sectiong see previous lecture
- Problems with the Psyche
• Psychiatric illnessesg may not have been previously disclosed by patientg psychiatric illness, even depression, can
lead to an h release of stress related hormones
• Increased release of stress related hormones:
r Reduce uterine contractility
r Reduce utero-placental perfusion
- Obstetric Emergencies (A PUP)
• Prolapsed umbilical cord
• Uterine rupture
• Placental abruption
• Amniotic fluid embolism
- Prolapsed Umbilical Cord (Emergency)
• Cord protrudes along or ahead of the presenting part of the fetus
• Total or partial occlusion of the cordg leads to rapid deterioration of fetal perfusion
due to cord compression
•
•
•
Risks for Prolapsed Cord
- Malpresentation
- Growth restriction
- Prematurity
- Hydramnios
- Grandmultiparity
(uterus is more lax; doesn’t
contract as well anymore)
- Multifetal gestation
- Ruptured membranes at
high station
If it happens:
r Put her in Trendelenburg to alleviate pressure on the cord and minimize reduction in blood flow
- If on bed restg flip mother over into knee-chest position
r Monitor fetal heart tones and apply oxygen if needed/ordered
r If you find the cordg nurse puts gloved hand into vagina and pushes up on
presenting part to keep it off the cordg not enough to just hold the cord, need to
physically push up on presenting part
r Prepare for emergency cesarean sectiong nurse gets on the bed to ride to OR
with hand in vaginag nurse may have to stay like that until C-section has started
and baby is out
What Can be Done to Avoid This?
r Verify station prior to artificial rupture of membranes
r Check fetal heart tones during artificial rupture, and after
- Abruptio Placentae (Emergency)
• Premature separation from a normally implanted placenta after 20 weeks
• Caused by forcing blood into the under layer of the placenta causing detachment
• Focus is on:
r The cardiovascular status of the mother (watch BP)
r Delivery of the fetus quickly by C/S if alive
- will deliver vaginally if the fetus is not alive
• Abruptio Placentae Risk Factors
- Any hypertensive problems - Trauma
- Coagulation defects
- Seizures
- Previous hx of abruption
- Smoking
- Uterine rupture
- Placental pathology
- Cocaine use
- Uterine Rupture (Emergency)
• Tearing of uterus at site of previous C/S scarg most often occurs at site of a classical incision (up and down) from
previous emergency C section
• First and most reliable sign is sudden fetal distress
• Acute, continuous abdominal pain with or without epidural
• Irregular abdominal contourg in labor fundus is up high, kind of like upside down pear. If rupture occurs on left side,
that side would be distorted
• Loss of the station of the presenting part of the fetus
• Hypovolemic shock of the fetus or motherg d/t blood loss
- Amniotic Fluid Embolism (Emergency)
• Break in barrier between maternal circulation and amniotic fluidg from a placental abruption or uterine trauma
• Significant maternal and newborn morbidity and mortalityg Rare and often fatal
• Sudden onset hypotension, hypoxia and coagulopathy (similar to a DVT causing a PE)
r Hypotensiong low BP
r Hypoxiag confusion, restless, SOB, agitation (RAT)
•
r Coagulopathyg blood not clotting properly
Suspect in any woman with sudden dyspnea ***
- Birth Related Procedures
• Amnioinfusion
r Warm, sterile Normal Saline or Lactated Ringer’sg infused into uterus through intrauterine pressure
catheter (IUPC) after membranes are ruptured
- 250mL to 500 mL by infusion pump over 20-30 minutes
- Watch for hypertonic uterus
- Observe for pad under mother for leaking infused liquidg want clear fluid draining
r Indications
- Oligohydramnios
- Thick meconium stained fluidg indicates that baby had a BM in utero (meconium)g want to flush
that outg if the newborn aspirates meconium with its first breath it can develop meconium
aspiration pneumonia
- Severe or prolonged variable decelerationsg caused by cord
compression
r Contraindications
- Amnionitis
- Hydramnios
- Uterine hypertonia
- Known uterine anomaly
- Placental abruption or placenta previa
- Assisted Delivery Devices
• Forcepsg performed by HCP
• Vacuum extraction
r Provider performed, not nursing
r Woman pushes while provider pulls suction attached to scalp
r Can be done a certain number of times if suction cap comes off
r Once maximum has been reached, must use alternate device or do C-section
r Nurse’s responsibility to track number of unsuccessful tries
- Vaginal Birth after Cesarean (VBAC)
• Risks for laboring after previous C/S
r Uterine rupture
r Hemorrhage
• Contraindications
r Previous classical uterine incision
r Myomectomyg removal of uterine fibroids can cause scar tissueg not able to stop bleeding after a C/S
r Previous uterine rupture
- C- Section Incisions
• High vertical incision (classical incision) g done in an emergency situationg
contraindicated for future VBAC deliveries
• Low transverseg done when it's scheduled and they have timeg it takes
more time to dissect through the layers in the transverse incisiong can
attempt to deliver vaginally
• Low vertical incisiongwhether or not VBAC should be tried afterwards is still
undecided
Postpartum Care
- Uterine Involution
• Involution: Uterus, cervix and vagina return to pre-pregnant sizeg Takes up to 6 weeks
! Uterus decreases in size 1cm (1 fingerbreadth) a dayg uterus size decrease by 1cm/day
! Fundus not palpable after ≈ 10 days after delivery
• Complications in labor, delivery or in the post partum period can delay involution; if not
decreasing by 1 cm/day, there is a problem that needs to be addressed
•
After-pains: contractions after postpartumg happen when breast feeding since
oxytocin is released during breast feeding; women with after pains can decrease them by
walking and they will go away eventually
- Lochiag postpartum bleeding that women have
• Rubrag lasts about 3 days (1-3 days postpartum)g bright red blood d/t removal of
placenta and vessels on the uterusg resembles a heavy period; 8-9 oz
• Serosag lasts about 1 week with decreased flowg thin and watery
• Albag lasts about 3 weeksg yellowy- creamish looking color with minimal flow
•
If any one of these stages reappear, this indicates a post partum complication ***
! So for instance, if woman is 7 days PP and still has rubra lochia, that is a problem
Do NOT want to see excessive bleeding, which is saturation within 15 min - 1 hourg possibly having a PPH
•
Quantified
•
- Scant: < 2” stain
- Light: < 4” stain
- Moderate: < 6” stain
- Large: > 6” stain in 2 hours
- Cardiovascularg recall that blood vol increase by 50% during pregnancy, so now blood volume needs to decrease
• Blood volume and cardiac output i are related to blood loss at deliveryg expulsion of placenta means
more blood returns to the heart and i cardiac output since placenta no longer needs blood flow
! Takes ≈ 4 weeks to return to normal
• Blood plasma further reduced due to diuresis
! Hematocrit stays stable or h due to plasma reduction, this is normalg this is because there is an h in Hbg/RBC
concentration in less plasma
! Acute i in hematocrit is unexpected and a sign of shock
! Pulse i is normal (40-60 bpm)
• Still in a Hypercoagulable state for 2-3 weeks PPg Increased risk for DVTs and PE during this time
- Gastrointestinal System
• No longer pressure on the abdominal organs so woman usually feels better
• Constipationg still a potential problem
! Decreased peristalsis causes decreased bowel tone
! Fear of pain with bowel movementg possibly due to episiotomy or c-section
! Pre-medicate with stool softener
• Increased appetite and thirstg due to energy expenditure from pushing and NPO status during labor
- Urinary System
• May have difficulty voiding:
! Anesthetic blockg inhibits neural functioning of bladder
! oxytocin (Pitocin)g has an antidiuretic effect
! Lacerations or swelling of the perineum
! Hematomas
• Full bladder displaces the uterus
! If we feel deviated fundus we need to empty her bladderg this distention inhibits contraction of the uterus
which can cause a boggy uterus, leading to non-contractions
! Inhibits contraction of uterus causing uterine atony
•
•
Outputg up to 3,000 mL/day is normal
! Diuresis of up to 3,000 mL a day, starts in the first 12 hours
! < 150 mL per void may indicate retention
! If she has not voided in 4-6 hours post delivery she may require catheterization ** (nursing intervention)
Assisting with Elimination
! Privacy, get up as soon as possible
! Pain management
! Increasing fluids
! Stool softener or laxatives, dietary changes
! For difficulty voiding:
- Warm water on the perineum
- Hearing the running tap water
- Musculoskeletal System
• Fatigue and exercise intoleranceg hip and joint pain due to i progesterone and relaxin
• Joints eventually return to pre-pregnant state
! Permanent increase in shoe size ** (patient teaching point)
• Abdominal wall stretchingg loss of muscle tone requiring specific exercises
• Need to exercise to firm muscle tone
- Integumentary System
• Darkened pigment to face, abdomen and nipples fade with i estrogen and progesterone
• Temporary hair loss can occur within 3 months of delivery due to i estrogen levels
•
•
Striae gravidarum (stretch marks) fade but don’t disappear
Diaphoresis can be profuse in early postpartum period in an effort to get rid of the increased body fluids of pregnancy
and return body to a normal fluid-volume state
! Sweating can be enough that a woman is chilledg body’s way to reduce the pre-delivery fluid
! Sometimes will need blankets and sheets changing
- Respiratory System
• Respiratory rate 16-24 breaths per minute
• Diaphragm returns to normal positiong pregnancy experienced SOB and rib pain resolve
• Lung function changes of pregnancy return to normal quickly
- Endocrine System
• Estrogen and progesterone levels drop quickly after delivery of placenta
! Decreased estrogen causes breast engorgement
! Engorgement is painful and is alleviated by breast feeding
- Breastfeeding keeps estrogen levels lowg Is dependent on frequency of breast feeding
• Estrogeng kept low with breastfeeding, and is dependent on frequency of breast feeding
• Progesteroneg levels begin to increase again with menstrual cycle
• Prolacting remains elevated in women who are breastfeeding (returns to normal for those who aren’t)
- Lactation
• Sucking on the breast stimulates hormone release
! Prolactin stimulates milk production **
! Oxytocin causes the let down release of milk **
•
•
First secretions are called colostrumg high in protein and carbohydrates but not milk fat; lasts for a few days
True breast milk begins to come it day 2-3 and comes in fully at 4-5 days
Postpartum Physical Assessment
- Postpartum Assessment
• Begins within an hour of deliveryg frequent vital signs and fundal checks per hospital protocol, usually Q4H
• On the post partum unit:
! Patient history, the pregnancy, labor and delivery events, and interventions
- Long or precipitous labor, large baby, etc; anything that could increase risk for PP complications
• Vital signs
! Temperature as high as 100.4 can be normal in first 24 hours
- Anything > 100.4 would indicate infection
- 100.4 after 24 hrs could indicate she is developing a fever
! Bradycardia (40–60 bpm) can be normal the first week
! B/P can vary with position but should be similar to ranges in labor
Pre-medicate for pain
! If persistent perineal pain despite medication, look for a hematoma (more on this in PP Complications notes)
! Vaginal delivery should only require non-opioid analgesics; even with c-sections we’re seeing more ketorolac IV
instead of opioids used
! Pain meds (ketorolac) should be given 2 hours prior to breast-feeding because it is excreted in breast milk
- FDA doesn’t approve its use in postpartum but AAP says that there is no harm if using the guidelines
- BUBBLE EEP
• B = Breasts (and nipples)
• U = Uterusg fundus needs to be at umbilicus and midline, firm
• B = Bladderg full bladder is not good especially with C- section
• B = Bowels
• L = Lochiag type and amount
• E = Episiotomy (or uterine incision) g need to assess
• E = Extremities (lower) g s/s of DVT
• E = Emotions (bonding)
• P = Pain
•
-
-
Breasts
• Soreness or cracking of nipplesg nurse should ask postpartum (PP) woman if she has soreness or cracking
! No no direct inspection is necessary if she is not having soreness/cracking
! If she reports a problem or pain, examine for cause and intervene.
• Flat or inverted nipples
• History of breast surgery that may interfere with milk production
• Milk production causing increased firmness of breasts
Uterus
• Firmness of fundus (firm, soft, or boggy)
• Fundal height related to umbilicus (+1, +2, at U, -1, -2)
• Fundal location (midline, deviated R or L)
• Fundal massage if fundus is not firm:
•
•
•
-
Non-dominant hand on pubis symphysisg to protect lower
segment of uterus from coming through the cervix
Dominant hand on fundusg make sure it is firm
Rub in circular motion to make it firm if it is not already
-
-
-
Bladder
• Amount of urine
! Women void up to 3 liters (3000ml) per day in the first few days after delivery g this is how they get rid of
extra blood volume from pregnancy **
• Color and odor of urine
Bowels
• Assess bowel soundsg especially if C-section delivery
• Ask about passing flatus or BMg not all mothers will have a BM in hospitalg reason: women are usually NPO during
labor and go home quickly after delivery so they may not have a BM in the hospital ***
• They still should have active bowel sounds and flatus g if they complain of feeling constipated you may give Colace
! or dulcolax suppositoryg these are routine PP orders.
Lochiag normal postpartum discharge seen for 4-8 weeks after giving birth
• Colorg amountg presence of clots
• Teach the mother about the normal progression of lochia
-
Episiotomy (or lacerations; uterine incision)
• Assess for skin approximation
• Assess for signs of infection (color, odor, drainage, warmth)
• Assess perineum for signs of developing hematoma **
! S/S of a Hematoma: if a patient complains of pain at the perineum that is not
in proportion to the size of the episiotomy or laceration, it may be a
hematoma forming (i.e. small laceration but lots of pain)
• Nursing interventions for pain at the perineum from an episiotomy or laceration:
! Ice packs to the perineum
! use of topical sprays (benzocaine, etc..)
! topical ointments (epifoam)
-
Extremities (lower extremity assessment)
• Assess for warmth or redness of calves
• Assess for pain in calves during ambulation or active motion of feet if on bed rest
•
•
Predisposition to DVTg venous stasis, hypercoagulability, localized vascular damage
! Venous stasisg compression of the large veins by gravid uterus slows blood flow back to the heart
- Leads to pooling blood to the feet and legs
- Can lower risk by moving her legs, being active as long as she is able to get up and walk, increasing fluids,
compression stockings
- Need to educate patient about s/s of dvt
! Hypercoagulabilityg simply due to pregnant state
! Localized vascular damageg can occur during the birthing process; damage causes activation of the body’s
clotting mechanism
Subtle Signs of DVTg we won’t know if we don’t examine the patient!
- Warmth, tenderness and/or redness in the
- Lower extremity tightness or aching g relieved
affected calf
by rest
- Edema in the affected leg (usually the left)
•
-
- Low grade fever
Homan’s sign is not recommended by some institutionsg we don’t do the dorsiflex test anymore because it is not
considered a good indicator
Emotions (bonding, attachment)
• Signs indicative that the mother is bonding with baby:
! cuddlingg talking tog talking aboutg interest in caring for, naming baby
• Are her emotions appropriate? or are there signs of baby blues or PP depression?
-
Paing the 5th vital sign
• Location and amount of pain
• Things that increase or decrease pain
•
Providing Comfort:
! Ice packs, numbing spray, sitz baths
! Peri bottle should be used on perineum to cleanse it **
Postpartum Psychosocial Assessment
- Psychological Responses
• Taking-ing talking about the birth and re-living it
! Immediately after birth until about 24-48 hours
! Mother depends on others to help meet her needs and relives the birth process
• Taking-holdg preoccupied with the present; becomes more independent, still needs support and reassurance
! 3 days postpartum and lasts for several weeks
! Mother is more self-sufficient but still needs reassurance
! Preoccupied with the present
• Letting-gog adapting new role and ready to re-establish friendships
! Reestablishes relationships with others
! Adapts to parenthood
! More confident in ability to care for newborn
- Bonding and Attachment
• Bonding is the emotional attraction that starts in the first 30-60 minutes to a few hours after the birth
! Continuation of the relationship that began during the pregnancy
! During this time, infant is quiet and alert and looks at the mother
! Bonding tips for a mother to use:
- Use of touch and skin to skin contact
- Read and sing to babyg baby can recognize moms voice from utero and possibly the fathers if he has
been well involved
- Talk and smile making eye contact
- Rock and hold baby as much as you can
- Feed the baby often and in your arms
- Put baby on your chest to hear your heartbeatg baby finds this comforting and likes hearing the
heartbeat
• Attachment is the strong affection between the infant and mother or significant other
- Emotions and Bonding
• Monitor mother’s interest in the newborn
! Is she feeding and caring for the newborn?
! Is she interested or disinterested?
! Does she want the baby in the nursery all the time?
! Use a standard postpartum screening tool on ALL post-natal women in hospital and 1 week after they go home
! Postpartum depression is the most common complication of pregnancy
• Need to find out what is going on if no interest
- Edinburgh Depression Scaleg mother fills out based on her perception
• Mother should fill it out herself
• Must answer all the questions
• Often done when she has already gone home
•
•
Questions are asked about her feelings for the last 7 days, not just the day she does it
If she has a borderline high score, it should be repeated at the end of the second week
- Emotions and Bonding
• Postpartum Bluesg transient emotional disturbances; does not last long
! Most benign of postpartum psychological problems
! Anxiety, irritability, insomnia, sadness
! Begin at 3-4 days and last up to 2 weeks; usually goes away around 2 weeks
! Typically resolves once mother gets better sleep
! No formal treatment other than reassurance; have someone help around the house if possible
! We need to also look at the partner or father if he has depression as well
- Factors Affecting Attachment
• Background of the parentsg How did pregnancy go for the woman? How did other pregnancies go?
• The infantg is this a difficult infant?
• Care practicesg baby and mom need to be skin-to-skin as SOON as cord is cut!
! If baby is taken right away to do shots and assessments this can affect attachment
! Encourage that mom and baby are in same room
! Also helps to know that mother is doing things correctlyg feeding, swaddling, bathingg best way to know is
return demonstrations (patient teach-back)
• Occurs most readily when parent’s expectations have been metg i.e. temperament, gender, health and appearance
- Cultural Influences
• Extended family expected to care for infant so mother can rest
• Breastfeeding not initiated until milk comes ing in some Asian cultures they consider the initial colostrum to be dirty;
some mothers wait for the real milk to come in; sometimes will not use their own colostrum but have another breastfeeding woman feed the newborn till the true milk comes in
• Food and drink dictated by cultural beliefsg may be giving honey or tea to baby while waiting for true milk to come in
! Honey is a source of botulism so you should NOT do this
• Other
! Modesty, hygieneg some women do not want to be seen during delivery or without clothes; some want only
female care providers/no males involved
! Emotional supportg some cultures don’t show as much emotional support as others
! Paternal presence at deliveryg some cultures don’t believe in paternal presence during delivery
! Sometimes feel that it’s too expensive to eat well enough to support good breast milk so they don’t breastfeed
- Newborn Feeding
• Support a woman’s infant feeding method
! What kinds of things influence her choice? (family, partner, comfort with her body (maybe only in private), etc.)
! Contraindications to breastfeeding
- Absolute contraindicationsg HIV; if infant has metabolic disorder called galactosemia; use of street
drugs (except methadone); some medications
- NOTE: if mother is in treatment for opioid addiction the newborn would get some methadone into the
system but doesn’t not harm them; the baby could be born addicted and need to be weaned itself
- Relative contradictionsg some medications; can go around this by timing
• Health People 2020g increase the number of mothers who breastfeed (ever, longer, and exclusively)
! We want to encourage breast feeding exclusively
! But if they choose not to, that is okay, we just want healthy baby
- Promoting Breastfeeding
• Initiate within 30-60 minutes of birth
• Exclusively breast feed on demandg at least every 2-3 hours
• Lactation consultant may be helpful with finding comfortable breastfeeding positions, help latching on, etc.
•
•
•
•
Encourage “rooming in”
h maternal caloric intake by 500 kcal/day and h fluid intake to 2 quarts/dayg mother actually needs more calories
when breastfeeding than she did during pregnancy itself
If infant is up and crying assume that they are hungryg need to make sure infant fully awake though before feeding
! Cannot let newborn sleep for longer than 3 hours in a row because they need the calories
Refrain from using lotions or soap on breasts except lanolin cream
! lotions and soaps on breast can dry them and cause itching
! Lanolin creamg does not need to be washed off and not harmful to baby; other lotions need to be washed off
and usually contain alcohol
- Breastfeeding Positions
• Breast feed in different positions to find one that is most comfortable and works best for mother and baby
- Breast Care
• Wear well fitting, supportive bra 24 hours/dayg bra should not be too tight (can i milk expression)
! Should wear bra that she can take down from the top to feed
! Should be soft on the top to accept the expanding breast size between feedings
•
•
•
•
Ice packs can be applied to sore breasts
In showerg should not be standing with breasts to waterg stand with back to water in shower
! Rationale: heat stimulates milk production
Air dry breasts after feedingg apply lanolin cream once dry
If bottle feedingg takes 1 week to 10 days for bottle feeding mother to feel more comfortable/stop milk stimulation
! No stimulation or heat applied to breastsg causes breasts to express milk
- Stand with back to water while showering
- Do not pump to try to get excess milk out; this just increases and encourages supply and demand, so it
will take longer for her to have her milk dry up and stop being stimulated
! Ice to breasts
! Cabbage leaves may help dry milk
- Discharge Education
• Family planningg when she can get pregnant, period and ovulation return at different rates
! Often period does not return right away, but ovulation does so she CAN become pregnant
! Breastfeedingg can take 3-18 months for those things to return
! Bottle feedingg can take up to 3 months
• No real rule about sex; most say wait 4-6 weeks until they’ve seen the obstetrician for that visit
•
•
•
•
•
•
•
Most postpartum complications will occur within 2 weeks
Vaccinations need to be discussedg Tdap should be made available to everyone around newborn by PCP; newborn
should be home; Can be in stroller but not out in public places because of the risk of infection
Live vaccinations can be given now that she is postpartum
Importance of taking breaks/taking care of herself g accept help from others
Postpartum depression is realg many people have it
Risk for DVT due to hypercoagulability;
Educate about when to return to HCP for check up, red flags to look out for, etc.
Postpartum Complications
- High Risk Postpartum Conditions: 4 Most Common
• Postpartum Hemorrhage
• Thromboembolic Conditions
• Postpartum Infection
• Postpartum Affective Disorders
- Postpartum Hemorrhage (PPH)g any loss of blood postpartum that puts her hemodynamic state at jeopardy (BP, HR, etc)
• Leading COD in postpartum and also the most preventable
• HCP may underestimate blood loss
• Symptoms are not apparent until a lot of loss has occurredg affects vital signs
! S/S of shock: tachycardia, hypotension
! Confusion will not been seen until a significant amount of blood loss (≈ 2000 mL)
! Hypovolemic shock is a LATE symptom of hemorrhage after delivery **
•
•
•
•
•
•
Usually happen within 4 hours of birth
Usually a consequence of 3rd stage of labor and the management (when the woman has delivered baby and the
placenta is delivering)
Loss of bloodg How much is too much:
! > 500 mL after vaginal birth
! >1000 mL after cesarean birth
! Major obstetric hemorrhage: > 1,500-2,000 mL blood loss and/or need for more than 5 units of blood
Early PPHg within 24 hours after birth
! Most common causeg uterine atony aka poor uterine tone
! Lacerations from trauma
! Hematoma
Late PPHg 24 hours to 12 weeks after birth
! Subinvolution of the uterus
! Clotting disordersg may show up later due to hypercoagulable state
Risk Factors for PPH
Labor
- Prolonged— lax
uterus
- Precipitous— can
cause trauma to
vaginal area or cervix
- Use of oxytocin can
also be a risk factor
Fetus
- multiple gestation
- large fetal head
- large baby > 4000g
- woman who has
had many babies
(grand multipara)
Uterus
- infection
- manual placenta
extraction
-hydramnios
(d/t overdistention
during pregnancy)
Maternal
- preeclampsia
- coagulopathies
Delivery
- vacuum extraction
- forceps extraction
- 5+ pregnancies
- Previous PPH
- If she has > 40 BMI
- Known coagulopathy
- Prior uterine surgery
- Baby more than 4,000g
- Low platelet count
- Infection
- Pushing for a long time
- Acreta
- Use of oxytocin for 24+
hrs during labor
- Poor progression of
labor
- Specific Causes of PPH
1. Toneg abnormal uterine muscle tone
2. Tissueg placental tissue
3. Traumag physical injury
4. Thrombing coagulation issues
5. Tractiong excessive pulling on umbilical cord during delivery
- Toneg abnormal uterine muscle tone
•
•
Risk Factors:
-
Overdistention of uterus*
-
Bacterial toxins
-
Use of magnesium sulfate
-
Distended bladder*
-
Use of anesthesia
-
Prolonged, rapid or forceful
labor
Uterine Atonyg failure of the uterus to contract
! Role of uterus: to remain contracted to prevent bleeding from placenta site of detachment
- Contractions temporarily cut off blood supply to uterus by constricting blood vessels to stop blood flow; so
anything that causes the uterus to relax will cause bleedingg (this is why we give oxytocin after vaginal
delivery, especially a shoulder-presentation delivery)
- If the placenta releases while the uterus is not contracting, bleeding will occur and we need to give a med to
stop it (such as oxytocin)
! Most common causes:
- Distended uterus in pregnancy
- Distended bladder postpartum
! Treatment
- Fundal massage
- Fluid bolus and increased IVFsg lactated ringers (LRs)
- Administer uterine stimulant medication
! Nursing Care
- Immediate fundal massage if uterus is not firm, midline and at
umbilicus
" Rationale: a soft, boggy uterus that deviates from the midline
suggests that a full bladder is interfering with uterine involution.
If the uterus is not in correct position (midline), it will not be able
to contract to control bleeding.
- Have to take sheets, chucks, everything and weigh them to measure
blood loss
- Have to look under the patientg check lochia saturation and what kind of clots there are (if any)
- Watch I&O and H/Hg transfusion may be necessary
- Monitoring VS is essential (but not most reliable here)
•
Uterine Stimulant Medications
Medication
oxytocin (Pitocin)
**
Dosage
- 20-40 units/L IV
infusion or
- 10 units IM (for
lesser bleeds)
Nursing Considerations
- Give as a bolus IVBP to a Lactated Ringer
as soon as shoulder is delivered (usually
over 4 hours)
- Assess fundus for evidence of
contraction and compare
amount of bleeding q15 min
- Monitor VS q15 minutes
- Monitor uterine tone to prevent
hyperstimulation
- Never give as an undiluted IV bolus
SE/Adverse Effects
misoprostol
(Cytotec)
- 800 mcg rectally
(PR)
- used to
ripen/soften cervix
dinoprostone
(Prostin E2)
- 20 mg vaginally
or rectally
prostaglandin
PGF2a
(Hemabate)
0.25mg IM
methylergonovine
(Methergine)
**
- 0.2mg IM
- Then continue as
PO after acute
bleeding stops
- Use with caution in women with asthma
- Know healthy hx prior to giving it
- Never give if drug allergy
- Contraindicated if active CVD or hepatic
disease
- Monitor BP frequently
- Contraindicated if active cardiac,
pulmonary, renal, or hepatic disease
- May be repeated q15-90 min up to 8
doses
- Contraindicated if active cardiac,
pulmonary, renal, or hepatic disease
- Assess baseline bleeding, uterine tone,
and VS q15 minutes or per protocol
- Contraindicated with current HTN
- Report any complaints of chest pain
promptly!!
- hypotension
- N/V/D
- temperature elevation
- Fever, chills, flushing
- Headache, N/V/D
- Bronchhospasm
- HTN, seizures,
- uterine cramping
- nausea, vomiting
- palpitations
** Oxytocin and methylergonovine are the preferred ones to give if patient has chronic illness related to cardiovascular
or pulmonary disorders
- Tissueg placental tissue
• Retained placental fragments which may lead tog uterine inversion, fundal prolapse to or through the cervix, and/or
subinvolution
•
Subinvolutiong incomplete involution of uterus or failure to return to normal state after birth
! Causes
- Retained placental fragments (RPOC)g doesn’t allow for the uterus to fully contract due to presence of
foreign bodies in thereg can lead to uterine inversion– uterus prolapses out through the cervix;
Note: may also have retained blood clot as well as retained placental fragments
" Prevention: thoroughly inspect placenta to confirm it is intact after it is expelled
" Nursing responsibility is to take another look after HCP to make sure nothing is missing from placenta
- Distended bladderg interferes with uterine contractions needed to expel the placenta
- Infection or uterine myoma
" Infectiong causes inflammation that can interfere with contractions
" Uterine myomag a fibroid that may interfere with contraction of the uterus
! Clinical Signs
- Boggy uterusg feels like an IV bag or wet sponge
- Lochia progression abnormalg should not regress in stage, and should not stay the same
- Post partum fundal height higher than expectedg if fundal height is not going down by 1 cm/day
! Involution should take 4-6 weeks
! Treatment
- Uterine stimulants
- Antibiotic prophylaxisg body may detect placenta as a foreign body and cause infection, hence why we give
antibiotics just in case
- Traumag damage to the genital tract
• Lacerations (vaginal, perineal, or cervical)
! Continuous trickling of bright red blood with contracted uterus/ firm fundus
! Causesg pushing too soon; precipitous delivery; abnormal fetal presentation; forceps delivery **
! CALL HCP IMMEDIATELY! Lacerations need to be fixed right away
•
Uterine ruptureg can be caused by delivery after previous cesarean section or surgery
•
Hematomag is a collection of blood due to tissue trauma; can lead to significant PPH
! Symptomsg Vaginal or perineal
- Visible as swelling, bluish purple or skin colored palpable collection of blood
" Bluish purple with severe pain is emergent; skin colored is not emergent
- Pain may be severe
- Change in VS disproportionate to blood loss
! Treatment
- Ice packsg if non emergent type (skin-colored without severe pain)
- Pain medication
- Decreased pressure when sittingg use donut for sitting so not sitting on hematoma
- Monitor closely for rupture
! Need to call HCP to come look at it; HCP may need to possibly drain it or pack it to stop bleeding
- Thrombin
• Coagulopathiesg disorders that interfere with clot formation
• Determine risk during pregnancy g Family and personal history
• Common abnormal results:
-
•
i platelet and fibrinogen
levels
-
h PT and PTT
-
Prolonged bleeding time
Clotting Disorders
! Idiopathic Thrombocytopenia Purpura (ITP)
- Platelet destruction by autoantibodiesg platelet destruction means clotting i so patient bleeds
- Temporary disorder that usually follows a viral infection
- Treatment: glucocorticoids and immune globulin (IVIG)
! von Willebrand Disease (vWD)
- Inherited disorder (autosomal dominant) **
- Deficiency of von Willebrand factorg leads to prolonged bleeding time and impaired platelet function
- vWD factor h during pregnancy due to high hormone levelsg causes increased bleeding during pregnancy,
and some of the associated symptoms may linger into postpartum as well (except menorrhagia)
" Common symptomsg nosebleeds, menorrhagia, hematomas *
! Disseminated Intravascular Coagulation (DIC)
- Life threatening— Emergency!!
- Clotting system abnormally activated, causing clotting and bleeding to occur at same time
- Always a secondary diagnosisg e.g. severe preeclampsia, septicemia, etc
- Symptoms
" Bleeding from multiple sites, petechiae
" Bleeding where there shouldn’t beg nose bleeds, IV site, gums bleeding
" Abnormal lab values and VSg dx through clinical findings and lab work
- Treatment
" Correct underlying causeg maintain tissue perfusiong aggressive fluidsg blood products
- Traction
• Excessive force on umbilical cord during 3rd stage of labor
! Pulling on cord to hasten 3rd stage, causing lack of uterine separation from placenta during placental delivery
• Can cause placental fragments to be left behind
• With enough force, can also pull uterus down through cervix and vaginag called uterine inversion
•
Uterine Inversiong prolapse of uterine fundus through cervix; uterus turns inside out; rare (1 in 6,000 births)
! Prompt recognition and treatment is essential
! Treatment
- Gentle replacement of uterus (anesthesia) by HCP
- Uterine stimulants and antibiotics
- Prevention: avoid pulling on umbilical cordg nurse needs to recognize hard traction performed by HCP
- PP Hemorrhage
• Recognition and prevention
! Risk factors are evaluated on admission to L & Dg need full hx and hx of any prior pregnancies
! If RFs are present, type and screen her or crossmatch for blood
! Review protocol for hemorrhage
! Risk Factors:
•
•
•
•
•
- 5+ pregnancies
- Previous PPH
- If she has > 40 BMI
- Known coagulopathy
- Prior uterine surgery
- Baby more than 4,000g
- Low platelet count
- Infection
- Pushing for a long time
- Acreta
- Use of oxytocin for 24+
hrs during labor
- Poor progression of
labor
Readiness
! Clearly defined protocol, reviewed frequently
! Mass Transfusion Protocol in place & hemorrhage cart ready
! Who to call, how does the blood get to the OR, is it available?
Response
! Get help & assign rolesg someone’s doing labs, someone's taking and announcing vital signs
! 2nd IV 16-18 gauge
! Stat labsg CBC, coagulation studies, fibrinogen
! Announce vital signs & cumulative blood loss throughout
! If transfusing, do not wait for lab results, just transfuse it
Reporting
! Huddle about high risk patients and post event debrief
! Conduct multidisciplinary review for all events
! Monitor outcomes of all hemorrhages to increase response and positive outcomes
Nursing Management of PPH
! Focus on underlying cause so it can be fixed
! Assess/estimate blood loss
! Assess uterine toneg if boggy, massage immediately; use uterotonic drugs, IV fluids, vital signs, pad
counts/weighing pads
! Assist client to voidg if patient is actively bleeding, may need to insert a catheter though so she doesn’t get up
! Prepare for removal of retained partsg assess what is coming out of vagina
! Assess for hemorrhagic shock
! Institute emergency measures for DIC, know what to look for to identify DIC *
Prevent PPH
! Have control and management of third stage of labor
! Gentle cord removal
! Uterotonic drugs; monitoring lab values
! Uterine massage after placenta is out
! Being alert to abnormal bleeding– bright, red continuous trickling (laceration)
- Thromboembolic (TE) Conditions
• Types during postpartumg can happen up to 3-4 weeks about patient goes home
! Superficial venous thrombosis
! Deep venous thrombosis (DVT)
! Pulmonary embolismg usually from legs to lungs
•
Causes (triad)
! Venous stasisg from standing a lot at a job without compression socks, bed rest, etc.
! Hypercoagulation
! Injury to blood vessel
•
Risk Factors for TE Conditions:
! Pre-Pregnancy factors:
-
Use of OCP
Hx of TE disease
! Pregnancy-related factors
- Bedrest
- Maternal age < 35 (AMA)
•
-
Smoking
Hx of endometritis
-
Prolonged standing
Current varicosities
-
Maternal DM
Multiparity
-
Maternal obesity
C- Section
Nursing Assessment of DVT/PEg have to feel calf
! DVTg redness, warmth, edema, pain
- S/Sg pain in lower extremities; redness/warmth along vein; calf edema
- Positive Homans’ sign-no longer done
! Pulmonary Embolism-PE ***
- Sudden onset SOB/chest pain
- Diaphoresis, anxiety; change in mental status
- Change in vital signs: h RR, h HR, i BP, i pulse-ox
- If a DVT is thrown and becomes a PE, the S/S are very sudden
•
Prevention of DVT/PE
! Encourage range of motion (active or passive)g this can even just be walking daily
! Use compression stockings/devices
! Elevate legs (even if there is a DVT)
! Do NOT massag the affected lg though!!!
! Avoid smoking, OCP, trauma, prolonged standing
•
During Treatment
! Promote adequate circulation during treatment
- Analgesia; rest; elevate affected leg; antiembolism stockings; warm compresses **
-
Anticoagulant therapyg IV heparin and then warfarin
-
NOTE: use of compression stockings as part of treatment plan for CURRENT DVT is currently debated, with
some research showing it being beneficial and others disagreeing. Go by what your instructor says **
! Education
- NO NSAIDS or excessive alcohol *
- Needs to be checked every 6 weeks for INR while taking medications for it; need to take med at correct time
- Postpartum Infections
• Postpartum Infection— defined as:
! Fever of 100.4 or higher
! Occurs after the first 24 hours post birth and needs to be present for 2/10 days (at least 2 out of the first 10
days)
• Risk Factors
- Surgical birth
- Low socioeconomic status
- Anemia
-
Prolonged ROM
-
Patient age extremes
< 20 or > 35
-
Prolonged labor + multiple
vaginal checks
•
Puerperal sepsisg infection of the genital tract
! Happens within 28 days of abortion or birthg caused by strep
! Can be deadly
•
Metritisg infection of uterine lining
! Sterile environment until rupture of sacg vaginal checks or prolonged membrane
rupture may introduce bacteria
! Occurs within 6 weeks of birthg increased risk after Cesarean birth
! Symptoms: mother needs to know the s/s and come in if she experiences them
- Pain
- Backache
-
Foul-smelling lochia **
-
Abnormal lochia progression
! Maintain upright position while being treated!! **
•
Wound Infection
! Surgical incision, episiotomy, lacerations
! > 24-48 hours post delivery
! S/Sg Redness, warmth, swelling, tenderness; REDA/COCA
•
Urinary Tract Infectiong small, frequent, painful urination
! Caused by urinary catheterization, manipulation, trauma
! 2-7 days post delivery
! S/Sg Dysuria, frequency, urgency, low-grade fever; hematuria (blood in urine)
! 3 L of urine in first 24 hrs is normal after birth *
•
Mastitisg clogged milk duct
! Most often unilateralg can still breast feed effectively
! Occurs in first 2 weeks postpartum
! Causes:
- Unrelieved engorgementg milk stasis
- Infectious organismg S. aureus is most common
! Risk factorsg poor fitting bra; missed feedings; rapid weaning
! Symptoms:
-
Fever
Leukocytosis (h WBC) *
-
Flu-like symptoms (chills, fever, malaise)
Red/warm/very painful
! Treatmentg antibiotics
- Can use antibiotics and still continue breast feeding as long as antibiotic is safe for baby
•
Nursing Management of PP Infections
! Administer appropriate antibiotics and analgesia
! Promote fluid and electrolyte balance
! Provide emotional support
! Assess perineum, wounds and vital signs frequentlyg REEDA/COCA
! Prevention by aseptic technique and hand hygiene
! Post birth, give mother a sheet with the following info: POST BIRTH (mnemonic) *
Call 911
if you have:
Call your HCP
If you have:
(if can’t reach HCP,
go to ER or call 911)
P ain in chest
O bstructed breathing or shortness of breath
S eizures
T houghts of hurting yourself or your baby
B leeding, soaking through one pad per hour, or blood clots the size of an egg or bigger
I ncision that is not healing
R ed or swollen leg that is painful or warm to touch
T emperature of 100.4 or higher
H eadache that dosen’t get better even after taking meds, or bad HA + vision changes
- Postpartum Affective Disorders
• Extraordinary changes in the life of the patientg varied reactions to it
! i estrogen and progesterone **
•
Risk factorsg those at higher risk need to be assessed and monitored frequently
-
Poor coping skills
-
Numerous life stressors
-
Substance abuse
-
Low self-esteem
-
Previous psychological
problems or family Hx
-
Limited social support
network
•
Observationsg poor personal hygiene, weight loss, not responding to infant’s cues
! Someone needs to step up and help the mother if observe these
•
Classification:
Baby Blues
•
Postpartum Depression
Mild depression s/s
Clinical depression requiring tx
Fear of hurting baby or self
Onset: Initial days PP
Resolves: within 10 days PP
Onset: Initial days PP
More severe than baby blues and
lasts longer
Postpartum Psychosis
Emergency!
Baby is the devil; hallucinations, etc
WILL hurt baby; has plans to
Onset: within 3 months after
delivery
Baby Blues (BB)g most common of the three; affects 50-90% of women
! Mild depression symptomsg anxiety, sensitivity, overwhelmed, mood swings, forgetfulness, lethargy, loss of
appetiteg self-limiting
! Peaks on day 4-5 and resolves by day 10
! No formal treatment, but follow-up necessary
- Rationale: although BB itself is considered minor, it does have the potential to progress on to PPD
•
Postpartum Depression (PPD)g affects up to 1 in 5 women
! Form of clinical depressiong feelings worsen over time; symptoms last longer and are more severe than BB
- Requires treatment
- Large number of adolescent mothers develop itg need to be able to recognize s/s to get help
! Treatment
- Antidepressant or antianxiety meds
- Psychotherapy
- Marital counselingg assess father’s status too; consider pumping breast milk to let father feed baby
! Edinburgh Postnatal Depression Scale
- Questionnaire that patient answers truthfully
- 10-questions, with each answer valued at 0 to 3; total up score—if score is > 12 they likely have depression
- Borderline score will be repeated in a week to assess for BB or PPD
•
Postpartum Psychosisg Emergency psychiatric condition!!
! Onsetg within 3 months of delivery
- Sleep disturbances, depression, delusional thinking, hallucinations, mood lability
- Escalates to thoughts of suicide or infanticide
! Should not be alone with infant!!
! Treatmentg need to take to emergency room right away
- Hospitalization
- Psychotropic meds
- Psychotherapy and/or group therapy
- What can a nurse do to help?
• Become educated & educate family about life changes
• Encourage verbalization of feelings
• Assist in structuring patient’s day/care
• Reinforce need for good nutrition/rest/exercise
• Provide referrals for support after discharge
• Use Edinburgh Postnatal Depression Scale
• NEVER tell her things could be worse
• Believe the patient
- What Family/Partner Can do to Help
• Help clean house, help her rest
• If she wakes up at night wake up with her
• Cook food for her
Common Terms Used in Obstetrics
AMA—advanced maternal age; defined as pregnancy at age 35 or older
APGAR—score of 1 to 5 assigned to newborns that assesses five parameters –
1. heart rate (absent, slow, or fast)
2. respiratory effort (absent, weak cry, or good strong yell)
3. muscle tone (limp, or lively and active)
4. response to irritation stimulus
5. color
These are used to evaluate a newborn’s cardiorespiratory adaptation after birth.
Ballottement— the examiner pushes against the woman’s cervix during a pelvic examination and feels a rebound from the
floating fetus; sign of probable pregnancy
Braxton Hicks contractions—spontaneous, irregular, and painless contractions. Braxton Hicks contractions are typically felt
as a tightening or pulling sensation of the top of the uterus. They occur primarily in the abdomen and groin and gradually
spread downward before relaxing
Breech—occurs when the fetal buttocks or feet enter the maternal pelvis first and the fetal skull enters last.
a.
b.
c.
d.
Frank breech
Complete breech
Single footing breech
Double footing breech
Caput succedaneum-fluid collecting in the scalp; presents as edema of the scalp at the presenting
part. This swelling crosses suture lines and disappears within 3 to 4 days. No pathological significance.
Cephalohematoma— bleeding between periosteum and skull bone appearing within first 2 days; does
not cross suture lines; localized subperiosteal collection of blood of the skull which is always confined
by one cranial bone characterized by a well-demarcated, often fluctuant swelling with no overlying
skin discoloration, usually appearing on the second or third day after birth and disappearing in weeks
to months. This condition is due to pressure on the head and disruption of the vessels during birth. It
occurs after prolonged labor and use of obstetric interventions such as low forceps or vacuum
extraction. Large cephalohematomas can lead to increased bilirubin levels and subsequent jaundice.
Cervix/cervical— the lower part of the uterus, is sometimes called the neck of the uterus. It opens into the vagina and has a
channel that allows sperm to enter the uterus and menstrual discharge to exit. Has an alkaline environment to protect sperm
from acidic environment in vagina.
a. Nulliparous cervical os (never birthed a child)
b. Parous cervical os (post child birth)
Cesarean section (C/S)—use of surgery to deliver a baby
Chadwick's sign—Cyanosis (blueish purple color) of vaginal and cervical mucosa, associated with pregnancy
Chadwick = Cyanotic
Colostrum—dark yellow fluid secreted in the days before milk production after childbirth. Contains more minerals and
protein, but less sugar and fat than mature breast milk, and rich in antibodies. Continues for about a week before start to
produce mature breast milk
Decelerations—decrease in FHR
Dystocia-labor—abnormal or difficult labor; can be influenced by Problem’s with the 4 Ps
- Problems with Power—dysfunctional uterine contractions
- Problems with Passenger—any abnormalities with the fetus; includes presentation (how the baby is positioned), size, etc.
- Problems with Passageway—issues with pelvis or birth canal; related to a contraction of one or more of three planes of
maternal pelvis (inlet, midpelvis, and outlet).
- Problems with Psyche—emotions such as anxiety lead to sympathetic nervous system stimulation, which relaes
catecholamines, which leads to myometrial dysfunction. Epinephrine and norepinephrine can lead to uncoordinated or
increased uterine activity.
Dystocia-shoulder—“shoulder presentation”; occurs when the fetal shoulders present first, with the
head tucked inside. The issue is that the anterior shoulder can't get past symphysis pubis in this
position. The head slowly emerges but then retracts back into vagina as you try to pull baby out (this
is called the “turtle sign”). HCP may try pulling on baby by the head to try to get it out. Can result in
brachial plexus injury.
Ectopic pregnancy—ectopic means “out of place”; any pregnancy in which the fertilized ovum implants outside the uterine
cavity.
EDD (EDC)—Estimated Due Date
Engagement— the stage of pregnancy when the baby’s head descends into the mother’s pelvis in preparation for birth.
Colloquially referred to as when someone’s baby bump “drops”.
Epidural anesthesia—general anesthesia used in birth
Fetal Heart Tones-(FHT or FHR)—the fetal heart rate (should be 110-160 bpm)
Fundus— convex portion of uterus above the uterine tubes; in other words, it is the top of the
uterus, and is palpable; it is used to measure the gestation based on height of uterus
Goodell's sign—softening of the cervix
Gravida/Gravidity—total number of times a woman has been pregnant, regardless if resulted in abortion of multiple births
Hegar's sign—include softening of the lower uterine segment or isthmus; softening of the fundus of the uterus, associated
with the first semester pregnancy
HELLP Syndrome—Life threatening pregnancy syndrome that requires emergent delivery; Do NOT need all 3 to be Dx with
HELLP!
Hemolysis
Elevated Liver enzymes
Low Platelets
Hydramnios (aka polyhydramnios)— a condition in which there is too much amniotic fluid (more than 2,000 mL) surrounding
the fetus between 32 and 36 weeks. Associated with fetal anomalies of development such as upper gastrointestinal
obstruction or atresias, neural tube defects, and anterior abdominal wall defects, together with impaired swallowing in
fetuses with chromosomal anomalies, such as trisomy 13 and 18.
Hyperbilirubinemia—total serum bilirubin level above 5 mg/dL resulting from unconjugated bilirubin being deposited in the
skin and mucous membranes. S/S include jaundice
Hyperemesis gravidarum—a severe form of nausea and vomiting of pregnancy associated with significant costs and
psychosocial impacts; persistent, uncontrollable nausea and vomiting that begins in the first trimester and causes
StudentNurseGuides
dehydration, electrolyte imbalance, ketosis, and weight loss of more than 5% of pre-pregnancy body weight
Isoimmunization—the development of antibodies against the antigens of another individual of the same species; Occurs
when Mother is RH – and fetus is RH +
Leopold's maneuver— a method for determining the presentation, position, and lie of the fetus through the use of four
specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for
malpresentation. A longitudinal lie is expected, and the presentation can be cephalic, breech, or shoulder.
To perform maneuver’s: start by placing the woman in supine position and stand beside her.
Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)?
Used to determine presentation
Facing the woman’s head, place both hands on the abdomen to determine fetal position in
the uterine fundus. Feel for the buttocks and head. A buttocks that feels soft and irregular
indicates a vertex position; a head that feels hard, smooth, and round indicates a breech
presentation
Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the
back of the fetus.)
Used to determine position.
While still facing the woman, move hands down the lateral sides of the abdomen to palpate on
which side the back is located (feels hard and smooth).
Continue to palpate to determine on which side the limbs are located (irregular nodules with
kicking and movement).
Maneuver 3: What is the presenting part? Used to confirm presentation.
Move hands down the sides of the abdomen to grasp the lower uterine segment and
palpate the area just above the symphysis pubis.
Place thumb and fingers of one hand apart and grasp the presenting part by bringing
fingers together. Feel for the presenting part.
If the presenting part is the head, it will be round, firm, and ballottable; if it is the
buttocks, it will feel soft and irregular.
Maneuver 4: Is the fetal head flexed and engaged in the pelvis? Used to determine attitude.
Turn to face the client’s feet and use the tips of the first three fingers of each hand to palpate
The abdomen. Move fingers toward each other while applying downward pressure in the
direction of the symphysis pubis.
If you palpate a hard area on the side opposite the fetal back, the fetus is in flexion, because
you have palpated the chin. If the hard area is on the same side as the back, the fetus is in
extension, because the area palpated is the occiput.
*Note how your hands move: If the hands move together easily, the fetal head is not
descended into the woman’s pelvic inlet. If the hands do not move together and stop because of resistance, the fetal
head is engaged into the woman’s pelvic inlet
Lightening—subjective sensation as fetus descends into the pelvic inlet. It occurs up to two weeks prior to delivery in
primipara and may not occur until labor begins for multipara
Linea Nigra—pigmented line of skin in the middle of the abdomen that extends from the umbilicus to the pubic
area; not all women develop this
Multigravida/multipara—woman pregnant for at least the third time/ woman who has had 2 or more pregnancies of at least
20 weeks gestation resulting in viable offspring
Nagele's rule—used to determine the due date of the child. Use the first day of her last menstrual period (LMP), then count
back 3 months and add 7 days.
Nullipara—woman who has produced no viable off spring (para 0)
Nulligravida—woman who has never been pregnant
Oligohydramnios—decreased amount of amniotic fluid (less than 500 mL) between 32 and 36 weeks’ gestation. May result
from any condition that prevents the fetus from making urine or blocks it from going into the amniotic sac
Para—number of times a woman has given birth to a fetus of at least 20 gestational weeks (viable or not); multiple births as
count as one birth event.
Pica—Craving and chewing substances that have no nutritional value, such as ice, clay, soil, or paper.
Placenta previa— a bleeding condition that occurs during the last two trimesters of pregnancy. In placenta previa (literally,
“afterbirth first”), the placenta implants over the cervical os
Placenta abruption—the premature separation of a normally implanted placenta after the 20th week of gestation prior to
birth, which leads to hemorrhage.
Preeclampsia & Eclampsia— multisystem, vasopressive disorder that targets the cardiovascular, hepatic, renal, and central
nervous systems. Can be classified as mild or severe with a potential progression to eclampsia.
Symptoms
Blood pressure
Proteinuria
Seizures/coma
Hyper-reflexia
Edema
Headache
Urine output
Vision
Cerebral
Epigastric Pain
-
Mild Pre
>140/90mm Hg
1+
No
No
Mild-hands/face
No
Normal (30 mL/hr)
—
—
—
-
Severe Pre
>160/100 mm Hg
>3+
No
Yes
Can worsen
Yes
Oliguria
Blurred/blind spots
Disturbances
Yes
-
Eclampsia
>160/110 mm Hg
Marked
Yes
Yes
Generalized/above waist
Severe
Renal failure
Disturbances
Hemorrhage
Yes
Preterm—the occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of
the 37th week of gestation.
Primigravida—woman pregnant for first time
Quickening— is the first time life or fetal movement felt by the mother. It is felt 16 to 20 weeks for a multipara and about 18
weeks by a primipara.
Rupture of the fetal membrane (ROM)—a commonly-used blanket term which includes the following conditions:
-
Artificial rupture of membrane (AROM): In certain cases where labor has been initiated but the amniotic membrane
has not been broken, a nurse may perform AROM to expedite delivery and reduce the risk of complications.
-
Spontaneous rupture of membrane (SROM): SROM is the most common kind of fetal rupture. Commonly referred to
as one’s “water breaking” (i.e. “My water just broke”); it is a natural part of labor that requires no additional
management or intervention.
-
Premature rupture of membrane (PROM): the rupture of the fetal membrane before the onset of labor. Occurring at
37 weeks or later, PROM is an easy-to-manage complication of an otherwise normal birth.
-
Preterm premature rupture of membrane (pPROM): PROM that occurs before 37 weeks is known as pPROM.
Compared to PROM, preterm PROM is more rare and difficult to manage. The condition has been cited as a cause
in as many as 20% of perinatal deaths.
Station—refers to where the presenting part (the part of the baby that leads the way through the birth canal) is in the pelvis
Striae gravidarum—stretch marks; irregular reddish streaks that appear on the abdomen, breasts,
and buttocks in up to 90% of pregnant women. Result from genetics, reduced connective tissue
strength resulting from the elevated adrenal steroid levels, and stretching of the structures secondary
to growth
Surfactant—a surface tension–reducing lipoprotein found in the newborn’s lungs that prevents alveolar collapse at the end of
expiration and loss of lung volume
Tachysystole— condition of excessively frequent uterine contractions during pregnancy. defined as more than 5 contractions
in 10 minutes, averaged over a 30-minute window
VBAC—vaginal birth after cesarean
Wharton's jelly— (a specialized connective tissue) that surrounds these three blood vessels in the umbilical cord to prevent
compression, which would cut off fetal blood and nutrient supply.
Gravida vs Para
• Gravid = state of being pregnant
• Gravida/Gravidity = total number of pregnancies, including this one; total number of times pregnant, regardless of
whether resulted in termination or if multiple infants were born from single pregnancy
• Para- number of times a woman has given birth to a fetus of at least 20 gestational weeks (viable or not); multiple births
as count as one birth event.
[think para = people (both 2 syllables)- aka actual fetuses considered viable and could therefore be a person]
• Parity = the number of pregnancies (NOT the number of fetuses) carried to a viability (at least 20 weeks), regardless of
the outcome
[Think parity = pregnancy (both 3 syllables)- # of pregnancies carried to a point where it could be a person aka viable]
• Nullipara = never given birth— Includes miscarriage or abortion prior to 20 weeks
G/P
• Used in clinical setting to record the gravidity and parity
• (often written ie: G2/P1, meaning someone is in second pregnancy with 1 successful birth previously)
GTPAL—acronym that provides a more detailed breakdown of parity
G-Gravidity = Number of pregnancies, including any current pregnancies (regardless of current gestational age)
T-Term births = Number of pregnancies carried to 37+ weeks
P-Preterm births = Number of births between 20-37 weeks
A-Abortions/Miscarriages = number of pregnancies which ended in miscarriage or abortion. Include in parity if past 20weeks.
L-Living children = the number of living children (this is where multiples count individually)
Common OB Lab Tests:
Maternal Serum alpha-fetoprotein (MSAFP)—biomarker screening test that is now recommended for all
pregnant women along with other prenatal screening test depending on risk profile; high levels linked to
neural tube defects; low levels associated with possible down syndrome. Minimally Invasive—requires
only venipuncture for blood sample.
Alpha-fetoprotein (AFP)— used to screen for neural tube defects such as spina bifida.
- AFP is performed at 16-18 weeks of gestation. AFP can also be done by analysis of amniotic fluid.
- An elevated alpha-fetoprotein (AFP) level is consistent with neural tube defect (spina bifida, hydrocephalus), done at
16-18 weeks.
- It is done by drawing the mother’s blood to analyze for the amount of AFP that the liver normally re-releases at a
known and increasing amount as the pregnancy progresses.
Presence of Amniotic Fluid— membrane rupture and leaking amniotic fluid can be detected in 3 ways:
1. Nitrazine paper—put fluid on nitrazine paper, which detects alkaline substances; if it turns
blue, the fluid is alkaline and is amniotic fluid
2. Put fluid on slide and view under microscope; will look like “ferning” under microscope
3. Speculum examination, where HCP looks for pooling of fluid
Triple screen— screens for AFP, hCG, and unconjugated estriol
Quad screen— Screens for everything triple does (AFP, hCG, unconjugated estriol) plus a fourth marker, inhibin A (a
glycoprotein secreted by the placenta)
The quad screen is used to enhance the accuracy of screening for Down syndrome in women younger than 35 yrs old.
Low inhibin A levels indicate the possibility of Down syndrome
Coombs' test—antibody screen typically done when mother is RH – to determine if fetus is RH – or +
• Direct— done on a sample of red blood cells from the body. It detects antibodies that are already attached to
red blood cells
• Indirect—done on a sample of the liquid part of the blood (serum).
Fetal fibronectin— glycoprotein found at the junction of the chorion and decidua (fetal membranes and uterus) that acts as
biologic glue, attaching the fetal sac to the uterine lining. It is usually present in cervicovaginal secretions up to 22 weeks of
pregnancy and again before delivery.
The test is a useful marker for impending membrane rupture within 7 to 14 days if the level increases to greater than > 0.05
mcg/mL. If test is negative, means pre term labor in next 2 weeks is unlikely.
Group B Streptococcus (GBS) –naturally occurring gram-positive bacterium that colonizes in the female genital tract and
rectum and is present in 10% to 30% of all healthy women. Women who test positive for the GBS bacteria are considered
carriers, and GBS can be passed to the newborn via vertical transmission during labor or horizontal transmission after birth.
Hep B Surface Antigen (HbSAg) –CDC recommends that all pregnant women should be tested for hepatitis B surface antigen
(HBsAg) regardless of previous HBV vaccine or screening. Hep B can be transmitted to fetus.
RPR/VDRL—(Raid Plasma Regimen and Venereal Disease Research Laboratory) – Nontreponemal serologic test used to screen
for syphilis and make a presumptive diagnosis of syphilis
Newborn screen (PKU)—aka newborn screening for phenylketonuria; Newborn needs to ingest enough breast milk
or formula to elevate phenylalanine levels for the screening test to identify PKU accurately, so newborn screening
for PKU testing should not be performed before 24 hours of age.
StudentNurseGuides
OB SBAR
Initials:
DD:
Baby:
Room #:
Gravida:
BW:
Age:
Para:
Time:
Allergies:
Gest. Age:
APGARs:
M
F:
CS (reason):
VD:
MOTHER
Blood Type:
Rh:
Diet:
Last Void:
Last BM:
GBS:
Chlamydia:
Prenatal Hx:
BABY
Hep B:
Rubella:
GC:
RPR/VDRL:
Other:
Blood Type:
Rh:
Coombs:
Bottle/BF:
Void:
Stool:
Blood C/S:
Complications:
Glucose:
Hbg:
Hct:
Bii:
Other:
MOTHER
BABY
T:
P:
R:
BP:
Pain:
T:
P:
R:
BP:
Pain:
Intake:
Incision:
/10
/10
T:
P:
R:
Pain:
T:
P:
R:
Pain:
Intake:
Episiotomy:
Output: (void/Foley, Stool)
Laceration:
Output: (void/Foley, Stool)
Head shape/Size/Fontanelles:
Cardiac/Resp:
Cardiac:
Uterus:
Resp:
Abd/bladder:
Abd./Cord:
Perineum/Lochia:
Skin/Circ.:
Legs:
Reflexes:
Sleep/Rest:
Parent bonding:
MOTHER:
RhoGAM :
Interventions:
MMR:
BABY:
Bath:
PKU:
Cord:
Circ.:
Hep B:
/10
Bands:
Bulb Syringe:
Breasts:
Tdap:
/10
Education:
Mother’s needs:
Infant’s needs:
Cap:
O2:
O2:
/10
/10
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Med Sheets for Student Learning
Med /Dose / Route/
Frequency
Classification/
Indication
Nursing Implications &
Considerations
Adverse Effects
Time Given
Newborn Assessment
APGAR Score
Appearance
0 Blue all over
1 Pink torso, blue
extremities
2 Completely pink
Pulse
0 Absent
1 Slow, < 100
2 > 100
Grimace (reflex irritability)
0 None
1 Grimace, limited cry
2 Vigorous cry
Activity (muscle tone)
0 Flaccid
1 Some flexion of
extremities,
Limited movement
2 Well flexed, actively
moving
Respiratory Effort
0 Absent
1 Slow, weak cry;
hypoventilation; irregular
2 Strong, loud cry
Total
1 minute
5 minute
1 minute
5 minute
1 minute
Normal Measurements- Reference Ranges
Weight: 2,500 – 4,000 g (5.5 to 8.8 lbs)
Length: 45 cm – 55 cm (18 to 22 in)
Head Circumference: 32 – 36.8 cm (12.6 to 14.5 cm)
Chest Circumference: 30 – 33 cm ( 12 to 13 in)
T: 97.7°F to 99.5°F
RR: 30 – 60
HR: 110 – 160
BP: 30 – 90 / 20 – 60
5 minute
Labs and Meds
Coombs’ Test: done if mother Rh-neg
Immunizations: Hep-B can be given before discharge
1 minute
5 minute
Vitamin K: prevents hemorrhage
Optic Antibiotic: prevents newborn blindness
PKU Level: Within 24 hrs of birth feedings begin
Fontanelles
1 minute
5 minute
8-10 normal, 4-6 moderate depression, 0-3 aggressive resuscitation
Newborn Assessment
General Appearance: pink, loud cry, well-flexed, full ROM
Fontanelles:
Anterior (diamond-shaped)
Posterior (triangular)
Respirations:
Assess breathing for
1 full minute
Irregular pattern is
considered normal
Umbilical Cord: AVA
1 vein, 2 arteries
Clamped
Mouth:
Assess for cleft lip or
palate; clear airway
Heart:
Assess for murmurs
Take apical pulse for
1 full minute
Palpate brachial
pulse
Extremities:
Should be equal length
10 fingers and toes
Genitalia:
Males: testes are palpable
Females: discharge of blood or mucous is a normal finding
Possible Delivery Complications
r
r
r
r
r
Meconium Aspiration
Limb Presentation
Cord Presentation
Postpartum Hemorrhage
Breech Presentation
Newborn Weight Loss
Newborns can lose up to 10% of their weight after
birth, and most will gain it back by 10-14 days
Newborns are weighed daily in grams.
% of Weight (Wt.) Loss:
1) Birth Wt.– Current Wt.
= Loss
2) Loss ÷ Birth Wt Í 100
= % Weight loss
Conversions:
1 lb = 454 grams
1 ounce = 28 grams
1 lb = 16 ounces
1 kg = 2.2 lbs
1 g = 1 mL
StudentNurseGuides
Newborn Assessment
APGAR Score
Appearance
0 Blue all over
1 Pink torso, blue extremities
2 Completely pink
Pulse
0 Absent
1 Slow, < 100
2 > 100
Grimace (reflex irritability)
0 None
1 Grimace, limited cry
2 Vigorous cry
Activity (muscle tone)
0 Flaccid
1 Some flexion of extremities,
Limited movement
2 Well flexed, actively moving
Respiratory Effort
0 Absent
1 Slow, weak cry;
hypoventilation; irregular
2 Strong, loud cry
Total
1 minute
5 minute
1 minute
5 minute
Normal Measurements- Reference Ranges
Weight: 2,500 – 4,000 g (5.5 to 8.8 lbs)
Length: 45 cm – 55 cm (18 to 22 in)
Head Circumference: 32 – 36.8 cm (12.6 to 14.5 cm)
Chest Circumference: 30 – 33 cm ( 12 to 13 in)
Labs and Meds
1 minute
5 minute
1 minute
5 minute
Coombs’ Test: done if mother Rh-neg
Immunizations: Hep-B can be given before discharge
Vitamin K: prevents hemorrhage
Optic Antibiotic: prevents newborn blindness
PKU Level: Within 24 hrs of birth feedings begin
Fontanelles
1 minute
5 minute
8-10 normal, 4-6 moderate depression, 0-3 aggressive resuscitation
Newborn Assessment
General Appearance: pink, loud cry, well-flexed, full ROM
Fontanelles:
Anterior (diamond-shaped)
Posterior (triangular)
Respirations:
Assess breathing for
1 full minute
Irregular pattern is
considered normal
Umbilical Cord: AVA
1 vein, 2 arteries
Clamped
Possible Delivery Complications
Mouth:
Assess for cleft lip or
palate; clear airway
Heart:
Assess for murmurs
Take apical pulse for
1 full minute
Palpate brachial
pulse
Extremities:
Should be equal length
10 fingers and toes
Genitalia:
Males: testes are palpable
Females: discharge of blood or mucous is a normal finding
r
r
r
r
r
Meconium Aspiration
Limb Presentation
Cord Presentation
Postpartum Hemorrhage
Breech Presentation
Newborn Weight Loss
Newborns can lose up to 10% of their weight after
birth, and most will gain it back by 10-14 days
Newborns are weighed daily in grams.
% of Weight (Wt.) Loss:
1) Birth Wt.– Current Wt.
= Loss
2) Loss ÷ Birth Wt Í 100
= % Weight loss
Conversions:
1 lb = 454 grams
1 ounce = 28 grams
1 lb = 16 ounces
1 kg = 2.2 lbs
1 g = 1 mL
Maternal Postpartum Assessment
Initials:
PATIENT ID LABEL
Room #:
Age:
Allergies:
Blood Type:
GBS:
GC:
Hep B:
Diet:
Rh:
Chlamydia:
RPR/VDRL:
Rubella:
General
Appearance
Vital signs
Time:
Time:
Cardiac
r S1/S2
Respiratory
O2 Source: r Room Air r NC r NR r Other: _____________
Sounds: r Clear: _____________ r Diminished: _______________ r Adventitious:__________________
r WOB Describe: ______________________
r Notes: _______________________________________
I&O
T:
T:
P:
P:
r Rate: ___________
r Oral: _______
r IV: _______
R:
R:
BP:
BP:
r Rhythm: ___________ r Murmur/Extra Sounds: ___________
Intake
r Tubes/TPN: __________
r Other: __________
r Emesis: _______
r BM: _______
r Void: _______
Output
r Suctioning: _______
r Tubes: _______
r Other: _______
Skin/IV Site
REDA/COCA:
Breasts
Uterus
Bladder
r Engorgement
Breast Feeding: r Y r N
Nipples: r Flat/Inverted r Soreness or Cracking
r Any Surgical Hx: ______________________ r Any Abnormal Findings: ______________________
Bowels
Lochia
Episiotomy
BS: r Hypoactive
Flatus: r Present
Extremities
Emotions
Pain
Pedal Pulses: r L: _____ r Rt: _____ r Pain or Tenderness: ______________
Fundus: r Firm
r Soft
r Boggy
Fundal Location: ______________ Fundal Height ___________
r Distention
r Foley Catheter Last Void: _____________ Color: _____________ Odor: ____________
Amount: _______________
Frequency: _______________
Any Notes: ________________
r Normoactive
r Not present
r Color: _________________
r Hyperactive
r Absent
Any Notes: ________________
Last BM: __________________
r Odor: _________________
r Episotomy r Type: _________________
r Laceration r Type: _________________
r C-Section incision r Type: _________________
r Amount: _________________
r Redness: ______________ r Edema: ____________
r Drainage: ______________
r Approximation: _______________
r Swelling: ________
Skin: r Hot r Warm
r Cool
r Dry r Moist r Color: _____________ r Edema: _________
r Appropriate r Describe: ______________
r Other: __________________
r Signs of PP Depression or Malattachment
r Describe: ____________________
r Numeric Scale: ______________
r Location/Characteristics:______________
r Intervention: ______________
r Reassessment: ______________
r Numeric Scale: ______________
r Location/Characteristics:______________
r Intervention: ______________
r Reassessment: ______________
CONTRACEPTION:
Barrier
- Male/Female Condom
- Diaphragm (Rx only)
- Cervical cap (Rx only)
- Sponge (has spermicide)
Behavioral
- Abstinence
- Coitus interruptus
- Fertility awareness (BBT)
- Individual Standard Days
- Lactation amenorrhea
Hormonal
- OCP
- Progestin only
- Progestin & Estrogen
- Transdermal patch
- Injectable (progestin only)
- Implantable
- Vaginal ring
- IUD *
Other:
- IUD *
- Copper (nonhormonal)
- progestin only (hormonal)
- BBT—take oral temp before getting out of bed
• Illness can inc temp
• Temp dips at mid point
- Lactation amenorrhea method—works b/c prolactin suppresses gonadotropin
- Hormonal OCP
• Suppress ovulation
• Inhibits FSH and LH
• Thickens mucous and prevents implantation of endometrium
! Patient Teaching:
- Not effective on antibiotics
- No pap required
- Take at same time every day
! Pros
i RF osteoporosis and RA
i RF endometrial, colorectal, and ovarian cancer
i acne, PMS, cramping, anemia due to bleeding, and shortens cycle
! Cons
- h RF breast cancer
- Hypercoagulable state b/c mimic pregnancy = RF DVT
- h RF migraine, MI, stroke, HTN, and depression
! ACHES = complications
- A= Abdominal paing may indicate liver or gallbladder problems
- C= Chest pain or SOBg may indicate a PE
- H= Headachesg may indicate HTN or impending stroke
- E= Eye problemsg may indicate HTN or related attack
- S= Severe calf paing could be related to DVT
- Injectable is progestin only so RF bone density loss
- IUD—works by causing inflammation to uterine lining and thickens cervical mucous
• Hormonal (progestin only) and non hormonal
• Nonhormonal can be used as Emergency Contraception up to 7 days post
• PAINS = complications
! P= Period late, pregnancy, abnormal spotting, or bleeding
! A= Abdominal pain, pain with intercourse
Permanent
- Tubal ligation
- Vasectomy
! I= Infection exposure, abnormal vaginal discharge
! N= Not feeling well, fever, chills
! S= String length shorter or longer or missing
- EC works like high dose BC pill
• Uses levonogesterol a form of progesterone
- Trans cervical tubal ligation is not immediately effective g takes up to 3 months to work
Contraception Practice Questions
1. When discussing contraceptive options, which method would the nurse recommend as being the most reliable?
A) Coitus interruptus
B) Lactational amenorrheal method (LAM)
C) Natural family planning
D) Intrauterine system
2. A client is to receive an implantable contraceptive. The nurse describes this contraceptive as containing:
A) Synthetic progestin
B) Combined estrogen and progestin
C) Concentrated spermicide
D) Concentrated estrogen
3. The nurse discusses various contraceptive methods with a client and her partner. Which method would the nurse explain as
being available only with a prescription?
A) Condom
B) Spermicide
C) Diaphragm
D) Basal body temperature
4. A woman has opted to use the basal body temperature method for contraception. The nurse instructs the client that a rise
in basal body temperature indicates which of the following?
A) Onset of menses
B) Ovulation
C) Pregnancy
D) Safe period for intercourse
5. A nurse is preparing a class for a group of women at a family planning clinic about contraceptives. When describing the
health benefits of oral contraceptives, which of the following would the nurse most likely include? (Select all that apply.)
A) Protection against pelvic inflammatory disease
B) Reduced risk for endometrial cancer
C) Decreased risk for depression
D) Reduced risk for migraine headaches
E) Improvement in acne
6. A nurse is preparing a class for a group of young adult women about emergency contraceptives (ECs). Which of the
following would the nurse need to stress to the group. Select all that apply.
A) ECs induce an abortion like reaction.
B) ECs provide some protection against STIs
C) ECs are birth control pills in higher, more frequent doses
D) ECs are not to be used in place of regular birth control
E) ECs provide little protection for future pregnancies.
Answers
1. D
2. A
3. C
4. B
5. A,B,E
6. C,D,E
ANTEPARTUM CARE
1.
LHg tells ovary to release mature follicle/ovum
2.
Umbilical cordg consists of 3 vessels (AVA) g artery, vein, artery
a. Brings O2, blood, nutrients to fetus and removes waste
b. Length determined by genetics, space and fetal activity
Signs of Pregnancy
a. Probable (Objective)- uterus related or a + blood pregnancy test
i. + blood pregnancy test
ii. Hager’s signg softening of lower part of uterus just above cervix (softening of the uterus)
iii. Chadwick signg blueish color of vagina and cervical tissue due to increased vascularization
iv. Goodell’s sign- softening of vaginal portion of cervix
v. Ballottement of head—the examiner pushes against the woman’s cervix during a pelvic examination
and feels rebound from the fetus due to fetus coming down and hitting top of cervix
b. Positive- only in a fetus
i. Confirmation of fetus visually via ultrasound
ii. FHR on ultrasound or doppler
iii. Fetal movement palpated by experienced practitioner
c. Anything else is presumptive
3.
4.
5.
6.
Naegels’s rule to determine due date:
a. First day of last menstrual period+ 7 days – 3 months = due date
Physiologic changes
a. Hemodilution anemia
b. GI changes: Inc appetite, dec peristalsis, N/V, heart burn, reflux, constipation, hyperemic gums
c. At 20 weeks fundus is at level of umbilicus
d. Increased urinary frequency in early and late pregnancy, increased GFR due to progesterone’s vasodilation
e. Lordosis due to relaxin
f. Orthostatic hypotension from uterus pressing on vena cava when in supine position
g. Fetal movement may be felt at
i. 18 to 20 weeks if primigravida
ii. 14-16 weeks in multigravidas
Nutrition
a. Gain 25 –30 lbs in pregnancy
b.
c.
d.
e.
5 lbs 1st trimesterg then 1 lb/week after that
300 additional calories/day
30% h in protein and iron intake
25% h in folic acid intake
7.
Food concerns
a. Mercury—eat less fish and avoid seafoods high in mercury
b. Listeria—no uncooked meats (deli meat, hot dogs, rare-cooked meats)
c. No unpasteurized milk, no unwashed fruits or vegetables
d. Limit caffeine intake
8.
Toxoplasmosis—found in cat fecesg no changing cat litter box; also found in raw/undercooked meatsg do not eat those
9.
Psychosocial Adaptations
a. 1st trimester—possible ambivalence; more focus on self
b. 2nd trimester—sees fetus as separate entity
c. 3rd trimester—questions herself i.e. if she can be a good mother
10. Initial Visitg Date of last period, weight, VS, attempt to hear FHR, urinalysis
a. Glucose screening for high risk women (age > 25 y/o) ***
b. STI testing for chalmydia and ghonnorrhea
c. Baseline lab work: CBC, rubella titer, Hep B antigen test, GBS test, RH and ABO test
11. Follow up Visitsg urine dip stick, FHT, fundal height, fetal movement assessment (baby kicks)
a. 24-28 weeksg glucose challenge test (done earlier with risk factors like diabetic or > 25 y/o)
i. if result is > 140, then a 3-hour glucose challenge test
1. If 3 hr test comes back normal then it is not considered GT diabetes
b. 37 weeksg screening for GBS, chlamydia and gonorrhea
12. G/P
a.
b.
Gravida (pregnancies) g any pregnancy the woman has had including current one regardless of the outcome
Para (deliveries) g any delivery > 20 weeks
13. GTPAL
i.
ii.
iii.
iv.
v.
Gg all pregnancies including the current one
Tg number of term gestations delivered (38-42 weeks)
Pg number of preterm deliveries >20 weeks to 37 weeks, 6 days
Ag number of pregnancies ending before 20 weeks
Lg number of currently living children
14. Testing
a. NST— measures utero-placental function by measuring FHR while baby is at rest and then after a meal to see if
moves more; looking for acceleration
i. Reactiveg 15 bpm above the baseline for 15 seconds (15 x 15) In a 20-minute period
b. BPP—normal score is 8g done if abnormal NST
c.
d.
Screening
i. Quad screeng offered to ALL womeng AFP, Estriol, beta hCG, inhibin A
1. Abnormal results— may indicate neural tube defect
2. i inhibin A—possibly down syndrome
3. Abnormal hCG, i estriol, i AFP— mean possible chromosomal abnormality
Diagnostic
i. Chorionic villus sampling— detects > 98% of chromosomal abnormalities and paternity at 10-13 weeks;
takes sample from placenta
ii. Amniocentesis—confirms findings from a screening test, done at 15-18 week; takes sample from
aspirated amniotic fluid
1. 2nd trimester – used for confirming a Dx from another screening
2. 3rd trimester—used for assessing fetal lung maturity
15. ABO incompatibilityg only occurs in mother’s with Type O bloodg less severe than Rh incompatibility
a. If fetus has non Type O blood her anti-A or anti-B antibodies can attack fetal RBC and cause RBC hemolysis in itg
s/s is early onset jaundice in newborn
i. Type A and B are dominant over O
1. Type A and B are considered co-dominantg AB together = Type AB
ii. Type O is recessiveg Must have 2 ‘O’ s to have blood type O
16. RH Incompatibilityg Mom Rh (-) baby Rh + g Rh factor is autosomal recessive
a. Mom has no symptoms
b. Maternal antibodies attack baby’s RBCsg results in hemolytic disease of the newborn *
c. Rhogam given to mother to prevent it:
i. At 28 weeks
ii. within 72 hours PP if the newborn Rh +g protects future babies, not this one
iii. after spontaneous or induced abortion, amniocentesis, or chorionic villi sampling
17. When to worry
a. 1st Trimesterg bleeding, S/S of infection (fever etc), severe vomiting, low abdominal pain
b. 2nd Trimester (14-20 weeks) g regular contractions, leaking vaginal fluid, calf pain, dec. fetal movement
c. 3rd Trimesterg sudden weight gain, eye edema, severe upper gastric pain, HA + visual disturbances
+ any from trimesters 1 and 2
18. Immunizations that are Contraindicated In pregnant womeng due to being live viruses
a. MMRg give post partum ***
b. Influenza (Nasal) g need the inactivated one which is an injection
c. Varicellag need done in post partum
Mother g MMR
Is Not g Influenza (Nasal)
Vaccinated g Varicella
19. Normal Lab Values during 3rd trimester:
Hemoglobin
> 11 g/dL (110 g/L)
Hematocrit
> 33% (0.33)
RBC
5.00 – 6.25 x 106/mm3
WBC
5,000 – 15,000 /mm3
Platelets
150,000 – 400,000 /mm3
20. Normal Maternity values overall:
Fetal Heart Rate
120– 160 bpm
Variability
6 – 10 bpm
Amniotic fluid
500 – 1,000 mL at term
Contractions
2 – 5 min apart, duration < 90 s, intensity < 100 mmHg
SaO2
> 95%
ANTEPARTUM COMPLICATIONS:
1.
Spontaneous abortions
a. 1st trimesterg due to abnormal fetusg something makes it incompatible with life
b. later trimestersg issue with reproductive system specifically cervix
2.
Ectopic pregnancyg implants somewhere besides uterusg fallopian tubes most common
a. RFsg STIs, previous Sx, Hx of pelvic/uterine infections
b. S/Sg 6-8 weeks after missed periodg abdominal paing spotting
i. Symptoms typical of early pregnancyg breast tenderness, nausea, fatigue, shoulder/low back pain
c. S/S of rupturegthose of internal bleeding (dizziness w/ standingg low BPgconfusiong unilateral pain if in tube
d. Dxg i beta HCG, visualization
e. Txg Unruptured: single IM dose methotrexate; Rupturedg laprascopy/laparotomy + weekly bloodwork
3.
Placenta Previagplacenta implants in lower uterusg causes bleeding in 2nd or 3rd trimester
a. S/Sg intermittent, bright red bleeding with no pain
b. RFsg uterine fibroids or myomas, > 35 y/o, multiple fetuses in uterus, Smoking, HTN, Diabetes
a. Txg Bed Rest
a. Active bleedingg Pad count, V/S, FHTs, abdomen palpation
i. NO vaginal examsg delivery by c-section
4.
Abruptio Placentaeg a placenta in the normal location (upper 1/3 of uterus) separates from it at > 20 weeks
a. S/Sg constant knife like pain, dark red blood, rigid abdomen, tenderness on palpation
i. Report unusual bleeding (bleeding gums, IV oozing, etc.)
ii. Fetal distress or absent/decreased fetal movement
b. RFsg cocaine use, trauma to abdomen, smoking, membrane rupture for > 16-18 hrs g chorioamnioitis and can
lead to preeclampsia
c. Txg bed rest/left lateral position g immediate C section
5.
Placenta Accretag attachment of placenta in the too deeply into the wall of the uterus g can cause PPH and need for
emergency C-section and hysterectomy
a. Dxg prenatal screening via MRI or ultrasound; birth
b. RFsg placenta previa, advanced maternal age ( > 35 years old), smoking, previous cesarean births (h # of
cesarean births = h risk for accretea
c. Does not penetrate the uterine muscle
d. Placenta Accreta is further subcategorized as:
i. Placenta increta: placenta extends into myometrium
ii. Placenta percreta: placenta extends into myometrium, uterine serosa, and adjacent tissue
6.
Uterine rupture g often happens in women who give birth vaginally after a C-section
7.
Hyperemesis Gravidarumg vomiting from 1st into 2nd trimester leading to 5% weight loss
a. RFsg young mothers, obesity, h. pylori, had HG before, first pregnancy
b. Priorityg stop all intake of food and fluid for a period of time until no more vomiting
c. Drink liquids between meals, not with them
d. Txg NPO 24-36 hrs; IV or IM promethazine, prochlorperazine, ondansetron; IV NS + electrolytes
i. G-tube if oral intake is unsuccessful
8.
HTNg > 140 systolic and/or > 90 diastolic g no proteinuria in either of these
a. Chronic HTNg HTN developed before 20 weeks
b. Gestational HTNg HTN developed after 20 weeks
i. BP > 140/90 at least twice, taken 6 hours apartg same device and positions
ii. returns to normal by 12 weeks’ postpartum
9.
Pre-eclampsia g Eclampsia
a. Pre-eclampsia is very dangerous and is related to maternal High Blood Pressure.
b. Initiate seizure precautions
c. Plan on administering magnesium sulfate (mag)
d. Goal is to prevent it from advancing to seizures (eclampsia)
e. Need to check deep tendon reflexes though; do not want to give so much mag that DTR are absent
f. RFsg chronic or gestational HTN, Adolescent, abruptio placentae or chorioamnionitis, PROM for > 16-18 hrs,
pregnant with multiple fetuses
10. Magnesium Sulfateg vasodilator, prevents seizures from eclampsia
a. 4-6 g loading dose, then 1-4 g/hour
b. Reversal agentg Calcium gluconate (give if hypotension, i DTR, i RR < 12 ), i U/O, blurry vision
c. Normal magnesium levels are 1.3-2.1
11. Give Tdap to mom to give passive immunity to fetus in every pregnancy ***
12. Eclampsiag generalized seizure that begins with facial twitching
a. Priority is oxygenation
b.
Turn to side lying positiong stay with herg call for help (do not leave her)g raised bed rails with padding
i. Valium may be given at bedside to stop seizure
ii. After seizureg continue patient on magnesium sulfateg monitor FHTg put O2 on herg quiet and dim
environmentg document timeg prepare for delivery (patient will be sent to delivery room ASAP)
S/S of Preeclampsia and Eclampsia:
Symptoms
Blood pressure
Proteinuria
Seizures/coma
Hyper-reflexia
Edema
Headache
Urine output
Vision
Cerebral
Epigastric Pain
Mild Pre
-
>140/90mm Hg
1+
No
No (2+ is normal)
Mild-hands/face
No
Normal (30 mL/hr)
—
—
—
Severe Pre
-
>160/100 mm Hg
>3+
No
Yes (3+ or more)
Can worsen
Yes
Oliguria
Blurred/blind spots
Disturbances
Yes
HELLP syndrome
Eclampsia
-
>160/110 mm Hg
Marked
Yes
Yes
Generalized/above waist
Severe
Renal failure
Disturbances
Hemorrhage
Yes
13. Amniotic Fluidsg normal is approx. 1,000 mL at termg minor daily fluctuations
a.
Oligoydramniosg < 500 mL at 32-36 weeks
i. Causes of itg fetal renal abnormalities, uteraoplacental insufficiency, post-date pregnancy
ii. Complicationsg surgical delivery and low birth weight infants
b.
Hydramnios aka polyhydramniosg > 2,000 mL at 32-36 weeks
i. RFsg maternal diabetes and maternal diseases
ii. Caused byg neural tube/CNS defects or GI tract defects in fetus
iii. S/Sg dyspnea and fundal height > gestation
iv. Complicationsg PROM, cord prolapse, preterm delivery
14. Membrane ruptureg PROM is 38 weeks or more; PPROM is < 38 weeks
a. RFsg UTI, smoking, low socioeconomic status
b. Testing fluidsg nitrazine paper turns bluegferning under microscopegspeculum inspection shows fluid pooling
c. Concernsg cord compression/prolapse, infection, immature fetal lungs (give betamethasone)
d. Infection S/S:
i. h maternal temperature and pulse rate
ii. Abdominal/uterine tenderness
iii. Fetal tachycardia more > 160 bpm
iv. h white blood cell count (> 10,000) and h C-reactive protein
v. Cloudy, foul-smelling, or yellow amniotic fluids
15. Gestational diabetesg develop Type II sometime during pregnancyg insulin resistance
a. RFsg age > 25; Hx of HTN, fam or personal diabetes, BMI > 30
i. Previous baby > 4,000 g or 9 lbsg previous fetal death or anomaly
ii. PCOS, yeast infections, smoker
iii. Hispanic, African American, Native American, Pacific Islander
b. BG done at first prenatal visit if at risk g Normal = fasting glucose < 126 mg/dL
c. Blood glucose challenge at 24-28 weeks if no risk factorsg 1 hour testg abnormal if > 140 mg/dL
i. If abnormal, do a 3 hour challenge done at a later time to dx gestational diabetes
d. Regularly monitorg Urinary protein, ketones, Creatinine, HbA1C
i. Eye exams
ii. nitrates in urine are indicative of infection
iii. Weekly NSTs, BPP prng amniocentesis for fetal lung maturity at 34 weeks
16. TORCH infectionsg infections that can cross the placenta and have teratogenic effects on fetus
a. T- Toxoplasmosis
i. Caused by raw or undercooked meat or handling cat feces
ii. S/S: usually none; otherwise may experience s/s similar to influenza or lymphadenopathy
(malaise, muscle aches, fever, tender lymph nodes, flu-like symptoms)
b.
O- Other (Group B Strep, HIV, Syphilis)
c.
R- Rubellag can cause miscarriage, congenital anomalies in fetus, and fetal death
i. S/S: joint and muscle pain; rash; fever
d.
C- Cytomegalovirus
i. S/S: none, or mononucleosis-like manifestations
e.
H- Herpes Simplex Virus (HSV)g can cause miscarriage, preterm labor, and intrauterine growth restriction
i. Can also pass it on to infant during birthg risk highest in vaginal birth with active lesions
ii. S/S: painful blisters and tender lymph nodes
17. Contraindicated & Teratogenic Medications during Pregnancy
INTRAPARTUM CARE:
1.
Gynecoid pelvis is best for vaginal delivery
2.
True vs False Labor
Parameters
Contraction
timing
Contraction
strength
Contraction
discomfort
Change in activity
Stay or Go?
3.
True Labor
False Labor
Regular
Progressiveg become closer together
4-6 min. apart lasting 30-60 sec.
Become stronger over time
Vaginal pressure usually felt
Starts in back and radiates to front
Irregular
Not becoming closer together
Contractions continue no matter what
positional change is made
Stay home until contractions are 5 min apart
and 45-60 seconds OR cannot talk through
them
Contractions stop or slow with walking or
positional change
Drink fluids and walk. If contractions diminish,
stay home
Weak; not getting stronger
Usually felt in front of abdomen
Labor Stages
Fist Stage
Effacement and dilation of
cervix
(onset of labor until
completely dilated)
Three stages –
Latent: 0 -6 cm cervical
dilation
Active: 6-10 cm (complete)
cervical dilation
Transition- Getting ready to
push
Mother is talkative and eager
in latent phase,
becoming tired, restless,
anxious as labor intensifies
and contractions become
stronger
Second Stage
Expulsion of fetus
(30 min to 3 hrs)
Third Stage
Separation of placenta
(takes a few min- 30 min)
Fourth Stage
Physical recovery
(right after delivery for 1-4
hours)
Pushing stage
Expulsion of placenta
1-4 hr after expulsion of
placenta
Mother has intense
concentration on pushing
with contractions; may fall
asleep between contractions
Mother is relieved after birth
of newborn; mother is
usually very tired
Mother is tired, but is eager
to become acquainted with
her newborn
Nursing responsibilities:
- Assess FHR & contractions
q 15 min
- Document communication
with HCP
- if AROM need to listen to
FHR for 1 min
Nursing responsibilities:
- Assess FHR & contractions
q 5 min
- Allow rest between pushing
- Encourage her
Bonding
Nursing responsibilities:
- Assess fundus & perineum
- Placenta and membrane
examination x2
Nursing responsibilities:
Watch for :
-PPH, bladder distention
-check that fundus is still firm
a.
NCLEX Note: What do you do when a pt comes in and she is in active labor?: nurses FIRST action is to listen to fetal rate/tone
4.
Determining Cervical Dilation and Effacement
a. Full term, no matter whatg do a vaginal exam
b. Pretermg limit the number of vaginal exams if membranes are rupturedg but if in active labor you will need to
assess to get a baseline
5.
Cranial sutures allow for overlapping of skull to squeeze thru canal during labor
6.
Lieg C-Section needed if baby in transverse lie or breech (frank breech can attempt vaginal delivery but all other breech
types need C section)
7.
Presentationg vertex/cephalic is best
8.
Left occiput anterior (LOA) is most common and favorable fetal position for birthing
a. Posterior occiput more painful and causes back pain, baby born facing ceiling
First letter
Presenting part on Left or
Right side of the woman’s
pelvis
9.
Second Letter
Presenting part
Occiput,
Mentum (chin), or
Sacrum
Third Letter
Front or back of the woman’s
pelvis
Anterior, Posterior, or
Transverse
Stationg in cm g +/a. 0 station is when presenting part at ischial spines of mother
b. (-) g 0 g (+)
c.
NCLEX Note: If laboring mom's water breaks and she is any minus station, then there is a risk of prolapsed cord
10. Documentation: Cervical Dilation, Effacement, and Station
a. How we document this:
i. Dilation cm 1st
ii. % Effacement 2nd
iii. Station 3rd
b. Example: halfway dilated, halfway effaced, and 3 cm above ischial spineg 5/50/-3
11. Contractions
a.
Frequencyg how often they occurg beginning of one
contraction to beginning of the next (in minutes)
i. If contractions are too frequent, the relaxation period i and
the lack of blood flow can cause baby to become hypoxic
b.
Durationg how long it lastsgmeasured from beginning of one
contraction to end of same one (in seconds)
c.
Intensityg strength of contractiong can feel top of fundus
during contraction
i. fundus during a mild one feels the tip of your nose if you press
on it
a. Normal— contractions are 4-6 min. apart lasting 30-60 sec.
b. Hypertonic (aka Tachysystole)— means ³ 5 contractions in 10 mingno relaxation or
rest interval between contractions
c. Hypotonic— £ 3 contractions in 10 ming usually happens during dilation part of
labor, around 4 cm
i. Possible Causes: overstretching of the uterus (possibly from a macrosomnia
baby, or multiple fetuses in uterus)
ii. lack of contractions puts woman at risk for PPH (no contractions to stop the
bleeding)
Normal
Hypertonic
Hypotonic
12. FHR
a.
b.
Moderate variabilityg good thing, indicates baby doing well (variability of 6-25 bpm)
Minimal variabilityg concerning, change in baby status from moderate g could be simply baby went to sleep,
so just need to monitor it ( variability £ 5 bpm)
c.
Accelerations (Increased FHR)g increases in FHR by 15 bpm+ for 15 seconds (15 x 15) rule
iv. This is goodg denotes healthy fetusg often due to fetal movement
Decelerations
v. Both Early and Late decelerations are shaped like a “U”
vi. Early decelerationsg occur with start of contraction and returns to baseline at end of the contraction
d.
vii. Late decelerationsg deceleration occurs after the start of the contractiong Late decelerations are
MOST concerning! Because indicate lack of O2 to fetus Late = Lethal (potentially)
viii. Variable decelerationsg abrupt decreasesg have a “variable” onset which means they occur at any
point before, during or after a contractiong go down quickly and come back up quickly
1. Variable decelerations are shaped like a “V”
13. Monitoring Fetus—NST and BPP
a. NST— measure of utero-placental fxn by measing FHR
ix. 15x15 rule is good and reactive
b. BPP—score of 8 or more is normal
c. Internal vs External monitoring
x. External allows freedom of movement but may not catch important FHTs
xi. Internal requires membrane rupture, 2-3 cm dilation, and used in high risk only; electrode into fetal
scalp
Fetal Heart Monitoring Changes- VEAL CHOP TO A STOP
V
Fetal Heart Observation
Variable decelerations
C
Related To
Cord compression
Early decelerations
H
Head compression
O
Intervention
Turn patient on side to relieve
pressure on cord
OK-no intervention needed
E
A
Accelerations
O
Okay! (normal)
A
Acceptable- no intervention
L
Late decelerations
P
Placental insufficiency
S
T
O
P
Stop Pitocin/Oxytocin
Turn pt. on side
O2 via facemask
↑ Plain IV fluid
g
g
T
14. Maternal positiong encourage movement
d.
Squatting enlarges the pelvisgeasier to deliver this way because it helps with fetal descent due to gravity ***
a.
Kneeling helps rotate the fetus
15. Supineg mother laying on vena cavag reduces blood flow to placenta and back to heart
a. Other positions are betterg gives mother control, reduce use of labor assisted deliveries, reduce
tears/episiotomies, and help fetal gravity descent
16. Meds
a. Misoprotosol—ripen cervix—must wait 4 hrs after last dose of it to start on oxytocin
b.
Oxytocin—IVPB to start or augment labor; also given after labor to stop PPH
c.
Butorphanol to take edge off
d.
Anti emetics to potentiate med (Promethazine, Hydroxyzine)
17. Epiduralg no getting up afterwardsg insert foleyg local anesthetic then opioid injected
a. SE is hypotensiong give fluids before and during
18. Placenta
a. Gush of dark red blood once placenta separates
b. Umbilical cord lengtheningg happens because once placenta detaches cord will be getting closer to you
c. Firm fundusg if not firm, then you need to massage it to firm it up in order to prevent blood loss
xii. With a firm fundus g normal bleeding is intermittent like a period
1. Bright, red, continuously trickling blood is NOT normalg indicates internal laceration
xiii. If the fundus is “boggy”(will feel like a bag of IV saline)g abnormal is bright red flowing blood and dark
blood with clots
INTRAPARTUM COMPLICATIONS:
1.
Preterm Labor (PTL)g < 37 weeks
a. Management:
i. Tocolyticg Magnesium Sulfateg relaxes uterine muscle to stop and prevent contractions
ii. Corticosteroidsg betamethasoneg helps mature the fetus’ lung
b.
iii. Testingg Fetal fibronecting produced by the fetus and found in the cervixgif test is positive (+) it
means that the woman will probably rupture her membranes in the next two weeks
RFs for PTLg mom < 18 or ³ 35 y/o, African American, Low Socioeconomic status, Alcohol/drugs, Hx of it,
Diabetes or HTN, Multiple fetuses in pregnancy, PROM
2.
Prolonged labor g over 42 weeks
a. Risks associatedg placental insufficiencyg macrosomiag Cephalopelvic Disproportion
b. NST twice a week and daily fetal movement monitoring
3.
Labor induction
a. Indicated ifg uterine infection, post term, bad HTN, gestational diabetes, PROM, placental insufficiency, non
reactive NST
b. Contraindicated ifg abruption, transverse lie, prolapsed cord, previous c section, mom has active genital herpes
4.
Bishop Scoreg Lower the score, Longer the Labor = give them misoprostol if score is £ to a 6
a. Score of 8 means labor is going along fine and well
5.
Assess contraction and fetal heart rate patterns:
a. q. 15 minutes in first stage
b. q. 5 minutes in second stage
6.
Dystocia: Abnormalities in Length of Labor
a. Arrested dilation— when woman stops dilating/fetal head not engaging and still in the (-) for 2 or more hours
b. Arrested descent of the head— no fetal head descent in station for 1 or more hours
c. Protracted disorders— means L&D lasts more than 18-24 hours
d. Precipitous— starts and ends in 3 or less hours
e. Shoulder Dystociag anterior shoulder can't get past symphysis pubis g can cause Brachial plexus injury
i. Brachial Plexus Injuryg all on affected side
1. Arm limp, no Moro Reflex, weak or absent grasp reflex on affected side
2. Affected shoulder and arm are adducted, extended, and internally rotated with a pronated
wrist
ii. McRobert’s Maneuverg do if shoulder dystociag pull mother’s legs back toward her abdomen; may
also use application of suprapubic pressure with this
7.
Placenta previag do C section
8.
Cord Compression
a. May be caused by prolapsed cord
b. Place mother in the Trendelenburg positiong this removes pressure of the presenting part off the cord. (If her
head is down, the baby is no longer being pulled out of the body by gravity)
9.
Prolapsed Umbilical Cord
a. RFsg hydramnios, grandmultiparity, premature, multifetal, rupture membranes at high station
b. Interventionsg Trendelenburg and knee-chest position
i. Trendelenburg to alleviate pressure on the cord and minimize reduction in blood flow
ii. If on bed restg flip mother over into knee-chest position
iii. If nurse sees the cordg lift presenting part off of it and hold it like that
iv. Cover cord with sterile saline gauze to prevent drying of the cord and to minimize infection
v. Emergency C section
10. Abruptio Placentaeg placenta separates from uterus
a. Priorityg cardiovascular status of the mother (watch BP) + Delivery of the fetus quickly by C/S if alive
i. Deliver vaginally if the fetus is not alive
b. RFsg uterine rupture, seizure, trauma, coagulation issues, HTN, cocaine and smoking
11. Uterine Rupture g tearing of uterus at site of previous C/S scarg most often occurs at site of a classical incision
a. Main concern is hemorrhage
b. First and most reliable sign is sudden fetal distress
c. Acute, continuous abdominal pain with or without epidural, irregular abdominal contour, Loss of the station
12. Amniotic Fluid Embolismg suspect in any woman with sudden dyspnea
a. Break in barrier between mom circulation and amniotic fluid ie from abruption
b. Sudden hypotension, hypoxia (RAT), and poor clotting
13. Amnioinfusion procedureg infuse warm, sterile NS or LR via IUPC after membranes ruptured via IV 20-30 min
a. Watch for hypertonic uterus
b. Observe pad under mother for leaking infused liquidg want clear fluid draining
c. Indicationsg oligohydramnios, meconium stained fluid, variable decelerations
d. Contraindicatedg amnionitis, hydramnios, hypertonic uterus, abruption or previa
14. Assisted Delivery Devices
a. Forcepsg performed by HCP
b. Vacuum extractiong nurse needs to track # of unsuccessful tries (after 3 tries it wont work)
15. Vaginal Birth after Cesarean (VBAC)
a. RF rupture and hemorrhage
b. Contraindicated if women has had classical incision before, previous rupture, or previous removal of uterine
fibroids (myomectomy)
Practice Questions
1. The nurse is explaining the events that lead up to ovulation. Which hormone would the nurse identify as being primarily
responsible for ovulation?
A) Estrogen
B) Progesterone
C) Follicle-stimulating hormone
D) Luteinizing hormone
Ans: D
2. A group of students are reviewing the signs of pregnancy. The students demonstrate understanding of the information
when they identify which as presumptive signs? (Select all that apply.)
A) Amenorrhea
B) Nausea
C) Abdominal enlargement
D) Braxton-Hicks contractions
E) Fetal heart sounds
Ans: A, B
3. Which of the following would indicate to the nurse that the placenta is separating? (Select all that apply)
A) Uterus becomes globular
B) Fetal head is at vaginal opening
C) Umbilical cord lengthens
D) Mucous plug is expelled
E. Increased level of Pain
Ans: B, C
5. A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse reviews the woman’s medical
record to ensure which of the following as being required?
A) Intact membranes
B) Cervical dilation of 2 cm or more
C) Floating presenting fetal part
D) A neonatologist to insert the electrode
Ans: B
6. Which of the following data on a client’s health history would the nurse identify as contributing to the client’s risk for an
ectopic pregnancy?
A) Use of oral contraceptives for 5 years
B) Ovarian cyst 2 years ago
C) Recurrent pelvic infections
D) Heavy, irregular menses
Ans: C
7. Which assessment finding would lead the nurse to suspect infection as the cause of a client’s PROM?
A) Yellow-green fluid
B) Blue color on Nitrazine testing
C) Ferning
D) Foul odor
Ans: D
8. A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for
possible infection. Which of the following would lead the nurse to suspect that the woman is developing an infection?
(Select all that apply.)
A) Fetal bradycardia
B) Abdominal tenderness
C) Elevated maternal pulse rate
D) Decreased C-reactive protein levels
E) Cloudy malodorous fluid
Ans: C, E
9. A nurse is assessing a pregnant woman with gestational hypertension. Which of the following would lead the nurse to
suspect that the client has developed severe preeclampsia?
A) Urine protein 300 mg/24 hours
B) Blood pressure 150/96 mm Hg
C) Mild facial edema
D) Hyperreflexia
Ans: D
10. A nurse is assessing a pregnant woman with gestational hypertension. Which of the following would lead the nurse to
suspect that the client is developing preeclampsia?
A) Urine protein 2+
B) Blood pressure 150/96 mm Hg
C) Mild facial edema
D) Hyperreflexia
Ans: A
11. A woman with gestational hypertension experiences a seizure. Which of the following would be the priority?
A) Fluid replacement
B) Oxygenation
C) Control of hypertension
D) Delivery of the fetus
Ans: B
POSTPARTUM CARE:
- Involution: Uterus, cervix and vagina return to pre-pregnant sizeg Takes up to 6 weeks
• Uterus decreases in size 1cm/day (1 fingerbreadth) a dayg uterus size decrease by 1cm/day
• Fundus not palpable after ≈ 10 days after delivery
- After-pains: contractions after postpartumg d/t breast feeding since oxytocin is released during breast feeding; walk to
make them go away
- Lochiag postpartum bleeding that women have
Rubra
Serosa
Alba
- bright red bloody with small clots
d/t removal of placenta and vessels
- Fleshy odor
- pink to pink brown
- serous, no clots; thin and watery
- No odor
- yellowy- creamish looking color
with minimal flow
- No odor
- 1 - 3 days PP
- 5 -7 days PP
- 1 - 3 weeks PP
- Heavy to moderate flow like a
heavy period (8-9 oz)
- Decreased flow
- Scant
•
•
Never back-staging
Saturation within 15 min - 1 hr = BAD; possible PPH
r Scant: < 2” stain
r Light: < 4” stain
r Moderate: < 6” stain
r Large: > 6” stain in 2 hours
- Body Changes PP
• Hematocrit stays stable or h due to plasma reduction, this is normal
r Acute i in hematocrit is unexpected and a sign of shock
•
•
•
•
•
•
•
•
•
•
•
•
•
Pulse i to (40-60 bpm) = normal
Still in a Hypercoagulable state for 2-3 weeks PPg Increased risk for DVTs and PE during this time
RF constipation
Voiding may cause difficulty d/t anesthetic block, oxytocin, laceratiosn or swelling hematoma
r Full bladder causes atony and displace uterus
PP output of 3,000 mL/day normal
r < 150 mL per void may indicate retention
r No void in 4-6 hours post delivery may require cath
r Help pee by warm water on perineum and running water sound, stand up, etc
Permanent inc shoe size *
Fatigue/exercise intolerance due to i Progesterone and Relaxin
Darkened pigment to face, abdomen and nipples fade with i estrogen and progesterone
Temporary hair loss can occur within 3 months of delivery due to i estrogen levels
Profuse diaphoresis= effort to rid body of extra fluid; can cause chills but is normal
r Sweating can be enough that a woman is chilledg body’s way to reduce the pre-delivery fluid
RR is 16 – 24
r Diaphragm back to normal position and lung fxn improves
i estrogen = breast engorgement g breast feed to alleviate
r Estrogeng kept low with breastfeeding, and is dependent on frequency of breast feeding
r Progesteroneg levels begin to increase again with menstrual cycle
r Prolacting remains elevated in women who are breastfeeding (returns to normal for those who aren’t)
Sucking stimulates:
r Prolactin stimulates milk production **
r Oxytocin causes the let down release of milk **
•
•
Colostrum first = high protein and carb but not fat
True milk starts day 2-3 thru 4-5
- Postpartum Assessment—within 1 hr of delivery
• Temp 100.4 normal first 24 hrs
r Infection = > 100.4
r Fever = 100.4 after 24 hrs
• HR of 40 – 60 bpm is normal first week
• Pain
r Persistent perineal pain after meds = possible hematoma
r Non-opioid vaginal delivery
- Fundal massage technique
• Non-dominant hand on pubis symphysisg to protect lower segment of uterus from coming through the cervix
• Dominant hand on fundusg make sure it is firm; Rub in circular motion to make it firm if it is not already
- Comfort Measures
• Ice packs, numbing spray, sitz baths
• Peri bottle should be used on perineum to cleanse it **
- Predisposition to DVTg venous stasis, hypercoagulability, localized vascular damage
• Venous stasisg compression of the large veins by gravid uterus slows blood flow back to the heart
r Leads to pooling blood to the feet and legs
r Can lower risk by moving her legs, being active as long as she is able to get up and walk, increasing fluids,
compression stockings
r Need to educate patient about s/s of dvt
• Hypercoagulabilityg simply due to pregnant state
• Localized vascular damageg can occur during the birthing process; damage causes activation of the body’s clotting
mechanism
- DVT
•
Triad – venous stasis, hypercoagulability, localized vascular damage
r Dec RF venous stasis by moving legs, walk, inc fluids, compression stockings
r NOTE: use of compression stockings as part of ongoing DVT treatment plan is currently debated, with some
research showing it being beneficial and others saying the risk of dislodging the thrombus outweighs the
benefits. Go by what you instructor tells you for testing purposes as more research comes out. **
•
S/S—Edema (usually left calf), pain, warmth/redness, low fever, tightness/aching in lower extremity relieved by rest
- Psych Responses –taking in, taking hold, letting go
- Bonding—the emotional attraction that starts in the first 30-60 min to a few hours after the birt
• Baby recognize moms voice
• Spend as much time with baby as possible
- Attachment— strong affection between the infant and mother or significant other
• Skin to skin ASAP once cord cut
- Cultural influences—some asian cultures think colostrum is dirty
• DO NOT give honey or tea while waiting for true milk to come in!
- Breastfeeding—CANNOT be done if mom has HIV, infant has galactosemia, or mom uses street drugs
• Initiate 30-60 min after birth
• Rooming in and lactation consultant to help
• Inc calories by 500 cal/day and Inc fluids by 2 quarts/day
• Baby up and crying = hungry; never let sleep longer than 3 hrs in row they need the food
• Lanolin cream only
- Breast Care
• Wear well fitting, supportive bra 24 hours/dayg bra should not be too tight (can i milk expression)
• Ice packs can be applied to sore breasts
• In shower stand with back to water in shower
• Air dry breasts after feedingg apply lanolin cream once dry
- Bottle-feeding— takes 1 week to 10 days for bottle feeding mother to stop milk stimulation
• No heat to breasts
r Stand with back to water while showering
• No pumping/manual stimulation of breasts
• Ice to breasts to reduce production
• Cold cabbage leaves to help dry it up
• Wear supportive bra 24 hrs/day
- Can still get pregnant after birth even without period yet
POSTPARTUM COMPLICATIONS:
•
PPD most common complication
- Postpartum Hemorrhageg loss of blood
• Leading and most preventable COD in PP womeng likely d/t underestimated blood loss
r Vitals aren’t affected until lots of blood loss has occurred
r Hypovolemic shock (tachycardia, hypotension) are late symptoms
r Confusion not until 2,000 mL blood loss
•
Usually occurs within 4 hrs of delivery; consequence of 3rd stage of labor
r > 500 mL after vaginal birth
r >1000 mL after cesarean birth
r Major obstetric hemorrhage: > 1,500-2,000 mL blood loss and/or need for more than 5 units of blood
•
Early PPHg within 24 hours after birth
r Uterine atony aka poor uterine tone
r Lacerations from trauma
r Hematoma
Late PPHg 24 hours to 12 weeks after birth
r Subinvolution of the uterus
r Clotting disorders
•
•
•
Risk Factors for PPH
Labor
- Prolonged— lax
uterus
- Precipitous— can
cause trauma to
vaginal area or cervix
- Use of oxytocin can
also be a risk factor
Fetus
- multiple gestation
- large fetal head
- large baby > 4000g
- woman who has
had many babies
(grand multipara)
Uterus
- infection
- manual placenta
extraction
-hydramnios
(d/t overdistention
during pregnancy)
Maternal
- preeclampsia
- coagulopathies
Delivery
- vacuum extraction
- forceps extraction
- 5+ pregnancies
- Previous PPH
- If she has > 40 BMI
- Known coagulopathy
- Prior uterine surgery
- Baby more than 4,000g
- Low platelet count
- Infection
- Pushing for a long time
- Acreta
- Use of oxytocin for 24+
hrs during labor
- Poor progression of
labor
Causes of PPH
r Toneg abnormal uterine muscle tone
- Uterine atonyg d/t distended uterus in pregnancy *, distended bladder PP *; anesthesia, mag sulfate,
bacterial toxins
Ø Tx: Fundal massage, Fluid bolus + LRs, uterine stimulant meds
- Overdistended uterusg d/t hydramnios, multiple gestation, macrosomia
- Muscle fatigueg d/t prolonged, rapid, or forceful labor, oxytocin
- Inflammation due to infectiong d/t prolonged membrane rupture
r Tissueg placental tissue
- Retained Placenta Fragments (RPOC) g may lead to uterine inversion, fundal prolapse, subinvolution
- Subinvolutiong uterus not involuting completely or failure to return to normal state agter birth
Ø d/t retained placenta fragments (RPOC), distended bladder, infection, or uterine myoma
Ø Prevention: inspect placenta
Ø S/S: boggy uterus, abnormal lochia progression, PP fundal height too high
Ø Tx: prophylaxis antibiotics, uterine stimulant meds
-
Placenta accrete, increta, percreta
Placenta previa and placenta abruption
r Traumag physical injury
- Lacerations—continuous trickling of bright red blood w/ contracted/firm fundus uterus
Ø d/t precipitous delivery, malpresentation of fetus, pushing too soon, forceps/instrument delivery **
Ø Hall HCP ASAP!!!
- Uterine rupture—d/t VBAC when classical incision
- Hematoma—collection of blood; change in VS will be disproportionate to blood loss
Ø Bluish purple + pain is emergent
Ø Skin colored is non emergent—ice packs, donut to sit, pain meds
r Thrombing coagulation issuesg typical to see i platelet and fibrinogen, h PT and PTT, prolonged bleed time
- ITPg antibody destruction of platelets
- vWDg decrease in vWd leads to impaired platelet fxn and prolonged bleeding
Ø autosomal dominant
Ø S/S: nosebleeds, menorrhagia, hematomas
- DICg abnormal clotting system activation, so clot and bleed at same time
Ø Emergency and always a secondary dx, so fix the underlying cause
Ø S/S: bleeding from multiple sites, bleed in abnormal places, abnormal labs
r Tractiong excessive pulling on umbilical cord during delivery
- Uterine inversion—pull uterus thru cervix; HCP needs to gently reinsert it
- Placenta fragments left behind
- Thromboembolic Conditions
• Superficial venous thrombosis
• DVT—warmth, redness, edema, pain in lower extremities
• PE—sudden SOB/chest pain; anxiety/diaphoresis, change in LOC, h RR, h HR, i BP, i pulse-ox
- Postpartum Infectiong Fever of 100.4 or more after first 24 hrs that occurs for at least 2 out of first 10 days PP
• Puerperal sepsisg genital tract infection
• Metritisg uterine lining infection
• Wound Infection
• UTIg frequent urination of small amounts + pain with urination
• Mastitisg clogged milk duct leading to infection
Call 911
if you have:
Call your HCP
If you have:
(if can’t reach HCP,
go to ER or call 911)
P ain in chest
O bstructed breathing or shortness of breath
S eizures
T houghts of hurting yourself or your baby
B leeding, soaking through one pad per hour, or blood clots the size of an egg or bigger
I ncision that is not healing
R ed or swollen leg that is painful or warm to touch
T emperature of 100.4 or higher
H eadache that dosen’t get better even after taking meds, or bad HA + vision changes
- Postpartum Affective Disordersg use Edinburgh Depression Scale
• Baby Blues
• Postpartum Depression
• Postpartum Psychosis
- Meds for Treatment of PPH:
Medication
Dosage
Nursing Considerations
oxytocin (Pitocin)
**
- 20-40 units/L IV
infusion or
- 10 units IM (for
lesser bleeds)
- Give as a bolus IVBP to a Lactated Ringer
as soon as shoulder is delivered (usually
over 4 hours)
- Assess fundus for evidence of
contraction and compare
amount of bleeding q15 min
- Monitor VS q15 minutes
- Monitor uterine tone to prevent
hyperstimulation
- Never give as an undiluted IV bolus
misoprostol
(Cytotec)
- 800 mcg rectally
(PR)
- used to
ripen/soften cervix
dinoprostone
(Prostin E2)
- 20 mg vaginally
or rectally
- Use with caution in women with asthma
- Know healthy hx prior to giving it
- Never give if drug allergy
- Contraindicated if active CVD or hepatic
disease
- Monitor BP frequently
- Contraindicated if active cardiac,
pulmonary, renal, or hepatic disease
prostaglandin
PGF2a
(Hemabate)
0.25mg IM
methylergonovine
(Methergine)
**
- 0.2mg IM
- Then continue as
PO after acute
bleeding stops
- May be repeated q15-90 min up to 8
doses
- Contraindicated if active cardiac,
pulmonary, renal, or hepatic disease
- Assess baseline bleeding, uterine tone,
and VS q15 minutes or per protocol
- Contraindicated with current HTN
- Report any complaints of chest pain
promptly!!
SE/Adverse Effects
- hypotension
- N/V/D
- temperature elevation
- Fever, chills, flushing
- Headache, N/V/D
- Bronchhospasm
- HTN, seizures,
- uterine cramping
- nausea, vomiting
- palpitations
Practice Questions
1. A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client’s fundus,
expecting it to be at which location?
A) Two fingerbreadths above the umbilicus
B) At the level of the umbilicus
C) Two fingerbreadths below the umbilicus
D) Four fingerbreadths below the umbilicus
2. The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which of the following
would the nurse include in the teaching plan to facilitate suppression of lactation?
A) Encouraging the woman to manually express milk
B) Suggesting that she take frequent warm showers to soothe her breasts
C) Telling her to limit the amount of fluids that she drinks
D) Instructing her to apply ice packs to both breasts every other hour
3. A client who is breast-feeding her newborn tells the nurse, “I notice that when I feed him, I feel fairly strong contraction-like
pain. Labor is over. Why am I having contractions now?” Which response by the nurse would be most appropriate?
A) “Your uterus is still shrinking in size; that’s why you’re feeling this pain.”
B) “Let me check your vaginal discharge just to make sure everything is fine.”
C) “Your body is responding to the events of labor, just like after a tough workout.”
D) “The baby’s sucking releases a hormone that causes the uterus to contract.”
4. A group of students are reviewing the process of breast milk production. The students demonstrate understanding when
they identify which hormone as responsible for milk let-down?
A) Prolactin
B) Estrogen
C) Progesterone
D) Oxytocin
5. A nurse teaches a postpartum woman about her risk for thromboembolism. Which of the following would the nurse be
least likely to include as a factor increasing her risk?
A) Increased clotting factors
B) Vessel damage
C) Immobility
D) Increased red blood cell production
6. The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which of the following would be a
priority?
A) Placing the call light within her reach
B) Teaching her how the sitz bath works
C) Telling her to use the sitz bath for 30 minutes
D) Cleaning the perineum with the peri-bottle
7. A group of students are reviewing the causes of postpartum hemorrhage. The students demonstrate understanding of the
information when they identify which of the following as the most common cause?
A) Labor augmentation
B) Uterine atony
C) Cervical or vaginal lacerations
D) Uterine inversion
8. When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum
hemorrhage based on the knowledge that:
A) These measurements may not change until after the blood loss is large
B) The body’s compensatory mechanisms activate and prevent any changes
C) They relate more to change in condition than to the amount of blood lost
D) Maternal anxiety adversely affects these vital signs
9. A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is
experiencing subinvolution based on which of the following?
A) Nonpalpable fundus
B) Moderate lochia serosa
C) Bruising on arms and legs
D) Fever
10. A nurse is massaging a postpartum client’s fundus and places the nondominant hand on the area above the symphysis
pubis based on the understanding that this action:
A) Determines that the procedure is effective
B) Helps support the lower uterine segment
C) Aids in expressing accumulated clots
D) Prevents uterine muscle fatigue
11. A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect
that the client may be developing postpartum delirium?
A) “I just feel so overwhelmed and tired.”
B) “I’m feeling so guilty and worthless lately.”
C) “It’s strange, one minute I’m happy, the next I’m sad.”
D) “I keep hearing voices telling me to take my baby to the river.”
Ans: 1. C
2. D
3. D
4. D
5. D
6. A
7. B
8. A
9. B
10. B
11. D
Common Terms Used in Obstetrics
AMA—advanced maternal age; defined as pregnancy at age 35 or older
APGAR—score of 1 to 5 assigned to newborns that assesses five parameters –
1. heart rate (absent, slow, or fast)
2. respiratory effort (absent, weak cry, or good strong yell)
3. muscle tone (limp, or lively and active)
4. response to irritation stimulus
5. color
These are used to evaluate a newborn’s cardiorespiratory adaptation after birth.
Ballottement— the examiner pushes against the woman’s cervix during a pelvic examination and feels a rebound from the
floating fetus; sign of probable pregnancy
Braxton Hicks contractions—spontaneous, irregular, and painless contractions. Braxton Hicks contractions are typically felt
as a tightening or pulling sensation of the top of the uterus. They occur primarily in the abdomen and groin and gradually
spread downward before relaxing
Breech—occurs when the fetal buttocks or feet enter the maternal pelvis first and the fetal skull enters last.
a.
b.
c.
d.
Frank breech
Complete breech
Single footing breech
Double footing breech
Caput succedaneum-fluid collecting in the scalp; presents as edema of the scalp at the presenting
part. This swelling crosses suture lines and disappears within 3 to 4 days. No pathological significance.
Cephalohematoma— bleeding between periosteum and skull bone appearing within first 2 days; does
not cross suture lines; localized subperiosteal collection of blood of the skull which is always confined
by one cranial bone characterized by a well-demarcated, often fluctuant swelling with no overlying
skin discoloration, usually appearing on the second or third day after birth and disappearing in weeks
to months. This condition is due to pressure on the head and disruption of the vessels during birth. It
occurs after prolonged labor and use of obstetric interventions such as low forceps or vacuum
extraction. Large cephalohematomas can lead to increased bilirubin levels and subsequent jaundice.
Cervix/cervical— the lower part of the uterus, is sometimes called the neck of the uterus. It opens into the vagina and has a
channel that allows sperm to enter the uterus and menstrual discharge to exit. Has an alkaline environment to protect sperm
from acidic environment in vagina.
a. Nulliparous cervical os (never birthed a child)
b. Parous cervical os (post child birth)
Cesarean section (C/S)—use of surgery to deliver a baby
Chadwick's sign—Cyanosis (blueish purple color) of vaginal and cervical mucosa, associated with pregnancy
Chadwick = Cyanotic
Colostrum—dark yellow fluid secreted in the days before milk production after childbirth. Contains more minerals and
protein, but less sugar and fat than mature breast milk, and rich in antibodies. Continues for about a week before start to
produce mature breast milk
Decelerations—decrease in FHR
Dystocia-labor—abnormal or difficult labor; can be influenced by Problem’s with the 4 Ps
- Problems with Power—dysfunctional uterine contractions
- Problems with Passenger—any abnormalities with the fetus; includes presentation (how the baby is positioned), size, etc.
- Problems with Passageway—issues with pelvis or birth canal; related to a contraction of one or more of three planes of
maternal pelvis (inlet, midpelvis, and outlet).
- Problems with Psyche—emotions such as anxiety lead to sympathetic nervous system stimulation, which relaes
catecholamines, which leads to myometrial dysfunction. Epinephrine and norepinephrine can lead to uncoordinated or
increased uterine activity.
Dystocia-shoulder—“shoulder presentation”; occurs when the fetal shoulders present first, with the
head tucked inside. The issue is that the anterior shoulder can't get past symphysis pubis in this
position. The head slowly emerges but then retracts back into vagina as you try to pull baby out (this
is called the “turtle sign”). HCP may try pulling on baby by the head to try to get it out. Can result in
brachial plexus injury.
Ectopic pregnancy—ectopic means “out of place”; any pregnancy in which the fertilized ovum implants outside the uterine
cavity.
EDD (EDC)—Estimated Due Date
Engagement— the stage of pregnancy when the baby’s head descends into the mother’s pelvis in preparation for birth.
Colloquially referred to as when someone’s baby bump “drops”.
Epidural anesthesia—general anesthesia used in birth
Fetal Heart Tones-(FHT or FHR)—the fetal heart rate (should be 110-160 bpm)
Fundus— convex portion of uterus above the uterine tubes; in other words, it is the top of the
uterus, and is palpable; it is used to measure the gestation based on height of uterus
Goodell's sign—softening of the cervix
Gravida/Gravidity—total number of times a woman has been pregnant, regardless if resulted in abortion of multiple births
Hegar's sign—include softening of the lower uterine segment or isthmus; softening of the fundus of the uterus, associated
with the first semester pregnancy
HELLP Syndrome—Life threatening pregnancy syndrome that requires emergent delivery; Do NOT need all 3 to be Dx with
HELLP!
Hemolysis
Elevated Liver enzymes
Low Platelets
Hydramnios (aka polyhydramnios)— a condition in which there is too much amniotic fluid (more than 2,000 mL) surrounding
the fetus between 32 and 36 weeks. Associated with fetal anomalies of development such as upper gastrointestinal
obstruction or atresias, neural tube defects, and anterior abdominal wall defects, together with impaired swallowing in
fetuses with chromosomal anomalies, such as trisomy 13 and 18.
Hyperbilirubinemia—total serum bilirubin level above 5 mg/dL resulting from unconjugated bilirubin being deposited in the
skin and mucous membranes. S/S include jaundice
Hyperemesis gravidarum—a severe form of nausea and vomiting of pregnancy associated with significant costs and
psychosocial impacts; persistent, uncontrollable nausea and vomiting that begins in the first trimester and causes
dehydration, electrolyte imbalance, ketosis, and weight loss of more than 5% of pre-pregnancy body weight
Isoimmunization—the development of antibodies against the antigens of another individual of the same species; Occurs
when Mother is RH – and fetus is RH +
Leopold's maneuver— a method for determining the presentation, position, and lie of the fetus through the use of four
specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for
malpresentation. A longitudinal lie is expected, and the presentation can be cephalic, breech, or shoulder.
To perform maneuver’s: start by placing the woman in supine position and stand beside her.
Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)?
Used to determine presentation
Facing the woman’s head, place both hands on the abdomen to determine fetal position in
the uterine fundus. Feel for the buttocks and head. A buttocks that feels soft and irregular
indicates a vertex position; a head that feels hard, smooth, and round indicates a breech
presentation
Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the
back of the fetus.)
Used to determine position.
While still facing the woman, move hands down the lateral sides of the abdomen to palpate on
which side the back is located (feels hard and smooth).
Continue to palpate to determine on which side the limbs are located (irregular nodules with
kicking and movement).
Maneuver 3: What is the presenting part? Used to confirm presentation.
Move hands down the sides of the abdomen to grasp the lower uterine segment and
palpate the area just above the symphysis pubis.
Place thumb and fingers of one hand apart and grasp the presenting part by bringing
fingers together. Feel for the presenting part.
If the presenting part is the head, it will be round, firm, and ballottable; if it is the
buttocks, it will feel soft and irregular.
Maneuver 4: Is the fetal head flexed and engaged in the pelvis? Used to determine attitude.
Turn to face the client’s feet and use the tips of the first three fingers of each hand to palpate
The abdomen. Move fingers toward each other while applying downward pressure in the
direction of the symphysis pubis.
If you palpate a hard area on the side opposite the fetal back, the fetus is in flexion, because
you have palpated the chin. If the hard area is on the same side as the back, the fetus is in
extension, because the area palpated is the occiput.
*Note how your hands move: If the hands move together easily, the fetal head is not
descended into the woman’s pelvic inlet. If the hands do not move together and stop because of resistance, the fetal
head is engaged into the woman’s pelvic inlet
Lightening—subjective sensation as fetus descends into the pelvic inlet. It occurs up to two weeks prior to delivery in
primipara and may not occur until labor begins for multipara
Linea Nigra—pigmented line of skin in the middle of the abdomen that extends from the umbilicus to the pubic
area; not all women develop this
Multigravida/multipara—woman pregnant for at least the third time/ woman who has had 2 or more pregnancies of at least
20 weeks gestation resulting in viable offspring
Nagele's rule—used to determine the due date of the child. Use the first day of her last menstrual period (LMP), then count
back 3 months and add 7 days.
Nullipara—woman who has produced no viable off spring (para 0)
Nulligravida—woman who has never been pregnant
Oligohydramnios—decreased amount of amniotic fluid (less than 500 mL) between 32 and 36 weeks’ gestation. May result
from any condition that prevents the fetus from making urine or blocks it from going into the amniotic sac
Para—number of times a woman has given birth to a fetus of at least 20 gestational weeks (viable or not); multiple births as
count as one birth event.
Pica—Craving and chewing substances that have no nutritional value, such as ice, clay, soil, or paper.
Placenta previa— a bleeding condition that occurs during the last two trimesters of pregnancy. In placenta previa (literally,
“afterbirth first”), the placenta implants over the cervical os
Placenta abruption—the premature separation of a normally implanted placenta after the 20th week of gestation prior to
birth, which leads to hemorrhage.
Preeclampsia & Eclampsia— multisystem, vasopressive disorder that targets the cardiovascular, hepatic, renal, and central
nervous systems. Can be classified as mild or severe with a potential progression to eclampsia.
Symptoms
Blood pressure
Proteinuria
Seizures/coma
Hyper-reflexia
Edema
Headache
Urine output
Vision
Cerebral
Epigastric Pain
-
Mild Pre
>140/90mm Hg
1+
No
No
Mild-hands/face
No
Normal (30 mL/hr)
—
—
—
-
Severe Pre
>160/100 mm Hg
>3+
No
Yes
Can worsen
Yes
Oliguria
Blurred/blind spots
Disturbances
Yes
-
Eclampsia
>160/110 mm Hg
Marked
Yes
Yes
Generalized/above waist
Severe
Renal failure
Disturbances
Hemorrhage
Yes
Preterm—the occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of
the 37th week of gestation.
Primigravida—woman pregnant for first time
Quickening— is the first time life or fetal movement felt by the mother. It is felt 16 to 20 weeks for a multipara and about 18
weeks by a primipara.
Rupture of the fetal membrane (ROM)—a commonly-used blanket term which includes the following conditions:
-
Artificial rupture of membrane (AROM): In certain cases where labor has been initiated but the amniotic membrane
has not been broken, a nurse may perform AROM to expedite delivery and reduce the risk of complications.
-
Spontaneous rupture of membrane (SROM): SROM is the most common kind of fetal rupture. Commonly referred to
as one’s “water breaking” (i.e. “My water just broke”); it is a natural part of labor that requires no additional
management or intervention.
-
Premature rupture of membrane (PROM): the rupture of the fetal membrane before the onset of labor. Occurring at
37 weeks or later, PROM is an easy-to-manage complication of an otherwise normal birth.
-
Preterm premature rupture of membrane (pPROM): PROM that occurs before 37 weeks is known as pPROM.
Compared to PROM, preterm PROM is more rare and difficult to manage. The condition has been cited as a cause
in as many as 20% of perinatal deaths.
Station—refers to where the presenting part (the part of the baby that leads the way through the birth canal) is in the pelvis
Striae gravidarum—stretch marks; irregular reddish streaks that appear on the abdomen, breasts,
and buttocks in up to 90% of pregnant women. Result from genetics, reduced connective tissue
strength resulting from the elevated adrenal steroid levels, and stretching of the structures secondary
to growth
Surfactant—a surface tension–reducing lipoprotein found in the newborn’s lungs that prevents alveolar collapse at the end of
expiration and loss of lung volume
Tachysystole— condition of excessively frequent uterine contractions during pregnancy. defined as more than 5 contractions
in 10 minutes, averaged over a 30-minute window
VBAC—vaginal birth after cesarean
Wharton's jelly— (a specialized connective tissue) that surrounds these three blood vessels in the umbilical cord to prevent
compression, which would cut off fetal blood and nutrient supply.
Gravida vs Para
• Gravid = state of being pregnant
• Gravida/Gravidity = total number of pregnancies, including this one; total number of times pregnant, regardless of
whether resulted in termination or if multiple infants were born from single pregnancy
• Para- number of times a woman has given birth to a fetus of at least 20 gestational weeks (viable or not); multiple births
as count as one birth event.
[think para = people (both 2 syllables)- aka actual fetuses considered viable and could therefore be a person]
• Parity = the number of pregnancies (NOT the number of fetuses) carried to a viability (at least 20 weeks), regardless of
the outcome
[Think parity = pregnancy (both 3 syllables)- # of pregnancies carried to a point where it could be a person aka viable]
• Nullipara = never given birth— Includes miscarriage or abortion prior to 20 weeks
G/P
• Used in clinical setting to record the gravidity and parity
• (often written ie: G2/P1, meaning someone is in second pregnancy with 1 successful birth previously)
GTPAL—acronym that provides a more detailed breakdown of parity
G-Gravidity = Number of pregnancies, including any current pregnancies (regardless of current gestational age)
T-Term births = Number of pregnancies carried to 37+ weeks
P-Preterm births = Number of births between 20-37 weeks
A-Abortions/Miscarriages = number of pregnancies which ended in miscarriage or abortion. Include in parity if past 20weeks.
L-Living children = the number of living children (this is where multiples count individually)
Common OB Lab Tests:
Maternal Serum alpha-fetoprotein (MSAFP)—biomarker screening test that is now recommended for all
pregnant women along with other prenatal screening test depending on risk profile; high levels linked to
neural tube defects; low levels associated with possible down syndrome. Minimally Invasive—requires
only venipuncture for blood sample.
Alpha-fetoprotein (AFP)— used to screen for neural tube defects such as spina bifida.
- AFP is performed at 16-18 weeks of gestation. AFP can also be done by analysis of amniotic fluid.
- An elevated alpha-fetoprotein (AFP) level is consistent with neural tube defect (spina bifida, hydrocephalus), done at
16-18 weeks.
- It is done by drawing the mother’s blood to analyze for the amount of AFP that the liver normally re-releases at a
known and increasing amount as the pregnancy progresses.
Presence of Amniotic Fluid— membrane rupture and leaking amniotic fluid can be detected in 3 ways:
1. Nitrazine paper—put fluid on nitrazine paper, which detects alkaline substances; if it turns
blue, the fluid is alkaline and is amniotic fluid
2. Put fluid on slide and view under microscope; will look like “ferning” under microscope
3. Speculum examination, where HCP looks for pooling of fluid
Triple screen— screens for AFP, hCG, and unconjugated estriol
Quad screen— Screens for everything triple does (AFP, hCG, unconjugated estriol) plus a fourth marker, inhibin A (a
glycoprotein secreted by the placenta)
The quad screen is used to enhance the accuracy of screening for Down syndrome in women younger than 35 yrs old.
Low inhibin A levels indicate the possibility of Down syndrome
Coombs' test—antibody screen typically done when mother is RH – to determine if fetus is RH – or +
• Direct— done on a sample of red blood cells from the body. It detects antibodies that are already attached to
red blood cells
• Indirect—done on a sample of the liquid part of the blood (serum).
Fetal fibronectin— glycoprotein found at the junction of the chorion and decidua (fetal membranes and uterus) that acts as
biologic glue, attaching the fetal sac to the uterine lining. It is usually present in cervicovaginal secretions up to 22 weeks of
pregnancy and again before delivery.
The test is a useful marker for impending membrane rupture within 7 to 14 days if the level increases to greater than > 0.05
mcg/mL. If test is negative, means pre term labor in next 2 weeks is unlikely.
Group B Streptococcus (GBS) –naturally occurring gram-positive bacterium that colonizes in the female genital tract and
rectum and is present in 10% to 30% of all healthy women. Women who test positive for the GBS bacteria are considered
carriers, and GBS can be passed to the newborn via vertical transmission during labor or horizontal transmission after birth.
Hep B Surface Antigen (HbSAg) –CDC recommends that all pregnant women should be tested for hepatitis B surface antigen
(HBsAg) regardless of previous HBV vaccine or screening. Hep B can be transmitted to fetus.
RPR/VDRL—(Raid Plasma Regimen and Venereal Disease Research Laboratory) – Nontreponemal serologic test used to screen
for syphilis and make a presumptive diagnosis of syphilis
Newborn screen (PKU)—aka newborn screening for phenylketonuria; Newborn needs to ingest enough breast milk
or formula to elevate phenylalanine levels for the screening test to identify PKU accurately, so newborn screening
for PKU testing should not be performed before 24 hours of age.
INTRAPARTUM
DilaFon Sizes- Actual Size
4 cm
5 cm
3 cm
2 cm
1 cm
8 cm
7 cm
6 cm
10 cm
9 cm
The Placenta
- The placenta is formed in part from the chorionic villa
- How well the placenta works depends on how much blood gets to it, which is determined by blood pressure (BP)g so, the
functionality depends on the mother’s BP supplying blood circulationg low BP = less blood getting to placenta = functions less
well
- What does the placenta do?
•
Acts as a barrier against certain harmful things, but not all. (i.e. Chickenpox, measles, etc can still cross placenta)
•
Protects the fetus from attack by the mother’s immune system-things that would be seen as a foreign body
•
Nourishes the fetus with oxygen and nutrients thru the umbilical cord to baby
•
Removes fetal wastes g waste comes back thru cord, and is excreted out thru mother
•
Produces hormones (Estrogen, Progesterone, and Relaxin)
•
Estrogeng enlarges breasts and uterusg stimulates contractility of the uterus when it’s time to start labor
•
Progesterone g maintains endometriumg decreases contractility of uterus to avoid pre-term labor
•
Relaxing works with progesterone to maintain pregnancyg to soften cervix and pelvic ligaments for delivery
- Nutrient/Waste Exchange: AVA (artery, vein, artery)
1. Maternal uterine arteries take oxygenated blood and nutrients g to the placenta
and diffuses it over the placental barrier
2. Umbilical vein takes that diffused blood and nutrientsg to the fetus
3. Maternal uterine veinsg remove deoxygenated blood and waste from the placenta
- So where is the placenta even at?
•
•
It can actually attach at a couple different spots in the uterus, which is where some problems can come in.
The most “normal” place for placenta attachment is at the top (near the fundus, or uppermost part of the uterus) or
side of the uterus.
Side attachments: Posterior vs Anterior
To understand why certain
placenta attachments can be
problematic, it’s important to
Yup! The
realize that the placenta is
placenta is
just this one part right here
that thing
attached to the uterus.
right there
shaped kind
of like a
breast implant
Attachment at top of
uterus
Posterior
attachment
Anterior attachment
- Any of these 3 attachments are fine for the baby.
- With an anterior attachment, you just might have a little more trouble feeling the baby kick (because you’ve got
another layer to cushion it a bit) and might have some more difficulty locating the fetus during ultrasounds and
when trying to hear fetal heart tones. This isn’t a problem for the baby, just a little less convenient for the mother
and doctors.
Problems with the Placenta
- Now that you know what the placenta does and where it’s actually at, we can get into problems that can happen.
- Most notable are Placenta Previa and Abruptio Placente (placenta abruption).
Placenta Previa
- What it isg Implantation of placenta in the lower uterus (remember that implantation in upper 1/3 of uterus is best)
•
Can be total, partial, marginal, low lying
•
Remember, the lower portion of the uterus doesn’t contract as well as the upper 1/3, and contractions are part of what
- Problem g Can cause bleeding in the 2nd or 3rd trimester and during labor
helps stop bleeding
- S/Sg Painless, intermittent bright red bleeding
- Tx: bed rest
- If actively bleedingg NO vaginal examsg can disrupt placenta
and cause hemorrhage
- Facts: Placenta Previa means “afterbirth first”
•
This is because the placenta (called the afterbirth) is the
first thing expelled during labor
Placenta Abruption
-
What it isg the placenta, attached in a normal location, (upper 1/3 of
uterus) is now physically separating from the uterus
-
When it happensg > 20 weeks
-
Why is it happening? g blood (perhaps from an old clot that formed
behind the placenta) gets between the placenta and uterus lining, causing it
to separate from the uterus (think of how if water gets under something,
like peel-and-stick wallpaper or tile, or when water gets under your fake
nails when you’re overdue for a fill. It causes it to start lifting)
- The separation of the placenta from the uterus compromises the fetal blood supply g leads to fetal distress
•
Most often due to chronic or severe interruption of perfusion to the placenta
- S/Sg Pain!!! (“Knife-like” abdominal pain that can be rigid)
•
Dark red vaginal bleeding (port-wine color) in 80% of cases (dark red color is due to the blood being old blood)
•
Uterine tenderness g contractions g decreased fetal movement
- Tx: If mild: Bed restg left lateral position
•
If severe: immediate c-section delivery g straight to OR
Placenta Accreta
- What it isg attachment of placenta in the too deeply into the wall of the uterus
•
Does not penetrate the uterine muscle
- Placenta Accreta is further subcategorized as:
•
Placenta increta: placenta extends into myometrium
•
Placenta percreta: placenta extends into myometrium, uterine serosa, and adjacent tissue
normal
accreta
increta
pecreta
- Causeg specific cause is unknown
•
Risk factors g placenta previa, advanced maternal age ( > 35 years old), smoking, previous cesarean births
§
h # of cesarean births = h risk for accreta
- Problem g Poses a risk for life-threatening hemorrhaging during manual attempts to detach the placenta during birth and
postpartum hemorrhaging (PPH)
•
Why though….? Because if the placenta is not expelled properly and in its entirety, parts of the placenta can get left
behind. The body detects these placental remnants as foreign bodies, causing the uterus to stop contracting.
§
•
No contractions = blood supply is not being cut off = lots of bleeding
Often results in the need for an emergency hysterectomy (in 50% of all cases)
§
Risk factors for emergency hysterectomy d/t placenta accrete areg multiparous; C-section in previous or
current pregnancy; abnormal placenta implantation
- Diagnosisg MRI or ultrasound as part of prenatal screening
•
If no prenatal sreeningg dx after birth when placenta does not separate from the uterine wall
•
Otherwise, Dx made at birth when placenta fails to separate normally from uterine wall
- Managementg early detection and intervention
•
Early detection via screening can significantly reduce morbidities and mortalities from it
•
Counsel patient about possibility of the need for a C-section and possible hysterectomy
Placenta Previa vs Abruptio Placentae
Manifestation
Description
Onset
Bleeding
Blood
Discomfort pain
Placenta Previa
Abruptio Placentae (Placental Abruption)
• Attachment of the placenta over the cervix
• As cervix dilates, a portion of the uterus
becomes detached from the uterine wall
• Detachment of the placenta from the uterine wall
• Disrupts flow of oxygen to fetus
• Emergency (will be delivered in OR)
• Delivery will be via C-section
• Bed rest may be indicated for this patient
Insidious
Always visible; slight, then more profuse
Sudden
Can be concealed or visible
Bright red
None (painless)
Dark red
• Constant, “knife like”
• Uterine tenderness on palpation
Firm to rigid
Uterine tone
Fetal heart rate
Soft and relaxed
Usually normal range
Fetal
presentation
RFs
• Maybe breach or transverse lie
• Engagement is absent
• Hx of myomas and uterine fibroidsg surgical
removal of uterine fibroids in past
• hx of placenta previa
• being > 35 y/o
• having multiple fetuses in uterus
• smoking
• HTN
• diabetes
• smoking
• cocaine use
• trauma to abdomen
• hx of abruptio placentae
• chorioamnioitis (infection of chorion) preceded by
membrane rupture for > 16-18 hrs g preeclampsia
• Most often due to chronic or severe interruption
of perfusion to the placenta
Management
• May be diagnosed with a transvaginal US early
on, then regular ultrasound later
• May be treated with bed rest
• If Actively bleeding:
- Pad count, V/S, FHTs, abdomen
palpation
• No vaginal examsg can disrupt placenta and
cause hemorrhage
• Delivery by c-section
• Oxygen at the bedside
• Bed restg left lateral position
• Immediate c-section delivery g straight to OR
• Frequent V/Sg fundal height checksg peri pad
count
• Foley and large bore IV insertion
• Fetal and contraction monitoring g fetal heart
tones
• Watch for unusual bleedingg report bleeding
gums, oozing from IV siteg clotting problem
Complications
Potential loss of perfusion to fetus due to
partial/poor attachment of placenta to uterus
Disseminated intravascular coagulation (DIC)
Postpartum hemorrhage
• Fetal distress or absent FHR
• Rigid, board like abdomen in mother
• Abdominal pain by mother
• Possible external bleeding
• Late decelerations on monitor
• Fetal bradycardia
No relationship
Student Nurse Guides
Labor Summary
Fist Stage
Second Stage
Third Stage
Fourth Stage
Effacement and dilation of
cervix
(onset of labor until
completely dilated)
Three stages - latent, active,
and transition
Expulsion of fetus
(30 min to 3 hrs)
Separation of placenta
(takes a few min- 30 min)
Physical recovery
(right after delivery for 1-4
hours)
Pushing stage
Expulsion of placenta
1-4 hr after expulsion of
placenta
Mother is talkative and eager
in latent phase,
becoming tired, restless,
anxious as labor intensifies
and contractions become
stronger
Mother has intense
concentration on pushing
with contractions; may fall
asleep between contractions
Mother is relieved after birth
of newborn; mother is
usually very tired
Mother is tired, but is eager
to become acquainted with
her newborn
Fetal Positions
Vertex Positions
Face Positions
Breech Positions
Other
ROA (right occipitoanterior)
RMA (right mentoanterior)
LSA (left sacroanterior)
Brow
LOA (left occipitoanterior)
LMA (left mentoanterior)
LSP (left sacroposterior)
Shoulder
ROP (right occipitoposterior)
RMP (right mentoposterior)
LOP (left occipitoposterior)
ROT (right occipitotransverse)
LOT (left occipitotransverse)
Fetal Heart Monitoring Changes- VEAL CHOP TO A STOP
Fetal Heart Observation
Related To
g
g
Intervention
V
Variable decelerations
C
Cord compression
T
E
Early decelerations
H
Head compression
O
Turn patient on side to relieve
pressure on cord
OK-no intervention needed
A
Accelerations
O
Okay! (normal)
A
Acceptable- no intervention
L
Late decelerations
P
Placental insufficiency
S
T
O
P
Stop Pitocin
Turn pt. on side
O2 via facemask
↑ Plain IV fluid
Postpartum Complications: Outline
- Postpartum Hemorrhage
! Loss of bloodg > 500 mL after vaginal birth or >1000 mL after cesarean birth
! Major obstetric hemorrhage: > 1,500-2,000 mL blood loss and/or need for more than 5 units of blood
•
•
•
Early PPHg within 24 hours after birth
! Uterine atony aka poor uterine tone
! Lacerations from trauma
! Hematoma
Late PPHg 24 hours to 12 weeks after birth
! Subinvolution of the uterus
! Clotting disorders
Risk Factors and Causes of PPH
! Toneg abnormal uterine muscle tone
-
Uterine atonyg d/t anesthesia, mag sulfate, bacterial toxins
-
Overdistended uterusg d/t hydramnios, multiple gestation, macrosomia
-
Muscle fatigueg d/t prolonged, rapid, or forceful labor, oxytocin
-
Inflammation due to infectiong d/t prolonged membrane rupture
! Tissueg placental tissue
-
Retained Placenta Fragments (RPOC) g may lead to uterine inversion, fundal prolapse, subinvolution
-
Subinvolutiong d/t retained placenta fragments (RPOC), distended bladder, infection, or uterine myoma
Placenta accrete, increta, percreta
Placenta previa and placenta abruption
! Traumag physical injury
- Lacerations
- Uterine rupture
- Hematomag collection of blood due to tissue trauma
! Thrombing coagulation issues
- ITPg antibody destruction of platelets
- vWDg decrease in vWd leads to impaired platelet fxn and prolonged bleeding
- DICg abnormal clotting system activation, so clot and bleed at same time
! Tractiong excessive pulling on umbilical cord during delivery
- Uterine inversion
- Placenta fragments left behind
- Thromboembolic Conditions
• Superficial venous thrombosis
• DVT
• PE
- Postpartum Infectiong Fever of 100.4 or more after first 24 hrs that occurs for at least 2 out of first 10 days PP
• Puerperal sepsisg genital tract infection
• Metritisg uterine lining infection
• Wound Infection
• UTIg frequent urination of small amounts + pain with urination
• Mastitisg clogged milk duct leading to infection
- Postpartum Affective Disordersg use Edinburgh Depression Scale
• Baby Blues
• Postpartum Depression
• Postpartum Psychosis
Medications for Pregnancy, L & D, & Postpartum
- Note: oxytocin and misoprotosol can be used before, during, and after labor for various reasons.
oxytocin (Pitocin)—oxytocic agent; uterotonic agent; hormone
Reason it is given
Induction or augmentation of
labor
Administration
• IVPB on pump
- 10 units in 1000 mL LR
(Lactated Ringers)
- Start at 1-2 mU/hour
Prevent and/or manage PPH
- 20-40 units/L IVPB infusion
or
- 10 units IM (for lesser
bleeds)
Nursing Considerations
Adverse Effects/ What to Look out for
- Baseline and ongoing vital signs and FHR assessments
- Monitor I/O and voiding, VS, and pain
- Assess contractions/FHR patterns q 15 min. in first stage
- Assess contractions/FHR patterns q 5 min. in second
stage
- hypertonic uterus and contraction
pattern
- decreased fetal heart rate variability
- Rapid dilation of cervix
- precipitous delivery, cervical
laceration, or uterine rupture
- Fluid intoxication
- Never give as an undiluted IV bolus
- Give as a bolus IVBP to a Lactated Ringer as soon as
shoulder delivered (usually over 4 hrs)
- Assess fundus for evidence of contraction and compare
amount of bleeding q15 min
- Monitor VS q15 minutes
- Never give as an undiluted IV bolus
- Monitor uterine tone to prevent hyperstimulation
- Hyper-stimulated uterus (also called
hypertonic uterus)
- fluid intoxication
misoprostol (Cytotec)—antiulcer agent; cytoprotective agent; prostaglandin
Reason it is given
Induction or Augmentation of
Labor
- Off label use
Administration
- Inserted into cervix q6h
Pregnancy termination
- Inserted into cervix q 6h
- Off label use
Prevent and/or manage PPH
- Off label use
- 800 mcg rectally (PR)
Nursing Considerations
- Causes cervical ripening (softening of cervix) & uterine
contractions
- Induction (via oxytocin) cannot be done for 4 hours after
last dose
- Monitor FHR and contraction pattern closely
- Causes uterine contractionsg used to expel rest of
contents of uterus if evacuation was not complete
- Know health hx prior to giving it
- Use with caution in women with asthma
- Never give if drug allergy
- Contraindicated if active CVD or hepatic disease
What to Look out for
- Hypertonicity of uterus
- FHR changes
- Angioedema— rare
- Diarrhea/constipation
- Abdominal pain
- Hypertonic uterus
- Angioedema— rare
- Diarrhea/constipation
- Abdominal pain
- May cause hypertonic uterus
- Angioedema— rare
- Diarrhea/constipation
- Abdominal pain
Original indicationg a
prostaglandin analogue that
decreases gastric acid
secretion and increases
protective mucosa
—
- Do not give to a pregnant woman for tx of GI issues if she
wants to keep the babyg can cause contractions and
spontaneous abortion
- May cause hypertonicity of uterus or
FHR changes
- Miscarriage **
- Angioedema— rare
- Diarrhea/constipation
- Abdominal pain
Medications for Pregnancy, Antepartum, & Intrapartum
Medication
Indication for Use
Medication’s for Preventing Complications
Rhogam
- Prevent isoimmunizaion
Rhogam binds fetal RBCs with
the D antigen before the
mother is able to produce an
immune response and form
anti-D antibodies.
- All Rh-negative mothers must all
receive Rhogam to prevent
sensitization to the D antigen of a
potentially Rh-positive fetus
betamethasone
- Promotes fetal lung maturity by h
surfactant
- Given to mother’s of infants < 34
weeks, especially if there’s a concern of
Hydramnios
- Not necessary after 34 weeks
(long-acting corticosteroid)
Nursing Considerations
Adverse Effects
Given:
- at 28 weeks of gestation
- within 72 hours post partum, IF the
newborn is Rh positive
- after spontaneous or induced abortion
- after amniocentesis or chorionic villi
sampling
N/A
- 2 doses IM 24 hours apart
- May repeat in 7 days if has not delivered
- Improvement in lung maturity can be
seen after 24 hours
- monitor mother for infection
- One dose of methotrexate IMg based
on body surface area
- Assess for diarrhea, pain, GI bleed
- Assess LFTs, H/H, and vitals
- Miscarriage
• Do not give to a pregnant woman for tx
of GI issues if she wants to keep the
babyg can cause contractions and
spontaneous abortion
May cause hypertonicity of uterus or
FHR changes
- hyperglycemia
Medications to Facilitate Labor or Abortion
methotrexate
(Trexall, Rheumatrex)
(antineoplastics, antirheumatics
(DMARDs),
immunosuppressants)
misoprostol
(antiulcer agent, cytoprotective
agent, prostaglandin)
- methotrexate original useg
immunosuppressant, cancer therapy,
and for tx of mild to moderate UC and
crohns.
- Side effect (SE) of miscarriage means
it has the off-label use of inducing
abortion
- Used to induce abortion in ectopic
pregnancies if fallopian tube is
unruptured
- Original indicationg a prostaglandin
analogue that decreases gastric acid
secretion and increases protective
mucosa
- Off label useg for cervical ripening
- Liver dysfunction
StudentNurseGuid
es
Multiple uses
oxytocin (Pitocin)
(oxytocic, hormone)
(softening)
- Off label useg for pregnancy
termination
• Causes uterine contractions
- Used to expel rest of contents of
uterus if evacuation was not
complete
-
Used to stimulate contractions
to induce or augment labor
-
Used to reduce risk of
Postpartum Hemorrhage (PPH)
(i.e. especially in women with
hypotonic contraction rates)
- uterotonic agent used for induction or
augmentation of labor
• Baseline and ongoing vital signs and FHR
assessments
• Monitor I/O and voiding, VS, and pain
• Assess contractions/FHR patterns q 15
min. in first stage
• Assess contractions/FHR patterns q 5
min. in second stage
• hypertonic uterus and contraction
pattern
• decreased fetal heart rate variability
• Rapid dilation of cervix
• precipitous delivery, cervical
laceration or rupture of uterus
• Fluid intoxication
- For preeclampsiag i cerebral
excitability and thus i risk of seizures in
women with preeclampsia
- For preterm laborg relaxes uterine
muscle to stop and prevent
contractions
• Loading dose (4-6 g), then 1-4 g/hour
• Continuous monitoring of FHRs/FHTs
• Calcium gluconate is reversal agent
Monitor and Report:
• Hypotension and/or depressed DTRs
• LOC, blurred vision, headache *
• U/O less than 30 mL/hour *
• Respiratory rate < 12 breaths per
minute
- Prevents nausea and vomiting
- For N/V such as in Hyperemesis
Gravidarum
- May be given with opioids for their
potentiative effect
- Assess for N/V and effectiveness of
parenteral admin 30 min after giving
- I&Os, emesis quantity
- IV patency
- Excessive sedation
- Respiratory Depression
- Other SE: Diarrhea, constipation, HA,
abd. Pain, fatigue, drowsiness
• For labor: IVPB on pump
- 10 units in 1000 mL Lactated Ringers
- Start at 1-2 mU/hour
To Prevent Labor
Magnesium Sulfate
Multiple uses
Reversal agent:
calcium gluconate
Anti- Emetics
ondansetron (Zofran)
metoclopramide (Reglan)
(anti-emetics)
• If being used for abortion, induction, or
augmentation:
- Inserted into cervix q6h
- Induction (via oxytocin) cannot be
done for 4 hours after last dose
- Monitor FHR and contraction
pattern closely
hydroxyzine (Vistaril, Atarax)
(antihistamine)
promethazine (Phenergan)
(anti-emetic and antihistamine)
prochlorperazine (Compazine,
Compro)
(anti-emetic and antipsychotic)
Diuretics
furosemide (Lasix)
- currently contraindicated in 1st trimester
due to lack of data available on it’s effects
during pregnancy
- Given for fluid accumulation,
hydramnios, reducing BP in preeclampsia
- Helps to i BP by reducing preload
- Excrete increased volume
- Measure I&Os, daily weights
- Vitals, labs, nutrition
- s/s dehydration
- Give IV or POg works very fast
- Electrolyte imbalances
- Hypokalemia
- Dehydration
Opioid timing:
want to time giving an opioid either
within 1 hour of delivery or 4 hrs
before delivery
- Can give Narcan to the mother if it
looks like she's going to deliver
within 1-3 hours of receiving opioid
- RF maternal respiratory depression,
newborn respiratory depression,
decreased alertness, decrease sucking,
delay of or ineffective feeding
- IM or IV
- Can be given with opioids
- Has antipyretic and anti- inflammatory
properties
Drowsiness, anaphylaxis
Stroke
GI bleeding
HF/MI
- Performing epidural is a sterile
procedure
- Left lateral position after placement
- As long as epidural is in won’t be able to
use bathroom so insert Foley
(Many possible complications)
- increases risk for use of assisted
devices
Pain Management During Labor
Opioid Agonists:
- Used during labor for pain
management
butorphanol tartrate (Stadol)
- takes the edge off, but doesn’t take
merperidine (Demerol)
pain away completely during labor
- Can be given with anti-emetics (i.e.
promethazine, hydroxyzine) which can
Reversal agent:
potentiate the effects of opioids
Narcan (naloxone)
Ketorolac
(Sprix, Toradol)
(NSAID, nonopioid analgesic)
- Dizziness, drowsiness
- Excessive sedation
- For N/V in Hyperemesis Gravidarum
- Can help with anxiety, has sedative
effects
- For N/V in Hyperemesis Gravidarum
- Helps control pain, N/V
- Can be used as sedative
- For severe N/V as in Hyperemesis
Gravidarum
- Also can treat anxiety and
schizophrenia
- Moderate pain relief
- Can’t use DURING labor, but is most
often given after a C-section
Regional Anesthesia—Pain Management During Labor
Epidural
- For pain management during labor
- Local anesthetic injected into lumbar
- injected opioids: fentanyl,
epidural space first
morphine
Potential for SE in newborns, so should
only be taken if prescribed
- Dizziness, drowsiness
- Excessive sedation
- Respiratory Depression
- Dry mouth
- Dizziness, drowsiness
- Insomnia/ strange dreams
- HA, blurry vision
- hypotension
- constipation
- Then opioid (i.e. fentanyl or
morphine) is injected into lumbar
epidural space
- Prolongs second stage of labor (pushing
stage)
- Need to increase fluids before epidural
- Need at least 1 L IV fluid running
Medications for Treatment of Pre-Eclampsia
Medication
Misoprostol (Cytotec)
(antiulcer agent, cytoprotective
agent, prostaglandin)
Multiple uses
Why patient receiving
Nursing Considerations
- Original indicationg a prostaglandin
analogue that decreases gastric acid
secretion and increases protective
mucosa
• Do not give to a pregnant woman for tx of
GI issues if she wants to keep the babyg can
cause contractions and spontaneous
abortion
- Off label useg for cervical ripening
(softening)
•
- Off label useg for pregnancy
termination
Causes uterine contractions
- used to expel rest of contents of
uterus if evacuation was not
complete
OR
Used to stimulate contractions to induce
or augment labor
•
If being used for abortion, induction, or
augmentation:
- Inserted into cervix q6h
- Induction (via oxytocin) cannot be
done for 4 hours after last dose
- Monitor FHR and contraction pattern
closely
Adverse Effects
- May cause hypertonicity of uterus or
FHR changes
- Miscarriage **
- Angioedema— rare
- Diarrhea/constipation
- Abdominal pain
Diuretics
furosemide (Lasix)
- Given for fluid accumulation/
hydramnios/ reducing BP in pre-eclampsia
- Helps to i BP by reducing preload
- Excrete increased volume
- Measure I&Os, daily weights
- Vitals, labs, nutrition
- s/s dehydration
- Give IV or POg works very fast
- Electrolyte imbalances
- Hypokalemia
- Dehydration
• h contractility g h cardiac output
• Slows conduction thru AV nodeg i HR
• Inhibits sympathetic activity
• If its working, should see:
- adequate urine output
- absorbed thru GI track—don’t take with
antacids— blocks absorption
- High K+ interferes with therapeutic
effects
•Assess vitals, labs, K+, I&O, dysrythmias
• Excreted through renal system- need good
kidney fxn
• Hold med if HR < 60 and notify HCP
• absorbed thru GI trackTake pulse for 1 full min before taking med
- Take dose at same time every day
- do not skip doses or double dose
- Call HCP if miss a dose
Know s/s of toxicity: **
• Blurred vision
- Yellow halo
• Anorexia
• Fatigue
• m. weakness
• confusion
- low potassium = RF toxicity
Inotropics
digitalis (Lanoxin)
• therapeutic levels: 0.5 – 2.0
ng/dL
-
Must have stable potassium level;
take K+ supplement as directed
Report toxicity s/s to HCP
Anti-hypertensives
labetalol (Trandate, Normodyne)
• To try to bring BP down
(non-cardio selective
beta blocker)
nifedipine (Procardia)
(Ca channel blocker)
hydralazine (Apresoline)
(vasodilator)
• To try to bring down BP
• Reduces catecholamines, leading to:
- dilated vascular beds
- slower HR
- lower BP
• Treats HTN, angina
• Goal: i BP
• usually used in postpartum period to
prevent post partum pre-eclampsia
symptoms
• labetalol usually used first to try to bring
BP downg if doesn’t bring it down enough
move onto nifedipine
PO or IVPB
• Bradycardia
• Bronchoconstiction
(see above considerations)
• Bradycardia
• Hypotension
• EKG changesg Heart block
Do not use with:
SBP < 90 mm Hg or HR < 50
• Hypotension
• Headache is a common side effect
• Improves blood flow to myocardium
• Take acetaminophen (Tylenol) for HA
• Dilates blood vessels; vasodilation of
coronary & peripheral arteries
Anti-coagulants
acetylsalicylic acid (aspirin)
(anti-platelet)
enoxaparin sodium
(anticoagulant)
Antidote: protamine sulfate
- used to help with BP and clotting issues
due to hypercoagulability
experienced in pregnancy
- Antipyretic
- Anti-inflammatory
- Inhibits platelet aggregation
- used to help with BP and clotting issues
due to hypercoagulability experienced in
pregnancy
Labs: INR, PT, PTT, platelets
- Ototoxicity
- Bleeding
- Gastric ulcer
• warfarin (Coumadin) is Category X, so can’t
use it, only enoxaparin
• At higher risk for bleeding
• Labs: Platelets, H/H
• Hemorrhage
• HIT
Medications for Postpartum
Medication
Indication for Use
Nursing Considerations
- Moderate pain relief
- Most often given after a C-section
- May also be given after an episiotomy
or other laceration/trauma from birth
- IM or IV
- Can be given with opioids (but opioids
are rarely given for postpartum pain, even
after C-Sections now)
- Has antipyretic and anti- inflammatory
Properties
- Need to time breast-feeding
appropriately—med at least 2 hrs before
feeding
- Need to time breast-feeding
appropriately (med at least 2 hrs before
feeding until child is 6 months or older)
- Monitor Hgb/Hct levels
- Not to exceed 4g / day
- Acetaminophen is okay for an infant < 6
months old, so no to time breast feeding
(can still wait 2 hours after taking med to
breastfeed to ere on the side of caution
though)
Side Effects & Adverse Effects
For Postpartum Pain Management
Ketorolac
(Sprix, Toradol)
(NSAID, nonopioid analgesic)
ibuprofen (Motrin)
(NSAID, nonopioid analgesic)
- Mild pain relief
acetaminophen (Tylenol)
(nonopioid analgesic,
antipyretic)
- Mild pain relief
- Drowsiness
- anaphylaxis
- Stroke
- GI bleeding
- Heart failure/MI
- Gastric ulcer
- Bleeding
- Ototoxicity
- Hepatotoxicity
- Elevated liver function tests
- Jaundice
- Give with food to decrease GI upset
For Treatment & Management of Postpartum Hemorrhage (PPH)
oxytocin (Pitocin)
**
Prevent and/or manage PPH
- 20-40 units/L IVPB infusion or
- 10 units IM (for lesser bleeds)
- Give as a bolus IVBP to a Lactated Ringer
as soon as shoulder is delivered (usually
over 4 hours)
- Assess fundus for evidence of
contraction and compare
amount of bleeding q15 min
- Monitor VS q15 minutes
- Never give as an undiluted IV bolus
- Hyperstimulated uterus (also called
hypertonic uterus)
- fluid intoxication
-Monitor uterine tone to prevent
hyperstimulation
misoprostol (Cytotec)
Prevent and/or manage PPH
- 800 mcg rectally (PR)
- used to ripen/soften cervix
- Know health hx prior to giving it
- Use with caution in women with asthma
- Never give if drug allergy
- Contraindicated if active CVD or hepatic
disease
- may cause hypertonic uterus
- R/F bronchospasms in asthmatics
dinoprostone (Prostin E2)
Prevent and/or manage PPH
- 20 mg vaginally or rectally
- Monitor BP frequently
- Contraindicated if active cardiac,
pulmonary, renal, or hepatic disease
- hypotension
- N/V/D
- temperature elevation
prostaglandin PGF2a
(Hemabate)
Prevent and/or manage PPH
- 0.25mg IM
- May be repeated q15-90 min up to 8
doses
- Contraindicated if active cardiac,
pulmonary, renal, or hepatic disease
- Fever, chills, flushing
- Headache, N/V/D
- Bronchhospasm
methylergonovine
(Methergine)
**
Prevent and/or manage PPH
- 0.2mg IM
- Then continue as PO after acute
bleeding stops
- Assess baseline bleeding, uterine tone,
and VS q15 minutes or per protocol
- HTN, seizures,
- uterine cramping
- nausea, vomiting
- palpitations
- Contraindicated with current HTN
- Report any complaints of chest pain
promptly!!
** methylergonovine (Methergine) & oxytocin (Pitocin) are preferred in the treatment of PPH for women with a history of chronic cardiovascular or pulmonary
diseases and problems.