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Chapters 1: Contemporary Issues & Trends in Women and Newborn’s Health
❖ 17th / 18th century
➢ Fear of maternal death
➢ Fear of infant mortality
❖ Early 1900s
➢ Physicians delivering middle class woman
➢ Midwives care for poor woman
➢ Hospitals for the wealthy
➢ Sold it by the medication use
■ Patient will not have pain at all when they deliver (impossible realistically)
■ Used twilight sleep - Narcotics and amnesiacs (Medication to forget what childbirth is)
❖ 1950s
➢ Natural childbirth practices
■ Dick-Reed method (40s)
● Focus on education to understand what is happening to be able to work with it
● Fear-tension-pain problem
◆ If you’re fearful you will tense ; tense up increase pain
■ Lamaze method (60s)
● Distraction technique and Breathing techniques
◆ Early labor
➢ Nice and slow
◆ Active stage
➢ Faster breathing
◆ End of labor
➢ Panting breathing ; short breaths
■ Bradley method (60s)
● Partner coached
❖ 1980s to present
➢ Access to healthcare
➢ LDR → labor delivery recovery
➢ LDRP → labor delivery recovery postpartum
➢ C Section rates increasing
■ First big issue ; not good
■ Procedure is safe but it is not safer than a vaginal delivery
■ 1:3 births
■ Began with the use of fetal monitoring
● Overall fetal monitoring improved outcomes for HIGH RISK PREGNANCIES
; but majority of patients are not high risk
● Outcomes did not improve for normal risk deliveries
➢ Family and medical leave act 1993
■ Up to 12 weeks unpaid leave
❖ Current Trends
➢ Family centered care (FCC)
■ Safe, Satisfying, Focus of physical needS, Focus on psychosocial needs
➢ Basic principles of FCC
■ Childbirth is a normal healthy event and we do not need to medicate everything
■ Affects entire family → Families can make decisions
➢ Doula: Birth assistants →Support but not nurses
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➢ Maternal mortality: During pregnancy/childbirth or within 42 days postpartum
Current issues
➢ Women’s responsibilities
■ Women are very busy humans
➢ Health care costs are soaring
■ Decrease hospital stays: Health insurance will pay for 2 days for standard delivery and 3
days for c-section
Disparities in healthcare
➢ Black woman have a 3-4x higher rate of being ill or dying with labor
➢ Infant mortality is 2.32x greater for black infants than white infants
➢ Lack of prenatal care
■ Especially 1st trimester
➢ Money
➢ Health insurance
➢ Healthcare worker bias
■ Stop judging patients
■ They are with you now so what can you do
➢ Lack of quality care in community
➢ Language / cultural
➢ Legal
➢ Barriers to healthcare
■ Financial, Transportation, Language, Cultural , Clinic hours/location, Poor attitudes of
healthcare workers
Nursing implications
➢ Nurses can be proactive not just reactive
■ Preconception screening / counseling
■ Identify risk factors early
● Full body assessment
■ Referrals
● Psychosocial, Medical, Social Services
■ Education
● Nutrition, Prenatal care, Exercise, Good hygiene
Education
➢ Prevention
■ Folic acid intake to decrease neural tube issues
■ Substance abuse cessation
➢ Breastfeeding
■ Decrease infant infections
■ Boost immunities
■ Less expensive
➢ Back sleeping
■ Decrease SIDS
➢ Support groups
■ Postpartum depression
■ Child Rearing practices
➢ Hypertension
■ Baselines are very important
■ #1 killer of women
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➢ Cancer
■ #2 leading causes of death in women
■ Lung cancer (#1) - Do not get any signs of it until we got it and it's pretty bad
■ Breast cancer (#2)
❖ Social Issues
➢ Poverty
■ 1 in 8 women
■ Leads to
● Deficiencies
◆ Literacy, education, skills, employment opportunities
● Malnutrition
◆ Iron deficiency anemia
➢ Violence against women
■ Can start or escalate during pregnancy
● Abuse will most likely happen for the first time or will escalate if it is already
happening
■ RADAR
● Routine screening → Ask direct, supportive, non judgemental questions : affirm
feelings, assess abuse
❖ Legal/Ethical Issues
➢ Abortion, Substance abuse, Intrauterine therapy, Maternal-fetal conflict, Stem cell research,
Umbilical cord blood banking, Informed consent and refusal of medical treatment,
Confidentiality
Chapter 3: Female Reproductive A&P Review
❖ External reproductive organs: Vulva
➢ Vulva: Mons pubis, labia majora / minora, clitoris,
vestibule, and perineum, Protect urethral and vaginal
opening
➢ Mons pubis: Fleshy, fatty, tissue, hair ; protects
symphysis pubis
➢ Labia
■ Majora: Sweat and sebaceous glands, hair,
protects vaginal opening
■ Minora: Highly vascular, highly sensitive, abundant
nerves, hairless, lubricate the vulva
➢ Clitoris: Abundant blood supply and nerves
■ Function : sexual stimulation
➢ Prepuce: Joins folds above clitoris forming hood
■ Site for female genital mutilation / cicumcision in
some cultures
➢ Vestibule: Area enclosed by labia minora, 6 openings
■ Urethra (bladder)
■ Vagina
■ Bartholin’s glands → mucous lubrication for
intercourse
■ Skene’s glands → mucous for urethra opening
➢ Hymen: Elastic mucous covered tissue surrounds vaginal
opening, may or may not tear with first intercourse (does not confirm sexual activity)
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➢ Perineum: External region between vulva and anus made up of skin, muscle, and fascia
❖ Internal reproductive organs
➢ Vagina
■ Fibromuscular organ, lined with mucous membrane, tubular canal, transverse folds
(rugae)
■ Rugae allow the dilatation of canal for birth
■ Smooth before puberty and after menopause d/t low estrogen
■ Canal= 3-4 inches long
■ Entrance for intercourse and receives sperm
■ Exit for menstruation and fetus during childbirth
■ Acidic environment; Resistant to bacteria
■ Acidic balance can be disrupted by antibiotics, douching, perineal hygiene
sprays/deodorants
➢ Uterus
■ Pear shaped, muscular organ, located at top of vagina
■ Site: menstruation, implantation, fetal development, labor
■ Measures (prior to first pregnancy) 3” long, 2” wide, 1” thick
➢ Uterine wall
■ Endometrium: mucosal innermost layer, lots of glands and blood vessels
■ Myometrium: Major portion; Smooth muscle linked by connective tissue and elastic
fibers
■ Perimetrium: Outer layer covers body of uterus
➢ Cervix
■ Lower part of uterus, channel (mucous secreting glands), fibrous connective tissue
■ Opens into vagina, sperm enter here
■ Covered with mucous, smooth, firm, doughnut shaped
■ Central opening: external os
➢ Cervical channel mucous
■ Thick before ovulation but thins at ovulation to help sperm swim for fertilization
■ Stores live sperm 2-3 days (therefore, intercourse 1-2 days prior to ovulation, can lead to
pregnancy)
➢ Corpus
■ Main body of the uterus, muscular
■ Holds fetus
■ Endometrium changes d/t hormones/cycle
■ Thickest for embryo implantation
■ Thinnest after menses (sheds)
➢ Fallopian tubes
■ Hollow, 4” long, 0.7cm diameter, flares into funnel shape, opening for egg to fall into
■ Cilia (“beating hairs” ) move egg toward uterus and sperm from uterus toward egg
■ Egg fertilization: Divides over 4 days, moves down tube slowly
➢ Ovaries
■ Pair of glands
■ Pearl color, oblong, 4 cm long, 2 cm wide, 1 cm thick, held by ligaments
■ Produce ova (eggs)
■ Produce female sex hormones (Estrogen and Progesterone)
➢ Breasts
■ Mammary glands, accessory organs
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Secrete milk after pregnancy
Areola: pigmented area, 9 lobes (range 4-18) containing glands (alveolar), and a duct
(lactiferous), leads to nipple opening
■ Connective and adipose tissue supports weight of breast
■ Pregnancy: estrogen/progesterone stimulate development
■ Breasts increase in size
■ Glandular tissue replaces adipose tissue
❖ The female reproductive cycle
➢ Female puberty review
■ 3 Progression stages
● Thelarche: develop breast buds
● Adrenarche: pubic hair, then axillary hair, and growth spurt
● Menarche: first menses: Average age 12.8 with a range 8-18; usually about 2 yrs
after the start of breast development
■ Menstruation Cycles/Reproductive Cycles vary
● Frequency: 21-36 days, average 28 days
● Duration of Flow: 3-7 days
● Irregularity: due to ovulation, stress, disease, hormonal imbalance
❖ Ovarian cycle
➢ Finite supply of ova released slowly over childbearing years
➢ Follicular cells (ovum and others) swell and mature
➢ Maturing follicle=graafian follicle
➢ Many follicles but only one matures to ovulation
➢ 3 phases of ovarian cycle
➢ Follicular phase
■ Follicles in ovary grow=mature egg
■ Begins: Day 1 of menstrual cycle until ovulation (10-14 days later)
■ Varies in length=different lengths of menstrual cycles
■ Begins: Hypothalamus initiated
■ Estrogen levels increased-secreted by maturing follicular cells
■ Causes endometrium and myometrium to thicken
■ Helps support implanted ovum if pregnant
■ Hypothalamus prompts pituitary gland to release FSH (follicle stimulating hormone)
■ FSH Stimulates ovary immature follicle production
■ Remember: follicle has immature egg inside, when follicle is mature, ruptures, releases
egg
■ Increase in LH (luteinizing hormone) (surge from anterior pituitary gland)
■ Finishes the maturation and helps rupture follicle
■ FSH and LH at highest levels in this phase
➢ Ovulation phase
■ Mature follicle ruptures=release mature ovum
■ Usually day 14 ( in a 28 day cycle) but always 14 days before menstruation
■ Estrogen decreases
■ Ovulation=10-12 hrs after LH peak
■ 24-36 hrs. after estrogen peak
■ Fallopian tubes create current, move ovum
■ Ovum lasts 24 hrs, then dies if not fertilized
■ Symptoms: abdomen cramping, rise in basal body temp., increased libido
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■ Pain on side released “mittelschmerz” “middle pain”
■ Cervical mucus thins, clear, stretchy, receptive to sperm
➢ Luteal phase
■ Starts with ovulation ends with menstrual phase of next cycle
■ Follicle ruptures=releases egg=follicle closes forms corpus luteum
■ Corpus luteum= secretes Progesterone
■ Prepares endometrium for implantation
■ Increases body temp. slightly until menses start
■ 0.5 to 1 degree increase 1-2 days after ovulation occurs
■ If no fertilization= corpus luteum dissolves
■ Estrogen/progesterone levels decrease
■ FSH and LH at lowest levels in this phase
■ Menses begins 14 days after ovulation if no pregnancy
❖ Endometrial cycle
➢ 4 phases:
■ Proliferative
■ Secretory
■ Ischemic
■ Menstrual
➢ Proliferative
■ Endometrial glands enlarge d/t Estrogen levels increase
■ Blood vessels dilate
■ Endometrium thickens
■ Begins day 5 of menstrual cycle lasts until ovulation
■ Ovarian follicles must stimulate estrogen for this phase to occur
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This phase coincides with the follicular phase of the ovarian cycle
➢ Secretroy
■ Starts with ovulation ends 3 days before menses
■ Progesterone=changes in endometrium
■ Thicker
■ Vascular (spiral arteries)
■ Glandular- glycogen/lipids secretion increases
■ Estrogen levels decrease
■ Progesterone dominates
■ This phase coincides with luteal phase in ovarian cycle
➢ Ischemic
■ If no fertilization; estrogen and progesterone drop sharply
■ Corpus luteum degenerates
■ Arterioles spasm, leads to ischemia of basal layer of endometrium
■ Basal layer sheds, leads to menstrual flow
➢ Menstrual
■ Ischemia leads to spiral arteries rupture
■ Releases blood into uterus
■ Endometrium sloughed off, passes through vagina
■ Menstrual flow begins next menstrual cycle
❖ Menstrual cycle hormones
➢ Gonadotropin Releasing Hormone: GnRH
■ Induces release of FSH and LH for ovulation
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➢ Follicle Stimulating Hormone: FSH
■ Matures ovarian follicles
➢ Luteinizing Hormone: LH
■ Final maturation of follicles, Helps rupture the follicle, Stimulates follicle to produce
estrogen
➢ Estrogen
■ Develops and matures follicle, Before ovulation, levels high, inhibits output of LH,
Causes uterus to increase size and weight
➢ Progesterone
■ Peaks 5-7 days after ovulation, Maintains pregnancy
➢ Prostaglandins (oxygenated fatty acids)
■ Technically not hormones, produced by all tissues not just glands, Free the ovum inside
the graafian follicle
❖ Perimenopause
➢ 2-8 years prior to menopause (symptoms from decreased estrogen: vasomotor, sleep
disturbances, forgetfulness, mood changes, depression)
❖ Menopause
➢ Defined: cessation of regular menstrual cycles
➢ Atrophy: breasts, uterus, fallopian tubes, ovaries
➢ Vasomotor: hot, cold, sweating, headache, insomnia, irritability
➢ Natural menopause: 1 yr. without menses
➢ Average age= 50-51
➢ Hormonal treatments for symptoms controversial
➢ Nontraditional CAM (complementary /alternative medicine)
➢ Impact on the body systems :
■ Brain: hot flashes, sleep, mood, and memory problems
■ Cardiovascular: lower levels of HDL; increased risk of CVD
■ Skeletal: bone density loss; increased risk of osteoporosis
■ Breasts: duct and gland tissue replaced by fat
■ Genitourinary: vaginal dryness, stress incontinence, cystitis
■ Gastrointestinal: less Ca+ absorbed in GI tract leads to increased fractures
■ Integumentary: skin dry, thin; collagen decreases
■ Body shape: more abdominal fat; waist size swells
Chapter 2: Family Centered Community Based Care
❖ Levels of prevention in community-based nursing
➢ Primary
■ Education
■ Preventing the disease or condition before it occurs through health-promotion activities
■ Talking about prevention methods to avoid STIs
➢ Secondary
■ Detecting and treating adverse health conditions early
■ Diagnosing ; assessing ; start on proper treatment
➢ Tertiary
■ Reducing or limiting the progression of a disease or disability after an injury
■ Someone already has the disease for years ; experiencing other effects from it ; the whole
systematic problem
■ Cannot fix that it already happened but can try to prevent it from worsening
❖ Community based health care settings
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➢ Physician offices, Clinics, Day surgery, Urgent care centers, Mobile units
Health department services
➢ Maternal / child, immunizations, family planning, STI/STD
■ WIC: Woman, infants, children
➢ Substance abuse programs
➢ Jails/prisons
Types of complementary and alternative therapies
➢ Aromatherapy, Homeotherapy, Acupressure, Feng shui, Guided imagery, Reflexology,
Therapeutic touch, Herbal medicine, Spiritual healing, Chiropractic therapy, Massage therapy
➢ Natural does not necessarily mean safe
■ Need to inform the healthcare provider when using herbs or other therapies
■ They are not FDA approved → Anyone can market it
■ If the product package contains ingredients and the amount of each that is more
reassuring
■ Some contradict with other medications
Clinical practice within the community
➢ Research, Quality improvement (Looking at data), Discharge planning / case manager , Staff
development, Program development, Community education, Advocate and resource manager
Community based nursing interventions
➢ Communicator (work with interpreters), Education (individual, family, community, health
education programs), Health screening, Medication administration, Telephone consultation,
Health system referral, Instructional, Nutritional counseling, Risk identification
Women’s health in the community
➢ High risk OB patients are being discharged so early
■ Still pretty ill but safe enough to be discharged
● IV home infusion, therapy DVT, pelvic infections
■ Less time is spent on education
➢ Community based care
■ Contraceptive services
■ Abortion services
■ Infertility services
■ Screening for STIs and cancer
■ Preconception risk assessment and care
■ Maternity care (including prenatal, birth, and postpartum / newborn care)
■ Prenatal care: early and adequate = improved pregnancy outcomes
● Identify problems and treat problems
● Early and continued risk assessment
● Health promotion
● Medical interventions
● Psychosocial interventions
● Follow up
■ Services
● Midwifery
● Childbirth classes
● La Leche League
■ Necessary family education
● Emergency vs non-emergency
● Equipment usage
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● Understanding prescriptions
● Services and Support groups
● Safety
Chapter 9: Female Partner Abuse/Intimate Partner Violence (IPV)
❖ An actual or threatned physical or sexual violence, or psychological / emotional abuse
➢ Can be physical, emotional, financial
➢ Lots of ways that one can control a person and limit their interactions with their support
systems
❖ It includes threatened physical or sexual violence when the threat is used to control a person’s actions
❖ Holistic approach in nursing of consequences
➢ Physical, psychological, social, economic
❖ 50-75% of cases where a parent is abused and so is the child
❖ Characteristics of Abuse
➢ Violence is a learned behavior that, without intervention, is self-perpetuating
■ Can intervene and prevent it from continuing to occur ; it is not a lost cause
■ If woman stays with the abuser and with the children ; the children will learn this
behavior and might actually become abusers themselves
➢ A cycle of violence exists in an abusive relationship
➢ Abusers use whatever it takes to control a situation, including:
■ Emotional/mental abuse, Physical abuse, Sexual abuse, Financial abuse
❖ Cycle of Violence
➢ Phase 1: Tension building
■ Tension escalates, verbal or minor battery may occur
■ Because it is a pattern ; most of the time the woman knows what is coming
● Natural response is to calm the abuser ; will say what they need to say ; agree not
argue because want to avoid phase 2
● Sometimes it can actually stop phase 2 from happening but most of the time it
does not
■ Ex: Name calling, hostility; victim attempts to calm the abuser
➢ Phase 2: Acute Battering
■ Explosion of violence, characterized by uncontrollable discharge of tension; violence is
rarely triggered by the victim's behavior: she is battered no matter her response
● Results in assault / death ; victim feels “lucky it’s not worse”
■ Most of the time actually happens because the abuser knows that it will ultimately calm
them
■ Battered no matter the response from the victim and it can often be the hardest part
■ Can abuse in parts that are not visible to the public; they get smart
➢ Phase 3: Reconciliation (honeymoon/calm phase)
■ The batterer becomes loving, kind, apologetic, expressed guilt, then makes the victim feel
responsible
■ Normally ends with the abuser getting the victim something
■ Apologizing but not taking ownership of it
● Always go backs to the victim ; always their fault
❖ Types of Abuse
➢ Emotional/mental abuse
■ Promise, swear, threaten to hit victim
■ Force victim to perform degrading acts
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■ Threaten harm on children or friends
■ Destroy possessions, harm pets
■ Demeaning remarks
■ Control victim’s life
■ Keeping a fear within the victim
➢ Physical Abuse
■ Hitting, grabbing, leaving marks
■ Throwing objects at victim
■ Pushing, choking, shoving
■ Kicking, punching, slamming
■ Attacking victim with knife, gun, rope, electric cord
■ Controls access to healthcare for injury
➢ Sexual Abuse
■ Forcing intercourse (vaginal, anal, oral) against victims will
■ Biting victim’s genitals/breasts
■ Shoving objects into victim’s genitals
■ Forcing victim to perform sexual acts on others or animals
➢ Financial Abuse
■ Prevent victim from getting job →Do not want them out of the house talking to others
■ Sabotage current job
■ Control how money is spent
■ Fails to contribute financially
Abuser Profile
➢ Comes from all walks of life
➢ Has feelings of inadequacy, insecurity, powerlessness, and helplessness
➢ Directs violence toward partner or children at home; refuses to share power with a partner or
family member
➢ May fail to accept responsibility or blame others for their own problems
➢ Might have substance abuse problems, mental illness, prior arrests, obsessive jealousy, erratic
employment history, and financial problems
■ We know that abusers might be addicted to drugs and alcohol however drug and alcohol
abuse DOES NOT MAKE someone become an abuser
➢ Finds their power in controlling others
Victim Profile
➢ Battered Woman Syndrome, Feel they have a personality flaw (inadequacy to keep man happy),
Feelings of failure reinforced by partner, Poor self esteem, May have been abused as child,
Depression, Insomnia, Hx of suicide attempts, injury, Drug or alcohol abuse
Mother and Child Risks
➢ Chronic anxiety, Miscarriage, Stillbirth Poor nutrition, insomnia, Substance abuse, Preterm
labor, Late prenatal care, STI, UTI, other infections, Low birth weight, premature, Physical and
Mental Trauma to mother and infant
Assessment
➢ SAVE Model (box 9.2)
■ Screen for abuse during every healthcare visit
● Do you feel safe at home → ASK ALONE
● If they do say yes; encourage them that they just admitted it
● Read body language at the same time
■ Ask direct or indirect questions about the signs of abuse
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■ Validate: you believe her, brave for telling you
■ Evaluate immediate safety
➢ Isolate patient immediately from family
➢ Assess survivors of rape for PTSD
➢ Document and report findings
➢ Educate victim about community services
➢ Provide emotional support
➢ Offer a safety plan (See Text, Teaching Guidelines 9.1)
➢ Provide care/treatment: Pregnancy, STI’s
■ Really assess head-to-toe
■ Assume that she has not seen a healthcare provider before
❖ Sexual Violence Types
➢ Sexual Abuse: Forced sexual contact without consent
➢ Incest: Sexual exploitation between blood relatives or surrogate relatives, closely related, illegal
to marry and/or culturally prohibited
■ Child incest abuse: Before victim is age 18
➢ Female genital mutilation/female gential cutting: Female circumcision, cultural practice, Age
4-10 without consent, intense pain, numerous health risks
➢ Human Trafficking: Enslavements of immigrants for profit
■ Identifying victims of human trafficking
● Female or child in poor health, Foreign-born child who doesn’t speak English; no
immigration documents available, Inconsistent explanation of injury, Reluctant
to give any information about self, injury, home or work, Appears fearful of
authority figure or “sponsor” if present, “Sponsor” will not leave victim alone with
healthcare provider; victim “lives” with the employer
➢ Rape: Act of violence, penile penetration, without consent
■ Types of Rape
● Saturarty Rape: Sexual activity between an adult and person under the age of 18
● Aquaintance Rape:p A person forced to have sex by a person he or she knows
● Date Rape: An assault within a dating or married couple without consent of one
of the participants
■ Symptoms affecting rape survivors
● Chronic pelvic pain, headaches, back ache, Sexually transmitted infections,
pregnancy, Anxiety, denial, fear, withdrawal, Sleep disturbances, Guilt,
nervousness, phobias, Substance abuse, depression, Sexual dysfunction, PTSD
■ S/S PTSD
■ Intrusion
● Re-experiencing of the trauma, including nightmares, flashbacks, recurrent
thoughts (“I cannot sleep because I keep reliving it”)
■ Avoidance
● Avoiding trauma-related stimuli, social withdrawal, emotional numbing, trouble
recalling events (EX: Not going out; not seeing friends)
■ Hyperarousal
● Increased emotional arousal, exaggerated startle response, irritability, difficulty
sleeping
❖ SANE RN: A registered nurse specially trained to conduct sexual assault evidentiary examinations for
rape victims: collect forensic evidence, provide access to crisis intervention, STI testing, and emergency
contraception
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Chapter 5: Sexually Transmitted Infections (STIs)
❖ Risk Factors
➢ Low socioeconomic status, urban residency, single status, multiple sex partners, contact with
casual sexual partners, risky sexual practices (rectal intercourse), alcohol and substance abuse,
age (15 to 30 years old)
❖ Possible Consequences of STIs:
➢ Infertility, chronic pelvic pain, ectopic pregnancy, cervical cancer, high risk for contracting
AIDS, transmission to offspring, litigation, low birth weight, Fetal and/or maternal death
❖ Contraceptives can play a role in the prevention of STIs: Condoms, Monogamy, Abstinence
❖ Infections Characterized by Vaginal Discharge
➢ Vulvovaginal Candidiasis
■ “yeast”, “monilia”, “fungal infection”
■ Vaginal Symptoms: may worsen before menses
● Pruritus, Discharge (white, curds), Soreness, Burning, Erythema, Dyspareunia
(pain w/intercourse), External Dysuria (pain w/urination)
■ Predisposing factors: Candidiasis
● Pregnancy: Affects the pH of the vagina
● OC with high estrogen content
● Broad spectrum antibiotics
● Diabetes Mellitus: Affects the pH of the vagina
● HIV infection
● Steroid/Immunosuppressive drugs
● Tight clothes, restrictive
● Chemical irritants/ douching
■ Treatment:
● Miconazole cream or suppository
● Clotrimazole tab
● Terconazole supp/cream
● Fluconazole oral tab (single dose)
● 3-7 day treatment
● If not treated during pregnancy
◆ Baby becomes infected and they prevent with thrush
◆ Fungal infection within the mouth and it is a white plaque that cannot be
wiped away
■ Prevention:
● Decrease sugar/soda, Cotton vs. nylon underwear, No tight pants, No baths with
bubbles/scents, Unscented soap, laundry detergent, Good hygiene, wiping
correctly, Remove wet swimsuits, No douching, tampons limited, Avoid warm,
dark environments
➢ Trichomoniasis
■ Protozoan parasite
■ Woman: Symptomatic or Asymptomatic
■ Man: Asymptomatic carriers
■ Localized infection BUT Increasing Evidence of Premature rupture of membranes,
Preterm births/PostPartum endometritis, low birth weight, infertility
● If woman has the infection it gets into the birth canal and the uterus causing
several issues related to the baby
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Signs/Symptoms:
● Yellow/green or gray frothy discharge, Pruritus & soreness, Dyspareunia &
Dysuria, Colpitis macularis (“strawberry” look cervix); petechiae on cervix
■ Dx: microscopic
■ Treatment:
● Oral metronidazole (Flagyl) *all partners*
◆ Single dose
◆ No alcohol: severe N/V
➢ Bacterial Vaginosis
■ Gardnarella vaginalis (gram neg. bacilli)
■ Most common cause of d/c and malodor
■ S/S:
● thin white discharge, “stale fish” odor when mixed with KCl “whiff test”
● 50% asymptomatic
■ Dx: Discharge, vaginal ph >4.5, “whiff test”, wet mount slide
■ Rx:
● Oral metronidazole or clindamycin cream
● No evidence supporting male partner treatment
❖ Infections characterized by cervicitis (inflammation and infection of the cervix):
➢ Chlamydia
■ BEST FRIEND WITH GONORRHEA
■ Symptomatic:
● Mucopurulent discharge, Urethritis, Endometritis, Dysfunctional uterine
bleeding, Chronic Pelvic Pain, PID, Ectopic Pregnancy, Infertility
● Men: Urethritis
■ Risk factors
● Adolescent, Multiple sex partners, New sex partner, No barrier contraceptive,
Oral Contraceptives, Pregnancy, History of another STI
■ Dx: Swab Culture of Vagina or Endocervix or First void urine specimen
■ Rx:
● Doxycycline or azithromycin
● Combo drugs: Ceftriaxone and above meds
● INFANT EFFECTS
➢ Neonatal Conjunctivitis or Pneumonitis
➢ Stillborn, Preterm, low birth weight
➢ Gonorrhea
■ BEST FRIEND WITH CHLAMYDIA
■ Becoming more resistant to antibiotics
■ 70% asymptomatic
■ S/S: same as previous (d/c, dysuria, cervicitis, vag. bleed, PID)
■ Newborn
● Ophthalmia neonatorum-contagious-blindness and sepsis
◆ erythromycin ophthalmic ointment- state law
■ If infection travels up through uterus, out fallopian tubes into peritoneal cavity=PID
■ Permanent scarring of fallopian tubes: Can lead to infertility, ectopic pregnancy
■ If enters blood stream= endocarditis, meningitis, arthritis, toxic hepatitis
■ Dx: Screen all pregnant women at the first prenatal visit and 36 weeks
■ Rx:
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Ceftriaxone (Rocephin) IM or Cefixime (Suprax)
Azithromycin (Zithromax) or doxycycline (Vibramycin) po if Chlamydia is
suspected (in addition to above meds)
❖ Infections with Genital Ulcers
➢ Genital Herpes Simplex (HSV)
■ Viral, recurrent, life long infection: 50 million USA
● HSV-1: Fever blisters/cold sores: lips, eyes, face (not sexually transmitted)
● HSV-2: Genital tract (sexual transmission)
■ Transmission
● Mucous membranes, skin breakdown
● Direct contact when shedding virus (may not know)
● Most have not been diagnosed/unaware
● Risk 30-50% for neonatal infection with primary outbreak
◆ Neonatal herpes simplex: ↑ Morbidity and Mortality (increases risk of
being ill and dying)
■ Primary Episode
● Most severe, shedding of virus, Systemic infection, Painful vesicular
lesions=open, drain, crust, Mucopurulent discharge, Candida superinfection
● Flu like symptoms: fever, chills, malaise, dysuria, Headache, lymphadenopathy
● Last up to 2 weeks, stays dormant in nerve cells for life
■ Recurrent infection
● Milder, shorter duration (Itching, tingling, unilateral lesions, ↓pain)
■ Outbreaks
● Most with no cause, Emotional stress, Menses, Sexual intercourse,
Immunocompromised
■ Dx: Signs/Symptoms, viral culture
■ Rx: No cure
● Antiviral drug therapy; for frequent occurrences
◆ Acyclovir, Famciclovir, Valacyclovir (Valtrex)
● Vaccine in the works → Will only help those not yet infected
● Drugs help decrease the symptoms and duration
➢ Syphilis
■ Bacterial: Treponema pallidum
■ Systemic: Cause death to a fetus if not Rx
● Crosses placenta during pregnancy
● Baby can be infected the entire time
● Can cause spontaneous abortion, premature, stillborn, multisystem organ failure,
mental retardation, bone damage
■ Five Stages: Primary, Secondary, Early Latent, Late Latent, Tertiary
● Primary syphilis
◆ Chancre (painless ulcer) at site of bacterial entry
◆ Disappears 1-6 weeks with no Rx
◆ Painless, bilateral adenopathy (swollen lymph nodes)
◆ Highly infectious period
◆ Untreated progresses to secondary stage
● Secondary Syphilis
◆ Appears 2 to 6 months after initial exposure
◆ Flu like symptoms
●
●
15
◆ Maculopapular rash on trunk, palm, soles
◆ Alopecia, adenopathy
◆ Fever, weight loss, fatigue, pharyngitis
◆ Lasts two years
◆ Highly infectious
● Early Latent period and Late Latent Period
◆ No symptoms
◆ Serology positive (VDRL)
◆ Can last up to 20 years
◆ Still infectious
● Tertiary/Late syphilis
◆ Life threatening heart disease
◆ Neuro disease: destroys heart, eyes, brain, skin, CNS
■ Dx: Test lesion exudate/tissue for early dx (check for spirochetes)
● Serology tests:
◆ Nontreponemal tests (Reagin test for screening)
➢ VDRL (venereal disease research lab)
➢ RPR (rapid plasma reagin)
◆ Treponemal tests (more specific, verify not false positive)
➢ FTA-ABS (fluorescent trep. Antibody)
➢ TP-PA (T. pallidum particle agglutination)
■ Rx:
● Azithromycin or Ceftriaxone, one dose
● Ciprofloxacin (3 days) or Erythromycin (7 days)
● Penicillin-G: IM or IV
◆ Less than 1 yr. infected: 2.4 million units IM x1 dose
◆ Unknown duration: 2.4 million Units IM, once a week x 3 weeks
● Doxycycline: if allergy to Penicillin
● Important to follow up, re-test, re-evaluate
◆ Should be seen around 6 months, 12 months, and 24 months
➢ Pelvic Inflammatory Disease: PID
■ Ascending infection, recurrent/chronic
■ Frequently caused by untreated chlamydia/gonorrhea
■ Complications: Pain, adhesions, depression, abscesses, ectopic pregnancy, infertility
■ Manifestations vary and are hard to diagnose
■ CDC criteria for dx:
● Minimal criteria
◆ Lower abdominal tenderness, Adnexal tenderness, Cervical motion tenderness
● Supporting criteria
◆ Abnormal discharge, Elevated temperature
◆ Abnormal labs: Sed rate, CRP elevated
◆ Known history of Gonorrhea or Chlamydia infection
● Definitive Diagnosis:
◆ Endometrial biopsy, Transvaginal Ultrasound, Laparoscopy
■ Risk factors: Multiple partners, early age sex, lack of contraceptive use, etc…
■ Treatment:
● Broad spectrum antibiotics: Parenteral Cephalosporin with doxycycline BID x14 days
● Bedrest, pain management, fluids
16
● Counsel regarding risk factors/prevention
❖ Vaccine Preventable STI’s
➢ Human Papillomavirus: HPV (Genital Warts)
■ Most common viral infection USA
■ Asymptomatic, unrecognized (most)
■ Occur: cervix, vagina, urethra, anus, mouth
■ S/S: pruritus, pain
■ Risk factors: multiple partners, age, immunosuppression, Socioeconomic
■ Dx
● Inspection: fleshy papules, granular, warty appearance, may be large/clusters
● May test to determine strain (thin prep test)
■ Rx:
● Wart removal, Topical trichloroacetic acid, Liquid nitrogen cryotherapy
■ HPV still remains after wart removal
● Viral shedding continues
■ Do not necessarily need C-section unless other factors are present
● If she does not have any active warts then she can deliver vaginal
■ Prevention: Gardasil Vaccine: Boys and Girls
● 3 injections over 6 months (age 9-26)
● Duration & long term effects: 5+ years unknown
➢ Hepatitis A and B; Hepatitis C
■ Transmitted sexually, acute, viral, systemic
■ Hep: A, B,C,D,E, and G
■ Inflammation of liver
■ Hepatitis A (HAV)
● Spread via GI tract
● Polluted water, uncooked shellfish in contaminated water
● Carrier with poor hand hygiene: food
● Oral/anal sexual contact
◆ Easily spread to others in the same household
◆ self limiting, doesn’t result in chronic infection
● S/S: Flu like symptoms: fever, malaise, anorexia, nausea, RUQ pain, pruritus
■ Hepatitis B (HBV)
● Spread through saliva, blood, semen, menses, vaginal secretions
● Can cause permanent liver damage
● S/S: Similar but less skin involvement or fever
■ Hepatitis C:
● Attacks Liver inflammation. Not usually sexually transmitted, but could be
sexually transmitted. Perinatal transmission is rare unless immunocompromised.
New treatment available but no vaccine yet.
■ Dx:
● Hep A: serology: IGM antibody to HAV
● Hep B: serology: Hep B surface antigen (HBsAg)
■ Rx: none, supportive
■ Preventive:
● Infants: Hep B vaccine, started after birth, 3 injection series within 6 months
➢ Zika Virus Disease:
17
Transmitted by infected mosquitoes, Caribbean, central and South America, with cases
in the USA too. If symptoms, flu like (e.g. fever, rash, joint pain, headache,
conjunctivitis), 80% no symptoms. Transmitted sexually, fetal effects include
microcephaly. No vaccine and no antiviral treatment yet. Use insect repellent, long
sleeved shirts and pants, check window screens, avoid travel to known areas if pregnant
or planning pregnancy.
❖ Ectoparasitic Infections
➢ Common cause of skin rash and pruritus
➢ Scabies
■ Dermatitis due to mite (intense itch)
■ Burrows, deposits eggs, hatch, itch, small papule lesion reddens, erodes, crusts
■ Diagnosis: check for burrows in webs of fingers and genitalia
➢ Pubic Lice
■ small, yellow, oval eggs attached to hair shafts or lice (insect), pruritus, secondary
infection from scratching, Rash from scratching, lice/nits in pubic hair, axillary, thighs,
beards, eyebrows
■ Transmitted through sexual contact/intimacy
■ Treatment:
● Permethrin cream, Lindane shampoo, RID, Triple X, Pronto, Kwell
■ Treat all in contact
● Remove nits, manage environment (washing all linens/clothing/hot water,
vacuum), Don’t share personal items
❖ HIV
➢ 50,000 new cases in the US every year: Public health crisis!
➢ Retrovirus: causes breakdown in the immune system= AIDS
➢ Causes the infected person to acquire opportunistic infections or malignancies, becomes fatal
➢ Transmits to newborn before, during birth or through breastfeeding
➢ Transmission HIV:
■ Sexual contact, Shared needles, MOTHER TO FETUS, Blood products
➢ Initial infection: acute, lasts 3 weeks
■ Onset 2-6 weeks after exposure
■ Flu like symptoms: fever, rash, myalgia, pharyngitis
■ Takes 3-12 months before seroconversion
■ Infectious during this time
■ Becomes asymptomatic after acute phase
➢ T-Cell count: normal 450-1200 cells/microliter, AIDS: <200
■ Eventually, all who are HIV + will develop AIDS (average 11 yrs. after infected)
➢ Diagnosis:
■ Oraquick rapid HIV-1 Antibody test
■ Fingerstick or oral fluid sample
■ 99% accurate, 20 min. result
■ Reveal rapid HIV-1 Antibody test
■ Uni-Gold Recombigen HIV test
➢ Treatment:
■ Combo HAART (highly active antiretroviral therapy): triple combination or more
● Goal: suppress viral replication
■ Pregnancy: Rx during pregnancy, labor and infant after delivery
● No treatment: 25% or more get HIV
■
18
● With treatment: 2% HIV
➢ Prevention/Behavior Modification:
■ No sex until marriage; then remain faithful
■ Reduce number of sexual contacts
■ Barrier Contraceptives: condoms
Chapter 4: Common Reproductive Issues
❖ Types of Menstrual Disorders
➢ Amenorrhea: the absence or lack of menses during the reproductive years
■ Primary: absence of menses by 14 (absence of growth and development of secondary
sexual characteristics) or absence of menses by 16 (normal development of secondary
sexual characteristics)
■ Secondary: absence of menses for 3 cycles or 6 months in women who previously
menstruated regularly, These women have already had their menses
➢ Dysmenorrhea: painful menstruation
■ Treatment options: NSAIDs, Hormonal Contraceptives, SERMs (Selective estrogen
receptor modulators, Complementary therapies (e.g. Vit E, Magnesium, Vit B, fish oil),
lifestyle changes
■ Treatment options are based on what they think is causing that pain
● If it is caused by endometriosis → put onto oral contraceptives / estrogen
hormone to control the growth of the endometrial tissue to keep this quitier.
➢ Abnormal Uterine Bleeding (AUB)
■ Big umbrella term for not being really sure about what is going on; Irregular, abnormal
bleeding; not caused by pregnancy, a tumor, or an infection
● Hormonal disturbance causes prolonged, excessive, irregular bleeding
● May overlap with other uterine bleeding disorders such as:
◆ Menorrhagia: abnormally long, heavy periods
◆ Oligomenorrhea: bleeding occurs at intervals > 35 days
◆ Metrorrhagia: bleeding between menstrual periods
◆ Menometrorrhagia: bleeding occurs at irregular intervals with heavy flow
lasting > 7 days
◆ Polymenorrhea: condition of having too frequent periods
➢ Premenstrual Syndrome (PMS)
■ Criteria for Establishing a PMS Diagnosis:
● A - anxiety: difficulty sleeping, tenseness, mood swings, clumsiness
● C – craving: headache, cravings for sweets, salty foods, chocolate
● D – depression: feelings of low self-esteem, angry feelings, easily upset
● H – hydration: weight gain, abdominal bloating, breast tenderness
● O – other: hot flashes, cold sweats, nausea, change in bowel habits, aches or
pains, dysmenorrhea, acne
➢ Premenstrual Dysphoric Disorder (PMDD)
■ More severe form of PMS: Woman cannot function
■ Treatment Options for PMS/PMDD
● Lifestyle Changes: Reduce stress, caffeine, smoking, alcohol, Increase water,
exercise, Balanced Diet
● Vitamin and Mineral Supplements: Multivitamin, Vitamin E, Calcium,
Magnesium
● Medications: OC (low dose), antidepressants, diuretics, NSAIDS, other hormones
➢ Endometriosis:
19
■
■
■
■
Condition in which bits of functioning endometrial tissue are located outside the uterine
cavity
Endometrial tissue responds to hormones, swells and bleeds, “mini-periods” throughout
the abdomen, wherever the tissue is present
Treatment: suppress estrogen and progesterone levels (surgery, meds- NSAIDs, oral
contraceptives, progestogens, antiestrogens, GnRH-a (Gonadotropin-releasing hormone
analogs
Sometimes they can do surgeries but very rare as it typically grows back; or it is is more
than one area → difficult to remove without the risks
❖ Infertility
➢ Inability to conceive a child after one year of regular unprotected sexual intercourse
➢ Secondary Infertility: Inability to conceive after a previous pregnancy
➢ Nurses role: Recognize & Understand
■ Educate: Treatment, prevention, & limitations
➢ Etiology/Risk factors: Women: Known and Unknown
■ Primary reasons for women:
● 40% ovarian dysfunction
● 40% tubal/pelvic pathology (uterus)
● Over wt., under wt.: Causes hormonal problems; cannot ovulate and release egg
● Hormonal imbalance: Irregular ovulation; what is usual menstrual cycle like?
● Fibroids: Tissue that is abnormal ; not a tissue ; can grow in many areas
● Tubal blockages: Fallopian tubes blocks → very narrow to begin with so it does
not take much to block it (inflammation, adhesions)
● Age (increases after 27yrs)
● Endometriosis
● PID History
● Smoking/Alcohol
● Multiple miscarriages
● Psychological Stress
■ Immune System Disorders
● Turner Syndrome; other chromosomal abnormalities
◆ Cannot menstruate and therefore cannot get pregnant
● Chronic Illness (asthma, diabetes, thyroid)
● STI’s
■ Risk factors: Men
● Toxic exposure (lead, mercury, x-ray), Marijuana or cigarette smoke, Alcohol,
Prescription drugs, High temp. exposure of genitals (sauna/hot tub), Hernia
repair, Obesity, Cushing Syndrome, Frequent long distance cycling, STI,
Undescended testicles, Mumps (after puberty)
➢ Leads to: Feelings of inadequacy, Guilt, Blame, Pressure from family/friends, Embarrassing,
Marital conflict
➢ Treatment: Least invasive to most invasive
■ Thorough health history → ‘Rule out’ in order to ‘rule in’ → START WITH MALE
➢ Male Factors
■ Semen analysis
● Abstain from sexual activity for 24-48 hrs prior to specimen collection
20
Examine within 1-2 hrs. of specimen collection: Adequate #, healthy and mature,
able to penetrate egg (motility, shape) (e.g. 20 million sperm/ml with >50%
motility)
■ Physical exam: Appropriate sexual development, Rule out abnormalities and prostate
problems
➢ Female Factors
■ Diagnostic Tests
● Ovulation Function
◆ History of menstrual cycles
◆ Ovulation predictor kits/Urinary LH (luteinizing hormone) level
➢ Check temp., dip urine, color change indicates LH level high, most
fertile (LH helps push the egg out after ovulation)
● Clomiphene Citrate Challenge Test (measures ovarian reserve: are eggs able to be
fertilized)
◆ Lab test: FSH level on cycle day 3, takes 100mg clomiphene citrate
(clomid) on days 5-9, draw lab on cycle day 10: abnormal if FSH level is
greater than 15, not likely to conceive with own eggs
◆ FSH(follicle stimulating hormone) starts the process of getting that egg
going
● Endometrial Biopsy
◆ Checks if progesterone (key for getting the endometrial tissue ready for
shedding) secretion is adequate
◆ Remove tissue just before menstruation and check histology pattern
● Post coital testing
◆ Sperm is fine; she is producing the egg; but for some reason they are not
getting into the tubes → Checks if cervical mucus is receptive
◆ Plan intercourse at ovulation, check mucous 2-8hrs after intercourse,
count # live sperm, mucus consistency/stretchability (spinnbarkeit)
◆ Normal: amt. moving forward, mucous stretches 2 inches, dries in fern
like pattern
● Hysterosalpingogram
◆ Contrast injected into endocervical canal to visualize tubes/uterus with
fluoroscopy and radiography
◆ Checks patency of tubes
◆ Dye flows upward and out tubes into peritoneal cavity if tubes are open
and not blocked
◆ Are the tubes open → if they are you should see the dye within the
abdominal cavity
● Laparoscopy
◆ Endoscope inserted in abdomen incision; use anesthesia, surgical risks
◆ Visualize endometriosis, adhesions, fibroids, occluded tubes, ovarian cysts
(polycystic)
◆ Performed early in menstrual cycle
❖ Treatments/Options
➢ Drugs: Clomid (non-steroid, induces ovulation) or Pegonal (direct stimulation/induce
ovulation)
➢ Surgery; Repair damage, blocked tubes
➢ Timed intercourse: Based on ovulation
➢ Egg and/or Sperm donation: Retrieved from donor then inseminated
●
21
➢ Surrogate: lab fertilized embryo implanted in another woman
■ Used when a woman has an issue with her uterus
➢ Artificial Insemination: Insert semen sample into cervical os or intrauterine cavity
➢ In vitro fertilization: Oocytes fertilized in lab then inserted into uterus
■ Use needle aspiration to retrieve mature ovum
➢ Gamete Intrafallopian transfer (GIFT)
■ Oocytes and sperm combined and immediately placed in fallopian tube
■ Fertilization can occur naturally; uses laparoscopic and general anesthesia
➢ Intracytoplasmic sperm injection
■ One sperm injected into cytoplasm of oocyte to fertilize it
■ Sperm retrieved by needle aspiration into epididymis
➢ Donor Oocytes or Donor Sperm: Retrieved, inseminated, transferred via IVF
➢ Preimplantation Genetic Diagnosis (PGD): Testing of embryos created through IVF
■ Parent(s) known genetic abnormality
➢ Gestational Carrier (Surrogacy)
❖ Issues: Ethical, Religious, Medical, Legal, Ownership, Financial, Insurance, Emotional, Coping,
Stress/Anxiety Management, Peer Support Groups
Chapter 11: Nursing Role Regarding Reproductive Education for Patients
❖ Reproductive Education includes considerations for the” Ideal Method” to prevent pregnancy:
■ Ease of use; consistent method, Safety, Effective, Minimal side effects, Naturalness,
Nonhormonal, Immediate reversibility
❖ Reversible Methods:
➢ Behavioral:
■ Abstinence: moral/religious beliefs, effective, disease prevention role
■ Fertility awareness: Abstinence during fertile days with highest risk of pregnancy
● Cervical mucus ovulation method, Basal body temperature, Symptothermal
method, Standard days method (Bead method in the book)
■ Withdrawal (coitus interruptus)
■ Lactational amenorrhea method
● Continuous breastfeeding can postpone ovulation, can be effective for 6 months
only if:
◆ No menses since birth of baby
◆ Breast feeds at least 6 times per day on each breast
◆ Breastfeeds on demand at least every 4 hours
◆ Provides nighttime feedings at least every 6 hours
◆ Does not rely on this method after 6 months
● Prolactin levels must remain high enough to inhibit gonadotropin (necessary for
ovulation)
➢ Barrier: Role in Disease Prevention (STIs) and Contraception
■ Condoms (male and female)
■ Diaphragm: Must be measured/fitted, prescription
■ Cervical cap
■ Contraceptive sponge
➢ Hormonal: Work by suppressing ovulation by adding estrogen and progesterone to a woman’s
body mimicking pregnancy → “trick the body into thinking it is pregnant so it does not ovulate”
■ Oral contraceptives, Injectable contraceptives, Transdermal patches, Vaginal rings,
Implantable contraceptives, Intrauterine contraceptives
■ Emergency contraception
22
Reduces the risk of pregnancy after unprotected intercourse or contraceptive
failure, reduce the risk by 80%; Used within 72 hours
● Prevent embryo creation and implantation, no effect on an implanted embryo
◆ Progestin only oral contraceptives
◆ Combination oral contraceptives,
◆ EC kit (plan B)
■ EARLY SIGNS OF COMPLICATIONS FOR USERS OF ORAL CONTRACEPTIVES
● A = Abdominal pain may indicate liver or gallbladder problems.
● C = Chest pain or shortness of breath may indicate a pulmonary embolism.
● H = Headaches may indicate hypertension or impending stroke.
● E = Eye problems may indicate hypertension or an attack.
● S = Severe leg pain may indicate a thromboembolic event.
❖ Permanent Methods:
➢ Sterilization: Considered Permanent
■ Tubal ligation
● Sterilization for women
● A laparoscope is inserted; fallopian tubes are grasped and sealed
● Easiest when performing the C-section
■ Vasectomy
● Sterilization for men
● Usually performed under local anesthesia
● Involves cutting the vas deferens, which carries the sperm
● Much lower risk than woman having a tubal
● Still ejaculate but semen does not contain sperm
➢ Abortion: Cxpulsion of embryo or fetus before viability; most done in first 12 weeks
■ Surgical abortion
● Dilation of cervix, suction and curettage (scraping)
■ Medical abortion → mostly done
● Methotrexate followed by misoprostol
● Mifepristone followed by misoprostol
● Causes the egg to release itself from the lining of the uterus ; can be done very
early but you have to know you are pregnant
Chapter 11: Maternal Adaptation During Pregnancy
❖ Signs and Symptoms of Pregnancy
➢ Presumptive (time of occurrence)
■ Fatigue (12 weeks)
■ Breast tenderness (3-4 weeks)
■ Nausea and vomiting (4-14 weeks)
■ Amenorrhea (4 weeks)
■ Urinary frequency (6-12 weeks)
■ Hyperpigmentation of the skin (16 weeks)
■ Fetal movements (quickening) (16-20 weeks)
■ Uterine enlargement (7-12 weeks)
■ Breast enlargement (6 weeks)
■ CAN STILL BE SOMETHING OTHER THAN A PREGNANCY
➢ Probable (time of occurrence)
■ Braxton-Hicks contractions (16 - 28 weeks)
■ Positive pregnancy test (4-12 weeks)
●
23
● HCG levels; can still be positive without pregnancy
■ Abdominal enlargement (14 weeks)
■ Ballottement (16-28 weeks)
■ Goodell’s sign (5 weeks): Softer
■ Chadwick’s sign (6-8 weeks): Blue
■ Hegar’s sign (6-12 weeks): Softer
■ CAN STILL BE SOMETHING OTHER THAN A PREGNANCY
● MORE LIKELY SHE IS PREGNANT
➢ Positive (time of occurrence)
■ Ultrasound verification of embryo or fetus (4-6 weeks)
■ Fetal movement felt by experienced clinician (20 weeks)
■ Auscultation of fetal heart tones via Doppler (10-12 weeks)
❖ Physical Changes during pregnancy
➢ Uterus
■ Uterus is getting larger
■ Walls thin to 1.5 cm or less from a solid globe to a hollow vessel
■ Volume capacity increases from 2 teaspoons to 1 gallon (10ml to 5,000ml)
■ 1/6 of total maternal blood volume is contained within the vascular system of the uterus
by term
■ Braxton Hicks
● Spontaneous, irregular, painless contractions; helps with effacement late in
pregnancy
● Come and go; get more frequent towards the end ; think of it as the uterus
practicing
■ Fundal height
● Indicates uterine size by measuring from the top of the symphysis pubis to the
top of the fundus (top of the uterus)
● Correlates with weeks of gestation between 20–30 weeks
◆ 20 weeks = 20 cm
◆ 24 weeks = 24 cm
◆ 30 weeks = 30 cm
◆ Not reliable after 36 weeks d/t fetal descent
➢ Baby is dropping down towards the pelvis so no longer accurate
● Why do we measure? Why do we care?
◆ Too Small
➢ Dates are wrong , Not nourished/small baby, Problems with the
placenta (not functioning well so baby is not getting nutrients so
baby is not growing), Low amniotic fluid
◆ Too Large
➢ Gestational diabetes , Too much fluid , Wrong dates , Multiples
■ Hegar’s sign
● Softening of the lower uterine segment or isthmus
➢ Cervix → know these
■ Chadwick’s sign
● Estrogen causes the cervix to become congested with blood
(hyperemic),
resulting in a bluish color that extends to include the vagina
● Becomes bluish because it is to vascular
■ Goodell’s sign
24
➢
➢
➢
➢
➢
● Increased vascularity causes the cervix to soften (6-8 weeks)
■ Mucus plug
● Increased mucus forms to seal off the cervix from outside bacteria (progesterone)
● Think it is due to progesterone
● Keeps bacteria out
● As long as cervix stays nice tight and close the mucus plug will stay in place until
woman starts to dilate and given birth than it will fall out
Ovaries
■ Cease ovum production during pregnancy
■ Elevated estrogen/progestin. block secretion of FSH & LH
■ Corpus luteum persists until 6-7 weeks to secrete progesterone until the placenta takes
over
Vagina
■ Increased vascularity and hyperplasia
■ Increased vaginal secretions (leukorrhea) and decreased pH (acidic) to prevent
infections
● Woman with pregnancy and diabetes are more likely to get yeast infections
■ Monilial vaginitis possible (s/s itching etc..)
Breasts
■ Increase in size and nodularity to prepare for lactation
■ Tenderness, vascularity, stretch marks
■ Nipples increase in size, become more erect, and more pigmented
■ Sebaceous glands prominent-lubricate nipple
■ Colostrum is produced= an antibody-rich, yellow fluid that can be expressed by the third
trimester (converts to mature milk after delivery)
● Has the igA antibody which cannot be found in formula
GI Tract
■ Reflux of gastric contents common due to relaxation of smooth muscles by progesterone
■ Increased vascularity
■ Progesterone influences the smooth muscle which is why they burp more
■ Ptyalism (excessive salivation) is a common condition of pregnant women (d/t less
swallowing when nauseated?)
■ Bleeding gums, swollen, acidic saliva
■ Decrease in intestinal motility causes constipation (iron supplements, decr. Activity)
■ Hemorrhoids: constipation, incr. venous pressure
● Due to increased vascularity
■ Nausea and vomiting (morning sickness) is due to high hCG levels from 6 to 12 weeks,
decreased motility
Cardiovascular
■ Blood volume increases by 40-50%
● A large amount of it is plasma
■ Cardiac output increases from 30-50% then decreases to 20%
■ Heart rate increases 10-15 bpm (beats per minute)
■ Slight heart enlargement
■ BP decreases initially d/t progesterone; vasodilation then returns to normal
■ Supine hypotension syndrome: uterus pressure on inferior vena cavareduces blood
flow
25
RBC increases 30% to transport Oxygen, but plasma volume exceeds
RBC=hemodilution=physiologic anemia of pregnancy
● That being said her H&H is low because her blood is diluted ; more plasma within
the makeup of her blood than she does everything else
● Not to worry because we understand it
Respiratory System
■ Uterus pushes diaphragm upwards, decreases space for lungs
■ Diaphragmatic excursion increases=tidal volume increases
■ Faster and deeper breathing
■ Diaphragm vs. abdominal
■ More vascular (estrogen) =nasal stuffiness, nosebleeds, change in voice tone
■ Once baby drops down ; mom can start to get deep breaths again
Renal / Urinary
■ Kidneys work harder, enlarge
■ More blood flow to kidneys=Increase GFR=increase urine flow/volume
■ Ureters elongate and widen
■ Go back to normal after
Musculoskeletal
■ Ligaments soften and stretch
■ Joints widen, more moveable
■ Postural changes
■ Lower back pain
■ Waddle gait
■ Hormone called relaxin helps to relax muscles and stretch and work
Integumentary
■ Increased pigmentation (hyperpigmentation) areola, axillae, perineum, umbilicus
● Tends to go away after pregnancy
■ Striae gravidarum: “Stretch marks”
■ Skin color changes/complexion
■ Hair loss or decline in hair growth
■ Chloasma “Mask of pregnancy”: blotchy brown pigment (dark haired women)
■ Linea nigra: pigmented line down abdomen
■ Vascular spider marks
■ Palmar erythema
● Red palms
■ Nail growth increases; brittleness may increase
■ Nipples getting darker
Endocrine
■ Thyroid gland: slight enlargement; increased activity; increase in BMR
■ Pituitary gland: enlargement; decrease in TSH, GH; inhibition of FSH & LH; increase in
prolactin, MSH; gradual increase in oxytocin with fetal maturation
■ Pancreas; insulin resistance due to hPL and other hormones in 2nd half of pregnancy
(see Box 11.2)
● Happens later in pregnancy
● Most woman can handle this ; get this resistance but the pancreas will produce
more insulin
● If they cannot handle this ; this is when gestational diabetes happens
■ Adrenal glands: increase in cortisol and aldosterone secretion
■
➢
➢
➢
➢
➢
26
■ Prostaglandin secretion
■ Placental secretion: hCG, hPL, relaxin, progesterone, estrogen (see Table 11.3)
➢ Immune system
■ Enhanced innate immunity (inflammatory and phagocytosis response) but Suppressed
adaptive immunity (so not to reject fetus); increases risk for developing infections.
Varied responses to chronic disorders/autoimmune
■ Has to not thin that the baby is bad
● Corrects adaptive immunity
◆ Makes mom more vulnerable to getting sick
➢ Nutritional needs
■ Direct effect of nutritional intake on fetal well-being and birth outcome
■ Need for vitamin and mineral supplement daily
■ Dietary recommendations
■ Increase in protein, iron, folate, and calories (see Table 11.5)
■ Use of USDA’s Food Guide MyPlate (see Figure 11.5)
■ Avoidance of some fish due to mercury content
● Damaging to the fetus
➢ Maternal weight gain
■ Healthy weight BMI: 25 to 35 lb
● 1st trimester: 3.5 to 5 lb
● 2nd & 3rd trimesters: 1 lb/week
■ BMI < 19.8: 28 to 40 lb
● 1st trimester: 5 lb
● 2nd & 3rd trimesters: 1+ lb/week
■ BMI > 25: 15 to 25 lb
● 1st trimester: 2 lb
● 2nd & 3rd trimesters: 2/3 lb/week
■ Weight gain depends on her BMI to begin with
■ First trimester is very little weight gain
➢ Nutrition Promotion
■ USDA Food Guide MyPlate
■ Client education (see Teaching Guidelines 11.1)
■ Special considerations
● Cultural variations
● Lactose intolerance
● Vegetarianism
● Pica: Abnormal cravings that are not food
◆ Theory behind it is that the body is missing some kind of minerals
❖ Psychological
➢ Response to pregnancy
■ Ambivalence: initial response; no visible body change yet
■ Introversion: turning in on oneself; preoccupied with self and fetus
● Further into the pregnancy
■ Acceptance: triggered by quickening (mom feels the baby move for the first time) in 2nd
trimester
■ Mood swings: from great joy to despair, Come from stress and the hormone changes
■ Body image change: the “picture” you have of your body and of yourself
❖ Maternal Roles
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Ensuring safe passage throughout pregnancy and birth
Seeking acceptance of infant by others
Seeking acceptance of self in maternal role to infant (“binding in”)
Learning to give of oneself
■ 1st trimester: identifying what must be given up to assume new role
■ 2nd trimester: identifying with infant, learning how to delay own desires
■ 3rd trimester: questioning ability to become a good mother to infant (Rubin, 1984)
❖ Other changes/adaptations to consider
➢ Pregnancy and sexuality
■ Numerous changes, possibly stressing sexual relationship
■ Changes in sexual desire with each trimester
■ Sexual health and link to self-image
■ Can continue to be intimate throughout the pregnancy
➢ Pregnancy and partner
■ Family-centered emphasis
■ Partner’s reaction to pregnancy and changes
● Couvade syndrome (get similar symptoms: n/v, gain wt.)
◆ Dad get the same syndromes as mom
● Ambivalence
● Acceptance of roles (2nd trimester)
● Preparation for reality of new role (3rd trimester)
➢ Pregnancy and siblings
■ Age-dependent reaction
■ Sibling rivalry with introduction of new infant into family
■ Sibling preparation imperative
Chapter 10: Fetal Development and Genetics
❖ Preembryonic Stage: Fertilization through 2nd week
➢ Fertilization=conception
➢ BEFORE: Cell division
■ Sperm: Meiosis while in the testes
■ Ovum: Primary oocyte completes first meiotic division before ovulation, Secondary
oocyte just prior to ovulation
■ Formation of gametes by meiosis= gametogenesis
■ 23 chromosomes
➢ Zona Pellucida:
■ Blocks all sperm but one from entering
■ Clear protein layer that forms around the egg and protects
➢ When sperm & ovum join:
■ Form a Zygote
■ 46 chromosomes
■ Sex determination based on sperm: XX (Girl) XY (Boy)
➢ Fertilization and transport of zygote:
■ Implantation in upper uterus (normally)
■ Rich blood supply: food & oxygen
■ 7-10 days after conception
■ Cells continue to differentiate to form fetal structures
➢ Three embryonic layers of cells formed:
■ Ectoderm: forms the central nervous system, special senses, skin and glands
➢
➢
➢
➢
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■ Mesoderm: forms skeletal, urinary, circulatory, and reproductive organs
■ Endoderm: forms respiratory system, liver, pancreas, and digestive system
❖ Embryonic Stage: End of 2nd week through 8th week
➢ Basic structures of all major organs and main external features completed
■ Moms need to be careful what they are doing in first trimester because everything is
developing
➢ Fetal membranes: Makes up Amniotic Sac
■ Chorion (trophoblast cells/mesodermal lining)
■ Amnion (thin membrane with fluid)
■ Role of Amniotic Fluid:
● Helps maintain a constant body temperature for the fetus, Permits symmetric
growth and development, Cushions the fetus from trauma, Allows the umbilical
cord to be relatively free of compression, Allows fetus to move and takes nutrients
in and waste out, Promotes fetal movement to enhance musculoskeletal
development
■ Amniotic Fluid:
● 98% water: 2% organic matter
● Fluctuates throughout pregnancy
● Normal 800-1000ml by 37 weeks
● Oligohydramnios (<500ml)
◆ Too little amniotic fluid
◆ May be uteroplacental insufficiency or
◆ Fetus may have renal abnormalities
◆ Problems with the placenta or problems with the fetus?
● Hydramnios/Polyhydramnios (>2000ml at term)
◆ Too much amniotic fluid
◆ May be seen with diabetics
◆ May be due to GI or CNS malfunction, neural tube defects
➢ Umbilical Cord
■ Formed from the amnion
■ 1 Large Vein - 2 Small Arteries
■ Wharton’s jelly (inside the cord): Surrounds the vessels to prevent compression
■ At term, the average umbilical cord is 22 inches long and about 1 inch in width
● Length needed so the baby can move freely
● Normal: 3 vessels ; AVA → artery, vein, artery
➢ Placenta:
■ Serving as the interface between the mother and fetus (Mom’s body will not attack fetus)
■ Making hormones to control the physiology of the mother
■ Removing waste products from the fetus
■ Inducing the mother to bring more food to the placenta
■ Producing hormones that mature into fetal organs
● HCG= Basis for preg. Tests
● hPL- human placental lactogen
● Estrogen (Estriol)
● Progesterone (progestin)
● Relaxin
■ Supplies nutrients and oxygen to fetus
➢ Placental Barrier:
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■ Fetal tissues that prevent mixing of mom and fetus blood
■ Diffusion: material exchange
■ Maternal uterine arteries: deliver nutrients
■ Uterine veins; carry oxygen, remove fetal waste
➢ Teratogen
■ “any substance, organism, physical agent, or deficiency state present during gestation
that is capable of inducing abnormal postnatal structure or function by interfering with
normal embryonic and fetal development”
● e.g. viruses, bacteria, lead, drugs, radiation…
❖ Fetal Stage: End of the 8th week until birth
➢ Growth and refinement of organs/systems
➢ Fetal Circulation: Different circulation patterns than full
birth humans
■ 3 Shunts
● Ductus venosus: connects the umbilical vein
to the inferior vena cava
● Ductus arteriosus: connects the main
pulmonary artery to the aorta
● Foramen ovale: anatomical opening
between the right and left atrium
■ Placenta
● Oxygen from the placenta before birth vs.
lungs after birth
● Fetal liver: no metabolic function yet
■ Primary Function: carry highly oxygenated blood to vital areas (heart/brain), away from
lungs and liver (placenta covers these functions)
❖ Autosomal Errors
➢ Numerical Abnormalities
■ Trisomy
● Entire single added chromosome
● Down syndrome (3 copies of chrom 21)
◆ Small, low-set ears (Eyes typically
measure above the ears),
Hyperflexibility, Muscle hypotonia,
Deep crease across palm – termed
simian crease, Flat facial profile,
Small white-crescent-shaped spots
on irises, Open mouth with
protruding tongue, Broad, short
fingers
● Klinefelter syndrome (extra x: XXY) only
males
◆ Mild mental retardation, Small testicles, Infertility, Long arms and legs,
Enlarged breast tissue (gynecomastia), Scant facial and body hair,
Decreased sex drive (libido)
● Trisomy 13/Polydactyly: Extra toe
■ Monosomy
● Entire single chromosome missing
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Turner Syndrome (females) (one X)
◆ Short stature, delayed puberty, infertility, heart defects, learning
disabilities
● All others incompatible with life
■ Polyploidy
● One or more added sets of chromosomes
● Early abortion, incompatible with life
➢ Structural Abnormalities
■ Part of a chromosome missing or added (number of chromosomes are correct)
● Cri du Chat Syndrome (missing piece chrom 5)
◆ Laryngeal defect=‘meowing cat infant cry’, mental retardation, Failure to
thrive, organ problems
■ Rearrangements of material within the chromosomes
■ Two chromosomes that adhere to each other
■ Fragility of a specific site on the X chromosome
● Fragile X syndrome: x chrom has breaks/gaps
◆ Mental retardation, hyperactivity, autistic behavior
❖ Inheritance Patterns:
➢ Autosomal Dominant
■ Abnormal gene pair dominates normal gene pair, 50% children affected
■ e.g. Familial hypercholesterolemia, neurofibromatosis, Huntington Disease
➢ Autosomal Recessive
■ Mutations of two gene pairs on a chromosome
■ Both genes of pair abnormal=disease
■ One gene in pair abnormal=no disease or mild
■ Single defective gene=carrier
■ Seen ethnic groups: Tay Sachs disease
■ e.g. Sickle cell, PKU, Cystic Fibrosis (CF), Thalassemia
■ Seen when blood related parents (first cousins)
■ Offspring 25% affected, 50% carrier
➢ X Linked
■ Gene mutation on x chromosome - Follows dominant or recessive pattern
■ Usually only men (women-other X compensates unless dominant x)
■ e.g. Hemophilia, color blindness, childhood muscular dystrophy
➢ Multifactorial Inheritance Patterns:
■ Combination of many genes and environmental factors (health, age, pollutants)
■ Tend to run in families
■ e.g. Cleft lip, HTN, Diabetes, Heart disease, CA, mental illness
➢ Nontraditional Inheritance Patterns:
■ Don’t follow normal patterns
■ e.g. mitochondrial inheritance, genomic imprinting
❖ Genetic Evaluation and Counseling
➢ Process by which patients or relatives, at risk of an inherited disorder, are advised of
consequences, nature of the disorder, probability of developing it, andoptions for management
and family planning in order to prevent, avoid, or ameliorate (improve/better) it
➢ Ideal time: before conception
●
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➢ Have already identified someone that is at risk for a disorder ; explain the pedigree chart and
then explain what it is like to have a child with the disease ; what can they do to prevent or avoid
it
➢ Role and Responsibilities of Nurse in Genetic Counseling
■ Beginning the preconception counseling process and referring for further genetic
information
■ Taking a family history: includes pedigree chart
■ Focused health assessment/genetic history (Box 10.3)
■ Scheduling genetic testing and Explaining the purposes, risks/benefits
● Alpha fetoprotein (AFP)
● Amniocentesis
◆ Needle to enter into the uterus while looking under the scope ; take the
fluid to do genetic testing on it
◆ Risk: infection; rupture of the amniotic fluid ; bleeding
● Chorionic Villus Sampling (CVS)
● Percutaneous umbilical blood sampling
● Fetal nuchal translucency (FNT)
● Level III ultrasound/Fetal Scan
● Triple and Quad Screening Tests
● Preimplantation Genetic Diagnosis (PGD)
● Cell-free fetal DNA (cffDNA)
➢ Questions/Support
➢ Discussing costs, benefits, and risks of using health insurance, and potential risks of
discrimination, Recognizing ethical, legal, and social issues
➢ Referring to appropriate support group
Chapter 11: Maternal Adaptation During Pregnancy and Chapter 12: Nursing Management
During Pregnancy
Preconception Care Focus:
❖ Immunization Status
➢ *While not pregnant, want up-to-date immunizations:
■ Vaccines to be considered if otherwise indicated (safe during pregnancy):
● Rabies
■ Vaccines contraindicated during pregnancy:
➢ If already pregnant, should not be receiving live vaccines (Box 12.5, CDC Guidelines) (MMR,
Rubella, Nasal Flu, etc…)
❖ Underlying Medical Conditions (Complete History and Physical)
➢ Treat problems prior to pregnancy if possible; want the healthiest “you” possible preconception
❖ Reproductive Healthcare Practices
➢ Contraception Practices
➢ Usually like to have 3 normal cycles before getting pregnant!
❖ Sexuality and Sexual Practices: How many partners do you have? Last pap smear? Have you ever had
STI testing?
❖ Nutrition: Calcium? Vegan? How do you get your protein?
❖ Lifestyle Practices: What do you do for exercise? (Unless HIGH RISK – Can keep doing regular
activity!)
➢ Job Exposures: EX – Radiology Tech exposed to radiation while pregnant take a different form
of job for the duration of the pregnancy
❖ Psychosocial Issues: Are you safe at home? Do you have support? Do you need social worker services?
❖ Medication and Drug Use:
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➢ Folic Acid 400 mcg/day
➢ What meds are you on? Can they be continued while pregnant?
❖ Support system
➢ Support System, Place to Live, Help with Baby
❖ Characteristics of the Initial Health History
➢ A. Reason Seeking Care; “What brings you here today?”
➢ B. Past Med/Surg History (Includes family and partner’s history
➢ C. Reproductive History (LMP, Age of Menarche, # of Partners, Pap Smears, Abortions)
❖ **Establish a trusting relationship, focus on education for wellness, attempt to detect and prevent
potential problems**
❖ If Pregnant at visit… Determine Due Date: Naegele's Rule
➢ Use the first day of last menstrual period (LMP)
■ 11/21/21
➢ Subtract 3 months
■ 8/21/21
➢ Add 7 days
■ 8/28/21
➢ Correct year by adding 1 year
■ 8/28/22 (+/- two weeks)
■ Also called
● EDB (estimated date of birth)
● EDC (estimated date of confinement)
● EDD (estimated date of delivery)
➢ Also use ultrasound, birth wheel to determine EDD
Terminology Used to Document an Obstetric History (Table 12.1)
❖ Gravida: A pregnant woman (Including current pregnancy in count)
➢ Gravida I (primigravida): First Time
➢ Gravida II (secundigravida): Second Time Pregnant
❖ Para: # of births at 20 weeks or greater (multiple births counted as 1 event)
➢ Primipara: First time making it to 20 weeks
➢ Multipara: Made to 20 weeks several times
➢ Nullipara: Never made it to 20 weeks
❖ GTPAL
➢ G: Gravida including current pregnancy
➢ T: (term births) # of pregnancies delivering between 38 and 42 weeks
➢ P: (preterm births) # of preterm pregnancies ending > 20 weeks or viability but before
completion of 37 weeks
➢ A: (abortions) the number of pregnancies ending before 20 weeks
■ Covers miscarriage and medically induced abortion
■ Spontaneous/Elective
➢ L: (living children) number of children currently living
Preparing Pregnant Woman for Physical Exam
❖ Provide Gown
❖ Bathroom: Obtain urine specimen (urinalysis, culture/sensitivity, UTI?)
❖ Vital Signs, Height, Weight (BASELINES!)
❖ Head-to-toe assessment: head, neck, chest, abdomen, back, extremities
➢ Pelvic Examination
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❖
❖
❖
❖
■ Examination of external and internal genitalia
■ Bimanual (Palpate vaginal wall between vagina and rectum)
➢ Pelvic Shape and Measurements: (Don’t need to know #s only concept!)
■ Gynecoid: Common Pelvic Shape (Favorable to deliver vaginally)
■ Android: Shaped more like a heart or a wedge – more like a male pelvis
■ Anthropoid: Narrow and deep like an upright egg or oval
■ Platypelloid: Flat pelvis, wide but shallow, like an egg or side lying oval
➢ Lab work (See Table 12.1)
■ Urinalysis: albumin, glucose, ketones, bacteria
■ Blood work: CBC, blood type, Rh, glucose, rubella titer, Hep B
■ Surface antibody antigen, HIV, VDRL, RPR (Syphilis)
■ Cervical smears: STI detection
■ Other (if indicated): Genetic Screening for Diseases, Rubeola, Blood Lead Screening, Rh
Factor, Blood Type
Visit Schedule:
➢ Up to 28 weeks: Every 4 weeks
➢ 29-36 weeks: Every 2 weeks
➢ 37 weeks to birth: Weekly
Every Visit:
➢ Weight and blood pressure measurements; compared to the baseline values
➢ Urine testing for presence of protein, glucose, ketones, nitrites
➢ Gestational diabetes can happen at ANY time!
➢ Fundal Height Measurement to assess fetal growth:
■ How does it compare to Naegel’s Rule?
■ Between 12-14 weeks, fundus palpated above symphysis pubis
■ By 20 weeks; fundus at level of umbilicus and should measure 20 cm.
■ Fundal Height Measurement should equal approx. # weeks pregnant, until 36 weeks,
then not accurate, due to lightning
Assessment for Quickening/Fetal Movement to determine well-being
➢ 16-20 weeks: Teach “kick counts”
➢ Feeling 10 movements in less than 2 hrs.
➢ Keep Chart and Contact physician if less movements or longer than 2 hrs. to get 10 movements
➢ Try to assess for same time every day
➢ Assessment of Fetal Heart Rate: Range between 110–160 bpm
■ CAN BE LOWER IF BABY IS SLEEPING/RESTING
Other Assessments:
➢ Blood Glucose: Done between Weeks 24-28 (earlier if risk factors)
■ Drink Oral 50g glucose load, check plasma glucose level in one-hour, normal result if
<140 (If abnormal patient goes for 3hr GTT)
➢ 3 hr. Glucose Tolerance Test (GTT)
■ Done if first test is >140 mg/dL
■ Drink oral 75-100g glucose load
■ Check blood glucose level fasting and at 1, 2, and 3 hr. intervals
■ One or more abnormal values= Gestational Diabetes Diagnosis
● FBS: less than 92 mg/dl, 1hr <180, 2hr <153, 3hr <140)
➢ Evaluate for preterm labor:
■ Signs/Symptoms: Abnormal Bleeding, Contractions, Frequent Bowel Movements, Lower
Back Pain/Constant, Pelvic Pressure/Pain, Water Breaking
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➢ Assess comfort, complaints, answer questions, reminders on nutrition, prenatal vitamins,
exercise
❖ Danger Signs of Pregnancy
➢ 1st Trimester
■ Hyperemesis Gravidarum: Excess Vomiting in 1st trimester
● Should not be so much that Mom cannot eat or drink and keep it down!
■ UTI: Painful Urination
■ Miscarriage: Spotting or bleeding
■ Fever higher than 100°F (37.7°C): Indicative of infection
■ Ruptured Ectopic Pregnancy: Lower abdominal pain with dizziness and accompanied by
reflective shoulder pain
➢ 2nd Trimester
■ Preterm Labor: Regular uterine contractions (preterm labor)
■ DVT: Pain in calf, often increased with foot flexion
■ Prelabor Rupture of Membranes: sudden gush or leakage of fluid
■ Possible Fetal Distress/Demise: Decrease in fetal movement for more than 12 hours
➢ 3rd Trimester:
■ Edema: Check for gestational hypertension
● Persistent Headache or Headache with Visual Changes
● Preeclampsia
● Eclampsia
■ Rh Factor: Check antibody titer (Is Mom Rh-?)
● If needed give RhoGAM now (prophylactic at 28 weeks, and after spontaneous
ab, amnio, after birth (if Rh+ baby)
● Give anytime chance of fetal cells entering maternal circulation – prophylactically
prevents development of antibodies to Rh+ cells
● If Mom is Rh- and baby is Rh+ and is not given the shot, her body will attack any
future Rh+ babies
● Rh- babies will not have any effect on Rh+ moms
■ Perform Leopold’s Maneuver
● Practitioner can assess how the baby is feeling and assess positioning of baby in
uterus
■ Fetal Movement Monitoring
● Risk for fetal distress or demise
● Decrease movement for more than 24 hours
■ H/H for Anemia
■ Pelvic Exam: Cervix position, Consistency, Length, Dilation
● ** DO NOT keep doing pelvic exams through the pregnancy unless it is
necessary**
● Risk of infection, rupture, causing early labor
■ Check for Group Beta strep, Gonorrhea, Chlamydia
● GBS+ and not treated with antibiotics during labor – Baby will be infected
◆ Can be septic and cause death!
◆ Tested in beginning and end of pregnancy
◆ Assessment of Fetal Well-Being
❖ Other Testing
➢ Ultrasonography (noninvasive)
35
3D/4D Transducer-high frequency sound waves-visualize fetus; usually 18-20 weeks, 34
weeks
■ Checks placenta placement, amt. of amniotic fluid, verify dates, growth, fetal
development
■ FULL BLADDER
Doppler Flow Studies
■ Measure velocity of blood flow, identify abnormalities in umbilical vessels, fetal vessels,
Non-invasive
Alpha-Fetoprotein (AFP) Analysis:
■ Blood test: maternal serum
■ AFP produced by fetal liver at 13-20 weeks
● Optimal test at 16-18wks but can be done 12-14wks
■ High levels: detects 80% open neural tube defects, GI defects (open abdominal walls),
under-estimation of gestational age, multiple fetuses present, low birth wt.,
oligohydramnios, decreased maternal weight
■ Low levels: should rule out Trisomy 21/Down Syndrome, over-estimation of fetal age,
fetal death, hydatidiform mole, increased maternal weight, maternal type 1 diabetes,
Trisomy 18
■ Can have false positives, combine with other biomarker screening test
Marker Screening Tests
■ Triple Screen: AFP, hCG, and unconjugated estriol
■ Quad Screen: the above and Inhibin A
■ Low AFP, estriol, high hCG, Low inhibin A
● Possible Down’s Syndrome 15-22 weeks; ideally test 16-18 weeks
● Multiple maternal factors can lead to inaccurate interpretation
■ Cell-free Fetal DNA (CffDNA): Uses maternal blood plasma, checks fetal sex for sex
linked disorders and/or other genetic conditions; done at 10 weeks
Nuchal Translucency Screening (Ultrasound)
■ 11-14 weeks
■ Increased nuchal translucency; increase in fluid accumulating behind fetal neck may
indicate chromosome or structural abnormalities
Amniocentesis
■ Transabdominal perforation of amniotic sac to remove fluid for analysis, empty
bladder first
■ Looks at
● Chromosome abnormalities
● Hereditary metabolic defects
■ 15-18 weeks ideal (150ml present)
● More risk when done earlier (11-14 weeks considered “early amnio”)
● Provides time for option of abortion; test results take up to 3 weeks
■ 35 weeks or later: Check fetal lung maturity
■ PRIOR TO TESTING: Administer RhoGAM to mother if she is RhChorionic Villus Sampling (CVS)
■ 10-13 weeks, trans abdominal or transcervical with Ultrasound, tissue sample is removed
■ Full Bladder
■ Looks For: Chromosomal abnormalities, Gender, Sex linked disorders
■ Results in 48hrs
■
➢
➢
➢
➢
➢
➢
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Administer RhoGAM to mother if she is Rh negative- prevents potential sensitization to
fetal blood
➢ Percutaneous Umbilical Blood Sampling (PUBS)
■ Collect blood directly from fetal umbilical vein
● Ultrasound
■ Looks for:
● Genetic Anomalies
● Blood disorders
■ After 16 weeks; usually late 2nd trimester
➢ Nonstress Test (NST) (noninvasive)
■ Mother eats meal, lies on left side, monitored for uterine activity and fetal heart rate
■ Push button when feel fetal movement
■ FHR increases with fetal movement (normal)
■ Results are charted as Reactive or Nonreactive
● Reactive
◆ At least 2 FHR accelerations, from baseline of at least 15 bpm for at least
15 seconds (15 x 15 rule) within 20 minutes. Allow 40 min. to achieve
● Non Reactive
◆ Absence of 2 FHR accel. Using 15 x 15 rule; consider additional testing
➢ Contraction Stress Test (oxytocin challenge)
■ Suspect placental insufficiency: Placenta may not be functioning properly
■ Cause 3 uterine contractions in 10 minutes
● Want to see NO FHR decelerations
● Monitor fetal response: r/o intolerance to labor
■ Oxytocin infusion induced or nipple stimulation, after 37 wks
● Complications: Could start contractions that don’t stop
◆ AKA: Can put patient into early labor - Done when doctor comfortable
with patient delivering baby if labor is started due to complications of
testing
■ Results are charted as Negative vs. Positive
● Negative: “Good” results; no late decelerations noted with 3 contractions in 10
minutes
● Positive: “Bad” results; late FHR decelerations were seen with 50% or more of the
contractions
◆ Ultrasound to view placenta → May deliver via C-section
➢ Biophysical Profile:
■ Uses Ultrasound; up to 30 minutes to score
● Score of 8-10= normal (if adequate amniotic fluid volume)
● Less than 6: suspicious of compromised fetus
■ Score the following: (*Two points each if meet criteria)
● Fetal Tone (Babies like to be flexed!)
● Breathing (Lungs go through the motion of breathing)
● Motion (Baby moving)
● Amniotic Fluid Volume (Correct amount)
● NST (Results of Testing)
❖ Pregnancy Discomforts:
➢ First Trimester Discomforts
■ Urinary frequency or incontinence
■
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● Hcg levels being high gives urinary frequency in first trimester
● Check UTI
■ Fatigue, Nausea and vomiting, Cravings, Breast tenderness, Constipation, Nasal
stuffiness, bleeding gums and epistaxis, Leukorrhea (Vaginal Discharge)
➢ Second Trimester Discomforts
■ Backache, Leg cramps, Varicosities, Hemorrhoids, Bloating/Flatus
➢ Third Trimester Discomforts
■ SOB/Dyspnea
● Baby is pressing on diaphragm and lungs cannot fully expand
■ Constipation
■ Dependent Edema
● Watch BP for preeclampsia/eclampsia
■ Heartburn/Indigestion
● Frequent smaller meals, sit-up after you eat
■ Braxton Hicks Contractions
■ Urinary Frequency
● Weight of baby on the bladder
● Check for UTI
❖ Perinatal Education
➢ Breast/Bottle Feeding, Infant Care, Transition to Parenthood, Relationship Skills, Family Health
Promotion, Sexuality, Nutrition, Birth Options, Exercise
➢ Danger Signs of Pregnancy: Specific to Trimester
➢ Fetal Movement Counts: See Kick Counts (previous pages & text)
Chapter 13: Labor and Birth Process
❖ Theories of Labor Onset
➢ Etiology – unknown, multifactorial: fetal, placental, and maternal
■ Uterine stretch
■ Progesterone withdrawal, increase in estrogen during last trimester of pregnancy
■ Increased oxytocin sensitivity
■ Increased release of prostaglandins
❖ Premonitory Signs of Labor → not every woman has all the signs/symptoms; can vary
➢ Lightening → fetus settles into pelvic inlet; engagement occurs
■ Primipara: 2 weeks before labor
● First time moms will get in further is advance
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■ Multipara: may not occur until labor begins
➢ Braxton Hicks contractions → irregular, intermittent contractions that can be mistaken for false
labor
■ Become stronger and more frequent closer to true labor
■ Will decrease if walking, eating, changing position
■ Are felt at top of uterus (true labor contractions felt in back first)
■ What to tell the woman:
● Go eat, rest, take some time to rest, change positions, go for a short walk
➢ Cervical changes → cervix becomes soft (ripening) and begins to efface and dilate slightly
■ Assisted by prostaglandins, and Braxton hicks contractions
■ Effacement: It has to soften so that it can thin out
➢ Spontaneous Rupture of membranes (SROM) → spontaneous labor usually begins within 24
hours after this occurs
■ May be gush of fluid or slow leak
● Does not always come out completely
■ Continuous supply produced to protect fetus, even after rupture
● Even after it ruptures there is more fluid being continuously made
■ Infection possible due to lack of membrane barrier
● Knowing what time is therefore important
● Start antibiotics to protect the baby
● Yellowish with an odor = infection
● Green = meconium fluid (baby pooped in the water while inside mom; big deal
because baby can breathe in and go into respiratory distress)
■ Cord prolapse risk if presenting part not engaged
● Check fetal HR
● Medical emergency
● Full term = cord will be at top
● Premie = cord is at higher risk for coming out first
■ Woman needs to be evaluated when membranes rupture
● Hospital right away to know if baby is ok
● Need to know: what time it ruptured, what color the fluid was
● Even if confused be on the safe side and bring mom is to check
➢ Bloody show → mucus plug is expelled, see small amount of blood from exposed cervical
capillaries
■ Result of pressure of presenting part & cervical softening
■ Falls out because cervix is getting softer, dilating, and allows the plug to fall out
➢ Sudden burst of energy: (nesting instinct)
■ 24-48hrs before labor begins
■ Increase in epinephrine caused by decrease in progesterone (Inverse Relationship)
❖ Signs of True Labor
➢ Contractions
■ Coordinated, involuntary & intermittent, regular intervals, starts in back and radiates to
front (pushes cervix from posterior to anterior position), fundal to pelvis
■ Increase in frequency, duration, intensity
■ Results in progressive effacement & dilation
■ Stay home until contractions are 5 min apart, lasting 45-60 seconds, difficult to talk
during
➢ Spontaneous ROM
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❖
❖
❖
❖
■ Maybe 1st sign starts in 8- 12 hours
■ 25% SROM before the onset of labor
■ 90% will start labor within 24 hours
➢ Bloody show
■ due to cervical dilation
■ Mucus, discharge, some blood in it
■ Everything is very vascular and so when she does bleed it tends to be more
False Labor = in later weeks of pregnancy; irregular uterine contractions, no changes to cervix
Five Additional Factors Impacting the Labor Process
➢ Critical Factors Affecting Labor and Birth (5 Ps):
■ Passageway
■ Passenger → Baby
■ Powers
■ Position → Mom
■ Psychological response → working with it, excited, panicking?
➢ Additional “P”’s that affect labor process:
■ Philosophy → scared to death / want meds or is she willing to work
■ Partners
■ Patience → both mom and providers
■ Patient Preparation → class ; is she prepared
■ Pain management → is she comfortable
Passageway: Shape/Measurements (continued from chapter 12)
➢ Gynecoid: Most favorable
➢ Android: Not Favorable
➢ Anthropoid: Usually adequate
➢ Platypelloid: Not Favorable
➢ Pelvic Measurements
➢ Passageway (birth canal)
■ Must be normal size and configuration
■ Soft Tissue - cartilage softens due to ↑
production of relaxin and estrogen
■ Bony Pelvis
■ Pelvic Inlet
■ Mid-Pelvis
■ Pelvic Outlet
■ False Pelvis: True Pelvis
● False pelvis has nothing to
do with birthing a baby has
everything to do with the
outlet
Factors Affecting the Labor Process: Passenger
(fetus/placenta)
➢ Fetal Skull
■ Cranial bones can overlap (due to the suture lines holding the skull together) = molding
● Frontal, parietal, occipital
● Baby skull is held together by suture lines which help the head mold
■ Fontanelles : « soft spots », allow for molding, used to determine fetal position
● Anterior
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◆ 2-3 cm
◆ Closes around 12 - 18 months
● Posterior
◆ 0.5 - 1cm
◆ Closes around 2-3 months
● Normal assessment of them
◆ Fontanelles are soft, flat, and open
● Abnormal
◆ Sunken = dehydration
◆ Bulging = bleeding within the brain
■ Fetal Skull Diameters: measured and can affect the birth process
● Biparietal and Suboccipitobregmatic: most important
● Submentobregmatic, Occipitofrontal, Sub Occipitomental
■ Sutures: spaces between cranial bones, allow them to overlap
● Lambdoidal, Sagittal, Coronal, Frontal
➢ Fetal Attitude → refers to the posturing → flexion
■ Flexion/Extension of the joints & relationship of fetal parts to one another
● Ex: full flexion, no flexion, extension
■ Attitude → everything is well flexed; full flexion will help baby go through the birthing
much easier
➢ Fetal Lie
■ long axis of fetus related to long axis of the mother (spine r/t
spine)
● Longitudinal
● Transverse
➢ Fetal Presentation
■ Cephalic : 95-97% (*as long as it is related to the head
presenting first than it is cephalic*)
● Vertex → fully flexed head, easiest, helps dilate, molds
● Military → straight up and down
● Brow → partly extended
● Face → full extension
■ Breech Presentation:
● Butt first
● ↑ with maternal pelvis abnormalities, preterm deliveries
and congenital anomalies, 3% term births
● Frank → “cannon ball”
● Complete or Incomplete → criss-cross applesauce
● Footling
◆ Single or Double
● Kneeling
■ Shoulder Presentation; shoulder dystocia
● Increased in multiparity, premature ROM, hydramnios, previa (0.2%), transverse
lie
■ Can attempt to do a version for breech presentation
● Push up into the uterus to try to change baby
● If they do version too early baby will just go back to original position and you run
the risk of beginning early labor
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➢ Fetal Position
■ Looking at the landmark on the presenting fetal part (what is going into the pelvis)
● O → occipital bone (vertex presentation)
● M → mentum, chin (face
presentation)
● S → sacrum, buttocks (breech
presentation)
● A → acromion process, scapula
(shoulder presentation)
■ Identify where the presenting part is facing
or tilted toward → staring at the presenting
part; no where else
● Four quadrants pelvis
◆ Right Anterior
◆ Left Anterior
◆ Right Posterior
◆ Left Posterior
■ 3 Letters indicate position
● Indicates if presenting part is tilted
toward left or right side of the
maternal pelvis (R or L)
● Presenting Part (O, M, S, A)
● Location of presenting part r/t Anterior, Posterior, or Transverse portion of the
maternal pelvis (A/P/T)
■ Differences in Labor Progress: LOA most common/favorable, then ROA
● OP = back labor
● OP and Other positions: anxiety, long/difficult labor, may not be compatible with
vaginal birth, increases potential for fetal and maternal injury
➢ Fetal Station
■ 0 station is right at the ischial spine which is the
NARROWEST PART OF PELVIS → most
likely where baby will get stuck and not
progress
■ Negative numbers – above spines (floating –4 is at
inlet to -1 (1cm above ischial spines)
■ Positive numbers below spines +1 to +4 is on
perineum
➢ Fetal Engagement
■ Babies head has dropped into pelvis but does not tell us anything until baby is at 0
station
■ Fetal head passes the inlet only confirms adequacy of inlet not midpelvis or outlet;
presenting part reaches 0 station
❖ Mechanisms of Labor → 6 Cardinal Movements
➢ Engagement, Descent: (0 station)
➢ Flexion: Head is forced chin to chest
➢ Internal Rotation: Fetus turns its head (45*) so the
largest diameter is with the widest part of the pelvis
➢ Extension: Fetal head passes under symphysis pubis
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❖
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➢ Restitution or External Rotation: Fetal head turns (45*) outside to allow the shoulders to turn
pass through
■ Shoulder Dystocia: Shoulders are stuck; McRoberts!
➢ Expulsion: Anterior shoulder then posterior shoulder, under symphysis pubis
Powers Affecting Labor and Delivery
➢ Uterine contractions → UC: primary powers
■ Described by frequency, duration, and intensity
■ Pressure on cervix releases prostaglandins which helps soften the cervix
➢ Intra-abdominal Pressure → secondary powers
■ compresses the uterus and adds to the power of the expulsion forces of the uterine
contractions
Uterine contractions (UC) → (Primary Power)
➢ Labor progresses ↑ lengthens & intensity ↑ to about 2-3 min
➢ Originate at pacemaker near tubal insertion & move over uterus like a downward wave
➢ STRONGEST IN FUNDAL AREA
➢ Myometrial Changes:
■ each UC contraction shortens the muscle fibers to move the fetus ↓ this is known as
brachystasis or a ↓ in uterine space
■ Uterus is making less space ; myometrial fibers are shortening which helps to push the
baby out due to less uterine space for baby to be in
➢ Types of muscle fibers: longitudinal, interlacing, circular fibers
➢ Cervical Changes
■ Normally 2cm long
● Effacement - thinning, cervical canal reduced from 2cm length to 0cm length
(paper thin- expressed in % → 0 to 100%
■ Dilation
● Refers to external openness expressed in cms or fingers 1-10 cms
■ Can begin to push when 100% effacement and 10cm dilated with no lip
● If pushing begins to early then we increase the risk for swelling and less space for
baby → DO NOT PUSH UNTIL THE BODY IS READY
Describing Uterine Contractions:
➢ Frequency
➢ Duration
➢ Intensity: SUBJECTIVE
■ Palpated with fingertips or
internal monitor
● Mild → early labor;
can still talk; NOSE
● Moderate →CHIN
● Strong → FOREHEAD
■ Measuring with a IUPC (intrauterine pressure catheter): TRUE PRESSURE
● Normal resting tone is 10-12 mm Hg of pressure
◆ 25-40 early labor
◆ 50-70 active labor
◆ 80-100 transition
◆ >100 when pushing
Positions for Pushing (review in text)
➢ Side-Lying, Kneeling, Hands and Knees, Squatting, Standing, Sitting Upright, Semi-sitting
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❖ Physiological Effects
➢ Maternal: Increase HR, BP, Resp, Temp, basal metabolic rate, WBC. Decrease GI motility, GI
ph, n/v, glucose levels. Muscle aches and cramps.
➢ Fetal: Heart accelerations or decelerations, decrease circulation during contractions
(compensates)
❖ Psychological Effects
➢ Perceptual factors influencing women’s' response
➢ Cultural - must establish an accepting relationship
➢ History - previous experiences - coping mechanisms used
➢ Interpretation of Pain - SUBJECTIVE & difficult to measure objectively
❖ Variables that Influence Pain
➢ Intensity of labor, Cervical readiness, Fetal position (such as OP- sacral pain), Fatigue, Medical
Interventions (augmentation, IV, preps), Pelvic Configuration
❖ Nurses Role to Educate
➢ Part of a Normal Process:
■ Prepare antepartal - know what will happen
■ discuss the sensation as a UC not "pain"
■ word pain may generate needless anxiety
■ intermittent
■ labor ends with the birth of a baby – self-limiting
■ anxiety and fear - increases muscle tension
■ use support systems: family/friends
➢ Paternal Role (any partner):
■ they enter the focusing phase
■ becomes involved in childbirth classes
■ L&D for partner
■ Begins to think of himself as a "father"
● feel responsible and protective
➢ Styles of Paternal Involvement:
■ Observer style - happy about pregnancy do not take active role
■ Expressive style - display strong emotional response to pregnancy and want to be fully
involve may even experience psycho‑symptomatic symptoms
■ Instrumental style - task oriented role, comfortable is they can do something like be
the coach, take pictures, cut cord
➢ Red Flags to poor parental adjustment:
■ direct rivalry with fetus - C/O interference with sex
■ adamant about the way she feeds baby
■ escalation of violence
❖ 4 Stages of Labor & Birth
➢ First Stage: true labor to complete cervical dilatation (10 cm) (Table 13.2)
■ Latent (Early) phase → Early phase ; 0-6 cm
■ Active phase → middle ; 6-8 cm
■ Transition phase → hardest part; 8-10 cm; getting ready to push; shortest phase
➢ Second Stage: cervix is 10 cm dilated to birth of baby
■ Pelvic Phase (fetal descent)
● Effacement
■ Perineal Phase (active pushing)
● pushing or expulsion stage
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10 cms, 100% effaced to birth of baby
average time 20 min multipara, 50 min nullipara
UC may ↓ slightly to 2-3 min, 40-60 sec.
◆ Push starts the contractions are a little bit slower than before which is
normal
● Urge to Push: Pressure on pelvic floor & rectum
● Ring of Fire: Crowning - tearing sensation
● Emotions: tired, relieved, excited, drowsy between UC’s
● Pushing:
◆ Spontaneous Pushing
➢ active pushing → regains control ; pushing with the contraction
➢ open glottis pushing → pushing during exhaling ; bearing down
and letting some air out
➢ closed glottis → holding breath may cause valsalva maneuver; not
recommended
◆ Directed Pushing
➢ Seen more with Epidurals
➢ Looking at monitor and telling mom to push because the epidural
keeps her from feeling contraction
➢ Third Stage: After Birth - Includes placental separation and expulsion
■ Shortest → 5-10 min OR up to 30 min.
■ Mild to mod UC’s
■ 4 signs of placental separation
● Uterus rises
● Uterus becomes globular
● Gush of blood (250-300ml)
● Cord lengthens
■ Placental Expulsion
● Schultz’s Mechanism
◆ (Shiny Shultz)
◆ Shiny fetal side (gray) - Side Facing Baby
● Duncan’s Mechanism
◆ (Dirty Duncan)
◆ Rough maternal side (red raw side) - Attached to Uterus
➢ Fourth Stage: 1 to 4 hours following delivery
■ Uterus initially between umbilicus and symphysis pubis, then rises to level of umbilicus;
Firm
● Check q15min x 1hr
■ Lochia – Moderate flow; Rubra
■ Chills, cramping, limited bladder sensation, perineal discomfort – ice
● Hungry, thirsty, shivering and shaking is normal
■ Both mom and baby alert – Breastfeeding, happy, crying, excited
■ Monitor for hemorrhage, bladder distention, and venous thrombosis (GET MOVING!)
■ Bladder needs to empties regularly to decrease the risk of hemorrhage
●
●
●
Chapter 14: Nursing Management During Birth and Labor
❖ Information Obtained in a Phone Assessment
➢ Estimated DOB determine if term or preterm
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Fetal movement as to frequency in last few days
Other premonitory signs of labor experienced
Parity, gravida and previous childbirth experiences
Timeframe in previous labors
Characteristics of contractions → Determines how far along she is
Appearance of any vaginal bloody show present
Membrane status, whether ruptured or intact
■ IF THEY ARE RUPTURED MUST COME IN
➢ Presence of supportive adult in household or if she is alone
Nursing Interventions for L&D Admission:
➢ When a patient/family comes into L&D:
■ Establish a therapeutic relationship, Determine family expectations, Convey confidence,
Therapeutic Touch, Identify/Respect cultural values, Provide privacy, Components of an
Admission Assessment, Maternal health history, Physical assessment, Fetal assessment,
Lab studies, Assessment of psychological status
Conduct a Health History
➢ Introduction
■ Reason for admission – what brings you here today?, Perinatal care (When did they
start), EDD (EDC), Gravida/Para, Pregnancy histories, Present pregnancy, Labor history,
UC (Uterine Contractions), ROM (rupture of membranes), Bloody show, Allergies, Food
intake, Recent illnesses, Medications, Tobacco or alcohol use, Birth
plans/preferences/cultural practices, Consents, Advanced directives, Current weight
Admission
➢ Ask to go to BR put gown on
➢ Urine Specimen: UA
➢ Labwork: Hgb/Hct, CBC, Blood Type, Rh, VDRL (Syphilis)
➢ Maternal VS (in between UC's) ALL 5!
➢ Temp Q4 or Q2 with ROM
➢ Vitals: Q1 Latent phase & Q 30 Min. active phase
➢ FHR: 10-20 min continuous FHR assessment
Assessments Made During Physical Examination of Woman in Labor
➢ Fundal height measurement
➢ Uterine activity: Contraction frequency, duration, and intensity
➢ Vaginal Exam (sterile glove): gently, aseptic technique
■ Status of membranes (intact, bulging, ruptured)
● Nitrazine Swab/Paper
◆ Blue = Alkaline (amniotic fluid) or Yellow/Green =Acidic (vaginal fluid)
● Fern Test: Microscopic slide
● Amniotic Fluid
◆ Clear fluid (normal)
◆ Cloudy/odor/yellow (infection)
◆ Green (meconium in fluid): CALL NICU
■ Cervical dilatation (closed “0” to 10cm) and position (anterior vs. posterior) and degree
of effacement (0% to 100%)
➢ Fetal Status: including heart rate, presenting part, position and
station
■ Leopold’s Maneuvers:
● Maneuver 1: What fetal part (head or buttocks) is
located in the fundus (top of the uterus)?
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➢
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➢
➢
➢
➢
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❖
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Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones
are best auscultated through the back of the fetus.)
● Maneuver 3: What is the presenting part?
● Maneuver 4: Is the fetal head flexed and engaged in the pelvis?
➢ Pain level (0-10)
➢ Behavior/Psychosocial
➢ Monitor/Palpate UC's - duration, frequency & intensity → how often do we need to get her
back into bed to check contractions?
■ Every hour during latent phase
■ 30 mins during active phase
■ 15 mins during transition and active stage
■ With contractions let the mom walk; up and moving during contractions is best
➢ Notify Doctor or Certified Nurse Midwife (CNM)
❖ Impending/Precipitous Birth
➢ If delivery is imminent get:
■ Important information only: Name of patient, Physician, G/P, due date, Allergies, Last
meal, VS and FHR, Evaluate using SVE, Call Dr.
■ Set up: Equipment, O2, blankets, start IV, blood to lab
■ Apply pressure to head to guide out
● Allows baby to be a little more controlled and not flying out
➢ What MUST you do:
■ Delivery table set up, Warm bed, O2 and suction for baby!
■ Safety first → Everything else can be done after!
❖ Uterine Activity
➢ Resting tone: 5-10 mm Hg
■ Important because it should be at this to confirm that it is calibrated
➢ Uterine Contraction intensity: 50-80mm Hg
■ Only with IUPC: External monitor cannot tell true intensity, only internal monitor can
evaluate pressure of amniotic fluid & uterine muscle intensity
➢ TOCO must be placed over the most contractible portion of the upper uterine segment fundus
■ Belt should be comfortable but tight → Calibrated by (UA) reference
➢ Normal uterine contraction resembles shape of a bell
❖ Fetal Monitoring
➢ Primary objective of FHR Monitoring: get information regarding fetal oxygenation; prevent fetal
injury, Detect FHR changes early before prolonged or profound issues occur
➢ Controversy: Increased use of FHR monitoring is associated with increased number of
c-sections and not a decrease in the Cerebral Palsy rates
➢ FETAL HEART RATES ARE BEST HEARD THROUGH THE FETAL BACK
➢ Auscultate FHR – latent phase
■ low risk – every. hour
■ high risk – every. 30 mins
➢ Active phase
■ low risk – every. 30 mins
■ high risk –every. 15 mins
➢ 2nd Stage
■ low risk – every.. 15 mins
■ high risk – every. 5 mins
●
47
➢ listen 1 min between UC (baseline rate) and every 30 sec after the uterine contraction (periodic
change)
❖ Types of Fetal Monitoring
➢ Fetoscope – hand held, head gear
➢ Dopplers – high frequency sound waves detect fetal heart movement
➢ External fetal monitors (EFM) use two ultrasound transducer – high frequency sound waves
reflect mechanical action of the fetal heart
■ TOCO Transducer
● Placed over fundus to monitor UC → pressure sensitive
■ 2nd transducer used for fetal heart rate
● straps, stockinet, bedside monitor– singleton, twins
➢ Recording can be compromised by:
■ fetal size, movement, malpresentation, abdominal fat, maternal position, location of
transducer
■ Artifact: irregular or absent FHR on record, electrical interference, mechanical
malfunction, or unknown
➢ Intermittent: allows patient to move freely when not being monitored
➢ Continuous electronic monitoring (external and internal):
■ External: limits mobility, encourages supine position: decreases placental perfusion,
continuous pattern, no gaps, accurate but can’t detect short term variability
■ Internal: can detect short term variability and FHR dysrhythmias, not as sensitive to
maternal movement
➢ Internal Fetal Monitoring: FSE and/or IUPC
■ fetal scalp electrode/spiral electrode (FSE) record fetal ECG and converts it into FHR
pattern → high risk pts
● Physician puts it on; nurses do not, Breaks skin integrity; scabs on its own, Can
infuse fluids right into uterus; help move the cord
■ intrauterine pressure catheter (IUPC) double lumen, placed inside uterus, can record
uterine pressure/contractions at catheter tip along with intra-amniotic pressure → high
risk pts
■ Used with electronic fetal monitoring if non-reassuring FHR patterns
■ Must have: ruptured membranes, at least 2cm dilation, presenting part low enough for
scalp electrode, experienced/skilled practitioner
❖ Reading/Interpretation of FHR
➢ Normal pattern (no intervention needed) OR Indeterminate/unclear/monitor OR
Abnormal/must act (correct or deliver)
➢ General nursing assessments during each uterine contraction → there is a transient temporary ↓
in maternal blood flow through the placenta
❖ Factors that influence FHR reading
➢ VS, position, labor phase, procedures, maternal/fetal disease, drugs
➢ Maternal and Fetal Factors
■ adequate maternal blood flow & volume, O2 & maternal blood must reach spiral arteries
& intervillous spaces, fetal waste removed from intervillous spaces via the endometrial
veins, UC cut off O2 by compressing spiral arteries must have 1-2 min reserve
➢ Factors that influence maternal blood flow
■ reduction in maternal circulating volume (hypovolemia) – hemorrhage
■ hypotension decreases placental blood flow
■ epidural anesthesia
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■ supine hypotension
■ hypertension or vasoconstriction
■ chronic HTN or from Pregnancy
■ drugs
➢ Influence adequate Maternal O2 intake
■ respiratory abnormalities – asthma, smoking, good placental exchange of O2 & CO2
■ hypertonic uterine activity (uc’s > 90 sec, <2min apart, relaxation time <30 sec. or
relaxation pressure elevated) - oxytocin
■ placental condition
➢ Potential Problems with circulation in the cord
■ cord compression, oligohydramnios, knots, nuchal/body cord
❖ Episodic Changes in FHR
➢ Not associated with UC’s
■ Variables – cord compression
■ Accelerations – ↑ FHR with movement
■ Changes in baseline – over 10 min period or 30 BPM change over 10 min period
❖ Baseline FHR
➢ Thicker dark vertical lines are minutes in between uterine contractions
➢ FHR with no stress or stimulation to the fetus:
■ when the patient is not in labor, when fetus is not moving, between uterine contractions,
when there is no stimulation
➢ Refers to the range of FHR observed between contractions during a 10 minute period of
monitoring, can vary up to 20 beats
■ Varies because baby is moving around and happy
➢ The range is where FHR falls 80% of the time, usually 110-160 bpm.
❖ Variability
➢ Heartbeat change from beat to beat; with walking you would expect to have normal changes
■ Line should be jagged not just flat and smooth and measured as amplitude of peak to
trough in bpm
➢ Clinical indicator: Predictive of fetal acid-base balance and cerebral tissue perfusion
➢ Baseline Variability Classifications:
■ Absent → Undetectable; staying a flat line
■ Minimum → less than or equal to a change of 5 bpm
■ Moderate (Normal) → 6-25 bpm
■ Marked → a change of at least 25 bpm or higher
➢ Increased Variability
■ Causes: Early/mild hypoxia, fetal stimulation, uterine contractions, uterine palpation,
Fetal movement, awake state, Marked variability: could be due to cord prolapse, cord
compression, maternal hypotension, uterine hyperstimulation, placenta abruption
■ Significance – may be early hypoxia
➢ Decreased Variability
■ Not a lot of squiggles; not really changing much
■ Causes: Fetal sleep, narcotics, hypoxia, prematurity, cardiac or CNS anomalies
➢ Absent or Minimum Variability = MUST ACT
■ Causes: Fetal acidemia, secondary to uteroplacental insufficiency, preterm, cord
compression, maternal hypotension, placental abruption, uterine hyperstimulation, fetal
dysrhythmias
■ Significance =Indeterminate/Unclear if not fetal sleep state or medication related
49
CNS desensitized by hypoxia and acidosis; causes decreased FHR, decreased
variability, eventually smooth line- poor outcomes
■ Contractions can decrease FHR in 3 ways:
● Compression of myometrial vessels, umbilical cord, or fetal head
■ Periodic pattern/changes → FHR Changes with Contractions
■ Episodic pattern/changes → not associated with uterine contractions
❖ Baseline Variations
➢ Tachycardia: Fetal Heart Rate >160 bpm for 10 or more minutes
■ Causes: Maternal fever, early fetal hypoxemia, parasympathetic drugs (atropine,
vistaril), Beta Sympathomimetics (ritodrine), amnionitis - prolonged ROM, maternal
hyperthyroidism, fetal anemia, hypovolemia, prematurity, arrhythmias, fetal HF
■ Significance: Indeterminate/Unclear, depends on other variables with FHR
● Can be Must Act if decrease in variability and late decels.
■ Nursing Interventions
● Check maternal temp and monitor closely for association with other concerns
■ WHEN ANY FHR PATTERN IS “MUST ACT” GO TO THE NEXT STEP
● Intrauterine Resuscitation Goal: Increase placental perfusion & decrease UC
◆ O2@ 8-10 L (tight face mask)
◆ Put mom on L side (or R)
◆ Stop Oxytocin/Pitocin if infusing
◆ Hydrate (^ isotonic IV) – increases blood pressure and volume
◆ Call primary care practitioner
◆ Tocolysis if ordered (ex: Mag Sulfate)
➢ Bradycardia: Fetal Heart Rate less than 110 bpm for 10 or more minutes
■ WILL INTERVENE BEFORE 10 minutes
■ Causes: Late fetal hypoxia, beta-adrenergic blocker (ex: Lopressor), anesthetics
(epidural spinal), maternal hypotension, umbilical cord compression, hypothermia, fetal
heart block
■ Significance:
● Minimal variability=Indeterminate/Unclear
● Absent variability, late decels=MUST ACT
➢ Decelerations
■ Transient drop in the FHR caused by parasympathetic nervous system stimulation
■ Determined by the nadir (lowest point) in bpm below the baseline
■ Counted in minutes and seconds from the beginning to the end of the deceleration
■ Early Decelerations
● Gradual decrease in FHR: Nadir occurs at peak of contraction
● Onset to Nadir is > or = to 30 seconds
● Typically mirrors the contraction
● Cause: Head compression
● Significance: Normal pattern, no intervention necessary
■ Late Decelerations
● Gradual decrease in FHR: Nadir is after contraction peaks
● Onset to Nadir > or = to 30 seconds
● Onset is after the beginning of contraction
● Cause: Uteroplacental insufficiency
◆ Fetus getting less oxygen
◆ Compromises blood flow to fetus
●
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Uniform shape
Late decelerations persisting after the contraction has finished
◆ Frequently associated with tachycardia and or minimal variability
◆ Cause: Uteroplacental insufficiency → Placenta not functioning right
◆ Significance - Indeterminate if moderate variability; Must Act if absent
variability
Variable Decelerations
● Abrupt, transient (not regular), decrease in FHR from baseline
● Onset to Nadir is <30 seconds
● Drop in FHR is 15 bpm or greater, lasting ≥15 seconds, but less than 2 minutes
● Can occur at times other than UC
● Characterized by a sudden drop in FHR in a V, U, or W pattern
● Cause: Umbilical Cord Compression
◆ Not related to the contraction!
● Significance: Indeterminate/Unclear if min/mod variability; Must Act if absent
variability
◆ Recommendation → Amnioinfusion
◆ LR/NSS infused into IUPC to cushion cord or dilute meconium
➢ Inserted through cervix into a pocket of amniotic fluid
➢ 250 bolus then 15-20 ml/min
Prolonged Decelerations
● Transitory decrease in FHR at least 15 bpm below baseline, lasting longer than 2
minutes but less than 10 mins before returning to baseline
Sinusoidal Pattern
● Smooth, sine wave-like pattern
● Can indicate severe hypoxia, fetal anemia, and fetal hypovolemia
● Fetus needs transfusion (only treatment)
●
●
■
■
■
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❖ Accelerations
➢ Transient Increase in FHR greater than 15 bpm from baseline for at least 15 seconds, but less
than 2 minutes (15 x 15 rule), PREEMIE (<32 weeks): 10 x 10 rule
➢ Prolonged Accelerations: Last 2 minutes or more, but less than 10 minutes
■ If longer than 10 minutes, it’s a baseline change
➢ Causes: Fetal movement, sterile vag. exam, Uterine Contraction, mild cord compression,
breech, Can be episodic=not associated with uterine contractions
➢ Significance – Normal Pattern/No intervention needed
❖ Three Tier FHR Classification System
➢ Category 1: Normal Pattern/No intervention needed
■ FHR Baseline: 110-160
■ Moderate Variability
■ Absence of FHR decelerations (late or variable)
■ Early decelerations: present or absent → ok to have
■ Accelerations: present or absent → ok to have
■ Normal pattern; just continue what we are doing
➢ Category 2: Indeterminate/Unclear/continue monitor
■ Variable decelerations: min/mod baseline variability
■ Absent variability but no decelerations with contractions
■ Tachycardia (>160) without decels
■ Bradycardia (<110) but has minimal variability
■ Late decels with moderate variability
■ Prolonged decels (>2 min but less than 10 min)
■ No accelerations after fetal stimulation
■ Marked Baseline Variability
■ Not normal but not enough to need a stat section
● Continue to monitor
➢ Category 3: Must Act- Need correction or delivery
■ Absent Variability AND any one of the following:
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❖
❖
❖
● Bradycardia
● Recurrent Late Decelerations
● Recurrent Variable Decelerations (cord is crushed)
■ Sinusoidal Pattern (up and down waves; cardiac condition)
■ ABSOLUTELY HAVE TO GET BABY DELIVERED OR CORRECT
Documentation
➢ Initiation of monitoring pertinent info. should be made directly on monitor strip, in computer
and record #
➢ Initial documentation: Name, date, hospital #, MRN, gravida/para , VS, dilation, station,
position, high risk factors
➢ During monitoring document:
■ Sterile vaginal exams (SVE), maternal repositioning, analgesia or anesthetic, meds, VS,
emesis, pushing, adjusting toco, ANY NURSING CARE OR INTERVENTION
Other Fetal Assessment Methods:
➢ Cord Blood Gasses
■ Checks for fetal acidosis at birth (low ph=acidosis)
■ After delivery pH, pO2, pCO2 and bicarbonate
■ Umbilical artery blood, clamped 20-30 sec after birth (4 - 8”)
■ Heparinized syringes and read within 30 min
➢ Fetal Scalp Sampling
■ Sample of fetal scalp blood
■ Measures ph
● normal 7.2-7.3
● acidosis <7.2
■ done on the fetal scalp or on the breech when fetal hypoxia is present
➢ Fetal Pulse Oximetry
■ Placed on cheek, forehead
■ Normal 30-70%
➢ Fetal Stimulation
■ Fetal Scalp stimulation or sound/vibration to mother’s lower abdomen.
■ Promote fetal movement, FHR acceleration 15x15 (15 bpm above BL lasts 15 sec) means
well oxygenated fetus, CNS is intact and ph is more than7
■ Don’t do scalp stimulation if placenta previa is present, infection, or maternal temp.
elevated, preterm fetus
Comfort/Safety During Labor
➢ Non urgent L&D care
■ IV access – 18 angio in case you need to give blood – do procedures between UC's
■ Environmental controls
● Lighting, Temperature, Phone, Visitors, Clear liquids – ice chips – snow cones
Non-pharmacological measures of pain management
➢ Know culture & techniques
➢ Advantages: no side effects, can use if advanced stage, does not interrupt labor
➢ Disadvantages: may not achieve desired level of comfort, Need motivated clients
➢ Continuous labor support: care, comfort, advocacy, information, advice: decreases c-section
rates and pain medication requests
➢ Hydrotherapy: shower, whirlpool bath: decreases c-section rates, decreases perineal trauma,
shorter 2nd stage of labor, less pain meds
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➢ Ambulation and position changes: walking, upright positions decrease length of labor, gravity,
change shape of pelvis, contractions effective
➢ Acupuncture and acupressure: research limited, need trained/certified clinician, reduces labor
pain, Chinese medicine
➢ Application of Heat and Cold: back, muscles, perineum, forehead, pain, edema, muscle spasms,
reduces inflammation
➢ Attention focusing and imagery: tactile stimulation (touch, massage, stroking), auditory (music,
verbal), and visual imagery
➢ Therapeutic touch and massage: promote relaxation and pain relief/therapeutic touch: energy,
learned and practiced
➢ Other: transcutaneous electrical nerve stimulation (TENS)
❖ Recommended Positions in the Second Stage of Labor
➢ Lithotomy/feet up in stirrups – most convenient position for caregivers
■ least effective, commonly seen in USA
➢ Lateral/side-lying with curved back and upper leg supported by partner
➢ Kneeling-lean forward: hands on bed and knees comfortably apart
➢ Hands and Knees
➢ Squatting/supported squatting: gives woman sense of control
➢ Standing
➢ Sitting Upright (on birthing stool – opens pelvis, enhances gravity and helps pushing)
➢ Semi-sitting: with pillows underneath knees, arms, and back
❖ Breathing Techniques: Breathing Patterns
➢ Abdominal breathing is sequenced and even
➢ Five Levels of Breathing During Contractions
■ 1st level – slow chest breathing involves 6 to 12 full respirations per minute; starts and
ends with cleansing breath
■ 2nd level – breathing heavy enough to expand rib cage, but light enough so diaphragm
barely moves
■ 3rd level – shallow, sternal breathing usually at a rate of 50 to 70 breaths/minute; used
during transition phase of labor
■ 4th level – pant-blow pattern of breathing; taking three to four quick breaths in and out
and then forcefully exhaling
■ 5th level – continuous chest panting involve shallow breaths at a rate of about 60
breaths/minute
❖ Pharmacological Pain Management
➢ OB Analgesia and Anesthesia
■ Maternal Effects
● avoid supine even for regional anesthesia
● ↓ respiratory capacity -↑ sensitivity to inhalants
● GI tract ↓ & ↑ regurgitation -↑ aspiration
● circulating endorphins ↓ need for pain med.
● ↓ labor if too early (primips 5-6, multips 3-4)
● contraindicated in substance abuse
■ Fetal Effects
● Decreased variability
● Resp. Distress Syndrome (RDS) & ↓ muscle tone if given within 1-2 hours before
birth
◆ hypoxia, hypoxemia and acidosis (anoxia-no O2)
◆ newborns metabolize drugs slowly
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❖ Pharmacological Measures
➢ Systemic meds (the whole body) - narcotics, sedatives, tranquilizers
■ Opioids: Butorphanol (Stadol) or Nalbuphine (Nubain) or Meperidine (Demerol),
Fentanyl (Sublimaze), Morphine
■ Antiemetics: Hydroxyzine (Vistaril) or Promethazine (Phenergan), Prochlorperazine
(Compazine)
■ Benzodiazepines: Diazepam (Valium) or Midazolam (Versed)
➢ Inhaled analgesics: Nitrous Oxide (“laughing gas”)
■ New to U.S., not new in Europe or Canada
■ Self administered; difficult to overdose with self admin.
■ Mask or mouthpiece
■ 50% oxygen & 50% nitrous oxide
■ No FHR abnormalities noted
■ Rare side effects Maternal: n/v, dizziness, dysphoria
➢ Regional analgesia/anesthesia - nerve blocks & locals
■ Local: Into perineal muscle for repair short duration, repeat as necessary
● Lidocaine is used, onset 3-4 min
● Nerve block for episiotomy or repair of tear
■ Pudendal Block
● Direct injection of pudendal nerve transvaginally, which is located near ischial
spines, takes 15 min. for full effect
● Ex: Bupivacaine or Ropivacaine
➢ Epidural: Most Popular
■ Location –Needle inserted usually 3-4th lumbar vertebrae, thread catheter into epidural
space
■ Advantages: Pain relief without sedation, relaxation, used for both vaginal and C/S
■ Complications/side effects
● Hypotension → fetal gets bradycardia but eventually goes back
● dura puncture and spinal headache
● bladder distention & prolonged 2nd stage
● catheter migration
● N/V & pruritus & respiratory depression
● inadvertently become a spinal
● must be 3-4 cms or slows labor
● allergic or toxic reactions
● light headed & slurred speech
● metallic taste in mouth
● muscle twitching, convulsions
■ Epidural Medications
● Combination of local anesthetic and opioid
◆ ex: Bupivacaine with Fentanyl
● Continuous infusion or single injection
➢ PCEA → Patient controlled epidural analgesia
➢ Combined Spinal-Epidural (CSE)
■ “Walking Epidural”
■ Rapid onset:3-5 min lasts up to hrs
■ Motor function is active
■ Still feel fatigue, sedation → most don’t encourage women to walk d/t fear of injury
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➢ Spinal: Subarachnoid
■ subarachnoid space under arachnoid membrane of spinal cord C/S T-8 (Low spinal saddle block T-10)
■ intrathecal opiate - subarachnoid Fentanyl
■ Complications: Hypotension & fetal bradycardia, spinal H/A (leakage of CSF into
meninges)
➢ Blood Patch: used to treat spinal headache
■ 10-15ml of maternal blood withdrawn from arm
■ replaced into spinal or epidural via injection to clot over leak
■ can be repeated if first attempt fails at reducing spinal headache
Nursing Considerations
➢ prevent respiratory depression
➢ vs every 1 min for 1st 15 min: every 5 for 15
➢ prevent hypotension - left side
➢ elevate legs
➢ O2 at 8-12 L
➢ increase IV fluids
➢ 5 –10 mg ephedrine, vasoconstriction
➢ monitor fetus - check FHT
➢ SVE may not have urge to push
➢ vacuum and forceps ready
➢ counteract convulsions allergic reactions
➢ drugs to support cardiac function – ET tube
➢ resuscitation equipment high block due to catheter migration
➢ prevent bladder distention - check every 2
General Anesthesia
➢ EMERGENCY
➢ Advantages: Fast - loss of consciousness
➢ Disadvantages: ↑ aspiration, postpartum hemorrhage, gen. anesthesia crosses the placenta
within 2 min. vigorous neonatal resuscitation needed
➢ Medications: Nitrous oxide 40-60% O2 Penthathal (balanced – used with succinylcholine),
Barbiturates IV
Assessments Made During the Third Stage of Labor
➢ Monitoring placental separation
➢ Assessing for any perineal trauma, such as the following:
■ Firm fundus with bright red blood trickling → laceration
■ Boggy fundus with red blood flowing → uterine atony
■ Boggy fundus with dark blood and clots → retained placenta
■ Inspecting the perineum for condition of episiotomy
● REEDA
■ Assessing for perineal lacerations and securing repair
Assessments during Fourth Stage of Labor
➢ Vital Signs, Uterine fundus Status, Perineal status, Comfort level, Lochia amount, Bladder status
Immediate Newborn Care
➢ Airway: establish and maintain airway - cleared when head is delivered with sterile bulb syringe,
mouth first than nose (M before N), to prevent mucus from being aspirated with first breath,
usually this manipulation elicits a gasp or cry
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➢ Dry and Warm: Place under preheated Radiant Warmer; neutral thermal environment, dry baby
immediately and remove wet linen, provide stockinette hat, warmed blankets, drying infant
provides tactile stimulation
■ Evaporation - Wet skin exposed in DR insensible water loss from skin and lungs
■ Conduction - Direct contact with cooler environments
■ Convection - Heat loss to air currents
■ Radiation - Heat loss transferred to cooler objects from a distance (such as a window)
➢ Position: Suction further if needed (Bulb, DeLee, Mechanical)
➢ Evaluate Breathing:
■ Effective respirations
■ Gentle stimulation rub back or soles of feet
● If respirations are still delayed the next step is 100% O2 with bag and mask and
lastly intubation
➢ Normal Circulatory Adaptation:
■ Shortly after 1st cry HR 175-180, then 120-160 while awake, slower when sleeping
■ murmurs may or may not be significant and most disappear by 6 mo.
■ 1st and 2nd heart sounds should be clear and well defined; count for full minute
➢ Physical Assessment: immediately after birth, initial assessment done in delivery room
❖ Nursing Care
➢ Apply 2 cord clamps 1/2 -1" from umbilicus and cut between clamps with sterile scissors - check
cord for 3 vessels (2 associated with anomalies)
➢ voids or meconium
➢ foot printing - mom's right index finger and baby's footprint
➢ ID bands - 2 baby, wrist and ankle (or both ankles) and one mom double check that numbers
match and record on footprint sheet, security system
➢ Bonding: 1st hour
❖ Cord Blood Harvesting (started 1990)
➢ Saving cord blood for future use in stem cell replacement used to build body’s immune system
➢ Blood is drawn from cord and sent to lab on ice and stem cells are separated out and frozen, can
be used later by infusing through IV → Public or Private Cord Banks Available
OB Exam 3: Chapters 15, 16, 17, 18
Chapter 15: Maternal Adaptation During the Postpartum Period
❖ Postpartum Period: Delivery of placenta →6 weeks
❖ Reproductive System Adaptations → Uterus
➢ Three Retrogressive Processes of Involution
■ Contraction of muscle fibers to reduce those previously stretched during pregnancy
■ Catabolism that reduces enlarged individual myometrial cells
■ Regeneration of uterine epithelium from the lower layer of the decidua after upper
layers have been sloughed off and shed in lochia
➢ Involution
■ Fairly rapid → Day 10 in true pelvis, cannot palpate
■ Wt of uterus decreases from 1000g to 60g by 6 weeks
■ Endometrium is thin
■ Descends 1cm/day
■ Factors that Facilitate Uterine Involution
● Complete expulsion of amniotic membranes and placenta at birth
● Complication-free labor and birth process
● Breastfeeding
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● Early ambulation
■ Factors that Inhibit Involution
● prolonged labor, anesthesia
● difficult delivery
● grand multiparity (decreased tone): Uterus stretched out many times so it takes
longer to get back; works harder to get back to normal
● full bladder → most common cause
● retained placenta, amniotic membranes
● Uterine infection
Palpation of Uterus
■ Void before exam
■ Support the bottom of the uterus before touching the top
■ Note fundal relation to umbilicus
■ Describe → normal = firm, midline, at U
● Boggy (mushy) → massage → always use 2 hands
● displaced to right or left → usually bladder (should be center)
Danger Signs
■ Boggy - feels soft and spongy associated with excessive bleeding or clots
■ Uterus firm but lochia heavy may be laceration or retained fragments
■ Persistent lochia after 2 weeks or return to pink or red discharge after it has cleared
indicates subinvolution of placental site or late pp hemorrhage
Lochia
■ Less in C/S due to uterine debris removed manually with placenta
■ Fleshy smell (If Offensive odor = infection while baby was within the uterus)
■ Three Stages of Lochia
● Lochia rubra (day 1– 3-4 days)
◆ deep red mixture of mucus, tissue debris, and blood
● Lochia serosa (3 – 10 days postpartum)
◆ pink to brown in color; contains leukocytes, decidual tissue, red blood
cells and serous fluid
● Lochia alba (days 10 – 14, could last 3-6 weeks)
◆ creamy white or light brown in color; consists of leukocytes, decidual
tissue, and reduced fluid content
Postpartum Hemorrhage
■ Causes
● Uterine atony (tone) → not staying firm
● Retained placental fragments
● Cervical or perineal lacerations
● Subinvolution (failure of uterus to return to normal size)
● Bleeding disorders
■ Management
● Fundal massage
● Meds to stimulate the uterus to contract
◆ Oxytocin (Pitocin); Methylergonovine maleate (methergine);
Misoprostol (Cytotec), Prostaglandin (PGF2), Carboprost (Hemabate)
● Teach woman to massage own fundus and assess bleeding
◆ Too much bleeding = pad full of blood within an hour
● Monitor CBC
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➢ Afterpains
■ Painful uterine contractions
■ Due to involution caused by uterine contractions
■ Stronger with breastfeeding due to oxytocin- strengthens uterine contractions
B
Breasts
U
Uterus
B
Bowel
B
Bladder
L
Lochia
E
Episiotomy
H
Homan’s Sign
E
Emotional
❖ Cervix & Vagina
➢ Cervix
■ By 6 weeks=pre=pregnant state
■ Changes in appearance (slit)
➢ Vagina
■ After delivery: edematous, bruised & small lacerations, thin, few to no rugae
■ 3 wks: mucosa thickens, rugae, stays slightly larger than prepreg.
■ Non BF: 1 to 3 months menstruation begins
■ BF: average 6 months menstruation begins
➢ Perineum
■ Perineum - pressure of descending head stretches & thins the muscle of pelvic floor,
edematous & bruised
■ Episiotomy
● Inspection - Sim's position
● May take 4-6 months to heal with episiotomy/laceration
■ Hemorrhoid: distended rectal veins which are pushed out
➢ REEDA
■ R – redness
■ E – edematous
■ E -- ecchymosis
■ D – discharge
■ A- approximate
➢ Comfort Measures
■ Ice packs x 24hrs, warm packs p 24 hrs
■ Warm water over the area via a peri bottle
■ Witch hazel pads ex: TUCKS
■ Anesthetic sprays: ex: Dermoplast
■ Sitz baths after 24 hrs
■ Hydrocortisone cream- hemorrhoids
❖ Cardiac Adaptations
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➢ Cardiac output remains high for the first few days postpartum; gradually declines to
nonpregnant values within 3 months of birth
➢ Blood volume, which increased substantially during pregnancy, drops rapidly following birth
and returns to normal within 4 weeks postpartum (also diuresis)
➢ Blood Loss: 500ml Vag, 1000ml C/S (averages)
➢ If Tachycardia (>100 bpm) noted consider
■ Hypovolemia
■ Dehydration
■ Hemorrhage
➢ BP: decreases first 2 days, then may have slight increase days 3-7, returns to pre-preg.by 6 weeks
■ If elev. BP and H/A consider Preeclampsia
■ Decr. BP= ortho. Hypotension or hemorrhage
➢ Coagulation
■ Clotting factors increased during pregnancy and elevated for 2-3 wks post-partum
■ Combine with immobility, vessel damage during birth= risk for thromboembolism
Urinary
➢ Bladder → may be subjected to trauma that results in edema & diminished sensitivity to fluid
pressure, can lead to over distention & incomplete emptying, may have difficulty voiding the 1st
2 days (↑ with epidural)
➢ Hematuria in early PP period reflects trauma, later may be UTI
➢ Diuresis - usually begins within 12 hours after delivery which eliminates excess body fluid,
continues for 1 week, normal by 4 weeks
Gastrointestinal
➢ Normal bowel function is interrupted in 1st week due to ↓ mobility, pain meds, low fiber diet,
fluid loss and perineal discomfort, usually reestablished by end of 1st week as fluids ↑, ↓
progesterone and perineal discomfort ↓
➢ Nursing Measures
■ Appetite → early PP increased appetite, provide snacks & fluids as needed
■ Bowel Function
● BS - listen q shift - ask about passing flatus
● high fiber diet and 300ml fluid intake
● Stool softeners - docusate sodium (colace) to decrease discomfort
● Dulcolax supp. or fleets enema if needed
Musculoskeletal
➢ Hormones decrease (relaxin, estrogen, progesterone)
➢ All joints return to normal within 6-8 weeks except feet
➢ Fatigue, Activity Intolerance, Distorted body image
➢ Careful to prevent low back pain, joint injury until stabilized-normal state
➢ May have separation of Rectus Abdominis muscles= Diastasis Recti (d/t stretching, tone loss)
Integumentary System Adaptations
➢ Darkened pigmentation on the abdomen (linea nigra), face (melasma), and nipples fades
➢ Some women experience hair loss during pregnancy and postpartum periods
➢ Striae gravidarum (stretch marks) gradually fade to silvery lines
➢ Profuse diaphoresis (sweating) is common to reduce fluid levels to pre-pregnancy state
Other Systems
➢ Respiratory: Remain in normal range
■ Anatomic changes back to pre-pregnancy state
■ SOB relieved
➢ Neurological
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■ chills/tremors - self-limiting and normal
➢ Endocrine
■ Quick drop of estrogen and progesterone, hCG, hPL
■ Lower estrogen= Breast Engorgement
■ Estrogen increases 2 weeks after birth for non BF moms
■ BF moms- estrogen increases when freq. of feedings decreases
■ After first menses= progesterone production reestablished
■ Prolactin=stay elevated if BF, drop within 2 weeks non BF mom
Lactation
➢ Colostrum “pre milk”
■ Thin, yellow color
■ Protein and carbohydrates
■ No milk fat
➢ Breast Milk
■ After estrogen/prog. levels drop:
■ Prolactin stimulates glandular cells to secrete milk
■ Oxytocin acts so milk is ejected from alveoli to nipple
■ Stimulated by sucking=releases milk
■ 2-3 days after birth
➢ Engorgement
■ S/S: Hard, tender to touch
■ Frequent emptying of breasts, also helps with discomfort
■ Warm shower
■ Warm compresses
Cultural Considerations
➢ Balance of hot and cold: Latin American, Asian, African American
➢ Confinement after childbirth: rest, recuperation, avoid illness
➢ Ask cultural preferences; support preferences as able
Psychological Adaptations
➢ Attachment → begins before birth, acceptance and nurturing fetus
➢ Bonding - term 70's & 80's to describe attachment felt by parents, enhanced in first 30-60
minutes after birth - sensitive period, not critical - attachment can still happen, baby state of
consciousness – alert, reactive, -deterrents: hospital routines, eye medications
Reva Rubin’s Three Phases of Adaptation to the Maternal Role
➢ Taking In Phase
■ Passive and dependent; preoccupied with self
■ Reviews birth experience
■ Interacts with newborn; identifies specific characteristics; “my nose”
➢ Taking Hold Phase
■ Resumes control over her life; concerned about self care
■ Gains self-confidence
■ Becomes preoccupied with present
■ Takes care of self and infant but needs reassurance
➢ Letting Go Phase
■ occurring later in the postpartum period as the woman reestablishes relationships with
other people (2-4 weeks)
■ Maternal role attainment and Relationship adjustment
Paternal/Partner Adaptations
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➢ Influenced by
■ Participation in childbirth
■ Relationship with significant others
■ Competence in childcare
■ Family Role Organization
■ Culture
■ Method of Infant feeding
■ Develop bond
■ Intense absorption
■ Preoccupation
■ Interest = ENGROSSMENT
➢ 7 Behaviors of Engrossment
■ Visual (Beautiful)
■ Tactile (Touch)
■ Perfect (Attraction)
■ Attention (Awareness)
■ Pick out Baby in NBN
■ Elation
■ Self Esteem (Proud/Mature)
Three Stages Role Development Process for Fathers/Partners
➢ Stage 1 (expectations)
➢ Stage two (reality)
➢ Stage three (transition to mastery)
Stages of the Transition to Parenthood (Mercer, 1985)
➢ Anticipatory stage: allows parents to seek out other role models
➢ Formal stage: allows parents to become acquainted with the infant and begin to take cues
➢ Informal stage: encourages parents to respond to the infant as a unique individual
➢ Personal stage: attained when the parents feel a sense of harmony in their roles
Critical Attributes of Attachment
➢ Proximity: the physical and psychological experience of the parents being close to their infant
■ Contact: touching/holding
■ Emotional State
■ Individualization: differentiate infants needs from own
➢ Reciprocity
■ the process by which the infants’ capabilities and behavioral characteristics elicit
parental response
■ Complementary behavior: infant stares-parent stares
■ Sensitivity: recognize and respond to infant communication
➢ Commitment
■ the enduring nature of the attachment relationship
■ Centrality: infant is placed in center of lives
■ Parent role exploration: Find their own way; integrate new identity
Nursing Interventions
➢ Identify positive and negative attachment behaviors
■ Ex: holding, caring for infant
➢ Recognize Cultural Diversity
➢ Some begin BF after discharge when milk comes in
➢ Limited time in hospital to address concerns
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➢ Pain/Discomfort, immunizations, nutrition, activity, exercise, lactation, d/c teaching, sexuality,
contraception, follow-up care
➢ Don’t Forget Extended Family (Siblings and Grandparents)
Chapter 16: Nursing Management During the Postpartum Period
❖ Postpartum (PP) Assessment
➢ Postpartum Assessment: VS
■ BP (pre-pregnant level)
■ Pulse (60-80, bradycardic)
■ Respiration (12-20 bpm)
■ Temperature (98-100 degrees F)
● temperature greater than 100.4 within the first 24 hours after birth may indicate
infection, or anytime up to and equal to 100.4 may be d/t dehydration during 1st
24 hrs
■ Pain status
➢ PP Assessment
■ First Hour: every 15 min.
■ Second Hour: every 30 min.
■ First 24 hrs: every 4 hrs.
➢ Postpartum Physical AssessmentL BUBBLE-HE
❖ Lochia: How much is too much?
➢ Scant: 10 ml = 1-2” stained pad
➢ Light/Small: 10-25ml = 4” stained
➢ Moderate: 25-50ml = 4-6” stain
➢ Heavy/Large: Saturated pad within 1 hr. of changing pads
➢ Evaluate if saturating more than 1 pad per hour
➢ Amount, odor, clots, size of clots, color
❖ Perineum
➢ Sim’s position
➢ Irritation, ecchymosis, tenderness, hematoma, hemorrhoids
➢ Perineum tissue surrounding episiotomy may be edematous, slight bruising (normal)
❖ Classifications of Lacerations
➢ 1st degree laceration – involves only skin and superficial structures above muscle
➢ 2nd degree laceration – extends through perineal muscles
➢ 3rd degree laceration – extends through the anal sphincter muscle
➢ 4th degree laceration – continues through anterior rectal wall
❖ Signs of Hematomas
➢ Large area of swollen, bluish skin
➢ c/o severe pain
➢ Assess for s/s of infection
❖ Cold and Heat Applications
➢ Ice pack/pad 1st 24 hrs
■ Reduce edema, Prevent hematomas, Decrease pain, Promote healing
■ Apply for 20 min, remove for 10min.
➢ Pads leave in place, change to room temp. quicker
➢ Peri Bottle: Warm water, Cleanses peri area after voiding, defecating, or pad changes
■ Direct water from front to back
➢ Warm pack/pad after 24 hrs
➢ Sitz Baths after 24 hrs: (see teaching guidelines 16.1 ebook)
■ Helps vascular circulation and healing
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■ Use peri bottle to cleanse before sitz bath
➢ Stay in room if first time OOB or any c/o dizziness
Analgesics
➢ Topical Preparations: Dermoplast spray, Tucks Pads, Hydrocortisone Cream
➢ Mild/Moderate pain: Tylenol or Ibuprofen
➢ Moderate/Severe: Codeine/oxycodone combined with Tylenol/Aspirin, Tyl #3, Percocet
■ Educate on Side Effects: Dizziness, n/v, constipation, sedation
➢ Can medicate 1 hr. prior to BF to promote comfort if needed
Breast Care Postpartum
➢ Lactating woman: Supportive bra, Warm showers, Correct position, Correct latch-on technique,
Nipple inspection, Exposure to air, Frequent nursing, Increase fluid intake
➢ Non-lactating woman: Avoid stimulation, Cold showers, Supportive bra on 24 hrs, Use ice packs
or cabbage leaves for engorgement, Avoid manually expressing milk from breasts, Take mild
analgesic for discomfort
Postpartum danger signs: (Box 16.2)
➢ Fever, foul smelling lochia or unexpected change in color or amount, saturates pad in an hour,
large blood clots, severe headaches/blurred vision, calf pain, Episiotomy/epidural
site/abdominal site – swelling, redness, discharge, shortness of breath, dysuria or burning or
difficulty voiding, depression or extreme mood swings
Postpartum Hemorrhage
➢ Causes: Uterine atony, Retained placental fragments, Cervical or perineal lacerations,
Subinvolution, Bleeding disorders
➢ Management
■ Fundal massage; Meds to stimulate the uterus to contract: Oxytocin (Pitocin);
Methylergonovine maleate (methergine); Misoprostol (Cytotec), Prostaglandin (PGF2),
Carboprost (Hemabate)
■ Teach woman to massage own fundus and assess bleeding
Bladder Care
➢ Immediately postpartum, bladder is edematous and hypotonic due to labor
➢ Profuse diuresis (>3000 mL/day) occurs 24 to 48 after birth
➢ Problems: Urinary distention, incomplete emptying, retention with overflow
➢ Management
■ early ambulation; void within 4-6 hours after birth, using nursing interventions to
stimulate voiding (sound of water running, warm water over perineum, hands in warm
water)
Emotional
➢ Postpartum Blues
■ Cry one minute, laugh next minute
■ S/S: Crying spells, sadness, confusion, insomnia, poor appetite and anxiety
■ Begins day 3 pp resolves by day 10
■ Affects 75% of all new mothers
■ Self-limiting, mildest form
➢ Postpartum Depression
➢ Postpartum Psychosis
Immunizations
➢ Rubella
■ If not immune (titer <1:8)
■ Consent form
■ Inform side effects: rash, soreness, joint symptoms, fever
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Avoid pregnancy for at least 4 weeks, some suggest up to 3 months (risk for teratogenic
effects)
➢ Rhogam (Rh immunoglobulin)
■ For Rh negative mothers with Rh positive infant
■ Give injection within 72 hrs. after birth
■ Prevent sensitization reaction
■ 2 doses: One at 28 weeks gestation, second before 72 hrs. after childbirth
■ Consent required
➢ Tdap (Tetanus, Diphtheria, Pertussis)
■ After delivery before d/c, if have not received
❖ Discharge Planning
➢ No lifting for the first few weeks
➢ Pelvic rest for 4 to 6 weeks
➢ Sleep when infant sleeps
➢ Accept help from others when offered
➢ Use a lubricant to help with vaginal dryness
➢ Keep postpartum follow-up appointment
➢ Report any signs of sickness to healthcare provider
➢ Exercise (see teaching guidelines 16.2 ebook)
➢ Self Care Misc.
■ Frequent pad changes
■ No tampons
■ No tub baths 4-6 weeks
■ Hand Washing!
➢ Safety
■ Check BP before ambulating
■ Elevate HOB a few minutes before ambulating
■ Dangle patient
■ Assist to stand and stay with patient
■ Frequent questioning: How do you feel?
■ Stay close with ambulating
➢ Sexuality
■ 3- 6 weeks must be healed, bleeding stopped
■ Contraception counseling
■ Some ovulate before menses returns
■ Possible to become pregnant before first follow up visit
➢ Nutrition
■ Greater needs for BF moms (+500 cal/day)
■ Adequate fluids: at least 2500ml daily
■ Discourage Diets
■ Easy recipes
■ Avoid Fast Foods
➢ Baby Care
■ (return demo)> ease in handling - encouragement & praise
■ Involve family members
❖ Nutritional Needs of the Newborn
➢ RDA 100-115 kcal/kg/day
➢ Contraindications of BF – HIV & Metronidazole (flagyl)
■
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➢ Contraindications to bottle – Allergies, over dilution
➢ Formula
■ Milk Based: Enfamil, Similac
■ Specialized/Therapeutic (Protein allergies): Nutramigen, Alimentum
■ Soy Based: Isomil, Prosobee, Nursoy
■ Preparations: Powder, Concentrate, Ready to Feed
➢ Birth Weight
■ Formula fed regain to birth wt 10 days – double 3.5 - 4 mo
■ BF – 14 days – doubles 5 mo
➢ BF Education
■ BF problems
● Leaking
● Supplemental bottles
● Pumping
● Storing
◆ refrigerator – 2 days
◆ freezer 2 wks
◆ deep freezer 3-4 months
● Nipple soreness
● Mastitis: inflammation of breasts; sore, pain, red, fever, edema
◆ Causes: Blocked milk duct, Cracked nipple-bacteria
◆ Rx: Rest, Warm compress, Antibiotics, Breast support
➢ Continue BF: infection will not pass into breast milk
● BF within first 20-30 minutes – alert stage
● On demand 8 – 10 feeds/day
● Cluster feed: At least every 2-3 hrs, wake up for feeds in hospital
● Positioning
◆ C hold or scissor hold
◆ belly to belly
◆ most areola in baby’s mouth
◆ offer each breast q 2 hours initially
● Limited to no pacifier recommend
➢ 3 Stages of Milk
■ Colostrum
● Last 2-4 days
● High in protein, vit, minerals and IgA
● Transitional milk
● 4 days to 2 wks
● Increased in calories & fat
● Mature milk (20 cal/oz)
● 10% solids and rest H2O
■ Foremilk
● Beginning of feed
● High in H2O, protein and minerals
■ Hindmilk
● After letdown
● High in fat
➢ Bottle Fed Babies
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Never prop bottle up
Elevate head
Feed every 3-4 hrs.
Burp often (initially every ½ oz)
Appropriate nipple, inspect for tears/wearing, keep nipple full of formula- less air
ingested
■ Nipple on top of tongue and all the way in mouth
■ Regurgitation
■ Don’t over feed
Chapter 17: Newborn Adaptations
❖ Neonatal Period: Newborn Transitioning
➢ First 28 days of life
➢ First 24 hrs. most precarious
➢ Most transitions occur during first 6-10 hrs. of life → magic time to see if something is going to
happen
❖ Normal Newborn Vital Signs
■
■
■
■
■
Temperature
97.7–99.5F (36.5-37.5C) degrees, AXILLARY
Preferred site over rectal temperature (Risk for
perforation of rectum, bowel)
Heart Rate
110-160 bpm; Regular Rhythm
Respirations
30-60 bpm
Respirations IRREGULAR, shallow, unlabored
Babies may have short periods of apnea when
breathing
Symmetrical chest movements
Obligatory nose breathers and abdominal breathers
(Look at the belly when counting breaths)
O2 Saturation
Should be @95% or higher
❖ Physiologic Adaptations → Cardiovascular
➢ Refresher on Fetal Circulation
■ Umbilical Vein= carries O2 blood from placenta to fetus
■ Ductus Venosus: Allows most of umb. Vein blood to bypass liver to get to heart sooner
● Closes approx 15 hours post birth
■ Foramen Ovale: Allows most blood entering RA to cross directly into LA bypassing
pulmonary circulation
● Closes within 1-2 hours post birth
■ Ductus Arteriosus= connects pulm. Artery to aorta (bypasses pulm. Circuit)
➢ At Birth
■ Switch from placenta to Pulmonary gas exchange
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Force of contractions labor/birth, mild asphyxia, incr. ICP d/t cord compression and UC,
and cold stress lead to:
■ Increase release of catecholamines
● Epinephrine and Norepinephrine stimulate
◆ Increased cardiac output
◆ Increased cardiac contractility
◆ Incr. surfactant release
◆ Promotes Pulmonary Fluid Clearance
Why does the heart switch from fetal to adult circulation at birth?
■ The transformation is triggered by
● Increased pulmonary pressure
● Cutting off blood flow from umbilical cord (clamp/cut cord)
Shunt #1
■ Ductus arteriosus
■ which shunts the major portion of the blood from the pulmonary artery to aorta allowing
only a small amount of blood to go to the lungs for nutritive purposes (closes within first
few hours after birth- usually within 15 hours) decreased prostaglandin E2 from placenta
& now the lungs need 02
■ Closure depends on high 02 content from aeration of lungs
Shunt #2
■ (foramen ovale)
■ ↑ pulmonary pressure, the pulmonary arteries dilate in response to oxygenation of lung
tissue, pulmonary vascular resistance ↓ which ↓ pressure in right side of heart
■ It simultaneously increases the pressure in the left atrium causing closure of the foramen
ovale
■ Occurs 1-2 hrs of birth
■ Now oxygenated blood is separated from non-0x blood
Shunt #3
■ Ductus Venosus ■ Previously shunted blood from umb. Vein to inf. Vena cava, closes within a few days after
birth, liver now functioning (no placenta)
■ fibrosis within 2 months because there is no longer blood flowing through it
Ductus Arteriosus, Ductus Venosus, Umb. Vessels
■ no longer needed, -become non functional ligaments
Normal Circulatory Adaptation
■ shortly after 1st cry may increase (e.g. 120-180), then decreases slightly
■ 1st and 2nd heart sounds should be clear & well defined
■ Count for FULL MINUTE
■ blood pressure – higher immediately after birth then reaches plateau within a week - is
sensitive to blood volume
■ Transient functional heart murmurs may be heard
● One of the fetal circulation ducts (from above) are still open; will hear a murmur
● Most of the times it is benign and it will close
● Check their BP and check their O2 saturation
◆ BP taken on every limb for comparison
● Any doubt? Call in a cardiologist
■ HR and BP change with behavior state
● Crying, Movement, Awakeness
■
➢
➢
➢
➢
➢
➢
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Tachycardia → start to think why is the HR up?
◆ Volume Depletion
➢ Placenta doesn't look healthy
➢ Mom lost a lot of blood during delivery
➢ Cut cord too fast
◆ Cardio/Resp. Disease
◆ Drug Withdrawal
◆ Hyperthyroidism
● Bradycardia
◆ Apnea: Short periods is normal
➢ Bad when their color starts to change
◆ Hypoxia: Lack of Oxygen
● Fast breathing and fast HR?
◆ Could they just be adjusting to life? … less concerned at 1 hour vs 1 day
➢ Monitor Transition
■ Blood Volume
● Depends on amt. of blood transferred from placenta at birth
◆ Timing of cord clamping ***
➢ Early → 4 - 30 seconds
■ Baby does better when there is more time
■ Benefits of Waiting:
● Improves cardiopulmonary adaptation
● Prevents anemia
● Increases BP
● Increases RBC flow
● Improves O2 transport
➢ Late → After 3 min
■ Problems with Waiting too Long
● Fluid Volume Overload
● Polycythemia: Too much RBC (Baby at risk for
jaundice)
◆ Gestational Age
➢ Preemies do not have as much blood volume
➢ Post Term babies may have too much volume
◆ Hemorrhage During Delivery
➢ Baby does not get what it needs since mom was bleeding
➢ Normal Newborn Blood Values
●
Lab Data
Normal Range
Hemoglobin
16-18 g/dL
Hematocrit
46-68%
Platelets
150,000-350,000
RBC
4.5-7.0
WBC
10-30,000 /mm3
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❖ Respiratory Adaptations
➢ Fetal Life → fluid filled lungs
➢ Extrauterine → fluid must be removed and replaced with air
➢ Vaginal birth → thorax is squeezed, helps rid fluid from lungs
■ Section will have more issues respiratory wise
■ Babies who are sectioned didn't get the squeeze of the birth canal
➢ Pulmonary capillaries and lymphatic system rid rest of fluid
➢ Fluid may be removed too slowly or inadequately
■ Decreased thoracic squeezing during birth (c-section)
■ Diminished resp. effort (newborn sedation)
● Baby will not be breathing well due to getting rid of medication Mom got
(Anesthesia etc…)
➢ Results = transient tachypnea (RR>60bpm) (Transient = TEMPORARY)
■ Chest wall is floppy
● High cartilage content
● Poorly developed musculature
● Results
◆ Ineffective accessory muscles and Abdominal/Diaphragmatic Breathers
● Surfactant lining alveoli enhances aeration
➢ Events Precipitating Respiratory Function in the Newborn
■ Initiation of Respiratory Movement
● 1. Expansion of the lungs
● 2. Establishment of functional residual capacity
◆ Ability to retain some air in the lungs upon expiration
● 3. Increased pulmonary blood flow
● 4. Redistribution of cardiac output
➢ Breathing
■ Initial breath= reflex (theories)
■ Pressure changes
■ Noise & light (sensory stimulation)
■ Chilling (room temp) (thermal brain sensors)
■ Compression of chest during delivery
■ High CO2 & Low O2 in newborn blood
● Sensed by Chemoreceptors in brain - transitory asphyxia - increase respiratory
drive
➢ After Respirations are established → what is regular for us
■ Shallow & irregular
■ Average = 30-60 breaths/min
■ Short periods apnea (<15 sec)
■ Rate changes with activity
■ Periodic Breathing → apnea of 5-10 sec is ok, no color change, no change in HR
● May be seen in first few days
● Need to monitor closely for further changes
➢ Characteristics of Normal respirations
■ Consider how old the infant is; ex: 60-80 resp up to 2 hours (transitioning)
■ count for one full minute
■ obligatory nose breathers - reflex develop at 3 months to open mouth
➢ ABNORMALS:
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Labored breathing (moaning, nasal flaring, chest retractions)
● Chest retractions
◆ Need to chart where you see the restrictions
◆ Chest is sinking in with each breath
◆ Sternal; suprasternal; substernal; intercostal retractions
◆ CAN BE MORE THAN ONE LOCATION
■ Tachypnea (rapid, above 60)
■ Asymmetrical chest movements
■ Apnea >15 seconds
■ Cyanosis and HR changes
❖ Thermoregulation
➢ Maintaining balance between heat production & heat loss
■ Stable body temp is one of the most important to transition and survive
➢ Newborns vulnerable to BOTH under and over heating
➢ Amniotic fluid on newborn cools and evaporates
➢ Temp. drops up to 5 degrees within minutes after birth
➢ DRY infant quickly after birth
➢ Mechanisms of Heat Loss
■ Conduction
● Heat loss from one surface to another due to direct contact
● PREVENTION: Warm blankets, warm hands, paper on scale, t-shirt, hat and
booties left on when circ performed
■ Convection
● Flow of heat from body surface to cooler surrounding air (or air circulating over
body surface); not direct contact
● PREVENTION: Transport in warmed isolette, Clothing, blankets
■ Evaporation
● Loss of heat when liquid is converted to vapor
● Insensible evaporation → from skin and respiration (unaware)
● Sensible → from sweating (observed)
● PREVENTION: Dry IMMEDIATELY after birth (and bath) with warm blankets
and hat, Prompt changing of wet linens (INCLUDES DIAPERS), ONLY uncover
what washing when bathing
■ Radiation
● Loss of body heat to cooler, solid surfaces near infant but not in direct contact
● PREVENTION: Keep cribs away from cold windows, etc…, Use radiant warmer
when transporting, performing procedures, admission assessment
➢ Overheating
■ Prone to overheating due to:
● Large body surface area
● Limited insulation
● Not able to sweat yet
● Immature CNS (hypothalamus)
◆ Complex neg. feedback system
● difficult to balance temp.
■ PREVENTION:
● Check isolette or radiant warmer temp, Check infant temp, Monitor cribs near
sunny window
■
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➢ Newborn Physiologic Changes with Thermoregulation
■ Attempt to conserve heat and increase heat production
● Increasing metabolic rate
● Increasing muscular activity through movement
● Increasing peripheral vasoconstriction
● Assuming fetal position to hold heat minimize exposed body surface area
➢ Neutral Thermal Environment
■ Body temp. is maintained without an increase in metabolic rate or O2 use
■ Thermal balance
■ Newborns have trouble maintaining temp. = need higher environmental temp.
■ If environmental temp. decreases
● Newborn consumes more O2 in response
● Resp. rate increases (tachypnea)
● Metabolic rate increases
➢ Newborn Heat Production
■ Primary Method
● **Non-Shivering Thermogenesis: Babies will control their temperatures and
generate heat
■ Babies have brown fat (highly vascular, adipose tissue)
● Can be oxidized if infant is cold
● Capable of intense metabolic activity: GENERATE HEAT
● Brown color from lots of blood vessels and nerve endings
● Brown Fat= 2-6% of body wt.
■ Primary Source of Heat Conservation: Use brown fat which first appears in fetus 26-30
wks gestation & lasts up to 2-5 wks pp
➢ Importance of babies needing to thermoregulate→ Newborn heat loss through any of the four
mechanisms leads to
■ Cold Stress → CAN BE DEADLY
● Excessive heat loss requires the newborn to use compensatory mechanisms to
maintain body temp
◆ Cold stress will ↑ O2 needs & ↑ acidosis- babies can't shiver (that is
primary method of heat retention) may increase voluntary muscle activity
● Cold stress can be fatal to an infant (Less subQ fat = Poor Insulation)
● S/S Cold Stress (this tells if they have cold stress without a temp)
◆ Less active
◆ Lethargic
◆ Hypotonic → more limp; not as contracted
◆ Weaker
● All infants are at risk for the first 12 hrs.
◆ Premies greater risk- MORE DANGEROUS
● If not reversed (BABY IS CRASHING!!!!)
◆ Depletes brown fat stores, Hypoglycemia, Respiratory distress, Jaundice,
Hypoxia, Metabolic acidosis, Decreased surfactant production
● PREVENTION:
◆ Prewarm blankets/hats/socks/robes
◆ Transporter/isolette warmed
◆ Dry baby immediately after birth
◆ Skin to skin contact (kangaroo care)
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◆
◆
◆
◆
◆
◆
Early Breast feeding (nutrients)
Heated/humidified 02
Radiant warmers
Environment should be 32-34 degrees C
Don’t bathe infants until stable! (Do Under Warmer)
Skin temp. probe not accurate if on bone or on brown fat
➢ MUST BE OVER SOFT TISSUE
❖ Hepatic Adaptation
➢ Iron Stores
■ Released and stored by liver until new RBC’s needed
■ Newborn stores last 4-6 months
■ Gets it from mom’s blood/ placenta
➢ Carbs-Glucose Metabolism
■ Initially decrease after cord cut
■ Main source of energy first few hours
● Released from liver glycogen stores
■ Stabilized by feedings
■ Dextrostix at birth and PRN per protocol
➢ Bilirubin Conjugation
■ Newborns produce bilirubin more than double adult rate (6-8mg/kg/day)
■ Conjugated (water soluble) can be excreted
■ Bilirubin (unconjugated) → indirect bilirubin
● Fat soluble (binds to albumin, can’t be excreted by kidneys)
◆ to big to be excreted
● BAD
● Indirect Bilirubin: Lab Test can be done to check how much bilirubin in the
infant's system is unconjugated
■ Processed into conjugated bilirubin → direct bilirubin
● Water soluble→ GI system via bile → Excreted in feces and urine → small amt.
excreted by kidneys
● GOOD
● Direct Bilirubin: Lab Test can be done to check how much bilirubin in the
infant's system is unconjugated
■ Immature Liver Pathways
● Can’t conjugate quick enough
● Jaundice (icterus): Increases in unconjugated amt. in blood, deposits in skin,
sclera, mucous membranes
◆ Extreme levels Bilirubin = toxic
◆ Kernicterus= permanent brain damage
● Lab Test: Total Bilirubin = combined direct and indirect levels
■ Risk Factors for Jaundice
● Fetal-maternal blood group incompatibility (Rh or ABO Incompatibility)
● Prematurity
● Breast Feeding
● Drugs (diazepam, oxytocin, sulfisoxazole/erythromycin, chloramphenicol)
● Maternal Gestational Diabetes
● Trauma- results in cephalhematoma (increases hemolysis)
● Bruising
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● Male Gender
● Polycythemia: a lot of RBC formed
● Previous sibling with hyperbilirubinemia
● TORCH infections (EX: toxoplasmosis, rubella, cytomegalovirus)
● Asian/Native American ethnicity
■ Incidence - 60% term and 80% preterm
■ Before birth bilirubin is transferred across placental barrier to maternal circulation,
normal cord levels at birth are 1.8 to 2.8 mg%
■ Three groups of jaundice based on mechanism of accumulation of bilirubin:
● Overproduction
◆ Blood incompatibility, drugs, trauma, polycythemia, delayed cord
clamping, Breast milk jaundice
● Decreased Conjugation
◆ Physiologic jaundice, hypothyroidism, BF
● Impaired Excretion
◆ Biliary obstruction, sepsis, chromosome abnormality (ex; Turner
syndrome, trisomy 18 & 21, drugs (aspirin, acetaminophen, sulfa, alcohol,
steroids, antibiotics)
❖ Types of Hyperbilirubinemia
➢ Physiological Jaundice (60% of term babies, 80% preterm)
■ Term infant jaundice increases 3-4 days after birth to serum levels up to 10mg/dl and
then the levels fall rapidly
■ Serum (indirect) unconjugated bilirubin levels exceed 2.0 in 90% of infants
■ Normal is 0.1-1.0
■ Direct or conjugated bilirubin is normally 0 - 0.4 (Total is both direct and indirect)
➢ Pathologic Jaundice
■ Yellow really quick; visible within the first 24 hours (GLOWING YELLOW)
■ Impairment of albumin binding
■ Kernicterus or bilirubin encephalopathy – neurological disorder: hearing/vision loss,
mental retardation, death
■ Total bili concentrations rising by more than 5mg/dl/day
■ Total bili above 17mg/dl in term
■ Visible jaundice for more than one week in term
➢ Other Types of Jaundice:
■ Preterm Jaundice (80%)
■ Breast Milk Jaundice (1%) – specific type of jaundice that shows after a few weeks
■ Biliary Atresia – severe jaundice d/t defect
❖ Treatment/Care Options for Jaundice
➢ Phototherapy Treatment:
■ Phototherapy lights
■ Bilirubin Graph: Plot Total Bilirubin vs. age (in hours) to determine treatment
➢ Nursing Care for Hyperbilirubinemia
■ Early feeds stimulate gut motility,
■ ↑ protein for conjugation
■ Phototherapy - light break down bilirubin or photo-oxidizes it in the skin and the
byproducts are water-soluble which can be excreted in the bile and urine
■ Bilirubin drops 2-4mg within 12 hours of treatment
■ Prevent cold stress
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■ Monitor phototherapy light output: Bili Light Meter
■ Feed q 3-4 hours, frequent feeds-frequent stools
■ Protect the eyes and the genitals
❖ GI System Adaptations
➢ Can digest simple carbs and protein
➢ Limited ability to digest complex carbs and fats (d/t amylase/lipase levels low)
■ Result= fatty stools
➢ Bacterial colonization in gut is happening
■ Occurs usually within 24 hrs, but may take several days; needed for Vit. K production
■ Gut makes vitamin K so give the shot to help this
➢ Immature sphincters = regurgitation (spit-up)
➢ Avoid overfeeding, yes- frequent burping/bubbling
➢ Normal term newborns have wt. loss 5-10% birth weight in first week of life
■ Insufficient caloric intake, intracellular water shift, insensible water loss
■ Needs 108 kcal/kg/day for wt. gain from birth to 6 months
➢ Stool Changes
■ Meconium (goose-poop)
● Greenish-black color
● Tar consistency
● Passed 12-24 hrs. after birth
■ After feedings (bacteria introduced) TRANSITIONAL STOOLS
● Thinner and seedy appearance (IF BREAST FED)
● Different appearance of stool BF vs. bottle
◆ BF: yellow, seedy, stringy, sour smell, no odor
◆ Bottle: yellow, green (iron in formula), loose or formed, odor
➢ Depends on formula type
■ After initial stool there is no magic number of how many stools a day
● What we use for normal stools is the colors
◆ Within the first 24 hours → one wet diaper
◆ Second day → two wet diapers
◆ Third day → three wet diapers
◆ After → 6-10 wet diapers a day
❖ Renal System Changes
➢ Void after birth= adequate renal function
➢ Limited ability to concentrate urine until 3 months (immature kidneys)
■ Frequent voids, low specific gravity
➢ Urease→normal variation that could be a sign of dehydration but is not uncommon to see
without dehydration.
■ Brick color d/t urates (patch in diaper orange/clay colored - may be pasty)
➢ Low GFR, limited excretion and conservation ability=
■ Fluid overload possible (IV therapy- carefully!)
➢ One wet diaper per day of life
■ Average 6-10 wet diapers at 6-10 days old
❖ Immune System: Purpose of Defense
➢ Defense: protection from invading organisms
➢ Homeostasis: elimination of worn-out host cells
➢ Surveillance: recognition and removal of enemy cells
➢ Categories of Immunity
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Natural
● Does not require previous exposure
● Physical barriers (skin, mucous memb.)
● Chemical barriers (gastric, enzymes)
● Resident non-pathological organisms
● Ingests and kills microorganisms by phagocytic cells
■ Acquired Immunity
● IgG only one to cross placenta (most abundant)
◆ Baby gets this in utero and already has it when it is born
◆ Produces antibodies against bacteria, bacterial toxins, viral agents
● IgA → major source found in breast milk
◆ Protects mucous memb. from bacteria/viruses
● IgM → levels low, protects blood borne infections
Integumentary
➢ Protective barrier between body and environment
➢ Limits water loss, prevents trauma, prevents absorption of harmful substances
➢ Limited sweat gland function
■ Babies cannot really sweat; develops around age 2-3yrs
➢ Less mature skin function (more risk injury)
➢ Color, age, race/ethnic, temperature, crying
Neurological System → Senses
➢ Hearing: well-developed at birth; responds to noise- turns to sound
➢ Taste: distinguish between sweet/sour by 72 hours old
➢ Smell: can distinguish between mother’s breast and breast milk from others
➢ Touch: sensitive to pain, responds tactile stimuli
➢ Vision: ability to focus on objects close by; tracks objects
Congenital Reflexes → reflexes they are born with
➢ Most disappear as child gets older
Behavioral Patterns/Newborns: (Predictable)
➢ First Period of Reactivity: Birth - 30 minutes after birth
■ Newborn is alert, moving, may appear hungry (start breastfeeding)
■ Keep their blood sugar up; helps with the temperature; everything is all connected
■ DON'T MISS THIS WINDOW TO FEED BECAUSE THEY ARE SLEEPING FOR 2
HOURS IN NEXT STAGE
➢ Period of Decreased Responsiveness: 30 minutes - 120 minutes old
■ Period of sleep or decreased activity (no interest in sucking)
■ Babies out; sound asleep
➢ Second Period of Reactivity: 2 – 8 hours
■ Newborn awakens and shows an interest in the stimuli
➢ Newborn Behavioral Responses (Predictable)
■ Orientation= response to stimuli
● Stare at face close by
■ Habituation= process and respond to environment (visual & auditory)
● Block out noise in nursery- sleep through
■ Motor maturity= posture, tone, coord., movements
● Depends on gestational age
● Rhythmic & spontaneous movements
● Put hand in mouth
■
❖
❖
❖
❖
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Self-quieting ability= comfort self, consolability
● Sucks fingers
■ Social behaviors= nestles into parent’s arms, cuddling
■ Newborn observation: “Consolability” from these states
● Crying, Active Alert, Quiet Alert, Drowsy, Sleep
Chapter 18: Nursing Management of the Newborn
❖ Immediate Newborn Period
➢ Initial assessment done in DR: new tool for rapid newborn assessment
■ RAPP Assessment
● Respiratory (effort), Activity (alert, crying), Perfusion (skin color), Position
(head, neck, nares/mouth, flexion extremities)
❖ Admission assessment done 1-4 hrs. after birth (average) (usually in NBN)
➢ (FULL HEAD TO TOE in NURSERY)
➢ Initial Assessment: evaluate transition to extrauterine life
❖ Signs Indicating a Problem During Initial Newborn Assessment
➢ Nasal flaring, Chest retractions, Grunting on exhalation, labored breathing, Generalized
cyanosis, Abnormal breath sounds, Abnormal respiratory rates, Flaccid body posture, Abnormal
heart rates , Abnormal newborn size(SGA, LGA, AGA)
❖ APGAR Scoring
➢ Interpretation:
■ 7-10 good condition
■ 4-6 fair condition, moderate CNS depression, some muscle
flaccidity, and cyanosis, must have airway cleared and O2
■ 0-3 extremely poor, resuscitation needed immediately by
pediatrician or neonatologist
➢ Criteria: Ranked from 0-2
➢ Heart rate: most important sign and the last to be absent if the situation is grave 150- 180 in
first few minutes and 130-140 during the first hour, a rate below 100 requires resuscitation
➢ Respiratory effort: regular respirations should be established within a minute
➢ Muscle tone: keeps extremities well flexed and resist attempts to extend them
➢ Reflex irritability: withdraw from pain
➢ Color: Cyanosis is seen in almost all infants at the moment of birth, the body of a healthy infant
usually turns pink in approximately 3 minutes, Acrocyanosis - normal for 24 hrs or so, score of 1
❖ With Newborn Depression…
➢ Predictable change in newborn status
■ Lose Color: First thing that you will see is a color change
■ Respiratory effort: Flip them over and pat the back; trying to get mucus out
■ Tone: Next thing that goes; Flexed and firm extremities relax
■ Reflex Irritability
■ Heart Rate: Last thing that happens
❖ Measurements → be comfortable with both metrics
➢ Weight
■ No diaper, ZERO SCALE
■ 5lb 8oz - 8lb 13oz, 2500g-4000g
● LBW <2500g, Very LBW <1500g, Extreme LBW <1000g
➢ Length
■ Tape measure or Built in tape on scale
■ Supine: head to heel (fully extend leg)
■
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■ 44-55cm average; can range from 17-22”
➢ Head Circumference – average 32-38 cm (13-15”) large ¼ of total body size (2cm >chest)
■ Widest part of the occiput
➢ Chest Circumference - nipple line 30-36 cm or 12-14” (2-3cms < head)
➢ Abdominal Girth – measure at umbilicus
■ Should be a little less than the chest
❖ Vital Signs
➢ HR: 110-160 bpm
■ Full minute count
■ Regular rhythm
■ Apical: count one minute
■ Brachial present and equal bilateral
■ Femoral pulses present & equal bilaterally
■ No bulging in inguinal area
● Could be born with a hernia
➢ Resp: 30-60 bpm (breaths/min)
■ Count when sleeping
■ irregular, shallow, unlabored
■ Symmetrical chest movements
➢ Temp: 97.7-99.5F (36.5-37.5C)
■ Axillary
■ Rectal not used due to chance of perforation
➢ BP
■ 50-75 mmHg (systolic)
■ 30-45 mmHg (diastolic)
■ USE DYNAMAP
■ Sensitive to movement, crying
➢ 5th VS: Pain (FLACC scale, PIPP, CRIES Scale)
■ Anything higher than a 2 addressing & reassessing
❖ Gestational Age Evaluation
➢ Ballard Scoring System/Dubowitz (for gestational age)
■ Range -1 (immaturity) to 5 (post maturity)
● Add scores from each category
■ Physical Maturity (within 2 hrs birth)
● Looking at the skin
■ Neuromuscular Maturity (within 24 hrs)
■ Total 12 scores, add up scores, Compare to standards on chart
● Determine # weeks gestation
➢ Gestational Age Classifications
■ Preterm → <37 weeks
■ Term → 38-42 weeks
■ Postterm → after 42 weeks
■ Postmature → after 42 weeks/placenta aging
➢ Classification using Gest. Age and Weight
■ SGA → wt. less than 10th percentile
■ AGA → wt. between 10-90th percentile
■ LGA → wt. more than 90th percentile
❖ Nursing Interventions immediate newborn period
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➢ Maintain Airway Patency
■ Bulb suction: mouth then nose
■ M before N (like the alphabet)
● Mouth can hold more than the nose
● go into side, don't go straight in because you will hit the tongue
➢ Ensure Correct Identification
■ Match bracelets, on before leaves LDR (don't prewrite)
■ Instant photo
■ Foot printing
➢ Medication Administration: Review Instructions in lab day modules folder
■ Phytonadione (Vitamin K) 0.5-1mg IM (takes infant 1 week to produce own)
■ Erythromycin ophthalmic ointment 0.5% OU (prevention of Ophthalmia
Neonatorum-blindness)
➢ Maintain Thermoregulation 97.7-99.5
■ Sensor probe (warming unit)
■ Dry, wrap, hat, warmer unit
❖ Newborn Assessment
➢ Results vary based on #hrs. old, completion of transition
➢ Do least invasive first
➢ Skin Assessment
■ Skin Variations – Color
● Pink – no central cyanosis - lips trunk
● Acrocyanosis peripheral - normal due to poor blood perfusion
● Ruddy (polycythemic) - increase RBCs, blotchy, darker than normal
● Pallor - decreased RBC’s
● Jaundice – bilirubin accumulation, yellowing
■ Skin Variations
● Harlequin sign - red on one side, white on other “clown suit” vasomotor
disturbance,
◆ 1-20 min, may have multiple episodes
● Peeling skin (desquamation)- post term
● Vernix caseosa- thick white substance (preemies have more!)
● Mottled → blotchy skin
● Stork bites or salmon patches- superficial vascular area
● Milia- immature sebaceous glands
● Mongolian spots- blue/purple splotches (back/buttocks)
● Erythema toxicum- newborn rash (face, chest, back)
● Nevus flammeus- port wine stain (does not fade)
◆ will resolve over time
● Nevus vasculosus- strawberry mark (raised, head, resolves)
● Lanugo- fine downy hair (shoulders/back) (preemies have more!)
● Cafe Au Lait- light brown marks, oval, r/o neurofibromatosis
● Other marks noted on skin:
◆ Petechiae, Ecchymosis, Lacerations, Forceps/Vacuum marks
➢ Head Assessment
■ May be asymmetrical
■ Molding – elongated shaping, overriding of cranial bones
■ Fontanels
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➢
➢
➢
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➢
● anterior 4-6 cm diamond shaped - closes 12-18mo. (up to 24mo)
● posterior- triangle 0.5-1 cm closes 2-3 mo.
● open and flat - should not be depressed or edematous
● Normal is → soft, flat, closed
■ Caput succedaneum - localized edema and soft area
of scalp resulting from long and difficult labor
(serous fluid)
● edematous from sustained pressure of
presenting part against cervix, swelling may
cross sutures fluid is reabsorbed in 12 hour
● Feels mushy; can move it
● Serous fluid from swelling; not blood or a
bruise
● It will go away!
■ Cephalhematoma - bleeding over bone and under
periosteum, does not cross suture lines appears later
12-24 hours, usually parietal bones, reabsorbed few
weeks
Face: Symmetry, Facial nerve paralysis,
■ Drooping one side, Unable to make seal on nipple,
Forcep delivery, Resolve over time (usually)
Eyes
■ Symmetrical & gray -blue color (true color in few months)
■ Usually edematous & subconjunctival hemorrhage 10% from ↑ vascular tension during
delivery - gone in 1-2 weeks
● Subconjunctival hemorrhage → redness in the eye due to popping of a blood
vessel ; considered normal ; will go away on its own
■ Sight - can see but not well developed
■ Tracks objects to midline, may be uncoordinated
■ Red reflex present
Ears
■ Assess ears for placement - imaginary line from inner to outer canthus should cross over
top 1/3 of ear, stiffness of cartilage & curve of pinna for gestational age
■ Assess hearing loss – hearing screen required
■ Preauricular skin tags - sometimes ligated
■ NO OTOSCOPE: vernix, amniotic fluid in canals
■ Low set ears can be a sign of down syndrome
Nose
■ Midline, symmetrical, Patent nares (can smell & taste, can differentiate mother’s breast
milk)
■ Milia common → little white dots (“Baby Acne”)
Mouth
■ Lips pink, intact, no clefts, no lesions
■ Thin upper lip (fetal alcohol syndrome)
■ Mouth – pink, moist and saliva scant,
■ sucking blisters, inspect for precocious teeth
■ Suck reflex
■ Palates (hard and soft intact), no clefts
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■
■
■
■
➢ Neck
■
■
■
■
● Put a glove on hand and feel them
Epstein’s pearls (epidermal cysts) common
Thrush (candida albicans during birth)
● S/S: white plaque, can’t be wiped
● Thicker coating of white on the tongue
Tongue: Size, movement, short frenulum “tongue tied” (too short will have frenectomy)
Cleft lip & Cleft lip/palate
● Cleft lip can use a cleft nurser to feed baby
● Cleft lip/palate will most likely aspirate on the food
Movement
Ability to support head
Lots of skin folds
Clavicles - palpate and observe arm movement
● crepitus – Most common broken bone in delivery
● Large babies more common
◆ May or may not x-ray
● Rx: Immobilization, minimize pain
● Do not need to x-ray ; we do not do anything for it ; it will heal on its own
➢ Chest
■ Chest measure 1-2 cm smaller than head, barrel shape, xiphoid may protrude (normal)
■ Breasts - may secret small amount of whitish fluid 2-3 days after birth due to maternal
hormones,
■ Term babies have breast tissue
■ Supernumerary nipples- familial, extra nipple 5cm below nipple, small, raised,
pigmented, no glandular tissue
■ Symmetrical rise/fall, clear breath sounds but fine crackles possible after birth (until
fluid clears)
➢ Abdomen
■ Round, soft, protrudes but not distended
■ Bowel sounds + shortly after birth
■ Absent or hyper could indicate obstruction
■ Check umbilical cord for redness and oozing
● Keep clean and dry
■ Remove cord clamp second day if dry and no alarm on clamp
● 3 Cord Vessels (A-V-A)
● 2 vessel cord could have renal/GI anomalies
➢ Pulses
■ Apical: count one minute
■ Brachial present and equal bilateral
■ Femoral pulses present & equal bilaterally
■ No bulging in inguinal area
● Could be born with a hernia (if bulging)
➢ Female Genitalia
■ Enlarged labia (majora & minora)
■ Vaginal discharge- white mucus - normal may be blood tinged due to maternal hormones
– pseudomenstruation
■ May be seen during first few weeks
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May have vaginal tag – common
● Seen more with premature
● Extra tissue between the vagina and anus
● Full term usually is absorbed with rest of tissue
■ Babies majora covers minora
■ Pink or dark in darker skin populations
Male Genitalia
■ Uncircumcised- foreskin covers glans
■ Meatus should be midline
● Hypospadias= glans on ventral surface (closest to scrotum)
◆ Bottom side
● Epispadius= glands on dorsal surface (less common)
◆ Top side
◆ Closest to the abdomen
● No circ for either one (skin used later for surgical correction)
■ Scrotum
● PALPATE BOTH TESTES
◆ Pea Sized
◆ Undescended (cryptorchidism) unilateral or bilateral
➢ “Floating”, common with premature dates
● Appears large, rugae present, edematous (r/o hydrocele)
● Pink or dark in darker skin populations
Back/Buttocks
■ Lie prone (on belly) to assess
■ No curvature of spine
■ Tuft of hair, dimple or sinus in sacral area may indicate spinal problem, cover any cysts
● Could be neural tube defect
■ Gluteal folds should be equal
■ Patent anus - should pass meconium 24-48 hours after birth
Extremities
■ Assess ability to move all 4
■ Muscle tone - usually flexed up to 2 months,
■ Polydactyly (extra digits)
■ Syndactyly (webbed digits)
● In the feet tends to be genetic in families
■ Normal= 3 palmar creases
● Simian crease (one crease) (s/s down syndrome)
■ Short fingers, broad hand, fingernails to end of fingers
● Examine for signs of crepitus sign of fracture, brachial and femoral pulses creases
–
● Clubfoot – talipes equinovarus (turns inward)
◆ OK as long as the foot can be
moved back and forth
■ Hip Dysplasia:
● Ortolani Maneuver & Barlow
Maneuver
Nervous System
■
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Transient tremors of mouth, chin & extremities
● Should NOT be present after one month
■ Check
● Alertness
● Posture
● Muscle Tone
● Reflexes
◆ Moro/startle → sudden lowering of head and back 30 degrees, arms &
legs extend and abduct, fingers open & thumb & finger forms C, startle
reflex
◆ Palmar grasp reflex → infant grasps if something is put by base of fingers
◆ Plantar grasp reflex → touch below toes they curl
◆ Babinski reflex → toes flare outward when stroke the heel of foot to ball
◆ Rooting reflex → touch the side of the mouth the infant turns toward it
◆ Sucking reflex → to illicit touch the mouth or palate
◆ Tonic Neck/Fencing → lie on back, turn head one way (arm on that side
extends straight away, opposite arm is flexed)
❖ Other Nursing Management
➢ Observe for S/S of Distress
■ Nasal flaring or grunting
■ VS Q30 min
■ Initial bath under warmer; wear gloves until bath is complete
■ Replace under heat
■ Phytonadione (vitamin K) and erythromycin – if not given in delivery room
■ Different things depending on how the delivery went
● Glucose monitoring
● Group Beta Strep protocol
● Meconium protocol if indicated (frequent VS)
➢ Glucose Levels (monitor)
■ Test every baby at birth to have a baseline
■ Glucose levels of 50-80mg/dl, by day three, normal glucose levels are 60-70mg/dl
■ Hypoglycemia is blood glucose <30mg/dl, plasma glucose <40 mg/dl
● Most hospitals treating if <50 (60 NICU)
■ Risk for Hypoglycemia
● IDM, LGA, low APGAR or stressed
● S/S of hypoglycemia
◆ Lethargy, tachycardia, resp. distress, jittery, hypothermia
◆ poor feeding, weak cry or high pitched cry, hypotonia (tone starts to go),
seizures
● Treat low glucose per hospital protocol
◆ Ex: bottle feed, recheck level after 30 min
◆ Check sugars before two feeds → If they both come back normal then stop
➢ Group Beta Strep (GBS)
■ Diagnosis → positive vaginal or cervical culture of mother – known to cause sepsis and
death in otherwise healthy newborns
■ Management/nursing care → CBC, blood culture, septic workup, frequent VS Q4 hours
■ Maternal → screen all women prenatally at 35-37 week antibiotics intrapartum at least
4 hours before delivery (Ampicillin, Clindamycin or Erythromycin)
■
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If unknown → look at risk factors, follow protocols
GBS risk factors
● Premature ROM
● Fever during labor
● Less than 37 weeks gestation
● History of + GBS in previous pregnancies
● Clinical manifestations - signs of neonatal sepsis
➢ Circumcision
■ Surgical excision of the foreskin or prepuce that covers the glans penis
■ Elective procedure, routine, value is controversial
■ Incidence → most common surgical procedure in USA
■ Advantages → may reduce UTI and cancer, needed for a phimosis or hygienic problems,
culture, can use skin to correct hypo or epispadias, what is the family pattern →“look like
dad”
■ Disadvantages → surgical risk (bleeding) & pain
■ Methods → usually done 12-24 hours after delivery
● Gomco (Yellen) clamp
● Mogan, Sheldon
● Plastibell
■ Baby monitored in nursery for 2 hours post circumcision
■ Nursing Measures for Circumcision
● Make sure Phytonadione (Vit K) given prior to circumcision
● Informed consent
● no longer NPO before procedure
● Suction handy
● Restrain (Circ board)
◆ KEEP BABY WARM
● Antibiotic cream if ordered (not with plastibell)
● Check voiding and chart (before & after)
● Vaseline Gauze wrap
● Keep clean and dry
● Risks after procedure:
◆ Check for Bleeding - apply pressure
➢ Liquid epinephrine used on gauze with pressure if needed
◆ Infection
➢ Rare; shows up later
● Parent education
● Tissue healing around the circumcision will appear yellow in color → this is
normal and is not an infection
❖ Newborn Screening
➢ Metabolic screening - Errors can cause mental retardation, handicap & death
■ Errors in metabolism: PKU, hypothyroidism, galactosemia, maple syrup urine disease,
CF, cong adrenal hyperplasia
■ Supplemental screening in some states
■ 4 or 8 circles on paper and sent to state lab
■ Results to pediatrician office
➢ Testing for metabolic and endocrine problems
➢ Baby must have fed for 24 hours prior
■
■
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➢ Heel stick blood test after 24 hours po intake (don't do on heel it will damage plantar nerve)
■ Outer ⅓ of the foot - Picture a V!
❖ Hepatitis B Vaccine
➢ Recommended in NB period, 2 months & 6 mo.
➢ Some ped. give first dose in office
➢ IM: Vastus Lateralis (how you give it is very important)
■ Dosage 5-10mcg
■ Needle Size and Gauge Important (see text and lab day modules)
NEW INFORMATION
Chapter 19: Nursing Management of Pregnancy at Risk - Pregnancy Related Complications
❖ High Risk Pregnancy
➢ Condition that jeopardizes the health of the mother, fetus, or both.
■ May be result of pregnancy OR pre-existing
■ 1:4 women
■ Increases incidence of morbidity & mortality
■ Risk status can change during pregnancy
➢ Early Identification
■ Prompt interventions
■ Provide positive outcome
❖ Categories of Risk in Pregnancy
➢ Biophysical: genetic, physical conditions, nutritional problems
➢ Psychosocial: smoking, drugs, alcohol, violence
➢ Sociodemographic: poverty, no prenatal care, age
➢ Environmental: drugs, pollutants, stress, radiation
❖ Conditions Complicating Pregnancy
➢ Bleeding during pregnancy
➢ Hyperemesis gravidarum
➢ Gestational hypertension
➢ HELLP syndrome
➢ Gestational diabetes
➢ Blood incompatibility
➢ Hydramnios and oligohydramnios
➢ Multiple gestation
➢ Premature rupture of membranes
➢ Preterm labor
❖ Bleeding During Pregnancy
➢ Abortions (spontaneous vs. induced)
➢ Ectopic
➢ Molar pregnancy
➢ Cervical insufficiency
➢ Previa
➢ Abruption
❖ Spontaneous Abortion
➢ Loss of early pregnancy
➢ Before 20 week gestation (usually)
➢ Natural causes
➢ Miscarriage
➢ 15-20% of USA pregnancies
■ 80% occur in first trimester → due to fetal genetic abnormality-most common cause
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■ 2nd trimester → maternal conditions are most likely cause
➢ Examples: Infection, DM, drug use, virus-HSV, CMV, cervix incompetent
➢ Stillbirth: loss after 20 weeks gestation; approximately 1:160 pregnancies
❖ Six Categories for Spontaneous Abortion (Table 19.1)
➢ Threatened abortion
■ Spotting, no dilation, mild cramps, closed os
■ Decrease activity, adequate hydration
■ Diagnose with Ultrasound
➢ Inevitable abortion
■ More bleeding, ROM, dilation, strong cramps
■ possible passage of products of conception
■ Vacuum curettage (suction & scraping) (decrease risk of excessive bleeding/infection)
■ Diagnose with Ultrasound
➢ Incomplete abortion
■ Heavy bleeding, intense cramps, dilation
■ pass some products of conception
■ Ultrasound, Dilation & Curettage (scraping): D&C
➢ Complete abortion
■ Passage of all products of conception
■ Hx of bleeding (now less), hx abd. Pain (now less)
● History of bleeding, cramps, but now feeling better
● The symptoms she had led to the spontaneous abortion
■ Support, F/U appt.
➢ Missed abortion
■ Non Viable embryo (dies but is retained), at least 6 weeks, irreg. Spotting
● Still in the uterus
■ Body may do what it needs to do which is progress with the excretion
● May progress to inevitable ab
● If not, need to evacuate uterus
■ Suction curettage (1st trim), D & Evacuation (2nd trim)
■ Can also induce labor with PGE2 (prostaglandin) suppository; empties uterus without
surgical intervention
➢ Habitual abortion
■ History of 3 or more consecutive spontaneous abortions
● 3 in a row …
● Need to think about why this is happening
■ ID & Rx problem (chromosomal, infections, incompet. Cervix)
● Incompetence cervix → opens up way before it should and loses fetus
❖ Medications Used with Spontaneous Abortions (Review in Text)
➢ Misoprostol (Cytotec)
➢ Mifepristone (RU-486)
➢ PGE2, dinoprostone (Cervidil, Prepidil Gel, Prostin E2)
➢ Rh (D) immunoglobulin (RhoGAM, MICRhoGAM, Gamulin, HydroRho-D)
❖ Bleeding during Pregnancy:
➢ Needs to be seen ASAP
➢ Color
➢ Amt of bleeding
➢ Freq. of pad changes
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➢ S/S: severity, duration (ex: cramping, low back pain)
➢ VS
➢ Physical & Emotional Assessment
■ Monitor amt. bleeding, passage of contents, pt. understanding, counseling, guidance
■ Grieving process → up to 2 yrs, support groups
❖ Ectopic Pregnancy
➢ Implantation outside uterus (most commonly in the fallopian tube)
■ Potential for rupture & hemorrhage
➢ Incidence → 1:50
➢ People at Risk:
■ Previous ectopic pregnancy
■ History of STI’s; endometriosis
■ Previous tubal or pelvic surgery
■ Infertility and infertility treatments
■ Uterine abnormalities (fibroids, PID-scarring)
■ Presence of intrauterine device (IUD)
■ PP or post-abortion infection
■ Increasing age >35 years old; cigarette smoking
➢ Signs of ectopic pregnancy
■ First clue is typically the pain
■ amenorrhea usually X 1 month
■ Abdominal Pain
● Dull, acute bilateral or unilateral
■ Spotting
■ Breast tenderness, low back pain
➢ Rupture of tube → MEDICAL EMERGENCY; Life Threatening!
■ Severe Pain
■ Hypovolemic Shock
■ Blood in peritoneum & shoulder pain
■ Bleeding in the belly? → referred pain in the shoulder
➢ Diagnosis:
■ Low levels of hCG → normal pregnancy hCG levels keep increasing peaking at 60-90
days after conception → with ectopic hCG levels decrease after 10-11 weeks
■ Transvaginal US: Will not see a pregnancy in the uterus, Absence of gestational sac
■ Laparoscopy: See where the eggs have attached and then removed
➢ Treatment:
■ Tube Intact → If no bleeding, 4cm, mass intact
● Medical: Methotrexate, prostaglandins, misoprostol, and actinomycin
◆ 90% success rate
● Surgical: Linear Salpingostomy
■ Tube Ruptured
● Surgical: Laparotomy with salpingectomy (tube removal)
■ Rhogam → Rh- mothers exposed to Rh+ blood; prevent isoimmunization
■ hCG levels → Monitor until return to zero (so that we know there is no residual tissue)
➢ Nursing
■ VS, bleeding, pain, emotional, grieving, educate on risk factors, no pregnancy for 3
months to heal
❖ GTD → Gestational Trophoblastic Disease (molar pregnancy)
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Woman thinks she is pregnancy but it is not a fetus
Neoplastic Disorders → originate in placenta
Gestational tissue present but not viable
1:1500 pregnancies
Two types:
■ Hydatidiform Mole (partial and complete)
● Benign neoplasm of the chorion, fluid filled vesicle
● It is not cancerous
● If it is complete there is a very good chance that is can become a
choriocarcinoma
■ Choriocarcinoma
● Chorionic malignancy from the trophoblastic tissue
◆ Very virulent → High risk of death if not treated!
● Carcinogenic: One of the worst cancers you can have
➢ Characteristics of molar pregnancies:
■ Trophoblastic cells that should form placenta, proliferate; chorionic villi swell , become
fluid filled, look like grape-like clusters
■ Ability to invade into the wall of the uterus
■ Can metastasize to other organs
■ Do recur in subsequent pregnancies
■ Can develop into choriocarcinoma, a virulent cancer with metastasis to
organs
■ Occur more in Asia (1 in 120 pregnancies) when compared to the United States (1 in 1500
pregnancies)
■ Influenced by nutritional factors (carotene deficiency, protein deficiency)
■ Tend to impact older women more than young
● Tend to just do a hysterectomy with older women
■ Cause: Unknown; Genetics? Ovular defect? Stress?
➢ Signs/Symptoms
■ Amenorrhea, breast tenderness, fatigue
■ Bleeding, Brownish vaginal bleeding/spotting
■ Anemia
■ Rapidly increasing uterine size; more than number of weeks “pregnant”
● Growth grows fast and big very quickly
■ ↑ incidence of lutein cysts on ovaries
■ No FHR or Fetal Movement → early dx or preeclampsia before 24 weeks ;15%
■ Expulsion of grape like vesicles
■ Extreme high hCG levels
■ Transvaginal Ultrasound confirms molar pattern
➢ Treatment
■ Dilation & suction curettage to evacuate contents immediately on Dx
■ Send tissue to lab: check for choriocarcinoma
■ Serum beta hCG levels weekly, monthly, one year
● FOLLOW UP! hCG level needs to go to and stay at ZERO!
● No pregnancy for at least 1 year!
■ Chest x ray q6 mos → check for metastasis
■ Systemic evaluations → metastasis
■ Because the cancer is a bad one they will recommend a hysterectomy
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■ Chemotherapy possible
➢ Nursing:
■ Emotional Support & Extensive follow up
■ Educate patient re: importance of follow up
● Do not miss the lab appointments for hCG levels
❖ Cervical Insufficiency → incompetence cervix
➢ They normally do not know about this until the very first pregnancy
➢ Cervix starts to open and dilate in the 2nd trimester on its own
■ Painless dilation
■ Usually happens before viability
➢ Pink tinged vag. Discharge, pelvic pressure, dilation-ROM-contractions
➢ Loss of pregnancy d/t occurring before viability
➢ Incidence: less than 1%, 20-25% midtrimester losses
➢ Possible causes of cervical insufficiency:
■ Congenital cervical hypoplasia, increased amts. of relaxin and progesterone
■ In utero exposure to diethylstilbestrol (DES)
■ Trauma to the cervix from previous gynecologic/obstetric procedures (cone biopsy, D&C)
■ Damage to the cervix from a previous difficult birth (cervical lacerations from forceps)
■ Increased uterine volume (multiple gestation, hydramnios)
■ Dx: past hx midtrimester loss w/ painless dilation
■ Cervical shortening=funneling, US performed
➢ Treatment:
■ Bed rest
■ Pelvic rest (Nothing in the pelvic area- No intercource etc…)
■ No heavy lifting
■ “Purse string sutures”= Cervical cerclage; can place up to 28 weeks
● Remove around 37 weeks
● Risk of infection, ROM, -careful use
➢ Nursing:
■ Support, monitor for s/s preterm labor, thorough hx
❖ Placenta Previa
➢ Low lying placenta, over cervical os, bleeds in the last two trimesters, 1:400 if first pregnancy,
increases in frequency after c-sections
■ Leads to hemorrhage, abruption, EMERGENCY C/S
➢ Placenta attaches very low in the uterus in danger … previa = low lying
➢ Depends on where they see it on ultrasound … indicative of if they had prenatal care!!
➢ Very concerning bleeding issue
➢ Categories:
■ Total/Complete Placenta Previa
● Internal cervical os is completely covered by the placenta
■ Partial Placenta Previa
● Internal os is partially covered by the placenta
■ Marginal Placenta Previa
● Placenta is at the margin or edge of the internal os
■ Low-lying Placenta Previa
● Placenta is implanted in the lower uterine segment and is near the internal os but
doesn’t reach it
➢ Cause: unknown/multifactorial; scarring/damage in upper segment?
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➢ Risk factors
■ Maternal age, Prev. c/s, Multiparity, Uterine injury, Cocaine & smoking, Prev. placenta
previa, African American & Asian, Multiple Gestations, Hx abortions, HTN, Diabetes,
Infertility treatment
➢ Signs/Symptoms
■ Painless bleeding; usually not profuse
● Placenta does not have the nerves to feel the pain from bleeding
■ Bright red
● Means new blood ; right at the surface ; active bleeding
■ 2nd or 3rd trimester
■ Bleeding starts, stops, recurs
■ May have contractions
■ Uterus usually soft and nontender
➢ Dx:
■ Transvag. Ultrasound
■ Avoid vaginal exam to prevent further bleeding
■ NO VAGINAL EXAMS
➢ Rx:
■ Depends on gest. Age
■ Position of placenta-?
● If it is complete or even touching that os then we do a c-section
● If placenta tears and bleeds that is a big deal because that is baby’s lifeline
● If low lying and out of the way of the os then a vaginal delivery may be allowed
■ Bedrest, no sex, NOTHING ENTERS VAGINAL CANAL
■ Kick count: Fetal monitoring
➢ 10% of Placenta Previa variation (defective vascularization) → only 10% of the population
■ Placenta Accreta (1:2500)
● Causes: placenta previa, advanced age, smoking, previous c-sections, unknown?
● Into the wall of the uterus (further then it should be) but does not penetrate the
muscle
◆ Could result in postpartum hemorrhage
■ Placenta Increta
● Extends further into myometrium (penetrates muscle)
■ Placenta Percreta
● Penetrates myometrium into peritoneal covering; ruptured uterus
● Can then attach to other organs (bladder, rectum)
● High morbidity and mortality; possible hysterectomy
● Prenatal care is the solution
❖ Abruptio Placenta/Placenta Abruption
➢ Separation of the placenta before fetus is born, after week 20 → hemorrhage
➢ Painful, DARK RED vaginal bleeding!
■ Placenta is pulling off from uterus
■ Dark because of the collection
➢ Incidence → 1% of all pregnancies, 20 - 40% fetal mortality vs 6% maternal mortality
➢ More at risk:
■ ↑ in maternal HTN, smoking, abdominal trauma, history of abruptio, cocaine usage,
multiparity, very young and older
➢ MEDICAL EMERGENCY
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➢ Classified → Mild, Moderate, Severe
➢ Grade 1 (mild) 10-20% detached
■ minimal vag bleeding, uterine tenderness
■ no fetal/maternal distress
➢ Grade 2 (moderate) 20-50% separation
■ Moderate bleeding: Possible 1000-1500ml vag bleeding
■ Abdominal pain, mild shock, uterine hyperactivity
■ no maternal distress; BP normal but tachycardia/may have fetal distress (decr. FM)
➢ Grade 3 (severe) >50% separation
■ Extreme abdominal pain, uterine tetany
■ Absent to moderate bleeding
■ Disseminated intravascular coagulopathy (DIC- Mini clots in small blood vessels- need
to replace the blood!!), maternal shock, fetal death
■ MINUTES to correct before deaths occur!
➢ Types
■ Concealed Hemorrhage - bleeding behind
■ Placenta with margins intact (retroplacental hemorrhage)
■ Non-concealed - margin breaks away
■ Complete – entire placenta
■ Partial – portion of placenta
➢ Etiology – unknown
➢ Risk factors: HTN, drug use, smoking, age, multiples, poor nutrition, trauma
➢ Dx: Ultrasound, Labs (CBC, PT/aPTT, Kleihauer-Betke test- detects fetal RBC in maternal
circulation), nonstress test, biophysical profile
➢ RX:
■ Blood and IV fluid replacement
● ID and correct DIC (replace coagulation factors through transfusion)
■ Delivery by C/S
■ VS (may be normal until 40% blood volume lost)
■ Continuous fetal monitoring
■ Maternal assessments- uterine tenderness, pain, rigidity, LOC, s/s shock
■ O2, bedrest, side-lying, monitor bleeding, urinary catheter (NEED ACCURATE I/O),
emotional support, education
❖ Hyperemesis Gravidarum
➢ Persistent N/V – weight loss, greater than 5% of pre-pregnancy weight lost
➢ Dehydration, electrolyte imbalance, ketosis
➢ Not morning sickness - 50-70% to 12wks
➢ Incidence – 5 out of 1,000;
➢ Peaks 8-12 weeks, lasts up to 20 weeks
➢ May require hospitalization
➢ Unknown etiology, multifactorial; high hCG, Vitamin B6 deficiency, stress?
➢ Elevated hCG levels longer than usual; beyond first trimester
➢ Fetal Problems
■ Neuro disturbances, renal damage, retinal hemorrhage, death if not treated
➢ Treatment
■ I&O
■ IV & parenteral nutrition (D5LR, vitamines)
■ NPO 24-36 hours after vomiting
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■ Lab: Electrolyte studies, liver enzymes, CBC, urine sp. gravity, BUN,
■ Daily Weights
■ Low fat, small, frequent meals
■ Sit up after meals to ↓ reflux
■ Emotional support; dietary and lifestyle changes
■ Meds: Phenergan, Compazine, Zofran
❖ Gestational Hypertension
➢ Gestational HTN (not chronic HTN)
■ Vasoconstriction→vasospasm→poor tissue perfusion→all organs
■ Starts after 20 weeks gestation
■ NO proteinuria, NO edema
■ Return of normal bp after pregnancy
■ 140/90 or higher x2 readings more than 6 hrs apart
● or systolic increase of 30mmHg or diastolic increase of 15 mmHg from pre-preg.
baseline
■ Leading cause of maternal death
■ Most common complication of preg.
■ All races, ethnic groups, greater <20yrs, >40yrs old
■ If occurs before pregnancy, or before 20 weeks gestation= Chronic HTN
➢ High Risk factors
■ Primipara, Prev. hx of Gestational HTN, Obesity, Multiples gestation, Diabetes, Chronic
HTN, Rh incompatibility, Molar pregnancy, Chronic renal disease, Age <20, >40
➢ Nursing Interventions for the Pregnant Woman with Hypertension
■ Following Dietary Approaches to Stop Hypertension (DASH) diet
■ Starting aerobic exercise
■ Avoiding smoking and alcohol
■ Losing weight prior to pregnancy
■ Using home blood pressure monitor
■ Monitoring fetal growth
■ Monitoring for maternal complications
■ Stressing the importance of daily rest periods
➢ Classifications of Gest. HTN
■ Etiology: unknown
■ Resolution: delivery
■ Mild Preeclampsia (add proteinuria & edema)
● BP: > 140/90 after 20 weeks gestation
● Proteinuria: 300mg/24 hrs, +1-+2 dipstick
● Wt. gain >4.4 lb/wk (2nd/3rd trimester)
● Mild edema: hand, face
● Increases risk of: eclampsia, abruptio placenta, DIC, cerebral hemorrhage,
Liver/renal failure, pulmonary edema
■ Severe Preeclampsia
● BP: > 160/110
● Proteinuria: >500mg/24hr collection, +3-+4 dipstick
● Oliguria (<500 ml/24hr)
● H/A, Blurred vision, blind spots, confusion
● Hyperreflexia (DTR)- brachial & patella
● Severe peripheral edema,
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Pulmonary edema (SOB, decr. BS, crackles) or cardiac involvement, hepatic
dysfunction
● Epigastric Pain, RUQ pain
● Thrombocytopenia (<platelets), >creat, HCT, Uric acid, liver enzymes, HELLP
syndrome
● Fetal growth restriction
■ Eclampsia
● Is severe preeclampsia (same symptoms) PLUS Seizures or Coma
● Severe H/A, severe epigastric pain, hyper reflexes are warning signs- lead to
seizure activity
● Cerebral hemorrhage, renal failure, HELLP syndrome, generalized edema
● Seizing = worst one
■ Dx/Management
● Dip urine for protein
● 24 hr. urine collection
● Liver enzymes, BUN, Creat., Uric Acid, Magnesium, CBC, clotting studies, Chem.
Profile, Non stress Test, US, Biophysical profile, doppler blood flow analysis
● BP, O2 sat, resp rate, Lung Sounds, VS, daily wt., strict I/O, LOC
● DTR: brachial, patella; also check for ankle clonus
● BR - ↑ peripheral perfusion, reduce stimuli
● fetal – KC, BPP, EFM
● B/P monitoring - 2-4 x/day, same arm, sitting, heart level
● diet - ↑ protein, monitor Na
● Seizure
● maintain airway, suction, turn head to side, O2 via mask
● IV MgSO4 or phenobarbital IVP if not controlled
● monitor for abruption
● Lasix for pulmonary edema
➢ Magnesium Sulfate
■ Anticonvulsant that works by:
● Lowers BP and depresses CNS
■ IV: Infusion Pump: loading dose (4-6g in 100ml over 15-20 min) then 2g/hr
continuous IV infusion
■ Therapeutic range 4-8 mg/dl - excreted by kidneys
■ Nursing Care
● Risk for respiratory depression, check resp Q1hr
● Check the deep tendon reflex (DTR)
● Toxicity - absent DTR, resp <12, LOC decrease, Output <30ml/hr → stop
infusion! Administer Calcium Gluconate
● Antidote → Calcium Gluconate
■ Monitor output (want over 30ml/hr) → urinary catheter for accurate I/O
■ Can give MgSo4 and Pitocin at same time → two pumps
● LR running
● Pit running to get the baby out
❖ HELLP Syndrome
➢ Variation of Gestational HTN (INCLUDES hepatic dysfunction)
➢ Acronym
■ Hemolysis, Elevated Liver Enzymes, Low Platelets
●
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➢ Occurrence
■ occurs in about 20% of pregnant women diagnosed with severe preeclampsia
■ Diagnosed usually between 22 and 36 weeks gestation
➢ Signs and Symptoms:
■ Nausea, malaise, epigastric pain, upper right quadrant pain, demonstrable edema,
hyperbilirubinemia (jaundice), petechiae
■ Labs: thrombocytopenia, abnormal bleeding, clotting, elevated liver enzymes, low
HCT-anemia
➢ Increased risk for:
■ Maternal/fetal death
■ Hemorrhage (bleeding precautions)
■ Respiratory distress
■ Subcapsular Liver hematoma, rupture (don’t palpate abdomen)
■ Stroke/Cardiac Arrest
■ Renal Failure
■ Seizure, Sepsis
➢ Treatment:
■ Mag. Sulfate
■ Antihypertensive
■ Blood components
■ Packed RBC
■ Platelets
➢ Prevent seizures, lower BP, correct coagulopathies
➢ Diagnose, Stabilize, Deliver
❖ DIC: Disseminated Intravascular Coagulation
➢ Coagulation Disorder
➢ At risk: Triggered by abruption, eclampsia, missed ab, sepsis, amniotic fluid emboli
➢ Etiology
■ Thromboplastin released → maternal circ. due to vascular insult, too much released-clot
or emboli
■ Produces multifocal clotting in sm. vessels
■ Fibrinolytic agents → to lyse clots, too much released-cause bleeding at
sites-hemorrhage
➢ Diagnosis
■ Decreased fibrinogen and platelets
■ Prolonged PT & PTT
■ Increased fibrin products
➢ Management
■ Determine cause and correct
■ Blood transfusions – whole or packed RBCs and Cryoprecipitate “cryo” (frozen blood
product from plasma)
■ Maintains volume, provides o2 to cells
❖ Blood Incompatibility → Rh
➢ Incidence - 15% of white population is Rh negative
■ slightly lower incidence in Blacks and Asians
➢ Etiology
■ mom is Rh negative & fetus is Rh + like the father
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Rh negative moms have no Rh antigen (D antigen), so when Rh + are imposed into blood
stream antibodies are built up
■ maternal and fetal blood should not mix unless an antepartal procedure is done (amnio,
ab)-give rhogam
■ at delivery blood mixes and women must receive RhoGAM or immunoglobulin to
prevent antibody formation
■ if antibodies are present they will cross placenta and attack fetus RBC's and produce
erythroblastosis fetalis and hydrops fetalis, fetal heart problems, breathing difficulties,
jaundice, hemolytic disease/anemia
➢ Isoimmunization- Sensitization
➢ Clinical Manifestations - positive indirect coombs or antibody titer
➢ Diagnosis - Rh negative mom with positive coombs (measures amount. of antibodies in
maternal blood)
■ + coombs, RhoGAM won’t work, already has antibodies; infant at risk for hemolytic
anemia
■ + coombs means that the blood has already mixed and it is too late
➢ Management/Nursing Care
■ RhoGAM (if neg. coombs) -28 weeks IM & within 72 hours of birth
■ monitor fetus for hemolytic disease if mom sensitized
❖ Blood Incompatibility → ABO
➢ Not as severe as Rh incompatibility
➢ No antepartum treatment
➢ Mom: Type O, with fetuses who are Type A or Type B; anti A & anti B antibodies (Type O moms:
most antibodies are IgG- some cross placenta-destroy fetal blood cells; hemolysis)
➢ Watch infant (A, B, AB, and + coombs) for jaundice
➢ Can prepare through prenatal visits (mom O, Dad A, B, or AB)
❖ Hydramnios (Polyhydramnios)
➢ Too much amniotic fluid
➢ >2000 ml (32-36 weeks)
➢ Associated with fetal development anomalies and poor fetal outcomes
■ Increased risk of preterm birth
■ Fetal malpresentation
■ Cord prolapse
➢ Causes:
■ Maternal disease, fetal anomalies, unknown
■ Diabetes, Multiple gestation, Chromosomal
➢ Fetal:
■ Esophageal or intestinal atresia, neural tube defects, fetal hydrops (fluid in 2
cavities-ascites, cardiac or pulmonary effusion), CNS, Cardiovascular, hydrocephalus
➢ Dx: Ultrasound, s/s: uterus larger than expected, SOB, Edema LE, hard to palpate fetus and
FHR hard to hear
➢ Rx: Monitor, decrease fld: amnio, AROM,
❖ Oligohydramnios
➢ <500 ml amniotic fluid between 32-36 week gestation
➢ Increases perinatal morbidity/mortality risk
➢ Cord compression, hypoxia, death
➢ Causes
■ Uteroplacental insufficiency, PROM, HTN, DM, IUGR, Post term, polycystic kidneys,
obstruction in urinary tract
■
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➢ S/S
❖
❖
❖
❖
■ Leaks fluid, Fundal height smaller than expected, poor fetal growth
➢ Dx → Ultrasound
➢ Rx → Monitor, amnio infusion if needed
Multiple Gestation
➢ Incidence – 12:1000 in US (doubled since 1991)
➢ ↑ in Black women, ↓ in Asian
➢ Maternal complications
■ 1. AP – SOB, fatigue, n/v, back ache, pedal edema
■ 2. ↑ UTI, Gest. HTN, Preterm labor, previa, hydramnios, hyperemesis gr., anemia,
preeclampsia
■ 3. Labor complications – abnormal presentation, uterine dysfunction, prolapsed cords &
↑ hemorrhage
➢ Fetal complications
■ Premature, resp. distress, asphyxia, congenital anomalies, twin-twin transfusion, IUGR,
conjoined
Types of Twins
➢ Fraternal: Dizygotic
■ two separate ova
■ two placentas, 2 chorions and 2 amnions
■ ↑ in age up to 35 and parity
■ genetic predisposition
➢ Identical: Monozygotic
■ Single fertilized ovum splits; share placenta, two amnions, one chorion
PROM: Premature rupture of membranes
➢ Incidence - 10%
➢ Definitions
■ PROM → before the onset of true labor, after 37 weeks
■ PPROM → preterm PROM (before 37 weeks), before onset of labor
➢ Etiology
■ vaginal, cervical infections, chorioamnionitis
■ incompetent cervix
■ fetal anomalies and malpresentation
■ hydramnios
■ nutritional deficits
➢ Prolonged ROM: Chorioamnionitis, endometritis, sepsis, neonatal infections, ↑ after 24 hrs
➢ Diagnosis → Nitrazine (paper turns blue) or fern test with sterile speculum exam
➢ Delivery if term - induction
➢ Preterm
■ Conservative tx → L/S ratios, BR, temp q2h, VS, CBC
● Corticosteroids (Betamethasone, Dexamethasone)
◆ Studies suggest ↑ lung maturity & ↓ Intraventricular hemorrhage, & NEC
(necrotizing enterocolitis) (24 to 32 wks gestation)
● Monitor s/s infection, adequate hydration, FHM, antibiotics, fluid color, odor
Preterm Labor
➢ 20-37 wks
➢ First thing we are doing → 2 doses of betamethasone 24 hours apart
➢ Incidence → 1:8
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➢ Increased with pre-existing medical conditions
■ OB conditions
● Previous preterm labor/delivery, Incompetent cervix, Hydramnios, Infection,
Dehydration, Gest. HTN, PPROM, Anomalies, Multiple fetuses, Cervix > 1cm at
32 weeks, Uterine irritability, Bleeding after 12 weeks, Hx of cervix biopsy,
Uterine abnormalities, Lack of prenatal care, 2 or more 2nd trimester AB's
■ Other Contributing Factors
● Domestic Violence, Abdominal Surgery, Febrile Condition, DES exposure,
Environmental, Poor nutrition, Under 18 over 35, Poor education, Nonwhite,
Smoking, Substance abuse, Low income
➢ Cause: Unknown; multifactorial
➢ S/S
■ Cramping (with or without diarrhea)
● Menstrual type cramps
■ Backache usually below waist
■ Pelvic Pressure
■ UC's → painful or painless
■ Change or increase in vaginal discharge
➢ Diagnosis
■ Monitoring and SVE
■ Management
■ Risk Factors
● Early prenatal care
● Nutritional (WIC), Drug, or Smoking counseling
● Education
● Teach S/S of Preterm Labor - written material no higher than 6th grade level
➢ Treatment
■ Early identification & intervention increases gestational age
■ Hydrate, Bladder-empty
■ Bedrest (strict BR may be detrimental)
■ Monitor if 4 UC/hr - call
■ SVE → effacement and dilatation
■ Treat any prenatal infections
■ Test fetal fibronectin from swab for intactness of fetal membranes
■ Transvaginal US
➢ Home Monitoring
■ 2x/day for 60 min. electronically hooks up to phone and records uterine activity at
perinatal evaluation center
■ Try to stop labor before 3 cms
■ Lab work → CBC, UA to detect any asymptomatic infections
■ Vaginal & cervical cultures & amnio if chorioamnionitis
■ Prophylactic antibiotics?
➢ Tocolysis/Tocolytic Therapy
■ Drugs to stop labor → delay preterm birth
● Benefit mom, baby, or both to delay the delivery
■ Criteria for Use:
● 20-37 weeks
● < 80% effaced & <than 2 cm dilated
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UC 4/20 min or 8/60 min.
Most necessary before 34th week
Delay gives a chance for mom to be given corticosteroids to ↑ lung maturity for
the fetus or maternal transport
■ Tx Contraindicated → abruption, eclampsia, active bleeding
■ Meds
● Ritodrine (Yutopar)
◆ Only FDA approved
◆ Others are “off label”-effective but not tested
● Terbutaline (Brethine)
● Magnesium Sulfate
● Procardia (Nifedipine)
● Indomthacin (Indocin)
Chapter 20: Nursing Management of Pregnancy at Risk: Selected Health Conditions/Vulnerable Populations
❖ Importance
➢ Medical conditions present before pregnancy can have a negative effect on the pregnancy
➢ Effects Maternal, Fetal, or both outcomes
➢ Knowing previous medical conditions:
■ Guides Assessment
■ Plan appropriate interventions
■ Increase potential for positive outcomes
❖ Factors Affecting a Favorable Outcome for a Pregnant Woman with Diabetes
➢ Frequent prenatal visits
➢ Dietary restrictions
➢ Self-monitoring of blood glucose levels
➢ Frequent lab tests
➢ Intensive fetal surveillance
➢ Potential hospitalization
❖ Classifications of DM
➢ Type 1 diabetes: absolute insulin deficiency ; autoimmune, 10% of DM
➢ Type 2 diabetes: insulin resistant or deficiency ; obesity, 90% of DM
➢ Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT): hyperglycemia at a level
lower than what qualifies as a diagnosis of diabetes
➢ Gestational diabetes mellitus (GDM): glucose intolerance onset during pregnancy, or first
diagnosed in pregnancy
➢ Metabolic Alterations: Pathophysiology
■ Placental hormones cause insulin resistance
■ hPL & somatotropin increase w/ growth of placenta
■ Causes insulin resistance (peaks last trimester)
■ Insulin secretion increases to overcome resistance
■ Non-diab.= pancreas can respond to incr. demand
■ Diabetics= pancreas can’t meet insulin demand
➢ Symptoms
■ polydipsia – excessive thirst-caused by polyuria
■ polyuria –↑ in vascular fluid volume excess
■ glycosuria –kidney’s attempt to flush out fluid & hyperglycemic state of the blood
■ polyphagia –↑appetite in response to the hypoglycemia state of the “starving cells” and
metabolizes protein and fat for energy
●
●
●
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➢ Maternal Risks
■ ↑ risk for Preeclampsia
■ Infection: UTI, chronic monilial vaginitis
■ Hydramnios & cord prolapse
■ Ketoacidosis (d/t uncontrolled hyperglycemia)
■ PROM & PTL
■ C/S birth & vaginal trauma
■ PP hemorrhage (d/t overdistended uterus)
■ Stillbirth
➢ Fetal Risks
■ Congenital anomalies
■ Macrosomia
■ Birth trauma
■ Preterm - IUGR
■ Death due to placental insufficiency
■ RDS due to hyperinsulinemia
■ Polycythemia (extra RBC prod. d/t hypoxia)
■ Hyperbilirubinemia
■ Hypoglycemia & hypocalcemia
■ Childhood obesity
➢ Maternal Surveillance During Pregnancy
■ Fingerstick blood glucose levels at every prenatal visit
■ Urine check for protein and for nitrates and leukocyte esterase
■ Urine check for ketones
■ Kidney function evaluation every trimester for creatinine clearance and protein levels
■ Eye examination done in first trimester to evaluate retina for vascular changes
■ HbA1c every 4 to 6 weeks to monitor glucose trends
➢ Fetal Surveillance
■ US for growth
■ AFP (r/o open neural tube defects)
■ Fetal echo
■ Daily Kick Count
■ NST’s after 28 weeks
■ Amnio: L/S and Pg ratios-lung maturity
➢ Gestational Diabetes Mellitus
■ Glucose intolerance of pregnancy
■ Risk Analysis Assessment at First Prenatal Visit
■ Risk factors: obesity, existence of other auto-immune disorders, age > 30, family history,
previous GDM, history of macrosomic infant or fetal demise or infant with unexplained
congenital anomalies, African American, Hispanic, Native American women with risk
factors deserve early GDM testing
➢ Lab Studies
■ Screening at 24 – 28 weeks; earlier if risk factors
■ Glucose Tolerance Test (GTT): 75g (not timed with meal)
■ 1 hr later, test blood glucose: over 140= abnormal, then do 3hr GTT
■ 3 hr GTT: Normal Values are:
● FBS : less than 92 mg/dL
● 1hr < 180
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● 2 hr: < 153
● 3hr: < 140
■ One or more abnormal values= Dx of Gestational Diabetes
➢ Management
■ May be asymptomatic or small signs
■ usually not associated with congenital malformations
■ needs diet, changes in lifestyle, weight management but no dieting during pregnancy,
education glucose monitoring, insulin needs, s/s hypo vs. hyperglycemia
■ Minimize risks and complications
➢ Nursing Care - communication, patient control, inclusion of normal pregnancy care and
education
■ Labor & Delivery
● IV Saline or LR
● Monitor BG Q 1-2 hrs: Keep below 110 mg/dl
● Example of IV infusion of Regular Insulin:
● Prepare 100 units of Regular Insulin in 100 mL of 0.9% sodium chloride
● Example of IV orders:
◆ 110 - 150 = 0.6U/hr
◆ 150 – 170 = 0.8 U/hr
◆ 171 – 200 = 1U/hr
◆ 201 – 250 = 2U/hr
◆ 250 – 300 = 3U/hr
◆ Over 300 call pharmacy
■ Postpartum
● Insulin needs drop drastically in first 24 hours
● Check BG q 2-4 hrs or as ordered for 48 hrs
● oral hypoglycemics contraindicated in BF
● BF may decrease dev of diabetes in infant and helps control maternal blood
glucose levels
● oral contraception is usually contraindicated in diabetes due to vascular
consequences
● 50% chance of developing Type II Diabetes
❖ Cardiovascular Disorders
➢ Cardiac Disease
➢ Incidence - 1% of pregnant women
➢ CVD= leading cause of death in women
➢ At Risk: Heart failure, arrhythmias, stroke
➢ Fetal Risk: Premature, LBW, RDS, Intraventricular hemorrhage, death
➢ CV Review
■ Normal cardiac Δ during pregnancy
■ Blood volume increases 30-50%-physiologic anemia-increases heart rate
■ systolic murmurs are functional
■ Decrease vascular resistance= decrease B/P
■ Hypercoagulation= thrombus-emboli risk
■ Cardiac filling increases
■ Increased SV
■ Increased respiratory effort
■ Possible edema
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➢ Diagnostic Criteria:
■ Level of decompensation
■ Diastolic, pre-diastolic, or continuous murmur
■ Cardiac enlargement
■ Loud, harsh systolic murmur
■ Severe arrhythmias
➢ Prognosis:
■ Depends on:
● Functional capacity
● Likelihood of other complications
● Quality of care
● Severity of arrhythmias
➢ Classification of CD in Pregnancy (New York Heart Association)
■ Class I: asymptomatic with no limitation of physical activity
■ Class II: symptomatic (dyspnea, chest pain) with increased activity
■ Class III: symptomatic (fatigue, palpitation) with normal activity (bedrest with
pregnancy)
■ Class IV: symptomatic at rest or with any physical activity (should avoid pregnancy)
➢ Risk Groups (Don't need to memorize defects just know the risk level!)
■ Group I (mortality 1%) (min. risk)
● Corrected tetralogy,Pulmonic/tricuspid disease,Mitral stenosis, classes I and
II,Patent D. Arteriosus,Ventral Septal Defect, Atrial septal defect
■ Group II (mortality 5-15%) (mod. Risk)
● Mitral stenosis with atrial fib., Artificial heart valves, Aortic stenosis, classes III
and IV, Uncorrected tetralogy, Aortic coarctation (uncomplicated)
■ Group III (mortality 25-50%) (major risk)
● Aortic coarctation (complicated), previous MI, Pulmonary hypertension
➢ Other CV
■ Congenital Heart Conditions
● May be advised not to get pregnant (EX: uncorrected congenital conditions)
● Ex: Tetralogy of Fallot- uncorrected
■ Acquired Heart Disease
■ Rheumatic origin
● Less since Strept. Diagnosed easier and quicker
■ Maternal Age- delaying pregnancy
● May already have high cholesterol, diabetes, HTN
■ Management
● Pre conceptual counseling
● More Frequent Prenatal Visits: q2 weeks, then q 1 week in last month
● History taking for S/S
◆ Chest pain - rest or exertion
◆ Edema hands and face
◆ ↑ B/P, Palpitations, heart murmurs
◆ Nocturnal dyspnea, diaphoresis
◆ Pallor, cyanosis, syncope, increasing fatigue
◆ Hemoptysis, SOB, orthopnea
● Future pregnancies dependent on residual effects
◆ Digitalis, diuretics, Na restriction, bedrest
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◆ WATCH FOR FLUID OVERLOAD (ex: SOB, crackles, edema)
● Class I & II
◆ Limit activity, control wt gain, prevent anemia, prevent infection, watch
symptoms
● Class III & IV:
◆ Prevent cardiac decompensation & CHF
● Heparin/Lovenox, Antiarrhythmics, Anti-infective, Diuretics (Lasix)
◆ NO Warfarin/Coumadin: crosses placenta; teratogenic: Class X drug
● Intrapartum Care -I & O, position for better breathing, O2, quiet, cardiac
monitoring, EFM, 1st choice is vag. del. with assistance if needed ↓ 2nd stage
◆ Fully dilated and pushing - exhale when pushing to decrease pressure on
heart - use vacuum or forceps to help decrease stage of pressure on heart
◆ Still SAFER than C/S
● 4th Stage
◆ After delivery! ↓ fluid overload, maintaining legs at body level (Bed level
or a little bit higher), careful cardiac assessment
■ PostPartum
● OK to breastfeed if stable, monitoring for S/S infection, hemorrhage, thrombosis
& cardiac decompensation
● Peripartum & Postpartum cardiomyopathy
◆ Rare not associated with underlying heart disease
◆ Develops at end of pregnancy or 1st several months’ postpartum
◆ S/S: CHF, dyspnea, edema, weakness, chest pain, & palpitations
➢ Nursing Interventions for the Pregnant Woman with Hypertension
■ Following Dietary Approaches to Stop Hypertension (DASH) diet:
● Na limit 2.4g, adequate K+, Ca++, Magnesium
■ Starting aerobic exercise
■ Avoiding smoking and alcohol
■ Losing weight prior to pregnancy
■ Using home blood pressure monitor
■ Monitoring fetal growth
■ Monitoring for maternal complications
■ Stressing the importance of daily rest periods
■ 1 hr, left lateral recumbent position- gains max perfusion
❖ Respiratory Conditions
➢ URI’s –self limiting, usually not a problem
➢ Chronic: effect fetal growth, well-being
➢ Important to maintain O2 saturation to avoid hypoxia of the fetus.
➢ Asthma: Chronic, obstructive lung disorder
■ In pregnancy 1/3 of women will not experience symptoms, 1/3 symptoms will worsen,
1/3 will improve
■ Increased risk for
● Infant death, preeclampsia, IUGR, preterm birth and low birth weight
● Risk increases as Asthma becomes more severe
■ S/S & Management
● SOB, wheezing, rales, restricted activity, ↓ O2 sat, rales, cough, “tight chest”
● Management – education, home peak flow monitoring, bronchodilators, steroids,
anti-inflammatory meds, in extreme cases hospitalize, if good control is obtained
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there is no/little effect– if not then O2 to fetus is compromised (IUGR, preterm
birth)
● Benefit of preventing attacks outweighs the risk of meds
■ Nursing Management of the Pregnant Woman with Asthma
● Working together with the healthcare team and the client to manage care
● Completing assessment of risk factors that could trigger an asthma attack
● Recommending strategies to reduce exposure to triggers
● Reviewing medication therapy with the client
● Educating the client about controlling the symptoms
■ Teaching Topics for Pregnancy & Asthma
● Signs and symptoms of asthma progression and exacerbation
● Importance and safety of medication to fetus and to herself
● Warning signs that indicate the need to contact the healthcare provider
● Potential harm to fetus and self by under-treatment or delay in seeking help
● Prevention and avoidance of known triggers
● Home use of metered dose inhalers
● Adverse effects of medications
➢ Tuberculosis
■ Communicable disease caused by Mycobacterium tuberculosis & transmitted by
aerosolized droplets inhaled & taken into the lungs
■ S/S: general malaise, fatigue, loss of appetite, wt loss, fever, night sweats, chronic cough
& mucopurulent sputum, risk population – poverty, malnutrition, HIV, immigrants,
elderly
● May be asymptomatic- organism can lie dormant
■ Dx – PPD skin test if + chest x ray
● Confirmed with a + sputum specimen
■ Fetal Effects
● Very small risk of possible infection while in utero
■ Infant
● FTT, lethargy, RDS, fever, death, enlargement of liver, spleen, & lymph nodes &
may acquire TB after birth if exposed to droplets/inhaled
■ Management – Meds (isoniazid, rifampin, ethambutol)-minimal risk on fetus, ok to BF,
prevent transmission-cover mouth-sneeze, cough, etc…
❖ Anemias
➢ 1:4 Pregnancies iron-deficiency anemia
➢ Due to inadequate intake of iron
■ Poor nutrition, hemolysis, pica, multiple gestation, blood loss, close pregnancies (may be
bad for mom because her body may not fully recover from the last one)
➢ Increases risk of hemorrhage (impaired plt. Function), infection, preterm, LBW
➢ Iron-Deficiency Anemia - Hgb < 11g/dl, Hct <35%
➢ Fe supplements 30mg/day
■ Best between meals-NOT with coffee/tea/chocolate for most effective absorption
➢ S/S
■ Fatigue, weakness, malaise
■ Anorexia
■ Susceptibility to infection (frequent colds)
■ Pale mucous membranes
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Tachycardia, pallor
Abnormal lab results
Low hemoglobin, low hematocrit, low serum iron, microcytic and hypochromic cells, and
low serum ferritin
➢ Folic-acid Anemia (Megaloblastic)
■ Large megaloblasts or immature RBCs, fetal anomalies (Neural Tube Defects) &
spontaneous abortion
■ Incidence - ↑ with Fe deficiency, hemolytic anemias, medications such as dilantin &
malabsorption
■ Etiology - Co-enzyme needed to synthesize DNA, Folic acid needs double during
pregnancy
■ Diagnosis - Megaloblastic RBCs
■ Management/Nursing Care - Nutritional & supplements (liver, kidney beans, lima beans
& dark leafy vegetables)
➢ Thalassemia
■ Group of hereditary anemias- defective synthesis of one or both chains of the
hemoglobin molecule (alpha and beta)
■ Manifestation: low hgb, hypochromic & microcytic anemia
■ Thalassemia minor (alpha) - heterozygous (one parent)
● Minor anemia during preg., doesn’t respond to iron, don’t prescribe iron
● Offspring is carrier or may have disease (depends on fathers genetics)
■ Thalassemia major (beta) (Cooley's anemia) - inherit gene from both parents
(homozygous)
● Difficult to get pregnant d/t lifelong severe hemolysis, anemia, premature death
● Incidence - ↑in Mediterranean, Asian, Greek, African Americans
■ Dx: CBC, Bone marrow exam, iron studies, peripheral blood smear
■ Rx: Rest, avoid infections, Genetic Counseling, supportive care
➢ Sickle Cell Anemia
■ Incidence -1:12 African-Americans carriers
■ Etiology - autosomal recessive disorder
■ Clinical Manifestations – Defective Hemoglobin S molecule; if not fully oxygenated,
sickle shape, clumps & clogs vessels- cause ↑ infections & obstructed blood vessels,
increased crises in pregnancy
■ Diagnosis – childhood
● Hgb studies, fetal well being studies, adequate hydration, nutritional counseling,
folic acid for RBC production, rest, avoid infections, hygiene, comfort measures,
O2 during labor, emotional support, pain management
■ Risk of Preeclampsia, Eclampsia, preterm labor, placental abruption, IUGR, and low
birth weight
❖ Autoimmune Disorders
➢ Two categories:
■ Localized Disorders (ex: Grave’s disease)
■ Systemic Disorder (ex: Lupus)
➢ Avoid Pregnancy when Disease is Active
➢
Take Medications to prevent flare-ups during pregnancy
➢ Most considered High Risk d/t potential for complications
➢ Examples:
■
■
■
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■
■
■
Sytemic Lupus Erythematosus: May flare during pregnancy, still birth, IUGR,
preeclampsia, preterm birth, miscarriage, Treat with NSAIDs, plaquenil, minimum meds
if possible
Multiple Sclerosis: No adverse effects on fertility, labor, or birth
Rheumatoid Arthritis: No adverse effect on pregnancy; may feel better, Postpartum
flare-ups are common, Some medications contraindicated during pregnancy
❖ Common Infections Affecting Pregnant Women
➢ TORCH Infections
■ Viral & Non-viral Infections: Toxoplasmosis, Other (such as hepatitis), Rubella,
Cytomegalovirus, Herpes type II
■ Identified group of infections that can cross the placenta and harm fetus
■ 1:1000-1500 pregnancies
■ Most Exposure during first 12 weeks can cause developmental anomalies
➢ Other Infections
■ Cytomegalovirus
● Incidence – 30-40% transmission to fetus
● Most preventable of TORCH group
● ↑ in day care workers & health professionals
● Etiology - found in blood & body fluids, nasopharynx secretions & breast milk,
after primary infection becomes latent, can cross placenta any time during
pregnancy, during labor, or postpartum. Permanent disability greater in utero
during the first trimester
● Maternal: asymptomatic
● Fetal: complications: deafness, intellectual disabilities, seizures, blindness, dental
deformities, abortion, stillbirth, IUGR, LBW, jaundice
● TX: none (Ganciclovir -experimental)
■ Herpes Simplex Virus
● 50 million cases
● Type 1 & 2 (both can occur in either oral or genital region)
● 30 – 50% risk primary transmission-near or during birth
● 1 – 3 % risk neonatal infection from recurrent genital infection
● Transmitted prenatal, intrapartum, or postpartum period
● Majority during vag. birth
● Tx: Acyclovir (antiviral) if known, culture positive
● Fetal: Neurologic impairment or death
■ Hepatitis B Virus
● 2 Billion infected worldwide
●
Life threatening Liver Disease
●
Transmitted through contaminated blood, sexual contact, illicit drug use
● VERTICAL TRANSMISSION to fetus
● Risk for preterm birth, low birth weight, neonatal death
●
70-90% born will have chronic Hep B by 6 months old
● Infant of positive mom
◆ Gets Hep B vaccine AND Hep B immunoglobulin within 12 hrs of birth
◆ Complete vaccine schedule at 1 and 6 months
● Mom
◆ Can breastfeed; vag delivery, c-section doesn’t reduce transmission risk
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■
■
■
■
■
◆ Can be vaccinated while pregnant
Rubella (German Measles)
● Droplet transmitted virus or direct contact w/ contaminated item
● Incidence - 20% of adults susceptible, vaccine developed in 1969
● Etiology - crosses placental barrier -test mom for titer
◆ (1:8 or greater- antibody titer=immune)
● If not: Immunize pp before discharge- no preg. for 28 days to 3 months
● Clinical Manifestations – maternal - general malaise, maculopapular rash
● Fetus: if affected during 1st Δ: deafness, cardiac malformation, cataracts, mental
retardation, IUGR, microcephaly, 1/3 spontaneously AB, contagious for months,
should be isolated, if contracted during 1st mo - 50% affected, 2nd - 25%, 3rd 10%
Varicella-Zoster (VZV)(Chickenpox)
● Incidence - 1-7/10,000 preg
● Etiology – herpes virus transmitted by respiratory tract or direct contact, latent
form shingles (nerve ganglia), or chicken pox
● Maternal: preterm labor, encephalitis & varicella pneumonia
● Fetal: 1st Δ - limb hypoplasia, cutaneous scars, cataracts, microcephalic, IUGR in
2-3% if active, mental retardation, death limited in crossing placenta
● Transmitted through placenta, ascending infection, or direct contact with lesions
● Neonatal varicella syndrome
● Diagnosis - Immune testing
● NEVER VACCINATE WHILE PREGNANT: NO LIVE VACCINES!
Parvovirus B19 Infection
● 5th disease, benign, self-limiting, childhood virus
● 65% women have immunity
● Oropharyngeal casual contact and blood transfer
● Fetal: severe anemia, spont. ab, congenital anomalies, myocarditis, learning
disabilities, can lead to hydrops fetalis if contracted in first 20 weeks
● Maternal: Rash face “slapped” and then general maculopapular rash, fever,
malaise, arthralgia
Group B Streptococcus
● (GBS) 25% of all women carry GBS, colonized in vagina, rectum
● women are usually asymptomatic, but can cause UTI, endometritis,
chorioamnionitis,
● Need vaginal/rectal & cervix culture at 35-37 weeks
● Fetal/Newborn - sepsis, pneumonia, neuro damage
● Rx: Ampicillin 4 hours before delivery ; Clindamycin if penicillin allergy
Toxoplasmosis
● Protozoan, parasitic infection-toxoplasma gondii
● Incidence: 1/1000-8000
● Etiology - raw or poorly cooked meat, contact with cat feces
◆ Tell moms to not change cat litter, do not dig in dirt, etc..
● If contacted before 20 wks can cause: spontaneous AB, preemie, stillbirth,
enlarged liver & spleen, chorioretinitis, jaundice, anemia, neuro damage
● S/S: Asymptomatic or fatigue, malaise, muscle pain, lymphadenopathy
● Dx: IgM fluorescent antibody testing
● Rx: sulfadiazine and pyrimethamine
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All pregnant pts are offered screening, risk assessment, consents with proper
counseling is important
● Early treatment has proven beneficial, 2% of infants HIV + with medication
compared to 35 % without medication - Zidovudine
● Maintaining good health status is important, support/education, grieving issues,
confidentiality issues, barriers to care
◆ TAKE YOUR MEDS!
● C/S without ROM ↓ risk of perinatal transmission
● NO BREASTFEEDING
● Fetus: Risk for prematurity, IUGR, low birth weight, and infection
❖ Special Populations at Risk for Adverse Pregnancy Outcomes
➢ Adolescent Pregnancies
■ Incidence: All socioeconomic but higher with poor women and minorities
■ Early Adolescence
● 10-14 Years Old
● Self-absorbed
● Seeking peer approval, and identify formation
■ Middle Adolescence
● 15-17 yrs old
● Establishing independent identities & breaking away from parents
■ Late Adolescence
● 17-18 years old
● Start to become less narcissistic
■ Problems
● Inconsistent birth control use lack of knowledge & lack of availability
● Psychological development, invulnerable
● Fear of reporting sexual activity
● Peer pressure
● Poor or late care
● Sex Education
◆ Teach correct terms
◆ Teach to set limits communicate self confidence
◆ Educate about STI; common with adolescents
◆ Contraception
◆ Termination
◆ Adoption
■ Risks & Parenting
● ↑ incidence of Preeclampsia, anemia and poor nutrition, maternal mortality, LBW
and prematurity, STI’s (Chlamydia and gonorrhea), non-nurturing/
inappropriate behavior, insensitive to cues, lack of understanding about infant
growth and development, inappropriate reactions to stress, in uninvolved
partners (many men are older, average 3-6 years)
● Partners- less education – responsibility difficult
■ Emotional Costs
● Achievement of a stable identity
● if stable identity has not been established → difficulty adapting to parenthood
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Encourage school based pregnancy program, prenatal classes, and parenting
classes for both parents
Achievement of comfort with body image
◆ She must deal with drastic changes in body before comfortable with
puberty changes
Encourage to verbalize feelings about body changes and emphasize the
importance of not dieting, watch for anorexic behaviors
◆ Acceptance of sexual role and identify
Pushed into an intimate relationship before ready and peer relations are
disrupted
◆ Encourage to express feelings in peer group of expectant teenage mothers
Development of personal value system
May still be at a stage of “following rules” without progressing to dev a sense of
what is right and how it affects others
Explore views on motherhood and encourage expression about how this changes
her life
◆ Preparation for vocation or career
◆ Interrupt school and increases poor socioeconomic status
◆ Encourage continuing High School education, referral to school based day
care programs
Achievement of independence from parents
◆ Dependent on parents more due to finances
Referrals: WIC, head start, paternity papers
Assessment
● Physical
● Somplete sexual history
◆ Screen for STDs
● Monitor for smoking, alcohol, and drug abuse
● Assess knowledge of infant needs
● Egocentrism
◆ Can she defer personal satisfaction to help infant
◆ EX: such as when the baby is sick
● Present-Future Orientation
◆ what are their plans to finish school, do they have daycare
● Abstract Thinking
◆ Can they understand the importance of things that are not tangible such
as prenatal care
● Participation of Father
◆ Parental support usually takes one of 3 forms
● Teenager’s mother assumes mothering role
◆ Mothering is left to adolescent but family
◆ Provides food and shelter
◆ Family shares care, allows teenager to develop
● Analysis
◆ Ongoing during prenatal care
◆ Monitor consistency of kept appointments
● Planning
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◆ Transportation and time of appointments
◆ Recommend group classes
◆ Establish open communication and help line
Teach Parenting
◆ Include significant other and family when possible
◆ Shield from negative attitudes that deter return visits use therapeutic
teaching/learning principles
➢ Small peer groups, Repetition, Discussion
■ Audiovisuals may be more effective than reading
◆ Avoid parenting new teen mom
➢ Help her to arrive at good decisions
➢ # of appointments demonstrates learned knowledge of infant care,
has supportive services secured
Nutritional
◆ Ex: Best selections at fast food restaurants
Stress Reduction
◆ Help identify stresses especially basic needs, food, clothing, shelter, fears
about L&D, stress about telling family
Infant Care
◆ Explain how infant react to environment, startles, tremors, teach Growth
& Development, explain infant cues, what crying means
Promote Support
◆ Communicate plans with family
Referrals
◆ Confidential and assessable, can include churches, WIC, high school
programs, gov. based programs, social service, legal if incest or rape
National Prevention Program 2020: Community based with teen involvement
and planning by professionals
➢ Older Mothers
■ Definition – Mature primigravida (old-elderly primip) deliver at age 35 or >
● Social Reasons – career, $, better technology
■ Teaching Topics:
● Getting early and regular prenatal care
● Taking a multivitamin containing 400 micrograms of folic acid daily
● Consuming a variety of nutritious foods
● Drinking at least 6 to 8 glasses of water daily
● Avoiding alcohol intake during pregnancy
● Avoiding exposure to secondhand smoke
● Taking no drugs unless they are prescribed
● Increased risk for complications- infertility, GDM, HTN
➢ Mothers with Substance Abuse
■ General - Nicotine, Caffeine
■ Alcohol – CNS depressant
● Causes Fetal Alcohol syndrome and Fetal alcohol effects -one of leading causes of
mental retardation
● Maternal Malnutrition
■ Cocaine – 1:10 per 1,000 births exposed
● Vasoconstrictor, tachycardia, hypertension of mom and fetus
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● Remains in maternal system >2 days, fetal 4 days
● IUGR, Abruption, SIDS
Marijuana – most common illicit drug
● S/S: tremors, CNS effects, long term effects on brain function; tachycardia,
inflamed airways, orthostatic hypotension; spontaneous abortions, pre-term
birth
Opiates and Narcotics: Heroin, opium, morphine codeine, oxycodone
Intense addiction to mother and newborn
● Preeclampsia, IUGR, preterm labor, brain development, crosses placenta,
behavior problems
● Withdrawal- neonatal abstinence syndrome
◆ S/S: high pitched cry, nausea, diarrhea, resp. distress, seizures, excessive
sneezing, poor sucking, poor sleeping)
● Methadone – help prevent severe withdrawal from drugs, but also has
withdrawal effects
Sedatives: cross placenta, birth defects, behavioral problems
Methamphetamines: highly addictive stimulant; more common than cocaine
● Preterm births, placental abruption, IUGR, congenital anomalies
Nursing Assessment:
● Assess for Drug Use
● Drug Screen and Prevention Focus
● Counseling
● Education
● Support
Positive Maternal Drug Use: Investigation by state agency prior to discharge with infant
but not liable for criminal prosecution; be non-judgmental; culturally sensitive
Chapter 21: Nursing Management of Labor and Birth at Risk
❖ Dysfunctional Labor
➢ Dystocia; “failure to progress”
■ Number one reason that they go ahead with a section
■ Defined → Abnormal or difficult labor
■ Characteristics
● Slow and/or abnormal progression of labor
● Lack of progressive cervical dilation, lack of head descent, or both
● 8-11% of all labors
● Won’t know if Dystocia is present unless adequate “trial of labor”
➢ Outcome depends on
■ Size/shape of maternal pelvis
■ Quality of Contractions
■ Size, presentation, and position of fetus
➢ Diagnosed during labor; not before
➢ Assess: VS, UC, FHR, labs, Position-Leopolds, emotions, pain, bladder/bowel status, hydration,
S/S of infection
➢ Interventions
■ Labor support, comfort, nourishment, vag. exams, positioning, meds, coach, document
■ Evaluate
■ Results of meds, positioning, progress, I/O, FHR strips
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❖ Factors Associated with an Increased Risk for Dystocia
➢ Epidural analgesia, excessive analgesia
➢ Multiple gestation
➢ Hydramnios
➢ Maternal exhaustion
➢ Ineffective maternal pushing technique
➢ Occiput posterior position
➢ Longer first stage of labor
➢ Nulliparity
➢ Short maternal stature (< 5’), overweight, high caffeine intake
➢ Fetal birth weight (>8.8 pounds)
➢ Shoulder dystocia
➢ Abnormal fetal presentation or position (breech)
➢ Fetal anomalies (hydrocephalus)
➢ Age > 35 years
➢ Gestational age >41 weeks
➢ Chorioamnionitis
➢ Ineffective uterine contractions
➢ High fetal station at complete cervical dilation
❖ Areas of Problems that Can Result in Dystocia:
➢ Expulsive forces → problems during Labor
■ Hypertonic Contractions:
● Uterus never fully relaxes, placing the fetus in jeopardy
● Hypertonic Uterine Dysfunction
◆ Painful, uncoordinated, erratic UC with ↑ resting tone ↑ incidence in
latent phase
◆ Prolonged latent phase, stay at 2-3cm and don’t progress, nulliparous
more
◆ Etiology
➢ Unknown
◆ Clinical Manifestation
➢ Constant cramping pain
➢ Increased abruptio placenta
➢ Exhaustion, frustration and anxiety
◆ Management
➢ Relief of pain (muscle anoxia)
➢ Possible medications → sedation to reduce pain and promote
relaxation;
➢ IV therapy
➢ Monitor for fetal distress
➢ Bed rest, relaxation techniques
➢ Hydrate
➢ Maternal position change
■ Hypotonic Contractions:
● Uterus relaxes too much, causing ineffective contractions
● Hypotonic Uterine Dysfunction
◆ ineffective contractions, weak, lack intensity to dilate cervix or increase
effacement
◆ Active Phase
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➢ Begins normal → then around 4 cm, freq./intensity decrease
◆ etiology
➢ Fatigue/inactivity
➢ Dehydration
➢ Hypoglycemia
➢ Excessive analgesia
➢ Catecholamine secretion due to anxiety
➢ Bowel/bladder distention
➢ CPD, malposition
➢ Multiple fetuses, LGA, hydramnios
◆ Clinical Manifestations
➢ Exhaustion
➢ Frustration
➢ Eventual fetal hypoxia
➢ Weak contractions become milder, less intense
◆ Management:
➢ Hydrate
➢ Maternal position change
➢ Amniotomy (rupture membranes)
➢ Augment labor (oxytocin)
➢ C-section if unsuccessful
➢ RISK OF HEMORRHAGE AFTER BIRTH D/T INEFFECTIVE
CONTRACTING - if the uterus does not contract well during labor
the uterus probably will not contract well postpartum
■ Precipitous Labor:
● Uterus contracts with such frequently and intensity that a very rapid birth takes
place
● Precipitate/Precipitous Labor
◆ Fast delivery is not good
◆ Can be less than 3 hours
◆ Intense, frequent UC → fetal trauma & hypoxia
◆ Progress through labor stages very quickly
◆ ↓ resistance in tissues or oxytocin excess
◆ Risks
➢ ↑ risk of rupture, lacerations, amniotic emboli
➢ increase incidence of pp hemorrhage
➢ increased incidence of infection
➢ Exhaustion
◆ Management
➢ Vag. delivery if adequate pelvis
➢ Tocolytic medications to slow labor … only if conditions met!
➢ Post Term/Prolonged Labor/Birth
■ Past the end of the 42nd week
■ Etiology
● Unknown
■ Causes
● Wrong dates d/t irregular menses
● Extrauterine pregnancies
● Estrogen deficiency, progesterone secretion→ inhibits uterine contraction
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● Previous post term gestation
■ Maternal Risks
● Dystocia of labor
● Birth trauma
● Postpartum hemorrhage
● Potential infection
■ Fetal Risks
● Macrosomia
● Shoulder dystocia and brachial plexus injuries
● Cephalopelvic disproportion
● Increased mortality
■ CLINICAL SIGNS
● Oligohydramnios → placental insufficiency
● Meconium leading to RDS
● LGA
● Postmature fetus
● Look at the fluids and ultrasound
■ Diagnosis
● Fundal height measurements, US
■ MANAGEMENT
● Cervical ripening
● Continuous fetal surveillance tests
● Induction of labor
● Must ripen the cervix before we induce
■ Key areas of assessment post term preg.
● Pregnancy date to ascertain the most accurate one
● Client’s understanding of the various fetal well-being tests
● Client’s stress and anxiety concerning her lateness
● Client’s coping ability and support network
➢ Potential Problems with the Passenger
■ Occiput Posterior Position
● Most common malpresentation 15%
● Leopold’s maneuvers and Vag exam to determine position
● Slows progress, slow descent, long labor
● More painful
◆ c/o severe back pain
● Allow to proceed
● Hands/knee, rocking
● Pain management
■ Face/Brow presentation
● Rarer: Seen with multips, placenta previa, hydramnios, low birth wt., fetal
abnormalities
● Assess with Vaginal exam
● Longer labor
● Head must flex to deliver vaginally
● Watch for late decels, hypoxia
● Possible c-section depending on amount of head flexion
■ Breech presentation
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3-4% of all births
Increased with multips, advanced maternal age, previa, hydramnios, preterm
Frank, Complete, footling, incomplete presentation
Scheduled C/S
External cephalic version
Breech extraction internal → usually done to delay 2nd baby, dangerous,
emergency situations only
Shoulder Dystocia
● Fetal head delivered but shoulders stay wedged behind pubic bone
● Difficult birth
● Potential injury to both
● Emergency
● High Risk for Umbilical Cord compression
● McRoberts Maneuver
◆ Flex and abduct thighs; straightens pelvic curve
● Suprapubic pressure
● Check for injury, fractures
● Versions (tried with breech/transverse)
◆ ECV → External Cephalic version
◆ abd pressure to cause fetus to move → after 36 wks, US, EFM, RhoGAM
even if successful fetus may turn again
◆ VS must be stable, NST before, IV terbutaline given
◆ Monitor 30 minutes after
◆ Be ready for C/S if Fetal Distress
Multifetal Pregnancy
● Risks: ↑ dysfunctional labor, Fetal hypoxia, hypotonic uterus postpartum
● monitor each fetus separately → 2 separate FHR’s
● know positions of each fetus
● Labor complications → abnormal presentation, uterine dysfunction, prolapsed
cords & ↑ hemorrhage
● Vag del. If first is longitudinal
● Deliver in OR usually (just incase they need to be back there)
Excessive Size (macrosomia) as it relates to cephalopelvic disproportion (CPD)
● Etiology
◆ Macrosomia → over 4000gms (>8.1 lbs)
● Risk of postpartum hemorrhage, soft tissue laceration, fetal injuries, asphyxia
● CPD/fetopelvic disproportion
● May see very slow cervical dilation during active stage of labor
● Fetal Abnormalities
● Hydrocephalus
● Large mass on neck or head
● Ascites
● Maternal diabetes
● Over distended uterus-strength of contraction reduced-prolonged labor
● C-section or vaginal, Trial of labor
● Vacuum/Forceps common
Structural Anomalies
● Passageway Problems
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◆ Problems are related to a contraction of one or more of 3 planes of the
maternal pelvis (inlet, midpelvis, outlet)- CPD
➢ Remember → gynecoid and anthropoid good prognosis for vag.
delivery, android & platypelloid poor prognosis for vag. delivery.
◆ Contraction in mid pelvis most common
➢ Result → Arrest of fetal descent
◆ Difficult to diagnose
◆ Soft tissue dystocia (obstructions in birth canal)
◆ Placenta previa, Fibroids, HPV warts, Full bladder/rectum
◆ Edematous cervix (pushed too early)
● S/S: poor contractions, slow dilation, prolonged labor
● Trial of labor or C-section
➢ Problems with Psyche
■ Emotions → anxiety, tired, psychological stress
■ Stress related hormones released → catecholamines, epinephrine., cortisol, etc..
■ Cause uterine smooth muscle reduction in contractility- leads to dystocia
■ Cause decreased uteroplacental perfusion
■ Nursing support
● Physical and Emotional
● Minimize stress
● Coping skills, help relax
● Educate to Empower
❖ PreTerm Labor
➢ Regular contractions with effacement and dilation before end of 37th week
➢ Increase risk of perinatal morbidity and mortality
➢ Neurodevelopmental disorders and behavioral and social problems
➢ Risk
■ RDS, hypoglycemia, heart defects, temp. regulation, etc….
➢ Treatment
■ Tocolytic Drugs (interfere with uterine contractions)
● BENEFIT MUST OUTWEIGH THE RISK
● Works for 2-7 days
● Time for steroids to work to help fetal lung development (24-34 weeks); 2 doses,
24 hrs. apart to work. Research shows benefits after 24 hrs.
● If infection suspected: antibiotics
■ Tocolytic Drugs to Review: Monitor patients for serious side effects of all these drugs!
● Magnesium Sulfate
● Brethine
● Indocin
● Nifedipine (Procardia) (calcium channel blocker)
➢ Lab and Diagnostic Testing:
■ Fetal Fibronectin → collected vaginal secretion; predicts if preterm labor is unlikely
■ Transvaginal US → cervical length/width, Funnel length/width, percentage of funneling;
measures closed portion of cervix; short cervical length greater risk of preterm labor
❖ Induction and Augmentation of Labor
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➢ Induction
■ Artificially started LABOR through cervical ripening and stimulation of uterine
contractions via medical or surgical means
● CERVIX MUST BE RIPENED FIRST
■ Result = delivery before onset of spontaneous labor
■ Risks r/t induction
● Cesarean birth → rates have increased
◆ As soon we induce the chance of csection goes up
● Instrumented delivery: Harder for mom to deliver naturally
● Use of epidural analgesia → increased discomfort
● NICU admission= prolonged stay
➢ Augmentation
■ Strengthening what we already have: LABOR HAS ALREADY STARTED
■ Enhances ineffective contractions to make more efficient contractions
● Mom is already having these contractions on her own
■ Continuous electronic FHR monitor
■ Indications & Risks
● Gestational HTN, Maternal diabetes, Prolonged PROM, Rh isoimmunization,
Post maturity, Fetal death, Renal Disease, Chorioamnionitis, Dystocia,
Hypertonicity of uterine muscle, Uterine rupture
➢ Bishop Score: add points for dilation, effacement, station, position, consistency
■ Score: >8 successful vag. birth likely
■ If Score is <6, must use a cervical ripening agent before induction
➢ Contraindications:
■ Previous uterine trauma, Abnormalities of uterus, Placenta previa/abruptio, Active
Genital Herpes, Over distended uterus, Abnormal uterine lie, Fetal distress on EFM or
abnormal stress test, Invasive cervical CA, Cord prolapse, CPD
➢ Methods of Induction/Augmentation
■ Non-Pharmacological (less common)
● Herbal (evening primrose oil), enemas, castor oil, hot bath, intercourse (semen
has prostaglandins-ripen cervix), Breast stimulation- release oxytocincontractions
● Unknown risks, efficacy, safet, need research
■ Mechanical: Apply local pressure to cervix → stimulates prostaglandin release
● Foley cath inserted into uterus → fill balloon
● Hygroscopic dilator → absorbs fluid → expands
● Risk: ROM, bleeding, infection, placenta disruption
● Benefits: Lower cost, simplicity, fewer side effects then pharmacological methods,
preserves cervical tissue
■ Surgical
● Stripping membranes ; insert finger internal cervical Os, move in circle pattern;
causes membranes to detach; induces ripening; labor
● Amniotomy → uses amnihook to rupture membranes; presenting part pressures
cervix; prostaglandin increase
◆ Have to be 2cm dilated, baby not breached
● Risks → cord prolapse, compression, infection, decelerations, pain, bleeding
■ Amniotomy
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Most common method used in the US - artificial ROM
◆ cervix 2 cm for instrument, usually go into labor in 12 hrs or ↑ UC once
labor started
◆ fetus must be assessed for:
➢ position
➢ station–engaged to ↓risk of prolapsed cord
➢ presentation
➢ FHR
● Nursing Care
◆ Monitoring The Pt Before And After Procedure
◆ ↑ Risk Of Infection Especially After 24 Hours, Temp. Q2 H
◆ ↑ Risk For Abruptio Placenta - Disrupted Iu Pressure
◆ Allow Access For Internal Fetal Monitoring
◆ Pad Bed
◆ Equipment Ready → Sterile Glove, Lubricant, Amnio Hook, Monitor Fh
◆ Note Color, Amount And Odor, Assess Variations
➢ Normal Clear With Specs Of Vernix
➢ Hydramnios → Preterm Or Fetal Anomalies
➢ Oligohydramnios → Placental Insufficiency Or Kidney
Abnormalities
➢ Greenish → Meconium Stained; Postterm, Fetal Or Placental
Insufficiency (Breech)
➢ Cloudy, Yellowish Or Odor → Chorioamnionitis
Pharmacologic Agents
● Prostaglandins
◆ Ripens and softens cervix
◆ Prepidil (gel), Cervidil (insert) removable treatment, FDA approved,
Cytotec (oral or gel)
◆ Can cause excessive uterine contractions
◆ Some women go into labor others need further induction
● Pitocin (naturally produced by post. Pituitary)
◆ Used after ripening to induce or augment labor
◆ Side effect → hyperstimulation of uterus ; titrate carefully,
➢ Hypertonicity (UC’s < 2 min >70sec, too tense or an ↑ in resting
tone), Hypotension
➢ Antidiuretic effect → decrease urine flow → water intoxication
(s/s H/A and vomiting)
◆ IVPB infusion via pump (ex: 10U/1 liter LR (isotonic solution), titrate
until UC q2-3min, 40-60 sec. duration, uterus needs to relax between UC
<20 mm Hg: continuous FHR monitoring
◆ Observe non-reassuring patterns
➢ DC oxytocin & run plain IV. Notify MD
◆ Advantages → Short half-life (1-5 min.), doesn’t cross placenta, well
tolerated
➢ Turn it off? → out of system quickly
● Nursing Measures
◆ Consents Signed
◆ Pitocin Protocols
➢ Example: 0.5-1mu/Min, Incr. 1-2 Mu/Min Q 30-60 Min.
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◆ Close Frequent Assessment
◆ Dilation, Effacement, Station
◆ Fetal Tolerance To Labor
◆ Fhr Monitoring
◆ Uc: Freq, Intensity, Duration, Resting Tone
◆ Pain Management
◆ S/S Infection, Bleeding, VS
◆ Education
❖ Vaginal Birth After Cesarean (VBAC)
➢ Giving birth vaginally after having at least one cesarean section
➢ Risk: Uterine rupture; if happens, high fetal mortality
➢ Contraindicated
■ Prior classical uterine scar, prior transfundal uterine surgery, contracted pelvis
■ Ok if low-transverse uterine scar; Allow for trial of labor
➢ Nursing Management
■ Consent, Documentation, Surveillance, Readiness for Emergency: OR Team Must be
Ready and OR available
❖ Intrauterine Fetal Demise
➢ Causes
■ Prolonged pregnancy
■ Infection, hypertension
■ Advanced maternal age
■ Rh disease
■ Uterine rupture
■ Diabetes, congenital anomalies
■ Cord accident
■ Abruption
■ Premature rupture of membranes, hemorrhage
■ Unexplained
➢ S/S: Absence of movement, no FHR, confirm US, induce labor
➢ Nursing
■ Support, chaplain, refer, discuss, unlimited time w/stillborn
■ Staff support → own grief and how to deal with grieving family
❖ OB Emergencies
➢ Placenta Previa and Placental Abruption
➢ UC Prolapse
■ Etiology → cord protrudes alongside or ahead of presenting part
● Do not push it back it; get hips in the air and mom to OR
■ Predisposing Factors:
● ROM (increased with hydramnios)
● unengaged presenting part
● preemie or SGA
● breech (increased in footling)
● transverse lie
■ Types:
● Occult (hidden) Prolapsed → in front of presenting part but not seen
● Complete Prolapsed → seen outside vagina
■ Diagnosis → a cord visually seen or palpated on SVE
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FHR → bradycardia or variable decelerations
Causes partial or total occlusion: lack of O2→ fetal demise
Relieve cord pressure → sterile gloved hand hold presenting part off cord (HOLD
HEAD/FOOT/BUTT→ NEVER CORD), change position, knee-chest, modified sims,
trendelenburg, elevate hips, O2, emergency c-section
● General Anesthesia
➢ Uterine Rupture
■ Defined: Tear in uterus; site of previous uterine scar -into abdominal cavity
■ Risk: ↑ in previous C/S or uterine scars, ↑ classical scar, blunt abd. trauma, hypertonic
UC, oxytocin, cocaine use, molar preg., prior rupture, placenta percreta or increta,
malpresentation, induction
■ Clinical Manifestations
● Acute severe abdominal pain, and/or chest pain
● Min. or diffuse Vag bleeding, hematuria
● Hypovolemic Shock
◆ BP tanks (hypotension)
◆ HR increase (tachycardia)
● Sudden fetal distress → bradycardia or death (fetal/maternal)
● Cessation of UC
● Uneven abdomen contour
◆ No longer smooth and round; divots and dipping
■ Management → type and crossmatch, IV, foley, O2, C/S, hysterectomy
➢ Inverted Uterus
■ Etiology
● Turns Completely Inside Out
● Pulling On Umbilical Cord
● Fundal Pressure; Unsupported Uterus
● Increased Intra-Abdominal Pressure
● Congenital Weakness Of Uterine Wall
● Fundal Placental Implantation
■ Manifestations
● Uterus Absent From Abdomen
● Visualization & Palpation Through Cervix
● Pelvic Pain
● Hemorrhage
■ Manage/Nursing Care
● Replace Uterus (Under General Anesthesia)
● Laparotomy, Hysterectomy
● Iv's, Foley, Type And Crossmatch, O2
● Oxytocin To Help Contract, Antibiotics For Infection
● Immediate Life Threatening Hemorrhage; Maternal Death
➢ Amniotic Fluid Embolism (SAME CONCEPT AS PE)
■ Etiology
● Amniotic Fluid (with debris- meconium, vernix) enters maternal bloodstream &
obstructs pulmonary vessels- cause respiratory distress or circulatory collapse
● Predisposing factors include an outlet in the amnion & chorion, opened maternal
veins & a pressure gradient strong enough to force fluid into maternal circulation
● 50% mortality rate → within 1st hour of symptoms
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85% permanent hypoxia induced neurological damage
Prevention: May be preceded by vigorous labor, marginal separation of placenta,
uterine tear
Clinical Manifestations: Acute onset; CAN’T PREDICT
◆ respiratory distress, hypoxia, hypotension, seizures, uterine atonyhemorrhage, pulmonary edema, difficulty breathing, cyanosis, circulatory
collapse, coagulopathy, DIC, tachycardia, cardiac arrest
Management/Nursing → FULL CODE, CPR, O2, IV, meds- improve cardiac
output, control hemorrhage, steroids, blood transfusion-DIC, VS, Maintain
oxygenation, hemodynamic function, and correct coagulopathy
❖ Birth Related Procedures
➢ Amnioinfusion: For cord being compressed
■ LR or NSS infused into IUPC to cushion cord compression (increase fetal oxygenation)
or dilute meconium, oligohydramnios
■ Warmed infusion inserted through cervix into a pocket of Amniotic Fluid
● ex: 250 ml bolus than 15-20 ml/min
■ Nursing Interventions: Monitor VS, FHR pattern, contractions, maintain bedrest, I/O,
prepare for c-section if needed
➢ Forceps Assisted
■ Have locking mechanism → prevents skull compression
● High → before engagement - never done
● Mid-forceps → station 0 to +2 station
● Low Forceps → station +2 to +5 (outlet)
■ Useful in rotating fetal head
■ Indications
● Shorten 2nd stage of labor
● Terminate labor quickly
● Maternal exhaustion
● Inability to push effectively
● Prolapsed cord
● Cardiac or pulmonary disease
● Infection
● Premature separation of placenta
● Fetal Distress
■ Contraindications
● High fetal station
● Cephalopelvic Disproportion
● Risks:
◆ Mid forceps: ↑mat. & fetal morbidity & mortality
◆ Facial nerve damage
◆ Low Forceps - maternal lacerations, hematomas
◆ Fetal ecchymoses, facial & scalp laceration
■ Prerequisites for applications
● Head must be engaged
● Must be vertex, or mentum anteriorly
● Position of head must be precisely known
● Must be 10 cms and ROM
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● No Cephalopelvic Disproportion
● Empty bladder
● Episiotomy and anesthesia
Vacuum Assisted
■ Mom should be pushing; vacuum at same time mom pushes
■ Instrument → cup-shaped, attached to suction, helps pull fetal head
■ Kiwi, plastic cup (Older = metal)
■ Criteria
● Must have ROM, Must be vertex, Cup should only go on occiput, No
Cephalopelvic Disproportion
■ Adverse reactions
● Ecchymosis
● Fetal damage with poor application; facial nerve injury
● Tissue Trauma → cephalhematoma, caput, lacerations
● Marks/swelling usually disappear in 2-3 days
Episiotomy
■ 2-4cm incision made → lowest aspect of vag opening into perineum
■ Incision is made when head is on the perineum
■ Done to prevent tearing, increased in primips but decreasing numbers
■ Local anesthesia → 1 -2% Lidocaine
■ Types:
● Median → can extend to rectal sphincter
● Mediolateral (should be this one) → R or L → ↑ room for OB maneuvers, ↑
difficulty to repair and longer healing, ↑ blood loss
Emergency Delivery
■ General Anesthesia → used in emergency
■ loss of consciousness
■ barbiturates IV
■ Nitrous oxide 40-60% O2
■ ↑ aspiration from intubation and pp hem.
■ C/S → 4 min.
■ neonatal resuscitation
Cesarean Section
■ Indications
● Dystocia (difficult labor), Macrosomia, Cephalopelvic Disproportion (CPD),
Gestational HTN, maternal disease, active herpes, previous classical uterine scar,
fetal distress, prolapsed cord, Malpresentation, abruptio/previa
■ Contraindications
● severe preterm
● fetal demise
● Maternal coagulation defect
■ C/S Risks
● Increase In:
◆ Maternal morbidity & mortality, infection, hemorrhage, urinary tract
trauma, thrombophlebitis, paralytic ileus, atelectasis, anesthesia
complication, preterm delivery, increased persistent pulmonary
hypertension, injury
■ C/S Management
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● EFM
● Epidural
● Foley #16Fr. indwelling
● Labs → CBC, RPR, type Rh, U/A,
● US, amnio possible for checking lung maturity
● Prophylactic antibiotics
● Prep: Abd. scrub and drape
■ C/S incisions
● Uterine
● Low Transverse
◆ (Kerr) → limited in size d/t uterine artery, ↓ rupture, ↓ blood loss and
easiest to repair; most commonly used
● Low Vertical
◆ (Kronig) → lower uterine segment, used for multiples, abnormal
presentation, higher risk of rupture next preg., can’t VBAC after this type
● Classical (vertical)
◆ Rarely used now, upper uterine segment, high rupture next preg., can’t
VBAC, higher blood loss, hard to repair
■ Events:
● Consents
● Closure → sponge count
● Staples
● Sub. cutaneous with steri strips
● Adhesive
Chapter 22: Management of the Postpartum Woman at Risk
❖ Postpartum Hemorrhage
➢ Blood Loss
■ VAGINAL: Greater than 500ml
■ C/S: Greater than 1000ml blood loss
➢ Types
■ Early - first 24 hours (most)
■ Late - after 24 hours to 6 wks
➢ Incidence
■ Leading cause of maternal mortality & morbidity
■ 1 maternal death every 4 minutes (most within 4 hrs. of delivery)
➢ Early Postpartum Hemorrhage
■ Causes
● Tone- uterine atony
● Tissue- retained fragments
● Trauma
● Thrombosis
■ Etiology:
● Early PP Hemorrhage
● Tone: uterine atony - 90%
● Prevents uterus from contracting around blood vessels of myometrium
● Can lead to hypovolemic shock
■ Clinical Manifestations
● Difficulty locating fundus
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Boggy uterus that firms up with massage than loses tone
Excessive lochia: Soak through a pad within an hour!
◆ 1g=1mL of Blood
■ Causes:
● Tone: uterine atony, distended bladder
● Tissue: retained placenta and clots
● Trauma: vaginal, uterine, or cervical injury
● Thrombin: coagulopathy
● Traction: causes uterine inversion
■ Predisposing Factors:
● Overdistended Uterus
● Multiparity
● Prolonged Labor
● Precipitous Labor
● Oxytocin/Stim. Of Labor
● Retained Placenta
● Prev. Uterine Surgery
● Clotting Disorders
● C/S
● General Anesthesia
● Mgso4
● Forceps/Vacuum
● Low Implanted Placenta
● Incomplete Dilatation
■ Management & Nursing Care:
● Massage uterus - 1st response, 2 hands, express clots
● Catheterize (if unable to void or use BR)
● 2nd IV, type and crossmatch
● VS, q15-30 min. as needed
● Weigh pads- 1 gm pad wt = 1ml blood
● H&H
● Hysterectomy possible
➢ Trauma Postpartum Hemorrhage
■ Trauma → 2nd leading cause of postpartum hemorrhage (vaginal, cervical or perineal
lacerations or hematomas)
● Predisposing factors:
◆ LGA
◆ precipitous deliveries
◆ Oxytocin, prolonged labor
◆ Forceps Or vacuum
● Lacerations and Hematomas:
◆ Vaginal
◆ Perineal
◆ Deep tissue - can bleed into broad ligament
● Manifestations
◆ Swelling, Ecchymosis, Severe Pain, Tachycardia, Low B/P, Pale
● Management & Nursing Care
◆ Surgical repair of lacerations & evacuation of hematoma
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➢ Can contain up to 500ml
◆ Antibiotics
◆ Blood replacement
◆ Alternate heat & cold
➢ Late PP Hemorrhage: 3 days to 6 weeks
■ Etiology
● Subinvolution (delay of returning uterus to prepregnant state)
● Retained placenta
● Infection
■ Predisposing factors
● Manual removal of retained placenta
● Accreta- chorionic villi- placenta-adhere to myometrium- don’t separate at
delivery
■ Manifestations
● Bleeding- slow trickle, oozing, bright clots, or frank hemorrhage
● Pelvic/back pain
● Boggy/tender uterus
■ Management
● Oxytocin (ergotrate or methergine)
● Curettage
● Antibiotics
● Inspect placenta at delivery
■ Hemorrhagic/Hypovolemic Shock (Review from Med-Surg)
● Code Crimson: 30-40% loss of blood volume
● Etiology: ↑ 1500ml blood loss = constriction of peripheral =blood vessels→ shunt
blood to major organs & metabolic acidosis
● S/S: cold clammy skin, ↑ catecholamines & vasoconstriction, ↓ pulse pressure,
tachycardia, metabolic acidosis, highly anxious/lethargic, decreased urine output
- ↓ 30ml/hr
● Management and Nursing Care:
◆ VS Q5 min
◆ O2 at 6L
◆ Type & cross match
◆ Continuous Pulse oximetry
◆ IV's: 18 angio
◆ Uterine packing
◆ Ligate ovarian/hypogastric artery
◆ Hysterectomy
◆ Correct bleeding disorders
❖ Thrombosis (Review)
➢ CLOTTING PREVENTS PP HEMORRHAGE IMMEDIATELY AFTER BIRTH;
➢ THROMBUS RESULTS FROM:
■ VENOUS STASIS
■ HYPERCOAGULATION
■ INJURY TO BLOOD VESSEL
➢ COAGULOPATHIES LEAD TO PP HEMORRHAGE
➢ ITP: Idiopathic Thrombocytopenic Purpura
■ Unknown cause!
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Increased platelet destruction caused by autoantibodies: thrombocytopenia, capillary
fragility, increased bleeding time
■ Decreased number of circulating platelets
■ Medical therapy: Glucocorticoids and Immune globulin
vWD: von Willebrand Disease
■ Congenital bleeding disorder; autosomal dominant
■ Prolonged bleeding time, impaired platelet adhesion, deficiency of von Willebrand factor
■ Symptoms: nosebleeds, hematomas, excessive menstrual bleeding
DIC: Disseminated Intravascular Coagulation
■ Life threatening- wide spread clot formation of small vessels, depletes platelets and
coagulation factors- ICU
■ Symptoms: petechiae, ecchymoses, hematomas, tachycardia, uncontrolled bleeding
■ Treatment: IV fluids, oxygen, heparin, and blood products
■ DIC is secondary to other underlying disorders
● EX: abruption, amniotic fluid emboli, HELLP syndrome
● Must treat the primary disorder first
Thrombophlebitis
■ Clot in vessel (D/T venous stasis or hypercoagulation) causes vessel inflammation
■ Can lead to thromboembolism
● Superficial: lower leg, lithotomy position-stirrups
◆ S/S: calf area of leg is usually locally swollen reddened and tender,
discomfort when walking
● Deep vein: From foot to pelvis
◆ S/S: possible positive Homan's sign, pedal edema, can be asymptomatic,
“Milk-leg” - pale, cool with decreased peripheral pulses
● Can dislodge and cause a pulmonary emboli
■ Doppler study confirms
Management Nursing Care:
■ Prevention
■ Early Ambulation
■ Rom Exercises
■ Avoid Knee Gatch, Rolls, No Crossing Legs
■ Avoid Holding Under Calf In 2nd Stage Of Labor
■ No Smoking
■ Limit Time In Stirrups During Delivery
■ Post C/S:
● TEDS
● Compression devices
● Incent. Spirometer
● OOB
● Encourage fluids
■ Superficial Thrombophlebitis
● elevate leg
● TEDs
● bed rest - 48 hours
● warmth - K pad
● compression boots
● anticoagulants not necessary
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● NSAIDs may be used
■ Deep Vein
● BR and elevate leg
● TEDs
● Compression devices
● Anticoagulants (Heparin, coumadin-no BF)
◆ Prolong clotting time- prevent clot extension
● Warm moist compresses
● Monitor APTT values: normal 35-45 sec
Pulmonary Emboli
➢ Pulmonary artery obstructed- can cause sudden death
➢ 2nd leading cause of pregnancy related deaths
➢ Predisposing factors
■ Varicose veins, obesity, hx of thrombophlebitis, smoking, C/S, maternal age over 35,
Multiparity, Oral contraceptives before pregnancy, Diabetes
➢ S/S: sudden SOB, tachypnea, chest pain, tachycardia, sweating, hemoptysis, apprehension,
change in mental status, arrhythmia
➢ Treatment
■ O2, IV heparin, Bedrest, Analgesics, Thrombolytic agents (tPA – dissolve clot),
Cardiopulmonary support, Transfer to ICU
Septic Pelvic Thrombophlebitis
➢ Clot in the pelvic area that can get infected thus causing sepsis
➢ Etiology
■ 2-4 days to 2 weeks
■ Infection (Anaerobic strep) along venous system involving major veins
● Ovarian, uterine and hypogastric vein
● ↑ right side because the ovarian vein goes right into the inferior vena cava than
general circulation
● Left vein meets renal vein and can spread to kidney
➢ S/S: groin pain, fever, chills, ↑ pulse, decrease B/P,
➢ Rx: antibiotics, anticoagulants, chest X-Ray, CBC, PT
PP Infection
➢ Up to 8% births
➢ Greater in C/S than vagina birth
➢ S/S:
■ Fever 100.4 or higher after 24hrs post delivery
● Occurs for 2 or more days of the first 10 days (not counting first 24 hrs)
■ Chills, h/a, malaise, tachycardia, anxious, restless
■ Vaginal acidity decreased after childbirth, more alkaline=more prone to bacteria
● Most common - gram- negative bacteria, E-Coli, Staph & Strep
➢ Normal in vagina & cervix - ascend
➢ ↑ with PROM >24 hours
➢ Retained placenta, poor hygiene, pp hem.
Metritis or Endometritis (commonly called)
➢ Metritis: Infection involving endometrium, decidua, and myometrium of uterus
■ Bacteria that normally reside cause problems (E. coli, kleb. Pneumoniae, G. vaginalis)
➢ 10-20% C/S births
➢ Can be from Chorioamnonitis present before birth
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➢ Tx: broad spectrum antibiotics
Wound Infections
➢ Surgical Incision
➢ Episiotomy
➢ Laceration
➢ s/s may appear after d/c (48 hrs. later)
➢ Teach: s/s to watch
■ Don’t forget low grade fever (<100.4), poor appetite, low energy, in addition to REEDA
➢ Tx: Parenteral antibiotics, analgesics, drainage of wound
UTI
➢ Causes: Catheters, Vaginal exams, Trauma
➢ S/S: dysuria, frequency, chills, fever, flank pain
➢ Tx: antibiotics, fluid hydration, pericare
Mastitis
➢ Breast infection (interstitial tissue) within 2-3 weeks pp BF
➢ Incidence: 2-33% of BF moms, ↑ at 2 & 5 weeks, may be preceded but not caused by
engorgement
➢ Etiology - S. aureus and E-Coli -cracked nipples, missed feeding- poor drainage of duct,
infection, too tight bra
➢ S/S:
■ temp, chills, ^pulse, malaise, flu-like S/S
■ localized redness, inflammation, tender area firm & reddened, may be confined to one
lobe, hot to touch
■ red streaks along lymphatics
■ may be drainage (abscess)
■ Engorged
➢ Tx: Frequent emptying of breasts (infant or pump), antibiotics, ice or warm packs, analgesics
Thyroid Disorder
➢ PPTD (Postpartum Thyroid Dysfunction)
➢ Incidence - 5-9% may have transient hyper or hypo or both (reoccurs in subsequent
pregnancies)
➢ the thyroid glands enlarged normally during pregnancy but does not return to pp state
➢ at 6-12 weeks there is a hyperthyroid state that lasts for 1-2 months followed by hypothyroid
goiter that lasts for up to 12 mo.
➢ can have hyper state without hypo
➢ Dx: lab thyroid levels
➢ Tx: medication as indicated
Risk Factors for Postpartum Emotional Disorders (Review)
➢ Poor coping skills
➢ Low self-esteem
➢ Numerous life stressors
➢ Mood swings and emotional stress
➢ Previous psychological problems or a family history of psychiatric disorders
➢ Substance abuse
➢ Limited social support networks
➢ PP Blues
■ 50-90%
■ Mild depressive symptoms
■ Anxious, fatigue, teary, mood swings
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■ Peak days 4-5, resolve by pp day 10
■ No psychopathology
■ Can take care of self and infant
■ Self limiting, no treatment if resolves
■
➢ PP Depression
■ 20 %, up to 60% adolescent mothers
■ See text: signs/symptoms
■ Feel worse over time, does not go away on own
■ Gradual onset, evident by 6 weeks pp
■ Antidepressants, Antianxiety drugs
■ Psychotherapy
■ Prophylactic therapy= since predictable onset
➢ PP Psychosis
■ 1 per 500
■ Within 3 weeks pp
■ Sleep disturbance, fatigue, depression, tearful, guilt, anger, hallucinations
■ Thoughts of hurting self and/or infant
■ Hospitalization required
■ Psychotherapy, support groups, psychotropic meds.
Chapter 23: Nursing Care of the Newborn with Special Needs and Chapter 24: Nursing Management of the
Newborn at Risk - Acquired and Congenital Newborn Conditions
❖ Factors: Place a Newborn at Risk for Gest. Age or Birth Wt. Variations
➢ Maternal nutrition (malnutrition or overnutrition)
➢ Substandard living conditions
➢ Low socioeconomic status
➢ Maternal age <20 to >35 years old
➢ Substance abuse
➢ Failure to seek prenatal care
➢ Smoking or exposure to passive smoke
➢ Periodontal disease
➢ Multiple gestation
➢ Extreme maternal stress
➢ Abuse and violence
➢ Pregnancy complications – previa or abruption
➢ History of previous preterm birth
➢ Maternal disease, such as hypertension or diabetes, renal, autoimmune
➢ Maternal infection, such as urinary tract infection or chorioamnionitis, TORCH
➢ Exposure to occupational hazards (Gilbert & Harmon, 2003)
➢ Placental Factors
■ previa, abruption, abnormal cord insertion, insufficiency
➢ Fetal Factors
■ chromosome, infection, anomalies, multiples, radiation exposure
❖ Birth Weight Variations
➢ Appropriate for gestational age (AGA): approximately 80% of newborns; normal height, weight,
head circumference, and body mass index
➢ Small for gestational age (SGA): weigh less than 2500 grams (5 lb, 8 oz) at term due to less
growth in utero than expected or one below the 10th percentile
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➢ Large for gestational age (LGA): birth weight is above the 90th percentile on a growth chart;
weigh more than 4000 grams (8 lb, 13 oz) at term
❖ Marginal Birth Weights and of Any Gestational Age
➢ Low birth weight (LBW)
■ Infant weighing < 2500 grams or 5.5 pounds
➢ Very low birth weight (VLBW)
■ Infant weighing <1500 grams or 3 lbs, 5 oz
➢ Extremely low birth weight (ELBW)
■ Infant weighing <1000 grams or 2 lbs, 3 oz.
❖ SGA & IUGR
➢ Intrauterine growth restriction
■ Rate of growth is not as expected
■ Not all SGA are IUGR
■ Early detection/management decreases morbidity/mortality
➢ Symmetric IUGR
■ Early insult (<28 weeks)
■ Overall growth restriction, all organs small
■ Equally poor growth head, abdomen, long bones
■ Don’t catch up
➢ Asymmetric IUGR
■ Late insult (>28 weeks)
■ Result- intrauterine malnutrition
■ Catch up later postnatal with good nutrition
■ Poor growth abdomen, and organs; head and long bones not affected
➢ Typical appearance of SGA newborn
■ Head disproportionately large compared to rest of body
■ Wasted appearance of extremities
■ Reduced subcutaneous fat stores
■ Decreased amount of breast tissue
■ Scaphoid abdomen (sunken appearance)
■ Wide skull sutures secondary to inadequate bone growth
■ Poor muscle tone over buttocks and cheeks
■ Loose and dry skin that appears as if it is over-sized
■ Thin umbilical cord (Verklan & Walden, 2004)
➢ Typical problems of SGA
■ Perinatal Asphyxia
● Stress of labor
● Acidosis
● Hypoxia
● Bradycardia and decels during labor
● Resuscitate
■ Hypothermia
● Less muscle mass, brown fat, subq fat,
● Depleted glycogen & subq fat stores
● Metabolic stress (acidosis, hypoglycemia)
● Temp <36.4C
● Prevent cold stress
■ Hypoglycemia
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Incr. metab. rate, lack of glycogen stores
Lethargy, tachycardia, resp. distress, jittery, hypothermia, poor feeding, weak cry
or high pitched cry, hypotonia, seizures
● Monitor BG, early feeding
■ Polycythemia
● HCT >65%
● Hypoxia- increases eryth. production
● Weak suck, ruddy, tachypnea, jaundice, lethargy, poor feeding, hypotonia,
seizures
● Partial exchange transfusion to incr. volume, adequate hydration, monitor HCT
■ Meconium Aspiration
● Clear airway
● Support ventilation
❖ Risk factors for LGA
➢ Maternal diabetes mellitus or glucose intolerance
➢ Male fetus
➢ Multiparity
➢ Genetics
➢ Prior history of a macrosomic infant
➢ Postdates gestation
➢ Maternal obesity
➢ Common problems associated with LGA newborns
■ Birth trauma due to fetopelvic disproportion (FPD)
■ depressed skull fracture, cephalohematoma, fracture of the clavicle or humerus, brachial
plexus injuries, or facial palsy
■ Hypoglycemia: blood glucose level below 40 mg/dL
■ Polycythemia: a venous hematocrit over 65% resulting in the blood becoming sluggish,
viscous
■ Jaundice secondary to hyperbilirubinemia: due to the breakdown of an increased
numbers of RBCs in circulation
❖ Gestational age variations
➢ Preterm: a newborn born before completion of 37 weeks
■ Characteristics of Preterm
● BW less than 5.5lb
● Scrawny appearance
● Min. subcut. Fat
● Thin, transparent skin
● Lanugo plentiful
● Undescended testes
● Poor muscle tone
● Fused eyelids
● Flat pinna
● Absent plantar creases, or few
● Minimal scrotal rugae
● Prominent clitoris and labia
● Vernix plentiful
● Lack of breast tissue
■ Watch preterm for:
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Resp: Apnea, RDS, atelectasis, obstruction, tachypnea
CV: congenital anomalies, continued fetal circulation- patent ductus arteriosus,
intracranial hemorrhage
● GI: malnutrition, wt. loss, poor suck, shunting of blood to vital organs- intestine
ischemia- NEC, may require gavage feed
● Renal: reduced ability to concentrate urine; drug toxicity, fld. retention,
● Immune: IgG doesn’t transfer until after 34 weeks, immature immune system,
risk for infection
● CNS: problems regulating temp., prevent cold stress
➢ Late Preterm: born between 34-36 6/7 weeks
➢ Term: the infant born from the first day of 38th week through 42 weeks
➢ Full Term: born between 38-41 6/7 weeks
➢ Postterm: a pregnancy that extends beyond 42 weeks’ gestation
■ Postterm characteristics
● Dry, cracked, wrinkled skin
● Long, thin extremities
● Creases cover entire soles of feet
● Wide-eyed, alert expression
● Abundant hair on scalp
● Thin umbilical cord
● Limited vernix and lanugo
● Meconium-stained skin
● Long nails (Green & Wilkinson, 2004)
■ Post Term complications
● Perinatal Asphyxia
◆ Placental deprivation or oligohydramnios- cord compression
● Hypoglycemia
◆ Hypoxia-2* to depleted glycogen-Placental insufficiency
● Hypothermia
◆ Loss of subcut. Fat- d/t placental insuff.
● Polycythemia
◆ Hypoxia-incr. RBC product., sluggish perfusion, hyperbiliru.
● Meconium Aspiration
◆ Hypoxia in utero
◆ Suction airways, support ventilation
❖ Nursing Interventions for the Newborn with Gestational Age or Birth Weight Variations
➢ Promoting oxygenation
■ Asphyxia
● Lack of sustained, adequate resp.
● Impaired gas exchange-less O2 in blood= hypoxia
● Excess CO2= Acidosis
● Result
◆ brain injury
◆ Mental retardation
◆ Cerebral Palsy
◆ Seizures
● Increased risk for pre and postterm
■ Resuscitation of newborn
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Airway: open, suction
Breathing: blow by or intubate if needed- ppv=pos. pressure ventilation
Circulation: chest compressions (at least 100/min)
Drugs:
◆ If reacting to Narcotics- give narcan
◆ If in Metabolic Acidosis- give Sodium (Na) Bicarb.
◆ To increase HR- epinephrine (ET or IV)
● Oxygen therapy
● O2 sat range, amt., length varies by hosp.
■ Retinopathy of prematurity (ROP)
● Major cause-blindness in preterm
● Abnormal blood vessels grow, spread, leads to retinal detachment
● Infants less than 1250g at greater risk;
● If on extensive O2 and preterm: seen by Ophthalmology 4-6 wks
● Link to duration of O2 used, not just the high oxygen concentration
● 100% to resuscitate is ok
● Oxy hood, n/c, blowby, PPV, CPAP, mechanical
● Humidified oxygen (long term- now short term too)
Maintaining thermoregulation
■ Dry, warmer, prevent heat loss
■ S/S: cool to touch, cyanosis, RDS, lethargy, poor feed, weak cry, hypoglycemia
Promoting nutrition and fluid balance
■ Parenteral (TPN) via central venous catheter
■ Enteral: NG tube, gavage, oral (bottle/formula or breast milk)
● Don't want them to suck if they can't breathe!
■ Check daily weights, I/O, Abdomen girth, lab work (e.g. electrolytes, bun, creatinine,
HCT, specific gravity)
■ S/S of dehydration: decreased urine output, sunken fontanels, elevated temp., lethargy,
elevated resp.
Preventing infection
■ Hand washing, no hand jewelry
■ S/S: apnea, poor feed, temp unstable, RDS, pale, hypoglycemia., tachycardia
■ Common: Candida albicans, staph aureus, E. Coli, Enterobacter, Klebsiella, Serratia,
Pseudomonas, Group B Strep.
Preventing complications
■ Ex: RDS, anemia, hyperbilirubinemia, hypoglycemia.
Providing appropriate stimulation
■ Rock, hold, music, massage, sucking
■
gain wt. faster
■ Careful not to over-stimulate
● Noise, lights, procedures, alarms, handling
● Use more oxygen-stress infant
Managing pain
■ many procedures done
■ Gentle handling, rocking, bundled
■ Sucrose pacifier, limit noise/lights
Promoting growth and development
■ Cluster care
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■ Manage environment
■ Kangaroo care
➢ Promoting parental coping
■ Anxiety reduction
■ Perinatal loss
➢ Preparing for discharge
■ Starts when stable
■ Home assessment
■ Resources
■ Perinatal Loss: support, acknowledge, sincerity, cultural beliefs/practices (see text) ,
anticipatory guidance, support groups
❖ Other conditions seen with newborns at risk
➢ Transient Tachypnea (TTN)
■ Fluid in lungs removed slowly or not all of it
■ Self-limiting, resolves within 72hrs
■ Risk: c/s, sedation, long labor, maternal asthma/smoking
■ S/S: grunting, moaning, retractions, nasal flaring, mild cyanosis, rr 100-140
■ Rx: supportive- O2, sat, chest PT, positioning (shoulder rolls), IV fluids or gavage, no
oral feeds until resolves
➢ RDS: Respiratory Distress Syndrome
■ d/t lack of alveolar surfactant, lung immaturity
■ Work harder to breathe
■ Risk:
● c/s, early gest. age, DM, perinatal asphyxia
● Fetus chronic stress in utero (ex: Prolonged ROM, IUGR) actually produce more
surfactant- less chance RDS
■ S/S:
● Same as TTN…. AND: crackles, HR150-180, general cyanosis
● Silverman-Anderson Index rates degree of distress (see book)
■ Self-limiting disease but will worsen if not treated
■ Mechanical Vent, CPAP, surfactant replacement
■ supportive care until more surfactant produced
➢ Meconium Aspiration Syndrome
■ Inhaled amniotic fluid mixed with mec while in utero or with first breath
■ Leads to resp. distress, obstruction, hypoxia, infection, possible death
■ Risk: postterm, breech, forcep/vac, DM, HTN, prolapse, placental insufficiency, fetal
distress
■ S/S: same Resp. distress,
■ Rx: Suction before first breath!, visualize cords
■ Supportive: O2, cluster care, VS, antibiotics, blood gasses, prevent hypothermia
➢ Persistent Pulmonary Hypertension
■ Previously called persistent fetal circulation
■ Pulm htn causes shunting from right to left (thru ductus arteriosus & foramen ovale),
bypassing lungs into systemic circulation
■ Result: hypoxemia
■ Risk: perinatal asphyxia, RDS, mec, sepsis, pneum., hypoglycemic, hypothermia, heart
defects
■ S/S: same as before: add: murmur, hypotension
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■ Rx: resuscitation, O2, correct acidosis, minimize stimulation
➢ Bronchopulmonary Dysplasia/Chronic Lung Disease
■ Chronic lung disorder following a lung injury
■ Multifactorial: d/t mechanical vent., oxygen toxicity (high O2 concentration), pulm.
Edema, surfactant deficiency.
■ Risk: males, white, severe RDS, preterm, sepsis
■ S/S: same resp. distress.. And: poor wt. gain, bronchospasm, abnormal breath sounds,
hypoxia, acidosis, high CO2 (hypercapnia), cardiomegaly, infiltrates
■ Rx: O2, meds: bronchodilators, anti-inflammatories, diuretics
➢ Periventricular-Intraventricular hemorrhage (IVH)
■ Bleeding in the brain- subependymal germinal matrix into ventricular system
■ Thin capillaries, rupture easily
■ Lead to CP, seizures, hydrocephalus, developmental impaired
■ Classified: I to V (least to most severe)
■ Risk: preterm <32 weeks, asphyxia, acidosis, hypoxia, suctioning, handling
■ S/S: low hgb and low Hct, pale, Resp. distress, seizure, shock, tense ant. Fontanelle,
lethargy, weak suck, high pitched cry, hypotonia,bradycardia, hypotension, increase head
circumference, “waxy” skin color
■ Rx: limit handling, stimuli, supportive care , correct anemia, acidosis, hypotension with
IV and meds
➢ NEC: Necrotizing Enterocolitis
■ GI disease of unknown origin
■ More common preterm day 3-10
■ Pathogenic organism, hypoxic/ischemic event…blood shunted to brain and heart (vital
organs) during hypoxia, enteral feeding….allows bacteria to flourish, altered mucosal
integrity
■ Result: necrosis of part of the intestine…usually distal ileum
■ Acute and chronic morbidity and mortality
■ S/S: abd. distension, tender, bile emesis, intolerance to feeding, lethargy, resp. distress,
bloody stools
■ Rx: NPO, orogastric tube/suction, antibiotics, IV fluids, surgical resection if necrosed
and/or perforated
❖ Infant of diabetic mother
➢ Monitor BG, keep over 40 mg/dl
➢ S/S of hypoglycemia
■ Lethargy, hypotonia, poor feed, apneic, temp. instability, tremors, irritability, seizures.
Jitteriness
➢ Prevent cold stress
➢ Check for birth trauma
➢ Labs: baseline calcium, mag., bilirubin
➢ Frequent feedings, assessment, correct low lab values, o2 support if needed
❖ Birth Trauma
➢ Fractures
■ Breech, shoulder dystocia, macrosomic
■ Midclavicular: s/s: limited movement, pin sleeve to shirt
➢ Brachial Plexus Injury (breech/shoulder dystocia)
■ Erb’s Palsy: upper brachial plexus injury
■ Paralysis in upper portion of arm, moro absent, absent shoulder movement
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Klumpke’s palsy: lower brachial plexus- hand/wrist weakness, no grasp reflex (less
common)
■ Immobilize, ROM
➢ Cranial Nerve Trauma (forceps)
■ Facial asymmetry, one side effected, self limiting
➢ Head trauma
■ Caput, cephalhematoma, hemorrhage….apnea, seizures, lethargy, skull fracture
❖ Substance Abuse Drugs
➢ Fetal alcohol syndrome
■ Alcohol related birth defects: no safe amt.
■ Small head, small palpebral eyelid fissures, thin upper lip, low wt, short length, mental
retardation, poor suck, poor feed
➢ Tobacco/Nicotine
■ LBW, SGA, preterm, >SIDS, chronic resp. Illness
➢ Marijuana
■ IUGR, irritable, abnormal sleep, tremors, high pitched cry
■ Studies on development in progress
➢ Methamphetamines
■ LBW, preterm, symptoms of withdrawal
■ Agitated, jittery, poor wt. gain, poor sleep, high pitched cry, resp. distress
■ Limited studies
➢ Cocaine
■ LBW, preterm, cognitive problems, memory, defects: genitourinary, cardiac, CNS,
absence of abd. Muscles (“prune belly syndrome”)
➢ Heroin
■ Infant born dependent on heroin
■ Stillbirth, IUGR, premature, LBW, hypoxia, >SIDS, withdrawal symptoms
■ Methadone
● Benefit vs. risk: used for heroin addicts
● LBW, >SIDS, withdrawal symptoms
❖ Neonatal Abstinence Syndrome
➢ W = Wakefulness- 1-3hrs sleep duration post feed
➢ I = Irritability
➢ T = Temperature variation, tachycardia, tremors
➢ H = Hyperactivity, high-pitched cry, hyperreflexia, hypertonus
➢ D = Diarrhea, diaphoresis, disorganized suck
➢ R = Respiratory distress, rub marks, rhinorrhea
➢ A = Apneic attacks, autonomic dysfunction
➢ W = Weight loss or failure to gain weight
➢ A = Alkalosis (respiratory)
➢ L = Lacrimation
❖ Neonatal Sepsis
➢ Presence of bacterial, fungal, or viral microorganisms or their toxins in blood or other
➢ tissues
➢ Congenital, or acquired in-utero, or perinatal (shortly before or during birth, or after in
➢ nursery)
➢ Risk Factors (see text); e.g.: immature immune system, decreased gastric acid, prolonged ROM,
UTI, preterm labor, maternal infections, maternal fever
■
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➢ Newborns vulnerable: poor skin integrity, premies, low birth wt., trauma, invasive procedures,
numerous caregivers, environment, unable to have inflammatory response yet
➢ ** Not easy to recognize, early recognition, know risk factors, be suspicious!
➢ Assess for s/s of infection; may be non-specific (see text) e.g. hypothermia, pallor, hypotonia,
cyanosis, poor wt. gain, irritable, seizures, jaundice, grunting, nasal flaring, apnea, bradycardia,
lethargy, hypoglycemia, poor feeding, abdominal distention
➢ Strict hand washing, thorough assessments every shift and prn
➢ Diagnose: Lab: blood culture, CSF, chest and abdominal x ray, urine cultures, CBC with
differential, elevated CRP levels (inflammation)
➢ Treatment: antibiotics right away, d/c if cultures negative; supportive therapy: circulatory,
respiratory, nutritional, and developmental
Other conditions prev. Discussed
❖ Hyperbilirubinemia
➢ Physiologic jaundice (day 3-4)
■ Early-onset BF jaundice- peaks day 4
■ Ineffective BF practices, caloric deprivation, less volume, frequency- mild
dehydration-delay in passing meconium- reuptake of bilirubin
■ Late-onset BF jaundice (day 6-14)
■ Unknown- Possibly r/t change in milk composition
➢ Bottle feeding jaundice
■ Peaks day 3, rapid decline in Bili level
➢ Pathological Jaundice
■ Within the first 24 hrs.
■ ABO or RH incompatibility
■ May lead to Kernicterus
❖ Congenital Condition → Classifications of Cong. Heart Disease
➢ Defects causing incr. pulmonary blood flow, such as atrial septal defect (ASD), ventricular septal
defect (VSD), patent ductus arteriosus (PDA)
➢ Defects causing obstructed blood flow out of the heart, such as pulmonary or aortic stenosis
➢ Defects causing decreased pulmonary blood flow, such as tetralogy of Fallot
➢ Defects with cyanosis and increased pulmonary blood flow or mixed defects, such as truncus
arteriosus or transposition of the great arteries
❖ Congenital Heart defects
➢ Most develop in first 8 weeks of pregnancy
➢ Genetics and environment
➢ DM, alcohol, >40 age, meds.
➢ PDA common – doesn’t respond to O2
➢ Fetal shunts usually close due to increases systemic pressure
❖ Inborn errors of metabolism
➢ Genetic disorders-defect in enzyme or transport protein
➢ Early Dx, prompt intervention
■ Poor feed, vomit, resp distress, lethargy, poor tone, seizures
➢ Newborn metabolic screening
■ PKU
■ Maple Syrup Urine Disease
■ Galactosemia
■ Congenital Hypothyroidism
❖ Congenital CNS structural defects
➢ Neural tube defects
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Spina Bifida
● Caudal defects below T12
● Treatable
● Cause paralysis
● Meningocele
◆ Opening in spine, herniation of meninges and spinal fluid (not spinal
cord/nerve roots)
◆ Surgical repair
● Myelomeningocele (94% of cases)
◆ More severe
◆ Spinal cord and nerve roots herniate into sac
■ Spina Bifida “Occulta” (internal)
● Not able to see (no outside sac), internal closed defect
● s/s: hairy patch, dimple, lipoma, hemangioma
➢ Microcephaly
■ Small brain in normal size cranium
■ Neuro impairment, no treatment
➢ Anencephaly
■ Absent cranial vault
■ absent or small cerebral hemispheres
■ No brain tissue above brain stem
■ Stillborn or die soon after birth
➢ Hydrocephalus (water on brain)
■ Production and absorption problem
■ Rx: shunt
➢ Severity varies
■ Closed (covered by skin/membrane)
■ Open (neural tissue exposed)
■ Prevent: Folic Acid
■ Dx: US, MS AFP, amnio
■ Rx: avoid trauma to sac, cover with moist dressing, prevent hypothermia
❖ Resp. anomalies
➢ Choanal Atresia
■ Narrowing of nasal airway by membrane or bony tissue
■ Result= resp. distress, asphyxia, poss. Death
■ Unilateral or bilateral
■ Unknown cause
■ Can’t suck and breathe at same time; turn blue when feeding
■ Rx: surgery
➢ Congenital diaphragmatic hernia
■ Abd. Contents herniate into thoracic cavity thru defect in diaphragm
■ Respiratory Distress
■ Lungs can’t expand, may not have developed completely
■ May have other system anomalies
■ Rx: surgery, NPO, O2, ET intubation, VS, IV, I/O, check weight
❖ GI structural anomalies
➢ Cleft Lip/Palate (prev. discussed)
➢ Esophageal Atresia & Tracheoesophageal Fistula
■
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Esophagus and trachea don’t separate normally…may also have CHD, anorectal and GU
anomalies…. no known cause but may be seen with preemies and polyhydramnios
pregnancies
■ Upper segment ends in blind pouch, doesn’t meet lower segment, or narrowing, or fistula
forms between esophagus and trachea
■ Cough, choke, turn blue with feeds, drool, resp. arrest, aspiration pneumonia
■ 3 C’s” cough, choke, cyanosis
■ Rx: surgery
➢ Omphalocele
■ Defect of umbilical ring- abdominal contents (bowel with peritoneal covering) eviscerate
into external peritoneal sac
■ Assoc. with other anomalies; trisomy 12,18,21
➢ Gastroschisis
■ Herniation of abd. contents through abd. wall defect (left or right of umbilicus)
■ Not assoc. with other anomalies
■ No peritoneal sac to protect organs
■ Thickened, edema, inflammation- >high morbidity and mortality
■ Rx: surgery
➢ Imperforate anus
■ Malformation, high or low
■ Blind pouch or fistulas, rx: surgery
❖ GU structural anomalies
➢ Hypospadias (prev. discussed)
➢ Epispadius (prev. discussed)
➢ Bladder Exstrophy
■ Bladder protrudes into abdominal wall; clean with NS after diaper change, cover with
non-adherent dressing
■ Separated rectus abdominis muscles
■ Usually see epispadias too- males
■ Rx: surgery reconstruction, until surgery clean with NS after diaper changes and cover
with sterile non-adherent dressing
❖ Musculoskeletal structural abnormalities.
➢ Clubfoot (talipes equinovarus)
■ Inversion & adduction of forefoot
■ Inversion of heel and hindfoot
■ Limited extension of ankle & subtalar joint
■ Internal rotation of leg
■ Rx: Casting after birth- plaster casts, also use prolonged bracing
■ Surgery possible…minor, used less than previously
➢ Developmental Hip Dysplasia
■ Abnormal growth/development. of hip
■ Unstable, dislocated, or malformed
■ “short” leg, uneven gluteal/leg folds, limited hip abduction, unequal knee height if bend
knees when infant lying down
■ Ortolani’s sign and Barlow’s maneuver
■ Rx: Pavlik harness
■ Stabilize hip, prevents adduction
■