Ch. 10 - Fetal Development & genetics - LEARNING OBJECTIVES
Characterize the process of fertilization, implantation, and cell differentiation: For conception
to occur, a healthy ovum from the woman is released from the ovary, passes into an open
fallopian tube, and starts its journey downward. Sperm from the male is deposited into the
vagina and swims approximately 7 in to meet the ovum at the outermost portion of the
fallopian tube, the area where fertilization takes place. This process occurs in about an hour.
Implantation occurs 7 to 10 days after conception in the endometrium. The embryonic stage of
development begins at day 15 after conception and continues through week 8.
Examine the functions of the placenta, umbilical cord, and amniotic fluid: While the placenta
is developing (end of the second week), the umbilical cord is also formed from the amnion. It
contains one large vein and two small arteries. Wharton jelly (a specialized connective tissue)
surrounds these three blood vessels in the umbilical cord to prevent compression, which would
cut off fetal blood and nutrient supply. The precursor cells of the placenta—the trophoblasts—
first appear 4 days after fertilization as the outer layer of cells of the blastocyst. The
trophoblasts make human chorionic gonadotropin (hCG), a hormone that ensures that the
endometrium will be receptive to the implanting embryo. Enough amniotic fluid help maintain
a constant body temperature for the fetus, permit symmetric growth and development,
cushion the fetus from trauma, allow the umbilical cord to be relatively free from compression,
and promote fetal movement to enhance musculoskeletal development. Too little amniotic
fluid (<500 mL at term), termed oligohydramnios, too little amniotic fluid (<500 mL at term),
termed oligohydramnios, is associated with uteroplacental insufficiency, fetal renal
abnormalities, and a higher risk of surgical births and low–birth-weight infants. Too much
amniotic fluid (>2,000 mL at term), termed hydramnios, is associated with maternal diabetes,
neural tube defects, chromosomal deviations, and malformations of the central nervous system
and/or gastrointestinal tract that prevent normal swallowing of amniotic fluid by the fetus.
Chorionic gonadotropin (CG)—preserves the corpus luteum and its progesterone production so
that the endometrial lining of the uterus is maintained; this is the basis for pregnancy tests.
Prolactin—mediates maternal metabolic adaptations to pregnancy by regulating insulin
production and sensitivity; and plays an important role in lactation. Human placental lactogen
(hPL)—modulates fetal and maternal metabolism, participates in the development of maternal
breasts for lactation, and decreases maternal insulin sensitivity to increase its availability for
fetal nutrition. Estrogen (estriol)—causes enlargement of a woman’s breasts, uterus, and
external genitalia; stimulates myometrial contractility. Progesterone (progestin)—maintains
the endometrium, decreases the contractility of the uterus, stimulates maternal metabolism
and breast development, provides nourishment for the early conceptus. Relaxin—is a potent
vasodilator and regulates maternal hemodynamics. It acts synergistically with progesterone to
maintain pregnancy, causes relaxation of the pelvic ligaments, softens the cervix in preparation
for birth
Outline normal fetal development from conception through birth: Zygotic stage: fertilization
of sperm and egg through the second week. Blastocyst stage: Zygote divides into a solid ball of
cells which attaches to the uterus. Embryonic stage: Major organs and structures begin to
emerge by end of the second week through the eighth week. Fetal stage: Differentiation and
structures specialize by end of the eighth week until birth. The average pregnancy lasts 280
days from the first day of the last menstrual period. The fetal stage is the time from the end of
the eighth week until birth. WEEK 3: Beginning development of brain, spinal cord, and heart.
Beginning development of the gastrointestinal tract. Neural tube forms, which later becomes
the spinal cord. Leg and arm buds appear and grow out from body. WEEK 4: Brain
differentiates. Limb buds grow and develop more. Stomach, pancreas, and liver begin to form.
WEEK 5: Heart now beats at a regular rhythm. Beginning structures of eyes and ears. Some
cranial nerves are visible. Muscles innervated. WEEK 6: Beginning formation of lungs. Fetal
circulation established. Liver produces RBCs. Further development of the brain. Primitive
skeleton forms. Central nervous system forms. Brain waves detectable. WEEK 7: Straightening
of trunk. Nipples and hair follicles form. Elbows and toes visible. Arms and legs move.
Diaphragm formed. Fetal heartbeat can be heard. Mouth with lips and early tooth buds. WEEK
8: Rotation of intestines. Facial features continue to develop. Heart development complete.
Resembles a human being. WEEKS 9–12: Sexual differentiation continues. Buds for all 20
temporary teeth laid down. Digestive system shows activity. Head comprises nearly half the
fetus size. Face and neck are well formed. Urogenital tract completes development. Red blood
cells are produced in the liver Urine begins to be produced and excreted. Fetal gender can be
determined by week 12. Limbs are long and thin; digits are well formed. WEEKS 13–16: A fine
hair develops on the head called lanugo. Fetal skin is almost transparent. Bones become harder.
Head still dominant. Fetus makes active movement. Sucking motions are made with the mouth.
Amniotic fluid is swallowed. Fingernails and toenails present. Weight quadruples. Fetal
movement (also known as quickening) detected by mother. WEEKS 17–20: Rapid brain growth
occurs. Fetal heart tones can be heard with stethoscope. Kidneys continue to secret urine into
amniotic fluid. Vernix caseosa, a white greasy film, covers the fetus Eyebrows and head hair
appear. Sebaceous glands appear. Brown fat deposited to help maintain temperature. Nails are
present on both fingers and toes. Muscles are well developed. WEEKS 21–24: Eyebrows and
eyelashes are well formed. Fetus has a hand grasp and startle reflex. Alveoli forming in lungs.
Body is lean but well proportioned. Skin is translucent and red. Lungs begin to produce
surfactant. WEEKS 25–28: Fetus reaches a length of 15 in. Rapid brain development. Eyelids
open and close. Nervous system controls some functions. Fingerprints are set. Blood formation
shifts from spleen to bone marrow. Fetus usually assumes head-down position. WEEKS 29–32:
Rapid increase in amount of body fat. Increased central nervous system control over body
functions. Rhythmic breathing movements occur. Lungs are not fully mature. Fetus stores iron,
calcium, and phosphorus. WEEKS 33–38: Testes are in scrotum of male fetus. Lanugo begins to
disappear. Increase in body fat. Fingernails reach the ends of fingertips. Small breast buds are
present on both sexes. Mother supplies fetus with antibodies against disease. Fetus is
considered full term at 38 weeks. Fetus fills uterus.
Compare the various inheritance patterns, including nontraditional patterns of inheritance:
Analyze examples of ethical and legal issues surrounding genetic testing:
Research the role of the nurse in genetic counseling and genetic-related activities:
Ch. 11 - Maternal Adaptation during Pregnancy - LEARNING OBJECTIVES
Differentiate between subjective (presumptive): What the mom says – Amenorrhea, tired,
enlarged breasts, urinary frequency, quickening perceived, emesis & nausea. objective
(probable) what the doctor says – Positive pregnancy test with high levels of hCG hormone,
ballottement is returning of the fetus when the uterus is pushed up, Braxton Hick’s
contractions, Goodell’s sign is a softened cervix, Chadwick’s sign is a bluish color of the cervix,
Hegar’s sign is a lower uterine segment soft, and enlarged uterus. Diagnostic (positive) signs of
pregnancy: Fetal movement palpated by dr or RN, fetal heart tones, delivery of the baby,
ultrasounds detect baby, seeing visible movement. 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 known as quickening (16–20 weeks), Uterine enlargement (7–12 weeks), Breast
enlargement (6 weeks). Probable (Time of Occurrence) Braxton Hicks contractions (16–28
weeks), Positive pregnancy test (4–12 weeks), Abdominal enlargement (14 weeks),
Ballottement (16–28 weeks), Goodell sign (5 weeks), Chadwick sign (6–8 weeks),Hegar sign (6–
12 weeks). 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).
Describe maternal physiologic changes that occur during pregnancy: Human chorionic
gonadotropin (hCG)• Responsible for maintaining the maternal corpus luteum, which secretes
progesterone and estrogens with synthesis occurring before implantation• Production by fetal
trophoblast cells until the placenta is developed sufficiently to take over that function• Basis for
early pregnancy tests because it appears in the maternal bloodstream soon after implantation•
Production peaks at 8 weeks and then gradually declines. hPL (also known as human chorionic
somatomammotropin [hCS]): • Preparation of mammary glands for lactation and involved in
the process of making glucose available for fetal growth by altering maternal carbohydrate, fat,
and protein metabolism • Antagonist of insulin because it decreases tissue sensitivity or alters
the ability to use insulin • Increase in the amount of circulating free fatty acids for maternal
metabolic needs and decrease in maternal metabolism of glucose to facilitate fetal growth
Relaxin: • Secretion by the placenta as well as the corpus luteum during pregnancy • Thought
to act synergistically with progesterone to maintain pregnancy • Increase in flexibility of the
pubic symphysis, permitting the pelvis to expand during delivery • Dilation of the cervix, making
it easier for the fetus to enter the vaginal canal; thought to suppress the release of oxytocin by
the hypothalamus, thus delaying the onset of labor contractions. Progesterone: • Often called
the “hormone of pregnancy” because of the critical role it plays in supporting the endometrium
of the uterus • Supports the endometrium to provide an environment conducive to fetal
survival • Produced by the corpus luteum during the first few weeks of pregnancy and then by
the placenta until term • Initially, causes thickening of the uterine lining in anticipation of
implantation of the fertilized ovum; from then on, it maintains the endometrium, inhibits
uterine contractility, and assists in the development of the breasts for lactation. Estrogen: •
Promotes enlargement of the genitals, uterus, and breasts, and increases vascularity, causing
vasodilatation • Relaxation of pelvic ligaments and joints • Associated with hyperpigmentation,
vascular changes in the skin, increased activity of the salivary glands, and hyperemia of the
gums and nasal mucous membranes • Aids in developing the ductal system of the breasts in
preparation for lactation.
Ch. 12 - Nursing Management during Pregnancy - LEARNING OBJECTIVES
Relate the information typically collected at the initial prenatal visit.
Prepare an appropriate reproductive life plan based on a couple’s risk profile.
Select the assessments completed at follow-up prenatal visits.
Evaluate the tests used to assess maternal and fetal well-being, including nursing
management for each.
Outline appropriate nursing management to promote maternal self-care and to minimize the
common discomforts of pregnancy.
Examine the key components of perinatal education.
Ch. 13 – Labor & the birth process - LEARNING OBJECTIVES
Identify premonitory signs of labor.
Compare and contrast true versus false labor.
Categorize the critical factors affecting labor and birth.
Analyze the cardinal movements of labor.
Evaluate the maternal and fetal responses to labor and birth.
Examine the concept of pain as it relates to the woman in labor.
Classify the stages of labor and the critical events in each stage.
Characterize the normal physiologic/psychological changes occurring during all four stages of
labor.
Ch. 14 – Nursing Management during Labor - LEARNING OBJECTIVES
Examine the measures used to evaluate maternal status during labor and birth.
Discuss the advantages and disadvantages of external and internal fetal monitoring, including
the appropriate use for each.
Choose appropriate nursing interventions to address the categories of fetal heart rate patterns.
Outline the nurse’s role in fetal assessment.
Appraise the various comfort promotion and pain relief strategies used during labor and birth.
Summarize the assessment data collected upon admission to the perinatal unit.
Relate the ongoing assessments involved in each stage of labor and birth.
Analyze the nurse’s role throughout the labor and birth process.
Exam 2 Study guide - MOD 3 & MOD 4
Ch. 15 – Postpartum Adaptations - LEARNING OBJECTIVES – MOD 3
Examine the systemic physiologic changes occurring in the woman after childbirth.
Integrate dimensions of postpartum care for the multicultural family.
Determine the psychological changes that occur in women in the postpartum period.
Plan postpartum nursing care with interventions to foster maternal–infant bonding.
Assess the phases of maternal role adjustment and accompanying behaviors.
Analyze the psychological adaptations occurring in the mother’s partner after childbirth.
Ch. 16 - Nursing management during the Postpartum period - LEARNING OBJECTIVES – MOD 3
Characterize the normal physiologic and psychological adaptations to the postpartum period.
Determine the parameters that need to be assessed during the postpartum period.
Compare and contrast bonding to the attachment process.
Select behaviors that enhance or inhibit the attachment process.
Outline nursing management for the woman and her family during the postpartum period.
Examine the role of the nurse in promoting successful breastfeeding.
Plan areas of health education needed for discharge planning, home care, and follow-up.
Ch. 17 - Newborn Transitioning - LEARNING OBJECTIVES – MOD 3
*Examine the major physiologic changes that occur as the newborn transitions to
extrauterine life.
- Although the transition usually takes place within the first 6 to 10 hours of life, many
adaptations take weeks to attain full maturity. The newborn’s most dramatic and most rapid
extrauterine transitions occur in four interdependent areas: circulatory, respiratory,
thermoregulation, and their ability to stabilize their blood glucose levels.
*Describe the cardiovascular changes that take place from fetal circulation to extrauterine
circulation after birth.
-Cardiovascular System Adaptations: The umbilical vein carries oxygenated blood from the
placenta to the fetus. The ductus venosus allows most of the umbilical vein blood to bypass the
liver and merge with blood moving through the vena cava, bringing it to the heart sooner. The
foramen ovale allows more than half the blood entering the right atrium to cross immediately
to the left atrium, bypassing the pulmonary circulation. The ductus arteriosus connects the
pulmonary artery to the aorta, which allows bypassing of the pulmonary circuit. Only a small
portion of blood passes through the pulmonary circuit for the main purpose of perfusion of the
structure, rather than for oxygenation. The fetus depends on the placenta to provide oxygen
and nutrients and to remove waste products.
Fetal to Neonatal Circulation Changes During the first few minutes after birth, the newborn’s
heart rate is approximately 110 to 160 bpm. It is usually highest after birth and reaches a
plateau within a week after birth. Cardiac defects may be identified in the newborn nursery by
conducting a thorough and systematic physical assessment, including inspection, palpation,
auscultation, and measurement of blood pressure and oxygen saturations.
*Interpret the factors that influence the initiation of newborn respirations.
Before the newborn’s lungs can maintain respiratory function, certain events must occur:
Initiation of respiratory movement. Expansion of the lungs. Establishment of functional residual
capacity (ability to retain some air in the lungs on expiration). Increased pulmonary blood flow.
Redistribution of cardiac output. Hypercapnia, hypoxia, and acidosis resulting from normal
labor become stimuli for initiating respirations.
Surfactant is a surface tension–reducing lipoprotein found in the newborn’s lungs that prevents
alveolar collapse at the end of expiration and loss of lung volume.
Passage through the birth canal allows intermittent compression of the thorax, which helps
eliminate two thirds of the fluid in the lungs. Pulmonary capillaries and the lymphatics remove
the remaining fluid. If fluid is removed too slowly or incompletely (e.g., with decreased thoracic
squeezing during birth or diminished respiratory effort), transient tachypnea (respiratory rate
above 60 bpm) of the newborn occurs. Examples of situations involving decreased thoracic
compression and diminished respiratory effort include cesarean birth and sedation in
newborns.
Respirations: After respirations are established in the newborn, they are shallow and irregular,
ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds).
TAKE NOTE! Apneic periods lasting more than 15 seconds with cyanosis and heart rate changes
require further evaluation
TAKE NOTE! A neonate born by cesarean section does not have the same benefit of the birth
canal squeeze as does the newborn born by vaginal birth. Closely observe the respirations of
the newborn after cesarean births.
*Relate characteristics that predispose newborns to heat loss after birth.
On average, a newborn’s temperature ranges from 97.9°F to 99.7°F (36.6°C to 37.6°C). Skin-toskin contact should be the first line of treatment for hypothermia and as a measure to establish
successful breastfeeding immediately after birth.
Newborns have several characteristics that predispose them to heat loss: thin skin with blood
vessels close to the surface. Increased skin permeability to water. Lack of shivering ability to
produce heat until 3 months old. Limited stores of metabolic substrates (glucose, glycogen, fat).
Limited use of voluntary muscle activity or movement to produce heat. Large surface area-tobody mass ratio. Lack of subcutaneous fat, which provides insulation. Little ability to conserve
heat by changing posture (fetal position). No ability to adjust their own clothing or blankets to
achieve warmth. Inability to communicate that they are too cold or too warm.
Ways to heat loss in newborn: CONDUCTION - Conduction involves the transfer of heat from
one object to another when the two objects are in direct contact with each other. CONVECTION
- Convection involves the flow of heat from the body surface to cooler surrounding air or to air
circulating over a body surface. EVAPORATION - Evaporation involves the loss of heat when a
liquid is converted to vapor. Evaporative loss may be insensible (such as from skin and
respiration) or sensible (such as from sweating). RADIATION - Radiation involves the loss of
body heat to cooler, solid surfaces that are in proximity but not in direct contact with the
newborn.
Effects of Cold Stress in the Newborn’s Brown Fat Metabolism: The newborn first experiences
an increase in norepinephrine in response to a cold environment. This then influences the
triglycerides to stimulate brown fat metabolism. Brown adipose tissue is a unique tissue that
can convert chemical energy directly into heat when activated by the sympathetic nervous
system.
Cold stress in the newborn can lead to the following problems if not reversed: depleted brown
fat stores, increased oxygen and glucose consumption, respiratory distress, depletion of
glycogen leading to hypoglycemia, pulmonary vasoconstriction, metabolic acidosis, jaundice,
hypoxia, and decreased surfactant production
TAKE NOTE! Nurses must be aware of the thermoregulatory needs of the newborn and must
ensure that these needs are met to provide the newborn with the best start possible.
Maintenance of temperature stability should be focused on preventative measures.
To minimize the effects of cold stress, the following interventions are helpful: Prewarming
blankets and hats to reduce heat loss through conduction. Keeping the infant transporter
(warmed isolette) fully charged and always heated. Drying the newborn completely after birth
to prevent heat loss from evaporation. Encouraging skin-to-skin contact with the mother if the
newborn is stable. Promoting early breastfeeding to provide fuels for no shivering
thermogenesis. Using heated and humidified oxygen. Always using radiant warmers and double
wall isolettes to prevent heat loss from radiation. Deferring bathing until the newborn is
medically stable and using a radiant heat source while bathing.
*Distinguish primary immunoglobulins that help strengthen the newborn’s immunologic
system.
The newborn is protected from certain infections, in part because of maternal antibodies
circulating in their systems until about 6 months of age. Immunoglobulin G (IgG) crosses the
placenta to the fetus while in utero. Healthy infants begin to produce their own antibodies
starting at 2 to 3 months of age. Responses of the immune system serve three purposes:
defense (protection from invading organisms), homeostasis (elimination of worn-out host
cells), and surveillance (recognition and removal of enemy cells).
Acquired immunity involves two primary processes: (1) the development of circulating
antibodies or immunoglobulins capable of targeting specific invading agents (antigens) for
destruction and (2) formation of activated lymphocytes designed to destroy foreign invaders.
Acquired immunity is absent until after the first invasion by a foreign organism or toxin. IgG is
the major immunoglobulin and the most abundant, making up about 80% of all circulating
antibodies. It is the only class able to cross the placenta, with active placental transfer
beginning at approximately 20 to 22 weeks’ gestation. IgG produces antibodies against
bacteria, bacterial toxins, and viral agents. IgA is the second most abundant immunoglobulin
in the serum. IgA does not cross the placenta, and maximum levels are reached during
childhood. IgA is predominantly found in the gastrointestinal and respiratory tracts, tears,
saliva, colostrum, and breast milk.
TAKE NOTE - A major source of IgA is human breast milk, so breastfeeding is believed to have
significant immunologic advantages over formula feeding. Breast milk has high levels of IgA
that is thought to contribute to the colonization of the infant gut microbiome.
*Determine the primary challenges faced by the newborn during the transition to
extrauterine life.
A period of decreased responsiveness (30 minutes to 3 hours) with rapid shallow respirations,
lower heart rate, decreased muscle activity interspersed with jerks and twitches and sleep.
Damage to the nervous system (e.g., from birth trauma, perinatal hypoxia) during the birthing
process can cause delays in the normal growth, development, and functioning of the newborn.
Early identification may help to identify the cause and facilitate start early intervention to
decrease long-term complications or permanent sequelae.
*Differentiate the behavioral patterns that newborns progress through after birth.
The newborn usually demonstrates a predictable pattern of behavior during the first several
hours after birth, characterized by two periods of reactivity separated by a sleep phase. First
Period of Reactivity: The first period of reactivity begins at birth and may last from 30
minutes up to 2 hours. This period is characterized by myoclonic movements of the eyes,
spontaneous Moro reflexes, sucking motions, chewing, rooting, and fine tremors of the
extremities. Muscle tone and motor activity are increased. Respiration and heart rate are
elevated but gradually begin to slow as the next period begins. Many newborns latch on the
nipple and suck well at this first experience.
Period of Decreased Responsiveness: At 30 to 120 minutes of age, the newborn enters the
second stage of transition—that of the sleep period or a decrease in activity. Movements are
less jerky and less frequent. Heart and respiratory rates decline as the newborn enters the
sleep phase. The muscles become relaxed, and responsiveness to outside stimuli diminishes.
During this phase, it is difficult to arouse or interact with the newborn. No interest in sucking is
shown. This quiet time can be used for both mother and newborn to remain close and rest
together after labor and the birthing experience.
Second Period of Reactivity: The second period of reactivity begins as the newborn awakens
and shows an interest in environmental stimuli. This period lasts 2 to 8 hours in the normal
newborn. Interaction between the mother and the newborn during this second period of
reactivity is encouraged if the mother has rested and desires it. This period also provides a good
opportunity for the parents to examine their newborn and ask questions.
TAKE NOTE! Teaching about feeding, positioning for feeding, and diaper-changing techniques
can be reinforced during the second period of reactivity.
*Assess the typical behavioral responses triggered by external stimuli of the newborn.
How they react to the world around them is termed a neurobehavioral response. Expected
newborn behaviors include orientation, habituation, motor maturity, self-quieting ability, and
social behaviors. Any deviation in behavioral responses requires further assessment because it
may indicate a complex neurobehavioral problem.
Orientation: The response of newborns to stimuli is called orientation. Orientation reflects
newborns’ response to auditory and visual stimuli, demonstrated by their movement of head
and eyes to focus on that stimulus. Newborns prefer the human face and bright shiny objects.
As the face or object comes into their line of vision, newborns respond by staring at the object
intently.
Habituation: is the newborn’s ability to process and respond to visual and auditory stimuli.
During the first 24 hours after birth, newborns should increase their ability to habituate to
environmental stimuli and sleep. Habituation provides a useful indicator of neurobehavioral
intactness.
Motor Maturity: depends on gestational age and involves evaluation of posture, tone,
coordination, and movements. These activities enable newborns to control and coordinate
movement. When stimulated, newborns with good motor organization demonstrate
movements that are rhythmic and spontaneous. Bringing the hand up to the mouth is an
example of good motor organization. Such motor behavior is a good indicator of the
newborn’s ability to respond and adapt accordingly, it indicates that the CNS is processing
stimuli appropriately.
Self-Quieting Ability: also called self-soothing, refers to newborns’ ability to quiet and comfort
themselves. “Consolability” is how newborns can change from the crying state to an active
alert, quiet alert, drowsy, or sleep state. They console themselves by hand-to-mouth
movements and sucking, alerting to external stimuli, and motor activity. Recent research
outlines five things (the five “Ss”) that parents can do to calm a fussy infant: Swaddling
tightly, Side/stomach position on the lap of the caregiver, shushing loudly or continuous white
noise, Swinging using any rhythmic movement, Sucking.
KEY CONCEPTS: The neonatal period is defined as the first 28 days of life. As the newborn
adapts to life after birth, numerous physiologic changes occur.
At birth, the cardiopulmonary system must switch from fetal to neonatal circulation and from
placental to pulmonary gas exchange.
One of the most crucial adaptations that the newborn makes at birth is the adjustment of a
fluid medium exchange from the placenta to the lungs and that of a gaseous environment.
Neonatal RBCs have a lifespan of 80 to 100 days in comparison with the adult RBC lifespan of
120 days. This difference in RBC lifespan causes several adjustment problems.
Thermoregulation is the maintenance of balance between heat loss and heat production. It is a
critical physiologic function that is closely related to the transition and survival of the newborn.
The newborn’s primary method of heat production is through nonshivering thermogenesis, a
process in which brown fat (adipose tissue) is oxidized in response to cold exposure. Brown fat
is a special kind of highly vascular fat found in all humans.
Heat loss in the newborn is the result of four mechanisms: conduction, convection,
evaporation, and radiation.
Responses of the immune system serve three purposes: defense (protection from invading
organisms), homeostasis (elimination of worn-out host cells), and surveillance (recognition and
removal of enemy cells).
In the newborn, congenital reflexes are the hallmarks of maturity of the CNS, viability, and
adaptation to extrauterine life.
The newborn usually demonstrates a predictable pattern of behavior during the first several
hours after birth, characterized by two periods of reactivity separated by a sleep phase.
Ch. 18 - Nursing Management of the Newborn; LEARNING OBJECTIVES – MOD 3
*Perform the assessments needed during the immediate newborn period.
Assessment - The initial newborn assessment is completed in the birthing area to determine
whether the newborn is stable enough to stay with the parents or whether resuscitation or
other immediate interventions are necessary.
The RAPP assessment (respiratory activity, perfusion/color, and position/tone) provides a
method to swiftly evaluate the newborn’s condition so that decisions can be made regarding
newborn stability.
A second assessment may be performed within the first 2 to 4 hours, when the newborn is
admitted to the nursery or the labor and birth room. A third assessment is usually completed
before discharge. The purpose of these assessments is to determine the newborn’s overall
health status.
During the initial newborn assessment, look for signs that might indicate a problem, including
Nasal flaring. Chest retractions, grunting on exhalation, Labored breathing, Generalized
cyanosis, Abnormal breath sounds: rhonchi, crackles (rales), wheezing, and stridor. Abnormal
respiratory rates (tachypnea, more than 60 breaths/min; bradypnea, less than 25 breaths/min),
Flaccid body posture, Pallor, Apneic episodes, Abnormal heart rates (tachycardia, more than
160 bpm; bradycardia, less than 100 bpm), abnormal newborn size: small or large for
gestational age.
Apgar Scoring: Used worldwide to evaluate a newborn’s physical condition at 1 minute and 5
minutes after birth. 10 min if the 5 minute is > 7. Five parameters are assessed with Apgar
scoring.
A: appearance (color). P: pulse (HR). G: grimace (reflex irritability). A:
activity (muscle tone). R: respiratory (respiratory effort). Each parameter is assigned a score
ranging from 0 to 2 points. A score of 0 points indicates an absent or poor response; a score of
2 points indicates a normal response. A normal newborn’s score should be 8 to 10 points.
Scores of 4 to 7 points signify moderate difficulty and scores of 0 to 3 points represent severe
distress in adjusting to extrauterine life.
TAKE NOTE! Although Apgar scoring is done at 1 and 5 minutes, it can also be used as a guide
during the immediate newborn period to evaluate the newborn’s status for any changes
because it focuses on critical parameters that must be assessed throughout the early transition
period.
Length and Weight: length range of a full-term newborn is usually 44 to 55 cm (17 to 22 in)
Typically, the term newborn weighs 2,500 to 4,000 g (5 lb, 8 oz to 8 lb, 14 oz.) Birth weights less
than 10% or more than 90% on a growth chart are outside the normal range and need further
investigation.
Newborns can lose up to 10% of their initial birth weight by 3 to 4 days of age secondary to
loss of meconium, extracellular fluid, and limited food intake.
Newborns are classified by birth weight regardless of their gestational age: Low birth weight:
>2,500 g (>5.5 lb). Very low birth weight: >1,500 g (>3.5 lb). Extremely low birth weight:
>1,000 g (>2.5 lb)
Vital Signs: Heart rate, obtained by taking an apical pulse for 1 full minute, typically is 110 to
160 bpm. The newborn respiratory rate is 30 to 60 breaths/min with symmetric chest
movement. Heart and respiratory rates are usually assessed every 30 minutes until stable for
2 hours after birth. Vital signs are assessed at birth, within 1 to 4 hours after birth. In term
newborns, the normal axillary temperature range should be at 97.7° to 99.5° F (36.5° to 37.5°
C). Blood pressure is not usually assessed as part of a normal newborn examination unless
there is a clinical indication or low Apgar scores. If needed, then the typical range is 50 to 75
mm Hg (systolic) and 30 to 45 mm Hg (diastolic).
Gestational Age Assessment: Gestational age is determined by using a tool such as the Ballard
gestational age assessment or Ballard Scale. A score is assigned to the various parameters, and
the total score corresponds to a maturity rating in weeks of gestation.
Points are given for each assessment parameter, with a low score of –1 point or –2 points for
extreme immaturity to 4 or 5 points for postmaturity. The scores from each section are added
to correspond to a specific gestational age in weeks. The physical maturity section of the
examination is done during the first 2 hours after birth. The physical maturity assessment
section of the Ballard examination evaluates physical characteristics that appear different at
different stages depending on a newborn’s gestational maturity. The areas assessed on the
physical maturity examination include Skin texture—typically ranges from sticky and
transparent to smooth, with varying degrees of peeling and cracking, to parchment-like or
leathery with significant cracking and wrinkling. Lanugo—soft downy hair on the newborn’s
body, which is absent in preterm newborns, appears with maturity, and then disappears again
with postmaturity. Plantar creases—creases on the soles of the feet, which range from absent
to covering the entire foot, depending on maturity (the greater the number of creases, the
greater the newborn’s maturity). Breast tissue—the thickness and size of breast tissue and
areola (the darkened ring around each nipple), which range from being imperceptible to full
and budding. Eyes and ears—eyelids can be fused, or open and ear cartilage and stiffness
determine the degree of maturity (the greater the amount of ear cartilage with stiffness, the
greater the newborn’s maturity). Genitals—in males, evidence of testicular descent and
appearance of scrotum (which can range from smooth to covered with rugae) determine
maturity; in females, appearance and size of clitoris and labia determine maturity (a prominent
clitoris with flat labia suggests prematurity, whereas a clitoris covered by labia suggests greater
maturity).
The neuromuscular maturity section typically is completed within 24 hours after birth. Six
activities or maneuvers that the newborn performs with various body parts are evaluated to
determine the newborn’s degree of maturity: Posture—How does the newborn hold his or her
extremities in relation to the trunk? The greater the degree of flexion, the greater the maturity.
For example, extension of arms and legs is scored as 0 points and full flexion of arms and legs is
scored as 4 points. Square window—How far can the newborn’s hands be flexed toward the
wrist? The angle is measured and scored from more than 90 degrees to 0 degrees to determine
the maturity rating. As the angle decreases, the newborn’s maturity increases. For example, an
angle of more than 90 degrees is scored as –1 point and an angle of 0 degrees is scored as 4
points. Arm recoil—How far do the newborn’s arms “spring back” to a flexed position? This
measure evaluates the degree of arm flexion and the strength of recoil. The reaction of the arm
is then scored from 0 to 4 points based on the degree of flexion as the arms are returned to
their normal flexed position. The higher the points assigned, the greater the neuromuscular
maturity (e.g., recoil less than a 90-degree angle is scored as 4 points). Popliteal angle—How
far will the newborn’s knees extend? The angle created when the knee is extended is
measured. An angle of less than 90 degrees indicates greater maturity. For example, an angle of
180 degrees is scored as –1 point and an angle of less than 90 degrees is scored as 5 points.
Scarf sign—How far can the elbows be moved across the newborn’s chest? An elbow that does
not reach midline indicates greater maturity. For example, if the elbow reaches or nears the
level of the opposite shoulder, this is scored as –1 point; if the elbow does not cross the
proximate axillary line, it is scored as 4 points. Heel to ear—How close can the newborn’s feet
be moved to the ears? This maneuver assesses hip flexibility: the lesser the flexibility, the
greater the newborn’s maturity. The heel-to-ear assessment is scored in the same manner as
the scarf sign.
After the scoring is completed, the 12 scores are totaled and then compared with standardized
values to determine the appropriate gestational age in weeks. Scores range from very low in
preterm newborns to very high for mature and postmature newborns. Typically, newborns are
also classified according to their gestational age as: Preterm or premature—born prior to 37
completed weeks’ gestation, regardless of birth weight. Term—born between 38 and 42 weeks’
gestation. Post-term or postdates—born after completion of week 42 of gestation.
Postmature—born after 42 weeks and demonstrating signs of placental aging. Using the
information about gestational age and then considering birth weight, newborns can also be
classified as follows: Small for gestational age (SGA)—weight less than the 10th percentile on
standard growth charts (usually >5.5 lb). Appropriate for gestational age (AGA)—weight
between 10th and 90th percentiles. Large for gestational age (LGA)—weight more than the
90th percentile on standard growth charts (usually >9 lb).
TAKE NOTE! Gestational age assessment is important because it allows the nurse to plot growth
parameters and to anticipate problems related to prematurity, postmaturity, and growth
abnormalities.
*Employ interventions that meet the immediate needs of the term newborn.
Maintaining Airway Patency: the newborn’s mouth is suctioned first with a bulb syringe to
remove debris and then the nose is suctioned. Suctioning in this manner helps prevent
aspiration of fluid into the lungs by an unexpected gasp.
TAKE NOTE! Always keep a bulb syringe near the newborn in case he or she develops sudden
choking or a blockage in the nose. It may be lifesaving.
Ensuring Proper Identification: Infant abductions have commonly been given security code
names such as “Code Pink” in many hospitals. Before the newborn and family leave the birthing
area, be sure that agency policy about identification has been followed. Typically, the mother,
the newborn, and the father or any significant other or support person of the mother’s
choosing receive ID bracelets. The newborn commonly receives two ID bracelets, one on a wrist
and one on an ankle.
Many states have stopped requiring newborn footprints, and thus other means of identification
are needed, such as collecting cord blood at the time of birth for DNA testing; facial biometric
recognition, and live scans to capture digital forensic-quality prints that are suitable for
identification purposes.
Administering Prescribed Medications: During the immediate newborn period, two
medications are commonly ordered: vitamin K and eye prophylaxis with either erythromycin or
tetracycline ophthalmic ointment.
VITAMIN K: Prophylactic treatment of newborns with intramuscular vitamin K has been the
standard of care for decades in the United States. Vitamin K, a fat-soluble vitamin, promotes
blood clotting by increasing the synthesis of prothrombin by the liver. A deficiency of this
vitamin delays clotting and might lead to hemorrhage. Supplementation of vitamin K at birth
has been recommended in the United States since 1961 and successfully reduces the risk of
bleeding in newborns. Generally, the bacteria of the intestine produce vitamin K in adequate
quantities. However, the newborn’s bowel is sterile, so vitamin K is not produced in the
intestine until after microorganisms have been introduced, such as with the first feeding.
Usually, it takes about a week for the newborn to produce enough vitamin K to prevent vitamin
K deficiency bleeding.
The efficacy of vitamin K in preventing early vitamin K deficiency bleeding is firmly established
and has been the standard of care since the AAP recommended it in the early 1960s. The
American Academy of Pediatrics (AAP, 2019) recommends that vitamin K be administered to all
newborns soon after birth in a single intramuscular dose of 0.5 to 1 mg.
EYE PROPHYLAXIS: All newborns in the United States, whether delivered vaginally or by
cesarean birth, must receive an installation of a prophylactic agent in their eyes within an hour
or two of birth. This is mandated in all 50 states to prevent ophthalmia neonatorum, which can
cause neonatal blindness. Ophthalmia neonatorum is a hyperacute purulent conjunctivitis
occurring during the first 10 days of life. It is usually contracted during birth when the baby
encounters vaginal discharge of the mother infected with gonorrhea and chlamydia. Most
often both eyelids become swollen and red with purulent discharge. Prophylactic agents that
are currently recommended (and in most states legally required) include erythromycin 0.5%
ophthalmic ointment in a single application. Regardless of which agent is used, instillation
should be done as soon as possible after birth.
TAKE NOTE! Ophthalmia neonatorum is a severe form of conjunctivitis caused by chlamydia
and/or gonococcal infections that is potentially a blinding condition in newborns.
Maintaining Thermoregulation: Newborns have trouble regulating their temperature;
especially during the first few hours after birth. Use of a Radiant Heater in Preventing
Newborn Heat Loss. A 1-day-old infant should have adequate thermoregulation to remain out
of the radiant heater. The best way to prevent heat loss is to ensure that the infant does not
come in contact with cold surfaces. Assess body temperature frequently during the immediate
newborn period. The baby’s temperature should be taken every 30 minutes for the first 2
hours or until the temperature has stabilized, and then every 8 hours until discharge or follow
hospital protocols. Nursing interventions to help maintain body temperature include Dry the
newborn immediately after birth to prevent heat loss through evaporation. Wrap the baby in
warmed blankets to reduce heat loss via convection. Skin-to-skin contact with mother as soon
as stabilized. Use a warmed cover on the scale to weigh the unclothed newborn. Warm
stethoscopes and hands before examining the baby or providing care. Avoid placing newborns
in drafts or near air vents to prevent heat loss through convection. Delay the initial bath until
the baby’s temperature has stabilized to prevent heat loss through evaporation. Avoid placing
cribs near cold outer walls to prevent heat loss through radiation. Put a cap on the newborn’s
head after it is thoroughly dried after birth. Place the newborn under a temperature-controlled
radiant warmer.
Assessment: The newborn requires ongoing assessment after leaving the birthing area to
ensure that his or her transition to extrauterine life is progressing without problems.
Perinatal History: Review the maternal history because it provides pertinent information, such
as the presence of certain risk factors that could affect the newborn. Historical information
usually includes the following: Mother’s name, medical record number, blood type, serology
result, rubella and hepatitis status, and history of substance abuse. Other maternal tests that
are relevant to the newborn and care, such as human immunodeficiency virus (HIV) and group
B streptococcus status. Intrapartum maternal antibiotic therapy (type, dose, and duration).
Maternal illness that can affect the pregnancy, evidence of chorioamnionitis, maternal use of
medications such as steroids. Prenatal care, including timing of first visit and subsequent visits.
Risk for blood group incompatibility, including Rh status and blood type. Fetal distress or any
nonreassuring fetal heart rate patterns during labor. Known inherited conditions such as sickle
cell anemia and phenylketonuria (PKU). Birth weights of previous live-born children, along with
identification of any newborn problems. Social history, including tobacco, alcohol, and
recreational drug use. History of depression or domestic violence. Cultural factors, including
primary language and educational level. Pregnancy complications associated with abnormal
fetal growth, fetal anomalies, or abnormal results from tests of fetal well-being. Information on
the progress of labor, birth, labor complications, duration of ruptured membranes, and
presence of meconium in the amniotic fluid. Medications given during labor, at birth, and
immediately after birth. Time and method of delivery, including presentation and the use of
forceps or a vacuum extractor. Status of the newborn at birth, including Apgar scores at 1 and 5
minutes, the need for suctioning, weight, gestational age, vital signs, and umbilical cord status.
Medications administered to the newborn Postbirth maternal information, including placental
findings, positive cultures, and presence of fever
*Demonstrate the components of a typical physical examination of a newborn.
A typical physical examination of a newborn includes a general survey of skin color, posture,
state of alertness, head size, overall behavioral state, respiratory status, gender, and any
obvious congenital anomalies. ANTHROPOMETRIC MEASUREMENTS: Length - The average
length of most newborns is 50 cm (20 in), but it can range from 44 to 55 cm (17 to 22 in).
Weight - At birth the average newborn weighs 3,400 g (7.5 lb), but normal birth weights can
range from 2,500 to 4,000 g (5 lb, 8 oz to 8 lb, 13 oz). Weight is affected by racial origin,
genetics, maternal age, size of the parents, maternal nutrition, maternal weight prenatally, and
placental perfusion. Head Circumference - The average newborn head circumference is 32 to
38 cm (13 to 15 in).
TAKE NOTE: Head circumference may need to be remeasured later if the shape of the head is
altered from birth.
The head circumference should be approximately one fourth of the newborn’s length or about
half the infant’s body length plus 10 cm. Expected head circumference for a term infant is
between 32 and 37 cm (12.5 and 14.5 in).
Chest Circumference: The chest circumference is generally 1 to 2 cm less than the head
circumference.
TAKE NOTE: The head and chest circumferences are usually equal by about 1 year of age.
VITAL SIGNS: In the newborn, temperature, pulse, and respirations are monitored frequently
and compared with baseline data obtained immediately after birth. Generally, vital signs
(excluding blood pressure) are taken: On admission to the nursery or in the labor and birth
room after the woman /parents are allowed to hold and bond with the newborn. Once every 30
minutes until the newborn has been stable for 2 hours. Then once every 4 to 8 hours until
discharge.
SKIN: The newborn’s skin is similar in structure to the adults, but many of the functions are not
fully developed. Skin Condition and Color: Check skin turgor by pinching a small area of skin
over the chest or abdomen and note how quickly it returns to its original position. The
newborn’s skin often appears blotchy or mottled, especially in the extremities. Persistent
cyanosis of fingers, hands, toes, and feet with mottled blue or red discoloration and coldness is
called acrocyanosis. Newborn Skin Variations: While assessing the skin, make note of any
rashes, ecchymoses or petechiae, nevi, or dark pigmentation. Vernix caseosa, Stork bites or
salmon patches, Milia, Mongolian spots, Erythema toxicum, Harlequin sign, Nevus flammeus,
Nevus vasculosus.
*Distinguish common variations that may be noted during a newborn’s physical examination.
Variations in head size and shape in the newborn: Variations – Molding, Caput succedaneum
(crosses the suture line. scalp swelling), Cephalhematoma. Abnormalities - Microcephaly,
Macrocephaly, Large, small, or closed fontanels.
*Characterize common concerns in the newborn and appropriate interventions.
Transient tachypnea of the newborn: Respiratory condition that results from incomplete
reabsorption of fetal lung fluid in fullterm newborns. Usually disappears within 24 to 48 hours.
Intervention: Providing oxygen, ensuring warmth, Observing respiratory status frequently,
Allowing time for pulmonary capillaries and the lymphatics to remove the remaining fluid.
Physiologic jaundice: ? Hypoglycemia: is an abnormally low level of glucose in the blood (< 45
mg/dL [< 2.5 mmol/L]). Normal blood glucose reference interval is 45 to 60mg/dL (2.5 to 3.4
mmol/L) in a 1-day-old newborn and 50 to 90 mg/dL (2.9 to 5.1 mmol/L) in a newborn older
than 1 day (institutional values for normal newborn blood glucose levels vary). Intervention:
Prevent low blood glucose level through early feedings. Administer formula orally or glucose
intravenously as prescribed. Monitor blood glucose levels as prescribed. Monitor for feeding
problems. Monitor for apneic periods. Assess for shrill or intermittent cries. Evaluate lethargy
and poor muscle tone.
*Compare the importance of the newborn screening tests.
PKU (after 24 hours of life), Congenital hypothyroidism, Galactosemia, Sickle cell anemia.
*Plan for common interventions that are appropriate during the early newborn period.
General newborn care, Bathing and hygiene, Gloves, Plain water on face and eyes; mild soap for
rest of body, Elimination, and diaper area care - Urine characteristics, Stool pattern, Diaper
area care. Cord care, Circumcision care, Safety, Prevention of abduction, Car safety, Infection
prevention, Sleep promotion, Bonding.
*Analyze the nurse’s role in meeting the newborn’s nutritional needs.
Physiologic changes, Nutritional needs, Calories, Fluid requirements, feeding method choice,
Feeding the newborn, Frequency, Measures to decrease air swallowing.
Breast feeding: Composition, Assistance, Positioning, Education, Storage and expression,
Concerns, Sore nipples, Engorgement, Mastitis. LATCH SCORE and interventions
Bottle feeding: Types of formula, Assistance, Positioning, Education, Weaning and
introduction of solid foods.
*Outline discharge planning content and education needed for the family with a newborn.
Preparing for discharge, Education, Cultural considerations, follow up care, Return visit,
Warning signs and symptoms, Immunization information. Car test.
KEY CONCEPTS: The period of transition from intrauterine to extrauterine life occurs during the
first several hours after birth. It is a time of stabilization for the newborn’s temperature,
respiration, and cardiovascular dynamics.
The newborn’s bowel is sterile at birth. It usually takes about a week for the newborn to
produce vitamin K in sufficient quantities to prevent VKDB.
It is recommended that all newborns in the United States receive an installation of a
prophylactic agent (erythromycin or tetracycline ophthalmic ointment) in their eyes within an
hour or two of being born.
Nursing measures to maintain newborns’ body temperature include drying them immediately
after birth to prevent heat loss through evaporation, wrapping them in prewarmed blankets,
putting a hat on their head, and placing them under a temperature-controlled radiant warmer.
The specific components of a typical newborn examination include a general survey of skin
color, posture, state of alertness, head size, overall behavioral state, respiratory status, gender,
and any obvious congenital anomalies.
Gestational age assessment is pertinent because it allows the nurse to plot growth parameters
and to anticipate potential problems related to prematurity/postmaturity and growth
abnormalities such as SGA/LGA.
After the newborn has passed the transitional period and stabilized, the nurse needs to
complete ongoing assessments, vital signs, weight and measurements, cord care, hygiene
measures, newborn screening tests, and various other tasks until the newborn is discharged
home from the birthing unit.
Important topics about which to educate parents include environmental safety, newborn
characteristics, feeding and bathing, circumcision and cord care, sleep and elimination patterns
of newborns, safe infant car seats, holding/positioning, and follow-up care.
Newborn screening tests consist of hearing and certain genetic and inborn errors of metabolism
tests required in most states for newborns before discharge from the birth facility.
The AAP and the American Dietetic Association recommend breastfeeding exclusively for the
first 6 months of life and that it continue along with other food at least until the first birthday.
Parents who choose not to breastfeed need to know what types of formula are available,
preparation and storage of formula, equipment, feeding positions, and how much to feed their
infant.
Common problems associated with the newborn include transient tachypnea, physiologic
jaundice, and hypoglycemia.
Transient tachypnea of the newborn appears soon after birth; is accompanied by retractions,
expiratory grunting, or cyanosis; and is relieved by low-dose oxygen.
Physiologic jaundice is a very common condition in newborns, with the majority demonstrating
yellowish skin, mucous membranes, and sclera within the first 3 days of life. Newborns
undergoing phototherapy in the treatment of jaundice require close monitoring of their body
temperature and fluid and electrolyte balance; observation of skin integrity; eye protection;
and parental participation in their care.
The newborn with hypoglycemia requires close monitoring for signs and symptoms of
hypoglycemia if present. In addition, newborns at high risk need to be identified based on their
perinatal history, physical examination, body measurements, and gestational age.
The schedule for immunizations should be reviewed with parents, stressing the importance of
continual follow-up health care to preserve their infant’s health.
Ch. 19 - Nursing Management of Pregnancy at Risk; Pregnancy-related complications
LEARNING OBJECTIVES – MOD 4
Compare and contrast a normal pregnancy to a high-risk one. Determine the common factors
that might place a pregnancy at high risk.
Examples of high-risk conditions include gestational diabetes, hypertension, polycystic ovary
syndrome, autoimmune disease, obesity, HIV/AIDS, Zika infection, older or younger age,
substance abuse, tobacco use, birth defects, previous preterm birth, multiple gestation, and
ectopic pregnancy. High-Risk pregnancy is when conditions exist that put the mother, fetus, or
both at risk. These women have a higher morbidity & mortality compared to other mothers in
this population. Assess and identify risk factors at the first antenatal visit. Risk assessment with
first antepartal visit; and ongoing.
High-Risk Complications in pregnancy: Hemorrhage is the biggest reason for mortality in the
obstetrical population so early recognition, assessment and resuscitation is a valuable skill for a
nurse. Hemorrhage - Early recognition. Early assessment. Early resuscitative management.
Familiarity with nursing management. Early Bleeding-patient education: Complications of sex
in the presence of placenta previa.
Know your pharmacologic methods to aid uterine contractions (manage hemorrhage)
OXYTOCIN, ERGOMETRINE, PROSTAGLANDINS, along with surgical methods (arterial ligations,
compression sutures and balloon tampanade).
Uterotonics: OXYTOCIN 10 units/ml: •Side Effects: Nausea, vomiting, hyponatremia (“water
intoxication”) with prolonged IV administration. BP and HR with high doses, especially IV push.
Contraindication: Hypersensitivity to drug. Dosing: IV: 10-40 units per 500-1000 ml, rate
titrated to uterine tone. METHERGINE 0.2mg/ml: Side Effects: Nausea, vomiting, Severe
hypertension, esp. if given IV, which is not recommended. Contraindications: Hypertension,
Preeclampsia, Cardiovascular disease, hypersensitivity to drug. Caution if multiple doses of
ephedrine have been used, may exaggerate hypertensive response w/possible cerebral
hemorrhage. Dosing: IM: 0.2mg (NOT to be given IV); Q 2-4 hours. TRANEXAMIC ACID
1000mg/10ml: Side Effect: Visual defects (eg, color vision change, visual loss) and retinal
venous and arterial occlusions. Contraindication: Hypersensitivity to drug. Prevents enzymes in
the body from breaking down blood clots. Recommended for the treatment of obstetric
hemorrhage when initial therapy fails. Dosing: IV: 1000mg over 10 minutes given within 3 hours
of vaginal birth or c/s. If bleeding continues after 30 minutes or stops and restarts within 24
hours after first dose, a second dose of 1000mg may be given. ERGOMETRINE: a medication
used to cause contractions of the uterus to treat heavy vaginal bleeding after childbirth. Side
effects: Nausea, vomiting, abdominal pain, diarrhea; headache, dizziness; tinnitus; chest pain,
palpitation, bradycardia, transient hypertension, and other cardiac arrhythmias; dyspnea,
sometimes rashes, shock. Contraindication: severe or persistent sepsis, patients with
peripheral vascular disease or heart disease, hypertension or a history of hypertension,
impaired hepatic or renal function exists.
Factors Placing a Woman at Risk During Pregnancy: Biophysical Factors - Genetic conditions,
Chromosomal abnormalities, Multiple pregnancy, Defective genes, Inherited disorders,
Cardiovascular disease, Infection, Diabetes. Psychosocial Factors: Smoking, Caffeine, Alcohol
and substance abuse, maternal obesity, Inadequate support system. Sociodemographic
Factors: Poverty status, Lack of prenatal care, Age younger than 15 years or older than 35
years, Parity—All first pregnancies and more than five pregnancies, Marital status—Increased
risk for unmarried women, Accessibility to health care, Ethnicity—Increased risk in non-White
women. Environmental Factors: Infections, Radiation, Pesticides, Illicit drugs, Industrial
pollutants, Second-hand cigarette smoke, personal stress.
Detect the causes of vaginal bleeding during early and late pregnancy.
Bleeding during anytime of a pregnancy is concerning. Conditions commonly associated with
the first half of pregnancy. Low beta-hCG levels are suggestive of an ectopic pregnancy or
impending abortion. Normal pregnancy hCG levels double every 2-4 days and peak at 60-90
days.
Outline nursing assessment and management for the pregnant woman experiencing vaginal
bleeding.
Spontaneous Abortion: A stillbirth is the loss of a fetus after the 20th week of development,
while a miscarriage is a loss before the 20th week. Non-medical term for spontaneous
abortion is miscarriage. Spontaneous abortion is the most common complication of early
pregnancy. Loss of an early pregnancy or first trimester: most common cause is fetal genetics &
chromosomal abnormalities. Usually occurs before 20 weeks gestation. Abortions are either
spontaneous or induced (elective or therapeutically induced by procedure). Incidence increases
with maternal age. Most 2nd trimester losses are related to more maternal disease.
Nursing assessment: Vaginal bleeding, Cramping or contractions, Vital signs, pain level, Client’s
understanding. When a pregnant woman calls and reports vaginal bleeding, she must be seen
as soon as possible by a health care professional to ascertain the etiology. Ask the woman
about the color of the vaginal bleeding (bright red is significant) and the amount—for
example, question her about the frequency with which she is changing her peripads (saturation
of one peripad hourly is significant) and the passage of any clots or tissue. Instruct her to save
any tissue or clots passed and bring them with her to the health care facility. Also, obtain a
description of any other signs and symptoms the woman may be experiencing, along with a
description of their severity and duration.
Nursing Management: Woman with a spontaneous abortion focuses on providing continued
monitoring and psychological support because the family is experiencing acute loss and grief.
PROVIDING CONTINUED MONITORING: Monitor the amount of vaginal bleeding through pad
counts and observe for passage of products of conception tissue. Assess the woman’s pain and
provide appropriate pain management to address the cramping discomfort. Assist in preparing
the woman for procedures and treatments such as surgery to evacuate the uterus or
medications such as misoprostol or prostaglandin E2 (PGE2). If the woman is Rh-negative and
not sensitized, expect to administer RhoGAM within 72 hours after the abortion is complete.
PROVIDING SUPPORT: Explaining some of the causes of spontaneous abortions can help the
woman understand what is happening and may allay her fears and guilt that she did something
to cause the pregnancy loss.
Pathophysiology: The most common cause for first-trimester abortions is fetal genetic
abnormalities, usually unrelated to the mother. Chromosomal abnormalities are more likely
causes in the first trimester and maternal disease is more likely in the second trimester. Those
occurring during the second trimester are more likely related to maternal conditions, such as
cervical insufficiency, congenital or acquired anomaly of the uterine cavity (uterine septum or
fibroids), hypothyroidism, diabetes mellitus, chronic nephritis, use of cocaine, inherited and
acquired thrombophilias, lupus, polycystic ovary syndrome, severe hypertension, and acute
infection such as that of rubella virus, cytomegalovirus, herpes simplex virus, bacterial
vaginosis, and toxoplasmosis.
Spontaneous abortion, Ectopic pregnancy, Gestational trophoblastic disease, Cervical
insufficiency all happen prior to 20 weeks. Placenta previa, Abruptio placentae, After 20th
week of gestation.
Ectopic Pregnancy: Fertilized ovum implants outside the uterine cavity due to obstructive or
slow passage through the fallopian tube to the uterus. Medical drug therapy: methotrexate,
prostaglandins, misoprostol, and actinomycin - will stimulate uterine contraction to terminate
the pregnancy. Monitor side effect, assess vaginal bleeding, monitor for signs and symptoms of
shock. Surgery: remove the tube if ruptured. Attempt to preserve the tube. At risk for
hemorrhage. Administer RhoGam: Why? Administer IM in deltoid area. Suppress immune
response of nonsensitized Rh negative moms & prevent isoimmunization.
Nursing assessment: Hallmark sign: abdominal pain with spotting within 6 to 8 weeks after
missed menses.
The embryo grows and pulls blood supply from the abnormal site where it is implanted so the
signs and symptoms vary. Most common site of implantation is the fallopian tubes. S&S:
Missed menstrual period, Pelvic fullness, Tenderness, Non-specific pain, Ectopic pregnancy can
lead to massive hemorrhage, infertility, or death. Nursing management: Preparation for
treatment, Analgesics for pain, Medications for medical treatment, Teaching about signs and
symptoms of rupture, Surgery , Emotional support, Education regarding prevention: (smoking
cessation, STI’s, increasing age). Contributing factors? Laboratory and diagnostic testing:
transvaginal ultrasound, serum beta hCG; additional testing to rule out other conditions.
TAKE NOTE: The hallmark of ectopic pregnancy is abdominal pain with spotting within 6 to 8
weeks after a missed menstrual period. Although this is the classic triad, all three of these signs
and symptoms occur in only about 50% of cases. Many women have symptoms typical of early
pregnancy, such as breast tenderness, nausea, fatigue, shoulder pain, and low back pain.
Gestational Trophoblastic Disease - Two types: Hydatidiform mole (partial or complete) - egg is
fertilized but replicates all 46 paternal chromosomes so it dies and there is no fetal tissue. Most
women present with vaginal bleeding, anemia, excessively large uterus, hyperemesis &
preeclampsia. Choriocarcinoma: possible results from the mole (chorionic malignancy from the
trophoblastic tissue) Frequent sites of metastases are lungs, lower GI tract, brain & liver. Exact
cause unknown. Therapeutic management: Immediate evacuation of uterine contents (D&C),
Long-term follow-up and monitoring of serial hCG levels. Nursing assessment: Clinical
manifestations similar to spontaneous abortion at 12 weeks. Ultrasound visualization. High hCG
levels. Nursing management: Preoperative preparation, Emotional support. Education:
treatment, serial hCG monitoring, prophylactic chemotherapy.
Cervical Insufficiency: Premature dilation of cervix. Cause unknown; possibly due to cervical
damage. Therapeutic management: Bed rest, pelvic rest, avoidance of heavy lifting. Cervical
cerclage: ACOG supports placement up to 28 weeks. Premature dilation or incompetent cervix
(might hear this term): Weak structure that spontaneously dilates in the absence of uterine
contractions. May occur in 2nd trimester or early 3rd trimester. Results in loss of pregnancy.
Cervical length shortening is associated. Possible resulting in preterm birth. Performed
transvaginally. Nursing assessment: Risk factors - Hypoplasia (underdevelopment) of the cervix,
Cervical trauma, Precipitous birth, Prolonged 2nd stage of labor, Increased amounts of relaxin &
progesterone, Increased uterine volume (multiple gestation & hydramnios). Pink-tinged vaginal
discharge or pelvic pressure. Cervical shortening via transvaginal ultrasound. Nursing
management: Continuing surveillance; close monitoring for preterm labor Emotional support,
Education. TAKE NOTE: The diagnosis of cervical insufficiency remains difficult in many
circumstances. The cornerstone of diagnosis is a history of a pregnancy loss during the second
or early third trimester associated with painless cervical dilation without evidence of uterine
activity.
Purse string closure (MacDonald procedure): Cerclage treatment is usually in conjunction with
progesterone supplementation. This treatment is recommended by ACOG for women that: Hx
of 2nd trimester pregnancy loss with painless dilation. Prior cerclage placement for the same
diagnosis. Hx of spontaneous preterm birth before 34 weeks gestation. Painless cervical
dilatation on physical exam in 2nd trimester.
Shirodkar Cerclage (Shoelaces). Complications with both: ROM and Chorioamnionitis.
Placenta Previa: Cause unknown; placenta implants over cervical os. Therapeutic
management: dependent on bleeding, amount of placenta over os, fetal development and
position, maternal parity, labor signs and symptoms. Nursing assessment: Risk factors, Vaginal
bleeding (painless, bright red in second or third trimester, spontaneous cessation then
recurrence) Nursing management: Monitoring of maternal–fetal status. Vaginal bleeding; pad
count, Avoidance of vaginal exams, FHR. Support and education: fetal movement counts,
effects of prolonged bed rest (if necessary); signs and symptoms to report. Preparation for
possible cesarean birth. Total or Complete placenta previa will always necessitate a C/Section.
This patient should absolutely get no vaginal examinations.
Placenta is implanted over the cervical. Bleeding disorder that occurs during the last two
trimesters of pregnancy. Chances of placenta previa rises with each cesarean section.
Consequences with Previa: Hemorrhage-Bright red painless bleeding, Abruption, Emergency
C/S. Classifications of previa are located on p679 figure 19.4 (classified by their degree of
coverage)
Placenta previa is classified according to the degree of coverage or proximity to the internal
os. Total placenta previa-completely covers internal os. Partial placenta previa-partial covers
internal os. Marginal placenta previa-at the margin or edge of the internal os. Low-lying
placenta previa- implanted in lower uterine segment, near internal os but does not reach it.
Abruptio Placentae: Separation of placenta leading to compromised fetal blood supply.
Etiology unknown, Classification, Therapeutic management: assessment, control, and
restoration of blood loss; positive outcome; prevention of DIC. Premature separation of a
normally implanted placenta after the 20th week of gestation prior to birth. Leads to
hemorrhage, Considered a medical emergency, severe abdominal pain, Rigid abdomen and
tenderness in all 4 quadrants, Bleeding may or may not be, present (depends on where the
placenta is implanted), Classified as mild, moderate & severe. Etiology is unknown but
suspicions of degenerative changes are possible. Risk factors: Experience abdominal trauma,
Smokers, Use of cocaine during pregnancy, Over the age of 35, Preeclampsia or hypertension,
History of previous placental abruption, Abnormalities in the uterus, Pregnant with multiple
gestations. Pathophysiology: Abruption occurs when the maternal vessels tear away from the
placenta and bleeding occurs between the uterine lining and the maternal side of the placenta.
As the blood accumulates, it pushes the uterine wall and placenta apart. If the abruption
continues, loss of placental function results in fetal hypoxia and possibly fetal death. Nursing
assessment: Risk factors, Bleeding (dark red), Pain (knife like), uterine tenderness, contractions,
Fetal movement, and activity (decreased), FHR, Laboratory, and diagnostic testing: CBC:
Determines the current hemodynamic status; however, it is not reliable for estimating acute
blood loss. Fibrinogen levels: Typically, are increased in pregnancy (hyperfibrinogenemia); thus,
a moderate dip in fibrinogen levels might suggest DIC, and if profuse bleeding occurs, the
clotting cascade might be compromised. PT/aPTT: Prothrombin time (PT)/activated partial
thromboplastin time (aPTT): Determines the client’s coagulation status, especially if surgery is
planned. Type and cross-match: Determines blood type if a transfusion is needed. Nonstress
test: Demonstrates findings of fetal jeopardy manifested by late decelerations or bradycardia.
Biophysical profile: Aids in evaluating clients with chronic abruption; a low score (less than 6
points) suggests possible fetal compromise. Rapid assessment & prompt, effective
interventions are needed to prevent maternal & fetal morbidity & mortality. This woman needs
two large bore IV’s: Lactated Ringers – tend to use LR more because it combats hypovolemia,
Normal saline, frequently assess fetal well-being, Set up for type and cross matching. Nursing
management: Tissue perfusion - left lateral position, strict bed rest, oxygen therapy, vital signs,
fundal height, continuous fetal monitoring. Support and education: empathy, understanding,
explanations, possible loss of fetus, reduction of recurrence. The treatment is intended to
assess, control, and restore the amount of blood lost. Provide a positive outcome for both
mother and newborn, Prevent coagulation disorders.
TAKE NOTE: Vital signs can be within normal range, even with significant blood loss, because a
pregnant woman can lose up to 40% of her total blood volume without showing signs of shock.
HYPEREMESIS GRAVIDARUM: Severe form of nausea and vomiting. Symptoms usually resolve
by week 20. Weight loss >5% of prepregnancy body weight. Dehydration, metabolic acidosis,
alkalosis, and hypokalemia. Therapeutic management: Conservative (diet and lifestyle
changes), Hospitalization with parenteral therapy. Morning sickness describes this when
symptoms are mild and usually affects the quality of life for the woman & her family and usually
dissipates first trimester. Hyperemesis gravidarum severe N&V resulting in dehydration, weight
loss of more than 5% body weight, electrolyte imbalance (ketosis) & hospitalization.
Uncontrollable nausea and vomiting beginning in 1st trimester. Nursing assessment: Onset,
duration, course of N/V; diet history; risk factors, weight, associated symptoms, perception of
situation. Liver enzymes, CBC, BUN, electrolytes, urine specific gravity, ultrasound. Nursing
management: Comfort and nutrition (NPO, IV fluids, hygiene, oral care, I&O) Support and
education: reassurance; home care follow-up. Effects: Decreased placental blood flow.
Decreased maternal blood flow. Acidosis. Preterm labor due to dehydration. If hyperemesis
progresses untreated, it may cause neurologic disturbances, renal damage, dehydration,
ketosis, alkalosis from loss of hydrochloric acid, hypokalemia, retinal hemorrhage, or death.
What are some medications that are safe in pregnancy to help control? Zofran (Ondansetron),
Promethazine, Compazine (causes orthostatic hypotension). Drugs for it: Promethazine
(Phenergan) - Diminishes vestibular stimulation and acts on the chemoreceptor trigger zone
(CTZ). Symptomatic relief of nausea, vomiting, and motion sickness.
TAKE NOTE: Every pregnant woman needs to be instructed to report any episodes of severe
nausea and vomiting or episodes that extend beyond the first trimester.
Develop plans of care for women experiencing preeclampsia, eclampsia, and HELLP
syndrome. P.682
Hypertensive disorders of pregnancy are associated with long-term cardiovascular risks in
women. Gestational: Blood pressure elevation (140/90) after 20 weeks of pregnancy that is not
accompanied by proteinuria. Can progress to preeclampsia. BP returns to normal by 12 weeks
postpartum. If it persists more than 6 weeks after delivery it diagnosed as chronic
hypertension. Treatment is individualized and based on the severity of the disease and fetal age
(viability). This disease is dependent on the presence of trophoblastic tissue (placenta). Therapy
is focused on: Controlling BP, preventing seizures, Preventing long-term morbidity. Preventing
maternal, fetal, or newborn death. Mild preeclampsia management: Bed rest, daily BP
monitoring, and fetal movement counts. Hospitalization; IV magnesium sulfate during labor.
Severe preeclampsia management: Hospitalization; oxytocin and magnesium sulfate;
preparation for birth. Eclampsia management: Seizure management, magnesium sulfate,
antihypertensive agents; birth once seizures controlled. Nursing assessment: risk factors, BP,
nutritional intake, weight, edema; urine for protein; other laboratory tests if indicated. Nursing
management: Home management for mild preeclampsia. Hospitalization for severe
preeclampsia; quiet environment, sedatives, seizure precautions, antihypertensives DTR
testing, assessing for magnesium toxicity and labor. Gestational hypertension can be
differentiated from chronic hypertension, which appears before the 20th week of gestation; or
hypertension before the current pregnancy, which continues after the woman gives birth. Lung
auscultation assessment – crackles ihypertensives DTR testing, assessing for magnesium toxicity
and labor.
Preeclampsia: Preeclampsia can be described as a multisystem, vasopressive disorder that
targets the cardiovascular, hepatic, renal, and central nervous systems. BP >140/90 after 20
weeks at least 4 hours apart on a previously normotensive patient. Accompanied by proteinuria
(>3g/24hr). Pr/cr ratio 0.3 or greater. Can be diagnosed 4-6 weeks postpartum. Severe range
160/110. Multisystem disease process. Generalized vasospasms. Increased peripheral vascular
resistance. Characterized by increased blood pressure. Vasoconstriction. Characterized by signs
of damage to another organ system. Platelet aggregation. Associated with IUGR. Normal
physiologic adaptations to pregnancy are altered in the woman who develops preeclampsia.
Underlying mechanism is Vasospasm – cause BP elevation. Hypoperfusion – hypertension,
proteinuria & edema. Vasospasms reduce the blood vessel diameter & impede blood flow
causing elevation of the blood pressure. Risk Factors for Preeclampsia: First pregnancy, First
pregnancy for father of baby, Men who have fathered one preeclamptic pregnancy Age >35
years, Anemia, Chronic hypertension or preexisting vascular disease, Chronic renal disease
Obesity, Diabetes mellitus, Multifetal pregnancy, Pregnancy from assisted reproductive
techniques. Affected Organs in Preeclampsia: Liver: Decreased circulation impairs the liver
function & causes hepatic edema & subcapsular hemorrhage. When the liver enzymes are
drawn and come back elevated-ALT,AST, Liver dysfunction manifests Epigastric Pain-clinical
symptom. Kidney: Decrease renal perfusion causes reduction in the glomerular filtration rate,
Decrease urine output, Elevated BUN, creatinine, sodium & uric acid. What is your clinical
symptom? Protein in the urine (cellular damage + reduced renal blood flow) Brain:
Vasoconstriction of cerebral vessels cause pressure induced rupture of capillaries. Result in
small hemorrhages & arterial vasospasm. Clinical symptoms-visual disturbances i.e.,
headaches, blurred vision, spots before the eyes, & hyperreflexia (clonus). Placenta: Prolonged
vasospasms, vasoconstriction, IUGR & persistent fetal hypoxemia (late decelerations), Fetal
hypoxia & acidosis. Lungs: Pulmonary edema.
Treatment for Preeclampsia: Magnesium Sulfate, Antihypertensive medication, Consider
induction of labor & delivery. Magnesium sulfate is administered as part of the treatment for
preeclampsia. (Anticonvulsant to reduce the incidence of seizures) Antidote is calcium
gluconate, 160/110 is risk for stroke or congestive heart failure, Labetalol-reduce BP by
blocking the hormone epinephrine (beta-adrenergic blocker), Hydralazine-increase cardiac
output & blood flow to placenta, Nifedipine-calcium channel blocker (blocks calcium to lower
BP), Vaginal delivery is preferred due to depression of coagulation factors & multisystem
involvement. (Surgical risk) If the condition progresses and the management becomes more
aggressive the “cure” is always delivery. The placenta has influence on the disease. Magnesium
Sulfate & Preeclampsia: Most used drug. CNS depressant. Relaxes smooth muscle. Reduces
vasoconstriction. Promotes circulation to maternal vital organs. Increases placental circulation.
Improves diuresis. Blocks neuromuscular transmission & decreased acetylcholine. Excreted
solely through kidneys- with reduced urine output Magnesium accumulate to toxic levels.
Loading dose 4-6 gms IV over 20 min with maintenance dose of 2g/hr (Usual concentration is
20gm Magnesium sulfate/ 500ml NS). Therapeutic serum level is 4-7mg/dl. Causes decreased
FHR variability. Frequent assessment of serum levels, DTR’s, respiratory rate oxygen saturation:
RR >12. Deep tendon relfex’s are diminished but should be present. Prevention of maternal
seizures.
Edema - +1 edema: Minimal edema of the lower extremities. +2 edema: Marked edema of the
lower extremities. +3 edema: Edema of extremities, face & sacral area. +4 edema: Generalized
massive edema includes accumulation of fluid in the peritoneal cavity.
Nursing management (cont.): Seizure management for eclampsia; fetal monitoring; uterine
contraction monitoring; preparation for birth. Follow-up care. Safety: Position on left side.
Protect from injury. Manage a clear airway (suction & oxygen). Monitor fetal heart rate.
Eclampsia: Once stabilized the woman needs to be delivered. Progression of preeclampsia to
onset of generalized seizures. Chronic: Pre-existing elevated blood pressure present prior to
pregnancy (longer than 6 months after pregnancy). Can develop before 20 weeks gestation.
TAKE NOTE: The absolute blood pressure (value that validates elevation) of 140/90 mm Hg
should be obtained on two occasions 4 to 6 hours apart to be diagnostic of preeclampsia.
Proteinuria is defined as 300 mg or more of urinary protein per 24 hours or more than 1+
protein by chemical reagent strip or dipstick of at least two random urine samples collected at
least 4 to 6 hours apart with no evidence of urinary tract infection (UTI) (ACOG, 2019b). TAKE
NOTE: Although edema is not a cardinal sign of preeclampsia, weight should be monitored
frequently to identify sudden gains in a short time span. Current research relies on decreased
organ perfusion, endothelial dysfunction (capillary leaking and proteinuria), and elevated blood
pressure as key indicators (Carson, 2019). TAKE NOTE: Preeclampsia increases the risk of
placental abruption, preterm birth, intrauterine growth restriction, and fetal distress during
childbirth. Always be prepared if you see symptoms of preeclampsia.
HELLP: Hemolysis, Elevated Liver enzymes, Low Platelets. Nursing assessment: like that for
severe preeclampsia; laboratory test results. Nursing management: same as for severe
preeclampsia. Complication in women with severe hypertension during pregnancy. Usually
manifests after delivery. Can occur in the postpartum period. Decreased placental circulation
causing infarcts increasing the risk for abruption & HELLP. Hemolysis: The damaged blood
vessels are small so everything that passes through them become fragmented & distorted.
Elevated liver enzymes: Hepatic blood flow is obstructed by fibrin deposits. Low platelets:
because of the vascular damage from the vasospasms the platelets will aggregate at the
damaged site & cause systemic thrombocytopenia. All the damage congregates in the upper
chest & epigastric area & right upper quadrant, which is the location of the liver causing
tenderness, distention, shoulder pain, nausea, vomiting & sever edema. The liver can rupture
from a subcapsular hematoma resulting in internal bleeding & hypovolemic shock. Must go to
an ICU setting. Treat with RBC’s, platelets & plasma and as you would for preeclampsia. When it
is caught in time, they can recover in about 72 hours.
Describe Rh incompatibility and hemolytic disease of the newborn.P.693
Rh incompatibility is a condition that develops when a woman with Rh-negative blood type is
exposed to Rh-positive blood cells and subsequently develops circulating titers of Rh
antibodies. Nursing Assessment: At the first prenatal visit, determine the woman’s blood type
and Rh status. Also obtain a thorough health history, noting any reports of previous events
involving hemorrhage to delineate the risk for prior sensitization. Nursing Management: If the
indirect Coombs test is negative (meaning no antibodies are present), then the woman is a
candidate for RhoGAM. If the test is positive, RhoGAM is of no value because isoimmunization
has occurred. In this case, the fetus is carefully monitored for hemolytic disease. The current
recommendation is for every Rh-negative nonimmunized woman to receive RhoGAM at some
point between 28- and 32-weeks’ gestation and again within 72 hours after giving birth. Other
indications for RhoGAM include Ectopic pregnancy. Chorionic villus sampling. Amniocentesis,
Prenatal hemorrhage. Molar pregnancy. Maternal trauma. Percutaneous umbilical sampling,
Therapeutic or spontaneous abortion, Fetal death, Fetal surgery.
Examine the pathophysiology of imbalances in amniotic fluid and subsequent management.
P.694
Amniotic fluid develops from several maternal and fetal structures, including the amnion,
chorion, maternal blood, fetal lungs, gastrointestinal tract, kidneys, and skin.
Polyhydramnios, also called hydramnios, is a condition in which there is too much amniotic
fluid (more than 2,000 mL) surrounding the fetus between 32 and 36 weeks. Polyhydramnios
AFI 20-24cm around the fetus (32-36 weeks) Impaired swallowing in the fetus, 18% of all
women with diabetes will develop polyhydramnios during their pregnancy, Associated with
poor fetal outcomes: Increased incidence of preterm births. Fetal malpresentation, Cord
prolapse.
Therapeutic Management: In severe cases in which the woman is in pain and experiencing
shortness of breath, an amniocentesis or artificial rupture of the membranes is done to reduce
the fluid and the pressure. Removal of fluid by amniocentesis is only transiently effective. A
noninvasive treatment may involve the use of a prostaglandin synthesis inhibitor
(indomethacin) to decrease amniotic fluid volume by decreasing fetal urinary output, but this
may cause premature closure of the fetal ductus arteriosus.
Nursing Assessment: Begin the assessment with a thorough history, staying alert to risk factors
such as maternal diabetes or multiple gestations. Review the maternal history for information
about possible fetal anomalies including fetal esophageal or intestinal atresia, neural tube
defects, chromosomal deviations, fetal hydrops, CNS or cardiovascular anomalies, and
hydrocephaly. Polyhydramnios is initially suspected when uterine enlargement, maternal
abdominal girth, and fundal height are larger than expected for the fetus’s gestational age.
Determine the gestational age of the fetus and measure the woman’s fundal height. With
polyhydramnios, there is a discrepancy between fundal height and gestational age, or a rapid
growth of the uterus is noted.
Nursing Management: Nursing management of the woman with polyhydramnios focuses on
ongoing assessment and monitoring for symptoms of abdominal pain, dyspnea, uterine
contractions, and edema of the lower extremities. Explain to the woman and her family that
this condition can cause her uterus to become overdistended and may lead to preterm labor
and prelabor rupture of membranes.
Oligohydramnios is a decreased amount of amniotic fluid (less than 500 mL) between 32- and
36-weeks’ gestation that is associated with poor pregnancy outcomes. The volume of amniotic
fluid increases in a linear fashion until 38 weeks’ gestation to a mean volume of 1,000 mL and
then starts to decrease. AFI<5, Most common in last trimester of pregnancy. Increases fetal risk
of perinatal morbidity& mortality. Reduces ability of the fetus to move freely. Increases cord
compression. Increases intrapartal hypoxia. Often time amnioinfusion is needed to progress
through labor.
Therapeutic Management: The woman with oligohydramnios can be managed on an
outpatient basis with serial ultrasounds and fetal surveillance through nonstress testing and
biophysical profiles.
Nursing Assessment: Review the maternal history for factors associated with oligohydramnios,
including: Uteroplacental insufficiency, Rupture of membranes prior to labor onset,
Hypertension of pregnancy, Maternal diabetes, Intrauterine growth restriction, Post-term
pregnancy, Fetal renal agenesis, Polycystic kidneys, Urinary tract obstructions.
Explore multiple gestation and possible complications for both the mother and fetus. P.695
Multiple Gestation: Two or more fetuses (twins, triplets, quadruplets or higher) - Maternal risk:
Preterm labor, Polyhydramnios, Hyperemesis gravidarum, Anemia, Preeclampsia, Antepartum
hemorrhage. Fetal Risk: Prematurity, Respiratory distress syndrome, Birth asphyxia, Twin to
twin transfusion. Therapeutic management: serial ultrasounds, close monitoring during labor,
operative delivery (common). Nursing assessment: uterus larger than expected for EDB;
ultrasound confirmation. Nursing management: education and support antepartally; labor
management with perinatal team on standby; postpartum assessment for possible
hemorrhage.
Evaluate factors in a woman’s prenatal history that place her at risk for prelabor rupture of
membranes (PROM).P 696
Premature Rupture of Membranes: PROM—women beyond 37 weeks’ gestation. PPROM—
women less than 37 weeks’ gestation. Treatment: dependent on gestational age; no unsterile
digital cervical exams until woman is in active labor; expectant management if fetal lungs
immature. Nursing assessment: risk factors, signs and symptoms of labor, electronic FHR
monitoring, amniotic fluid characteristics. Nitrazine test, fern test, ultrasound.
Chorioamnionitis: Can be the cause and a result of PROM. Under no circumstances should an
unsterile digital exam be performed until the woman enter active labor. High risk problems
associated with rupture of membranes. PPROM: Preterm premature rupture of membranes.
Treat with IV antibiotics x 48 hours (try to get them steroid complete) if patient diabetic they
need to be covered with insulin for about 1 week. Oral antibiotics x 5 days. Usually a
combination of ampicillin and azithromycin. Nursing management: Infection prevention.
Identification of uterine contractions. Education and support. Discharge home (PPROM) if no
labor within 48 hours. With any patient that is ruptured you want to make sure they stay as dry
as possible. Peri care, Changing the chux or linen.
Nursing Care of PTL patient on Magnesium Sulfate: Head to Toe assessment. Assess lungs
every shift and prn. DTR’s, Reassure patient. Provide comfort. Safety measures. Continuous
fetal monitoring surveillance. A lot of tocolytic drugs cause pulmonary edema especially when
used in combination. Deep tendon reflexes may be depressed or less active, but they should
still be present. Comfort from flushing. Weakness & blurred vision & lethargy. Fetal monitoring
(What will happen to the variability?)
KEY CONCEPTS: Identifying risk factors early on and throughout the pregnancy is important to
ensure the best outcome for every pregnancy. Risk assessment should start with the first
prenatal visit and continue with subsequent visits.
The three most common causes of hemorrhage early in pregnancy (first half of pregnancy) are
spontaneous abortion, ectopic pregnancy, and GTD.
Ectopic pregnancies occur in about one in 50 pregnancies and have increased dramatically
during the past few decades.
Having a molar pregnancy results in the loss of the pregnancy and the possibility of developing
choriocarcinoma, a chronic malignancy from the trophoblastic tissue.
The classic clinical picture presentation for placenta previa is painless, bright red vaginal
bleeding occurring during the third trimester.
Treatment of placental abruption is designed to assess, control, and restore the amount of
blood lost; to provide a positive outcome for both mother and infant; and to prevent
coagulation disorders.
DIC can be described in simplest terms as a loss of balance between the clot-forming activity of
thrombin and the clot-lysing activity of plasmin.
Hyperemesis gravidarum is a complication of pregnancy characterized by persistent,
uncontrollable nausea and vomiting before the 20th week of gestation.
Gestational hypertension is the leading cause of maternal death in the United States and the
most common complication reported during pregnancy.
HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets.
Rh incompatibility is a condition that develops when a woman with Rh-negative blood is
exposed to Rh-positive fetal blood cells and subsequently develops circulating titers of Rh
antibodies.
Polyhydramnios occurs in approximately 3% to 4% of all pregnancies and is associated with
fetal anomalies of development.
Nursing care related to the woman with oligohydramnios involves continuous monitoring of
fetal well-being during nonstress testing or during labor and birth by identifying category II and
III patterns on the fetal monitor.
The increasing number of multiple gestations is a concern because women who are expecting
more than one infant are at high risk for preterm labor, hydramnios, hyperemesis gravidarum,
anemia, preeclampsia, and antepartum hemorrhage.
Nursing care related to PROM centers on infection prevention and identification of preterm
labor contractions.
Monitoring maternal vital signs for changes and the fetal heart rate once PPROM occurs is
essential to increasing the changes of a good outcome.
It is essential that nurses educate all pregnant women about how to detect the early signs of
PROM and what action is needed if it happens.
CH. 21 - Nursing management of Labor & Birth at Risk – MOD 4
Identify risk factors associated with dystocia.
Dystocia, or dysfunctional labor is a difficult or abnormal labor related to the five Ps of Labor
(passenger, passageway, powers, position, and psychologic response). Atypical uterine
contraction patterns prevent the normal processes of Labor and its progression. Contractions
can be hypotonic (weak, inefficient, or completely absent) or hypertonic (excessive, frequent,
uncoordinated, and of strong intensity) with inadequate uterine relaxation with failure to efface
and dilate the cervix.
Risk factors: short stature, overweight status, age grater than 40 years, uterine abnormalities,
pelvic soft tissue obstructions or pelvic contracture, cephalopelvic disproportion (fetal head is
larger than maternal pelvis), congenital anomalies, fetal macrosomia, fetal malpresentation,
malposition, multifetal pregnancy, hypertonic or hypotonic uterus, maternal fatigue, fear, or
dehydration, inappropriate timing of anesthesia, or analgesics.
Differentiate the major abnormalities or problems associated with dysfunctional labor
patterns, giving examples of each problem.
Problems with the Powers – When the expulsive forces of the uterus become dysfunctional,
the uterus may either never fully relax (hypertonic contractions), placing the fetus in jeopardy,
or relax too much (hypotonic contractions), causing ineffective contractions.
Hypertonic uterine dysfunction occurs when the uterus never fully relaxes between
contractions. Subsequently, contractions are ineffectual, erratic, and poorly coordinated
because they involve only a portion of the uterus and because more than one uterine
pacemaker is sending signals for contraction.
Hypotonic uterine dysfunction occurs during active labor (dilation more than 5 to 6 cm) when
contractions become poor in quality and lack sufficient intensity to dilate and efface the cervix.
Factors associated with this abnormal labor pattern include overstretching of the uterus, a large
fetus, multiple fetuses, hydramnios, multiple parity, bowel or bladder distention preventing
descent, and excessive use of analgesia.
Protracted disorders refer to a series of events including protracted active phase dilation
(slower-than-normal rate of cervical dilation) and protracted descent (delayed descent of the
fetal head in the active phase). A laboring woman with a slower-than-normal rate of cervical
dilation is said to have a protracted labor pattern disorder. Slow progress may be the result of
cephalopelvic disproportion.
Arrest disorders include secondary arrest of dilation (no progress in cervical dilation in over 2
hours), arrest of descent (fetal head does not descend for more than 1 hour in primiparas and
more than 30 minutes in multiparas), and failure of descent (no descent).
Examine the nursing management for the woman with dysfunctional labor experiencing a
problem with the powers, passenger, passageway, or psyche.
Hypertonic uterine dysfunction – Management: Bed rest and sedation. Evaluate fetal tolerance
to labor patterns. Provide pain management via epidural or IV analgesics.
TAKE NOTE: Prompt recognition and appropriate management of shoulder dystocia can reduce
the severity of injuries to the mother and infant. Immediately assess the infant for signs of
trauma such as a fractured clavicle, Erb palsy, or neonatal asphyxia. Assess the mother for
excessive vaginal bleeding and blood in the urine from bladder trauma.
Nursing Management: Nursing management of the woman with dystocia, regardless of the
etiology, requires patience. The nurse should provide physical and emotional support to the
client and her family. The outcome of any labor depends on the size and shape of the maternal
pelvis; the quality of the uterine contractions; and the size, presentation, and position of the
fetus. Thus, dystocia is diagnosed after labor has progressed for a time, not at the beginning of
labor.
TAKE NOTE: If dysfunctional labor occurs, contractions will slow or fail to advance in frequency,
duration, or intensity; the cervix will fail to respond to uterine contractions by dilating and
effacing; and the fetus will fail to descend.
Devise a plan of care for the woman experiencing preterm labor.
Outline the nontraditional family health care needs and best practices of nursing care to
address them. Pg 778
Outline the nursing assessment and management of the woman experiencing a prolonged
pregnancy.
Discuss the nursing management for the woman undergoing labor induction or
augmentation. Pg. 786
Evaluate the key areas to be addressed when caring for a woman that undergoes a vaginal
birth after cesarean (VBAC). Pg. 792
Identify risk factors associated with fetal demise and the management of the family
experiencing a stillbirth. Pg. 793
Assess obstetric emergencies that can complicate labor and birth, including appropriate
management for each.
Discuss forceps-assisted and vacuum-assisted birth.pg 799
Summarize the plan of care for a woman who is to undergo a cesarean birth. Pg. 800
KEY CONCEPTS: Risk factors for dystocia include epidural analgesia, occiput posterior position,
longer first stage of labor, nulliparity, short maternal stature (shorter than 5 ft tall), high birth
weight, maternal age older than 35 years, gestational age more than 41 weeks,
chorioamnionitis, pelvic contractions, macrosomia, and high station at complete cervical
dilation.
Dystocia may result from problems in the powers, passenger, passageway, or psyche.
Problems involving the powers that lead to dystocia include hypertonic uterine dysfunction,
hypotonic uterine dysfunction, and precipitate labor.
Management of hypertonic labor pattern involves therapeutic rest with the use of sedatives to
promote relaxation and stop the abnormal activity of the uterus.
Any presentation other than occiput or a slight variation of the fetal position or size increases
the probability of dystocia.
A multifetal pregnancy may result in dysfunctional labor due to uterine overdistention, which
may lead to hypotonic dystocia and abnormal presentations of the fetuses.
During labor, evaluation of fetal descent, cervical effacement and dilation, and characteristics
of uterine contractions are paramount to determine progress or lack thereof.
Antepartum assessment for a post-term pregnancy typically includes daily fetal movement
counts done by the woman, nonstress tests done twice weekly, amniotic fluid assessments as
part of the biophysical profile, and weekly cervical examinations to check for ripening for
induction.
Once the cervix is ripe, oxytocin is the most popular pharmacologic agent used for inducing or
augmenting labor.
Generally, the first and most reliable symptom of uterine rupture is fetal distress.
Anaphylactoid syndrome of pregnancy (ASP) is a rare but often fatal event characterized by the
sudden onset of hypotension, hypoxia, and coagulopathy.
Cesarean births have steadily risen in the United States; today, approximately one in three
births occurs this way. It is a major surgical procedure and has increased risks when compared
to vaginal birth.