Chapter 15: Pregnancy
Terminology:
 EDD – estimated date of delivery
 EBD – estimated date of birth
o Naegele’s rule: -3 months/+7 days/+1year
 Subtract and add according to last menstrual period (LMP)
o LMP + 9 months + 7 days
 EDC – estimated date of confinement
 Trimester – length of pregnancy divided into 3-month segments
o 1-14 weeks – 1st trimester
o 12-28 weeks – 2nd trimester
o 28-delivery – 3rd trimester
 GTPAL
o G (gravida): # of pregnancies total
o T (term): # of term infant born ended at term (37 weeks)
o P (preterm): # of pregnancies ended preterm (between 20-37 weeks)
o A (abortion): # of pregnancies that ended in spontaneous/elective abortion
o L (living): # of living children
 G/P
o Gravidity: # of pregnancies in lifetime
o Parity: # of pregnancies carried to viable GA (20-24 week GA)
 Presumptive pregnancy – “might be pregnant”
o Positive pregnancy test at home
o Absence of menses
o N/V, urinary frequency, breast tenderness/enlargement
 Probably pregnancy – “highly likely”
o Positive blood pregnancy test
o Ballottement (tapping lower uterine segment on a bimanual exam elicits fetus to
rise against abd wall)
o Chadwick’s sign (slight bluing of female genitalia; seen as early as 6 wks)
o Hegar’s sign: softening of isthmus (lower portion of uterus); 6-12 wks
 Positive pregnancy – “you’re def pregnant”
o Fetal movement felt by practitioner
o Confirmation of fetus on US; heartbeat (6-8 wks); doppler (12 wks)
Placenta and Umbilical Cord
 Three primary functions
 Circulation
 Deliver o2 and nutrient from mother to fetus
 Removes CO2 and cellular waste from fetal circulation
 Protection
 Transfers mother’s immunoglobulins (immunity)
 Prevents some viruses from entering circulation
 Rubella, substances, and bacterial infections not included (syphilis, parasites, gonorrhea,
etc)
 Hormone production
 Progesterone
 Relaxes muscles of uterus
 Estrogen
 Promotes mother breast development and preps for lactation
 Promotes contraction of myometrium
 Relaxin
 Joint laxity that allows pelvic muscles to move – however, more prone to injury
 Too much can trigger preterm birth
Integumentary
 Striae gravidarum – stretch marks
 Linea nigra – black line starting at pubic symphysis and varies in length
 More common in dark colored women
 Cholasma, “mask of pregnancy,” “melasma”– brownish patches over face
 Sun exposure tends to darken; sunscreen may help
 Can disappear after pregnancy or persist for months or years
 Palmar erythema – redness on soles of feet and palms of hands; harmless/painless
 Telangiectasia – blood vessels near surface of skin
 Hair – thicker, more abundant scalp hair; excessive hair loss within 4 months PP
Endocrine
 Fetus unable to produce own thyroid hormones until 12 weeks GA
 T4 and T3 critical to neurological dvlpmnt
 Insulin increases
 Oxytocin – helps in uterine contractions during and prior to labor; PP helps to prevent
atony and excessive bleeding
Respiratory
 Physiologic respiratory alkalosis; mild hyperventilation
 O2 increases 15-20%
 Dyspnea (SOB) from diaphragm elevating 5 cm; ribcage remodels and expands
 Estrogen = congestion of mucus membranes
 Epistaxis common from engorged capillaries
Cardiovascular
 CO increases 50%
 HR increases 15-20 BPM
 Leukocytosis (not sign of infection)
 Hct – 33-39; Hg – 11-13; WBC count – 9-15
 Supine hypotension – avoid laying flat on back
 Edema
Urinary
 GFR increases 50%
 Growth of uterus = ureters must also grow to retain larger volume of urine
 Blood flow to kidneys increases 80%
GI
 Progesterone slows peristalsis – increases risk of bloating, constipation, N/V
 Weight gain
Reproductive
 Breasts larger, fuller, and tender
 Colostrum production begins midway through pregnancy or earlier
Uterus
 Pattern and rate are predictable between 16-36 weeks; weeks=cm
 Grows from size of egg to grapefruit (10 cm)
 Braxton Hick’s
 Resolve with rest/relaxation, hydration, and ambulation
Vagina
 Chadwick’s sign
 Possible heightening in sexual interest – considered safe in absence of bleeding or ROM
 Leukorrhea – white, thick discharge; odor present okay so long as not fishy or foul or
bloody
Musculoskeletal
 Lordosis – contributes to back pain; increased risk for fall d/t shift in center of gravity
 Accounts for waddling
 Sharp pain at mons pubis from hyperactivity (walking, climbing stairs) – resolves aft
delivery
 Round ligament pain after long period of physical activity
Discomforts of Pregnancy
 Fatigue, lightheadedness, postural hypotension
 Dyspnea, edema, varicose veins, h/a, hemorrhoids
 Temporary carpal tunnel, breast tenderness
 Ptyalism (increased saliva), urinary frequency and incontinence, N/V, food cravings or
aversion (PICA)
 Constipation, back pain
Prenatal Care
 Low risk patient appointments
 Q 4 weeks until 28 week
 Q 2 weeks between 28&36 weeks
 Weekly after 36 weeks
 Appointment includes:
 H&P
 VS & wt
 FHR assessment
 Fundal height measurement after 16 weeks GA
 Pt. education
Nutrition
 Normal BMI (18.6-24.9) should gain 25-35
 Underweight BMI (<18.5) should gain 28-40
 Overweight BMI (25-29.9) should gain 15-25
 Obese (>30) should gain 12lb or less
 By trimester
 1-5 lb in first trimester
 1/lb per week in second and third trimesters
 24 hr nutrition recall is best method
 Avoid fish high in mercury
 Kind mackerel, shark, swordfish, tilefish from gold of Mexico
 Fish low in mercury
 Catfish, cod, light canned tuna, pollock, salmon, shrimp, tilapia
 Teratogenic
 Raw eggs, undercooked meats
 Soft unpasteurized meats, cod cuts
 Raw milk, raw seafood, fish high in mercury
 Alcohol, caffeine
 Saccharin
Toxoplasmosis
 Have someone else manage litter box, if possible; if not, wear disposable gloves
 Carefully wash hand with soap/water after
 Change litter daily bc parasite becomes infectious 1-5 days after it is shed in feces
 Do not obtain new cats during pregnancy
 Keep indoor cats indoors
 Feed car only cat food – no raw meat
Bathing
 Water should remain under 102 degrees
 Soaking no longer than 10 minutes
 Monitor for lightheadedness when coming out of a warm bath
Problems requiring urgent assessment during pregnancy
 Leakage of fluid from vagina
 Vaginal bleeding
 Reduced fetal activity
 h/a that does not improve w/ acetaminophen
 RUQ pain
 Vision changes
 Persistent contractions
 New-onset lower back pain
 Sensation of pelvic pressure
 Menstrual like cramps
 Dysuria
Routine lab tests
 UA
 Diabetes screening
o 24-28 weeks
o 1 step: non-fasting; drink 50g glucose; 1 h later draw BG; if >130 mg/dL
o 2 step: overnight fasting; draw BG; drink 100g glucose; at 1, 2, & 3 h after
ingestion draw BG
 H&H – anemia (Hg <11 and Hct <33% in 1st and 3rd trimester; 2nd = Hg<10.5, Hct <32%


STDs
o Chlamydia and gonorrhea; other is positive early in pregnancy
Group B Streptococcus Screening
o 35-27 weeks
o Rectum and introitus swabbed
Fetal Anomaly Screening
 Ultrasonography – transvaginal or abdominal
o Size, viability, position as appropriate for age
o Placenta size and position
o Biparietal diameter – head measurements
o Placental grade
o Amniotic fluid volume
o Gender
 Nuchal translucency testing (NTT)
o 11 & 13 weeks gestation (1st trimester)
o Measurement of the space at the back of the fetal neck
o Abnormal test = thick neck
 Alpha-fetoprotein (AFP)/ maternal serum AFP (MSAFP)
o 15-20 weeks
o High levels associated with neural tube defects, anencephaly, omphalocele, and
gastroschisis
o Low levels associated with trisomy 21 (down syndrome)
 Quad marker – MSAFP, hCG, estrol level, & inhibin-A
o 15-20 weeks
o Low MSAFP = trisomy 21, high MSAFP = NTD
o High hCG = down syndrome; low hCG = trisomy 18
o Low estriol = down syndrome and some NTD
o High inhibin-A = down syndrome
 cfDNA
o 9 weeks; uses cell-free DNA found in maternal circulation
o Trisomy 21, 13, 18, and abnormality in sex chromosomes
Diagnostic Test
 Amniocentesis – offered to high risk women
o Needle inserted into uterine cavity through abd wall to obtain amniotic fluid
o 15-17 weeks
 If done before 15 weeks, high rate of complications: leaking fluid,
miscarriage, needle injury for fetus, infection
o Used to remove excess amniotic fluid (polyhydramnios)
o Can assess hemolytic anemia and NTS
 Chorionic Villus Sampling (CVS)
o Placental tissue removed for chromosomal, DNA, and metabolic testing
o Ultrasound guidance via needle inserted in the abd or a cath introduced thru
cervix
o 10 weeks
 If done prior fetal loss, maternal bleeding, fetal limb reduction can occur
Chapter 16: Labor and Delivery
Current and past pregnancy status
 Gravida: a pregnant woman
 Multigravida: more than one pregnancy
 Multipara: carries a pregnancy past 20th week of GA or delivered infant weighing > than
500g more than once
 Nullipara: never pregnant prior
 Para: # of pregnancies carried to 20th week of GA or infant weighing > than 500g,
regardless of outcome
 Primigravida: pregnant for first time
 Primipara: formerly or currently pregnant for the first time past 20th week of GA
Components of labor
Five P’s
 Power: uterine factors (contractions and pushing efforts)
o Contraction phases
 Increment: buildup phase (as uterus contract, sensation more acute; longest
phase)
 Acme: peal/shortest, but more acute
 Decrement: relaxation of uterine muscles; second shortest phase
o Pattern of contractions
 Frequency: beginning of one contraction to the beginning of next
 Duration: active, contracting phase
 Intensity: mild (tip of nose), mod (chin), strong (forehead)
 Palpate the abd with fingertips
o Primary powers –
 Effacement – thinning/shortening of cervix; from 2-3 cm long and 1 cm thick
to absent
 Dilation – from 0-10cm; no longer palpable at 10 cm
 Ferguson reflex – urge to push
 Occurs in second stage of labor
o Secondary powers – bearing down efforts; voluntary, controlled by laboring woman
 Do not instruct before full dilation – not productive and cervix can become
edematous
 Passageway: woman’s pelvis (birth canal)
o Bony pelvis
o Soft tissues: cervix, pelvic floor muscles, vagina, introitus (opening of vagina)


Softens and dilated to allow fetal descent
o Engagement and station
 Ischial spines inside of midpelvis are used to describe descent of presenting
part
 Level of ischial spine = zero station
 Fetus engaged = presenting part has reached zero station
 +1 through +5
o +5 = crowning (fetus visible at introitus)
 Negative numbers = above station 0 and not engages
Passenger: fetus
o Size of fetal head: largest and least malleable
o Molding: sutures and fontanels move to change shape of head to accommodate birth
canal
o Fetal presentation and position:
 Fetal presentation: presenting part
 Cephalic presentation: head first
 Breech position: butt/feet first
 Shoulder presentation: shoulder first; not compatible w/ vag birth
 Attitude: position of fetal body parts in relation to each other
 Vertex presentation: general flexion w/ fetal chin on chest
o Most common
 Sinciput presentation (military): fetal chin off chest; neck straight
 Brow presentation: fetal chin off chest; neck extended
 Facial presentation: fetal chin off chest; neck sharply extended
 Fetal lie: similar to fetal presentation
 Longitudinal (vertical): cephalic or breech presentation
 Transverse (horizontal): shoulder presentation
 Oblique: neither cephalic nor transverse; convert during labor
 Fetal position: presenting part r/t maternal pelvis
 First letter: Left (L) or right (R)
 Second letter: Occiput (O) – back of head
o Mentum (M) – brow/face position
o Scapula (Sc) – transverse lie
o Sacrum (S) – breech position
 Third letter: posterior (P); anterior (A); transverse (T)
 Psyche: mother’s mental state
o Anxiety, fear, and stress delay progress of labor
o Labor = shorter when there is continuous support
o Relaxation augments natural process of labor
 Position: maternal position
o Frequent changes in position can relieve fatigue, improve comfort/circulation
o Sharply flexed hips (as if squatting) more conducive to passage of fetus
 Perfusion of uterus/placenta is superior when not in lithotomy position
 Upright/lateral position improve outcomes of labor
o Positions for labor
 Ambulation, leaning forward, sitting in chair, using a birthing ball
Onset of Labor
 Labor = 37-42 weeks
 Stretch Theory
o Uterine muscles stretch = release of prostaglandins
o Fetus on cervix = release of oxytocin
o Contractions = oxytocin & prostaglandins
 Hormones
o ↑ estrogen, ↓ progesterone
o Fetal cortisol = ↓ progesterone = ↑ prostaglandins = contractions
 411 rules for true labor
o New contraction q 4 mins, lasing 1 min, for at least 1 h
o Contact OB if SROM, bleeding, or intense pain
Signs of Labor – not always reliable
 Lightening or dropping – descent of fetal head into pelvis
 Bloody show – mucus streaked with blood
 Increased level of activity (nesting) – urge to organize/clean
 Regular contractions – 411 rule
 Ripening of cervix
 GI distress – heartburn, nausea, diarrhea
 Wt loss: 1-3 lbs prior to onset of labor
Inspection of Amniotic Fluid
 Color
o Normal = clear, may have flecks of white vernix
o Green stained = fetus passed meconium, can lead to fetal compromise (hypoxia)
 Odor
o Should not smell; in case it does, may indicate infection
 Amount
o Scant – trickle
o Moderate – 500 mL
o Large – >1000 mL
Stages of Labor
First stage
Begins with start of regular contractions; SROM or AROM
 Phases:
o Latent: mild contractions; 30-40 sec; minimal discomfort; 0-3cm dilated
 Feels like menstrual cramp + low back pain
o Active: moderate contractions; 30-45 sec; q 3-5 mins; true discomfort; 3-7 cm
 More frequent contractions
o Transition: severe; 40-60 sec; q 1-2 min; intense discomfort; 8-10 cm dilated
 Irritable, out of control, uncooperative, exhausted
 N/V, perspiration on upper lip and forehead
 Assessment: maternal exam
o Hx and chart review
o VS q 1 h
o Labs (blood, urine)
o Uterine contractions (length, intensity, and frequency)
o Physical exam – vaginal discharge (watery? Bloody?) & pain
o IV start (18 gauge)
o Leopold maneuvers – performed if fetal position undetectable by vaginal exam
 Noninvasive method of assessing fetal presentation, position, and attitude
 Place hand on mother abd and locating fetal body parts
o ROM
o Sterile vaginal exam – done to assess for fetal dilation, effacement, fetal station,
presentation, and position
 Dilation: sweep finger from one side of cervical os to other to estimate
distance in cm
 Effacement: estimate length of cervix; 2 cm = 0%, 1 cm – 50%, paper thin
= 100%
 Cervical position: posterior = towards mother’s back (unripe and not
ready for labor); anterior = opening toward vaginal introitus
 Station: same as mentioned before
 Presentation: same as mentioned before
 Fetal position: same as mentioned before
 Nursing care
o Change positions
o Voiding – q2h and assess bladder periodically
o Support – soothing, positive affirmations, reassurance, breathing techniques
 DB during contractions and relax in between
o Pain mgmt.
o Amniotomy (AROM)
Second stage
 Full dilation (10 cm) to birth
 Cardinal Movements
o Engagement, Descent, Flexion, Internal Rotation, Extension, External Rotation,
and Expulsion (Past Question)
 Nursing care
o
o
o
o
FHR q 5-15 mins or after every contraction
Mother’s VS q 1 h
Positioning for birth – according to woman’s preference
Pushing – beginning of the Ferguson reflex (latency period)
 Open glottis pushing: push without holding breath – pos impact on fetal
oxygenation
o Perineal cleaning
o Episiotomy – incision of the perineum to widen introitus (midline or mediolateral)
o Birth – after fetal head is born, OB checks for nuchal cord (umbilical cord
wrapped around neck of fetus)
Third stage
 Birth of infant to delivery of placenta (detaches approx. 5-30 min after neonate is born)
 Nursing care
o Placental delivery – active or passive
 Active: use of uterotonic (oxytocin); early cord clamping; gentle traction
 Passive: without intervention
o Cord clamping and cutting
 Immediate: associated with lower rate of neonatal jaundice
 Delayed: associated with higher birth wt/ Hg, increased CV stability,
possible reduction in NEC and hemorrhage
o Skin to skin
 Should happen immediately after birth or place baby under warmer
o VS Q 15 min, fundal assessment
Fourth stage
 Up to four hours after delivery of placenta
 Nursing care
o Oxytocin
o Perineal repair
o Assessment of fundus, perineum, lochia
 Fundus: tone, position, and location
 Within hour after birth, level of umbilicus
 Each day PP it should descent 1 cm
 Perineum: icepack as tolerated, assess for unusual swelling (Sx of
hematoma)
 Lochia: lochia rubra is common first few days and includes clots
o Recovery after epidural
 Assess bladder function
Cardinal movements
 As the fetus descends, it rotates
 Engagement: zero station – head reaches ischial spines
 Descent: past zero station
 Flexion: head moves so chin touches chest
 Internal rotation: head rotates to align widest part of body w/ widest part of pelvis
 Extension: fetal chin comes off chest; neck arches
 External rotation (restitution): fetus moves to fit through pelvic outlet
 Expulsion: body of fetus is born
Fetal Monitoring
 Assesses fetal wellbeing and condition; looks at FHR
 Normal (reassuring) = positive outcomes
 Abnormal (non-reassuring) = hypoxia which could lead to potential issues
 Intermittent Fetal Monitoring
o Checking FHR at predetermined intervals
o Auscultated on back or doppler US placed on abd
o 30-60 secs after contraction to note baseline HR, accels, and decels
o Not recorded on graph paper
 Continuous Electronic Fetal Monitoring
o Commonly done externally – can limit pts mobility
o Contractions: use tocodynamometer or pressure transducer
 Positioned over uterine fundus
 Less sensitive on obese pts
 Converts pressure exerted into electronic signal – recorded on graph paper
 Doesn’t test contraction strength – must be done by abd palpation
o Fetal heart rate: ultrasonic sensor
 Positioned at level of fetal chest
 Converts fetal heart movements into a beeping sound – recorded on graph
paper
 Internal Fetal Monitoring
o More accurate bc it’s not impacted by external stim or fetal/maternal mvmt
o Contractions can be assessed for intensity, frequency, and duration
o Only done when membranes ruptures and cervix dilated by few cm
o Fetal scalp electrode: passed through vagina and attached to fetal scalp
 Fetal ECG signal received and recorded on graph paper
o Intrauterine pressure catheter: end passed through vagina and beside fetus
 Contraction causes pressure exertion on catheter that records
 Measured in mmHg
FHR Tracing
 Three parameters
o Baseline FHR
 Normal: 110-160
 Bradycardia: <110
 Tachycardia: >160
o Variability – sawtooth, irregular pattern of fluctuation in baseline FHR
 Absent variability = amplitude undetectable
 Minimal = < 5 BPM
 Moderate = 6-25 MPB
 Marked = > 25 BPM
o Periodic changes – temporary fluctuations in FHR, lasts secs to mins
 Episodic: not regular w/ contractions
 Accelerations – suggests fetus is well oxygenated
o Rise in FHR from baseline of at least 15 BPM lasting > 15
secs
o If longer than 10 min, considered change in baseline
o Absence of accels is not indicative of fetal compromise
 Decelerations –
o Decrease in FHR lasting < 10 minutes
o If longer than 10 min, considered change in baseline
 Early: benign change; when contraction is at its
strongest, FHR is at its slowest
 Variable: abrupt drop d/t disruption of blood flow;
occasional is not worrisome
 Diminished/lost variability concerning
 Late: nadir occurring after peak of contraction d/t
disruption in transfer of o2 to fetus
 Diminished/lost variability concerning
 Prolonged: decrease in FHR of >15 bmp lasting 210 min
 Diminished/lost variability concerning
 Periodic: regular in relation to contraction
 Sinusoidal pattern
 Categories of abnormal FHR patterns
o Category I (normal): associated with normal acid-base balance
 Patterns not associated with fetal hypoxia
 Baseline FHR WDL (110-160)
 Moderate variability w/ or w/o accelerations
 W/ or w/o early decelerations
 No variable decels
 No late decels
o Category II (indeterminate): insufficient data to classify as normal or abnormal
 Patterns bear further observation and evaluation
 May not require intervention
 Bradycardia w/ variability
 Tachycardia
 Minimal variability
 Absent variability w/o recurrent decels
 Marked variability
 Absence of accelerations w/ fetal scalp stimulation
 Recurrent variable decels w/ minimal or moderate variability
 Prolonged decels
 Recurrent late decels w/ moderate variability
o Category III (abnormal): predictive of abnormal acid-base status
 Patterns associated ith fetal hypoxia
 Absent variability w/ recurrent late decels or variable decels
 Absent variation and bradycardia
 Sinusoidal pattern
Intrauterine resuscitation interventions
 Turn to lateral side lying position
 IV fluid bolus (18-gauge) for hypotensive mothers; epinephrine may be ordered
 8-10 L/min nonrebreather mask


Stop oxytocin and/or tocolytic administration
Amnioinfusion – infusion of warmed LR or NS into uterus after ROM via catheter
inserted through cervix to relieve cord compression
o Uterine hypertonicity and vaginal bleeding are CI
 Alteration in pushing technique
 Fetal scalp stimulation – gloved finer through cervix; 1-5 secs stimulation can produce
acceleration of FHR
o Do not complete if bradycardia present
 Vibroacoustic stimulation
Pain and Discomfort
 Pain increases oxygen demand, less oxygen for fetus
 Manifestations of pain are visceral and somatic
o Somatic: can be pinpointed
o Visceral: mechanical pressure and ischemia; generalized pain
o Pain in abd, lower back, or thighs w/ contraction
o Continuous pain in lower back = fetus in OP position
o Continues abd pain = placental abruption
 Pharmacological mgmt.
o Parenteral meds
 Opioids – watch for RD
 Meperidine (Demerol) – lasts 3-4 h
 Sublimaze (Fetanyl) – short acting, crosses placenta
 Antidote: Naloxone (Narcan)
 Mixed
 Nalbuphine (Nubain) – lasts 3-6 h, less risk for RD
 Butorphanol (Stadol) – lasts 3-4 h, dysphoria common
 Nausea
 Promethazine (Phenergan) – monitor for hypoTN
 Hydroxyzine (Vistaril) – IM only, no IV
o Regional anesthesia
 Epidural – IV, help position woman, BP monitoring, fetal surveillance
 Before receiving epidural, nurse must administer a fluid bolus
through IV line to reduce risk of hypotension
 Aftercare: VS and monitor for complications
 Spinal – common for emergency or c-section; IV, BP monitoring, fetal
surveillance
 After care: assess VS, look for complications (spinal headache)
o Local anesthesia – local infiltration
 Pudendal block – given in second stage of labor right before baby is
delivered
o Nitrous oxide – helps increase pain threshold
 Inhale before start of contractions
 SE: N/V, lightheadedness
o General anesthesia – only used in emergencies

Equipment: laryngoscope, ETT, breathing bag, O2, suction cath, suction
source
 Nonpharmacological
o Support from doula or coach
o Therapeutic touch, massage, effleurage; yoga, meditation
o Relaxation, focusing/imagery, spirituality
o Breathing techniques, aromatherapy/essential oils
o Heat/cold application
o Bathing, hydrotherapy
Hyperventilation
 S/S: dizziness, tingling of hands and feet, cramps and muscle spasms of hands, numbness
around nose/mouth, blurring of vision
 Interventions: breathe slow, especially on exhale; breathe into cupped hands; hold breath
for a few secs before exhaling
Chapter 17: After Delivery
Postpartal Period
 6 week period after birth
 Involution of uterus and vagina
o Involution: uterus returns to non-pregnant size
 Occurs immediately after birth
 Fundus 2 cm below level of umbilicus immediately after birth
 After few hours, it rises 1 cm above umbilicus and slowly descends
 By 24h it is at umbilicus
 By 2 wks it should be a pelvic organ
 By 6 wks, it should have completely involuted
 Assessing: stabilize lower uterus while feeling fundus with the other
 Starting at umbilicus and move down, palpate deeply but gently
 Boggy uterus = uterus not contracting, can l/t uterine atony + hemorrhage
 Massage w/ palm of one hand while stabilizing lower segment
 Oxytocin, empty bladder
o Subinvolution: failure to shrink at expected rate
o Inversion: fundus of the uterus prolapses toward or though cervix
o Afterpain: afterbirth contractions to maintain a tone uterus
 Warmth to abd, ibu/acet, empty bladder – interventions
 BF can stimulate; give analgesic prior to BF
 Production of milk for lactation, return of menstrual cycle, beginning of a parenting role
 Uncomplicated vaginal birth – hospital stay = 48 h
 Assessments
o Q 15 min – 1st h
 Q 30 min – 2nd h
 Q 4 h – first day
o Q 8 h – til discharge
o Head-toe, infant feeding, infant bonding, maternal response to parenting
o BUBBLE-EE
Breast
Uterus
Bladder
Bowel
Lochia
Episiotomy
Extremities
Symmetrical,
Midline,
Encourage
Motility
Assess
Assess
Assess for
soft, nontender
descending
frequent
slow to
and record wound/lacerat unilateral
for first 24 h.
from
emptying.
recover;
per
ion + general edema,
Slowly will feel umbilicus
Full bladder
flatus and protocol
condition of
warmth,
more full as
can displace
bowel
perineum.
induration,
breast milk
uterus or
sounds ok
Assess for
or
comes in (2-5 d
cause
for
hemorrhoids
tenderness
PP)
atony/cystitis discharge
Lochia
 Rubra: dark red; 3-4 d
 Serosa: lighter red, pink, or brown; 10-14 d
 Alba: yellow/white; 2-4 wks
 Excessive bleeding: change saturated pad and check again in 15 min
o Clots are normal; if bigger than plum sized = concern
Emotion
Concern:
extreme
mood
swings,
anxiety,
and
depression
o Lochia is a slow dark red trickle; laceration is pump/spurt, bright red
 Afterpains + ambulation can increase lochia
 Cesarean births more scant lochia than vaginal births
Perineum, Vagina, and Pelvic Muscles
 Assessment q shift, check pad/perineum, ask about pts last void and when pad was changed
last
 Comfort measure: ice packs, side lying position, sitz bath, ibu/acet, peri bottle (cleaning and
comfort), witch hazel pads, docusate sodium, kegel exercises
Breasts
 Engorgement – firm, larger, warm, and tender
o Nipple can flatten and make it difficult to breast feed
o Nurse check for bruising, blood blisters, and chapping – mastitis
 BF women – express milk
 Non BF women – avoid nipple stimulation
o Wear supportive bra all day until breasts no longer feel engorged
o Ice packs help relieve discomfort (no more than 15 min); heat discouraged
Parental bonding/attachment
 En face position: eye contact, looking directly at face
 Engrossment: staring at newborn, beginning bonding
 Reva Rubin theory (maternal adaptation phases):
o Taking in: 24-48 h
 Dependent on others for immediate needs; passive in her own role and care of
NB
o Taking hold:
 Dependent to independent; showers, looks, and touched baby; asks ?s
o Letting go:
 Independent family unit; individual members; establishes normal routine
 Partner Adaptation Phases
o First phase: prior to birth, imagine what kind of parent they want to be
o Second phase: reality of infant care (overwhelmed, isolated, and aloneness)
o Third phase: take hold of new role, positive reinforcement can build confidence
o Final phase: parent-child relationship; cooing; smiling; laughing
Cesarean Section
 Hospitalization 3-5 d, full recovery 6 wks
o Complications: endometritis, wound dehiscence/infection/hematoma, hemorrhage,
PE/TE/DVT, ileus
 First 24 h care
o VS: q 1 h – 1st 4 h
 Q 4 h until stable
 Q8h
o Pain – opioids and analgesics (naloxone on standby)
o Dressing – removed after 24h, assess w/ VS
 Splinting abd w/ coughing
o SCDs until ambulating
o Foley place prior to c-section
o Fundal checks; bowel sounds

o BF position for comfort – avoid pressure on abd and incision site
o Emotional support
Until discharge care
o VS, fundus, lochia, pain q shift
o Ambulate
o Clear liquid diet – advance as tolerated w/ return of bowel sounds
o No lifting anything heavier than infant for 4-6 wks after
o No driving w/ opioids – reqs Dr. approval
Chapter 18: The Newborn
Transition to Extrauterine Life
First Phase/Period of Reactivity (first 15-30 min)
 Started with first breath of neonate
 Lasts for up to 30 min after birth; sometimes up to 2 h
 Color: acrocyanosis is present
 Temperature: begins to fall from 100.6 F (38.1 C)
 Heart rate: tachycardia, 180 BPM + crying
 Respirs: irregular; 30-90 breaths/min + crying; some nasal flaring, occasional retraction
 Activity: alert, watching
 Response to stimuli: vigorous reaction
 Mucus: visible in mouth
 Bowel sounds: heard after first 15 mins
Resting Period (30-120 min)
 Color: begins to stabilize
 Temperature: stabilizes at about 99 F (37.2 C)
 Heart rate: slows to 120-140 BPM
 Respirs: slows to 30-50 breaths/min, barreling of chest possible
 Activity: sleeping
 Response to stimuli: difficult to arouse
 Mucus: small amount present while sleeping
 Bowel sounds: present
Second Phase/ Period of Reactivity (2-6 h)
 Color: quick color changes occur w/ mvmt or crying
 Temperature: increases to 99.8 F (37.6 C)
 Heart rate: wide swings in rate occur w/ activity but stabilizes at 120-140 BPM
 Respirs: irregular w/ activity but remains 30-60/min
 Activity: awakening
 Response to stimuli: becoming responsive again
 Mucous: mouth full of mucus, possible causing gagging
 Bowel sounds: often passage of first stool meconium
Respiratory System
 40-60 BPM; fast and shallow; pauses for up to 20 seconds
 Chest and abd should synchronously fall and rise
 Nurse should monitor for respiratory distress – best assessed when neonate is not crying
o Retractions, nasal flaring, grunting, cyanosis, tachypnea, seesaw breathing
Cardiovascular System
 Assess heart sounds for murmurs and rate
 Hg is higher than adults (14-24 g/dL vs adults 12.1-17.2 g/dL)
 Leukocytosis is normal at birth (9k-30k/mm3); platelets same (150k-300k)
 Clotting factors are low d/t low levels of vit K
o Shot given within 6 hours after birth, if not immediately so liver can stimulate
production
o IM, vastus lateralis
 Apical pulse – assess for 1 full min (while asleep or calm/quiet)
o 120-160 BPM; 85 BPM sleeping; 180 or > if crying
o Murmurs – come and go, resolve by 6 months
o BP not commonly assessed at birth
Physiologic Adaptations
Thermogenic System
 Heat regulation is critical to newborn survival; cold stress can lead to metabolic acidosis
o Convection: heat from the newborn goes to surrounding air
 Keep room temp at least at 72 F
 Avoid air current from open windows and fans
o Radiation: transfer of heat from or to the newborn to nearby surface
 Keep infant away from cool window and exterior walls
o Evaporation: heat loss d/t evaporation of liquid from body
 Dry neonates thoroughly after birth
 Stabilize temperature prior to bath and bathe in warm environment
o Conduction: transfer of hear by direct contact with cooler objects
 Place infants on prewarmed surfaces
 Skin to skin with mother
 If neonate needs to be unwrapped for assessment or intervention longer than the time
required to change a diaper, a warmer should be used
o Otherwise, only body parts being assess should be exposed at once
 Non-shivering thermogenesis – mobilization of store of brown fat that can double heat
production; production of heat without shivering
 Hyperthermia d/t sepsis – pale w/ cool hands and feet
 Hyperthermia not d/t sepsis – flushes and assumed extended posture; hand/feet warm to
touch
Gastrointestinal System
 Meconium usually passed within 12-24 hours
 Postterm infants can pass meconium in utero
 BF infants pass stool more frequently than formula fed infants
 Encourage parents to apply a barrier cream like petroleum jelly or zinc oxide
Renal System
 Adequate fluid intake = 6-8 diapers per day; straw colored
Hepatic System
 Increased energy needs leads to initial decrease in blood glucose
o BG levels stabilize in a couple hours (50-60 mg/dL)
o Risk factors to hypoglycemia
 Maternal obesity/diabetes, GA <37 weeks
 Intrauterine growth restriction
 Admission to NICU, perinatal stress
 Physiologic jaundice – expected (limited to face after 24h) and d/t high volume of RBCs
after birth
Immune System
 Not mature, but protected by passive immunity from mother
 Hand washing encouraged; limit exposure to crowds/ill people; immunizations
Integumentary System
 Sweat glands present, but do not respond to high body temperature
 Infants cannot be handled without gloves until they are bathes
Head
 Posterior fontanel closes within few months after birth
 Anterior fontanel loses within 18 months to 2 years after birth
 Caput succedaneum: generalized edema, crosses suture line, resolves spontaneously
 Cephalohematoma: edema, blood between skull and periosteum; doesn’t cross suture line,
longer to resolve, may cause jaundice
 Subgaleal hemorrhage: bleeding that doesn’t cross suture line; can lead to shock/death
Neuromuscular System
Tremors common – especially at hands and chin
o Not common at rest and can be d/t hypoglycemia or neuro condition
 Reflexes to check: grasp-and-suck, rooting, extrusion
Assessment & Care of the Newborn
 APGAR:
 0-3 severe distress
 4-6 moderate difficulty
 7-9 no difficulty adjusting to extrauterine life
Activity
Pulse
Grimace with
Appearance
Respirations
stimulation
Cyanotic
0 No pulse
0 Stoic
0 Limp
0 None
0
Acrocyanosis 1 <100/min
1 Half grimace 1 Half flexed
1 Weak, slow 1
All pink
2 >100/min
2 Crying face 2 Arms/legs flexed 2 Strong, cry 2
 Stabilization and resuscitation
o Excess mucous: suction w/ bulb
 Bulb should be inserted on one side, not center (stims gag reflex)
 Bulb should always be kept with infant in crib
 VS: within first 30 min after delivery, then hourly until fourth stage of labor
 Cord inspection: 2 arteries, 1 vein
 Weight: same time everyday
 Length: top of head to heel
 Head circumference: at greatest diameter
 Chest circumference: measure at nipple line
 Physical assessment sequence: skin, head, face, neck, chest, abd, extremities, back, genitalia,
anus/stools,
 4 hours after birth to discharge – basic assessment q shift
 Umbilical cord care: cord clamp removed when cord is dry, REEDASS q diaper change
 Circumcision: removal of prepuce of the glans
o Yellow exudate will appear in 24 h – normal
 Do not wipe off crust
o No diaper wipes; cleanse w/ water and use petroleum around glans after diaper
changes
o Report bleeding larger than a quarter or no voiding within 12 h after
Chapter 20: Conditions Occurring During Pregnancy
FIRST TRIMESTER:
Multiple pregnancy
 Multizygotic: 2 or more eggs fertilized at the same time; fraternal twins
 Monozygotic: all fetuses same ovum; identical twins
 Polyzygotic: triplets or higher
 Care considerations: more calories, protein, vit/minerals
Hyperemesis Gravidarum (HG)
 Acute nausea and vomiting l/t wt loss, malnutrition, dehydration, ketonuria, and electrolyte
imbalances
 May last throughout pregnancy, but usually starts at week 10 and ends by week 20
 Tx: priority is comfort and minimizing potential complications r/t dehydration &
malnutrition
o Antiemetics, metoclopramide, promethazine, complementary IV rehydration, and
TPN
Assessment of bleeding
 Confirmation of pregnancy and pregnancy length
 Duration of bleeding episode; still continuing?
 Intensity – how much bleeding? (tablespoon, cup)
 Description – mucous? Amniotic fluid?
 Associated symptoms – cramping? Sharp pain? Dull?
 Blood type
Miscarriage
 Occurs before 20 weeks of GA without surgical or medical induction
 Peak loss time: 5-8 weeks; likely d/t chromosomal abnormalities
 Complete: cervix closed; heavy clots and tissue passed + heavy cramping
 Missed: cervix closed, fetal contents don’t expel
 Inevitable: cervix open, some content passes; D&C or D&E
 Threatened: cervix closed, bleeding/cramping
 Recurrent: 2-3 losses in a row
 Women must receive Rhogam within 72 hours of loss (Rh-)
Ectopic Pregnancy
 Pregnancy outside of the uterus 00 ampulla, ovaries, intestine, and cervix
 Emergency and must be ended ASAP
 S/s: unilateral pelvic pain, bleeding Cullen sign (umbilicus ecchymotic), delayed meses, LQ
abd pain, referred shoulder pain
 Tx: methotrexate to end pregnancy or surgery to remove fallopian tube/ovary
 Risk factors: Hx of pelvic infection or previous ectopic pregnancy
Gestational Trophoblastic Disease (GTD) or Molar Pregnancy
 Fertilized eggs fail to develop properly l/t nonviable mass of trophoblastic tissue
 Rapidly growing uterus, high hCG, dark brown-bright red bleeding, passage of grapelike
cysts
 Tx: D&C, prophylactic chemo, serial hCG levels for one year, and no pregnancy for one year
SECOND TRIMESTER
Gestational Hypertension

Systolic BP > 140 &/or diastolic BP > 90 without protein in urine or signs of end-organ
dysfunction after 20 weeks
o 2 BPs taken 4 hours apart
o If BP is higher than 160 (SYS) or 110 (DIA), wait minutes not hours
 Complications: preterm birth, SGA, placental abruption
 Assessment: US, nonstress test, BPP, signs of preeclampsia
 Tx: women with BP < 160/110 can maintain normal activities while monitoring for
preeclampsia (h/a, visual changes, RUQ/epigastric pain)
o Women with BP >160/110 receive antihypertensives, mag sulf, and may deliver
early
Preeclampsia & Eclampsia
 Preeclampsia: HTN (>140/90) on 2 BP reading (4 h apart) + proteinuria w/ prev normal BP
OR
HTN with or w/o proteinuria + platelet count < 100k, serum creatinine live >1.1
mg/dL, elevated liver enzymes, pulmonary edema, or new-onset visual/cerebral symptoms
 Eclampsia: preeclampsia w/ tonic-clonic seizure activity
 Assessments: BP, h/a, blurred vision, restlessness, epigastric/RUQ pain, SOB, fetal mvmt,
urine output, unusual vaginal bleeding/discharge, reflexes, clonus, lab tests (CBC w/
platelets, liver enzymes, serum creatinine)
 Tx: at risk – aspirin and calcium supplements
o Mild: monitored on outpatient basis, no meds; carry to term
o Severe: induced and early delivery, mag sulf IV to prevent seizures, IV
antihypertensives (to prevent stroke, renal damage, and heart disease), corticoid
injection (fetal lung maturity), seizure precautions
 Mag sulf weakens contractions, so oxytocin may be given simultaneously
 Magnesium Sulfate
o Secondary infusion
o Loading dose 4-6 g over 15-30 min
o Maintenance dose of 1-3 g/h
o Serum magnesium levels of 4-7 mEq/L
o Toxicity: RD, oliguria, reduced/absent reflexed, lethargy, slurred speech, muscle
weakness, loss of consciousness
 Interventions: stop the infusion immediately, calcium gluconate (1g by IV
push over 3 min), supplemental o2 at 8-10L via nonrebreather mask
 HELLP Syndrome
o Hemolysis: RBCs broken down too quickly; can l/t anemia, DIC, placental
abruption, PE, acute renal failure
o Elevated Liver Enzymes: liver function compromised
o Low Platelet Count: risk for excessive bleeding
o Occurs as complication of preeclampsia
o Tx: delivery if 34 weeks or >; if <34 weeks, give IM corticosteroids to facilitate
fetal lung development
Gestational Diabetes
 All women screen 24-28 weeks
 Dx testing:
o Fasting 100g glucose tolerance test
 >95 mg/dL = diabetes
o One hour phase of two step OGTT: fasting not needed
 > 180 g/dL = diabetes
o Two hours phase: > 155 mg/dL = diabetes
o Three hours phase: overnight fasting to have blood drawn for fasting BG, then
drink 100g, BG checked at 1, 2, and 3 hours
 > 140 mg/dL = diabetes
 Tx: diet, exercise, medication sometimes (metformin, glyburide, or insulin)
o Outcomes: fasting BG <95; 1 h postprandial < 140; 2 h <120
o Exercise 3x/wk, 3 meals and 2-3 snacks/d (avoid carbs at brekky), keep food log,
do not go longer than 10h without eating
Infections: STIs
 Chlamydia/gonorrhea: bacterial infection, screened during 1st prenatal visit
o Tx: abx and retesting 3 months after Dx
 Herpes: can be transmitted to fetus and lethal; presence of lesions = c-section
o Tx: antiviral medication the month before due date
 HPV: warts can block birth passage or bleed excessively, vaginal delivery ok
 Hep B: hep B vaccine and hep B IG within 12 hours of birth
 Trichomoniasis: vaginal discharge and irritation
o Tx: abx
 Candidiasis vaginitis (yeast infection): Tx = topical vaginal creams
 TORCH (Toxoplasmosis, other [syphilis, parvovirus], rubella, CMV, herpes)
Cervical Insufficiency
 Painless, premature dilation of cervix – incompetent cervix
 S/s: unusual vaginal discharge, pelvic cramping, spotting, pelvic pressure
 Dx: measurement of cervical length by ultrasound
o 25 cm before 24 weeks if considered short
o High risk for miscarriage or premature birth
 Tx: maternal progesterone (starting at 16-20 weeks through 36 wks) or cervical clerage
(cervix stitched closed to keep it from dilating prematurely)
THIRD TRIMESTER
Trauma
 MVA, falls, IPV
 Care considerations:
o Wedge under woman’s hip to decrease risk of supine hypoTN
o Chest compressions can be more challenging and ineffective
o O2 consumption increases and women should be monitored closely for hypoxia
o Abd trauma may result in placental abruption – any trauma should be indication
for Rhogam in Rh- women
 Tx: c-section within 5 mins in event of unsuccessful cardiopulmonary resuscitation
Intrauterine Growth Restriction (IUGR)
 Not a disease itself, but condition indicates complication in pregnancy
 Asymmetric IUGR: fetal head normal, but body at slowed rate
o Uteroplacental insufficiency
o Maternal hypertensive disorders
o Severe maternal malnutrition
o Select maternal genetic disorder, acquired disease
o Abnormal placentation
o Multiple gestation
 Symmetric IUGR: head and body grow at same slower rate
o TORCH infection
o Maternal substance abuse, smoking, anemia
o Chromosomal abnormality of fetus
o Teratogenic medications
 Assessment: measurement of fundus/uterus; <3 cm = positive screen
 Tx: terminate pregnancy or maternal glucocorticoids
Polyhydramnios
 Excessive amniotic fluid
 Dx: US of 4 largest pockets of amniotic fluid
o # of fluid = amniotic fluid index (AFI)
o Abnormal AFI 20-25 cm
 Tx: amnioreduction, indomethacin to stabilize amniotic fluid(prior to 34 wks), induction of
labor
Oligohydramnios
 Decreased amniotic fluid
 Associated with fetal anomalies, PROM, uteroplacental insufficiency; increases incidence of
cord compression
 Dx: US AFI < 5 cm
 Tx: amnioinfusion of LR into amniotic sac, oral hydration (2L over 2h period)
Dermatoses of Late Pregnancy
 Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP): associated with
inflammatory process
 Resolves within a few weeks after delivery not harmful to fetus
 Tx: oral topical corticosteroids and antihistamines
Chapter 21: Complications Occurring Before Labor and
Delivery
Prolapsed Umbilical Cord
 Gravity washed cord to cervical os
 Dx: visible cord, prolonged/varied decels in fetal monitoring
o Place mother in modified sims position to improve fetal circulation
 Tx: O2 immediately @ 8-10 L/min via nonrebreather, elevate hips to elevate cord
compression, insert 2 fingers in vagina to decrease pressure on cord to promote oxygenation
to fetus, saline towel on cord to keep it from drying out
Preterm Premature Rupture of Membranes (PPROM)
 PROM: ROM prior to start of contractions at or after 37 weeks
o Increased risk of prolapsed cord, placenta abruption, chorioamnionitis, and cord
compression
o Presentation: gush of fluid from vagina
 PPROM: ROM prior to 37 weeks
o Increased risk for infection, cord prolapse, fetal malpresentation, and precipitous
labor
o Assess temp and uterine tenderness
 Assessment: speculum vaginal exam (sterile speculum used to assess pooling of fluid; ask
mother to bear down/cough if no fluid seen)
 Tx: corticosteroids for GA under 34 weeks, abx & monitoring for s/s of infection if under 37
weeks GA, tocolytics (slow labor), mag sulf (between 24-34 weeks), assess fetal lung
maturity (L/S 2:1 = lung maturity)
Preterm Labor
 Contractions that cause cervical change prior to 37 weeks; induced or spontaneous
 Precursors: high levels of stress, inflammation (UTI, periodontal disease, infection),
bleeding, uterus overdistention, dehydration, substance abuse, HTN, adolsence, lack of
prenatal care
 S/s: low backache, vaginal spotting, vaginal pressure, abd tightening, menstrual like
cramping, increase in vaginal discharge
o Call OB if:
 Fluid leaking from vagina; fishy/foul odor
 Vaginal bleeding
 Contractions q 10 min or less for an hour
o In absence of symptoms:
 Drink 2-3 glasses of water (dehydration can stim Braxton Hicks)
 Empty bladder (full bladder can stim cramping)
 Lie on side for an hours (Braxton Hicks resolve w/ rest)
o Resume light activity if symptoms resolve
 Dx: dilation 3cm or more, cervical shortening via US, presence of fetal fibronectin test (fFN)
 Tx: does not always indicate preterm birth
o Suppressions of labor, bedrest, progesterone, corticosteroids, abx, and pelvic rest
 Indomethacin: PO, limited to 48 hours total; CI w/ bleeding disorder, renal
dysfunction, aspirin allergy, and asthma
 Nifedipine (CCB): PO, limited to 48 h; CI w/ maternal hypoTN and
cardiac conditions
 Terbutaline (beta2agonist): SQ/IV, limited to 48 h; CI w/ poorly
controlled diabetes, placenta previa, and placental abruption
 Mag sulf: IV titrated
 Less effective tocolytic
Chorioamnionitis




Infection of the amnion, chorion, or both
Risk factors: PROM, multiple digital vag exams, prolonged labor, and preterm birth
Complications: neonatal sepsis, and PPH
Dx: maternal fever higher than 38 C AND 2 of the following: fetal tachycardia, uterine
tenderness, foul smelling discharge, elevated WBC (over 15k)
 Tx: broad spectrum abx (ampicillin, gentamicin)
o Clindamycin and flagyl added in case of c-section
Postterm Pregnancy
 42 weeks or 294 days since first day of LMP
 Risks: macrosomia, prolonged labor, birth injury, PPH
 Tx:
o Expectant mgmt: 2 wk NST and amniotic fluid volume or by BPP beginning at 41
wks
o Induction of labor: eval of cervix using Bishop score; 8 or higher = favorable; 6 or
less = lesser chance of successful vaginal delivery
Nonstress Test (NST)
 Records accelerations of FHR in relation to fetal activity
o Monitor for 20-40 minutes
 Interpretation
o Reactive = FHR increase 15 beats above baseline for 15 secs 2 times in 20 mins
o Nonreactive – no sufficient FHR accelerations in 40 minutes & further testing
needed
Biophysical Profile (BPP)
 NST w/ 30 min US observing fetal breathing mvmts, fetal mvmt, fetal tone, and
measurement of amniotic fluid
 Interpretation
o 8 or 10 = reassuring
o 6 – may need delivery depending on GA
o 4 or less = nonreassuring, consider delivery
Cervical Ripening
 Pharmaceutical ripening:
o Prostaglandins: Misoprostol (Cytotec), dinoprostone
 CI: previous c-section or uterine Sx
 Monitor: FHT and tachysystole
 Mechanical ripening
o Ballon cath, hygroscopic dilator (luminaria), membrane sweeping
Labor Induction
 Oxytocin: IVPB on pump, clearly labeled w/ bright color
o Titrated: 0.5-6 mU/min, increased by 1-2 mU/min until contractions are strong,
regular, 3-5 contractions in 10 min, lasting 40-90 seconds
o Continuous FHR monitoring
o SE: GI distress, water retention, tachycardia, hypotn tachysystole
o STOP OXYTOCIN when tachysystole + nonreassuring FHR and notify OB
 Amniotomy: AROM
o Cervix: partially dilated
 Vertex w/ engaged head
o Risk: cord prolapse and infections; assess FHT
Placental Abruption
 Premature detachment of placenta from decidua of uterus after 20 weeks GA
 Can cause DIC
 S/s: DARK RED bleeding, severe pain General s/s: fever beyond 24 hr after birth, onset 2-10
d PP, WBC continue to increase
 Tx: continuous monitoring, IV fluids, blood transfusion, delivery
DIC
 Clotting factor depletion and bleeding
o IV site, gums, nose, hematuria, petechiae, bruising
 Always a complication of another complication
 Emergency!
 Tx: IV, fluids/blood, O2
Placenta Previa
 Placental tissue overlies internal cervical os
 S/s: BRIGHT RED, painless vaginal bleeding
 Risk factors: prior Hx, smoking, AMA, cocaine, infertility Tx
 Dx: US
 Tx: no vaginal exam if suspected, pelvic rest, education on when to seek care for
bleeding/contractions
Vasa Previa
 When fetal blood vessels overlie internal cervical os
 Complications: fetal hemorrhage and exsanguination w/ ROM
 Tx: corticosteroids and c-section in presence of bleeding w/ nonreassurring FHR
Chapter 22: Complications Occurring Before Labor and
Delivery
Group B Streptococcus (GBS)
 Usually asymptomatic; screened at 35-37 wks
o Culture is taken from introitus and rectum
 S/S: neonatal sepsis, pneumonia, or meningitis
 Tx: abx give 4 h prior to delivery and given q 4 h until delivery
o Penicillin g, ampicillin, cefazolin only
 Preterm labor Txed for GBS without screening
Dystocia
 Any labor with an abnormally slow or fast progression
5 P’s of Labor: Power Complications
Dysfunctional uterine contractions
 Hypotonic uterine dysfunction: contractions soft on palpation and less than 3-4 q 10 min,
lasting < 50 sec
o Tx: rule out CPD or fetal malposition; amniotomy or oxytocin
 Hypertonic uterine dysfunction: frequent, uncoordinated, and irregular tone; no effacement,
dilation, or fetal descent – l/t fetal compromise
o Tx: rest by warm bath, opioid (morphine or meperidine), sleep meds
Ineffective pushing
 Laboring down – process allowing primary powers to slowly facilitate fetal descent w/o
augmentation by maternal pushing
Precipitous Labor
 Less than 3 hours of labor – start to finish
 Strong, frequent contractions w/o meds
 Risks: placental abruption, perineal lacerations, PPH, retained placenta
5 P’s of Labor: Passageway Complications
Bony Pelvis Dystocia
 Smaller than normal pelvis
Soft Tissue Dystocia
 Soft tissue impedes delivery of fetus
o Full bladder or bowel can be addressed
o Scar tissue on cervix, cervical edema, placenta previa, or large fibroid are reasons
5 P’s of Labor: Passenger Complications
Shoulder Dystocia
 Obstruction of fetal descent by the shoulder after birth of the head
 Risk factors: macrosomia, maternal diabetes
 Risk for: neonatal hypoxia, injury, maternal lacerations, atony
 Turtle sign: fetal head born but cheeks rest on maternal introitus
 Tx: McRobert’s Maneuver – nurse sharply flexes mother’s hips w/ knees pulled back toward
chest
 HELPERR
o Call for Help
o Evaluate Episiotomy
o Legs: McRobert’s Maneuver
o External Pressure – suprapubic
o Enter: rotational maneuvers
o Remove posterior arm
o Roll pt to her hands and knees
5 P’s of Labor: Pysche & Position Complications
Psyche:
 Anxiety = negative impact
 Support = helps ; doula, friends, family, nurse
Position
 Upright positions
o Sitting, kneeling, squatting, or standing
Intrapartum Procedures
Episiotomy
 Used if pt is at high risk for 3-4th degree perineal tear or if quick delivery is needed
 Risks: infection, bleeding, pain
 Epidural, pudendal, local
Operative Vaginal Birth
 Must have ROM, fully dilated, engaged head, known fetal presentation, epidural or pudendal,
empty bladder
 Pt consent req
 Must document time on and time off
 Risks: shoulder dystocia and tissue damage
 Forceps assisted: outlet (indicated when fetal scalp visualized), low (+2 or lower fetal
station), or midforceps (when scalp between 0 and +2 station)
 Vacuum assisted birth: creates suction against fetal head and aids in extraction
 C/B after 3 sets of pulls, 3 pop-offs, or time of 15-30 min
Cesarean Birth
 Complications: anesthesia, bowel/bladder injury, hemorrhage, air/amniotic fluid embolism,
infection
 Neonate at risk of RDS
 Indications:
o Failure to progress in labor
o Nonreassuring FHT
o Fetal malpresentation
o Umbilical cord prolapse
o Fetal macrosomia
 Unplanned: emergency – 30 min decision to incision
 Scheduled: known ag birth CI or previous C/B
 Incision: classic = low transverse
o Preop care:
 Fasting 8 h prior to procedure
 Med given to minimize aspiration of gastric contents
 At least 1 16-18 gauge IV line placed; 2nd place if risk for hemorrhage
 Hg, blood type, antibody screen if no current record
 Abx prophylaxis given within 1 h before incision made
 Pneumatic compression boots during and after Surgery until reg
ambulation
 Obese women receive heparin 6-12 h after delivery
 FHR tracing, continuous in labor, discontinue external when preppin
incision site, discontinue internal prior to incision
 Catheterize prior
 Vag prep – chlorhexidine or iodine; shaving no indicated, trim if needed
 If supine pos indicated – place wedge or rolled towel under hip
o Postop care
 VS q 15 min for 2h after surgery
 Temp twice in first 8h PP then once per 8 h shift
 Uterine tone, lochia, and oxytocin administration – freq assessment
 BF started in delivery room
 Bladder cath removed asap – as soon as safe ambulation started
 Wound dressing removal 24-48 h after delivery
 Staples removed 4-10 d PP
 Avoid heavy lifting and squatting for 1-2 wk after surgery
Vaginal Birth After Cesarean (VBAC)
 Previous C/B d/t fetal distress, malpresentation, or failure to progress
 Risks: uterine rupture
 CI: close spacing (<6 months between end of one preg and the beginning of next),
macrosomia, AMA, maternal comorbidity, more than 1 prior C/B, over 40 wk GA, classic
vertical incision
 Oxytocin ok to use
 Cytotec (prostaglandin) CI d/t association with uterine rupture w/ or w/o prior c-section
Uterine Rupture
 Tear in the wall of the uterus
 S/S: FH bradycardia, decels (cat II or III), hypoTN, tachycardia, weakening contraction, loss
of fetal station, abd pain, vaginal bleeding/hematuria
 Tx: emergency C/B, possible hysterectomy
Cord Prolapse
 Umbilical cord precedes the fetal head in birth canal
 s/s: severe fetal bradycardia and variable decels
o increases risk for cord compression and hypoxia to fetus
 Emergency, immediate C/B
 First step: call for help, OB/nurse should immediately resuscitate fetus by moving pressure
off cord
Retained Placenta
 Incarcerated placenta: completely separated from uterus, failure of expulsion phase within 30
min
 Placenta adherens – easily separated
 Placenta accrete – adhered to myometrium instead of decidua
 Risks: PPH and endometritis
 Tx: traction, meds, manual removal, D&C, hysterectomy
Lacerations
 Cervical/vaginal lacerations
o Fundus = firm
o Lochia = heavy; bright-red; gushing
Perinatal Loss
 Fetal demise, fetal death, stillbirth, stillborn
 < 20 wks – spontaneous abortion
 > 20 wks – stillbirth


Prevention
o Folic acid before/during pregnancy
o Routine syphilis screening and tx
o Screening and treating HTNsive disorders and maternal diabetes
o Screening for FGR
o Access to emergency OB care
Care considerations
o Support in grieving and saying goodbye
o Explanation of events, organized care, understanding of grief
Chapter 23: Conditions After Delivery
Postpartum Early Warning Criteria
 Maternal agitation, confusion, unresponsiveness
 Report of h/a, SOB by pt w/ preeclampsia
 Systolic BP <90 or >160; diastolic >100
 HR <50 or >120 BPM
 RR <10 or >30 /min
 O2 <95%
 Oliguria for 2 or more hour (<35 ml/h)
Postpartum Hemorrhage (PPH)
 Blood loss of >500 mL – vag birth
 Blood loss of >1000 mL – cesarean birth
 Early hemorrhage: first 24 h
 Late hemorrhage: 24 h – 12 wks after delivery
 Common causes: tone, trauma, tissue, thrombin
o Uterine atony – most common
o Lacerations, uterine inversion aka trauma
o Retained placental fragments
o Coagulopathies (VWD, DIC)
 Tx:
o Call for help
o Massage uterus – temp increases bleeding
o Assess for lacerations (vagina, perineum, and/or cervix)
o Foley cath
o IV access for oxytocin, 15-methylprostaglandin, methylergonovine
o Bimanual compression – more aggressive form of uterine massage, done by OB
o Bakri balloon
o D&C
o Hysterectomy – last resort
 Care considerations:
o O2 via nonrebreather
o Assess fundus/lochia q 4 h
o Educate woman to assess/massage fundus
o Increase PO and IV fluids
o Precvent overdistention of bladder
o Assist with ambulation
o Provide and encourage rest
o Ferrous sulfate 325 mg TID between meals, PT on iron rich diet
Uterine Atony
 Tone
o Fundal firmness – presence of boggy uterus?
o Fundal position in relationship to midline
o Amount of lochia – assess by pad saturation
Uterine Inversion
 Fundus prolapses into endometrial cavity, turning uterus inside out
 Acute: within 24 h
 Subacute: 24 h – 4 wks
 Chronic: 1 month
 S/s: severe bleeding (can l/t shock), uterus not palpable, visualization of uterus, pain (mild to
severe)
 Call for help ASAP, stop oxytocin, 2 IV sites (16-18 gauge), labs (blood collection), uterine
relaxant (nitroglycerin and terbutaline), possible sx
o After: oxytocin, abx
Lacerations & Birth Injuries
 Cervical/vaginal lacerations: fundus is firm, lochia is heavy, bright-red, and gushing
 Hematoma:
o Vulva, vagina – extremely painful; rectal pressure; inability to void
 Tx: IV, drain/monitor, VS and output q1h, analgesics, icepacks, foley, Sx
or embolization
o Retroperitoneal – emergency, risk of death; most likely to present with
hemodynamic instability
Hypovolemic Shock
 Can be caused by uncontrolled hemorrhage l/t underperfused and underoxygenated
organs and compromised function
 Emergency!
 S/S: hypotension, tachycardia, tachypnea, oliguria, restlessness/anxious,
cool/pale/clammy skin, slowed cap refill
 Not noticeable until 40% of blood volume is lost
 Tx: supportive care
 2 large bore IV
 NS or LR infused rapidly at 3:1:3 ml/1 ml of blood loss
 O2 @ 10-12 via nonrebreather
 Monitor output via foley (<30 = hypovolemia)
 Lab (RBC – watch for DIC)
 Blood transfusions – watch for reaction
Thromboembolic Diseases
 Warfarin monitored w/ INR – goal is 2.5
 Heparin w/ PT/PTT
Postpartum Infections
 General s/s: fever beyond 24 hr after birth, onset 2-10 d PP, WBC continue to increase
 Perineal:
o Risk factors: operative vag delivery prolonged second stage of labor, third/fourth
deg laceration, episiotomy, maternal smoking, meconium-stained amniotic fluid
o S/s: tenderness, swelling, redness, purulent discharge
o Tx: remove sutures and opening the wound; no abx unless evidence of cellulitis
 Cesarean,
o Usually 4-7 d PP
o S/s: induration, redness, warmth, pain at incision site, wound edges approximated,
purulent discharge, fever
o Tx: open and drain wound; moist gauze, open wound
 Endometritis—infection of lining of uterus
o Risk factors: chorioamnionitis, prolonged labor, prolonged ROM
o Uterus can become soft and subinvoluted
o S/s: fever, uterine tenderness, flu-lke symptoms, tachycardia, purulent lochia
o Tx: IV broad spec abx
 Mastitis
o Risk factors: delayed breast emptying, por drainage of ducts, inconsistent pressure
on breats, oversupply of milk, nipple trauma
o S/s: tender, red area on breast, malaise, high fever
o Tx: warm compress (first 12-24 h), NSAIDs, reg/complete emptying of breasts,
abx
UTIs
PP Psych Disorders
PP blues aka Baby Blues
 Transient and self-limiting and resolves within 2 weeks
 Starts within 2-3 days PP
 S/S: weepiness/crying for no reason, feeling like “im not myself”, impatient, irritable,
restless, anxious, sad, mood changes, poor concentration
PP depression
 Sleep and appetite disturbances, uncontrolled crying, anxiety, inability to concentrate,
little interest in infant; guilt, sadness, hopelessness
 Beyond 2 weeks of baby blues – major depression
 Less likely to BF
PP psychosis
 Delusions, paranoia, hallucinations, mood swings, agitation, depressed, distraught,
confused, disorganized thoughts and behaviors
 Priority: safety of pt and infant
 Tx: inpatient psych care, antipsych meds, psychotherapy
Chapter 24: Conditions in the Newborn R/T GA, Size,
Injury, and Pain
NICU
 Environment can be intimidating and noisy
 Nurse should decrease inappropriate stimuli and implement more appropriate care
(kangaroo care aka skin-to-skin, interactions with parents, cuddling, rocking, talking)


Keep infants swaddled/tucked
Parents may need assistance with focusing on infant; nurse should explain what is normal
for preterm infants and encourage parents to ask questions and express feelings
Tubes/Vents
 NG – used for feeing, suction of gastric contents
o Inserted through nose to stomach
o Placement should be verified (imaging is best)
 OG – starts in mouth rather than nose
 Umbilical Artery Catheter – directly placed into stump of umbilical cord
 Umbilical Vein Catheter – placed into stump of umbilical vein
 PICC – used when intermediate term IV access is req
o Cephalic vein of arm of saphenous vein of leg
 Nasal Cannula – low flow continuous O2
o Checked regularly for occlusions and cleaned
 Continuous Positive Airway Pressure (CPAP) – delivered by mask or nasal prongs
 Endotracheal tube (ET) – direct o2 support to lungs and HIGHLY invasive!
 Oxygen hood – for infant who don’t req supplemental pressure support
o If hood needs to be removed, o2 should be provided by alternate method
Preterm Infant (<37 wks GA)
 Systems are immature and lack adequate physiologic reserves to function out of womb
Low Birth Weight
< 2500g (5.5 lbs)
Very Low Birth Weight
<1500g (3.3 lbs)
Extremely Low Birth Weight
<1000g (2.2 lbs)
 Skin:
o Increased sensitivity and fragility
o Avoid adhesive, use skin barriers
 Respiratory:
o Low functional alveoli and surfactant
 Not mature and functional until 32 wks after GA
o Weak/absent gag reflex
o 30-60 breaths per minute
o Chest and abd rise synchronously
o Periodic breathing = 10 s paused followed by several rapid breaths over 10-15 s
o Early signs of RD:
 Apnea – no breathing for 20 secs or more
 Nasal flaring, grunting, retractions, increase resp effort, circumoral or gen
cyanosis, seesaw breathing
o Apnea of prematurity
 20 s of bradycardia (70-80 BPM) or hypoxemia (<85%)
 Cardiac monitoring, pulse ox, impedance pneumography
 Tx: tactile stimulation, CPAP, stimulant (caffeine)
o RDS
 Occurs immed after birth or within 6h; resolves within 72 h
 S/s: tachypnea, expiratory grunting, nasal flaring, retractions, decreased
lung sounds



R/t meconium aspiration syndrome, sepsis, and pneumonia
Tx: supportive, CPAP/PEEP, surfactant (30-60min after birth), maintain
thermoreg and nutrition
CV
o Patent Ductus Arteriosus
 Murmur – cyanosis, RD, poor feeding, failure to thrive 2-3 d aft birth
 High risk for NEC and IVH
 Tx: cyclooxygenase inhibitors, thiazide diuretics, O2 w/ CPAP/PEEP
 Hypotn: NS, albumin, fresh frozen plasma, inotropics
 Neurologic
o Intraventricular Hemorrhage
 Decreased movement, < respirs, seizures, coma, death
 Tx: supportive, oxygenation, nutrition, avoid triggers
 Immune
o More susceptible to infection than term neonate bc of skin
o Sepsis
 Systemic inflammation and damage to body tissues; GBS, E.Coli most
common
 Early onset: 7 d after birth
 Late onset: after 1st week of birth
 RD, lethargy/irritability (late signs), feeding intolerance, glucose
instability, tachycardia, bradycardia/hypoTN (late sign), hypothermia
 CM are often subtle and nonspeific
 Dx: blood cultures
 Tx: abx, IV fluids, ECMO (not for infants <34 wks), oxygenation
 Symptomatic infants improve within 48h of Tx
 Temperature
o Minimal insulation
o Inadequate muscle mass activity, poor muscle tone
o Immature temp reg center in brain
o S/s of hypothermia: pale, mottled, cyanotic, cool to touch
 Tx: rewarm w/ warmer, warming mattress, isolette
o Factors l/t cold stress: hypoglycemia, tachypnea, RD, ductus arteriosus
o Prevention is important: warm delivery room, drying appropriately, blanketing,
skin-skin, warmers, warm/humidified O2, hate
 Nutrition
o Metabolic func compromised: limited store of nutrient (small stomach capacity),
< ability to digest proteins/absorb nutrient
 May require IV or gavage feeding
o Nonnutritive sucking: improve oxygenation during feeding; helps w/ soothing
o Infants who are not breastfed given colostrum
o Feeding intolerance:
 Vomiting, gastric fluid residual, bradycardia, apnea, lethargy
 Tx by delay feeding and < volume of feed
Late Preterm Infant
 Born 34 0/7 - 36 6/7 weeks of gestation

High risk for: hypothermia, hypoglycemia, RD/apnea, jaundice, feeding difficulties
o Hypoglycemia Txed when BG <40-45 or showing signs of jitters, irritability, poor
feeding, weak/high pitched crying, tachypnea, diaphoresis, pallor, lethargy
 First line of Tx is feeding and then if BG still low give IV dextrose
 Associated with developmental/academic delayed
Postterm Infant
 Born after 42 weeks
 FGR and SGA from insufficient aging placenta
o Not receiving adequate nutrition and oxygen from placenta
 Characteristics
o Long and thin infant with meconium stained skin
o Wrinkled, loose, peeling skin
o Creases at joints more prominent
o More scalp hair; absence of vernix and lanugo
o Long nails
 Complications
o Birth injuries, hypoglycemia, impaired thermoregulation/immune function,
oligohydramnios, low APGAR scores, cerebral palsy, meconium fluid
Small for Gestational Age (SGA)
 Weight <10th percentile
 Characteristics: shrunken appearance
o Large fontanels, thin umbilical cord, meconium staining,
 Complications:
o Hypoglycemia, heat loss, asphyxia, polycythemia, and hypocalcemia
Large for Gestational Age (LGA/Macrosomia)
 Weight >90th percentile or birth weight of >4000g
 Higher risk for RDS, birth trauma (shoulder dystocia, brachial plexus fracture), asphyxia,
MAS, hypoglycemia, polycythemia
Birth Trauma
 Can occur during or after labor
 Bruising: self-limited; can add to hyperbilirubinemia
 Lacerations: during c-section
o Most common injury associated with c-section
 Fractures: most common is clavicle and generally heals spontaneously
 Subconjunctival hemorrhage: ocular bleed; looks alarming but resolves spontaneously
within 2 wks
 Brachial Plexus Injury: unilateral nerve damage that innervate muscle and skin on
arms/shoulder
o Can resolve spontaneously but Sx may be req for nerve repair
 Facial Nerve Trauma: prolonged pressure against pelvis or forceps delivery to CN VIII;
results in decreased mvmt on side of injury
o Resolves within hours but complete recovery can take months
Pain
 Pain mgmt
o BF, nonnutritive sucking


o Skin-skin, swaddling
o oral sucrose
o Topical anesthesia
o Acet/opioid analgesics
o Nerve block w/ lidocaine
Neonatal Infant Pain Score (NIPS)
o Facial expression
 Relaxed = 0; grimace = 1
o Cry
 No cry = 0; whimper =1; vigorous crying = 2
o Breathing patterns
 Relaxed = 0; change= 1
o Arms
 Restrained = 0
Assessment for indications of pain:
o Change in HR, RR, and BP
o Change in breathing pattern or O2 sat
o Sweaty palms, change in skin color
o Increased ICP, change in HR variability, change in pupil size
o Change in crying pattern, acoustic feature of cry, consolability
o Change in facial expression, hand/body mvmts, muscle tone
Chapter 25: Acquired Conditions and Congenital
Abnormalities in the Newborn
Hyperbilirubinemia
 Bilirubin = breakdown of RBCs
o Conjugate: excreted in stool
o Unconjugated: bound to albumin, not excreted
 Physiologic jaundice: expected and normal
 Pathologic jaundice: not normal and occurs from excess bilirubin production, decreased
clearance of bilirubin, and enterohepatic circulation
o Develops in first 24 h
o Reasons for increased pathologic bilirubin production
 ABO or Rh incompatibility




RDS


 Cephalohematoma or other reason for excessive breakdown of RBCs
 Sepsis
o Reasons for decreased clearance
 Maternal DM
 Congenital hypothyroidism
o Reasons for disruption of circulation from liver to bile
 Breast milk jaundice – pattern of jaundice 3-5 d after birth
 BF failure jaundice – jaundice occurring within first week of birth
 Intestinal obstruction
S/s: yellowing of skin, starting in face and moves down;
Severe: >25 mg/dL
o At risk for BIND/ABE -- lethargy, fever, jitters, irritable, hypotonia, poor feeding,
apnea, seizures
o Kernicterus: >35 mg/dL -- irreversible effects - cerebral palsy, hearing loss, gaze
abnormalities, dental enamel dysplasia
Assessments: visualization q 8-12 h
o Universal screening: transcutaneous bilirubin (TcB) measurements (can
underestimate bili), total serum bilirubin (TSB) measurements confirm
Tx:
o Phototherapy – nurse should minimize body surface covered by diaper, infant
positioned on back in an open bassinet/warmer
 Serum bili >20 should be continuously under lights; once under 20,
discontinue for feeding and bonding activities
 Risk for dehydration, feeding, and hyper-hypothermia
o Exchange transfusion – used in severe hyperbilirubinemia (>25 mg/dL)
Typically progresses for 48-72 hours and resolves within a week
Conditions causing RDS: bronchopulmonary dysplasia (BPD), persistent pulmonary
HTN (PPHN), transient tachypnea (TTN), and meconium aspiration syndrome (MAS)
 S/s: tachypnea, nasal flaring, expiratory grunting, retractions, cyanosis, pallor
 Tx: supportive, ventilation, surfactant
Bronchopulmonary Dysplasia
 Results from administration of O2 and mechanical ventilation for Tx of RDS
 S/s:
o Atelectasis, pulmonary edema
o Tachypnea, retractions, rales, expiratory wheezing
 Tx: resp support, nutrition support, resp disease vaccines; improvement over 2-4 months
o Infants are often fluid restricted d/t pulmonary edema
Transient Tachypnea (TTN)
 Self-limiting form of pulmonary edema
 S/s: tachypnea, nasal flaring, grunting, retractions, cyanosis, feeding difficulty
o Resolved within 24-72 h, if not, eval for pneumonia and sepsis

Tx: supportive care, oxygenation (SPO2 >90; hood/nasal cannula), feeding consideration,
may need NG/OG
Meconium Aspiration Syndrome (MAS)
 Respiratory distress d/t meconium stained fluid
 S/s:
o Mec stained amniotic fluid
o RD – cyanosis, rales/rhonchi (within 15 min aft birth)
o Pneumothorax, pneumonia
 Dx: chest x-ray, spo2, ABG
 Tx: prevention, supportive care, abx, surfactant, nitric oxide, ECMO
o Prevention: limiting duration of pregnancy to avoid postterm
 Adequate ventilation/perfusion -- correct acidosis and hypoglycemia
Retinopathy of Prematurity (ROP)
 Abnormal vascular growth of blood vessels of retina in premature infants
 Linked to: LBW, prematurity, excess O2 after birth
 S/s: edema, hemorrhage, scarring of retina
 Tx: laser photocoagulation, antivascular endothelial growth factor monoclonal antibodies
for severe disease
o Regresses and resolves spontaneously
Necrotizing Enterocolitis (NEC)
 Ischemic necrosis of intestine – EMERGENCY
 Often fatal, BF is protective
 S/s: feeding intolerance (first sign), abd distension, vomiting (bile/blood), RF, hypoTN,
temp instability, bloody stool
 Tx: supportive, abx, GI tract rest, gastric decompression, TPN, xrays q 6-12 h, bowel
resection
Neonatal Encephalopathy (NE)
 Infant born at or after 35 wks with disturbed neurologic function
o Seizures or reduce LOC
 S/s: weak reflexes & muscle tone, difficulty with resp func, low APGAR, weak/absent
cry, feeding difficulties
 Tx: maintain homeostasis, avoid hypoxemia, avoid hypotn/HTN, seizure control, control
brain edema by avoiding fluid overload
Maternal Diabetes
 Maternal glucose passes placenta but maternal insulin does not – fetus compensates with
increase in insulin
 Complications: congenital anomalies (CV, NTD, GI, cleft palate, GU), macrosomia/birth
trauma, perinatal asphyxia, RDS, hypoglycemia, hypocalcemia, polycythemia, low iron,
hyperbilirubinemia
 Nursing considerations after birth
o Monitor BG, observe for signs of hypoglycemia (jitters, apnea, tachypnea,
cyanosis)
Neonatal Abstinence Syndrome (NAS)
 Constellation of withdrawal symptoms that occur as a result of uterine exposure to drugs
 S/s:
o Irritability, tremors, seizure, hypertonia
o Abnormal sleep pattern
o Shrill, persistent, high-pitched cry
o Frequent yawning/sneezing, mottle skin, fever
o Poor feeding/sucking, vomiting, diarrhea
o Tachypnea
o Hypothermia, sweating
 Tx: opioids for symptoms (NICU admission req)
o Nonpharmacologic: swaddling, decrease stimuli, BF
 Assess mother’s sobriety/Tx plan and home environment for discharge
 Fetal Alcohol Spectrum Disorder (FASD)
o Characteristics: thin upper lip, short palpebral fissure (small eyes), smooth
philtrum, small head circumference, short nose, low nasal bridge, small midface
o Cognitive impairment, impaired planning/decision making, hyperactivity,
impaired motor func, poor social skills
o Care considerations: SW, OT, PT, ST, psych
GBS
 Most common cause of sepsis and meningitis
 Prophylactic abx given to mothers during labor
 Early onset: sepsis, pneumonia, meningitis
o Tachypnea, apnea, pale, hypotonic, grunting, nasal flaring, retractions
 Late onset: meningitis or focal infection
o Fever + recent resp infection, cellulitis, irritability, poor feeding, grunting,
tachypnea, nuchal rigidity (neck stiffness), seizure
Other sources of Neonatal Infections
 Congenital syphilis – Tx w/ penicillin G
o Stillbirth, prematurity
 Gonorrhea neonatorum – Tx w/ oral abx
o Leading cause of blindness; treated with abx eye ointment at birth
 Chlamydia
o Conjunctivitis or pneumonia; transmitted via vaginal birth or placenta
 Herpes – Tx w/ IV antiviral 14-21 d
o Vaginal delivery when mother experiencing outbreak
o S/s: temp instability, RD, apnea, lethargy, irritability, abd distention, ascites,
enlarged liver
 Hep B – Tx w/ HPsAG after birth and first dose of hep b vaccine within12 h
 HIV – Tx w/ ART 6-12 h after delivery
o BF CI in HIV+ mothers
o Most commonly transmitted during intrapartum period

Congenital CMV – Tx w/ IV antiviral meds
o Hearing loss and neurodevelopmental disability
 Varicella -- Tx w acyclovir ASAP
o If occurring within first 5 days of life, life threatening
 Candidiasis – Tx w/ antifungal meds
o Late onset neonatal sepsis; remove IV lines or caths
 Zika – no specific Tc
o Microcephaly, craniofacial disproportion, hearing loss
Congenital Heart Disease (CHD)
 Many infants appear normal, but will decompensate as ductus arteriosus closes
 S/s: HR <90 or >160; lack of s2 split w/ inspiration, extra heart sounds, murmur, < pulses
in lower extremities, enlarged liver
 Screened 24 h of age by SPO2
Neurologic Abnormalities
 Anencephaly: open defect of the skull; portions of brain missing
o Prognosis: no longer than a few days or weeks
o Screened routinely with alpha fetoprotein (AFP) levels and US
o Incompatible with life, no Tx
 Encephalocele: brain and/or meninges protrude through skull
o Routine screening with AFP an US
o Neurodevelopmental outcomes r/t size and location
o May require c-section
 Spina Bifida: incomplete closure of spinal cord
o Occulta: skin intact and neural tissue not exposed
 Most benign
 Indications: skin over vertebral opening, deep dimple, hairy patch
o Meningocele: skin covers defect, but meninges protrudes through spine
 Can be repaired with no long lasting nerve damage
o Myelomeningocele: both meninges and neural tissue through spinal opening
 Damage to both
 Can l/t complete paralysis, absence of sensation, fecal/urinary
incontinence or compromise
 Hydrocephalus: CSF accumulation in ventricles
o S/s: enlarging head circumference, h/a, behavioral changes, developmental delay,
N/V, lethargy
 Microencephaly: abnormally small brain
o Developmental delay, intellectual disability, epilepsy
o Can be present without microcephaly
 Microcephaly: head circumference 2 std dev below mean for GA and sex
o Almost always associated with microencephaly
Congenital Anomalies
 Cleft lip w/ or w/o cleft palate or cleft palate w/o cleft lip
o Feeding modifications and considerations: cleft lip = unable to form seal; cleft
palate = unable to suction to extract milk
o May req support for breathing
o Surgical repair usually at 3 mo for cleft lip and 6 mo for cleft palate
GI Anomalies
 Omphalocele: defect of abd wall; organs bulging but are covered by peritoneum, anion,
wharton’s jelly
o Wrapped in sterile gauze to prevent heat and fluid loss
o Stomach decompressed with NG
o Positioned on left side if vascular compromise
 Gastroschisis: protruding intestines from abd wall, no sac
o Similar process to omphalocele
GU Anomalies
 Hypospadias – urethra on ventral aspect of penis
o May also be on scrotum or perineum
 Epispadias – urethra on dorsal aspect of penis
o Associated with bladder exstrophy
 Ambiguous genitalia – genetic, hormonal, or embryonic abnormalities
Musculoskeletal Anomalies
 Hip dysplasia – assessed with Ortolani test
o Tx: Pavlik Harness to align acetabulum and femoral head – not initiated until 4
wks of age
 Clubfoot – feet sharply plantar flexed with sole facing inward
o Tx: frequent repositioning of foot for several months; start immed after birth
 Ponseti method most common
 Syndactyly – fusion of digits
o Txed with Sx at 6-24 months
 Polydactyly – extra digits
o Children can make a decision abt extra digits