Uploaded by Jackie Herrera


Chapter 15: Pregnancy
 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
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,
 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
 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
 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
 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
 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
 GFR increases 50%
 Growth of uterus = ureters must also grow to retain larger volume of urine
 Blood flow to kidneys increases 80%
 Progesterone slows peristalsis – increases risk of bloating, constipation, N/V
 Weight gain
 Breasts larger, fuller, and tender
 Colostrum production begins midway through pregnancy or earlier
 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
 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
 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
 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
 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
 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
 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%
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
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
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
 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
 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
 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
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 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
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
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
 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
 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
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
 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
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
 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
 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
Assess for
soft, nontender
slow to
and record wound/lacerat unilateral
for first 24 h.
ion + general edema,
Slowly will feel umbilicus
Full bladder
flatus and protocol
condition of
more full as
can displace
breast milk
uterus or
sounds ok
Assess for
comes in (2-5 d
atony/cystitis discharge
 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
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
 Comfort measure: ice packs, side lying position, sitz bath, ibu/acet, peri bottle (cleaning and
comfort), witch hazel pads, docusate sodium, kegel exercises
 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
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
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
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
 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
 0-3 severe distress
 4-6 moderate difficulty
 7-9 no difficulty adjusting to extrauterine life
Grimace with
0 No pulse
0 Stoic
0 Limp
0 None
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,
 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
o Report bleeding larger than a quarter or no voiding within 12 h after
Chapter 20: Conditions Occurring During Pregnancy
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
 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 &
o Antiemetics, metoclopramide, promethazine, complementary IV rehydration, and
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
 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
 Tx: D&C, prophylactic chemo, serial hCG levels for one year, and no pregnancy for one year
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
Preeclampsia & Eclampsia
 Preeclampsia: HTN (>140/90) on 2 BP reading (4 h apart) + proteinuria w/ prev normal BP
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)
 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
 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
 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
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
o Presentation: gush of fluid from vagina
 PPROM: ROM prior to 37 weeks
o Increased risk for infection, cord prolapse, fetal malpresentation, and precipitous
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
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
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
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
 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
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
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
 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
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
 Anxiety = negative impact
 Support = helps ; doula, friends, family, nurse
 Upright positions
o Sitting, kneeling, squatting, or standing
Intrapartum Procedures
 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,
 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
 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
 Placenta adherens – easily separated
 Placenta accrete – adhered to myometrium instead of decidua
 Risks: PPH and endometritis
 Tx: traction, meds, manual removal, D&C, hysterectomy
 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
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
 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,
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
 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
 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)
 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
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
 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
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 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
 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
 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
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
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,
 Nursing considerations after birth
o Monitor BG, observe for signs of hypoglycemia (jitters, apnea, tachypnea,
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
 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