MODULE 1 - HEALTH ASSESSMENT & HEALTH PROMOTION FOR WOMEN
READINGS
- Maternal Child Nursing (5th Edition): p. 1-31, 32-61, 61-95, 96-122
- ATI: p. 3-14, 47-55
Contemporary American women enjoy a level of social and health status that equals or surpasses the vast majority of women globally.
However, poorer women in America are among those who have more health problems and less access to health care compared to other
nations in the world. Approximately 35 million or 26% of American women belong to ethnic minority groups and these women are
disproportionately represented among the poor. Their poverty gives rise to their health status. Age is another factor which effects health.
Older women face different health problems, yet many also must contend with the health-related consequences of poverty. Women with
physical challenges or chronic health disorders face a host of personal and social challenges, and many lesbian women lack preventive
health care due to actual or potential alienation by healthcare providers.
Women often first encounter the healthcare system due to gender specific health issues. Some access the health care system for the first
time due to pregnancy. Once a woman enters the system it is imperative for health care providers to support her needs for health
promotion and health maintenance and to offer such services across the woman's life span.
TOPIC A: HEALTH ASSESSMENT OF WOMEN - WELL WOMEN
Women from all ethnic backgrounds view themselves as active participants in their own health care. Yet, many women feel less than
confident to make the right choices to take care of themselves. "Knowledge deficit related to...." may truly be one of the most necessary
nursing diagnoses a nurse may employ in working with well women. A knowledge deficit may occur in relation to information about he
own body and its functions, strategies for health promotion and disease prevention, and / or self -care for diseases that are encountered.
Well woman care encompasses screening programs and health examinations designed to provide anticipatory guidance and early
identification of threats to a woman's health. The role of the nurse is one of a guide / facilitator. The goal is an empowered woman ... a
woman capable and confident to make decisions regarding her health.
FEMALE REPRODUCTIVE SYSTEM
- External structures
- Mons pubis
- Labia majora and labia minora
- Clitoris
- Vestibular glands
- Vaginal vestibule
- Vaginal orifice
- Urethral opening
- Internal structures
- Vagina
- Uterus
- Cervix
- Fallopian tubes
- Ovaries
- Bony pelvis
- Protection of pelvic
structures
- Accommodation of
growing fetus during
pregnancy Anchorage of pelvic
support structures
- Breasts – Structure
- Mammary gland
composed of
a number of lobes, divided into lobules
- Lobules are clusters of acini
- Acinus is a saclike terminal part of a compound gland emptying through a narrow lumen or duct
- Acini are lined with epithelial cells that secrete colostrum and milk
- Breasts - Function
- Lactation
- Organs for sexual arousal
- Physiologic alterations in breast size reach minimal level about 5 to 7 days after menstruation stops
- Breast self-examination best carried out during this phase of menstrual cycle
MENSTRUATION
- Menarche and puberty
- Menstrual cycle
- Endometrial cycle
- Hypothalamic-pituitary cycle
- Ovarian cycle
- Other cyclic changes
- Prostaglandins
- Oxygenated fatty acids classified as
hormones
- Effects on:
- Ovulation
- Fertility
- Changes in cervix and cervical
mucus
- Tubal and uterine motility
- Sloughing of endometrium
(menstruation)
- Onset of abortion (spontaneous
and induced)
- Onset of labor (term and preterm)
- Climacteric and menopause
- Climacteric
- Transitional phase during which ovarian function and hormone production decline
- Spans the years from onset of premenopausal ovarian decline to postmenopausal time, when symptoms
stop
- Menopause
- Refers to the last menstrual period
- Dated with certainty 1 year after menstruation ceases
- Average age 51.4 years’ old
- Range of ages 35 to 60 years’ old
BARRIERS TO ENTERING THE HEALTH CARE SYSTEM
- Financial issues
- Racial and socioeconomic disparity
- Cultural issues
- Constantly changing demographics
- Gender issues
- Sexual orientation
CARING FOR WOMEN ACROSS THE LIFESPAN
- Disease prevention
- Adolescents
- Teenage pregnancies
- Young and middle adulthood
- Contraception
- Pelvic and breast screenings
- Late reproductive age
CARE AT SPECIFIC STAGES OF A WOMAN’S LIFE
- Preconception counseling and care
- Pregnancy
- Fertility control
- Infertility
- Menstrual problems
- Perimenopause
IDENTIFICATION OF RISK FACTORS
- Social, cultural, genetic
- Substance use and abuse
- Prescription drug use
- Illicit drug use
- Alcohol consumption
- Cigarette smoking
- Caffeine
- Nutritional problems
- Nutritional deficiencies
- Obesity
- Eating disorders
- Anorexia
- Bulimia nervosa
- Lack of exercise
- Stress
- Mental health conditions
- Sleep disorders
- Environmental and work place hazards
- Risky sexual practices
- Risk for certain medical or gynecologic conditions
- Female genital mutilation
SPIRITUAL APPROACHES TO WOMEN’S HEALTH - Helpful
in maintaining wellness and coping with illness - Refers
to the efforts of our being and humanity - Holistic
approach to women’s wellness
- Spiritual assessment
ASSESSMENT OF THE WOMAN
- Interview
- Ways to encourage sharing information
- Facilitation
- Reflection
- Clarification
- Empathic responses
- Confrontation
- Interpretation
- History
- Biographic data
- Reason for seeking care
- Present health or history of present illness
- Past health
- Family history
- Screen for abuse
- Review of systems
- Functional assessment
- Physical examination
- General appearance
- Vital signs
- Objective data is recorded by body systems
- Findings are described in detail
- Cultural considerations and communication variations
- Trust that woman is expert on her life, culture, and experiences
- If asked with respect and genuine desire to learn, woman will tell nurse how to care for her May be considered inappropriate for woman to disrobe completely for physical examination In many cultures a female examiner is preferred
- Women with special needs
- Women with disabilities
- Emotional or physical disorders
- Vision or hearing impaired
- Adapt to each woman’s needs
- Adolescents (ages 13 to 19 years old)
- Risky sexual behaviors
- Eating disorders
- Safety
- Pelvic examination
- External inspection and palpation
- Vulvar self-examination
- Collection of specimens
- Papanicolaou test
- Vaginal wall examination
- Bimanual palpation
- Rectovaginal palpation
- Pelvic examination during pregnancy
- Pelvic examination after hysterectomy
HEALTH SCREENING FOR WOMEN ACROSS THE LIFE SPAN
- Laboratory and diagnostic procedures
- The following laboratory and diagnostic procedures are ordered at
discretion of clinician
- Results of these tests may be reported in
person, by phone call, or by letter
- Hemoglobin
- Fasting blood glucose
- Total blood cholesterol
- Lipid profile
- Urinalysis
- Syphilis serology (VDRL or RPR) and other
screening tests for sexually transmitted infections
- Mammogram
- Tuberculosis skin testing
- Hearing
- Visual acuity
- Electrocardiogram
- Chest x-ray
- Pulmonary function
- Fecal occult blood
- Flexible sigmoidoscopy
- Bone mineral density
(DEXA scan)
- Tests for human
immunodeficiency virus and hepatitis B and
drug screening may be offered with
informed consent in high risk populations
TOPIC B: INTIMATE PARTNER VIOLENCE
Miserable Woman
Throughout a woman's life span, violence may threaten to disrupt her life. Rape occurs to one in every four women, peaking between the
ages of 18 and 24. Intimate partner violence (IPV) is the single most common injury to women, surpassing muggings, rape, and motor
vehicle accidents combined; and is the leading cause of violent injury to pregnant women. Yet, estimates of over 6 million incidents of
IPV go unreported each year. Race / ethnicity is not a barrier to IPV, each of the dominate races / ethnicities in the United States
(Caucasian, African American and Hispanic American) have similar rates of IPV across ages and socioeconomic lines. The role of the
nurse is first, assessment & recognition of cues. Listening is an important part of this assessment. The nurse's role then becomes
advocate and facilitator. The goal is safety - for the woman and her children; then empowerment.
VIOLENCE AGAINST WOMEN
- Intimate partner violence (IPV)
- Physical or emotional abuse
- Sexual assault
- Isolation
- Controlling all aspects of the woman’s life
- Money
- Shelter
- Time
- Food
- Cycle of violence
- Phase 1: Tension building
- That her experiences increased tension,
victim minimizes problems
- Tension becomes intolerable
- Phase 2: Abusive incident
- Batterer highly abusive, incident occurs
- Phase 3: Honeymoon period
- Loving, apologetic, promises change
- Battering during pregnancy
- Rates range from 4% to 8% and may be as high as 20% in some populations
- Incidence of intimate partner violence may escalate
- May happen for the first time during pregnancy
- Risk to the fetus includes increased rate of miscarriage, preterm birth, and stillbirt
TOPIC C: COMMON MENSTRUAL DISORDERS
Menstrual-Cycle (Emma Bryce you tube Videos)
Many women sail through their months with little or no concern about their reproductive health. Their menses come with clockwork
precision and pass with few or no difficulties. For others menses brings either or both physical and / or emotional turmoil. It is these
concerns that will be presented in this section.
Female Reproductive Physiology
•
Menarche: Median age in US 13 y/o. Although many girls are starting their periods earlier because
of the increased adipose tissue. Higher body fat correlated to starting menstrual cycle earlier.
•
•
•
Requires intact: Hypothalamus, anterior pituitary, ovaries & feedback mechanisms
Menstruation- periodic uterine bleeding that begins approximately 14 days after ovulation.
o Average menstrual cycle length: 28 day (14 day ovulation)
o Average duration of menses: 5 days
o Average blood loss: 50ml
All cycles happen simultaneously and all must be working or that’s when they have irregularities
o Know foundational knowledge don’t focus on increase and decrease hormones
Hypothalamic - Pituitary Cycle
o ↓ Estrogen(E2) & Progesterone (P4): stimulates hypothalamus to secrete (GnRh)
o ↑ GnRH stimulates anterior pituitary to secrete follicle-stimulating hormone (FSH)
o ↑ FSH stimulates development of the ovarian graafian follicles, which ↑ovarian production of E2
o A slight mid-cycle drop in estrogen (↓ E2) triggers GnRH to stimulate the anterior pituitary to secrete luteinizing hormone
(LH) (called LH surge tells body to ovulate)
o A surge of LH and small ↑ E2 stimulates ovulation (releases egg to be fertilized).
o If fertilization doesn’t occur- E2 & P4 decrease and the corpus luteum regresses …If there isn’t this surge of LH, then ovulation
doesn’t happen and the uterine lining will continue to thicken causing serious problems.
Ovarian Cycle
• Follicular phase
o Before ovulation FSH & E2 cause development of 1-30 follicles
o LH causes 1 oocyte to mature and is released (usually around day
14)
o Start period 14 days after ovulation
• Luteal Phase: everything dies if we don’t fertilize egg
o Begins after ovulation and ends with menstruation
o Corpus luteum secretes E2/P4 = peak day 8
o Corpus luteum regresses without conception
Endometrial Cycle- 4 Phases*** (lining of the uterus has to be rich in blood
flow for egg to implant; if lining is thin it’s a hormonal issue) estrogen is
what makes the lining thick
• Menstrual Phase:
o Shedding of the functional endometrium: uterine lining thins
• Proliferative Phase
o E2 causes: Rapid endometrial growth
• Secretory Phase
o P4 causes endometrium to thicken: ↑ blood (uterine lining thickens to
enable
implantation. You must have a
thick vascular lining to support a pregnancy)
• Ischemic Phase
o Spasm and necrosis of the functional layer of the endometrium (because no
sperm fertilized the egg, then the
uterine lining starts to thin off)
The surge of which hormone is responsible for maturation & release of an oocyte at midcycle?
▪ Progesterone
▪ Estrogen
▪ LH
▪ Prostaglandin
Menstrual Disorders
Amenorrhea: absence of menstrual flow
• S&S: absence of menstruation
• Assessment: history & exam, first thing we do is check for pregnancy
• Management: varies and depends on what the cause is
• Etiology:
o Primary: anatomical, disease process, where a lady has never had a menstrual cycle
o Secondary: where you stop having periods after having had them for at least 6 months (where we focus on)
▪ #1 reason for secondary amenorrhea is pregnancy
▪ #2 reason for secondary amenorrhea is Hypogonadotropic Amenorrhea
o Absence of menstrual flow due to hypothalamic suppression. (hypogonadotropic amenorrhea)
▪ This suppression occurs from the lack of hormones most likely caused by inadequate adipose tissue (adipose tissue helps
with E2 production).
▪ Happens a lot in adolescents, low BMI, athletes, fit and athletic, low weight range
▪ Etiology: major stress, low weight range, excessive exercise (example in bulimia and anorexia nervosa) ▪
S/S: absence of menstruation
▪ Assessment: history & physical examination; Hcg (pregnancy test), FSH, TSH (low or high impacts period), prolactin,
menopause
▪
Management: always rule out pregnancy, counseling & education
regarding stress, moderation in exercise, and weight loss.
▪ Treatment: ** OCA’s (oral
contraceptive agent; putting these women on the pill can help better manage these hormones such that the body will cycle but
not ovulate and they will bleed/uterine lining will shed), Ca supplements (when you don’t have menstrual cycles you’re at risk
for osteoporosis and depletion your Ca stores)
- Artificially allow them to cycle
- Low dose BC
- Calcium supplements
Dysmenorrhea
• Pain during or shortly before menstruation
• Primary dysmenorrhea (most common)
o Abnormally increased uterine activity (usually starts 6-12 months after they’ve started their menses)
▪ Usually teens or early twenties (most common complaint)
▪ Put on BC to control discomfort
o Etiology: Physiologic alteration; prostaglandin excess that causes the pain (cause vasospasm and discomfort)
o S&S: severe cramps, back pain, GI symptoms (loose stools or diarrhea)
o Management:
▪ Alleviating discomfort (heating pads, decrease sodium, decrease sugars, decrease red meats)
▪ Non-steroidal anti-inflammatory drugs***
▪ OCA’s (birth control pills decrease the prostaglandin levels): low dose
▪ Education: decrease sodium, fat, sugar, and red meat or ice cream
• Secondary dysmenorrhea
o Acquired menstrual pain associated with possible pelvic pathology (so this is when the lady has had normal periods for
years/normal prostaglandin levels, and now she has severe painful periods)
o Later in life than primary (28-30yo)
▪ All of a sudden
o Etiology:
▪ Adenomyosis (lining of the uterus grows into the wall of the uterus into the muscle; inside lining are prostaglandin receptors so
because its growing in it causes it to be painful and uterus bulky)
▪ Endometriosis (lining inside the uterus goes outside of the uterus to places such as bowel or bladder) ▪
PID (caused by infectious disease that didn’t get treated), fibroids (benign tumor in the uterus)
▪ fibroids
o S&S: heavy menstrual flow, dull lower abdominal ache
o Assessment:
▪ Pelvic exam (right size, place, mobile)
▪ USG (ultrasound) exam
o Management:
▪ Treatment directed to removal of underlyingpathology.
▪ Comfort: NSAIDS, OCA’s, diet (can reduce sodium intake to reduce the swelling that may be painful as well
and can also reduce sugars and red meat will help), exercise, heating pads, OBC pills
When a nurse is counseling a woman for primary dysmenorrhea, which non-pharmacologic intervention might be recommended?
A. Increasing the intake of red meat and simple carbohydrates
B. Reducing the intake of diuretic foods such as peaches and asparagus
C. Temporarily substituting physical activity for a sedentary lifestyle
D. Using a heating pad on the abdomen to relieve cramping
Prementrual Syndome (PMS):
• Cyclic symptoms occurring in luteal phase of menstrual cycle
• **Criteria
▪ 85% of women experience symptoms
▪ 5% to 14% report disabling symptoms
• Etiology: Poorly understood (change in Hormones)
• S&S: Cluster of physical, psychologic, and behavioral symptoms.
▪ They have to meet a certain number of symptoms to be classified as having PMS.
• Management: diet (again reduce sugar, NaCl, and red meat), exercise, and herbal therapies ** education, avoid caffeine, limit
ETOH, keep a diary of symptoms to show provider, can also give them OCA or Depo- provera which is an injection of
progesterone, and a low dose Aldactone to reduce the amount of swelling
In helping a client manage premenstrual syndrome (PMS), the nurse should:
a. Recommend a diet with more body-building and energy food such as red meat and sugar.
b. Suggest herbal therapies, yoga, and massage.
c. Tell the client to push for medications from the physician as soon as symptoms occur to lessen their severity.
d. Discourage the use of diuretics.
Endometriosis
• Presence and growth of endometrial (lining of the uterus) tissue outside of uterus
o Will attach to different parts of the pelvic region such as bladder, intestine etc. and cause pain
elsewhere because the tissue is specialized to react to hormones and will also contract
o Hard to see on Ultrasound- cant be seen unless it clusters together.
o Dx: based on physical exam (Bi-manual examhand in cervix and on abdomen to see if uterus is
mobile which means endometriosis is not attached outside of uterus and will show us if its painful)
• Etiology: possible retrograde menstruation.
o It’s essentially a bunch of scar tissue, from the uterus that migrates outside of the uterus, that
also
responds to same hormones the endometrial lining does and grows.
o Anatomoical changes: size of uterus
• S&S: most commonDysmenorrhea & dyspareunia (painful intercourse)
o But normal flow bleeding during cycle, can cause infertility because if the lining of the uterus, that tissue starts to migrate to the
tubes for instance this will block the egg from being transported down to the uterus
• Management:
o Drug therapy:
▪ Danazol or Lupron: to suppress the effects of the extra endometrial tissue increase testosterone growth (SE: facial hair, acne,
hot flashes, vaginal dryness- symptoms of psuedomenopause)
▪ OCA’s (start with a low dose pill and move up as you need to)
▪ NSAIDS (remember inflammation is what’s causing most of pain)
o Surgical intervention: need to need basis
▪ Lap 40% …done especially for women who are trying to get pregnant and are having trouble from this. (golden standard) ▪
Women must get pregnant shortly thereafter because as they start to cycle there will be more tissue growth. ▪ Surgery is
never the front-line treatment because if the woman isn’t treating this any other way, they will continue to proliferative over
time.
▪ You’re only buying so much time. And if you’re trying to get pregnant you don’t want too many incisions down there o
Education/Support: very painful but can manage, as you age it will get better
Fibroids
• Benign tumor that originates from the myometrium of the uterus, but can originate from really anywhere inside the uterus/any layer of
the uterus.
• They can also be off the uterus (inside or outside), what we call a pedunculate fibroid (hanging like a stalk) •
Etiology:
o genetic (if mom has fibroids, daughter has a higher chance of having them)
o higher rate in AA women
o hormone stimulated
o Older later in life (as we age they get more troublesome at 45)
o association with CHTN (women with HTN are at a greater risk as well)
S&S: menorrhagia (heavy bleeding), dysmenorrhea.
▪ For instance, patient comes in and says over time my period has
gotten worse and the pain has gotten worse.
▪ And you check her uterus and it’s bigger than it should be (stomach
will appear bigger than it should be) and she’s not pregnant, then it’s
probably a fibroid. (size of a 12 week uterus and not the size of a fist)
▪ We then do an US to confirm.
• Management:
o Medication: anything that suppresses hormones (OCAs, Depo, IUD which is progesterone inside the uterus, Danazol) o Some
patients get better during pregnancy (because pregnancy is a steady state), but few people do worsen o
Surgically-
myomectomy, typically reserved for large obstructive fibroids (causing severe
pain)
▪ If it’s small and on the uterusand she is trying to get pregnant, we don’t want to create a scar on uterus that will put us at
risk
as uterus grows.
▪ Most often done as women have moved past their fertility years and many times women with fibroids will
end up with a hysterectomy.
▪ Can get pregnant with the fibroid.
• Uterine leiomyoma, myoma, fibromyoma, fibroleiomyoma
Alterations in Cyclic Bleeding (doesn’t really test on these)
• Oligomenorrhea (bleeding less)
o Infrequent menses Q 40-45d.
o Longer cycles, instead of having period every 28 days, there’s this huge gap.
o They are not ovulating well.
o Etiology: pituitary tumor, excessive exercise, low BMI, PCOS (poly-cystic ovarian syndrome), perimeno (close to menopause – in their
forties)
• Hypomenorrhea
o Scant bleed, normal interval. So, every 28 days she is bleeding but only for 1-2 day.
o Etiology: similar as Oligo
• Metrorrhagia
o Intermenstrual bleed, aka breakthrough bleeding (spotting). In between her periods she also spots for let’s say a day.
o Etiology: pregnancy (first thing we do is get pregnancy test to make sure spotting isn’t from implantation), onset of
OCA always you’ll see light bleeding, endometriosis, fibroids, & cancer (do PAP smear)
• Menorrhagia (hypermenorrhea)
o Excessive menstrual bleed (duration or amount)
o More saturation for a longer period of time
o Soaking a pad every hour
o Etiology: fibroids, malignancy, cervical polyps
• Menometrorrhagia
o excessive menstrual bleed which is irregular & frequent
o Etiology: adenomyosis (inside of the uterine lining grows into the muscle, these women have a very hard time getting
pregnant, seen in women in late 30s and 40s when women are getting out of their fertility years - this usually precludes a
hysterectomy), fibroids
• Abnormal uterine bleeding
o Irregular in amount, duration or timing
o Usually start to see around menopause phase
o Etiology: Obesity (more adipose tissue the more estrogen you have), hyperthyroidism, hypothyroidism, PCOS.
o DUC- dx after rule out other causes
o Management: hospitalize prn, transfusion, D&C, endometrial bx, ablation (Novasure)
Problems of the Breast:
• 50% of women will have problem with breasts in lifetime
• Fibrocystic Breasts: benign breast changes characterized by small cysts
o Etiology: imbalance of estrogen/ progesterone, as you check your breast and notice a lump that then gets smaller in size at a
different stage of your cycle then it’s hormone derived and a fibrocystic cyst.
o Cyst may always stay there. Some women have a lot of them.
o Usually bilateral. If only in 1 breast, have it checked out (if it gets bigger needs to have biopsy).
o RF: high dose caffeine
o S&S: timing, characteristics
o Detection: breast exam, USG (to make sure it’s a cyst that’s fluid filled
and not a solid that’s cancer), aspiration (to make sure its normal), FNA (fine
needle aspiration)
o Management: conservative, Vit E, OCA’s, surgical removal of stubborn
cysts that remain and may be worrisome, NSAIDs, decrease caffeine, smoking &
ETOH
•
Other Problems of the Breast: (NOT TESTED ON THESE)
o Lipomas: very common; the only way to distinguish from cancer is to do a biopsy
o Nipple Discharge
o Galactorrhea
o Mammary Duct Ectasia
o Intraductal Papilloma
*** EDUCATION: BSE (breast self-exam), CBE (clinical breast exam), intervals, dietary changes, comfort measures
Breast Cancer
• American women leading cancer behind skin cancer
• Stats: 1 in 8 (12%) women in US: lifetime risk, at some point during their life they
may develop breast cancer • 10 Year Risk for breast cancer (2):
o Age 40: 1 in 69
o Age 50: 1 in 42
o Age 60: 1 in 29
o As we age, our risk for developing breast cancer rises dramatically
• In 2013, estimated 232,340 new cases of invasive breast cancer
o 64,640 new cases of in situ breast cancer (in situ is early cancer)
o 39,620 breast cancer deaths
• #1 risk factor to developing breast cancer is being female.
o Genetics account for ONLY 15% of breast cancers (much higher likely hood of developing cancer)
• 5% of all breast cancers are developed in women under 40 years of age
• 1% of all breast cancers are in men
• 13/100,000 pregnancies we will find breast cancer (more babies you have the higher the chance)
• Malignancy Screening BSE
o ACOG--BSE has the potential to detect palpable breast cancer and can be recommended.
o Newer concept called "breast self-awareness”
o Now doing BSE in a linear/lawn mower pattern, using index and middle fingers of both hands and pressing firmly at 3 different
depths and never lifting hands until the end to avoid missing any lumps
o Inflammatory breast cancer: no actual lump but looks like skin infection (staph etc.) one of the most deadly
• EDUCATION
o Detection: 90% breast lumps detected by woman herself, and 20-25% of those found are malignant •
S/Sx Breast Cancer:
o Hard, fixed lump (put it in 2 fingers and cant move it), irregular borders, nipple discharge, discoloration, unilateral (but can
certainly have it in both breasts)
•
•
o May show up as just a change in skin color…no lump can still be breast cancer
Prognosis: Great Improvement over last 10 yrs
o Node involvement & tumor size important
Management: Treatment plans change and are individualized
o Surgical
o Radiation
o Adjunct
o Hormone to suppress reoccurrence
•
o Chemotherapy
Nursing Considerations:
o Survivorship** because so many women are now living with
cancer/long-term
survivors
•
Key Points
o Menstrual disorders diminish quality of life.
o All menstrual disorders require assessment.
o Alternative therapies may relieve some
discomforts of menstrual disorders
o Breast lumps and changes should be worked up
A 23 y/o patient with history of fibrocystic breasts complains of a right breast cyst which has
progressively increased in size over the last 3 months. What would the next best step be?
A. Decrease caffeine intake
B. Eat more chocolate
Screening Guidelines:
Susan G.
Komen
for the Cure
(1)
Mammography
American
Cancer
Society
(4)
National
Cancer
Institute (3)
NCCN
(5)
U.S Preventive
Services Task
Force (2)****
ACOG (6)*****
Every year
beginning
at age 40.
Every
year
beginning
at age 40.
Every 1-2
years
beginning
at age 40.
Every
year
beginni
ng
at age 40.
Informed
decision
making
with a health care
provider
ages 40-49although (C
recommendation)
USPSTF
recommends
against.
Every 2 years
ages 50-74.
Screening mammography every
1-2 years for women aged 40-49
years Screening mammography
every year for women aged 50
years or older.
Clinical Breast Exam
At least
every 3
years
ages 20-39.
Every year
beginning
at age 40.
Every 3
years
ages 2039.
No specific
recommendation
Every year
beginning
at age 40.
Every 13 years
ages
20-39.
Every
year
beginni
ng
at age 40.
Use as
supplement.
Not enough
evidence to
recommend for
or against.
CBE every year for women aged 19
or older
Breast Self-Exam
Not
recommended
as screening
tool.
However, rec:
patients
become
familiar with
their breasts
Providers
should
discuss
benefits &
limitations.
Patient may
choose to
do BSE or
choose not
to.
Recommends
“breast
awareness”
Moderate
certainty
harm>benefit
(based on 2 trials
outside US).
Recommends
against teaching
breast self
examination (BSE).
BSE has the potential to detect
palpable
breast cancer and can be
recommended.
C. Continue to monitor progression
D. Breast ultrasound
Sexually Transmitted Infection
STIs (or sexually transmitted diseases) are a modern pandemic that exact a broad toll on the lives of women worldwide. Women suffer from
the discomfort of symptoms, the difficulty these conditions pose to partner relationships, the possibility that some conditions may be
passed vertically to unborn infants, and the threat to future fertility, sexuality, and life. More than 25 different infectious organisms can be
transmitted sexually; five of these (chlamydia, gonorrhea, HIV, syphilis, and hepatitis B) are among the most commonly reported
infections in the United States. STIs bear an enormous burden on the health care system as billions of dollars are expended annually on
their treatment and sequelae.
• The gift that keeps on giving
• The “POLITICALLY CORRECT” term is STI –Sexually Transmitted Infection. Includes most diseases or
“infections” transmitted between sex partners who engage in unprotected sex. VIA any type of SEX.
• The difference, really, is in the terminology itself. Way back in the day, sexually transmitted infections were called
“venereal diseases,” believed to have been so-called after the Goddess of Love, Venus.
• Today, professionals use the terms STD (sexually transmitted disease) or STI (sexually transmitted infection) to discuss infections that
are transmitted from one infected person to another through vaginal, anal or oral sex or through close intimate sexual contact. Using
either STD or STI is accurate, however more and more “STI” is being used as the most up-to-date term. The reason for this is that people
can have an infection without it actually turning into a disease.
• During early prenatal care, most women undergo tests to determine whether or not they have any STDs. Some STDs can be transmitted
to the fetus during pregnancy and others may be transmitted during the birth process if a woman has a STD at that time. If you have
intercourse with more than one partner during pregnancy, it is important to use latex condoms every time. If you are pregnant and
know or suspect that a partner is having sex with others, talk with your doctor about your risks for STDs and how to reduce the
chances of passing them to your baby.
Facts about STIs
• Includes more than 25 infectious organisms- transmitted sexually
• Most Common
o HPV
o Gonorrhea
o Herpes Simplex Virus type 2
o Human Immunodeficiency Virus
• Burden
o Financial: 14.7 billion annually
o Personal: physical/emotional/financial
Consequences of STIs
• Can be transferred to baby at birth
• Blindness
• Bone deformities
• Mental Retardation
• Death for infants infected by their mothers
• Pelvic Inflammatory Disease
• Infertility
• Ectopic or tubal pregnancy
• Cancer of reproductive tract
• Death
STI
• Primary Prevention
o Avoiding STI: sex, oral, anal, vaginal
o Identification of high risk behaviors before STI presents
o Effective counseling techniques. **Education: keep it confidential and don’t be judgmental
• Secondary Prevention
o Prompt diagnosis and treatments after patient already has the infection
o Asymptomatic?
o Education on treatment
o Make sure partner gets treated
Questions:
What teaching stratifies are important for a nurse to use when counseling a 16 years old female client about preventing STDs?
A. tell the client that she must abstain from all sexual activity or she will develop an STI.
B. Ask direct question about the client’s sexual behavior.
C. Acknowledge that sexual health is an important aspect of an individual’s total health.
D. Assume a judgment attitude when obtaining a sexual history.
Which of the following should receive priority when obtaining a client’s sexual history?
A. Determine the client’s primary concern about having an STD.
B. Assure the client of the confidentiality of any shared information.
C. Ask the client what symptoms are experienced.
D. Determine if the client has exposed another individual to the potential STD
Why are STIs dangerous?
• Many occur in teens and young adults due to a lack of sexual health knowledge in this population
• They are infections that are spread from person to person usually through sexual contact (vaginal, anal, oral).
• Some STIs cause long-term problems:
o Infertility (inability to have a baby)
o Can infect an infant at birth…can affectANYONE!
WAYS YOU CAN AVOID STI’S
•
Abstinence is the only fool proof way to avoiding STDs
ALTERNATIVE WAYS YOU CAN AVOID STI’S (FOR THOSE WHO SIMPLY CANNOT WAIT!)
• Condom use. Teach the public how to use a condom.
• Condom must be worn at each sexual encounter, and there must be no exchange of any
bodily
fluids.
• Other methods of birth control are not as effective because they do not provide a PHYSICAL
barrier.
Testing and Treatment of STIs
• Can be an effective tool in preventing HIV
• A single dose of antibiotic can kill bacterial infections
• Individuals infected with STIs are more likely than uninfected individuals to acquire HIV due to
immunodeficiency
• An HIV infected individual also infected with another STI is more likely to transmit HIV through
sexual contact
Categories
• STI: Bacterial
o Chlamydia: vaginal cultures
o Gonorrhea: vagina culture
o Syphilis: blood test and culture
o Pelvic Inflammatory Disease (PID): infection in women’s reproductive organs from not being treated from gonorrhea; leaves scars
and causes infertility (must go to hospital and get treated with antibiotics for 24 hours)
• STI: Viral
o Human Papillomavirus (HPV): warts; can lead to cervical, vulvar, and penile cancer, vaccines help prevent (Gardasil)
o Herpes Simplex Virus (HSV 1/ 2)
o Hepatitis (A/B/C)
o HIV
• VaginalInfections
o Bacterial vaginosis: most common vaginal infection in women between ages 15-44yo, not considered an STI, women complain of fowl
smelling vagina discharge, treatment unless asymptomatic
o Candidiasis: fungal infection caused by yeast; not an STI, can be caused by different factors (DM, diet, antibiotic use)SXS: vaginal
itching and discharge, medication diflucan (one pill)
o Trichomoniasis (also STI): treatment with medication
o Group Beta Streptococcus (GBS): bacteria in perineal area in lower intestinal track; will do vaginal swab in the last trimester to see if
she has it. Not dangerous for mom but it is for baby. Will both get antibiotics if positive after birth
▪ Harmless to mom but not to baby if a delivery is coming up
Chlamydia
• Chlamydia is currently the most common STI reported in the United States. Fastest spreading; silent (asymptomatic) and highly
destructive.
o Need to be treated will lead to bad things
• Gonorrhea co-infects with chlamydia. So if you have CT, you have GC
and will be treated for both • Risk Factors- Sexually active women <
age
20 and African- American
• Tx with antibiotics and make sure partners are treated as well
• Transmission
o Genital-to-genital
o Oral to genital
o Anal to genital
o Vagina to rectum
• An infected mother can pass to baby during childbirth. ALL babies get antibacterial (Erythoromycin) drops in their eyes
after birth as a prophylactic to prevent conjunctivitis and blindness
• CT complications: PID, ectopic pregnancy,
infertility
Chlamydia Trachomatis
•
Symptoms (vaginal discharge and dysuria)
o Asymptomatic (destructive) in 75% of women who carry the disease.
o It will show when they’re immunocompromised, for example when they’re
pregnant
•
•
•
•
Mucopurulent discharge, post-coital, itching, dysuria, nausea, fever–pain during sex
Bleeding between periods
Causes eye infection if you touch the eye
Detection/ Screening/ Diagnosis
o Screen asymptomatic high risk & pregnant women
•
o Diagnostic procedures- swab and culture
Management/ Nursing Considerations
o Antibiotic therapy for patient/ partner- Doxycycline or Azithromycin
o Education:
▪ Report to health department by HCP if partner doesn’t comply and you know that at follow up appointment the
health department will contact the individual
▪ Partner needs to be treated
o PAP Cultures: over the age of 21 or earlier if family history
o Pregannt owmen get tested for gonharea, syphilis and chlamydia
Gonorrhea
• Oldest known communicable disease.
o Caused by Neisseria gonorrhea
• Gonorrhea – other names:
o The Drip
o The Strain
o The Clap
• Increasing number of antibiotic resistant strains of gonorrhea
o Will be reported to health department
o ** Infant- can be affected. Mom will have following complications: PID, creamy discharge, heavy menses •
GONORRHEA: How do you get it?
o During vaginal, oral, or anal sex with an infected partner.
o Touching infected sex organs and then touching your eyes = eye infection.
o IT IS NOT spread by shaking hands or sitting on toilet seats.
o Can be passed to baby during delivery and leads to blindness, joint infection or blood
infections…death • Who is at Risk? (15-44yo)
o Anyone w/multiple or new sex partners
o Anyone that doesn’t use a condom correctly
o Sex workers
o Drug users
o People who have had other STIs in the past or have had it before more likely yo get it again
o Risk Factors: Age #1 factor: < 20 y/o
• Transmission
o Genital-to-genital (same as Chlamydia)
o Parenterally from mom to baby!!!!
o Essential to educate about prenatal care!!!
• SIGNS & SYMPTOMS
o Asymptomatic
o In women, symptoms can include:
▪ Pain or burning when urinating- dysuria
▪ Vaginal discharge – yellow/creamy
▪ Bleeding between periods.
▪ Pain during sex
▪ •••PID
▪ Newborn infants can get Gonorrhea eye: infection(conjunctivitis) that may lead to blindness, as they pass through an infected
mother's birth canal: Ophthalmic neonatorum. This is one reason ALL newborns get an antibiotic ointment (Erythromycin)
put into their eyes immediately after being born. The antibiotic ointment kills both Gonorrhea and Chlamydia neonatal
conjunctivitis.
• Detection/ Screening/ Diagnosis:
o Screen asymptomatic high risk & pregnant women
o Diagnostic procedures- vaginal culture
• Management/ Nursing Consideration:
o Antibiotic therapy for patient/ partner: Rocephen (nausea, vomiting, diarrhea) also diflucan
o LEGAL OBLIGATION: Reportable disease- report to local health department: CT, GC, HIV, Syphilis, Hep A, B,C o Education:
HCP will report it, Follow up appointment important at 4 weeks, need follow up culture, need partner to be treated o Teach
about antibiotic as ordered: (Ceftriaxone)
o Instill prophylactic medication into baby’s eyes after Delivery : Erythromycin ointment to eyes
• TREATMENT &PREVENTION
o Gonorrhea used to be 100% curable with Penicillin. Unfortunately, because antibiotics have been used so commonly (often
given out for simple colds - where they don't do anything) that the gonorrhea bacteria has developed RESISTANCE! o Usually
an extra-large dose of azithromycin (Zithromax) will kill the bacteria and cure the disease.
o Many people who have gonorrhea also have Chlamydia. So, doctors treat both STIs at the same time.
o You must take all your medicine even if the symptoms go away.
Syphilis
• Caused by Treponema pallidum (motile spirochete)
• Risk Factors: Age- 20-24 y/o age group
o Mom with multiple sex partners
• Transmission:
o Transmission by entry in subcutaneous tissue through microscopic abrasions that can
occur during sexual intercourse. * Kissing, biting or oral-genital sex ** oral
o Trans-placental transmission
• Symptoms: Primary, Secondary,Tertiary (KNOW)
o Primary
▪Primary – chancre sores appear between 10-91 days (21 avg)
▪Painless chancre on genitalia, anus, lips, mouth. If not treated, moves to secondary stage
o Secondary Stage Symptoms
- Typically starts w/ a maculopapular rash on 1 or more areas of body, most commonly on soles of feet and
palms of hands
- Includes fever, sore throat, hair loss, headache and muscle ache, weight loss,
tiredness, anoexia
- Liver and spleen enlargement !!!!
- Can be passed through contact of open sores
- Rash(on palms of hands and feet) & other symptoms will go away w/o treatment but will move to latent stage Diffuse maculopapular rash and Gumma – Atrophic scar
- Congenital Syphillis: Rhinitis or snuffles, peg shaped upper incisors
(Hutchinson’s teeth)
- You will only reach late stage if you do not receive treatment earlier
o Tertiary
- If secondary is untreated systemic damage results: cardiac, CNS
•
CNS involvement and cardiac
• Detection/ Screening/ Diagnosis:
o Screen pregnant women **False POSITIVES
o Diagnostic procedures: Blood Test (VDRL- Venereal Disease Research
Laboratories & RPR)
Will give us a titer: If they had symphilis before it will be high so might need to retest
• Management/ Nursing Consideration:
o Antibiotic therapy for patient/ partner (weekly x 3wk) in pregnancy (single
dose non-pregnant). Administer Penicillin G, which crosses placenta, thereby
additionally treating fetus
2.4 million units IM single dose: done at clinic before they leave
o Reportable disease- report to local health department
o Education: risk of getting it again if they are pregnant, follow up appointment, treat partner
Pelvic Inflammatory Disease (PID)
• Infectious process causing endometritis (multi-organism), is a complication of GC and CT. Adhesions may block
uterine tube and cause pain or infertility
• Most common cause- Gonorrhea & Chlamydia (1/2 cases)
• Risk Factors:
o Young age less than 25yo, history of STI, multiple partners.
• Symptoms: really sick
o Pelvic Pain, Fever, chills, anorexia, increased vaginal discharge, dysuria, irregular bleeding,
pain
during sex
• Detection/ Screening/ Diagnosis:
o CDC Criteria
o Diagnostic procedures- laparoscopy to detect PID
o Cervical motion tenderness: CMT take a swab and move the cervix around to see if it hurts so that’s positive
o Ultrasound: fluid in tubes shows PID needs to be treated
▪ Thickened fluid in the uterus area
• Management/ Nursing Considerations:
o Antibiotic therapy for patient: 24 hours IV antibiotics and hospitalized
o Education: finishing antibiotics on discharge, keep appointment, remind them, test for cure (follow up
culture) Regardless of risk factors, which STI screening should be done on every pregnant woman in the first visit? A.
Gonorrhea
B. Syphilis
C. Chlamydia
D. All of the above
Which are curable??
Human Papillomavirus (HPV) & Genital Warts
• HPV – group of viruses that include more than 100 different types. More than 40 can be passed
through sexual contact.
o Most prevalent (like 150 types)
• Over ½ of all sexually active people will have HPV at some point in their lives. Most will never know
it. Often HPV has no symptoms and goes away on its own.
• Risk factors- pregnancy (immunosuppression)
o History of lower tract infection
o Neoplasia
o High number of partners
o Early age of sexual activity
o Other STD/STI
o Long term steroid use
• Symptoms- often asymptomatic
o profuse irritating discharge
o vulva/labial bumps (called condylomata acuminata if warts are in genital area)
▪ look like cauliflowers on genital area
o sometimes no symptoms just get a culture
o Often none! Papilloma or warts can be benign and occur on fingers for instance
• Detection/ Screening/ Diagnosis:
o History of known exposures:
o Physical inspection- biopsy done to see what kind of HPV it is. HPV Types 6,11, 16, 18
cause cervical cancer. Immunize against these that cause cervical cancer
•
Pap smear
•
Colposcopy: look inside vagina with microscope to get biopsy of area
•
Biopsy: send to lab checking for cancer
• Passed by skin to skin and genital contact. It is less common to pass HPV during oral sex or
hand to genital contact
• Management/ Nursing Considerations:
o Can self resolve
o Can use acid to burn off warts
o Treat early
o Will grow back if cut off
o No proven therapy effective
• Education/prevention
o HPV vaccine. IMMUNIZATION: Cervarix and Gardasil to protect girls and young women o
11 and 12 yr. old girls: early as 9 and as late as 26 (insurance might not pay for it if over 26) o
Series of 3 shots:
▪ Given 6 months apart
o NO CURE FOR HPV/Warts, but surgery or laser removal can be done
• Cervical cancer kills about 300,000 women worldwide and 4,000 women in the United States
annually. Each year, about 12,000 women in the United States learn that they have this cancer.
Herpes Simplex Virus (HSV 1 & HSV 2)
• Infection characterized by multiple painful lesions. Sores are dormant in the nerve cells and are reactivated when
you’re stressed out.
• Risk Factors:
o Sexually active
o Healthcare workers- are at risk for instance if you touch a herpes sore with your hand/no glove, then
you instantly have it
• Types and Transmission ofHerpes
o HSV 1- Transmitted non sexually ** Causes mouth and lip rashes (i.e., cold sores & canker
sores). o HSV 2- Transmitted sexually. Causes the genitalherpes
▪ Pregannt with this type will not deliver vaginally even if asymptomatic because it can spread to baby •
SYMPTOMS OF HERPES
o Most people are not aware they are infected: NO SYMPTOMS!
o 1st outbreak usually happens within 2 weeks of sexual contact w/infected person
o Cluster like lesions that lead to uclers
o Screen high risk women who are pregnant, vaginal culuters, antivirals, educate on follow up
appointments o Symptoms can last 2-3 weeks
o Flu-like symptoms w/ fever. Painful cluster like lesions (vesicles →ulcers). Sores are small red bumps that may
turn into blisters or painful open sores. HSV 2 causes very painful sores!
• Genital Herpes
o Sexually transmitted viral infection that occurs when contact is made with contaminated genital
secretions. Within a few days, sores show up where virus entered body
o Itching, burning in genital/anal area, vaginal discharge, pain in legs, buttocks, or genital
area. o Infected women can infect the fetus
o Pregnancy may increase the risk for and severity of infection
o Cesarean delivery is used to protect the infant if there are symptoms
o Acyclovir (Zovirax) is treatment (can be used during pregnancy to decrease the # of outbreaks. Will not
cure!) • TREATMENT & PREVENTION OFHERPES
o Like most viral infections, there is no cure for Herpes!!!!!
o Anti-viral medications have come to market lately and have done a very good job at improving the duration of
an outbreak as well as the discomfort.
o EDUCATION!! Abstinence, proper condom use(covering all infected skin areas and avoiding sex
whensores are present), and vaccination against the herpes virus (experimental at the moment).
o Herpes can move to the brain and cause encephalopathy
• HSV TYPE 1
• HSV TYPE 2
Hepatitis
• Oh my – many DIFFERENT viruses! A, B, C, D, ANDE
• Infant — can be affected
Hepatitis A (HAV)
• Risk Factors: Practice food hygiene to prevent Hep A
o ** Infection cause by ingestion of contaminated food (milk, shellfish, polluted water or person to person contact)
o
Recreational Drugs
• Transmission- Fecal- oral route
• Symptoms- Flu-Like
• Detection/ Screening/ Diagnosis
o Serology Test
• Management/ Nursing Considerations: Hepatitis Avaccine!!!
o Supportive and keep follow up appointments
Hepatitis B (HBV)
• Infection most threatening to fetus & neonate
• Risk Factors- Multiple partners
o Sharing needles
o IV drug use
o Live with someone who has it
o Infant born to mom who was pregnant
• Transmission: body fluids
o Parenterally, orally (rare) and intimate contact (sex)- needles, sexual
o Chronic- 10-20% chance to infect baby/Acute- 90%
• Symptoms- Skin: flu like, fever fatigue, loss of appetite, N/V, rashes dark urine, clay color stools , skin rash &, jaundice, may lead to end
stage LIVER disease or liver cancer
• Detection/Screening/Diagnosis:
o Labs during Pregnancy (1st PNV screening for HBV is done & in 3rd trimester or L&D admission)
▪ Checking for hepatitis
• Management/ Nursing Considerations:
o No specific treatment * Hep B Immunoglobulin prophylactic
o Immunization- can get them no risk to pregnancy. If mom has it can cause death in mom and baby!
o Education- Breastfeed- YES if baby vaccinated (minimize transmission)
Hepatitis C Virus (HCV)
• Most common blood-borne infection in US. Rate is high in Egypt.
• No vaccine!
• Risk Factors:
o C infected blood
o Pregnant women with IV drug use history.
o Multiple sexual partners
o Hx blood transfusions
o Other STI’s: HBV, HIV
• Transmission- Blood exposure
• Symptoms- Asymptomatic or Flu-like
• Detection/Screening/Diagnosis- Screening for High risk groups
• Management/ Nursing Considerations:
o Interferon at 6-12 months
o No vaccines available
o There is a recent cure to HCV. But No Vaccine available
o Low transmission to baby (4%)
o Education- test baby at 18 months
o YES patients can breastfeed, unless cracked or bleeding nipple! Because there’s no evidence it can be passed to baby in breast milk.
Human Immunodeficiency Virus (HIV)
• A retrovirus (attacks CD4 cells, that are supposed to kill it! resulting in immunosuppression) transmitted by contact
with contaminated body fluids, including blood and semen
• Infected women can infect the fetus or newborn infant either across the placenta or by ingestion of breast milk
• No known cure exists but there are treatments available to prolong life, and prevent moving to AIDS
• Antiviral therapy with ACT (therapy of choice) decreases fetal transmission from 25% to 2%
• Transmission:
o Exchange of body fluids: semen, blood
o Maternal-neonatal: can cross placenta or ingestion of breast milk (will not be breast feeding), or by vaginal
birth • Current recommendations are to test all pregnant women and delivery by cesarean.
o If positive: Cesarean delivery preferred.
• Symptoms- Fever, malaise, lymphadenopathy, night sweats, weightloss
• Detection/Screening/Diagnosis:
o CONSENT is not needed anymore for HIV testing
▪ ** is needed to screen mom for HIV (opt out)/ counseling/ confidentiality
o Seroconversion- 6-12 wks.
o Blood work: done at first prenatal visit, and when going to hospital
• Management/ Nursing Considerations
o Antiviral (Prophylaxis)
o EDUCATION- Do NOT breast feed if you haveHIV!, follow up appointments
o Offer HIV screening to all pregnant women at INITIAL visit.
▪ Note: not done for CT/GC because it’s expensive.
▪ Although if mom is at a high risk, they’ll screen for those as well.
• IF positive, do CD4 AND T-CELLcounts
• Medications during pregnancy can reduce transmission to fetus. Anti-Viral for newborn
It is safe for a HBV (+) postpartum mother to breastfeed her newborn as long as her newborn has received the HBV prophylaxis as birth.
A. True
B. False
Trichomoniasis
• Caused by parasite Trichomonas vaginosis (only in the vagina)
• Risk Factors
o Multiple sexual partners
• Transmission- Sexually transmitted
• Symptoms:
o Yellow/green/grayish frothy vaginal discharge; dyspareunia(pain during sex), Strawberry cervix(inflammation)** will see on
vaginal exam
o If a male has it, he will show no signs and symptoms but he is a carrier and can pass it to a female.
• Detection/Screening/Diagnosis
o Physical Inspection
o Wet Prep (+) take a swab from the vagina and look under microscope for parasite
• Management/ Nursing Considerations:
o Metronidazole (Flagyl)- No alcohol because it will cause a disulfram like reaction (metallic taste)
o Partner treatment!!! And follow up appointments
o Education
• VaginalInfections
Candidiasis
• Vulvo candidiasis (yeast infection)- 2nd most common type of vaginal infections in the US
• Caused by Candida albicans, a yeast
• Symptoms- discharge-thick, white (cottage cheese like), vulvar/ vaginal pruritus (may be painful)
• Risk factors:
o Antibiotic therapy – common after abx therapy from a UTI because it kills the good and bad bacteria
o Diabetes
o Obesity
o Diet- high refined sugars (bacteria likes sugar)
o Immunosuppression- like those with HIV, chemotherapy
• Detection/ Diagnosis:
o Physical inspection
o Wet prep : instead of cultures
• Management/ Nursing Considerations:
- Antifungal (OTC/ Rx) Rx: Terazol, Nizoral, Diflucan ( one time oral); Miconazole (Monistat)
- Education
- Sitz baths with Aveeno powder
- No underwear at night: creates a moist/warm environment
- No tampons while on med regime
- No intercourse during treatment
Bacterial Vaginosis
• Bacteria is part of normal flora of vagina. BV develops there’s an imbalance of good and bad bacteria in vagina
• Most common vaginal infection
• Myths- cannot get from toilet seats, bedding, swimming pools, touching objects around you
• Symptoms:
o Vaginal discharge with “fishy” odor
o Thin, profuse, white/gray/milky foamy, watery appearance
o itchy and scratchy
• Detection/Diagnosis:
o A pelvic exam is done and a sample of
o the milky discharge is obtained
• Management/ Nursing Considerations:
o Education! You can’t get it from a toilet! Via sex!!!
• Treatment
o Antibiotic (metronidazole or clindamycin) taken orally or vaginally.
▪ Flagyl (antiprotozoal).
▪ Caution w/ETOHuse!! Will cause sick reaction
• Some authorities feel treatment of all sexual partners is crucial in preventing reinfection, though scientific studies
have not consistently proven this.
• PID, pregnancy problems, increased risk of HIV
Group Beta Strep (GBS)
• Present in 9-23% of healthy women as part of flora in GU & GI tract. It
doesn’t normally cause illness in adults. But if present during pregnancy, can be passed on to
and infect baby, and causing death if not treated.
o Testing in 3rd trimester
• Risk Factors: (+) GBS culture in current pregnancy, high amount of steroids
• Transmission: Vertical-neonatal (when delvierd can effect baby if not treated)
• Symptoms: Asymptomatic
• Detection/ Screening
o Recto-vaginal culture: on all pregnant women at 35-37 wks.
•
Management:
o Antibiotics in Active Labor--- 3 preferred.
▪ They enter babies blood stream and prevent infection as baby goes through birth
canal.
▪ Decrease change of neonatal sepsis
o If mom hasn’t been screened during pregnancy, she will get antibiotic as a prophylactic measure during labor and baby
gets it after
o ** 80% decrease in neonatal sepsis
o **Left untreated leads to poor pregnancy/ neonatal outcomes
A patient continues to have recurrent yeast infections. Which information should be included during when the nurse is providing education?
A. Wear tight fitting clothing
B. Decrease dietary sugars
C. Eat yogurt
D. Both B & C
During a speculum exam, a “strawberry” cervix is visualized by the nurse assisting with the procedure. What is the most likely cause of
this finding?
A. Gonorrhea
B. HPV
C. Trichomoniasis
D. HIV
When & Why tell a partner
• Before sexual intimacy
• It allows the person to make an informed choice
• Helps prevent transmitting an STI
• Choose a neutral setting
• If refuse to tell partner eventually health department will be contacted
• Practice what you’ll say
o Role play with a trusted friend or relative
o Choose comfortable words: “I want to tell you about myself. I have a virus. It’s similar to the sores you get
near your mouth but I get them in the genital area.”
Expedited Partner Therapy (EPT)
• Is the clinical practice of treating the sex partners of patients diagnosed with chlamydia or gonorrhea by providing
prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner
Safer Sex
• Condoms
• Low risk
o Wet kissing (without skin breaks)
o Vaginal, anal, or oral intercourse with a condom
o Urine contact with intact skin
• High Risk (unsafe)
o Unprotected vaginal, anal, or oral intercourse
o Oral-anal contact
o Any sex that causes tissue damage or bleeding (fisting; rough vaginal or anal sex)
o Multiple sex partners
o Sharing sex toys
o Blood contact, including menstrual blood
Which of the following STIs are potentially curable by specific antibiotics?
A. Chlamydia and gonorrhea
B. Herpes and Genital warts
C. HIV and HPV
Infection Control
• Healthcare providers
• Risk for occupational transmission
• Any risk warrants reasonable precautions
• Standard precautions
• Always read patient’s chart for their health history!!!
Which STI is a reportable infection?
A. HIV
B. Syphilis
C. Gonorrhea
D. All of the above
Key Points
• Nurses must communicate with patients about STIs….. Don’t be afraid to speak openly!
• Prevention is key
• Many infections can be treated with antibiotics, but the partner is important too
• Viral STIs cannot be eliminated, but medications and lifestyle choices can lessen burden on patients
• STIs impact mothers, partners and babies!!!
A woman is determined to be group B streptococcus (GBS)positive at the onset of her labor. The nurse should prepare this women for?
A. Cesarean birth
B. Intravenous administration of penicillin during labor
C. Isolation of her newborn after birth
D. Application of acyclovir to her labial lesions.
A woman's choice to control her reproductive capacity is one of the most influential aspects of a woman's lifestyle. Fertility regulation is a
conscious choice. A choice that affects a woman's physical, educational, economic, and social destiny. When a woman can control her
fertility, she has the opportunity to plan her life; controlling her family size or even preventing pregnancy from occurring. The choices
surrounding contraception are complex. Successful choices include the capacity to incorporate the method into the woman's daily
regimens without disrupting her major roles and responsibilities.
Infertility
• Incidence
o Affected:10% to 15% of reproductive-age population
o Sub-fertility: prolonged time to conceive
o Sterility: inability to conceive
• Definition: a year with unprotected intercourse and unsuccessful conception
o For a patient > 35, it is 6 months.
• Diagnosis and treatment of infertility require physical, emotional, and financial investment
• Factors:
o Female infertility: 1/3 of infertility cases
▪ Ovarian factors- something in production of eggs can go wrong
▪ Tubal and peritoneal factors: such as scarring from past infection
• (fibroids or endometriosis, or stenotic)
▪ Uterine factors and anomalies: HIGH likely hood of endometriosis!!! Because
of
retrograde flow from abnormality of uterus
• Picture ADidelphys: 2 uterine horns and each have own tube, 2 cervix
o Septum in between 2 horns
• Picture B: Bicornis: 1 cervix looks like a heart
o Implantation is difficult
• Picture C: Bicornic with horn that doesn’t develop or mature; does not connect to outside world •
Picture D: one horn is there
▪ In utero, all females have 2 uteri and 2 cervixes that merge and become
• These anomalies result in babies that don’t merge correctly.
▪ They will also often have issues with their heart.
▪ These uteruses are smaller and can’t hold a baby the way a normal uterus can.
o Vaginal-cervicalfactors:
▪ Isoimmunization: production by an individual of antibodies
against
constituents of the tissues of another individual, a woman being
allergic to
husband’s sperm.
o Male infertility: 1/3 of cases
▪ Can be caused by structural and hormonal disorders
▪ Undescended testes
▪ Hypospadias
▪ Varicocele (varicose vein of the scrotum)
▪ Low testosterone levels
▪ Substance abuse (most common): smoking can reduce the quantity and
quality of sperm.
o Other factors: 1/3 of cases. For ex. stress, nutritional factors, PCOS
Nursing Care Management
• Assessment of female
• Diagnostic tests
o Evaluation of the anatomy
o Detection of ovulation
o Hormone analysis
o Ultrasonography
o Endometrial biopsynot common
o Hysterosalpingography (HSG):
▪ is an x-ray procedure used to see whether the fallopian tubes are patent (open) and if the inside of
the uterus (uterine cavity) is normal.
o HSG is an outpatient procedure that usually takes less than 5 minutes to perform.
▪ Make sure you know LMS before performing and that they’re not pregnant. Die injected.
o Sonohysterogram:
▪ Is a technique in which fluid is injected through the cervix into the uterus, and ultrasound is used to
make images of the uterine cavity. (fluid can remove debris as well and help with egg implantation) ▪
The fluid shows more detail of the inside of the uterus than when ultrasound is used alone. ▪ Make sure
you know LMS before performing and that they’re not pregnant.
o Laparoscopy: know what it is
▪ shown on bottom right. is a surgery that uses a thin, lighted tube put through a cut (incision) in the
belly to look at the abdominal organs or the female pelvic organs. Laparoscopy is used to find
problems such as cysts, adhesions, fibroids, and infection.
▪ Tissue samples can be taken for biopsy through the tube (laparoscope).
• Assessment of male
o Semen analysis- front line, 2 samples tested a week or 2 apart
▪ Sperm count should be over 20-40 million for one sample!!!
▪ Should be abstinent from sex for 2-5 days before this test, but not more because then the sperm
won’t swim
▪ Avoid alcohol, smoking, etc. to increase the volume of sperm.
▪ In transportation don’t let the specimen get hot
o Hormone analysis
o Scrotal ultrasound
• Assessment of couple
o Post-coital test (checking mucous after sex to see if there is an interaction)
• Plan of care and implementation
o Psychosocial
o Must figure out what’s causing the infertility and treat that. Start with least invasive first.
o Non-medicalHerbal alternative methods & Acupuncture
• MedicalAssisted reproductive therapies
o IUI (intrauterine insemination): know risks!!
▪ Can have LOTS of babies!!!
▪ Medicine can be given to stimulate ovum production and ovulation, Clomid.
▪ If their problem is simply conceiving, IUI (intrauterine insemination) will work.
• If tubes are blocked this will not work!
▪ For IUIs, patients are given Clomid (follicle stimulating hormone)
• But sometimes, if you’re doing an insemination and giving a patient Clomid and
don’t check ovaries to see how many follicles are mature, then you’re likely to get multiple
babies from 10-12 follicles that all implant.
o Make sure to MONITOR therapy and see how many follicles she has
o Give GNRH injection to help her ovulate then will be ready for sperm
o Sperm is put in a syringe and injected into cervix through a catheter.
o Spermjust takes different/artificial route
• Often when this is seen early in the process, some are taken out if there are to many.
o IVF (In vitro Fertilization):
▪ Is more controlled & most common
• Sedate mom All Eggs pulled out of mom
o Graded: the best eggs are picked and the # and quality of eggs
o May put more lesser quality eggs to have a better chance if they don’t have good
eggs
• Best because if you just inject the sperm you can fertalize lots of eggs and have multiple
babies
• Put in Petri dish with sperm, placed back into uterus after egg is fertilized
• Eggs are pulled out during ovulation and the good ones are implanted back in to uterus
• Progesterone shot after to sustain pregnancy until eggs are placed back in!
▪ So here you can control the number of babies
▪ IVF costs $20,000/cycle.
▪ SE: weight gain, moody etc.
o Surgical
o Assisted reproductive therapies- More advanced/invasive treatment options.
▪ You don’t need to know the details of these, just know there are multiple options
▪ Gamete intra-fallopian transfer (GIFT)- shown to the right. Ovaries are stimulated and eggs are pulled
and placed in a dish and injected with sperm. A, through laparoscopy a ripe follicle is located, and
fluid containing the egg is removed. B, the sperm and egg are placed separately in the uterine tube,
where fertilization occurs.
▪ Ovum transfer (oocyte donation), Therapeutic donor insemination (TDI), Pre-implantation genetic
diagnosis (PGD), Embryo adoption, Reproductive alternatives (Adoption/Surrogate)
Contraception
• Intentional prevention of pregnancy
• Birth control is the device or practice to decrease the risk of conceiving
• Family planning is the conscious decision on when to conceive or avoid pregnancy
• May still be at risk for pregnancy
• Management
o A multidisciplinary approach to assist the woman in choosing an
appropriate
contraceptive method
o Ideally the method should be safe, readily available, economical, acceptable,
and simple to use
o The safety of a method depends on a woman’s medical history
Methods
• Coitus interruptus (withdrawal): high failure rate
• Fertility awareness methods (FAMs): 24% failure rate because the sperm stay around for a while. o Checking your basal
temperature. Tracking the start of period and length of cycle so that you don’t have sex 3- 4 days before and after
you ovulate (14 days after the first day of your period if you have a 28 day cycle)***
o Rely on avoidance of intercourse during fertile periods (day 14 when ovulation happens)
o FAMs combine charting menstrual cycle with abstinence or other contraceptive methods
• Natural family planning (period abstinence)
• Calendar rhythm method
o Someone would take your longest cycle and shortest and subtract days from both
o Gives you range of days
o Not great for someone who has irregular periods
• Standard days method
• Basal body temperature (BBT) method- graph shown to the right.
o When temp drops (0.5degree) – ovulation occurs.
o So pt would be abstinent until the rise (which occurs after the drop) x 3 days w/ sustained elevation of at least
0.2 degree
• Cervical mucus ovulation-detection method:
o cervical mucous characteristics picture on bottom right
(sticky mucous)
o 24 hours egg is viable but sperm is viable for 3-7 days
o Mucous would stretch on your finger
• Symptothermal method
• Predictor test for ovulation
• Two Day method
• Lactation amenorrhea method: not 100% effective
• Barrier methods
o Spermicides: have to use before and after intercourse
o Condoms, male (STI protection)
o Vaginal sheath (STI protection)
o Diaphragm: must use new spermicide with each intercourse
o Cervical cap: must use new spermicide with each intercourse
o Contraceptive sponge
• Hormonal methods – not good for women with breast or cervical cancer!!!!
o Generally, we start all women on the lowest dose of Estrogen and Progesterone possible. Because if we start
high, and it doesn’t work, then we don’t know if we should move up or down. If the person has extra adipose
tissue, we’ll have to start higher.
o If a patient has been on birth control pills, and then stop it, the first month they’re off of it is their highest
chance of having multiples.
o SE: irregular periods, moodiness, weight gain due to increased appetite. Most SE resolve within 3 months.
o Just progestin is good for women that are breast feeding
• Combined estrogen-progestin contraceptives (COCs): 9% failure rate
o Contraindications: smoker, past DVT, antibiotics and other meds that interfere with COCs, hx of cancer, over 35
years’ old
▪ Bad for those with breast or cervical cancer
o Side Effects: breakthrough bleeding (this tells us we need to adjust the dose)
o Decreased effectiveness by other meds
o Fertility return can return pretty quickly (the first time after the cycle you stop the pills is your highest chance
of getting multiples)
o The pill must be taken at the same time every day (even if you’re off by a couple of hours)
o For missed pills** see chart on next page. Will not be
tested on it.
Signs/symptoms to stop taking oral contraceptive:
ACHES (abdominal
pain, chest pain, HA, eye problems, swelling and/or
aching in the legs
and thighs)
• Transdermal contraceptive system (the patch): 9% failure rate
o Also, an estrogen-progestin combo patch.
o Not best option: for high BMI, lots of adipose tissue wont
be able to
maintain hormone level
o Is a once/week patch that you remove on the week you’re supposed to
have your period.
o Not as effective in patients with high adipose tissue. (Name Ortho Evra)
• Vaginal ring: also, an estrogen-progestin combo.
o Stays in for 3 weeks and comes out for the week you have your period.
o Placed inside vagina
• Progestin-only contraceptives:
o Oral progestin (mini-pill): for patients who are breastfeeding or postpartum, want some control without
altering their milk supply.
o This is not very effective by itself in oral form
o Not good for those who have mental health issues especially depression
• Injectable progestins (Depo-Provera): AE of bone depletion.
o Research has found that during the time of injection women were seeing a decreased absorption of Calcium,
but once they stopped medication this reversed itself. So, do this for only if you need it.
o SE: lots of weight gain
o Injected every 12 weeks. (stops menstrual cycle)
o Can be given during BF.
o Good for women who can’t keep up with the daily pills
• Implantable progestins (Nexplamon):
• IUD
o long-term BC
o Goes under arm
o SE: irregular cycles, weight gain, moody
o Long-term birth control, devices vary and can be left for 3 - 10 years.
▪ Small, T-shaped device inserted into the uterine cavity
▪ Medicated IUDs loaded with either copper or
progestin agent
▪ Creates a caustic environment, so that sperm will
die and not find follicles.
▪ IUD offers no protection against STIs.
▪ Increase chance of infection
▪ Start on depovera shot then do IUD to make sure body is ok with hormones
o Intrauterine devices.
▪ A: Copper T380A. Has no hormones
• Menstrual cycle should continue because no hormones
▪ B: Levonorgestrel-releasing intrauterine device.
o Educate:
▪ All IUDs will have 2 strings attached to them.
• These strings will dangle from the cervix and patient can feel it
• Make sure they are comfortable checking!
• If any are missing, or unequal in length, must notify providercan perforate uterus
▪ Greater risk for infection
▪ No discharge should be present and intercourse shouldn’t be painful.
▪ SE: cramping, spotting
• Emergency contraception:
o IUD: causes inflammatory response in body
▪ Implanted within 5 days
o Plan Bdecrease risk of pregnancy by 89%
▪ Used within 72 hours of unprotected intercourse
• Less than 16 must have prescription
• OTC >17yo
▪ Should not be used regularly, but only as an emergency.
• Egg last 24 hours
• Sperm last 3-7 days
▪ These are essentially extremely high dose birthcontrol pills.
▪ Remember estrogen must make a dip to make the LH surge, which stimulates the ovaries causing
ovulation.
▪ So, giving high dose estrogen will prevent this dip, and ovulation.
▪ SE: N, V,
• Recommend take with food and with antiemetic
▪ Reduces the risk of conception from 75-90%. Prevents ovulation.
▪ If used, patient must have pregnancy test done in 2-28 days.
o Three methods available in the United States
▪ High doses of estrogen or OCAs (causes N/V)
▪ Two days of levonorgestrel
▪ Insertion of the copper intrauterine device (IUD)
• Sterilization
o Female
▪ Tubal occlusion or ligation: eggs can’t enter fallopian
tubes
▪ Tubal reconstruction (reanastomosis)-This can happen
naturally where tubes
reconnect on their own.
• This reversion rate is ~3% will do IVF
• If tubes are surgically put back together for pregnancy, then there’s a
higher chance for ectopic pregnancy to occur. The zygote will choose to
implant along the scar tissue. Therefore, this is usually PERMANENT.
• EDUCATION**
o Male
▪ Vasectomy: Make sure patient goes back and has sperm levels tested after surgery
to make sure the surgery was effective (have to go to the follow up!!!!!)
▪ Tubal reconstruction (reanastomosis) more successful than woman’s
▪ A: Uterine tubes ligated and severed (tubal ligation).
▪ B: Sperm duct ligated and severed (vasectomy).
Abortion
• Purposeful Interruption of pregnancy before 20 weeks of gestation
• Elective: choosing to stop a pregnancy at any point
• Therapeutic:
o Mom has a condition where she shouldn’t be pregnant
o Baby is non-compatible with life anomalies meaning that they can be carried to term but will not live. •
Contributing factors: Rape, age, resources, Legal and moral issues
o Methods always progress from least invasive to most invasive
• First-trimester abortion: Done up to first 12 weeks
o Up to 80% of all abortions are done during first trimester
o Surgical (aspiration) abortion, Dilation & Curettage
▪ Often done at Planned Parenthood
▪ Checklist: US, see and hear heart beat, watch video, and have waiting period
▪ Must be surgical or hospital setting not clinic anymore
o Methotrexate (IM or PO)
o Misoprostol/Cytotec (PV: per vaginal) most common PO pill taken
▪ Causes uterus to contract and cervix to open
▪ Give this when the mom had a spontaneous abortion to complete the process
▪ Handle with care! Wear gloves can cause even if you touch it
▪ SE: cause cramping, pain, and miscarriage
o Mifepristone and Misoprostol
• Second-trimester abortion: Those done between 12-20 weeks
o Most of these are done because of mom or baby’s condition.
o Dilation and evacuation done because fetus is too large for alternative means
o Hypertonic and uterotonic (MISOPROSTOL) agents
• Education: Complications, SE, Resources, Support
o If they start to have abdominal pain, heavy discharge, abnormal bleeding, infection – these must be reported o
Up to 50% of pregnancies are unintended
• Key Points
o Infertility affects 10% to 15% healthy adults
o 1/3 female causes, 1/3 male causes, 20% of unexplained
o Know the male/female infertility work up
o Contraception choices are numerous
o Know contraindications for contraceptive method
o Know common side effects for contraception methods
o Know abortion methods and risks
o EDUCATE,EDUCATE,EDUCATE!
A physician prescribes clomiphene citrate (Clomid, Serophene) for a woman experiencing infertility. She is very concerned about the risk
of multiple births. The nurse’s most appropriate response is:
A. “This is a legitimate concern. Would you like to discuss this further before your treatment begins?”
B. “No one has ever had more than triplets with Clomid.” C. “Ovulation
will be monitored with ultrasound so this will not happen.” D. “Ten
percent is a very low risk, so you don’t need to worry too much.”
MODULE 2 - THE ANTEPARTUM PERIOD
READINGS
Maternal Child Nursing Care (5th Edition)- p. 140-167, 168-185, 186-225, 227-248, 249-266
Virtual Clinical Excursions, Obstetrics, Pediatrics (5th Edition)
ATI- p. 24-31, 32-42, 43-49, 50-64
Genetics
The maturation of a minute sphere of cells into tissues and then into specific organs that evolve into human form, all
governed by a power unseen, is a story to learn and tell, second to none. The greatest of Nature's miracles is the
conception, development, and birth of an infant.
The perinatal nurse shares in an experiment as old as humanity - the emergence of new life. The experience is entered with
a rich heritage of knowledge, skills, and technology, as well as greater freedom to apply that heritage than ever before.
Perinatal nursing holds unparalleled opportunity to care for and care about the childbearing family. However, to do and be
all that you can, the perinatal nurse must begin with a sound knowledge of the basic components of life and its continuity the anatomic structures and their functions in conception, pregnancy, and birth.
Although the male and female reproductive systems differ markedly in appearance, their structures are analogous. Each
performs a vital role in the propagation of the human species and the generation and maintenance of secondary sexual
characteristics. Each human life begins with the union of two single cells. Once united, these cells divide, differentiate, and
grow into a person, a replica of humanity's continuing generations yet a unique individual. The growth that takes place from
conception to birth is more rapid than at any one time in an individual's life; the microscopic union of sperm and ovum
increases in size more than 200 billion times during this period. In Nature's entire wide universe, there is no process more
wondrous and no mechanisms more fantastic.
Genetics
• Genetics: study of individual genes & their effect on rare-single gene disorders
o Provides the tools to determine the hereditary component of many diseases
o Improves our ability to predict susceptibility, onset, progression, and response to treatment
o A gradual shift from genetics to genomics
• Genomics: is the study of all genes in the human genome together, including their interaction with each other,then
environment & the influence of other psychosocial factors and cultural factors
• Genetic disease affects people of all ages, socioeconomic levels, and racial and ethnic backgrounds
• Genetic disease affects individuals, families, communities, and society
• Advances in genetic testing and genetically based treatments have altered care
Nursing Expertise in Genetics and Genomics
• Expanded roles
o Preconception counseling and testing
o Neonatal genetic screening and testing
o Palliative care for infants with life-threatening conditions
o The identification and care of individuals with genetic
conditions
o Specialized care of women with genetic conditions
during pregnancy
- Congenital heart disease
- Cystic fibrosis
- Factor V Leiden
Essential Competencies
• Essential Nursing Competencies and Curricula Guidelines for Genetics and Genomics
o Constructs pedigree from collected family history information
o Develops plan of care that incorporates genetics assessment
o Provides patients with genetic information, resources, and services
o Facilitates referrals for specialized services
o Evaluates the impact and effectiveness of genetic and genomic technology, interventions, and treatments
Human Genome Project
• Publicly funded international effort by the National Institute of Health (NIH) and US. Department of Energy in 1990.
• Completed in 2003
• Map the human genome (the complete set of genetic instructions in the nucleus of each human cell)
• Two key findings:
o All human beings are 99.9% identical at the DNA level
o There are approximately 20,500 genes in the human genome
Genetic Testing
• Genetic testing: What are the reasons to get different types of genetic testing?
o Carrier screening tests
o Predictive testing: used to clarify the genetic status of asymptomatic family members. Two types are: •
Pre-symptomatic testing: if the gene mutation is present, symptoms of the disease are certain to appear if the
individual lives long enough. (i.e Huntington's Disease)
• Pre-dispositional testing: BRCA 1 gene, a positive does not indicate a 100% risk for developing the
condition (breast cancer)
o Population-based screening: Newborn screening for phenylketonuria (PKU) and other inborn errors
of metabolism
• Genetic testing in Obstetrics
o Prenatal tests: used to identify the genetic status of a pregnancy at risk for a genetic condition - Maternal serum
screening: a blood test used to see if a pregnant woman is at increased risk for carrying a fetus with a neural tube defect
(NTD) or chromosomal abnormalities (Down syndrome = Trisomy 21, Trisomy 18 or Trisomy 13).
o Fetal ultrasound: an image of the fetus inside the uterus by using high-frequency sound
waves o Amniocentesis: Invasive procedure
o Chorionic villus sampling: invasive procedure
Genetic Therapy
• Gene therapy (gene transfer): is to correct defective genes that are responsible for disease
development.
• Involves inserting a healthy copy of the defective gene into the somatic cells of the affected
individual.
• These disease range from hemophilia and other single-gene disorders to complex disorders such as
cancer.
• Ethical, legal, and social implications (ELSIs):
• How do I protect my genetic information in regards to privacy and discrimination?
o Privacy and fairness in use and interpretation of genetic information
• Clinical integration of new genetics technologies
o Issues such as possible discrimination and stigmatization
o Genetic Information Nondiscrimination Act of 2008(GINA)
Decision making in Genetics
• Factors influencing decision to undergo genetic testing: What are reasons pts decide either to be tested or not?
o Seldom autonomous
o Based on feelings of and commitment to others
o Socioeconomic factors
o Cultural and ethnic differences
Clinical Genetics
• Genes and chromosomes
o DNA
o Chromosomes
o Genes
o Homologous
o Autosomes
o Sex chromosomes
o Loci
o Alleles
o Homozygous
o Heterozygous
o Genotype
o Phenotype
o Dominant
o Recessive
o Karyotype: a pictorial analysis of the number for and size of an individual's chromosomes
o Chromosomal Abnormalities
o A major cause of reproductive loss, congenital problems, and gynecologic disorders
o Abnormalities of chromosome number
o Down syndrome —>Can occur during mitosis (somatic cell) or meiosis (sex cells)
o Reciprocal translocation
o Balanced translocation
o Robertsonian translocation
• Pedigree Chart
o (A): Homozygous dominant parent and homozygous-recessive parent: All children are heterozygous: displaying
dominant trait
o (B): Heterozygous parent and homozygous-recessive parent: Children 50% heterozygous, displaying
dominant trait: 50% homozygous, displaying recessive trait.
o (C): Both parents are heterozygous: Children 25% homozygous, displaying dominant trait, 25%
homozygous, displaying recessive trait, 50% heterozysgouus, displaying dominant trait.
• What are the sex chromosome abnormalities and the classic characteristics?
• Turner syndrome
o Monosomy x
o Most common deviation in females
o Short in stature, webbing of neck, low hairline, intelligence may be impaired
• Klinefelter’s syndrome
o Trisomy xxy
o Most common deviation in males
o Affected males has poorly developed secondary sexual characteristics and small testes. Is usually infertile,
usually tall and may be slow to learn
• Trisomy 18- picture to the right
Patterns of Genetic Transmission
• What are the uni-factorial pattern of genetic transmission?
o A single gene controlling a trait, disorder, or defect
- Autosomal dominant inheritance:
- An affected parent who is heterozygous for the trait has a 50% chance of passing the variant allele to each offspring.
No skipping of generations.
- Males and females are equally affected
- Autosomal recessive disorder:
- Inheritance disorders in which both genes of a pair associated with the disorder must be abnormal for the disorder
to be expressed.
- The chance of the train occurring in each child is 25%
• Inborn errors of metabolism:
o More than 350 inborn errors of metabolism have been recognized
o Most are inherited in an autosomal recessive pattern
o Occur when a gene mutation reduces the efficiency of encoded
enzymes to a level at which normal metabolism cannot occur.
o Defective enzyme action interrupts normal series of chemical reactions from the affected point onward
(PKU) • X-linked dominant inheritance:
o Occurs in males and heterozygous females, but because of X inactivation, affected females are usually
les severely affected than affected males
o The affected males are more likely to transmit the variant allele to their offspring
o Heterozygous females have a 50% chance of transmitting the variant allele to each offspring.
o It is often lethal in affected males (Vitamin D-resistant rickets and Rett syndrome)
• X-linked recessive inheritance
o Abnormal genes for x-linked recessive inheritance disorders are carried on the X
chromosome. o Females may be heterozygous or homozygous for traits carried on the X
chromosome
o Males are hemizygous because thy have only one X chromosome
o X-linked recessive disorders are most commonly manifested in the male with the abnormal gene on his singe
X chromosome
o Female carriers (heterozygous for the trait) have a 50% probability of transmitting the disease-associated
allele to each offspring.
o An affected male can pass the disease-associated allele to his daughters but no to his sons( hemophilia,
color blindness, and Duchene muscular dystrophy are X-linked recessive disorders)
• What are the multifactorial patterns of genetic transmission?
o Most common genetic malfunction
o Combination of environmental and genetic factors
- Cleft lip and palate
- Congenital heart disease
- Neural tube defects
- Pyloric stenosis
Risk Factors for Genetic Disorders
Genetic Counseling
• Standard practice in obstetrics
• Goal is to identify risk
• Genetic history should be obtained using a questionnaire or checklist
• Genetic counseling
o Information
o Education
o Support
• Estimation of risk
o Occurrence risk- Parents are known to be at risk for producing a child with disease
o Recurrence risk- Once they have produced a child with disease
o Interpretation of risks
Conception (go over PP for this!!!)
• Cell division
o Mitosis: replication of the same genetic material
o Meiosis: divides into sex cells, each containing 1/2 of genetic material of the original
cell
• Gametogenesis
o Spermatogenesis: formation of sperm. When a man reaches puberty, his testes begin spermatogenesis and
undergo meiosis.
• Oogenesis: formation of ovum.
o During fetal life of a female there are 2 million eggs made, but only 400-500 reach maturity during the 35 years
of a woman’s reproductive life.
o Primary oocytes undergo first meiotic division. during fetal life and they are suspended there until puberty.
BORN WITH GAMETES.
• Conception:
• Day 1→ Ovum- fertilized ovum is called a zygote and has 46 chromosomes.
o Ovum = egg
• Sperm – can take 5 min to 6 hours to find ovum
• Capacitation
• Egg has a crown (zona pellucida) that protects from penetration. In order for the sperm to penetrate the ovum it has to
undergo some changes. Capacitation is the removal Of the protective cap on the sperm (acrosomal cap) to allow for
penetration of the egg. This occurs in the female reproductive tract and can take up to 7 hours. Once the protective hat
is removed, sperm are ready to penetrate the ovum. Process that prepares the sperm for fertilization.
o
Fertilization
• Sperm release Hyaluronidase (hyaluronic acid): breaks down the zona pellucida, allowing 1 sperm to completely
enter the ovum.
• Fertilization takes place in ampulla of the uterine tube, the outer third
baby
Implantation
Pre-Embryonic
• 8-10 days after fertilization
• Conception through day 14
• 10 luna•
Blastocyst imbeds into endometrial tissue
• Embryo: Day 1 through Week 8
• 9 calen
• Fetal: Week 9 through birth
• 40 wee
• 280 day
The Zygote (Day 2)
• The fertilized ovum
• Contains 46 chromosomes
o 23 from ovum
o 23 from sperm
• The sperm determines the sex because the ovum only has X
chromosomes and sperm has X or Y. • males determine the sex of
• Ideally, implantation will occur high in the upper portion of uterus because there area of the uterus is very muscular
and has rich blood supply. But blood supply to the lower area isn’t great. If the zygote does implant in lower area, it can
form placenta previa.
EMBRYONIC AND FETAL DEVELOPMENT
• Fertilization
o Morula (day 3): first undifferentiated cell mass- 12-16 cells
o Begins to travel through fallopian tube
o 3-4 days to migrate to uterine cavity
o Blastocyst day 4 through implantation (embeds in endometrium)
▪ First differentiation of the morula
▪ Develops in 3-4 more days
• Implantation (day 8-10 after implantation)
o Usually implanted in the fundus – the tissue is the thickest so it has the most
nutrients
▪ Might have dark brown spotting that can be confused with a period
o Once implanted two layers form:
▪ Inner layer form fetus and amnion
▪ Trophoblast: make the outer layer that anchors
into wall of uterus. About 8-10 after conception,
trophoblasts secrete enzymes that allow it to burry in to
endometrial wall.
• Forms chorion and placenta
o So you have 3 basic layers of cells: the endoderm,
mesoderm, and ectoderm.
o At 6 weeks, US can detect where zygote
embedded, where implantation took place.
• Spotting can occur at the first missed period, this is
implantation bleeding and not your period/uterine wall
shedding.
Stages of Intrauterine Development
• Ovum: Conception until day 14
• Embryo: day 15 until approximately 8 weeks. At 8 weeks, starts to look
more human-like. The embryo stage is the most critical period of fetal life***, when
organs are developed and most damage can occur. So, essentially the first month is
most critical before mom knows she’s pregnant.
• Fetus: starts at 9 weeks and lasts until term. Full term is 10 lunar months, 9
calendar months, 40 weeks from conception, or 280 days.
• First 13 weeks- critical period of organ development
• Second trimester- 14-26 weeks
• Third trimester- 27-38/40 weeks
• The legal definition of a viable fetus is 20 weeks. You need a birth/death certificate after 20 weeks in cases of
abortion/miscarriage.
Chorionic Villi: gives blood supply to fetus from mom
• Finger-like projections from trophoblast (the outer layer of embryo that eventually becomes placenta) o
Links to materenal blood that helps blood exchange occur
• Help nourish developing embryo
• Excrete waste until placenta formed (until about week 12 in 2nd trimester)
Embryonic & Fetal Structures
• Decidua: the thickened endometrium
o Decidua basalis- It is thickened uterine lining and lies directly under the embryo. It is the area of endometrium
between the implanted chorionic vesicle and the myometrium, which becomes the maternal part of the placenta. It
contains a large number of blood vessel and is where the chorionic villi come into contact with mother’s membrane.
Mom’s blood and baby’s blood never touch each other, if this happens could be a catastrophe. The baby’s trophoblasts
form a single cell barrier between mom’s blood and baby’s blood.
o Decidua capsularis- encapsulates the trophoblast (brings it in for blood supply from mom)
o Decidua vera- remaining portion of uterine lining
• Mom’s spiral arteries accommodate the growing embryo. Only small, regulated amounts of blood enter the
placenta at a time. As baby grows, serial arteries grow and more blood can flow into the placenta from
mom.
Embryo and Fetus
• Embryo develops into 3 primary “germ layers” (wont test on whats in
each
layer just understand)
o Ectoderm (outer part of embryo): upper/ outer layer that
becomes
the epidermis, glands, hair, nails, skin, nervous system
o Mesoderm: muscular system, lungs (epithelial layers),
circulatory
system, skeletal system
o Endoderm: lower layer that becomes epithelial lining, respiratory
(inner layers of lungs), GItract, liver, pancreas, digestive system
▪ Stems in yolk sac has early GI system
▪ When most things go wrong – most critical period of development!!!!!
▪ Most don’t know they are pregnant at this time
▪ Baby is most sensitive to teratogens at this time
• Development of the embryo: lasts from day 15 until 8 weeks of conception. This is the most critical stage of
development where the embryo is most vulnerable to teratogens. At 8 weeks, embryo starts to look like a human. •
Membranes – this is what ruptures when they say your water breaks
o Chorion: outer layer containing the major umbilical blood vessels and branches out over the placenta (closer to
moms surfaces)
▪ C→ closer to outside
o Amnion and amniotic cavity- inner layer becomes a fluid filled sac and where baby resides (closer to fetus)
▪ A→closer to baby
o Chorion and Amnion- together they form amniotic sac and surround baby as they develop
• Amniotic fluid – tells us about fetal well being
o Serves numerous functions▪ creates a constant temperature for baby
▪ cushions baby for protection
▪ freedom of movement for baby to develop musculoskeletal limbs
▪ barrier for infection, helps remove baby’s waste.
▪ It should always be clear and odorless.
o Volume is important to fetal well-being▪ Amniotic fluid volume increases over time up to 700-1000 mL by term.
▪ If mother doesn’t produce enough we call it oligohydramnios
• We are worried they may have a kidney issue because baby isn’t peeing it out
• Ex: HTN
▪ Or if she produces too much- that’s called polyhydramnios, which can denote GI malformations (because they
aren’t swallowing it think GI).
▪ The volume can be picked up via US or measurement of fundal height.
o Baby swallows fluid and at week 11 baby actually pees in fluid, but it is sterile.
▪ This is how amniotic fluid is made!!! COOL
o Has many ingredients other than water, including glucose, fat, leukocytes, protein, lanugo hair, albumin. •
Yolk sac
o At 4 weeks it folds in and becomes primitive digestive system. If this doesn’t happen, you’ll see gastroschisis.
o Blood vessels, blood cells, and plasma are manufactured in yolk sac as well.
o Helps with transferring mom’s nutrients and O2.
• Umbilical cord
o It’s the baby’s life line.
o Supplies the embryo with maternal nutrients (9 weeks and above) and oxygen and baby gives back waste products
and CO2 to mother, and she gets rid of them.
o 2 arteries and 1 vein (AVA) that lie in Whorton’s jelly→which provides protection from cord being compressed so it
helps cushion the AVA.
▪ Vein bring blood to baby, arteries bring it away
o Look for possible knots in the cord or nuchal cord: around baby’s neck.
• Placenta: attached to umbilical cord
o Structure→Formed by day 17
▪ Structure is completely developed by 12 weeks, but is small and continues to grow until 20 weeks gestation.
▪ Covers half of uterus. At 20 weeks it becomes thicker.
▪ Cotyledons are the approximately 15-25 separations of the decidua basalis of the placenta, separated by placental
septa.
• Each cotyledon consists of a main stem of a chorionic villus as well as its branches and subbranches etc. Picture to
the right is of one cotyledon.
▪ Maternal-placental-embryonic circulation
occurs by day 17
▪ Beefy red side is maternal side, touches the
deciduous basilis
▪ Grey side is baby’s side
• Function
• Endocrine gland
• Metabolic function and waste
• Nutrient storage
• It is considered a low-pressure shunt. It is
very sensitive to mom’s BP. So, maintaining
mom’s BP is very important, because if
mom’s BP is dropping then there’s not going
to be much blood flow to the placenta to
support the baby.
• hCG:
▪ Hormone produced right after conception shortly after
implantation and is basis for all pregnancy tests. It preserves function of ovarian corpus luteum until placenta
develops, making sure there’s a good supply of estrogen & progesterone, which are both needed to maintain
pregnancy Amount of hCG reaches its maximum at 50-70 days, then begins to decrease. Its rise is what contributes
to N/V experienced during 1st trimester because mom has never had this hormone before.
o hCS (human chorionic somatotropin)-Is produced by the placenta and stimulates growth and mom’s metabolism.
Increases resistance to insulin. This is done so that more glucose can be directed to baby.
• This is why mom’s often get GDM.
• Estrogen: Is increased. It stimulates uterine growth and stimulates blood flow.
o Speeds things up
o Increases breast tissue
• Estriol: week 12 placenta takes over and this increases
• A type of estrogen produced by the placenta and baby’s fetal adrenal glands.
Monitoring estriol levels gives us information on how well a baby’s doing on
inside. Low amounts of estriol can indicate fetal abnormalities, chromosome
congenital anomalies.
• Progesterone: quiets things down aka constipation. Along with hCG together suppress
immune system in mom to prevent it from attacking the baby.
o Slows things down
• Progesterone maintains endometrial lining and relaxes uterus (decreasing contractility). It is
given to decrease contractions in pre-term labor. When labor begins, progesterone drops and
estrogen levels rise. Is also increased during pregnancy.
Fetal Maturation:
• HR 110-160 normal fetal HR
• HR develops in 3 week of gestation
• Develop into 4 chamber heart by the 5th week
• KNOW how fetus gets oxygen from blood!!!
• The picture above shows fetal circulation. There are 3 shunts in operation in the fetus
to
allow for bypassing of the lungs, all of which close when baby takes their first
breath.
- DUCTUS VENOSUS***- HELPS BLOOD FROM PLACENTA TO BYPASS LIVER, BECAUSE THE BLOOD
DOESN’T NEED TO BE
cleaned, mom already does that. So umbilical vein blood goes straight to the
right atrium of the fetus.
the
and
- Foramen ovale***- once blood enters the right atrium, it enters the left atrium
via the foramen ovale,
because it’s already oxygenated and can go directly into the aorta to be delivered to body. A little bit of blood
does go into the lungs via the right ventricle, just enough the nourish them, but even as that blood leaves to the
lungs via the pulmonary artery, most of it is shunted to the aorta via the DA.
- Ductus arteriosus***- also helps shunt blood to the aorta to reach the body, after which it drains to the
placenta via the umbilical arteries.
• Fetal Hgb →
o A special kind of Hgb that carries O2 more efficiently that adult Hgb (20-30% more).
o The concentration is 50% greater than the mother’s.
o However, fetal Hgb doesn’t last as long as adult Hgb.
o Once the baby is delivered, those fetal RBCs break down (jaundice is thus seen in the first few days of life and is
totally normal) and there’s genetic switch and baby starts producing adult Hgb.
• Viability:
▪ >37 week is considered term (Usually 40 weeks)
▪ Capability of fetus to survive outside uterus- can be done as early as 23-24 weeks, but no younger.
• Cut off is determined by hospital
• Cant stop preterm labor or do anything really before 23 weeks
• Trx: betamethasone promotes surfactant develop and will give for preterm labor to promote lung development ▪
Limitations based on central nervous system function and oxygenation capability of lungs
• Fetal cardiovascular system:
▪ Heartbeat starts in 3rd week after conception, eventually 110-160 BPM
▪ Develops into a 4 chamber heart by 5th week
▪ Special circulatory pathway to avoid lungs
▪ Hgb carries 20-30% more oxygen than mother
▪ Hgb concentration is 50% more than mother
▪ Fetus receives blood through one fetal vein
• Hematopoietic system (enlarged liver, blood type by week 6)
• Respiratory system: last system to fully develop
▪ Lungs are not functioning the fetus, but only growing. Fetal lung fluid is produced by the lung parenchyma, when
the fetus is still in the uterus, and helps create lubrication and pressure in the alveoli until 27 weeks, when
primary surfactant is produced. Surfactant lowers surface tension and allows alveoli to open when baby takes
their first breath. Amniotic fluid is swallowed into esophagus and doesn’t touch the lungs.
▪ Fetuses do breathe. At the 11th week they can detect fetal respiratory movement. Chest wall muscle is developed and
helps to regulate the fetal lung fluid volume. The respiratory movement in the amniotic fluid helps move around the
fetal lung fluid that’s present, this movement helps develop lung function.
▪ Pre-term babies don’t have enough surfactant developed, so each time they breathe, when they exhale their
alveoli tend to collapse.
Primary surfactant is sufficient by week 32
• Gastrointestinal system:
▪ Mature by 36 weeks, the GI system matures and digestive enzymes become present, but only enough for to
digest breast milk or formula.
▪ Meconium is also present and is sterile. If mom has used drugs during her pregnancy, they will be present in
her meconium because meconium develops over time.
• Hepatic system:
▪ Iron is stored in baby’s liver and lasts for 5 months.
▪ Bile is formed by 12 weeks and if fetus doesn’t form bile ducts, then they can develop biliary atresia. For biliary
atresia babies, they are starting to do surgery in utero because if they wait until baby is delivered, then the bile is
trapped in the liver and liver is already destroyed. This surgery is risky, but has shown good results and if not
performed in utero, child will often need a liver transplant down the road. (cant congregate billi) breast fed babies
get it more
• Renal system:
▪ At 5 weeks, the kidneys begin to function and urine is excreted in the amniotic fluid. It helps form most of the
amniotic fluid. It is sterile. If there is little amount of amniotic fluid, oligohydramnios, then there’s something wrong
with fetal kidneys. So oligohydramnios is associated with GU
problems.***
▪ The kidneys are of course not fully mature and have trouble concentrating
urine and are
susceptible to
dehydration.
• Neurologic system
▪ By the 4th week, the neural tube is closed. So, if mom hasn’t taken good
sources of folic acid prior to becoming pregnant, the insult has already
happened and there’s a higher incidence of spinal bifida.
▪ Taste around 5 months gestation & sound around 24 weeks
• Endocrine system (insulin production around 20 weeks)
• Reproductive system (around 12 weeks)
• Musculoskeletal system (all throughout gestation)
• Integumentary system (vernix: its cheese waxy substance that covers baby skin and acts a barrier to prevent pruning, lanugo:
fine hair that covers the fetus in utero, the later term they are they will have less because they shed it, will fall off after
birth)
• Immunologic system (IgG antibody that passes through placenta, encourage mom to be up to date on immunizations but not
varicella or rubella because it caused infection for baby)
• The picture above***, the purple (rectangular rows in the first section) shows the highly sensitive periods where
major organ damage can occur. Occurs mostly in the embryonic period and not as much in the fetal period. •
Embryonic: the most highly sensitive period where a lot can go wrong (more major congenital anamolies) • More
functional defects in later pregnancy
• Internet site of fetal development- http://www.visembryo.com/baby/index. html
• In The Womb assignment -https://www.youtube.com/watch?v=s0WM9oRr07w
Non-genetic Factors Influencing Development
• Teratogens
o Drugs: Accutane
o Chemicals
o Infection: torch panel (toxoplasmosis, rubella, radiation) check for these and more
o Exposure to radiation
o Maternal conditions: nutrition
• Maternal nutrition
o Malnutrition- affect brain development during later half of pregnancy
A woman is 8 months pregnant. She tells the nurse that she knows her baby listens to her but her husband thinks she is
imagining things. The most appropriate response by the nurse is:
A. “Many women imagine what their baby is like.”
B. “Babies in utero do respond to their mother’s voice.”- fetuses can hear sounds by 24, and as early as 13 weeks. As they
get older, can also recognize sibling voices.
C. “You’ll need to ask the doctor if the baby can hear yet.”
D. “Thinking that your baby hears will help you bond with the baby.”
Multifetal pregnancy
• Higher rate now: because of fertility treatment ( IVF, Clomid to help with promoting pregnancy) •
Increased incidence with AMA (> 35 years)
o Occurs in families, genetic
o More common among AAs
• Twins→Happens in 1/43 pregnancies
• Dizygotic twins→means completely Fraternal twins: 2 eggs that were fertilized
o 2 separate embryos, 2 separate sperm, 2 separate blastocysts, 2 implantations, 2 chorionic villi, 2 amnions, 2
different placentas, 2 separate babies.
• Monozygotic twins→A single ovum is fertilized by a single sperm, children will be of
the
same sex, and have the same genotype.
o Mono-Mono: same placenta same sack
• Are the highest risk for complications during pregnancy because of cord
entanglement and they are right on top of each other
• 2 fetuses have to share one placenta (in which case one fetus will take more
nutrients than the other)
• OR in the case of C where separation doesn’t fully occur and fetuses become
conjoined twins. Conjoined twins→rare (Shown in part C of the picture)
o Di-Di: own placenta own sac
o Mono-Di: same placenta different sacks
• Ais one fertilization, 2 implantations, 2 placentas, 2 membranes.
• So, it really depends on when the blastocysts separate.
• The later separation occurs, the more dangerous.
• Other multifetal pregnancies:
HEALTH PROMOTION DURING THE REPRODUCTIVE CYCLE
• In this unit of study, you are going to be considering the effect pregnancy has on various family members. • Even when the
birth of a child is eagerly anticipated, there may be some self-doubts - bodily disfigurement, fear of labor, total
responsibility for the well-being of a helpless individual, paying doctor and hospital bills - these are just a few of the
thoughts to be considered.
• You will explore ways the professional nurse, utilizing her problem-solving ability, may assess patient problems and give
needed support or make appropriate referrals.
• During pregnancy, many changes occur in the mother's body to accommodate the pregnancy. These changes occur in all
body systems. You will need to be aware of what is normal in order to reassure the patient who may become alarmed
about a normal change. Also, you must recognize deviations from normal to provide early detection and prompt
treatment to avert serious problems.
• Diagnosis of pregnancy is not always a simple matter. The signs and symptoms of pregnancy have been classified
according to the degree of conclusiveness they offer toward a positive diagnosis. As a professional person, you may be
consulted by friends or neighbors and would be wise to learn the meaning of the various signs and symptoms.
• Also, at some point in time, you may have occasion to suspect that you (or your wife) are pregnant. In studying the signs
and symptoms of pregnancy, you will encounter many new terms which, if learned now, will enable you to converse
intelligently with other professionals, and interpret the literature and obstetric records.
Psychological Responses to Pregnancy
o Role adaptation requires:
• Acceptance→ is mom ready, has she been trying for awhile
• Assimilation→ in to the pregnant body and doctor’s appointments, is it different from her pregnancy before
etc.
• Ambivalence→even for those women who have been trying to get pregnant, they’ll feel conflicted and think
that maybe they’re not ready for a baby one day and are excited the next.
• This should only be seen in first trimester. Is it the right time for her?
• Emotional lability→they can have rapid change in moods, unpredictable changes in their moods triggered
by the smallest things and wonder how they’re going to make it through their pregnancy.
• Women think of their own mother- and become introspective as to what to repeat and not to
with her own child.
Psychological Tasks of Pregnancy
• 1st Trimester→Accepting pregnancy psychologically and deciding to take pre-natal vitamins and make life changes o
Until 12 weeks
• 2nd Trimester→Accepting baby. An US (at least one) is very helpful to the mother, seeing a picture of the baby • 3rd
Trimester→Preparing for the baby (this is when they decide if they’re going to breastfeed or not) & end of pregnancy
o Expecting baby to look like Gerber baby
Paternal Reactions to Pregnancy
• Announcement phase→
o shocked. “Oh, I’m going to be a dad”.
o Ambivalence is common also.
• Moratorium phase→
o helping partner adjust with pregnancy, getting snacks at night, etc.
o have cravings too with mom
• Focusing phase→
o begins in the last trimester, father is actively involved in pregnancy and developing a relationship with the child.
o For example, by talking/telling stories to the fetus in utero.
• Couvade Syndrome→
o father experiencing same physical symptoms of pregnant wife.
o Father gains weight too
• Men experience pregnancy in many different ways. What are the three phases experienced by expectant fathers? A.
Announcement, acceptance and focusing
B. ANNOUNCEMENT, MORATORIUM AND FOCUSING
C. Announcement, ambivalent and accepting
D. Announcement, moratorium and final acceptance
Sibling Adaptation
• Prepare other children for birth of baby- they can experience jealousy especially in the toddler years. • Don’t make big
developmental changes for the sibling at time of birth of second child, because if things go wrong or they aren’t successful,
then they will blame their baby sibling for it.
• Can bring other kids to appointments
Grandparent Adaptation
• Negative reactions→sometimes grandparents get too involved and take away mother’s role •
Positive reactions
ANTEPARTUM NURSING ASSESSMENT
• Care Management
o Goal of prenatal care→ is to promote the health and well-being of the pregnant woman, the fetus, the newborn,
and family
▪ Keep prenatal appointments (transportation?) – especially if they are high risk pregnancies o
Emphasis on preventive care and optimal self-care
▪ Even UTI or Kidney infection can cause preterm labor
o Prenatal care is sought routinely by women of middle or high socioeconomic status
• Barriers to obtaining prenatal care include:
o Lack of motivation to seek care
o Inadequate finances
o Lack of transportation
o Unpleasant clinic personnel
o Unpleasant facilities or procedures
o Inconvenient clinic hours (for example, 9-5. many need evening access to health care)
o Problems with child care
o Personal and cultural attitudes→if they didn’t have prenatal care last pregnancy then they don’t need it now •
Prenatal Visit Schedule
o Traditional→
▪ First visit within the first trimester: (12 weeks):
• Is longest and most tedious (long history, lab work) appointment.
• Let her know this is the longest visit, to facilitate her return for her next appointments.
• Want to see at 8-10 weeks
▪ Monthly (every 4 weeks) visits weeks until between 16 through 28
• Labs→ MSAFP done at this time
▪ Every two weeks from weeks 29 to 36
• Weekly here if elevated BG, or something
▪ Weekly visits week 30 (35 weeks/ last trimester) to birth
• Normally weekly visits at 35 weeks unless something is going on
• Initial Visit & History & PE
o Have family member or close friend come with them
o Chief concern - what brings them in? Get a good history and understand her feelings on the pregnancy.
o LMP date to calculate her due date
o Current Pregnancy: problems: cramping, bleeding
▪ Vaginal discharge? Ok for it to be thick but not stinky
• Not okay if it has an odor or vaginal itching
o Psychological response to this pregnancy:
▪ ambivalence (is normal)
▪ happy?
o Gynecological history: previous pregnancies, miscarriages, abortions, procedure etc.
▪ Anything that could prevent them from vaginal birth
o Current & past medical history: does she have any chronic illnesses?
o History of drug use and herbal preparations: they’ll always tell you no, but be non-judgmental and tell them why
you need this information. Can cause pre-term labor and miscarriage.
o Physical Examination
▪ Heart tones
▪ PAP
▪ Speculum for pelvic cultures
o Laboratory tests→at 2nd visit depends on GA ▪
Blood sugar test
Summarizing Obstetric History
- Two digits:
- G- gravida: number of times a female has been pregnant (gravidity)
- P- para: number of carried pregnancies to a viable gestational age (parity), regardless of if fetus is born alive.
- 5 digits
- GPTAL*** DON’T FORGET TO COUNT 1 IF SHE IS CURRENTLY PREGNANT!!!!!!
- Gravidity (# pregnancies)
- Preterm (deliveries > 20 weeks but < 37 weeks). Does not include a stillbirth (birth of infant died in womb)
- Term (deliveries > 37 weeks)
- Abortions (deliveries < 20 weeks spontaneous or induced)
- Living children
- GTPAL Example: Nancy is currently pregnant. Her OB history consists of the following:
- Cesarean section of twins at 35 weeks in 1997
- Spontaneous vaginal delivery (VBAC) singleton at 39 weeks in 2000
- Spontaneous abortion at 10 weeks in 2002
- All viable children alive
- What is Nancy’s GTPAL? 4-1-1-1-3
- What is Nancy’s GP? G4P2
Estimated Date of Delivery/Birth/Confinement
• Nägele's Rule*** (must know)
• First day of LMP (last menstrual period) →10/5 (October 5th)
• Subtract 3 months- 3 = 7/5 (When conception occurred, if her periods were regular)
• Add 7 days+ 7 = 7/12 (So, on July 12th she will have her baby)
• Most women give birth from 7 days before to 7 days after EDB
A nurse is caring for a client who is pregnant and states that her last menstrual period (LMP) was May 14, 2015. Which of
the following is the patient’s estimated date of delivery?
A. February 7, 2016
B. February 12 2016
C. FEBRUARY 21, 2016
D. February 27, 2016
Pregnancy Tests
• Human chorionic gonadotropin (hCG) is earliest biochemical marker of pregnancy
• Pregnancy tests based on recognition of hCG or β subunit of hCG
• Can be detected in serum or urine as early as 7 to 8 days after ovulation or missed period
• Many different pregnancy tests are available
• Enzyme-linked immunosorbent assay (ELISA) testing is most popular method of testing for pregnancy o
ELISA technology is the basis for most over-the-counter home pregnancy tests
o Medication use, hormone based tumors, or improper collection may cause inaccurate results o
Requires first urine of morning for it to work well!!! because it has the highest concentration of hCG Follow-Up Visits
• Interview- how are they adapting?
o N.V. changes in health? Eating drinking well?
• Physical examination→do you want someone in the room with you?
• Fetal Assessment→
o Fundal Height→ measuring from symphysis to top of uterus (fundus)
▪ Land mark: 20 weeks gestation it should be at belly button & 1 cm after each week
▪ Example: if mom is 22 weeks & her fundal height is 18cm, what does this mean? It is below what it
should be bc it should be 22cm
o Gestational age→
▪ Where she has measured
o Health status
• History
o Nutritional history an status
▪ Monitor weight every time they come in
▪ If obese no dieting
▪ Gain about a pound per week
o Drugs, alcohol, smoking history
▪ Have them cut back by half in smoking
o Family medical history and history of congenital anomalies→
▪ If parent has wide forehead so will baby
o Social data: WIC?
▪ education, economic level, support systems
▪ plans for child care after delivery
▪ resources can they feed themselves
o History of abuse/violence.
▪ If yes, must do a follow-up.
▪ Are they with same partner
▪ Document and draw picture of abuse
▪ Get case manager on board
▪ Give number to call and resources
Violence AgainstWomen
• Cycle of violence→ Many times first time they experience violence during pregnancy
o Phase 1: Tension building
▪ That her experiences increased tension, victim minimizes problems
▪ Increased Tension becomes intolerable
o Phase 2: Abusive incident
▪ Batterer highly abusive, incident occurs
▪ Victim may feel like they deserve it can cause miscarriage
o Phase 3: Honeymoon period
▪ Loving, apologetic, promises change, gives gifts
• Battering during pregnancy
o Rates range from 4% to 8% and may be as high as 20% in some populations
o Incidence of intimate partner violence may escalate
o May happen for the first time during pregnancy
o Risk→ to the fetus includes increased rate of miscarriage, preterm birth, and stillbirth
o Common for abuse to start during pregnancy because the husbands get jealous
• Be aware of communication
o Don’t ask, “Do you fight with you partner?” …everyone fights with their partner
o Ask, “Does your partner threaten or physically hurt you?” OR “Has anyone forced you to have sex or made you
uncomfortable?”
o Also, look for any obvious bruising during the physical exam
o Reassure them that what they tell is all confidential.
o Remember psych – review notes
Physical Assessment
• Gynecoid pelvis is “normal” female pelvis- rare to find this ideal!
o But overall, compared to the male pelvis, the female pelvis is round and accommodating to the baby’s head. o
The outlet is round, the walls are straight, pubic arch where the baby rests its head is wide and not narrow, etc.
• General appearance
• Vital signs
o High BP→ 135/80-89 retake later
• Objective data is recorded by body systems
o Findings are described in detail in notes
• Fundal Height→ gives gestational age
o one end at symposia pubis, over abdomen and end at top margin, fundal height in cm should correlate with
gestational age, + or - a few cm is ok.
• Auscultate fetal heart at each visit→ do at 10-12 weeks (can do at 9 if mom is thin)
o If you can hear the baby’s HR via stethoscope, the baby is 18 wks gestation.
o If you use a doppler, you can pick up the HR at 12 weeks. Use Leopold's Maneuvers to determine the position of
a fetus inside the woman's uterus so you know where to put stethoscope to listen for the HR, and also used to
estimate term fetal weight.
• Pelvic examination→only done for the first visit
o Normally in a lithotomy position, a supine position of the body with the legs separated, flexed, and supported in
raised stirrups.
o External inspection and palpation. →lumps or bumps that are new if so culture and swab
o During pregnancy the walls the vagina and cervix change colors.
• Collection of specimens
o Papanicolaou test (PAP)→ find cervix as landmark, use speculum and scrape with brush to get culture ▪
Done once and then if abnormal then do it postpartum as follow up
o Vaginal wall examination
▪ Look for moles or skin tags
o Bimanual palpation→here we are trying to move the uterus to see if there’s any tenderness or PID, first picture
shown on next page
o Rectovaginal palpation→here we are trying to see if the uterus is positioned more anterior or posterior toward
colon, 2nd picture shown on next page
• Lab Test:
o Review Table 8-1
o Fetal assessment
o Laboratory tests
o Multiple-marker or triple-screen blood test → 16 weeks
▪ MSAFP – screen for downs
o Other blood tests (RPR→syphilis/VDRL, CBC, anti-Rh)→20 weeks
▪ CBC at beginning of pregnancy
▪ Iron can cause GI symptoms (take with vitamin C, empty stomach, take at night)
▪ If taking iron retest levels in one month
o 1-hr glucose tolerance→ done at 28 weeks unless earlier they are obese, have hx of DM
o 3-hr glucose tolerance→ depending on results of 1 hr, come in fasting, four times they do FBG, drink the stuff,
then retake it for ever hour for three more tests
▪ If 2 values abnormal = GDM
• Other tests
o Ultrasonography
▪ Early & @ 20 weeks
▪ Unless reason for that can order
▪ Cervical length- if her cervix is short, she’s at risk for pre-term labor
o Amniocentesis→ genetic information
▪ Done if they have abnormal MSAFP
o Cardiac evaluation: ECG, chest x-ray film, echocardiogram
o CBC→ anemia
o Hgb Electrophoresis→
▪ to see if she’s at risk for of has history of sickled-cell anemia
o Blood type, Rh, and irregular antibody
▪ If she is Rh (-)→she will get an Rhogam shot
o Rubella titer→
▪ make sure it’s strong enough so if she’s exposed to Rubella and contracts it, she won’t pass it to baby o
TB skin test
o Urinalysis- to check for UTI
▪ Every visit
o Renal function tests
o Group B strep(GBS): 35 to 37 weeks of gestation- to see if there’s Strep B on her cervix
• Fetal Assessment
o Fundal height
o Gestational age
o Health status:
▪ Fetal heart rate
▪ Laboratory Tests: B-hCG, MSAFP (16-18), QUAD test or Penta Screen
o Diagnostic Tests:
▪ Ultrasound: can look for nuchal translucency (NT), indicative of possible Down’s Syndrome ▪
Amniocentesis
• Prenatal Visits
o Subsequent Prenatal Visits
▪ 11 – 14 weeks
▪ 15-20 weeks
▪ 24 – 28 weeks
▪ 28 weeks
▪ 32 – 34 weeks
▪ 36 weeks, remember they’ll come every week after 36 weeks
• Care Management
o Education about maternal and fetal changes
▪ Round ligament pain→normal baby is growing and it will cause discomfort take Tylenol o
Education for self-management
▪ Nutrition→ lots of protein, no diets
▪ Personal hygiene→increased vaginal discharge normal
▪ Prevention of urinary tract infections→increase water intake and call HCP if you have one ▪
Kegel exercises
▪ Preparation for breastfeeding newborn
▪ Dental health→ call clinic because they need to give you approval to see dentist
• if issues, need to see dentist ASAP as it can cause you to go into pre-term labor
• Nutrient Needs Before Conception
o First trimester crucial for embryonic and fetal organ development
o Healthful diet before conception ensures that adequate nutrients are available for developing fetus ▪
Need 600mg of folic acid during pregnancy
o Folate or folic acid intake important in the peri-conceptual period
o Neural tube defects are more common in infants of women with poor folic acid intake •
Key components of nutrition care
o Nutrition assessment→
▪ Finger nails healthy
▪ Mouth care→ sores? Diet deficiency
o Diagnosis of nutritional related problems or risk factors
o Intervention based on an individual’s dietary goals and plan for appropriate weight gain
o Evaluation with referral to a nutritionist or dietitian as necessary
• Nutrient Needs During Pregnancy
o Factors that contribute to the increase in nutrient needs→
▪ The uterine-placental-fetal unit
▪ Maternal blood volume and constituents, that all increase during pregnancy
▪ Maternal mammary development
▪ Metabolic needs→high protein and lots of fluid
• *******Energy needs→ 25-23lbs is normal weight gain for women with normal BMI (important)!!!!!!!! o
Weight gain is required during pregnancy→amount is important
▪ Body mass index (BMI) = weight/height2
▪ Ideal weight gain: 25-35 pounds for women with normal BMI
▪ About a pound every month→weight needs to be gradual
o Pattern of weight gain is also important
▪ Hazards of restricting adequate weight gain
▪ Excessive weight gain
• *******Weight Gain During Pregnancy!!!!!!
o Underweight Women (BMI less than 18.5)
▪ 12.5 - 18 kg (28 - 40 lb) - must gain more weight than others ▪
May give them a diet log to keep eating
o Normal-weight Women (BMI between 18.5 to 24.9)
▪ 11.5 - 16 kg (25 -35 lb)
o Overweight Women (BMI Between 25 and 29.9)
▪ 7 - 11.5 kg (15 - 25 lb)
o Obese Women (BMI equal or greater than 30)
▪ 5 - 9 kg (11 - 20 lb)
o Twin gestations- these numbers will vary
Tissues Contributing to Maternal weight gain at 40 weeks
gestation
Tissue
Kilogr
Pou
Fetus
ams
nds
3.2-3.
7-8.
9
5
Placenta
0.9-1.1
2-2.5
Amniotic Fluid
0.9
2
0.9
2
Breast tissue
0.5-1.8
1-4
Increased Blood
volume
1.8-2.3
4-5
Increased tissue fluid
1.4-2.3
3-5
Increased stores (fat)
1.8-2.7
Increase in uterine
tissue
- will only have a few lb of fat gain, and this fat will go toward developing breast tissue for lactation
- The rest of the weight is baby’s and tissue that supports baby
Pattern of Weight Gain
- Weight gain has to be gradual over the course of pregnancy
- Underweight Women
- 0.5 KG per week during the second and third trimesters for
underweight women
- Normal-weight Women
- 0.4 KG per week
- Overweight women
- 0.3 kg per week
- Obese women
- 0.2 kg per week
Calculate the BMI For each of the following Pregnant Women:
Patient
BMI Meaning
Weight Gain (total: Pattern)
a. June: 5 feet 3 inches and weighs
120 pounds
b. Alice: 5 feet 6 inches, weighs 180
pounds
c. Ann: 5 feet 5 inches, weighs 95
pounds
Possible Nursing Diagnoses(wont be tested on)
- Imbalanced Nutrition: more than Body Requirements r/t
- Deficient Knowledge r/t
- Risk for Injury (Fetus) r/t
- Ineffective health maintenance r/t
- Disturbed Body image r/t
Prenatal Nutrition
• Minerals & Vitamins→
• Iron→ necessary for hemoglobin formation
o Needs double during pregnancy
o Fetus needs high hemoglobin level to bind oxygen across placenta during intrauterine life
o Mother needs increased iron for her increased RBCs
o Sources: organ meats, eggs, green leafy vegetables, whole grain, dried fruit
o Give with vitamin C to increase absorption!!!!
• Foods toAvoid
o Mercury containing fish and shellfish like shark or swordfish
o Caffeine→increases incidence of low birth weight, increases heart rate, acid secretion in stomach
o Energy drinks that very high levels of caffeine
o Artificial Sweeteners: Aspartame; Stevia risk not determined
o Moderate amounts of tuna is okay
o No SOFT cheeses!!
• Calories: 300 kcal extra per day during pregnancy & 330 kcal extra during lactation.
o Fill these in with nutritious food.
o Ex: cheese and crackers or peanut butter and crackers
o Balanced Diet: Choose myplate.gov
• Carbohydrates:
o Promotes weight gain and growth of the fetus, placenta and other maternal tissues
• Fat:
o valuable sources of energy and aid in the absorption of fat-soluble vitamins. Should account for 20%-35% of
diet
• Protein: at least 60 gm daily (14 mg above non-pregnant recommendation) for increase in both maternal tissues and
developing fetus
o Sources: meats, fish, poultry, milk, eggs, legumes
• Fluid: 8-10 glasses/day
o Especially if taking iron!!!
• Calcium→ at least 1000mg/day
• Magnesium: increases
• Sodium: increases
• Potassium: adequate level associated with decreased hypertension
o Low potassium is linked to hypertension during pregnancy
• Zinc- increases
• Fluoride: no need for an increase or decrease, adequate amounts are usually present in tap water •
Fat-soluble vitamins→Vitamins A, D, E, andK
• Water-soluble vitamins
• Folate or folic acid→ at least 600 mcg
• Pyridoxine
• Vitamin C & Vitamin B12
Other nutrition issues during pregnancy
• Pica→The practice of consuming nonfood substances
o May be influenced by the woman’s cultural background
o Often seen in kids with iron deficiency anemia.
o Mom can also experience this during pregnancy. If we see this, then we know that we need to assess her diet
because something is missing in it
o Eating ICE→means need more iron
• Food cravings
o Proposed that food cravings during pregnancy are caused by an innate drive to consume nutrients missing
from the diet. This has not been supported by research.
• Preeclampsia→
o High BP during pregnancy. The cause is stillunknown (placental oxygen decreases?)
o Speculation that poor intake of specific nutrients may be a contributing factor
o An adequate diet remains the best means of prevention
• FOODS TO AVOID: caffeine (increases incidence of low birth weight, increases heart rate, acid secretion in stomach),
aspartame (artificial sweeteners), mercury containing fish, & soft cheeses
Adolescent pregnancy needs
• Adolescents are still growing and you have a baby growing inside you on top of that
• Improve nutritional health of pregnant adolescents by focusing on knowledge and planning of meals •
Nutrition interventions and educational programs effective with adolescents
• Understanding factors that create barriers to change in adolescent population
• For instance, they often don’t want to gain weight
• Promote access to prenatal care
• The most deficient nutrients found in this age group: Zinc, vitamin A, D, and B6
Physical activity during pregnancy
• Moderate exercise, such as walking, yields many benefits, including improving muscle tone, shortening course of labor,
and sense of well-being. Do not engage in vigorous exercise.
o No sky diving, marathon running or
• Liberal amounts of fluid should be consumed before, during, and after exercise
• Calorie intake sufficient to meet increased needs of pregnancy and exercise
o No exercising to loose weight right now
Nutrient Needs During Lactation
• Nutrition needs during lactation similar to those during pregnancy
o Loose about 500 calories a day during breastfeeding
• Needs for energy (calories), protein, calcium, iodine, zinc, the B vitamins, and vitamin C remain greater than non
pregnant needs
o Need prenatal vitamins still, lots of water
o Will make them loose weight
• Energy intake increase of 330 kcal more than woman’s non-pregnant intake recommended
• Increased maternal weight loss during lactation
• Smoking, alcohol intake, and excessive caffeine intake should be avoided during lactation
• Assessment→
o Nutrition and diet history
o Review of health record and previous OB/GYN history
o Physical examination
o Laboratory testing→ GBS 3rd trimester or 28 week labs RPR and ……
o Cultural influences
o Collaborative care
• Nursing Interventions
o Adequate dietary intake
o Pregnancy
o Postpartum
o Daily food guide and menu planning
o Medical nutrition therapy
o Counseling about iron supplementation
Assessment of a woman’s nutritional status includes a diet history, medication regimen, physical examination, and relevant
laboratory tests. A maternity nurse performing such an assessment should be aware that:
A. Oral contraceptive use may interfere with the absorption of iron.
B. Illnesses that have created nutritional deficits such as phenylketonuria may require nutritional care before conception. (In PKU, you can’t
eat a lot of protein, which you need for fetal growth).
C. The woman’s socioeconomic status and educational level are not relevant to her examination; they are the province
of the social worker, ifanybody.
D. The only nutrition-related laboratory test most pregnant women need is testing for diabetes.
Key Concepts
- Nutritional status before, during and after pregnancy contributes, to a significant degree, to her well-being and that
of her developing fetus and newborn
- Many physiologic changes occurring during pregnancy influence the need for additional nutrients and the efficiency
with which the body uses them
- Both the total maternal weight gain and the pattern of weight gain are important determinants of the outcome of
pregnancy.
- The appropriateness of the mother’s pre-pregnancy weight for height (BMI) is a major determinant of her
recommended weight gain during pregnancy
- Iron supplementation is usually recommended routinely during pregnancy Other supplements may be
recommended when nutritional risk factors are present
- The nurse and the woman are influenced by cultural and personal values and beliefs during nutrition counseling
- Pregnancy complication that may be nutrition related include anemia, gestational hypertension, gestational
diabetes, and IUGR
- Dietary adaption can be effective for some of the common discomforts of pregnancy including nausea and
vomiting, constipation, and heartburn.
ANATOMY OF PREGNANCY (LOOK AT POWER POINTS)
TERMS:
• Parity – number of pregnancies carried past period of viability (20 weeks)→NOT number of fetuses born regardless of
alive or still born
• Gravida – a woman who has been pregnant
• Primigravida – a woman pregnant for the first time
• Primipara – a woman who has delivered one child past age of viability (20 weeks)
• Multigravida – a pregnant woman who has been pregnant before
• Multipara – a woman who has carried two or more pregnancies to 20 weeks or more
• Nulligravida – a woman who has never been and is not currently pregnant
• Nullipara: not completed pregnancy with fetus that reached 20 weeks or more
• Preterm: pregnancy that has reached 20 weeks of gestation but before completion of 37 weeks of gestation •
AKA→ 20-36.6 weeks
• Viability: capacity to live outside uterus; about 22 to 25 weeks’ gestation are on the threshold of viability •
24 weeks (average) can be 2 weeks below or above to be viable
• These very premature infants are vulnerable to brain injury etc.
New Terms Per ACOG (2013):
• Term: routinely 40 weeks gestation→pregnancy from beginning of week 38 of gestation to end of week 42 of gestation •
Early Term- 37 0/7wk- 38 6/7wks
o Will not do anything to stop labor if it progresses
• Full Term- 39 0/7wks- 40 6/7wks
o Wont induce labor until “full term” for non-medical reasons
• Late Term-41 0/7wks- 41 6/7wks
• Post Term- 42 0/7wks and beyond
o Monitor placenta because it’s a timed organ and will not work as well past 40 weeks
o Close monitoring
Summarizing Obstetric History** (on test)
• Two digits→ GP (vague, doesn’t tell us a lot about pregnancy)
o G – gravida
o P – para
• 5 digits→GTPAL (more clear)
o Gravidity (# pregnancies)
o Term (deliveries >37 week)
o Preterm (deliveries >20wk but <37 week)
o Abortions (deliveries <20 weeks spontaneous or induced)-lose, demise, miscarriage
o Living children= where we may see twins or triplets here because numbers don’t match
Nancy is currently pregnant. Her OB history consists of the following:
• Cesarean section of twins at 35 weeks in 1997
• Spontaneous vaginal delivery (VBAC) singleton at 39 weeks in 2000
• Spontaneous abortion at 10 weeks in 2002
• All viable children alive
What is Nancy’s GTPAL?
• G4 (because she is currently pregnant) •
T1
• P1 (C-section of twins counts as one) • A1
Pregnancy Tests
• L3 (twins + full term delivery)
What is Nancy’s GP? • G4
• P2
• Human chorionic gonadotropin (hCG) is earliest biochemical marker of pregnancy
• Blood (more accurate), serum, or urine
• Can have false positives and negatives
• Pregnancy tests based on recognition of hCG or β subunit of hCG
• hCG peaks at 70 days and decrease at about 16 weeks
• Skewed result: seizure medications, diuretics
• First urination in the morning is the best indicator for pregnancy test
• Can be detected in serum or urine as early as 7 to 8 days after ovulation
• After they get a really high number in the blood test you should be able to see something in the uterus, if not think
ECTOPIC
• Many different pregnancy tests are available
– Enzyme-linked immunosorbent assay (ELISA)
testing is most popular method of testing for pregnancy
• ELISA technology is the basis for most over-the-counter home pregnancy tests
• Medication use, hormone based tumors, or improper collection may cause inaccurate results
Signs of pregnancy:
Presumptive Signs of Pregnancy**** (know understand!!)
• Someone thinks or feels theyare pregnant
• Least indicative of pregnancy (symptoms can be seen in other situations and be something other than baby) •
Amenorrhea→no period (low BMI)
• N/V
• Breast changing→tender, swelling, sensitivity (hormone changes with anything)
• Quickening→mother’s first feeling of baby movement (butterflies), often mistaken for gas
• Skin changes due to the high levels of estrogen
• Linea nigra: darkened line from symposia pubis up until the belly button (hormonal condition)
• Melasma: hyper-pigmentation or brown patches that appear on the face
• Striae gravidarum: stretch marks (gaining weight)
Probable Signs of Pregnancy
• More reliable & more diagnostic, but not true diagnosis
• Will be able to see or assess as a practitioner
• Positive lab tests
• Hormones goes up
• Chadwick’s sign: C for color. It is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood
flow. It can be observed as early as 6 to 8 weeks after conception, and its presence is an early sign of pregnancy.
• Goodell’s sign: is an indication of pregnancy. It is a significant softening of the vaginal portion of the cervix from
increased vascularization. This vascularization is a result of hypertrophy and engorgement of the vessels below the
growing uterus.
• Hegar’s sign: softening and compressibility of the lower segment of the uterus in early pregnancy (about the seventh
week) which, on bimanual examination, is felt by the finger in the vagina as though the neck and body of the uterus
were separated, or connected by only a thin band of tissue.
• Ballottement (bouncing of something in uterus): a sharp upward pushing against the uterine wall with a finger
inserted into the vagina for diagnosing pregnancy by feeling the
return impact of
the displaced fetus; also, a similar procedure for detecting a
floating kidney.
• Fetal outline felt by examiner: could be a tumor
Positive Signs of Pregnancy
• True of a diagnosis: can only be attributed to a fetus
• Ultrasound of fetus
• Fetal heart tones by Doppler or ultrasound →check moms HR to
make sure its not
same as baby
• Fetal movement felt by examiner→kick felt by baby
Comparison of Non-pregnant & Pregnant Uterus
• Once baby starts growing the uterus comes up into abdomen
• Uterus is initially as big as a pair and weighs about 2.5 ounces Cervix
Measurement Non-Pregnant & Pregnant (not tested on!!!)
Length
2.5 inches
12.5
in.
Width
1.5 inches
Displacement of Abdominal Organs with Growing Fetus • We
Depth
1 inch
8.5 in.
know that before 4 months, baby is in the pelvis
Weight
2.5 ounces
2.5
Uterine Growth through weeks gestation:
• Umbilicus =20 weeks
9.5
in.
Volume
> 10 ml.
5000
ml lbs.
• There are changes to the cervix as well during pregnancy. It becomes more vascular & edematous: all these form as a result of high
estrogen
• In the cervical area, the Endocervical glands hyper secrete forming a mucous plug that covers the opening of the cervix, eliminating
chances for bacteria to enter mom’s uterus. This plug is expelled when mom goes into labor. • Glands and tissues also become very
active during pregnancy and mom can have increased vaginal discharge. - PROBABLE SIGNS OF PREGNANCY
- GOODELL’S SIGN:
- Softening of cervix: throughout pregnancy to
prepare
for delivery
- Chadwick sign:
- Bluish hue of the cervix and vagina wall, because
there’s a lot of vasculature there (blue portion in
picture)
- Hegar Sign (right in the middle):
- Softening of the uterus: shown performed by the provider in the picture to the right —>
Ovaries
• Ovulation stops
• Corpus luteum secretes progesterone & estrogen up to 16 weeks and waits until placenta formed • Maintains
pregnancy until placenta formed & functioning, after which the corpus luteum goes away o Can cause pain on the
right or left side; make sure to monitor because could be ectopic pregnancy Vagina
• Chadwick’s sign
o Increased vascularity of vagina causing vagina and cervix to be purplish/blue color
• Increased acidity to resist bacteria
• Increased sensitivity: due to increased vascularity
• Increase in Leukorrhea: normal increased vaginal discharge caused by hormones, white, clear, odorless •
Patient Education
o frequent baths, can bathe as long as water hasn’t ruptured
o wear cotton underwear
Breasts
• Estrogen and progesterone cause many changes in mammary glands
• Increase in size, vascularity. Arreola darken. Nipples are more erectile. Stretch marks may be present. o
Good sign: means body is maintain pregnancy
• Feelings of fullness & tenderness as early as 6 weeks
• Colostrum present as early as 16 weeks: antibody rich, yellow secretions
o Wear supportive bra
• ***Patient Education
o reinforce self-breast exam because some women may develop breast cancer during pregnancy
o discuss value of breast feeding
o wear a good, supportive bra
Changes in position of heart, lungs, and thoracic cage in pregnancy Respiratory System
• Shortness of breath (dyspnea) – from hormones!!!!
• Diaphragm displaced upward from baby so breaths will be more shallow and
RR will be increased by about 10 breaths/minute. Lungs however do expand horizontally
to accommodate for the pressure on them from the diaphragm
- Patient Education:
- Encourage mom to prop up with pillows when in bed
- Teach to sit & stand erect/good posture to lift diaphragm up
• Nasal congestion and nosebleeds because of hormones
- As a result of the capillary engorgement produced from the elevated estrogen (stuffy nose)
- ** Patient Education:
- Use a humidifier to keep nasal passage moist, saline spray, warm compresses, position changes
Cardiovascular System
• Blood volume increases 1500 ml:
• 1000 ml plasma and 450 ml RBCs
• you’re seeing more plasma than RBCs, so it’s a pseudo-anemia called physiologic anemia of pregnancy
(apparent decrease in hemoglobin & hematocrit). This is normal
• Blood volume 25-50% greater than non-pregnant levels. Volume increases over the course of the 3 trimesters. •
She loses this volume after she delivers.
• It’s normal to lose anywhere from 500 - 1000 mL duringdelivery.
• RBC production increases 30-33% if mom has adequate iron supplementation (pre-natal vitamins). If she doesn’t have
supplementation, RBC production increases by only 18%.
• Hemoglobin: less than 11.5 g/dL or hematocrit less than 30% is considered anemia
• WBCs: increase to 5000-12000/cubic mm.
• Especially postpartum
• Cardiac output increases 30 – 50%
• Increased Pulse (14-20 week)
• Increased Cardiac output
st
• Decreased Blood Pressure (slight) in 1 trimester - 32 weeks.
rd
• Back to baseline in 3 trimester. This is what happens in a normal pregnancy. Some pregnant women
become hypertensive and that’s different.
Supine Hypotension Syndrome aka Vena Cava Syndrome***
• Lying supine the weight of abdomen and baby presses on the vena cava and aorta causing obstruction of blood
return to the heart from extremities, decreases cardiac output, hypotension, dizziness, N,V. - ** Education-
- Tilt into a side-lying position, maybe using a pillow as a wedge to put under hip.
- Change positions slowly to her side let her use arm to help her get up because she doesn’t not have abdominal
muscle support , don’t let woman in her third trimester lie on her back
- Slow movements for pregnancy women
• VaricoseVeins:
o Weight of fetus on saphenous veins of legs leads to increased
pressure
in veins
o Can occur in legs & vulva
o Prevention is easier than treatment
o Avoid restricting clothing, knee-highs
o Teach to elevate legs periodically
o Good fitting elastic stockings are useful
Renal System
• Urinary output (urinary frequency) increases because baby is putting
pressure on bladder. This is common in the first trimester and in third trimester as
baby’s head is moving toward pelvis again for delivery.
• Specific gravity decreases
o Proteinuria *** (shouldn’t be present in pregnancy except L&D or trace). Presence indicates pre-eclampsia. o If there is
protein found in the urine, then a creatinine clearance is done to f//u. (with preecalmpsia or previous renal issue)
• It is the best test of renal function.
• Test is done on 24-hour urine sample
o *** Patient Education:
• Patient still needs to drink their 8-10 glasses of water regardless of urinary frequency, but not before bed
time.
• Lean forward when peeing to help empty the bladder
• Reinforcing wiping front to back.
• Avoid caffeine as it increases urinaryfrequency.
• Limit fluid intake in the evening
• Empty bladder completely
A newly pregnant patient complains of occasional nose bleeds. The nurse’s priority action is which of the following?
A. Send her to the ED (emergency department)
B. ENCOURAGE COOL STEAM AND/OR SALINE DROPS: IT’S A NORMAL CONDITION RESULTING FROM INCREASED
VASCULATURE FROM HIGH ESTROGEN LEVELS. SALINE CAN BE HELPFUL.
C. Encourage patient to blow her nose frequently
D. Send her to an ENT (ear, nose, throat) specialist
Gastrointestinal System
• Nausea/vomiting: Causes hCG increase in the first trimester and taper off after 60 days. She’ll have N/V in first trimester.
o More babies or if nauseated outside of pregnancy they will have more Nausea
o Progesterone increase & Estrogen increase
• Glucose levels decrease in mom since they’re shunted to baby. This can also cause N/V. So mom needs to have frequent small
meals throughout the day to keep glucose levels even.
o For instance→keep crackers at bedside stand. Separate solids from liquids
• Heartburn (pyrosis) and acid reflux due to displacement of stomach by uterus.
o Progesterone also relaxes the esophageal sphincter.
• GI tract slows done and has decreased tone from the increased levels of P4 (progesterone) that cause smooth muscle
relaxation. This leads to constipation, flatulence, heartburn. The slowing down of GI motility helps to increase
nutrient absorption for the baby.
• Hemorrhoids common: from vasocongestion and increased venous pressure, exacerbated by constipation
• Pica: cravings for non-food items such as clay, laundry starch, and ice
• Gallstones: P4 causes relaxation of smooth muscle of the gallbladder. This cholestasis (condition where flow of bile
from liver stops or slows) can cause gallstones.
• Ptyalism: excessive salivation, cause unknown (spit cup)
• *** Patient Education: N/V is common in first trimester, lasts longer for some moms (HG/hyperemesis gravidarum)
o Separate liquids from solids
o Ginger, vitamin B6
o For nausea→Diclegis recently reapproved medication: formerly Bendectin.
- It has vitamin B6 and an anti-histamine: doxylamine
o High hCG and progesterone levels & changes in carbohydrate metabolism
o Avoid empty and overloaded stomach – eat more frequent smaller meals
o Dry toast/ crackers 30 minutes before getting out of bed
o Hot drinks
o Get up slowly
o Avoid greasy foods, gassy foods, triggers
o Sweet lemonade may help
o Eat crackers before getting out of bed
o Avoid greasy, spicy foods or triggers
• ***Patient Education: Constipation
o Stool Softeners→for constipation
• *** Patient Education: Heartburn
o Pressure of fetus on stomach and decreased GI
o Low fat diet
o Pat of butter before meals to inhibit excretion of acid in stomach.
o Eat several small meals rather than 3 large ones
o Aluminum (can constipate) or magnesium (can cause diarrhea) based antacids should be avoided
o Sit upright after meals- don’t lie down or go to bed right after eating
o Avoid coffee & cigarettes (stimulate acid secretion)
• ***Patient Education: Flatulence
o Due to undesirable bacterial action
o Eat small amounts of well-chewed foods
o Avoid constipation
o Avoid gas forming foods- such as broccoli or cauliflower
When educating a newly pregnant patient on the changes in early pregnancy, the nurse
should inform the patient that her nausea, vomiting and fatigue should begin to
subside by
which gestation?
A. 8-10 weeks
B. 12-14 WEEKS (ONCE THE PLACENTA TAKES OVER THE N/V STARTS TO GO AWAY)
C. 16-20 weeks
D. 22-26 weeks
Musculoskeletal System
• Diaphysis or symphysis pubis→
o The hormone Relaxin is also secreted during pregnancy.
o It helps with softening the pelvic round ligament/joints to accommodate baby as it’s coming through however, it also
causes these other effects- Pelvic ligaments soften
- Excessive mobility of joints- may fell discomfort
• Lordosis: “pride of pregnancy” from pulling of abdomen from fetus→sway back use pregnancy belt o Mom is walking
around all day, on her feet, she is 39 weeks pregnant, what symptom will she most likely complain about: Lordosis
• Diastasis recti muscle runs longitudinally and in some women, it separates apart due to the uterus pressing on it as shown
in the picture to the top right. This separation is very
painful.
• *** Patient Education:
o Encouraging use of maternity belts
o Encourage correct posture & ensure that they remain
mobile
o Postural changes of pregnancy: picture to the right
• Backache
o Teach good posture & body mechanics
o Teach to bend from knees rather than back
o Teach to wear shoes appropriate for
activity: no high heels! High heels put
greater stress on back and aggravate
lordosis, causing more pain.
o Exercises to strengthen back muscles- such as pelvic tilts, shown to the right
—>
• Good Body Mechanics
• Leg Cramps
o Pressure of enlarged uterus/fetus on nerves of lower extremities, fatigue, chilling
o Can be from a decreased serum calcium (or vitamin D), increased serum
phosphorus
o They should decrease milk intake and supplement with calcium supplements (Milk
increases phosphorus)
o Aluminum hydroxide gel (antacid) can help remove some phosphorus
o Regular exercise to promote circulation
o Immediate relief: dorsiflex foot & put pressure on knee to straighten leg- shown to
the right →
Integumentary System
• Changes are a result of increased estrogen levels
• Chloasma - “mask of pregnancy”, a condition where brown patches appear on face
o Goes away
• Linea nigra - dark pigmentation down center of abdomen to symphysis pubis (get darker and darker)
o Goes away
• Striae gravidarum - stretch marks (does not go away but may lighten)
• Which disappear? Chloasma and line nigra disappear. Stretch marks remain.
• Hair and nails grow very well during pregnancy. Hair does fall out afterwards but stops at 6-12 months.
Neurological
• Compression pelvic nerves: Sciatica (leg)
• Carpal Tunnel Syndrome: very common in 3rd trimester
o When tendons swell from being overused, it puts pressure on median nerve. If they start to feel tingling
and numbness in their thumb that’s a sign of carpal tunnel
rd
o Often seen in 3 trimester. About 25-50% of pregnant women can have thisproblem.
o Wearing a support brace/splint can help. But if it’s really bad and they’re losing sensation, surgery is
required. • Tension Headache (migraines): estrogen causes vasodilation of blood vessels in head
• Possible decrease concentration. Reverses after pregnancy
• Bells palsy: asymmetric face drooping will usually go away
Discomforts during Pregnancy
• Review Table 8-3
• First Trimester:
o HA, N/V, palpitations, shortness of breath, tender breasts, nasal
congestion, increased salivation, fatigue, urinary frequency,
leukorrhea (increased vaginal discharge which is normal)
o Diglecis for N/V
• Second and Third Trimester
o heart burn, ankle edema, GI issues, leg cramps, carpal
tunnel, difficulty sleeping due to the large size of baby, back ache,
abdominal discomfort from diastase recti
• Third Trimester
o Urinary frequency
Psychological Changes
• Maternal adaptation: This is normal and is because of hormones
• Emotional Lability: normal
• Extreme Fatigue: during first trimester mom feels like she has been run over by a truck
o Hemodynamic & metabolic changes
• *** Patient Education:
o discuss normalcy of emotional mood swings and mixed feeling early in the pregnancy
• If they are depressed before pregnancy they are more likely to get it after or during
o sxs of depression review, encourage naps, and exercise/healthy diet
SIGNS OF POTENTIAL COMPLICATIONS***
• First Trimester: RED FLAGS
o Severe vomiting: if they can’t hold anything down, they
may have to be admitted to have fluid and electrolytes stabilized
o Chills, fever: signs of infection
o Burning on urination: UTI
o Diarrhea
o Abdominal cramping; vaginal bleeding*****(always assess because its abnormal until its ruled out): potential for them
to lose their baby
• Second and Third Trimester:
o Persistent severe vomiting
o Sudden discharge of fluid
o Vaginal bleeding
o Severe abdominal pain
o Chills, fever, diarrhea
o Burning on urination
o Severe back or flank pain: pyelonephritis
o Change in fetal movement
o Uterine contractions before 37 weeks
o And the following sings of pre-eclampsia that require hospitalization because they can go into a coma and
die: - SEVERE HA (FREQUENT OR CONTINUOUS)
- muscle irritability or convulsions
- epigastric or abdominal pain
- visual disturbances- blurring, double vision, spots before their eyes
- swelling of face and hands
Health Promotion during Pregnancy
• Fetal Activity Monitoring
o Baby needs to be active and moving. If mom can’t feel the baby move, they need to see doctor. We firsttell them to eat
something and lie on their left side and then see if the baby moves then. If the baby doesn’t move after this, then they
really need to come in and be evaluated.
o Towards the end of pregnancy we teach them kick counts.
o No fetal movement in 12 hrs = fetal alarm!
• Breast care- cleanliness and a good supportive bra. Breasts are enlarging.
• Clothing
o Loose fitted clothing
o High heels are not good at all
• Bathing
o baths are ok, unless they have vaginal bleeding or amniotic sac has ruptured
o warn mom that warm water in bath causes vasodilation and dizziness, be careful getting in and out of tub. o
hot tubs aren’t encouraged because the temperature is hot and hot maternal temperature, especially in the first
trimester, can interfere with brain development.
• Employment
o She can work up until her due date ,no contraindications unless there is a problem and she needs
bedrest o Make sure she isn’t at risk for any fetal toxic hazards such as toxins in air (such as in nail salons
breathing acetone, etc.)
• Travel
o Is ok, but if she’s at risk for pre-term labor or bleeding, she can’t travel. Also, can’t fly beyond 36 weeks o
If she is driving, then every 2 hours, get out and walk around for 10 minutes. Seat belt worn any time in car. •
Activity and Rest
o If her membrane has ruptured, we don’t want her exercising
o If her cervix won’t hold her pregnancy, we don’t want her moving vigorously
o Rest if she is at risk for pre-term labor
o Stop if she experiences chest pain, vaginal bleeding, cramps, amniotic fluid leak
• Exercises to prepare for childbirth
o Pelvic tilts
o Kegel exercises, also helps with strengthening the urethra
• Sexual Activity- there is no contraindication for the entire duration of pregnancy if pregnancy is normal
• Dental Care
• Immunizations
o Never give live attenuated vaccines: MMR, Varicella, live flu
• Teratogenic Substances: AVOID!
o Medications
- Tetracycline: if mom is given this, turns baby’s teethgray
- Sulfa drugs can cause jaundice in the baby
o Caffeine
- Limit to 200 mg/day, about 2 cups of coffee
- 1 chocolate bar has 50 mg of caffeine
o Alcohol- NONE! can cause FAS (fetal alcohol syndrome) Not even 1 glass of wine in 3rd
trimester o Tobacco- NONE! can cause growth retardation, low birth weight babies
o Avoidance ofTeratogens
- Avoid cleaning cat litter boxes →risk for toxoplasmosis from inhalation and cause issues for mom and baby - Avoid
exposure to infectious diseases (teachers/nurses are at higher risk for that because of the sick kiddos→fifth disease,
CMV), large crowds, etc.
- Avoid all drugs, cigarettes( make SGA baby) not prescribed during pregnancy
ANTEPARTUM ASSESSMENT OF HIGH RISK PREGNANCY
• Complications during pregnancy sometimes threaten the well-being of either or both the mother and the fetus. • These
complications fall into two main categories: complications related to pregnancy, where the problems develop in the
normal process of pregnancy; and complications related to other usually pre-existing disorders that adversely affect the
pregnancy or are adversely affected by the pregnancy.
o 500,000 of 4 million births in United States
o Sooner we identify the better care we can give
• Etiology:
o Psychosocial factors
▪ Greatest barrier to lack Parental care is finances and is #1 reason they have high risk pregnancy o
Change in Demographics- women are sometimes waiting until later in life to have babies and this increasing our
chance of infertility (AMA- advanced maternal age), etc. or women are too young to afford to have babies
o Greatest barrier for women to receive PNC → financial costs of treatment, testing, travel to doctor***
o Importance of Identification of risks in timely fashion- earlier id allows for better outcomes • At Risk: (all of
the following factors can impact your pregnancy)
o Homeless, Single, Uninsured pregnant women without access to prenatal care, Lifestyle
o Age: over 35 years old or veryyoung (under 19 years old), History, Poor Nutrition
o *** others: anatomical anomalies, obesity (correlates highly with a lot of different complications in
pregnancy including HTN and GDM…both of which increase complications during pregnancy)
Definition and Scope of the Problem
• High risk pregnancy: life or health of mother or fetus is jeopardized
o For mother, high risk status arbitrarily extends through puerperium/pregnancy (30-45 days after childbirth). o
Maternal complications usually resolved within 1 month of birth. Meaning that most complications we see during
pregnancy often last for 6 weeks after delivery.
• High risk diagnosis imposes crisis on family
o Shortened pregnancy duration
o Burden of disease
▪ Example: GDM/ PTL- cost (long hospital stays), stress, bedrest and unable to care for other family o
Expectations for neonate
▪ Cultural: it can be very disappointing if their child is born sick since having this baby has been a dream,
etc.
▪ Some cultures see abnormalities as curse, that they must have done something to deserve a sick baby o
Societal Norms: congenital anomaly or chromosomal disorder
▪ Grieving process etc.
• Maternal health problems
o Leading causes of maternal mortality in the US*** All 3 of these tend to happen later in pregnancy of even
postpartum. And most get these diagnoses as a result of their high risk pregnancy. So we want to
prevent them from getting to these
▪ Pre-Eclampsia- HTN ***
▪ Pulmonary embolism ***
▪ Hemorrhage ***→# 1 postpartum
• Factors related to maternal death include:
o Age: < 20 years or > 35 years
o Lack of prenatal care- Healthy People 2020, one of the big pushes is getting people access to prenatal care.
o Low educational attainment
o Unmarried status
o Non-white race
• Fetal and neonatal health problems
o Congenital anomaly: exposures right before pregnancy or early in the first trimester are impactful ▪
Heart Defect
▪ Anencephaly
▪ Gastroschisis: part of the GI tract is on the outside of body
o Diabetes: Increased glucose level
• Causes of neonatal death include:
o Disorders related to short gestation and low birth weight- pre-term delivery (doesn’t grow well on inside and
comes early)
o Sudden infant death (SIDS)
o Respiratory distress syndrome (RDS)
o Effects of maternal complications during pregnancy can impact babies
o ** Healthy People 2020: Progress is being made in the following areas
o Reducing infant mortality (neonatal deaths) rate and prenatal care is improving in the US
Assessment of risk factors
• Biophysical Factors
• Psychosocial Factors - poverty
• Sociodemographic Factors – how far do you live from a clinic, do you have transportation to a clinic •
Environmental factors: what does she do for a living?
o Risk factors are interrelated and cumulative
o Presence of health disparities: no transportation lack of resources
o Cultural Restrictions: Some cultures prohibit women from doing certain things during pregnancy that will lead
to complication
• Nursing Role in Antepartum Assessment forRisk
o Assist with history intake
o Initial nursing assessment
o Education: every time you see patient so that you minimize the risks that she may have
o Support person: involve them
o Assists physician/ provider with procedures
o Performs non-stress tests (NSTs), contraction stress tests (CSTs),
BPPs
Antepartum Assessment for Risk- Antepartum Testing
BiophysicalAssessment
• Daily “fetal movement kick count”: shown to the right
o Is the most minimal/least invasive way for us to know how the baby is doing.
o Mom marks form each time baby kicks or moves, must mark at least 10 times a day(stop marking after 10).
o This gives us confidence that baby is doing well on the inside.
▪ Mark when baby is most active give 1-2 hours to get 10 kicks
▪ Always listen to your instinct
o If baby hasn’t been moving (didn’t move 10x), mom must visit doctor.
o Babies start moving (mom can feel it move) at average 20 weeks*! (and as with everything add 2 above and 2
below…so 18-22 weeks is acceptable).
o The bigger they get, the more active they get.
▪ This test is usually started at 28 weeks.
o “Fetal alarm”- when they don’t move for 12 hours, must contact provider
o If you notice the baby isn’t kicking much recommend:
▪ Eat something cold/sweet
▪ Lay down and play close attention to see if the baby is moving
• Ultrasonography:
o Indications:
▪ Can be done from the moment we suspect pregnancy and however often they need it done
▪ Can be done as early as 5-6 weeks or all the way through pregnancy
▪ Confirm its in uterus
▪ Fetal heart rate activity
▪ Gestational age→US to determine dates
▪ Fetal growth & fetal anatomy (18-20 weeks)
▪ Placental position & function: we want to make sure it’s not lying over cervix, or they’ll bleed out very
fast
▪ Dating purposes: how far along is she and due date
▪ Assess anatomy following an abnormal maternal blood screen:
• These blood screenings give us an idea if mom is at risk for certain complications, if so we do an
US to get more information.
▪ Adjunct to other invasive tests: Essentially don’t do other tests without US
▪ Fetal well-being: AFV, Doppler
• Amniotic fluid volume: adequate volume must be present for adequate development of lungs,
and all organs.
• As pregnancy progresses, amniotic fluid buildup might slow down, mom may be dehydrated,
baby might not be making enough urine
▪ Types:
• External/Pelvic: shown to the right (transducer)
• Internal/Transvaginal: bottom right (ultrasound)
o Better view of anatomy of uterus
o Use really early in pregnancy to see the fetal pole
o Look at cervix link
• Nursing role: ***
o Educate regarding procedures & limitations (might need to empty bladder for this)
o US doesn’t tell you everything.
o For example: won’t tell you alone if the baby has Down’s Syndrome.
o US can view certain signs such as thick NT (nuchal translucency) or depressed NB (nasal bridge) which are
markers of DS. But we really can’t do a diagnosis via US alone.
▪ 10.5-13.6 weeks
• Too much before or after skews results
▪ <3 millimeter thickness
• If its thick that means something is going on chromosomal wise and need further testing ▪
Nasal bridge: flat nasal bridge =downs
• Umbilical Artery Doppler Flow:
o High risk→ start at 28 weeks
o Use this test if you are worried the placenta isn’t doing it’s job
o Why?
▪ One twin big or small
▪ DM, HTN
▪ More than one baby
▪ Worried at all about placenta or perfusion
o Picture shown is a IUGR, placental perfusion
▪ Put US probe on outside of belly looking at blood flow and perfusion
o Looks for diastolic flow: MOST IMPORTANT PIECE
▪ how well blood flow is getting from placenta to baby.
▪ Is used to see how well placenta is doing
o Absent: no blood flow→BAD leads towards delivery because baby not getting blood flow
o Retrograde flow: blood if flowing backwards
• Biophysical Profile (BPP) Criteria:
o US & External fetal monitor: to assess baby from outside
▪ Categories→Looking for breathing (practice breathing=expansion and relaxation of lungs), fetal
movement (arms and legs in flexion), fetal tone, and amniotic fluid
• Each category they get 2 points if meet criteria
• Total of 10 points: last 2 points from NST (20 min external fetal monitoring strip→reactive or
nonreactive) gets 2 points if reactive!!
• Anything less than a score of 8 needs further evaluation, 8/10 is ok = repeat BPP
o Let’s say mom comes in for a checkup and a fetal monitor doesn’t give us enough information, we then go to
this test. It’s an US that has criteria that it’s measuring. It’s essentially a measurement of baby’s VS on inside o
Done after 28 weeks
o This gives us a score. If we get all 0, it’s very bad and baby is due for delivery.
o The Non-stress test score is also added to total.
o Indications:
▪ Fetal movement or lack there of! Put on
External Fetal
monitor!!!
▪ SGA → If baby is measured to be much
smaller than should be, we would also
do this test. We want to ensure that
placenta is intact and working well.
▪ If NST is nonreactive→ must finish
biophysical profile!!!!!!
• Magnetic resonance imaging (MRI):
• Indications
o Fetal and maternal structures
o Placenta:
▪ if we’re concerned about the placenta with conditions such as placenta previa- when placenta covers
the opening in mother’s cervix
▪ placenta accreta- where blood vessels and other parts of the placenta grow too deeply into the uterine
wall so that after childbirth part or all of the placenta remains firmly attached causing severe blood loss after
delivery where we can’t always see it in an US, we will have to use an MRI. o Also used to get a better image of
the presence of spina bifida.
o Also used to see hydrocephaly, cleft lip and palate.
o Quantity of amniotic fluid
o Biochemical status of tissues and organs
o Soft tissue, metabolic, or functional anomalies
o We don’t use contrast during pregnancy
• Questions to Ponder-Fetal Kick Counts- when and why?
o Consistent fetal movement occurs @28 weeks or older. This is when we do this test.
o Done to monitor baby health.
o Fetal movement begins at 20 weeks+
o Mom comes in at 16 weeks wondering when she will feel baby moving = approx. a month (at 20 wks)
• What are the nursing considerations for USG?
o Full or empty bladder
o It can’t detect everything, not diagnostic.
o Timing of USG? Anatomical US is done at 18-20 weeks
• When and why BPP?
o About 28 weeks or earlier if in major distress
o See how baby is doing/adapting to inside world- measuring
baby’s VS
▪ No/decreased fetal movement, SGA,
Biochemical Assessment
• All these tests are optional
o Abnormal blood test→ do US then amniocentesis
• Amniocentesis: So, if we do an US and find something suspicious, we then follow up with an amniocentesis because it is
a diagnostic test that tells us genetic information.
o 2nd trimester
o Age 35 or greater (most common reason given for test is chromosomal testing)
o Abnormal blood test or US
o Done at (anything over 15 weeks)16-18 weeks to determine genetic disorders or anomalies o Done at 34-37
weeks for L/S ratio (checking for surfactant production for baby to see if lungs are mature) • A needle goes into
abdomen to go into pocket of fluid and not puncture any of baby, and there’s an US on abdomen that is guiding the
needle position.
o Fluid retrieved will contain genetic information on baby.
• Indications
o Prenatal diagnosis of disorders (genetic/ anomalies)
o Fetal maturity: If we’re trying to weigh the risks vs benefits of having the baby early, we’ll do a fetal lung
maturity test.
▪ This is also done via an amniocentesis, where the fluid tells us lung maturity.
o It’s called an L/S ratio→surfactant production, amnio shows fetal lung maturity (BOX IN BOOK for mature/
immature )
▪ Done at 34 weeks & 36.7 weeks
▪ Mature lungs are > than or = to a 2:1 ratio.
▪ Diabetic babies take longer for lung development so has a 3:1 ratio.
▪ The lecithin–sphingomyelin ratio (aka L-S or L/S ratio) is a test of fetal amniotic fluid to assess for
fetal lung immaturity.
▪ Lungs require surfactant, a soap-like substance, to lower the surface pressure of the alveoli in the
lungs.
▪ Usually done in the third trimester. Again, when it’s done depends on why we’re doing it.
o For diabetics, the PG test is more sensitive.
▪ Like L/S, the presence of phosphatidylglycerol correlates with the production of surfactant and
indicates fetal lung maturity.
▪ Gives earlier indication of LS ratio
▪ It elevates sooner than the L/S ratio. So, in diabetics, do a PG as well as an L/S.
o Fetal hemolytic disease (Fetal anemia): if a baby isn’t growing well, we may suspect their RBC are being
attacked.
▪ Needle aspiration to detect for isoimunization
• Present if titir is > 1:8 ratio (read chapter of these!!!!)
▪ It’s very important to know mom’s Rh status.
▪ If mom is Rh (-) and doesn’t get adequate amounts of Rhogam during pregnancy or postpartum, then
she can develop Ab that will attack next pregnancy.
• Cause baby to cause chronic anemia
o Maternal Complications
▪ Hemorrhage
▪ Infection, Abruption (placenta pulls away from uterus)
▪ Organ injury (nick kids abdomen or foot)
▪ Amniotic embolism (anaphlayactic reaction that occurs in blood system)
o Fetal Complications: mom signs a consent saying she accepts all these risks
▪ Death
▪ Hemorrhage
▪ Infection (amnionitis)
▪ Injury from needle
▪ Miscarriage or preterm labor
▪ Leakage of amniotic fluid
• Nursing considerations: Anytime opportunity for cross in mom and baby blood (ca accident, needle in belly, Invasive
procedures like Amnio, CVS, PUBS) we need to make sure if she is RH- mom she gets Rhogam shot which protects
her from attacking her next pregnancy from being attacked (iso-immunization or hemolysis of RBC) (also give
rhogam after abortion!!!!)
o Informed consent must be signed by mom
o We also must know mom’s blood type: give Rhogam if Rh NEG (will get every single pregnancy from there on
out)
▪ MUST know if RH+/o Like the bladder to be empty
• Chorionic villus sampling (CVS):
o Gives us essentially the same information that an amniocentesis does, but it’s benefit is that it can be done
o much earlier at 10-13 weeks.
o So, if mom is deciding if she wants to continue pregnancy or not, then she’d rather know much earlier (and
be able to abort much sooner) at 10 weeks, rather than at 16 weeks.
▪ More information to make decisions earlier to prepare the better!
▪ Gives us genetic information
o Speculum through vagina and takes a sample to be looked at
▪ Removal of portion of placenta (biopsy) through abdomen or intra-vaginally through the cervix under
USG guidance for genetic studies.
o Earlier diagnosis and rapid results: 10 and 13 weeks of gestation
o Indications: same as amniocentesis
o Risks: spotting, SAB (spontaneous abortion or loss)
o Nursing consideration→Again, Rhogam if RH NEG
• Percutaneous umbilical blood sampling (PUBS):
o Insertion of needle directly into a fetal umbilical vessel under US guidance (want to see parts to avoid). ▪
Only do as necessary very risky procedures
o The needle stays in the cord (umbilical vein), and you as the nurse, take the blood to the lab so they confirm if
the blood pulled is baby’s or mom’s.
▪ Testing if its mom or babies blood depending on size of MCV (babies is larger than moms). Will leave
needle in place and everything until
samples say you are in the right
place.
o Only done when necessary!
▪ Tests for fetal hemolytic disease
▪ Assume they know where needle is but don’t
know until you aspirate back
▪ Sedate mom & baby IV to calm them down
because we don’t want to cause
complications
▪ Also done with twin pregnancies
o Usually after 24 weeks.
o Indications:
▪ Suspected Isoimmunization/hemolytic disease of newborn or erythroblastosis fetalis (a severe form
of anemia caused in a fetus or newborn infant by incompatibility with the mother's blood type,
typically when the mother is Rhesus negative and produces antibodies that attack Rhesus positive
fetal blood through the placenta).
▪ If they’re found to be severely anemic may follow through with blood transfusions.
o Risks→cord laceration (younger they are the smaller the cord) ,PTL (pre-term labor), infection, PPROM
(pre-term premature rupture of membranes)
o Nursing considerations:
▪ Mom on monitor
▪ FHT (fetal heart tones): listening to FHR the entire time
▪ Rhogam post procedure if needed
• Maternal assays: know MSAFP chart!!!!
o “Blood draw” → ONLY screening test not diagnostic and will not confirm (can give false positive)!!! o
Essentially just getting blood from mom to do some tests.
o Different screens for different gestational ages. Take blood sample and test it against what she is supposed to
be for maternal age and gestation age to see if its in range.
o Alpha-fetoprotein (AFP): Maternal serum levels (MSAFP) screened***
▪ Screening test ONLY – just because you test positive does not mean there is an
actual problem!!!
▪ Done at 15-22 weeks (in the blood)
▪ If the MSAFP is high →
• it could indicate a neural tube defect (NTD) or abdominal wall
defect such as a gastroschisis.
▪ If MSAFP is low→
• it could mean that baby is at risk for Down S: not a diagnostic but a risk.
• If this is the case, then US is done, followed by a chromosome analysis via
amniocentesis or CVS
o Recommended for all pregnant women
o Nursing considerations:
▪ EDUCATION: purely a screening test (tells us if you are at risk) if shows something do US next to look
for abnormalities!!!
▪ ACCURACY OF DATING and DOCUMENTATION
Don’t really test on these following!!!!!!
• Multiple Marker Screens
st
o 1 Trimester screen (11-13.6weeks)
nd
o 2 Trimester: Triple & Quad (16-18weeks)
o Nursing considerations
▪ EDUCATION: Again, this is just a screening test.
▪ If the results come back (+), first do an US, then an amniocentesis.
▪ ACCURACY OF DATING
▪ Nuchal Translucency scan→look at thickness of the back of baby’s neck (thick nuchal cord means
some kind of chromosomal abnormality)
• Coombs’ test:
o Rh incompatibility test→Detects antibodies for incompatibility with maternal antigens, such as antibodies
against RBCs that are present unbound in the mom's serum.
o If titer > 1:8=iso-immunization
o then further testing is done on the baby and baby is followed to make sure they’re growing
• Cell free DNA in maternal blood (Mat 21/ Harmony):
o A new screening for non-invasive prenatal genetic diagnosis: more accurate than other tests. ▪
Noninvasive & very expensive
▪ Checking for genetic chromosol abnormalities
o Extracts mom’s DNA and knows that what’s left is baby’s DNA. (some mixing of mom and baby blood normal)
▪ Works by amplifying cell free DNA of mom and DNA will see 2 different types in blood. Look at moms
first then what’s left is baby’s.
o Done after 10 weeks: it’s the only test that can detect sex this early
o Can detect:
▪ Fetal Rh status
▪ Fetal gender
▪ Assess for trisomy 13, 18, 21, turners syndrome
o If this test comes back positive for a genetic anomaly, we would still follow through with an US, and
amniocentesis or CVS.
• Questions to Ponder
o What are the indications for an amnio, CVS, PUBS?
▪ If we had an abnormal screen:
▪ Amniocentesis→genetic information, DM to look at lung surfactant LS ratio, hemolytic disease (>15
weeks)
▪ CVS → mostly genetic information NOT hemolytic (>10 weeks)
▪ PUBS→check for fetal anemia/hemolytic disease (28 weeks)
o Nursing considerations for amnio, CVS, PUBS?
▪ These are diagnostic tests
▪ Obtain signed informed consent
▪ Give Rhogam shot if mom is Rh- → because it’s invasive and there’s a possibility of mixing between
mom and baby’s blood don’t want antibodies to form for next pregnancy
o What are the maternal assays and who is eligible? MSAFP; Everyone is eligible
▪ Timing of the maternal assays? MSAFP is done at 15 >weeks
▪ Education for the maternal assays?
MSAFP is a screening
test ONLY
▪ High (abdominal etc) & Low
(Downs)
• Electronic Fetal Monitoring: wont be test on
interpretation of FM
o To determine if the intrauterine
environment is supportive to the
fetus
o Indications
o Assessing Variability
• Non-stress test (fetal activity determination)- Tested on this!!!!
o Need to know the different rules for the different gestations and whether they pass or fail (reactive or
non- reactive) *** Shown to right →
▪ NST→ info of how baby likes insdie environment
o We put mom on the monitor for 20 minutes, then we interpret strip.
o Interpretation: We look to see if it’s reactive or non-reactive:
o If baby is > 32 weeks→
▪ Reactive we look for 2 accelerations in 20 min period→ THESE ARE GOOD
▪ Meaning that the HR jumps up/increases 15 beats by 15 seconds twice in the 20 minutes. ▪ This
means that HR goes up by 15 beats and goes across 15 seconds, 2 accelerations in 20 minutes. ▪ Has to
meet them across and up! 30 beats up and 30 beats across
o If baby is less than 32 weeks→
▪ our criteria for the baby to pass this test is less (threshold goes down)
▪ They aren’t as developed so, we follow a 10 by 10 rule (10 beats across & 10 beats up)
▪ meaning that the baby has two accelerations of 10 beats above the baseline and it lasts for 10 seconds
across (need ot know this)
o Causes for non-reactive: didn’t meet 2 accelerations
▪ Sleep cycle, tobacco, meds, fetal distress not getting oxygen
▪ Reasons for why baby won’t respond to test well:
• If baby is tired, sleeping, if mom didn’t eat or drink well
o Do extended monitoring give mom something to eat or drink still ok just make
sure it still has 2 accelerations if 40 minutes
• We can perform a vibroacoustic stimulation to awaken baby for a maximum of 3 seconds o
Sleep wake cycle normal
• Contraction stress test (CST):
o This is a test done later in pregnancy if we want to know how well baby is going to tolerate labor, whether or
not they have good reserve.
o It’s an early indicator that the baby may be in trouble.
▪ Will make uterus contract in very control environment
▪ Low dose Pitocin
▪ Want contractions
o If the baby can’t handle this well, then they certainly can’t handle the stress of labor.
▪ Later in pregnancy
▪ Closer to term
▪ Baby isn’t moving well/growing well
▪ Biophysical profile that isn’t good
o Can provide a warning of fetal compromise earlier than NST.
o Procedure→
▪ Nipple-stimulated contraction test: nipple stimulation causes oxytocin release and minimal
contraction.
▪ Oxytocin-stimulated contraction test: start mom on an IV of very low dose oxytocin/Pitocin
o Interpretation***
▪ NEGATIVE (GOOD) ☺ =
• 3 UC (uterine contractions) in 10 minutes with no late or significant variable
decelerations
• When mom contracted she showed no signs of stress
▪ POSITIVE (BAD)
=
• Late decelerations with >/= 50% of UC (even is less than 3 in 10 min)
• Baby does not have enough reserve to tolerate test means during labor it might be
in C-Section
▪ EQUIVOCAL (SUSPICIOUS)=
• Late or variable decelerations < 50% of contractions → FURTHER TESTING IS
NEEDED in 24 hours with different test to check on baby
• Some contractions baby tolerates and others they aren’t ok
▪ UNSATISFACTORY=
• No UC in 10-minute window or unable to trace FHT → We have nothing to look at so
TEST NEEDS TO BE REDONE
• She didn’t contract
• Nursing Role in Antepartal Assessment for Risk
o Psychologic considerations→
▪ Anxiety for patient
▪ Tests because of suspected fetal compromise, deterioration of maternal condition, or both
▪ Third-trimester women concerned about protecting themselves and fetuses and consider themselves
vulnerable
o Psychological response→
▪ Anxiety, Low self-esteem and guilt, Frustration, Inability to function
o Education→
▪ Support person
▪ Assists physician with procedures
o Performs non-stress tests (NSTs), contraction stress tests (CSTs), BPPs
o Initial assessment
• Key Points
o High risk pregnancy: life or well-being of the mother or infant is jeopardized
o Pregnancy, fetus, or neonate can be placed at risk by biophysical, sociodemographic, psychosocial, and
environmental factors
o Psychosocial perinatal warning indicators include characteristics of parents, child, support systems, and
family circumstances
o Mortality rate decreases when risks are identified early and intensive care is applied
o Biophysical assessment techniques include fetal movement counts, ultrasonography, and MRI o Biochemical
monitoring techniques include amniocentesis, PUBS, CVS, maternal assays and maternal serum AFP
o Reactive NSTs and Negative CSTs suggest fetal well-being
o Risks, limitations should be discussed.
o Most assessment tests have some degree of risk for mother and fetus and cause anxiety for woman and
family
ATI:
• Page 33→ the top image is not labeled correctly not a positive CST should say NST (reactive) • Page 60→
talks about GHTN(label it High blood pressure in pregnancy not GHTN because it its own thing) o (put as a
title then labeled preeclampsia and other things that are confusing)
MODULE 3 - THE INTRAPARTUM PERIOD
READINGS
-
Maternal Child Nursing Care (5th Edition): p. 267-300; 302-340; 342-355; 356-381; 382-400; 401-440; 441-481
Virtual Clinical Excursions, Obstetrics, Pediatrics (5th Edition)
ATI: p. 50-64; 65-78; 79-91; 92-106; 107-118; 119-130; 131- 142; 143-155; 156-197.
TOPIC B: LABOR AND BIRTH PROCESSES
Labor is the process by which the products of conception are expelled from the uterus and the vagina into the external
environment. For the infant, the repetitive stress of labor culminates in delivery and the necessity for successful transition
from a dependent to an independent biologic state. For the mother and father, childbirth marks the time when each assumes
the role of parent with its personal and social connotations. The goals of the health care team are (a) the safe delivery of
mother and infant, and (b) the promotion of emotional fulfillment for the parents.
Every health care professional involved in perinatal care should recognize that few factors will shorten labor, but many will
prolong the process.
MANAG EMENT OF PAIN AND DISCOMFORT DURING LABOR
• When the body experiences pain, it appears to produce opiate-like substances called endorphins to reduce that pain.
The level of these naturally occurring substances, or the body’s ability to produce and maintain them, may
influence a person’s overall pain threshold.
• Everyone experiences pain differently, but labor causes severe pain for many women. The amount of pain you
experience during labor and delivery depends on your pain tolerance, contraction strength, and your baby's size
and position.
• There are many ways to prepare and deal with the pain, including:
o Taking prenatal classes to learn about labor and delivery→The more informed you are, the less anxious
and afraid you may be. This can help lessen the pain.
o Taking pain-relieving medicine during labor and delivery.
o Learning breathing and relaxation techniques.
o Taking a shower or bath, getting massaged, changing positions, or placing an ice pack on your back are
other options to help control your pain during labor.
• How mothers perceive their birthing experience a large extent depends on how they deal with labor pain. o Giving
birth is painful. It is well accepted that pain during labor is severe and usually exceeds the mother's
expectations.
o It has been described by some, as the worst pain a woman experiences.
o Although many mothers are able to deal with it well for some is overwhelming.
• Sometimes the maternal reaction-over reaction to the pain can adversely affect the labor/fetus. • A human body can
bear only up to 45 del (unit) of pain. Yet at the time of labor, a mother feels up to 57 del (unit) of pain. This is similar
to 20 bones getting fractured at once.
• Pain During Labor and Birth
o Neurologic origins- pain is a result of the uterine contractions
o First stage of labor→
▪ Visceral pain: from cervical changes, distention of lower
uterine
segment, and uterine ischemia, uterine pain during
contractions
• Located over lower portion of abdomen
▪ Originates in uterus (referred pain), but then results in
referred pain
radiating to abdominal wall, lumbosacral area of back,
iliac crests,
gluteal area, and down thighs (achy pelvic pain all
over)
o Second stage of labor→
▪ Neurologic origins – somatic pain: described as intense, sharp,
burning, and localized; during pushing; RING OF FIRE (pushing or
burning pain)
• Pushing and burning pain
▪ Stretching and distention of perineal tissues and pelvic floor to allow
passage of fetus from distention and traction on peritoneum and uterocervical supports during
contractions and lacerations of soft tissue
o Third stage of labor→
▪ Similar to the first stage; delivery of placenta
▪ Crampy after pains called visceral pain
Pain Distribution During Labor
A. Distribution of labor pain during first stage.
-
In early labor, pain is spread over a wide area of the back and lower abdomen. Although contractions begin in the
fundus, the pregnant woman may perceive the contractions as suprapubic pressure, back discomfort or pressure in other
areas.
B. Distribution of pain during transition and early phase of second stage.
C. Distribution of pain during late second stage and actual birth.
When a woman in active labor complains of continuous back pain, the fetus is most likely in an occipitoposterior position.
In active labor, the contractions are much stronger, pain intensifies and covers a greater area of the lower body. Pain is
particularly strong in the back and lower abdomen.
Pain can evoke a general stress response of “fight or flight”
This releases epinephrine, which causes peripheral vasoconstriction.
The uterus is a peripheral organ and responds with vasoconstriction during epinephrine release.
Epinephrine is similar to Terbutaline, a tocolytic, and it may therefore make labor takelonger.
Perception of pain
• Threshold remarkably similar in all, regardless of gender, social, ethnic, or cultural differences. o It has
been shown that if the husband is present during labor, the pain labor is more tolerable. • Differences play
definite role in person’s perception of and behavioral responses to pain
• Pain tolerance refers to the level of pain a woman is willing to endure
Expression of pain
• Pain results from physiologic effects and sensory (environmental: calm) and emotional (affective) responses •
Emotional expressions of suffering often seen
o Increasing anxiety→lots of adolescents have this
o Writhing, crying, groaning, gesturing (hand clenching and wringing), and excessive muscular excitability
o Cultural expression of pain varies
▪ Hispanic woman→very verbal
▪ Asian→doesn’t want pain meds
o Be supportive→find out what they need
Factors influencing pain response
• Physiologic factors: fatigue, fetal size, etc. Endorphins secretions
o BP will be up!
• Culture: as a nurse you must advocate for their pain relief, ask them what they need
• Anxiety: more catecholamine secretion.
• Previous experience
• Gate-control theory of pain
• Comfort and support
• Environment
Endorphin
• Natural pain killer produced from pituitary gland released during stressful events or in moments of need. It is
responsible for euphoric feelings known “runner’s high” and “adrenaline rush”
• Its secretion triggered by consumption of certain food “chocolate, chili peppers” also triggered by massage therapy or
acupuncture.
Thinking Critically
• A nurse working with a group of expectant fathers is asked if there really is “a physical reason for all the pain women say
the feel when they are in labor.” How would the nurse respond to this statement?
o Yes, the uterine contracts and causes visceral pain and somatic pain (a burning pain) when she is pushing
o Also, due to uterine ischemia, stretching of the cervical tissue, effacement, dilation, pressure
NON-PHARMACOLOGIC PAIN MANAGEMENT
• Ask about pain management in EARLY STAGE
• Non-pharmacological measures often simple, safe, few adverse reactions, and inexpensive
o Provide sense of control over childbirth
o Methods require practice for best results
o Can be done through all stages of labor, and most effective in the first stage
o Try variety of methods and seek alternatives, including pharmacologic methods, if measure used is not
effective
• Historically popular methods
o Dick-Read method
o Lamaze method: focus on using controlled breathing techniques to cope with labor
o Bradley method→emphasizes that birth is a natural process: mothers are encouraged to trust their body and
focus on diet and exercise throughout pregnancy; and it teaches couples to manage labor through deep breathing and the
support of a partner or labor coach. The partner will be the leader and coach. • Current offerings→
o Hypno-birthing→used more in a birthing center
o Birthing from Within
• Childbirth and Postpartum Professional Association
• Alternative therapies
o Relaxation
o Breathing techniques (Box 14-3)
▪ Ex→IN-OUT/IN-OUT/IN-OUT/IN-BLOW- This will help relieve the urge to bear down, delaying
contractions until you can get more help.
▪ This might not help with transition period
▪ However, it can cause hyperventilation, which is not good.
o Avoid hyperventilation: if a woman complains of tingling in her palms, she is hyperventilating (respiratory
alkalosis) and should breathe into her cupped hands or paper bag to relieve this.
o Effleurage →
▪ (a light touch in a circular motion- sometimes the husband can do this and it’s done at the start of
labor, she will not be able to handle any touch in the transition period) and Counter pressure
o Imagery and visualization (Focusing on a positive and calming image can often be enough to help women
focus and relax during labor. Some options include thinking about a favorite vacation or a happy moment) o
Touch and massage. Back rubs.
o Applications of heat and cold.
o Positioning→
▪ provide extra pillows
▪ rocking chair
▪ lateral position in bed to prevent vena cava compression
▪ birthing ball- keeps the mother in a desirable upright position while opening up the pelvis. Women
usually find this helpful because they can rock through the contraction.
o Water therapy (hydrotherapy)
▪ Waterproof monitoring
▪ Baths, shower etc.
o Intra-dermal water block – no longer used
o Transcutaneous electrical nerve stimulation (TENS)
▪ 2 pairs of electrodes (total of 4) attached to women back T10-L1 lower back
▪ Low intensity electrical stimulation is given continuously or applied by women herself as a contraction
begins
▪ Blocks afferent fibers and prevents pain travel from uterus to spinal cord synapses, and facilitates
release of endorphins
o Acupuncture→Based on the concept that illness results from an imbalance of energy.
o To correct the imbalance needles are inserted into the skin at specific body points, activation of these points
leads to release of endorphins
▪ Helpful in the first stage of labor
o Acupressure→Application of pressure or massage to heel of the hand, fist, or pads of the thumb and fingers.
o Aromatherapy
o Hypnosis
o Biofeedback
o Music
o Shower
o Warm bath (EFM still required)
o Whirlpool bath (Jacuzzi)- it will help with pain relief but you don’t often see this in the hospital because it can
result in infection
Thinking Critically
On admission to the labor unit Mrs. S. is in the early latent phase of labor. Her spouse states that they are glad that
they took Lamaze classes and researched extensively about childbirth. “We will not need any medication now that we
know what to do and know that our baby will be safe.” Describe how the L & D nurse should respond to this statement?
Be an advocate for mom’s pain! ASK THE PATIENT
PHARMACOLOGIC PAIN MANAGEMENT
• Should be implemented before pain becomes so severe that catecholamine increases and labor is prolonged •
Combinations of pharmacologic and non-pharmacological measures increased pain relief and create a more positive birth
experience
o Wont get IV pain meds close to birth because it will effect baby!
• Sedatives→
• H1-receptor antagonists & Serotonin receptor antagonist
o Help with nausea
• Analgesia and anesthesia
o Systemic→ helps her rest between contractions but will wake up when it comes up
▪ Ex: Stadol or Demerol
• Pharmacologic Pain Management
• WHAT ARE THE TWO TYPES OF PAIN-RELIEVING MEDICINES?
o Analgesics→These are medicines that decrease pain without total loss of feeling or muscle movement.
o Anesthetics→These are medicines that block all feeling, including pain. A total loss of consciousness.
Narcotic Analgesic (Opioid Analgesic): Systemic Analgesia
-
MOST SYSTEMIC ANALGESICS CROSS THE PLACENTA. SO YOU MUST ASSESS FHR AND MOM’S VS AT ALL TIMES. - Act
by decreasing sensation of pain
- Systemic pain medicines affect your whole body rather than focusing pain relief on the area of your body experiencing
pain. This type of medicine is given either through an IV tube in your vein or by a shot (injection) into your muscle. This
medicine will lessen your pain but will not stop it completely. It may also make you sleepy, but it will not make you lose
consciousness. Goal is to provide maximum pain relief with minimal risk.
- Alteration in maternal state affects fetus.
- Used 12-24 hours before active labor for pain. You won’t be giving any opioids to mom if she is dilated 9-10 cm. It is long
acting. And if it’s given 4 hours within birth, then baby will experience CNS or respiratory depression. - All drugs in this
category cause CNS depression, respiratory depression. Narcotic analgesic includes: - Demerol (Meperidine), Fentanyl,
Remifentanil, Morphine, Tramadol
- OPIOID AGONIST-ANTAGONIST: STADOL, NUBAIN (PREFERRED AND MORE COMMON DUE TO LESS RESPIRATORY DEPRESSION, LESS
N/V). IT IS EFFECTIVE ONLY IN THE EARLY PART OF ACTIVE LABOR. OF COURSE DON’T ADMINISTER TO MOM WITH OPIOID ADDICTION.
SE: N/V,BLADDER AND BOWEL INHIBITION. CHECK OF URINARY DISTENTION AND CONSTIPATION.
- Opioid agonists: Demerol is the most commonly used analgesic in labor because it has additional sedative
and anti- spasmodic actions, these make it effective not only for relieving pain but also for relaxing cervix
and providing feeling of euphoria and well-being. It is preferred over Morphine, because Morphine causes
respiratory depression. Demerol has a long half-life and remains active for a long time. You can’t give
Demerol if mom is expected to have baby in 4 hours because it can cause CNS depression in fetus.
- Narcotic antagonist: Naloxone (Narcan)*** reverses CNS depression but doesn’t reverse effects
Demerol, that’s why it’s preferred to use Fentanyl.
Fentanyl (Sublimaze): Rapid action opioid with short duration. Used for epidural or intrathecal analgesia, usually in
combination with a local anesthetic (Bupivacaine; any local anesthetic ends with “caine”). Adverse Effects: dizziness,
rash, respiratory depression, hypotension. Again, Fentanyl is given in the latent stage of labor, not when mom is
close to having the baby because this will put baby at risk for CNS depression
Slow IV push→1-2 mintues may space contractions out e
Continue to assess mom and baby!!
• FHR 110-160
• Reactive NST
• Normal to see moderate variability will decrease after pain medication
• Mom should be dialting 1cm per hour=good labor pattern
Intrathecal (spinal) Narcotic
- Refer to injection into spinal cord
- Opioid used alone:
- Fentanyl 1.30-3 hour with Multipara
- Morphine 4-7 hour with Nullipara or women with history of long labor
- Excellent pain relief for labor pain. They take effect in 15-30 minutes and last 4-7 hours
- Don't cause maternal hypotension or affect VS
- Women can feel contraction but no pain, her ability to bear down during second stage of labor is preserved
because the Bushing reflex is not lost and her motor power remain intact.
Systemic Analgesia
- To administer analgesia, check cervical dilatation first:
- Nulliparous, when cervix is dilated 5 to 6 cm
- Multiparous, when cervix is dilated 3 to 4 cm
- Ensure these are present before giving:
- well-established labor pattern
- Contractions occurring regularly
- Significant duration of contractions
- Moderate to strong intensity
- Give slowly (3 mins) by IV push into main-line Lactated Ringer’s solution or D5RL. Find a well-stablished labor
pattern, usually given over 2 - 3 contractions during the peak of the contraction.
- Have narcan ready because baby can come out sleepy if given too close to delivery
-
RAISE SIDE-RAILS ON THE BED
- Place call-bell within reach. Document
- Caution patient not to get out of bed
- Note time and dosage of all intra-partum medications on the Delivery Record
- Given via PCA, to give mom increased control.
- NOTE DECREASED FHR VARIABILITY (BECAUSE THEY CAN CAUSE RESPIRATORY DEPRESSION IN BABY TOO) - Also
document effectiveness of the analgesia after observing the patient’s reaction to contractions. - Note
mom’s VS, because they can cause respiratory depression
Advantages and Disadvantages of Narcotic (Opioid) Administration
- Advantages
- An increased ability for a woman to cope with labor
- The medications may be nurse-administered
- It has no amnesic effect but creates a feeling of well-being or euphoria
- Disadvantages
- Frequent occurrence of uncomfortable side effects, such as N/V, pruritis, drowsiness, and neonatal depression
because of this opioids are often given with sedatives or Reglan (anti-emetic)
- Pain is not eliminated completely
Anesthesia
- The use of medication to partially or totally block all sensation to an area of the body
- General Anesthesia- used in C-sections
- Intravenous analgesia
- Inhalation analgesia
- Local Anesthesia
- Reduce ability of local nerve fiber to conduct pain
- Used to numb the perineum just before birth to allow for episiotomy and repair
- Regional Anesthesia
- Injection of local anesthetic agent such as Tetracaine or Bupivacine to block specific nerve pathways that supply
a particular organ or area of body.
- Temporary and reversible loss of sensation. Prevents initiation and transmission of nerve impulses
- Types:
- Spinal Anesthesia- used more for C-sections.
- Subarachnoid injection
- Quick onset and short duration
- Spinal headache and itching
- Epidural: Injection of local anesthetic/narcotic into epidural space. Suitable for all stages of labor and types of
birth and for repair of episiotomy and lacerations.
- Combined epidural-spinal
- Pudendal nerve block: suitable during 2nd stage of
labor and for repair of episiotomy or lacerations.
Pain Pathways and Sites of Pharmacologic Nerve Blocks
- Pudendal block: done for episiotomy and birth, affects a small area.
Shown in A.
- Subarachnoid space- spinal block, the medication mixes with CSF fluid
(intrathecal anesthesia), used in some cesarean deliveries.
- Epidural space- used for labor pain relief. Shown in B.
Spinal Block/Spinal Anesthesia
- LOCAL ANESTHETIC AGENT SUCH AS (BUPIVACINE OR ROPIVACAINE)
injected in subarachnoid space through 3rd, 4th, or 5th lumbar
interspaces by using lumbar puncture technique.
- Anesthesia mixed with CSF, used on elective and emergent CS birth not suitable of vaginal birth because it’s useful
for shorter and simpler procedures. So, the patient is at risk for CSF leakage.
- Anesthesia normally rises to level T10, umbilicus, and both legs.
- A spinal block is similar to an epidural, but the medicine is injected into the spinal fluid, not the epidural space. A
spinal block is only given once. It starts to relieve pain quickly but lasts only 1–2 hours. Spinal blocks can also be
used for cesarean deliveries.
- About 4-5 cm of cervical dilation is required for spinal anesthesia, or else we face prolonged labor because it
paralyzes smooth muscles. Also, why they should empty bladder prior.
- Advantages
- Immediate onset of anesthesia
- Relative ease of administration
- Smaller drug volume
- Maternal compartmentalization of the drug
- Disadvantages
HIGH INCIDENCE OF HYPOTENSION
- Greater potential for fetal hypoxia
- Uterine atony (tone maintained), making intrauterine manipulation and contraction difficult→putting woman on wedge
to displace uterus
- Impaired placental perfusion
- Ineffective breathing patterns
- Short acting
Complications
• HYPOTENSION: FROM SYMPATHETIC BLOCKAGE LEADS TO IMPAIRED PLACENTAL PERFUSION AND INEFFECTIVE BREATHING
PATTERN, MAY OCCUR DURING SPINAL ANESTHESIA (DECELERATIONS HAPPEN)
BLOOD PATHC FOR LEAKING CSF
LUNG ISSUES IF ITS PLACED TOO HIGHT
- Drug reaction
- Total spinal neurologic sequelae
- Spinal HA→
- Nausea, Shivering, Urinary retention→full bladder we need to straight cath them
- Ineffective anesthesia
- Interventions:
- Turn patient to her left side
- Ensure side rails are up
- IV FLUID ADMINISTRATION (500-1000 ML) TO INCREASE BLOOD VOLUME AND EMPTYING OF BLADDER PRIOR TO
administration of opioid to prevent hypotension
- Highly recommended to have Foley catheter after epidural
- Vasopressin to increase BP (such as Ephedrine)
O2 may be used
CHECK VS EVERY 5-10 MINUTES
Spinal Anesthesia
- Nursing Care Management Prior to Administration
- Assess maternal and fetal status
- Assess labor progress
- Start an IV and administer preload→IV fluids of 500 ml to 1000 ml of isotonic fluids
- Help woman into position
- Nursing Care Management AfterAdministration:
- Monitor maternal and fetal vital signs. Assess for hypotension. Monitor RR.
- Take corrective measures for hypotension
- Administer antiemetic as needed
- Assess bladder and catheterize if unable to void
Complications
- Spinal HA: occur because of continuous leakage of CSF from the needle insertion site or by instillation of air
into CSF, shift in pressure of CSF causes strain in vertebral meninges
- Incidence reduced by using small gauge needle, and increase fluid intake to replace spinal fluid
- If HA occurred:
- Ask woman to lie flat
- Administer analgesic
- Blood patch technique: withdraw 10 mL of venous blood and then immediately injected into epidural space
over spinal injection site in order to form a blood clot, and seal any further leakage of CSF.
Epidural Anesthesia
- Anesthetic agent placed inside epidural space at L4-5, L3-4, L2-3
- Blocks not only nerve roots in the space but also sympathetic nerve fibers that travel with them. - Epidural anesthesia has
become a popular and effective form of childbirth pain relief. Epidural anesthesia is the injection of a numbing medicine into
the space around the spinal nerves in the lower back. It numbs the area above and below the point of injection and allows
you to remain awake during the delivery. It can be used for either a vaginal birth or a caesarean delivery (C-section). An
anesthesia specialist administers epidural anesthesia
• Patient in C-shaped position and epidural needle is inserted into epidural space
• To prevent the medicine from wearing off, a small tube (catheter) may be threaded into the epidural space and taped in
place to prevent it from slipping out. Medicine can then be given continuously in small doses through the tube until
you deliver.
• Epidural anesthesia involves the insertion of a sterile guide needle and a small tube (epidural catheter) into the space
between the spinal cord and outer membrane of the spinal cord (epidural space).
• The epidural catheter is placed at or below the waist.
• The doctor first uses a local anesthetic to numb the area where the needle will be inserted. Then the guide needle is
inserted and removed, while the catheter remains in place.
• The catheter is taped in place up the center of your back with the end taped in place on top of your shoulders • An
anesthetic medicine is injected into the catheter to numb your body above and below the point of injection, as needed. The
amount of discomfort or pain that you have depends on the amount of anesthetic used. Less anesthetic (often called a light
epidural) will allow you to be more active in your labor and feel enough to push effectively. With higher levels of
anesthetic, you will feel little or no pain from your contractions. You may be required to remain in bed when an epidural is
used. You will also have a tube placed in a vein (intravenous, or IV tube) and a fetal monitor. • Before delivery, the epidural
medicine dose can be decreased so that you can push more effectively while remaining alert and relatively comfortable.
The epidural catheter can also be used to numb the area between the vagina and anus (perineum) just before delivery.
• Because the amount of medicine given at one time is small, epidural anesthesia wears off during labor unless additional
medicine is given. So, the use of epidural infusion pumps has become more common. With an infusion
pump, the epidural medicine is given continuously in small amounts so that you don't have to worry that the pain
relief will wear off during your delivery.
• Advantages:
o Women remain alert/fully awake during labor and birth and more comfortable
o Airway reflex remains in tact
o Gastric emptying is not delayed
o Blood loss is not excessive
o It is the most effective in providing pain relief: In addition to more constant pain relief, another benefit of
having an infusion pump is that it allows you to have more control of your belly and leg muscles. It also
reduces the chance of side effects related to a standard epidural. It affects the uterus, cervix, vagina, and the
perineum.
- Fetal complications are rare but may occur
- Continuous technique allows different blocking for each stage of labor
- Dose of anesthetic agent can be adjusted
- Disadvantages:
- Maternal hypotension: So, preload patient with IV isotonic fluids
- Urinary retention
- Back ache, N/V
- Postdural puncture seizures
- Epidural may prolong 2nd stage of labor, make pushing more difficult, and additional interventions such as
Pitocin, forceps, and vacuum extraction, or C-section might become necessary
- Baby might experience respiratory depression, fetal mis-position, and in increase in FHR variability.
- MENINGITIS
- Cardiorespiratory arrest
- Vertigo
- Onset of analgesia my not occur for up to 30 minutes
- Bladder distention
- Instruct mom to stay still so she won’t displace the needle!
• Complications→
o Toxic reactions
o Unintentional placement of the drug or Excessive amount of the drug
- Accidental intravascular injection
- Spinal headache
- Side Effects
- The most common side effect from epidural anesthesia is lowering of the mother's blood pressure. Less common
side effects may include severe headache after delivery, difficulty urinating or walking after delivery, fever, and
prolonged labor.Arare side effect is seizure.
- Because a standard epidural can decrease your ability to push, a forceps delivery or caesarean delivery (C- section)
may sometimes be needed. Using less anesthesia (called a light epidural) may reduce the likelihood of needing a
caesarean delivery.
- After Delivery
- The epidural catheter may be removed right after delivery, or it may be left in place for several hours to a day and used
to give you pain-relieving medicine. This is usually done after a caesarean delivery. If you are planning to have a tubal
ligation before you leave the hospital (to prevent future pregnancy), catheter will be left in place.
- The effects of the epidural usually wear off within 2 hours after the epidural medicine is stopped. After the epidural
wears off, you may have some hip or back pain from childbirth. You may have a small bruise and the skin may be
sore where the epidural was put in your back. This will probably get better in 1 or 2 days.
Check platelets before epidural
Epidural Regional Anesthesia
- The Rolls Royce of labor pain relief is an epidural
- Before an epidural may be given, the nurse must have the lab results available, namely the H&H, no fever. CBC, vital signs
- Platelets must be > or = 100,000 to prevent chance of a hemorrhage
- No other risk factors for hemorrhage
- No maternal fever
- OB physician must be readily available while epidural is initiated
- Continuous FHR monitoring
- O2, suction available
- Crash cart: make sure you have Ephedrine in the cart
- May prolong labor
Epidural Anesthesia
- Prehydrate patient with 750-1,000 mls Lactated Ringers Soln. Given 20-30 mins before initiation of epidural Position patient sitting up, on edge of the bed. “Curled” around the baby so that vertebra stick out. Shoulders
relaxed
- Assist pt. to remain still during procedure
- Closely monitor BP (Q2 min initially) for hypotension
- Patient stays in bed. Foley catheter after the procedure.
- Monitor level of anesthesia
- Fentanyl can cause peripheral blood vessels to dilate, and this has the effect of dropping the BP.Anesthesiologist
first injects a testing dose. Wen testing dose goes in, the nurse starts recording the BP every 2 minutes.
Contraindications for Epidural: Maternal Complications
- Uncorrected hypovolemia
- Anticoagulant therapy or coagulation defects (risk of hemorrhage): Coagulopathy
- Hemorrhage
- Hypotension: preload with fluids
- Infection at injection site (risk of spreading infection)
- Scoliosis (epi. may be ineffective)
- Postdural puncture seizures
- Low platelet count (risk of hemorrhage)
- Medication allergy
- Maternal cardiac conditions
- Maternal refusal or inability to cooperate – cant lay still
- Morbid obesity: may be too difficult to place epidural. Morbidly obese patients are more likely to have failed
epidural placement and accidental dural puncture.
What Evidence Says About Epidural Analgesia
- The use of epidural anesthesia is associated with a significant increase in maternal temperature and in the
incidence of intrapartum maternal fever
- Severe hypotension (systolic BP 100 mmHg or less or > 20% decrease from baseline BP) as a result of
sympathetic block can be an outcome of epidural block.
- To prevent the medicine from wearing off, a small tube (catheter) may be threaded into the epidural space and taped in
place to prevent it from slipping out. Medicine can then be given continuously in small doses through the tube until you
deliver.
Combined Spinal Epidural Analgesia (CSE)
- Combination of opioid and local anesthesia injected inside spinal cord and in subarachnoid space, used to block
pain transmission without compromising motor ability.
- It is associated with greater incidence of FHR abnormalities than epidural analgesia alone.
- Combined spinal-epidural blocks combine the benefits of both the spinal and epidural blocks. The spinal part acts
quickly to relieve pain and the epidural provides continuous pain relief.
Pudendal Anesthesia/Block
- Local anesthetic is used to numb a small area of your body. The medicine is injected into the area of nerves that carry
feeling to the vagina, vulva, or the area between the vagina and anus (perineum A pudendal block is another form of local
anesthesia. It is used to relieve the pain associated with pushing or stretching of the perineum at the time of delivery. An
injection is given deep through the vaginal wall into the pudendal nerve in the pelvis, numbing the perineum. - Given in the
second stage of labor for perineal anesthesia and episiotomy repair.
- Advantage:
- ease of administration, the small amount of medication
- Absence of maternal hypotension
- Allows the use of low forceps or vacuum extraction
- Disadvantage:
- The urge to bear down during second stage of labor may be decreased
- Pudendal nerve block- suitable during 2nd and 3rd stages of labor and for repair of episiotomy or lacerations.
- Possible hematoma
- Epidural block- suitable for all stages of labor and types of birth and for repair of episiotomy or lacerations.
- Complications:
- Systemic toxic reaction, Broad ligament hematoma, Perforation of the rectum, Trauma to the sciatic nerve
Inhalation Analgesia
- During labor, involves the self-administered inhalation of sub-anesthetic concentration of agents at time when mom
feels a contraction, because she is pain free when she’s not having contractions.
- Mother remains awake and her protective laryngeal reflexes remain in tact.
- N2O does not interfere with uterine contractions. Has no effect on fetus.
- It is premixed N2O (50%) and O2 (50%)
- Entonox- cylinders with a capacity of 500L are available
- Inhalation should begin 45 seconds before the onset of pain.
- Used extensively in other countries, and is gaining popularity in the US as an alternative.
What Evidence Says About Inhaled Analgesia
- Inhaled analgesia appears to be effective in reducing pain intensity and in giving pain relief in labor
- N2O appears to result in more SE compared with Flurane derivatives
- Flurane derivatives result in more drowsiness when compared with N2O.
- N2O appears to result in even more SE such as N/V, dizziness, and drowsiness
General Anesthesia
- This type of medicine causes you to lose consciousness so you do not feel pain. It is usually used only in
emergency situations during labor. It is given through an IV tube or face mask.
- Used rarely for vaginal births, infrequently for elective cesarean section, and may be necessary if indications
necessitate a rapid birth
- Methods:
- Intravenous injection
- Sodium thiopental (Pentothal)
- Ketamine
- Inhalation of anesthetic agents
- Nitrous oxide
- Low-dose halogenated agents
Nursing Care Management:
- NPO; IV fluids
- Pre-medicate with oral antacid, histamine (H2)-receptor blocker and metoclopramide(Reglan) because a
common SE of opioids is N/V
- Wedge to displace the uterus
- Pre-oxygenated with 100% oxygen by non-rebreather face mask for 2 to 3 minutes
- Assist with cricoid pressure (neck)
- Complications
- Fetal depression: depth and duration
- Uterine relaxation
- Potential for chemical pneumonitis
- Decrease in gastrointestinal motility
- Acidic gastric secretions → GERD
Sedatives
• Use: latent phase of labor not usually active labor
• Purpose: relaxation and sleep, and decrease anxiety→not really pain relief
• Common Medications:
o Barbiturates: Seconal and Ambien. These aren’t used often due to respiratory depression.
o Phenothiazine: promethazine (Phenergan)
▪ Was often given with opioids to enhance the analgesic effect and reduce nausea and vomiting o
Metoclopramide (Reglan: more recommended) potentiate the effects of opioid analgesics (EBP) o
Benzodiazepines: diazepam, lorazepam (SE: Maternal amnesia)
H1 Receptor Antagonists & Serotonin Receptor Antagonist
• Use: early latent phase
• Purpose: sedative, antiemetic, and anti-pruritic (because epidurals sometimes cause itching) • Common
Medications: promethazine (Phenergan), hydroxyzine (Vistaril) and diphenhydramine (Benadryl), ondansetron
hydrochloride (Zofran; anti-emetic that acts by decreasing stomach acidity)
o Standing order for Benadryl because she will be itchy!
First Stage of Labor***
- Opioid agonist analgesics→demerol
- Opioid agonist-antagonist→Narcan have at bedside
- Epidural (block analgesia
- Combined spinal-epidural (CSE) analgesia
- Nitrous oxide
- Second Stage of Labor→cervix
complete dialated
- Nerve block analgesia and anesthesia
- Local infiltration anesthesia
- Pudendal block
- Spinal (block anesthesia→C-section)
- Epidural (block) analgesia
- CSE analgesia
- Nitrous oxide
Vaginal Birth
• Local infiltration anesthesia
• Pudendal Block
• Epidural (block) analgesia and anesthesia
• Spinal (block) anesthesia
• CSE analgesia and anesthesia
• Nitrous Oxide
Cesarean Birth
• Spinal (block) anesthesia→usually what is used for scheduled, NPO, consent signed, load with fluids •
Epidural (Block) anesthesia
• General anesthesia→rarely used, used or emergency because of the risk of the Side effects
Maternal Assessments
• Willing to receive medication
• Vital signs are stable
• Contraindications are not present
• Knowledge of other medications being administered
• Always have consent form prior to start of any procedures. If mom has any further questions, call the physician
because they are the ones responsible for giving additional information. You are acting as an advocate.
Fetal Assessments
• Fetal heart rate between 110 and 160 bpm
• Reactive non-stress test