Module 6: intrapartum processes
• Basically, the intrapartum period is the time in which the birthing process occurs.
Factors Important to Labor and Birth The 5 “p”
PASSAGE
BIRTH CANAL,Size of pelvis, Inlet,midpelvis and Outlet, Ability of cervix to dilate and efface, Ability of vag to distend
PASSENGER
FETUS, Fetal head shape, size, sutures, Ability of bones to overlap, Bones not fused, Molding.
-Important landmarks for fetal skull : mentum(chin), Sinciput (brow), Bregma (anterior fontanelle),
vertex (area between anterior fontanelle and posterior fontanelle), Posterior fontanelle( intersection
between posterior cranial sutures, occiput ( area of the fetal skull occupied by the occipital bone,
beneath posterior fontanelle )
POSITION
RELATIONSH BETWEEN, PASAGE AND FETUS, Engagement, Station (ischial spines = 0 station), Position(vertex,
breach,transverse,Left orRight)
-- importantant fetal factors
-Fetal attitude : relation of fetal parts to one another (flexion vs extension)
-fetal lie : the cephalocaudal axis compared to maternal cephalocaudal axis (baby spine in relation to
mother spine )
-Fetal presentation: the body of the fetus that enters the pelvic passage first (presenting part). Desired is
vertex. Various malpresentations ( brow, military, breach should, mentum, face )
Position relationship between passage and passanger:
Engagement: occurs when the largest diameter of the presenting part reaches of pass through the pelvic
inlet. Asses with vaginal exam (engaged and ballotable)
Station : relationship of the presenting part to and imaginary line drawn between the ischial spines of
the maternal pelvis. At 0 station the presenting part can be felt at the level of the spines. If above then
noted –1 ,-2 etc. If lower +1, +2 etc
Position: vertex, breach, transverse, left , right (LOA, LOP, ROA ROP)first letter L=left , R=RIGHT, second
letter O=occiput, M=mentum, S=Sacrum , third letter A= anterior, P=posterior, T = transverse
PHYSIOLOGICAL
FORCES OF LABOR,CONTRACTIONS, PUSHING, Maternal pushing effort, Contractions ( increment, acme,
decrement)
1. Maternal Pushing Effort
2. Contractions: rhythmic, intermittent uterine muscle contractions
• Increment: the building up of the contraction
• Acme: The peak
• Decrement: the letting up of contraction
Documenting contractions
-Frequency: the time between the beginning of one contraction and the beginning of the next
• Duration: measured from the beginning of one contraction to the completion of that same contraction.
• Intensity: the strength of the contraction during acme (estimated through examiner palpation:
cheek=mild, chin=moderate, forehead=strong)or directly monitored if internal monitors are placed.
Intensity CANNOT BE MEASURED ON AN EXTERNAL MONITOR!!!!
• Resting Tone: the period between contractions
Labor Onset: normally between 37and 42 weeks gestation. Exact cause of onset still not clearly
understood.
• Myometrial Activity: True labor each contraction (occurs in fundus) work to short the cervix and exert
longitudinal traction causing effacement (dilate and efface)
• Effacement: the thinning of the cervix which is drawn up into the uterine side walls.
• Dilation: the opening of the cervix: from closed to 10 cm (complete).
• Pelvic Floor: thins and stretches to less than 1 cm thick
PSYCHOLOGICAL
CONSIDERATIONS
Fear, Anxiety, birth fantasy, excitement, joy, anticipation
The Physiology of labor
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Labor onset: normally between 37-42 weeks gestation. Exact cause of onset still not clearly
understood
Myometrial activity: True labor each contraction (occurs in fundus) works to shorten the cervix
and exert longitudinal traction causing effacement( dilate and efface)
Effacement: the thinning of the cervix which is drawn up into the uterine side walls
Dilation the opening of the cervix from closed to 10 cm (complete)
Premonitory signs of labor
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Lightening: fetus settles into pelvic inlet (engagement) decreasing pressure on the
diaphragm, so breathing is eased but with increase downward pressure comes the
following: leg cramps/ thigh cramps, increased pelvic pressure, increased urinary
frequency, increased venous stasis leading to edema, increased vaginal secretions
Breathing is eased but increased downward pressure can cause leg cramps/thigh cramps,
urinary frequency, increased venous stasis leading to edema, Increased vaginal secretions
R/T venous congestion
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Braxton Hicks Contractions: irregular practice contraction that do no cause cervical
change
Cervical Changes (true sign of labor): dilation and eff \acement with regular contractions
(signs of true labor)
Bloody Show (labor will begin in 24-48 hours): release of mucous plug resulting in blood
tinged mucous discharge.
Rupture of Membranes (12% spontaneously rupture and if it does 90% will
have onset of labor within 24 hours)
Burst of energy=Nesting
Diarrhea, indigestion, nausea or vomiting
Stages of labor
First Stage: divided into latent, active and transition phases.
Each phase is characterized by physical and psychological changes (see table 3311, page 2279 vol. 2)
• Latent Phase: begins with start of regular mild contractions. Woman can cope, speak, laugh. May be
anxious, happy that pregnancy is over. (slow changes from 1 to 6 cm dilated and effacement is
progressive as is fetal descent)
• Active Phase: Increased intensity of contractions, pain, anxiety, fear loss of control, more focused.
Cervix dilates from around 6 to 8 cm and fetal descent is progressive
• Transition: Acute awareness of need for energy, focused, may feel out of control, increasing force and
pressure, irritability, restless. Contractions every 1.5-2 min lasting 60-90 seconds each—strong. As
dilation approaches 10 cm increasing rectal pressure and desire to bear down! (transition from 7/8 cm
to complete and ready to push)
Second Stage:
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Begins with complete cervical dilation and ends with the birth of the baby
For a primigravida usually completed within 3-4 hours after the woman is complete
For a multipara often less then 15 minutes long
Second stage incorporates pushing with contractions
Fetal descent and crowning, ending in the birth of the baby
Third Stage:
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The period of time from immediately after the birth of the baby until the completed delivery of
the placenta
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Should occur no longer than 30 minutes from the birth of the baby
Considered a retained placenta if more than 30 minutes has elapsed and can result in postpartum
hemorrhage or need for further intervention to remove it manually
Incorporates placental separation- which occurs as the uterus contracts firmly after delivery
causing the placenta to separate from the uterine wall. A hematoma is formed between the
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placenta tissue and the remaining decidua which accelerates the separation process- pushes it
out of the way. Membranes are last to separate.
Placental Delivery:
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Shiny shultz (fetal side )
Dirty Duncan (Maternal side)
Fourth stage:
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Occurs from 1 to 4 hours after birth, during which physiological readjustments of the mothers
body begins the recovery period
Regain system stability (VS, bleeding), may feel hungry, shaking chills, may have a hypotonic
bladder and difficulty urinating –retention
Alterations during the intrapartum Period
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Labor induction/augmentation (cervical ripening and contraction stimulation)
Episiotomy: a surgical incision of the perineal body to enlarge the outlet and facilitate delivery of
the fetus:
Cesarean:
TOLAC/VBAC
Prolapsed cord
Dystocia
Shoulder dystocia
Ruptured uterus
Induction and augmentation
induction: The use of cervical ripening,
and uterine stimulants to induce
contractions and facilitate the onset of labor
when labor has not yet started. May include
cervical ripening agents-pgel, cervadil,
misoprostol and/or mechanical methods
such as a Cook catheter.
Augmentation: The use of uterine
stimulants to facilitate an ineffective labor
pattern usually with Pitocin (oxytocin).
Indications for induction of Labor
Diabetes mellitius
• Renal disease
• PROM
• Chorioamnionitis
• Post term gestation
• Mild abruptio placentae without
evidence of non-reassuring fetal
status
• Intrauterine fetal demise
• IUGR
• Isoimmunization
• Oligohydramnios
• Non-reassuring fetal
status/antepartum testing
Bishop Score : a tool used to evaluate the cervix and the readiness of the cervix to labor look
this up in your text and make sure you know what it is.
Example Is on Slide 15 of Final review !!!!!
Operative Birth
Forceps: assist the birth of a fetus by providing traction or by providing the means to rotate the fetal
head to an occipitoanterior position. There are many types of forceps.
Vacuum Extraction: Assist delivery of fetus by applying suction to the fetal head. As mother contracts
and pushes the provider pulls.
Episiotomy: a surgical incision of the perineal body to enlarge the outlet and facilitate delivery of fetus.
May be mediolateral or midline
Preventive Measures
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Perineal massage during pregnancy and labor
Natural pushing and avoidance of lithotomy position
Side lying for pushing
Warm compresses to perineum with firm counterpressure
Encourage gradual expulsion of the baby, encourage push breath, and ease baby out slowly
Avoid immediately pushing after epidural placement
Discussin on Point: Intrapartum Alterations; Prolapsed Cord
• A prolapsed cord occurs when amniotic fluid washes the cord forward in front of the fetal head. The
head then applies constant pressure to the cord and affects perfusion and oxygenation of the fetus.
• Nursing Interventions: “You found it, you keep it!” Keep hand inside vagina and apply counterpressure
to fetal head to remove pressure from cord.
• Get help
• Place patient in Trendelenburg position or knee/chest
• Prepare for emergent cesarean section
Shoulder dystocia
• This alteration occurs when the anterior (usually) or posterior shoulder become impacted in the pelvis
against the bones. Head passes but shoulders are stuck.
• Turtle sign:
• McRobert’s Maneuver: two nurses pull the mothers legs back towards abdomen to flatten and rotate
her pelvis to allow fetus through
• Corkscrew Maneuver: when the obstetrician places a hand on the aspect of the posterior shoulder and
rotates the should toward the fetal back
• Suprapubic pressure: when provider uses their palm or fist to press down on your abdomen just above
you pubic bone
Module 7 : Postpartum Alteration
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Postpartum is birth to 6 weeks post birth
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now: Involution( fundus lowers into the pelvis) Exfoliation ( undermining and endometrium regrowth),
Lochia(rubra serosa alba) , healing of the cervix, return of ovulation and menstruation, Progression of
lactation, Postpartum diuresis and diaphoresis,blood values return to regular values
Weight loss
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Maternal role attainment and BAM
Engrossment: the father has a strong attachment to newborns and his feelings are similar the mothers
feelings of attachment. Characteristics include sense of absorption, preoccupation, interest in newborn.
Adolescent, Pregnancy and, Advanced Maternal, Age lifespan, considerations
BUBBLE HEEB REEDA (breast, uterus, bladder, bowels, lochia, episiotomy, Homans sign, edema,
emotional status, bonding behavior.)(redness, ecchymosis , edema, dehiscence, approximation ---acronym Reeda when assess surgical wounds)
Full bladder = uterine disposition up and to right and may be atonic
Psychological adaptions
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Maternal role attainment :process by which a woman learns mothering bx and identifies as a
mother
Bam (becoming a mother) a mothers first interactions with newborn influenced by many factors
which shape her. Characteristics that influence the process include : level of trust, self esteem
capacity to enjoy self, knowledge of child bearing , prevailing mood, reactions to pregnancy
Lochia Colors
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Dark red : Last 3-4 days, occuring a few lads after delivery, it is mainly made up of blood, bits of
fetal membrane and decidua
Pinkish brown: last 4-10 days, contains less red blood cells and has more white blood cells, wound
discharge from the placental and other sites
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Whitish yellow: last 10-28 days for about another 1 –2 weeks, whitish turbid fluid drains from
which mainly consists of deicdual cells
PIXX ON SLIDE 22 of final
Nursing Process: Planning/Goals of Care Tanner: Responding
-The mother demonstrates bonding with newbornas evidenced by using the en face
position
-The mother will meet the baby’s needs as they arise
-The mother will demonstrate adequate self-care to meet her needs as they arise
-The mother will seek assistance as needed to care for self and newborn
-The mother’s physical condition returns to a nonpregnant state
-The mother will gain competence in caregiving and confidence in herself as a parent
Nursing Process: Evaluation Tanner: Reflection
-Anticipated outcomes of your comprehensive nursing care:
-The mother is reasonably comfortable and has learned pain relief
measures
-The mother is rested and understands how to add more activity
during the next few days
-The mother verbalizes her understanding of self-care
-The mother can demonstrate how to care for her baby
-Breast tissue is soft without tenderness
• (see care plan on page 2351 of your text for an example)
Physiological Adaptation Alterations•
1. Subinvolution: is the rapid reduction in the size of the uterus and its return to a condition similar to
its non-pregnant state
PP day 1 fundus is located about 1 cm below umbilicus, on PP day 3 fundus is 3cm below the umbilicus,
*** descends about 1 cm or finger width per day
2. Uterine Atony:
3. Afterpains:
4. Hemorrhage (primary and secondary):
5. Cervical and Vaginal lacerations:
6. Episiotomy related wound healing:
7. Diastasis recti abdominis:
8. Breast and lactation related issues (plugged duct, engorgement, mastitis, yeast)
9. Urinary stasis or retention :
Care of the woman with postpartum hemorrhage
Early (primary) postpartum hemorrhage= first 24 hours after childbirth and is the more common of
the two
Late (secondary) postpartum hemorrhage=24 hours to 6 weeks postpartum
PIXX on slide 27
Contributing Factors of Uterine Atony
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Over distention of the uterus due to multiple gestation, polyhydramnios, or large faint infant
(macrosomia)
Dysfunctional or prolonged labor (Pitocin receptors full)
Oxytocin augmentation
Use of anesthesia, or other drugs such as magnesium sulfate, calcium channel blocker(relaxants)
Prolonged third stage of labor (more than 30 minutes )
Preeclampsia
Asian or Hispanic heritage
Retained placental fragments also placenta previa
Operative birth (includes vacuum extraction or forceps)
Signs of Postpartum Hemorrhage
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Excessive or bright red bleeding (saturation of more than one bad per hour)
A boggy fundus that doesn’t respond to massage
Abnormal clots
High temperature
An unusual pelvic discomfort or backache
Persistent bleeding in the presence of a firmly contracted uterus
Rise in the level of the fundus of the uterus
Increased pulse or decreased pulse
Hematoma formation or bulgy shining skin in the perineal area
Decreased level of consciousness
The leading cause of early PP hemorrhage
Uterine atony: may be slowed and steady, sudden and massive, ideally prevented, woman with no
identifiable risks
Clinical therapy: fundal massage, venous access, and fluid administration, bimanual massage, uterine
stimulants
Psychological alterations in postpartum
Baby blues: from birth to a few days or a couple weeks- self- limiting
Postpartum depression/depressive Disorder with peripartum onset(a couple weeks and longer –requires
intervention)
Postpartum Psychosis: (sever psychological maladaptation involving hallucinations and psychosis)
Nursing planning and implentation (responding )
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Offer realistic information
Anticipatory guidance
Social support teaching guides
Alert family members (caution regarding infant alone with mother until level of problem
accurately assessed )
Information and emotional support
Nursing Plan and Evaluation/Responding, Reflecting
-The patient’s signs of depression are identified, and she receives prompt treatment and intervention
-The newborn is effectively cared for by father or other support person until the mother is able
-The mother and newborn remain safe and are bonding
-mother will meet babys needs as they arise
-mothers condition will return to non pregnant state
-The newborn is successfully integrated into the family
Module 8:Normal Newborn and newborn alteration
-Newborn period is from birth- 28th day of life
-Period of adjustment from intra uterine to extra uterine life
-Involves virtually every organ system
Respiratory adaptation
• Initiation of Respiration
• Pulmonary ventilation established through lung expansion
• Marked increase in the pulmonary circulation must occur
• First breath stimulated in response to mechanical,
absorptive, chemical, thermal and sensory changes at birth
Pix on slide 35
The first breath of life
• Gasp in response to :
• Mechanical: asphyxia resulting is gasp
• Resorptive: lymphatic drainage and movement of fluid to interstitial lung spaces
• Chemical: aortic and carotid chemoreceptors trigger medulla to initiate breathing
• Thermal: temperature of room, cooling of baby
• Sensory: light, touch, ***Changes associated with the birth!
BREATHING
• AFTER THE FIRST INSPIRATION, THE NEWBORN EXHALES, WITH CRYING, AGAINST A PARTIALLY CLOSED GLOTTIS
WHICH CREATES POSITIVE INTRATHORACIC PRESSURE DISTRIBUTING INSPIRED AIR THROUGHOUT THE
ALVEOLI AND ESTABLISHING FUNCTIONAL RESIDUAL CAPACITY (FRC).
• FRC IS THE AIR LEFT IN THE LUNGS AT THE END OF A NORMAL EXPIRATION.
• ALSO INCREASES ABSORPTION OF FLUID VIA THE CAPILLARIES AND LYMPHATIC SYSTEM.
• THE NEGATIVE INTRATHORACIC PRESSURE CREATED WHEN THE DIAPHRAGM MOVES DOWN WITH INSPIRATION
CAUSES LUNG FLUID TO FLOW FROM THE ALVEOLI ACROSS THE ALVEOLAR MEMBRANE INTO THE PULMONARY
INTERSTITIAL TISSUE
SUSTAINED BREATHING
• EACH SUCCEEDING BREATH HELPS THE LUNGS TO EXPAND, STRETCHING THE ALVEOLAR WALLS AND
INCREASING THE ALVEOLAR VOLUME
• REMAINING LIQUID IS RESORBED BY INTERSTITIAL LUNG TISSUE
• BY 30 MINUTES AFTER BIRTH MOST NEWBORNS HAVE ACHIEVED SPONTANEOUS, SUSTAINED BREATHING
• SEE FIGURE 33-60 PAGE 2354 “INITIATION OF RESPIRATION IN THE NEWBORN”
Potential problems establishing spontaneous respiration
• Newborns may have problems clearing the fluid in the lungs and beginning respiration for a variety
of reasons:
• Underdeveloped lymphatic system
• Inadequate chest compression in very small newborns (SGA, IUGR)
• Absence of chest wall compression in a neonate born by cesarean section
• Respiratory depression related to maternal analgesia or anesthesia
• Aspiration of amniotic fluid, meconium or blood
Characteristics of newborn breathing
• Normal rate is 30-60 breaths per minute and pp 110-160
• Irregular and shallow
• Largely diaphragmatic with synchronous chest movement
• Periodic breathing: pauses in breathing for up to 20 seconds
without color change or desaturation (normal)
• Apnea: pauses in breathing for 20 seconds or longer or less if
color changes are present or decrease in oxygen saturation
Cardiovascular adaption: fetus to newborn
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Heart rate is 110-160 beats per minute initially, slowly decreases over days to weeks after
delivery
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Pink, well oxygenation newborn
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Acrocyanosis (blue hands and feet)
Increased aortic pressure and decreased venous pressure
Increased systemic pressure and decreased pulmonary artery pressure
Closure of the foramen ovale
Closure of the ductus arteriosus
Closure of the ductus venosus
Thermoregulation
• Newborn is “homeothermic”: attempt to stabilize their internal (core) temperature within a
narrow range.
• Thermoregulation is closely related to the rate of metabolism and oxygen consumption .
• Neutral thermal environment: the rates of oxygen consumption and metabolism are
minimal, and internal body temperature is maintained because of thermal balance: baby
does not need to burn through brown fat reserves to maintain temperature and blood
glucose because they are kept at the right temperature!
• Thin epidermis and less subcutaneous fat
• Blood vessels are closer to the skin so circulating blood is influenced by changes in
environmental temperature
• Flexed posture of newborn decreases surface area exposed to environment to prevent
heat loss
• Shivering is uncommon and newborns have “nonshivering thermogenesis” related to use
of brown fat reserves to maintain heat
Characteristics that effect thermal stability
THIN EPIDERMIS AND LESS SUBCUTANEOUS FAT
• BLOOD VESSELS ARE CLOSER TO THE SKIN SO CIRCULATING BLOOD IS
INFLUENCES BY CHANGES IN ENVIRONMENTAL TEMPERATURE
• FLEXED POSTURE OF NEWBORN DECREASES SURFACE AREA EXPOSED TO
ENVIRONMENT TO PREVENT HEAT LOSS
• SHIVERING IS UNCOMMON AND NEWBORNS HAVE “NONSHIVERING
THERMOGENESIS” RELATED TO USE OF BROWN FAT RESERVES TO MAINTAIN
HEAT
Cold stress
• Condition caused through excessive cooling of the newborn through heat
loss mechanisms of :
• Radiation: transfer of heat from
one object to another without
physical contact
• Conduction: Loss of heat through
physical contact with another
object
• Evaporation: conversion of water
to gas (wet skin)
• Convection: moving air across wet
skin
**** non-shivering thermogenisis doubles metabolic rate using brown fat reserves , hypothermia
ensues, oxygen consumption increases, signs and symptoms of respiratory distress: nasal flaring,
grunting, intercostal retractions and hypoglycemia
Prevention of cold stress
• Skin to skin
• Neutral thermal environment
• Reduction in heat loss mechanisms: have warmer ready at time of delivery, warm blankets. Preemies
wrapped in plastic wrap or ziplock baggies
• **keep baby warm and dry**
Other adaptations to be familiar with
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Hepatic
Iron storage
Carbohydrate metabolism: during the first two hours of life glucose levels drop then rise again
Conjugation of bilirubin/jaundice : risk for is babies with high beta D glucuronidase activity levels,
exclusive breast feeding, delayed bacterial colonization of the gut
Gastrointestinal : able to digest simple carbs proteins and fats ! Non solid foods until 4-6 months.
First stool should be passes within the first 8-24 hours of life and almost always before 48 hours\.
Urinary: newborns voids 2-6 times daily for first two days and increases to 5-25 times in 24hrs
Immunological : not fully activated, limited inflammatory response
Neurological
Neurologic and Sensory adaptations
• Born with reflexes
• Knee jerk - Plantar flexion
• Moro -Grasping
• Babinski -Rooting
• Sucking
-Tonic neck
• Stepping
• Self quieting behaviors
• Can bring hand to mouth (feeding
Periods of reactivity
Sleep States
• deep or quiet sleep
• Active or light sleep (active
eye movement—REM)
Alert states
• Drowsy
• Quiet alert
• Active alert
• crying
Initial Care :
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Newborn is placed on maternal abdomen
Infant is dried and stimulated to cry
Cord is clamped (note the number o0f vessels in the cords should be two veins and two arteries
aka as a smiley face to remember it
Apgar score are uptaned at 1 and 5 minutes
Infant moved to maternal chest to initiate breast feeding and bonding (skin to skin )and will
remain their at least 1 hour.(the golden hour ) if stable
Place warmed blankets over baby to maintain heat
Nose and mouth are suctioned with bulb
Initial set of vital signs can be obtained while infant remains on the chest with mom
Initial care contniued
-Newborn medications are administered (Vitamin K, Erythromycin,
hep B vac)
-After the golden hour the infant will be moved to the radiant warmer and a comprehensive
physical exam will be completed, measurements taken, footprints obtained, identification
bracelets will be placed on the ankle and wrist along with a security band
(hugs band).
-If the parents have a cord blood collection kit then nurse may also be involved in collecting
blood and maternal specimens
-Mother and baby are usually transferred to the postpartum unit after about two hours
Apgar scoring Add score together to achieve a number out of ten. Completed at 1 and 5 minutes after birth.
Additional scores are obtained if scores remain below 7. Complete at 5 minute intervals until 20
minutes after delivery . **** CHART example on slide 49
Characteristics of newborn
• VERNIX - LANUGO
• MILIA -NEWBORN RASH
• ACROCYANOSIS - CAPUT SUCCEDANEUM
• OVERRIDING SUTURES -MOLDING
• MONGOLIAN SPOTS/BIRTH MARKS - FORCEPS
MARKS/VACUUM
Modules 9
Factors that influence the outcome of at risk neonates
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Birth weight
Gestational age
Type and length of illness
Enviromental factors
Maternal newborn seperation
Predictable Risk Factors
• Low socioeconomic level of mother
• Limited access to healthcare or no prenatal care
• Exposure to environmental dangers, such as toxic chemicals, and illicit drugs
• Preexisting maternal conditions (heart disease, diabetes, HTN, hyperthyroid, renal disease)
• Maternal factors (age, parity)
• Pregnancy related medical conditions
• Pregnancy complications (abruption, oligohydramnios, PTL, PROM)
Definitions
Preterm: less than 37 weeks of pregancy
Term: 37-41 and 6/7 completed weeks of pregancy
Postterm: greater then 42 weeks of pregnancy
Late term infant (LPI) : refers to subgroup
Weight Related Alterations SGA (Small for Gestational Age)
• Diagnosis is dependent on measurements including birth weight, length,
occipital-frontal circumference, and gestational age
• Less than the 10th percentile for birth weight.
• The newborn may be preterm, term, or postterm.
• Maternal conditions that restrict blood flow to the fetus
• Increased risk of perinatal asphyxia, perinatal mortality, polycythemia and
hypoglycemia
• Short stature runs in families
• Treatment: promote growth, monitor for potential complications
Weight Related Alteration
LGA (Large for Gestational Age)
• Weight is at or above the 90th percentile
• Associated with maternal diabetes, genetic predisposition, multiparous women, erythroblastosis fetalis,
Beckwith-Wiedemann syndrome or transposition of the great vessels
• Treatment: accurate estimation of gestational age, assess for birth
trauma, monitor for hypoglycemia, polycythemia and
hyperbilirubinemia
Weight Related Alteration
IUGR (Intrauterine Growth Restriction)
• Decreased growth potential! Related to genetic or environmental influences.
• Pregnancy circumstances of advanced gestation and limited fetal growth most commonly associated
with lack of prenatal care, age extremes, low socioeconomic status, HTN, Mulitples, and grand
multiparity.
• May be related to environmental factors such as excessive exercise, exposure to toxins, high altitudes,
and maternal drug use.
• Treatment: early ID, assess for in utero infection, monitor for hypoglycemia, promote growth after
discharge and neonatal stimulation programs to promote neurological growth.
**** SOOOO WHILE AN NFANT WITH IUGR MAY ALSO BE SGA: NOT ALL SGA INFANTS CAN BE CLASSIFIED
AS IUGR !!! THIS IS IMPORTANT TO KNOW
*****THE TERM IUGR SHOULD NOT BE USED WHERE THEIR IS NO EVIDENCE OF ABNORMAL GENTIC OR
ENVIROMENTAL INFLUENCES AFFECTING GROWTH
Patterns of IUGR
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Symmetric (proportional ) : caused by Longterm maternal conditions (HTN, malnutrition,
infection, substance abuse, or fetal genetic abnormalities) ID in second trimester US – chronic
prolonged restricted growth
Asymmetric (disproportional) associated with an acute compromise of uteroplacental blood flow:
placental infarcts, preeclampsia, poor weight gain. May notbe evident before third trimester
because weight is decreased but head circumference and length remain appropriate for
gestational age
Conditions Present at Birth
IDM (Infant of Diabetic Mother)
• Often LGA, macrosomic, ruddy in color, and have excessive adipose tissue, decreased total body water,
edema, cardiomegaly, and trouble regulating blood sugar.
• Warrants close observation.
• Treatment: assess BS frequently, monitor for hypoglycemia(tremors, cyanosis, apnea, temperature
instability, poor feeding, hypotonia; watch for seizures, hypocalcemia,hyperbilirubinemia, and
polycythemia
• Assess for birth trauma! (Erbs palsy, broken clavicle, bruising etc.)
Conditions Present at Birth
Postterm Birth
• Born after 42 weeks of gestation
• More frequent in individuals from Australia, Greece and Italy
• Large normal
• Higher mortality rate (2-3X) and morbidity
• Complications include hypoglycemia, meconium aspiration, polycythemia, congenital
anomalies, seizures, and cold stress
Prematurity
-A baby born at less than 37 completed weeks of pregnancy is considered premature.
-Approximately 10% of all births in USA
-Modern technological advances allowing for survival at younger and younger gestational ages
but not without significant morbidity!
-Also, the rise in multiple birth rates related to fertility treatments has also increased the number
of preterm births
Thermoregulation of the preterm infant :
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Heat loss is a major issue related to limited availability of glycogen in the liver and the amount of
brown fat available for heat production
Both of these limiting factors appear in the third trimester
Cold stress triggers metabolism of brown fat metabolism to create heat production-premature
infant does not have much brown fat
A hypoxic infant cannot increase oxygen consumption in response to cold stress because already
limited reserves
Newborn becomes progressively colder
Smaller muscle mass and diminished muscle activity making them unable to shiver
Anatomic Factors That Increase Heat Loss in Premature Infants
1. The preterm newborn has a higher ratio of body surface to body weight
2. The preterm newborn has very little subcutaneous fat, which is the human body’s insulation
3. The preterm newborn has thinner, more permeable skin than the term neonate
4. The posture of the preterm newborn influences heat loss (degree of flexion)
5. The premature newborn has a
Nectrotizing Enterocolitis
Result of decrease blood flow and tissue perfusion to the intestinal tract because of prolonged hypoxia
and hypoxemia at birth ** pix on slide 66
Nutrition and fluid requirements
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Oral caloric intake necessary for growth in a healthy preterm newborn is 95-130kcal/kg per day
with added protein needs.
Breast milk or special preterm formulas
Early feedings are extremely valuable in maintaining normal metabolism and decreasing
possibility of complications including hypoglycemia, hyperbilirubinemia, hyperkalemia, and
osteopenia of prematurity Immaturity of digestive system
** know gavage feeding slide 68 pix
Long Term Needs of Premature Infant
1. Retinopathy of Prematurity (ROP): characteristic retinal changes which result in visual
impairment. Premature infants do not have all the blood vessels to the retina that a term
newborn has. When they grow, they grow abnormally and develop fibrous tissue that scar and
constrict and result in retinal detachment. Most acute changes with ROP regress spontaneously
with no long-term impairment.
• Treated with cryotherapy and laser photocoagulation
• Most incidences with VLBW (very low birth weight) infants
Alterations of Prematurity
1. Apnea of Prematurity: cessation of breathing for 20 seconds or longer, or for less than 20 seconds
when associated with cyanosis, pallor, and bradycardia
• Usually presents between day 2 and 7 of life related to neurological immaturity
2. Patent Ductus Arteriosus (PDA): DA fails to close because of decreased pulmonary arteriole
musculature and hypoxemia.
• Symptoms seen around the time when premature neonates are recovering from respiratory distress
syndrome
3. Respiratory Distress Syndrome: inadequate surfactant production (grunting, nasal flaring, cyanosis,
intercostal retractions)
4. Intraventricular Hemorrhage: greatest occurrence in infants weighing less than 1500g or less than 34
weeks gestation. Blood vessels of germinal matrix rupture in response to hypoxia.
5. Anemia of Prematurity: risk increased related to rapid rate of growth required, shorter red blood cell
life, excessive blood sampling, decreased iron stores, and deficiency of vitamin E. Hgb reaches
lowest level by 3-12 weeks and remains low for 3-6 months.
Benefits of skin to skin
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Improved oxygenation and saturation levels
Enhanced temperature regulation
Decline episode of apnea and bradycardia
Increased period of quite sleep
Stabilization of vital signs
Positive reaction between parent and baby bonding and attachment
Increased growth parameters
Early discharge
Module 10 sexuality ethics and advocay
Concept of sexuality:
DEFINITION: SEXUALITY IS AN IMPORTANT PART OF BEING HUMAN AND CONTRIBUTES TO HEALTHY
RELATIONSHIPS AND A SENSE OF WELL-BEING. SEXUALITY CAN BE GENERALLY DEFINED AS AN
INDIVIDUALLY EXPRESSED AND HIGHLY PERSONAL PHENOMENON, AND ITS MEANING EVOLVES FROM
LIFE EXPERIENCES
Definition of Concept of sexuality
Interrelated concepts: culture and diversity, safety, trauma, infection, reproduction Gender and gender
identity Sexual preference Sexual dysfunction
Nursing assessments interview
ASSESSING A PATIENT’S SEXUAL HEALTH HISTORY CAN BE CHALLENGING BECAUSE IT
MAY BE COMPLICATED BY PHYSIOLOGIC AS WELL AS SOCIAL, CULTURAL, AND
PSYCHOLOGICAL FACTORS. PATIENTS MAY BE HESITANT TO DISCUSS THESE SENSITIVE
TOPICS AND YOU, AS THE NURSE, MAY FEEL UNCOMFORTABLE ADDRESSING SUCH
INTIMATE, PERSONAL DETAILS.
HOW ARE EXAMS SIMILAR? Male Vs Femal exams
• INSPECT AND PALPATE BOTH
• AREOLA AND NIPPLE (BESIDES SIZE) SHOULD BE SAME AS FOR WOMAN
• STILL LOOKING FOR MASSES, ENLARGED LYMPH NODES, LESIONS, PEAU D’ORANGE, DRAINAGE
FROM NIPPLES
• BOTH HAVE MONTGOMERY TUBERCLES
HOW DO THEY DIFFER?
• DURING INSPECTION WOMEN ARE PLACED IN VARIOUS POSITIONS FOR EXAM
• WOMEN MAY NORMALLY HAVE SOME LUMPINESS TO BREAST ESPECIALLY DURING
MENSTRUATION
• MEN NOT “ROUTINELY” EXAMINED; USUALLY EXAMINED IF COMPLAINT IS PRESENT (LUMPS FELT
BY PATIENT OR PARTNER)
S/S of abnormal breast exams
RETRACTIONS OR DIMPLING OF SKIN AND TISSUE (PEAU D’ORANGE)
• LESIONS, EXCORIATION, DISCHARGE TO SKIN OR NIPPLE
• RECENT UNILATERAL INVERSION OF THE NIPPLE OR ASYMMETRY IN POINTING
DIRECTION OF NIPPLE
• TENDERNESS, FULLNESS, INFLAMMATION
• NODULES IN THE TAIL OF THE BREAST
• HARD, IRREGULAR, FIXED UNILATERAL MASSES THAT ARE POORLY
DELINEATED
s/s of abnormal penis findings
NARROW OR INFLAMED FORESKIN
• INFLAMMATION OF THE GLANS PENIS
• ULCERS, VESICLES, WARTS
• NODULES OR SORES ON GLANS
• ERYTHEMA OR DISCHARGE FROM URINARY MEATUS
• EXCORIATION OR INFLAMMATION OF PENIS SHAFT
NURSING INTERVENTIONS
• PATIENT EDUCATION (AGE AND DEVELOPMENT RELATED TO SEXUALITY)
• PATIENT EDUCATION ABOUT HUMAN SEXUAL RESPONSE
• EDUCATION: BIRTH CONTROL
• EDUCATION: SAFE SEX PRACTICES
• EDUCATION: STI S PREVENTION AND TREATMENT IF NECESSARY
• EDUCATION: BREAST SELF EXAM, TESTICULAR EXAM
• COUNSELLING: PHARMACOLOGY AND ITS EFFECTS ON SEXUALITY
• REFERRALS: COMMUNITY-BASED RESOURCES AS NECESSARY (PSYCHOLOGISTS, SUPPORT
GROUPS, SEX THERAPISTS)
Concept of Communication
• The term communication has various meanings depending on the context in
which it is used. It can be the interchange of information, thoughts, or ideas between two or
more individuals. It is any means of exchanging information or feelings between two or more
individuals and is a basic component of human relationships, including nursing. Communication is
used to elicit a response or to influence others to respond and to obtain information.
Communication may be verbal or non- verbal, electronic, or written
Introduction to ethical practice
A SYSTEM OF MORAL PRINCIPLES OR STANDARDS GOVERNING BEHAVIORS AND RELATIONSHIPS THAT
IS BASED ON PROFESSIONAL NURSING BELIEFS AND VALUES. ETHICS REFERS TO THE STANDARDS OF
RIGHT AND WRONG THAT INFLUENCE HUMAN BEHAVIOR, USUALLY IN TERMS OR RIGHTS, OBLIGATIONS, BENEFITS
TO SOCIETY, FAIRNESS, OR SPECIFIC VIRTUES. ETHICAL STANDARDS ARE. BASED ON THE VALUES OF THE GROUP
THAT HOLDS TO THOSE STANDARDS, WHETHER THE GROUP CONSISTS OF INDIVIDUALS OF THE SAME RELIGION,
PEOPLE FROM THE SAME COMMUNITY, OR INDIVIDUALS WHO SHARE THE SAME PROFESSION.
• IN NURSING THE MOST IMPORTANT ETHICAL STANDARDS RELATE TO THE RIGHTS OF PATIENTS AND THEIR
FAMILIES, SUCH AS THE RIGHTS TO PRIVACY AND SELF-DETERMINATION.
FACTORS THAT INFLUENCE ETHICAL PRACTICE
• MORALITY: PRIVATE, PERSONAL STANDARDS OF WHAT IS RIGHT. AND WRONG IN CONDUCT,
CHARACTER, AND ATTITUDE.
• VALUES: PROVIDE THE FOUNDATION ON WHICH AN INDIVIDUAL’S STANDARDS ARE BUILT;
PERSONAL BELIEFS ABOUT THE TRUTHS AND WORTH OF THOUGHTS, OBJECTS, OR BEHAVIOR.
ESSENTIAL NURSING VALUES: ALTRUISM, AUTONOMY, HUMAN DIGNITY,INTEGRITY, AND SOCIAL
JUSTICE.
• BELIEFS: AN INTERPRETATION OR CONCLUSION THAT ONE ACCEPTS AS TRUE
• PRINCIPLES AND PRACTICES OF ETHICAL DECISION MAKING: AUTONOMY, BENEFICENCE,
JUSTICE, VERACITY, APPLICATION OF THE PRINCIPLES
Factors that influence communication
-Developmental level, Gender, Sociocultural, Characteristics, Values and Perceptions,
Personal Space, Territoriality, Roles and Relationships, Environment, Congruence Interpersonal Attitudes.
-Barriers to Communication Include:
stereotyping, agreeing and disagreeing, being defensive, challenging, probing, testing, rejecting, changing
topics and subjects, unwarranted or false reassurance, passing judgement, giving common advice,
Concept: Teaching and Learning
• Teaching is a system of activities designed to produce learning
• Learning is a change in human disposition or capability that persists and cannot be solely
accounted for by growth. It is represented by a change in behavior; or ability to demonstrate what
has been learned.
• The teaching and learning process involves dynamic interaction between teacher and learner.
Each participant in the process communicates information, emotions, perceptions, and attitudes to
the other person
Concept of quality improvement
Quality improvement consists of “systematic and continuous actions that lead to measurable
improvement in healthcare services and the healthstatus of targeted patient groups” (Health
Resources and Services Administration, 2011).
Quality management includes evaluation of medical and nursing processes for quality and effectiveness
compared to accepted standards in order to correct problems before they harm patients and to prevent
errors in treatment. It also seeks to provide cost- effective care preventing overuse, misuse, and
underuse of medical resources
Examples of quality improvement in nursing
The profession of nursing uses quality improvement projects to improve patient
care and patient outcomes. One such QI project would be for example efforts
to improve infection rates related to foley catheter use. A QI project would
aim to evaluate nursing process such as insertion technique, care technique etc.,
and look at where those processes could be improved upon to reduce infection and promote successful
patient outcomes (audit and analyze). The six priorities for high quality care include patient safety,
person/family centered care, care coordination, effective prevention and treatment, healthy living,
and affordability.
Of quality improvement the healthcare system should
Safe: avoiding injuries to patients from the care that is intended to help them
Effective: provide services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to benefit
(underuse vs overuse)
Patient-Centered: care that is respectful and responsive to individual patient
preferences, needs and values that guide all clinical decisions
Timely: reducing wait times that result in harmful delays for both those who
receive and those who give care
Efficient: avoiding waste, including waste of equipment, supplies, ideas, and
energy
Equitable: provde care that does not vary in quality because of personal
characteristics such as gender, ethnicity, or geographic location
Evidence based practice as it relates to quality improvement
-Evidence based practice forms a bridge between research and nursing practice.
-Evidence is defined as clinical knowledge, expert opinion, or information resulting from research
-Evidence-based practice includes these three components: a) the best evidence from the most current
research available; b) the nurse’s clinical expertise, and c) the patient’s preferences, which
reflect values, needs, interests, and choices.
-Integration of these components of EBP into clinical decision making helps to individualize patient care
and provide best practice for patient centered care
Concept Introduction: Legal Issues
• Legal issues encompass the rights, responsibilities and scope of nursing practice as defined by state
and nurse practice acts and as legislated through criminal and civil laws. All patients have a privilege,
demand, or claim by virtue of law or right to expect competent nursing services. The student must be
equipped to provide safe nursing care consistent with legal requirements and to gain an awareness of
ways to minimize the risks of errors due to accident, carelessness, system failures or malpractice
WHAT TO REVIEW
Nursing practice act and what it is :describes and define the legal boundaries of nursing withing each
state
American nurses association and what is does : fosters high standards of nursing practice, promotes safe
and ethical work environment, bolstering health and wellness of nurses and advocating on health care
issues that affect nurses and public
HIPPA: Health Insurance Portability and Accountability Act: a far-reaching legislative act passed that
directs healthcare providers in how and with whom health care information can be shared
and utilized.
ETHICS ( Morality, values , beliefs, principles and practices of ethical decision-making)
Concept of patient advocacy :
Accountability : accountability is being answerable for the outcomes of a task or assignment. Nurses are
accountable for their own actions and behaviors, but they may also be accountable for the actions of others, such as
subordinates or trainees. Different than responsible. Responsibility is related to a specific obligation associated with
the
performance of duties or a particular role. Belongs to individual performing the duty.
EBD : use of best availibale research findings along with ones personal experiences, cultures valus and
personal preferences to provide individualized patient care using optimal appropriate care approach
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Best practice
Critical thinking and decision-making
Laws and proffesional regualtion
Professional accountability
Quality improvement efforts