ATI-Women's health
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ATI—Reproductive Cycle—Chapter 1 (1-19)
Infertility—no conception with unprotected sex for at least 12 months. Common factors—decreased sperm,
ovulation DOs, tubal occlusions, and endometriosis. Meds used increase risk of multiple births >
25% Assessment (p13) Age, duration of infertility, OB hx (spontaneous abortions), Medical hx,
surgical hx, sexual hx (coitus frequency, # past partners, hx STIs), occupational/environmental
exposure risk, provide infor on assisted reproductive therapies (in vitro fert., embryo transfer,
intrafallopian gamete transfer, surrogate partenting, adoption)
Genetic counseling—Identify clts in need of genetic counseling. Exp. Clt has Sickle cell trait, history of
birth defects, <16 yrs and >35 yrs. Provide info on risk of occurrence, assist in construction of
family medical histories of several generations, provide emotional support(denial, anger, grief,
guilt, self blame), make referrals to support groups p13
Prenatal assessments thru—chorionic villus sampling, PUB (percutaneous umbilical blood sampling), and
amniocentesis ---all have potential risks to fetus
Infertility Procedures:
Pelvic Exam—assess for vaginal or uterine anomalies
Hysterosalpinography—radiological check for patency of fallopian tubes, check for iodine and
seafood allergies.
Hysteroscopy—radiographic exam of uterus—defect, distortion, scar tissue
Laparoscopy—gas insufflation—visualize internal organs---general anesthesia used
Semen collection—used first, least invasive, 40% infertility RT men
Contraception Procedures
Vasectomy—infertility after approx. 20 ejaculations (1wk-several months)
Tubal ligation (salpingectomy)—from cutting, burning, or blocking
Hysterectomy—partial (uterus), complete (uterus, bilateral fallopian tubes and ovaries)
Contraception Assessment
BRAIDED—acronym for informed consent
B—benefits--advantages
R—risks--disadvantages
A—alternatives
I—inquires—clt ask questions
D—decisions
E—explanations—give info on selected method
D—documentation (info given U clts understanding)
Types of Contraception:
Abstinence
Adv.—most effective method, only safe sex if no genitalia contact
Disadv./Risks—required self-control, otherwise no risks
Coitus interruptus (withdrawl)—
Inst.—can have leakage of fluids from penis
Adv.—provides a form of Birth Control if no other option is available (?religious,area)
Disadv.—Lease effective method, no protections against STIs
Risks—men have to control ejaculation, fluid leakage from penis could contain sperm
Calendar Method(Rhythm)—based on sperm viable for 2-5 days & ovum for 1 day
Inst—record cycle for 6 months, subtract 18 days from # of days of shortest cycle,
Subtract 11 days from longest cycle. Fertile between these days of cycle.
Adv.—inexpensive, useful when used with other methods (BBT & cervical mucus)
Disadv.—not very reliable, requires record keeping & compliance of both partners
Risks—pregnancy from ovulation outside predicted days of cycle
Basal Body Temperature (BBT)—temp drops with ovulation
Inst.—take oral temp PRIOR to getting OOB each AM
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Adv.—inexpensive, convenient, no side effects
Disadv.—inaccurate Temp interpretation (stress, fatigue, illness, alcohol, ambient temp)
Risks—unwanted pregnancy
Billings Method—cervical mucus thick/sticky, greatest stretch at ovulation (spinnbarkeit sign)
Inst.-handwash first, obtain mucus from vaginal introitus
Adv.—with practice self-eval can be very accurate, can determine ovulation during
lactation or menopause
Disadv.—women may feel uncomfortable with method
Risks—may in inaccurate if: mucous mixed w/ semen, contraceptive creams, or
discharge from infections
Condoms
Inst.—leave empty space at tip, hold rim on withdrawal, use with spermicidal cream for
Improved effectiveness.
Adv.—some protections against STIs
Disadv.—high rate of noncompliance, reduces spontaneity, must withdraw while erect
Risks—rupture/leakage, allergies to latex, use only water-soluble lubricants
Diaphragm and spermicide
Inst—get fitted, refitted q 2 yrs & with 15 wt. gain, stays in 6+ hrs after coitus, empty
Bladder prior to insertion, reapply spermicide with additional coitus
Adv.—no surgery needed, gives woman control over contraception
Disadv.—inconvenient, reduces spontaneity, additional cream needed with each coitus
Risks—NOT recommended for clts with history of TSS (toxic shock ) or UTIs
TSS is a bacterial infections. S/S: high fever, faint feeling, drop in BP, watery
diarrhea, headache, and muscle aches. Prevention: hand washing & removal of
diaphragm after 6 hrs
Combined Oral contraceptives—estrogen & progestin—suppresses ovulation, thickens mucus to
Block semen, alters uterine decidua to prevent implantation
Inst—prescription needed, consistent use required, has SE: chest pain, SOB, leg pain from a
possible clot, headache, eye problems, CVA, HTN; miss 1 pill-take 1 ASAP, miss
2—take 2 for 2 days, miss 3—skip doses for 4 days, restart new packet and use
alternate birth control
Adv—highly effective, can alleviate dysmenorrhea, reduces acne
Disadv—no STI protection, increase risks of thomoses, breast tendersness, stoke, nausea,
Headacheds, hormone-dependent cancers, can te teratogenic, exacerbates conditions
Affected by fluid retention (migraines, epilepsy, asthma, kidney/heart disease)
Risks—Do not use if >35yrs, or have history of any of the above, or smokes, decreased
effective with meds that affect liver enzymes (anticonvulsants & some antibiotics)
Minipill—oral progestins
Inst—take pill at same time daily, do not miss fill, use other form of control for 1st month
Adv—fewer side effects to combination oral contraceptives
Disadv—less effective in suppressing ovulation, increases ovarian cysts, no STI protection
Breakthrough bleeding, increases appetite
Risks: decreased effectivness with meds that affect liver enzymes (see above)
Emergency oral contraceptives (morning after pill) (high estrogen & progestin)
Inst—take within 72 hrs, take with antiemetic 1 hr prior, check for pregnancy if menstration
doesn't occur within 21 days, counsel on contraceptive methods & risky behavior
Transdermal Contraceptive patch—progesterone & ethinyl estrodiol
Inst—appy to dry skin on buttocks, abdomen, upper arm, torso (not breast area)
Adv.—consistent blood levels of hormone, avoids liver metabolism of med, not forget pill
Disadv.—No STI protection, same SE as oral contraceptives
Risks—same as oral contraceptives, avoid areas of skin rashes or lesions for application
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Injectable progestins (Depo-Provera) IM injections q 11 – 13 weeks
Inst—injection during 1st 5 days of menstrual cycle & q 11 –13 wks thereafter
Adv—very effective, 4 shots/year, not impair lactation
Disadv—prolong amenorrhea/uterine bleeding, risk of thomboembolism, no STI protection
Risks—no not message injection site as may accelerate med absorption
Implantable progesin levonorgestrel (Norplant) surgicaql implantation of 6 capsules
Inst—avoid trauma to area of implantation (inner aspect of upper arm)
Adv—effective continuous contraception for 5 years, reversible
Disadv—irregular menstrual bleeding, no STI protection (use condom for STI protection)
Intrauterine device (IUD)—chemically active device, damages sperm, prevents implantation
Inst-monitor monthly after cycle to R/O migration or expulsion of device
Adv.—effective for 1-10 yrs, reversible, does not interfere with spontaneity
Disadv—increased risk for PID, uterine perforation, ectopic preg., No STI protection, report
abnormal bleeing, abdom. pain, pain w/coitus, foul discharge, fever, chills, change
in string length, or missing strings
Risk—CONTRAINDICATED if not in monogamous relationship and if never had child
Risk of bacterial vaginosis, uterine perforation, or uterine expulsion
Female Sterilization (bilateral tubal ligation)
Adv.—permanent contraception, sexual fxn unaffected
Disadv.—risks RT surgery, irreversible
Risks—ectopic pregnancy if pregnancy occurs
Male sterilization (vasectomy)
Inst—scrotal support & moderate activity post surgery, sterility delayed (20 ejaculations)
Adv—permanent, short/safe procedure, sexual fxn not impaired
Disadv—surgery, irreversible
Antepartum
ATI p20f
Gestation—conception to birth
Fertilization—union of egg & sperm to form ZYGOTE—cell divisions separate into trophoblast (outer
layer giving rise to placenta) & embryoblast ((inner core giving rise to embryo)
Implantation—Zygote implants into endometrium (called deciduas after inplantation) 6-10 days after
conception. Usually at uterine fundus
Chorionic villi—fingerlike projections from the trophoblasts that extend into maternal blood vessels of
deciduas. Place of oxygen & nutrition and waste exchange
Ovum stage (<14) –from cellular replication (morula), blastocyst formation, and differentiation into three
primary germ layers (endoder/ entoderm, mesoderm, ectoderm)
Embryo stage (day 15 to 8 wks)—most critical for development, greatest risk from teratogens. Women
should avoid lg groups of people to limit exposure to infections, Handwashing important
Layers of Embryo:
Endoderm/entoderm: inner most layer of cells that become internal organs (such as
intestines), epithelium of respiratory tract and other organs
Mesoderm: middle layer that becomes CT, bone marrow, muscles, blood, lymph tissue,
epithelial tissue, bones/teeth
Ectoderm: outer layer that develops into skin, nails, glands, CNS, PNS (peripheral NS)
Fetal Stage: (9wks to birth) viability possible >500g and 20 weeks, good chance viability >32 wks.
Viability dependent on oxygenation capabilities and CNS function
4 wk—fetal heartbeat starts, body flexed, C-shaped with arm and leg buds present
8 wk—all body organs formed, 1st indication of musculoskeletal ossification
8-12wk—FHR can be heard with Doppler
12wk—sex of fetus can be determined, blood forming in marrow, kidneys able to secrete urine
ATI-Women's health 4
16wk—face looks human, meconium present, heart muscle well-dev. Sensory organs differentiated.
20wk—preimitive Resp mov't begin, HR heard with fetoscope, quickening occurs, brain grossly
formed, vernix caseosa (protective cheese-like coating on skin) & lanugo (fine, downy hair)
24wk—body lean, but well-proportioned, lecithin (respiratory marker) begins to appear in amniotic
fluids, ability to hear.
28wk—brown fat present, eyes begin to open & close, weak suck reflex
32wk—subQfat increase, has fingernails/toenails, sense of taste present, hears sounds outside womb
38+wk—skin pink, body rounded, lanugo on shoulders & upper body only, vernix caseosa scant,
fetus receives antibodies from mother
Fetal circulation—blood oxygenated from placenta, fetal liver not in use as all nutrients from placenta
3 shunts reroute most of circulated blood past fetal lungs and liver
Ductus arteriosus—connects pulmonary artery with aorta (bypass lungs)
Foramen ovale—intra-atrial opening shunts blood from R L (bypass lungs)
Ductus venosus—shunts blood from unbilical vein to inferior vena cava (bypass liver)
Placenta—produces hormones needed to maintain pregnancy & performs metabolic fxns of respiration,
nutrition, excretion, and storage
Amniotic fluid—suspends the embryo/fetus and serves:
--maintain constant Temp., source of oral fluid, repository for waste, cushion to prevent injury,
allow fetal mov't & musculoskeletal devel., prevent umbilical cord compression, prevent
amnion ( inner membrane of the placenta) from adhering to the fetus.
Umbilical cord—2 arteries carry deoxygenated blood away, 1 vein carries oxygenated & nutrition to
fetus. Wharton's Jelly—surrounds cord & prevents pressure from interfering with fetal circulation.
Risk factors that can negatively impact fetal development & lead to complications:
Preterm LaborRDS (resp. distress syndrome)
Premature rupture of membranes fetal infection
Ectopic pregnancy
Ployhydramniosfetal congenital anomalies & abnormal fetal presentation
Oligohydramnios interuterine fetal death, cord compression, IUGR
Nuchal cord fetal asphyxia
Maternal diabeteslarge for gestational age fetus
Rh or ABO isoimmunization fetal hemolytic DO (erythroblastosis fetalis)
Maternal age <16 or >35- chromosomal anbnormalities.
Teratogenic effects in utero (maternal substance abuse, chemicals, radiation exposure, infections)
Smoking IUGR
Poor nutrition congenital anomalies (folic acid deficiency), IUGR
Multifetal pregnancy (dizygotic-2 ova & monozygotic-1 ova split)  abnormal attachment of
placenta, incomplete splitting of mono, tangling of cords, circulatory problems, IUGR;
3+ fetuses: restriction of blood flow available for each fetus & restrict uterine spaceIUGR
Uteroplacental insufficiencyt IUGR, fetal distress, neonatal morbidity, fetal death
Therapeutic & Diagnostic Procedures
Abdominal & transvaginal Ultrasound—assess fetal growth & development, fetal maturity
Biosphysical profile—assess amniotic fluid volume index, fetal breathing mov'ts, body mov'ts, fetal
muscle tone, fetal heart reactivity.
Amniocentesis—assess for genetic abnormalities or fetal lung maturity
Daily fetal kick counts—3x/day, count > 3 mov'ts / 60 minutes. No mov'ts in 12 hrs-notify Dr.
Complications of fetal development
Genetic abnormalities—defective genes, Inherited DOs, chromosone anomalies, multiple
pregnancy, ABO incompatibility
Congenital anomalies—malformations that are present at birth
IUGR (intrauterine growth restriction)—failure of fetus to grow at an expected rate
Fetal death or neonatal death
ATI-Women's health
Monitoring for abnormal diagnostic fetal assessments (decreased fetal mov'ts, abnormal FHR pattern,
abnormally excessive or inadequate fetal growth for duration of pregnancy, encourage early &
ongoing adherence or Drs recommendations and prescriptions.
Antepartum—Normal Physiological Changes of Pregnancy
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ATI p.33-44
Presumptive Signs of Preg—changes felt by the woman that makes her think she's pregnant
Amenorhea, M/V, fatigue, Urinary frequency, Breast changes, Quickening(Mov't felt at 16-20 wks),
uterine enlargement, linea nigra, chlosasma (mask of preg), striae gravidarum, darkened areola
Probable signs—changes observed by the examiner that makes the examiner think she's pregnant
Abdominal enlargement RT changes in uterine size, shape, or position; cervical changes, Hegar's
sign (softening and compressibility of lower uterus), Chadwick's sign (deepened violet-bluish color
of vaginal mucosa RT increased vascularity of area), Goodell's sign (softening of cervical tip),
Ballottement (rebound of unengaged fetus), Braxton Hicks contractions (painless, irregular
contractions relieved by walking), positive pregnancy fest, fetal outline felt by examiner.
Positive signs—signs that can only be explained by pregnancy
Fetal heart sounds, fetal mov't palpated by experienced examiner, visual of fetus w/ultrasound
Calculation of Delivery Date:
Nagele's Rule: subtract 3 months and add 7 days + 1 year to first day of LMP (or add 9mo.+7days)
McDonald method: measure fundal height in cm from 24-34 wks + 2 weeks (cm x 8, divided by 7)
Gravity—number of pregnancies
Nulligavida—never pregnant Primigravids—first pregnancy Miltigravida—2+ pregnancies
Parity—# of pregnancies in which the fetus reaches viability, whether born alive or not.
GTPAL=Gravidity, term births (38+ wks), preterm births, abortions/miscarriages, living children
Psysiological Stgatus of Pregnant client:
Reproductive- uterus increases in size, and changes shape and position; Ovulation/menses cease
Cardiovascular-CO (cardiac output) & blood volume increase; HR increases
Respiratory-maternal O2 need increase; during 3rd trimester chest size may enlarge
Musculoskeletal—body alterations and wt. increase necessitate an adjustment in posture. Pelvic
joints relax.
Gastrointestional- N/V (may be hormonal, or increased pressure of stomach / intestines)
Renal- GFR increases; urinary frequency is common
Endocrine-placenta  an endocrine organ- (hCG, progesterone, estrogen, etc) to maintain preg.
Serum & Urine Pregnancy tests—presence of hCG(human chorionic gonadotropin) earliest biochemical
marker for preg. (6-11 days in blood ; 26 days in urine) after conception following implantation;
--hCG begins w/implantation and peaks 60-70 days gestation, then declines until 140 days, then
increases until term.
--Higher hCG levels indicate multifetal preg., ectopic preg, hydatidiform mole (gestational
trophoblastic disease) or abnormal gestation such as Down syndrome.
--Slow increases or abnormal decreases may indicate threatened abortion
--Some meds may cause false + or — preg. results (anticonvulsants, diuretics, tranquilizers)
--urine samples should be first-voided moring specimens
Expected Vital signs
Blood pressure: same as prepreg. range 1st trimester and after 20 weeks.  5-10mmHg during 2nd
trimester. Position can affect BP-supine   BP due to pressure of uterus on vena cava and result
in fetal hypoxia (known as: supine hyptensive syndrome of supine vena cava syndrome) S/S are:
dizziness, lightheadedness, pale/clammy skin. Use wedge under one hop to alleviate pressure
Heart rate (HR):  10-15 BPM after 20 weeks and through pregnancy.
Respiration: RR  1-2 / min. Diaphragm may be elevated up to 4 cm, and SOB may be noted
Expected Physical Assessment findings:
ATI-Women's health
FH tones (110-160 baseline) w/ reassuring accelerations indicating an intact fetal CNS
Heart changes in shape and size to accommodate CO and  Blood volume, may hear murmurs
Uterine size: grows from 50g to 1000g (0.13 lbs). By 36 wks fundus at xiphoid process
Cervical changes: color changes to purplish-blue color, and softens in consistency
Breast changes: increase in size & areolas darken
Skin changes: Chlosma—mask of pregnancy ( pigmentation of the face)
Linea Nigra—dark line of pigmentations from umbilicus to pubic area
Striae gravidarum—stretch marks most notable found on abdomen & theighs
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Antepartum: Nutrition and Pregnancy ATI p. 45-54
Wt. gain: 25-35 lbs (11-14kg) : 3-4lbs (1-2kg) for 1st trimester and 1 lb ( ½ kg) per week
Excessive weight gain can  macrosomia and labor complications
Poor weight gain may low birth weight of newborn
300 calories / day increase in calorie for pregnancy. Breastfeeding 300-500 calorie increase
Increased protein and folic acid (crucial to neurological dev. & prevention of neural tube defects)
Sources of folic acid: leafy vegetables, dried peas/beans, seeds, orange juice & fortified products
Iron: supplements often needed. Iron absorption  w/ vit. C,  w/ milk, caffeine, tannin.
Sources of Iron: beef liver, red meats, fish, poultry, dried peas/beans, fortified cereals/breads
Calcium: 1000mg/ day for all women over 19yrs old; 1300 mg for those <19yrs
Sources: milk, Ca-fortified soy milk or OJ, nuts, legumes, & dark green leafy vegetables
Urine output > 30mL/hr
Nutritional Risk Factors:
Socioeconomic issues such as low income (WIC), teenagers, vegetarians (prone to low protein,
calcium, iron, zinc, Vit.B12), N/V, Anemia, Eating DO (anorexia nervosa or bulimia), PICA
Hgb, Hct:  Hcg & Hct due to plasma  exceeds red blood cell increase
Non-preg. Levels: Hgb: 12-16 g/dL
Hct: 36-47%
Pregnancy levels: Hgb: 10.5-16 g/dL
Hct: 32-47%
Hyperemesis gravidarum—persistent N/V  dehydration, wt. loss, possible electrolyte imbalances
Treatment: NPO, IV fluids, Control N/V, slowly progress to small feedings as tolerated
Pregnancy-induced HTN (PIH)—first occurs during pregnancy
 30mmHg SBP and  15mmHg DBP above baseline; elevation to >140/90
Other symptoms: edema, protein in urine
Treatment: monitor VS frequently, assess for edema & record daily weights, check for protein in
urine and ecourage high protein diet, monitor urine output w/foley if necessary, assess neurological
fxns (deep tendon reflex, headaccher, LOC), restrict activities, admin MgSO4 to prevent seizures
(med is a CNS depressant, monitor closely) S/S of toxicity: RR <12, loss of deep tendon reflexes, 
of urinary output to < 30 mL/hr, Calcium gluconate is antidote to MgSO4, C-Sec may be needed.
Gestational diabetes: first occurs during pregnancy
Treatment: restrict intake of calories and CHO; educate clt on monitoring BG & diet mgmt.;
educate clt on S/S of BG and BG
*Use insulin to BG, oral hypoglycemics can cause birth defects and are contraindicated*
Anemia: Hgb < 10.5-11g/dL and Hct < 32-33%
Treatment: Eat foods rich in iron: meat, poultry, fish. Fe supplements may be needed
Vit C helps in Fe aborption (green vegetables, citrus fruits, & potatoes)
Educate about constipation and darkened stools RT Fe supplements
Lactating women's nutritional plans: calorie intake, oral fluids, protein intake; avoid alcohol & caffeine;
avoid food substances that are not agreeing with the newborn.  of 300-500 calories/day
Anepartum: Perinatal Cultural Awareness
ATI p.55-64
ATI-Women's health
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Def of culture—values, beliefs, and practices of a particular gtroup athat incorportates attidudes and
customs learned through socialization with others. It includes language, communication style,
traditiosn, religions, art, music, dress, health beliefs, and heal practices
Ethnicity: bond or kinship a person feels with his or her country of birth or place of ancestral origin. It
exists regardless of whether or not a person has ever lived outside the US
Eliminating acultural nursing care: (care that avoids concern for cultural differences) It is the traditional
tendency to treat all clts as though no cultgural differences exist.
Culturally sensitive nursing: incorporates a client's cultural preferences into the prenatal care situation as
much as possible. It respects and is compatible with clt's culture and shows respect for the values
and beliefs of others.
Predominant culture is Anglicized or English-based.
Freely express positive and neg. feelings; Prefer direct eye contact, address people in a casual
manner; prefer a strong handshake; include fathers in childbirth classes, labor, and birth.
Native American—Indian nations found in N. America including Eskimos and Aleuts
Generally private, hesitate in sharing personal info, consider impatience disrespectful.; believe that
no person has the right to speak for another; lingering eye contact is an invasion of privacy and
disrespectful; may prefer a light passing of the hands vs strong handshake; stoicism during birth is
encouraged; father may be absent from birth; female family & friends attend birth; may want the
placent returned.
African American—ancestral origin in Africa
Hesitate to give more info than asked for; communication style is frequently loud and animated with
lots of body movement; comfortable with close personal space with family/friends; expressions of
pain are usually open and public; fathers and female attendants during labor and delivery.
Latinos—ethnic origins from Latin or So. America
Comfortable sitting close to interviewers; "evil eye" (bad omen or curse) can be given to child if the
child is admired and the admirer does not touch the child; eye contact is attentive and respectful;
prolonged staring is confrontational & intimidating; men are protective and authoritarian to women
and children and expect to be consulted in decision making; latino fathers may not prefer to play an
active role in labor & birthing process (prefer to observe or wait outside); generally vocal and active
during labor; prefer to keep their body covered.
Asian Americans—descend from China, Japan, Korea, Philippiines, Thailand, Cambodia, Laos, Vietnam
Respond with brief factual answers; do not openly disagree with authority figures; prolonged
lingering eye contact is invasion of privacy and disrespectful; prefer > an arms length distance
away; head should be touched only by close relatives; area between woman's waist and knee is
especially private (not to be touched by any man, except husband); tend to control their emotions
and expressions of physical discomfort; do not address by first name until told to do so; modesty is
important; father does not usually participate in birthing classes, labor, or delivery.
**Remember that diversity exists within cultural groups and not to stereotype
Ethnocentrism—belief that one's won ethnicity & culture are superior. Do NOT exhibit this.
Collect data about unique characteristics of a clt's culture to provide culturally sensitive care: (58-60)
Language & Communication style-eye contact, body space & distance, touch, emotional expression
Hygiene practices
Feelings about modesty—ask client whether the gender of her caregiver is of concern
Special clothing or ornamentation
Religion and religious practices (some muslin fathers whisper a prayer into neonates ear….p59)
Rituals surrounding birth—inquire about practices while pregnant
Family and gender roles
Proper forms of greeting and showing respect
Food habits and dietary restrictions (many Muslim and Jewish people do not eat pork)
Methods for making decisions
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Health beliefs and medical practices
Ask about expectations regarding newborn care and care of pregnant women
Mexicans- do not see eclipse—causes cleft palate
Native Americans & Asians—preg. women should be active and walk
Filipinos often believe any activity is dangerous
Latinos may think that sexual activity during pregnancy keeps canal lubricated
Vietnamese prohibit sexual intercourse during pregnancy harm to mom/fetus
Culturally sensitive nursing interventions of the perinatal client and family include:
Using a knowledgeable interpreter; Address the client as she prefers; Use culturally sensitive
communication techniques (cultural comfort zone & appropriate eye contact); respect the client's
food preferences; provide female caregiver if desired; respecting clt's decision regarding support
person; honoring the clt's health beliefs and practices; apologize if traditions/beliefs are violated.
Antepartum: Prenatla and Childbirth Education ATI 65-80
Prenatal education focus: self-care of discomforts of pregnancy, promoting safe outcome and positive
feelings regarding the childbearing experience.
The greatest period of danger to the developing fetus occurs between 17-56 days.
Stress healthy behaviors; avoid: OTC meds, alcohol, tabacco, substance abuse.
Nursing assessment in prenatal care includes:
Reproductive & obstetrical history; medical history (include immune status); family history (genetic
DOs), infections; current medications; substance abuse or alcohol use; psychosocial history
(emotional response to pregnancy), hazardous environmental exposure, diet/exercise.
Ascertain client's goals for birthing process.
Prenatal educations topics based on clt's learning needs (current knowledge, previous preg/birth experience)
1st trimester: physical/psychosocial changes; common discomforts of pregnancy and relief
measures; lifestye; complications and signs to report; choosing an obstetrician, fetal growth/devop;
prenatyal exercise, expected lab testing
2nd trimester: plans to breast/bottle feed; common discomforts and relief measures; lifestyle; fetal
mov't; complications, childbirth preparation
3rd trimester: birth plan; breathing/relaxation techniques; decisions about pain mgmt; S/S of labor;
labor process; infant carte; postpartum care; fetal mov't counts 2-3 X/day (3 mov'ts/hr)
Maternal adaptation to pregnancy: Emotional lability; ambivalence about pregnancy up to 3rd trimester
Common discomforts of pregnancy
--N/V—eat crackers/dry toast ½ to 1 hour before rising in AM; avoid empty stomach, spicy, greasy,
or gas forming foods; drink fluids between meals
--Breast tenderness—wear bra that provides adequate support
--urinary frequency—during 1st and 3rd trimester; empty bladder frequently, limit fluid intake before
bedtime, perform Kegel exercises
--UTI's—common during preg RT renal changes and vaginal flora becoming more alkaline
*Decreased risk: wipe from front to back, use soft, unscented TP, avoid bubble baths, use
cotton underpants, avoid tight-fitting pants, drink 8+ glasses of water per day
*Yogurt/acidophilus milk -- pH of urine and vaginal flora& cranberry juicepH of urine
*Urinate before and after intercourse to flush bacteria from ureathra
*Urinate as soon as the urge occurs—prevent retaining uringe
*notify Dr. if urine is malodorous or contains blood or pus
--Fatigue—during 1st and 3rd trimesters—engage in frequent rest periods
--Heartburn—2nd and 3rd trimester—eat small frequent meals, stomach not to empty or full, sit up
for 30 min after meals, ask Dr. prior to OTC antacids.
--Constipations—2nd &3rd trimester—drink plenty of fluids, high fiber diet, exercise regularly
--Hemorrhoids—2nd & 3rd trimester—warm sitz bath, witch hazel cool pads
ATI-Women's health 9
--Backaches—2 & 3 —exercise regularly, do pelvic tilts, proper body mechanics, good posture,
lie with legs slightly elevated.
--SOB/dyspnea occurs in 60% of women RT 4cm rise of diaphragm—maintain good posture, sleep
with extra pillows, do not overload stomach, contact Dr is symptoms worsen
--Leg cramps—3rd trimester RT compression of nerves & BVs & imbalance in Ca/P ratio; If
homan's sign is negative have client dorsiflex foot; stand with feet flat on the floor Message
and apply heat over affected muscle while leg is extended; a foot massage while the leg is
extended can help relieve cramping; Evaluate diet & Ca intake. Increase in milk will also
increase P and will not help. Ca supplements may be needed.
--Varicose veins & lower extremity edema—rest with legs elevated, avoid constrictive clothing,
wear support hose, avoid prolonged sitting/standing for long periods; do not sit with legs
crossed at the knee ?, drink plenty of fluids, moderate exercise to stimulate venous return.
--Gingivitis, nasal stuffiness, epistaxis—RT elevated estrogen levelsvasculaity & CT. Brush
teeth gently, good dental hygiene, use humidifier, use NS nose drops/spray.
--Braxton-Hicks contractions—change positions or walk can cause them to subside
--Supine hypotension—use side lying or semi-sitting position w/knees slightly flexed
Exercise during pregnancy—30 min of moderate exercise daily if not contraindicated
 wt. bearing exercise, avoid high-risk activities,  exercise level as pregnancy progresses
Maintain ability to converse easily during exercise to keep level within safe limits
Avoid becoming overheated, use of hot tubs/saunas; drink plenty of water
Danger signs during pregnancy
Gush of fluid ROM < 37wks;
vaginal bleeding;
abdominal pain --premature labor, abruptio placenta, ectopic pregnancy
persistent vomiting-- hyperemesis gravidarum
severe headaches, blurred vision, edema on face/hands, epigastric pain-- (PIH) preg. induced HTN
 temp--infection, UTI
Dysuria –UTI
Concurrent flushed dry skin, fruity breath, rapid breathing,  thirsts/urination, and headache--BG
Concurrent clammy pale skin, weakness, tremors, irritability, lightheadedness-- BG
Common birthing methods prepare a preg. woman,  her anxiety during labor/birth, provide education
about relaxation techniques and partner support during birthing process
--Dick-Read method—"childbirth without fear" focus is on relaxing all muscle groups
except the uterus
--Lamaze—focuses on partner-coached breathing techniques and relaxation with the woman
panting and using outside focal points during labor.
--Leboyer—not a childbirth preparation; focuses on reponses and need of the infant
"birth without violence" Reduce stress of infant in transition to extrauterine life.
--Bradley—stresses the partner's involvement as the birthing coach; uses abdominal
breathing techniques, focus on laboring woman's body; promotes general relaxation
with emphasis on a natural childbirth.
nd
rd
Antepartum: Diagnostic interventions Ch. 7 ATI p.80-98
Prenatal care dramatically reduces infant/maternal morbidity and mortality rates by the early detection of
potential problems. Majority of birth defects occur between 2-8wks. Prenatal care provides an
opportunity for: Ensure adequate daily folic acid, update immunization, encourage smoking
cessation, treat current infections, obtain genetic testing, provide counseling, ascertain maternal
exposure to hazardous materials.
Schedule: q monthly for 7 months; q 2 wks for 8th month; q weekly for 9th month
ATI-Women's health
10
Prenatal visit assessments:
Baseline weight, BP, fundal height (empty bladder first), leopolds maneuvers, pelvic exam (lst
visit); costovertebralo angle tenderness (indicitive of renal infection); Homan's sign, urine test
Routine Lab test during prenatal care:
Blood type, Rh factor, antibody screen, CBC w/differential, Hgb, Hct, hemoglobin electrophoresis
(identifiessicle cell /thalassemia), urinalysis (ID-DM, PIH, Renal disease, infection, occult
hematuria), 1hr glucose tolerance at 24-28wks (>135 requires follow up); 3hr glucose (fasting
overnight), venous blood sample checked at 1, 2, 3 hrs (2 elevated reading DM; PAP test;
vaginal/cervical culture (STIs, GB strep at 35-37wks); rubella titer; PPD (tuberculosis); Hep B,
Venereal Disease (syphilis screening mandated by law), HIV, TORCH (toxoplasmosis, other
infections, rubella, cytomegalovirus, herpes virus)
Ultrasound—20 min—early diagnosis of complications permitting earlier interventions
External—noninvasive, painless, safe procedure
Internal transvaginal—invasive procedure—more accurate evaluation; useful in obese clients,
during 1st trimester, detect ectopic pregnancy, ID abnormalities, establish gestational age.
During 3rd trimester used to evaluate preterm labor & accurate FHR patterns
Doppler ultrasound blood flow analysis—measures speed of RBCs traveling through fetal/uterine vessels
Useful in IUGR, identifying poor placental perfusion, adjunct in risk preg. RT HTN, DM, 2+fetuses
Ultrasound indications for use:
Pregnancy confirmation; gestational age; multifetal pregnancy; site of implantation; ectopic; fetal
growth and developemtn, maternal structure assess; fetal viability or death confirmation; R/O or
verify fetal abnormalities; vaginal beeding eval; amniotic fluid volume determination, fetal mov't
observation (FHR, breathing, activity), placedntal grading, adjust for other
procedures(amniocentesis, biophysical profile, PUB, etc.)
Ultrasound nursing management:
Drink 1-2 quarts of fluid prior to procedure
Place clt in supine position with wedge under right hip (prevent supine hypotension)
Nonstress test (NST)—eval of fetal well-being performed during 3rd trimester. Noninvasive procedure that
measures response of FHR to fetal mov't. Doppler transducer used to monitor FHR, tocotransducer
used to measure uterine contractions. Clt pushes button when she feels fetal mov't.
Reassuring/reactive/normal if FHR accelerates 15 bpm for > 15 sec and occurs 2-3 X/20min
(means placenta is adequately perfused and the fetus is well-oxygenated)
Nonreassuring/nonreactive/abnormal if FHR does not accelerate adequately with fetal mov't
or no fetal mov'ts occur. If nonreactive—further assessment with CST or BPP
Disadvantesages: high # of false "nonreactive" RT fetal sleep cycles, smoking, meds, immaturity
Indications for use of NST:
All pregnancies in 3rd trimester, twice/week for clt's with DM or risk for fetal death
NST nursing management
Have client drink OJ or be given glucose to  BG to stimulate fetal mov'ts; use semi-fowlers
position; have clt push button when feels fetal mov't; if no fetal mov'ts vibroacoustic stimulation for
3 seconds to waken fetus.
CST (contraction stress test)—stimulate contractions ( placental blood flow) and analyze FHR during
contraction to determine how fetus will tolerate stress of labor. Need 3-40 to 60sec contractions
within 10 minutes for assessment.
--Nipple stimulated CST—woman brushes her palm across her nipple for 2-3 min oxytocin
released contraction. Repeat process after 5 min. rest.
--hyperstimulation--contractions ( > 90 sec or more often then q 2 min) should be avoided.
Stimulate nipple intermittently with rest periods in between. Avoid bimanual stimulation of both
nipple unless one nipple is unsuccessful
ATI-Women's health 11
--oxytocin admin CST used if nipple stimulation is unsuccessful. Oxtocin given IV (contractions
started with oxytocin may be difficult to stop and lead to preterm labor)
Negative CST (normal finding)—no late decelerations of FHR during contractions
Positive CST (abnormal)-persistent and consistent late decals on > ½ of contractions. It
suggest uteroplacental insufficiency. Variable decals may indicate cord compression. Early decals
may indicate fetal heal compression.
Indications of CST: High risk pregnancies (DM, Postterm Preg), and nonreactive stress test.
CST nursing mgmt:
--obtain baseline of FHR, fetal mov't, and contractions for 10-20 min.
--initiate nipple stimulation if there are no contractions (roll nipple between thumb/forfinger or
brush with palm of hand). Stimulation should stop when contraction begins.
--monitor and provide adequate rest periods to avoid hyperstimulation
--initiate IV oxytocin admin if nipple stimulation fails to elicit uterine contraction pattern.
--monitor for contractions lasting > 90 sec and/or occurring more frequently than q 2 min.
**Biophysical Profile (BPP)—assess fetal well-being measuring 5 variables with a score of 2 for each
normal finding, 0 for abnormal finding. 8-10 being normal; 6 equivocal, < 4 abnormal
--Reactive fetal heart rate (reactive nonstress test = 2; nonreactive = 0)
--Fetal breathing mov'ts: (> 1 episode of 30 sec/30 min) = 2 (0 episodes or < 30 sec duration) = 0
--Gross body mov'ts: > 3 body/limb extensions w/return to flexion in 30 min = 2, < 3 episodes = 0
--Fetal tone: > 1 episode of extension w/return to flexion = 2; slow extension & flexion, lack of
flexion, or absent mov't = 0
--Amniotic fluid volume: > 1 pocket of fluid that measures > 1cm in 2 perpendicular planes = 2;
pockets absent or < 1 cm = 0
Indications for BPP include: nonreactive stress tests, suspected oligo/polyhydramnios, suspected fetal
hypoxemia/hypoxia, premature ROM, maternal infection
Amniocentesis—aspiration of amniotic fluid transabdominally with ultrasound after 14 weeks gestation.
Alpha-fetoprotein (AFP)—can be measured from maternal serum between 16-18 weeks, used to assess for
neural tube defects or chromosomal DOs
--High levels—assoc w/neural tube defects (spina bifida [open spine], anencephaly
[incomplete development of fetal skull/brain], omphalocele [abdominal wall defect]); may
be present with normal multifetal pregnancies.
--Low levels—assoc w/ chromosomal DOs (down's syndrome), gestational trophoblastic
disease (hydatidiform mole)
Tests for fetal lung maturity—in gestations < 37 weeks when PROM, preterm labor, early C-section needed
Glucocorticoids can be given to promote lung maturity
Fetal lung tests include:
--lecithin/ sphingomyelin (L/S) ratio; 2:1 indicating fetal lung maturity (3:1 for Diabetic)
Lecithin level increases after 24 weeks and sphingomyelin levels remain constant
--presence of phosphatidylglycerol (PG)—absence is assoc w/ respiratory distress
--foam stability index (FSI or shake test)—a ring of bubbles persists for 15 min after shaking
amniotic fluid sol'n indicates surfactant is present and fetal lungs are mature
Indications for amniocentesis: age > 35 yrs; previous birth w/chromosomal anomaly, family hx of neural
tube defects; parental genetic DO or congenital anomaly of fetal; alpha-fetoprotein level; pulmonary
maturity assessment; fetal hemolytic disease dx; meconium in the amniotic fluid; fetal fibronectin
levels elevated indicative of preterm labor.
Amniocentesis nursing mgmt:
Informed consent; empty bladder, supine position w/wedge; obtain baseline VS & FHR, monitor
VS during procedure, ultrasound 1 hr after to R/O bleeding or hematoma, admin RhoGAM if clt
Rh- ; clt to report fever, chills, leakage of fluid or bleeding from insertions site,  fetal mov't;
vaginal bleeding, or uterine contractions after procedure; clt to rest 24 hrs post procedure
--monitor clt's VS, T, resp. status, FHR, uterine contractions, vaginal D/C of amniotic fluid/blood)
ATI-Women's health 12
Amniocentesis risks: amniotic fluid emboli, maternal or fetal hemorrhage, fetaomaternal hemorrhage with
Rh isoimmunization, maternal or fetal infection, inadvertent fetal damage or anomalies involving
limbs, fetal death, maternal intestional or bladder damage, miscarriage or preterm labor, PROM,
amniotic fluid leakage;
Percutaneous umbilical blood sampling (PUB)—obtaining fetal blood sample from umbilical cord. Most
common method used for fetal blood sampling and transfusion. Blood studies:
--kleihauer-Betke test to ensure blood obtained is from fetus
--CBC w/differential
--Direct Coombs' test for Rh antibodies
--Karyotyping (visualizations of chromosomes)
Indications for PUB: diagnosing prenatal blood and chromosomal DOs, evaluating for isoimmune fetal
hemolytic anemia and if fetal blood transfusion is needed; karyotyping of malformed fetus,
detecting fetal infection, determining acid-base balance staus of fetus with IUGR, assessing and
treating isoimmunization and thrombocytopenia in the fetus.
PUB nursing mgmt: same as amniocentesis; plus continuous FHR monitoring for up to an hour after
Fetoscope—used to visualize the fetus to assess well-being by confirming the intactness of spinal column,
obtaining biopsy samples of fetal tissue, performing elemental surgery (shunts)
Chorionic villus sampling (CVS)—assessment of developing placenta and is a 1st trimester alternative to
amniocentesis with adv of earlier diagnosis of abnormalities. Can be performed at 10-12 wks with
chromosome studies avail in 1-2 days. Has  risk of fetal anomalies & death; client must drink fluid
to fill bladder; higher risk of spontaneous abortions with CVS than amniocentesis.
Indications for CVS: woman at risk for having infant with genetic chromosomal abnormality (can't
determine spina bifida or anencephaly). Other indications same as amniocentesis.
Antepartum: Complications of Pregnancy chapter 8 ATIp 99-131
Bleeding during pregnancy—always considered abnormal and needs to be investigated
Causes of bleeding by trimester:
1st—spontaneous abortion—vaginal bleeding, uterine cramping, partial/complete expulsion
ectopic pregnancy—abrupt unilateral lower quadrant abdominal pain with or w/o bleeding
nd
2 —gestational trophoblastic disease—uterine size increasing abnormally fast, hCG levels, N/V
( emesis), no fetus in ultrasound, scant/profuse dk brn/red vaginal bleeding
--incompetent cervix—painless bleeding w/cervical dilation
3rd—placenta previa—painless bleeding as cervix dilates
--abruptio placenta—vaginal bleeding, sharp abdominal pain, & tender rigid uterus
--preterm labor—pink-stained vag. d/c, uterine contractions becoming reg., dilation&effacement
Spontaneous abortion—terminated <20wks without intervention
Types of abortion—threatened (spotting/slight bleeding, mild cramping, no passage of tissue, no dilation
--inevitable—mild-severe bleeding, mild-severe cramping, no passage of tissue, dilation
--incomplete—severe bleed, severe cramp, passage of tissue, dilation w/tissue in cervix
--complete—slight bleeding, mild cramping, passage of tissue, no dilation
--missed—no bleed-spotting, no cramping, no tissue passed, no dilation (fetus died)
--septic—malodorous d/c, varied cramping, varies on passed tissue, usually dilated
--recurrent (>3 consecutive)-varied bleeding/cramping, passage of tissue, usually dilated
Risks factors for spontaneous abortions include:
Chromosomal abnormalities (account for 50%)
Maternal illness (insulin dependent DM)
Advancing maternal age
Chronic maternal infections
Maternal malnutrition
Trauma or injury
Anomalies in the fetus or placenta
Substance abuse
ATI-Women's health
13
Diagnostic & therapeutic procedures for abortions
Hgb, Hct if considerable blood loss; WBC for suspected infection; hCG levels to confirm pregnancy
Clotting factors for DIC (disseminated intravascular coagulopaty) from retained tissue
Ultrasound to determine presence of viable or dead fetus, partial/complete tissue in uterus
Examine cervix –open/closed
D&C-dilation&curettage-scrape uterine walls to remove contents of inevitable/incomplete abortion
D&E-dilate & evacuate-uterine contents after 16 weeks gestation
Prostaglandin-admin into amniotic sac or vaginal suppository to augment or induce labor to expulse
products of conception for late term, incomplete, inevitable, or missed abortion.
S/S for spontaneous abortion:
Vaginal spotting to moderate/severe bleeding with or w/o pain in early pregnancy
Passage of tissue (products of conception) Mild to severe uterine cramping
Backache;
ROM ; fever; abdominal tenderness; s/s of hemorrhage such as BP
Spontaneous abortion assessments:
Amt/color of bleeding (count pads), cervix for dilation; clt for pain (location/type/quality); amniotic
membranes; VS & T; risk for infections RT tissue; anticipatory grieving
Spontaneous abortion interventions:
Pregnancy test; use term "miscarriage"; bed rest w/ sedation for threatened, inevitable, incomplete;
Clt to avoid coitus; avoid vag. exam; help w/ultrasound; admin analgesics/blood products;
determine how much tissue has passed (saving all tissue); for septic abortion-amin broad
spectrum antibiotics; assist with D&C/D&E, admin RhoGAM to Rh- clt;
Ectopic pregnancy:
Risk factors: any factor that compromises tubal patency (PID, IUD, etc)
Procedures: transvaginal ultrasound showing empty uterus
Hormone levels of hCG (beta-human chorionic gonadotropin)
WBC elevated to 15,000/mm3
Methotrexate --to inhibit cell division/enlargement of embryo—prevent rupture of fallopian tube
(avoid alcohol & folic acid to prevent toxic response to methotrexate, protect from sun)
Rapid surgical treatment: linear salpingostomy to salvage tube if not ruptured/ removal if ruptured
S/S: missed menses, unilateral stabbing pain LAQ, scant, dk red/brown vaginal spotting; if tube
ruptures bleeding may be into intraperitoneal area; referred shoulder pain from blood
irritation of the diaphragm or phrenic nerve (common symptom); N/V frequent after rupture;
s/s of hemorrhage/shock (hypotension, tachycardia, pallor)
Nursing assess: abdominal unilateral pain, vag. Bleed, VS, T, skin color, respirations, urine output
Gestational trophoblastic disease (hydatidiform mole, choriocarcinoma, molar pregnancy)—is the
proliferation and degeneration of trophoblastic villi in the placenta which becomes swollen, fluidfilled, and takes on the appearance of grape-like clusters. They embryo fails to develop beyond a
primitive start and these structures are associated with choriocarcinoma, which is a rapidly
metastasizing malignancy. Two types of molar growths are identified by chromosomal analysis.
--complete mole—all genetic material is paternally derived; the ovum has no genetic material or it
is inactive; mole contains no fetus, placenta, amniotic membranes or fluid; there is no
placenta to receive maternal blood hemorrhage into uterine cavity & vag. Bleeding;
approx. 20% of complete moles progess toward a choriocarcinoma
--partial mole—genetic material is maternal and paternal; ovum fertilized by two sperm or one
sperm that failed to undergo meiosis (no chromosomal reduction & division); approx. 6% of
partial moles progress toward a choriocarcinoma.
Risk factors: low protein diet; < 18yrs, > 35yrs
Diagnosis/procedures/mgmt: levels of beta-hCG (1-2 million IU vs 400,000 IU for normal preg);
ultrasound will reveal dense growth/vesicle/no fetus; urinalysis for proteinuria; suction
curettage to aspirate & evacuate the mole; following evacuation—baseline pelvic exam &
ultrasound of abdoment with frequent follow ups; analysis of hCG levels q 1-2 wks until
ATI-Women's health 14
normal, then q 2-4 wks for 6 months, then q 2 mo for l years.  levels suggest malignant
transformation; chemotherapy for hCG levels, enlarging uterus, or find malignant cells
S/S: Rapid uterine growth (larger than expected for gestational age); vaginal bleeding (dk brownprune juice to bright red) that is scant to profuse and continues for a few days or is
intermittent for weeks, around 16 wks; may have vag d/c from clear fluid-filled vesicles;
hyperemesis gravidarum RT  hCG levels; s/s of PIH (BP, edema, proteinuria) prior to 20
wks [PIH usually does not occur until after 20 wks gestation]
assessments: fundal ht; vaginal bleed; GI status/appetite; VS; extremities & face for edema
Incompetent cervix—is painless passive dilation of the cervix w/o contractions; cerix in incapable of
supporting wt of growing fetus and results in expulsion around 20 wks of gestation.
Risk factors: cervical trauma (prev. lacerations, excessive dilations); in utero exposre of DES
(diethylstilbestrol)[ingested by clt's mother during pregnancy]; congenital structural defects,
maternal age; ultrasound showing short cervic (< 20mm in length) indicated cervical
competence; prophylactic cervicalo cerclage reinforces cervix—removed at 37 wks
assessments: s/s of incompetent cervix: bleeding or pink-stained vag. d/c,  pelvic pressure, ROM;
uterine contractions w/ expulsion of fetus;
interventions: activity restriction/ bed rest; hydrations (dehydration stimulates uterine contractions)
tocolytic meds, clt to refrain from: intercourse, prolonged standing, heavy lifting; clt to
report s/s of preterm labor (ROM, infections, strong contractions < 5min apart, severe
perineal pressure, and urge to push; use HUAM (home uterine activity monitor);
Placenta Previa—placenta abnormally implants in the lower segment of uterus (near/over) the cervical os,
which results in bleeding during 3rd trimester as cervix begins to dilate and efface.
3 types names for the degree in which the cervical os is covered by the placenta
--complete/total—cervical os is completely covered by placental attachment
--incomplete/partial—cervical os is partially covered by placental attachment
--marginal/low-lying—placenta is attached in lower uterine segment, but does not reach cervical os
Major complications: maternal hemorrhage and fetal prematurity or death
Risk factors: previous placenta previa, uterine scarring (prev. C-sec, curettage, endometritis),
>35yrs, multifetal gestation, multiple gestations or closely spaced pregnancies
Dx/procedures: transabdominal/transvaginal ultrasound-- placement of placenta; fetal monitoring,
Hgb, Hct, CBC, ABO typing, Rh factor, coagulation profile, emergency C-Sec
S/S: painless, bright red vaginal bleeding that  w/ cervical dilation; soft/relaxed, nontender uterus
w/ normal tone; fundal ht greater than expected; fetus in breech/oblique/transverse position;
palpable placenta, VS w/in normal,; urine output
Nursing interventions: bed rest; nothing inserted vaginally, Betamethasone for fetal lung maturity if
delivery of fetus is anticipated
Abruptio Placenta: premature separation, can be partial or complete detachment. Occurs after 20wks,
usually in the 3rd trimester. Is the leading cause of maternal death. DIC often assoc. with moderate
to severe abruption.
--key factors: HTN, abdominal trausma, cocaine abuse, previous abruptio, smoking, PROM, short
umbilical cord, multifetal pregnancy
--Dx/ procedures: ultrasound, BPP
--S/S: sudden onset of intense localized uterine pain; vaginal bleeding-bright red or dark; board like
abdomen that is tender; Firm, rigid uterus (uterine hypertonicity); fetal distress, s/s of
hypovolemic shock
--Assess: uterus for tenderness/tone; bleeding for rate/amt/color; FHR pattern; VS; Resp; cardiac;
skin color/turgor; capillary refll, LOC ,urinary output
ATI-Women's health 15
Hyperemesis Gravidarum HEG-is excessive N/V (RT hCG levels) prolonged past 12 wks & results in 5%
wt loss from prepregnancy wt, dehydration. Electrolyte imbalance, ketosis and acetonuria, may be
aqccompanied by liver dysfunction. --risk to fetus—IUGR and preterm birth
Risk factors: < 20yrs, obesity, lst preg, multifetal gestation, gestational trophoblastic disease, hx of
psych DOs, transient hyperthyroidism, VitB deficiencies, high stress levels
Dx: ketones & acetones in urine, spec gravity of urine,  liver enzymes, imbalance of electrolyes,
Hypokalemic acideosis from excess vomiting
S/S: excessive vomiting, dehydration, wt. loss, BP, HR, poor skin turgor
Interventions: NPO for 1-2 days, IV of lactated ringers, Vit B-6, antiemetic, advance diet to clear
liquids after 1-2 days, then advance as tolerated
Gestational HTN (GN), PIH
HTN disease in pregnancy is divided into clinical subset of the disease based on end-organ effect
and progresses along a continuum from mild GN, to mild and severe preeclampsia, eclampsia, and
hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome
GN—begins after 20 wks, BP > 140/90 or SBP  > 30mm or DBP  > 15 from pregnancy baseline
No proteinuria or edema; BP returns to baseline 6wks postpartum (PP);
GH and chronic HTN may occur simultaneously
Mild preeclampsia—is GN with additions of proteinuria of 1-2+, a wt gain > 1kg/wk in 2nd
Trimester and ½ kg/wk in 3rd trimester. Mild edema in upper extremities and face
Severe preeclampsia—BP > 160/100 or proteinuria 3-4+, oliguria, serum creatinine >1.2mg/dL,
Cerebral or visual disturbances (headache, blurred vision), hyperreflexia with possible ankle
clonus, peripheral edema, hypatic dysfxn, epigastric/RUQ pain, thrombocytopenia
Eclampsia—severe preeclampsia with seizures/coma. Preceded by: headache, severe epigastric
pain, hyperreflexia, hemoconcentrations (warning sign of probable convulsions)
HELLP—variant of GH in which hematologic conditions coexist with severe preeclampsia
involving hepatic dyfxn. HELLP syndrome is dx by laboratory tests-not clinically
--H—hemolysis resulting in anemaia & jaundice
--EL—elevated liver enzymes ALT & AST, epigastgric pain, N/V
--LP—low platelets (< 100,000/mm3) thrombocytopenia, abnormal bleeding/clotting time,
bleeding gums, petechiae, and possibly DIC
GH diseases are assoc w/ placental abruption, acute renal failure, hepatic rupture, preterm birth,
fetal/maternal death
Risk factors: no single profile identifies risks for GH disorders—some high risks include:
Age < 19 or > 40; 1st pregnancy; morbid obesity, multifetal gestation, chronic renal disease,
chronic HTN, diabetes, Rh incompatibility, molar pregnancy, previous hx of GH
Dx/Mgmt/procedures: Dip urine for proteinuria, 24hr urine collection for protein/creatinine
clearance; liver enzymes, serum creatinine, BUN and Mg  as renal fxn ; CBC; Blood
clotting; Nonstress test; doppler blood flow analysis
*Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the s/s of
pregnancy hypertensive disorders
S/S of hypertensive disorder of Pregnancy
Condition
Results
Generalized vasoconstriction HTN
Uteroplacental insufficiency IUGR, abruptio placenta, uterine contractablity
Glomerular damage
Proteinuria, plasma uric acid/creatinine, oliguria,  sodium retention
Generalized edema
Periorbital/facial/hand/abdominal edema, pitting edema after 12hr bed rest
Cortico brain spasms
Severe continuous headache, hyperreflexia of deep tendon, seizure activity
Pulmonary edema
Dyspnea/crackles, diminished breath sounds
Retinal arteriolar spasms
Dimming/blurring of vision; flashing lights/dots; scotoma(loss/dimin.vision)
Hemolysis of RBCs
hemoglobin, maternal hyperbilirubinemia, jaundice
Hepatic microemboli/
Liver damage
Platelet aggregation
Fibrin deposits
ATI-Women's health 16
liver enzymes (AST, LHD), N/V, epigastric pain, RUQ pain, BG (blood
glucose), liver rupture
Thombocytopenia (low platelets
DIC
Nursing assessments:
BP, edema, deep tendon reflexes, bicep/ankle reflexes, ankle clonus, FHR, RR, LOC, pulse
Oximetry, urine output, daily weights, VS
Nursing interventions: bed rest w/side lying position, diversional activities; avoid: foods w/Na,
alcohol, caffeine; 8glasses/day fluids; side rails up for seizure activity; dark quiet
environment to prevent seizure
MgSO4 med of choice as anticonvulsant (prophylaxis or treatment). It s BP & depresses CNS
Signs of MgSO4 toxicity : absence of patellar deep tendon reflex; urine output < 30mL/hr;
RR < 12/min;  LOC IF MgSO4 toxicity is suspected: D/C infusion, admin calcium
gluconate (antidote); prevent respiratory and cardiac arrest
SE: flushing and sweating
Gestational Diabetes is impaired tolerance to glucose w/ first onset during pregnancy (Norm 60-120mg/dL)
Symptoms my disappear a few weeks after birth. Approx. 50% of women will develop DM < 5yrs
Gestational Diabetes  risks for:
Spontaneous abortion RT poor glycemic control
Infections (urinary & vaginal) RT  glucose in urine
Hydramnios causes overdistention of uterusPROM, preterm labor, hemorrhage
Ketoacidosis RT untreated hyperlycemia, inappropriate insulin dosing
Hypoglycemia RT overdosing insulin , skipped/late meals,  exercise
Hyperglycemia excessive fetal growth (macrosomia)
Risk factors: age > 30yrs; obesity, family hx of DM, previous delivery of lg or stillborn infant
Dx/procedures/ Mgmt: routine urinalysis with glycosuria; glucola screening test (50g glucose load
w/ test 1hr after (at 24-28wks); 3hr glucose tolerance test w/overnight fasting, avoidance of
caffeine, no smoking12prior; fasting glucose is obtained, 100g glucose given, serum glucose
at 1,2,3 hrs. 2 tests above normal is positive test; BPP, Amniocentesis for alpha fetoprotein;
nonstress test ; ketones
S/S: hunger/thirst, frequent urination, blurred vision, excess wt gain during pregnancy
Interventions: teach s/s of BG and BG; oral hypoglycemic meds contraindicated (birth defects);
Have clt perform daily kick counts (10 fetal mov'ts in 12 hrs.)
TORCH is an acronym for infections that negatively affect a woman who is pregnant. They cross the
placenta and have a teratogenic affect on the fetus.
Infection
Risk factors
Maternal S/S
Management
T= toxoplasmosis Raw/undercooked meats
Flu s/s &/or
Spiramycin, sulfadine,
Handling cat feces
lymphadenopathy
pyrimethamine/sulfadiazine
O= other
Varies
Dependent of infection
Depends of infection
R= rubella
Contact w/infected
Rash,muscle ache, fetal
Vaccination—NO
German measles
person or infant w/
consequencesmiscarriage, Avoid crowds of children,
rubella during preg.
congenital anomalies, death vaccinate prior to preg.
C=
Transmitted via body
Asymptomatic or
No treatment exists
cytomegalovirus
fluids/droplet, trans. To
mononucleosis-like
Wash hands prior eating,
fetus in utero or birth
symptoms
avoid crowds of children
H= (HSV) herpes Direct contact w/ oral or
Lesions
Obtain HSV culture near
simplex virus
genital lesions. Transmit
term. Deliver C-sec w/
to fetus during vag.birth
active lesions
Intrapartum: Labor and Birth Process
ATI-Women's health
ATI chapter 9 p.132-146
17
5 fractors that affect the labor and birth process (5 "Ps")
Passenger –fetus & placenta fetal head size
Lie-relationship of spine to spine--Transverse & Parallel or longitudinal (cephalic/breech)
Attitude—relationship of fetal parts to one another-fetal flexion/ fetal extension (chin in/out)
Presentation—part entering pelvic 1st—occiput, mentum(chin), shoulder (scapula), breech
Fetal position(fetopelvic)—position RT maternal pelvic quadrants 3 letters
R/L; O (occiput)/S (sacram)/ M (mentum)/ Sc (scapula); A (anterior) /P (posterior)
/T (transverse)
Station—fetal descent 0 is at ischial spine, + is below and – is above
Passageway—birth canal composed of bonly pelvic, cerix, pelvic floor, vagina, introistus
Powers—uterine contractions that cause effecement and dilation; involuntary and voluntary pushing
Position of laboring woman—
Psychological response—stress, tension, anxiety can impair progress of labor
Therapeutic & Diagnostic procedures:
Leopold's maneuvers
External electronic monitoring (tocotransducer)—uterine contractions
Intrauterine pressure catheter (IUPC)—inserted into uterus to measure intrauterine pressure
Lab analysis—urinalysis, Blood tests,
Assessment: Frequency—beginning of one to beginning on next contraction
Duration—beginning to end of same contaction
Intensity—strength at it's peak—mild (tip of nose), moderate (chin), strong (forehead)
Resting tone—tone between contractions (prolonged duration or frequencyhypoxia & FHR)
Vaginal Exam—dilation/effacement; descent (station); fetal position/part/lie; membranes (ROM?)
Characteristics of true vs false labor
True labor
False Labor
Contractions: regular, stronger/longer/more frequent Painless; irregular; intermittent;  in frequency
Felt in lower back radiating to abdomen; walking
/duration /intensity w/walking/position change; felt
in lower back or above umbilicus; stop w/comfort
can intensity; continue despite comfort measures
measures such as oral hydration
Cervix: progressive dilation/effacement; moves to
Cervix: no sig. change in dilation or effacement;
anterior position; bloody show
remains in posterior position, no bloody show
Fetus: presenting part engages in pelvis
Fetus: not engaged in pelvis
Psysiologic changes preceding labor (premonitory signs) include:
Lightening-14 days before labor in primnips easier breathing, urinary frequency
Backache—constant low, dull backache RT pelvic muscle relaxation
Contractions; Bloody show; Weight loss (1-3lbs); Energy burst (nesting response)
ROM—labor usually within 24 hrs—prolonged ROM  infection
Amniotic fluid-assessment of:
Color—pale to straw yellow; Odor—not foul; Clarity—watery/clear; Volume— 500-1200mL
Nitrazine paper—detect pH—turns blue with alkalinity of amniotic fluid (urine is acid-yellow)
Fundal Height-assesment of:
16wks ½ way from smyphysis pubis and umbilicus
20-22 wks—at umbilicus
18-32 wks—empty bladder, McDonald's measurement; cm=weeks + 2 wks;
Mechanism of Labor—adaptations fetus makes as it progresses through birth canal
Engagement—station 0 as presenting part is at ht of ischial spines
Descent—progress of presenting part through the pelvis
ATI-Women's health 18
Look Flexion—when head meets resistance of cerix/pelvic wall/pelvic floor, chin to chest
at
Internal rotation—fetus rotates lateral anterior position past ischial spines in corkscrew motion
These Extension—occiput passes under symphysis
Steps Restitution and external rotation—after head is born rotates to transverse position
Expulsion—trunk born by flexing it towards symphysis pubis
Stages of Labor
Stage
Begins with:
Ends with:
Maternal characteristics:
st
1 stage
Onset of labor
Complete
Prinips-1cm/hr dilation
dilation
Multips- 1 ½ cm/hr
--Latent
Cervix 0 ; mild-moderate contr. Cervix 3
Some dilation/effacement talkative
phase
q 5-30 min for 30-35 sec.
and eager
6-8 hrs
--Active phase Cervix 4; reg. moderate-strong
Cervix 7
Rapid dil/efface; some fetal descent;
4-6 hrs
q 3-5 min for 40-70 sec
feel helpless; anxiety/restlessness
--Transition
Cervix 8-10; strong-very strong Cervix 10
Tired, restless, irritable; feeling out of
20-40 min q 2-3 min. for 45-90 sec
control "can't continue", N/V, urge to
push, rectal pressure, bloody show
nd
2 stage
Full dilation; intense contract.
Birth
Pushing results in birth of fetus
nul- ½ -3hrs
q 1-2 minutes
multip 5-30min
3rd stage
After delivery of infant
Delivery of Placental expulsion: schultze (shiny
5-30 min
placenta
side-most common); duncan dark side
th
4 stage 1-4hrs After delivery of placenta
Stabilization VS homeostatsis, Lochia scant –
of mat. VS
moderate rubra
Intrapartum: Pain mangement ATI ch. 10
p. 147-168
Expressions of pain and coping vary individually and culturally.
Analgesia—alleviates pain sensations or raises the threshold for pain perception
Anesthesia—loss of sensation in general
Anxiety and fear increased muscle tension increased pain (cyclic)
Cultural beliefs and behaviors p.149
Sources of pain during stages of labor
1st stage: internal visceral pain from dilation, effacement, stretching of cervix, distention of lower
uterine segment, contractions of uterus w/ resultant uterine ischemia
2nd stage: RT somatic pain; from pressure and distention of vagina/perineum "burn/splitting/tearing"
pressure/pulling on pelvic structures; lacerations of soft tissue
rd
3 stage: same as 1st stage RT uterine contractions, pressure/pulling of pelvic structures
4th stage: distention/stretching of vagina and perineum during 2nd stage
Non pharmacologic Pain mgmt includes childbirth classes, sensory/cutaneous strategies/ position changes
Breathing techniques: assess for hyperventilation (light headed, tingling of toes/fingers) –have clt
breathe into paper bag or cupped hands.
Sensory stimulation: aroma therapy, breathing tech., imagery, music, focal points
Cutaneous strategies: back rubs/message; effleurage; sacral counterpressure; hot/cold therapy;
hydrotherapy; intradermal water block, acupressure; TENS;
frequent maternal position changes: semi-sitting, squatting, kneeling with or w/o rocking
Pharmacologic: analgesia (sedatives, narcotics, ataractics); anesthetics ("caine" meds)
Sedatives (barbiturates)—promote safety with these meds
Adverse effects: resp depression; fall risk;  pain tolerance\
Narcotic (opiod) analgesics: IV route preferred; pain w/o loss of consciousness
ATI-Women's health
Butorphanol (stadol) and nalbuphine (nubain)-- pain w/o sig. resp. depression
Narcotic analgesic SE: resp depression of neonate;  risk N/V; HR; BP; FHR variability;
high incidence of pruritus, and risk of allergic rxn.
Antidote: Naloxone (Narcan)
Ataractics –control Nausea and anxiety and protentiate affects of narcotics
SE: dry mouth sedation—give ice chips or mouth swabs
Epidural/spinal regional analgesia—use fentanyl (sublimaze) into epidural or intrathecal space
SE: N/V; / HR; BP; resp depression, loss of sensation to urinate
Anesthesia—regional blocks or general (used in emergencies)
Regional blocks: pudendal, epidural, spinal, papacervical
Pudendal—"caine" med into space in front of pudendal nerve
Epidural—bupivacaine or fentanyl along with morphine—administered after 4 cm
SE: BP; FHR; inability to feel urge to urinate; loss of bearing down reflex
Interventions: admin a bolis of IV fluids to offset BP; monitor VS; continually
assess FHR; assess orthostatic BP;
Spinal block—injected into suybarachnoid space—numbs from nipples to feet—C-sec
Admin late 2nd stage or before C-sec
SE: BP; FHR; possible headache from leakage of CSF
Cerebrospinal fluid leak: use autologous blood patch; dark room supine position
Oral analgesics, caffeine, fluids
Paracervical block—injected into cervical mucosa in 1st stage—rarely used
General Anesthesia—NPO, etc.
Pain S/S: BP; HR; hyperventilation; clt verbalization
Primary responsibility of nurse w/ pharmacologic pain relief is assessing well-being of mother/fetus
1st Stage/ latent: Nonpharmacologic methods; sedatives
1st stage/ active: Nonpharmacologic methods; narcotics, epidural past 4 cm
1st stage/ transition: nothing past 8-9 cm depending on nultip/multip and how fast labor progessing
2nd stage: spinal block; pudendal; local infiltration
19
Intrapartum: fetal assessment during Labor ATI ch. 11 p. 169-188
During contraction Uteroplacental arteries are compressed  blood flow to uterus/placenta
FHR-reassuring: baseline 110-160; accelerations of 15bpm for >15sec & < 2 min. no decelerations
Absent variability(nonreassuring);minimal variability < 5bpm; moderate 6-25 bpm;marked >25bpm
Guidelines for intermittent auscultation or continuous electronic fetal monitoring include:
Low-risk women: q 60 min for latent; q 30 min for active; q 5 min second stage
High-risk women: q30 min
; q 15 min
; q 5 min
Routine: upon ROM; before & after ambulation/medication; peak of anesthesia; after vaginal exam;
After catheterization; after abnormal/excessive uterine contractions
Indications for intermittent auscultation & uterine contraction palpation: low risk labor & delivery
Indications for continuous fetal monitoring:
Multiple gestations; placenta previa; oxytocin infusioin; FHR; maternal complications; IUGR;
meconium-stained fluid; abruption placenta (suspected/actual); adnormal nonstress test/CST;
abnormal uterine contractions; fetal distress; dr.preference
Types of FHR pattern & contraction monitoring
Intermittent auscultation & uterine contraction palpation—low tech; hands on
Continuous external fetal monitoring:
Advantages: noninvasive & records FHR tracing
Disadv.: limits mov't of mother; contraction intensity not measurable; affected by obesity
Continuous internal fetal monitoring with scalp electrode-attached to presenting part of fetus and
ATI-Women's health
20
may be used with intrauterine pressure catheter (IUPC)
Adv.: early detection of abnormal FHR patterns; accurate recording and assessment
Disadv: ROM needed; cervix must be dilated 2-3cm; presenting part must have descended
enough to place electrode; potential risk of injury to fetus; contraindicated w/ vaginal
bleeding; risk of infection
FHR patterns:
Increment—beginning of contractions as intensity is increasing
Acme—peak intensity of the contraction
Decrement—decline of the contraction intensity as its ending
Non-reassuring FHR pattern include 160 <FHR< 110 or for > 10 minutes; late/variable decelerations
V—variable
C—cord compression (change position, 02, d/c oxytocin, R/O prolapsed cord)
E—early (Normal) H—Head compression (no intervention needed)
A--acceleration
O—okay (<15 for 15 sec to 2 min) (no intervention needed)
L—late
P—placental insufficiency (L side lying position; 02,IV rate)
Fetal HR: uteroplacental insufficiency, umbilical cord porlapse, maternal BP, prolonged umbilical cord
compression, anesthetic meds; Intervention: D/C oxytocin, notify Dr.; clt to side-lying position;
start IV administer tocolytic med as prescribed, stimulate the fetal scalp
Fetal HR: maternal infection, chorioamnionitis; fetal anemia; fetal heart failure, maternal use of cocaine/
meth, maternal dehydration: intervention: feverantipyrectics; admin O2 8-10L/min;bolus fluids IV
Decrease/loss of FHR variability: meds that depress CNS (narcotics, barbiturates, general
anesthetics); fetal hypoxemia w/ resulting acidosis; fetal sleep cycle; congenital abnormalities;
Interventions: stimulate fetal scalp; clt to left lateral position; assist Dr. in application of scalp
electrode
Leopold's maneuvers
Leopolds maneuver: number of fetuses; presenting part; fetal lie; fetal attitude; descent, PMI
PMI-(point of maximal impulse) is optimal location to hear FH tones (directly over fetal back)
Vertex presentation, PMI is R or L lower quadrant below umbilicus
Breech presentation, PMI is R or L upper quadrant above umbilicus
Perform: clt empty bladder; supine with wedge & knees slightly flexed
ID fetal part occupying the fundus; Locate & palpate the smooth contour of fetal back;
determine fetal presenting part, fetal attitude; outline fetal head & cephalic prominence to
determine attitude of the head;assess FHR post maneuvers to assess fetal tolerance;documen
Ultrasound Imaging: used to visualize fetus, placenta; provides assessment, confirmation, determination of:
Gesgtational age; placental & fetal position; fetal mov'ts (heartbeat, breathing, body mov't activity);
Amniotic fluid volume; vaginal bleeding; fetal and placental abnormalities
Doppler Ultrasound Blood flow—studies blood flow of maternal-fetal blood circulation; provides
information about any resistance to blood flow in a particular area; utilized in labor & delivery for:
multiple fetuses; preterm labor; poorly perfused placenta; maternal BP; DM; IUGR
Fetal scalp blood sampling: to assess fetal blood gases (pH, PO2, PCO2)
Fetal oxygen sat. monitoring/ fetal puse oximetry—sensor next to fetal cheek or temple to assess FspO2
Normal FspO2 is 30-70%. Must have single fetus, >36wks, vertex presentation, nonreassuring
FHR; ROM; dilated >2cm; fetal station > -2
Intrapartum: nursing care during stages of labor ATI ch.12 p.189-201
Admission: 20-30 minutes baseline monitoring of FHR and contraction pattern; VS; Status of
membranes; lab results; admission hx; in presence of vaginal bleeding-vag. exams avoided until
R/O placenta previa or placenta abruptio;
1st stage: Leopold's maneuvers; vaginal exam (effacement/dilation, ROM, fetal station); ROM (with ROM
ATI-Women's health 21
1 assess FHR to R/O prolapsed cord) Nitrazine paper, Ferning (w/amniotic fluid under
microscope), assess amniotic fluids (odor, color, amt, ); bladder palpations; BP, HR, RR q 30-60
min in latent phase, q 30 min in active phase, q 15-30 min in transition phase; T q 4hrs unless ROM
then q 1-2 hrs; contraction & FHR monitoring—latent phase q 30-60min, active q 15-30 min;
transition q 10-15 min;
nd
2 stage: VS q 5-30 min; assess: every contraction, pushing effort, bloody show, dilation status, FHR
continuously q 15 min & immediately following birth; assess peritoneal lacerations;
1st degree—laceration through skin & structures superficial to the muscles
2nd degree—through skin & muscles into the perineum
3rd degree—through skin, muscles, perineum, and anal sphincter muscle
4th degree—above plus anterior rectal wall
rd
3 stage: VS q 15 min.; assess s/s of placental separation –fundus firmly contracting, swift gush from
introitus of dark blood, umbilical cord appears to lengthens; vaginal fullness on exam; assign apgar
Interventions: instruct clt to push one signs of placental separtion are indicated; admin oxytocics/
analgesics, cleanse vulvar area, apply perineal pad or ice pack
st
Intrapartum: terapeutic procedures to assist w/ labor and birth ATI ch.13 p202-229
Amnioinfusion—of NS or lactated Ringer's sol'n into uterus to supplement volume of amniotic fluid; used
To  severity of variable decels caused by chord compression; or dilute meconium-stained fluid
Indications for amnioinfustion:
Oligohydramnios—scant amt amniotic fluid caused by: renal dysfxn; uteroplacental insufficiency,
PROM, postmaturity of fetus
Fetal cord compression RT: postmaturity of fetus (macrosomic, large body)cord compression
Meconium-stained amniotic fluid RT fetal distress postmaturity of fetus
Nursing assess: continuous monitoring to prevent overdistention and  uterine tone which can accelerate,
intensify contractions  nonreassuring FHR changes; use warmed fluid
Anmiotomy—artificial ROM with amnihook (labor often begins <12 hrs after ROM) risk: cord
compression and infection; Indications: too slow labor, corn compression, meconium-stained fluid
Interventions: assess FHR prior to and following AROM, character of fluid, record time of rupture
External cephalic version—attempt to manipulate abdominal wall to reposition fetus to cephalic > 37 wks;
use ultrasound to evaluate fetal position, locatge umbilical cord; asses placental placement, amt of
fluid; fetal age; presence of anomalies, asses pelvic adequacy for delivery, guide direction of fetus
Risks: of cord prolapse
Contraindications: uterine anomalies, previous C-sec, cepahlopelvic disproportion, placenta previa,
multifetal gestation, oligohydramnios
Interventions: do nonstress test before & after procedure; monitor FHR, imformed consent; RH immune
globulin administer at 28 wks, admin tocolytics to relax uterus, clt's BP to detect if vena cava
compression is occurring, maternal pain; Kleihauer-Betke test to determine if fetomaternal bleeding
occurred (if > 15 mL of fetal blood is present  dose of Rh immune globulin; post—monitor uterine
activity, contraction, ROM, bleeding, fetal activity.
Bishop score—determine readiness for labor by evaluate for favorable cervix:Each of 5 factors are assigned
a value of 0-3; score of > 9 for nulliparas or > 5 for multiparas indicates readiness for induction.
Cervical dilation;
Cervical effacement; Cervical consistency (firm, medium, soft)
Cervical position (posterior, midposition, anterior); Presenting part station
Cervical Ripening--success of labor induction and  dose of oxytocin needed
Mechanical methods: balloon catheters, hydoscopic dilators & sponges; laminaria tents (from
desiccated seaweed); synthetic dilators & sponges (contain MgSO4 )—absorb fluid and expand
Assess & interventions: urinary retention, ROM, uterine tenderness/pain, contractions, vaginal
Bleeding, fetal distress, document # of dilators/sponges
ATI-Women's health 22
Chemical agents: prostaglandin gel (cytotec, cervidil, prepidil) applied to cervix
Induction of labor:
Risk factors:
Methods: prostaglandin applied cervically, oxytocin, AROM, nipple stimulation
Indications: preg > 42 wks; PROM, dystocia (prolonged, difficult labor), inadequate contractions,
Prolonged ROM, maternal complications (Rh, DM, pulmonary diseas, PIH), fetal demise,
Chorioamnionitis, suspected feltal problems (IUGR, Hydrops[severe fetal hemolytic DO
from Rh isoimmunization  maternal attack of fetal RBCs])
Assessments: FHR & uterine activity after admin of ripening agents; notify MD if hyperstimulation
occurs; confirm that fetus is engaged in pelvic canal; IUPC used to monitor contractions;
maternal VS q 30 min; FHR q 15 min; obtain a Bishop score prior to starting
Interventions: oxytocin until desired contraction pattern obtained:
Contraction frequency 2-3min, duration 60-90 sec, intensity 40-90mmHg on IUPC, resting
tone 10-15mmHg, resassuring FHR between 110-160; D/C for hyperstimualtion
(contractions exceed above parameters) or nonreassuring FHRplace clt in side
lying position, IV flow 200mL/hr, admin O2 8-10L/min as prescribed, tocolytic prn
Augmentation of Labor—stimulation when progress of labor is inadequate see above section
Episiotomy—incision into perineum to enlarge vaginal opening & minimize soft tissue damage; procedure
Is controversial and not believed to be effective in minizing perineal trauma. Used for prolonged 2nd
stage of labor, macrosomic fetus, forceps/vacuum assisted deliveries; encourage alternate
positions and perineal stretching to reduce need for episiotomy; use mineral oil
Midline—towards the recum, most common, easier to repair, assoc w/  3rd & 4th degree lacerations
Mediolateral—blood loss greater, repair more difficult
Vacuum-Assisted birth—use of cup-like suction to apply traction during contraction to assist descent and
birth of head, then suction removed. Do NOT leave in place for > 25 minutes, vertex presentation,
absence of cephalopelvic disproportion, preferred over forceps;
Risks: cepalohematoma, scalp lacerations, subdural hematoma, lacerations(cervix,vagina,perineum)
Indications: maternal exhaustion, ineffective pushing, fetal distress
Nursing: assess FHR, bladder distention, infant for cephalohematoma, subdural hematoma,
lacerations, assess for caput succedaneum (normal & should resolve within 24 hrs)
LOOK How many attempts??? Difference in above conditions
Forceps-assisted birth—
Risks: lacerations of cervix, vagina, perineum; injury to bladder; facial bruising/palsy
Indications: fetal distress, abnormal presentations, arrest of rotation
Nursing: Monitor FHR (compression of cord w/forceps  FHR); empty bladder; asses infant for
injuries; assess maternal injuries (bleeding in spite of contracted uterus; urine retention RT
bladder/urethral injuries; hematoma formation in pelvic soft tissues from BV damage)
Cesarean Birth:
Complications:aspiration; amniotic fluid pulmonary embolism; wound infection, wound dehiscence,
Thrombophlebitis, hemorrhage, UTI, injuries to bladder/bowel, anesthesia assoc
complications; Premature fetus if GA was incorrect; fetal injuries during surgery;
Indications: cephalopelvic disproportion; malpresentation (breech); placental abnormalities
(placenta previa/abruptio); fetal distress; high risk pregnancy (HTN disorders); active gential
herpes outbreak, previous C-sec; multiple gestations; umbilical cord prolapse.
Vaginal Birth after cesarean birth (VBAC)—
Indications: prev documented low segment transverse incision; no current contraindications (LGA,
malpresentation, cephalopelvic disproportion, Prev. vertical uterine incision)
ATI-Women's health
Intrapartum: complication of labor & birth ATI ch. 14 p.230-269
23
Preterm labor—uterine contractions or cervical changes between 20-37 weeks
Risk factors: infections (UTI, vaginal, chorioamnionitis); prev. preterm birth, multifetal pregnancy,
Hydramnios, 17< age >35, low socioeconomic status, smoking, substance abuse, domestic
violence, Hx of multiple miscarriages/abortions, DM, HTN, lack of prenatal care, incompetent
cervix, placenta previa, abruptio placenae, PPROM (preterm premature ROM), short interval
between pregnancies, Uterine abnormalities, DES (diethylstilbestrol exposure in utero (1948-1971))
Diagnostic: test for fetal fibronectin ((protein found in amniotic fluid) if appears in vaginal secrections then
fetal membrane integrity is lost), ultrasound measurement of endocervical length, HUAM (not
considered effective in preventing preterm labor), Cervical cultures (look for infectious organisms),
BPP/NST for fetal well-being,
S/S: low backache, pressure in pelvis/cramping, increase/change/blood in vaginal d/c, regular uterine
contractions q 10min lasting > 1hr, GI cramping, maybe diarrhea, PROM, urinary frequency; Nurse:
monitor FHR/ contractions, obtain vaginal swab for fetal fibronectin testing, cervical cultures
Interventions: focus on stopping contractions (restricting activity, hydration, ID/treat infections, admin
tocolytic meds, assure fetal well-being, accelerate fetal lung maturity w/glucocorticoids); activity
restriction (modified bed rest w/ BRP, left lateral positioin), avoid sexual intercourse, preventing
dehydration will stop release of ADH & oxytocin by pituitary gland, T & HR could indicate
infection, FHR > 160 may indicate infection
Tocolytics-meds to relax uterine contractions
Contraindications: >34 wks gestation, acute fetal distress, severe PIH/eclampsia, vaginal bleeding,
Cervical dilation >6cm,
Assess-close monitoring of clt needed due to potential adverse SE
Monitor pulmonary fxn & daily wts, restrict oral/IV fluid to 1500-2400/24hr to reduce risk
of pulmonary edema (s/s: chest pain, SOB, Resp distress, Audible wheezing/crackles,
cough w/blood-tinges sputum—NEED to D/C tocolytic therapy)
Meds:
Ritodrine (Yutopar) admin IV—Beta-adrenergic agonist that relaxes uterine smooth muscle by
stimaulation of B2 receptors in smooth muscle fibers.
Adverse Effects: Maternal/fetal HR, BP, SOB, RR, chest pain, pulmonary edema, N/V,
Tremors, restlessness, apprehensive feeling
Nurse Interventions: D/C infustion and notify MD for: maternal HR >120-140/min, BP<
90/60, s/s of pulmonary edema, fetal HR > 180. Have propranolol to reverse CV effects
Terbutaline—admin sub Q or orally—same MofA as ritodrine; oral meds often given at home
SE: HR that should  over time, SOB, infection at site
Interventions: Assess VS, Resp Effort, Injection site for infection, educate clts when to contact MD
MgSO4—relaxes smooth muscle of the uterus; most commonly used tocolytic; causes fewer SE
Antidote is calcium gluconate & should be available to admin
SE: lethargy/weakness, visual blurring/headache, N/V, depression of deep tendon reflexes, RR,
 urine output, cardiac arrest
interventions: Monitor for mag.sulfate toxicity and d/c for any of these adverse effects:
Loss of deep tendon reflexes, Urinary output < 25-30 mL/hr, RR< 12, pulmonary edema,
chest pain
Nifedipine (procardia)-admin orally—CCB, inhibits Ca from entering smooth muscle cells   contraction
SE: maternal transient HR, BP, headache/dizzy, maternal flushing, peripheral edema, fetal
Uteroplacental insufficiency RT maternal hypotension
Interventions: do not combine nifedipine with mag sulfate (concurrent use severe hyptension)
Indomethacin (indocin)—admin orally/rectally NSAID—blocks prostagladi suppresses contractions.
Can cause secondary to severe fetal SE. Used only if other methods fail
ATI-Women's health 24
SE: GI distress, N/V, exacerbates peptic ulcer disease, Oligohydramnios,  platlett aggregation,
 bleeding/hemorrhage, neonate intracranial hemorrhage, contriction of fetal ductus
arteriosus leading to premature closure
Interventions: treatment < 48 hrs, only if GA > 32 wks, monitor pp hemorrhage, admin w/food
Betamethasone—glucocorticoid admin IM—requires a 24hr period of admin to be effective
SE: maternal infection, pulmonary edema if admin w/ B-adrenergic meds, may worsen DM, HTN
Interventions: deep IM 24-48hrs prior to birth, monitor mother/neonate for pulmonary edema &
BG, Educate clt of s/s of pulmonary edema(chest pain, SOB, crackles), monitor neonate for
changes in HR
Preterm Birth- between 20-37 weeks gestation (once dilation > 4cm preterm birth is probable)
Risk factors: preterm labor, PPROM, PROM, 50% have no risk factors
Assess neonate for RDS (retractions, nasal flaring, expiratory grunting, change in RR/HR)
PROM = rupture > 1hr prior to the onset of labor; risk factors: infection, onset of labor
PPROM = spontaneous rupture between 20-37 wks; risk: vaginal/UT infections, etiology unknown
Risks: infection (chorioamnionitis)  risk w/ rupture > 24 hrs
Assess: prolapsed umbilical cord, + nitrzaine test, cervical dilation/effacement (sterile), VS,T, FHR
Mgmt: at home if <3cm dilated, no infection, no contractions, no malpresentation
(encourage bed rest, hydration, antiobiotics, sedative, glucocorticoids, monitor foul-smelling
vaginal d/c, nothing vaginally, no sex, no tub baths, take T q 4 hrs & report > 38 C)
Prolapsed umbilical cord—proceds the presenting part of the fetus or protrudes thru cervix
Risk: ROM (check FHR), abnormal fetal presentation (any but vertex), not engaged, SGA,
unusually long cord, multifetal pregnancy, cephalopelvic disproportion, placenta previa,
hydoamnios (> 2L), oligohydramnios (< 300mL)
Intervention: assess FHR, relieve cord compression immediately,  fetal oxygenation, call for help
immediately, notify MD, position clt w/ hips higher than head (knee/chest position, trendelenburg,
or side-lying w/ towel under clt's hip; use sterile glove-insert 2 fingers into vagina on either side of
cord and elevate fetal presenting part off cord; apply sterile saline soaked towel to the cord to
prevent drying and maintain blood flow if proturuding out of vagina; admin 02 8-10L/min, closely
monitor FHR, amnioinfusion of NS or lactated ringers to alleviate cord compression is caused by
oligohydramnios,
Precipitate Labor—labor < 3 hrs from onset of contractions to birth
Risk: hypertonic uterine dyfxn, oxytocin stimulation
Interventions: assess maternal perineal area for signs of trauma/lacerations & neonate for trauma; no
not leave mother unattended, side lying position, do not attempt to stop deliver; control rapid
delivery by applying light pressure to fetal head to prevent cerebral damage and perineal lacerations
Assess for complications: lacerations (cervical,vaginal, perineal), uterine rupture,amniotic fluid embolism,
pp hemorrhage, fetal hypoxia (RT uteroplacental insufficiency), fetal intracranial hemorrhage
Meconium-stained amniotic fluid-typically not assoc w/ unfavorable fetal outcome; may be result of
chronic fetal stress, physiologic passage of meconium; presence of meconium aline in amniotif fluid
is not a sign of fetal distress, must be accompanied by variable or late decals with or w/o acidosis
(confirmed by scalp blood sampling to be considered ominous
Causes: normal physiologic fxn >38wks, umbilical cord compression  fetal hypoxia stimulates
vagal nerve which is responsible for HR and GI peristalsis release of meconium and fetal HR
assessments: consistency—thick, fresh indicataes fetal stress
timing—thick, fresh—first passed in late labor with variable or late FHR decals(ominous sign); be
prepared to suction nasopharyn (reduces incidence and severity of meconium aspiration syndrom)
Postterm Pregnancy—beyond 42nd week
Maternal risk: pp hemorrhage, bone maturation in fetus birth canal trauma or C-sec, infection,
labor induction, forceps-assisted or vacuum-assisted birth,
Fetal risk: fetal distress, prolonged labor, duystocial, shoulder dystocia, meconium-stained amniotic
ATI-Women's health 25
fluid, asphyxis, macrosomia, aging placenta may decline in fxn,  amniotic fluid
Neonatal risk: asphyxia, meconium aspiration syndrome, dysmaturity syndrome, BG,
polycythemia RT overproduction of RBCs, respiratory distress
Risk factors: placental estrogen deficiency  formation of oxytocin receptors in uterine myometrium
 in uterine contractibility; previous postterm preg  risk of another postterm preg by 30-40%
Assessment: wt loss > 3lb/wk &  in uterine size RT oligohydramnios; daily fetal mov'ts, nonstress test,
and CST, BPP, measuring Doppler flow, AFI, check cervix for favorability of inductions, vaginal
secretions for fibronectin, FHR, meconium stained fluid
Interventions: amnioinfusion if needed (oligohydramnios or dilute meconium in fluid); determine if
acidosis in fetal by scalp pH sampling, or fetal oxygen saturation
Dysocia (dysfunctional labor)—difficult/abnormal labor RT 5 powers of labor (passenger, passageway,
psyche, powers, position)
hypotonic contractions—weak inefficient, or completely absent
hypertonic contractions—excessively frequent, uncoordinated, strong intensity, w/o adequate
uterine relaxation.
Risk factors: short stature, overweight, age > 40, uterine abnormalities (congenital amlformations,
overdistention from multiple gestation or hydramnios), pelvic soft tissue obstruction or
pelvic contracture, cephalopelvic disoroportion , macrosomia, fetal malpresentation,
malposition, multifetal pregnancy, hypertonic/hypotonic uterus, maternal fatigue, fear,
dehydration, inappropriate timine of anesthesia or analgesics.
Interventions: fetal scalp electrode, ROM, regular voiding, position changes, ambulation,
hydrotherapy or other relaxation techniques, beneficial position for pushing; for hypotonic
(easily indentable at peak of contraction) –admin oxytocin; for hypertonic (not indentable
between contractions) —admin analgesics, hydration, comfort measures, lateral position
w/oxygen
Large for gestational age (LGA) > 4000 g
Risks: shoulder dystocia ( fetal injury to clavicals, or asphyxia), erb-duchenne paralysis due to
birth trauma, neonatal nypoglycemia
Factors: postterm pregnancy or maternal diabetes w/ hyperglycemic episodes
Interventions: prepare for forceps-assisted birth, place clt in McRobert's position (lithotomy position
w/ legs flexed to chest to maximize pelvic outlet); apply suprapublic pressure if needed,
assess neonate for birth trauma (broken clavical or erb-Duchenne paralysis)
Rupture of Uterus—extension of entire uterine wall muscle into peritoneal cavity or broad ligament is
complete rupture; extension into the peritoneum, but not into peritoneal cavity or broad ligament is
incomplete rupture (partial separation at old cesarean scar). Bleeding is usually internal
Risk factors: separation of prev. vertical c-sec scar; uterine trauma from accident/surgery;
congenital uterine abnormality, overdistntion of uterus from LGA, multifetal, or
polyhyramnios; hyperstimualtion of uters, fetal version, forceps-assisted delivery;
multigravida
Interventions: start IV fluids, start blood products, laparotomy for incomplete rupture, hysterectomy
for complete rupture, immediate c-sec
Amniotic fluid embolism—is caused by a rupture in the amniotic sac or maternal uterine veins
accompanied by a high intrauterine pressure that causes infiltration of the amniotic fluid and its
contents into the maternal circulation  travels to and obstructs pulmonary vessels and causes resp.
distress and circulatory collapse. (esp bad is meconium-stained fluid) Serious coagulation problems
such as DIC can occur
Risk factors: multiparity, tumultuous labor, abruptio placentae, oxytocin admin, fatal macrosomia,
fetal demise, meconium-stained amniotic fluid.
S/S: restlessness, dyspnea, cyanosis, pulmonary edema, respiratory arrest; circulatory collapse s/s:
Tachycardia, hypotension,shock, cardiac arrest. S/s of coagulation failure: bleeding from
ATI-Women's health 26
incisions and venipuncture sites, petechiae/ecchymosis, uterine atony
Interventions: admin oxygen 8-10L/min; assist w. intubation/mechanical ventilation if needed;
perform CPR if needed, position clit on side w/ pelvis titlted at 30 degree angle to displace
uterus; admin IV fluids/blood products if needed; insert foley,
Fetal Distress is present when:
FHR < 110/min or > 160/ min; meconium staining of amniotic fluid, fetal hyperactivity, no
activity, fetal blood pH < 7.2
Risk factors: complications of pregnancy/labor/birth, fetal anomalies, and uterine anomalies
Interventions: position clit on left side-lying reclining position w/ legs elevated; admin oxygen; D/C
oxytocin, IV fluid rate to treat BP; monitor maternal VS and FHR; prepare for C-sec prn
Postpartum: PP physiological changes
ATI Ch.15 p.270-288
4th stage of labor is maternal recovery period (1-4hrs) bonding should occur. PP (post partum ) AKA
puerperium, begins after delivery of placenta and ends with return to nonpregnant state (6wks)
Changes: uterine involution, lochia flow, cervical involutionm,  in vaginal destention, changes in
ovarian fxn and menstration, changes in breasts, urinary tract, GI tract, and CV (cardiovascular).
Initial dangers of PP are: hemorrhage, shock, infection
Oxytocin (from pituitary gland) coordinates and strengthens uterine contractions—stimulated by
breastfeeding, can be admin. as pitocin
Uterine contractions compress the intramyometrial BVs constriction of BVs and hemostasis(no bleeding)
Hormones  with expulsion of placenta (estrogen, progesterone, placental enzyme insuloinase)BG
estrogen breast engorgement, diaphoresis, diuresis, vaginal lubrication
progesterone  muscle tone throughout body
insulinase lower BG immediately PP
prolactin in nursing moms suppress of ovulation
Dx & therapeutic procedures/ interventions
Negative direct Coombs' test of fetal cord—fetus not sensitized to Rh factor of mother
Negative indirect Coombs' test of maternal blood—RH- mother not sensitized by Rh+ fetus
Kleihauer test—determines amt of fetal blood in maternal circulation
PP assessments: VS, uterine firmness/location/position (RT midline), amt of vaginal bleeding
q15 min X 4 (lst hour); q 30 min X 2 (2nd hour); q hr X 2 (3rd 4th hr), then q 4-8 hrs
PP physical assess: fundal ht/placement/consistency; locia color/amt/consistency; cervica,
vaginal,perineal healing; breats, VS, Bowel, bladder & GI fxn; comfort level, teaching needs
PP chill--< 2hrs pp, is uncontrollable shaking, RT Nervous system response, vasomotor changes, shift in
fluids, work of labor; is normal if no T occurs simultaneously
Uterus involution: fundal ht  1 cm/day; immediate pp-fundus at umbilicus & midline; q 24hrs fundus
descends 1-2cm/day; at 6 days is ½ way between umbilicus & symphysis; by 10 days not palpable;
Fundus palpation: cup one had over lower uterine segment and other had to palpate fundus ht.
If fundus boggy—lightly massage in circular motion
Admin oxytocics prn (pitocinBP, methergine, ergonate BP)
Empty bladder q 2 hrs to prevent uterine displacement and atony
Lochia: contains blood and debris from deciduas(thickened lining of uterine endometrium during preg)
L. rubra—bright red, fleshy odor, small clots,  during breastfeeding & rising; 1-3 days after birth
L. serosa—pinkish brown, serosanguineous (old blood, serum leukocytes, tissue debris) days 4-10
L. alba—yellowish or white creamy, fleshy odor, day 11 up to and beyond 6 wks
AMOUNT: scant < 2.5/1" cm , light < 10cm/4", moderate > 10cm/4", heavy-1pad saturated <2hrs
Excessive blood loss one pad saturated < 15 min/ or blood pooling under buttocks
Abnormal: spurting bright red blood; numerous lg clots; four odor; persistent rubra > 3days
ATI-Women's health 27
Cervical, vaginal, perineal healing: observe for erthema, edema, hematoma; assess episiotomy &
lacerations (bright red tricke of blood from episiotomy site early pp is normal)
Interventions: measures to soften stools; proper cleansing to prevent infection; apply ice packs first
1-2 days to reduce edema and provide anesthetic effect; sitz baths <40C 2Xday
Breast: colostrums 2-3 days, milk after; engorgement (lymphatic circulation, milk, temp. vasocongestion);
Assess for cracked nipples and mastitis (infection of milk duct-flu like symptoms); inform clt that
breast feeding releases oxytocin uterine cramping; education on breastfeeding techniques
CV system, fluid/hematologic status—
 blood volume RT blood loss during childbirth (500mL vag/ 1000mL C-sec); diaphoresis/diuresis
for first 2-3 days; hypovolemic shock prevented because: during pregnancy 50%  in blood vol.
--Readjustments in maternal vasculature RT: elimination of placenta diverting 500-750mL of blood
into maternal circulation & rapid reduction in the size of the uterus puts blood into circulation
--hct/hgb for 72 hrs RT diaphoresis/diuresis & greater loss of plasma volume than RBCs
--leukocytosis up to 20,000-25,000/mm3 for first 10-14 days w/o presence of infection
--coagulation factors & finbrinogen levels remain elevated for 2-3 weeks
-- risk of thrombus/thromboembolisms RT coagulability, BV, vessel damage, venus statis
--orthostatis hypotension may occur first 2 days RT splanchnic engorgement--can occur after birth
--of HR, SV (stroke volume), CO for 1st hour, then gradually declineing to baseline 8-10 wks pp
--T to 38C RT dehydration for first 24hrs, then returen to normal
Interventions: encourage early ambulation to prevent thombosis, venus statis, application of TED
(thomboembolism disease) hose, admin RhoGAM < 72 hrs birth
GI system / Bowel fxn:  appetite following deliver; constipation for 2-3 days pp; spontaneous bowel
mov't may not occurt 2-3 days RT  intestinal muscle tone during labor and pp, prelabor diarrhea,
and dehydration; clt may anticipate discomport RT perineal damage; operative vaginal births may 
risk for incontinence usually resolves < 6 months.
Urinary system/bladder fxn:
--urinary retention RT loss of bladder eleasticity/tone/sensation from trauma, meds, anesthesis
uterine atony and displacement (often to the R); PP diuresis begins <12hrs of birth RT  estrogen
levels and removal of venous pressure in lower extremities (1500-3000mL/day-Normal 2-3 days)
S/S: distended bladder: fundal ht above umbilicus, fundus displaced from midline, bladder bulges
above symphysis pubis, excessive lochia, tenderness ofer bladder, void <150mL is indicative of
urinary retention with overflow; measure first few voiding & encourage clt to void q 2-3 hrs
Musculoskeleatl system:
--joints restabilize, feet may remain larger, rectus abdominus may separate 2-4cmresolve 6wks
Immune: rubella titer of < 1:8 admin vaccine during pp (need informed consent—Not get pregnant for
3 months RT tetragenic effects on fetus); review Hep B (give infanct vaccine < 12 hrs if mother is
infected); review Rh status
Postpartum: Bonding & Integration of Infant into family ATI ch. 16 p.289-300
Bonding—the emotional process where parents come to love and accept their child and visa versa; can be
promoted during 1st hour of live by delaying nursing/medical interventions;
-- mother's emotions/ physical condition as well as infant's physical condition can affect bonding
--Separation can delay, culture, age, socioeconomic level can influence bonding
Physical adaptation & maternal adjustment PP:
--taking-in phase: lasts few hours to few days; characteristics include: passive-dependent behavior;
relies on others for needs; excited/talkative/ reviews labor/birth experience
--taking hold phase: 2-3rd pp day to 10days-several wks; asserts independence in competently caring
for infant; verbalizes anxiety, needs reassurance, may experience pp blues, open to teaching
ATI-Women's health 28
--letting-go phase: focus on forward mov't of family as a unity; reassert relationship w/ partner and
resume sexual intimacy at this time; demand may lead to mild depression
Bonding behaviors:
Views and takes in physical characteristics of infant; holds infant face to face, maintaining eye
contact ; recognizes infant as unique person & considers a family member; Ids infant's unique
characteristics and relates them to family members; touches infant & maintains close proximity and
contact; provides physical care; smiles, talks to, sings to infant; communicates pride in infant;
assigns meaning to infant's behavior and views positively
Impair bonding behaviors:
Apathy when infant cries; disgust of voids/stools/spit ups; expresses disappointment in infant; turns
away from infant; no close proximity; no talk about unique features; no pride handles roughly;
methodically cares for infant w/o evidence of bonding; view behavior as deliberately uncooperative.
Paternal adaptation:
Engrossment—absorbed and preoccupied with infant
Paternal transition to fatherhood
--expectations
--reality—may experience feelings of sadness, ambivalence, jealousy, frustration,
--transition to mastery—become more actively involved with infant
father-infant bond
--making a commitment—sense of duty/willingness to develop relationship
--becoming connected—feelings of joy, wonderment on first meeting
--making room for the infant—changes in work/personal time for more infant time
Sibling adaptation:
Positive feeling towards baby;  independence; Negative responses: signs of sibling rivalry
/jealousy; regression in behaviors; aggression towards infant;  attentions seeking behaviors
--Interventions: have gift from infant to sibling, tee shirt that promotes being brother/sister; etc
Postpartum: PP complications ATI ch 17 p.301-337
PP Hemorrhage: can result in hypovolemic shock; leading cause of morbidity & mortality; defined blood
loss of > 500 mL vag. & > 1000mL C-sec & 10% in admission Hct; nurse should monitor for
S/S: BP, HR w/ weak thready pulse; rapid shallow Respiration, oliguria; Interventions are to
restore circulating BV and treat cause of hemorrhage
--Key factors: uterine atony, complications during preg (placenta previa, abruptio placneta);
precipitous delivery, admin of mg sulfate; laceration/hematomas, inversion of uterus, subinvolution
of uterus, retained placental, fragments, DIC
--S/S: uterine atony, blood clots >a quarter; pad saturation < 15 min, return of lochia rubra after
locia serosa or alba, constant oozing, trickling, frank (visible) flow of bright red blood from vag.;
skin that is pale, cool, clammy with poor turgor & pale mucous membranes, oliguria
--assess for Source of bleeding: fundus height/firmness/position; lochia for color/quantity/clots;
bleeding from lacerations/episiotomy, hematomas; VS for rate/quality/equality
--Interventions include: Stop the bleeding; IV fluids (lactated ringers, NS, bolume expanders
w/colloids [albumin]; blood products [PRBC]); provide oxygen 2-3L/min; insert foley catheter;
elevating legs to 20-30 degree angle; avoid trendelenburg position
Uterine Atony: hypotonic uterus "boggy" inability of myometrium to contract or stay contracted around
oipen blood vessels of uteroplacental implantations site—most common cause of pp hemorrhage;
untreated can result in pp hemorrhage and uterine inversion
--Risk factors: retained placental fragments, prolonged labor, oxytocin induction or augmentation;
overdistentions of uterine muscles (multiparity, multiple gestation, hydramnios, macrosomic fetus);
precipitate labor; Mg sulfate as tocolytic; anesthesia/analgesia admin; trauma for operative delivery
ATI-Women's health
29
--therapeutic procedures:
--bimanual compression (fist into vagina-apply pressure w/knuckles against anterior side of
uterus while other hand messages posteriors side from abdomen.
--manual exploration of uterine cavity for retained placental fragments by MD;
--surgical management such as hysterectomy
--S/S of uterine atony: larger than normal uterus that is boggy w/ possible lateral displacement;
prolonged lochial d/c; irregular or excessive bleeding
--interventions: empty bladder; fundal massage of boggy uterus; express clots (**AFTER uterus
becomes firm—can invert uterus if press on uncontracted uterus); admin oxytocics
 oxytocin (pitocin)—monitor SE of water intoxication (lightheadness, N/V, headache,
malaise). Serious symptoms can progess to cerebral edema w/seizures, coma, death
 Methylergonovine maleate (Methergine) SE: BP, N/V, headache
 Ergonovine maleate (Ergotrate) SE: BP, headache, dizziness, N/V
 Progtoglandin F SE: fever, chills, headache, N/V, dearrhea
Subinvolutioin of the uterus: failure of uterus to resume its preprgnant state , maypp hemorrhage
Risk factors: pelvic infection and endometritis , retained placental fragments, excessive vigorous
massaging of the uterus
Interventions: cultures to check for infection/endometritis, D & E to remove retained fragments;
--Encourage client to utilize factors that can enhance uterine involution: breastfeeding,
early/frequent ambulation, frequent voiding;
--admin oxytocics: conservative treatment Methergine (contraindicated for BP)
*most commonly used is Ergonovine
Inversion of Uterus: turning inside out of uterus—partial (smooth mass palpated through dilated cervix)or
complete (rounded mass protrudes 20-30 cm outside introitus)—is an emergency situation
--Risk factors: most frequent in multiparous women with placenta accreta/increta; retained
placenta; multiparity; fundal implantation of placenta; vigorus fundal pressure, excessive traction
applied to umbilical cord, uterine atonay, leiomyomas (benign uterine fibroid tumor); abnormally
adherent placental tissue as described:
--placenta accreta—slight penetration of placenta into myometrium
--placenta increta—deep….
--placenta percreta—a perforation by the placenta into uterus
--Treatment: manual replacement by MD
Retained Placenta: entire of fragments of placenta retained in uterus prevents uterine contraction
uterine atony, subinvolution, possible inversion, hemorrhage, endometritis; common in preterm
births between 20-24 weeks
--Risk factors: partial separation of normal placenta, entrapment of partially or completely separated
placenta by constricting ring of uterus; excessive traction on umbilical or prior to complete
separation, abnormally adherent placenta
--procedures: manual separation/removal of placenta by MD; D&E by MD
--S/S: uterine atony, subinvolution/inversion; excessive bleeding, clots larger than a quarter; retrun
of lochia rubra; malodorous lochia, T;
--Interventions: admin oxytocics to expel retained fragments of placenta; admin tocolytics to relax
uterus prior to D& E; anticipate surgical intervention
Lacerations/hematomas: tearing of soft tissue ; perineal lacerations are the most frequent; hematoma is a
collection of 250-500mL of clotted blood w/in the tissues often a result of a breakage of BVs of the
soft tissues of the vagina or perineum; appear as bulging bluish mass (pain is the most
distinguishable symptom; can result in pp hemorrhage of infection of the laceration
--risk factors: operative vaginal birth, precipitate birth, fetopelvic disproportion; size/presentation
/position of fetus; prolonged pressure of fetal head on vaginal mucosa, previous scarring of maternal
birth canal from infection/injury/operation; Damage more pronounced in nulliparous women RT
ATI-Women's health 30
firmer/more resistant/less distensible tissues; light-skinned women (esp. redhead) less distensible
tissue.
--S/S: palpation of firm contracted uterus in spite of vaginal bleeding; constant oozing, slow trickle,
or frank blood from vagina/laceration that is bright red; severe rectal/perineal pain or a feeling of
pressure in the vagina may indicate vulvar/vaginal/retroperitoneal hematoma; inability to void RT
pressure on urethra from hematoma; urge to defecate RT pressure on rectum; signs of fluid volume
depletion from excessive blood loss.
Coagulopathies (ITP-idiopathic thrombocytopenia purpura; DIC-disseminated intravascular coasgulation)
ITP-autoimmune DO life span of platelets hemorrhage
Risk factors: genetic factors inherited from parents
DIC—clotting and anti-clotting mechanisms occur at the same time
--extensive clotting consumes & destroys substantial amts of clotting factors including
platelets, fibrinogen, prothrombin, and factors V and VII
--exhaustive depletion of clotting factors widespread bleedingformation of small clots
in the microcirculation that trigger vascular occlusion of small BVs vital organ ischemia
--Fibrinolysis first increases and then decreases w/ degradation of fibrin prolonged
prothrombin time.
--Suspected: when usual measures to stimulate uterine contractions fail to stop vaginal bleeding
--DIC can result in hemorrhage, renal failure, and organ ischemia  major organ failure
--Risk factors (DIC): abruptio placenta, amniotic fluid embolism; missed abortion; fetal death in
utero (fetus retained for >6wks); severe preeclampsia/eclampsia; septicemia; cardiopulmonary
arrest; hemorrhage, hydatidiform mole
--Dx: Lab tests (CBC, clotting factors [platelet/fibrinogen levels (), prothrombin time (), fibrin
split level ()]); splenectomy if ITP doesn't respond to medical treatment; hysterectomy for DIC
--S/S: unusual spontaneous bleeding from gums/nose (epistaxis); oozing, trickline, or flow of blood
from incision, laceration, opisiotomy; petechiae/ecchymoses; excessive bleeding from venipuncture,
injection sites, or slight traumas; HR, BP, and diaphoresis; oliguria
--Interventions for DIC: correct underlying cause (removal of dead fetus, tx infection, preeclampsia
/ eclampsia, or removal of placental abruption); admin fluid/blood products/oxygen/meds
Thrombophlebitis—is inflammation of BV wall that causes attachment of blood clot to that wall  partial
occlusion of the vessel (Thrombosis)—can lead to pulmonary embolism
--2 types: superficial venous thrombosis (involves saphenous or surface veins);
deep vein thrombosis(DVT) involves deep venous system from foot to iliofemoral region
Key factors: venous statis & hypercoagulation are major causes. Presents risk to all pp women RT
normal hypercoagulability of blood during pregnancy and early PP period and venous stasis
of lower extremities
Risk factors (other): PP immobility/inactivity; prolonged sitting/standing; C-sec ; varicose
veins/varicosities; DM; smoking; multiparity; Hx of venous thrombosis; obesity; age > 35
Dx: arterial blood gas anaysis; daily platelet count, PT, PTT (if pt on heparine/warfarin);
venography-invasive, most definitive method of dx; noninvasive: Doppler , CT, MRI
S/S: tenderness, pain, heat on palpation; +homan's sign; localized redness & enlarged, superficialhardened veinsuperficial vein thrombosis; unilateral leg pain that extends above the knee,
calf tenderness, swelling, extremity coolness, & pale color  DVT; diminished pulse w/
blood flow unilaterally; extremity diameter w/ edema of an affected extremity and
swelling attributable to venous inflammation; low-grade fever/chills
Nsg assess: lower extremities for color/temperature; bilateral lower extremity pulses, pain level;
serial calf & thigh circumference measurements; VS & T
Nsg interventions: clt education about prevention; early/frequent ambulation PP; avoid prolonged
standing/sitting/ immobility; elevate legs when sitting; avoid crossing legs; fluid intake of
2500mL; d/c smoking; for Superifical venous thrombosis--admin analgesics (NSAIDS),
ATI-Women's health 31
affected extremity elevated, apply local heat; measure extremity for TED hose; for DVT—
admin anticoagulants (initially IV heparin [protamine sulfate-antidote], then warfarin
(coumadin) orally for 3 months [Vit.K-antidote]
SE: bleeding from gums/nose, vaginal bleeding, hematuria, bruising easily
Drug precautions: avoid taking aspirin/ibuprofen (bleeding tendencies), use electric razor, avoid
alcohol use (inhibits warfarin), brush teeth gently, avoid rubbing or massaging legs, avoid
periods of prolonged sitting or crossing legs
Pulmonary embolus—complication of DVT—embolus (clot moving through circulation) carried to
pulmonary artery or one of its branches occluding BV and obstructing flow to the lungs.
--Dx: ventilation/perfusion lung scan; Chest/lung x-ray; pulmonary angiogram
embolectomy-surgical removal of embolu
--S/S: dyspnea; tachypnea, cough, hempotysis (blood streaked sputum); pleuritic chest pain; heart
murmurs and/or Rsided heart failure; periperal edema; distended neck veins; elevated T;
chills, hypotension; apprehension
--assessments: VS, T, Resp status/lung sounds, heart sounds, chest pain level, mental status, neck
vein distension
--Interventions: semifowlers position; admin oxygen, admin IV heparin (monitor clt for excessive
anticoagulation), admin analgesic
Puerperal infections (endometritis, mastitis, wound infections)—PP infection is any infection of genital
birth canal w/in 28 days of miscarriage, abortion, birth w/fever of 38C for > 2consecutive days
during 1st 10 days PP (not counting the first 24 hrs) other s/s: flu-like symptoms (body aches, chills,
fever,malise), HR, anorexia, nausea—major complication is septicemia
--Endometritis—infection of the endometrial lining, deciduas, adjacent myometrium of uterus.
Untreated  parametritis--infection spread by lymphatic system thru uterine wall to broad
ligament or entire pelvis and can continue to spread causing peritonitis or possible pelvic
abscess. It is the most common pp infection. Usually begins on 2nd – 5th day, starting as a
localized infection at placental attachment site and spreading to involve the entire uterine
endometrium.
--risk factors: C-sec; retained placedntal fragments, prolonged ROM, internal monitoring,
multiple vag.exams after ROM, prolonged labor, pp hemorrhage
--S/S: pelvic pain, uterine tenderness/enlargement; scant/normal/profuse malodorous or
purulent lochia
--Wound infection sites include: C-sec incisions, episiotomies, lacerations
--S/S: erythema, edema, warmth, tenderness, pain, seropurulent drainage, wound
dehiscence/evisceration
--Mastitis—infections of the breast involving interlobular CT usually unilateral, may abscess; more
common in first-time breastfeeding mothers; Staphylococcus is usually infecting organism
--risks: milk stasis from blocked duct, nipple trauma (cracked), poor breastfeeding
technique decreased frequency RT bottle feeding, poor hygiene RT inadequate hand
washing
--S/S: painful/tender localized hard mass and reddened area, axillary adenopathy
--interventions: breast hygiene; breastfeeding techniques; ice/warm packs; continue
breastfeeding q 2-4 hrs; completely empty breast at each feeding; encourage 3L/day fluid;
--Risk factors for all pp women: open cervix, well-supplied exposed BVs, wounds, alkalinity of
amniotic fluid, blood, and lochia decrease acidity of the vagina
UTIs (urinary tract infections)—common pp RT bladder trauma or break in aseptic technique w/foley
insert.; complication is pyelonephritis w/ permanent renal damage  acute/chronic renal failure
Risk factors: pp hypotonic bladder/ urethra (urinary stasis/retention); epidural anesthesia, bladder
catheterization, freqent pelvic exams; genital tract injuries; hx of UTIs , C-sec
S/S: urgency/frequency,dysuria; urinary retention/hematurea,pyuria; pain in suprapubic area; pain at
ATI-Women's health 32
costovertebral angle (pyelonephritis); T, chills; malaise, malodorous cloudy urine
Interventions: obtain urine sample; admin antibiotics; teach proper hygiene; 3L/day fluids,
cranberry juice to promote urine acidification to inhibit bacterial multiplication
PP "blues" Depression—50-80% experience this first few days PP up to 10 days.
S/S: tearfulness, insomnia, lack of appetite, wt loss, flat affect, ambivalence towards infant/family;
feeling of letdown, may be unable to cope with slightest problems—feeling fear/anxiety,anger; may
become despondent
PP depression postpartum psychosis (delusional thinking & possible hallucinations)
Assure safety of clt & infant
Contributing factors of PP depression:
Hormonal changes w/ rapid decline in estrogen/progesterone levels; PP physical discomfort
/ pain; fatigue/ socioeconomic status;  in social support; anxiety, hx of prev depressive
episode; low self- esteem; dissatisfaction w/ education/ economics, choice of partner
Postpartum: discharge
ATI ch 18 p.338-348
Discharge planning begins at the time of admission—clt taught s/s of complications
Danger signs to report to primary care provider:
--Chills, fever > 38C for 2+ days; --fundus not midline and firm; --change in vaginal d/c
(increased amount, large clots, foul odor, back to bright red lochia); --abnormal lochia flow
or pattern (2-3 days—bright red (rubra), days 4-10 blood tinged serous (serosa), days 11-16 white
(alba); --pain/tenderness in abdominal /pelvic area, --episiotomy/laceration/incision pain, foulsmelling drainage, redness, or edema; --calf w/localized pain, tenderness, redness, and swelling.
Lower extremity with areas of redness, warmth, coolness, paleness;--breast with localized area of
pain, tenderness, redness, swelling, or cracks/fissures of nipples; --urination w/ burning, pain,
frequency, urgency. Urine that is cloudy or bloody; -- postpartum depression (feels apathy towards
infant, cannot provide care, feeling of hurting herself/others
Breast care: hygiene, engorgement, proper breastfeeding technique, breast milk on nipples and let air dry to
tough nipples, adequate fluid; roll flat nipple between fingers just before feeding,
Activity: no heavy lifting for 3 weeks (nothing heavier than the infant), avoid sitting for prolonged periods
of time w/ legs crossed, limit stair climbing the first few weeks; w/c-sec limit activity & heavy
lifting until 6 week check up.
Nutrition: high in protein, balanced diet of all food groups, fluid 8-10/day, 500 cal/day if lactating
PP exercises: kegal exercises—10 tightenings 8x/day; pelvic tilt
Sexual intercourse: avoid until lacerations healed and discharge alba (2-4 wks); physiological responses
may be slower and less intense for first 3 months; recommend water soluble lubricants for
discomfort RT vaginal dryness
Contraception: Mensees for non-lactating mothers may resume 4-10 wks, for lactating 3mos
Newborn care: newborn assessment ATI Ch. 19 p349-368
Resp. & circulatory fxn changes w/ first breath, cutting of cord
3 shunts in heart functionally close: ductus arteriosus, ductus venosus, foramen ovale
Apgar scores at 1 & 5 minutes: HR, RR, Muscle tone, reflex irritability, color rated 0-1
Scores of 0-3 indicate severe stress; 4-6 moderate distress; 7-10 no distress
Quick initial assessment (can be performed while observed the infant lying with the mother, or during
drying and wrapping infant us): eternal assess, chest, abdomen, neurologic (fontanels, moro reflex)
Gestational age at 2-12 hrs old with use of ballard scale
Physical measurements: weight 2500-4000g; length 45-55cm (18-22"), head circumference 3335cm (13-14"); chest 30-33cm (12-13")
Ballard scale:
ATI-Women's health 33
--Neuromuscular maturity: Posture, square window (wrist), arm recoil, popliteal angle (knee), scarf
sign (arm over chest), heel to ear
--Physical maturity: skin textures (transparent – leathery/cracked/wrinkled), lanugo, plantar surface
(creases from minimal to entire sole [ 2/3 normal]), breast tissue (imperceptible tofull areola w/ 510cm bud), eyes & ears—amount of opening and ear cartilage, genitalia—M: scrotum (flat smooth
– pendulous w/ deep rugae) F: prominent clitoris w flat labia to labia majora covering labia minora
and clitoris,
Classifications by age & wtl
--LGA >90th percentile; AGA 10th to 90th percentile, SGA < 10th percentile
--LBW < 2500g; VLBW < 1500g; IUGR- rate of growth does not meet expected norms
--preterm/premature born prior to completion of 37th week
--term 38th wk – 42nd week --Posterm > 42 wks --postmature after 42 wks w/ placental
insufficiency.
Extensive physical exam w/in 24 hrs (cephalocaudal [head to toe])
--VS w/ RR first before infant becomes active or irritated w. stethoscope 30-60/min; apnea < 15 sec
--HR 100-160 take apical pulse for 1 minute (4th or 5th intercostal space/ mid clavicular line
--BP 60-80 SBP and 40-50 DBP
--Temp 36.5 – 37.2 axillary (97.7 –98.9)
If neonate becomes chilled (cold stressed) oxygen demands can increase and acidosis can
occur. Fetal hypoxia results in depressed respirations rather than increased
Physical exam:
--skin: color, turgor, texture, vernix caseosa, lanugo, Milia (small raised white spots), Mongolian
spots, telangiectatic nevi (stork bites-- flat pink/red marks that easily blanch and are found on
upper eyelids, back of neck, middle of forehead. Usually fades by 2nd year of life); nevus flammeus
(port wine stain—capillary angioma below the surface of the skin, does not blanch or disappear),
erythema toxicum (newborn rash—pink popular rash that appears suddenly during first 3 wks)
--HEAD—1-2cm larger in diameter than chest (more may be hydrocephalus);
--fontanels—anterior & posterior; may bulge w/crying. Bulging may indicate ICP, infection,
or hemorrhage. Depressed may indicated dehydration
--sutures palpable, unjoined, may be overlapped (molding)
--caput succedaneum (localized swelling of the soft tissues of the scalp RT pressure during
birth) Soft fluctuant mass that may cross over the suture line. Usually resolves 3-4 days
--Cephalohematoma—collection of blood between the periosteum and the skull bone it
covers. Does not cross suture. RT trauma in birth such as fetal heal against maternal pelvic
in prolonged difficult labor or forceps deliver. Appears 1-2 days after birth, resolves 3-6wks.
--Eyes—symmetry, placement, jaundice, papillary & red reflex
--Ears—placement (low set may chromosome abnormality (down syndrome) or renal DO
--Nose—obligate nose breathers, do not develop response of opening mouth with nasal obstruction
until 3 weeks
--Mouth—assess for palate closure & strength of sucking, Epstein pearls (small white cysts found
on gums and joint of hard palate-are normal—disappear after a few weeks
--Chest—respirations should be diaphragmatic
--abdomen—umbilical cord-1vein/2arteries, should be odorless, Bowel sounds 1-2 hrs after birth
--anogenital—Female-vaginal blood-tinged d/c RT maternal preg. hormones; urine/meconium
should be passed w/in 24hrs, uric acid crystals can produce rust colored urine 1-2 days
--extremities should be flexed, gluteal folds should be even, soles well-lined over 2/3 of foot
--Reflexes: sucking, Moro [(startle) (arms/legs extend then abduct & fingers for "C")], rooting,
tonic neck (fencing), babinski (sole of foot on side of small toe toes fan), grasping, stepping,
startle
--Vision—able to focus 9-12", hearing similar to adult
ATI-Women's health
Lab values: Hct: 44-64
RBC 4.8-7.1
leukocytes 9,000-30,000/mm
Platelets 150,000-300,000/mm
Glucose 40-60mg/dL
Bilirubin day1 0-6mg/DL
day2 <8
day 3 < 12
day 7 < 2
Blood pressure cuff is 2 ½ inches wide
Newborn Care
34
ATI Ch. 20 p.369-384
Newborn care in 3 phases: stabilization , assessment completion, nursing interventions/family teaching
Maintain a secure environment—match identification bracelets
Factors: infants w/DM mothers are higher risk for hypoglycemia
Genetic screening: 24hrs after birth and initial feeding
--PKU phenylketonuria—accumulation of amino acid phenylalamine  mental retardation
Heel stick—warm heel, no deeper than 2.4mm to prevent penetration of bone, necrotizing
osteochondritis, use outer aspect, 3 drops of blood onto filter paper, apply pressure w/dry gauze
--Newborn screening test
assessments: VS q 30min x 2; q 1hr x 2; q 8hrs
--Weight, length, head, chest circumference,
--Inspect umbilical cord
--observe for periods of reactivity (first 6 hrs of life)
1st—alert, rapid HR/RR lasts 15-30 minutes after birth
2nd –quiet resting/sleeping, slowing HR/RR ½ hr to 2 hrs
3rd- reawakens, responsive again 2-6hrs
Suctioning—gentle percussion over chest w/percussion cup; hold head slight lower; compress bulb before
insertion into mouth, suction mouth before nose to prevent inhaling pharyngeal secretions; suction
each side of infant's mouth avoiding center to prevent gag reflex
Thermoregulation—provide a neutral thermal environment, infant has lg surface to weight ratio, reduced
metabolism per unit area, BVs close to surface, small amts of insulation. Keep warm by
metabolizing brown fat (unique to newborns). Becoming chilled can increase oxygen demands
S/S of hypothermia: T<36.5, cyanosis, RR
Heat loss: conduction (contact w/cooler surface); convection (cooler ambient air); evaporation (liquid to
gas); radiation (loss of body heat to a cooler solid surface nearby) Newborn's T stabilizes < 4hrs
Prophylactic eye care—antibiotic ointment (erythromycin) to prevent Ophthalmia neonatorum caused by
Neisseria gonorrhoeae or Chlamydia tachomatis blindness
Apply 1-2cm ribbon in lower
conjunctival sac starting w/ inner canthus and moving outward, close eye for 5 seconds.
SE: chemical conjunctivitis (redness, swelling, drainage, temp blurred vision ) for 1-2days [normal]
Vit K (aquamephyton)—prevent hemorrhagic DO.Vit k produced in GI tract > 8 days.Admin ½ -lmL <2hrs
Hep B—recommended for all infants. Do not give in the same leg as Vit K
Sleep: 6 states: deep sleep, light sleep, drowsy, quiet alert, active alert, irritability (crying)
Sleep 17hrs/day in 4hr stretches
Elimination: Urine: 1in 24hrs; 6-10/day after 4 days
Meconium: 1in 24hrs: 3-4/day depending on if breastfed or formula fed
Clean perineal area w/water or mild soap—avoid wipes w/ alcohol A&D ointment may be used
Bath within 1-2 hrs under heat source. Then complete baths 2-3 /wk; face, diaper area, skin folds/daily
Complications & Nursing implications:
Cold stress—ineffective thermoregulationhypoxia, acidosis, hypoglycemia
S/s: cyanotic trunk depressed respirations
Hypoglycemia
S/S: jitteriness, irregular resp. effort, cyanosis, weak high-pitch cry, lethargy, twitching, eye
rolling, seizures, BG < 40 Treatment; feed NOW or give glucose to prevent brain damage
Cord infection/ hemorrhage from cord—apply second clamp—if still bleed call MD
S/S of infection: moist, red, fowl odor, purulent drainage
ATI-Women's health
Newborn care: meeting nutritional needs ATI ch.21 p 385-401
35
Wt. gain/loss—5-10% immediately after birth (regained by 10-14 days) then gain 110-200g/wk for 3 mo.
Fluid intake 100-140mL/kg/day (newborn)
Solids > 6 months
Caloric intake 0-3mo: 110 kcal/kg/day 3-6mos 110 kcal/kg/day milk/formula=20kcal/oz
1oz = 30mL
CHO needs to make up 40-50% of calories (lactose)
Fat 15% of cal (formula corn oil substituted for cow milk fat)
Protein 2.2g/kg/day
Vitamins: D may be needed for dark-skinned babies w/limited exposure to sun
Iron/Fluoride—none for 1st 6mo. Then provide by food or supplement
Breastfeeding benefits: risk for infection RT IgA antibodies,lysozmes,leukocytes,macrophages,lactoferrin
--rapid brain growth RT lg amts of lactose
--provides protein and nitrogen for neurological cell building, contains electrolyes & minerals
--easily digestible, convenient and cheap
--improves ability to regulate Ca and P levels
--sucking assoc w/breastfeeding reduces dental problems
Failure to thrive (infant causes): inadequate breastfeeding, illness, infection, malabsorption, circumstances
that increase newborn's energy needs
Maternal factors: inadequate emptying of the breast, pain w/feeding, inappropriate timing of
feeding, inadequate breast tissue, maternal hemorrhage, illness, infections
Monitor wt gain: adequate growth is between 10th and 90th percentile
Feeding-readiness (cues): hand-to-mouth or hand-to-hand mov'ts; sucking motions, rooting, mouthing
Breastfeeding: wash hands; have fluids; explain let-down and cramping; express milk and spread on nipple
to entice infant; proper latch-on position (babys' mouth will cover some areola and nipple, its
cheeks, chin, and nose will touch breasts); basic breastfeeding positions (football, cradle, modified
cradle, across the lap, and side lying); burp infant between breasts; alternate which breasts you start
on each time; adequate milk if 6-8 wet diapers per day; avoid nipple confusion by not using formula
supplement or pacificer.
Milk storage: stored in refrigerator < 48 hrs; stored in freezer < 1 yr; thaw in refrigerator for 24 hrs to
preserve immunoglobulins; can also be thawed in lukewarm water; microwaving destroys
lysozomes and immune factors
Formula can be stored in refrigerator < 48 hrs; hold infant in a semi-upright position (never supine RT risk
of aspiration); burp newborn after each ½ oz of milk; discard remainder left in bottle RT bacterial
contamination; sufficient formula if—gaining wt, content between feedings, 6-8 wet diapers/day
Interventions for baby not getting enough nutrition:
--Sleepy baby: unwrap the infant, change the infant's diaper, hold the infant upright and turn from
side to side, talk to the infant, message the infant's back, rub hands/feet, apply cool cloth to face
--Fussy newborn: swaddle the infant, hold close/move/rock gently, reduce environmental stimuli,
place the infant skin to skin
Failure to thrive is slow to gain weight and usually falls below 5th percentile
*breastfeeding infant—evaluate positioning and latch-on, message the breast during feeding
*formula fed—evaluate how much and how often being fed; if baby is spitting up/vomiting a lot—
may have an allergy or intolerance to cow's milk and may need to switch to soy-based formula
Newborn care: Circumcision ATI ch.22 p.402-411
Circumcision-surgical removal of foreskin of penis is contraindicated w/ hypospadias and epispadias
because prepuce skin may be needed for repairs of the defect.; not done immediately after birth RT
cold stress and low levels of vit K  risk for hemorrhage; few medical indications for
circumcision except for phimosis (tightness of foreskin on the penis)
Surgery—7 methods, anesthesia is now mandatory(ring block, dorsal penile nerve block, topical anesthetic)
ATI-Women's health
36
Methods: yellen, mogen, gomco clamp procedures—cut the foreskin off
Plastibell procedure—tissue distal to suture around foreskin causes ischemic tissue to atrophy and
fall of in 5-8 days
Contradictions: hypospadias/epispadias, hx of bleeding tendencies in family (hemophilia/clotting 'DO),
Religion, ambiguous genitalia, illness or infection of newborn
Post procedure interventions: assess: bleeding q 15 for 1 hr, q 25hrs; assess for first voiding; apply loose
diaper; change diaper < 4 hrs and clean penis w/ each change; apply petroleum jelly w/ each daper
change for 24 hrs; diaper should be fan folded to prevent pressure ; avoid wrapping penis in tight
gauze; no tub baths until healed; notify MD if redness, discharge, swelling, strong odor, tenderness,
decrease in urination, excessive crying of infant; yellowish mucus may form over glans by day 2
and is not to be washed off; avoid towelettes w/ alcohol;
Interventions: signed consent; document—circumcision type, date, time, parent teaching provided,
excessive bleeding, time newborn urinates before d/c
Complications: hemorrhage—apply pressure w/4x4gauze—if persists call MD
Cold stress or hypoglycemia: monitor for excess loss of heat (RR and T); provide heat source
during procedure and swaddle/feed infant as soon as finished
Other complications: infection, urethral fistula, delayed healing, scarring, fibrous bands
Newborn: Newborn complications
ATI ch. 23 p.412-454
Complications of a preterm infant:
RDS-respiratory distress syndrome (surfactant regardless of age)
BPD-bronchopulmonary dysplasia (lungs stiff and noncompliant)
Aspiration-RT ineffective suck/swallow; not intact gag reflex
Apnea of prematurity RT immature neurological/chemical mechanisms
Intraventricular hemorrhage—bleeding in/around the ventricles of the brain
ROP-Retinopathy of Prematurity—abnormal growth of retinal BVs—complication of 02 admin
PDA-patent ductus arteriosus (ductus arteriosus reopens after birth RT hypoxia)
NEC-necrotizing enterocolitis (inflammatory disease of GI mucosa RT ischemia)
Risk factors to preterm births:
Gestational hypertension; multiple pregnancies; adolescent preg; lack of prenatal care; smoking;
substance abuse; prev. hx of preterm; abnormalities of uterus; incompetent cervix, placenta previa
Assess. for S/'S of preterm infant: Ballard assessment; periodic breathing (5-10 pauses followed by 5-10
sec rapid respirations); signs ofrespiratory effort; Apnea; low birth wt.; wrinkled features; skin
(thin, smooth, shiny, maybe translucent); veins clearly visible under thin, transparent epidermis;
lanugo over body; soft,pliable ear cartilage; minimal sole/palm creases; skull/rib cage soft; few
scotal rugae; eyes closed < 22-24wks; prominent labia/clitoris; flat areola w/o breast buds; weak
grasp reflex; heels fully movable to ears, posture extended and frog-like, inability to coordinat
suck/swallow, weak gag/suck/cough relexes; hypotonic muscles; lethary/tachycardia, poor wt. gain
S/S dehyration: urine output < 1mL/kg/hr; urine specific gravity > 1.015; wt loss; dry mucous membranes;
por skin turgor, depressed fontanel.
S/S overhydration: urine ouput > 3 mL/kg/hr; urine specific gravity < 1.001; edema; wt.gain; rales, I>O
Interventions: Main priority is supporting CARDIAC and RESPIRATORY systems
Thermoregulation; resp.support; minimize stimulation (touch very smoothly/lightly, lights
dim,noise); position in neutral flexion w/ extremities close to body, prone & side lying positions
preferred; provide non-nutritive sucking; protect against infection
RDS—deficient surfactant characterized by poor gas exchange and ventilatory failure
Surfactant is phospholipidalveoli expansion
Atelectasis-collapsing of portions of lung work of breathing resp. acidosis/hypoxemia
Complications: RT O2 therapy & mechanical ventilation
ATI-Women's health 37
Pneumothorax, pneumomediastinum, ROP, BPD, infection, intraventicular hemorrhage
Risk factors: preterm; perinatal asphyxia (meconium staining, cord prolapse, nuchal cord);
maternal DM, PROM; maternal substance use (barbiturates/narcotics) close to birth; maternal
hypotension; C-sec w/o labor; hydrops fetalis (massive edema RT hyperbilirubinemia;
S/S: RR > 60/min; intercostal/substernal retractions; labored breathing; fine rales; nasal flaring;
expiratory grunting, cyanosis, as RDS worsens—unresponsive, flaccis,apneic, w/breath sounds
Accelerate lung maturation in utero: gestational age, intrauterine stress, oxogenous steroid use, ROM
Nursing Interventions: Suction prn; maintain thermoregulation; correct resp acidosis by ventilatory support;
correct metabolic acidosis by admin Na bicarbonate; maintain adequate O2 to prevent lactic
acidosis and avoid toxic effects of oxygen;  stimuli
Postterm infant- assoc. with:
--Dysmaturity from placental degeneration and uteroplacental insufficiencyfetal hypoxia/distress
Fetal response is polycythemia, meconium aspiration, resp. problems. Perinatal mortality is
higher RT  O2 demands during labor that are unmet by insufficient placenta
--Continued growth in utero cepphalopelvic disproportion, high insulin reserves/poor glucose
reserves at birth. Fetal response: birth trauma, asphyxia, clavicle fractures, seizures,BG, cold stress
--may be LGA or SGA depending on how well placenta fxns during last weeks
-- risk for meconium aspiration
--persistent pulmonary HTN (persistent fetal circulation) RT meconium aspiration. Shunts stay open
S/S of postterm infant: wasted appearance, thin w/loose skin (sued some of subQ fat); peeling/cracked/dry
skin (leathery from  protection of vernix); long thin body; meconium staining of fingernails;
hair/nails long; more alert; BG; s/s of cold stress; neurological symptoms, macrosomia
Nursing Interventions:
Assist w/surfactant lavages to prevent meconium aspiration; suctioning meconium (mouth/nares
before first breath); admin O2, Ivprn; exchange transfusion if hct is high; thermoregulation in
incubator to avoid cold stress; early feeding to avoid hypoglycemia, ID/treat birth injuries
LGA/Magcrosomic- > 90th percentile or >4000g (8lbs12oz) (may be preterm, postterm or full term). They
are at risk for birth injuries (clavicle fracture, C-sec, BG, polycythemia [hct > 60%])
--uncontrolled BG during preg (leading risk factor for LGA)  Congenital defects (most common
being: heart/ tracheoesophageal fistula, CNS anomalies)
Contributing factors: postterm infant; maternal DM (BG levels), transposition of the great vessels; genetic
factors; obesity, multiparous mother
Assessments: wt > 90th percentile; plump/full-faced (from  subQ fat); hypoxia, birth trauma (fractures,
intracranial hemorrhage, CNS injury); sluggish/hypotonic muscles; tremors from Ca;
Interventions: early/frequent heel sticks to monitor glucose; early feedings or IV to maintain normal BG;
thermoregulation; admin surfactant by endotracheal tube prn;
Hypoglycemia—blood glucose (BG) < 40mg/dL (2 consecutive low BG levels)
(in Preterm hypoglycemia = BG < 25)
Untreated hypoglycemia can result in mental retardation
Risk Factors: maternal diabetes (DM); preterm infant; LGA, stress at birth (cold stress/asphyxia), maternal
epidural anesthesia
Assessments: poor feeding; jitteriness/tremors; hypothermia; diaphoresis; weak shrill cry; lethargy; flaccid
muscle tone, seizures/ coma
Interventions: heel stick for BG levels; frequent feedings early after birth
SGA/ IUGR (intrauterine growth restriction) < 10th percentile
Common complications: perinatal asphyxia, meconium aspiration, BG; polycythemia, instable T
Risk factors: congenital/chromosomal anomalies; maternal infections/disease/malnutrition; gestational
HTN/DM; smoking/drug/alcohol use; multiple gestations; placental factors (small placenta,
placenta previa, placental perfusion); fetal congenital infections (rubella/toxoplasmosis)
ATI-Women's health 38
Assess s/s: wt < 10 percentile; normal skull, but reduced body dimensions;  sub Q fat; loose/dry skin;
muscle mass (esp. over cheeks/buttocks); drawn abdomen vs well-rounded; thin/dry/yello9w
umbilical cord vs gray/gloistening/moist; scalp hair sparse; wide skull sutures RT inadequate bone
growth; resp distress;hypoxia; wide-eyed and laert RT prolongedfetal hypoxia; s/s of meconium
aspiration/ hypoglycemia/hypothermia
Interventions: support resp efforts/suction; prevent cold stress; early feedings; partial exchange transfusion
prn; adequate hydration; prevent skin breakdown; protection from infections
Hyperbilirubinemia—elevation of serum bilirubin levels  jaundice (appears cephalocaudal manner)
--Physiologic jaundice—benign (resulting from normal physiology of  bilirubin production RT
shortened lifespan and breakdown of RBCs and liver immaturity) s/s > 24 hrs w/o other symptoms
rises from 2mg/dL to peak < 13
--Pathologic jaundice is result of underlying disease; s/s <24 hrs or is persistent > day 7 ;Bilirubin
levels  > 0.5mg/dL/hr(according to book it is per 4-8 hrs not per hour & >5mg/day) (term infant)
and peak at > 13mg/dL; preterm > 10mg. Usually caused by blood group incompatibility, infection,
or possibly RBC disorders
--Kernicterus –chronic and permanent results of bilirubin toxicity RT bilrubin encephalopathy
--Bilirubin encephalopathy—results from untreated hyperbilirubinemia with levels > 25mg/dL.
Bilirubin is able to cross the blood brain barrier if unbound to a protein. It is deposited in the brain
(basal ganglia, cerebellum, hippocoampus) (in preterm infants can occur at levels of 10-12)
Survivors may develop cerebral palsy, epilepsy, mental retardation.
Risk factors:  RBC production/breakdown; Rh or ABO incompatibility;  liver fxn; maternal enzymes in
breast milk; ineffective breastfeeding; some meds( aspirin, tranquilizers, sufonamides);
hypoglycemia, hypothermia, anoxia
S/S: yellowish tint to skin/sclera/mucous membranes (check by blanching skin on cheek, chest; signs of
hypoxia, hypothermia, hypoglycemia, and metabolic acidosis can result from hyperbilirubinemia
S/S of kernicterus—yellowish skin, lethary, hyptonic, poor suck, untreated-infant will become hypertonic
with backward arching of the neck and trunk; high pitched cry, fever
SE of phototherapy: bronze discoloration (not serious); maculopapular skin rash (not serious); development
of pressure areas; dehyration (poor skin turgor, dry mucous membranes, urinary output); T
Interventions: feed early and frequently (promotes bilirubin excretion in the stools [stools will be loose and
green]); maintain adequate fluid intake;
--Set up phototherapy: eye mask; newborn undressed (M- use surgical mask[metal strip
removed] as bikini over genitalia to prevent possible testicular damage RT heat/light waves;
do not use lotions/ointments (absorb heat); remove from light q 4 hrs-remove mask and
check for signs of inflammation/injury; reposition infant q 2hrs to expose all body surfaces
and prevent pressure sores; turn off lights before drawing blood for testing.
Congenital Anomalies—are present at birth and involve any body system. Major anomalies:
Congenital heart disease
Neurological defects (neural tube defects; hydrocephalus, anencephaly, encephalocele,
meningocele, myelomeningocele)
GI (clept lip/palate, diaphrag;matic hernia, etc)
Musculoskeletal deformities ( clubfoot, polydactyly, devel. Dysplasia of the hip)
Genitourinary deformities (hypospadias, epispadias, exstrophy of the bladder)
Metabolic DO (phenylketonuria PKU [guthrie test]; galactosemia [blood/urine levels of galactose],
hypothyroisidsm [thyroxine])
Chromosomal abonormailies (Down syndrome)
Risk factors: age >40; chromosome abornalities; viral infections (rubella); excessive body heat exposure
during 1st trimester [neural tube defects]); meds/substance abuse during pregnancy; radiation
exposure; maternal metabolic DO (DM, PKU); poor maternal nutrition (folic acid-neural tube
defect); premature infants; SGA; oligohydramnios/polyhydramnios
th
ATI-Women's health 39
Diagnostic: prental-amniocentesis, chorionic villi sampling, ultrasound, alpha fetal protein; routine testing
for metabolic DOs (see above) ; cytologic studies (karyotyping of chromosomes); dermatolyphics
(examine patterns of ridges on digits, palms, soles [down synd]
S/S and interventions of congenital anomalies:
--cleft lip/palate (failure of lip, hard/soft palate to fuse)
interventions: determine most effective nipple; feed in upright position burping often;
cleanse mouth with water after eating
--Tracheoesophageal atresia—failure of esophagus to connect to the stomach, escessive mucous
secretions/drooling, periodic cyanotic episodes/choking, abdominal distentions after birth,
immediate regurgitation after birth
interventions: Tracheoesphageal atresia—with hold feedings until determination of
esophageal patency; elevate head of boed to prevent reflux; supervise first feeding of all
newborns to observe for this
--phenylketonuria (PKU)—inabnility to metabolize the aa phenylalanine-mental retardation
interventions: special synthetic formula; restrict meat, dairy, diet drinks, protein, aspartame
--Galactosemia—imability to metabolize galactose into glucosefailure to thriva, cataracts,
jaundice, cirrhosis of the liver, sepsis, mental retardation if untreated
interventions: give infant a milk substitute since galactose is present in milk
--hypothyroidism—slow metabolism caused by maternal iodine deficiency or maternal antithyroid
meds during pregnancy hypothermia, poor feeding, lethargy, jaundice, cretinism if untreated
--neurologic anomalies (spina bifida) neural tube defect that vertebral arch fails to close, may be
protrusion of the meninges and/or spinal cord
**interventions: protect membrane w/sterile covering and plastic to prevent drying; observe
for leakage of CSF; position prone or side lying;
--hydrocephalus—excessive spinal fluid accumulation in the ventricles of the brain causing the head
to enlarge and the fontanels to bulge. Common sign is sun-setting eyes (whites visible above iris)
**interventions: measure circumference of head daily (1-2cm larger than chest); assess for
ICP (vomiting/ shrill cry); frequently reposition head to prevent sores
--PDA-patent ductus arteriosus—noncyanotic heart defect where duct fails to close. S/S: murmurs,
abnormal HR or rhythm, breathlessness, fatigue while feeding
--tetralogy of fallot—cyanotic—4 defects: VSD, pulmonary stenosis, overriding aorta, hypertrophy
of L ventricle. S/S: resp.difficulties, cyanosis, HR, RR, diaphoresis
interventions: conserve infant's energy to  workload on heart; admin. gavage feedings or
use special nipple for oral feedings; elevate infant's head/shoulders to improve respirations
and reduce cardiac workload; prevent infection; place infant in knee-chest position during
resp. distress.
--Down syndrome—s/s—upward slant of eyes, epicanthal folds, flat facial profile w/ depressed
nasal bridge, and a small nose, protruding tongue, small low-set ears, short broad hands w/ 5th finger
that has one flexion crease instead of 2, deep crease across the center of the palm (simian crease),
hyperflexibility, and hypotonic muscles
Interventions for congenital anomalies: est./maintain respiration/circulation/thermoregulation/nutrition
Birth trauma/injury—most are minor
Types: scalp (caput succedaneum, cephalohematoma); skull (fracture); intracranial
(epidural/subdural hematoma, cerbral contusion); spinal cord) spinal cord transaction/injury,
vertebral artery injury); plexus (total brachial plexus injury, klumpke paralysis); cranial/ peripheral
nerve (radial nerve palsy, diaphragmatic paralysis)
Risk factors: maternal, intrapartum, obstetric birth techniques, newborn factors
Fetal macrosomia; abnormal/difficult presentations; uterine dysfxn; cephalopelvic disproportion,
multifetal gestation, congenitgal abnormalities, Internal FHR monitoring, forceps/vacuum
extractions; external version, C-sec.birth
ATI-Women's health
40
S/S: subarachnoid hemorrhage—irritability, seizures, depression
--facial paralysis—eye remaining open; facial flattening/ unresponsiveness to grimace
--laryngeal nerve palsy from excessive traction on the neck—weak/hoarse cry
--joint dislocations/separations—flaccid muscle tone
--nerve plexus injuries/long bone fractures—flaccid muscle tone of extremities
--clavicular fractures—limited motion of arm, crepitus over a clavicle, absence of Moro reflex
-- Erb-Duchenne paralysis (Brachial)—flaccid arm w/ elbow extended and hand rotated inward,
absence of moro reflex on affected side, sensory loss over the lateral aspect of the arm,
intact grasp reflex
Neonatal infection/Sepsis (Sepsis Neonatorum)—presence of micro-organism/toxins in blood/tissues of
infant during the 1st month after birth. S/S are often subtle. Prevention includes sterile and aseptic
techniques during delivery.
Risk factors: PROM; TORCH; chorioamnionitis, premature birth; low birth weight; substance abuse,
maternal UTI, meconium, HIV
Common organisms: Staphylocuccus aureus/epidermidis; E. coli, Haemophilus influenze, Group B strep
S/S: temperature instability; suspicious drainage; poor feeding pattern; Vomiting/diarrhea; poor wt gain;
abdominal distension; large residual if feeding by gavage; apnea, sternal retractions, grunting, nasal
flaring, decreased oxygen saturation; color changes such as jaundice, pallor, petechiae; tachycardia
or bradycardia, poor muscle tone and lethargic
Maternal substance abuse during pregnancy—any use of alcohol or drugs during pregnancy
Assessments: monitor s/s of neonatal abstinence syndrome using neonatal abstinence scoring system that
assess for and scores the following:
--CNS-irritablity, tremors, high-pitched/shrill cry, incessant crying, hyperactive w/ Moro
reflex,  deep tendon reflexes, muscle tone, wakefulness, excoriations on the knees, face
and convulsions
--Metabolic, vasomotor, and respiratory—nasal congestions w/flaring, tachypnea, sweating,
frequent yawing, skin mottling, RR>60, T>37.2 (99)
--GI—poor feeding, vomiting, regurgitation (projectile vomiting), diarrhea, excessive/
uncoordinated, and constant sucking
Opiate withdrawal can last for 2-3 wk- s/s: rapid changes in mood, hypersensitivity to noise and external
stimuli, dehydration, poor wt. gain
Heroin w/drawal—s/s: low birth wt., SGA, moro reflex, hypothermia/hyperthermia
Methadone w/drawal—s/s:  incidence of seizures, higher birth wts,  risk for SIDS
Marijuana w/drawal—s/s: preterm birth and meconium staining
Amphetamine w/drawal—s/s: preterm or SGA, drowsiness, jitters, resp. distress, frequent infections, poor
wt gain, emotional disturbances, and delayed growth/devel
FAS-fetal alcohol syndrome from chronic intake of alcohol: --Facial anomalies: epicanthal folds,
strabismus, ptosis, mouth w/ poor suck, cleft lip/palate, small teeth; Deafness; abnormal palmar
creases and irregular hair; many vital organ anomalies (heart defects); developmental delays and
neurologic abnormalities, prenatal and postnatal growth retardation; sleep disturbances
--Risks: feeding problems, CNS dysfxn (mental retardation/cerebral palsy); behavioral difficulties
(hyperactivity); language abnormalities; future substance abuse; delayed growth/dev; poor
maternal-infant bonding
Tabacco: prematurity; low birth wt;  risk SIDS;  risk for bronchitis, pneumonia, and devel. Delays
Nursing interventions for the effects of substance abuse on neonate or substance withdrawal:
--meds to CNS irritability and control seizures; reducing external stimulation; swaddling; frequent
small feedings of high-calorie formula; elevating head during and following feedings, and burping
the infant well to reduce vomiting and aspiration; various nipples to compensate for poor suck
reflex; for cocaine addicted infants, avoiding eye contact and using vertical rocking & pacifier.
ATI-Women's health
Newborn care: Discharge (d/c) teaching ATI 24 p.455-468
41
D/C is often from 6 – 48 hours. Parents should be taught the areas of: crying, quieting, sleeping, feeding,
bathing, and clothing, well-checks, immunization, s/s of illness, safe environment, safe car,
--crying: hungry, need burping; overstimulated, wet, cold, hot, bored
--quieting: carrying; swaddling; rhythmic monotonous noise/movement; place infant on its stomach
across lap and bounce legs; close skin contact, en face, stimulation for bored infant
--sleeping: 16 of 24 hrs in 2-3 hours lengths; develop a routine—keep infant in center of activity
from afternoon until bedtime, bath before bed, last feeding at 11:00
--positions for holding: cradle, upright, football, colic(prone on holder's forearm)
--bathing: 2-3x/wk; face & perineal area daily; water 98-100F (38C) & room warm/avoid drafts; use
mild soap (no hexachlorophene); do not use lotions, oils, powders; powder can be inhaled
--safety: crib slats 2 ½ inches apart and space between crib and mattress < 2 finger widths; all
visitors should wash their hands before touching the baby; individuals w/infections should stay
away
--car: rear-facing car seat until 20lbs (l yr) and then a toddler seat in rear seat of car
--well checks: at 2-6wks, and then q 2 months until 6 months, 9,12, 15, 18 months
--vaccinations: diphtheria, tetanus, pertussis, hep B, Haemophilus influenzae, polio, measles,
mumps, rubella, varicella
S/S of illness to report:
--T > 38 (100.4) for T < 97.9 (36.6)
--poor feeding or little interest in food
--forceful vomiting or frequent vomiting
--diarrhea or  bowel mov'ts
-- urination
--Labored breathing w/ flared nostrils or an absence of breathing for > 15 seconds
--cyanosis
--Jaundice
--lethargy
--difficulty waking
--inconcolable crying
--bleeding or purulent drainage around umbilical cord or circumcision
--drainage developing in eyes
CPR and Airway obstruction relief should be taught to parents