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Nur 263 (OB) - test units 1-3

STUDY
PLAY
Common Discomforts
First Trimester
• Nausea & Vomiting
• Urinary Frequency
• Fatigue
• Breast Tenderness
• Increased Vaginal Discharge
• Nasal Stuffiness
• Epistaxia
• Ptyalism - excessive saliva
Common Discomforts
Second & Third Trimester
• Heartburn
• Ankle Edema
• Varicose Veins
• Hemorrhoids
• Constipation
• Backache
• Difficulty Sleeping
• Leg Cramps
• Faintness
• Dyspnea
• Flatulence
• Carpal Tunnels
• Round Ligament Pain
(Basic Teaching for the Pregnant Women) Fetal Activity Monitoring
• Recommended to begin at 28 weeks
• Lie down on left side and count fetal movements
• Should have at least 10 movements in 2 hours
• Decreased movement or no movement indicate possible fetal hypoxia
• Fetal activity affected by fetal sleep, sound, time of day, blood glucose level, cigarette smoking or drug use
(Basic Teaching for the Pregnant Women) Breast Preparation
• Advised not to use soap on nipples because of drying affect
• Braless - clothing rub against nipples and toughen them
• Expose nipples to sunlight and air
• Nipple rolling/stimulation
- Contraindicated in women with a history of pre-term labor
- Nipple stimulation triggers release of oxytocin
• Inverted nipples - can place "breast shells" in bra
(Basic Teaching for the Pregnant Women) Bathing
• No contraindications
• Caution related to safety factors in late pregnancy
• Avoid tub baths if membrane is ruptured - increased risk of infection
(Basic Teaching for the Pregnant Women) Travel
• No restrictions
• Avoid if history of bleeding, pre-eclamspia, multiple gestation
• Automobiles are particularly fatiguing and uncomfortable
- Recommend stopping every 2 hours to walk
- Should wear lap and shoulder belt
- Abruptio placenta major complication with MVA
• Long distance trips best by plane
(Basic Teaching for the Pregnant Women) Exercise
Normal participation can continue through uncomplicated pregnancy
• Contraindications - ROM, pre-eclampsia, incompetent cervix, persistent vaginal bleeding, pre-term labor, IUGR
• Is not a time to begin new activities
• Improves self image, promotes regular bowel function, controls weight gain, associated with improved postpartum recovery
• Avoid exercising in supine position
(Basic Teaching for the Pregnant Women) Exercise
• Walking, swimming and cycling best because of low risk for injury
• Avoid overheating - has a potential teratogenic effect on fetus
- Core body temperature should not be above 100.4
- Avoid sauna and hot tubs
- May soak in hot tub for 10 mins if temperature is maintained at LESS THAN 98 degrees
(Basic Teaching for the Pregnant Women) Sexual Activity
• No contraindications in a healthy pregnancy
• Refrain from intercourse if multiple pregnancy, threatened abortion, incompetent cervix, STDs
• Avoid intercourse if ROM or preterm labor
- Increased contractions with orgasm and/or ejaculation
(Basic Teaching for the Pregnant Women) Dental Care
• Link identified between periodontal disease and pre-term labor and low birth weight infants
Immunizations
• Avoid those with attenuated live viruses such as rubellla, chicken pox, mumps or smallpox vaccine
• Vaccines using "killed" viruses may be used
• Consult with health care provider about complementary & alternative therapies
- Some herbs are dangerous during pregnancy
Dangerous Signs in Pregnancy
• Premature ROM - sudden gush of fluid from vagina
• Vaginal Bleeding - Abruptio placenta, Placenta Previa, bloody show, miscarriage
• Abdominal Pain - premature labor, abruptio placenta
• Infection - temperature above 101
• Toxemia/Pre-Eclampsia (PIH) - dizziness, blurred vision, spots before eyes, severe headache, edema of hands, legs, face and feet
Dangerous Signs in Pregnancy
• Severe Toxemia/Pre-Eclampsia - epigastric pain
• Hyperemesis Gravidarum - persistant vomiting
• Oliguria - renal impairment, decreased fluid intake, PIH
• Dysuria - UTI
• Absence of fetal movement - maternal medication, obesity, fetal death
Teratogenic Substances
Any substance that adversely affects normal growth and development of fetus
• Greatest risk during first trimester
• Certain medications, psychotropic drugs, alcohol, tobacco
• Environmental factors such as pesticides, x-rays
• Need to weigh benefits of prescription medication
- Only Category A drugs considered safe
- Also caution with OTC drugs
Recommendation For Tobacco Use
• Stop or decrease number of cigarettes smoked per day
• Associated with low birth weight, preterm, placenta previa, placenta abruptio, ectopic pregnancy, premature ROM, increased risk of cleft lip/palate, SIDS, acute respiratory illness in infant, chronic respiratory problems
• Adverse effects related to carbon monoxide and nicotine
Recommendation For Alcohol Consuption
• No safe limit has been identified
• Recommened that pregnant woman abstain from ALL alcohol intake
• Heavy intake associated with Fetal Alcohol Syndrome
Recommendation For Caffiene Intake
• Increased risk of miscarriage in early pregnancy
• Advised to limit intake to no more than 3 cups of coffee or cola a day
• Decreases iron absorption
Recommendation For Illicit Drugs
Marijuanna
• No identified teratogenic effects because of it being an illicit drug
• Thought to have adverse effects on CNS
Cocaine
• Risks for mom and fetus
• Associated with abruptio placenta, preterm, fetal distress, low birth weight, neonatal withdrawal, SIDS, spontaneous pneumothorax, congenital anomalies
• Urine screening only accurate for 1st 24-48 hours after drug use
• Can test meconium of baby for drug use during pregnancy
Historical Perspective of Childbirth Education
• 1933, Grantly Dick-Reed published book, Childbirth Without Fear. Talked about the fear-tension-pain syndrome
• 1951, Ferdinand Lamaze abserved the Psychorophylactic Method of Childbirht Preparation
- Method based on conditioned response to pain
• 1961, American Society of Psychoprophylaxis in Obstetrics (ASPO) founded
• Bradley Method - first to introduce husband as host
• Today's childbirth education - education, controlled relaxation, breathing patterns, exercises
Test That Assess Fetal Well Being
• Nonstress Test (NST)
• Biphysical Profile (BPP)
• Ultrasound
• Amniocentesis
• Chorionic Villus Sampling
Nonstress Test (NST)
Ordered to assess how well the placenta is functioning
• Indications: Post-dates, Maternal history of pregnancy complications, SGA, Decreased amniotic fluid
• Monitors externally, non-invasive
• Reactive test demonstrates 2 accelerations in 20 mins
• Statistically, a "reactive test" suggests that the placenta will provide adequate oxygen to the fetus for approximately the next 7 days
• Test will be ordered weekly
Biophysical Profile (BPP)
Utilizes ultrasound to evaluate fetal breathing movements, fetal movement of body and limbs, muscle tone, amniotic fluid volume and reactive NST
• A score 2 is assigned to each category for a total of 10
- Score of 8 is considered normal
• Also ordered to assess how well the placenta is functioning
- MORE definitive than NST
Ultrasound
Assess fetus for genetic or congenital problems, abnormalities in size, shape or structure
• Gestational dating most accurate in 1st trimester
• Best done at 18-20 weeks
Amniocentesis
• Indications: Advanced maternal age, previous child born with chromosomal abnormality, parent carrying a chromosomal abnormality, family history of neural tube defects (anacephaly, spina bifida, omphalocele),
• Done at 16-18 weeks gestation
Chorionic Villus Sampling
Diagnostic capability similar to amniocentesis
• Done at 8-10 weeks gestation
Abortion (Miscarriage)
Expulsion of fetus prior to 20 weeks gestation
• A 1st/2nd trimester problem
• Major cause of bleeding during this time
• Types:
- Spontaneous (Miscarriage): occurs "naturally"
- Induced: result of artificial or mechanical interventions
- Missed: fetus dies in utero but is not expelled
- Threatened: unexplained bleeding, cramping, backache but cervix is closed
Abortion (Miscarriage)
Signs & Symptoms
• Spotting, bleeding
• Cramping & Backache
Treatment
• Bedrest, IVs, blood transfusion, D&C
• Give Rhogam if RH negative
• Prepare woman for possible fetal loss
• Remember that ambivalence is common in 1st trimester. Might have guilt
• Encourage expression of feelings
• Give accurate information
• Support groups
Ectopic Pregnancy
Implantation of blastocyte in a site other than the endometrial lining of uterus
• Most common site: ampulla of tube
• Major symptom: pain
• Diagnosis: Ultrasound, serial serum hCG, serum progesterone levels
• Treatment: IVs, blood transfusion, surgery
Abruptio Placenta
Premature separation of a normally implanted placenta from the uterine wall
• Dark red bleeding associated with abdominal pain
• Uterus hard, firm and painful
• Cause Unknown
- Theory: caused by decreased blood flow to placenta, excessive uterine pressure, MVA, cocaine use, HTN, smoking, alcohol or drug ingestion, increased maternal age, increase parity, trauma
• Major concern is that circulation of fetus is affected when placenta separates
Placenta Previa
Placenta implanted in the lower uterine segment instead of in the upper portion of uterus
• Painless bright red bleeding
• Uterus is soft
• Major Concern is fetal hypoxia
- placenta circulation is affected when placenta detaches as cervix "opens up"
• When placenta detaches, bleeding occurs
- scant to profuse
- may hemorrhage rapidly
Incompetent Cervix (Cervical Insufficiency)
Premature dilation of cervix, 4-5 mons
• Associated with repeated 2nd trimester abortion
• Causes: cervical trauma, previous surgery on cervix, congenital defects
• Diagnosis: from history of multiple miscarriages, repeated pre-term delivery
• Treatment: Cerclage (Shirodkar-Barter)
Torch Infections
Group of infectious diseases that can cause serious harm to the embryo/fetus
• Toxoplasmosis
• Rubella
• Cytomegalovirus
• Herpes
Torch Infections
Toxoplasmosis
• Avoid poorly cooked or raw meats, wild game such as deer or rabbit, unwashed fruit/vegetables
• Avoid contact with the cat litter box
• Stress importance of wearing gloves while gardening
Rubella
• Stress importance of receiving rubella vaccine AFTER delivery if non-immune
Torch Infections
Cytomegalovirus
• Can be transmitted through placenta to baby
• Causes birth defects and developmental disabilities (hearing loss, lower IQ, small head, cerebral palsy)
• Contracted by pregnant woman through exposure to child's saliva or urine
• Counsel pregnant woman to:
- wash hands after changing diaper or wiping runny nose
- avoid sharing food, drink or utensils with younger children
Herpes
• C-Section will be method of delivery if herpes is active
• Valtrex given prophylactically to prevent outbreak
Premature Rupture of Membrane
Spontaneous rupture & leakage of fluid prior to onset of labor
• Pre-Term ROM - prior to 37 weeks gestation
• Associated with infection, previous history of ROM, polyhydraminos, multiple pregnancies, smoking, incompetent cervix, maternal reproductive tract abnormalities
• Assess: nitrizine paper, ferning, how long ROM, calculate gestational age to determine if baby is safe to deliver
Premature Rupture of Membrane
Risk To Mother
• Infection in uterus from ascending pathogens
• Stress related to condition of child
• Prolonged hospitalization
Risk to Fetus/Infant
• Fetal sepsis due to ascending pathogens
• Prolapse of umbilical cord
• Malpresentation
• Increased perinatal morbidity and mortality
Preterm Labor
Labor that occurs between 20-37 completed weeks
• Symptoms:
- Mild, menstrual like cramps in lower abdomen
- Uterine contractions every 10 mins or less
- Pelvic pressure: constant or intermittent
- Low backache
- Change in vaginal discharge: increased amount, more clear and watery, pinkish tinge
- Abdominal cramping with or without diarrhea
Preterm Labor
Teaching
• Rest on left side
• Drink 2-3 quarts of fluid each day
• Avoid caffeine drinks
• Empty bladder every 2 hours
• Avoid lifting heavy object, nipple stimulation, sexual activity
Scope of Practice For LPN
• Assist with collection of data during labor process
• Assist the RN, APN, or MD during delivery
• Identify basic problems (actual & potential) and assist with developing the plan of care
• Provide basic teaching from established teaching plans
Scope of Practice For RN
• Comprehensive assessment of laboring woman
• Analyze assessment findings
• Care for patients with complex problems during L&D
• Establish nursing diagnosis and plan appropriate care
• Plan and carryout teaching based on individual needs
Five P's of Labor
• Passage
• Pasennger
• Powers
• Positionof Mother
• Psyc
The Passage
Pelvis & Birth Canal
• Type of Pelvis - gynecoid (open, roomy)
• Ability of cervix to change:
- efface: 0-100%
- dilate: 0-10cm
• Ability of vaginal canal and external opening of vagina (introitus) to distend
• More than 6 vaginal exams during labor increases risk for infection
The Passenger
Fetus & Placenta
• Fetal Head
• Fetal Attitude
• Fetal Lie
• Fetal Presentation
• Fetal Position
• Placenta Implantation Site
Position of Fetus
• Determines type of delivery
• Affects nursing care given to patient
• Abnormal positions may lead to difficult delivery
- breeched - buttock first
• Can change up until "engagement" occurs
• Ballotable - ability of baby head to be pushed from cervix
• Determined by Leopold's Maneuvers and Ultrasound
Engagement
• Occurs when the largest diameter of fetus reaches or passes through the pelvic inlet
• In primigravida, usually occurs 2 weeks before term
• Multipara, may occur several weeks before labor or during labor
• Confirms the adequacy of the pelvic inlet (not midpelvis or outlet)
• Fetal presentation - occipital should be facing front. (baby looking back towards moms spine) pelvis is narrower in front
Station
Relationship of presenting part to an imaginary line drawn between ischial spines of maternal pelvic
• Narrowest diameter
• Designated as "0" station
• Higher than ischial spines = -number
• Lower than ishcial spines = +number
The Powers
• Primary force is uterine muscular contractions
- begins in fundus where greatest concentration of muscle fibers are located
• Causes dilation and effacement of cervix
• Causes changes in station
• Secondary force is use of abdominal muscles to "PUSH"
Uterine Contractions
• Rhythmic but intermittent
- relaxation provides rest for uterine muscles, rest for laboring woman and restores uteroplacental circulation
• Three Phases:
- Increment: Building up
- Acme: Peak
- Decrement: Fading Away
• May monitor externally or internally with Intrauterine Pressure Catheter (IUPC)
• Essential to assess fetus' tolerance to contractions
Frequency
How often contractions occur
• Determined from the beginning of one contraction to the beginning of the next contraction
- round to nearest half minute
• Normal frequency is 5 contractions or less in a 10 minute period
• Tachysystole - more than 5 contractions in a 10 minute period for over 30 minutes
- increases risk for fetal distress
- decrease Pitocin, side-lying position
Duration
How long a contraction lasts
• Determined from the beginning of a contraction to the end of that contraction
• Should NOT last longer than 90 seconds
Intensity
How strong a contraction is
• Mild, moderate, strong
• When monitoring externally, palpate the fundal area
• MVU's - when monitoring internally
Resting Tone
Uterus should be relaxed between end of one contraction and beginning of next contraction
• Need to have 30 seconds or more of resting period between contractions
• Palpate fundal area
The Position of Laboring Woman
• Upright position recommended
- walking, sitting, kneeling, or squatting
• Lateral position when lying down
The Psyc
• Uncertain of what labor will be like
• Concern that she will live up to her own expectations of self
• Fear of injury
• Fear of lack of support
• Disruption of lifestyles, relationships and self image
• Concern about loss of control of bodily functions, emotional responses and reaction to pain
Pre-Labor Signs
• Lightening - baby moving down pelvis
• Braxton-Hicks Contractions
- irregular, intermittent, painless
- become more painful as term approaches
- described as "drawing" sensation
• Ripening of cervix
• Bloody Show - pink tinged secretions from cervical capillaries
• Burst of energy
• Diarrhea, nausea and vomiting (can be caused by Prostaglandins)
• Increased backache and sacroiliac pressure
- results from hormones
• 1-3 pound weight loss
- results from fluid loss and electrolyte shift
True Labor
• Contractions are regular
• Interval between contractions gradually shorten
• Increase in duration and intensity of contractions
• Discomfort begins in back and radiates to abdomen
• Intensity increases with walking
• PROGRESSIVE cervical dilation and effacement
False Labor
• Contractions irregular
• No change in duration and intensity of contractions
• Discomfort usually in abdomen
• Walking has no effect on contractions or lessens severity of contractions
• NO cervical change
Stages of Labor
• First: from beginning of labor to complete dilation and effacement of cervix
- Latent or early phase: 0-3 cm
- Active phase: 4-7 cm
- Transition phase: 8-10 cm
- Inducing labor increases risk for c section because it's doesnt allow cervix to naturally dilate
• Second: begins with complete dilation of cervix and ends with birth of baby. "PUSHING"
- Crowning
- Episiotomy: midline or mediolateral
Stages of Labor
• Third: begins with birth of baby and ends with delivery of placenta
• Fourth: first 1-2 hours after delivery of placenta; initial recovery time
- Expected amount of blood loss: 250-500ml for vaginal delivery
- Essential for uterus to remain contracted
- Priority Problems during this stage: Risk for hemorrhage, hypotonic bladder
Maternal Physiologic Response to Labor
Cardiovascular
• Increased CO and heart rate
• Increased BP, especially during contractions
• Supine Hypotensive Syndrome
• Stage 2: Valsalva maneuver
Fluid & Electrolytes
• Diaphoresis
• Hyperventilation
...
Maternal Physiologic Response to Labor
Body Temperature
• Slight elevation due to muscle activity
• Temperature over 100.4 is a sign of infection
- need to asses every 2 hours for rupture of membranes
• Increase fluid loss from sweating and evaporation of skin
Respiratory
• Increase respiratory rate
• Increased oxygen demand and consumption
• Hyperventilation and fall in PaCO2 results in RESPIRATORY ALKALOSIS
• No more than 30 breaths per min
Amniocentesis
A procedure in which a needle is inserted through the abdominal and uterine walls into the amniotic fluid; fluid is withdrawn; used for assessment of fetal health and maturity.
• Possible after 14 weeks
• Performed to obtain amniotic fluid (which contain fetal cells) for the purpose of a biochemical assessment/analysis of the amniotic fluid.
• Clinical significance: to evaluate for genetic disorders or congenital anomalies, assessment of pulmonary maturity, and diagnosis of fetal hemolytic disease
Maternal Physiologic Response to Labor
Gastrointestinal
• Gastric motility decreased
• Gastric emptying prolonged
• Increased risk of aspiration with anesthesia
Hematology
• Increased WBC - may be 15,000 or higher
• Increased fibrinogen
• Decreased blood glucose
• Slight proteinuria
Fetal Response to Labor
• Positive effects: decreased respiratory tract secretions
• Potential adverse effects: decreased placental perfusion, hypoxia
Pain Theories
• Gate-Control Theory - suggest a gating mechanism controlling transmission of painful stimuli
• Endogenous Pain Control Theory:
- Internally produced substances called endorphins that affect pain perception
- Endorphin levels higher just prior to labor
• Increased labor pain is correlated with decreased placenta perfusion
Pain Relief Options
Non-Pharmacological - • Relaxation techniques
- muscle tension causes fatigue and increased oxygen demand
- comfortable position
• Cutaneous stimulation
- Massage of large muscle groups stimulates gate-control theory
- Efflurage - massage of abdomen (flat hand stroking)
- Heating pad, warm shower, bath
- counter-pressure to low back
• Breathing techniques
- form of distraction
- enhances relaxation and provides good O2 exchange
- teach slow deep breathing if no prenatal education
• Patient hygiene and comfort measures
Pain Relief Options
Pharmacologic - • Nubain - systemic analgesia
- drug of choice
- recommended to wait until labor established
- IM, SubQ or IV
- should not be given within a few hours of birth because it may depress neonatal respirations
- antidote is Narcan
• Pudenal Block - provides perineal numbness
- used during stage 2
Pain Relief
Anesthesia - • Local - used during 2nd stage to provide perineal numbness
• Regional - Epidural (into dura, 75% numbness)
- Major side effect: hypotension
- Bolus of fluid prior to procedure, monitor BP ever 5 mins after procedure, side-lying down position, monitor for urinary retention
- Contraindications: low platelets, increases hemorrhage risk
Pain Relief
Anesthesia - • Regional - Spinal (L4,L5)
- Major side effect: hypotension
- Immediate effects
- Used during 2nd stage
- Tilt patient to side during C-section to lessen hypotensive effects
• General - only used for EMERGENCIES, high risk for fetal depression
Maternal Assessment
• Review prenatal history
• Identify risk factors
• Maternal VS, labor status, uterine activity, fetal status and alb values
- once patient in active phase must assess at least every 30 mins
• Don't forget assessment of pain and psychosocial status
Assessment of Fetus
• Fetal Heart Rate Pattern
- evaluate at least every 30mins
- external or internal
- membranes must be ruptured for internal monitoring (scalp electrode)
• Fetal movement
• Fetal response to scalp stimulation or sound
• Umbilical cord acid-base determination - done AFTER delivery
• Presence of meconium in amniotic fluid (yellow/green fluid)
- Suggest fetal stress (hypoxia)
- is sterile, but irritating to lungs
- Risk to infant's respiratory system once born
Fetal Heart Rate
Gives information about wellness of fetus
• Baseline 110-160
- recorded in increments of 5
• Look at 10 minute period of time EXCLUDING accelerations and decellerations
- prolonged decel over 10 mins indicates a baseline change
• Record average
• Monitor internally or externally
• Assess in relation to uterine contraction
• Reaction to scalp stimulation
Baseline Fetal Heart Rate Changes
• Bradycardia - baseline less than 110 bpm for 10 minutes or longer
- hypoxia, decreased BP, cord compression or prolapse
Tachycardia - baseline more than 160 bpm for 10 mins or longer
- prematurity, maternal fever, early hypoxia, medications, nicotine
Variability
Interplay of sympathetic and parasympathtetic nervous system causing fluctuations in FHR
• Can determine when monitoring externally
- Absent: no change in FHR (BAD)
- Minimal: change less than 5 bpm
- Moderate: change of 6-25 bpm (IDEAL)
- Marked: change greater than 25 bpm
• Important indicator of oxygen reserve
• Decreased variability could be due to fetal sleep, drugs, hypoxia, prematurity
- NON-REASSURING
• Increased could be due to early hypoxia, fetal activity or stimulation
Accelerations
Reassuring
• Abrupt increase if FHR of at least 15 beats lasting at least 15 seconds
• Indicate good oxygen reserve
• Scalp stimulation should cause accelerations
- if not, then baby might be hypoxic
Early Decelerations
Reassuring
• Results of head compression that results in a reflex vagal response
• Occurs at the same time as the contraction and is back to baseline by the end of contraction
• Gradual slowing of FHR (onset to lowest point of the deceleration, "nadir", is more than 30 seconds
• Usually a result of baby moving down the birth canal
• No intervention necessary
Variable Decelerations
Non-Reassuring
• Result from decreased umbilical cord perfusion, usually caused by cord compression
• Abrupt decrease in FHR of at least 15 beats
• Onset of decel to lowest point occurs in LESS than 30 seconds
• Are sharp V shaped, or other odd shapes and can happen at any point during a contraction
• Interventions - change position, give O2, stop Pitocin, amnioinfusion
Late Decelerations
Non-Reassuring
• Restult of uteroplacental insufficiency
• Gradual decrease of FHR associated with a contraction
• Lowest point of the decel (nadir) occurs after the peak of the contraction
• Takes 30 seconds or more from baseline to nadir
• Interventions: left side position (PRIORITY), O2, increase rate of IV (increases CO which increases placental perfusion), elevate legs, stop Pitocin
Prolonged Decelerations
Non-Reassuring
• Decelerations of at least 15 beats lasting longer than 2 minutes but less than 10 minutes
• Could be result of hypotension, vagal stimulation, cord prolapse, uterine rupture, rapid fetal descent, oligohydraminos
Sinusoidal Fetal Heart Rate
Non-Reassuring
• Smooth, wave-like, "undulating" pattern in FHR baseline
• Has a cycle frequency of 3-5 minutes lasting for more than 20 minutes
Veal Chop
Periodic Change Cause
V ariable decelerations = C ord compression
E arly Deceleration. = H ead compression
A ccelertion. = O ptimal oxygenation
L ate deceleration. = P oor perfusion/placental insufficiency
Goals for Treatment of Non-Reassuring FHR Patters
• Maximize Utero-Placental Blood Flow
- Position patient on side
- IV Hydration
- Ephedrine: restores normal blood pressure
- Reduce pain & anxiety
• Maximize Umbilical Circulation
- Position change
- Elevation of presenting part off cord (cord prolapse)
- Amnioinfusion
Goals for Treatment of Non-Reassuring FHR Patters
• Maximize Oxygenation
- Position change
- O2 at 10 L
- Guide breathing techniques
- Correct underlying maternal disease
• Reduce Uterine Activity
- Position change
- Reduce/Discontinue Pitocin
- Hydration
- Terbutaline: medication to relax uterus
Fetal Distress
Situation that if untreated may lead to serius injury or death of fetus
• Identified through FHR pattern, i.e. persistane late decels, persisiten severe variable decels or prolonged decels
- suggest compromised oxygen supply to fetus
- treat with O2, position change, IV fluids, pharmacologic relaxation of uterus
Fetal Heart Rate Classification System
Category I (Normal)
• Baseline rate 110-160 bpm
• Moderate variability
• No late or variable decelerations
• May have accelerations or early decelerations
Fetal Heart Rate Classification System
Category II (Indeterminate)
• Bradycardia not accompanied by absent variability
• Tacycardic FHR baseline
• Minimal variability or absent variability NOT accompanied by reccurent decels
• Marked baseline variability
• No accelerations in response to fetal scalp stimulation
• Recurrent variable deceleration, prolonged decelerations, reccurent late deceleration with moderate variability
Fetal Heart Rate Classification System
Category III (Abnormal)
• Absent baseline variability and recurrent late decels, recurrent variable decels or bradycardia
• Sinusoidal Pattern
Group B Strep
• Vaginal culture done at approximately 36 weeks
• If positive: mother will be given prophylactic antibiotics during labor
- optimal: receives treatment at least 4 hours before delivery
• Risk for baby developing infection from mother's GBS
First Stage of Labor: Interventions
• Admission assessment, H&P
• Ongoing assessment every hour
- VS, contraction pattern, FHR, urine output, pain
• Assessment of cervical status PRN
- limit vaginal exams especially if ROM
• Assess status of membranes
- ALWAYS assess FHT's immediately after ROM - risk of prolapsed cord
• Encourage ambulation unless ROM without "engagement"
- side lying position while in bed
• Shave prep and enema
- not routinely done today (done routinely to prevent contamination of vaginal area during delivery)
First Stage of Labor: Interventions
• NPO except ice chips
- may allow clear liquids
- assess for dehydration
• Comfort and hygiene measures
• Teach patient information to get though labor
- explain procedures, keep informed
- latent/early phase is best time
• Respect privacy
• As patient approaches the end of stage 1, she often complains of increased perineal pressure and urge to push
• She may complain of need to defecate
• Check cervical status
• Have patient breathe through contraction or pant
Second Stage of Labor: Interventions
• S&S: sudden increase in bloody show, uncontrolled bearing down efforts, bulging of perineum
• Teach pushing technique
- breath holding technique - causes valsalva
- exhalation pushing
• Continuous support
• Active participant
• Keep perineal area clean
Second Stage of Labor: Interventions
• Position: head elevated approximately 45 degrees, flexed on chest, shoulders rounded, legs bent and pulled towads head
• Change position: particularly if FHR complications
- side-lying, hands and knees, squatting
• Inform patient of progress
• Episotomy: mid-line or mediolateral
• Responsible for infant once born
Third/Fourth Stage of Labor: Interventions
Infant Responsibilities - • Suction immediately after birth
- if meconium present, extremely important to prevent meconium aspiration
- have support team/neonatologist present
• Maintain body temperature
- dry infant, radiant warmer, wrap in blanket
• Identify: bracelets, footprints
• Apgar: DOES NOT direct care
- done at one minute after birth and 5 minutes after birth
- heart rate, respiratory effort, muscle tone, reflex irritability, color
Fourth Stage of Labor: Interventions
• Care for Mom
- assess every 15 minutes: VS, fundus, lochia
- fundal massage if fundus is relaxed/boggy
- monitor IV
- may have PO fluids/food
• Care for Baby
- assess temp, HR, RR, color ever 30 minutes
- suction PRN
- encourage bonding
• Initial bonding extremely important
- encourage to hold, breastfeeding
- dim lights
- delay eye prophylaxis
• Support patient
• Oxytocin after delivery of placenta
Fetal Malposition
• Posterior position most common
- also: brow, face, breech, shoulder presentations
• Labor length icnreased
• Increased need for intervention
• External version may be attempted
- usually attempt to turn the fetus from breech to cephalic
- significant risk of cord compression &/or entanglement
- NEVER done with multiple gestation
- medicated with Terbutaline prior to procedure to relax uterus
Amnioinfusion
Infusion of warmed, sterile fluid into the uterine cavity through intrauterine catheter
• Indications: Oligohydraminos, thick meconium stained fluid, variable decels
• Itnerventions: Monitoring, comfort measures, peri-care, bed rest
Induction of Labor
Artifical stimulation of labor
• Reasons:
- medical condition of mother or fetus
- post-dates
- decreased amniotic fluid
- non-reasuring antenatal testing
- large infant
• Assess: position, presentation of fetus, gestation
- the more favorable the cervix; the more likely the induction will be successful
Induction of Labor: Types
• Amniotomy: not color, odor, amount
• Pharmacological: Oxytocin & Cervical Ripening Agents
• Oxytocin: major complication - tachysystole (more than 5 contractions in 10 mins or less than 30 second rest period)
- causes contraction to become irregular
- risk of abruptio placenta or uterine rupture
- assess for signs of fetal distress
• Cervical Ripening Agents
- Prostaglandin Gel - Prepidil & Cervidil
- Misoprostal - Cytotec
Induction of Labor: Nursing Responsibilities
• Monitor VS of mother
• Monitor fetal response to contractions
- FHR baseline
- Variability
- Presence of decels
• Monitor contraction pattern
• Monitor I&O
• Major concern is tachysystole resulting in:
- fetal distress
- uterine rupture
Episiotomy
Surgical incision of perineum
• Mid-line or Mediolateral
• Purpose: minimize stretching of perineum, decrease chance of infection , decrease trauma to fetal head, shorten length of second stage
• Disadvantages: may extend into longer incision or laceration, infection, increased pain
• Performed just before birth when presenting part is crowning
• Ice may be used during stage four
Laceration
Can occur in conjunction with episiotomy
• 1st Degree: limited to superficial tissue
• 2nd Degree: involves skin, mucous membrane, and muscle of perineum
- similar to episiotomy
• 3rd Degree: extends to the anal sphincter but does not rip through the rectal mucosa
• 4th Degree: laceration extending through the rectal mucosa
Forceps Delivery
Use of an instrument to provide traction or assist in rotating fetus
• Indications:
- provide assistance during 2nd stage when client is exhausted or has decreased pushing efforts related to anesthesia
- speedy delivery with non-reassuring FHR
• Disadvantages:
- vaginal or perneal lacerations, postpartal hemorrhage
- trauma to fetus: ecchymosis/edema of face, facial paralysis
Vacuum Assisted Delivery
Use of suction to help deliver baby
• Soft silicon cup is attached by tubes to suction bottle or pump
• Traction applies with contraction
• Indications same as forceps
• Risks:
- cephalohematoma
- brachial plexus palsy
- elevated bilirubin
- retinal & intracranial hemorrhage
Cesarean Section
Surgical delivery of infant though abdominal tissue
• Indications: fetal distress, dystocia (difficult labor), malpresentation, CPD, cord prolapse, failure to progress, previous c-section, multiple gestation, preterm, active herpes, placenta previa or abruptio
• Risk:
- maternal: infection, hemorrhage, blood clots, injury to bladder
- infant: wet lungs
Cesarean Section
• Types:
- lower uterine segment: least blood loss and scar less likely to rupture
- classic: not done today except acute emergencies. Incision made up high in uterine body. Associated with complications with subsequent pregnancies and deliveries
• Prep: shave, foley, IV, medication to decrease gastric secretions/acidity, educate
• Major surgery
• Recovery during postpartum period will be longer
VBAC (Vaginal Birth After Cesarean)
• Need to asses why prior c-section was done
• never done if patient had classical incision
- increase risk of uterine rupture
• Assess frequently: contraction patter, signs of fetal distress, maternal VS
• May use Pitocin, but need to evaluate carefully during labor
Complications of Labor & Delivery
• Uterine Rupture
- may occur late in pregnancy or during labor
- extreme pain and cessation of uterine contractions
- increased risk with previous c-section
• Intrauterine Fetal Death
- prolonged retention of fetus may lead to DIC
- most women have spontaneous labor within 2 weeks
- may induce
Accelerations (Fetal)
Is defined as a visually abrupt (onset to peak less than 30 seconds) increase in FHR above the baseline rate
• The increase is 15 beats/min or greater and lasts 15 seconds or more, with the return to baseline less than 2 minutes from the beginning of the acceleration.
• An acceleration lasting > 10 minutes is considered a baseline change.
Acceleration
Causes
• Spontaneous fetal movement,
• Vaginal contractions,
• Electrode application,
• Fetal reation to external sounds,
• Breech presentation,
• Occiput posterior position,
• Uterine contractions,
• Fundal pressure,
• Abdominal palpation
Acceleration
Clinical Significance:
• Normal patter: Acceleration with fetal movement signifies fetal well being representing fetal alertness or arousal states.
- Nursing intervention: None required
Baseline Fetal Heartrate
Average FHR during a 10 minute period that excludes periodic and episodic changes and periods of marked variability,
• Recorded as a single number not a range.
Fetal Bradycardia
Baseline FHR < 110 BPM lasting More than 10 minutes
• Can Indicate: atrioventricular dissociation, structural defect, viral infections, medications, fetal heart failure, maternal hypoglycemia)
Fetal Tachycardia
Baseline FHR > 160 BPM lasting longer than 10 minutes
• Can Indicate: early fetal hypoxemia, fetal cardiac arrhythmias, maternal fever, infection, parasympathetic drugs
Normal Fetal Heartrate
110 - 1160 beats/min
Acme
The segment of uterine labor contractions during which muscle tension is greatest.
• Highest point; Peak.
Apgar Score
Permits a rapid assessment of the newborn's transition to extra-uterine life base on 5 signs: heart rate, respiratory effort, muscle tone, reflex irritability, color
• Scores of 0 - 3 indicate severe distress
• Scores of 4 - 6 indicate moderate difficulty
• Scores of 7 - 10 indicate infant is having no difficulty adjusting to extrauterine life
• Assigned at 1 min and 5 mins after birth.
Apgar Score
Heart Rate
• Absent = 0
• Slow (< 100 BPM) = 1
• > 100 BPM = 2
Apgar Score
Respiratory Effort
• Absent = 0
• Slow weak cry = 1
• Good Cry = 2
Apgar Score
Muscle Tone
• Flaccid = 0
• Some flexion of extremities = 1
• Well Flexed = 2
Apgar Score
Reflex irritability
• No Response = 0
• Grimace = 1
• Cry = 2
Apgar Score
Color
• Blue - Pale = 0
• Body Pink, extremities blue = 1
• Completely pink = 2
Bloody Show
Vaginal discharge that originates in the cervix and consists of blood and mucus; increases as cervix dilates
• Labor usually results in next several weeks
• Pink-tinged secretions from cervical capillaries
- distinguished from bleeding by the fact that it is pink and feels sticky (related to mucoid nature).
• Very little bloody show in the beginning, the amount increases with effacement and dilation.
Braxton-Hicks Contractions
Contractions that facilitate uterine blood flow through the intervillous spaces of the placenta, promoting O2 delivery to the fetus.
• Pre-labor sign;
• Irregular, intermittent painless.
- Become painful as term approaches. Described as drawing (pulling up) sensation.
• After 4th months uterine contractions can be felt through abdominal wall.
• Usually ceases with walking or exercise
Cervical Dilation
Enlargement or widening of the cervical opening and canal that occurs once labor has begun.
• The diameter of the cervix increases from less than 1 cm to full dilation (approx. 10 cm) to allow birth of a term fetus.
• Cervix can not be palpated when fully dilated and completely retracted it
- Full dilation marks the end of the first stage of labor.
• Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by presenting part can promote cervical dilation.
• Scarring of the cervix (as a result of prior infection or surgery) may slow cervical dilation
Crowning
Occurs when the widest part of the head (the biparietal diameter) distends the vulva just before birth.
• Stage of birth when the top of the fetal head can be seen at the vaginal orifice as the widest part of the head distends the vulva
Uterine Contractions
Each contraction exhibits a wave like patter:
• Increment - build up
• Acme - peak
• Decrement - fading away
• Interval of rest ends when next contraction begins
Uterine Contractions
Frequency
• How often: Beginning of 1 contraction to beginning of next
• Normal frequency 5 or less in 10 minute period
Uterine Contractions
Duration
• How long: Beginning of contraction to end of contraction
• Should last no longer than 90 seconds
Uterine Contractions
Intensity
• How Strong: Mild, moderate, strong
• Need to palpate fundal area when monitoring externally
Uterine Contractions
Resting Tone
• Uterus should be relaxed between end of 1 contraction and beginning of next
• Between contractions need 30 seconds or more resting period
• Palpate in fundal area
Deceleration
• 4 Types:
- Early,
- Late,
- Variable,
- Prolonged
• Defined according to their visual relation to the onset and end of a contraction and by their shape
Early deceleration
A visually apparent gradual (onset to lowest point 30 seconds or more) decrease in and return to baseline FHR associated with uterine contractions;
• Generally the onset, Nadir, and recovery of the deceleration correspond to the beginning, peak, and end of the contraction.
• Cause - Head compression resulting from the following:
- Uterine contractions
- Vaginal examination
- Fundus pressure
- Placement of internal mode of monitoring
• Nursing interventions - None
Late Deceleration
A visually apparent gradual (onset to lowest point 30 seconds or more) decrease in and return to baseline FHR associated with uterine contraction;
• Begins after the contraction has started, and the lowest point of the deceleration occurs after the peak of the contraction;
• The deceleration usually does not return to baseline until after the contraction is over
Late Deceleration
Cause - Uteroplacental insufficiency caused by the following:
- Uterine Tachysystole,
- Maternal Supine Hypotension
- Epidural or Spinal Anesthesia
- Placentaprevia
- Placental Abruption
- Hypertensive Disorders
- Post Maturity
- Diabetes Mellitus
- Intra-Amniotic Infection
Late Deceleration
Clinical Significance:
• Abnormal pattern associated with:
- Fetal hypoxemia, acidemia, and low Apgar scores.
• Ominous if persistent and uncorrected, especially when associated with fetal tachycardia and loss of variability
• Nursing Interventions:
- Change maternal position (lateral),
- Correct maternal hypotension by elevating legs,
- Increase rate of maintenance of IV solution,
- Palpate uterus to assess for tachysystole,
- Discontinue Oxytocin,
- Administer O2 at 8 -10 L/min by NRFM (non-rebreather face mask)
• May have vaginal assist or C-section if pattern cannot be corrected
Variable Decelerations
A visually abrupt (onset to lowest point < 30 seconds) decrease in FHR below the baseline;
- The decrease is 15 BPM or more, lasts at least 15 seconds and returns to baseline in less than 2 minutes from time of onset;
• Are not necessarily associated with uterine contractions, they have a U, V, or W shape.
Variable decelerations
• Cause - Umbilical cord compression caused by following:
- Maternal position with cord between fetus and maternal pelvis,
- Cord around fetal neck, arm, leg, or other body part, knot in cord, prolapsed cord
• Nursing interventions:
- Change maternal position (side to side, knee to chest),
- D/C oxytocin if infusing,
- Administer 02 8 - 10 L/min by non-rebreather facemask,
- Notify physician or nurse-midwife,
- Assist with vaginal or speculum examination to assess for cord prolapse
Prolonged Deceleration
A visually apparent decrease (may be either gradual or abrupt) in FHR of at least 15 BPM below the baseline and lasting more than 2 minutes but less than 10 minutes;
• Indicates a disruption in the fetal O2 supply.
• Causes: They may be caused by prolonged cord compression, profound uteroplacental insufficiency, or sustained head compression.
• A deceleration lasting more than 10 minutes is considered a baseline change.
Fetal Cardio Note
Sinysoidal FHR, smooth, wavelike undulating pattern in FHR baseline has a cycle frequency of 3 - 5 minutes lasting > 20 minutes
FHR variability
Normal irregularity of fetal cardio rhythms or fluctuations from the baseline FHR of 2 cycles or more; the 4 possible categories of variability are absent, minimal, moderate, marked.
Variability
Interplay of sympathetic and parasympathetic nervous system causing fluctuations in FHR
• Can determine when monitory externally:
- Absent - no change in FHR
- Minimal - change in FHR < 5 Bbpm
- Moderate - change in FHR 6 - 25 bpm
- Marked - change in FHR > 25 bpm
• Variability is important indicator of: O2 reserve; decreased variability could be due to fetal sleep state, drugs, hypoxia, prematurity.
Effacement
Thinning and shortening or obliteration of the cervix that occurs during late pregnancy or labor or both;
• degree of is express in percentages from 0% to 100%
Engagement
The entrance of the fetal presenting part into the superior pelvic strait and the beginning of the descent through the pelvic canal,
• Usually the lowest part of the presenting part is at or below the level of the iscial spines.
• Usually corresponds to station 0.
• Occurs in weeks just before labor with nulliparas,
• May occur before labor or during labor in multiparas.
Episiotomy
Surgical incision of perineum, may be midline or media lateral. • The purpose is to minimize stretching of perineum, decrease chance of infection, decrease trauma to fetal head, shorten length of second stage.
• Performed just before birth when presenting part is crowning
Fetal Head
Flexibility of the cranial vault allows movement so the fetal head can adapt to the pelvis
Fetal Attitude
Relation of fetal body parts to each other in uterus
• Fetus assumes a characteristic posture in utero partly because the mode of fetal growth and partly because of the way fetus conforms to shape of uterine cavity.
• Normally back of fetus is rounded so chin is flexed on chest, thighs flexed on abdomen, legs flexed at knees. Arms are crossed over thorax and umbilical cord lies between arms and legs.
• Termed general flexion.
Fetal Lie
The relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. Two Types:
• Longitudinal (Vertical) - long axis of fetus is parallel to long axis of mother.
- Are either cephalic or breech
• Transverse (horizontal or oblique) - long axis of fetus is at right angle or diagonal to the long axis of the mother
- Vaginal deliveries cannot occur when fetus stays in transverse lie
Fetal Position
Relationship of a reference point on the presenting part of the fetus such as occipitant, sacrum, chin or scapula to its location in the front back or sides of the maternal pelvis
Fetal Position
Denoted by three part abbreviation;
• First letter denotes location of the presenting part in right or left side of mother pelvis
• Middle letter denotes the specific presenting part of the fetus
- O = occiput
- S = sacrum
- M = mentum [chin]
- Sc = scapula [shoulder]
• Third letter denotes location of presenting part in relation to portion of maternal pelvis
- A - anterior
- P - posterior
- T - transvers
Fetal Presentation
The part of the fetus that first enters the pelvis and lies over the inlet;
• 3 Main Presentations:
- Cephalic,
- Breech,
- Shoulder
Presenting Part
The part of fetus that lies closest to the internal os of cervix
Molding
The shaping of the fetal head by the overlapping of cranial bones to facilitate movement though the birth canal during labor
Mucous Plug
Thick mucous that has obstructed cervical canal since conception
• A sign of preceding labor
Nuchal Cord
Encircling of the fetal neck by one or more loops of umbilical cord
• After head is born gentle palpation to feel for cord if present, health care provider gently slips cord over head,
• If tight or a 2nd loop, provider will probably clamp cord twice, cut between clamps, unwind cord from neck before birth is allowed to continue
Perineum
A skin covered muscular area that covers the pelvic structures,
• Forms the base of the perineal body,
• a wedge shaped mass that serves as an anchor for the muscles, fascia, and ligaments of the pelvis.
• An area between the anus and vagina in the female.
Post-Term Labor
One that extends beyond the end of week 42 of gestation or 294 days from 1st day of LMP
• Fetal risk
- Abnormal Fetal Growth: Macrosomia = more than 4 kg
- Oligohydraminos: cord compression, hypoxemia
- Low Apgar scores - Post Maturity Syndrome, Meconium Aspiration Syndrome
• Pregnancies are not normally allowed after 42 weeks due to high risk factors
Precipitous Birth (Precipitous Labor)
Labor that lasts less than 3 hours from onset of contractions to time of birth.
• May result form hypertonic uterine contracions that are tetanic in intensity.
• Conditions also associated with this type of contractions:
- Placental Abruption,
- Excessive number of uterine contractions
- Recent cocaine use
Precipitous Birth (Precipitous Labor)
Possible Complications
• Maternal:
- Uterine rupture
- Lacerations of birth canal
- Analphylactoid Syndrome of Pregnancy (amniotic fluid embolism)
- Postpartum hemorrhage
• Fetal:
- Hypoxia caused by decreased periods uterine relaxation between contractions
- Intracranial trauma related to rapid birth; RARE.
Premature/Preterm labor
Defined as cervical changes and uterine contractions occurring between 20 and 27 weeks of pregnancy
• Risk factors:
- Genital tract infection
- Non-Caucasian race
- Multifetal gestation
- 2nd trimester weight
- History of previous spontaneous preterm birth
• Diagnosis (Three Major Criteria)
- Gestational age: between 20 - 37 weeks
- Uterine activity: (e.g. contractions)
- Progress cervical change: e.g. effacement of 80%or cervical dilation 2 cm or greater
Premature/Preterm Labor
Sign & Symptoms - Uterine Activity
• Uterine contractions occurring more frequently than every 10 minutes persisting for 1 hr or greater
• Uterine contractions may be painful or painless
• Lower abdominal cramping similar to gas pains; may be accompanied by diarrhea
• Dull, intermittent low back pain (below the waist)
• Painful, menstrual like cramps
• Supra pubic pain or pressure
• Pelvic pressure or heaviness feeling that baby is pushing down, urinary frequency
Premature/Preterm Labor
Sign & Symptoms - Vaginal Discharge
• Rupture of amniotic membrane,
• Change in character of vaginal discharge or amount,
• Thicker (mucoid) thinner,
• Bloody brown colorless,
• Increased amount and odor.
ROM (Rupture of Membranes)
Rupture of amniotic sac and leakage of amniotic fluid beginning before the onset of labor.
• If there has been a discharge that may have been ROM.
• Woman is a asked: Date and time 1st noticed, fluid characteristics (e.g. amount, color, odor).
• A sterile speculum examination and a nitrazine (pH) and fern test can confirm.
Nitrazine Test for pH
A test that can distinguish between amniotic fluid and urine.
• Used when rupture of the amniotic sac is suspected.
• A Cotton tipped applicator impregnated with Nitrazine dye for determining pH
• Differentiates amniotic fluid, which is slightly alkaline, from urine and purulent material which are acidic.
• Dip cotton tipped applicator deep into vagina to pick up fluid
Nitrazine Test for pH:
Results:
• Membrane probably intact. Below indicates fluids are acidic
- Yellow pH 5.0
- Olive - Yellow pH 5.5
- Olive - Green pH 6.0
• Membranes probably ruptured. Below indicates fluids are alkalinic
- Blue - Green pH 6.5
- Blue - Gray pH 7.0
- Deep Blue pH 7.5
Abruptio Placenta
Premature separation of the normally implanted placenta away from the uterine wall.
Placenta Previa
Pregnancy in which the placenta is implanted in the lower part of the uterus (instead of the upper part)
Amniocentesis
Procedure
• Properly drape and position.
• Have necessary supplies close by. Assist physician as well as woman.
• Assist with positioning for ultrasonography, locating fetus, placenta, and pockets of amniotic fluid for sampling.
• Once pocket is located and confirmed by physician, remove gel and prepare woman with antiseptic solution.
• Prepare woman if physician determines to inject a small amount of .
• On a tray have a 3 inch 20 gauge spinal needle and a 20 ml syringe ready for physician.
Amniocentesis
Procedure
• Under direct ultrasonography visualization, physician inserts needle trans abdominally into uterus. The physician removes and discards 1 to 2 ml of amniotic fluid then obtains 20ml for analysis.
• Amount withdrawn depends on gestational age and reason for testing. RN prepares sample and sends to lab
• After procedure, give woman injection of Rh immunoglobulin if ordered to prevent sensitization (observe closely).
• Reassess fetal heart rate while woman recovers for a couple of hours.
Amniocentesis
Complications
• To Mother: hemorrhage, fetomaternal hemorrhage with possible maternal Rh isoimmunization, infection, labor, placental abruption, inadvertent damage to intestinal bladder
• To Fetus: death, hemorrhage, infection, direct injury from needle, miscarriage or preterm labor, leakage of amniotic fluid.
• Because of the possibility of fetomaternal hemorrhage, administering RhoD immune globulin to the woman who is Rh negative is standard practice after an amniocentesis.
Abortion
Termination of pregnancy before the fetus is viable and capable of ectrauterine existence, usually less than 20 weeks of gestation. (or when the fetus wheighs less than 500 grams)
Complete abortion
In which fetus and all related tissue have been expelled from uterus
Elective Abortion
Termination of pregnancy chosen by the woman that is not required for her physical safety
Habitual Abortion (recurrent)
Loss of 3 or more successive pregnancies for no known cause
Incomplete Abortion
Loss of pregnancy in which some but not all the products of conception have been expelled from the uterus
Induced Abortion
Purposeful interruption of a pregnancy before 20 weeks of gestation
Inevitable Abortion
Threatened loss of pregnancy that con not be prevented or stopped or is imminent
Missed Abortion
Loss of pregnancy in which the products of conception remain in the uterus after fetal death
Septic Abortion
Loss of pregnancy in which there is an infection in the products of conception and the uterine endometrial lining, usually resulting from attempted termination of early pregnancy
Spontaneous Abortion
A pregnancy that ends as a result of natural causes before 20 weeks of gestation; preferred term is miscarriage
Therapeutic Abortion
Pregnancy intentionally terminated related to medical reasons
Threatened Abortion
Possible loss of pregnancy, early symptoms present (i.e. cervix begins to dilate)
Amniocentesis
A procedure in which a needle is inserted through the abdominal and uterine walls into the amniotic fluid; fluid is withdrawn; used for assessment of fetal health and maturity. • Possible after 14 weeks
Nagele's rule
Method for calculating the estimated date of birth or "due date".
• After determining the first day of the last menstrual period subtract 3 calendar months and add 7 days;
• Or add 7days to the LMP and count forward 9 calendar months
NST- Non Stress Test
Evaluation of fetal response (fetal heart rate) to natural contractile uterine activity or to an increase in fetal activity.
EDC
Estimated date of confinement, ,
EDD
Estimated date of delivery
EDB
Estimated Date of Birth
Fundus
Dome shaped upper portion of the uterus between the points of insertion of the uterine tubes
Gestation
Period of intrauterine fetal development from conception through birth; the period of pregnancy
Gravida
A woman who is pregnant
GTPAL
System for summarizing the womans obstetric history.
• Acronym stands for Gavidity, Term, Preterm, Abortions, Living children.
- Gravidity = number of pregnancies,
- Term = number of deliveries after 37 completed weeks gestation',
- Preterm = number of deliveries after 20 weeks but before 37 weeks gestation,
- Abortion = number of pregnancies ending before 20 weeks,
- Living children = number of currently living children
Leopold's Maneuvers
Four maneuvers for diagnosing the fetal position by external palpation of the mothers abdomen while lying on her back.
• Prep: empty bladder, supine with one pillow under head and knees slightly flexed.
- Small rolled towel right or left hip to displace uterus off major blood vessels (prevents supine hypotensive syndrome
• Identifies:
- Number of fetus's
- Presenting part, fetal lie/attitude
- Degree of (presenting parts) descent into pelvis
- Expected location of the PMI of the FHR
Lightening
Sensation of decreased abdominal distention produced by uterine descent into the pelvic cavity as the fetal presenting part settles into the pelvis,
• It usually occurs 2 weeks before the onset of labor in nulliparas.
• After the woman breaths easier and feels less congested.
• Usually bladder pressure results from the shift.
• In multipara woman this may not occur until after contact ions start
LMP
Last menstrual period
Multigravida
A woman who has had 2 or more pregnancies
Nulligravida
A woman who has never been pregnant
born
Para (parity)
Number of pregnancies ending after 20 weeks counted as para whether baby is born living or dead
• Counts the pregnancy not the number of babies
Physiologic Anemia (Pseudoanemia)
A modest decrease in the hemoglobin concentration and hematocrit in pregnancy, caused by the relative excess of plasma
Primigravida
A woman who is pregnant for the first time
Quickening
Maternal perception of fetal movement (feeling of life) usually occurs between weeks 16 and 20 of gestation, but may be felt earlier by multiparous woman.
Stillbirth
The birth of a baby after 20 weeks of gestation and 1 day or weighing 350g (depending on the state code) that does not show any signs of life.
Supine Hypotension Syndrome (Shock)
Fall in blood pressure caused by impairedvenous return when gravida uterus presses on ascending vena cava,
• Occurs when woman is lying flat on her back
• Vena Cava Syndrome
Trimester
- one of three periods of about 3 months each into which pregnancy is divided
Contemporary Childbirth
• Family Centered
• Nurse Roles:
- LPN
- RN
- RNC
- Nurse Practitioner - does not deliver babies
- Clinical Nurse Specialist
- Certified Nurse Midwife - delivers babies
• Standards of Care
• "Right to Privacy"
Maternal-Fetal Issues
• Fetus viewed as separate client with "rights"
- Considered "criminal behavior" to engage in activities that are harmful to fetus
- Abortion is legal prior to "viability"
• Intrauterine fetal surgery
- involves opening the uterus during 2nd trimester (C/S required for delivery)
- Used to correct problems incompatible with life
• Reproductive Technology - multiple birth risk
• Preterm Birth
Cord Blood Banking
• Collect cord blood at time of birth
• Plays a role in combating leukemia, other cancers, immune and blood system disorders
• Better than bone marrow
• Can be used by individual, family or donor
Cultural Factors Affecting Maternity Care
• Some culture groups view pregnancy as "normal"; thus don't see value in prenatal care
• Difficult communication
• Comfort or discomfort with touch
• Family Roles: Mexican and Arabs view birthing as a female affair
Alternatives For Traditional Maternity Care
• Acupressure
• Herbs, herbal teas - for morning sickness, lactation support or menopausal symptoms
- Always have patient defer to physician
• Pregnancy massage
Risk Assessment For Maternity Care
• Age of mother
• Socioeconomic status
• Substance use or abuse
- Cigarette smoking associated with negative pregnancy outcomes
- Impairs fertility in both men and women
• Decreased placental perfusion during pregnancy
• Alcohol
Assessment For Maternity Care
• Prescription or Illicit drugs
- Category A drugs are the safest
• Nutrition
- Poor nutritional intake
- Obesity
- Anorexia and Bulimia
• Medical or gynecologic conditions
• Environmental hazards
• Violence
Statistics
• Birthrate: the number of live births each year per 1,000 people
• Infant mortality rate: the number of deaths in the first year of life for every 1,000 live births
• Neonatal mortality rate: number of deaths of infants less than 28 days of age per 1000 live births
Statistics
• Perinatal mortality rate: number of stillbirths and the number of neonatal deaths per 1000 live births
• Fetal death rate: number of fetal deaths 20 weeks or more gestation divided by the sum of live births and still births in the year
• Maternal mortality rate: annual number of deaths of women during childbirth
Basic Anatomy & Physiology
Female and male reproductive organs are homologous: same origin different function
• Major Function: produce gametes
- Eggs (ovum) & Sperm
- Transport the gametes to a place where their union will occur
- Gametes are produced in specialized organs called gonads
Spermatogenesis
The process of male gamete production
• The male gonad: testes
• The male gamete: spermatozoa
Oogenesis
The process of female gamete production
• The female gonad: ovary
• The female gamete: ovum/egg
Puberty
A developmental period between childhood and attainment of adult sexual characteristics and functioning
• Gradual process
• Girls average age: 13 yrs
• Characteristics: growth spurt, appearance of secondary characteristics and onset of menstruation (menarche)
• Physiology
- Complex process controlled by CNS
- CNS releases a neurotransmitter that causes hypothalamus to release Gonadotropin Releasing Factor (GNRF)
Gonadotropins
• GNRF acts on anterior pituitary to secrete the gonadotropins:
- Follicle Stimulating Hormone (FSH)
- Luteinizing Hormone (LH)
• Small amounts of these hormones are present prior to puberty
• Amount increases after puberty
Gonadotropins
Functions
• Male
- Causes maturation of sperm
- Causes the testes to produce the male hormones, primarily testosterone
• Female
- Causes maturation of the egg
- Stimulates the ovary to produce the female hormones; primarily estrogen and progesterone
• The hormones produced by the gonads influence the development of secondary sexual characteristics
Interaction of Female Gonadotropins & Ovarian Hormones
• FSH & LH act on ovary to produce mature egg
• Stimulate secretion of estrogen and progesterone
• Cause changes in the endometrium of uterus
First Half of Cycle
• FSH is primarily responsible for beginning maturation of ovarian follicle (ovum)
• As follicle matures, it secretes increased amounts of estrogen
- Level peaks just before ovulation
• Assists in development of the follicle but also affect development of endometrium
• Estrogen causes endometrial lining to proliferate (increase in thickness)
Second Half of Cycle
• High levels of estrogen inhibit FSH production (negative feedback) and stimulate LH production
• LH causes final maturation of ovum
- level peaks 18-24 hours before ovulation
• Follicle becomes the corpus luteum
• Estrogen decreases and progesterone increases
• Progesterone causes the endometrium to become more vascular. Also increases glycogen stores
• Uterus becomes ready for implantation
Corpus Luteum
Function
• Produces large amounts of progesterone
• 7-8 days after ovulation, the corpus luteum decreases
• If fertilization occurs, the corpus luteum will continue to function
- Maintained by hormones produced by developing egg (embryo)
• If fertilization does not occur, hormone levels will decrease
- Corpus luteum will degenerate and endometrial lining will be sloughed off
Estrogen
Functions
• Causes the endometrium to thicken in preparation for implantation
• Controls the development of secondary sexual characteristics
• Aids in maturation of ovum
• Causes changes in cervical mucus
- Mucus becomes thinner and watery - "spinnbarkeit"
• Increases contractibility of tubes
• Propels large ovum through tubes
Progesterone
Functions
• Called the hormone of pregnancy
• Causes the endometrium to increase in vascularity
• Increases glycogen stores in the endometrium
• Causes cervical mucus to become "thick and sticky"
• Relaxes smooth muscle
Ovulation
Theoretically occurs at about day 14 of a 28 day cycle
• Discharge near the fimbriated end to fallopian tube
• Fertile for about 6-24 hours
• Reaches uterus 72-96 hrs after ovulation occurs
• May be associated with "mittelschmerz", mid-cycle pain or spotting
Menstruation
Theoretically occurs every 28 days
• Duration: 3-6 days
• Blood loss: 20-80 ml
• Composed of blood, vaginal & cervical secretions, endometrial fluid, bacteria, and other cellular debris
Genetics Review
• All cells are made up of chromosomes
• Chromosomes contain DNA and protein
• Genes are regions on the DNA strands that determine unique characteristics of the individual
• Humans have 23 pairs of chromosomes
- 22 chromosomes called autosomes and one pair of sex chromosomes
- Each chromosome carries homozygous (similar) or heterozygous (dissimilar) genes
Meiosis
Process by which gametes are produced
• Gametes must have a haploid (half) number of chromosomes
• When the egg and sperm unite, the diploid number of chromosomes is reestablished
• The cell that is formed when the ovum and sperm unite is called a zygote (23 pairs of chromosomes)
• Consist of two separate divisions
• End up with 4 cells each having 23 single chromosomes
Oogenesis
Produces cells of unequal size
• Meiotic cellular division occurs to form 4 cells with 23 single chromosomes
• Primary oocyte has most of the cytoplasm
- Remaining three polar bodies are reabsorbed by the body
Spermatogenesis
Division occurs to form 4 sperm
• Equal size
• Each has a haploid number of chromosomes (23)
• Lost most of cytoplasm
• Head of sperm covered by cap called the acrosome
• Long tail formed from one of the centrioles
Sex Determination
The 2 sex chromosomes determine the sex of the offspring
• Females have 2 "X" chromosomes
• Males have an "X" and a "Y" chromosome
• Sex chromosomes also carry other genes
- e.g. colorblindness
Fertilization
• Takes place in the ampulla or outer third tube
• Ovum is large but has high levels of estrogen to help propel egg
• Ovum is fertile for 24 hrs
• Sperm survive for 72 hrs
• Male deposits 200-500 million sperm in vagina
• Prostaglandins in semen cause smooth muscle contractions
Fertilization
The sperm undergo two processes for fertilization to occur
• Capacitation: removal of plasma membrane covering acrosomal area
• Acrosomal Reaction: as the sperm come in contact with the cell membrane of the ovum, it deposits an enzyme which allows breakdown of the ovum cell membrane and allows penetration by the sperm
Twinning
• Fraternal or Dizygotic
- 2 separate ovum fertilized by 2 sperm
- Same sex or different
- Can be associated with fertility drugs
• Identical or Monozygotic
- Develop from 1 ovum; will ALWAYS be same sex
- Division occurs at some time during fetal development
- Random event
Cellular Multiplication
• Cleavage: period of rapid mitotic division
• Cells called blastomeres
• Eventually form solid ball called a morula
• Takes 3 days to reach uterus, float in uterine cavity for few days
• Cavity forms within the cell mass
• Inner solid mass called blastocyst
- develops into embryo
- also develops into inner embryonic membrane - the amnion
• Outer layer of cells called trophoblast
- develops into chorion - the outer embryonic membrane
- part eventually develops into placenta
Implantation
• The trophoblast attaches itself to surface of endometrium
- most frequent site of attachment is fundus
• 6-10 days after conception, burrows into uterine lining
- coincides with end of "secretory phase" of ovarian cycle
• Cells of trophoblast grow down into the endometrium forming fingerlike projections called "villi"
• Allow early exchange of oxygen and CO2
Cellular Differentiation
• 10-14 days after fertilization, blastocyst cells differentiate into primary germ layers
- Ectoderm
- Mesoderm
- Endoderm
• All tissue, organs and structures will develop from one of these three layers
Development of Embryonic Membranes
Chorion - Outermost
• Encloses amnion and embryo
• Fingerlike projections on surface called chorionic villi
• Villi grow into endometrium and form fetal part of placenta
Rest of chorion lose villi except where it attaches to uterine wall
Development of Embryonic Membranes
Amnion - Inner
• Thin, protective membrane
• Contains amniotic fluid
• Comes in contact with chorion as baby grows
• Eventually the chorion and amnion "fuse" to form the "bag of water"
Amniotic Fluid
Functions as a cushion to protect FETUS & CORD against injury
• Helps control embryo's temperature
• Allows symmetrical external growth of embryo
• Prevents adherence of amnion to embryo
• Allows freedom of movement
• Can be analyzed to determine fetal health and maturity
Amniotic Fluid
Amount of Amniotic Fluid
• 10 weeks = 30 ml
• 20 weeks = 350 ml
• After 20 weeks = 800-1200 ml
• Amniotic Fluid Index: method to evaluate the 'wellness' of baby
Placenta
Development
• Means of O2, CO2 and nutrient exchange between embryonic and maternal circulation
• Begins to function about 3rd week after fertilization; 5 weeks after LMP
• Two Parts:
- Maternal portion: red and flesh like
- Fetal portion: shiny gray
• Eventually forms a single layer of cells called the "syncytium" where exchange takes place
- Fetal blood and maternal blood should NOT mix
Placenta
Development
• Blood flow within the intervillous spaces of the placenta depends on maternal blood pressure
- Blood flows from area of high pressure to low
- Braxton-Hicks to enhance circulation
- Decreased blood flow with labor and high blood pressure
• As placenta "ages", circulation decreases
• Fetal RBCs can pass into maternal circulation through breaks in placental membrane
- RH sensitization
- A.B.O incompatibility
Placenta
Functions
• Fetal respiration
• Nutrition
• Excretion
• Protection
• Endocrine: produces hCG, progesterone, estrogen, human chorionic somatomammotropin
• Immunity: passive
Umbilical Cord
Development
• Formed from amnion
• 1st referred to as "body stalk"
• Fuses with fetal portion of placenta to provide circulatory pathway
• ONE VEIN AND TWO ARTERIES
- VEIN carries OXYGENATED blood, ARTERIES carry UNOXYGENATED blood
• Contains special connective tissue called Wharton's Jelly (protects umbilical vessels)
Fetal Circulation
Most of fetal blood bypasses fetal lungs
• O2 rich blood enters right atrium, passes through FORAMEN OVALE into left atrium and is pumped into fetal tissues
• Some fetal blood enters pulmonary artery but then the majority passes through the DUCTUS ARTERIOSUS into aorta, bypassing the lungs
Circulatory Adaptations to Birth
• Blood flow must go through baby's lungs
• Closure of foramen ovale (right to left atrium)
• Closure of ductus arteriosus (pulmonary artery to the aortic arch)
• Closure of ductus venosus (shunts half of blood from umbilical vein to IVC)
Fetal Development
Embryonic Stage: conception to 8 weeks
• Baby is most vulnerable to teratogens during this period
- Teratogens: any agent (drug, virus, radiation, etc) that can cause development of abnormal structures
• Primitive heart is beating by the end of third week
• Resembles a human at 8 weeks
• Beginnings of all essential internal and external structures are present
Fetal Development
Fetal Stage: end of 8th week to term
• Every organ system and external structure found in full-term infant is present
• Heart tones can be heard at 8-12 weeks
• 20 weeks: fetal movement can be felt by mom. Called "quickening"
• Development of organs and structures continues
Fetal Development
Fetal Stage
• At 24-25 weeks, fetus has sufficient lung and CNS development to POTENTIALLY survive outside uterus
• Last 12 weeks is period of rapid weight gain
• Lung maturity occurs around 35 weeks gestation
• 20 weeks through first 6 months of life is when the CNS develops and matures
Preconception Health Teaching
• Avoid potentially dangerous activities
• Healthy Diet: e.g. Folic Acid
• Establish a regular exercise program
• Stop hormonal contraception 2-3 months prior to attempting pregnancy
Childbearing Decisions
• Care provider
• Birth Plan
• Birth Setting
• Childbirth Education
Scope of Practice LPN
• Assist with collection of data
• Care for patients with common problems during pregnancy
• Identify basic problems (actual & potential) and assist with developing the plan of care
• Provide basic teaching from established teaching plans
Scope of Practice RN
• Complete assessment of pregnant woman, analyze assessment findings
• Care for patients with complex problems during pregnancy
• Establish nursing diagnoses and plan appropriate care
• Plan and carryout teaching based on individual needs
Gravida
Refers the the number of pregnancies a woman has had
• Includes ALL pregnancies regardless of duration or outcome
• Includes the present pregnancy
- If pregnant, the "gravida" will be one more than the sum of para and abortions*
- If not pregnant the "gravida" will be equal the sum of para and abortion
Para (Parady)
Refers to the number of pregnancies ending AFTER 20 weeks
• Counted as a "para" whether the baby is born living or dead
• Counts the pregnancy NOT the number of babies born
• Para does not change until baby is delivered!
Abortion
• ANY pregnancy ending before 20 weeks
GTPAL
Replaces para; G = Gravida, stays the same
• T = number of deliveries AFTER 37 completed weeks gestation
- Twins, triplets, etc. count as ONE delivery
• P = number of deliveriese AFTER 20 weeks but BEFORE the completion of 37 weeks gestation
- T & P should equal G when not pregnant and should be one less when pregnant
• A = number of pregnancies ending before 20 weeks
• L = number of currently living children
Pregnancy Tests
Variety of blood & urine "assay techniques" that detect the presence of hCG
• Urine test
- OTC tests
- Should be done using 1st early morning void
- Positive as early as 7-10 days after conception
- Encourged to wait to perform test until missed period
- Repeat in one week if continue to have pregnancy symptoms after negative result
• Medications can give false negative or positive results
Determination of Due Date
Figured from first day of last menstral period
• EDC (Estimated Date of Confinement), EDD (Estimated Date of Delivery), EDB (Estimated Date of Birth)
- ESTIMATE!!
• Nagle's Rule - 1st day of LMP (Last Menstrual Period). Subtract 3 months add 7 days
• Can also use fundal height, ability to hear FHR with fetoscope, report of quickening
- McDonald's rule - fundal height in CM equals weeks of gestation within 2 weeks
• Today ultrasound is often used
- Most accurate in first trimester
Signs of Pregnancy
Presumptive (Subjective)
• Pregnancy symptoms
• Urinary frequency, breast tenderness, fatigue, amenorrhea, N&V, changes in breast, quickening
Signs of Pregnancy
Probable (Objective)
• Pregnancy "signs" that the doctor and/or nurse will note on assessment
• Could be caused by something other than pregnancy
• Enlargement of the uterus, positive pregnancy test, Chadwick's sign, Goodells sign, changes in skin, Uterine souffle, contractions
Signs of Pregnancy
Positive (Diagnostic)
• Fetal heart rate, fetal movements felt by the doctors or nurse, presence of fetus on ultrasound (visualization)
• "Positive" proof of pregnancy
Reproductive System
Uterus
• Weight increases almost 17 times the pre-pregnant weight
• Capacity increases from 10ml to 5000ml; 500 times the pre-pregnant state
• Enlargement due to hypertrophy of pre existing myometrial cells
- Influence of estrogen
- Distention caused by growing fetus
• 16% of the total maternal blood volume is contained within the vascular system of the uterus
• Braxton-Hicks contractions start around 4th month
Reproductive System
• Fundal Height - measure from symphysis pubis to top of fundus
- 10-12 weeks - fundus slightly above symphysis
- 20-22 weeks - fundus at level of umbilicus
- measurement should correlate within 2 cm
Reproductive System
Fetal Heartbeat
• Normal range 110-160 bpm
• May be heard with doppler at 8-12 weeks
• Heard with fetoscope at 16-20 weeks
Reproductive System
Fetal Movements
• Palpated by caregiver at 18 weeks
• Balottement - fetus moves then returns to original position when uterus is tapped sharply.
- 4-5 months
• Ultrasound evaluation
- Detect gestational sac 5-6 weeks after LMP
- Fetal heart activity at 6-7 weeks
Reproductive System
Cervix
• Estrogen stimulates the glandular tissue
• Increased vaginal discharge
• Thick, sticky mucous accumulates in cervical canal forming "plug"
- Prevents ascent of organisms into uterus
- Abnormal discharge associated with vaginal infection
• Increased vascularity
- Goodell's Sign: Softening of cervix
- Chadwick's Sign: bluish discoloration of cervix and vagina
- Hegar's Sign: softening of isthmus of uterus
Reproductive System
Ovaries
• Corpus Luteum continues to function for 10-12 weeks
Vagina
• Estrogen causes thickening of mucosa, loosening of connective tissue ad increase in vaginal secretion
- Secretions are acidic which inhibits bacterial growth but allows proliferation of yeast organisms
Reproductive System
Breast
• Tenderness and tingling: one of first signs noted when missed period
• Both estrogen and progesterone cause changes necessary for lactation
- Nipples are more erectile
- Areolas darken
- Superficial veins more prominent
• Colostrum present after 12 weeks
Respiratory System
• Increased oxygen requirements
- progesterone decreases airway resistance allowing a 15-20% increase in O2 consumption
• Normal 16-24 breaths per min - thoracic breathing
• Normal stuffiness and nosebleeds (epitaxis) result of estrogen induced edema and vascular congestion
Cardiovascular System
• Blood volume progressively increases
- Rapid increase in 2nd trimester
- Peaks mid 3rd trimester at approximately 40-45% above non-pregnant levels
• Heart rate increases 10-15 bpm
Cardiovascular System
Blood pressure decreases slightly
• Lowest point during 2nd trimester
• High blood pressure associated with:
- Pre-Eclampsia/Toxemia: increase in blood pressure after 20 weeks gestation accompanied by proteinuria. Greater than 140/90
- Eclampsia: severe form characterized by seizures, liver involvement and possible coma. Can occur in first 48 hrs AFTER delivery
- Gestational Hypertension: increase in blood pressure after 20 weeks gestation with NO protein in urine
Cardiovascular System
• Stasis of blood in lower extremities because of pressure from enlarging
uterus
- Slight edema of lower extremities normal (dependent edema)
- Generalized edema associated with Pre-Eclampsia
- Varicosities of veins in legs, vulva and rectum (hemorrhoids)
• Postural Hypotension
• Supine hypotensive syndrome or vena cava syndrome
- Results of decreased blood return to heart; decreased blood pressure
- Always lie on left side or place pillow under right hip
Hematology
Physiologic Anemia of Pregnancy
• RBCs increase 35% while plasma volume increase 50%
- Necessary to transport additional O2 needed
- Increased need for iron
• Hematocrit lower than pre-pregnancy levels
- 32-42%
- Plasma volume increases more than cells
• Hemoglobin
- 10-14g/dl
- Less than 10g/dl requires nutritional counseling or iron supplement
Hematology
WBC production
• Increases up to 15,000
• Increases is primarily in the granulocytes
- Need to look a differential
• Plasma fibrinogen and various clotting factors (Factor VII, VIII, IX, X) increase
- Pregnancy described as "hypercoaguable state"
- Increased risk of developing blood clots during pregnancy
- Associated with early pregnancy loss
Gastrointestinal System
• Nausea & Vomiting - morning sickness
- Result of increased hCG and changed carbohydrate metabolism
• Constipation and bloating
- Result of effects of progesterone on smooth muscle
- Delayed gastric emptying, decreased peristalsis
Gastrointestinal System
• Heartburn - reflux of gastric secretions into lower esophagus
- Relaxation of cardiac sphincter
- Upward pressure from enlarging uterus
- Severe heartburn could be a sign of severe Pre-Eclampsia called HELLP Syndrome
- Hemolysis of RBCs, Elevated Liver enzymes & Low Platelets.
Gastrointestinal System
• Hemorrhoids
- Occurs 3rd Trimester and is associated with constipation and pressure on vessels
• Gallstone Formation
- Prolonged emptying time of gallbladder caused by progesterone
- Elevated cholesterol in bile
Urinary Tract
• 1st trimester: pressure from enlarging uterus causes frequency
• Decreased during 2nd trimester when uterus becomes an abdominal organ
• Reappears during 3rd trimester when presenting part descends into pelvis
• Glycosuria may be seen because kidneys unable to reabsorb all glucose filtered by glomeruli
- Could be a sign of GDM so need to check
• UTI increases risk for pre-term labor
Integumentary System
• Changes in skin pigmentation stimulated by estrogen, progesterone, and other hormones
- Primarily in areas that are already pigmented: Areolas, nipples, vulva, perianal, linea nigra, chloasma
• More prominent in dark-haired women
• Aggravated by sun exposure
• Striae Gravidarum:
- Results from decreased connective tissue strength due to increased steroid levels
Musculoskeletal System
• Joints of pelvis relax
- Results of the hormone relaxin
- Waddling Gait
• Low backache
- Center of gravity changes causing rectus abdominal muscle to separate
- Will need to regain muscle support after pregnancy to support subsequent pregnancies
• Diastasis Recti - pressure of enlarging uterus causes rectus abdominus muscle to separate
- Will need to regain muscle support after pregnancy to support subsequent pregnancies
Eyes
• Intraocular pressure decreases and cornea thickens
• Contacts may become uncomfortable
Metabolism
Water Metabolism
• Increased water retention
- Increased level of hormones affects sodium & fluid retention
- Lowered serum protein
- Increased intracapillary pressure and permeability
- Needed for fetus, placenta, amniotic fluid, increased blood volume, etc
Nutrient Metabolism
• Fetus greatest demand for protein and fat during 2nd half of pregnancy
• Fetus doubles in weight last 6-8 weeks
• Fats more completely absorbed
- Intake of dietary fat or decreased carb intake can lead to ketonuria
Endocrine System
• Basal metabolic rate increases as much as 25%
• Most functions increase due to demands of growing fetus
Endocrine System
Anterior Pituitary
• FSH and LH
• Prolactin - responsible for initial lactation
- Increase early in pregnancy
- High levels of estrogen and progesterone inhibit lactation until after birth
Endocrine System
Posterior Pituitary
• Vasopressin (ADH)
- Causes vasoconstriction which results in increased BP
- Helps regulate water balance
• Oxytocin
- Causes uterine contraction (high levels of progestrone prevent contractions until near term)
- Stimulates ejection of milk from breast
• Pancreas
- Progressive need for increased amount of insulin during pregnancy
- Pregnancy hormones decrease ability to use insulin
- Thus, Gestational Diabetes may result
(Plancenta Hormone) hCG
Human Chorionic Gonadotropin - • Stimulates estrogen & progesterone production by the corpus luteum
• Basis of pregnancy test
(Plancenta Hormone) hCS
Human Chorionic Somatomammotropin - Antagonist of Insulin
• Increases amount of circulating free fatty acids needed for maternal metabolic needs
• Decreases maternal metabolism of glucose to allow fetal growth
(Plancenta Hormone) Estrogen
• Increases vascularity causing vasodilation
• Promotes enlargement of the genitals, uterus, and breast
• Causes relaxation of pelvic ligaments and joints
• Alters metabolism of nutrients
• Causes retention of fluid in body - peripheral edema
(Plancenta Hormone) Progesterone
• Plays great role in maintaining pregnancy
• Maintains endometrium
• Prevents uterine contractions
• Causes fat to be deposited in subcutaneous tissue
• Helps develop acini & lobules of breast
Prostaglandins
Proposed that they aid in decreased placental vascular resistance
• Decreased levels may contribute to pre-eclampsia/toxemia
• Also believed to play a role in initiation of labor
Recommended Weight Gain During Pregnancy
Based on pre-pregnant BMI
• Pattern of weight gain is essential to well-being of fetus
- First trimester: 3-5 lbs
- Second/Third trimester: approximately 0.8-1 pound per week
- Total: 25-35 pounds
• Overweight or underweight women will have different recommendations
• Sudden weight gain associated with pre-eclampsia/toxemia/PIH
Distribution of Weight Gain
• 11-13 lb = Fetus, placenta, amniotic fluid
• 2 lbs = Uterus
• 1-4 lbs = Breast tissue
• 4-5 lbs = Increased blood volume
• 3-5 lbs = Increase tissue fluid
• 4-6 lbs = Maternal fat stores
Nutritional Needs Before Conception
• First trimester critical because embryonic and fetal organ development
• Folic Acid recommended PRIOR to conception
Nutritional Needs During Pregnancy
• RDA for almost all nutrients increases during pregnancy
• Increased nutritional needs determined by stage of pregnancy
• Factors affecting increased needs:
- Uterine-Placental-Fetal unit
- Maternal blood volume
- Maternal mammary development
- Metabolic needs
Nutritional Needs During Pregnancy
Vitamins & Minerals
• Folic Acid and Iron are the only supplements needed with a well balanced diet
• Folic Acid 0.4 MG daily during childbearing years
• Iron needs double during pregnancy - recommended 30 MG daily support
- Absorption increases when taken with a Vitamin C source
- Decreased when taken with calcium, egg yolks or caffeine
• Many care providers recommend Pre-Natal Vitamins because of poor intake
Nutritional Needs During Pregnancy
Vitamins & Minerals
• Calcium - same recommendation for nonpregnant and during pregnancy
- Increases 33% with lactation
- Need 4 serving from milk group instead of 2-3
• Sodium needs increase slightly during pregnancy
- Not recommended to entirely eliminate "salt" intake unless underlying medical condition
- May season food to taste during cooking
- Avoid using extra salt at table, high salt containing foods such as potato chips, ham, sausage, sodium based seasoning, and prepared foods
Nutritional Needs During Pregnancy
• Increase of approximately 300-450 kcal per day in 2nd & 3rd trimester
• An additional 200 kcal with breastfeeding
- Inadequate caloric intake will reduce milk volume
• Breastfeeding mom does not need to avoid certain foods
• Protein requirements increase 50%
- If vegetarian, need to ingest grains, legumes, nuts, fresh fruits and veggies
• Avoid mercury-containing fish
- King mackeral, shark, swordfish or tilefish/tuna
- affects baby's CNS
Pica
Persistant eating of non-food substances
• Dirt, clay, cornstarch, freezer frost
• Iron Deficiency Anemia most common concern
- Interferes with iron absorption and other nutrients
• Also can cause fecal impaction, excessive weight gain
• May have cultural association
Psychologic Adjustment To Pregnancy
First Trimester
• Ambivalence
• Disbelief
• Introspective and Passive
• Emotionally Labile - mood swings
Second Trimester
• Begins to see baby as separate person
• Excited
• Emotional Lability persists
Third Trimester
• Anxiety about labor and birth
• Physical discomforts increase
• Eager for pregnancy to end
• Nesting
Maternal Adaptation to Pregnancy
• Accepting the pregnancy
• Identifying with the maternal role
• Reordering personal relationships including establishment of relationship with fetus - "binding in"
• Preparing for childbirth
Paternal Adaptation to Pregnancy
• Initial "pride" in virility
• 1st Trimester - may feel left out
- Confused by partners mood swings
- May resent attention she's getting
- Pregnancy seems "unreal" until more physical signs
- Concerned with ability to provide financially
• 2nd Trimester - involvement increases as he "feels" fetal movement, "sees" enlarging abdomen and "hears" fetal heartbeat
• 3rd Trimester - attends childbirth classes and makes concrete plans for baby
• "Couvades Syndrome" - mimicking pregnancy symptoms
Prenatal Assessment/Care
• Review history and identify risk factors
- Potential negative outcome for mother or child
• Physical exam done at first prenatal visit to determine health status
• Identifty lifestyle factors that need to be adjusted during pregnancy
• Ongoing assessment of well-being done at each prenatal visit
• Identify learning needs
• Provide teaching
• Perform activities that encourage psychological adjustment to pregnancy
Recommended Schedule of Antepartum Visits
• Every 4 weeks until first 28 weeks
• Every 2 weeks until 36 weeks
• After week 36, every week until childbirth
Antepartal Laboratory Testing
Prenatal Panel
• CBC
• Blood Type and RH
- RH negative mother will receive RhoGam at 28 weeks
- Concern for RH sensitization or ABO incompatibility with women who are "O" blood type or RH "negative"
Triple Screen or Multiple Marker Screen
• Done at 16-18 weeks gestation
• Screens for maternal serum alpha fetaprotein (MSAFP), estriol and hCG
- Increased MSAFP sugests neural tube defect (anencephaly, spina bifida, omphalocele), multiple gestation, underestimated gestational age
- Decreased MSAFP suggest Trisomy 18 or 21
• Increased hCG and decreased estriol and MSAFP suggests Downs Syndrome
Glucose Screen
Suggested Lab Test During Pregnancy
• 50 gram 1 hour test
• Done between 24-28 weeks
• Plasma glucose level greater than or equal to 130 mg/dl - need to do 3 hour GTT to rule out Gestational Diabetes
• Gestational Diabetes is dangerous during pregnancy because it negatively affects placental functioning
- Can decrease oxygen delivery to fetus
- Can also increase risk of congenital heart defects in the fetus
Other Suggested Lab Test During Pregnancy
• Syphilis Test - RPR or VDRL
• Urinalysis
• Rubella Titer - 1:8 titer indicates woman is immune (If less than 1:8, woman is susceptible to German Measles)
• Hepatitis B - Infants born to a woman that is positive will receive HBIG soon after delivery AND first dose of hepatitis vaccine
• HIV Screen
• Antibody titers for RH negative women
- Indirect Coombs
- RH antibodies indicate maternal sensitization