Upgrade to remove ads
Only $35.99/year

OB final

Terms in this set (184)

Gravida
total number of pregnancies including current pregnancy
Para
number of times a woman has given birth after 20 weeks gestation (viable or non-viable); multiple birth one event
EDD
First day of last normal menstrual period; subtract 3 months and then add 7 days and then add one year
Estimated due date
GTPAL
G: gravida
T: term births (38-42 weeks)
P: preterm births (20-37 6/7 weeks)
A: abortions- spontaneous or elective before 20 weeks
L: living children
Prenatal testing / Assessment NST
Accelerations imply an intact CNS
Acceleration patterns are affected by gestational age (after 28 weeks)
Reactive → two or more accelerations within 20 minutes at least 15 beats above baseline and lasting 15 seconds
Nonreactive → insufficient accelerations over 40 minutes or longer
NST Nursing care
Application of monitor
Assessment of test
NST Indications:
High risk pregnancies requiring increased surveillance
Diabetes
Intrauterine growth restriction (IUGR)
Pregnancy induced HTN (PIH)/ Preeclampsia
Maternal chronic HTN
Post term pregnancy
Sickle Cell Anemia
Decreased fetal movement
Prenatal testing / Assessment Quad Screen
Alpha-fetoprotein analysis (AFP)
16-18 weeks gestation ideal
Maternal serum alpha fetoprotein (AFP)
Unconjugated estriol (UE)
hCG
Inhibin A
Neural Tube Defects:
High AFP
Down syndrome
Low inhibin A
Low AFP
Prenatal testing / Assessment NIPT:
Non-invasive prenatal testing:
11-13 weeks gestation
Blood test and nuchal translucency exam screens for down's syndrome etc
Marker Screening Tests:
Counts fragment of DNA (called cell-free DNA) from placenta that circulates in maternal blood
92%-99% accuracy in detecting down syndrome, trisomy 18, and trisomy 13
Gender determination
Nuchal Translucency screening:
Measures nuchal thickness
Fetuses with an increased fluid at the base of their necks (nuchal fold) may have chromosomal problems
Such as down syndrome, cardiac defecs, diaphragmatic hernia
Expected Maternal Physiological Changes: Uterus
Enlargement due to hyperplasia and hypertrophy, then mechanical stretching of uterus by growing fetus
Exits pelvis at 12 weeks gestation
Braxton-Hicks contractions
Spontaneous, irregular, painless contractions
More noticeable 3rd trimester
Hegar's sign → lower uterine segment softening
Fundal Height (how much uterus has grown)
Most accurate 18-32 weeks gestation
Xiphoid process ~ 36 weeks
Lightening
Expected Maternal Physiological Changes: Supine Postural Hypotension
Occlusion of vena cava and aorta due to growing uterus
Decreased cardiac return, cardiac output, and blood pressure
Light-headedness, nausea, dizziness, syncope
Lateral recumbent position to optimize cardiac output and uterine perfusion
Expected Maternal Physiological Changes: Cervix:
Goodell's sign → softening of cervix
Chadwick's sign → bluish discoloration
Mucus plug → provide barrier to outside world to protect fetus
Expected Maternal Physiological Changes: Vagina:
Estrogen induced changes
Leukorrhea- Increased whitish vaginal secretions
Glycogen rich environment - Candida Albicans
Expected Maternal Physiological Changes: Breasts:
Tenderness, feeling of fullness, enlargement
Colostrum by 3rd trimester
Expected Maternal Physiological Changes: GI:
Nausea and vomiting in 1st trimester related to hCG
Pyrosis (heartburn), constipation, hemorrhoids
Gallbladder becomes hypotonic and emptying is delayed
Increased risk of gallstones
Hyperemia:
Softening and bleeding of gums
Ptyalism (excessive salivation)
Pica (ingestion of nonnutritive substances)
Expected Maternal Physiological Changes: Cardiac:
Blood volume ↑up to 50% in volume
Increased plasma (1 liter) and RBCs (450 mL) but not in same proportion
Hemodilution → physiologic anemia of pregnancy
Cardiac output increases
Heart rate increases up to 10-15/20 bpm between 14-20 weeks of gestation
Decrease in systemic and pulmonary vascular resistance
1st trimester pre-pregnancy level (normal BP)
2nd trimester decreases slightly (BP ↓ slightly)
3rd trimester pre-pregnancy level (BP ↑ to normal)
CBC values:
Appendix A, pg 1903
Iron requirements increase
Pregnancy = Hypercoagulable state
Increased fibrin, plasma fibrinogen, clotting factors
Decreased risk of postpartum hemorrhage (PPH)
Increased venous stasis
Expected Maternal Physiological Changes: Respiratory
Maternal oxygen needs increase
Decreased space for lungs
Breathing changes from abdominal to thoracic
Breathe more deeply
Expected Maternal Physiological Changes: Renal:
Urinary frequency common in the 1st and later part of the 3rd trimester (after lightning)
Mild proteinuria is common
UTI's (if untreated can lead to pyelonephritis or preterm labor) (frequency, hematuria dysuria, urgency)
Expected Maternal Physiological Changes: Musculoskeletal:
Changes in posture and gait
Lordosis: Lumbar spinal curve becomes accentuated, posture changes
Lower back and round ligament pain
Expected Maternal Physiological Changes: Integumentary:
Hyperactive sweat and sebaceous glands
Hyperpigmentation
Linea nigra line (dark linear line from umbilicus to top of ...)
Chloasma or melasma gravidarum
Striae gravidarum
Table 11.3 Placental Hormones
Signs of Pregnancy Presumptive Signs:
Changes experienced by the woman that makes her think she might be pregnant
Subjective:
Fatigue
Amenorrhea
N/V
Urinary frequency
Breast tenderness and enlargement
Quickening
Skin hyperpigmentation
Signs of Pregnancy Probable Signs:
Changes observed by an examiner during a physical exam that make the examiner suspect a woman is pregnant
Objective:
Changes in the pelvic organs:
Chadwick's sign (bluish discoloration of the cervix)
Goodell's sign (softening of the cervix)
Hegar's sign (softening of the uterine segment → most narrow part; allows uterus to expand)
Abdominal enlargement
Braxton-Hicks contractions → irregular mild tightening of the uterus throughout pregnancy
Ballottement → up and down movement of the amniotic sac during exam
Positive pregnancy tests
Signs of Pregnancy Positive Signs:
Signs that can only be explained by pregnancy
Auscultation of fetal heartbeat (110-160 bpm)
Fetal movement felt by experienced practitioner
Visualization on ultrasound of embryo or fetus
Nutrition
Direct effect on pregnancy, fetal well- being and birth outcomes
**Daily prenatal vitamins
Supplements:
27 mg of ferrous iron daily
Folic Acid:
400-800 mcg daily
Increase of 300 calories/day
ACOG handout
Singleton pregnancy
25-35 lbs weight gain with normal BMI
Common GI Discomforts of Pregnancy, Teaching Guidelines 12.1 Urinary Frequency or Incontinence
Try pelvic floor exercises to increase control over leakage.
Empty your bladder when you first feel a full sensation.
Avoid caffeinated drinks, which stimulate voiding.
Reduce your fluid intake after dinner to reduce nighttime urination
Common GI Discomforts of Pregnancy, Teaching Guidelines 12.1 Fatigue
Attempt to get a full night's sleep without interruptions.
Eat a healthy balanced diet.
Schedule a nap in the early afternoon daily.
When feeling tired, pause and rest.
Common GI Discomforts of Pregnancy, Teaching Guidelines 12.1 Nausea and Vomiting
Avoid an empty stomach at all times.
Eat dry crackers/toast in bed before arising.
Eat several small meals throughout the day.
Avoid brushing teeth immediately after eating to avoid gag reflex.
Acupressure wristbands can be worn daily.
Drink fluids between meals rather than with meals.
Avoid greasy, fried foods or ones with a strong odor, such as cabbage or Brussels sprouts.
Common GI Discomforts of Pregnancy, Teaching Guidelines 12.1 Backache
Avoid standing or sitting in one position for long periods.
Apply a heating pad (low setting) to the small of your back.
Support your lower back with pillows when sitting.
Use proper body mechanics for lifting anything.
Avoid excessive bending, lifting, or walking without rest periods.
Wear supportive low-heeled shoes; avoid high heels.
Stand with your shoulders back to maintain correct posture.
Common GI Discomforts of Pregnancy, Teaching Guidelines 12.1 Leg Cramps
Elevate legs above heart level frequently throughout the day.
If you get a cramp, straighten both legs and flex your feet toward your body.
Ask your health care provider about taking additional calcium supplements, which may reduce leg spasms.
Common GI Discomforts of Pregnancy, Teaching Guidelines 12.1 Varicosities
Walk daily to improve circulation to extremities.
Elevate both legs above heart level while resting.
Avoid standing in one position for long periods of time.
Don't wear constrictive stockings and socks.
Don't cross your legs when sitting for long periods.
Wear support stockings to promote better circulation.
Common GI Discomforts of Pregnancy, Teaching Guidelines 12.1 Hemorrhoids
Establish a regular time for daily bowel elimination.
Avoid constipation and straining during defecation.
Prevent straining by drinking plenty of fluids and eating fiber-rich foods and exercising daily.
Use warm sitz baths and cool witch hazel compresses for comfort.
Common GI Discomforts of Pregnancy, Teaching Guidelines 12.1 Constipation
Increase your intake of foods high in fiber and drink at least eight 8-oz glasses of fluid daily.
Pre-Gestational Diabetes
Increased risk of severe congenital anomalies
Gestational diabetes
Most common complication in pregnancy, increasing incidence
Common complications- page 877-888
Macrosomia--birth trauma
Respiratory distress syndrome due to inadequate phospholipids
Hypoglycemia
Polycythemia
Jaundice
Congenital anomalies
Hypoglycemia
Blood sugar <40mg/dL
Signs & Symptoms
Tremors & jitteriness
Hypothermia
Poor feedings
Respiratory Distress
Apnea & Cyanosis
Hypotonia & Lethargy
Gestational Diabetes Nursing Care of the newborn-- focus is early detection of hypoglycemia
Screen within 30 minutes of birth
Dextrostix
Early, frequent feedings of formula/breast milk
Recheck blood glucose 30-45 minutes post feeding
D5-D10W Infusion
Needs careful titration
Assess respirations, temperature along with blood sugar
Preeclampsia- multisystem disorder
Blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy accompanied by proteinuria > 0.3g in 24hr (urine dipstick 1+ or more)
Eclampsia
Progression of preeclampsia to generalized seizures
Preeclampsia Pathopathology
Normal physiology--vasodilation w/ decreased peripheral vascular resistance
Generalized vasospasm and hypoperfusion affecting every organ
Liver, brain, placenta, lungs, kidneys
Preeclampsia
Normal physiology--vasodilation w/ decreased peripheral vascular resistance
Generalized vasospasm and hypoperfusion affecting every organ
Liver, brain, placenta, lungs, kidneys
Preeclampsia Manifestations-Mother
HTN & Proteinuria
Epigastric pain
Headaches, visual disturbances, blurred vision, and brisk DTR's w clonus
Decreased UOP (30ml/hr)
Increased Na, BUN, Uric Acid & Creatinine peripheral vascular
Generalized non-specific edema & pulmonary edema
Preeclampsia Fetus-Poor Placental Perfusion
IUGR (baby is not going to grow adequately)
Abruption
Fetal Hypoxia
Preeclampsia Labs
CBC , Electrolytes ,BUN, Creatinine, LIver enzymes, 24hr urine, urinalysis
Management for Mild Preeclampsia
Home, Teaching Guidelines
Activity restrictions
Positioning (Internal, ↑02+ circulation to placenta)
Adequate hydration
Monitor fetal activity (kick counts)
Blood pressure twice daily
Weight
Urine dipstick
Adequate fluids
Diet- no sodium restriction, high protein, high fiber
Fetal surveillance
Ultrasounds, NST, BPP
Preeclampsia Inpatient Therapeutic Management
Bedrest (Lateral, no bright lights, sounds)
Medications
Drug guide (19.3, page 688)
Magnesium Sulfate- seizure precautions
Monitor for magnesium toxicity- indications
Therapeutic levels= 5-8 mg/dl
Hydralazine (apresoline)
Labetalol (lasix)
Nifedipine (Procardia)
Furosemide (Lasix)
Lancet, August 2019- Best control of blood pressure
Calcium Channel Blocker= Nifedipine
Reduces BP faster and significant increase in urine output
Delivery
Induction--Pitocin, vaginal birth preferred
Delivery is always in the best interest of the mother
Preeclampsia Nursing Management
Complete bed rest, lateral position
Room dark & quiet
Seizure patients
Monitor B/P
Assess reflexes and for clonus
IV fluids, may be restricted to decrease pulmonary edema
Medications and side effects
Magnesium Toxicity
Continuous fetal monitoring
Lab results-- which ones?
Continue to monitor closely after delivery
Rh Isoimmunization
Mother is Rh negative & Fetus is Rh positive (father)
Maternal immune system creates antibodies against fetal Rh blood factors
Fetus
Anemia - Hemolytic Disease of the Newborn
Heart problems
Jaundice
Rh isoimmunization rare today due to anti-D immune globulin given prophylactically
RhoGAM (anti immunoglobulin)
Occurs during pregnancy & birth (most common time)
Amniocentis, abortion, ectopic pregnancy, placental problems, IUFD, MVA etc.
Rh Incompatibility
First pregnancy: Rh- woman becomes sensitized by exposure to Rh+ fetal blood antigens inherited from father (if father is Rh positive)
Subsequent pregnancy with Rh+ fetus provokes increasing amount of maternal antibodies that cross the placental barrier, attach to RH+ cells in the fetus and cause fetal hemolysis and anemia
To compensate for this, the fetus steps us production of RBC's
Erythroblastosis fetalis--increased immature RBC production
Extensive hemolysis results in release of large amounts of unconjugated bilirubin, which the liver can't conjugate and excrete , causing hyperbilirubinemia and hemolytic immunizations
Hyperemesis Gravidarum
Persistent, severe uncontrolled vomiting
Genetic and hormonal components (2019)
hCG levels remain high after 1st trimester
May continue throughout pregnancy
Hyperemesis Gravidarum Characteristics
Dehydration
Weight loss
(> 5% of pre-pregnancy body weight)
Electrolyte imbalance
Fetus at risk for abnormal development, IUGR, hypoxia
Prenatal vitamins for 1 month before fertilization to reduce incidence and severity
Hyperemesis Gravidarum Therapeutic Management
Labs and Diagnostics
Treatment
Pyridoxine (Vitamin B6) (ACOG, first line Rx)
Vitamin B6 with Doxylamine (Unisom) (ACOG)
Drug guide 19.2 page 680
Persistent HG
IV fluids, electrolyte replacement
In-patient Nursing
NPO 24-36 hrs
IV Fluids & antiemetics
Daily weights
Uterine & fetal monitoring
Comfort measures
Fetal Presentation
Refers to the body part of fetus entering the pelvic passage first
Presenting part:
Cephalic or vertex
Breech
Complete, frank, footling (complete)
Transverse/shoulder
Fetal Position:
Describes location of a fixed reference point on the presenting part of the fetus in relation to the four quadrants of the maternal pelvis
Right (R) or left (L)
Fetus is in the right or left side of the maternal pelvis
Presenting part of fetus:
Occiput (O) → vertex
Mentum (M) → face presentation
Sacrum (S) → breech presentation
Anterior (A), Posterior (P), or transverse (T)
Fetal in the anterior (back is towards mother front) or posterior (back is towards mother back) quadrant of the pelvis
Transverse if neither anterior nor posterior
Effacement:
Thinning of the cervix
0-100%
Dilation:
Opening of the cervix
0-10cm
Station
Measurement of the baby relative to ischial spine
Labor Stages First stage:
Effacement and dilation of cervix to 10 cm
Labor Stages Second stage: pushing phase
Begins with complete dilation and full effacement of cervix and ends with birth of newborn; up to 3 hours
Labor Stages Third stage (uterine contractions continue)
Separation and delivery of placenta; usually 5-10 minutes, can take up to 30 minutes
Labor Stages Fourth stage (stabilization of mother)
Immediate period after delivery of placenta
Early/Latent Phase of Labor:
Cervical dilation → 0-6 cm
Effacement up to 40%
Contractions:
Frequency → irregular then becoming regular, every 5-10 min
Duration → 30-45 seconds
Intensity → mild to moderate palpation
Maternal characteristics:
Independence, anticipation, excitement, happiness, relief, and apprehension
May grimace with contraction
Usually alert, talkative and sociable
Starts to become more serious
Active Phase:
Cervical dilation → 6-10 cm
Effacement → 40-100%
Contractions:
Frequency → 2-5 min
Duration → 45-60 seconds
Intensity → moderate to strong by palpation
Fetal descent progressive
Maternal Characteristics:
Bloody show heavy
Anxiety increase, restless
May exhibit decreased ability to cope
Increased dependence
Hyperventilation, diaphoresis
Leg tremors, N/V, rectal pressure
Second Stage:
From full dilation to delivery of baby
Descent of the presenting part through the pelvis
Accomplished by voluntary pushing efforts (bearing down) and involuntary (laboring down) with uterine contractions
Crowning
Delivery of fetus → skin to skin
Third Stage:
Begins after birth of newborn, uterine contractions continue and ends with expulsion of placenta
Lengthening of cord and gush of blood
After delivery → Pitocin
Fourth Stage:
Initial physiologic adjustment and stabilization of the mother and neonate
Repair of episiotomy/laceration
Postpartum and newborn assessment
Nonpharmacologic pain relief:
Continuous labor support
Relaxation
Cutaneous simulation
Effleurage, massage
Hydrotherapy and aromatherapy
Acupuncture and acupressure
Application of heat and cold
Mental stimulation
Imagery, music
Breathing patterns:
Cleansing breath
Paced breathing
Ambulation and frequent position
Epidural Pain Measures
Injection of local anesthetic into epidural space
Inclusion of opioids ↓ amount of local anesthetic
Advantages:
Produces good analgesia
Woman fully awake during labor and birth
Disadvantages:
Maternal hypotension
Usually within 1 hour of initiation or repeat bolus
Bladder distention
Prolonged second stage
Migration of catheter
Adverse effects of epidural opioids
Epidural Pain Measures Nursing Care: Pre-administration:
Review med records and have CBC
Screen for allergies
IV in and bolus IV fluids
Anesthesiologist explained
Assess FHR and contraction pattern (established labor → 3 min in 10)
Empty bladder
Pain assessment
Epidural Pain Measures Nursing Care: During administration:
Help with position
Continuous monitor of FHR
Epidural Pain Measures Nursing Care: After administration lm
Get her into lateral position on bed
Continuous uterine and fetal monitoring
BP checks (continuous assessment)
Induction of Labor
Deliberate stimulation of UC's before onset of spontaneous labor
Cascade of interventions
Clinical factors considered
Confirm EDD
Induction of Labor Indications:
Clear medical indication
Induction of Labor Absolute Contraindications:
Breech
Transverse
Active genital herpes
Augmentation of Labor
Start Pitocin on a woman who is in labor
Preterm Labor
Onset of regular contractions of the uterus resulting in cervical change (dilation and effacement) before 37 weeks gestation
Preterm Labor Risk factors:
Prior preterm labor and birth
Multifetal gestation
Uterine/cervical abnormalities (fibroids, previous surgeries)
Other → IVF, infection, premature rupture of membranes, short pregnancy interval, problems such as HTN and diabetes, age < 17 years or >35 years, late or no prenatal care, inadequate nutrition, ancestry and ethnicity
Preterm Labor Manifestations:
Pelvic or lower abdominal pressure
Menstrual like cramps
Change or increase in vaginal discharge
Constant low, dull backache
Vaginal spotting
Uterine tightening/contractions
Preterm Labor Management:
Activity restriction → not effective
Hydration → can be effective
Identify and treat infections
Tocolytics to delay delivery
Corticosteroids before 34 weeks gestation (promote fetal lung maturity)
Require at least 24 hours to be effective
Preterm Labor Nursing assessment:
Dehydration
FHR, contraction pattern
ROM, infections
Preterm Labor Nursing Management:
Optimal positioning
Assess cervical status with SVE
IV fluid bolus
Obtain cultures
Administer tocolytics, antenatal steroids
Vital signs
Strict I & O
Review lab results
Provide emotional support
Preterm Labor Medications:
Tocolytics
To delay delivery up to 48 hours
Beta-Adrenergic Drugs:
Terbutaline (Brethine) → decrease frequency, duration and intensity of uterine contractions
Calcium Channel Blockers:
Nifedipine (Procardia)
Nonsteroidal anti-inflammatory drugs
Indomethacin (Indocin)
Magnesium Sulfate
New indication → fetal neuroprotection
Betamethasone (Celestone)
Vacuum Delivery
Traction to fetal head during birth to aid maternal expulsive efforts (2nd stage of labor)
Vacuum Delivery Indications:
Shorten second stage for well being of mother and/or fetus
Rotation of fetus
Vacuum Delivery Risks
Maternal → requires episiotomy
Laceration, hematoma
Fetal:
Vacuum → cephalohematoma
Baseline FHR:
Average FHR rounded to 5 bpm for at least 2 minutes within a 10 minute window frame -- uterus must be at rest
Normal → 110-160
Bradycardia
< 110 bom; persisting for at least 10 minutes
Tachycardia
>160 bpm, persisting for at least 10 minutes
Variability
Irregular fluctuations in baseline FHR-irregular wave like appearance
Push and pull effect on FHR from parasympathetic & sympathetic nervous systems
Absent--amplitude undetected (very abnormal)
Minimal--Undetectable to ≤ 5pm (few irregularities, r/t to opiods)
Moderate--6-25 bpm (normal)
Marke→ 25 bpm (rare conductive cardiac issue)
Decreased variability may be caused by:
Opioid analgesics in labor (morphine,fentanyl)
Accelerations
Heart beat goes up more than 150bpm and > 15 sec
Temporary increase in FHR
15bpm above baseline and lasts 15 seconds
Related to fetal movement
Always reassuring
Decelerations
Periodic Decelerations
Based on shape and relationship to uterine contractions
Early
Late
Variable
Interventions for FHR early Patterns
Continue to monitor
Chart
Active phase
Labor progress
Interventions for FHR late Patterns
Reposition (turn to left side)
Start Oxygen (8-10/minute)
Increase rate of LR (IV Fluids)
Notify provider
Interventions for FHR variable Patterns
Reposition
Oxygen (if continuous variable decelerations)
Increase IV fluids
Notify HCP
Postpartum
Normal physiologic changes Involution of the uterus
Tone → firm vs boggy/uterine atony
Pitocin
Location/Height → descent of uterine fundus
Position
Should always be midline
Involution → uterine contractions
Afterpains
More acute → multiparous women, during breastfeeding
Oral analgesics
Postpartum
Normal physiologic changes Lochia
reflects exfoliation and regeneration of endometrium -- reflects healing stages of placental site
Rubra:
Day 1-4
Bloody with clots
Characteristic odor
Serosa:
Day 3/4-10
Pinkish brown
Characteristic odor
Alba
After day 10
Can last for weeks
Clear to white/light brown
Postpartum
Normal physiologic changes Perineum:
Healing of episiotomy, laceration
Assess for REEDA
Assess anteriorly and side lying
Expected findings
Mild edema, minor bruising, approximation of edges, mild to moderate pain
Complications:
Excessive swelling, infection, hematoma, bleeding
Comfort:
Ice packs first 24 hours
Sitz baths after 24 hours
Peri-bottle
Sitting measures
Lying on side
Topical anesthetics
Analgesia
Reduce risk of infection
Pelvic floor muscle training exercises
Postpartum
Normal physiologic changes Cardiovascular:
EBL up to 500 mL vaginal delivery
EBL up to 1000 mL C/S
Postpartum anemia → < 11 g/dL and 32 %
Risk for orthostatic hypotension
Excess plasma volume reduced by:
Diuresis → first 12 to 24 hours post delivery
Diaphoresis → at night, usually post discharge, decreasing estrogen levels
Predisposition to thromboembolism related to activation of coagulation cascade in pregnancy
Postpartum
Normal physiologic changes Urinary:
Risk for over-distention, incomplete bladder emptying, inability to void
Adequate bladder elimination immediate PP concern
Void 2-4 hours post delivery
Measure voids (at least 300 mL within 4 hours of delivery)
Assess for sign and symptoms of UTI
Postpartum
Normal physiologic changes GI:
Hunger common post vaginal delivery
Assess for constipation and hemorrhoids
Teaching for constipation, hemorrhoids
Postpartum
Normal physiologic changes Lactation:
Secretion of milk by the breasts
Interaction of progesterone, estrogen, prolactin, and oxytocin
Breastfeeding:
Coordinated mechanisms:
Periodic motion by newborn's jaw
Undulation of newborn's tongue
Breast Milk ejection reflex
Goal → exclusive 1st six months of life
Skin to skin contact in 1st hour of life is gold standard to initiate breastfeeding → golden hour
Engorgement:
Distention and swelling of breast tissue, precursor to lactation
Frequent feedings to empty breasts; supply and demand
Positioning
Manuel expression
Warm compresses
Support bra
Cabbage leaves
Suppressing Lactation:
Absence of physical stimulus such as infant suckling suppresses breastmilk development
Still, moderate to severe milk leakage and discomfort before milk production ceases
Comfort measures:
Tight supportive bra 24 hours a day
Avoid any type of breast stimulation
Avoid exposing breasts to warmth, shower spray etc
Recurrence of Ovulation and Menstruation:
Non-breastfeeding mothers:
~ 8 weeks after delivery
All resume menstruation within 6 months
Breastfeeding mothers:
Related to length of time the woman breastfeeds and frequency of breastfeeding
Hemorrhage:
EBL > 500 mL vaginal delivery or EBL > 1000 mL cesarean delivery
Risk factors:
Large infant, multiple gestation, multiparity, precipitous delivery, prolonged labor, magnesium sulfate, polyhydramnios etc
Primary (early; immediately post delivery) or delayed (late; after patient has gone home)
Primary causes → 4 T's
Tone → uterine atony, distended bladder
Tissue → retained placental fragments
Trauma → lacerations, hematoma, rupture of uterus, inversion
Thrombin disorders → disseminated intravascular coagulopathy (DIC)
Hematoma:
Vulvar, vaginal, retroperitoneal
Deep severe, unrelenting pain
Rapid bleeding into soft tissue that may cause visible hematoma -- discolored bulging mass
Observation vs surgical excision
Peripad normal blood amount and uterus firm
Laceration:
Most common after operative delivery
Uterus is firm; but peripad is saturated
Steady stream of blood without clots from vagina
Requires repair
Complications Indications/Assessment Findings
Saturation of peripad within 15 minutes
Uterus that remains boggy after fundal massage
Uterus may be firm but still assess copious vaginal bleeding
Presence of large blood clots
Indications of hematoma
Indications of laceration
Clinical manifestations
Mild
Moderate
Severe
Complications Nursing Care:
Be aware of risk factors
Massage boggy uterus
Check bladder and encourage voiding
Consider laceration with firm uterus
Increase IV fluid rate
Assess VS
Administer medications
Insertion of foley
Elevate legs 15-30 degrees
Anticipate type and crossmatch 2 units RBCs
Complications Medical Management:
Medications
Bimanual compression of uterus by PCP
Uterine packing
Surgical intervention
Complications Pharmacologic Management:
IV pitocin 20-40 units in 1000 mL IV solution
Methylergonovine (Methergine)
Carboprost (Hemabate)
Misoprostol (Cytotec)
Newest recommendation:
Oxytocin and Misoprostol:
Combination more effective than oxytocin alone in reducing frequency of PP blood loss greater than 500 mL
Immediate Newborn Care
Skin to skin contact with mother while drying, neonate
Clamp of cord while wait for placenta to be delivered
Cover with dry warm blanket
Cover head
APGAR SCORE: Chapter 18
Rapid, Objective reporting of newborn status
At 1 and 5 minutes
ID bands
Bonding
Breastfeeding
Golden hour-transition is dramatic and critical
Physiology Transitioning of the newborn
Dramatic & Rapid Extrauterine Transitions first 6-10 hours of life

Four Interdependent areas
Circulatory
Respiratory
Thermoregulation
Ability to stabilize blood sugars
Circulatory and Respiratory of the newborn
Transition from fetal to neonatal circulation
Newborn must transition from fluid-filled environment to air-breathing, independent, extra-uterine life
Clamping/cutting of the cors is the most critical extrauterine adjustment
Clamping and cutting of the umbilical cord immediately closes the umbilical vein and umbilical arteries, shunts close (ductus venosus, foramen ovale, ductus arteriosus)
First breath of life -- a gasp in response to chemical changes,etc.
As alveoli expands, surfactant allows them to remain partially open between respirations
Initial respirations shallow and irregular, 30-60 breaths per minute with short periods of apnea (<15/20 seconds in duration)
Periodic breathing
Cessation of breathing 5-10 seconds in duration with no changes in color or heart rate
Temperature regulation of the new born
Neonate must produce and maintain heat to prevent serious effects of cold stress in transition from warm uterus to cooler outside environment
Newborn's temperature may drop several degrees after delivery without interventions
Skin-to-skin contact, drying and hat to reduce temperature loss
Thermoregulation in the newborn is closely related to the rate of metabolism (glucose) and oxygen consumption
Newborn characteristics related to Temp regulation
Skin is thin w/ blood vessels closer to skin-circulating blood influenced by environmental changes (1st line)
Less subcutaneous fat
Inability to shiver first 3 months of life to produce heat
Newborns maintain a flexed body position to decrease the exposure of body surface to heat loss
Temp: 97.9-99.7 (36.6-37.6) axillary
Heat loss
Cold stress (hypothermia) in a newborn can be lethal even in a healthy full-term newborn
Rapid heat loss occurs by evaporation, conduction, convection, and radiation
Conduction
Heat from baby and comes into direct contact with baby so heat flows to cold
Skin to skin is primary intervention
Baby put in radiant warmer

movement of heat away from body when newborns come into direct contact with objects cooler than skin (scale, hands, stethoscope)
Convection-
Air movement
Heat moves from baby to cool air
Closed doors
No windows, windows kept shut,

transfer of heat to the air surrounding the newborn
Prevention: Warm, draft free environment
Evaporation
Air drying of the skin that results in cooling
Insensible water loss from the skin & respiratory tract increases loss via evaporation
- primary intervention dry baby when born !!!
Radiation
Transfer of heat to cooler objects not in direct contact with newborn
Prevention: Don't place cribs near cold windows/walls
Effects of Cold Stress
Increased oxygen needs
Respiratory distress & hypoxia
Hypoglycemia
Increased risk of jaundice
Behavioral Adaptations: First period of reactivity (eyes moving; rolling around )
30 minutes to 120 minutes after birth
Good opportunity to initiate breastfeeding
Good opportunity for bonding
Period of decreased responsiveness
Difficult to awaken, unresponsive to stimuli
No interest in sucking
Respiratory and heart rates decline
Second period of reactivity
Interest in environmental stimuli
Respiratory and heart rates increase
Increased bladder and bowel activity (first bowel movement → meconium)
Behavioral Responses:
Orientation:
Respond to auditory and visual stimuli
Ability to be alert to, to follow, and to fixate on complex visual stimuli that have appeal and attraction
Habituation
Ability to block out external stimuli after newborn has become accustomed to the ability
Increase ability to habituate to stimuli and sleep
RAPP: Rapid newborn assessment tool
To assess stability of newborn
Respiratory Activity
Perfusion/color
Position/tone
Indications of a Problem in the newborn
Labored breathing
Grunting on expiration
Generalized cyanosis
Nasal flaring
Tachypnea, tachycardia
Flaccid body posture
Pallor
Weight of the new born
2,500-4,000 grams with up to 10% weight loss
length of the new born
17 - 22 inches
head circumference of the newborn
32 - 38 cm
Chest Circumference
Equal to or 2-3 cm less than head circumference
Vital signs
Temperature → 97.9 - 99.7 F (36.6-37.6C) axillary
HR → 110-160 bpm, transient heart murmurs common
RR → 30-60 bpm
Oxygen saturation
> 95%
Gestational Age Assessment → Ballard Score
Assess neuromuscular and physical maturity of baby; should correlate with gestational date (#of weeks)
Nursing Actions of the newborn
Nursing Actions:
Skin:
Pink or tan with acrocyanosis (hands and feet are bluish; lasts 12-24 hrs)
Normal variations
Vernix → white, cheese substance
Lanugo → soft, fuzzy hair
Milia → plugged cysts; little white spots
Telangiectatic nevi (stork bite) → red discoloration at back of neck
Nevus vasculosus (strawberry mark/hemangioma) → usually fade and decrease in size
Nevus flammeus (port wine stain) → run in families
Erythema toxicum → diffuse red rash that comes and goes
Mongolian spots → dark discoloration of the lower spine
Head of the newborn
Anterior fontanel (front)
Diamond shaped, closes by 18 months
Posterior fontanel (back)
Triangular shaped, closes by 2-3 months
Variations:
Molding → elongated shape of baby's head so it can get through the birth canal
Caput succedaneum → occurs with molding; diffuse swelling at top due to pressure on fetal head; circular and covers multiple cranial bones
Cephalohematoma → off to the side of the head; due to vacuum; bleeding occurs on cranial bone; bluish discoloration increases risk of jaundice
Face of the newborn
Symmetrical at rest and with crying
Nose and lips at midline
Bilateral patency of nares
Eyes of the newborn
May be edematous (due to medication)
Ears:
Symmetrical with upper part of pinna at or above outer canthus of eye (if lower → may be indication of genetic disorder such as down syndrome)
Pinna curved with firm cartilage
Skin tags → can likely have genitourinary issue
Nose of the newborn
Obligate nose breathers
Sneezing common
Mouth of the newborn
Mucosa and gums pink and moist
Intact palates
Epstein pearls → tiny white cysts; normal
Abnormal → cleft lip or palate
Neck, clavicles, and shoulders:
Neck is short with flexible movement to each side
Intact clavicles with full range of motion
Chest:
Round, symmetrical and cylindrical
Breast engorgement may be noted
Breath sounds:
Symmetrical
Most alveoli are expanded within 1 hour after birth
Most fluid is removed by absorption and lymphatic drainage within 6-12 hours of birth
Abdomen:
Umbilical cord
AVA
Observe and palpate abdomen
Symmetrical
Cylindrical
Slightly protruding
Kidneys:
Uric acid crystals → pinkish reddish brown appearance and is shiny; its normal
External genitalia: Male:
Meatus tip of penis
Scrotum pink to brown, symmetrical and pendulous with rugae
Testes descended
External genitalia: Female:
Labia majora meet midline
Vagina and urinary meatus present
Hymenal tag
Mucous discharge
Pseudomenstruation → b/c of withdrawal of maternal hormone
Extremities:
Symmetrical appearance in size, length
Full range of movement
Flexed
Assess for hip dysplasia
Hands and feet:
Palmar and plantar creases present
Hands held fisted
Lower extremities
Assess for hip dislocation, clubfoot
Spine
Straight and intact without tuft of hair or dimpling
Reflexes:
Newborn has many primitive reflexes
Times at which these reflexes appear and disappear reflect maturity and intactness of the developing CNS
Absence of reflexes may indicate CNS damage
Moro → startle
Tonic neck → turn head to right or left and the arm they are turned to is up
Palmar grasp
Plantar grasp
Rooting → stroke cheek
Sucking → put finger in mouth or pacifier
Babinski → toes expand
Nursing Interventions of the newborn
Bathing:
Thermal and C/R stability
Hospital policy
Skin to skin or radiant warmer
Assess urinary output → minimum of 6 wet diapers per 24 hours
Assess stools → meconium, transitional, feeding dependent
Umbilical cord card
Circumcision care
Safety
Prevent infant abduction
SIDS prevention
Car seat safety
Infection prevention
Promoting sleep:
Sleep up to 15 hours a day
No co-sharing
Safest place → crib or bassinet in same room with parents for at least 6 months
Circumcision Nursing responsibilities pre procedure::
Consent signed
Baby has voided
Baby should have Vitamin K shot
Make sure anatomy is correct (no hypo/epispadias)
Emla cream (anesthetic)
NPO for minimum of 2 hours
Make sure baby is stable
Circumcision: Nursing responsibilities during procedure
Baby is strapped down
Not exposed to too much cold air
Pacifier to cope with pain
Circumcision: Nursing responsibilities post procedure
Release baby's feet and slip diaper on them
Put vaseline on penis to protect when voiding
Any degree of bleeding → sterile gauze with vaseline with pressure
Get dressed and give to mom
Void post procedure
Circumcision: Parent education:
Apply vaseline with every diaper change
Exudate → normal; don't remove
Diagnostic Tests:
Newborn Genetic and Inborn Errors of Metabolism Screening
After 24 hours of age and ingestion of breastmilk or formula
Newborn Hearing Screen
Breastfeeding
Optimal method
Exclusive for first 6 months
Benefits for mother and infant
Contraindications
Stages of Human Milk: Colostrum (white to yellow):
Concentrated levels of protein, fat soluble vitamins and minerals (has antibodies)
High levels of IgA and IgG
Production begins in pregnancy, lasts several days after birth
Stages of Human Milk: Transitional:
Approximately day 3-6 to day 10-13
Stages of Human Milk: Mature Milk:
Foremilk:
High in water, vitamins and protein
Hindmilk:
Higher fat concentration
Initial feeding
First hour of life
Establishing a feeding pattern
8-12 times per day with no time limits
Feeding technique
Positioning is key
Supply and demand
More baby demands the more breast will make
Formula Feeding:
No need to routinely sterilize
Feeding techniques
Head elevated, keep bottle tipped, no propping of bottle or going to bed with bottle, discard formula left in bottle
Types of formula
Preparation of Formula:
Powder
Concentrated
Ready to feed
MEDICATIONS of the Newborn
Wrythromycin (0.5% or 1% Tetracycline eye ointment)
Use: Prophylactic, treat or prevent STIs (Chlamydia and Gonorrhea)
Vitamin K (IM, Vastus lateralis)
Use: Trigger clotting factors
If Mom is Hep B +
Hepatitis Immune Globulin
Use: Provides immediate passive antibodies
Hep B Vaccine
Use: Part of immunization series
Uterine contractions
frequency: measured by the beginning of one contraction to the beginning of the next contraction, measured in minutes apart
duration: how long contractions last, measured in seconds
intensity - palpation (mild, feel uterus is tightening but can still push in with fingertips moderate fingertips push down a little bit, strong (boardlike,
patient perception
resting tone
optimal blood flow
Infants of Diabetic Mothers, page 886 Pre-gestational diabetes
Increased risk of severe congenital anomalies
Infants of Diabetic Mothers, page 886 Gestational diabetes
Most common complication in pregnancy, increasing incidence
Infants of Diabetic Mothers, page 886 Common complications - page 887 - 888
Macrosomia - birth trauma
Respiratory distress syndrome due to inadequate phospholipids
Hypoglycemia
Polycythemia
Jaundice
Congenital anomalies
Hypoglycemia Blood sugar < 40 mg/dL Signs & Symptoms
Tremors & jitteriness
Hypothermia
Poor feedings
Respiratory Distress
Apnea & Cyanosis
Hypotonia & Lethargy
Nursing Care - focus is early detection of hypoglycemia
Screen within 30 minutes of birth
Dextrostix
Early, frequent feedings of formula / breast milk
Recheck blood glucose 30 - 45 minutes post feeding
D5 - 10W infusion
Needs careful titration
Assess respirations, temperature along with blood sugar
Fetal Alcohol Syndrome (FAS), pages 895 896
´Clinical Picture, Box 24.2, page 896
´Growth restriction
´Craniofacial structural anomalies
´CNS dysfunction - Irritable, hypersensitive, hyperactive, high pitchedcry
´Interventions
´Reduce stimuli
´Pacifier
´Swaddle, sway and swish
´Assess nutrition & hydration status, I & O, daily weight
´Assess bonding
Neonatal Abstinence Syndrome, pages 896 - 900
´Group of signs and neurological behaviors resulting from abrupt discontinuation of intrauterine exposure to various substances

´Indications of drug withdrawal dependent on timing of last exposure, specific substance abuses, route of administration, length of exposure to substance and half-life of the substance.
Neonatal Abstinence Syndrome, pages 896 - 900 assessment
´Maternal history
´Indications of withdrawal appear within 48 - 72 hours of delivery
´Withdrawal Acronym, page 898
´Focused assessment
´Newborn Behaviors of Withdrawal, Box 24.4, page 898
´Nursing Assessment
´NAS Scoring System, page 897
´Toxicology results
Neonatal Abstinence Syndrome, pages 896 - 900 interventions
´Promote neonatal comfort
´Low lighting in quiet environment
´Minimal stimulation
´Use soft voices
´Decrease environmental stimuli
´Gentle handling
´Swaddle, sway and swish
´Rockers
´Pacifier
´Nutritional needs
´Promote parent-newborn interactions
´Hyperbilirubinemia - page 900
´Elevated total serum bilirubin levels
´Jaundice evident with serum bilirubin of > 5 mg/dL
´Clinical significance based on age of neonate in hours and total serum bilirubin level
´Kernicterus
´Abnormal accumulation of unconjugated bilirubin in brain cells.
´Toxic to brain tissues
´Deafness
´Delayed motor skills
´Hypotonia
´Intellectual deficits
´Goal: prevent kernicterus
Jaundice
´Major function of liver is conjugation/breakdown of bilirubin
´Primary source of bilirubin is hemolysis of erythrocytes
´Bilirubin released in an unconjugated form that is not soluble in water
´Liver must change unconjugated bilirubin to a water solubleform by process called conjugation → conjugated or direct bilirubin
´Conjugated bilirubin is not toxic to the body and can be excreted
´Unconjugated bilirubin is fat soluble and absorbed by subcutaneous fat → jaundice
Physiologic Jaundice
´Appears after 24 hours of age - 1stweek of life
´Due primarily to
´Increased RBC volume (polycythemia)
´Short RBC life span
´Immature hepatic update
´Delayed passage of meconium
´Blood tests
´Total Serum Bilirubin (TSB) - typically peak day 3 - 5 of life
´Levels typically peak at 10mg/dL
´May or may not require phototherapy
]Non-physiologic or Pathologic Jaundice
§Appears before 24 hours of age
§Levels increase by > 5mg/dL/day
§Total serum bilirubin (TSB) levels > 20 mg/dLin term infant
§Causes
§Rh incompatibility
§ABO incompatibility
§Nursing Actions
´Assess for risk factors
´Assess degree of jaundice
´Monitor labs: Hemoglobin level, RBC, Blood type & Rh, Direct Coombs, TSB level
´Ensure adequate hydration status
´Implement phototherapy if ordered
´Phototherapy
´Decisionby level of bilirubin and age of neonate in hours
´Exposure of the newborn to high-intensity light to convert unconjugated bilirubin to to less toxic water-soluble form that can be excreted in urine and stool
´Does not alter the underlying cause of jaundice
´
´Bank of fluorescent lights
´Phototherapy
´Cover eyes and shield genitals
´Minimal clothing
´Maintain neutral thermal environment
´Assess temperature at least every 4 hours
´Provide optimal nutrition
´Adequate, frequent (every 2 - 3 hours) feedings to promote bilirubin excretion and prevent dehydration
´Intake and output
´Stools - loose, green and may contain some bile
´Urine - dark in color
´Daily weight


´
´Turn infant every 2 hours
´Assess skin frequently
´Frequently dry & cracking
´No lotions
´Usually remove infant from lights for feedings & bonding
´Remove eye shields and assess eyes for drainage
´Monitor TSB
´Teaching parents and bonding
´Turn of lights before blood draw
´Discontinuation of phototherapy
´Often have slight elevation of TSB after discontinuation of phototherapy


´
Goodell's sign
→ softening of cervix
Sets with similar terms