Exam 2 Flashcards
Women older than 35 years
referred to as “advanced maternal age”
have greater chance of preexisting conditions
have increased genetic risk
increased miscarriage
ectopic pregnancy
preterm birth
DM
HTN
placenta previa
placental abruption
cesarean birth
postpartum hemorrhage
LBW
multiple gestation
Multifetal Pregnancy
increased risk for a variety pregnancy complications
miscarriage
hyperemesis
anemia
gestational HTN
preeclampsia
postpartum hemorrhage
maternal death
most likely preterm birth
risk increase with # of fetuses
-IUGR
-discordant growth
-LBW
-VLBW
-congenital abnormalities
-neonatal death
cerebral palsy
shaunting of blood
transfusion of blood between placenta (twin to twin transfusion)
recipient is bigger in size; the donor is smaller in size
pallid
dehydrated
malnourished
hypovolemic
larger twin can develope CHF within 24 hours after birth
Selective reduction
done for more than 3 fetuses
reduced premature birth
improve opportunity for remaining fetuses to grow to term
uterine distention
cause backache
leg viscosities
support hosed used
presence of premature dilation of cervix or bleeding present
abstinence from orgasm and nipple stimulation during last trimester is recommended to avert preterm labor
classes offered in third trimester
Lamaze
Bradley
prepared parents for labor and birth
provided by birthing facilities, obstetric care provider office or clinics, health department, private individuals or other organizations
planning for labor and birth
free standing birth center–midwife or midwife practice
hospital setting–HCP obstetrician
birth setting choices
hospital
free standing birth center
home
hospital births
labor, delivery, and recovery (LDR) and labor, delivery, recovery and postpartum (LDRP) room offer families a comfortable, private space for labor and birth
1-2 hours in LDR room then transfer to postpartum unit and nursery or mother and baby unit for duration of stay
LDRP provide care from admission to discharge - 6-48 hours after giving birth
have emergency resuscitation equipment for mother and newborn heating crib/warming unit for newborn
Doula
trained to provide physical, emotional, information support to women and their partner during labor and birth
-not involved in clinical task
-provide support and care for women, newborn, and families during the first weeks after birth
certified
-Doula Internation (DONA)
-Postpartum Professional Association (CAPPA)
others provide care without certification
Benefits of having doula
-decreased need for pain meds
-decreased used of epidural analgesic
-shorter labor
-increased satisfaction w/birth experience
-likely hood of spontaneous vaginal birth
-decrease risk of c-section or instrument assisted vaginal birth
-reduced risk associated with low 5-apgar score
birth plan
understood to be a preference list based on a best-case scenario
nutrition factors that influence outcome of pregnancy
low birth weights
preterm infants
assess nutritional status
- weight and height
- if they have adequate and the quality of dietary intake
- their eating habits
diagnosis of nutrition-related problem or risk factors
diabetes
phenylalanine hydroxylase (PAH) deficiency (formally known as phenylketonuria [PKU])
obesity
interventions based on individuals’ dietary goals to promote appropriate weight gain
ingesting in variety of foods
appropriate use of dietary supplements
physical activity
nutrient needs before conception
first trimester fetal and embryonic development
healthy diet before conception and during pregnancy
folate
vitamin B9 a form found naturally in foods
folic acid
form used in fortification of grain products and other food and in vitamin supplements
lack of folic acid
failure in closure of neural tube
proper closure required for normal formation of spinal cord
this occurs at first month of gestation
amount of folic acid
pregnant women should take 0.4mg (400 mcg) of folic acid every and consume dietary source of folate
take 4mg of folic acid 1 month prior to attempting to conceive and continue throughout first trimester
food that providing 500mcg or more folic acid
liver: chicken, turkey, and goose
food that providing 200 mcg of folic acid
liver: lamb, beef, veal
losing weight before pregnancy are likely to have healthier pregnancy
maternal and fetal risk increase when mother significantly underweight or overweight
nutrient needs during pregnancy
determined by stage of gestation
first trimester the embryo is small-slightly increase over those before pregnancy
last trimester is period of acceleration fetal growth when most of the fetal store of energy source and minerals are deposited
second and third trimester increased greatly
factors that contribute to the increase in nutrient needs
development and growth of uterine-fetal unit
total blood volume (TBV), plasma, RBC volume increase significantly (40-50%)
maternal mammary development
20% increase in metabolic rate during pregnancy
Dietary Reference Intake (DRI)
recommendations for daily nutritional intakes that meet the needs of almost all the healthy members of the population
divided into age, sex, and life stages (infancy, pregnancy, lactation
Reference Daily Intake (RDI)
nutritional labels on food
Protein
non-pregnant 46 g
first: 46g
second/third: +25g
lactation: +25g
source: meat, eggs, cheese, yogurt, legumes (dry beans, peas, peanut), nuts, grains
Water
non-pregnant 2.7 L
pregnant 3L
lactations 3.8 L
source: water, beverage made with water, milk, juice, all foods especially frozen dessert, fruits, lettuce, and other fresh vegetables
Fiber
nonpregnant 25
pregnant 28
lactation 29
source: whole grains, bran, vegetables, fruits, nuts and seeds
fat soluble vitamines
A, D, E
vitamin A
cell development, tooth bud formation, bone growth
source:
dark leafy veg
dark yellow veg
fruits
liver
fortified margarine and butter
Vitamin D
involved in absorption of calcium and phosphorous, improves mineralization
source:
fortified milk
breakfast cereals
salmon, tuna
oily fish
butter
liver
Vitamin E
antioxidant (protect cell membrane from damage), especially important for preventing breakdown of RBC
source:
veg oil
dark leafy green veg
whole grains
liver
nuts and seeds
cheese
fish
water soluble vitamin
vitamin D, folate, Vit B6, Vit B12
vitamin C
tissue formation/integrity, formation of connective tissue, enhancement of iron
source:
citrus fruits
strawberries
melon
broccoli
tomatoes
peppers
raw dark green leafy veggies
folate
prevention of NTD, increase maternal RBC formation
source:
fortified ready to eat cereal and other grain product
dark leafy green veg
Vit B6
known as pyridoxine
protein metabolism
source:
meats, liver, dark leafy green vegetables, whole grains
Vit B12
production of nucleic acids and proteins, formation of RBC and neural functioning
source:
milk and milk products
eggs
meats
liver
fortified soy milk
energy needs
additional kcal needed during second trimester can be provided by adding one additional serving of milk, yogurt, or cheese (all skim products), fruits, vegetables, brad, cereal, rice, and pasta
in third trimester 1/3 serving
energy is met by carbs, fats, and proteins in diet
primary role is to provide amino acid for synthesis of new tissue
weight management
normal weight gain is 25-30 pounds
underweight gain 28-40 pounds
overweight gain is 15-25 pounds
obese gain is 11-20 pounds
underweight women during pregnancy
have preterm labor and give birth to LBW infants
normal and underweight women who does not gain adequate weight during pregnancy
have increase risk for intrauterine growth restriction (IUGR)
evaluate appropriate weight gain for body mass index (BMI)
BMI= wt / height^2
weight categories
less than 18.5 underweight
18.5-24.9 normal
25-29.9 overweight or high
30 or greater obese
pattern of weight gain
growth takes place in maternal tissue during first and second trimester
third trimester, growth primarily in fetal tissue
first trimester weight gain
(normal weight) 2-4 pounds (0.9-1.8 kg)
recommended wt gain increases to 1 pounds (0.45 kg) per week for underweight/normal women
second and third trimester weight gain
0.6 pounds (0.3 kg) for overweight and 0.5 pounds (0.2 kg) for obese women
cause for weight deviation
inadequate and excessive dietary intake
measurement reading error
clothing
time of day
high weight gain
fluid accumulation
gain more than 6.6 pounds (3kg) in a month, especially after 20th wks of gestation, could be associate with preeclampsia
low pregnancy weight and inadequate weight gain
increase term of preterm birth
risk of small-for-gestation-age (SGA) infant
adverse effects of poor maternal nutrition–poor weight gain
lactation
promote weight loss
dietary restriction
results in catabolism of fat stores = production of ketones
short term effect of ketonemia during pregnancy are unclear
may be associate with preterm labor
obesity and excessive weight gain
outcomes:
miscarriage
birth defects
stillborn
abnormal fetal growth
preterm birth
maternal risk:
gestational diabetes
hypertensive d/o
vacuum and forcep assisted birth
c-section
surgical site infection
venous
thromboembolism (VTE)
depression
excessive gestational weight gain (GWG)
gestational diabetes
gestational HTN
fetal macrosomia
hypoglycemia
stillbirth
long term maternal and childhood obesity
proteins
essential constituent nitrogen
nutritional element basic to growth
growth of fetus
enlargement of uterus, supporting structure, the mammary glands, and placenta
increase maternal circulating blood and subsequent demand for increase of plasma protein colloidal osmotic pressure
formation of osmotic fluid
source: meat, cheese, egg, milk are complete protein source food
legumes, whole grain, nuts
also source for calcium, iron, and B vitamins
protein supplements
not recommended b/c of potentially harmful effects on fetus
Fats
intake 20-35% of daily calories
avoid trans-fatty acid–detriment of fetal development
fetal development and neurologic function
-long chain polyunsaturated fatty acid (LC-PUFA)
-docosahexaenoic acid (DHA)
- arachidonic acid (AA)
Omega-3 LC_PUFA during pregnancy
reduced preterm birth and improved neurologic and visual development in off spring
DHA
healthy fetal brain and eye development
fish is a good source of DHA
300mg/day
1-2 serving of fish per week
fish high in mercury
shark
sword fish
king mackerel
tilefish
fish self caught-check advisory (limit 6 oz and no other fish that week)
how much fish to consume
12 oz
type:
shrimp
salmon
pollock
catfish
canned light tuna (limit albacore, “white” tuna, and tuna steak to 6 oz)
nutritional assessment is performed
before conception so that any recommended change in diet, lifestyle, and weight can be initiated before pregnancy
information obtained from
-health records
-physical examination
-lab results
done at first prenatal care and throughout pregnancy nutritional status is monitored
health history
past medical history
bariatric surgery (has serious implications for nutritional health during pregnancy)
current medication
use of tobacco, alcohol, and other drugs
herbal supplement
nutritional reserves
depleted in multiparous women, or one who has had frequent pregnancy (3 pregnancies within 2 years)
signs of inadequate dietary intake
preterm birth
LBW
small gestational age (SGA) infant
what cause large gestational age (LGA)?
indication maternal diabetes mellitus
IUD
menstrual blood loss occurs during first 3-6 months after placement of IUD
low iron store or iron deficiency anemia
oral contraceptives
associated with decrease menstrual loss
increase in iron stores (interferes with folic acid metabolism)
assessment on maternal diet
collect info on usual food and beverage intake
use self administered questionnaire
include income and other sources to meet nutritional needs
–dietary modifications
–food allergies/intolerance
–all medications/nutritional supplements
–usual cravings, pical, cultural dietary practices
determine presence and severity of nutrition related discomfort
nausea and vomiting
constipation
pyrosis (heartburn)
cues of eating disorder
anorexia nervosa
bulimia
frequent and rigorous dieting before/during pregnancy
lactose intolerance in pregnancy and breast feeding
explore their intake of other calcium source`
eval financial status and sound dietary practices
quality of diet improves with increasing social economic status and education levels
healthy eating patterns
eating a variety of fruits from all subgroups
dark greens
red and orange
legumes (beans and peas)
starchy and other
whole fruits
whole grains
fat free or low fat dairy (milk, yogurt, cheese, fortified soy beverage)
protein foods (seafood, lean meats and poultry, eggs, legumes (beans and peas), nuts, seeds, and soy products
oils
what food should pregnant women limit
saturated fats and trans fat (added sugar and sodium)
less than 10% kcal from add sugar/day
less than 10% kcal from added fats/day
less than 2300kg sodium/day
alcohol consumption
women- 1 drink
men - 2 drink
alcohol not recommended during pregnancy
anthropometric (body) measurements
provide short and long term information on women nutritional status and essential to assessment
height and weight and BMI
used to establish appropriate weight gain recommendation during pregnancy
what cause lower extremity edema
when kcalories and protein deficiencies present
who is the primary educator on nutrition
nurse
dietitian is a consultant unless patient has preexisting conditions such as diabetes
interprofessional team of nutritionists
nurse
dietitian
obstetric care provider
other specialist if needed
social worker
concept involved in nutritional teaching
nutritional needs
appropriate weight gain based on BMI and risk of excessive/inadequate weight gain
dietary planning
strategies for coping with nutrition discomfort of pregnancy
appropriate use of supplements
avoidance of alcohol, tobacco, and other harmful substance
seafood preparation and handling
two source that provide assistance with nutrition
supplemental nutrition assistance Program (SNAP-food stamp)
Supplemental nutrition for women, infant, and children (WIC)
-provide vouchers for pregnant women and lactating women, infant, and children at nutritional risk
-include food such as eggs, milk (cheese, soymilk, tofu), juice, fortified cereal, legumes, and peanut butter
-participants receive nutritional counseling and encourage breast feeding
help women plan daily meals that follows plan
affordable
realistic prep time
compatible with personal preference and cultural practices
foodborne illness
E. coli
salmonella
listeriosis
toxoplasmosis
brucellosis
safe food practices
- careful hand hygiene
- clean food prep surfaces and utensils frequently
- avoid contact between raw meat, fish, poultry and other food that will not be cook before consumption
- wash fruits and vegetables
- store food properly
- meat, poultry, egg and fish cook at safe internal temperature
- pregnant women should not consume raw fish that is part of sushi or sashimi
listeriosis
from bacteria listeria
risk for miscarriage
premature birth
stillborn
food to not consume
unpasteurized milk or products made with unpasteurized milk
soft cheese
-brie
-camembert
-Mexican cheese
queso blanco
queso fresco
panela
asadero
hot dog, luncheon meat, bologna, deli meat
only consume if reheat to steaming hot
deli made and store-bought salad
- eggs
- ham
-seafood
nausea and vomiting
common during first trimester
to reduce nausea
- antiemetic
- vit B6
- Ginger
- P6 acupressure
hyperemesis gravidarum
severe or persistent vomiting
causes weight loss, dehydration, and electrolyte abnormalities
interventions:
IV F&E replacement
enteral tube feeding
parenteral nutrition (rate)
acupressure and ginger have limited evidence to work
managing N/V during pregnancy
eat dry starchy food in the morning and other times nausea occurs
-toast
-melba toast
-crackers
avoid consuming excess fluid early in day
eat small meals
- have snack such as cereal with milk, small sandwich, or yogurt before bedtime
avoid sudden movements-getting out of bed
decrease intake of fried and other fatty food
-try high carb such as toast, rice, potato
-high protein meals or snacks are helpful
breath fresh air
- keep environment ventilated
- go for walk outside
-decrease cooking odor by using exhaust fan
eat food served at cool temp and give off little aroma
avoid spicy food
avoid brushing teeth immediately after eating
try salty tarte food (potato chips, lemonade)
herbal teas made with raspberry leaf or peppermint
try some form of ginger
-gingerale
- candied ginger
- fresh ginger tea
ear motion sickness wristband
vit B6 or med such as diclegis (made of B6 and doxylamine)
constipaton
increase fiber intake (28g)
include in diet
-bran
- whole wheat product
- popcorn
-raw or lightly steam veg
-adequate fluid intake
-physical activity
walking
swimming
water aerobics
pyrosis
caused by reflux of gastric content into esophagus
minimized by eating small frequent meals
don’t consume water with food (distention of stomach)
drink adequate amounts of water in between meals
avoid spicy foods
avoid lying down after eating (worsen reflux)
avoid tight clothes around abdomen
adolescent pregnancy
less than recommended calcium and iron uptake
growth of pelvis delayed in comparison with growth on suture
cephalopelvic disproportion and other mechanical problems
encourage to choose wt goal at upper end of range of BMI
have higher % of fat and visceral fat (associated with metabolic syndrome and cardiovascular disease
nutritional health of pregnant adolescent focus on following
improve nutrition knowledge, meal planning, and food prep skills
promote access to prenatal care
developing nutritional intervention and education program
striving to understand factors that create barrier to change
pregnancies after bariatric surgery
cause deficiency in macro and micronutrients
-folate
-vit B12
-iron
-calcium
-vit D
roux-en-y gastric
cause malabsorption and carry high risk for nutritional deficit
laparoscopic adjustable gastric banding
restrictive type
associated with nutritional problems
iron long term problem after bariatric surgery
increase risk for
- prematurity
- SGA
-NICU admission
risk is greater if surgery and birth less than 2 years
five factors that affect the process of labor and birth
passenger (fetus and placenta)
passageway (birth canal)
powers (contractions)
position of the mother
psychologic response
what affects the way the fetus moves through the birth canal?
size of the head
fetal presentation
fetal lie
fetal attitude
fetal position
what is the fetal skull composed of?
two parietal bones
two temporal bones
frontal bones
occipital bones
sutures
connective tissues that connect bones
sagittal, lambdoidal, coronal, and frontal
fontanels
areas where more than two bones meet
two most important fontanels
anterior and posterior fontanel
anterior fontanel
diamond shape
approximately 3 cm by 2 cm
lies at the sagittal, coronal, and frontal sutures
closes by 18 months after birth
posterior fontanel
lies at junction of the sutures of the two two parietal bones and occipital bone
triangular in shape
1 cm by 2 cm
closes at 6-8 weeks after birth
molding
slight overlapping during labor to adapt to the various diameter of the maternal pelvis
assume normal shape within 3 days after birth
fetal shoulders
one shoulder may occupy a lower level than the other, creating a diameter that is smaller than the skull, facilitating passage through the birth canal
presentation
part of the fetus that enters the pelvis inlet first and leads through birth canal during labor at terms
three main presentation
cephalic presentation (head first); 97%
breech presentation (buttocks, feet, or both first); 3%
shoulder presentation
presenting part
part of the fetus lies closes to the internal os of cervix
cephalic presentation= occiput (noted as vertex)
breech presentation = sacrum
shoulder presentation = scapula
factors that determine the presenting part
fetal lie
fetal attitude
extension or flexion
fetal lie
relation of the long axis (spine) of the fetus to the long axis (spine) of the mother
parallel with the long axis of the mother
transverse, horizontal, or oblique in which the long axis of the mother
longitudinal lies are either cephalic or breech presentations
fetal attitude
relation of the fetal body parts to one another
fetus assumes a characteristic posture (attitude) in utero partly because of the mode of fetal growth and partly because of the uterine cavity
general flexion
the arms are crossed over the thorax, and the umbilical lies between the arms and the legs
deviation from normal attitude
cause difficult birth
extended or flexed in a manner that presents a head diameter that exceeds the limits of the maternal pelvis
prolong labor, forceps or vacuum-assisted birth, or cesarean birth
biparietal diameter
about 9.25 cm at term (fetal head measured by ultrasound)
longest transverse diameter and an important indicator of fetal head size
in well-flexed cephalic presentation, the biparietal diameter is the widest part of the head entering the pelvis inlet
the smallest and the most critical one is the suboccipitobregmatic diameter (9.5 cm in term)
when the head is in complete felxion, this diameter allows the fetal hea dto pass easily through the true pelvis
as head is more extended, the anteroposterior diameter widens, and the head may mot be able to enter the true pelvis
Fetal position
the relationship of a reference point on presenting part (occiput, sacrum, mentum (chin) or sinciput (defelxed vertex)) to the four quadrants of the mother’s pelvis
denoted by the location of the presenting part in the right(R) or left(L) side of the mother’s pelvis.
middle leter stands for the specific presenting part of the fetus (O for occiput, S for sacrum, M for mentum, and Sc for scapula)
the final letter stands for the location of the presenting part in relation to the anterior (A), posterior (P), or transverse (T) portion of the maternal pelvis
ROA = occipital is the presenting part nad is located on the right anterior quadrant of the maternal pelvis
LSP = presenting is sacrum and is located on the left posterior quadrant of the maternal pelvis
station
the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spine and is a measure of the degree of the descent of the presenting part of the fetus theough the birth canal
ischial spine is 0 above ischial spine is -5 to -1 and below ischial spine is +1 to +5
engagement
used to indicate that the largest transverse diameter of the presenting part (usually the biparietal diameter) has passed through the maternal pelvic brim or inlet into the true pelvis and usually corresponds to statio 0.
week just before labor begins in nulliparas and may occur before or during labor in multiparas
determined by abdominal or vaginal examination
category I fetal heart rate
baseline rate 110-160 beats/min
baseline FHR variability: Moderate
Late or variable decelerations: absent
Early decelerations: Either present or absent
accelerations : Either present or absent
Category II FHR
Baseline rate: bradycardia not accompanied by absent baseline variability
tachycardia
category III FHR
absent baseline variability and any of the following:
recurrent late deceleration
recurrent variable decelerations
bradycardia
sinusoidal pattern
intrapartum FHR monitoring
identify and differentiate the normal (reassuring) patterns from the abnormal (nonreassuring) patterns, which can indicate fetal compromise.
hypoxemia
deficiency of oxygen in the blood
hypoxia
inadequate supply of oxygen at the cellular levels that can cause metabolic acidosis
acidemia
increased hydrogen ion content (decreased pH) in the blood
metabolic acidemia
interruption of fetal oxygenation, leading to cellular dysfunction, tissue dysfunction, or death
method of fetal assessment during labor and delivery
Intermittent auscultation (IA) (low risk women because it promotes mobility during labor, may be used with hydrotherapy, and provide more natural birthing experience.)
Electronic Fetal Monitoring
IA
involves listening to the fetal heart sound at periodic intervals to assess the FHR
performed with pinard stethoscope, doppler fetoscope, ultrasound stethoscope, a DeLee-Hillis fetoscope
doppler u/s and u/s stethoscope
transmit ultra-high frequency sound waves, reflecting movement of the fetal heart valves, and convert these sounds into an electronic signal that can be counted
Pinard stethoscope and DeLee Hillis fetoscope
applied to the listener’s forehead because bone conduction amplifies the fetal heart sound for counting
Leopold’s maneuvers
palpate the maternal abdomen to identify fetal presentation and position
intensity
described as mild, moderate or strong
duration
measured in seconds from beginning to end of contractions
frequency
measured in minutes, from beginning of one contraction to the beginning of the next
resting tone
between contraction
described as soft or hard
EFM
assess the adequacy of fetal oxygenation during labor
two modes
- external mode: uses external transducers placed on maternal abdomen to assess FHR and UA
-internal mode: uses a spiral electrode applied to fetal presenting part to assess the FHR and an intrauterine pressure catheter (IUPC) to assess UA and uterine resting tone.
ultrasound transducer
works by reflecting high-frequency sound waves off a moving interface, fetal heart and valves
standard paper speed in the US
3 cm/min
tocotransducer (tocodynamometer)
measure UA transabdominally
placed over fondus above the umbilicus and held securely in place with elastic belt
can record frequency and duration but not intensity
telemetry monitors
allow observation of the FHR and UC patterns through centrally located electronic display stations.
allow woman to walk around during electronic monitoring.
Montevideo units (MVUs)
calculated by subtracting the baseline uterine pressure from the peak contraction pressure for each contraction that occur in a 10 minute window and then adding together the pressure generated by each contraction that occurs during that period
spontaneous labor begins when MVU are between 80 and 120
baseline fetal heart rate
average rate during a 10-minute segment that excludes periodic or episodic changes, period of marked variability, and segments of the baseline that differ by more than 25 beats/min.
approximate mean rate is rounded to the closest 5 beat/min interval
variability
irregular waves or fluctuation in the baseline FHR of two cycles per minute or greater
beats/min and measured from the peak to the trough of single cycle
four category: absent (not detected, minimal (5 beats/ min or less), moderate (6-25 beats/min), and marked (> 25)
sinusoidal pattern
regular, smooth, undulating wavelike pattern that persists for at least 20 minutes
uncommon pattern classically occurs with severe fetal anemia
occur with chorioamnionitis, fetal sepsis, and administration of opioid analgesics
Tachycardia
baseline FHR greater than 160 beats/min
sign of fetal hypoxemia, especially with late deceleration and minimal or absent variability
caused by maternal fever or infection or fetal anemia
response to medications: atropine, hydroxyzine (Vistaril), terbutaline (Brethine), or illicit drugs such as cocaine or methamphetamines
second stage of labor
stage in which the infant is born.
begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby’s birth
what factors influence the length of second stage?
woman’s age
body mass index (BMI)
emotional state and adequacy of support
level of fatigue
sometimes fetal size, position, and presentation
acceptable length of second stage of labor
nullliparous
- w/o 2 or more hours
- w/ 3 or more hours
multiparous
- w/o 1 hour
- w/ 2hours
latent phase
delayed pushing, laboring down, or passive descent
period of rest and active calm
fetus continue to descend passively through the birth canal and rotate to an anterior position as a result of ongoing uterine contractions.
relax and eyes closed between contractions
urge to bear down is not strong, some do not experience it at all or only during acme (peak) of a contraction
delay pushing
increase in second stage labor length by an hour or more
small increase in cesarean and operative vaginal birth
increased risk for hemorrhage and need for transfusion
ferguson reflex
during descent, push on stretch receptors of the pelvic floor, which stimulate release of oxytocin from posterior pituitary glands, which provokes stronger expulsion uterine contractions.
active pushing phase
strong urges to bear down
stronger uterine contractions
change position frequently to find comfortable pushing position
becomes more vocal
bearing down intensifies as descent progress and presenting part reaches the perineum
more verbal about pain
signs that suggest the onset of second stage
increase in frequency and intensity of uterine contractions
urge to push or feelings need to have a bowel movement
episode of vomiting
increase bloody show
uncontrolled shivering
verbalizations of feeling out of control or unable to cope
involuntary bearing-down efforts
physical assessment during second stage of labor
performed every 5-10 minutes; BP, Pulse, Respiration
assess every 5-15 minutes FHR and pattern
assess every 10-15 minutes vaginal show, fetal descent
assess every contraction and bearing down effort
intervention during latent phase
help to rest in a position of comfort; encourage relaxation to conserve energy
promote progress of fetal descent and onset of urge to hear down by encouraging position changes, pelvic rock, ambulation, showering
intervention during active pushing phase
1:1Nursing care. Do not leave woman alone
help woman to change position, encourage her to use pushing technique she prefers and believes is best for her
help woman to relax and conserve energy between contractions
provide comfort and pain-relief measures as needed
cleanse perineum promptly if fecal material is expelled
coach woman to pant during contractions and to gently push between contractions when the fetal head is emerging
keep informed regarding progress
create calm and supportive environment
offer mirror to watch birth
offer woman to touch fetal head when it is visible at the perineum
frequency of intensity during active pushing phase
2-3 minutes progressing to every 1-2 minutes
duration 9of 90 seconds
upright position
increase profusion of the uterus
beneficial to CO
less pain, fatigue, perineal trauma, fewer episiotomy, fewer forceps or vacuum assisted birth
few FHR immoralities
Squatting position
pushing efforts maximized
gravity assists woman’s effort
a firm surface required with side support
birth ball help woman maintains squatting position
sitting on chairs, stools, toilets, or commodes
increase perineal edema and blood loss
change position every 10-15 minutes
semirecumbent position
legs are forced against her abdomen as she bears down
increase the risk of transient or permanent peroneal nerve damage
hands and knees position
facilitate rotation, if fetal position is posterior
prolong flexion of knees or hips greater than 90 degrees
should be avoided
lithotomy, squatting, and kneeling
valsalva maneuver
breathing techniques that involves forceful exhaling against a closed airway
increases intrathoracic and cardiovascular pressure
reduce CO and decrease perfusion of the uterus and the placenta
cause fetal hypoxia and subsequent acidosis associated with this type of pushing
FHR begins to slow, absent or minimal variability occurs, or if abnormal (late, variable, or prolonged) deceleration patterns develop
first action is to turn the woman on her side to reduce the pressure of the uterus against the ascending vena cava and descending aorta.
other measures include
supplement oxygen
increase IV fluid
if not return to normal inform mid-wife or physician
position assumed in a delivery table
sims or lateral position
dorsal position (supine with hip elevated)
lithotomy position
position in birthing room (labor bed)
lithotomy with feet on stirrups
side lying position with legs supported by coach or nurse or squat bar
foot of bed may be removed
preparing woman during labor
cleanse vulva and perineum
prepare oxytocin (pitocin)
Hospital delivery room
standard precaution used
-cap
-mask that has shield
-protective eye wear
-shoe cover
explaining reason for care, comfort them, describe progress
three phases of spontaneous birth of a fetus in vertex presentation
birth of head
birth of shoulders
birth of the body and extremities
crowning
when the widest part of the head (biparietal diameter) distends the vulva just before birth
nuchal cord
umbilical cord wraps around the baby’s neck during pregnancy or labor
stage of birth
first stage
oval slit, with vertex visible during contraction
oval opening and the vertex presenting
second stage
crowning
baby’s head comes through the vaginal opening
check for nuchal cord
complete when baby completely out
third stage (shortest)
baby place on mom and cord is clamped and cut
increase bleeding as placenta separates
expulsion of placenta ends the third stage
skin to skin contact
positive affect maternal infant bonding
breastfeeding duration
cardiorespiratory stability
body temperature
blood glucose higher in first 2 hours in those who did not get immediate skin to skin contact
clamping umbilical cord
wait 30-60 seconds to allow for physiologic transfer of blood to newborn
cut 2.5 cm (1inch) above clamp
delay clamping increase hemoglobin levels at birth and increase iron store in the first several months of life in term infants
also increase in jaundice
lotus birth
cord is not clamped and cut at all
cord and placenta attached to baby until cord naturally separates from the baby several days after birth
how many nurse present for each birth
2 nurses
one for baby and the second nurse help delivery of placenta and care of mother
apgar score
done at 1 minute and 5 minutes after birth
priorities for immediate newborn care
patent airway
support respiratory effort
preventing cold stress by drying and preferably covering newborn with warmed blankets
or placing them on radiant warmer
perineal lacerations
first degree: confine to the skin
second degree: extends into perineal body
third degree: involves injury to external anal sphincter muscle
fourth degree: lacerations that extends completely through the anal sphincter and the rectal mucosa
episiotomy
incision made in the perineum to enlarge the vaginal outlet
two types:
median (midline)–higher incidence of third and fourth degree laceration
mediolateral (diagnal) –more painful
signs of placenta separation
lightening of umbilical cord
gush of blood from vagina
woman is instructed to push to aid in expelling of the placenta
expelled within 15 minutes of birth
after placenta expelled
uterine fundus is massage
medication given (oxytocin/pitocin)
sign that suggest the onset of the third stage
firm contracting fundus
-change in uterus from discoid to globular -ovoid shape as placenta moves into lower uterine segment
-sudden gush of dark blood from introitus
-lightening of umbilical cord as placenta descends to the introitus
-finding of vaginal fullness (placenta) on vaginal or rectal examination or of fetal membrane at the introitus
fourth stage of labor
from after placenta is expelled to when mother and baby is stable
two hours after birth
BP and pulse
assess every 15minutes for the first two hours
temperature
assess every 4 hours for the first 8 hours after birth and then at least every 8 hours
boggy uterus
clots not expelled
distended bladder
-bulge (water filled balloon)
-uterus above umbilicus and the right side
post anesthesia recovery (PAR)
assess every 15 minutes
include activity, respiration, blood pressure, level of consciousness, and color
diet after birth
vaginal -regular diet and fluids
c-section - clear liquid and ice chips
breastfeeding
initiated within the first hour after birth
postpartum period
interval between birth and the return of the reproductive organs to their normal nonpregnant state
aka puerperium or fourth trimester of pregnancy
last 6 weeks
involution
return of uterus to a nonpregnant state after birth
begins immediately after expulsion of placenta with contraction of the uterine smooth muscle
uterus at the end of third stage of labor
2 cm below the umbilicus
within 2 hours 2 cm above umbilicus
at 24 hours, same size as 20 week gestation
fundus descend every 1-2 cm every 24 hours
6th day between umbilicus and symphysis pubis
after 2 week nonpalpable
subinvolution
failure of uterus to return to a nonpregnant state due to ineffective uterine contractions
most common is retain placental fragments or infection
afterpain
periodic relaxation and vigorous contractions can cause uncomfortable cramping
resolve 3-7 days
breastfeeding and oxytocin intensify afterpain
lochia
4-6 weeks after birth
1-3 days rubra (bright red)
4-10 days serosa (pinkish brown)
10-14 days alba (whitish yellow)
smell like normal menstrual flow
cervical os
never gain its prepregnancy appearance
no longer circular shape, jagged slit often described as “fish mouth”
ovulation
occurs as early as 27 days after birth
nonlactating women, 7-9 weeks
in breastfeeding about 6 months
dyspareunia
localized dryness and coital discomfort
lactogenesis II
breast milk coming in (72-96 hours after birth)
prolactin
fall in progesterone triggers a rise in prolactin
produced by anterior pituitary, hormone that stimulate milk production
oxytocin
produced by posterior pituitary in response to suckling or nipple stimulation with milk expression.
triggers milk ejection or let down reflex; releasing milk to nipple from alveoli in the breast where it is produced
vaginal birth stay
discharge within 24-36 hours
typical stay is approximately 48 hours
stay should be sufficient length to identify early problems and determine that the mother and family are prepared and able to care for the newborn at home
postpartum temperature
36.2 - 38 C (97.2 - 100.4 F)
less than 38 C - sign of infection
postpartum pulse
50-90 bpm
tachycardia: pain, fever, dehydration, hemorrhage
postpartum respiration
16-20 breaths/min
bradypnea: effects of opioid medications
tachypnea: anxiety, may be signs of respiratory disease
postpartum breath sounds
clear to ausculatate
crackles: fluid overload
postpartum breast
days 1-2 soft
days 2-3: filling
days 3-5: full, soften with breastfeeding (milk is in)
engorgement: firm, heat, and pain
postpartum nipples
skin intact, no soreness reported
latching problems: bruising, cracks, fissures, abrasions, blisters
postpartum uterus (fundus)
first 24 h: firm, midlines, at level of umbilicus
involutes 1 cm (1 fingerbreadth)/day
postpartum lochia
day 1-2: rubra (dark red)
days 4-10: serosa (brownish red or pink)
after 10 days : alba (yellowish white)
amount: scant to moderate
few clots
fleshy odor
large amount of lochia, large clots: uterine atony, vaginal or cervical laceration
foul odor: infection
diuresis
begins 12 hours after birth
can void up to 3000mL/day
what is done to evaluate blood loss during birth?
hemoglobin and hematocrit
most frequent cause of excessive bleeding after birth?
uterine atony (failure of uterine mucle to contract firmly)
two interventions for preventing excessive bleeding are
maintaining good uterine tone
preventing bladder distention
result of uterine atony
retained placental fragments
what is considered excessive blood loss?
perineal pad saturated in 15 minutes or less and pooling of blood under the buttocks
most accurate way to objectively determine blood loss
weighing clots and items saturated with blood (1mL =1g)
hypovolemic shock
BP not reliable indicator of impeding shock from early postpartum hemorrhage–compensatory mechanism prevents significant drops until woman has lost 30-40% of her blood volume
respirations, pulse, skin condition, urinary output and level of consciousness are more sensitive indicators
intervention to alleviate uterine atony
stimulation by gentle massaging the fundus until firm
administer IV fluids
medication such as oxytocin
empyting bladder
preventing bladder distention
empty bladder spontaneously asap
assist to the bathroom or bedpan
(listen to running water, placing hand in warm water, pouring water from a squeeze bottle over perineum; shower or sitz bath; analgesic for pain; or cath)
full bladder cause uterus to be displace above umbilicus and well to one side of midline in the abdomen. prevents uterus from contracting normally
infeciton prevention
clean environment (linen changed)
wear slippers
hand hygiene (standard precaution)
proper hygiene
perineal lacerations, epiostomy, and hemorrhoid care
perform hand hygiene before and after cleaning perineum and changing pads
wash perineum with mild soap and warm water at least once daily
apply pad front to back to protect inner surface of the pad from contamination
change pad with each void or defecation or at least 4 times per day
nonpharmaological measures to reduce postpartum discomfort
distraction
imagery
touch
relaxation
acupressure
aromatherapy
music therapy
transcutaneous electrical nerve stimulation (TENS)
heating pad or lying prone with uterine contraction
lying on side with episiostomy or perineal lacerations
applying ice pack
topical application of anesthetic spray or cream
pharmalogical interventions for postpartum discomfort
first step
nonopioid analgesiac
- acetaminophne or nonsteroidal antiinflammatory drugs (NSAIDs)
step 2
mild opioid
-hydrocodone
-oxycodone
step 3
stronger opioid
-fentanyl
- morphine
-hydromorphone
top three problems women experience within the first 2 months after giving birth
sleep loss
stress
physical exhaustion
interventions
- promote rest
- ambulation (venous thromboembolism, safety)
- excercise (start with simple excercise, 4-6 weeks after cesarean)
- nutrition
- bladder and bowel (6-8 hours after giving birth, pelvic floor training-kegel excercise)
- lactation
health promotion
rubella (MMR) and vericella vaccination before discharge from hospital
(should not become pregnant for 1 month after vaccination due to teratogenic effects o fetus)
Tdap vaccine to protect from pertusis (2 week prior to contact with infant
Rh immunization (given RhoGAM; 72 hours after birth)
kleihauer_Betket test
detects the amount of fetal blood in the maternal circulation
Rh immune globulin
suppresses immune response
recheck in 3 months to see if immunity to rubella, if not another dose needed
afterpains
intermitten contractions of the uterus
decrease within 3 days
may increase with breastfeeding or multiparity
uterus
by end stage of labor, uterus is 2 cm below umbilicus
rises to 1 cm above within 12 hours and descends 1 to 2 cm every 24 hours
sixth postpartum day, the uterus is between teh umbilicus and symphysis pubis
the uterus is not palpable by 6 weeks postpartum
colostrum
thin, clear or light-yellow substance that is antibody-rich and meets newborns’ nutritional requirement
lactation
expulsion of the placenta, decrease estrogen and progesterone levels help initiate the lactation process
prolactin hormones responsible for milk production that occurs 3-5 days after birth
increased oxytocin levels are responsible for milk ejection or letdown (lactogenesis stage II)
dyspareunia
vaginal dryness and painful intercourse due to decrease estrogen levels
hCG hormone levels
remian elevated for 3-4 weeks after birth
prolactin levels
cessation within 14 days after birth for nonlactating mothers
average blood loss
vaginal 500 mL
cesarean 1000 mL
