Final Review Flashcards
Week 9
Genetic Diseases-Recessive
- both parents must have
-cystic fibrosis, sickle cell anemia, Tay-Sachs Disease, Thalassemia
Genetic Diseases-Dominant
-Only one parent may have
-Huntington’s Disease, Familial Hypercholesterolemia, Xeroderma Pigmentation
Teratogens
-causes birth defects
-effects depend on; length of exposure, amount of exposure, and time during development
-drugs, viruses, chemicals, and infection
-Most vulnerable during organogenesis (Weeks 3-8 Embryonic-Embryo- Development)
Teratogenic Drugs; TERA-TOWAS
T-Thalidomide
E-Epileptics (Valproic Acid, Phenytoin)
R- Retinoid (Vitamin A)
A- Ace Inhibitors/ ARBS
T-Third Element (Lithium)
O-Oral Contraceptives
W-Warfarin (Coumadin)
A-Alcohol
S-Sulfonamides/ Sulfones
Teratogens- TORCH Infections
T- Toxoplasmosis
Parv-O- Virus B19 (fifth disease)
R- Rubella
C-Cytomegalovirus
H-Herpes Simplex Virus
Embryonic/ Fetal Development
*Weeks 3-8-organogenesis
-3-8, heart-beats at wk. 4
-3-38, CNS (brain/ spinal cord)
-4-8, Arms/ Legs
-4-38, eyes
-6-38, Teeth/ palate
-7-38, external genitals
-4-20 ears
Menstrual Cycle-Ovarian Cycle-egg development
*maturation of ova
1) Follicular (makes estrogen) Phase (1st day menstruation, last 12-14 days)-help from LH and FSH
2) Ovulatory Phase (Starts when estrogen levels peak-ends w/ release of oocyte (egg)-12-36 hrs. LH surges, estrogen drops, progesterone rises
3) Luteal Phase-Starts after ovulation, last about 14 days-corpus luteum breaks down/ progesterone production ends (if not pregnant), menstruation starts
Menstrual Cycle-Endometrial Cycle
*changes in the endometrium of the uterus in response to hormonal changes during the ovarian cycle
1) Proliferative phase- occurs following menstruation and ends with ovulation, estrogen thickens uterine lining
2) Secretory phase- begins after ovulation and ends with onset of menstruation, lining thickens even more due to progesterone, no pregnancy lining breaks down
3) Menstrual phase- sloughing off and expulsion of the endometrial tissue (period)
Conception-Fertilization
*sperm reaches egg (outer fallopian tube). Fertilized egg (zygote- 46-chromosones needed for life to form)
For Conception to occur three things must happen
1) Ovulation- egg released into the fallopian tube
2) Sperm must be able to travel all the way up to meet the egg
3) One sperm must be able to penetrate the egg
Ones an egg is fertilized…
It becomes a zygote (one cell-cleavage), which travels to the uterus rapidly dividing along the way. On third day becomes a 16 cell sphere (marula). Day 5-blastocyst entering the uterus.
The blastocyst has 2 main parts
1) embryoblast-becomes the embryo
2) trophoblast- assist w/ implantation (occurs day 5 or 6), becoming part of the placenta
Progesterone
*thicken the uterine lining, makes it rich with blood which supports the developing embryo
The trophoblast once implanted into the uterus is then called the chorion
*the chorion releases enzymes to secure the blastocyst to the uterine wall
Primary Germ layer-develop around day 14 (three)
1) Ectoderm
2) Mesoderm
3) Endoderm
Organogenesis- Ectoderm (outer layer)
*Outer surface -epidermal cells of skin
*CNS-neuron of brain
*Neural Crest- Pigment of cell (melanocyte)
Organogenesis-Mesoderm (middle layer)
-dermis, bones, cartilage, muscles, kidneys, adrenal cortex, bone marrow, blood, and lining of blood vessels
Organogenesis- Endoderm (Internal Layer)
-creates mucosa of the esophagus, stomach, intestines, respiratory tract, liver, gallbladder, thyroid gland, and pancreas
Fetal Development (Week 9 until birth)
*organ system continue to grow/ mature
Fetal Circulation- oxygen is provided through the placenta not the lungs
1) Ductus Venosus - connects umbilical vein to the inferior vena cava.
2) ForamenOvale - opening between R and L atria, closes after birth-full closure can take up to 3 months-by pressure of blood from L. atrium
3) DuctusArteriosus- connects pulmonary artery with descending aorta, constricts (higher )2 levels/ prostaglandins)
Placenta Functions
Metabolic and gas exchange( oxygen and carbon dioxide), acts as liver/ lungs for the fetus, nutrients (glucose/ amino acids), electrolytes between mom/ fetus, removes fetal waste products, hormone production
The placenta produces several important hormones
1) Progesterone-helps w/ implantation/ reduces uterine contractions
2) Estrogen- promotes growth of breast/ uterus
3) HCG (human chorionic gonadotropin)- maintains the corpus luteum, secretes hormones until the placenta takes over
4) Human placenta lactogen- supports fetal growth regulating glucose availability and stimulates breast development for lactation
Amniotic Sac (bag of waters)
*embryonic membranes; amnion (inner layer-from embryoblast), chorion (outer layer-from trophoblast)
*function- hold embryo/ amniotic fluids, maintains sterile environments
Amniotic Fluid-first trimester (amniotic membrane produces), second/ third trimester- produced by fetal kidneys)
*mostly water, contains proteins, carbs, lipids, electrolytes, and fetal cells, lanugo, vernix caseosa
Amount of amniotic fluid
*34 weeks- 800- 1,000 mL
*At term- 500- 600 ms
Amniotic Fluid function
*cushions fetus, prevents the fetus from sticking to the amniotic membrane, fetal movement (aids in symmetrical/ musculoskeletal development, maintains consistent thermal environment for fetus
Amniotic fluid abnormalities
Polyhydramnios- 1500-2000ml
Oligohydramnios- <500ml at term or less than 50% reduction from normal amount at time of gestation.
Reproductive System (Antepartum)
1) breast
2) uterus
3) vagina
4) ovaries
Cardiovascular system (antepartum)
1) Cardiac Output increases 30-50%
2) Blood volume increases 40- 50%
Respiratory System (antepartum)
-Increase tidal volume (30-40%)
-Increased oxygen consumption (20-40%)
Integumentary (antepartum)
1) Chloasma
2) Striae Gravidarum
3) Linea Nigra
Physiological Changes in Pregnancy
*Estrogen/ Progesterone rises
*blood volume increase
*shallow breathing
*increased urinary output
*mood changes
*nausea/ taste changes
*loosened ligaments
* breast changes
*damaged skin
Preconception Education
*optimize health and wellness of person to have a healthy baby
*maintain a healthy weight (18.5- 24.9 normal BMI)-weight gain 25-25 Lbs. occurs during pregnancy
*avoid caffeine, high mercury fish, undercooked foods, unpasteurized products, and alcohol
*prenatal vitamins (folic acids)
*Exercise-walk, swim, stretch
Diagnosis of pregnancy (three signs)
*presumptive
*probable
*positive
Presumptive signs (early subjective signs)
*amenorrhea, N/V (common weeks 2-12), breast changes, increased blood flow (2-3 weeks), fatigue, frequent urination (hormone changes/ growing uterus pressing on bladder), quickening (18-20 weeks 1st time moms-fetal movement)
Probable Signs of Pregnancy (objective/ physiological changes)
*Chadwick’s sign (bluish purple area around vaginal area), Goodell’s sign (softening of cervix/ > vaginal discharge), Hegar’s Sign ( softening of isthmus-lower part of cervix), visible uterine/ Abd. growth, skin hyperpigmentation. darkening of areolas/ nipples, positive HCG test (urine/ blood)
Positive Signs of Pregancy
*only explained by pregnancy
*fetal heart beat (heard w/ doppler 10-12 weeks), fetal movement (felt5 by examiner-20 weeks), ultrasound (4-8weeks, w/ vaginal probe)
Naegele’s rule
*Firs day of last menstrual period, minus 3 months, plus seven days, plus one year
GTPAL
*Gravida-total # of times pregnant (do not get fooled by number of babies, still considered 1)
*Term- 37 weeks or more
*Preterm-20 weeks- 36 weeks/6 days
*Abortion-Ending before 20 weeks
*Living-currently living children
First Trimester (1-13 weeks)-Timing, Screenings, Labs, Education, Assessments
*Initial; Hx, Physical/ Pelvic exam, assessment of uterine growth
*Fetal Heart Tones-US/ doppler (10-12 weeks, 110-160 BPM)
*Lab/ Diagnostics; Prenatal Panel-Blood type with Rh factor, Hep B, RPR/VDRL, Rubella, HIV
*anticipatory guidance, monthly visits, physical/ emotional changes, signs/ symptoms to occur, what foods to avoid
Second Trimester (14- 26 weeks)
*Office visits every 4 weeks
*Confirm due date
*Anatomy Scan at 20 wks.-detailed US of fetus
*education on preterm labor/ other signs/ symptoms HTN
Screening for Gestational Diabetes (GDM) at 24-28 wks.
1-hour glucose tolerance test (GTT), if elevated (>140mg/dl) 3-hour GTT required
+GDM if 2 elevated readings
*At 28 weeks Rhogam, if Rh-negative/ antibody screen negative)
Third Trimester (27 weeks- delivery)
Assessment of fetal well-being
FHT, kick counts (at least 10 kicks in 2hrs.)
Pelvic examination
Leopold’s maneuver (ATI Video)
Nutritional follow-up
Screening for group B streptococcus 35-37 wks.
Laboratory tests
Client Education-classes, reassurance, family help, impending labor signs
Danger Signs During First Trimester
burning with urination
Severe vomiting (HG)
Diarrhea, fever/chills
ABD cramping/vaginalbleeding
Danger Signs Second/ Third Trimester
Edema of face/hands
Epigastric pain
Severe headache
Changes in fetal activity
Vaginal bleeding/leaking of fluid
ABD pain
Maternal Adaption to Pregnancy
Parity
Maternal age
Sexual orientation
Single parenting-most at risk for depression and difficulty adjusting
Multiple pregnancies
Socioeconomic
Abuse
Military deployment
Paternal/ Partner Adaption to pregnancy
*may feel anxiety/ conflicting emotions, societal expectation, parenting skills, health of partner, neglected, announcement phase (mixed emotions about news), moratorium phase (limited conscious thought of pregnancy), focusing phase (end, increased involvement), relationship syndrome, Couvade Syndrome
Family Adaption to Pregnancy in the home
Changing structures of the family
Eight stages in the life cycle of a family
Developmental tasks
Grandparent adaptation
Sibling adaptation
Maternal adaptation to pregnancy
Psychosocial adaptation to pregnancy complications
Clomid (estrogen modulator-for infertility)
Used during anovulation, a condition where the ovaries do not release an egg (ovum) during the menstrual cycle. It is a common cause of infertility, as without ovulation, pregnancy cannot occur.
Terbutaline (Brethine)
*Beta-2 Adrenergic Agent
*Stops/Prevents preterm labor
*Given IV/ SQ
*AE= tachycardia, pulmonary edema, SOB, palpitations, provide education about increased anxiety
Nifedipine (Procardia)
*CA channel blocker
*Stop/ prevent preterm labor & treat HTN
*PO
Oxytocin (Pitocin)
*Stimulates smooth muscle that stimulates contractions
*IV (adjust rate with labor assessment (up to 500 ml/hr)
Methylerglovine (Methergine)
*Ergot alkaloid – stimulate smoothmuscle to producecontractions.
*PO- 0.2 mg, IM 0.2 mg, IV should only be used in life threatening situations.
*Contraindication: HTN
Carboprost Tromethamine (Hemabate)
*Prostaglandin- stimulatesmoothmuscle
*IM 0.25mg (do not exceed 2mg).
*Indication uterineatony
*Contraindication: asthma/chronic pulmonary disease (vasospasm).
Antenatal Testing-Ultrasound
Abdominal and Transvaginal
*Transvaginal (detailed/ accurate)-first trimester; for obese or visual obstruction of uterus also
*Abdominal (later in pregnancy)-full bladder-elevates the uterus
*: fetus appropriate gestational age size, viability, position and functional capabilities., viability
Antenatal Testing-US-Umbilical Artery Doppler flow studies (noninvasive)
*Purpose- assess placental perfusion (lifeline), rate/ volume of blood flow
*dx. for: IUGR, poor placental perfusion, high-risk (HTN, DM, Multiples, PTL)
*explain, address ?’s, comfort, schedule follow-up
Antenatal Chorionic Villi Sampling (CVS)-biochemical testing
*Aspiration of a small amount of placental tissue for chromosomal, metabolic,or DNA testing (10-13 weeks-early)
*transvaginal with US guidance (speculum)
*risk-fetal loss, assess fetal/ maternal well-being w/ doppler (2x every 30 minutes) after procedure
Antenatal- Amniocentesis- biochemical testing
*Needle aspiration through abdominal wall into the uterine cavity to obtain amniotic fluid US guided.
*Genetic testing (16-18 weeks)/ genetic disorders, NTD, infections, gender ID
*Risks- trauma to fetus/ placenta= bleeding, preterm labor, maternal infection, miscarriage, Rh sensitization (administer Rhogam after if needed)
*Assess FHR, educate on warning signs to return, no lifting for 2 days
Antenatal Testing-Percutaneous Umbilical Blood Sampling (PUBS)- biochemical
*sample of fetal blood from umbilical vein
*test formetabolic and hematological disorders, fetal infectionand fetal karyotyping
*US guided, done if there’s a anomaly detection at 18 weeks
*risks similar to amniocentesis
*Terbutaline ready for UC to relax uterus
Antenatal- Maternal Serum Alpha-Fetoprotein (MSAFP) Screening
*Blood test for AFP - a glycoprotein produced by fetal liver, GI tract and yolk sac in early gestation.
*Performed at 16-18 weeks
*Increased AFP= neural tube defects
*Decreased AFP= trisomy 21 (Downs)
Antenatal Testing- Quad marker screening-biochemical
*Maternal blood screening for AFP (alpha fetoprotein), hCG (human chorionic gonadotropin), Estriol (estrogen), Inhibin-A (protein)
*Performed at 16-18 weeks for NTDs and trisomies (Downs/ NTD)
Daily Fetal Movement Count (Kick Count)
*Maternal record of fetal movement
*Performed after 28 weeks
*normal 10X in 2 hours
*any movement counts, keep hands on belly, stay still, quiet environment
Antenatal Testing- Nonstress Test (NST)
*External Monitoring (fetal well-being)
*performed for unsuccessful kick count and high-risk pregnancies (disease/ trauma)
*Done for 20 minutes (to 40)
*Reactive (reassuring); 15 beat X 15 seconds (>32 weeks) and10 beats X 10 seconds (<32 weeks)
*Nonreactive-insufficient accels. in 40 minutes, follow w/ BPP or US
Antenatal Testing- Contraction Stress Test- CST
*Similar to NST, but w/ contractions
*assess the ability of thefull-term fetus to maintain normal FHR inresponse tolabor
*Monitor FHR/ activity for 20 minutes, no UCs (nipple stimulation/ Oxytocin IV)
*Negative CST (good=no decels.)
*Positive CST (bad=late decels w/ 50% UCs)
Biophysical Profile (BPP)-points system
*US measurement of fetal status w/ an NST.
*Perform NST, then 30 min. of US.
*US for five indicators; FHR, breathing movements, fetal movements, fetal tone, amniotic fluid
*Reassuring (8/10), Equivocal (6/10), Nonreassuring (4/10), certain asphyxia (2/10)
The onset of labor
*True labor-regular contraction that increase in intensity which cause cervical dilation and effacement, if this does not occur= false labor
*ROM/ SROM/ AROM (provider)- no more cushion; date/ time-18+ prolonged ROM=risk for infection (chorioamnionitis), amount, color, odor, FHR/ response.
*Bloody should
First Stage of Labor
*latent (0-5 cm), active (6-10 cm)
*Monitor V/S, FHR, UCs, SVE, Fetal position/ descent
-latent; effaced, mild/ short UCs (q 5-30 min at 30-45 sec.), mild discomfort, cramps
-Active; effaced 80%+, UCs q 3-5 mins at 40-90 seconds. Monitor FHR (15-30 min, pit?), V/S Q 2 hrs., 1 hr. if ROM, SVE, comfort (pain, ice chips)
Second Stage (push!)
*starts w/ complete dilation-delivery of baby
*Latent (laboring down)-not pushing yet, active-pushing
*UCs Q 2-3 minutes (no more than 5 Q 10 minutes)
Third Stage of Labor
*Signs placenta is imminent; uterus rise (ball shape), umbilical cord lengthen, gush of blood.
*5-30 minutes after baby is delivered
*Administer uterotonics (oxytocin), uterine massage to help w/ delivery
Fourth Stage of Labor (beginning of postpartum period)
*Delivery-4 hours
*Stabilize maternal vitals, homeostasis
*skin-to-skin, uninterrupted first hour (golden)
*repair lacerations/ episiotomy, placenta intact?
Labor/ Delivery Discomfort Management- pain
*Nonpharmacological; relaxation, breathing techniques, muscle massage, light effleurage, is this helpful-touch or no go?, counterpressure (open hand sacral pressure), in water, warm/ cold packs, relaxation distractions, acupuncture/ acupressure, positioning (for pain/ cardinal movements), aromatherapy, support
*Pharmacological; IV meds (can cause resp. depression for both fetus/ maternal), anesthesia; local/ regional (During 2nd stage in the ischial spine, epidural (1st/ 2nd stage, most common, SE, urinary retention (catheter), hypotension-IVF bolus before or during, ephedrine), bleeding risks, consent, spinal block (cesarean), general (emergent, cesarean w/ no other options)
Fetal Monitoring External
*External; Leopold’s maneuver first, UC transducer (fetal head) for FHR assessment for well-being, toco on fundus (pressure change for contraction, not strength- mild, moderate, strong, measured w/ hand)
Fetal monitoring- -requires ROM
*FSE (fetal scalp electrode); presenting part- head, accurate electrical activity for FHR monitoring
*IUPC (intrauterine pressure catheter); contraction occurrence/ intensity/ resting tone, amnioinfusion, mm Hg
FHR influences
*utero-placental unit-main transfer of O2/ CO2, need adequate blood flow, sufficient placenta area, free flowing umbilical cord
*fetal ANS; parasympathetic < HR-vagal stimulation, sympathetic > HR
* baroreceptors-stress receptors (heart), detects pressure changes
*CNS; immature causing variation in baseline
*Chemoreceptors, changes in O2, CO2, and pH levels
*hormonal regulation
FHR pattern interpretation
1) FHR baseline
2) Variability
3) Accelerations
4) Decelerations
Variable Decelerations
Abrupt-< 30 seconds from baseline to nadir. Change maternal position, then NRB 10L O2, stop oxytocin, possible amnioinfusion
Accelerations
*Abrupt increase in FHR baseline, good!
*> 32 weeks 15 X15, < 32 weeks 10 X 10
Early decelerations
*Gradual decrease, nadir and peak contraction
*caused by fetal head compression
*no intervention, possible SVE-imminent delivery status
Late decelerations
*gradual/ symmetrical decrease of FHR associated w/ UCs
*Due to fetal intolerance of labor, nadir at lowest point after peak of contraction
*Caused by placental insufficiency
*Change maternal position, stop oxytocin, assess hydration (IV bolus), O2 10 L/ min, Notify MD
Category 1
Must include, 110-160 bpm, moderate variability, no late or variable decelerations can be present!
Category III-abnormal
*Absent variability must be present along with either:
-bradycardia, recurrent late or variable decelerations
*Sinusoidal pattern
Intrauterine Resucitation
1) change maternal position
2) IVF bolus (500 mL LR)
3) Correct Hypotension
4) O2 10 l/ min NRB
5) Uterine Activity reduction abnormalities, decrease as delivery is imminent
6) stop oxytocin/ remove medications if compromising fetus, if needed to slow contraction give terbutaline (Brethine)-consider amnioinfusion
VEAL-CHOP-MINE
*V- variable>C-cord Compression>M-move/ reposition
*E-early, H-head compression, I-Identify labor progress
*A-accelerations, O-O2= OK, N-no action needed
*L-late, P-placental insufficiency, E- Execute actions immediately
Leopold Maneuver
1) palpate fundus, determine fetal presentation
2) Gently palpate the Abd. to determine location of fetal back.
3) place one hand above symphysis, determine engagement in birth canal
4) palpate down sides of uterus to determine whether fetus is facing L or R
Postpartum period (delivery-6 weeks)-Physiological Changes
*Reproductive System
-uterus, cervix, vagina, perinium
-increased risk for hemorrhage/ infection, dramatic changes following birth
BUBBLE Assessment
BreastUterusBowelsBladder Lochia*Episiotomy/Laceration
Postpartum Breast Assessment
*Decreased estrogen/ progesterone w/ increase in prolactin= milk production
*First Milk=Colostrum, liquid gold
*PP day 3 (24-48 hours), primary milk
*Subsequent engorgement-express milk!
*Mastitis; due to cracks. poor latch/ subsequent engorgement.
-Do not stop breastfeeding, urgent care/ antibiotics needed, painful
Postpartum Uterus
*Involution-after placenta delivery, 6-8 weeks, contractions/ cell reduction return uterus to prepregnant size
*Breastfeeding/ Multiparous (afterpains)
*provide fundal checks, massage, oxytocin?, pain management
*after birth-between umbilicus/ symphysis pubis, 12 hours= level w/ umbilicus, 24 hours= 1cm below, descends 1 cm for 14 days
*void frequently
Risks for boggy uterus
*not contracted= hemorrhage
*risks; macrosomic baby, multiples, precipitous delivery, multips
*support lower uterus w/ one hand (above pubis symphysis), palpate fundus at expected position w/ other hand
Lochia
*RBCs, sloughed tissue, epithelial cells, and bacteria
*Assess stage (rubra-red, serosa-pink brown, alba-clear/ whitish), amount, odor, clots at same time as uterus
Episiotomy/ Laceration
*vaginal/ perineum changes= edema, bruising, tears, stretching
*1st degree (2 things); vaginal mucosa-perineal skin
*2nd degree; now to fascia of perineal body
*3rd degree; now to rectal sphincter
*4th degree; now to rectal mucosa and lumen
-infections are a primary concern, give stool softener
Assessing REEDA for episiotomy/ laceration (vaginal/ cesarean)
Redness, edema, ecchymosis, discharge, approximation
*Assess on side, look for hemorrhoids, lochia, provide comfort, use warm water front to back (hygiene)
PP-Cardiovascular System
*from plumping blood to placenta to maternal system again
*EBL- Approximately 500 mL (vaginal), C-section- 1,000 mL
NORMAL:
-Elevated Blood flow, returns w/in 10 days
-< vascular resistance in pelvis causes orthostatic hypotension
- postpartum chills from hormonal shift/ vascular instability
PP cardio assessment
*Vitals q15X4, q30X2, q4hours
*CBC if ordered, HGB/ HCT will drop 3-4 days, WBC’s > 20-30,000, temperature (chills), bradycardia (6-10 days PP)
*monitor for DVT, hydrate, assist
Lower Extremities-DVT
*> circulating clotting factors= > for thromboembolism PP
*Clotting factors < w/in 2-weeks PP
*Life-threatening possibility- pulmonary embolism
*Calve/ groin for unilateral tenderness, edema, warmth, compare pulses
*No crossed legs, compression socks, frequent ambulation
PP Respiratory System
*Physiological Changes-diaphragm returns to normal
*RR 16-24 Ol2 sat >95%
*Check breath sounds-pulmonary edema
-causes oxytocin, IV fluids, Magnesium Sulfate, terbutaline, multiple births, infections, preeclampsia, bed rest
PP Immune System
*Physio Change: Increased temperature (1st 24 hrs.) from muscular exertions/ exhaustions/ dehydration/ hormonal changes. Not > than 100.4 F following 24-hr period
-Non-Immune Rubella=give MMR-no conception (28 days)
-T-dap, Influenza, Varicella, and Hep B.
-Isoimmunization for Rh negative (mom), Rh positive (baby), 1st dose at 28-weeks, 2nd dose w/in 72 hours PP
-relax, drink water, recheck w/in water-64 ounces (8 glasses)
PP Endocrine System
*Estrogen, Prolactin, Progesterone decrease
-nonlactating-, prolactin 1st 3 weeks decreases w/ ovulation 7-9 wks., menses by 12 weeks
-lactating-elevated prolactin stays (suppressing menses), ovulation 17 wks. PP
-Normal Diaphoresis from decreased estrogen levels (check temp.)
-Edu.-birth contro-breastfeeding not birth control
PP muscular/ nervous system
*Normal= reduced muscle tone, soreness, fatigue
*ambulation ability, muscle separation, soreness, fatigue
*give ice packs, heat, warm shower
PP GI system
*Decreases GI muscle tone/ motility, returns by 2nd wk.
*Progesterone=constipation
*no enemas for 3rd/ 4th lacerations
*drink H2O/ consume fiber
PP-Bowel
*normal; constipation
*give stool softeners, side-lying, sitz baths, increase fluids (10 glasses), fiber, walking, active
PP-Bladder
*Urinary complication risks due to pelvic muscle function
-2-4 hours PP take to restroom, amount/ color/ frequency/ burning>, if < 150 ml each time bladder scan, urinary retention= straight cath.
-diuresis (< estrogen) w/in 24 hours PP
*voiding allows uterus to contract < bleeding
Tdap PP important b/c…
*pertussis prevention (whooping cough
Transition to parenthood!
*fatigue, financial stress, loss of self, partner strain, life-balance
Maternal Phases (Rubin’s phase)
1) taking-in (24-48 PP); personal comfort/ physical recovery, dependent, talk about birth, < decision skills
2) taking-hold (can last weeks); become independent, infant focused, learn ready (babies cues/ needs), embrace role, insecure/ fatigue, baby blues
3) letting-go; full embrace of new role, fluid w/ taking hold phase, grieve previous roles, regain independence *back to work/ school
Paternal Phase
*reflect on fathers, imagine parenting an older child, shaped by culture, beliefs/ expectations evolve during pregnancy, weight of stress
*education can enhance confidence/ skills, partners can influence fatherly role
Bonding-Attachment
*bonding> unidirectional (parent to baby)
*attachment> bidirectional> both ways
*engrossment> intense preoccupation w/ newborn
Baby Blues-1st few weeks PP
*normal PP depression; hormonal changes/ fatigue/ stress
*S/S anger/ agitation/ mood swings/ weeping/ irregular sleep-eating
*Explain PP baby blues, rest, support, contact provider if longer than 2 weeks
*can still maintain self
Postpartum Depression
*in addition to baby blue S/S;
Extreme mood swings, weight gain/ loss, feelings of inadequacy, low sex drive, fear for the baby’s well being
Breastfeeding
*drugs, TB, HIV, active HSV on nipple, infant galactosemic
*Stages of human Milk; colostrum 2-3 days (high protein/ fat/ < carb), 3-10 days transition milk, mature milk 20 solid/ 80 water ( foremilk-start of feed, higher in water, stored between feeds, hind milk (more fat-end feed)
*prolactin= milk production
*oxytocin (let-down reflex)
EDPS (Edinburgh, screening not diagnostic)-max score 30
*score > 10 possible depression
*score> 13 suffering from depressive illness w/ varying severity
*follow-up, provide support, for not leave alone if SI (item 10)
Medications After Birth for Newborn
*Erythromycin- chlamydial/ gonococcal prevention, inhibits folic acid synthesis, 1/4 inch under each lower eyelid
*Vitamin K-for hepatic synthesis, IM 0.5-1 mg at 1 hour of birth
*Hep B vaccine
*HBlg-Hep B exposure
neonatal period
*birth to 28 DOL
*maintain body heat, maintain respiratory function, decrease risk of infection
Newborn Respiratory
*first breath/ clamping of umbilical cord
*Stimuli for breathing; mechanical (squeeze through birth canal clearing lung fluid/ expanding lungs), chemical (mild hypoxia/ surfactant), sensory (drying, light, temp.)
*5-15 min at 90% SpO2
Newborn Thermoregulatory System
*Important, response to cold; increase metabolic weight/ oxygen consumption, restless, crying, peripheral vascular constriction, metabolism of BAT (non-shivering thermogenesis)
*issues-higher body-surface area, etc.
Types of Heat Loss
*Evaporation-keep dry/ warm, moisture from skin/ lungs
*Convection-keep ambient temp warmer, body heat to cold air
*Conduction: direct contact heat loss, keep surfaces warm
*Radiation; body heat to cooler objects nearby-keep area warm
Cold Stress
*Cold can lead to respiratory distress and hypoglycemia. Hypoglycemia and Cold Stress are interrelated.
*Risk Factors-prematurity, SGA, hypoglycemia, sepsis, prolonged resuscitation, neuro/ cardio issues
*monitor temp, RR, HR q 5 minutes while rewarming
Normal glucose: 40-60 mg/ dL, < 30mg/ dL critical
Newborn Metabolic System
*fat/glycogen storage in third trimester-energy requirements
*Risk Factors for hypoglycemia: GDM, SGA/ LGA, pre-term, hypothermia, infection, resp. distress, birth trauma
*S/S: jitteriness, hypotonia, irritability, apnea, lethargy, temp. instability, poor feeding
*early feeds, oral dexterous gel then IV dextrose, warm environ.
Newborn Hepatic System (liver)
*limited glucose stores (early feeds), vit K deficient (give 1st hour)
*Indirect-produced by RBC breakdown
*direct-conjugated from liver enzymes
*Hyperbilirubinemia- high unconjugated levels, physiological jaundice (after 24 hours), pathological jaundice-before 24 hours-dangerous (conjugated-investigate or unconjugated)
Newborn GI System-Stool
*1st 24 (2-10 ml), day 4 30-60 ml/ feed
*24-28 meconium, transitional day 3, breastfed-demi formed/ seedy, formula fed-formed/ brown/ creamy, diarrhea- loose/ green
Newborn Renal System
*5-10 % weight loss 1st week
*Immature can lead to dehydration, electrolyte disorder, over-hydrate, monitor I/O chart
Newborn Immune System-passive immunity
*IgG maternal primary antibodies cross placenta, to fetus via passive immunity. Protects from bacterial and viral infections (Rubella, Tetanus, and Diphtheria).
*IgA maternal antibodies do NOT cross placenta and are found in breastmilk.
Nursing Care Neonate-1st 4
*dry, heat lamp, RR support, APGAR, V/S 30 min/ hour, then Q hour, ID, assessment-first 2 hours, administer Erythromycin/ vitamin K
Gestational Age Assessment
*New Ballard Score (NBS):
-preterm, term, post-term, physical maturity
APGAR
A- appearance (color)
P-pulse (heart rate)
G-grimace (reflex irritability)- grimace (1), vigorous cry/ cough/ sneeze (2)
A-activity (muscle tone)-some flexion (1), active motion (2)
R-respirations (cry)-slow/ irregular-1, good cry (2)
Newborn Measurements
RR=30-60, B/P: 60-80/ 40-50, T: 36.5-37.5, weight= 2,500-4,000 g, L=45-55 cm, OFC=32-36, CC=30-33, after first 10 minutes SpO2 >90%
Newborn Chest and Lungs
*Barrel-shaped/ symmetrical, lungs clear/ equal after transition, first few hours scattered crackles
*Anormal-retractions, crackling, wheezing, grunting, etc.
GI and GU
*soft/ round Abd, symmetric/ rise fall w/ RR (belly breather), bowel sounds (absent at birth, hypo first few days)
*pass stool, 1st day-meconium
*grey/blue umbilical cord-Warton jelly-after day dry/ dark falls off 10-14 days
*red/ orange urine w/ crystal-normal
Newborn Musculoskeletal
*polydactyl-more than 10 digits
*Syndactyl-webbed digits
*normal straight spine; abn. C-shaped spine-no dimples, full ROM, no clicking joints, equal gluteal folds (congenital hip dislocation if abnormal)
Galant reflex
*stroking of infants back near spinal cord, baby curves to stroked side and looks like fencer
*primitive reflexes-neuro assessment, disappears over times w/ neuro development
Neonate-4hrs to discharge
*care teachings, complete assessment once a day, bath- after 24 hours, Hep B vaccine, PKU lab draw
Newborn Skincare
*Change diapers q1-3 hours, apply barrier products, educate on proper hygiene, sponge baths until cord falls off
Newborn/ Diagnostic Test
*State/ national requirement: PKU, metabolic/ genetic disorders
*Critical congenital heart disease (CCHD)-pulse on r. hand and either foot-both O2 sats are above 95%, w/out difference of 3%
*Newborn hearing screening:
-OAE- otoacoustic emissions-brain activity w/ auditory stimulation
-Auditory brainstem response (ABR)- soundwaves through ears pick up bounce back from inner ear-high fail rate-clogged ears
Newborn WBC count
9,000-30,000
Plastibell, Gomco, Mogen
*Mogen and Gomco clamp-Vaseline on diaper, Plastibell-not
Newborn Education
*Elimination, follow-up 2 weeks, jaundice/ floppy/ void/ stool irregularity bring baby in, abusive head trauma, shaken baby syndrome, safety
Warning Signs-Newborn-Call the Provider
*T. >37.5
*change/ appetite loss/ refuse eating
*signs resp. distress
*sunken/ bulging fontanels
*watery/ green diarrhea and emesis
*bleeding-cord/ circumcision (foul odor)
*decreased wet diapers
*skin rash
*lethargic/ does not wake up for feedings, weak/ no cry
Successful Breastfeeding
-good latch
-breast soft
-break latch with clean finger to corner of mouth
8 wet diapers/ several stools
-back to birthweight in 2-weaks
-tugging felt
-pain < 10 seconds
-different positions
-swallowing/ spontaneous release/ well fed/ relaxed
-no nipple tissue breakdown
-caloric intake 450-500 more
-if feeding started-not finished discard after 2 hours
When should bottle fed formula be discarded after making
*2 days, taking in more air (tip filled), burp in middle and end of feeding
Preterm Labor
*viable at 25 weeks
*preterm labor=20-36.6 weeks
*infection-biggest factor,
*3 most common RF= Prior PTB-most consistent RF, multiple gestations, Uterine/ Cervical abnormalities
Medical Management-preterm labor- Tocolytics-Uterine Relaxants
“Its Not My Time”
I-Indomethacin- NSAID-cause early closure of ductus arteriosus, assess contractions
N-Nifedipine-Calcium Channel Blocker, Asses contractions, B/P-not indication its working
M-Magnesium Sulfate
T-Terbutaline (Adrenergic Agonist)-Assess HR/ Hear palpations
*up to 48 hours, to deliver antenatal steroids, not for women without cervical change or less than 2 cm
Medical Management- preterm labor- Progesterone
*therapy w/ hx. of PTB
Cerclage-Preterm Birth medical management
*placement before 24 weeks gestation for shortened cervical length
Preterm labor Management-Magnesium Sulfate
*neuroprophylaxis to prevent brain hemorrhage in fetus before 32 weeks gestation
*used for fetal neuro protection
*q 1 hour V/S/ DTR assessment, lung sounds, 4-8 therapeutic range (test), <12 RR or < 95% stop infusion
*SE: weak, foggy, flushed, warm, uncomfortable, maternal/ fetal respiratory depression
*Calcium gluconate at bedside
Preterm Labor Management- Corticosteroids
*given from 24-34 weeks, delivery w/in 7 days, fetal lung maturation
*bethamethasone
PROM and PPROM
*diagnostic= ferning, then amniotic fluid, swab/ microscope
*PROM=before onset of labor > than 18-24 hours increased risk for infection
*PPROM= before 37 weeks also, related to infection or S/P procedures
*Assess FHR/ AFI/ NST, V/s for infection
*fetus at risk for hypoxia from cord compression, sepsis
*Give ABX (ampicillin/ erythromycin), Corticosteroids, Mag Sulfate
Chorioamnionitis/ Intraamniotic Infection (IAI)
*Inflammation of fetal membranes (amnion/ chorion) by bacterial infection
*Induce or progress labor w/ uncompromised fetus or need C-section
*Give Ampicillin 2 g IV for 6 hours and Gentamicin 5 mg/kg IV once daily
Incompetent Cervix
*cervical dilation, w/ no signs of labor after 1st trimester w/ expulsion before 24 weeks
*Inability of uterine cervix to retain a pregnancy in absence of S/S of UCs in 2nd-3rd trimester
*S/S: backache, cramping, spotting, painless cervical dilation, short/cervical funneling >50% before 25 weeks w/ transvaginal US
*Cerclage, remove if signs for labor/ infection/ vaginal bleeding occur or 36-37 weeks
Multiple Gestations
*Monoxygotic-1 egg-1 sperm
*Dizygotic-2 eggs-2 sperm, always dichorionic/ diamniotic
*Mono/ Mono twins high-risk infant mortality
*At risk for Preterm labor, abnormal presentation, cord prolapse, abruption, and PPH
Hemorrhage Medications
*Pit, Methergine, Hemabate/ Cytotec
Hyperemesis Gravidarum
*uncontrolled vomiting requiring hospitalization
*caused by increase in hCG, progesterone, estrogen peaking at 9 week-subsides by 20 weeks
*can cause ketonuria, etc.
*IV hydration, hospitalization, bedrest, B6 medication, histamine blockers, daily weights (>5% weight loss), labs for electrolyte imbalances
Pregestational Diabetes
*Risks for spontaneous abortion and oligohydramnios in women
*Risks to newborn=congenital defects, macrosomia due to hyperinsulinemia, hypoglycemia, stillbirth if poorly controlled (especially after 36 weeks)
*provide extensive education and arrange antenatal testing (NST, BPP)
Gestation Diabetes
*develops in 2nd or 3rd trimester
*maternal risks= hypoglycemia/ DKA, pre-eclampsia, C/S
*Risks for Fetus/ Newborn; macrosomia, IUGR, hypoglycemia, shoulder dystocia, still birth, Respiratory distress
*mostly asymptomatic
*GTT, urine analysis, S/S of hyperglycemiaw
Glucose Tolerance Test (GTT)
*Routine for all pregnant women
1) no fasting/ nothing different, baseline glucose or post glucose elevated-130 (drink 50-grams of glucose in 1 hour), step 2
2) Measure baseline fasting venous plasma or serum glucose, give 100-grams oral glucose, measure at 1/2/3 hours after admin. Positive test if glucose elevated at two or more time points
Chronic HTN
*Before Conception, < 20 weeks gestation
*>140/90
Gestational HTN
*at least 2 elevated B/’s four hours apart
*After 20 weeks, elevated B/P 140/90
Preeclampsia
*After 20 weeks, >140/90 w/ proteinuria
*<20 or >35, mulitple babies, lupus, DM or hx of.
*Treatment: dim lights, < stimuli, < anxiety, lateral pos., Mag Sulfate 4 gm over 20 minutes (6gm neuro protection), then to 2 g for maintenance to prevent seizures, 1 gm if out of therapeutic range=DTRs/ RR/ I&Os
-BP above 160-110 =
Labetalol 20mg, 40mg, 80mg,(beta blocker) IVP
Hydralazine 5-10mg IVP per MD order
Nifedipine (after control)
ASA (low dose aspirin) treatment if previous Pre-E or at high risk.
Preeclampsia w/ Severe features
*Preeclampsia, B/P> 160/ 110 or Crt>1.1 mg/ or platelet<100,000, increase in LE, epigastric pain, visual disturbances
Eclampsia
*Everything+ seizure due to cerebral edema/ vasospasm
*warning signs; Severe sudden headache, epigastric pain, N/V, Hyperreflexia w/ clonus
Superimposed/ CHTN
*CHTN with new onset of proteinuria or decreased platelets. UA +1/+2 protein. 0 admit, treatment with BP meds.
Magnesium Sulfate-Seizure prophylactic (BURP)
*BP decrease
*Urine Output decrease
*Respiratory rate decrease, <14
*Patellar reflex absent
*loading 4-6gm/100mL (15-20 minutes)
*Continuous infusion-1-2 g/ 100mL every hours
*serum Mag level draw q 4-6 hrs., therapeutic level 4-8 mEq/ L
*Mag Tox: BURP+ cardiac arrest, give calcium gluconate 1 g in D10 IVP over 5-10 minutes
HELLP
Severe form of preeclampsia associated with increased morality rates.
H – Hemolysis- 1st stage
E – Elevated-last stage
L – Liver Enzymes 2x normal values (BILI >1.1)
L – Low 2nd stage
P – Platelets <100,000
Risk for mom: placenta abruption, renal failure, death. Fetus, preterm birth/ death.
*Immediate delivery
Placenta Abnormalities
*placenta previa, painless bleeding, C/S
*placenta abruption: RF (drugs/trauma). Hemorrhage/ hysterectomy. Severe abd pain/ bleeding/ tachysystole. Stat C/S
*Placenta accreta: abnormal implantation to uterine wall, hysterectomy (must), hemorrhage, gestational delivery as placenta will not deliver intact. S/S hypotension, tachy, blood loss of 3,000-5,000 ml
Ectopic Pregnancy
*fertilized egg outside fallopian tube
*medical emergency-may need surgery (salpingostomy)
*S/S unilateral pain (Abd.) radiating to shoulder, spotting, bleeding risk
*perform transvaginal US
*administer methotrexate to dissolve, hemorrhage (blood transfusion), Rhogam (Rh neg.) if needed
Hydatidiform MoleGestational Trophoblastic Disease (GTD)
*abnormal trophoblast growing after conception, benign
*not viable
*RF: previous molar pregnancy or under 18/ older than 40
*S/S; dark vaginal bleeding, hyperemesis, pelvic pain
*D&C-no conception for a year, Routine hCG levels for at least 6 months at risk for cancer
STIs
*RF: PID, chronic hep, cervical cancer, PTM, PROM, uterine infections
*Many times no symptoms
Provide routine screening
UTI-Pyelonephritis
*most common bacterial infection during pregnancy
*Infection can cause PTL/PTB. if untreated may develop into pyelonephritis
S/S: Urine retention, ATBX Rocephin 1 gm Q 24 hours, hospitalization
Group Beta Streptococcus (GBS)
*Colonizes in female genital tract and rectum. Normal gut flora, colonizes in female genital tract and rectum (30-50% of women have +GBS).
*treat w/ ampicillin during labor-2 doses before delivery 4 hours apart
*collect vaginal/ rectal cultures. screen at 36-37 weeks gestation
Trauma
*assess for placental abruption
Substance Abuse
*Risks for: PTL, PPROM, poor weight gain/ nutritional status, placental abnormalities
*Risk for newborn: prematurity, stillbirth, low birth weight, preterm birth, physical deformities, IUGR, SIDS, neonatal w/drawal
*Screen
Elevated liver enzymes are present in?
*cholestasis and preeclampsia
a negative fetal fibronectin (fFn) predicts what
The Pt will probably not deliver in the next 2 weeks
Dystocia
*failure to progress, an abnormally long labor
Hypertonic Uterine Dysfunction
*RF-1st time moms
*S/S uncoordinated/ hyperactive uterine activity, ineffective contractions, painful
*SVE, fluids, Rest, pain meds, inform MD
Hypotonic Uterine Dysfunction
**IUPC MD order needed, insufficient contractions < 25 mm Hg
*RF: multips
*< frequency/ strength and duration, SVE, IV fluids, ambulation, admin pit, no progress 4 hours and no progress for 6 hours w/ pit»>consider C-section
MVUs for IUPC
*10 minute strip, resting tone, peak of each contraction, subtract resting tone, add together
Precipitous labor
*< 3 hours, increased pain, risk for hemorrhage
*grand multips at high risk
*S/S hypertonic UC/s, long, cat II or III
*monitor strip q 15, anticipate PPH, evaluate newborn for ecchymosis/ hypoxia, CNS suppression
Fetal dystocia
*caused by fetal size, malpresentation, multiple pregnancy, fetal anomalies
Pelvic dystocia
*contraction of 1 or more of 3 planes of pelvis:
inlet-widest part too small
mid pelvis- narrow sacrosciatic notch
outlet-anteroposterior diameter of 14 cm
*SVE and check station
Labor Interventions
*induction-artificial start of labor
*augmentation-speeds up labor
Do not induce w/
*placenta previa
*transverse fetal lie
*prolapse
*classic cesarean
*active HSV
Oxytocin Induction IV only
*goal, cervical dilation 1 cm/ hour
*once oxy starts stop use
*start/ increase slowly 1-2 q 30-60 minutes until 3-4 contraction q 10
*fail to induce after 24 hours, high doses=water intoxication, if elective has to be min of 39 weeks
Tachysystole
*more than 5 every 10, 2 minutes or longer UCs or within 1 minute (need 1 min)
*turn to side, 500 LR, 10-15 minutes not normal reduce pit by half, after not normal discontinue (stop at CAT II/ III-give O2)
BISHOP score
*>8 successful vaginal delivery
*< 6 requires cervical ripening for successful SVE
*dilation, position of cervix, effacement, station, cervical consistancy
Cervical ripening-not favorable for induction yet; mechanical, pharm, membrane sweep
*Cervical ripening is the process of physical softening and opening of the cervix in preparation for labor and birth.
*prostaglandins= no prior uterus incision due to uterine rupture
-misoprostol (cytotec)-25 mcg inside
-dinoprostone (cervidil)-10 mg in place for 12 hours
Amniotomy-AROM
*to induce// augment w/ amnihook during SVE at 2 cm or more/ multips
*Risk- infection, prolapse, bleeding from undiagnosed previa, variable decels
Augmentation
*stimulating already present contractions
*contraindications-placenta previa, cord prolapse, active infection, etc.
Trial and Labor after cesarean (TOLAC), VBAC vaginal birth after cesarean
*risks= uterine option, failure, neonate death
*do not use misoprostol
shoulder dystocia
*turtle signs, unpredictable, stop pushing, never any fundal pressure, lower HOB 45degrees, call for help, NICU, large episiotomy, McRoberts/ suprapubic pressure
Use methergine-oxytocic for absent tone in uterus
*IM 0.2 mg, indication-uterine atony, not for HTN clients
Carboprost (Hemabate)-prostaglandin F2a analog
*IM 0.25 mg no more than 2 mg
Indication-uterine atony, not for pt w/ asthma
Umbilical Prolapse
*below/ in front of presenting part, c-section is preferred
Uterine Rupture
*complete tear of uterine muscles, high risk vaginal after cesarean, stabilize/ provide emergency cesarean
