Maternity Flashcards
Gravida
A person that is pregnant
Gravidity
A pregnancy
Multigravida
A person who has had 2 or more pregnancies
Multipara (multip)
A person that completed 2 or more pregnancies to 20+ weeks gestation
Parity
Number of pregnancies in which fetus(es) have reached 20 week gestation.
Not affected if fetus is alive or stillborn.
Primigravida
A person who is pregnant for the first time
Primipara (primip)
A person who has completed one pregnancy in which the fetus(es) have reached 20 weeks gestation
Viability
Capacity to live outside the uterus. Typically 22 to 25 weeks gestation.
Term
A pregnancy from the beginning of 37 weeks to 40 weeks and 6 days
Preterm
From 20 weeks to 36 weeks and 6 days
Early term
A pregnancy between 37 and 38 weeks and 6 days
Full term
A pregnancy from 39 weeks to 40 weeks and 6 days
Late term
41st week of pregnancy
Post term
Pregnancy after 42 weeks
Abortion
Can be spontaneous or therapeutic.
Loss of pregnancy typically before 20 weeks.
Living
Number of living children
Puerperium
6 week period after childbirth in which mothers reporductive organs return to pre-pregnancy state (as close as it will get)
What are the 6 periods of Perinatal Continuum of Care?
1. Preconception ANTEPARTUM 2. 1st trimester: conception to 12 weeks 3. 2nd trimester: 13 weeks to 26 weeks 4. 3rd trimester: 27 weeks to delivery 5. Intrapartum: labour and birth 6. Postpartum (or 4th trimester): 6 to 8 week period that begins an hour following the birth of the fetus and expulsion of the placenta. (High risk time for health changes)
What care should a person have during the preconception period of the Perinatal Continuum of Care?
Before a person gets pregnant, ideally they would have a healthy lifestyle, and mindset before hand
And be immunized
What is the typical length of stay (LOS) for vaginal and C Section?
Vaginal- 24 hrs
CS- 48 hrs
As long as clients meet criteria.
Factors that influence psychosocial postpartum adaptations?
- pregnancy and birth experiences (some need to share story, empathetic listen)
- physical recovery
- role attainment
- bonding and attachment behaviours
- newborn and infant characteristics
- fatigue: implication for postpartum depression
- ability to meet needs
- emotional responses
- socioeconomics
- family dynamics
- social support
- cultural considerations
These can preexist and intensify during pregnancy. Difficult for attention to shift from pregnant person to baby for some.
How does a nurse assess bonding and attachment behaviours?
Assessed (and charted) by watching interactions
- making eye contact
- holding baby
- responding when baby cries
- they way they speak about their baby
- calling baby by name if they have one
Phases of Maternal Postpartum Adjustment
Rubin,1961
- TAKING IN (DEPENDENT) first 24 hrs
- Focus: self and meeting your own basic needs
- Exited and talkative, shows wonderment
- Desire to review birth experience
- Reliance on others to meet needs (comfort, closeness, rest, nourishment)
- May seem passive and not taking active role - TAKING HOLD (DEPENDENT-INTERDEPENDENT) lasts 10 days to several weeks
- Focus: care of the baby and competent mothering
- Desire to take charge, may still not feel confident
- Readiness to learn. Optimal time for teaching
- Handling of physical discomforts, emotional changes
- Nurturing and acceptance by other is still important
- Postpartum blues possible
- Partner may feel ignored due to maternal preoccupation with baby - LETTING GO (INTERDEPENDENT)
- Focus: forward movement of the family as a unit
- Reassertion of relationship with partner
- Reassumption of sexual activity
- Resolution of individual roles.
Stages of becoming a mother
Mercer, 2004
- Committment, attachment to unborn baby. Preparation for birth and motherhood during pregnancy
- Acquaintance/attachment of the infant. Learning to care for the infant. And physical restoration during the first 2 to 6 weeks following birth
- Moving towards a new normal
- Achievement of a maternal identify through redefining self to incorporate motherhood (around 4 months)
When does parental development or role attainment start?
Pregnancy. Accepting you are pregnant is the first step.
Cultural considerations and influences in maternity?
Beliefs and values differ. Cultures often more visible during ‘rights of passage’
- health, self care and newborn care practices
- interaction with healthcare providers
- family dynamics
- newborn and infant feeding practices
- lying in periods to take care of self, while others care for baby
Ask your client what pregnancy, birthing and feeding practices mean to them and provide client centered care.
Parental development tasks for fathers
- New expectations and priorities
- Strike a balance between work, own needs, partners and baby’s needs
- redefining role
- reaping rewards: often when baby can interact with dad
Parental development tasks: LGBTQ+
Similar challenges to mother and father
- become attached during pregnancy to baby
- new priorities and new normal
- striking a balance with work, partner, self and baby
- redefining role as parent
Added challenges:
- lack of family acceptance
- public or provider ignorance
- parental care is heteronormative, which results in unfavourable health care outcomes. People need to feel safe when accessing health care.
Learning needs:
Common needs vs individualized needs
Nursing teaching priorities can differ from clients learning priorities. So find out what’s important to them to know before going home. Assess readiness to learn.
Common needs: often discharge classes.
- information
- shared experiences
- car safety, sleep safety
- psychological support
- social and community support
Individualized needs:
- things important to your client. Nurse at bedside can provide.
Community resources examples
Assess a client’s need for social support. Needs change overtime.
Community health centres
Online resources
Healthy baby healthy child (screening tool)
Describe ways a nurse may facilitate transition home for client?
- Provide common need and individualized need information
- Support mom physically and psychologically
- Advocate for mom and baby apart and together
- Community program awareness
- Pay attention to baby and mom’s needs
- Assess, monitor and support adaptations: physical, social and emotional.
- Provide non judgmental, inclusive care to all parents.
Where does childbearing, healthcare and teaching predominantly take place?
In the community.
Postpartum Assessment
BUBBLL-EE
breasts Uterine fundus Bowels Bladder Lochia Legs Episiotomy/laceration/incision Emotional status ... And vital signs!!
How does breastfeeding decrease risk of PPH
Breastfeeding immediately after birth and early postpartum stimulates release of oxytocin which decreases blood loss and risk of PPH
How do you assess breasts
- inspect for size, shape, symmetry
- palpate for degree of fullness (soft, filling, full, engorged), tenderness, lumps (blocked milk duct), pain
- inspect nipples for shape (erect, flat, inverted), redness, bruising, blisters, discomfort, fissures
How to assess uterine fundus?
- Palpate for consistency: boggy or firm
- palpate for location: midline/deviated to left or right
- palpate for heigh of fundal involution: in relation to umbilicus (1/U, @U or U/U, U/1)
How do you assess bladder?
- Assess amount voided, fullness after void, burning and pain while voiding
- Assess for distension (or fundus deviated): sign of bladder full
Assess bowels
Assess for last BM - common to not occur for 2 to 3 days
- if no BM, assess for abdominal discomfort and distention
- Auscultate for bowel sounds in all 4 quadrants.
How to assess lochia?
Assess colour (rubra, serosa, alba) Assess amount (scant, small, moderate, heavy) Foul odour?
How to assess legs?
Peripheral edema Venous thromboembolism (red, tender, unilateral leg pain, localized edema)
How to assess episiotomy/laceration/incision
Visually assess perineum for edema
Assess REEDA: Redness, edema, ecchymosis, discharge/discomfort, approximation.
Assess for hemorrhoids (number, size, discomfort)
How to assess emotional status
Assess coping
Assess bonding/attachment behaviours.
Puerperal phase of role attainment.
Normal vital adult ranges and expected changes in postpartum
BP, HR, RR, T
BP: 120/80.
Tends to run lower in women so check pregnancy baseline to compare. Influenced by blood loss, epidural and orthostatic hypotension
HR: 60-100 BPM
10-15 BPM increase over pregnancy baseline can be normal due to demands of labour, physical shifting of diaphragm and rotation of heart.
RR: 12 to 20 breaths/minute
May take shallow breaths more rapidly (increase to 16 to 24) but quickly returns in postpartum
T: 36.5 TO 37.5 (axillary)
Epidurals can cause a higher temp, but should come down quickly. Dehydration can cause higher temp. Watch for infection.
What is the function of the placenta?
Delivers oxygen and nutrients to fetus, removes waste and O2 from fetuses blood
Anchors fetus to uterus.
Why does the uterus have to contract to stop bleeding after placenta detaches?
The uterus consists of layers of muscle fibers with veins weaved within layers. It does not have coagulation factors like the rest of the body. So the uterus has to squeeze (contract) to restrict the blood flow.
What is the effect of oxytocin in the body post birth?
It is released by the posterior pituitary gland naturally during orgasms and birth. It contracts smooth muscle in the ducts of the breast to let milk down, and contracts the uterus which decreases PPH
How is the risk of PPH minimized?
Exogenous oxytocin is routinely administered after 2nd or 3rd stage of birth to stimulate uterine contraction.
We palpate and massage fundus to confirm its contracted or stimulate it to contract.
Having babies breastfeed immediately reduces PPH due to triggering endogenous oxytocin release
What happens to uterine contractions during first 1 to 2 hrs?
Can decrease in intensity and become uncoordinated. Why it’s important to give exogenous oxytocin.
Afterpains
Uterine contracting while returning to pre-pregnancy state brought on by oxytocin.
Who is more likely to experience after pains?
Multips experience more often than primips because it’s more difficult to fully contract
Breastfeeding and exogenous oxytocin increase after pains
Uterine involution
What is it and what is the rate?
Multip vs primip?
The process of the uterus returning to as close to pre-pregnancy state. Begins as soon as the placenta is born. Shrinks from abdominal organ to pelvic organ.
RATE: initial rise in first 12 hours, then involutes 1 to 2 cm q24hrs.
First 12 hours= just above umbilicus. Pelvic organ by 9 days to 2 weeks.
Increased under oxytocin influence.
Multip vs primip: think of uterus as elastic band. Every time it’s stretched, it involutes to a little bigger than last time.
24 hrs post birth, where do you expect the fundus?
About the same place as 20 weeks pregnancy. About 1/U
What is Subinvolution? Why may it occur?
Not involuting the way it should be. Could be due to placental fragments left behind or infection, preventing the uterus from contracting.
Often present with fever and other signs.
How do you Palpate the uterus fundus?
Two hand technique:
- stand on side of bed with pt supine. Use non dominate hand to anchor uterus at symphysis pubis and support lower segment of uterus, as you apply pressure with the dominant hand at the top of fundus.
- start high and palpate down. Feels like a round hard ball if firm
- as you assess, note how much blood is coming out of vagina. As you squeeze it may gush, which does not indicate a PPH unless it doesn’t stop.
- assess for height, consistency, and location.
During a fundal assessment, if you do not anchor the uterus, what are you risking?
Uterine inversion
What can a full bladder do to the uterus postpartum?
Make the uterus boggy and deviated to side
Describe the 3 types of lochia:
- Rubra (red): lasts 3 to 4 days and is heavy
- blood, small clots, tissue debris - Serosa (pink-brown): 22 to 27 days (some women 10 days)
- old blood, serum, leukocytes, tissue debris - Alba (yellow-white): 2 to 6 weeks (can be 4-8)
- serum, leukocytes, mucus, epithelial cells
How would you describe lochia after 2 hours of bleeding (on pad)?
Scant: 5 cm
Small: 10 cm
Moderate: 15 cm
Heavy: >15 cm
PPH vs blood gushing from breastfeeding?
Breastfeeding can cause gushes because of oxytocin. Lochia would gush, trickle, then stop. PPH would continue heavily bleeding
Clots vs placental clots
Clots are normal within the first few hours after birth, placental clots are concerning and are reportable to avoid infection or PPH
Clots are described in terms of size (in relation to coins or fruit). Anything bigger than a plumb is likely placental fragments.
How to tell the difference: pull apart or break with fingers. A placental clots cannot break.
How to determine if heavy bleeding is lochia vs non lochia blood flow?
If the uterus is firm, yet blood is consistently gushing from vagina, it is likely a laceration at the cervix or vaginal wall that was missed or cannot be seen visually.
Report to dr or midwife.
Laceration degrees
Tissue that spontaneously rips
1st degree: most superficial. Sometimes requires stitches, sometimes doesn’t
2nd degree: goes through perineal muscle
3rd degree: continues through perineal muscle and anal sphincter
4th degree: tears through pernieal muscle, anal sphincter and rectum.
3rd to 4th risks takes weeks to recover. Includes laxitivr and plenty of fluids. Greater risk for genital and urinary issues in current and older adult life.
Episiotomy
Midline vs mediolateral?
No longer standard practice. It is done to avoid laceration
happens at time of crowning or when forceps need to be used during 2nd stage of labour.
Midline runs the risk of extending into the anus, causing a 3rd to 4th degree laceration.
Mediolateral line is used to avoid further tearing.
Therapies for perineum pain
Ice therapy: first 24 hrs helps reduce swelling and provides relief (20 mins on, 20 mins off)
Peri bottle: teach to clean and dry self by patting with towel. Can dilute urine while voiding if stinging
Sitz bath: after 24 hrs, placed on toilet and client can sit in it. Warm water.
How does a maternal assessment differ for a client who had a C/S?
vital signs
BREAST- same
UTERUS FUNDUS- becareful of incision. Do while they are still numb or pain meds are in peak effect.
BLADDER: foley catheter usually in for 12 hrs post
BOWELS: more abdominal pain, encourage them to move around as soon as they can. Absent of bowel sounds can be post-op complication
LOCHIA: often slightly less, surgeon sometimes wipes uterus
LEGS: increased risk of venous clot, encourage movement
INCISION/PERNIEUM: assess sutures when dressing comes off. Assess pernieum as sometimes clients push before C/S
EMOTIONAL STATUS: Can be difficult if C/S wasn’t planned
What is the diet restrictions for C/S and vaginal birth?
Vaginal: can tolerate regular diet
C/S: also surgical patient so special considerations.
Ice chips to clear fluid to solid foods. Only once peristalsis returns to prevent bowel obstruction if there is a post op complication.
Identify 3 types of postpartum complications
- Infection
- Postpartum hemorrhage
- Perinatal mood disorders
What is postpartum hemorrhage (PPH)?
Blood loss causing hemodynamic instability. Any amount that causes the client to have symptoms (weak, dizzy)
Life threatening with little warning.
PPH Risks- 4 T’s
- Tone: uterine tone, anything that reduces tone is a risk factor
- Tissue: retained placenta fragments
- Trauma: trauma to placenta (placenta fragments separating prematurely)
- cloTting: pre existing issues or develops clotting issue bc of labour complication.
Early vs late PPH
Early PPH: Most commonly caused by uterine atony being boggy
Later PPH: up to 6 weeks postpartum until uterus is completely involuted. Usually caused by infection of placental fragments
What would you do if you were alone with a patient during a PPH
stay with patient, use call bells and begin fundal massage. If you have oxytocin, administer.
What are 3 types of perinatal mood disorders (PMD)
- Postpartum blues
- Postpartum depression (no psychosis)
- Postpartum depression (psychosis)
Postpartum blues
50 to 80%
Duration: peaks day 5, decreases by day 10
Symptoms: labile emotion, fatigue, sadness, anger, insomnia
No functional impairment.
Intervention: reassurance. Most clients will experience blues, give anticipatory guidance. These feelings are normal and expected. Assess support and community resources.
Postpartum depression (no psychosis)
10 to 15 %
Duration: weeks to 1 year
Insomnia/hypersomnia, fatigue, appetite change, worthlessness, guilt, irritability, inability to cope, crying, intense irrational fears.
Treatment: counselling, meds, peer support, CBT, psychotherapy
Postpartum depression (psychosis)
1-2 in 1000 births
Duration: 2 to 8 weeks. Usually a preexisting condition
Depression, delusion, thoughts of harm to self or baby, overactive, disorganized behaviour. Inability to care for infant
Treatment: mental health emergency, hospitalization. Baby can be slowly reintroduced under supervision once client is stable.
Postpartum depression risk
Strong
Moderate
Weak
STRONG
Prenatal depression or anxiety
Personal or family history of depression.
MODERATE
stressful life events
Lack of social support
Partner violence
LOW single parent Stress of child care Low socioeconomic status Unwanted or unplanned pregnancy
What is postpartum infection? (Puerperal infection)
Common Types?
An infection of the genital tract that occurs within 28 days after miscarriage, induced abortion, or birth.
Endometriosis
Wound infection
UTI
Mastitis
Endometriosis?
Infection of lining of the uterus. Incidents higher after C/S.
signs- fever, increased pulse, pelvic pain, uterine tenderness, foul smelling, profuse lochia
Wound infection
C/S incision or repaired laceration or episiotomy.
More common after C/S (given prophylaxis antibiotics)
Urinary tract infection (UTI)
Increased risk factors are catheterization, epidural, frequent pelvic exams, history of UTI.
Mastitis
Breast infection. Obstructs milk flow Almost always unilateral and develops well after milk has been established. If not treated can lead to breast abscess.
Localized pain, edema, redness
Infected mastitis: S. Aureus enters through nipple fissure
Non infected mastitis: blocked duct that wasn’t addressed.
Breast milk composition
Very diff for each baby depending on needs and development. Preterm would be diff than term. Changes over time to meet babies needs.
Immune factors Growth factors Protein (70% whey, 30% casein) Digestive enzymes Fats: change from feed to feed Carbohydrates Vitamins (A,B,C,D,E,K) Mineral (calcium, sodium, chlorine, copper, zinc, iron, selenium, iodine, fluoride) 87% water
Benefits of breastfeeding for infant
Easily digested and absorbed Laxative effect Transfer of antibodies and immune factors Maturation of GI tract Neurodevelopment advantage Analgesic effect Better facial, oral, speech development
Risk factors of not breastfeeding
GI infections Otitis media Atopic dermatitis Respiratory tract infections Asthma Childhood leukemia Celiac disease Ulcerative colitis Crohn's disease Atherosclerosis Hypertension High cholesterol Reduce immune protection Obesity Lower cognitive function Type 1 and 2 diabetes SIDS Necrotizing enterocolitis
Benefits of breastfeeding for client
Decreased risk of cancer, rhumatoid arthritis, type 2 DM, hypertension, CVD
Convenient and less expensive than formula
Promotes uterine involution and return to pre-pregnancy weight
Provides bonding experience
Contraindications to breastfeeding for clients
Chemotherapy Active TB or varicella HIV Human T-Lymphotrophic virus Herpies lesion on breast Substance abuse Select medication Chagas disease (parasite)
Contraindications of breastfeeding for infants
Galactosemia: rare disorder, cannot have breastmilk
Metabolic disorder: limited human milk volumes, supplement with formula
Current recommendation for breastfeeding and solid foods
Exclusive breastfeeding for first 6 months, plus vitamin D drops
Introduce complementary foods at 6 months, while continuing breastfeeding
Feed on demand when baby shows cues
Baby led: follow baby’s cues for introducing foods
Continue breastfeeding for up to 2 years and beyond.
Baby Friendly Initiative (BFHI)
Launched by WHO and UNICEF 1991
Designed to:
Protect, promote, and support breastfeeding
Remove hospital barriers to breastfeeding
Provide evidence based training to health care workers
Promote international standard
Baby Friendly designed is achieve when:
Free or low cost substitutes are not accepted
Feeding bottles and teats are not acceptable
Successful implementation of the 10 steps
10 steps of breastfeeding (baby Friendly)
- Have a written breastfeeding policy that is routinely communicated to all health care staff
- Train all health care staff in skill necessary to implement this policy
- Inform all pregnant women about the benefits and management of breastfeeding
- Help mothers initiate breastfeeding within half an hour of birth (skin to skin)
- Show mothers how to breastfeed and how to maintain lactation. Even if they are separated from infant
- Give newborn infants no food or drink other than breast milk unless medically indicated
- Practice “rooming in”: allow mothers and infants to remain together 24 hours a day
- Encourage breastfeeding on demand
- Give no pacifiers of artificial nipples to breast feeding infants
- Foster the establishment of breastfeeding support groups and refer mothers to them on discharge
Medically indicated reasons for giving infants formula
Low blood sugar
Not gaining enough weight
Medical condition requiring extra calories
Preterm may need extra protein.
Lactogenesis
Stages
The synthesis of milk
Lactogenesis I: differentiation
Lactogenesis II: activation
Lactogenesis III: maintenance
Lactogenesis I
Occurs mid pregnancy.
PROLACTIN stimulates cell differentiation so that the breasts are able to produce milk
PROGESTERONE inhibits the inset if copious milk secretion. After the placenta is delivered, the hormone decreases which tells the body to make milk
Colostrum produced in this stage.
Colostrum
Thick, clear yellowish Birth to 2-3 days Volume depends on babies needs: 2-20 mLs/feed Lower in fat and sugar than mature milk High in protein and minerals Contains IgA Easily digestible Laxative effect
Lactogenesis II: Activation:
day 2 to5 - 2 weeks
Milk coming in - transition from colostrum to mature milk. (Transitional milk)
Changes in hormones after birth of the placenta (30-40 hrs)
decrease: progesterone, estrogen, placental lactogen
Increase: oxytocin and prolactin
Feedback inhibitor of lactation (FIL): whey protein feedback mechanism
Lactogenesis III- Maintenance
Whiter, thinner than transitional milk
Mature milk= fore milk + hind milk gradient
Establishment of mature milk
Supply and demand: depend on effective removal
Fore milk and hind milk
Fore milk:
Bluish white
Low fat, high water at start of feed
Hind milk: Creamy in appearance Hugh fat and calorie, released well into feeding Satisfies hunger, promotes weight gain Stools seedy
Stimulating milk production
Suckling on the breast (stimulate nipple, areola, grasping) cause the hormones to be released in the brain
- The alveoli in the breast begin to make milk in response to PROLACTIN (ant. Pituitary)
- OXYTOCIN contracts the muscle cells around the alveoli and causes ‘let down’ which send milk down the ducts. (Post. pituitary)
Stimulating and inhibiting milk ejection reflex (MER)
STIMULATING Baby crying Thinking about baby Usual time the baby feeds Sitting in chair they use to feed baby Preparing for breastfeeding INHIBITING fear Pain Anxiety Embarrassed Breast surgery
Skin to skin benefits to baby
Thermo and cardiovascular regulation Stabilize blood sugar Reduce crying Self latching Improves exclusivity of breastfeeding Reduces cortisol
Skin to skin benefits for client
Increased oxytocin and prolactin
Improves milk volumes
Promote bonding
Feeding cues
Early and late
EARLY
rooting, lip smacking, fussing, light sleep
LATE
Crying. More difficult to breast feed
Ideal state of infant for breastfeeding
Quiet alert
Breastfeeding position
- Cross cradle
- Football hold (good for C/S)
- Cadle
- Side lying
How do you latch on
- Position fingers in C or U parallel with babies lips to support and shape breast
- Tummy to tummy
- infants nose to nipple
- stimulate rooting reflex
- when baby opens mouth wide, bring baby to breast
When breast feeding where should the nipple be in the babys mouth?
On soft palate towards back of mouth. Deep enough they can milk the breast
( Breast feed not nipple feed)
Latch assessment
- asymmetric (more aerola on bottom)
- wide open mouth
- lips visible and flanged outward
- tongue over lower gum line
- no pain or discomfort
- no indrawing or dimpling of cheek
- no clicking or smacking sounds
- hands relax during feed
Suck and swallow assessment (breastfeeding)
Chin moves in rhythmic pattern
Audible or visible swallowing
Nutritive vs non-nutiritive suckling
Pattern changes from short sucks to stimulate milk to come down (non-nutiritive) 2 sucks/sec
Nutritive long slower sucks once milk transfers/let’s down (1 suck/sec)
Frequency and duration of breastfeeding
- Minimum 8 to 12 feeds/24 hours
- minimum q3hrs for first few weeks then feed on demand
- duration: 20 to 30 mins newborn up to 45 mins
When are typical growth spurts of newborns?
How do you feed?
Growth spurts at 10 days 3 weeks 6 weeks 3 months 4 to 6 months
Cluster feed to build up supply and meet babies needs (1 to 2 hrs)
What are signs the milk is transfering: client
Softening of breast as feed progresses
Signs of milk transfer- baby
Sustained rhythmic suck-swallow patterns Gradual decrease of intensity and number of sucks as breast emptied Relaxed arms and hands Moist mouth Satisfied after feeding Audible swallowing Absence of hunger cues Weight gain Elimination pattern
Signs of MER for client
Signs milk had let down
Thirst Relaxation and drowsiness Milk leakage of opposite breast Uterine cramping Increased lochia flow
Elimination pattern infant
24 hrs: 1 wet and 1 stool (meconium) Day 2: 2 or more wet, 1 to 2 stool Day 3: 3 or more wet, 3 ore more stool Day 4: 4 or more wet, 2 or more stool Day 5 and beyond: 6 or more wet, 3 ore more stools
Infant stool changes
Meconium
Transitional (green brownish)
Yellow, soft, seedy (when hinde milk, day 5ish)
Infant weight gain
Loss less than 10% loss in 3 to 5 days
Return to birth weight by week 2
Weight gain of 4 to 8 oz per week until baby doubles birth weight
What effect could a vacuum assisted birth have on the baby?
Vacuum can make baby drowsy. Cause hematoma on head. Increase risk of jaundice.
Engorgement
Painful overfilling of breast. Milk stasis + increased blood flow caused edema which compresses milk ducts.
Firm, tender, swollen, hot, shiny, red
Latching difficulty
Commonly occurs 3 to 5 days postpartum, but can anytime they go too long without expelling milk
Difficult for infant to latch on rock hard breast.
Engorgement treatment
Adequate and frequent emptying of breast
Pain: cabbage leaves, cold therapy, massage, analgesic and anti-inflammatory.
Reverse pressure softening: pressure near areola around breast to push milk back so infant can latch.
Blocked milk duct
Painful lump on breast.
May see a white dot: bleb
If not expressed can lead to infection or abscess
Need to get the milk out: feed, hand express, pump. Use warm heat and massage.
Formula Feeding: frequency, amount, techniques and principles
6-8 feedings/24 hrs
Average intake: 10-15 mls, increase to 90-150 mls by week 2
use skin to skin, do not overfeed (watch for cues)
Side Lying Bottle Feeding: recommended, keep nipple half full and extend babys hips
What nutrients require for first 6 months
vitamins minerals sugars essential amino acids iron fortified
Formula Feeding Risks
GI Infection Asthma Allergy Otitis media Diabetes Childhood Cancer Obesity Increased risk of infection or illness from contaminated formula/supplies Errors when mixing formula Cost
Newborn Sleep-Wake States
- Crying
- Deep sleep
- Light sleep
- Drowsy
- Quiet-alert: ideal state for feeding and social interaction
- Alert
Newborn Assessment Phases:
- Immediate: at birth (do a lot S2S)
- Complete: head to toe system
3: ongoing: until discharge
Newborn: immediate assessment (at birth)
- APGAR: evaluation of adaptation to extrauterine life
- Airway maintenance (ABSs)
- body temp maintenance
- brief physical exam (vitals, weight, circumference)
- universal medication administration
- promote parent-newborn bonding
APGAR
what does it stand for?
what is the timing?
Appearance, Pulse, Grimice, Activity, Respiration
Done at: 1 and 5 minutes
(will continue if needed)
How to score APGAR
Score= 0, 1 or 2 for each category. Start at 10 and subtract.
Heart rate: absent; below 100 bpm; above 100 bpm
Respiratory effort: absent; weak/irregular/gasping; good/crying
Muscle tone: Flaccid; some flexion of arms & legs; well flexed or active movement
Reflex/Irritability: no response; grimace of weak cry; good cry
Colour: Blue all over/pale; body pink, hand and feet blue; pink all over
An APGAR score of 7 to 10 would indicate:
responding well
An APGAR score of 0 to 3 would indicate:
severe distress
Newborn Vital Signs
HR, RR, T, BP, O2
HR: 100-160 bpm (use umbilical cord for 6 sec, then apical pulse for 1 min) RR: 30-60 breaths/min T: 36.5 - 37.5 axillary BP: 60/40 to 80/50 mmHg O2: 97% +
Skin to Skin benefits immediately post C/S
physiologic stability of birth parent and baby emotional well being for parent and baby potential reduction in pain for parent improve breastfeeding outcomes improve parent-infant communication
Universal Newborn Medications
Eye Prophylaxis: Erythromycin Ointment to prevent opthalmia neonatorum (infection) (within 2 hrs)
Vitamin K Prophylaxis IM Injection: to prevent/tx hemorrhagic disease (2-6 hours after birth)
Newborn key respiratory adaptation
Establishment of respirations is most critical and immediate adjustment
- initially respirations are shallow, irregular, fine crackles may be heard
- apnea >20sec=WNL
- apnea >20sec=concerning
Newborn key cardiovascular adaptations
Fetal circulation to Neonatal Circulation
- First breath causes closures of shunts
- lung inflation & cord cutting –> pressure and resistance changes –> allows pulmonary blood flow .
The transition period (newborn)
A period of vulnerability and instability after birth for the baby
- First period of reactivity: 30 mins up to 2 hrs
- HR increases to 160-180, gradually goes down to baseline 120-160, can be irregular
- RR: 60-80, irregular
- Activity: alert state, startles, crying - Period of decreased responsiveness: 1-4 hrs
- HR: normal 120-160
- RR: rapid, shallow up to 60 breaths/min
- Activity: sleep or decrease in activity - Second period of reactivity: couple of days
- HR: Transient/ brief tachycardia
- RR: Trabsient/ brief tachypnea
- Activity: increased muscle tone, colour, mucous
What is acrocyanosis
Bluish purple colour in hands and feet from poor circulation
4 modes of heat loss
- Radiation: heat loss from body to cooler surface that is not in direct contract with the body (window)
- Convection: flow of heat from body surface to the cooler air in the room
- Evaporation: losing heat through being wet and it’s evaporating
- Conduction: loss of body heat from body surface to cooler surface via direct contact
Cold stress for newborns
Contributing factors
Larger body surface area than weight
Higher metabolic rate with limited stores. (glycogen stores used up quickly)
Cannot shiver (non-shivering thermogenesis=brown fat)
4 moder of heat loss: radiation, convection, evaporation: conduction
What is brown fat? What’s the purpose for infants
Brown fat has a richer blood supply than white fat.
Used for non-shivering thermogenesis. Can increased infants temp by 100%
Ideally infants should be dressed for the environment and not have to use up brown fat stores
Newborn complete physical assessment (head to toe system)
Done within first 24 hrs of life
Assess: vitals, cardiovascular, respiratory, food intake and waste excretion
General appearance, skin, HEENM, chest, abdomen, genitals, extremities, back, anus, reflexes.
Newborn assessment
Respiratory redflags
Tachypnea Bradypnea Indrawing, grunting, nasal flaring Unequal breath sounds Poor colour Apnea >20 sec
Newborn assessment
Cardiovascular red flags
Tachycardia Bradycardia Abnormal heart sounds Abnormal heart location Weak, absent or unequal pulses
Newborn assessment
CNS red flags
Jitters or tremors Lethargy Irritability Bulging fontanelles Hyper or hypotonic (muscle tone) Seizure
Sudden infant death syndrome SIDS
the sudden death of an infant less than 1, which remains unexplained after autopsy
Peaks at 2-4 months
What is the ABC’s of safe infant sleep?
Alone (without people or blankets)
Back to sleep
Crib (or other approved structures)
The 5+1 P the affect labour
- Passanger: fetus and placenta
- Passageway: bony pelvis and soft tissue
- Powers: contraction (involuntary) pushing (voluntary)
- Position: diff positions to give birth
- Psychological (emotional dystocia)
- People (care givers, nurse)
Psychological (5th P)
Affect on labour
Fear-Tension-Pain cycle: fear causes tension, which increases pain
Emotional dystocia: increased anxiety causes increase catecholamine secretion, causes increased muscle tone, decreased uterine contractility which amplifies pain, causing a decrease in confidence and decrease in labour progress.
Tocophonia: fear of childbirth
People (the 6th P) of factors that affect labour
Effective caregivers are respectful, supportive, available, protective, encouraging, kind, comforting, professional, present.
1:1 nursing care
Companion of choice for labour support
People (the 6th P) of factors that affect labour
Effective caregivers are respectful, supportive, available, protective, encouraging, kind, comforting, professional, present.
1:1 nursing care
Companion of choice for labour support
What factors affect pain experience
Physiological (some have more pain receptors)
Pain threshold
Psychological
Emotional: fear and sleep deprivation magnify pain
Social
Cultural
Environmental
Childbirth experience satisfaction relies on
Caregivers attitude and behaviours
Quality of caregiver client relationship
Involvement in decision making
Degree of control
What is support care in labour?
Nonmedical care that includes Comfort measures Emotional support Info and instructions Advocacy
Associated with decreased epidural use, assisted birth, length of labour, C/S and postpartum depression
Passenger: the 1st P of labour
Fetus and placenta
Vertex presentated: head first, rather than breached (bum first)
FONTANELS allow head to be molding while moving through the birth canal
Passageway: the 2nd P of labour
Explain Cervix changes from before labour to complete dilation
Bony pelvis + soft tissue
Before labour: longer in length, not open, amniotic membrane intact
Early changes: starts to dilate, become thinner, amniotic membrane intact
Complete effacement: thinning of cervix, couple cm dilated, head is applying mechanical pressure to start open
Complete dilation: 10 cm, cervix out of the way and baby’s head descends
Station and engaged
Station: presenting parts relationship to ischial spine. When palpating an imaginary line is drawn across from one ischial spine to the other. That is 0 station. (-5 to +5)
Engaged: widest diameter of head or presenting part reaches 0 station
Power: the 3rd P of labour
Involuntary: contractions
A wave pushing the fetus down, while pulling on the cervix.
Voluntary: pushing
Open and closed glottis pushing
Position: 4th P of labour
Many different types of positions (squatting, hands a knees, walking). Upright is best as it reduces pain and uses gravity to aid in birth
Why is lying on the back not recommended for those 20 weeks + gestation or labour?
The uterus applies pressure on major vessels running down the body, which can cause hypotension for the mom and fetal HR to go up and down leading to fetal distress
Overtime, fetal distress can use up glucose reserves
Prelabour vs labour? How do you know
Prelabour: irregular contractions, felt in back and all over abdomen (not at cervix), stops with walking or position change
Cervix- may be soft, no significant dilation/effacement, no blood show.
Labour: regular uterine activity, strong longer and closer together contractions. Walking increases the intensity. Felt in lower back, lower abdomen and does not stop with rest.
Cervix: softening, effacement, dilation and bloody show
What is show?
The mucous plug mixed with blood as cervix effaced. (capillaries break)
ROM
Rupture of membranes
SROM
spontaneous rupture of membrane
PROM
Premature rupture of membrane (37+ weeks)
PPROM
Preterm premature rupture of membrane (before 37 weeks)
AROM or ARM
Artificial rupture of membrane
Mucous plug
Sits in cervix, created by hormones. Creates a shield and sterile environment for fetus
How do you assess amniotic fluid (once membrane ruptures)?
COAT
COLOUR: should be clear, could be meconium stained
ODOUR: normal= raw chicken; foul smell= infection
ASSESSMENT: depends on what you see, how much fluid is there
TIME: time of rupture. The longer it takes to deliver = more chance of infection.
FETAL HEART RATE should be monitored no matter how it ruptured
TESTS: nitrazine strip tests and ferning test
Group B streptococcus (GBS): what is it? When is it tested? What if a pregnant person is positive?
What are signs of baby being infected?
A bacteria found in the vagina or rectum of about 25% of healthy people. Can be colonized or comes and goes. Not dangerous to adults, but it is to infants and there is a chance of transmission during birth.
It is tested at 35 to 37 weeks gestation by swabbing to see if there is a culture.
If positive: before rupture, 2 doses of prophylaxis antibiotics are given 4 hrs apart to mom to protect baby
Signs for baby: sepsis, respiratory distress
What are the stages of labour?
1ST STAGE: onset of uterine activity to complete cervical dilation and effacement
A. Latent phase
B. Active phase
2ND STAGE: full dilation to birth of fetus: passive and active
3RD STAGE: birth of fetus to birth of placenta
4TH STAGE: 1 to 2 hours post birth
Latent vs active phase: 1st stage of labour Dilation &effacement Duration Contraction: strength, rhythm, duration Fetal descent Show: colour & amount
DILATION &EFFACEMENT
Latent: 0-3 cm; <1cm 75%
Active: 4-10 cm; thin 75-100%
DURATION
Latent: 6 to 8 hrs
Active: 3 to 6 hrs
CONTRACTION: STRENGTH, RHYTHM, DURATION
Latent: mild-mod; irregular; q5-30 mins; 30-40 sec
Active: mod-strong; regular; q2-5 min; 40-90 sec
FETAL DESCENT
Latent: 0 to -2
Active: varies
SHOW: COLOUR & AMOUNT
Latent: brownish-pink; scant
Active: pink-blood mucous; scant-copious
Client response in latent vs active stage
Latent: alert, excited, open to communication and instruction, coping
Active: absorbed in work of labour, turned inward, cannot converse during contractions, unable to follow direction, decreased ability to cope
Pharmacological pain managment;: RNs role
Meet informational needs for informed decision making
Advocate
Initiate IV if needed
Assist anaesthesiologist
Monitor and manage side effects (adult and fetus)
Assess and monitor: min every 30 mins
- vital signs
- fetal HR
- contraction and labour progress
- response and pain level
- sensory and motor function, level of block and LOC
- return of sensory and motor function once d/c’d
2nd stage of labour
Ave duration
Full cervical dilation to birth of the fetus.
2 phases: active and passive
When epidural or spinal block happens
Primips: 50-60 mins
Multip: 20-30 mins
Epidural: what does it do, where is it inserted.
Benefits and side effects
Baths the nerve endings to block pain sensation, but not pressure sensation which is needed to push.
Puncture below the dura mater into the epidural space
Usually between L3-5.
Benefits: alert, pain free. Maintain some mobility. Control
Side effects: #1 hypotension (so IV must be given) effect is decrease FHR.
Pruritis
Nausea
Postdural puncture headache: dura mater is punctured, causing loss of CSF which causes an intense headache. Client lies flat and anesthesiology inserts clients blood into epidural space.
Spinal block.
Puncture dura mater and introduce medication into spinal space. It produces a solid block below site, client cannot wiggle toes.
2nd stage of labour. Passive vs active/descent.
Clients response
Passive: calm, passive fetal descent ‘labouring down’
During labouring down contraction pattern falls off. This is the rest phase until head is low enough to push (engaged) (don’t have to push bc they are 10 cm)
Active/descent: urge to bear down. Intense pain. ‘ring of pain’. Once the mechanical pressure of the head is pushing on the cervix they feel the urge to bear down.
RNs role in 2nd stage of labour
Assess signs of full dilation 1:1 nursing care Supportive care Assist birth attendant Ongoing assessment and monitor of client and fetus NEVER leave a patient in 2nd stage.
When should a client start pushing (labour)?
Not until 10 cm, and head is laboured down (station and engagement).
Can feel weight of head and urge to push as early as 6 cm.
Pushing too early risks: cervix severely lacerated (scar tissue doesn’t stretch so issues in subsequent pregnancies).
3rd stage of labour
Birth of fetus to placental seperation and expulsion.
Duration: few mins to 1 hr; increased length = more risk of infection
Seperation signs:
Change in uterine shape
Sudden gush of dark blood
Lengthening if umbilical cord
Clients response in 3rd stage of labour
Surge of energy despite being exhausted
Varying emotions
Some discomfort with placental seperation (some don’t feel)
3rd stage of labour: RNs role
1:1 care
q15 min monitoring up to 1 hr
Promote and facilitate bonding
Documentation
4th stage of labour
First 2 hrs after labour. Uterine tone reestablished as uterus contracts to expelling remaining content
Increase via oxytocin and breastfeeding.
Signs of pregnancy
Presumptive: changes experienced by woman
Probably: changes observed by examiner
Positive: signs related to fetal presence
Presumptive signs of pregnancy
Changes the woman notices Amenorrhea Fatigue Breast changes Nausea/vomitting
Probable signs of pregnancy
Changes the examiner notices:
+Goodell’s test: softening of cervix
+Beta hCG: first biomarker of pregnancy but can be present for other reasons
Braxton-hicks contractions: uterine toning, especially 20+ weeks.
Positive signs of pregnancy
Signs related to presence of fetus
Fetal heart tones
Visualize of fetus
Palpate fetal movement
How do you calculate EBD (estimated birth date)
Naegele’s rule: assumes 28 day cycle regularly
First day of LMP, add 7 and count forward 9 months.
Or the wheel: use date of LMP, follow wheel for 40 weeks.
Confirm via ultrasound at T1 appointment.
What ultrasound are routinely done during pregnancy
T1: 8-10 weeks: confirm EBD as growth is predictable. Beyond this time there is variables
T2: 18-20 weeks: at minimum last ultrasound, unless high risk.
RNs role in each trimester
- Testing that needs to be done, confirm positive pregnancy, assess family and social situation, help client adjust to being pregnant
- Teach what is expected vs concerning signs. Coach around work requirements, prenatal classes
- Deal with discomforts of pregnancy. Make sure they know what is concerning and what is normal variation.
ABO incompatibility
O- A, B; B- A, AB; A- B, AB
If mom has O blood and fetus had A: the anti A antibodies from mom’s blood can attack fetal RBCs causing a breakdown of RBC intrauterine.
Breakdown of RBC can cause jaundice, brain damage or death
Rh incompatibility
A concern if mom is Rh-
If - mom is pregnant with first + baby, blood can mix during birth and mom will create anti-Rh antibodies.
Subsequent pregnancies with + fetus: antibodies will attack and break down RBCs intrauterine.
Can cause jaundice, brain damage or death
Rh- mom will receive deantigen RhoGAM at 26-28 weeks. After birth baby’s blood will be checked and if +, mom will be given another dose.
What If Mom is HBsAG
Hep B surface antigen: if positive, has been exposed or infected.
Infant will be given vaccine and immunoglobulin (within 4 hrs)
Pregnacy development task
- Accepting pregnancy (taking vit, asking appropriate questions, happy to hear heart beat)
- identify with role as parent
- reordering relationships
- establishing relationship with fetus (1T focused on self, 2T distinguish self from fetus)
- preparing for childbirth
Prenatal care goals
Promote client, fetus and family health and well being
Monitor status of client and fetus health
Identify and minimize risk factors
Provide education and support
Pre-conception and prenatal health promotion
Healthy diet (folic acid) Exercise and rest Healthy bmi Supporting relationships Use of risk reducing health and sexual practices
Frequency of prenatal health care appointments
1st trimester: initial visit, then monthly
2nd trimester: monthly
3rd trimester: q2 weeks until 36 weeks; q1 week to birth
Unless high risk, then more frequently
Pregnancy DOs and DON’T s
DOs: Healthy diet with adequate hydration Folic acid + PNV Adequate sleep and rest Physical activity Flu shot, Tdap
DON'Ts: Food to avoid: raw meat, fish Smoking, alcohol (low is 2 drinks/week) Substance abuse Hot tub/sauna Risky activity Avoid cat litter
Pregnancy red flags
Vaginal bleeding Vaginal discharge/leaking (amniotic?) Contractions (especially preterm) Pain: abdominal, back, urination, epigastric Decreased fetal movement: first thing to go with fetal distress SOB, chest pain Fever Severe headache Visual disturbances Accidents/falls/injuries Any other concerns
(Visual disturbances, severe headache, epigastric pain can be repeated to preeclampsia)
Uterus height during pregnancy
Length of uterus around gestational age (20 cm around week 20)
Week 20 is roughly @U and same size as 24 hr postpartum.
Uterus steadily raises each week, highest at 36 week. At 36-40 weeks the baby descends and uterus height decreases to prepare for delivery.
Pre-eclampsia
Onset of high blood pressure (140/90) and significant amount of protein in urine brought on around 20 weeks of pregnancy. Can affect blood flow to uterus
135/85 could be preeclamptic for some, know baseline.
Rooting reflex
Baby’s cheek is stroked/touched. The baby turns head and opens mouth in direction of stroking. Helps baby find the breast
Suck reflecx
Sucks when roof of mouth is touched.
Moro reflex
Aka startle
Loud sound or movement, baby throws back head and extends arms and legs, cries, and pulls arms and legs in
Grasp reflex
Stroke palm makes baby close fingers in a grasp
Plantar reflex
Stroke toes and toes curl
How to monitor fetal movement (kick count)
6 kicks in 2 hrs
Fetal distress- first thing to go is movements
Open vs closed glottis pushing
Open (directive)- coach to push for 10 seconds at beginning of contraction. Take breath and push again. May push 3x a contraction
-labour quicker, higher chance of tears, fatigue and fetal HR problems
Closed: encouraged to trust your body and push when feel the urge to bear down (or BM). May push for around 5 sec for 3-5 x per contraction.
-longer labour, less chance of tears or fatigue, less chance of FHR issues
