Maternity Flashcards
APGAR Scores
♦ Assigned based on a quick review of systems that is completed at 1 and 5 min of life.
♦ Assesses extrauterine adaptation (appearance, pulse, grimace, activity, respiration)
- 0 to 3 indicates severe distress
- 4 to 6 indicates moderate distress
- 7 to 10 indicates no distress
Heart rate
0 = Absent
1 = Less than 100
2 = Greater than 100
Respiratory rate
0 = Absent
1 = Slow, weak cry
2 = Good cry
Muscle tone
0 = Flaccid
1 = Some flexion
2 = Well-flexed
Reflex irritability
0 = None
1 = Grimace
2 = Cry
Color
0 = Blue, pale
1 = Pink body, cyanotic hands and feet (acrocyanosis)
2 = Completely pink
Newborn
Expected Reference Ranges
of
Physical Measurement
Expected reference ranges of physical measurements
■ Weight: 2,500g (5.5lbs) to 4,000g (8.8lbs)
■ Length: 45 to 55 cm (18 to 22 in)
■ Head circumference: 32 to 36.8 cm (12.6 to 14.5 in)
■ Chest circumference: 30 to 33 cm (12 to 13 in)
Newborn Vitals
Sequence: respirations, heart rate, blood pressure, and temperature. Observe respiratory rate first before newborn becomes active or agitated.
Respirations: 30 to 60/min with short periods of apnea (<15 sec, greater than 15sec needs to be reported)
Heart rate: 100 to 160/min with brief fluctuations above and below this range depending on activity level (crying, sleeping)
- NCLEX: 120-160 (apical); 80-100 (sleeping); up to 180 (crying)
Blood Pressure: 60-80 mmHg systolic over 40-50 mmHg diastolic
Temperature: 36.5° to 37.2° C (97.7° to 98.9° F) axillary
Milia
♦ Small raised white spots on the nose, chin, and forehead of a newborn.
♦ These spots disappear spontaneously without treatment (parents should not squeeze the spots).
Mongolian Spot
♦ Bluish purple spots of pigmentation
♦ Commonly noted on the shoulders, back, and buttocks.
♦ Frequently present on newborns who have dark skin.
♦ Be sure the parents are aware of Mongolian spots, and document location and presence.
Telangiectatic Nevi (Stork Bites)
♦ Flat pink or red marks that easily blanch
♦ Found on the back of the neck, nose, upper eyelids, and middle of the forehead.
♦ Usually fade by the second year of life.
Nevus Flammeus (Port Wine Stain)
♦ A capillary angioma below the surface of the skin that is purple or red, varies in size and shape, is commonly seen on the face
♦ Does not blanch or disappear.
Erythema Toxicum (Erythema Neonatorum)
♦ A pink rash that appears suddenly anywhere on the body of a term newborn during the first 3 weeks.
♦ Frequently referred to as newborn rash.
♦ No treatment is required.
Caput succedaneum
♦ Localized swelling of the soft tissues of the scalp caused by pressure on the head during labor
♦ An expected finding that may be palpated as a soft edematous mass and may cross over the suture line.
♦ Usually resolves in 3 to 4 days and does not require treatment.
Cephalohematoma
♦ A collection of blood between the periosteum and the skull bone that it covers.
♦ Does not cross the suture line.
♦ Results from trauma during birth such as pressure of the fetal head against the maternal pelvis in a prolonged difficult labor or forceps delivery.
♦ Appears in the first 1 to 2 days after birth and resolves in 2 to 3 weeks.
Epstein’s pearls
♦ Small white cysts found on the gums and at the junction of the soft and hard palates
♦ Expected findings
♦ Result from the accumulation of epithelial cells and disappear a few weeks after birth.
Sucking and Rooting reflex
♦ Elicited by stroking the cheek or edge of mouth.
♦ Newborn turns the head toward the side that is touched and starts to suck.
♦ Timeframe: Birth to 4 months
Palmar grasp
♦ Elicited by placing an object in the newborn’s palm.
♦ The newborn grasps the object.
♦ Timeframe: Birth to 6 months
Plantar grasp
♦ Elicited by touching the sole of the foot.
♦ The newborn responds by curling toes downward.
♦ Timeframe: Birth to 8 months
Moro Reflex
♦ Elicited by striking a flat surface that the newborn is lying on, or allowing the head and trunk of the newborn in a semisitting position to fall backward to an angle of at least 30°.
♦ Arms and legs symmetrically extend and then abduct while fingers spread to form a “C.”
♦ Timeframe: Birth to 4 months
Startle reflex
♦ This reflex is elicited by clamping hands or by a loud noise.
♦ The newborn will abduct arms at the elbows, and the hands will remain unclenched.
♦ Timeframe: Birth to 4 months
Tonic neck reflex (Fencer position)
♦ The newborn extends arm and leg on the side when head is turned to that side with flexion of arm and leg of opposite side.
♦ Timeframe: Birth to 3 to 4 months
Babinski’s reflex
♦ Elicited by stroking outer edge of sole of the foot, moving up toward toes.
♦ Toes will fan upward and out.
♦ Timeframe: Birth to 1 year
Stepping
♦ Elicited by holding the newborn upright with feet touching a flat surface.
♦ The newborn responds with stepping movements.
♦ Timeframe: Birth to 4 weeks
Newborn Complications: Hypothermia
♦ Monitor for an axillary temperature of less than 36.5º C (97.7º F).
♦ If temperature is unstable, place the newborn in a radiant warmer, and maintain skin temperature at approximately 36.5º C (97.7º F).
♦ Assess axillary temperature every hour until stable.
♦ All exams and assessments should be performed under a radiant warmer.
Newborn Reference Ranges: Glucose
40 to 60 mg/dL
Newborn Reference Ranges: Bilirubin
Day 1: 0 to 6 mg/dL
Day 2: 8 mg/dL or less
Day 3: 12 mg/dL or less
Menopause: S/S
♦ Vasomotor symptoms – Hot flashes and irregular menses
♦ Genitourinary – Atrophic vaginitis, shrinking of labia, decreased vaginal secretions, dyspareunia, increased vaginal pH, vaginal dryness, incontinence
♦ Psychologic – Mood swings, changes in sleep patterns, and decreased REM sleep
♦ Skeletal – Decreased bone density
♦ Cardiovascular – Decreased HDL and increased LDL
♦ Dermatologic – Decreased skin elasticity and loss of hair on head and in the pubic area
♦ Reproductive – Breast tissue changes
Gravidity
Gravida = pregnant woman
Gravidity = number of pregnancies
Nulligravida = never been pregnant
Primigravida = first pregnancy
Multigravida = at least second pregnancy
Parity
Parity = the number of pregnancies (NOT the number of fetuses) carried past 20wks (regardless of outcome)
GTPAL
G = gravidity (# of pregnancies, including the present pregnancy)
T = term births (longer than 37wks)
P = preterm births (less than 37wks)
A = abortions or miscarriages (included in gravida if <20wks; included in parity of >20wks)
L = # of living children
Signs of Pregnancy: Presumptive
- Amenorrhea
- N/V
- Increased size and increased feeling of fullness in breasts
- Pronounced nipples
- Urinary frequency
- Quickening (first perception of fetal movement)
- Fatigue
- Discoloration of vaginal mucosa
Signs of Pregnancy: Probable
♦ Uterine enlargement
♦ Hegar’s sign: compressibility and softening of the lower uterine segment that occurs at about week 6
♦ Goodell’s sign: softening of the cervix that occurs at the beginning of the second month
♦ Chadwick’s sign: violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4
♦ Ballottement: rebounding of the fetus against the examiner’s finger on palpation
♦ Braxton Hicks contractions: irregular painless contractions that may occur intermittently throughout pregnancy
♦ Positive pregnancy test for determination of the presence of human chorionic gonadotropin
Hegar’s Sign
- Compressibility and softening of the lower uterine segment that occurs at about week 6
- Probable sign of pregnancy
Goodell’s Sign
- Softening of the cervix that occurs at the beginning of the second month
- Probable sign of pregnancy
Chadwick’s Sign
- Violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4
- Probable sign of pregnancy
Ballottement
- Rebounding of the fetus against the examiner’s finger on palpation
- Probable sign of pregnancy
Braxton Hicks Contractions
- Irregular painless contractions that may occur intermittently throughout pregnancy
- Probable sign of pregnancy
Signs of Pregnancy: Positive (Diagnostic)
- Fetal heart rate detected by electronic device (Doppler transducer) at 10-12wks
- Active fetal movements palpable by examiner
- Visualization of fetus via radiography or ultrasonography
Fundal Height
♦ Measured to evaluate the gestational age of the fetus
♦ During 2nd and 3rd trimesters, fundal height in cm approximately equals fetal age in weeks (+/- 2cm)
♦ At 16wks, fundal height is usually halfway btwn symphysis pubis and umbilicus
♦ At 20-22wks, the fundus is approximately at the umbilicus
♦ At 36wks, the fundus is at the xiphoid process
Interventions for N/V
eating dry crackers before arising
avoiding brushing teeth immediately after arising
eating small, frequent, low-fat meals during the day
drinking liquids b/w meals rather than at meals
avoiding fried foods and spice foods
asking the HCP about accupressure or use of herbal remedies
Adolescent Pregnancies: Concerns
♦ Poor nutritional status
♦ Emotional and behavioral difficulties
♦ Lack of support systems
♦ Increased risk of stillbirth
♦ Increased risk of low-birth-weight infants
♦ Increased risk of fetal mortality
♦ Increased risk of cephalopelvic disproportion
♦ Increased risk of maternal complications including: hypertension, anemia, prolonged labor, and infections
Pregnancy & Rubella (German Measles)
♦ Maternal infection during the first 8wks of gestation carries the highest rate of fetal infection
Pregnancy: Physiological Changes
Cardiovascular System: blood volume increases, plasma increases, total RBC volume increases (40-50%); H&H levels decline due to increased plasma volume
- A decreased hemoglobin to less than 10g/dL and/or a decreased hematocrit to less than 30% indicates anemia
Respiratory System: O2 consumption increases 15-20%, diaphragm is elevated
GI System: progesterone and decreased motility can cause consitpation
GU: urinary frequency usually occurs in 1st and 3rd trimesters
Endocrine System: basal metabolic rate increases
Skin: progesterone and estrogen levels trigger an increase in melanocyte-stimulating hormone which may increase pigmentation (e.g. striae, chloasma)
Renal: glycosuria is a common result of decreased renal threshold to glucose
Pregnancy: Psychological Stages
- Acceptance of the biological fact of pregnancy
- Acceptance of growing fetus as distinct from herself and person to be nurtured
- Prepares realistically for birth and parenting of child
Pregnancy: Common Discomforts
- Breast tenderness
- Increased vaginal discharge
- Nasal stuffiness
- Fatigue
- Heartburn - results from increased progesterone and decreased GI motility, esophageal reflux, and displacement of the stomach by the enlarging uterus
- Eat small, frequent meals; remain upraight for 30min after eating; drink milk btwn meals; avoid fatty and spicy foods
- Ankle edema - results from vasodilation and venous stasis and increased venouspressure below the uterus
- Varicose veins
- Headaches
- Hemorrhoids
- Constipation
- Backache
- Leg cramps - result from an altered calcium-phosphorous balance and pressure of the uterus on nerves (or from fatigue)
- SOB
Pregnancy & Birth: Blood Type & Rh Factor
If client is Rh- and has a negative antibody screen, she will need repeat antibody screens and should receive RhoGAM at 28 weeks’ gestation.
Pregnancy & Birth: Rubella Titer
♦ A negative titer (less that 1:8) indicates susceptibility to the rubella virus
♦ Rubella vaccine is NOT given during pregnancy - the live, attentuated virus may cross the placenta
♦ Rubella vaccine is administered postpartum prior to discharge
♦ Assess client for allergy or sensitivity to eggs (the vaccine is made from duck eggs)
Pregnancy: Biophysical Profile (Fetal)
Noninvasive assessment of the fetus that includes:
- Fetal breathing movements
- Fetal movements
- Fetal tone
- Amniotic fluid index
- Fetal heart rate patterns via nonstress test
Pregnancy: Tests
♦ alpha-Fetoprotein Screening: assess the quantity of fetal protein levels
- abnormal levels are associated with open neural tube and abdominal wall defects (spina bifida, down syndrome)
- done at 16-18wks gestation
♦ Chorionic Villus Sampling: for the detection of genetic abnormalities
- done at 10-13wks gestation
- Rh-negative women ay be given RhoGAM b/c of increased risk of Rh sensitization
♦ Amniocentesis: for the detection of genetic disorders, metabolic defects, and fetal lung maturity
- Performed btwn 15-20wks gestation
** After chorionic villus sampling and amniocentesis, if the client experiences chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping, notify HCP immediately **
Pregnancy: Kick Counts
♦ Notify HCP if there are fewer than 10 kicks in two consecutive 2-hour periods
Pregnancy: Nonstress Test
♦ Performed to assess placental function and oxygenation
♦ Determines fetal well-being via fetal heart rate response to fetal movement
♦ “Reactive” = “normal,”healthy fetus
- 2 or more FHR accelerations of at least 15bpm lasting at least 15sec in association with fetal movement in a 20min period
♦ “Nonreactive” = “abnormal”
- No accelerations or acceleration less than 15bpm ar lasting less than 15sec during 40min observation
♦ “Unsatifactory”= results cannot be interpreted due to poor quality of FHR tracing
Pregnancy: Contraction Stress Test
♦ Assesses placental oxygenation and function
♦ Determines fetal ability to tolerate labor and determines fetal well-being
♦ Fetus is exposed to stress of contractions to assess the adequacy of placental perfusion under simulated labor
♦ Performed if nonstress test is abnormal
♦ Procedure
- Baseline fetal monitoring of 30min
- Dilute dose of oxytocin is administered (or nipple stimulation) to produce 3 or more contractions in a 10min period
- Maternal blood pressure assessed frequently esp during increases in oxytocin administration
♦ Results
- “Negative” = “Normal”
- No late decelerations or signs of fetal distress
- “Positive” = “Abnormal”
- Presence of late decelrations w/ 50% of contractions in the absence of hyperstimulation of the uterus
- “Equivocal” = decelerations present but with less than 50% of the contractions or uterine activity shows a hyperstimulated uterus (?)
- “Unsatisfactory” = adequate uterine contractions cannot be achieved or the FHR is of insufficient quality
Pregnancy & Lactation: Nutrition Basics
♦ Women of normal prepregnancy weight are expected to gain 25-35 lbs
♦ An increase of approx 300 calories a day is sufficient (calorie needs are greater in the 2nd and 3rd trimester)
♦ An increase of approx 500 calories is needed during active lactation
♦ A diet high in folic acid is necessary to prevent neural tube defects
♦ Pica = eating nonfood substances such as dirt, clay, starch, and freezer frost; cause is unknown
Pregnancy Risk Conditions: Anemia
♦ Anemia predisposes the client to postpartum infection
Assessment
♦ Fatigue, headache, pallor, tachycardia
♦ Hemoglobin <10g/dL
♦ Hematocrit <30%
Pregnancy Risk Conditions: Abortions
♦ Spontaneous – pregnancy ends due to natural causes
♦ Induced – therapeutic or elective reasons exist for terminating pregnancy
♦ Threatened – spotting and cramping without cervical change
♦ Inevitable – loss of some of the products of conception with part of the products retained (most often placenta)
♦ Complete – loss of all products of conception
♦ Missed – products of conception are retained in utero after fetal death
♦ Habitual – spontaneous abortions occur in three or more successive pregnancies
Pregnancy Risk Conditions: Chorioamnionitis
♦ Bacterial infection of the amniotic cavity
- May result from premature or prolonged rupture of membranes, vaginitis, amniocentesis, or intrauterine procedures
- May cause development of postpartum endometritis and neonatal sepsis
♦ Assessment
- Uterine tenderness and contractions
- Elevated temp
- Maternal or fetal tachy
- Foul odor to amniotic fluid
- Leukocytosis
♦ Interventions
- Monitor maternal vitals and FHR
- Monitor blood cultures
- Prepare for amniocentesis to obtain amniotic fluid for Gram stain and leukocyte count
- Administer antibiotics
- Prepare to obtain neonatal cultures after delivery
Pregnancy Risk Conditions: Diabetes Mellitus
♦ Maternal glucose crosses the placenta but insulin does not
♦ Fetus produces its own insulin and pulls glucose from the mother predisposing the mother to hypoglycemic episodes
♦ Newborn of a diabetic mother is at risk for:
- hypoglycemia
- hyperbilirubinemia
- respiratory distress syndrome
- hypocalcemia
- congenital anomalies
♦ During 1st trimester, maternal insulin needs decrease
♦ During 2nd and 3rd trimesters, placental hormones may cause an insulin-resistent state requiring increases in insulin doses
♦ Immediately after placental delivery, insulin needs decrease
Pregnancy Risk Conditions: Ectopic Pregnancy
♦ Implantation of the fertilized ovum outside of the uterine cavity (most commonly in the ampulla of fallopian tube)
♦ S/S:
- missed menstrual period
- abdominal pain
- vaginal spotting/bleeding that is dark red or brown
- increased pain and referred shoulder pain may indicate rupture
♦ Interventions
- Methotrexate (folic acid antagonist) may be prescribed to inhibit cell division in the developing embryo
- Laparotomy and removal of the pregnancy and tube (if necessary) or repair of the tube
Pregnancy Risk Conditions: Hepatitis B
♦ Hepatitis B is transmitted through blood, saliva, vaginal secretions, semen, breast milk, and can cross the placenta
♦ Infection of the neonate can be prevented by administration of Hep B immune globulin and Hep B vaccine soon after birth (then 1mo and 6mo)
- CONTRAINDICATED IN PT THAT HAS YEAST ALLERGY
♦ Suction all fluids and bathe newborn immediately
♦ Breastfeeding is NOT contraindicated if the newborn has been vaccinated; it is encouraged
Pregnancy Risk Conditions:
Gestational Hypertension
Complications:
- abruptio placentae
- DIC
- thrombocytopenia
- placental insufficiency
- intrauterine growth restriction
- intrauterine fetal death
- HELLP (hemolysis, elevated liver enzyme levels, low platelet)
Pregnancy Risk Conditions: Hypertension
Classifications
Gestational Hypertensive Disorders
♦ Gestational Hypertension – blood pressure elevation detected first time after mid-pregnancy without proteinuria
♦ TransieNt Hypertention – gestational hypertension with no signs of preeclampsia present at time of birth; resolves by 12th wk postpartum
♦ Preeclampsia – pregnancy-specific syndrome that usually occurs after 20wks gestation and is determined by gestational hypertension plus proteinuria
♦ Eclampsia – occurrence of seizures in a preeclamptic woman
Chronic Hypertensive Disorders
♦ Chronic Hypertension – hypertension that is present and observable before pregnancy or that is diagnosed before 20th week of gestation
♦ Preeclampsia superimposed on chronic hypertension – chronic hypertension with new proteinuria or exacerbation of hypertension (previously well-controlled) or proteinuria, theombocytopenia, or increases in hepatocullular enzymes
Pregnancy Risk Conditions: Mild Preeclampsia
♦ Pregnancy-specific syndrome that usually occurs after 20wks gestation and is determined by gestational hypertension plus proteinuria
♦ S/S include
- Hypertension: BP: 140-160 / 90-110
- generalized edema
- Proteinuria: 1+ on dipstick
Interventions
♦ Bed rest, lateral position
♦ Monitor blood pressure & weight
♦ Monitor neuro status – changes can indicate hypoxia or impending seizure
♦ Monitor DTRs – hyperreflexia (or clonus) indicates increased CNS irritability
♦ Provide adequate fluids and monitor output
♦ Increase dietary protein and carbohydrates w/o added salt
♦ Monitor for HELLP syndrome
- H (hemolysis, which is the breaking down of red blood cells)
- EL (elevated liver enzymes)
- LP (low platelet count)
Pregnancy Risk Conditions: Severe Preeclampsia
♦ Pregnancy-specific syndrome that usually occurs after 20wks gestation and is determined by gestational hypertension plus proteinuria
♦ S/S include
- Hypertension: BP: >=160 / >=110
- Generalized edema
- Proteinuria: >=3+ on dipstick
- Elevated creatinine
- Decreased platelets
- Elevated liver enzymes
- Oliguria
- Severe headaches
- Visual disturbances
- Persistant RUQ or epigastric pain (indicative of hepatic involvement)
- Fetal growth restriction; reduced amnioic fluid volume
♦ Interventions
- Bed rest
- Magnesium sulfate (to prevent seizures)
- Monitor for mag toxicity (flushing, sweating, hypotension, depressed deep tension reflexes, CNS depression
- Antidote is calcium gluconate
- Prepare for induction of labor
*
Pregnancy Risk Conditions: Eclampsia
♦ Occurrence of seizures in a preeclamptic woman
♦ S/S
- Seizures usually begin w/ twitching around the mouth
- Body becomes rigid in a state of tonic muscular contractions for 15-20sec
- Facial muscles and all body muscles contract and relax in rapid succession
- Respiration ceases during seizure b/c diaphragm remains fixed
- Postictal sleep occurs
♦ Interventions
- Remain with client and call for help
- Ensure open airway, turn client on side, and administer O2 by face mask (8-10L/min)
- Administer medications to control seizures as prescribed
- After seizure, suction mouth and maintain airway
- Prepare for delivery of fetus after stabilization
Pregnancy Risk Conditions: Infections
Infections that can be transferred to the fetus/newborn:
♦ Toxoplasmosis (rash, acute, flulike infection in mom) –thru placenta
♦ Rubella –thru placenta
♦ Cytomegalovirus
♦ Herpes
♦ Group B Streptococcus (GBS)
♦ Syphilis (can be transferred to fetus after 4th month as congenital syphilis
♦ Gonorrhea (can be transmitted to newborn’s eyes during delivery)
♦ TB (transplacental transmission is rare but transmission can occur via aspiration of infected amniotic fluid during birth)
Labor & Delivery: “Four P’s”
♦ Labor is the coordinated sequence of involuntary, intermittent uterine contractions
♦ Delivery is the actual event of birth
♦ Four P’s:
- Powers
- Passageway
- Passenger
- Psyche
♦ Powers
- Uterine contractions – forces acting to expel the fetus
- Effacement – shortening and thinning of the cervix during the first stage of labor
- Dilation – enalrgement of the cervical os and cervical canal during first stage of labor
- Pushing efforts via the mother during the second stage
♦ Passageway – pelvis, cervix, pelvic floor, vagina, and introitus (external opening to the vagina)
♦ Passenger – fetus, membranes, placenta
♦ Psyche – the woman’s emotional structure tha can determine her entire response to labor
Labor & Delivery: Attitude
♦ Attitude is the relationship of the fetal body parts to one another
♦ Normal attitude is flexion in which the fetal back is rounded, the head is forward on the chest, and the arms and legs are folded in against the body
Labor & Delivery: Lie
♦ Relationship of the spine of the fetus to the spine of the mother
♦ Longitudinal or Vertical
- Fetal spine is parallel to the mother’s spine
- Fetus is in cephalic or breech presentation
♦ Transverse or Horizontal
- Fetal spine is at a right angle or perpendicular to mother’s spine
- Presenting part is the shoulder
- Delivery by cesarean is necessary
Labor & Delivery: Presentation
♦ Presentation is the portion of the fetus that enters the pelvic inlet first
- Cephalic = head first
- Breech = buttocks
- Shoulder = transverse lie
♦ Presenting part is the specific fetal structure lying nearest to the cervix
Labor & Delivery: Position
♦ Relationship of assigned area of the presenting part or landmark to the maternal pelvis
- Occipito- = head first
- Sacro- = butt first (breech)
- Mento- = face first
♦ Directional designations are in relation to the baby’s spine
- ROP = right occipitoposterior = the baby’s spine is facing the back of the mother’s body is angled to the R
- ROA = right occipitoanterior = the baby’s spine is facing the front of the mother’s body and is angled to the R
- See image for more positions
Labor & Delivery: Station
♦ The measurement of the progress of descent in cm above or below the midplane from the presenting part to the ischial spine
♦ Station 0 – at ischial spine
♦ Minus station – above ischial spine
♦ Plus station – below ischial spine
Labor & Delivery: Mechanisms of Labor
♦ Lightening (dropping, engagement) – occurs when the fetus descends into the pelvis about 2wks before delivery
♦ Other S/S
- Increased Braxton Hicks
- Vaginal discharge increases
- Brownish or red-tinged cervical mucos is passed
- Mother may have a sudden burst of energy (“nesting”) 24-48hrs prior to labor
- Mother may lose 1-3 lbs due to fluid shifts
- Spontaneous rupture of membranes
♦ False labor (prodromal labor) – contractions are felt in the abdomen and groin and are irregular (don’t progress)
♦ True labor – contractions are felt more in the back and are regular, stronger, and progress
Labor & Delivery: Cardinal Movements
♦ Engagement
♦ Descent
♦ Flexion
♦ Internal Rotation
♦ Extension
♦ Restitution
♦ External Rotation
♦ Expulsion
Labor & Delivery: Leopold’s Maneuvers
♦ Methods of palpitation to determine presentation and position of the fetus and aid in location of fetal heart sounds
♦ If the head is in the fundus, a hard, round, moveable object is felt
♦ If the buttocks are in the fundus, a soft, irregular, and difficult to move object can be felt
Labor & Delivery: FHR Monitoring
♦ Accelerations – brief, temporary increases in FHR of at least 15bpm more than baseline and lasting at least 15sec; often associated with fetal movement
♦ Early decelerations – occur during contractions as the fetal head is pressed against the mother’s pelvis and return to baseline by the end of the contraction; not associated with fetal compromise and require no intervention
♦ Late decelerations – appear similar to early decelerations but occur well after the contraction begins and return to baseline after the contraction ends; related to uteroplacental insufficiency and require intervention
- Change mother’s position
- Administer O2
♦ Variable decelerations – caused by conditions that restrict flow through the umbilical cord; they do not have a uniform appearance fall and rise abruptly with the onset and relief of cord compression; require immediate intervention
- Change mother’s position
- Administer O2
- Discontinue oxytocin
- Asses vitals
- Prepare to assest with amnioinfusion (instillation of warm saline to decrease cord compression)
♦ VEAL CHOP
VariableCord compression
Early Head compression
Accelerations O2 (sufficient, good)
Late Placental utero insufficiency
Labor & Delivery: Uterine Tone During Labor
♦ Uterus should relax between contractions for at least 60sec
♦ Resting tone (if measured with an interuterine pressure catheter, IUPC) should be 5-15mmHg
♦ Uterine tone during contractions may be 50-75mmHg and meay even reach up to 110mmHg while pushing in second stage
♦ Hypertonic uterine activity involves a resting tone that is too high during contractions and thus reduces uterine blood flow and decreases fetal oxygen supply
♦ Oxytocin is discontinued if uterine contraction frequency is less than 2min or duration is longer than 90sec or if fetal distress is noted
Labor & Delivery: Stages of Labor
Stage 1
- Latent Phase
- Cervical dilation 1-4cm
- Uterine contractions q15-30min; mild
- Mother is often talkative and excited
- Active Phase
- Cervical dilation 4-7cm
- Uterine contractions q3-5min; moderate
- Mother becomes more tired and restless
- Transition Phase
- Cervical dilation 8-10cm
- Uterine contractions q2-3min, 45-90sec in duration; strong
- Mother may become anxious
Stage 2
- Cervical dilation is complete
- Progress measured by change in fetal station
- Contractions occur q2-3min and last 60-75sec
- Pushing stage
- Ends with birth of fetus
- Mother has intense concentration on pushing with contractions; may work so hard she falls asleep btwn contractions
Stage 3
- Contractions occur until the placenta is expelled
- Placental expulsion occurs 5-30min after birth of baby
- Mother is relieved and exhausted
Stage 4
- Period of 1 - 4 hours after delivery
- BP returns to prelabor level
- Pulse is slightly lower than during labor
- Fundus remains contracted, midline, and 1 or 2 fingerbreadths below umbilicus
- Mother is tired but eager to bond with baby
Labor & Delivery: Bishop Score
♦ Used to determine maternal readiness for labor and evaluates cervical status and fetal position
♦ Five factors are assigned a score of 0 to 3; a score of 6 or more indicates a readiness for labor induction
- Dilation
- Effacement
- Consistency
- Position (of cervix)
- Station of presenting part
Labor & Delivery Complications: Prolapsed Cord
♦ Ubilical cord is displaced btwn the presenting part and the manion or protruding through the cervix causing compression of the cord and compromising fetal circulation
- Elevate fetal presenting part that is lying on the cord by applying finger pressure with a gloved hand
- Place client in extreme Trendelenburg, modified Sims, or knee to chest
- Administer O2, 8-10L/min
- Monitor FHR
- Prepare to start IV fluids or increase rate
- Prepare for immediate birth
Labor & Delivery Complications: Placenta Previa
♦ Improperly implanted placenta in the lower uterine segment near or over the internal cervical os
S/S
- Sudden onset of painless, bright red vaginal bleeding during last half of pregnancy
- Uterus is soft, nontender
- Fundal height may be more than expected for gestational age
Interventions
- Monitor vitals, FHR, etc.
- Avoid vaginal examinations or other actions that would stimulate uterine activity
- Monitor amount of bleeding
- Bed rest, side-lying position
Labor & Delivery Complications: Abruptio Placentae
♦ Premature separation of the palcenta from the uterine wall after the 20th wk and before the fetus is delivered
S/S
- Dark red vaginal bleeding; but, if higher in uterus, bleeding may not be evident
- Uterine pain and tenderness
- Abdominal pain
- Uterine rigidity
- Fetal distress
Interventions
- Monitor vitals and FHR
- Bed rest
- Administer O2 and fluids
- Trendelenburg if indicated to decrease pressure of fetus on placenta OR lateral position with HOB flat if hypovolemic shock occurs
- Prepare for delivery of fetus as quickly as possible
- Monitor for DIC in postpartum period
Labor & Delivery Complications: Preterm Labor
♦ Labor that occurs after the 20th wk but before the 37th wk
Interventions
- Focus on stopping the labor – identify and treat infection, restrict activity, and ensure hydration
- Maintain bedrest and a lateral position
- Monitor fetal status
- Administer fluids
- Administer medications as prescribed and monitor for side effects
Tocolytics
-
Indomethacin (Indocin) – prostaglandin inhibitor
- Use only if other methods have failed and gestation is <32wks
- May cause N/V, dyspepsia, dizziness
-
Magnesium sulfate – CNS depressant (relaxes smooth muscle, including uterus)
- Monitor respirations and deep tendon reflexes
- May cause respiratory depression, depressed DTRs, hypotension, muscle weekness, flushing, and more
-
Nifedipine (Procardia) – calcium channel blocker (relaxes smooth muscles, including uterus by blocking calcium entry)
- Avoid concurrent use with mag sulfate or monitor very carefully
- May cause tachycardia, hypotension, dizziness, flushing, headache and more
-
Terbutaline – beta-adrenergic agonist (relaxes smooth muscle)
- May cause tachycardia, palpitations, pulmonary edema, chest pain, and more
Labor & Delivery Complications: Precipitous Labor
♦ Labor lasting less than 3 hrs
Labor & Delivery Complications: Dystocia
♦ Difficult labor that is prolonged or more painful
♦ Fetus may be excessively large, malpositioned, and or in an abnormal presentation
Interventions
- Monitor FHR and contractions
- Monitor maternal HR and temp
- Possible administration of prophylactic antibiotics
- Comfort measures
Hypotonic contractions (short, irregular weak)- amniotomy and oxytocin may be prescribed
Hypertonic contractions (frequent, uncoordinated, painful)- pain medications and rest may be prescribed
Labor & Delivery Complications:
Amniotic Fluid Embolism
♦ The escape of amniotic fluid into the maternal circulation
♦ Debris-containing amniotic fluid deposits in the pulmonary arterioles; usually fatal to the mother
S/S
- Abrupt onset of respiratory distress and chest pain
- Cyanosis
Interventions
- Emergency measures to maintain life
- O2; prepare for intubation
- Monitor fetal status
- Prepare for emergency delivery
Pospartum Complications: Hemorrhage
♦ Bleeding of 500mL or more after delivery
- early sign: restlessness and increased pulse rate
- late sign: decrease in BP
♦ Primary cause of maternal mortality
Causes
- Uterine atony
- Laceration of the cervix or vagina
- Hematoma development in the cervix, perineum, or labia
- Retained placenta fragments
Interventions
- Massage fundus
- Monitor vitals q5-15min
- Assess and estimate blood loss by pad count (1gm=1mL)
- Turn client to assess for pooled blood
- Administer fluids and monitor I&O
- Monitor H&H
- Maintain asepsis b/c hemorrhage predisposes to infection
Pospartum Complications: Thrombophlebitis
♦ A clot forms in a vesselwall as a result of inflammation of the vessel wall; partial obstruction of the vessel can occur
- Increased blood-clotting factors in the postpartum period place the client at risk
- Early ambulation is key!
Types
- Superificial – palpable thrombus that feels bumpy and hard with tenderness and pain in the affected lower limb; warm and pinkish red color over area
- Femoral – malaise, chills and fever; dimished peripheral pulses; pain, stiffness, and swelling of affected leg
- Pelvic – severe chills; dramatic changes in body temp; pulmonary embolism may be first sign
Patient Education
- Never massage leg
- Avoid crossing legs; avoid prolonged sitting
- Avoid constrictive clothing
- Avoid pressure behind knees
- Apply warm, moist heat
- Anticoagulant therapy
- Proper application & use of stockings
Newborn Care: Initial Care
♦ You know the basics already, I’m not writing them all down
♦ Suction mouth before nose!
♦ Place newborn on side with rolled blanket supporting back to promote drainage of mucos
- This is, of course, after the baby has already been placed on mom’s abdomen or chest
Newborn Care: Phases of Newborn Instability
♦ Phases of newborn instability occur during the first 6 to 8 hrs after birth
♦ Transition period between intrauterine and extrauterine existence
♦ First Period of Reactivity
♦ Period of Decreased Responsiveness
♦ Second Period of Reactivity
Newborn Care: Fontanels
Anterior
- Soft, flat, diamond-shaped
- Closes btwn 12-18months
Posterior
- Triangular
- Located btwn occipital and parietal bones
- Closes btwn birth and 2-3months
Newborn Care: Umbilical Cord
♦ Three vessels
- 2 arteries (take deoxygenated blood and waste products away from fetus to placenta/mother)
- 1 vein (brings oxygenated blood to fetus)
Newborn Care: Jaundice
Normal (Physiologic) Jaundice
- Appears after first 24hr in term babies and 48hrs in preterm babies
- Feed early to stimulate intestinal activity and to keep the bilirubin level low
Pathological Jaundice
- Appears within the first 24hrs
- The appearance of jaundice, at any serum level, within the first day of life indicates a pathological process
- May indicate early hemolysis; should be reported to HCP
Newborn Care: Cold Stress
Cold temp leads to …
- Increased O2 consumption, leads to …
- Increased respiratory rate, leads to …
- Vasoconstriction, leads to…
- Decreased O2 uptake in lungs and tissues, leads to …
- Anaerobic glycolysis, leads to…
- Decreased pH, leads to…
Metabolic acidosis.
Newborn Care: TORCH Syndrome
♦ Infections of the fetus or newborn
- Toxoplasmosis
- Other (gonorrhea, syphilis, varicella, hepB, HIV, HPV)
- Rubella
- Cytomegalovirus
- Herpes simplex virus
Newborn Care: Hypoglycemia
♦ <40mg/dL in first 72 hrs
♦ May occur due to maternal diabetes
♦ S/S
- Twitching, tremors
- Tachypnea, apnea, cyanosis
- Difficulty feeding
- Lethargy, seizures
Maternity & Newborn Medications:
Magnesium Sulfate
CNS depressant and anticonvulsant; causes smooth muscle relaxation
Antidote: calcium gluconate
Adverse effects: respiratory depression, depressed DTRs, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema
Considerations
- Continuous infusion s increase risk of mag toxicity in newborn
- IV admin should be discontinued 2hrs prior to delivery
- May be continued 12-24hrs postpartum if for preeclampsia
- Contraindicated in clients with heart block and kidney impairment
- Target range: 4-7.5 (5-8) mEq/L
Interventions
- Monitor vitals q30-60min
- Monitor mag levels
- Always use an infusion pump
- Monitor DTRs – assess prior to administration to determine baseline
- 0 = no response
- 1 = sluggish or diminished
- 2 = active or expected response
- 3 = more brisk than expected; slightly hyperactive
- 4 = brisk, hyperactive; possible intermittent or transient clonus
- Monitor I&Os
- Monitor for respiratory depression
Maternity & Newborn Medications:
Prostaglandins
♦ Ripen the cervix, making it softer and causing it to dilate and efface; may stimulate uterine contractions
Indications
- Preinduction cervical ripening for Bishop score <=4
- Induction of abortion
Adverse effects
- GI irritation, N/V, diarrhea, cramps
- Fever, chills, flushing, headache, hypotension
- Tachysystole – >=12 uterine contractions in 20min w/o an alteration in the FHR pattern
- Hyperstimulation of the uterus
Interventions
- Have client void prior to administration
- Maintain supine with lateral tilt or side-lying position for 30-60min (up to 2 hrs)
- Tx is discontinued when Bishop score is >=8 or an effective contraction pattern is established
Examples
- misoprostol (Cytotec)
- dinoprostone (Cervidil, Prepidil)
Maternity & Newborn Medications:
Oxytocin (Pitocin)
IV – increase force, frequency, and and duration of uterine contractions
Intranasal – promotes milk letdown
Interventions
- Monitor vitals q15min
- Use infusion pump
- Stop infusion if hypertonic or nonreassuring FHR occur
- Turn client on side
- Increase rate of NS infusion
- Administer O2
Maternity & Newborn Medications:
Management of Postpartum Hemorrhage
Medications
- Ergonovine maleate
- Methylergonovine (Methergine)
- Oxytocin
- Carboprost tromethamine (Hemabate)
Interventions
- Ergo alkaloids can cause severe hypertension– check vitals prior to administration to determine baseline and monitor regularly
- Can produce vasoconstriction and vasospasm of coronary arteries
*
- Can produce vasoconstriction and vasospasm of coronary arteries
Maternity & Newborn Medications:
Rho (D) Immune Globulin (RhoGAM)
Neonatal Sepsis
temperature instability
tachypnea
nasal flaring
irritability
Terbutaline
tx of preterm labor
- adverse effect is hypokalemia so K+ should be checked
Proteinuria
Protein dipstick grading
Designation Approx. amount
Concentration[6] Daily[7]
Trace 5–20 mg/dL
1+ 30 mg/dL Less than 0.5 g/day
2+ 100 mg/dL 0.5–1 g/day
3+ 300 mg/dL 1–2 g/day
4+ More than 300 mg/dL More than 2 g/day
