NURS 330 (OBS) Flashcards
When does Preconception Start?
At least 3 months before conception
How many pregnancies are planned vs unplanned
50-75% = unplanned
25-50% = planned
Folic Acid and Iron Preconception
0.4mg/day of folic acid (400mcg) and 16-20mg iron/day
How much weight should a woman gain during pregnancy?
1st trimester: 6lb
2nd Trimester: 12lb
3rd Trimester: 12lb
About 30 lbs
Screening Pregnant Client: Blood Group and Rh
If fetus is Rh+, moms body may react and attack fetus. If both parents are Rh-, there is no risk.
Screening Pregnant Client: Infectious Diseases
STI, HIV, Hepatitis B&C, Rubella
Screening Pregnant Client: Gestational Diabetes
Glucose Tolerance Test 24-28wk
Screening Pregnant Client: Perinatal Serum Screening
15-20wks
Screening Pregnant Client: Group B Strep
35-37wks
Common bacteria which are often found in vagina, rectum or urinary bladder of 15-40% of women
- Treated by antibiotics IN LABOUR
Screening Pregnant Client: Asymptomatic bacteria
UTI can cause pre-term labour
Screening Pregnant Client: For Fetus
Fetal movement
Fetal HR
Ultrasounds
Ultrasounds in pregnancy
between 8-12wks (age/ due date) and between 18-22wks (anatomy)
Purpose of Ultrasounds in Pregnancy
- Confirmation and EDC dates
- # of fetuses
- Size for gestational age
- How baby’s internal organs are growing
- Placental position and size
- Women’s uterus, fallopian tubes, ovaries
- Check for signs of possible genetic problem
F = RP
< 6 movements in 2hr = RED FLAG
F - Fetal movement
R - Reduction in fetal movement
P - Potential for distress/fetus already in trouble
Amniotic Fluid Measurement
1L at birth
Adequate volume needed for proper G&D:
- protection of fetus
- temp control
- infection control
- lung and GI development
- Muscle and bone development
- umbilical cord support
Oligohydramnios
Less amniotic fluid
Polyhydramnios/Hydramnios
Too much amniotic fluid
Nuchal Scan for Translucency
Collection of fluid under skin at the back of fetus neck
- From measuring this + maternal age, RISK of chromosomal abnormality can be calculated.
Non-Invasive Prenatal Testing (NIPT) or Cell Free DNA Testing (cfDNA)
- blood sample: analyze abnormalities of chromosomes
- not publicly funded
Amniocentesis
Done between 15–16wks, very invasive
5 P’s of Labour and Delivery
Passage
Passenger
Powers
Position
Psychology
Stages of Labour
1st (Cervical): Early, active, transition
2nd (Pushing)
3rd (Placental)
4th (Postpartum)
Four Classic Pelvis Types and which is best?
Gynecoid
Android
Anthropoid
Platypelloid
GYNECOID & ANTHROPOID = BEST
Passage (way)
Ability of pelvis & cervix to accommodate passage of fetus
Passenger
The ability of fetus to complete the birth process
Suboccipitobregmatic
Smallest diameter of fetus’ head
Molding
Cranial bones overlap under pressure of the powers of labour and demands of unyielding pelvis
Passenger components
Fetal:
- attitude
- lie
- presentation
- position
- station
Fetal Attitude
Relationship of fetal parts to one another
- Head can be Extended, brow or flexed
Optimal Fetal Attitude
FLEXED
Fetal Lie
Relationship of fetal spine (cephalocaudal axis) to maternal spine (cephalocaudal axis)
- Longitudinal, transverse, oblique
Optimal Fetal Lie
Longitudinal
Fetal Presentation
Determined by fetal lie and body part of fetus that enters pelvic passage first (presenting part)
Cephalic Presentation
HEAD (vertex, brow, face, chin)
Breech Presentation
Buttocks (Complete, frank, incomplete)
Shoulder presentation
Oblique or transverse lie - CANNOT deliver vaginally
Compound Presentation
> 1 part of body coming out (ex. hand on head)
Fetal Position
Position of Fetus in relation to the pelvis (R=right, L=left, O=occiput, S=sacral, M=mentum)
Optimal Fetal Position
ROA and LOA
Fetal Station
Relationship of presenting part to imaginary line drawn between ischial spines of maternal pelvis
Head at “0” = engaged
Engagement
Presenting part at “0” = engaged
Largest diameter of presenting part reaches or passes through pelvic inlet
Powers
Characteristics of contractions & effectiveness of expulsion methods
PRIMARY AND SECONDARY
Primary Powers
Uterine Muscular Contraction
Secondary Powers
Use of abdominal muscles to push during second stage of labour
How to Assess Contractions?
Frequency (interval)
Duration (length)
Intensity (strength)
Resting tone
Assessing Frequency of Contractions
From start of one to start of next, reported in minutes or # of contractions/10 mins
What is normal frequency of contractions
2-3mins = as close as they should be (5 in 10 mins)
Assessing duration of contractions
From start to end (reported in seconds)
Assessing intensity of contractions
Weak, Moderate and Strong
- non-invasive: palpate (subjective)
- invasive: IUPC (objective)
Why assess resting tone between contractions?
Need to know if it FULLY relaxes due to decreased fetal perfusion during contractions
Position (materal)
Certain maternal positions can promote comfort and enhance progress
Repeated position change is often helpful
Premonitory Signs of Labour
Lightening
Braxton Hicks
Vaginal Mucous increase
Cervical Changes
Bloody Show
Rupture of membranes
Sudden energy burst
Loss of 0.5-1kg
Diarrhea, indigestion, N/V
Lightening
Fetus engaged, descended into pelvic inlet
Braxton Hicks
“tighten”, intermittent, irregular.
Increase closer to term, painless, no cervical change
“False Labour”
Prodromal labour (irregular, does not progress, felt at the FRONT of abdomen)
Cervical Changes
Cervix begins to soften and weaken
Bloody Show
Loss of cervical mucous plug
Rupture of membranes
Usually, labour starts within 24hours after this.
First Stage of Labour
Early/Latent
Active
Transition
Early/Latent Phase
Cervix dilates 0-3cm
Regular, mild contractions begin and increase intensity and frequency
Active Phase
cervix dilates 4-7cm
Contractions increase intensity, frequency and duration
Fetus descends into pelvis
Transition Phase
Cervix dilates 8-10cm
Contractions increase intensity, duration and frequency
Fetus descends rapidly into birth passafe
N/V, diaphoretic, increased bloody show
Second Stage
“PUSHING”
Cervix fully dilated to delivery of infant
use of intra-abdominal pressure to push
Perineum bulge, flatten, move anteriorly
Crowning - head visible, does not retract between contractions
Third Stage
Delivery of infant to delivery of placenta
Strong uterine contractions
lengthening of cord
Slight blood loss
Uterus smaller, rounder, firmer, fundus rises in abdomen, harder and increased mobile
Pressure to bear down
Placental separation and delivery
Fourth Stage
1-4hrs after delivery of placenta
Increased pulse, decreased BP due to redistribution of blood
Uterus contracted between umbilicus and symphysis pubis
Shaking chill
Urinary retention r/t decreased bladder tone and possible trauma
CV changes of Labour
Decreased BP in each contraction, may increase with further pushing
Resp changes in Labour
Increase oxygen demand and consumption
Mild resp acidosis can occur
GI/GU Changes in Labour
Edema in bladder due to pressure from fetal head
Delayed gastric motility and gastric emptying
Hematological and Immune
WBC increases, blood glucose decreases
Initial Assessment of Labouring Client
Due date? # of pregnancies? Contractions? Baby activity? ROM or bleeding? Complications? Allergies?
Baseline Assessment of Labouring Client
FHR
BP, TPR
Contractions
Cervix
Membranes
Bleeding
Edema
Other Anomolies
Weight change
Assess urine (glucose, ketones, proteins, UTI)
Laboratory Assessment of labouring client
CBC, infection, blood dyscrasia or coags, serologic testing, blood type, Rh and antibodies, HIV, Hep B&C, Ultrasounds, GBS, diabetes
Characteristics of NORMAL labour
Frequency: no more than q2mins
Duration: less than 90 seconds
Intensity: IUPC - 25-75/80mmHg above baseline
Resting Tone: uterus soft between contractions for min 30 sec or 7-25mmHg with IUPC
Tachysystole
Frequency: >5 in 10 mins
Duration: > 90sec
Resting tone: resting period of < 30 seconds or remains firm on palpation b/w contractions
Assessing dilation and effacement
Sterile Vaginal Examination (SVE)
- Membrane status
- amniotic fluid
- fetal position
- station
Dilation
Opening of cervix
Complete dilation - 10cm
Effacement
Thinning of cervix (0-100%)
Muscles of upper uterine segment shorten, causes cervix to thin & flatten
Can occur before labour (primiparous/multiparous) or during labour (multiparous)
ROM
Rupture of Membrane
SROM
Spontaneous rupture of membrane
AROM
Artificial rupture of membrane (amniotomy)
PROM
Premature rupture of membrane (pre-term)
PPROM
Preterm Premature rupture of membrane
Goal of comfort measures and labour support
Promote relaxation
Doula
Not medically trained, provides emotional support and comfort in labour and delivery
Indigenous birth support worker
Trained midwives, reserved for Indigenous patients but can help out with others. Always 1 available on shift.
Registered Midwife
Specialist in normal births, medically trained. Only 12 in SK
5 Categories of labour support
- Physical
- Emotional
- Instructional/Informational
- Advocacy
- Partner/Coach care
PAIN
Physical sensation
SUFFERING
Emotional reaction, should be NONE in childbirth
3 R’s of Labour
Relaxation
Rhythm
Ritual
Mental Activities in Labour
distraction, meditation, imagery, non-focused awareness, hypnosis
Basic Needs in Labour
Hygiene, eat/drink, clean up bed, mouth care, peri-care, lip balm
Heat and Cold in Labour
Preference of the client - water at temp they life, magic bag/hot water bottle, ice pack, bath
Simkin Breathing
- Slow (Slow paced)
- Light (modified paced)
CLEANSING BREATH = most important
Massage Techniques in Labour
- Double hip squeeze
- criss-cross - back massage
- break popsicle stick - hand massage
- head, back, neck, feet - preference of client
Hydrotherapy in Labour
shower or tub/whirlpool during labour
Benefits of Hydrotherapy
Decreased pain and anxiety, warmth, buoyancy, decreased perineal trauma, recommended by research
Risks of Hydrotherapy
Hypo/hyperthermia, HR changes, fetal tachy, unplanned water birth
Why is position change important during labour?
- Promote circulation and relaxation
- Promote contraction
- changes pelvic shape
- relieve discomfort
- provide distraction
- increase fetal oxygenation
- COMFORT
Benefits of birthing/peanut ball
Increased balance
Counter pressure on perineum
- ease back pain
- widens pelvic outlet
Other comfort measures in labour
acupuncture
acupressure
aromatherapy
TENS (transcutaneous electrical nerve stimulation)
Sterile water injection (for back pain)
Environment for labour
- dim lights
- peaceful surroundings, talk quietly
- privacy, avoid interruptions
- temp - adjust to pt preference
- music
- encourage personalization
- safety
Nitrazine Swab
To confirm rupture of membranes (blue = pos, yellow = neg)
Intermittent Auscultation (IA)
for low-risk women, findings classified as normal or abnormal. Allow mom to move around, use doppler to assess FHR
Electronic Fetal Monitoring (EFM)
For women at risk of adverse outcomes, findings classified as normal, atypical, and abnormal.
Normal FHR
Rate: 110-160
Regular Rhythm
Accelerations
Steps of starting EFM
Leopold’s first
Palpate radial pulse (compare MHR to FHR)
Put baby monitor on back of baby
Put contraction monitor on top
FHR - Tachycardia
Rate above 160bpm for longer than 10 mins
FHR - Bradycardia
Rate below 110 for longer than 10 mins
FHR Variability
Fluctuations in baseline FHR/minute (not accels or decels) - amplitude of peak to trough in bpm
Absent variability
A = undetectable
Minimal Variability
MN = < 5 bpm
Moderate Variability
NORMAL
MD = 6-25bpm
Marked Variability
MK = >25 bpm
Sinusoidal
FHR pattern that is smooth, repetitive sine wave-like pattern that persists for > 20 mins, amplitude of 5-15 bpm, and frequency of 3-5 cycles/min
Accelerations
Abrupt (<30sec) increase in FHR at least 15 bpm above baseline for at least 15 seconds and < 2 mins
NORMAL, but not necessary
Accelerations in < 32 wks
10 bpm above baseline for 10 seconds
Decelerations
Decrease in FHR that is abrupt or gradual and termed early, late, or variable (categorized by abruptness and relationship to contractions)
Variable Decelerations
CORD COMPRESSION
visually apparent ABRUPT FHR < 15 bpm below baseline for > 15 seconds
Can be periodic or episodic
Can be complicated or uncomplicated
Early Decelerations
HEAD COMPRESSION
gradual decrease in FHR associated with uterine contraction (mirror)
Late Decelerations
UTEROPLACENTAL INSUFFICIENCY
gradual decrease in FHR AFTER the contraction
Fetal acidemia
ATYPICAL (intermittent) or ABNORMAL (recurrent)
Prolonged Decels
Profound changes
Visually apparent decrease in FHR below baseline > 2 mins but <10
Profound change in fetal environment, increased chance of fetal hypoxia
Full Normal EFM Features
Normal Contraction Pattern
110-160BPM
Moderate variability (<5 for < 40min)
Accelerations present (not required)
Decelerations (absent, early or variable if non-repetitive and uncomplicated)
Atypical or abnormal EFM features
Bradycardia (<110)
Tachycardia (>160)
Absent, minimal, or marked variability
Reccurent LATE decels
Complicated or repetitive variable decels
Intrauterine Resuscitation nursing interventions
Reposition, decrease oxytocin, maternal VS, correct hypotension, admin IV fluids, pause/modify pushing efforts, vaginal exam, tocolysis (to relax uterus), initiate EFM, oxygen
Main Physiologic changes in post-partum
uterus involutes, lochia, breasts begin milk production, intestines sluggish for a few dats, ovarian function and menstruation retun in 6-12wks in non-lactating mother
BUBBLEES
Breasts
Uterus
Bladder
Bowels
Locia
Epistiotomy/Laceration/Perineum
Emotions
Signs (vitals, pain)
Bubblees (B)
Breasts:
assess nipples for soreness, comfort, bruising, blisters, inversion
assess breasts for softness, filling, engorged
assess signs of mastitis (red streak/spot, soreness, warm/tender spot, malaise)
How to avoid stimulation of nipples
Wear a tight bra, cabbage leaves in bra, ice packs
bUbblees (U)
Uterus:
Involution - rapid decrease in size of uterus to non-pregnant state
What impedes involution?
Overdistension (large baby, polyhydramnios, multiples, # pregnancy)
Exhaustion (long labour, induction)
Retained placental fragments/membrane shreds
What enhances involution?
Oxytocin (from breastfeeding), fundal massage, complete expulsion of placenta, early ambulation
Fundal Position PP
At level of umbilicus PPD1, gradually moves down
Afterpains
Involution contractions (increase with number of labours)
pain in breastfeeding (due to oxytocin release)
fundus should not be painful to palpate
Diastasis Recti Abdominus
Stretching/space in abdominal muscles
Assessing Fundus in C section or tubal ligation
Palpate abdomen (gently)
Should be some non-operative pain (generalized)
Uterus/Abdomen Documentation
Height, firmness, position, incision, musculature, interventions
buBblees (B2)
Increased bladder capacity, decreased sensation, effect of anesthetic, increased swelling/bruising, PP diuresis = Risk of UTI
bubBlees (B3)
Bowels: bowel sounds for c/s
BM might now happen for 2-3 days
Elimination pattern returns in 1 wk
SE: constipation, hemorrhoids, flatulence
bubbLees (L)
Lochia (vaginal flow)
Normal: heavy flow expected immediately after and then heavy is 1pad/hr, moderate is <6”/hour, light is < 4”/hr, scant is < 1”/hr
What increases Lochia flow?
Ambulation
Fundal Massage
Abnormal Lochia
Foul smell, large clots, heavy flow, reappearance of red lochia, lasts more than 4wks
Rubra
PP days 1-3
- dark red blood
- fleshy, musty, stale odor
- clots < loonie
- persistance of rubra indicates sub-involution
Serosa
PP days 3-10 days
- pinkish brownish (serous)
Alba
PP days 10-24 days
- yellow to white
- may last up to 6 wks
Lochia Documentation
Type, quantity, odor, clots, hygiene, intervention
bubblEes (E1)
Episiotomy: surgical incision to prevent soft tissue damage during delivery
Vaginal/Perineal Lacterations
first degree tear
skin torn just below vaginal opening
second degree tear
muscle torn below vaginal opening
third degree tear
anal sphincter torn
fourth degree tear
rectum torn
Hemorrhoids
present in pregnancy or develop with labour and/or pushing
ice/frozen pad, tucks, analgesics
Hematoma
Perineum as soft tissue offers little resistance (250-500mls of blood) relentless pain = cardinal sign
ice can prevent
Perineal Care PP
Peri wash bottle, wipe front to back, change pads frequently, sitz bath, ice packs/pads, pain meds
Perineal Tone - Kegel exercises
strengthen pubococcygeus muscle
- improves support to pelvis organs
- compare to elevator (1-4 floors)
- stop the flow of urine (uses that muscle)
Perineum Documentation
Intact, episiotomy, laceration, hemorrhoids/hematoma, hygiene, interventions
bubbleEs (E2)
Emotional
Taking-in: PPD 1-2 (pre-occupied with own needs, tells story, explores infant)
Taking-Hold: PPD 2-3 (ready to resume control, eager to learn, rapid mood swings)
Letting go: (infant as unique person, allows others to care)
Bonding
Process by which parents form emotional relationship with infant
Postpartum/Baby Blues
“normal” transient response in up to 75% of women (PPD 3-5) and resolves spontaneously in a few weeks
due to decrease estrogen and progesterone
Care for PP blues
recognition, reassurance, education, awareness of blues as a risk factor for PP depression
Pinks of PP
Mild elation/euphoria hours/days after birth
normal - but may be a warning sign
Postpartum depression
Up to 20% of people with PP blues goes on to develop postpartum depression
Use edinburgh postnasal depression scale
Postpartum psychosis
rare - 1/1000 live births, emergency!
bubbleeS (S)
Signs: vital signs, pain, signs of DVT (pain, pallor, paralysis, pulse, paresthesia, perfusion, polar)
C/S Monitoring
Foley: observe flow and urine output
IV: monitor
DB&C
Early ambulation
Sedation score
Analgesia
Rh neg PP assessment
Mom may get WinRho ONLY if baby positive
Rubella assessment
If non-immune offer vaccine, advise not to get pregnant for 3 months
Hgb PP
1st day PP
anemia
Nutrition assessment PP
at least 200 calories more if breastfeeding
Recurrence of ovulation & menstruation
non-lactating: 6-8wks, delayed but not reliable birth control
exclusive breast feeding: longer than this
Progestin only BC
recommended as safe for BF and less risk of VTE
Combination estrogen-progestin
not recommended until after 6 wks (increase risk of VTE)
Common PP complications
Hemorrhage, infection, depression, thrombophlebitis/DVT
PP symptoms to report
vaginal flow (foul smelling, heavy, clots), chills or fever, constant lower abdomen pain, pain/burning/insufficient urination, redness/swelling/pain in leg, SOB or CP, headache or problems seeing, tender red area in breast, CS incision hot, red, painful, draining
Priority needs of the newborn
Respirations, extrauterine circulation, control of body temp, nutrition, waste elimination, prevent infection, parent-infant relationship, developmental care
Adaptation of Newborn: Respiration
Production of lung fluid decreases before labour
Epidural Complications
HYPOTENSION, fetal bradycardia, headaches, bladder dysfunction, decreased ambulation, decreased ability to push, pruritis/tremors, N/V, neuro problems, failed block
Contraindications for Epidural
Pt refusal, bleeding, sepsis, spinal injury, sensitivity to local anesthetics, unavailable personnel/equipment
Epidural
Anesthetic and/or analgesic (morphine or fentanyl), injected into the epidural space
Nursing care for epidural
VS & FHR baselines, IV access & bolus (500-1000mls), BP/P q5mins x 20 mins, sensory level (30-60mins), motor function q1h, bladder function
Spinal Block
Local, quick onset, longer duration
Pudenal Block
Local into pedunal nerve (local to vagina, vulva, and perineum)
Local infiltration
local into perineum pain relief
General Anesthesia
Quickest for emergency (increased risk)
General Anesthesia Complications
fetal depression, uterine relaxation, vomiting, aspiration, difficult/failed intubation
Neonatal Resuscitation Pre-Delivery
gestational age, clear amniotic fluid, risk factors, umbilical cord management/pain
Neonatal resuscitation Time of Birth
Term gestational age, good tone, breathing/crying
APGAR
Appearance
Pulse
Grimace
Activity
Respirations
Apgar (A1)
Appearance/color: 2= completely pink, 1= acrocyanosis, 0=pale/blue.
aPgar (P)
Pulse/HR: 2= >100, 1= <100, 0= absent
apGar (G)
Grimace/irritability: 2= vigorous cry, 1=. grimace, 0= none
apgAr (A2)
Activity/muscle tone: 2= well flexed/active movement, 1= some flexion, 0= flaccid
apgaR (R)
Respirations: 2= good crying, 1 = slow-irregular, 0= absent
Arterial Cord Blood
Deoxygenated
Venous Cord Blood
Oxygenated
Metabolic Acidosis Characteristics
pH < 7.0, base excess >12mEq/L & APGAR < 3 for 5 mins = increased risk of anoxia brain damage
Normal Venous & Arterial pH
V: 7.30-7.35, A: 7.24-7.29
Normal pO2
V: 28-32mmHg A: 12-20mmHg
Normal pCO2
V: 38-42mmHg A: 45-50mmHg
Normal Base deficit
V: 5mEq/L A: 10mEq/L
Normal Newborn Temp
36.5-37.5
Normal Newborn HR
110-160
Normal Newborn resp rate
30-60
Normal Newborn BP
50-75/30-45
How to open up a newborns airways
Tick them off to make them cry to open alveoli
Signs of Resp distress in newborns
tachypnea, cyanosis, grunting/cooing, nasal flaring, retractions/indrawing, accessory muscle use, poor feeding, apnea
Why are infants at greater risk for heat loss?
Large head, increased SA, less adipose tissue, brown fat, decreased ability to shiver
Non-Shivering thermogenesis (BAT)
Primary source of heat in hypothermic newborns
Heat loss in Newborns
evaporation: wet with amniotic fluid
convection: body heat into cooler air
radiation: cold objects near incubator
conduction: cold stethoscope
Risks of insufficient thermo regulation in newborns
fist 8-12hrs of life, premature, SGA, CNS problems, increased resuscitation efforts, sepsis
Cold Stress
Acrocyanosis, pallor, tachypnea, tachycardia, fussiness/irritability, no shivering
Prevention of Cold Stress
23-25 degrees in labor room, dry quickly, hat, warm blankets, STS, warmer, keep away from drafts, warm scale/stethoscope, guard against hyperthermia
Normal Newborn Glucose
2.2-6.0mmol/L
Infants at risk for Hypoglycemia
SGA, LGA, diabetic parent, premature, stressed/sick/cold
Symptoms of Hypothermia in newborns
jittery/tremors, apathy, cyanosis, convulsions, apneic spells or tachypnea, weak/high-pitched cry, limpness, lethargy, difficulty feeding, eye rolling, sweating/sudden pallor, cardiac arrest
Treatment for asymptomatic hypoglycemia
feeding interventions (increased breastfeeding frequency and supplement with formula)
Treatment for symptomatic hypoglycemia
<2mmol/L - IV infusion of glucose, target CPS > 2.6mmol/L
Vitamin K
To prevent hemorrhagic disease
- 1mg IM within 6hrs of birth
- newborn lacks intestinal flora needed for vitamin K production
- Prothrombin low during 1st few days of life
- risk of hemorrhage
Erythromycin ointment
prevent opthalmia
- apply inner to outer conjunctival sac
- 2hr delay or within 1hr of birth
- both eyes, single application tube
Newborn Behavior patterns (1st period)
REACTIVITY
- 30-120mins of life
- awake & active
- appears hungry (strong reflex)
- start breastfeeding
- encourage en-face
- VS evaluated
Newborn Behavior patterns (2nd period)
DECREASED RESPONSIVENESS (sleep)
- after 30-120mins, activity decreased
- HR & RR decrease as baby sleeps
- difficult to wake, decreased sucking
Newborn Behavior patterns (3rd period)
REACTIVITY
- last 2-8hrs
- HR & RR increase, alert for apneic periods
- passes meconium, voids, sucks, roots, swallows
General Newborn Care Order
- VS q1h for first 4 hrs, q4h for 24-48hrs, then BID
- head to toe BID
- wt at birth and before discharge
- I&O - feeds and diapers
- cord care: air dry, falls off 5-15 days, r/o infection
- bilirubin screen at 24 hrs (TCB first)
- facilitate family’s effort to care NB
Overall Assessment of newborn
- color: pink, acrocyanosis, pale, jaundice
- skin: dry, anomalies
- tone: flexed, limp, free movement, # of digits, palm creases
- cord: clamped (moist, drying), care, DRY
- Fontanelles: open/sunken/bulging
Anterior Fontanelles
Diamond shape, ossified at 9-18months
Posterior Fontanelles
Triangle shape, ossified at 8wks
Cephalohematoma
Collection of blood between cranial bone and periosteal membrane
cause = hemorrhage, does not cross suture lines
Caput succadaneum
Collection of fluid and edema on scalp
cause = pressure or truama, crosses suture lines
Newborn Eyes (visual)
placement relative to ears, subconjunctival hemorrhage (10%), tearless x2 months, follow stimuli for short periods, immature muscular control x 3months
Newborn Mouth (Taste)
palate, tongue (frenulum - ankyloglossia, TOT), precocious teeth, epstien’s pearls, selective response to tastes
Newborn Ears (auditory)
Ear cartilage recoil, pre-auricular skin tags, alert and react to stimuli, habituation, hearing screening
Newborn Nose (olfactory)
preferential nose breathers, patency of nares, can identify people by smell
Newborn Reflexes
sucking, rooting, grasping (palmar & plantar), moro (startle), tonic neck (fencing), babinski, stepping, galant
Newborn Bath
Basin, low water level, test temp with elbow
Have all supplies ready to go
2 consecutive temps of 37
work from clean to dirty
DRY WELL, STS right after
Stools in Newborns
1) meconium (48hrs)
2) transitional stools (thin, brown to green)
3) breastfed infant (yellow gold, soft, seedy, mushy, after 2-3 days)
4) Formula fed infant (pale yellow, formed and pasty)
Newborn Voiding
Bladder capacity = 6-44mls
6 per day for 6 days
Brick Urine
NORMAL in first week
Induction
The initiation of contractions in the pregnant patient NOT in labor
Augmentation
Enhancement of contractions in the pregnant patient already in labor
Cervical Ripening
Use of pharmacological other means to soften, efface, and/or dilate the cervix to increase likelihood of vaginal delivery when induction is indicated
Indications for induction
Post term pregnancy (41+weeks), HTN, DM, maternal disease not responding to treatment, stable antepartum bleeding, chorioamnionitis (infection), oligohydramnios, fetal compromise, Rh isoimmunization, IUGR, PROM (esp is GBS+), intrauterine fetal death, advanced age, logistical concerns
Maternal Risk of Post Term
Placental “expiry date”, starts to shrivel/die
Fetal risk of post term
large babe, complicated labor
Cautions for Induction
Grand multiparity (faster labor), vertex not fixed in pelvis (worried about cord & head position), brow or face presentation, over distension of uterus, lower segment uterine scar, pre-existing hypertonus, prior difficulty in delivery, availability of C-section delivery
Contraindications to Induction: Placental
Complete placenta previa
Contraindications to Induction: Cord
Presentation/Prolapse
Contraindications to Induction: Fetal malpresentation
Transverse lie, breech
Contraindications to Induction: History
Previous uterine surgery/C-section
Pelvic abnormalities/absolute CPD
Active genital Herpes
Gyne/Obs/Medical Conditions
Contraindications to Induction: Convenience
Lack of consent from patient
Bishop’s Scoring System
A cervix that is soft & effaced is the MOST important factor for successful induction
- Dilation (cm)
- Position of Cervix
- Effacement (%)
- Station (-3 to +3)
- Cervical Consistency
Unfavourable = <6
Preventing Induction of Labor
Nipple stimulation, Sexual intercourse, acupuncture, enema, herbal supplements, stripping/sweeping membranes
Methods of Inducing Labor
Amniotomy (ARM/AROM), mechanical dilation (foley, ripening balloon, laminaria/seaweed), pharmacological, stripping/sweeping of membranes
Stripping/Sweeping of Membranes
Mechanical separation of membranes from cervix or uterus, NO monitoring or other assessments, not used for induction when there are high priority indications
Amniotomy - AROM
Augment or induce labor, committed to delivery, apply internal fetal or contraction monitors, or to obtain fetal scalp blood sample for pH monitoring
Prostaglandin
Prostin: into posterior fornix of vagina
Cervidil: into posterior fornix - continuous slow release
Misoprostol/Cytotec: 50mcg orally or 25mcg vaginally
Advantages of Prostaglandin
Less invasive, more physiologically similar to labor, simple administration
CAN go home on cervidil
INDUCTION use, not augmentation
Oxytocin Infusion
Syntocinon/Pitocin
For INDUCTION and AUGMENTATION
half life 1-6mins
Protocol: gradual increase > 30min increments
Oxytocin Induction - Nursing care
Continuous observation by an RN as per facility protocol
Contractions and FHR q15min/maternal VS q15-30min
Tachysystole
Excessive uterine activity often with atypical or abnormal FHR tracing
- >5 contractions in 10 mins
- resting periods b/w contractions < 30 sec
- high resting tone
- contraction lasting more than 90 seconds
Tachysystole (uterine hyperstimulation)
Can cause placental abruption, fetal hypoxia, precipitous delivery, PP hemorrhage/uterine atony
Tachysystole (uterine hyperstimulation): Nursing care
Re-position to left lateral, side to side, or knees to chest
Reduce uterine stimulation (decrease or stop oxytocin, remove cervadil, swab prostin)
monitor, administer tocolytic if needed
O2 and IV bolus if needed
Complications of Induction and Augmentation
INCREASED RISK FOR MOM AND FETUS
failure to establish labor
tachysystole
chorioamnionitis
Uterine rupture
PPH/blood transfusion/hysterectomy
Placenta implantation abnormalities in future pregnancies
Longer hospital stay
Increase r/o assisted vaginal birth or C/S
adverse neonatal outcomes associated with iatrogenic preterm or early term birth
After Delivery of induction or augmentation
risk of PPH/PP atony is increased with induction
Watch for signs of PPH
Consider continuous infusion of oxytocin titrated to fundus/flow
4 Causes of Dystocia
Problems with Powers
Problems with Passenger
Problems with the Passageway
Problems with Psyche
Problems with Powers (dystocia)
Hypertonic uterine dysfunction
Hypotonic uterine dysfunction
Precipitate Labor
Problems with the Passageway (Dystocia)
Pelvic contraction
Obstructions in maternal birth canal
Problems with Passenger (dystocia)
Breech/shoulder dystocia, cord prolapse
Persistent occiput posterior position
Face or brow presentation
Macrosomnia
Problems with Psyche (dystocia)
Psychological distress
Labor Dystocia interventions
Non-progression in active labor
amniotomy and pharmacologically (oxytocin)
Hypertensive Disorders of Pregnancy
Pregnancy Induced Hypertension (PIH)
Gestational Hypertension (GH)
Pre-Eclampsia
Toxemia
Incidence = 10%
Risk Factors of gestational HTN
Nullipara or first pregnancy
hx of pregnancy with HTN/preeclampsia, hx of chronic HTN/CKD/SLE, poor nutrition, obesity, advanced maternal age, multiple gestation, pre-gestational diabetes, previous stillbirth/IUGR/abruption
Chronic HTN
HTN that develops either before pregnancy or at <20 weeks
Gestational HTN
Systolic >140mmHg and/or Diastolic > 90mmHg
>20 weeks and up to 12 weeks PP
Severe HTN
Systolic > 160mmHg and/or dialstolic > 110mmHg
Preeclampsia
Systolic > 140mmHg and/or diastolic > 90mmHg
Proteinuria (2+ or greater) or 1 or more adverse conditions or severe complications
Eclampsia
Seizure
Adverse conditions of HTN
Headache, visual disturbances, abdominal/epigastric/RUQ pain, N/V, chest pain/SOB, abnormal maternal lab values, fetal morbidity, edema/wt gain, hyperreflexia
Severe Complications of Preeclampsia: Maternal
Stroke, pulmonary edema, hepatic failure, jaundice, seizures, placental abruption, acute renal failure, HELLP syndrome and DIC
Fetal Consequences of Preeclampsia
IUGR, oligohydramnios, absent or reversed end diastolic umbilical artery flow by doppler, prematurity (iatrogenic), fetal compromise (metabolic acidosis), intrauterine death
Preeclampsia Etiology - Multi-organ involvement
Abnormal placentation OR excessive fetal demands
Mismatch b/w uteroplacental supply and fetal demands (decreased plasma volume/vasospasm)
Maternal & fetal manifestations of Preeclampsia
Prevention of vasospasm and hypoperfusion
Low dose aspirin starting pre-pregnancy or before 16wks for increased risk patients
Calcium supplementation for all clients with low dietary intake of calcium (,900mg/day), oral calcium supplementation of at least 500mg/day is suggested
Lifestyle change (exercise and dietary)
Initial mgmt of vasospasm and hypoperfusion
assessment of pregnancy client and fetus, stress/activity reduction, treat BP with antihypertensives, treat symptoms (N/V, epigastric pain), consider seizure prophylaxis
Home-Care mgmt if non-severe HTN
Client monitors own BP
Measures weight and tests urine protein daily
NST’s performed daily or bi-weekly
Advised to report signs of adverse conditions
mgmt if severe HTN/preeclampsia
Fetal eval (movement counting, NST, biophysical profile, ultrasound, measurement of AFI, serial U/S to assess growth, umbilical artery doppler flow)
Hourly I&O
Frequent BP, pulse and resps
Blood work (liver enzymes, plateletes, Hct)
Monitor adverse conditions
HTN medications
Labetalol
Nifedipine (adlat) - Ca channel blocker
Hydralazine (apresoline) - arteriolar dilators
Aldomet (methyldopa) - centrally-acting syympatholytic
What Medications for HTN cannot be used in pregnancy
ACE inhibitors
Magnesium Sulfate MgSO4
Tachycardia, NB to test reflex, monitor urine output, can slow labor, muscle weakness, lack of energy/drowsiness, resp depression, lower BP
Magnesium Toxicity
CNS depression (resp rate < 12, Oliguria <30mls/hr, diminished or absent DTR, serum magnesium 4.8-9.6mEq
Antagonist: vitamin A
Eclampsia Treatment: Medications
Anticonvulsants (bolus of magnesium sulfate)
Sedation and other anticonvulsants (dilantin)
Diuretics to treat pulmonary edema (furosemide/lasix)
Digitalis (for circulatory failure)
HELLP Syndrome
Hemolysis
Elevated Liver enzymes
Low Platelets
HELLP syndrome patho
thrombocytopenia
- platelets aggregate at sites of vascular damage (need to admin platelets if < 20)
Epidural anethesia may not be an option
Disseminated Intravascular Coagulation (DIC) Causes
Can be cause be preeclampsia, hemorrhage, intrauterine fetal demise, emniotic fluid embolism, sepsis, HELLP
Disseminated Intravascular Coagulation (DIC)
Over-activation of normal clotting mechanism - mini clots develop and platelets and clotting factors deplete
= EXCESSIVE BLEEDING
Gestational Diabetes Incidence
Incidence b/w 3-20%, 3.5% of non-aboriginal women and up to 18% of aboriginal women
How does pregnancy alter carbohydrate metabolism 2 ways in
- fetus continually takes glucose from mother
- placenta creates hormones, which alter effects of and resistance to insulin and glucose tolerance
Carbohydrate metabolism: first trimester
rise in hormones stimulate insulin production & increase tissue response to insulin (insulin sensitivity)
Carbohydrate metabolism: second and third trimester
Placental secretion of hPL begins
increased resistance to insulin to facilitate transfer to fetus for growth
Insulin needs increase (double or triple)
More insulin required to maintain normal concentration
Gestational Diabetes: Pregnancy/Maternal effects
Preeclampsia/eclampsia increase due to vascular damage
Polyhydramnios, PROM
Preterm labor
r/o shoulder dystocia
r/o C/C
Worsening myp
