Orientation (August 23)

Dr. Booth

205-454-6040

Carruth (Northport)

205-242-9768
First day meeting at 6:20am
Park outside Women’s pavilion or ED
Do not park outside Fitness One
Tuesday and Wednesday

Dr. Woods

205-454-6419

Johnson (St. Vincent’s)

817-614-5666
Tuesday 3-11pm
Friday 7-3pm

Turner

Tuscaloosa DCH, meet at 6:45am, Tuesday and Wednesday

205-292-4891

Sherpath Course ID

158049_ltubbs8_1002

Clinical

Four hospital days

One outside clinical experience
Fill out (HIPAA) form for community site

Chapter 17 and 18: Postpartum Physiologic and Psychosocial Adaptations

Postpartum: the first six weeks after childbirth

Every body system of the woman goes through changes, not just the reproductive
system

Reproductive System

Involution of the uterus (involution: the uterus returning back to pre-pregnancy

size, shape, and location)
Three processes
Contraction of the muscle fibers
Also referred to as “afterbirth pains”
Helps decrease hemorrhaging immediately following childbirth
Nurses can help this process with uterine massage
Palpating for a hard, firm uterus that is able to clamp down
and prevent hemorrhage
Education is important because the massage can also be
painful
Breast feeding will also help
Oxytocin or Pitocin IV medication will aid in firming of the
uterus, as well
Catabolism: converting cells into simpler, more basic compounds
Regeneration of uterine epithelium
The site of placental attachment heals by a process of exfoliation
Leaves the endometrium smooth and without scars

Descent of the Uterine Fundus

Fundus: the term for the top of the uterus

Involution can be evaluate by measuring the descent of the fundus
About 1 cm per day
About one finger-breadth down
Note: “U-2” means two finger-breadths below umbilicus
Note: “U+2” means two finger-breadths above umbilicus
It may be above due to a blood clot or a full bladder
14 days after childbirth, the fundus should no longer be palpable
The day of delivery, the uterus will be approximately at the umbilicus and
needs to go back down to sitting in the pelvis
During uterine massage, be sure to support lower abdominal muscles to
avoid prolapsing the uterus out of the vagina
Afterpains, or intermittent uterine contractions, cause discomfort for many
women
 A “mushy”, not-firm uterus should be massaged extra until it becomes firm, in
order to decrease bleeding

Lochia

Lochia: bleeding after delivery

Vaginal discharge
Lochia rubra: bright red discharge immediately after delivery
Lochia serosa: serosanguineous pink/brown tinge
Lochia alba: lighter white/yellowish color
Assessment
Color
Amount, type, and odor
Foul odor suggests endometrial infection

Ask about size of any clots being passed, continue to massage uterus, etc.
It is normal to bleed on and off for several weeks after delivery, but women
should notify physicians if bleeding returns to bright red
Bleeding on a peri-pad:
 Women should use these external pads, and not tampons, especially if
they have stitches on their perineum
Moderate: women may describe this as “having a normal period”
Heavy: saturating a pad in an hour

Vagina and Perineum

Vagina
It takes 6-10 weeks for the vagina to regain its non pregnant size and contour
Perineum
After childbirth, it may be edematous and bruised
Episiotomy or trauma
Episiotomy is when the physician will cut open the perineum to give the
baby more room, and then stitch it up after delivery
Any perineal stitches will be dissolvable and disappear on their own in
about 6 weeks or so
Healing takes up to 4-6 months
Use the acronym REEDA
Redness, edema, ecchymosis, discharge, approximation of edges (for
episiotomy or laceration)

Lacerations of the Birth Canal

Perineum
Perineal lacerations are classified in degrees to describe the amount of tissue
involved
First-degree: involves superficial vaginal mucosa or perineal skin
Second-degree: involves vaginal mucosa, perineal skin, and deeper
tissues, which may include fascia and muscles of perineum
Third-degree: same as second-degree lacerations but involves the anal
sphincter
Fourth-degree: extends through the anal sphincter into the rectal mucosa
Episiotomy is physician-made, while a laceration is a naturally-occurring tear
Periurethral area
 A laceration in the area of the urethra may cause women difficulty urinating after
birth
An indwelling catheter may be necessary for a day or two
Vaginal wall
A laceration involving the mucosa of the vaginal wall
Cervix
Tears in the cervix may be a source of significant bleeding after birth
Uterine massage with a firm uterus but still extensive bleeding, may
indicate a cervical tear

Providing Comfort Measures (for swelling, edema, and bruising)

Ice packs
Sitz baths
Perineal care
Topical medications
Sitting measures
Analgesics

Cardiovascular System

Cardiac output
Transient increase in maternal cardiac output after childbirth
Excess plasma volume is eliminated by diuresis and diaphoresis
Gradually cardiac output decreases and returns to normal in 6-12 weeks
Coagulation
Increased clotting factors predispose the postpartum woman to clot formation
Check clotting factors prior to childbirth to be aware of any conditions
H/H following childbirth to make sure they haven’t lost too much blood
Average blood loss is 200-500 mL from vaginal delivery and 500-1000 mL from a
cesarian delivery
Replenish with IV fluids and the women are able to typically quickly
replenish themselves, too

Gastrointestinal System

Soon after childbirth, the woman has increased hunger due to energy expenditure
Constipation may occur due to
Decreased food and fluid intake during labor
Reduced muscle and bowel tone
Fear of pain during defecation
Patients placed on stool softeners to prevent pain with first bowel movement, in
addition to increasing fluids, fiber, and ambulation
Important to assess bowel sounds and passing gas
First stool is typically 2-3 days post birth
Urinary System

Increased bladder capacity and decreased sense of fluid pressure may result in urinary
retention
Stasis of urine allows time for bacteria to grow and can lead to urinary tract infection
Reminded patients (with epidurals) to go to the bathroom if they have decreased
sensation of full bladder
The distended bladder can displace the uterus and interfere with uterine contraction,
causing excessive bleeding as a result
Signs of a distended bladder
Location of fundus above baseline level
Fundus displaced from midline
Excessive lochia
Bladder discomfort
Bulge of bladder above symphysis
Frequent voiding of less than 150 mL of urine, may indicate urinary retention
with overflow
Woman may void 500-1000 mL at a time because the bladder fills rapidly
due to diuresis from hormonal changes

Musculoskeletal System

Muscles and joints

First 1-2 days after childbirth, muscle fatigue and aches
Especially from stirrup positioning, grasping handrails, contracting body for
pushing
Abdominal wall
Diastasis recti

Reduction in musculoskeletal discomfort

Exercises to strengthen the abdominal muscles
Good posture
Body mechanics

Integumentary System
 Skin gradually returns to non-pregnant state
Decrease in hormone levels
“Mask” pregnancy with dark marks on face will fade after childbirth
Stretch marks (striae gravidarum) fade
Do not disappear, though
Loss of hair
Normal response to hormone changes
Begins 4-20 weeks after delivery
Regrown in 6-15 months

Neurologic System

Discomfort and fatigue

Complaints of headache need careful assessment (where, pain scale, etc.)
Bilateral and frontal headache are common due to change in fluid and electrolyte
balance
Spinal headaches due to spinal anesthesia
If they are laying completely flat, they do not have a headache
When they sit up, the pain becomes excruciating (“worst headache ever”)
Treatment with caffeine can sometimes help
Blood patch treatment by anesthesia
The hole in epidural space before labor has caused spinal fluid to
continue to leak and cause the spinal headache
The physician will put another epidural in as you pull out 10 mL of
blood from antecubital space
He injects the blood into the epidural needle to clot and “patch” the
hole initially created
Headache should immediately subside with this treatment
Blurred vision, dizziness, photophobia, and abdominal pain may indicate
preeclampsia

Endocrine System

Hormones
Human chorionic gonadotropin is present for 3-4 weeks
Resumption of ovulation and menstruation
Breastfeeding may delay the return of ovulation and menses
Ovulation may occur before the first menses
Lactation
Prolactin initiates milk production within 2-3 days of the birth
Breastfeeding moms can not depend on lactation as birth control, because they
may ovulate during that time (even if they do not menstruate)

Weight loss
 Approximately 5.5 kg (12 pounds) is lost during childbirth
From the fetus, placenta, and amniotic fluid
Another 4 kg (9 pounds) is lost over the next 2 weeks
Another 2.5 kg (5 pounds) is lost by six months post delivery
Adipose tissue is used for energy expenditure during labor and breastfeeding
Breastfeeding moms may lose weight quicker

Immune System

Temperature
Not uncommon to have low grade temperature (less than 100) within the first 24
hours due to muscular exertion and exhaustion
Any fever of 100.4 or higher on several occasions is important for the physician
to know and evaluate for infection
Rho(D) immune globulin
Rh negative mother (i.e. A-, B-, O-) and develops antibodies to her Rh positive
baby (A+, B+, O+)
Any Rh negative woman will receive Rhogam injection around 28 weeks
IM injection in doctor’s office
This prevents the mother from becoming iso-immunized in case her baby
is Rh positive
If baby is Rh negative, everything is good
If baby is positive, the mother needs another Rhogam shot to prevent her
from developing antibodies for a future pregnancy (antibodies would
cause her body to attack the baby)
Immunizations
Will test for rubella and other disease immunity at prenatal appointments
If the mother is non-immune, they will vaccinate after childbirth before sending
the mom and baby home (while they are a postpartum patient)
Follow hospital policy for vaccine consent and educate woman on how long to
avoid additional pregnancy

Risk factors for Postpartum Hemorrhage

Grand multiparity
Pregnant many, many times (i.e. 19 kids and counting)
Overdistension of uterus (twins)
Rapid or prolonged labor
Retained placenta, placenta previa, or abruptio placentae
Medications (tocolytics or oxytocin)
Tocolytics slow down labor
Operative procedures (cesarean birth, vacuum extraction)
Preclampsia or coagulation defects

Risk Factors for Postpartum Infection

 Operative procedures (c-section, vacuum extraction, forceps)
Multiple cervical examinations
Once the water breaks, you want to do as few vaginal examinations as possible
Prolonged labor
Prolonged rupture of membranes (water breaking)
Manual extraction of placenta
Diabetes
Catheterization

Focused Assessment Following Vaginal Birth

Vital signs
Blood pressure
Orthostatic hypotension
Pulse
Respirations
Temperature
Pain
Fundus and lochia
Perineum
Bladder elimination
Breasts
Lower extremities
Homan’s sign
Edema and deep tendon reflexes
BUBBLE HE
Breasts, uterus, bladder, bowels, lochia, episiotomy, Homans’ sign, emotional
status

Nursing Care After Cesarean Section (1/3 of pregnancies end up with c-section)

Number of deliveries by cesarean section

Pain relief
Abdomen/incision
Low transverse incision is most common
Vertical incision usually indicates emergency surgery
Dressing only stays on for the first 24 hours
Staples usually on the incision, some only have steri-strips
Intake and output
Caring for self and infant

Discharge Teaching

Signs and symptoms of possible complications

Breast pain, persistent abdominal pain, burning with urination, leg pain or clot
 indications, foul-smelling drainage, etc.
Health promotion
Nutrition and fluids
Activity and exercise
Rest and comfort
Contraception
Sexual activity
Prescribed medications
Signs/symptoms to report

Becoming Acquainted

Bonding
Describes the initial attraction felt by parents for their infants
Enhanced when parents and infants are not separated in the first hour of the
birth
Unidirectional: parent to the baby (i.e. when baby is placed skin to skin with
mother)
Attachment
The process by which an enduring bond between a parent and child is
developed
Bidirectional: when baby cries and parent comforts her
Begins in pregnancy and extends for many months after birth

Reciprocal Attachment Behavior

Newborn infants have the ability to

Make eye contact and engage in prolonged, intense, mutual gazing
Move eye to attempt to “track” parent’s face
Grasp and hold parent’s finger
Move synchronously in response to rhythms and patterns in voice (called
entrainment)
Root: latch on to the breast and suckle
Be comforted by parent’s voice or touch
Maternal touch
En face
Fingertipping

Enfolding: holding baby with hand

 Claiming or “binding in”
“The baby has my nose” or “she has your eyes"
Verbal behaviors
Mothers speak in high-pitched voice
Calls infant by name

Maternal (Puerperal) Phrases (KNOW)

Taking-in phase
Mother is focused on her own need for food and sleep
Passive dependent behavior for 1-2 days
Taking-hold phase
Becomes more independent and concerned for her self-care
Not fully independent
Shifts attention to the newborn
Letting-go phase
Relinquishes her previous roles and refocuses on relationship with partner
May give her care to a caretaker
Adjusting to disappointments
May go back to work in this phase

Family Adaptations

Fathers
Relationship, marriage, age, his own father experience, emotional age, financial
situation
Engrossment or intense fascination with baby
Demonstrate infant care and praise father for performing well
Involve him in teaching
Encourage parents to negotiate division of child care and household chores
Siblings
“Big brother” or “big sister” stickers
Educate on potential sibling rivalry
 Educate on expecting jealousy
Encourage quality time with older sibling
Grandparents
May be an asset by helping with other children or household chores

Factors that Affect Adaptation

Lingering discomfort or pain

Chronic fatigue
Knowledge of infant needs
Available support system
Financial aid and community resources
Expectations of the newborn
Previous experience with infants
Maternal temperament, age
Mom could be 13 or 45 with first child
Infant characteristics
Baby was product of rape and the child looks like that man
Other factors: cesarean birth, preterm or ill infant, birth of multiples

Cultural Awareness

Food preferences
Hot vs. cold water at bedside (for Asian population?)
Family may bring food from home
Communication
Religious rituals

Postpartum Blues

Mild depression: “baby blues”

Affects 70-80% of new mothers
Begins first week postpartum
Should not last longer than 2 weeks
Must be distinguished from postpartum depression or postpartum psychosis
May be visible in the first few days postpartum while she is still in the hospital
May be crying and hysterical and nurse may need to educate the husband on
patience and hormone flooding
August 28
The Labor Experience

Labor “experience"

Begins at the onset of labor through the delivery and lasts until the expulsion of the
placenta
Factors that may trigger labor
Maternal factors
Stretching of uterine muscles
Estrogen/progesterone changes
Oxytocin release
Starts to stimulate contractions in the body
Release of prostaglandins
Fetal factors
Fetal cortisol changes
If the baby is stressed, it releases cortisol, which could stimulate
labor
Placenta aging
Prostaglandins increase causing contractions
Symptoms that may precede labor
Lightening
Time of engagement
“Fetus has engaged into the pelvis”
Mom may describe as the “baby has dropped” and can breathe
easier, but may void more frequently
Vaginal mucus increases
“Bloody show”
As baby pushes on the cervix more and it dilates, some of the
tissue sloughs away like a menstrual cycle
Braxton Hicks contractions
Like “practice” contractions
Can happen a lot during dehydration
Burst of energy/nesting
Women start get everything ready for the baby to come
GI changes
Constipation or diarrhea
Cervical changes
Beginning to dilate
Backache
Contractions can be in the back
“Back labor”

Factors Affecting Labor (4 Ps)

Powers
Uterine contractions
Primary force that moves the fetus through the maternal pelvis
Maternal pushing efforts
Woman feels an urge to push and bear down as the fetus distends her
vagina and puts pressure on her rectum
“Push through your bottom”
Passage
Bony pelvis
Usually more important to the outcome of labor than the soft tissue
Bones and joints do not readily yield to the forces of labor
Passenger
The passenger is the fetus, membranes, and placenta
Several fetal anatomic and positional variables influence the course of labor
Fetal head
Cephalic presentation (head first, optimal position)
Sutures the two frontal bones on the forehead
Fontanels

Fetal variations
Fetal lie
Orientation of the long axis of the fetus to the long axis of the
woman
In more than 99% of pregnancies, the lie is longitudinal and parallel
to the long axis of the woman

Transverse lie
Attitude
Relationship of fetal body parts to one another
 Flexion or extension

Presentation
Fetal part that enters the pelvis first
Cephalic
Vertex, military, brow, face

Breech
Frank, full, footling

Shoulder
Desired position is ROA
The fetal part (O- occiput) is to the right (R) side of the mother’s
anterior pelvis (A)
It is the most advantageous position that most nearly aligns the
fetal to the maternal pelvis
Variations
LOA, occiput to left anterior
ROP/LOP, occiput to right/left posterior
RSA/LSA/RSP/LSP, sacal to right/left anterior/posterior
Psyche
Anxiety
Culture and expectations
Scientology has to have a silent birth experience with no noise from the
woman
Birth as an experience
 Support
Impact of technology

Maternal Adaptations (during labor)

Cardiovascular
Increased blood volume
Blood pressure very slightly increases to compensate
More than “slightly” is a sign of a bigger issue
Lower pulse
Can cause some orthostatic hypotension
Respiratory
Hyperventilation
Due to contractions or pain
Help the woman control her breathing
Gastrointestinal
NPO causes decreased motility
Urinary
Decreased sensation and decreased frequency
Hematopoietic
Lose some blood
Vaginal- average of 500 mL
Cesarean- average of 1000mL
After delivery, surge of clotting factors to prevent hemorrhage

Fetal Adaptations

Placental circulation
Exchange of oxygen, nutrients, and waste products
Most placental exchange occurs during the interval between contractions
Cardiovascular system responds to stress
Heart ranges from 110 to 160 beats per minute
Pulmonary system
Lungs produce fluid to allow normal development of the airways
C-section babies don’t get to expel fluid from lungs during the delivery the way
that a vaginal birth does

Normal Labor: Theories of Onset

Factors with a role in starting labor

Progesterone withdrawal
Increased prostaglandins
Increased oxytocin
More oxytocin receptors in uterus
Increased stretching and pressure of uterus and cervix
 True vs. false labor
False
Contractions but no change in cervix
Activity doesn’t change pattern
Drink a glass of water and rest for a few minutes
Hydration or sedation slows/stops contractions
True
Regular contractions increase in frequency and intensity
Change in cervix
Greater dilation
Causing effacement and dilation

Time to go to the Hospital

Contractions
Ruptured membranes
Water broke
Bleeding
Decreased fetal movement
Other
Vomiting, fever, etc.

Mechanism of Labor

Engagement, descent, flexion, internal rotation, extension, external rotation, and

expulsion
Terms you hear as the baby is born
Will not be tested over these

Rupture of Membranes (ROM)

Spontaneous
Water broke on its own; it just happened
“SROM”
Artificial
Amniotomy
Indications
Induce labor
Not prepared for labor and have not started labor
Add oxytocin
Augment labor
“To add to”
They are contracting, but not enough to dilate their cervix
Add oxytocin
Allow internal fetal monitoring
 Don’t want to do this if we don’t have to because of infection
possibility
“AROM”
Interventions
FHR
Fetal heart rate
Keep it monitored because the water breaking can affect the baby’s
safety
This the first and foremost priority
TACO
Timing
Amount
Polyhydraminos
Color
Odor
Hygiene
Once the fluid is out, it is time to change the woman’s pad
frequently, because fluid will continue to drain
Amniotic fluid is mostly urine from the fetus, which will
continue throughout the labor process
Risks
Prolapse cord
The cord could float down when the membrane ruptures and gets
under the baby’s head before the head is fully engaged in the pelvis
The cord is the baby’s lifeline and circulation source, so this is an
emergency for the baby
Infection
We don’t want the water to be broke for longer than 12 hours
because of chance for infection
Abruption of placenta
Placenta can break away
Contraindications
Placenta previa
Placenta can fall from its high position at top of uterus
Could potentially sit over cervix opening, which would prevent a
vaginal delivery
C-section would be required
Can not rupture membranes if placenta is in the way
It would poke the placenta and not the membranes
Fetal position
Could not rupture membranes if the baby is breech
Could damage baby’s rectum by accident
Cord prolapse
You wouldn’t want to poke the cord or cause further fetal distress
Sterile procedure
Amniotomy: Artificial ROM

Nursing considerations
Obtain baseline information
FHR 20 to 20 minutes before procedure
Assist with procedure
Place absorbent pads
Open equipment packet
Provide care after procedure
Identify complications
Notice color
Yellowish/pinkish
Shouldn’t be bright red
Promote comfort

Induction of Labor

Chemical (oxytocin) or mechanical (AROM) initiation of uterine contractions

Indications
If mom or baby is in distress
If mom is past her due date
Contraindications
Breech position
Gastresis or encephalopathy in fetus
Pitocin (or oxytocin) may augment labor
Amniotomy
Prostaglandin E
Cervideel (?)
Inserted like a tampon right next to cervix
Releases prostaglandins to help soften and condition cervix for it to be ready for
labor
Prostaglandins are also in semen, hence the old wives’ tale that sex will “induce"
 labor
Misoprostol (Cytotec)
Only used in stillborn cases (no heartbeat at all)
Causes extremely strong contractions to get the baby out quickly
Not compatible with fetal life
Risks
Oxytocin is a strong drug, so the baby could have decels and not handle labor
very well

Induction or Augmentation

Oxytocin (Pitocin)
Causes contractions to begin or become regular to cause dilation of cervix
Mixed with IV fluids, usually 10 units per 1000 mL
Always give via infusion
Piggyback to site/port closest to patient on IV
Use pump to control the exact amount
Usually ordered by protocol
Only give a sufficient amount to cause an effective labor pattern
Stepping up pattern with increasing dose
Follow doctor’s orders/typical hospital protocol
Discontinue if FHR is non-reassuring
Notify the MD, give oxygen, turn to side, and give medications
Don’t slow it down, just cut it off completely
Contractions are like a bear hug for the baby, which squeezes out its
oxygen during that time
When the baby is in utero, we want to be specific about “squeezing time”
During just placenta delivery, oxytocin can be turned all the way up

External Version

Attempts to turn fetus from a breech or shoulder presentation to a vertex presentation

Attempted after 37 weeks gestation
Tocolytic is given to relax uterus
Ultrasound evaluates fetus and uterus
Contraindications
Risks

Labor

Stage 1
Begins with onset of labor and ends with complete cervical dilation (1-10cm)
Latent phase
Cervix 0-3 cm dilation and 0-40% effacement
Effacement is thickness
 Contraction every 5-10 minutes, mild intensity, lasting 30-45 seconds
Discomfort described as feelings of strong menstrual cramps
Medical interventions
Nursing actions
Great opportunity for teaching
Especially breathing techniques
Pain plan
NPO (ice chips, maybe popsicles)
Hygiene for ruptured membranes
Active phase
Average dilation is 1.2 cm per hour depending on gravies (which number
pregnancy)
Dilation progress is 4-7 cm and 40-80% effaced
Fetal descent
Increased contractions; every two to five minutes for 40 to 60 seconds
Increase in pain
May want an epidural at this time
Medical interventions
Nursing actions
Transition phase
Dilation from 8 to 10 cm with 100% effaced
Contractions are intense; every 1-2 minutes and last 60 to 90 seconds
Exhaustion and difficulty concentrating
Bloody show
N/V, backache, diaphoresis, and trembling
Strong urge to bear down
Medical interventions
Possible for a woman to get an epidural at any time, but they have
to be able to sit totally still for the anesthesiologist to place the
epidural
Nursing actions
Stage 2
Begins with complete cervical dilation and ends with delivery
Starts with pushing
Effective pushing using abdomen and bearing down, rather than
face pushing
Complete dilation
Sudden burst of energy, improved focus
Shorter duration with multips than primips
Meaning it is not their first baby
Intense contraction every 2 minutes for 60-90 seconds
Increase in bloody show
Perineum flattens, with bulging rectum and vagina
Medical interventions
Nursing actions
Stage 3
Begins after delivery of baby and ends with delivery of placenta
 Shortest stage
Lasts 5-20 minutes

Mom might have to bear down a little to get the placenta out and have it
break away
The area where the placenta tears away is an open wound site, and we
will apply pressure at the uterine fundus to discourage bleeding and
hemorrhage
Can give pain medicine during this time
Stage 4
Begins after delivery of placenta and is completed up to 4 hours later
Recovery time is typically 1 hour
Mechanism of homeostasis occurs
Ideal time for breastfeeding and bonding
Greatest risk is from hemorrhage secondary to uterine atony
Continue to monitor fundus and make sure it says firm

Cervical Exam Findings

Cervical effacement
Thinning of cervix as it is ‘taken up’ into lower part of uterine segment
Expressed in percents
100% is completely effaced

Dilation
Opening of cervix
0-10 cm
Ten centimeters is "complete"
Station
Relationship of presenting part (PP) to spines (ischial spines in pelvis)
Progresses from negative to positive numbers
 Negative not to see your baby, so if the baby is higher up than the ischial
spines then the numbers are negative
Numbers going down and out the birth canal are positive

Pain and the Laboring Woman

Realize that pain is highly individualized

Varies with cultures
Even request no medication as a result of their culture
May have fear of epidural
May vary with culture
Individual perception
Fear and anxiety association
RN should assess needs, offer teaching, and offer non-pharmacological relief (CAM)
Guided imagery, using a Doula (birthing coach), lighting, music, aromatherapy,
etc.
If these are ineffective, other methods may be requested
Pharmacologic methods
IV sedation
Sedatives
Narcotics
The baby may need Narcan after birth if narcotics are used
as a pain medicine
Must have Narcan available
Nerve blocks
Pudendals
Just nerve blocking saddle area
Not very common
Spinals
Done with a C-section
If the woman already has an epidural, they will change the
 medication in the epidural to convert the anesthesia
Epidurals
Before
Asess, educate, and document
Epidurals can cause hypotension, so try to give her
lots of fluids
Mom is lifeline to baby, and if she loses blood
pressure, the baby will lose circulation
During
Assist healthcare provider
After
Assess and monitor
General anesthesia
Reserved for emergency deliveries

Operative Vaginal Birth

What is it?
Using tools to get the baby out vaginally
Episiotomy
Forceps

Vacuum

Indications
Pushing too long and the baby’s heart rate goes down
 Needing to shorten the pushing stage
Contraindications
If it will compromise the baby’s health, do a c-section instead
Cephalopelvic disproportion (baby’s head too big for the pelvis)
Risks
Forceps can cause nerve damage to face or neck
The physician cannot do this unless it at least +2 station
Can cause bruising or soft tissue damage on baby’s head
Technique
The physician only pulls when the mom is pushing

Episiotomy

Types
Midline or medio-lateral

Extend
First through fourth degree
Usually only cut to the second degree, and may tear beyond that to fourth
degree
Often more likely to continue tearing once you’ve been cut
Purpose
To enlarge vaginal opening
Possible alternatives
Warm compresses
Ice packs for afterwards to control swelling
Manual support
Massage
Perineal massage during pushing to help stretch
Nursing considerations
Colace, sitz baths, etc.

Cesarean Birth

Birth of fetus through incision in abdomen and uterus

Planned or emergency
Indications
 Baby didn’t tolerate labor
Baby is breech
Mom or baby could be in distress
Contraindications
Maternal and fetal risks
Excess fluid in lungs for baby since it is not squeezed through birth canal
Nursing considerations
It is major surgery and treated as such
Still have to massage fundus
Could be incredibly painful with surgical incision

Fetal and Maternal Monitoring

Assessment of uterine contractions

External vs. internal

Internal (AKA tugboat)

Duration, frequency, and intensity
Assessment of FHR
Internal

Intradermal needle in baby’s fontanel

Baseline rate
Periodic vs. non-periodic changes
i.e. changes that occur when there is a contraction
Presence of reassuring signs
Presence of non-reassuring signs
Is the baby in distress?
Assessing Uterine Activity

For FHR
Time going on x axis
BPM going up and down
Contractions
How high up it is shows its intensity
But mainly only with intrauterine monitoring
How wide it is shows its duration
You can also see frequency (beginning to beginning)

Assessment of FHR

Baseline rate is 110 to 160, determined between contractions

Periodic changes vs. non-periodic changes
 Consider heart rate relationship to contractions
Reassuring signs (baby is doing well)
Accelerations, variability in heart rate
An increase in fetal heart rate above baseline
Must be at least 15 beats above baseline and last for at least 15 seconds
Causes
Fetal movement, contractions, sounds or scalp stimulation
Presence of accelerations indicates positive fetal well being

Decelerations

Early deceleration
Head compression
Vagal response as it is in the birth canal
Mirrors contractions (goes down as a contraction happens)
 By the time the contraction is over, the heart rate is back to normal
Baby is adjusting to new and different environment in birth canal
Treatment
None is needed; it is common to see this type of a decel in this stage of
labor
If cervix has not been checked, assess
If these decels are happening at only 4 cm, it may indicate CPD
May indicate cephalopelvic disproportion (CPD)
Fetal head larger than maternal pelvis
Treatment for CPD is a cesarean section
Late deceleration
Impaired uteroplacental function
Delay in beginning and end of deceleration in relation to contractions

The decel happens after the contraction starts, and the recovery is taking
longer
The baby will not be able to recover between stress of contractions
Caused by utero-placental insufficiency
 Placenta not delivering adequate blood supply to fetus
Post due-date, the placenta is “old”
Hypertonic contractions (too strong) causes hyper stimulation to the baby
Treatment
Reposition patient onto side
Increases blood flow through mom’s vena cava
This is the priority if the patient is not on oxytocin
Discontinue pitocin (which could be amplifying contractions)
This is the first priority in a patient on oxytocin
It is the least invasive
Hydration and oxygen
C-section if the heart rate pattern persists
Variable deceleration
Cord compression
Vary in timing, shape, depth with relation to contractions
Not related at all to the contraction pattern
If it is a sudden drop with rapid return (v-shape), it is a variable decel

Causes
Cord compression
Cord may be wrapped around neck or elsewhere and cause
decelerations during a contraction
Severity is measured by the depth and duration of
deceleration
Treatment
Reposition
Replace fluid with amnioinfusion
C-section may be indicated if decelerations become too severe
If the decels are becoming too deep and/or too wide

FHR

VEAL CHOP MINE

Variable - Cord compression - Move patient
Early - Head compression - Identify labor progress
Accel - Okay! - No action needed
Late - Placental insufficiency - Execute action immediately
Evaluation of Fetal Monitoring

Review strips
Moderate variability (the amount the FHR fluctuates on a strip)
Marked variability (the amount the FHR fluctuates on a strip)
Calm variability
Could be sleeping, but after about 20-30 minutes, the baby should wake
up
Or could be a baby whose mom just got narcotics
Baseline FHR
Periodic and episodic changes
Need for nursing care
Position change
Stop oxytocin
Oxygen
Notify healthcare provider

Questions

Interpretation of variability for this strip would be

Absent variability
Minimal variability
Moderate variability
Marked variability
Interpretation of deceleration for this strip would be
 Early decel
Variable decel
Late decel
Acceleration
Interpretation of the baseline for this strip would be

Normal
Bradycardia
Tachycardia
Combined
September 18
***Pay attention to the IHI Map on Well Newborn Care***

Under “Additional Resources” on the learning module page with the powerpoint
This also helps with other material outside of OB (ICU, peds, community, etc.)
"Well Newborn Care" is all the way at the bottom
Click on it, and there are some important newborn overviews, outcomes, and
other information (and things that the academy of pediatrics looks at)
“Key Measures” are currently being looked at by JC (Joint Commission) and IHI
THESE MIGHT SHOW UP ON AN EXAM

Chapters 19-23: Normal Newborn

Neonatal Period

Definition
From birth to first 28 days of life
Focus of nursing care (even though the nurses will not be around for all of those days)
Maintain body heat
Maintain respiratory function
Decrease risk of infection
Assist parents in providing appropriate nutrition and hydration
Assist parents in learning to care for their newborn

Initiation of Respirations

Physiological changes
Mechanical, chemical, and sensory stimuli
Exposure to temperature changes, baby hears sound/sees light
Lungs are filled with amniotic fluid and 30mL is forced out during the
birthing process as it is being squeezed through the birth canal
Surfactant
Slippery, detergent-like protein within alveoli that assists in helping the
lungs to mature
Helps the alveolar sacs remain partially open at the end of
exhalation (so they don’t collapse)
So, the first breath the baby takes is the hardest one because it has
to open the alveolar sacs for the first time
Important in helping the baby breathe
Initiation of first breath
Signs of respiratory distress
Cyanosis, apnea, tachycardia, retractions (the muscles retract towards the back
bone as they try to breathe), grunting, nasal flaring
Cardiovascular Adaptation: From Fetal to Neonatal Circulation

Physiological changes
Initiation of changes
Ductus venosus
In the umbilical cord, there are two arteries and one vein
The ductus venosus connects the umbilical vein to the vena cava
This closes by day three of life and becomes a ligament
Foramen ovale
Opening between the right and left atrium
Closes when the left atrial pressure is higher than the right atrial
pressure
Ductus arteriosus
Connects the pulmonary artery with the descending aorta
Usually closes within 15 hours after birth

Thermoregulation (very important for a neonate)

A fetus is used to its temperature being regulated in-utero by mom and amniotic fluid,
etc.
Now it has to regulate its own temperature
When it’s first warm, we warm it off, and wrap it in warm blankets to start
the process
Physiological changes
Neutral thermal environment (NTE)
Where a baby has to constantly change its O2 consumption depending on what
is going on
Sometimes it requires minimal oxygen changes and no body temperature
changes
Brown fat
Adipose tissue that babies have (BAT: brown adipose tissue)
Dense and highly vascular tissue
Neonates have a lot in their neck, thorax around adrenal glands and
kidneys, under arms, etc.
Helps them stay warm
Factors that negatively affect thermoregulation
Decreased subcutaneous fat
Decreased brown fat in pre-term infants
Early babies look scrawny and thin because they don’t have as much
Large body surface
Loss of heat from convection, radiation, conduction, and/or evaporation
Convection: loss of heat from cooler air currents blowing across them (i.e.
oxygen mask or air conditioning vent)
Radiation: transfer of heat from neonates to cooler objects that are not in
direct contact with them (i.e. cold walls or isolette)
Conduction: transfer of heat from neonates to cooler substances through
 direct contact of skin (i.e. cold caregivers’ hands or cold, metal scale)
Evaporation: loss of heat through water vapors (i.e. when babies get a
bath or get wet)
Should get a bath quickly or under a radiant warmer

Cold Stress (excessive heat loss that leads to hypothermia and results in a major decrease in
baby’s body temperature… causes them to go to respiratory distress)

Cold stress occurs:

Decreased environmental temperature causes decreased body temperature
Decreased body temperature causes increased heart and respiratory rates,
increased oxygen consumption,
An increased depletion of glucose will cause a decreased amount of surfactant
Decreased surfactant leads to respiratory distress
Risk factors
Premature neonates
SGA: babies that are small for gestational age
Babies that are already hypoglycemic and having low blood sugars
Babies that had cardiorespiratory issues at birth
Signs and symptoms
Watch and assess for cool skin
If you get an axillary temperature of 97 or less, take a rectal temperature
Assess for pallor and paleness
Are they grunting?
Do they have a weak suck?
Are they lethargic?
Nursing actions
Actions to decrease risk
At birth, dry them off quickly and move wet blankets away
Wrap them in warm blankets
Put them skin to skin with mom
Put them under radiant warmers
Put a stocking cap on them
Babies lose a lot of heat through their head
Swaddle them well with a blanket
Actions when neonate displays signs of cold stress

Metabolic System

Babies become metabolically independent once they are born and separated from
mom
Regulating their own blood sugars and producing their own insulin
Hypoglycemia (a blood sugar less than 40 for a neonate)
Optimal range is 70-100
Risk factors
Infants of diabetic moms
 LGA: large for gestational age
Hypothermia
Respiratory distress
Birth trauma
Signs and symptoms
Similar to adults
Jittery, irritable, lethargic
Spell of apnea
Temperature instability
Nursing actions
Assess vital signs
Assess glucose
Most hospitals have specific protocols for when to run glucose
tests
Heel stick for blood sugar based on assessment, too
Decrease cold stress and keep them warm

Hepatic System

Physiological changes
Immature at time of birth
Increase in red blood cell turnover in neonates
They look yellow, or jaundiced, because bilirubin is trying to leave the body, but
the immature liver can’t filter it out fast enough
Bilirubin conjugation
Indirect bilirubin
AKA unconjugated bilirubin
Fat-soluble substance produced from the breakdown of RBCs
Converted to direct bilirubin
This is the kind that causes the yellowish skin color
Direct bilirubin
Comes from indirect bilirubin
AKA conjugated bilirubin
Water-soluble substance
In a form that can be excreted through urine and stool
This kind is desirable because we want it to be excreted this way
Hyperbilirubinemia
Put babies under the “bili-lights”
Must keep their eyes covered because the light can damage their
vision
Eye covering can only come off if they are not under the lights
They draw bilirubin levels to make sure it doesn’t get too high
Kernicterus (disease of too high bilirubin) causes brain damage
Blood coagulation
Vitamin K
Should get within an hour of birth
IM injection given to prevent hemorrhagic disease
 In thigh (vasterus lateralis)
Vitamin K helps with blood clotting

GI System

Stomach
Does not hold much when they are born, but eat more and more as time passes
Within 7 days, it can hold about 60 mL every three to four hours
Gastric emptying is initially delayed, but speeds up after the first stool
Characteristics of stools
Meconium
Amniotic fluid can be meconium stained
This is the first stool (if it was not passed in-utero)
It forms during the fourth gestational month
Thick, sticky, black, tarry stool that is passed within 24-48 hours (not
smelly)
Sticks to baby’s bottom like glue
Mom and dad may need help changing the diaper
Transitional
Begin around the third day and continue for three to four days
Black to greenish-brown or greenish-yellow
These occur in breast-fed and formula-fed babies
Breast-fed
Golden yellow/honey mustard, semi-formed stool
Pasty consistency
Smell kind of sour
Formula-fed
Drier consistency, not quite as yellow
More brownish-yellow
Unpleasant odor… really smell bad
Diarrhea
Not normal in neonates or infants
Loose, watery, green
If they have a watery stool, the parents need to call a pediatrician

Urinary System

Kidney function
Immature at birth
This can place them at risk for over-hydration or dehydration
Watch for quantity of wet diapers
Output
How many wet diapers they have
Void about 6 times in a 24 hour period (six wet diapers a day)
Use of water
Most pediatricians don’t recommend giving an extra bottle of water because it is
 empty calories
**hiccups will go away
The babies get plenty of fluids from formula or breastmilk, so if they need a
drink, choose the food that has calories (not water)

Immune System

Immature at birth
Physiological changes
Active humoral immunity
When antibodies are produced to help them fight things
Acquired immunity happens with immunizations
Passive immunity
This is not permanent
Happens with antibiotics from the mother to the fetus
Risk factors for infection
Immature defense systems
Lack of experience with different organisms
Breakdown of skin (like dry cracks), dry mucous membranes
To prevent infant infections, good hand washing is key
Mom, dad, visitors, caretakers, etc.

Periods of Reactivity

First period of reactivity

Begins at birth and lasts for 30 minutes
Important to be with mom and spend time with her at the beginning
They are very active and awake and alert during this time
Appear hungry, moving around, respirations and heart rate are up
Good time to try to breast feed
Don’t be the nurse that does their assessments for thirty minutes
Make sure the baby is okay, but let mom be with them at first
Finish footprints and long assessments during the period of
inactivity
Period of inactivity
Thirty minutes to two hours after birth, they fall into a deep sleep
Heart rate and respirations drop
Second period of reactivity
Lasts 4-6 hours
More awake and alert
Interested in eating, usually pass their meconium stool

Neonatal Assessment

Head to toe assessment

 General survey of the baby when they are born
General survey
Review prenatal and labor record for risk factors
What has mom’s labor been like?
Has she had pain meds?
Any drug use?
Etc.
Observe respiratory pattern
Observe posture
Assess skin for color, birthmarks, and birth trauma
Assess alertness/activity
Assess muscle tone
Head to toe
Posture
Head circumference
“Cone head” for a day or so from coming through the birth canal
Usually the head comes first and is the biggest part of the baby
If the head comes through, the rest of the baby will, too
Microcephaly
Small head
Macrocephaly
Big head
Chest circumference
Around the nipple line
Length
Weight
Temperature
Axillary is taken first
Rectal is taken, too, to check for patency of the anus
Respirations
Pulse
Check all the pulse points throughout the assessment
Blood pressure
Itty bitty cuffs with a machine
Too tiny to be done manually
Integumentary (important to be pink and pretty and cute)
Acrocyanosis
Normal (even hours later)
The palms of the hands and the soles of the feet stay blue
If they are blue around the mouth or the trunk is blue, that is NOT
OKAY
Need some oxygen
Pilonidal dimple
At the top of their butt crack
Pediatricians will sometimes send for an ultrasound to make sure
the spine has closed and its not open to the skin
Head
 Molding
Skull will round up on its own
Fontanels
Anterior and posterior
Caput
Swelling of the head that can cross suture lines
CAput CAn cross suture lines
Like a cap
Cephalohematoma
Swelling of the head that does not cross suture lines
Neck/clavicles
Make sure there are no fractures
Large babies could fracture a clavicle
Eyes
In relation to ears
Ears
Nose
Two nares
Mouth
Feel inside mouth
Do they have a suck reflex?
Feel roof of mouth for cleft palate
Chest/lungs
Cardiac
PMI (point of maximum impulse)
Murmur
Abdomen
Listen for bowel sounds
Palpate abdomen
Cord
Two arteries and a vein
Even with the cord clamp, you can see those three vessels at the end
Extremities
Moving all four
Vertebral column
Turn them over and run hand down spine
Is it straight?
Rectum
Rectal temp. for patent anus
Genitourinary
Girls
Are their labia minor covered by the labia majora
Pseudomenstruation
Little spots of blood in diaper
Does not mean they are getting their menses
Just a hormonal rush from mom
Hypospadias
 Instead of the meatus at the end of the penis, it’s a little bit
underneath
Referral to urologist, and instead of circumcising him before
discharge, they will use some of the foreskin to correct the issue
Epispadias
Instead of the meatus at the end of the penis, it’s more on the top
Hydrocele
Enlarged scrotum due to excess fluid
Sometimes it corrects itself, but usually it doesn’t
May need surgery
Undescended testes
Feel for the testes: has one or both or neither descended
Musculoskeletal
Are the baby’s extremities flaccid or toned?
Polydactyly
Extra digits (too many fingers or toes)
Not uncommon
May have extra on both or just one hand/foot
If it is just skin and there is no bone (skin tags), the pediatrician can
tie it off with a suture and it will dry up and fall off
If there is a bone, it will have to be surgically removed
Syndactyly
Digits are webbed together
Usually just a webbing of skin
Requires a surgical procedure to split the webbing and
separate the fingers or toes
Neurological
Tremors/jitteriness
Hypoglycemia
Pitch of cry
High pitches can be due to mom’s drug use
Reflexes
Moro/startle
Tonic neck
On guard in a sword fight
Rooting
Hungry and looking for nipple
Sucking
Palmar grasp
Stroke palm and they grasp
Plantar grasp
Stroke bottom of foot and grasp with their toes
Babinski
Toes fan out
Normal reflex up to one year of age
Outside of that, indicates spinal cord injury
Stepping/dancing
 GI/GU
Stool
Urine
Genitalia
Skin
Breasts
Hair and nails
Born with hair and nails

Gestational Age Assessment

Ballad Maturational Score

Sometimes called Dubowitz (Dubowitz neurological examination)
Seen in textbook and in learning modules
Determines gestational maturity of infants
Physical and neuromuscular maturity
To see how the baby developed
Where does the baby fall in the following categories?
SGA: small for gestational age
Below the 10th percentile for gestational age
AGA: appropriate for gestational age
LGA: large for gestational age
Above the 90th percentile for gestational age

Pain Assessment

Assess baby just like adults, they just can’t tell us they are hurting
Do this if we were doing blood work, injection, heel stick, circumcision, etc.
Gave “sweeties” (sugar water)
Reassess pain after event
Document intervention (i.e. swaddling tight, cuddled, comforted, etc.)
Sources of pain
Premature Infant Pain Profile (PIPP)
Neonatal Infant Pain Scale (NIPS)

Early Care

Administering vitamin K (within 1 hour)

Infants cannot synthesize vitamin K
Prevents bleeding problems
IM
Providing eye treatment (within 1 hour)
Erythromycin ophthalmic ointment
Prevents ophthalmia neonatorum
Injects from syphilis or gonorrhea
 Squeeze in from inner to outer canthus
Cardiorespatory status
Positioning status
Suctioning secretions
Mouth and then nose
Close observation

Continuing Care

Thermoregulation
Prevent heat loss
Perform expanded assessments
Interventions
Dry and covered
Avoid contact with cold surfaces
Keep away from drafts
Skin to skin with mom

First 4 Hours

Universal precautions
Maintain body heat
Dry immediately
Support respirations
Apgar score
Performed at 1 minute and 5 minutes
Receive 0-2 in 5 categories:
Heart rate, color, reflexes, muscle tone, and respirations
Total score will be between 0 and 10
Review Clinical Skills (Apgar Score) in Sherpath
Vital signs
Identifying bands
Number on baby’s band that matches mom and dad’s bracelet
BEFORE they ever leave to go to the nursery
Most hospitals also have alarm systems
Beep if baby is close to an exit
Doors lock if baby gets closer to exit
Neonatal assessment
Gestational age assessment
Administer erythromycin ophthalmic ointment
Administer vitamin K injection
Bath with neutral pH soap
Get vernix off
If they maintain their temperature
Dress them all up to send back to momma
Promote parent infant attachment
Care 4 Hours to Discharge

Vital signs
Neonatal assessment
Promote parent-infant attachment
Promote sibling attachment
Prevent infant abduction
Tell on admission to not let anybody take their baby without a name tag with a
picture
People may come to their house and pose as a community health nurse to take
their baby
Don’t signify outside that you have had a baby
“It’s a Girl” signs, stroller/carseat boxes on the curb, etc.
Instruct parents to place neonate on back to sleep
Assist with feedings
Provide information on newborn care
Provide information on normal newborn characteristics

Providing Other Care

Blood glucose
Assess all infants for risk factors and signs of hypoglycemia
Perform screening test for blood glucose
Maintain safe levels per policy
Bilirubin
Assess risk for jaundice
Ensure infant is feeding well
Explain condition to parents
Providing skin care
Bathing
As long as cord is still attached
Clean several times a day with alcohol (the cord has no nerve
endings or feeling
The alcohol makes it dry up
Give baby a sponge bath every day
Fold down front of diaper to give cord some room
Once it falls off, they can give baby a full bath
If they see dark spots on baby, they are not bruises or trauma marks
They are Mongolian spots
Usually with darker complexion babies (Asian or African
American)
Babies may have a lot of lenugo (on arms, ears or back)
This rubs off
Sometimes born with a tooth
Milia: white pimples on cheeks or nose
Do not pop, they will go away if left alone
 Vernix: may be in groin or armpits
Newborn rash: may look like mosquito bites
Cleaning the diaper area
Assist with feedings

Protecting Infant

Identification bands
Preventing infant abduction
Nurse’s role includes teaching parents how to safeguard their infants
Doors have locks and badge swipes, etc.
Preventing infection
Scrupulous hand washing
Mom needs to watch for this, because baby will be back in hospital with a fever

Circumcision

Reasons for choosing circumcision (not mandatory procedure)

Religious reasons
More circumcisions in the south than in the north
To prevent certain conditions
Parental preference
Lack of knowledge regarding care of the foreskin
Reasons parents reject circumcision
Belief that uncommon conditions do not necessitate surgery and pain in the
infant
Procedure
Done by OB doctors (“surgeons”) as opposed to pediatricians
Put on Emla cream or lidocaine to numb the nerves on the penis
Gomco Clamp

PDF File

Loosen foreskin around the glans

Put metal cone in between
Cut the end of the foreskin away
Needs vaseline each time they change the diaper
Clean well with water (NOT ALCOHOL LIKE THE CORD)
Vaseline keeps diaper from sticking to circumcision
Keep away from diaper wipes just in case
PlastiBell

PDF File

Insert a plastic ring around the glans, tie a string to put plastic ring in
place
 5-7 days, the plastic ring will loosen and fall off in the diaper
Does not require vaseline or anything

Complications of Circumcision

Hemorrhage
Infection
Unsatisfactory cosmetic effect
Urinary retention
We like for them to void within 4-6 hours afterwards
Stenosis or fistula of the urethra
Adhesions
Necrosis
Injury to the glans
Pain during and after surgery
Use the sweeties sugar water and the numbing pain medication prior to the
surgery

Signs of Complications

Bleeding more than a few drops with first diaper changes

Failure to urinate
Signs of infection: fever or low temperature, purulent or foul-smelling drainage
Dry, crusty drainage may be normal
Not normal if it is foul-smelling
Displacement of the PlastiBell
It should loosen up and fall off
Should not loosen and fall down the shaft of the penis
If more penis is visible at the end, call the pediatrician

Immunization

Hepatitis B
Now included with other routine childhood vaccinations
Although not required
Newborns of hepatitis-positive mothers should receive vaccine and hepatitis
immune globulin
Newborns of uninfected mothers may also receive the vaccine prior to discharge

Newborn Screening

Hearing loss
Most common congenital abnormality
Newborns should be screened by 1 month of age
 Metabolic screening
Phenylketonuria (PKU)
Several drops of blood on a paper that is sent to the state
Serious disease that can cause them to be mentally retarded
Easily treated with a supplement in their diet
So every baby is tested for it
Hypothyroidism
Galactosemia
Cannot properly metabolize galactose (a milk sugar)

Parents Want to Know

Positioning/head support
Safe sleep (SIDS)
American Academy of Pediatrics recommends all infants be placed supine
to sleep
If the baby turns itself over, that’s different
Avoid overheating
Baby’s room should be cool
Pacifier use in infants over 1 month of age
Sucking can prevent SIDS sometimes
Should not sleep in a bed or couch with adults
Plagiocephaly (flattened back of the head)
Supervised periods of lying prone each day
“Tummy time”
When the baby is awake
Wrapping
"Burrito" swaddling
Babies breath kind of irregularly
That is normal
Use of bulb syringe
Show them how to clean it
Taking temperature/use of thermometer
Digital thermometer
Urine/stool
Bathing/skin care/cord care
Start baby lotion on just legs
Just in case they have a rash or are sensitive
Use baby sensitive things
Laundry detergent, soap, etc.
Diaper changing and diaper area care
Sleeping/awake/socializing/stimulating
Feeding
Breast feeding every 2-3 hours
Bottle feeding every 3-4 hours
Discharge and Follow-Up Care

Discharge
48 hours after vaginal birth
96 hours after cesarean birth (usually 72 hours)
Normal vital signs, fed successfully at least twice, passed urine and stool, no
bleeding from circumcision
Follow-up care
American Academy of Pediatrics (AAP) recommends follow-up within 48 hours
for early discharges
Home visits, clinic visits, telephone counseling
Otherwise pediatricians will see them in a week or two
Because there is so much information to give the parents in such a short
period of time

Infant Feedings

Nutritional needs of newborn

Calories
Nutrients (carbs, proteins, fats)
Water
Breastmilk composition (6% protein, 42% carbohydrates, 52% fat)
Colostrum
“First milk”
Thin, yellowish fluid that is present the first 2-3 days before the actual
breast milk comes in
Transitional milk
Colostrum and breastmilk mixture
Lasts for about 3-10 days
Mature milk (foremilk and hind milk)
Foremilk: produced and stored between feedings
Released at the beginning of a feeding
Hindmilk: produced during feeding
Released at the end of a feeding
A lot higher in fat content
20% solids and 80% water
Formula composition
50% more protein than human milk

Choosing a Feeding Method

Breastfeeding
Advantages/disadvantages
Less diarrhea, less respiratory infections, less ear infections, and
decreased childhood obesity
Father feels left out of the feeding process
Breast changes
Change in shape and sensitivity
Milk production and let-down reflex
Prolactin causing milk production
Let-down reflex is milk being ejected into milk-duct system
Spurred by baby crying or because it is “time to feed”
Cross arms and press firmly on breast to stop let-down reflex
Infant’s signs of hunger/feeding
Rooting
Lip smacking or sucking on fingers
Hands in their mouth
Crying is a late sign of their hunger
Behaviors
Proper positioning and latch
Cradle, football, and cross-cradle positions

PDF File

Football good for c-section mommas or big breasted women

Side-lying is good for c-section moms or at night time
Positioning the newborn
Nutritive vs. non-nutritive sucking
Do not let baby use your nipples as pacifiers
Signs of successful breastfeeding
Cheeks should not suck in
If they do, remove the baby, and re-latch
Ear and jaw should move and you can hear the baby swallow
Removal from the breast
Take a finger to slide into baby’s mouth
Break the seal the baby has on her breast
Teaching topics
Infant problems
Comfort
Mom should be comfortable
Bring the baby to her, not her to the baby
Medications
Always consult with doctor to figure out if medicines are safe to take when
breastfeeding
Storing milk
Breast milk is good in the refrigerator for a week
Breast milk is good in a refrigerator freezer for 6 months
Breast milk is good in a deep freezer for a year
Warm it up under warm water, never in the microwave
Previous breast surgery
Reduction/augmentation
Still possibility of breastfeeding
Just try
Breastfeeding multiples
 Twins are easy; one on each side at the same time
Weaning
Sometimes they wean themselves
Start skipping a daytime feeding or only a nighttime feed
Your body will start regulating the time that milk is produced
Whole cow’s milk at one year
Formula feeding
Advantages/disadvantages
Either parent can feed the baby
Decrease amount of feedings (3-4 hours instead of 2-3)
Mom can leave if necessary
But, more time to prepare bottles, increased cost, increased risk of
childhood obesity
Teaching topics
Holding the baby slightly inclined, bottle is straight up, nipple stays full of
formula
How to burp the baby (after about an ounce)
On the shoulder or forward sitting
Mother’s knowledge of bottle feeding
Types of formula
Ready-to-feed (most expensive)
Concentrate (half formula and half water)
Powdered
Equipment/preparation/expense
Bottles, nipples, sterilizing (container, boil, dishwasher)
Feeding techniques
Combination feeding
Factors influencing choice
Support from others
Culture
Employment
Staff knowledge

Home Care of the Infant

Home visits
Clinic/Office visits
One week after discharge to pediatrician
Breastfeeding nurse
Phone calls

Early Concerns

Crying
Normal
Colic
 Tummy-ache, pains, etc.
Talk to pediatrician before giving gas drops
Don’t listen to old wives tales
Sleep/sleep patterns
Sleep when baby sleeps
Dressing and warmth
Dress for the weather and keep temperature appropriate for weather
Smoking
None
Could attribute to SIDS
Nails
Should not have nails clipped but filed
They are not detached from finger skin yet
Common rashes
Seborrheic dermatitis (cradle cap)
Like dandruff
Spitting-up
Normal
Projectile vomiting or throwing up all of their bottle is not normal
Tell pediatrician
May need to change formula
Introduction of solid foods
When they can sit in a high chair and turn their head to deny food
Uncircumcised
Parents do not need to force foreskin down over penis
It will retract around 3 years of age
Just gently clean penis as normal in the bath and at diaper changes

Health Care Provider

Growth and development

Well-baby checkups
Calling HCP when newborn is sick
Potential signs of illness

Safety Consideration

Abusive head trauma (Shaken baby syndrome)

Don’t shake baby
Car safety seats
Strapped in the backseat facing the back window
Birth announcements/mailbox bows
Cribs
Blinds
Unannounced home health nurse visit
September 25
Women’s Health Today

Trends and Issues

Historical Perspective

Centuries ago
Utilized layman midwives
Someone already married, because virgins could not help with births
Usually a mother or aunt
Gave birth at home
If you went to the hospital, you were going there to die
Leeches, blood letting, etc.
High rate of maternal deaths
Typically hemorrhaging or infection
Some cultures believed
High rate of infant deaths
50 years ago
90% of births occurred in hospital
Women received “twilight sleep”
Scopolamine so they would act crazy
Hours after birth before they were coherent enough to know the baby was
born
Fathers not allowed in delivery room
Delivered in OR
Labor in one room and rushed down to the OR room, even for a vaginal
delivery
Rectal exams
Inductions were rare
Maternal and infant deaths declined slightly
Now
Hospital births/birthing at home/birthing centers
Labor, deliver, and recover in one room
Sometimes postpartum, too
Family allowed at bedside
Multiple people, even other siblings, etc.
Vaginal exams
Use of epidural
Aware of everything, just cannot feel from the waist down
Most women today are induced
We have more c-sections
The population that is giving birth is sicker
Hypertension, diabetes, etc.
Use of birth plans
Tentative plan of what the mother wants to happen in the birthing room
 Increased survival rate of premature infants

The Family

Traditional family
Nontraditional family
Blended family
Single parent
Alabama has one of the highest rates of adolescent pregnancies
Extended family
Same-sex parents
Adoptive family
Surrogate family
More popular as fertility technology increases
Women carries baby, usually with a fertilized egg from the parents

Factors that Interfere with Family Function

Lack of financial resources

Poverty
Homelessness
The most common homeless person is a mother and her child
Absence of adequate family support
The parents need a break sometimes
Infant with special needs
Take a lot of extra love and time and attention
Sometimes the stress of taking care of them causes the parents to split up
Unhealthy lifestyle
Domestic violence
Pregnant women are targets
Small, defenseless children, too
Smoking/substance abuse
Second-hand smoke can cause a lot of issues
Inability to make mature decisions for care of infant
If the mother is very young

Question

Which health history questions should be assessed about factors that interfere with
family function?
Is anyone abusing you verbally, mentally, emotionally, or physically at this time?
Do you have a place to live with running water and power?
Do you ever go hungry because you cannot afford food?
Do you or anyone in your household drink or use illegal substances?
Culturally Congruent Care in Childbearing (KNOW THIS)

Just because someone belongs to a culture, does not mean they follow every part of
that practice
Western beliefs
Democracy
Everyone should have a voice
Individualism/self-sufficiency
Cleanliness
Preoccupation with time
Time and schedules
Reliance on machines/technology
Optimal health is a right
We believe that it is a human right to have perfect health
Other places believe it is a privilege
Admiration of self-sufficiency and financial success
We emulate those with independence and a lot of wealth
Southeast Asian
If they speak a different language, we need an interpreter
An interpreter takes the advanced medical terminology and put it in the
correct terminology for comprehension
Speak softly
Avoid prolonged eye contact
Large area of personal space
Show respect to elderly, priest, and physician
The elderly are more important than children
Oldest male in the family makes the decisions
Husband or father in the delivery room to make decisions for the woman
Want to be kept warm during childbirth
Some diseases are hot and some diseases are cold
Even want warm water for medicine
Hang “hot” things on the door, like chili peppers
May not ask many questions
Teach as if they don’t know anything
May not show pain or fear
Hispanic/latino
Polite and gracious in conversation
Enjoy small talk first
Men are head of household
Usually have close extended family
Spanish primary language in the home
Often are stoic/do not express pain
Unacceptable to talk about reproductive issues in front of a man
Use belly band for infants until cord falls off
Afraid evil spirits may enter the umbilical cord as it dries
Often they do not breastfeed
 Male children are preferred
African-American
Single women are head of household
Higher rate of adolescent pregnancy that leads to single parent household
Close extended family
Loyalty to people and community
May have distrust of majority (caucasian) group
Use idioms, colloquial expression, or speech patterns that are unfamiliar
Minister is influential
Use of religious rituals or prayer may be used
Native American
Close family relationships
Health = state of harmony with nature
May work with herbs or medicine men
Do not seek prenatal care or delay until third trimester
Pregnancy is a natural, not medicinal state
Often single parent families
High incidence of alcohol abuse
Will not easily sign consents due to historical abuse
Stoic about pain
Some tribes bury or burn placenta
Good luck for baby
May use traditional healers
Native Hawaiian and Pacific Islanders
High rates of homelessness, drug abuse, poverty and teenage pregnancy
High cost of living there
Often single mother is head of household
Fathers often present at delivery
90% breastfeed
Believe anything circular will cause umbilical cord to wrap around fetus’ neck
Like ID band or heart rate monitor
After birth, it does not matter
Often are stoic/do not express pain
Always offer some sort of pain relief measures
Middle Easterners
Family affairs kept in family
No insight to psychosocial issues
Strangers do not use woman’s legal name, but her title
Same sex health attendants
Doctors and nurses will be female
Decisions made by male head of household
Islamic believers kneel to pray five times a day
Adjust beds if they are kneeling facing Mecca
Do not eat pork or use alcohol
Uncomfortable with direct eye contact
May be very expressive with pain
Male children preferred
 Could abort female fetuses
Female family member assists mothers in labor
Mom, sister, or aunt
May want to bury the placenta
Often breastfeed, but they will not breastfeed in public

Statistics in Childbearing

Maternal mortality: death of a woman during pregnancy or within 42 days of

termination of pregnancy
Causes: hemorrhage (#1), infection (#2), eclampsia, obstructed labor,
complications of abortion
Infant mortality: death before the age of one year
Causes: congenital anomalies, SIDS, newborn problems after pregnancy
complications, respiratory distress syndrome
Neonate mortality: death before 28 days of life
Causes: premature birth or congenital anomalies

PDF File

To prevent hemorrhage, massage the fundus, give pitocin, give clotting factors
(Methergine or Hemobate)
Developing countries use something like a condom with ice cold water
and place it in the uterus to cause vessels to clamp down
Antihypertensive meds for hypertension
Reduce preterm birth with prenatal care, education, reduce adolescent
pregnancy

Issues that Affect Statistics in Childbearing

Health disparities
Poverty
Access to healthcare
Adolescent pregnancy
More likely to die because their young bodies can’t handle birth
Women’s health
Hypertension
Obesity
Smoking/drug use
Drug screen depending on doctor or if you suspect

Healthy People 2020 Maternal and Neonate Health Goals

Reduction in maternal mortality rates

Increase in maternal prenatal care
 Reduction in number of cesarean births
More likely to have complications like blood clots or atelectasis
Reduction in use of tobacco and illicit drugs during pregnancy
Reduction in fetal and infant deaths
Reduction in low birth weight neonates
Increase in number of mothers who breastfeed

Nurse’s Role in Maternity Care

Nursing Roles

Collaborator
Researcher
Advocate
Manager
Teacher

Advanced Preparation for Maternal-Newborn Nurse

Certified Nurse Midwife

Master’s degree
Allowed to deliver babies depending on state rules
Legal in Alabama
Low-risk pregnancies
Can prescribe medication
Nurse practitioner
Family Nurse Practitioner
Women’s Health Nurse Practitioner
PAP smears, prenatal, post-care, cannot deliver baby
Can prescribe medication
Clinical Nurse Specialist
Often educators and evidence-based enforcers
Cannot prescribe medications

Therapeutic Communication (examples in textbook)

Clarifying
Paraphrasing/restating
Reflecting
Silence/presence
Structuring
Ask open questions
Directing
Summarizing
Active listening
 Empathy

Non-therapeutic Communication

Lack of interest
Sense of haste
Close posture
Interrupting
False assurance
Failing to acknowledge comments or feelings
Stereotype

Teaching and Learning Principles

Depends on readiness of individual to learn

Active participation increases learning
Repetition of skill increases retention
Praise and positive feedback
Role modeling
Conflict and frustration can impede learning
Present simple to complex
Variety of teaching methods
Present small segments over time

Factors Influencing Teaching/Learning

Developmental level
Language
Culture
Previous experiences
Physical environment
Organization and skill or instructor

Ethical, Social, and Legal Issues

Ethical principles

Autonomy
Right to self-determination
Beneficence
Obligation to do good
Nonmaleficence
Obligation to do no harm
Justice
 Equal treatment of others
Respect
All people are valued
Fidelity
Obligation to keep a promise
Veracity
Obligation to tell the truth
Confidentiality
Keep information private
Accountability
Accept responsibility for actions

Standards of Practice

American Nurses Association

Nurse Practice Act (every state)
What is in your scope of practice for your state?
i.e. LPNs can do IVs in some states
Standard Procedures/Protocols (laws)
Alabama just passed a law that lay-midwives can practice
Association of Women’s Health, Obstetrics, and Neonatal Nurses (AWHONN)
Suggestions, standards, and protocols
Health Care Agency Policies

Childbearing Ethical Dilemmas

Abortion
Mandated Contraception
Fetal injury
Fetal therapy
Infertility issues

Social Issues

Poverty
Homelessness
Access to health care
Where you live (rural)
Transportation
Finances/insurance
Care vs. cure
Care is more targeted to health promotion
Late preterm infants
Increase of inductions
36 and 37 week babies struggle to suck and struggle to breathe
 39 weeks is preferred

Legal Issues

Informed consent
Competence to sign the forms
No pain medicine first, or they are incompetent to sign forms
Physician goes over the “informed” part
Full disclosure
Physician gives full disclosure
If the patient says, “I’m not sure exactly about this procedure”
You go get the doctor
Understanding of information
Open question to see if they understand
Voluntary consent
Refusal of care
Should always have the option to say no
Documentation
Didn’t chart it, it didn’t happen
Documenting fetal monitoring
Fetal monitoring strips are a legal part of the chart
Nothing can be missing
OB is the most litigious of all nursing professions
Documenting discharge teaching
Document ALL teaching
Documenting incidents
Variance report (incident report) should be separate from patient’s chart
Do not refer to variance report in the patient’s chart
This report can not be pulled by the court unless you reference it
Make sure charting is objective
Patient advocate
Maintaining expertise

Reproduction

Sexual Development: Prenatal

Genetic sex determined at conception

First 6 weeks is sexually undifferentiated
12 weeks external genitalia is differentiated
16 to 18 weeks is when the ultrasound can tell
Both ovaries and testes secrete primary hormones in fetal stage
Estrogen and testosterone
Fetal endometrium and breast buds will respond to maternal hormones
Sexual Development: Childhood

Sex glands are inactive

Hypothalamus stimulates gonads to produce hormones at sexual maturity
Females start around 12-13
Males between 12-16

Sexual Development: Female Sexual Maturation

Puberty: time during during which reproductive organs become fully functional
Hypothalamus secretes gonadotropin-releasing hormone (GnRH)
Pituitary secretes follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
Ovary secretes estrogen and progesterone
Primary and secondary sex characteristics develop
Females: hips get wider, breasts fill in, oily skin, acne, etc.
Body hair, skeletal growth, reproductive organs, menarche
A girl can get pregnant before her first period
Ovulation begins before period
Estrogen stops growth at a certain point
Males: penis and scrotum enlarges, muscle mass increases, etc.
Testosterone is weaker than estrogen at stopping growth, which is why
they are taller

Sexual Development: Male Sexual Maturation

Hypothalamus secretes gonadotropin-releasing hormone (GnRH)

Pituitary secretes follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
FSH and LH stimulate secretion of testosterone
Testosterone causes spermatogenesis
Primary and secondary sex characteristics develop
Nocturnal emissions, body hair, body composition, voice changes

Hormones

Menstruation begins cycle

Estrogen peaks prior to ovulation
FSH and LH peak at ovulation (when egg is released)
Progesterone peaks after ovulation
Drop in estrogen, progesterone, FSH, and LH ends the cycle

PDF File

Build up in hormones causes build up in blood supply and arteries in endometrium

Drop in hormones causes oxygen supply to cut off to those build ups
Female sloughs this off for menstruation
Female Decline in Fertility

Decreases during climacteric

Hormone production declines
Reproductive organs atrophy
A lot of FSH are released before menopause
Higher incidence of mutations because of releasing more than the “prime” egg
Higher incidence of multiples
Menopause
No distinct marker event in males

Female Breast Development

Inactive until puberty

Increased estrogen levels stimulate growth
Pregnancy
High levels of estrogen and progesterone
Prolactin secretion by anterior pituitary
Active milk production occurs in response to infant’s sucking
Every woman has same number of milk ducts, regardless of breast size

Genetics

Genes

Genes make up chromosomes

Sex chromosomes
XX or XY
23 chromosomes
22 non-sex related
1 sex chromosome
Recessive trait
Dominant trait

Punnett Square

B (dad) b (dad)

b (mom) Bb bb

b (mom) Bb bb
 50% chance of the kid having the dominant disease (i.e. Huntington’s)

Genogram

Build a genogram of multiple generations to see how it is being carried through the
family

PDF File

Autosomal Dominant Traits

Dominant gene on a non-sex chromosome

Different severities of disease
A person with two dominant traits will have worse than someone with a
dominant and a recessive
i.e. Huntington’s disease, polycystic kidney disease, cerebellar ataxia

Autosomal Recessive Traits

Recessive trait occurs if a person inherits two copies of recessive gene

Incidence is low
Increased likelihood includes blood relationship or parents or groups isolated
If mom and dad are related, they have increased chances of these genetic
anomalies
Small islands or cultural groups marry within the groups and have smaller variety
Most are severe and do not live to reproduce
Many die in-utero
Exception is Phenylketonuria (PKU) and Cystic fibrosis

X-Linked Traits

X-linked recessive is more common than x-linked dominant

X-linked recessive is more severe in males
Females are protected by a compensating X chromosome
i.e. Hemophilia, colorblindness

Chromosomal Abnormalities

Numerical: too many or too few chromosomes

Structural: part of chromosome is missing or added
Numerical Abnormality

Trisomy: three chromosomes

Trisomy 21: Down’s syndrome
Trisomy 13: Patau syndrome
Not compatible with life
Trisomy 18: Edward’s syndrome
Clubbed foot
Small head
Klinefelter Syndrome (XXY)
Typically they are male
Gynecomastia, wide hips, infertile, small penis and testicles
Can develop osteoporosis like women
Monosomy: one chromosome
Turner syndrome (one X)
Always female
Always infertile
Usually short stature
Polyploidy: one or more extra sets of chromosomes
Majority of first-trimester miscarriages are caused by chromosomal
abnormalities
1 in 4 women will have a miscarriage

Structural Abnormality

Translocate
One end swaps with another end
Fragile X syndrome (most common inherited form of male mental retardation)
Elongated face, high ears, always male, etc.

Multifactorial Disorders

Result as interaction of genetics and environmental factors

Typically cleft palate/cleft lip, heart issue, etc.
Present and detectable at birth
Isolated defects
Most common birth defects nurses encounter

Environmental Influences

Teratogens: increase likelihood of birth defects

Diseases like rubella or toxoplasmosis
Alcohol, medications (aldactone and metformin can cause feminization of boys),
etc.
Pregnancy categories from A to X
 X is the worst)
Pollutants, chemicals
Ionizing radiation
Maternal hyperthermia (no hot tubs or warm baths)
Diabetes mellitus and PKU
Controlled sugars are usually fine
Typically cause more than one defect
Can affect differently at varying prenatal developmental stages

Conception and Fetal Development (Know this Section Well)

Gametogenesis

Development of ova in women

Every girl is born with every ova that she will ever have
There are usually a couple million, many of them are not healthy enough to be
released and are resorbed by the body
One cell will make one usable egg
Development of sperm in men
One cell will make 4 sperm
Meiosis divides gamete
Contains 23 unpaired chromosomes

Conception

Must have correct timing

Ovulation and ejaculation must occur within 24-48 hours of each other
Occurs in outer (distal) third of fallopian tube
Zygote is created by joining of ovum and sperm
First cell of the fetus

Pre-embryonic Period

Zygote undergoes cell division, becoming a morula

Morula (12-16 cells) secrete fluid forming a blastocyst
Blastocyst implants in uterine lining between days 6 to 10

Embryonic Period

Starts from day 15 until 8th week

Starts as just a neural tube
Most susceptible to teratogens
Rapidly dividing cells are most susceptible most to these
If a problem happens genetically, it happens during this time
 Always be sure to test females for pregnancy, even if they think they aren’t fertile
Embryo always grows in the same way
Cephalocaudal
Central-to-peripheral
Simple to complex
Fingers, then fingernails, then fingerprints
General to specific
Gestational age: age after last menstrual period
The book does it by ovulation, though
Week 5: three germ layers are created
Week 6: neural tube closes and heart starts beating
Week 7: head is large and upper limb buds form
Week 8: facial development begins with eyes and ears
Week 10: external genitalia start to differentiate
Week 10-12

Fetal Period

Starts from the 9th week until birth

All major systems are present in their basic form by 8 weeks gestation
All that is left is refining the systems and gaining weight
Teratogens may still harm but less likely to cause major structural abnormalities
Most women don’t know until at least week 4 that they are pregnant

Weeks 11-14

First fetal movements begin

Eyes fuse at 11 weeks (reopen at 28 weeks)
Intestinal contents leave umbilical cord and enter abdomen
Blood production begins in liver and shifts to spleen at week 14
Begins producing urine
Urine is part of amniotic fluid
Fingernails begin developing
Week 14, gender can be determined by external genitalia

Weeks 15-18

Quickening
Mom can feel baby movement
A first time mom might be 16-20 weeks
Face starts to look human
Starts to swallow amniotic fluid and produces meconium
Fingerprints developing
Weeks 19-22

Vernix caseosa covers skin

Skin protectant to stop skin from separating from body in a water environment
Lanugo covers body
Eyebrows and head hair appear
Brown fat is deposited
Keeps good temperature around organs
Testes begin descent toward scrotum
Nipples begin development
Typically not viable if born
Mainly because lungs do not have surfactant

Weeks 23-26

Skin translucent/red and little subcutaneous fat

Lungs begin producing surfactant
Decreases surface tension to open alveoli
Fingerprints and footprints developed
Eyebrows and eyelashes present
Age of viability
Depending on size and weight
Celestone given before 34 weeks
Skipped human drug trials because it was so helpful
Increases lung maturity
One dose when they come in and another 24 hours later
Immature blood vessels in brain
If they are born and pass away, it is frequently from brain bleeds
Testes have descended into scrotum by this time

Weeks 27-30

Maturation of lungs, pulmonary capillaries, CNS

Developing to not be as sensitive to outside stimulation
Eyes reopen
Bitter taste buds active
Subcutaneous fat deposit
Blood formation shifts from spleen to bone marrow
Typically, presents in head down position

Weeks 31-32

Skin is pigmented according to race

Toenails are present
Fetal heart rate variability increases
 Lanugo disappearing
High rates of survival with intensive care

Weeks 35-40

Growth or all body systems decrease in rate

Gaining weight
Half a pound a week
Surfactant increases tremendously in last two weeks
Should not induce until 38 weeks or after
Palpable breast tissue
Ear cartilage firm
Lanugo on shoulder and upper back only
Vernix in creases only
Visual acuity 20/600 at birth
From your elbow to your face

Placenta

Formed from both fetal and maternal tissue

Fetal blood and maternal blood do not mix
That’s how children can have different blood type than mom or precautions
could work for baby to not get HIV
Maternal component
Fetal component
Function
Function
Gas exchange
How the baby can live under water
Nutrient transfer
Folic avid
Waste removal
Get rid of CO2 and electrolyte waste
Antibody transfer
Passive immunity
Transfer of maternal hormones
Estrogen affects breast buds of baby
Endocrine function
Help baby regulate sugar and other hormones that the baby is too
immature to handle
This is why a diabetic mom needs to control her sugars
Alcohol, drugs, and infections may not be filtered out by the placenta and will
affect the baby

Umbilical Cord
 Structure
Two umbilical arteries
Take waste to the mom/placenta
One umbilical vein
Brings oxygen to baby
Wharton’s jelly
White substance inside the cord to prevent its collapse
Function
Transports oxygen
Transports nutrients
Transports waste

Fetal circulation

Three characteristics to allow fetus to obtain oxygen

Fetal Hgb carries 20-30% more
Hgb concentration is 50% more
FHR is 110-160 increasing cardiac output

PDF File

Ductus arteriosis
Foramen ovale
Opening between right and left atrium
Ductus venosus
After birth, the ductus become ligaments and the foramen ovale closes

PDF File

Fetal membranes

Amnion membrane
Closer to fetus
Chorion membrane
Closer to mom
Often break together with rupture of membranes
Can break separately
Rare

Amniotic Fluid

Composition
Fetal urine, fluid transported from mother, fetal skin cells, vernix
Production
Function
 Cushion infant
Allow symmetrical growth
Maintain temperature
Prevents adherence of membranes to feturs
Allow room for fetus to move
Abnormalities
Polyhydramnios: over 2000 mL at 40 weeks
Usually due to severe congenital anomalies, more than one fetus, or
diabetes
Oligohydraminos: less than 300 mL at 40 weeks
Poor perfusion of placenta, infants kidneys not working, or a premature
rupture of membranes

Multi-Fetal Pregnancy

Monozygotic twinning
One ova fertilized by one sperm and divides into two
Indentical twins with identical DNA
Occurs at random
Dizygotic twinning
Come from two ova released and fertilized by two different sperm
Family history
Increased incidence in women over 40
October 9
High-Risk Neonatal Nursing Care/Grief and Loss

Adolescent Pregnancy

Incidence
2010 was the lowest rate ever recorded for births to women 15 to 19 years old in
the U.S.
Factors associated with teenage pregnancy
We don’t educate them enough
Sex education
Not the right terminology
No teaching on consistent use of birth control or the correct way to use birth
control
Options
Termination
Putting baby up for adoption
Keeping the baby
Often need help in dealing with their decisions
Socioeconomic implications
WIC (Women Infants and Children through Medicaid)
Cost the public $11 billion a year
Health care, foster care, etc.
Maternal health implications
Anemia
Poor nutrition
High risk of infection/STD
Partner violence/abuse
Late/no prenatal care because they didn’t know or were trying to hide it
Fetal-neonatal health implications
Baby is at risk
No doctors’ visits, no prenatal visits, no proper nutrition
Teenage expectant father
Often not involved at all or involved long term
Impact on parenting

Nursing Process of Pregnant Teenager

Assessment
Determine the degree of participation by the father
Amount of family support
Is mother supportive?
Does she like the boyfriend?
Nursing diagnosis
Expected outcomes
 Interventions
Eliminate barriers to health care
Apply teach/learn principles
Text to
Counseling
Family support
Referrals
Evaluation
They do not always openly share their concerns
We may have to pull it out with open-ended questions
Do not ask questions with one word answers
Tell me about your week
What kinds of things are causing you stress?
Can she demonstrate back the infant care

Delayed Pregnancy

Get pregnant late in life due to career or earlier infertility issues

Maternal and fetal implications
Aging process of the ovaries may cause difficulty in conceiving
Higher risk for gestational diabetes
Higher risk for spontaneous miscarriage
Higher risk for baby to have trisomy 21 (Down’s syndrome)
Higher risk for a cesarean delivery
Advantages
The mother is more mature and settled in life (financially, too)
Have support systems
May have a significant other
Disadvantages
May need extra recovery time (especially with a c-section)
No peer support
Friends probably already have teenagers and do not relate will to this
stage of parenting
May have sick or ill parents trying to care for on top of an infant
Nursing considerations
Help with emotions
Give parenting information

Substance Abuse

Incidence
Maternal and fetal effects (statistics are only from women who actually reported)
Tobacco
1 in 6 pregnant women smoke cigarettes
Most common form of substance abuse
Alcohol
 1 in 9 women report drinking
0.5% report heavy drinking during pregnancy
2.5% report binge drinking during pregnancy
Most commonly used drug
Marijuana
Most commonly used illicit drug
Cocaine
Amphetamines/methamphetamines
Antidepressants
Opioids
5.5% reported using illicit drugs
Diagnosis and management
Are they using, or are they abusing?
Monitor them, especially high-risk IV use
Exposure to HIV or hepatitis
More frequent ultrasounds
Non-stress tests (NST)
Try to get mom on methadone instead of drugs
Methadone clinic every day for dose
Give urine specimens to prove drug clean
This is a synthetic opiate
They can become addicted to methadone
Baby is addicted to methadone, too, and will go through
withdrawals

Maternal Substance Abuse

Antepartum period
Assessment
Nursing diagnosis
Expected outcomes
Intervention
Evaluation
Intrapartum period
Assessment
Nursing diagnosis
Expected outcomes
Interventions
Evaluation

Adoption

Process
Nurses help through this process
Could be due to rape, unplanned pregnancy, too many children, etc.
Could bring up sad emotions or satisfied closure through giving the child to a
 better home
Therapeutic communication
Establish trusting relationship with the patient giving up their baby for adoption
Be open and honest
Many have really thought this through
With teen moms, acknowledge her maturity and affirm her decision
Proud of her
Don’t try to change her mind or coerce her
Support her decision
Be open with her about the adoption parents coming to the hospital
“Is there anything I can do to help you prepare?"
Teaching infant care to adoptive parents
Room for adoptive parents to stay in and prepare them
Infant care teaching
Car seat, crib, other preparation

Intimate Partner Violence

Effects during pregnancy

May receive late prenatal care
Factors that promote violence
Pregnancy makes the partner feel trapped
Could happen post-partum
You’ll see them miss appointments
Characteristics of the abuser
The partner will never leave their side and will even answer questions for the
woman
It’s all about power and intimidation and control
Cycle of violence
Tension building phase
The partner is getting tense and mad about something
Battering phase
This is where the abuse happens
The actual battering
Honeymoon phase
“I’m so sorry, you know I love you, that won’t ever happen again, I’m so
sorry, please don’t leave me, here are some presents and flowers” etc.
Then the cycle repeats
Nurse’s role in prevention
Try to get the pair apart
Maybe get the partner to sign some papers or get coffee
Try to get a few minutes alone with the mother to ask her a few questions

The Battered Woman

Assessment
 Nursing diagnoses
Expected outcomes
Intervention
Listening
Developing a personal safety plan
She should know where the closest shelter to her home is
She should know the quickest way out of her house
Hide a house key and car key somewhere in case she couldn’t grab her
purse/keys on the way out
Memorize some telephone numbers
She may not have her phone
May need to hide some money with the keys
Affirming she is not to blame
SHE IS NOT TO BLAME
Education
Referrals
Evaluation

Late Preterm Infants

Infants born between 34 0/7 and 36 6/7 weeks of gestation

Anything less than 37 weeks is “preterm"
Incidence and etiology
Premature rupture of membranes (PROM)
Advanced maternal age
Preeclampsia
Obesity
Characteristics of late preterm infants
Appearance
Look like full term infants
5-6 pound range
Behavior
Risk for respiratory disorders/issues
Problems with thermoregulation (temperature maintenance)
May not have adequate brown fat
Hypoglycemia risk
Problems feeding
Assessment and Care
Thermoregulation
Hypothermia
Turn into cold stress easily
Kangaroo care with skin to skin contact
Take temperature every 4 hours
Put in isolette or radiant warmer
Feedings
Immature suck (cannot suck and swallow coordinated properly)
Shorter awake periods
 They don’t have a lot of muscle tone, so they need to breastfeed
when awake
Discharge
Need to stay at least 48 hours
Even if mom goes home earlier
Need to have good feedings and stable vitals
Car seat challenge test
Cardiac monitors and O2 sats while they are in their car seat
Have to make sure they don’t have bradycardia or apnea spells
while sitting in the car seat

Preterm Infants

Born before the beginning of the 38th week gestation

Low birth weight (LBW)
Less than 2500 grams
About 5.8 pounds
Very low birth weight (VLBW)
Less than 1500 grams
About 3.5 pounds
Extremely low birth weight (ELBW) - “micro premie"
Less than 1000 grams
About 2.3 pounds
Incidence and etiology
Causes
We know there are risk factors, but no exact cause of preterm labor
Prevention
Characteristics of preterm infants
Skin is so red and thin
Cannot tell race
Can see blood vessels
No subcutaneous fat
White or brown
Absent plantar creases on feet (less than 32 weeks)
Eyes may still be fused
Assessment and care
Respiration
Assessment
Nursing interventions
Working with equipment
Ventilators to breathe or OxiHood (moisture, too) or nasal
cannulas
Suctioning
Hydration
Skin gets dried out so easily
Positioning them in certain ways to breathe better
Problems with thermoregulation
 Assessment
Nursing interventions
Neutral thermal environment
Weaning to open crib
Problems with fluid and electrolyte balance
Assessment
Nursing interventions
Problems with skin
Skin is frail
Can breakdown easily, touch as little as possible
Frequent barrier ointment to prevent breakdown and keep hydration
Problems with infection
Prone due to skin breakdown
Immature immune system
Problems with pain
Preterm Infant Pain Scale (PIPS)
Can see them crying, even when intubated

Respiratory Distress Syndrome (RDS)

Caused by insufficient production of surfactant in the lungs

Because the baby is born prematurely
Surfactant decreases surface tension to prevent lungs from being stiff
Keeps alveolar sacs partially open even once they exhale
Pathophysiology
Insufficient surfactant production
Manifestations
Tachycardia
Retractions
Nasal flaring
Cyanotic
Therapeutic management
Instill surfactant in ET tube
Nursing considerations

Bronchopulmonary Dysplasia (BPD) AKA Chronic Lung Disease

Chronic condition
Damage to the infant’s lungs requires prolonged dependence on supplemental oxygen
Chronic condition in lungs because of being on mechanical ventilation for
extended time
Pathophysiology
Manifestations
Tachypnea
Retractions
Crackles
 Increased need for oxygen
Wheezing
Pulmonary edema
Therapeutic management
Starts before they’re born
Give mom steroids to help mature baby’s lungs
Celestone IM injection
Minimize the exposure to ventilation and oxygen as much as possible
Don’t routinely give oxygen

Intraventricular Hemorrhage (IVH)

Bleeding into and around the ventricles of the brain

Grade I (mild) to Grade IV (most severe bleed)
Could have bleeds on each side of the brain that are different grades
Depends on the trauma to each side of the head
Pathophysiology
Immature brain blood vessels
Manifestations
Found through routine brain scan (no symptoms)
Symptoms
Lethargic, poor muscle tone, cyanosis, apnea, drop in hematocrit,
decreased reflexes, bulging fontanels, seizure activity
Therapeutic management
Ultrasound of head after 7 days
Bleeds happen within the first week
If a bleed is found, routine scans are done to determine if it is getting worse or
better
Try not to do anything that would make them cry or increase pain
Central line in umbilical cord
Minimal stimulation
Nursing considerations

Retinopathy of Prematurity (ROP)

Injury to the blood vessels in the eye

May result in visual impairment or blindness in preterm infants
If retina is permanently damager
Pathophysiology
Exact cause in unknown
High level of oxygen is a risk factor
Therapeutic management
Dilate their eyes to look in and make sure their retinas are attached and healthy
Nursing considerations
Necrotizing Enterocolitis (NEC)

Serious inflammatory condition of the intestinal tract

Intestine is becoming necrotic and dying
This can cause death
May lead to cellular death of areas of intestinal mucosa
Abdomen will be very round and can turn black within a matter of hours
Intestines will erupt/dehisce and baby will die quickly
Pathophysiology
Mortality rate of 10-30% of babies who develop this
Usually develops several days after birth
Those who survive have longterm GI issues
Manifestations
Big abdominal girth/abdominal distension
Absent bowel sounds
Vomiting
Bloody diarrhea
Abdominal tenderness… a lot of pain
Vital signs (increased HR and RR)
Flinching
Tense muscles
Therapeutic management
Ventilator
Antibiotics
Gastric suctioning
d/c PO feedings
Baby needs to be NPO
Surgery needed if bowel perforates
Sometimes surgery even if this doesn’t happen

Post-Term Infants

Born after 42nd week gestation

Scope of the problem
Problems with placenta (it can calcify)
Cord and placenta gets small
Baby was getting less and less blood and oxygen
May have passed meconium in-utero
Assessment
Big babies
Long fingernails, peeling skin, no vernix
May be meconium stained
Therapeutic management
Observe for injuries (broken clavicle, forcep/vacuum extractor marks)
Hypoglycemia
Because they were so dependent on mom for insulin and sugar control
Mom may come in for tests and be monitored for complications
 Nursing considerations

Small for Gestational Age Infants

Causes
Poor placental function
Alcohol/drug abuse
Smoking moms
Multiple gestation
Genetic factors
Scope of problem
High morbidity and mortality rate
Have problems with thermoregulation due to lack of fat
Characteristics
Weight is less than the 10th percentile for their gestational age
Therapeutic management
Nursing considerations

Large for Gestational Age Infants

Causes
Multipara
Babies get bigger as she gets more pregnant
Big parents
Obese moms
Scope of problem
Birth injuries and clavicle fractures
Mom may have longer labors
Higher risk for c-section
Characteristics
Weight is more than the 90th percentile for their gestational age
Therapeutic management
Nursing considerations

Respiratory Complications (even for bigger babies)

Asphyxia
Transient tachypnea of the newborn
Meconium aspiration syndrome
Get meconium in their lungs
Persistent pulmonary hypertension of the newborn (PPHN)

Infection
 Transmission of infections
Vertical transmission
Passing of infection from mother to baby before or during the birth
i.e. rubella, syphilis, HIV, GBS (group beta strep), herpes, hepatitis
Mom often has GBS active in her vaginal flora during pregnancy
We test all mothers
Horizontal transmission
Nosocomial infections- from hospital staff or equipment to baby
Sepsis neonatorum
Causes
Therapeutic management
Nursing considerations
Nursing interventions

Infant of Diabetic Mother

Scope of problem
Babies are five times more likely...
Characteristics
Macrosomic
NSTs ?
Therapeutic management
Nursing considerations
Help mom control sugar to help with baby
Nursing interventions

Prenatal Drug Exposure

Identification
Important to try to figure out what she is taking
Urine drug screen
If it is positive for illicit drugs, we will also bag baby when they are first
born
We want to get their first urine to get most concentrated sample of
any drug in their system
With adhesive urine collection bag
Therapeutic management
Difficult to watch a baby go through withdrawals
Apneic spells, diarrhea, excessive crying, frantic sucking, very irritable,
uncontrollable sneezing, seizure activity, very high-pitched cry, hard to soothe
Cry is very distinctive to a baby in withdrawals
Nursing considerations
Feeding
Don’t have a good suck/swallow reflex
Do not feed well
Rest
 Want to be very tightly swaddled and held
Poor sleep patterns due to excessive activity
Inability to rest due to jitteriness
Bonding
Mom is also jittery and irritated (because she can’t soothe her baby)
DHR usually gets involved, especially if baby has positive drug screen
Marijuana is treated more like alcohol these days
Babies can also have withdrawals from nicotine

Helping Parents Help Their Drug-Exposed Infant

Swaddle the infant with the hands brought midline

Hands across their chest (like a mummy)
Provide a pacifier
Slowly and smoothly rock in a vertical or horizontal motion with the infant held upright
Coo softly and gently
Coo Bear
Place infant over should and gently stroke the back
Keep the room fairly dark because some will be sensitive to light
Avoid simultaneous auditory and visual stimuli
Curtail stimulation if the infant shows signs of stress (yawning, sneezing, jerky
movements, or spitting up)

Birth of an Infant with Congenital Anomalies

Factors influencing emotional responses of parents

Grief and mourning
Leading cause of death in first year of life
May grieve the loss of a “perfect” child that they expected to have, not
necessarily a child’s death
Nursing considerations
Common anomalies
Cleft lip/cleft palate
May see lip on ultrasound, but not palate
Easily repaired
Clubbed feet
May put casts on feet at first
Initially, it is upsetting to see
Eventually will be able to run and play
Spina bifida
Neural tube did not close and part of spine is on outside of the body
Needs surgery
Depends on the severity as to any development problems
Some are wheelchair bound and did not have fully developed limbs
Not mental, though, just physical disabilities
Polydactyly
 Webbed fingers
Easily repaired

Pregnancy/Infant Loss

Early loss
Concurrent death and survival in multifetal pregnancy
Perinatal palliative or hospice care services
Previous pregnancy loss
Assessment
Nursing diagnosis
Expected outcomes
Interventions
Evaluation

Terms

Ectopic pregnancy: implantation of the fertilized ovum outside the uterus

This mom has had a positive pregnancy test
Early in the pregnancy she has a lot of pain (it’s frequently in the fallopian tube)
It’s not long before the pregnancy ends
Miscarriage: loss of pregnancy that occurs naturally
The body ends the pregnancy
Alabama is less than 20 weeks
Stillbirth: the birth of a deceased infant
Alabama is past 20 weeks
Newborn death: the death of an infant (no matter how many weeks gestation) after a
live birth
If it was born with any signs of life
Trying to breathe, trying to beat its heart, any signs of life, etc.
Grief: physical, emotional, social, and cognitive response to a loss
Grief is the response to a loss
You can grieve the loss of your job or the end of your job
The inward feeling of sorrow
Mourning: the act of sorrow
The outward expression of sorrow
Rituals: done in accordance with social custom or as part of a ceremony
i.e. funeral, visitations, etc.

Phases and Stages of Grief

Denial and isolation

“No my baby hasn’t died. You’re wrong."
Anger
“You are crazy! Get a different doctor in here!"
 Bargaining
“God, if you’ll just the baby be okay, I promise I’ll start… (tithe, Sunday school,
Bible study, etc.”
Typically God or some higher power
Depression
Over weeks and months
Acceptance
These stages happen fluidly and can go back and forth until acceptance
The order is not absolute

Signs and Symptoms of Grief

Physical
Complain of pain
Contractions
Body aches, headaches, arms aching (empty arms), body fatigue
They will either go into labor or we will have to induce them
Emotional
Sadness, depression, crying, etc.
Social
Not wanting to socialize or be around others, withdrawing, anger with friends
(especially those who are pregnant)
Spiritual
“Why did you let my baby die? I’m a good person?”
Afraid to go back to church because she got angry with God
Recovery

Communicating with Grieving Families

Words and actions that comfort-assist with birth/death certificate, assist with funeral
arrangements, provide privacy, provide information, sensitive discharge information
Be open and honest
Introduce yourself, “I’m so sorry that this happened”
Don’t say nothing
Don’t say: “Just be glad you have an angel in heaven,” “I understand
exactly how you feel,” “You’re young, you can have other babies,” “You
can still take this off of your income tax at the end of the year”
We can’t suggest a funeral home, but we can call the home once the family has
chosen one
Be there for them and provide them privacy
Sensitive discharge materials
Not “nurse your baby every 2-3 hours” or “rest when your baby rests”
Select “fetal demise” for discharge paperwork selection
Do’s and dont’s
Communication “leads”
Introduce self, do head to toe assessment, acknowledge death of infant, call
 infant by name, allow patient to talk about her baby
Still check fundus and BUBBLEHE, etc.
Call the baby by name if it was named
Lets them know that you respect the baby
Refer to “your daughter” or “your son” if they have not named it; or
“your baby” or “your child"
DO NOT CALL THE BABY “IT”
You can sit down and let the mom talk about her delivery or her
experience
Listen if she needs it
Ways family and friends can help
Friends and family brochures
Don’t say “let me know if I can do anything”
“I’m already at the grocery store, do you want me to get you some bread
and milk?"
Helpful suggestions for parents
Encourage reading, keeping a journal, attend a support group, allow support
from friends and family
Helping Children and Teens with Grief:
Developmental stages
Parents don’t know how to tell other siblings about the baby
Depends on the other children’s development
4 year old vs. 12 year old is very different
Be open and honest
Children are very literal
Talk to them on their level
It comes better from their parents because the parents
knows the right words to use
Children are comforted by touch
Sit on the chair with them or on the bed beside them
Use the words “the baby died and is not going to come home and
live with us”
Don’t say, “mommy lost the baby” or “the baby went to
sleep”
Children from religious backgrounds sometimes do better
Child can have some understanding of “where” the baby is
Teen relationships
If the teenager is the sibling, they will understand differently
If the teenager is the bereaved mother, the family is sometimes happy this
happened
Your primary job is a patient advocate
“Your daughter is grieving the loss of her child. I understand that
you feel that way, but she needs you to not say those things in front
of her and be a support"

Making Memories
At the hospital is the only and last time they will see this child
Bereavement boxes
Journal
Other items
Handprint and footprints
Wisp of hair to clip and keep
Anything you touched the baby with
Hair brush, name card (if it was alive for a while), tape measure, their
blanket
The parents want to know everything about their baby: length and weight
Clothes
We can put their clothes on them (gowns)
No matter the size
Sometimes they donate things back to the hospital
Birth/death certificate
Rituals
Priest may come if the parents want the baby baptized
RNs can do that
Sprinkle water on them and baptize in the name of the Father, Son,
and Holy Spirit
Arrangements for infant
Photos
Black and white may be better
October 16

Preconception

Pre-pregnancy weight

Recommended to have normal BMI at conception (18.5-24.9)

Low pre-pregnancy weight
Preterm labor
SGA baby
Increased perinatal mortality
Mostly adolescents
High pre-pregnancy weight (BMI <25)
Miscarriage (spontaneous abortion)
Gestational diabetes
Pre-eclampsia
Cesarean birth
Congenital anomalies
Macrosomia
Postpartum hemorrhage
Thromboembolic disorders

Folic Acid/Folate

Vital nutrient in early weeks of pregnancy

Prevents neural tube defects, such as spina bifida and anencephaly
Recommended dosage is 400 mcg daily for any woman in childbearing years
Recommended once pregnant is 600 mcg daily

Pre-Conception Testing

Time to identify any potential problems

Vital for women who have a history of miscarriage or complicated birth
During visit
Complete social and medical history
Physical exam
Assess chronic health issues
Screen for STIs
Screen for immunity to rubella, varicella, and hepatitis B
Medications are assessed and are altered
Use of complementary and alternative therapies
Encourage weight loss or gain
Smoking cessation programs
First Trimester (1-12 weeks)

Signs of pregnancy
Presumptive
Other things can cause the symptoms
Chadwick sign
Estrogen makes the blood pool and the area is vascular
Labia change color to dark bluish purple
Amenorrhea (absent period)
Also could be stress or weight loss
N/V
Fatigue
Urinary frequency
Breast and skin changes
Quickening
Fetal movement felt by mother
Could be mistaken as gas or peristalsis
Probable
Most likely pregnancy, but it could still be something else
Abdominal enlargement
Goodell sign
Cervical softening
First feel like your nose, then your lip
Hegar sign
Can compress cervix to the thinness of paper
Ballottement
Sudden tap on cervix during vaginal exam causes fetus to rise in
amniotic fluid and rebound to original position
Fibroids or cancer could technically feel like that
Braxton Hicks contractions
Uterine contractions that do not cause cervical dilation
Also known as false labor
Palpation of fetal outline
Not well-trained physician could palpate a tumor
Uterine souffle
Soft, blowing sound auscultated over uterus
Positive pregnancy test
Positive
Fetal heart tones
Fetal movements detected by experienced examiner
Visualization of embryo or fetus through ultrasound
Verifying
Serum and urine pregnancy test
Detects human chorionic gonadotropin (hCG)
False positive
 Some medications (anticonvulsants, diuretics, tranquilizers) can
cause false results
Other condition that excretes hCG (cancer, pituitary problems,
ovarian cysts)
User error
Evaporation line
Test sat out too long (they will all turn positive eventually)
Residual hCG
If they’ve been pregnant in the last six weeks
Test was expired
False negative
Took test too early to detect required level of hCG
After you’ve missed your period is ideal time
Urine is too diluted
Certain medications (such as diuretic or antihistamine)
Test is expired

Nagele’s Rule

To find estimated due date (EDD)

Subtract last missed period (LMP) by three months
Add seven days
Change year (if applicable)
For example
August 4, 2017
Subtract: May 4, 2017
Add seven days: May 11, 2017
Change year: May 11, 2018

Physiological Changes

Progesterone
Developed by corpus luteum and then placenta
This is what expels egg into fallopian tube
Placenta doesn’t form to 10-12 weeks
Decreases smooth muscle tone
Maintenance of endometrium
Suppresses FSH and LH
Stimulates development of breast lobes and ducts of lactation
Increased sensitivity to carbon dioxide
Estrogen
Suppresses FSH and LH
Stimulates uterine growth
Increases blood supply
Hyper-pigmentation
Reacts with melanin
 Antagonist to insulin
May cause gestational diabetes
Increases deposit of maternal fat stores
Causes Chadwick’s sign (congested blood vessels)
Endocrine changes
Anterior pituitary glance increases in size
FSH and LH are suppressed
Thyroid enlarges
Glucose levels are lower and may experience hypoglycemia
Increased cortisol and thus metabolism
Relaxin produced
Loosens the joints in the body
Mainly the sacral area
Reproductive changes
Uterine, breast growth
Hyperplasia (more cells)
Hypertrophy (bigger cells)
Cervical change in color and consistency (due to estrogen)
Cervical consistency changes
Respiratory changes
Progesterone relaxes smooth muscle in respiratory tract
Increase respiration rate (normal: 16-24)
Body is more sensitive to CO2
Oxygen consumption increases 20%
Estrogen causes increased vascularity of mucous membranes causing nasal
congestion
Normal to feel “stuffy”
Cardiac changes
Myocardium enlarges
Total blood volume increases by 6 weeks gestation
Plasma volume increases (significantly more than red blood cell count)
Physiologic anemia of pregnancy (too much plasma, not enough RBCs)
Cardiac output increases 30-50%
Increased stroke volume and increase o heart rate about 15-20 bpm
above
Increased clotting factors
Risk for PE and strokes
Blood flow altered to include uterus/placenta
Systemic vascular resistance decrease
Lower BP
GI
Nausea and vomiting
Possibly due to increased smell
Emptying of intestines increases
Emptying time of gallbladder is prolonged
Reduced gallbladder tone
Heartburn from loose sphincter
 Urinary
Increased renal plasma flow
Retention of sodium and water
Bladder tone decreased
Dilation of ureters and renal pelvis
Glucose excretion increases
Integumentary
Melasma (brownish patches of skin around the face)
Palmar erythema (redness of palms)
From estrogen increases vascular
Immunity
Decreased function
Cortisol is released
Autoimmune diseases improve
Sensory
Corneal edema
Intraocular pressure decreases
Glaucoma is improved

Prenatal Care

First visit (if no preconception care)

Verify pregnancy
Urine test is qualitative (yes or no)
Blood test is quantitative (amount of hCG)
Better to rule out residual hCG
Evaluate obstetric history, menstrual history and EDD, contraceptive history,
med/surg history, family and partner’s family history, psychosocial history
Draw CBC, H/H, hCG, Rh factor, titers for immunizations (rubella), RPR (test for
syphilis), HIV
Obtain vital signs, height and weight
Perform physical exam
Pap smear an cultures for STIs
Schedule of assessments
Conception-28 weeks is every 4 weeks
29-36 weeks is every 2 weeks
37-birth is every week
Research shows that women who receive prenatal care have better outcomes

Obstetrical History

Gravid/gravida
Number of pregnancies (not births)
Nulligravida- no pregnancies
Primigravida- first pregnancy
Multigravida- many pregnancy
 Para
Number of pregnancies that reached 20 weeks
Nullipara: no pregnancy past 20 weeks
GTPAL
Gravida (number of pregnancies)
Term births (37+ weeks)
Preterm births (<36 weeks)
Abortions/miscarriages (<20 weeks)
Living children
Woman has 5 pregnancies, one miscarriage, three deliveries at 39 weeks, one
delivered at 36 weeks, and four are living
53114

Discomforts of Pregnancy

N/V
Crackers before they even get out of bed
Happens when too full/empty
Happening past first trimester- referral to doctor
Ginger helps
Constipation
Add fiber and water
Because GI tract has slowed down
Urinary frequency
Fatigue
Breast sensitivity
Lightheadedness/dizziness
Mood swings

Warning Signs

Bleeding
Severe abdominal cramping
Severe one sided pain
More severe than appendix
Could be ruptured ectopic pregnancy
Blacking out frequently
Bottomed out blood pressure
Absence of fetal heart tones
Dysuria, frequency, urgency
UTI
Woman is more at risk to get a UTI when pregnant
Vagina pH goes from 3 to 6
Fever
Hyperthermia can cause birth defects
Always want to get a fever down quick
 Prolonged nausea/vomiting

Psychosocial Adaptations

Uncertainty
Unsure if she’s pregnancy
Monitors for changes in body
Ambivalent
Conflicting feelings about pregnancy
The self
Her primary focus is on herself
How does this pregnancy affect me?
Fetus seems vague and unreal
Her moods may be labile

Question answer: normal ambivalence

Nutrition

Pattern of weight gain

1-4.5 pounds gain during first trimester
Mother may be nauseated
Fetus needs very little nutrients
Calorie intake
Same is non-pregnant woman
Do not limit macronutrients
Encourage nutrient dense options
Vitamins
Encourage prenatal vitamins with folic acid
Be careful not to overdose on fat soluble vitamins
Vitamin A overdose can cause fetal anomalies
Yellow/carrot vegetables
Can cause fetal brain damage
Water intake
Encourage water intake to prevent dehydration
If able to hold down, drink 8-10 cups of fluids each day
Limit sodas, juice, coffee or tea (high sugar, low nutrient value)
Nutrition precautions
Reduce intake of caffeine
One cup of coffee or two 12 oz sodas per day
Too much caffeine can cause fetal harm
Eliminate alcohol
No amount of alcohol is safe
Reduce tuna, salmon, and other large fish/shellfish
Less than 6 oz
Do not consume raw eggs or meat
 No raw cake batter or sushi
Toxoplasmosis could kill the baby
Heat luncheon meats and hot dogs
Listeria could harm baby
Do not consume unpasteurized milk or milk products
Wash all fruits or vegetables
Toxoplasmosis can live in soil around vegetables
Don’t limit macronutrients
This is not the time to restrict a certain food group

Fetal Testing

Ultrasound
Use of high-frequency sound waves
More opaque structures are denser tissues (bone)
Black areas are areas of fluid
Types of probes
Trans-abdominal
Transvaginal
Images
2D images
3D images
Indications in first trimester
Verification of pregnancy
Measure gestational age
Identifying multifetal pregnancies
Site of fetal implantation (uterine, ectopic)
Assessing maternal structures
Fetal viability or death
Locate site of placental attachment
Observe fetal movement and heart beat
Risks/disadvantages
Slight risk to infant
Too many sound waves could increase temperature of baby
Ultrasound machine indicates when it is “too much"
May cause undue anxiety or false reassurance
Cost is expensive
Advantages
If early enough, accurately determine gestational age
Clear visibility of infant(s) and surrounding structures
Noninvasive and comfortable
Immediate results
Procedure
Transvaginal
Empty bladder
Place mom in lithotomy position
Usually stirrups
 Probe is encased in disposable cover and coated with gel
Usually latex
Woman may insert probe herself
Not painful but causes pressure
Often used in early pregnancy
Trans-abdominal
Encourage mother to drink 24-32 ounces of water
Must have full bladder
Place on back
Gel placed on probe or abdomen to see structures
First trimester screening
Maternal blood test with ultrasound
Measures
Pregnancy-associated plasma protein-A
Human chorionic gonadotropin (hCG)
Nuchal translucency in infant
Neck has transparent part to it
Detects possibility of chromosomal anomaly
Trisomy 21 (Down’s Syndrome), or 18, or 13
Increased hCG
Anyone over 35 is recommended to have this
Performed in between 10-14 weeks gestation
Can find out gender
Chorionic villus sampling
Assessment of portion of developing placenta
Performed at 10-13 weeks
Aspirate chorionic villus through syringe/catheter through abdominal wall or
intra-vaginally using ultrasound guidance
Indications
Rule out genetic chromosomal abnormalities
Risk
Miscarriage
Limp amputation of arms/feet (especially before 10 weeks)
Chorioamnionitis
Benefits
Results known before amniocentesis
Procedure
Signed informed consent
Trans-cervical CVS
Before procedure, cultures for GBS (group B strep), chlamydia,
gonorrhea
Treat if positive
Lithotomy position
Slim catheter placed through cervix to retrieve sample
Trans-abdominal
Best position for insertion
Abdomen prepped
 Needle inserted
After procedure, fetal heart activity is monitored
If mom Rh negative, she will receive RhoGAM
Could introduced fetal blood to mom’s circulation
Spotting is normal
Report if heavy bleeding, clots, amniotic fluid occurs

Perinatal Education

Adapting to pregnancy
What to expect in months ahead
Obtain prenatal care
Avoid hazards to fetus
Fetal development

Second Trimester (13-18 weeks)

Physiological Changes

Reproductive
Continued uterine growth through hypertrophy
Vaginal rugae (folds) are prominent
Cardiovascular
Heart is pushed up and to the left
Third heart sounds is heard (90% women have this and it is normal)
Splitting of first heart sound or systolic murmur
GI
Lower esophageal sphincter is relaxed
Heartburn (pyrosis)
Increased abdominal pressure
Endocrine
Hyperplasia of thyroid
Enlarged is normal
Integumentary
Linea nigra (dark line from fundus to symphysis pubis)
Striae gravidarum (stretch marks)
Do not disappear
Hair grows more rapidly and does not fall out
Musculoskeletal
Relaxin causes relaxation in connective tissue
At 28-30 weeks, pelvis symphysis separates
Lean back to maintain balance (lordosis)
Backache

Prenatal Care
 Regular check up
Vital signs, weight, fundal height
14 weeks- fundus is outside of pubic symphysis
20 weeks- hits belly button
Approximately 20 cm
36 weeks- hits xiphoid process
Urinalysis
Fetal heart rate
Glucose screening
Usually at 24-28 weeks gestation
1 hour glucose challenge test
If over 140, 3 hour glucose
If they fail, they have gestational diabetes
Some are diet controlled and some need insulin
Iso-immunization
Tested when woman is Rh negative and partner is unknown of Rh positive
If unsensitized, RhoGAM given at 28 weeks gestation
RhoGAM is a human blood plasma
IM injection in hip
2 RNs sign off
Obtain vital signs before giving ad 20 minutes after
Not as likely to have reaction as a true blood transfusion
Anatomy scan
Ultrasound of anatomical structures of infant (around 18-22 weeks)
Brain, heart (with four chambers), kidneys, etc.

Common Discomforts

Backache
Fetal movement
Change position or rub uncomfortable spot to get baby to move
Heartburn
Round ligament pain (right sided sharp pain)
Ligament that holds uterus up is pushed to the side
Knife-stabbing twinges of pain
Varicose veins (legs, vulva, rectum- hemorrhoids)
Take breaks from standing
Compression stockings
High fiber diet and topical cream for hemorrhoids
Constipation
Leg cramps
Periodically flex and extend legs
Could be low magnesium

Warning Signs
 Abdominal pain
Bleeding
Absence of fetal movement
Prolonged nausea/vomiting
Gush of fluid
Fever
Dysuria, frequency, urgency

Psychosocial Adaptations

Physical evidence of pregnancy

Makes baby seem real
Fetus as primary focus
Concerned about producing a healthy baby
Information about diet and fetal development is welcomed
Narcissism and introversion
Undue preoccupation with oneself
Concentration on the self and body
Wonder and daydream about baby
Body image
Changes could be welcomed
Signify growth of fetus
Can contribute to negative self image
Changes in sexuality
Unpredictable
May increase, decrease, or remain unchanged
Increased sensitivity of labia and clitoris
Increased vaginal lubrication
Orgasm may occur more frequently or with greater intensity
Pregnancy may change partner’s attraction
It is okay to have sex in a non-high risk pregnancy
Men often fear they will “hit” the baby, but they won't

Nutrition

Weight gain
Should gain 0.5-1 pound weekly
For the rest of pregnancy
Calorie intake
Increase total calories to 340 above normal diet
Metabolism is higher
Most need 2200-2900 calories a day
Increase protein intake (71 g)
Normal is 45-46
Baby needs it for amino acids
Increase carb intake (175 g)
 Extra glucose used for baby
Iron
Pregnant women need 1000 mg above normal diet
Only nutrient that cannot be supplied completely and easily by diet
Supplements can cause dark stools and constipation
Vitamin C increases absorption
Cooking with iron pan increases intake
Red meat, spinach, liver, legumes. dried food
Milk, tea, coffee, and red wine decrease iron absorption
Tannins
Coffee binds iron
Typically prescribed 30 mg/day
Sodium
Avoid excessive amounts
Soda, canned food, ketchup/condiments

Fetal Testing

Alpha-fetoprotein (MSFAP)
AFP: predominant protein in fetal plasma
Low levels indicate chromosomal abnormalities
High levels indicate anencephaly or spina bifida
Anencephaly is no brain
Spina bifida is when spinal cord is outside of body
Procedure
Offered between 16-18 weeks
Evaluate for for factors that affect MSFAP
Blood sample taken from mother
Multiple-marker screening (Quad-screen)
Uses MSAFP, hCG, estriol, and placental hormone inhibin A
Increases detection of trisomy 18 and 21
MSAFP and estriol and hCG is high indicates higher potential for chromosomal
anomalies
Placental hormone inhibin A used when women are younger than 35
Doppler ultrasound
Ultrasound wave directed at a moving target
Assess umbilical blood flow
US that also detects blood flow
Can also be used to detect fetal heart rate
Amniocentesis
Aspiration of amniotic fluid
Best performed at 15-20 weeks
18-22 weeks (15 cc. fluid)
Indications
Chromosomal abnormalities
Erythroblastosis fetalis
Uterine infection
 Lecithin/sphingomyelin (L/S ratio)
L/S ratio
Performed in third trimester
Estimates fetal lung maturity
How mature is baby’s lungs
Done if mom is at risk for early labor
Do they have enough surfactant to breathe on their own
L/S ratio of 2:1 indicates adequate lung maturity
Procedure
Informed consent
Asses maternal BP and FHR
Risk for bradycardia and baby and hypotension in mom
Ultrasound locates fetus, placenta, and largest pocket of fluid
Abdomen prepped, anesthetic applied
Needle inserted and aspirate amniotic fluid
Electronic fetal monitoring (EFM) afterwards
Give RhoGAM (if Rh negative)
Report
Persistent uterine contractions
Vaginal bleeding
Leakage of amniotic fluid
Fever
Percutaneous umbilical blood sampling (PUBS)
Also known as cordocentesis
Rare because of potential complications
Aspiration of fetal blood from umbilical cord
Procedure
Sam as amniocentesis
Benefits
Used to treat blood diseases
Used to deliver therapeutic drugs
Could be twin to twin transfusion
Limitations
Can result in life-threatening complications
Must be prepared for emergency
Complications
Fetal bradycardia
Prolonged bleeding
Cord laceration or hematoma
Thrombosis
Thromboembolism
Preterm labor
Premature rupture of membranes

Perinatal Education

Benefits of breastfeeding
 Common discomforts
Lifestyle
Fetal movement
Pregnancy complications
Preterm labor
Premature ROM
Gestational diabetes
Gestational hypertension
Headache, double vision, red face

Third Trimester (28-40 weeks)

Physiological Adaptations

Reproductive
Uterus thins and expands upward
Can almost see outline of the baby
Displaces intestines upward and laterally
About an inch and a half
Tubercles of Montgomery (sebaceous glands on the breast) become more
prominent
Nipples get darker and bigger
Thick, yellowish fluid (colostrum) is secreted
As early as 16 weeks
Do not express the milk or they could put themselves into labor
Respiratory
Diaphragm is lifted about 1.6 inches
Decreased total lung capacity
Baby is taking space and you can’t take a full breath
Ribs flat and substernal angle widens
Transverse diameter of chest expands by almost an inch
Dyspnea
Cardiovascular
Supine hypotensive syndrome
Baby could lay on vena cava and drop blood pressure
Body pillows help
Mom should lie on side and not on her back
Due to partial occlusion of vena cava and aorta
Advise women to lie on side (left)
Advise to take breaks when sitting for long periods of time
Musculoskeletal
Abdominal muscles stretched beyond capacity
Diastasis recti: separation of rectus abdominis muscles
Does not always come back and may need a surgical repair
Endocrine
Estrogen increases oxytocin receptors in uterus
 Oxytocin causes uterine contractions and milk let down
Dependent edema is common due to fluid shifts

Prenatal Care

Regular check up (every week or so)

Vital signs, weight, fundal height
Urinalysis
Fetal heart rate
Pelvic and cervical checks
At 36 weeks
Are the Braxton Hicks actually real?
Could be dilated a few centimeters for first time moms
Assess for signs of labor
Group B strep testing
Culture vagina and rectum at 36 weeks
If positive will receive antibiotics during labor
Two doses, four hours apart
Most common cause of infant mortality

Common Discomforts

Backache
Fetal movement
Babies do not stop moving right before birth
If it is decreased, it needs to be addressed
Heartburn
Round ligament pain
Varicose veins
Constipation
Leg cramps
Urinary frequency
Braxton Hicks contractions
Can the woman talk during a contraction?
If they walk for a bit, the contractions may dissipate
Real labor will make it more intense

Warning Signs

Abdominal pain
Bleeding
Decreased or absent fetal movement
Prolonged N/V
Gush of fluid
Color and amount
 You want to deliver within 24 hours of ROM
Fever
Dysuria, frequency, urgency
UTIs can put you into labor
Usually GBS causing UTI
Contractions that are regular in duration and length
Signs of hypertensive disorders
Extreme swelling (face, hands, legs, etc.)

Psychosocial Adaptations

Vulnerability
Pregnant mother worries about losing or harming her baby
Fantasies or nightmares
Increasing dependence
On her partner
Increasing fear about safety of partner
Anger and irritability normal
Difficulty concentrating or focusing on new tasks or content
Preparation for birth
Concerned about birth
Will I need an epidural?
Fear not knowing if in labor
Nesting behavior
Cleaning and preparing everything
Prepare meals in the freezer
Mixed feelings about impending birth

Nutrition

Weight gain
Should gain 0.5-1 pound weekly
Total weight gain
Normal BMI: 25-35 pounds
Underweight BMI: 28-40 pounds
Overweight BMI: 15-25 pounds
Obese BMI: 11-20 pounds
Weight distribution
Baby is 6-8 pounds
Placenta/amniotic fluid
Increased plasma
Maternal reserves in last trimester (collects fat to get ready to lactate)
Lose about half of what they gained right after delivery
Calorie intake
Increase total calories to 452 above normal diet
(2200-2900)
 Total calories intake same as 2nd trimester
Iron
Continue taking supplementation
Infant iron stores double during last weeks of pregnancy
Inadequate intake - anemia in infant for first year of life
Calcium
Transferred to fetus
Needs are highest in last trimester
Fortified calcium juice, leafy greens, orange juice, milk,
sardines/anchovies
Important for mineralization of bones and teeth
Calcium is not taken for mother’s teeth

Fetal Testing

Non-stress test
Monitors fetal wellbeing using EFM
Usually mom has button to press when she feels the baby kick
Procedure
Place mother on monitor from 30-40 minutes
Reactive (reassuring)
FHR accelerates with fetal movement
Nonreactive (non reassuring)
No FHR acceleration present
They could be hypoxic
There are false negatives, this includes when baby is sleeping
Additional testing needed if nonreactive (CST or BPP)
Contraction stress test
Assesses fetal response under stress
Stress = contractions (hypoxic environment)
Procedure
Place on EFM
Stimulate contractions
Manipulate nipple
Could also try very very low amount of oxytocin
Need three contractions in 10 min period
Results
Negative (reassuring)
 This baby would do well in labor
Postive (abnormal)

This baby has late decels and could not handle the hypoxic
event
May need a c-section
Equivocal (suspicious/hyper-stimulation)
Could happen if mom has too many/too intense of a contraction
after stimulation
No baby would be able to do well in that kind of environment
Unsatisfactory

Question: first thing is to turn off oxytocin

Biophysical profile
Assess five parameters of fetal status (each one gets 2 points, so a score of 10
is a really good baby)
FHR reactivity
Fetal breathing movements
Gross fetal movements
Fetal tone
 Amount of amniotic fluid
Sign of chronic hypoxia is low amniotic fluid
Uses NST and ultrasound
Benefits
Noninvasive
Decreases number of non reassuring NST
Limitations
Each variable is given equal weight
i.e. Low amniotic fluid could be a sign of something bad happening
soon
More predictive at the extremes
In between score of 5-6 isn’t very predictive
Kick count
Mother monitors fetal movement by counting kicks
Procedure
Count kicks for one hour (once of twice a day)
Typically once in morning and once in night
Baby may be more active at night
Less than 10 kicks an hour - report to healthcare provider
Or if they aren’t as intense or less
Try drinking caffeine/sugar to wake them up
If they still don’t move or if something doesn’t feel right, go into
doctor
Benefits
No cost and noninvasive
Convenient
Limitations
Fetal resting state decreases movement
Drugs can affect fetal activity
Mothers do not count consistently

Perinatal Education

Childbirth prep
Birth plan
Coping methods (Bradley or Lamaze)
Pain management
Doula
Indications of labor
Kick counts
Fetal testing
Breastfeeding
Infant care
Postpartum care

Postpartum
Physiological Adaptations

Uterine size reduction

Breast enlargement and milk letdown
Lochia
Fluid shifts
Hormone shifts
Night sweats, hot flashes, etc.

Nutrition

All postpartum women should continue taking prenatal vitamins

Lactating mothers
First 6 months: 330 calories above normal
Second 6 months: 400 calories above
Increase carbohydrates to 210 grams
Same protein intake (71 grams)
Vitamin D is low in breast milk
May give infant supplements
Dieting should be postponed at least 3 weeks after birth
Calcium content of breastmilk is not affected by maternal intake
Limit alcohol and caffeine
Pump and dump with alcohol
Fluids (8-10 cups daily)

Families Adaptation

Father

Major psychosocial changes

Reality of pregnancy and child
Struggle for recognition as a parent
Creating role of involved father
Parenting information
Couvade
Pregnancy-related symptoms and behavior in expectant fathers

Siblings

Toddlers
Believe getting a sibling that is their size
May show feelings of jealousy/resentment
Older children (3-12)
Worry about being replaced
 Benefit form sibling classes
Adolescents
Embarrassed
Indifferent (unless it affects them)
Involved
Grandparents
Age
Number and spacing of other children
Perceptions and role of grandparents

Risk Factors

Delayed or No Prenatal Care

Cultural perspectives
Native Americans or Guatemalan don’t come in until birth
Adolescent
No insurance/low income women
Can’t take off work for appointments
Working women
Absence of social support
Partner violence
Substance abuse
Considering abortion
Realize that they are pregnant

Nutrition

Vegetarian mother
Vegetarian diets are low in calories and fat
Increase caloric intake by eating snacks and higher calorie foods
Snacks of cheeses, etc.
Complete proteins
Contain all essential amino acids
Soybeans/tofu
Cheese/milk
Combination foods: grains and legumes
Beans and rice
Incomplete proteins
Lack one or more of essential amino acids
Mostly plant proteins
Iron supplements are important
Vegan mother
Avoid all animal products
Calcium
Obtained through leafy greens, but high fiber reduces absorption
 Drink calcium-fortified juiced or soy products
Iron supplements are important
May need zinc supplements
Vitamin B12 can be obtained through fortified cereal or soy
Make sure to evaluate vitamin A intake (prenatal vitamins)
Lactose intolerant mother
Deficiency of the small intestine enzyme lactase necessary for absorption of
lactose
Causes diarrhea, nausea, bloating, flatulence, and intestinal cramping
Women who avoid dairy - inadequate calcium intake
Encourage soy milk, low-lactose milk, and milk treated with lactase
Calcium supplements may be indicated
Adolescent mother
Greatest nutritional needs
Mother’s body is still growing
Choose poor nutrition
Educate on better options
Diets are low in vitamin A, folic acid, calcium, iron, and zinc
Consumption of fast food
Ability to obtain food
May be kicked out of house for being pregnant
Body image
Social stigma
Peer pressure
Multigravida mother
If babies are born close together mother may not have time to store essential
nutrients
Encourage mothers to space 18-23 months apart
May be too busy meeting needs of family
May require supplementation to help nutritional deficit
Multifetal mother
Must provide enough nutrients to meet needs of each fetus
Weight gain
Twins: 37-54 pounds
Triplets: 50-60 pounds
More: need 300 calories more per day for each fetus
When met the recommended weight gain, less likely to deliver before 32 weeks
Vitamin supplementation may be needed to meet recommended requirements

Pica

Practice of eating substances not considered part of normal diet

Often hide they are doing this
Items eaten
Ice, clay, starch, toothpaste, ashes, chalk, coffee grounds
Do you eat items that you shouldn’t?
Causes
 Cultural
Iron deficient diet
Education
October 30
Chapter 25: Complications in Pregnancy

Hemorrhagic Conditions of Early Pregnancy

Abortions
Spontaneous abortions are also known as miscarriages
6 types of spontaneous abortions
Threatened
Bleeding
Complete
Incomplete
Some things have been expelled, but not everything
Missed
Inevitable
Water breaks, bleeding
Recurrent
Typical manifestations
Vaginal bleeding
Worse than a period
Cramps
Worse than a period; backache
Pelvic pressure
Baby is descending
Asymptomatic
Treatment
Teach all pregnancy clients about symptoms for abortion
1 in 4 women will have a miscarriage
Diagnostics
Ultrasound
Usually when the no heart beat is discovered
hCG blood levels
Typically doubles throughout pregnancy
If it drops, that could be a sign of miscarriage
Teaching
Advised to limit sexual activity
How to measure bleeding
How many saturated pads are they having
When to call healthcare provider
Passing clots or fetal tissue
Fever (infection)
Severe pain
Complications of abortion
Threatened abortions
Happens when vaginal bleeding occurs during first half of pregnancy
May have spotting after sex due to Chadwick’s sign and vasculature
 All vaginal bleeding in first trimester should be treated as threatened abortions
Must seek PHP if vaginal bleeding occurs
Complete abortions
Happens when all products of conception are expelled from the uterus
Therapeutic management
Support client through anxiety and grief
She is not guilty
Most first trimester abortions are chromosomal anomalies
No other interventions needed
Some women don’t realize they’ve had a miscarriage because it
happens around the time she may have her period
Should not have sexual intercourse until after her follow-up appointment
Due to risk of pregnancy again
Incomplete abortions
Happens when some but not all of the products of conception are expelled from
the uterus
Part of the placenta or amniotic sac left behind
Scary because they can go into disseminated intravascular coagulation
Therapeutic management
Support client through anxiety and grief
Many are very sad even though 50% of pregnancies are unplanned
Retained placenta causes excessive bleeding
You need uterus to clamp down to stop bleeding, but it can’t if
parts remain
Dilation and Curettage (D&C) under 14 weeks
Induced labor after 14 weeks
With Pitocin and Cytotec
The cervix may not need to dilate to 10 centimeters though
Medications to reduce hemorrhaging afterwards
Methergine, Pitocin (high dose)
QUESTION
A CLIENT WHO IS EXPERIENCING VAGINAL BLEEDING IN FIRST TRIMESTER
OF PREGNANCY, FEARS SHE HAS LOST HER BABY AT 8 WEEKS. WHICH
DEFINITIVE TEST RESULT WOULD INDICATE THAT THE CLIENT’S FETUS HAS
BEEN LOSS
C- ULTRASOUND DEMONSTRATING LACK OF FETAL CARDIAC
ACTIVITY
Dilation and Curettage (D&C)
Physician stretches cervical os in operating room
Then physician removes products of conception using a vacuum curet
During this, we are a circulating nurse and get tools, towels, or needles
Nursing implications
Post-opereation monitoring
Monitor bleeding
Very important to watch
Support client emotionally
Complications
 Infection
Fever or foul discharge
Suction out too much uterus and cause it to have a hole or turn inside out
Uterine injury/scar tissue build up
This is why numerous abortions/D&C can cause infertility
Future pregnancies won’t be able to implant in the right place
Oxytocin (Pitocin)
Causes uterine contractions by increasing calcium inside muscle cells of uterus
Titrate through physician orders
Give enough to stimulate effective labor pattern (typically contractions that are
2-5 minutes apart and 60-120 seconds long)
After delivery, given bolus to assist in uterine involution
Nursing implications
Pain management, uterine tone, monitor bleeding
May still need an epidural
Make sure there isn’t too much uterine activity
Titrate pitocin
Don’t want to burst uterus
Complications
Uterine rupture
Misoprostol (Cytotec)
Binds to prostanoid receptors that increase strength and frequency of uterine
contractions
Is a prostaglandin (which stimulates fever)
Huge side effect is fever
May go ahead and medicate with Tylenol when given
In first trimester, PO form can be taken to induce abortion
In second or third trimester, vaginal/rectal form can induce labor/abortion
Implications
Pain management
Monitor for pyrexia
Monitor for bleeing
Complications
Uterine rupter
Methylergonovine (Methergine)
Directly acts on uterine smooth muscle to increase tone, rate, and amplitude
Clamps it down
Avoid in clients with hypertension
Implications
Monitor bleeding, N/V
Pain management
Fundal massage
Complications
CVA
Hypertensive crisis
MI
IM injection given postpartum
 Looks a lot like Vitamin K
Missed abortions
Happens when fetus dies during first half of pregnancy (20 weeks or less) but is
retained in the uterus
Heart isn’t beating upon ultrasound
Sometimes the woman’s second ultrasound
No bleeding
Management
Same treatment and nursing implications as incomplete abortion
D&C should be performed within 4 to 6 weeks
They may send her home to see if she passes the fetus on her own
Complications
Can cause DIC or infection
Infection from dying tissue
Dr. Woods told story of black amniotic fluid
Inevitable abortion
When membranes rupture and the cervix dilates (abortion cannot be stopped)
Therapeutic management
Same treatment and nursing implications as complete or incomplete
abortion
Complication
DIC or infection
Recurrent abortions
When a client has three or more spontaneous abortions
When there is a second trimester loss, it is typically a maternal defect
Is there something wrong with her cervix?
Anatomy can be different
Thalidamide from 70s caused incompetent cervix
Cervix dilates too early
Causes
Chromosomal abnormalities
Anomalies of reproductive tract
Immunologic system malfunction
Mom’s body started attacking baby
Sexually transmitted infections (STIs)
Trichomonas or gonorrhea, etc.
Therapeutic management
Genetic counseling
Examination of reproductive system
Depending on cause
Cerclage
For incompetent cervix
Clip the suture before delivery
Supplemental hormones
Progesterone
After 20 weeks, it would be a pre-term birth
QUESTION
 NURSE’S CARE OF A WOMAN, WHO IS EXPERIENCING A SECOND
TRIMESTER MISCARRIAGE, WOULD B BASED ON KNOWING WHICH CAUSE
OF SPONTANEOUS ABORTIONS IS MOST COMMON IN THIS TRIMESTER?
D- MATERNAL FACTORS
Blighted ovum
Also known as a chemical pregnancy
Two sperm came in, no genetic material, etc.
Something wrong with chromosomes
All products of conception form except the embryo
Women often spontaneously abort these pregnancies
Usually first 10 weeks
Cause
Chromosomal anomalies
Therapeutic management
Treated like spontaneous abortion
Depends ont type of abortion
Treat mom with all grief counseling
Even if there was never a baby forming, the woman’s positive pregnancy
test made it feel like there was
Disseminated Intravascular Coagulation (DIC)
Life threatening condition that causes massive micro-clotting that uses up all the
clotting factors and causes hemorrhaging
If you already see them bleeding, it is very serious because that is the
second stage
Causes
Sepsis
Amniotic fluid embolism
Abruptio placentae
Prolonged retention of a dead fetus
Longer than 4-6 weeks
Severe preeclampsia
HELLP syndrome
Clinical manifestations
Sometimes depends on how far into the bleeding they are
Pain from clotting
Bleeding from IV site, incisions, gums, nose, placental attachment sites
Vaginal
Eyes
Diffuse bruising
Increased heart rate and respiration rate
Decreased blood pressure
Hypotensive; hemorrhagic shock
Late sign
May not be able to save them (too much bleeding)
Pallor
Pale, pale white
Decreased urine output
 Late sign
Changes in level of consciousness/altered mental status
Late sign
Diagnostic tests
D-dimer serum assay
If positive, typically DIC
PT, PTT, platelet panel
Treatment
Prevention
Treat the cause!
Retained fetus… then evacuate fetus
Preeclampsia… give meds
Embolism… hard to treat
In early phase, we give heparin
Later phase, clotting factors
Blood transfusions
Ectopic pregnancy
Implantation of fertilized ovum in an area outside of the uterus
Majority of ectopic pregnancies implant in fallopian tube
Sometimes attaches outside of uterus or in bladder
Fetus in tube cannot survive because it will rupture
Extremely high risk of maternal death
Causes
Pelvic inflammatory disease (PID)
Sexually transmitted infections (STI)
Chlamydia is a major cause because it scars fallopian tubes
Girls will not have symptoms until it goes far into uterus and
causes PID
Failed tubal ligation
Assisted reproduction
InVitro
Multiple induced abortions
Due to uterine scar tissue
If you have one ectopic, you are more likely to have another
Manifestations
Early
Missed menstrual period
Positive pregnancy test
Abdominal pain
Severe one-sided is probably ruptured
Vaginal “spotting”
Late signs
Severe one-sided pain
Hypotension
Syncope
Board-like abdomen
Bleeding could be internal
 Profuse sweating
Tachycardia and hyperventilation
Diagnostic
Beta-hCG
Ultrasound
Therapeutic management
Methotrexate
Linear salphinogostomy
Incision to remove
If ruptured, salpingectomy
Have to take out ovary
RhoGAM given to Rh negative mothers
Support mothers through anxiety and grief
QUESTION
BEFORE SURGERY TO REMOVE AN ECTOPIC PREGNANCY AND THE
FALLOPIAN TUBE, WHICH CLINICAL MANIFESTATION WOULD ALERT THE
NURSE TO THE POSSIBILITY OR TUBAL RUPTURE
B- PROFUSE SWEATING
THIS IS A SIGN OF SHOCK
Methotrexate
Inhibits folic acid which inhibits cell division in developing embryo
Only used through 49 days of pregnancy
For ectopic pregnancy or therapeutic abortion
Implications
Monitor for nausea and vomiting
Big side effect
Pain management
Monitor bleeding
Psychological support
Teaching
Refrain from drinking alcohol
Refrain from folic acid supplements
Decrease effect of methotrexate
Refrain from sexual intercourse
Don’t want to get re-pregnant
Gestational Trophoblastic Disease
Hydatidiform Mole/Molar pregnancy
Peripheral cells that attach fertilized ovum to the uterine wall develop abnormally
Chorionic villus going haywire
Partial or complete mole
Partial- baby cannot survive
Usually triploid (three sets of chromosomes)
Risks
Very young or very old mothers
Asian descent
Had a previous molar pregnancy
Can turn into metastatic cancer
 Manifestations
Uterus larger than gestational age
Grows too fast
Usually show at 14 weeks (normally)
Excessive nausea and vomiting (too high hCG)
Early development of preeclampsia
Diagnostic
High levels of hCG
Snowstorm appearance on ultrasound
Management
Evacuation of molar pregnancy
Continuous follow-up
Management of preeclampsia or HEG
Teach patient to delay pregnancy for 1 year
Choriocarcinoma could be re-triggered by new pregnancy
Increased hCG without pregnancy could indicate the malignancy
Getting pregnancy during this time could mask it
Complications
Can be malignant (choriocarcinoma)
Metastasize to lungs, vagina, liver and brain

Hemorrhagic Conditions of Late Pregnancy

Placenta previa
Implantation of the placenta in the lower uterus
Three classifications
Total
If placenta comes out before baby, the baby will die (it won’t be
getting oxygen)
Partial
Marginal
Risks
Older mothers
Multiparas
Placenta wants to attach to healthy tissue
Many pregnancies = more scar tissue
History of cesarean births
History of D&Cs
Previous placenta previa
African or Asian ethnicity
Cigarette smoking/cocaine use
Male fetus
Manifestations
Main symptom: painless bleeding in third trimester
Diagnostics
Ultrasound
Management
 No vaginal exams!
If you don’t know where their placenta is and they have the painless
bleeding, don’t examine them
Do not use oxytocin (pitocin)
Electronic Fetal Monitor (EFM)
Depends on type of previa
If premature gestation, place on bedrest
If full term or unstable condition, cesarean section is indicated
QUESTION
WHEN ASSESSING A MULTIGRAVID CLIENT AT 34 WEEKS GESTATION
EXPERIENCING MODERATE VAGINAL BLEEDING, WHICH CLiNICAL
MANIFESTATION WOULD MOST LIKELY ALERT THE NURSE THAT PLACENTA
PREVIA IS PRESUMED?
A- PAINLESS VAGINAL BLEEDING
Abruptio placentae (abruption)
Abruption is separation of normally implanted placenta before fetus is born
High maternal and infant mortality
Can be apparent or concealed
Bleeding or no bleeding
Can be complete or partial
All is no longer attached (stillbirth)
Partial (part is unattached)
Causes
Clot formation between maternal side and placenta
Trauma to abdomen
Risks
Maternal hypertension
Cocaine use
Anything that clamps down blood vessels
Cigarette smoking
Multigravida status
Short umbilical cord
Abdominal trauma
Car accident
Partner violence
Fall on abdomen
Premature rupture of membranes (PROM)
History of abruption
Manifestations
Bleeding (sometimes)
Uterine tenderness
Board-like abdomen
Uterine irritability/poor relaxation of uterine tone
Abdominal pain or backache
Not always
Symptoms of hemorrhagic shock
Non-reassuring fetal heart rate
 Decreased fetal movement
Tachycardia and hyperventilation
Hypotension
Pallor
Decreased urine output
Changes in LOC/AMS
Diagnostic
Ultrasound
Keihauer-Betke test (“KB”)
Positive
High amount of fetal blood cells in maternal blood could
mean she has abrupted and blood is mixing
Therapeutic management
Mother must be hospitalized
Electronic fetal monitoring (EFM)
No vaginal exams!
Notify healthcare provider immediately
Setup for ultrasound
Depends on condition of mother and fetus
Severe compromise requires immediate delivery
If close to crowning, a vaginal delivery may be attempted
Otherwise, emergency Cesarean section will be performed
If condition is mild, conservative management
Bedrest
Tocolytic medications to reduce uterine tone
Celestone for fetal lung maturity
RhoGAM needs to be administered after birth for Rh negative mothers
Cultural considerations
During a hemorrhagic event that requires blood products as treatment, must ask
client if they consent to blood
Requires consent to receive blood
Jehovah Witnesses to not believe in receiving blood products due to the
prohibition of ingestion of blood in Bible
Treatment often involves using volume expanders (such as Hespan)
Educate what will happen without blood products
Advocate for wishes of client
QUESTION
A NURSE IN THE EMERGENCY DEPARTMENT IS CARING FOR A CLIENT WHO
REPORTS ABRUPT, SHARP, RIGHT-SIDED LOWER QUADRANT ABDOMINAL
PAIN AND BRIGHT RED VAGINAL BLEEDING. THE CLIENT STATES SHE
MISSED ONE MENSTRUAL CYCLE AND CANNOT BE PREGNANT, BECAUSE
SHE HAS AN INTRAUTERINE DEVICE. THE NURSE SHOULD SUSPECT WHICH
OF THE FOLLOWING
B- ECTOPIC PREGNANCY

Hyperemesis Gravidarum (HEG)

 Persistent, uncontrollable vomiting that begins in the first weeks of pregnancy and
continues throughout pregnancy
Unknown cause
Risk
Unmarried, caucasian women
First pregnancies
Multifetal pregnancies
Allergy to fetal proteins
Clinical manifestations
Severe N/V
Weight loss
Electrolyte imbalance
Potassium, sodium, magnesium
Signs of dehydration
Therapeutic management
Rule out other conditions
Cholecystitis
Molar pregnancy
Due to high hormones
Peptic ulcer disease (PUD)
Medications
Pyridoxine (Vitamin B6)
Promethazine (Phenergen) or Ondansetron (Zofran)
Zofran pump
Famotidine (Pepcid)
Metoclopromide (Reglan)
IV fluid and/or electrolyte replacement
Severe cases, total parenteral nutrition (TPN)
Education
6 small meals throughout the day
Carbohydrate in morning to prevent empty stomach
Ginger is antiemetic
Avoid foods with strong odors or fried
Sit up right after eating
Encourage foods rich in potassium, sodium, and magnesium
Potassium: potatoes, tomatoes, avocado
Magnesium: seeds and legumes
Emotional/psychological support

Hypertensive Disorders

Pregnancy Induced Hypertension (PIH)

Also known as gestational hypertension (HTN)
Blood pressure elevates after 20 weeks
Can progress to preeclampsia
If persistent after birth, chronic hypertension is diagnosed
Medications
 Antihypertensives
Beta blockers (labetalol or propranolol)
Alpha adrenergic agonist (methyldopa)
ACE inhibitors are contraindicated for pregnancy (increased fetal
renal damage)
No diuretics
Preeclampsia
Systolic blood pressure of 140 mm/Hg or greater (or 30% increase from pre-
pregnancy blood pressure) after 20 weeks gestation accompanied by significant
proteinuria
Damage to kidneys causes protein in urine
Very common completion (5-10% of all pregnancies)
Major cause of perinatal death and IUGR
Can progress to eclampsia
Risks
Obesity
Diabetes mellitus
First pregnancy
Older than 35
African-American
Family history of preeclampsia
Chronic HTN
Renal disease
Multifetal pregnancy
Lupus or clotting disorder
Pathophysiology
Peripheral vascular resistance increases
Sensitive to angiotensin II
Decrease in natural vasodilators
Decrease perfusion to organs
Kidneys, liver, brain, placenta
Spiral vessel connecting to placenta is too short
Manifestations
Hypertension
Decrease perfusion to liver causes intra-hepatic hemorrhage and it
encapsulates
Edema/rapid weight gain
Cerebral edema
Epigastric pain
Visual disturbances and headache
From brain swelling
Proteinuria
Chronic hypoxia
May be seen with low amniotic fluid amount
Can progress to eclampsia
Seizures
Diagnostic
 Serial blood pressures
Different times of day in different settings
24 hour urine test
Management
Only cure is delivery of baby
Treatment based on gestational age of baby and severity of mothers’
condition
Is it safer to leave baby in or take baby out?
Surveillance
Kick counts
NST/BPP for fetal well-being
24 hour protein test
Test for amount of protein in the urine in 24 hours
≥ 300 mg of protein in urine diagnosis preeclampsia
Collect weight, height, name and hospital number of client
After client empties bladder, start the 24 hour urine test (mark
downrate and time)
Mark down height and weight, too
Discard first void
24 urine collection container on ice
If client has a catheter, put catheter bag on ice
Collect for 24 hours after first void
Weight
Gaining more than 3 pounds over a few days is not a good
sign
Lie left lateral
Rest often (but it may not always be total bedrest)
Inpatient manag
Vaginal birth is preferred
Platelets can be affected by preeclampsia
Bedrest in left lateral position
Decreased external stimuli
No pen lights in a pregnant woman’s eyes
Electronic fetal monitoring
Medications
Magnesium sulfate
Decreases cerebral edema
Less likely to seize
Hydralazine (Apresoline)
Acute hypertensive crisis treatment
Nifedipine (Procardia)
Labetalol
Especially effective in African-American population
Magnesium sulfate
Calcium antagonist relaxes smooth muscle
Also protects blood brain barrier and prevents cerebral edema forming
Give bolus amount (4-6g IV over 15 to 20 minutes)
 Burns like fire in veins
Will feel very hot
Then maintenance drip (2 g/hr IV)
Labs (magnesium level) should be drawn every 6-8
We want it 5-6.5
Instead of 1.5-2.5
7 to 8 is toxicity
Antidote: calcium gluconate (IV push)
This will work instantly to reverse magnesium
Assess (check all of these hourly)
Blood pressure
Can cause hypotensive moments
Respiration rate and oxygen saturation
Too much magnesium can stop breathing
Deep tendon reflexes
Decrease
I’s and O’s
If not excreting, building up magnesium and getting toxic
Fetal heart monitor
Baby can get non-reactive
Baby might be born floppy and blue
Eclampsia manifestations
Edema
Headache
Visual disturbances
Nausea/vomiting
Seizures
Epigastric pain
QUESTION
WHICH CLINICAL MANIFESTATIONS IN A CLIENT ON MAGNESIUM SULFATE
SHOULD BE REPORTED TO THE HEALTHCARE PROVIDER? SELECT ALL
THAT APPLY.
A- URINE OUTPUT OF 150 ML FOR 3-11 SHIFT (8 HOURS)
SHOULD BE 30 ML/HOUR
C- PATELLAR REFLEX- 0
E- NEW ONSET SEVERE HEADACHE
Eclampsia
Progression of preeclampsia to generalized seizures
Seizures caused by cerebral edema
We can no longer keep baby in
Immediately c-section
Can happen any time in second half of pregnancy through 48 hours after birth
Give magnesium after labor to prevent
Therapeutic management during seizure
Place client side lying position
Prevent aspiration
Ready suction equipment
 Do NOT place anything in their mouth
Pad the side rails of the bed
Therapeutic management after seizure
Suction airway
Administer oxygen (10L through face mask)
Electronic fetal monitoring
Administer magnesium sulfate
Deliver fetus
In a real seizure, they will not remember what happened
Tonic, clonic, and post-ictal
Complications
HELLP syndrome
Hemolysis
Platelets not produced like they should
Elevated
Liver enzymes
Low
Platelet count
Life threatening occurrence
Half also have severe preeclampsia
Can happen int he antepartum or postpartum period
Manifestations
RUQ or epigastric pain
Severe edema
N/V
Jaundice
Diffuse bruising/bleeding
Therapeutic management
Do NOT palpate liver
It could rupture because it is encapsulated
Medications
Magnesium sulfate
Hydralazine
Deliver the fetus
Induction is favorable
May not be able to have epidural
If platelets below 1,000
DIC
Status epilepticus
They don’t stop seizing and both may die
Chronic Hypertension
When hypertension lasts after 6 weeks postpartum or hypertension occurs
before 20 weeks gestation
Risks
Older clients
Obese
Diabetes
 Therapeutic management
Medications
Methyldopa, beta blocker, or calcium channel blocker
ACE inhibitors and diuretics are contraindicated
Diet modifications
More frequent prenatal visit
NSTs and BPPs may be indicated at end of pregnancy

Rh Incompatibility

Only occurs when mother is Rh negative and baby is Rh positive

Rh negative is autosomal recessive trait
Rh negative clients build up antibodies against Rh positive blood
These antibodies will attack any fetus with Rh positive blood
Only affect any fetuses after the first pregnancy
Assessment
Indirect Coombs’ test
Amniocentesis
Percutaneous umbilical blood sampling (PUBS)
Management
Hydrops fetalis
Swollen liver and severe abdominal swelling
Mom’s blood attacks fetal blood cells and baby tries to make them again
and liver hypertrophies
Administer RhoGAM at 28 weeks and within 72 hours after childbirth
Administer RhoGAM after any invasive procedure or gavial bleeding occurs
IM injection and blood product
Need two nurses and vital signs
Collect umbilical cord blood for blood type, Rh factor, and antibody titer (direct
Coombs’ test)
Positive Coombs’ test means baby might need transfusion
Emotional/psychological support
QUESTION
WHAT INFORMATION IS IMPORTANT FOR THE NURSE TO ASSESS IF SHE
KNOWS THE CLIENT WHO IS PREGNANCY IS RH NEGATIVE? SELECT ALL
THAT APPLY.
A- BLOOD TYPE OF FATHER
B- HISTORY OF ANY TYPE OF ABORTION
D- HISTORY OF INVASIVE PROCEDURES
E- HISTORY OF PREGNANCIES
F- HISTORY OF BLOOD TRANSFUSIONS

Chapter 26: Concurrent Disorders with Pregnancy

Diabetes
Diabetes Mellitus
Partial or complete lack of insulin secretion by the beta cells of the pancreas
Accumulation of glucose in blood stream
Manifestations
Polyuria
Polydipsia
Polyphagia
Unexplained weight loss
Fruity breath (ketosis)
Effects on early pregnancy
Uncontrolled sugar = fetal anomalies
May not have issues if tightly controlled
May experience hypoglycemia
May need to add carbs, especially in the morning
Effects on late pregnancy
Estrogen, progesterone, and human placental lactogen (hPL) increases
resistance to insulin
Resistant to insulin makes them break down fat
Leaves diabetic mothers without any insulin
Hyperglycemia
Causes accelerated growth in fetus
Hypoglycemia in neonate
Makes baby really big
Effects on neonate
Hypoglycemia
Accelerated fetal insulin production
Need to check neonate blood glucose immediately after birth
May need glucose drip
Hypocalcemia
More commonly seen with poor glycemic control
300s nearly the whole pregnancy
Large amounts of calcium is transported across placenta in second
half or pregnancy
Associated with preterm birth and perinatal asphyxia
Baby may not survive
Hyperbilirubinemia
Recurrent hypoxic events = increased production of erythrocytes
After birth, the extra RBCs are broken down into bilirubin
Prematurity further complicates metabolism and excretion of
excess bilirubin
Respiratory distress syndrome
Hyperinsulinemia slows cortisol production
Cortisol is needed for synthesis of surfactant
Poor glycemic control contributes to RDS
Amniocentesis ay be performed before elective induction/cesarean
section
To test for lung maturity with L/S ratio
 Therapeutic management near birth
Insulin needed before birth
If NPO, periodic glucose checks
Therapeutic management in postpartum
Encourage breastfeeding
Helps with blood sugar control
Often have to decrease amount of insulin as hormones fall
Therapeutic management
Insulin requirements
Decreased in first trimester
Increased remarkably in second and their trimester
May use Insulin drip for labor
Or just monitor glucose periodically
Avoid glucose-bearing IV solutions
Lactated-ringers
Decreased in postpartum
Check blood glucose four times a day after birth
Other anti diabetics
Currently insulin is safest medication
Glyburide is being investiageted/researched
Do NOT use metformin
Blocks testosterone and could cause issues in boy
babies
Gestational Diabetes Mellitus (GDM)
Carbohydrate intolerance of different severity that develops during
pregnancy
Women who have GDM have 35-60% chance of developing diabetes in
next 10-20 years
Risks
Overweight or obese
Maternal age older than 25
Previous pregnancy with GDM
History of abnormal glucose tolerance
History of diabetes in close relative
African-American, Hispanic/Latino, American Indian, Asian
American or Pacific Islander
Diagnostics
One hour glucose challenge test (24-28 weeks)
Fasting not required
Drink 50 g of oral glucose solution
If 140 mg/dL or greater, you fail
Will do oral glucose tolerance test (OGTT)
Three hour OGTT
Fasting close check
Drink 100g of oral glucose solution
Check glucose every hour for 3 hours
Abnormal results:
 Fasting greater than 95
1 hour greater than 180
2 hours greater than 155
3 hours greater than 140
Therapeutic management
Diet modifications
Eliminate simple sugars
Limit carbohydrates (30g) in morning
Later in the pregnancy when morning sickness is gone
Decrease percentage of carbohydrates in diet
Decrease simple carbs (candies, cakes, cookies, ice
cream, “whites”- bread/rice)
Blood glucose monitoring
Medication
Insulin
Fetal surveillance
Kick counts
Ultrasound for fetal growth and amniotic fluid volume
BPP/NST/CST for fetal wellbeing
Amniocentesis for lung maturity
QUESTION
A PREGNANT CLIENT HAS AN ABNORMAL 1-HOUR GLUCOSE SCREEN AND
COMPLETE A THREE HOUR ORAL GLUCOSE TOLERANCE TEST. WHICH
TTEST RESULT WOULD A NURSE INTERPRET AS BEING ABNORMAL
B- 1 HOUR = 186 MG/DL

Infections

TORCH
Toxoplasmosis
Other (Syphilis, Fifths disease, Zika)
Rubella
Cytomegalovirus
Herpes simplex/Hepatitis B/HIV
Toxoplasmosis
Protozoan infection transmitted through raw/undercooked meat and contact of
infected cat feces or soil
Heat lunch meat, don’t eat sushi, don’t change cat litter box, don’t garden
without gloves
Neonatal effects
Spontaneous abortions
Severe neonate complications
Therapeutic management
Prevention is key
Medications
Sulfonamides
Spiramycin
Syphilis
STI
Crosses placenta to infant
Neonate effects
Nose doesn’t form, teeth are curved, hepatomegaly, rash, etc.
Spontaneous abortions
Therapeutic management
First prenatal visit will test for syphilis (RPR)
Treat with penicillin
Fifth Disease
Common in preschools and daycare
Also known as Parvovirus B19
“slapped cheek” appearance with generalized rash
Neonatal effects
Severe fetal anemia
Fetal death
Therapeutic management
Prevent because no known treatment
QUESTION
WHICH CLIENT IS MOST AT RISK AT CONTRACTING FIFTH DISEASE?
C- WOMAN WHO WORKS AT A DAYCARE
Zika
Viral infection transmitted through infect mosquitoes or through sexual contact
No vaccine available
Transmitted through mosquito bites or sexual activity
Neonatal effects
Microcephaly
Other severe brain defects
Therapeutic management
Prevention
Teaching to avoid areas with zika
Rubella
Viral infection transmitted through drooled or contact
Do not give MMR to pregnant client because it is a live virus
“Measles mumps and rubella”
Must wait a month before getting pregnant
Neonatal effects
Spontaneous abortions
Deafness, developmental delay, cardiac defects, microcephaly, cataracts
Therapeutic management
Prevention
Immunization before pregnancy
Check titers at prenatal visit
Cytomegalovirus
Part of herpesvirus group transmitted through human secretions
Symptoms are vague and asymptomatic
Neonate effects
 Cytomegalic inclusion disease
Development delays, seizures, enlargement of spleen and liver,
chorioretinitis, dental defects, and hearing loss
1 in 5 infected babies will be born with a disability
Management
Prevention
No effective therapy available
Herpes simplex
Viral infection transmitted through silvery of infant during active lesions
Neonatal effects
Spontaneous abortions and preterm birth
Systemic herpes infection will cause 50% to die
Therapeutic management
No known cure
Pregnancy client takes acyclovir (Valtrex) a few weeks before expected
birth
Baby will get this, too
Pelvic check by HCP
No active lesions- vaginal delivery
Active lesions- cesarean section
Hepatitis B
Viral infection transmitted through body fluids
Neonatal effects
Prematurity
Low birth weight
Neonatal death
Therapeutic management
Maternal immunization
Newborn vaccination
Prevention
If hepatitis B surface antigen (HBsAG) is positive
Hepatitis B immunoglobulin within 12 hours of birth
Human Immunodeficiency Virus (HIV)
Retroviral infection that imparts the immune system
Transmitted through contaminated blood, sexual intercourse, and perinatal
exposure
Neonatal Effects
HIV infection
Recurrent bacterial infections
Therapeutic management
Prevention (condoms)
HIV testing in first prenatal visit
Antiviral regimen
Zidovudine (ZDV or AZT)
Only 1% chance of transmitting with treatment
Cesarean section (bloodless with a lot of cauterization for every
vessel) and absolutely NO breast feeding
Group B Strep (GBS)
Gram-positive bacterial infection
1 in 4 women have GBS
Lives in bladder, vaginal canal, and rectum
Does not affect women, but does affect baby
Number one cause of neonatal death
Neonatal effects
Neonatal death
Permanent neurological damage
Therapeutic effects
Culture of GBS (36 weeks)
Medication
Ampicillin 1 gram every four hours in labor for GBS positive or
unknown status
2 doses
Cesarean section before rupture of membranes do not need medications
QUESTION
WHICH CLIENTS SHOULD A NURSE PREPARE TO RECEIVE A GROUP BETA
STREPTOCOCCUS (GBS) CULTURE? SELECT ALL THAT APPLY.
A- WOMEN EXPERIENCING PRETERM LABOR
C- ALL PREGNANY WOMEN BETWEEN 35-37 WEEKS
November 6
Chapter 27/28: Intrapartum Complications and Postpartum Complications

Dystosia: problems with labor/difficult birth

Shoulder dystosia: problems with labor due to shoulder placement

5 P’s

Help labor, but could hurt it, too

Dysfunctional Labor

Problems of the powers

Ineffective contractions
Not enough contractions (hypotonic)
Could have labor standstill
Ineffective maternal pushing
Pushing for a long time because she isn’t pushing correctly, has maternal
fatigue, size of baby, epidural could be hindering her pushing ability
(excessive anesthesia)
Mom isn’t ready to “let go” of baby
Love being pregnant so much and they aren’t ready to be done
Problems with the passenger
Fetal size
Multifetal pregnancy
Shoulder dystosia
McRobert’s maneuver and suprapubic pressure to help get baby out
Pressure could cause broken collar bone
Pull knees up (or squat in natural childbirth)
Problems with presentation
What comes out first?
Brow presentation
Head is coming out correctly (OP)
Problems with position
Breech, transverse, etc.
Fetal anomalies (like hydrocephalus or intestines on outside
Problems with the passage
Different shapes pelvis
Soft tissue obstructions
Full bladder
Problems with the psyche
Stressed/anxious about being a mom
Doesn’t have support
 In a lot of pain
Tense, so baby cannot get down into birth canal
Abnormal labor duration
Prolonged
Precipitate
Labor for short time
Doesn’t mean the delivery is quick

Premature Rupture of Membranes (PROM)

Etiology
If the ROM happens before the onset of true labor
Complications
Infection
Prior to 37 weeks
Immature lungs (respiratory distress syndrome)
Oligohydraminos
Losing fluid (need to help with lung maturity)
Preterm Premature Rupture of Membranes
Therapeutic management
Consider gestational age
Can we augment them? Are they far enough along?
Nursing considerations
Give antibiotics
Monitor for fever and FHR and contractions
Is it true ROM?
Check that its amniotic fluid and not semen
“Ferning”
Amniotic fluid under microscope “ferns” out
Q-tips have a yellow tip
If it turns blue, could be amniotic fluid
KY jelly can turn it blue too, so before they check their cervix
Causes
Uterus is overextended
Infection
Chorioamnionitis
Previous pre-term delivery (with PROM)
Fetal abnormalities
Incompetent cervix
Don’t stay shut like they are supposed to and dilate too early
Hormone changes
Progesterone must maintain pregnancy
Stress
Nutritional deficiency
Recent sexual intercourse
Preterm Labor

Associated factors
Previous history
Incompetent cervix/short cervix (≤25 mm)
IVF infertility treatments
Illnesses
Gestational diabetes or even dental problems
Signs and symptoms
Contractions
Preterm contractions may just feel like menstrual cramps
“Baby feels like its balling up”
Backache, pain/pressure in groin or thighs
Bleeding
Feels like a cold
Subtle
Preventing preterm birth
Bedrest?
Education
Know signs and symptoms
Could catch it early and give tocolytics to slow it down
Improve access to care
Promote nutrition, smoking cessation
Therapeutic management
Predicting
History
Short cervix = risk
Fetal fibrinectin test
Found in vaginal secretions at 16 weeks (normal fetal tissues)
Goes away between around 25-34 weeks
If it comes back, they can see if you are excreting this, and at risk
for preterm delivery
Identifying
Come to preterm visits
Ultrasounds, check FHR, do education, check for contractions
Stopping
Prevent preterm labor
Accelerating fetal lung maturity
Celestone (betamethasone)
Steroid to increase lung maturity
2 doses 24 hours apart (IM injection)
Be in system another 24 hours before effective
Not given before 24 weeks
Drugs for Preterm Labor
Table 27-2 page 584
Terbutaline
Procardia
 Magnesium sulfate
NCLEX and HESI

Prolonged Pregnancy

Complications
Stressed out baby
Meconium (bowel movement in utero)
Not going to tolerate labor well
Placenta gets wrinkly, in water to long
Therapeutic management
Has mom had prenatal care
Nursing considerations
Is baby thriving?
Non-stress test (reactive?)
Biophysical profile
Teaching for any fetal assessments
Support fatigue that mom has from being too pregnant

Intrapartum Emergencies (p.590)

Placental abnormalities
Placenta previa
Partial or complete covering of cervical opening
C-section
Painless bleeding
Placenta accreta
Abnormally adherent placenta
Can cause intrapartum hemorrhage
You don’t know you are bleeding (very fatal)
Prolapsed umbilical cord
Cord comes out before baby or is around baby’s neck
Emergency
When inducing, doctors check that baby is high station
Umbilical could fall as baby descends
Polyhydraminos could cause umbilical cord to flush out around
baby’s head
Keep mom’s head down, and keep hand in mom pushing baby’s head up
Keep pressure off the cord
Variable decels
Prolonged v-shape (deep and wide) and will not get better
Uterine rupture
Placenta has torn away from uterus (painful)
Additional tear in the uterus and contents could spill into abdominal
cavity
A little more serious than abruption
 If uterine scar tears open during VBAC
Full or partial
May stop seeing uterine activity
Uterine inversion
Uterus turns inside out
Rare
Happens during third stage (delivering placenta)
Can be fatal
Could then prolapse, too
Trauma
Leading cause of non obstetrical death in pregnant women
Falls, MVA, abuse
ABCs (mom’s life comes before baby)

Postpartum Complications

Hemorrhage

Blood volume increases about 1000 cc for pregnancy

Normally lose about 500 cc during birth
Hemostasis following delivery is affected by:
Smooth muscle clamps down
Factor 8 (increases during delivery) and factor 5 (increases after placenta
separates)
Contractions of uterine myometrium
Hyper-coagulability during delivery

Postpartum Hemorrhage (PPH)

By definition
Vaginal delivery blood loss > 500 mL
Cesarean delivery blood loss > 1000 mL
With a 10% drop in hemoglobin and/or hematocrit
Primary causes
Uterine atony (doesn’t clamp down), retained placental fragments, lower genital
track lacerations
Major complication is hemorrhagic shock
Primary (early) occurs within first 24 hours after delivery
Hematomas, uterine atony or lacerations
Secondary (late) occurs after 24 hours post-birth
Mainly due to hematoma, sub involution, or retained placental tissue
Risk factors
Macrosomia (big baby)
Operative vaginal delivery could tear sides of vaginal wall
High parity (more babies)
Won’t always “work” like usually
 Precipitous delivery
Really fast delivery
Obesity
Too much oxytocin use
A lot of magnesium sulfate (relaxes)
Decreases muscle tone (hard to get fundus firm)
“Redhead”

Critical Component

Maternal vitals (late sign)

Maternal patients may not show changes until 1/3 of blood volume is lost
Careful assessment is key!
Indications of primary PPH
10% decrease in hgb/hct
Saturation of the peripad within 15 minutes
Pad count
We can weigh pads (chucks pads, too)
1g = 1 mL of blood
A fundus that remains boggy after fundal massage
Tachycardia (late sign)
Decrease in BP (late sign)

Uterine Atony

Fundus staying boggy, not staying firm

Major cause of PPH
Risk factors
Assessment findings
Fundus- firm or boggy?
Deviated or midline
Bleeding/pad count
Gush, slow, clots (could weight those)
Skin
Diaphoretic
VS
Overall appearance
Impending doom, feeling like passing out
Medical management
Bimanual compression
From inside and outside
Fundal Massage
Isotonic fluids (3L of fluid for each 1L of blood loss)
Medications
Oxytocin, methylergonovine, carboprost
Methylergonovine (Methergine)
 Side effects: nausea, vomiting, cramps
IM or IV; 200 msg every 2-4 hours- only one IV dose
Can increase BP
Contraindicated in PIH patients, so notify HCP before
administration
Carboprost tramethamine (Hemabate)
PPH that is not responding to oxytocin or methergine
Side effects: diarrhea, nausea, vomiting, fever
Lomotil and Tylenol
IM 250 mpg, which can be repeated every 15-90 minutes
Total dose not exceeds 2mg
Don’t like
Non-surgical and surgical interventions
D&C
Hysterectomy
Nursing actions
Risk reduction
Fundal massage

Lacerations

Second most common cause of primary PPH

Common sites: cervix, vagina, labor, and perineum
Risk factors: macrosomia, forceps/vacuum, precipitous labor and/or birth
Assessment findings
Fundus
Will be firm
Bleeding
Must be coming from laceration
Steady blood flow without clots
VS
Late vital signs
Medical management
Cervical exam
Inspect area to watch repair
Nursing actions
Know risk factors and assessment findings

Hematoma

Occurs when blood collects within the connective tissues of the vagina or perineal
areas related to a vessel that ruptures and continues to bleed
Risk factors
Episiotomy, use of forceps, prolonged second stage (pushing)
Assessment
Pain
 Vaginal pain
Could be outside or inside
Management
Small, could go away on its own (use ice)
Large, surgically excise and drain
Feel better right away
Could displace uterus and cause boggy palpation
Nursing action
Risk reduction
Comfort measures

Subinvolution

Uterus does not decrease in size and descend into the pelvis
Risk factors
Fibroids, metritis, retained placental fragments
Assessment
Uterus
Soft and larger
Won’t decrease one finger breadth each day
Start to decrease slowly, but then go back up
Lochia
Go back to rubra and get heavier each day
Pain
Back pain
May need to confirm with US
Medical management
Medications
Antibiotics, etc.
Surgical intervention
D&C for fragments
Nursing actions
Patient education
S/S to watch for and hand washing

Retained Placental Tissue

Small portions of placenta remain attached to uterus during third stage of labor
Primary cause of secondary PPH
Risk factor- manual removal of the placenta
Assessment
Bleeding
Profuse bleeding up to 1 week postpartum
Uterus
Sub-involution
Cant go back down like supposed to
 VS
Medical management
D&C
Antibiotics
Patient education

Coagulation Disorders: DIC

Patho
Coagulation pathways are hyper stimulated; clotting factors are depleted which
leads to hemorrhage and death
Risk factors
Abruptio placentae; HELPP syndrome; amniotic fluid embolism
Assessment findings
Bleeding from everywhere
Medical management
Nursing actions
Quick replacement of volume
Oxygen

Amniotic Fluid Embolism (Anaphylactoid Syndrome of Pregnancy)

Patho
Amniotic fluid has hair and skin cells and vernix
Rarely, this can seep into the blood stream from veins in placenta and act like an
embolus
Risk factors
No reliable risk factors
Assessment
Die within one hour
Baby also dies, when oxygen cuts off
Go into DIC first
Medical management
Nursing actions

Thrombosis

Blood clot within the vascular system

Risk factors
Normal changes in coagulation, c-section birth, metritis, decreased mobility,
obesity
Check for warm areas, confirm with doppler, Roman’s sign
Medical management
Heparin therapy
Nursing action
 Risk reduction through movement after surgery, etc.

Pulmonary Embolism

Pathophysiology
Clinical s/s
Dyspnea, chest pain, tachycardia, and tachypnea
Pulmonary rales, cough
Hemoptysis (expectoration of blood or bloody sputum)
Abdominal pain
Low-grade fever
Management
Nursing considerations

Infections: Metritis

Infection of the endometrium, myometrium, and/or parametrial tissue

Starts at placental site and spreads to entire endometrium
Risks
C-section, PROM, prolonged labor, internal monitoring, meconium fluid, multiple
cervical exams, obesity
Assessment
Temperature, pain, lochia (foul-smelling)
Tenderness in abdomen
Medical management
Hand washing
Antibiotics
Nursing actions
Risk reduction

Cystitis

Infection of bladder
Common in postpartum period
Risk
Epidural, over distended bladder, catheter placement, forcep/vacuum, vaginal
exams, birth process
Assessment
Dysuria, frequency, cloudy urine
Medical management
Actions
Risk reduction
Hand washing
Mastitis

Inflammation/infection of breast
Usually within first 2 weeks after milk flow has been established
Unilaterally
Risk
Previous history, cracked or sore nipples, use of anti fungal cream
Assessment findings
Recommend still pump
Use warm compresses if still breastfeeding, to increase flow
If not breastfeeding, use cold (it will bind up the breastmilk)
Medical management
Antibiotics
Actions
Risk reduction

Wound Infections

Occur at any postpartum site

Episiotomy, c-section incision, laceration
REEDA
Redness
Ecchymosis
Edema
Drainage
Approximation of edges
Risk factors
Malnutrition, obesity
Assessment findings
Fever
Anything that indicates infection
Medical management
Antibiotics
Nursing actions
Risk reduction
Hand-washing

Postpartum Depression (PPD)

Baby blues are normal from crazy pregnancy hormones in first 4 weeks or so
Definition
Mood disorder characterized by severe depression that occurs within the first 6-
12 months postpartum
Loss of interest or pleasure in activities for at least 2 weeks plus 4 of the
following
weight loss/gain, sleep pattern change, change in psychomotor activity,
 decreased energy, feelings of worthlessness, decreased ability to
concentrate or make decisions, recurrent thoughts of death/suicide
Tell daddy risk factors to watch out for, too
Risk factors
Increased stressors, no support, sick, complications during delivery
Assessment findings
Medical management
Skin to skin contact
Promotes bonding

NEED TO KNOW DIFFERENCES

Postpartum Psychosis (PPP)

Definition
Variant of bipolar disorder and most serious form of postpartum mood disorder
They may kill themselves or their children
Andrea Yates story
Risk
Known bipolar disorder of personality disorder… family history
Assessment
Medical management
Nursing considerations
Risk reduction

Postpartum Anxiety Disorders

PTSD
Panic disorder
Postpartum obsessive compulsive disorder
November 30

Chapter 31: Family Planning

*3.2 million unplanned pregnancies

*Nurses more likely to talk about contraceptives with female patients
*Healthy People 2020 goal to decrease unintended pregnancies

Information About Contraception

Common sources
Friends, relatives, televisions, newspapers, magazines, and the internet
Nurses in clinics, physicians’ offices, birth settings
Social settings
Role of the nurse is to provide counseling on
Types of contraception available
Women’s personal choice
Table 31.1 page 682
Ricks and benefits of each
Proper use of each method
What to do if an error is made
Emergency contraception (EC)
Backup methods
Change of methods
Questions and concerns

Considerations When Choosing a Method

Safety
Some women have to take into account cardiovascular risk factors
Protection from STIs
Barrier methods
Effectiveness
Acceptability
Convenience
Education needed
Benefits
May also help decrease acne
Decreases bleeding in heavy periods
Side effects
Interference with spontaneity
Birth control better for “spontaneous” sex
Availability
Expense
How pricey is it?
 Preference
Religious and personal beliefs
Culture
Other considerations
Need informed consent for any method that has side effects

Age Considerations

Adolescents
Adolescent knowledge
Misinformation
47% of high school students in 2011 had had sex
Think they can’t get pregnant the first time they have sex
Do not need to have an orgasm to get pregnant
“Pulling out” does not work
“Spillage” can still cause pregnancy
Risk-taking behavior
Education because the birth control failure rate is higher
Feel invincible
Counseling adolescents
Don’t talk down to them
Condoms to prevent STIs
Peri-menopausal women
Thought they were going through menopause, but was actually pregnant

Sterilization

Female sterilization
Tubal sterilization
Usually within 48 hours of childbirth
Permanent sterilization
1 in 3 couples choose sterilization
Male sterilization
Vasectomy
Can be reversed
Snip vas deferens and cauterize/tie off
Have to go back and get a sperm count
Make sure they got it all
Usually easier for males

Intrauterine Devices

Actions
Copper or hormonal kind
Make the environment unstable (acidic) so fertilization cannot occur
 Copper lasts for 10 years and other lasts for 5 years
Need to be comfortable with their own body to check string for placement
Works immediately upon placement, and once it is out, they can get pregnant
immediately
Side effects
May be more expensive up front
Cramping and bleeding
Placed through cervix and in uterus
Teaching
Check for string
History of pelvic infection, ectopic pregnancy, or STI, doctor may request
different option

Hormonal Contraceptives

Hormone implants
SubQ in arm
Prevents ovulation
Thickens cervical mucus
Cervical mucus get thin so sperm can go through during ovulation
Becomes impenetrable for sperm
Hormone injections
“Depo” shot
IM or SubQ
Prevents ovulation for 15 weeks (about 3 months)
Need to make sure appointment is before that 3 months so that it doesn’t lag
No estrogen
Delay in fertility after shot
Oral contraceptives
Inhibits ovulation
Leading method of contraceptive
Combination pill estrogen and progestin
Or estrogen only
Usually 21 pills and one week of menstruation
Progestin only is never a “placebo” pill
If used perfectly
3 in 1,000 people will still become pregnant
Stroke and blood clot risk
Smokers should not use BCP
Table on page 689
Cautions
Side effects
Nausea
Breakthrough bleeding
How to use
Page 691
Emergency contraceptive
 Plan B or morning-after pill
For after unprotected sex
Does not abort a baby
Sends so many hormones to the uterus, that it makes it unstable for an embryo
to implant
Take within 120 hours of unprotected sex
If it is already implanted, it will not abort the baby
Transdermal contraceptive patch
Not effective in women greater than 198 pounds
New patch each week
Fourth week is bleeding
Contraceptive vaginal ring
Nuvaring
Soft, flexible ring
Insert to cervix
Releases hormone there
Prevents fertilization with thick mucus and prevents ovulation
Removes for fourth week for cycle
Be comfortable to place it where it belongs

Barrier Method

Chemical barriers
Mechanical barriers
Male condom
Page 694-695: putting on a condom properly
Ask about latex allergies
Female condom
Sponge
Diaphragm
Only effective for an hour after put in
Spermicides placed, too
Doesn’t prevent STDs
Cervical cap

Natural Family Planning

Calendar
Judge your own cycle to when you are going to ovulate
Table 31.6
Stay away from sex 24 hours before and 24 hours after 3 days of
ovulation
Based on 28 days
Standard days method
Basal body temperature
Temperature rises just after ovulation
 When it goes up, wait 24 hours and you won’t be fertile
Cervical mucus
2-day method
Symptothermal methods
What you feel in your body
Thinner mucus, weight fluctuation, etc.
Abstinence

Least Reliable Methods of Contraception

Breastfeeding
Coitus interruptus
“Pulling out"

Chapter 32: Infertility

Factors in the Man

Abnormalities of the sperm

Too small, two-headed, two tails, short tails, coiled tails, etc.
Abnormal erections
Abnormal ejaculation
Semen needs to “shoot” to cervix
If hypospadias/epispadias not corrected, it might not work
Retrograde ejaculation goes backward into bladder
Abnormalities of seminal fluid
Characteristics
Fluid nourishes the sperm and keeps it healthy
If its not a good consistency, the sperm can’t be healthy

Factors in the Woman

Disorders of ovulation
Anovulation: don’t ovulate at all
Day 14 of 28 is typical ovulation
Pituitary problems
Tumors, obesity, hormone imbalance, anorexic, etc.
May not release a mature egg that can be fertilized and won’t survive
implantation
Abnormalities of the fallopian tubes
Endometriosis causing scar tissue that blocks tubes
Hysterosalpingogram
Shoot dye in to check patency of tubes
STDs can cause scarring, too
Abnormalities of the cervix
 Incompetent cervix
Hormone imbalances can make cervix acidic
Can be allergic to partner’s sperm

Repeated Pregnancy Loss

Abnormalities of the fetal chromosomes

Abnormalities of cervix or uterus
Endocrine abnormalities
Immunologic factors
Allergy
Environmental agents
Men should not be in hot tubs and not wear tight underwear
Infections

Evaluation of Infertility

Preconception counseling
History and physical exam
Diagnostic tests
Therapies to facilitate pregnancy
Medications
Ovulation induction
Medications on table 32.2
Hyper-ovulation: may release more than 1 egg in a cycle and could have
multiples as a result
Surgical procedures
Therapeutic insemination
Egg donation
Someone else’s egg and already fertilized
Might have 8 fertilized eggs, and what do you do with the other fertilized
embryos?
Do you throw away the extras?
How many do you implant in someone?
Surrogate parenting
Someone else uses their egg and sperm
Assisted reproductive technology
In vitro fertilization
Transfer egg at any point
As a zygote or transfer as embryo
Gamete intrafallopian transfer
Zygote intrafallopian transfer
Intracytoplasmic sperm injection
Preimplantation genetic testing
Responses to Infertility (More Psychological)

Assumption of fertility
May cause depression when they find out they are infertile
“Woman are made to have babies"
Growing awareness of a problem
Bigger problem since women are waiting longer to have kids
Seeking help for infertility
Very expensive

Outcomes After Infertility Therapy

Pregnancy loss after infertility therapy

Spent all this money, and then they lose the pregnancy
Very hard
Parenthood after infertility therapy
Choosing to adopt
May have fears about adopting
May struggle with cost, too

Chapter 33: Preventive Care for Women

National Emphasis on Women’s Health

Women’s Health Initiative

Health People 2020 goals
Increase the proportion of adults ≥ 20 years who are at a healthy weight
Lower breast cancer deaths
Reduce deaths from cancer of the cervix
Increase cervical cancer screening
Increase proportion of adults who receive a colorectal screening
Increase proportion of cancer survivors who are living 5 years or longer after
diagnosis
Reduce the hip fracture hospitalizations among women ≥ 65 years
Reduce the incidence of gonorrhea in women between ages of 15 and 24
Reduce congenital syphilis
Reduce coronary heart disease deaths
Reduce stroke deaths

Health Maintenance: Health History

Identifies risk factors for variety of conditions

History of heart disease or cancer in family
Page 719, box 33.1
Risk factors in women
 Complementary and alternative meds (assess use of herbals)
May be obtained from sources such as questionnaires, interviews, and previous
records
The focus depends on the woman’s age, but some topics should be discussed with all
women
Family history identifies many risk factors that cannot be modified
A psychosocial assessment
Assess culture, too

Health Maintenance: Physical Assessment

Blood pressure, temperature, pulse, respirations, and weight are measured at each
visit
Height is taken at the initial examination and yearly after that
Examine for indicators of osteomalacia or osteoporosis
Consider diet
High risk indicates doing a follow up
Auscultation of the lungs
Extremities examined
Abdomen palpated for tenderness, masses or distention
Additional assessments are necessary if the woman is in high-risk group
Testing for sexually transmitted infections (STIs) if multiple sex partners
Always better to prevent something than treat once they have it

Health Maintenance: Preventive Counseling

Opportunity to counsel women about preventive measures that often reduce their
physical problems
Counseling about self-care measures to improve health
Self-care, diet, etc.
Counseling about diet may identify measures that improve multiple problems
Counseling for the woman to deal with complex social problems
Less expensive to prevent than cure

Health Maintenance: Screening Procedures (page 721)

Prevention is better than a cure

Early diagnosis allows early treatment
Some screening procedures are recommended for all women of reproductive age
Other screening procedures are recommended for older women or those with higher
risk
Breast self-awareness/breast self-exam
Look at page 721
Clinical breast exam
Doctor completes exam
 Mammography
Diagnostic exam
Recommended started at 40 (or baseline at 35)
Inflammatory breast cancer shows up more as an infection
Spreads a lot by the time you catch it
Vulvar self-exam
Knowing if you have infections or identifying bumps/masses
Pelvic exam
Gynecologist visit
Cervical cytology or Pap test
Pap smear checks for any dysplasia in cervix
Rectal exam
For hemorrhoids or changes in bowel movements
Screening
Blood test for BRCA (breast cancer mutation gene)
Immunization
Gardasil vaccine
Recommended for males and females
Female genital mutilation on page 723

Chapter 34: Women’s Health Problems

Breast Disorders: Diagnostic Evaluation

Ultrasound
Differentiate fluid-filled cysts vs. solid cyst
Fine needle aspiration biopsy
Test fluid in cyst with fine needle
Core needle biopsy
Thicker needle tests tissue
Open or surgical biopsy
Removes a mass and then runs pathology
Any very suspicious mass/tissue = biopsy

Benign Breast Disorders

Fibrocystic breast changes

Before menopause
Benign
Firm, but moveable nodules (not-fixed)
Check each month to make sure it still moves and decreases
Usually go away
Usually in upper outer quadrants near underarm
Get looked at if they don’t go away
Can be painful
CAM: primrose oil can decrease pain
 Fibroadenoma
Can resemble a tumor or malignant mass
Get it checked in case
Ductal ectasia
Milk ducts can get inflamed from cellular debris
Breast cancer can cause similar signs
Do biopsies to check for benign nature
May need to be removed if it becomes an abscess
Nursing considerations
Easing fears, teaching, waiting for results
Education about what to expect

Malignant Breast Tumors

Incidence
1 in 8 women in the U.S.
Higher for caucasian women over age 25
Higher for African American women before age 35
More deadly outcome because it is more aggressive and caught later
Occur to 1 in 1000 men
Deaths in women expected to be
1 in 36 cases
Major type of cancer among women of all races
Risk factors
Mutation of the BRCA1 and BRCA2 genes
Also with family history
Mutation of CHEK-2 gene in men and women
Pathophysiology
Staging

Confirm the malignancy (TMN- tumor, mets, nodes)

Stage 1: area that is malignant, no mets, no lymph involvement
 Stage 4: involved with lymph nodes and has mets
Management
Surgical treatment
Adjuvant therapy: added treatment to enhance action of primary treatment
Radiation therapy
Chemotherapy
Hormonal therapy
Estrogen modifiers (tamoxifen)
Helps prevent reoccurrence from happening
Immunotherapy
Breast reconstruction (after mastectomy)
Timing
Some people want it right away or want to wait
Method
Tissue expansion
A bag in breast to expand each week (needle on outside) and use
their own tissue
Breast implants
Psychosocial consequences of breast cancer
Nursing considerations
Emotional support
Preoperative and discharge teaching
What to expect before and after
Provide printed information
Because they might not listen to anything you say

Cardiovascular Disease

Women are more likely to die of CV disease

More likely to ignore pain
Especially when it doesn’t mimic traditional “heart attack” pain
Recognition of coronary artery disease
Fatigue, weakness, unexplained anxiety
Angina (chest pain with exertion) or pain at rest
Dyspnea
Sometimes paroxysmal nocturnal dyspnea
Dizziness, faintness, lightheadedness
Upper abdominal pain, heartburn, loss of appetite
Nausea, vomiting, sweating
Pain in upper body, other than the chest
Risk factors (page 724 box 33.4 for risk factors)
Fixed or unmodifiable
Can’t change age or family history
Factors that can be changed
Diet exercise, etc.
Prevention
Hypertension
 Exercise and weight control
Smoking cessation
Diet and glucose control
Increased activity
Exercise
Aspirin
If not contraindicated

Menstrual Cycle Disorders

Usually start cycle about 2 years after they start developing

Amenorrhea (absence of menses)
Primary
Never even began cycle
Genetic or ovulation problems
Check at adolescent age if never started
Secondary
Started a cycle, but it stopped for several months
Abnormal uterine bleeding
Etiology
Thyroid issues
Pituitary problems
Family history
Pregnancy
Menorrhagia: prolonged or heavy bleeding
Metrorrhagia: irregular or heavy cycles
Management
Pregnancy test
Coagulation studies
Ovulation studies
Check for anemia
Nursing considerations
Encourage to get treatment
May not have to live with it
Want to know cause of this

Cyclic Pelvic Pain

Mittelschmerz (middle pain)

Most common cause of cyclic pain
Can last for a few hours of a few days throughout ovulation
Primary dysmenorrhea (painful menstruation)
Cramps are normally for 48 or 72 hours
Usually happens 1-3 years after cycle starts
Endometriosis
Pathophysiology
 Tissue outside the uterus that resembles endometrial tissue
Can be very painful and lead to infertility
Tissue resembles endometrial tissue but is scar tissue
Signs and symptoms
Management
BCP can help with this
Surgical procedure to scrape off scar tissue
Nursing considerations
Important to get checked since it can cause infertility

Premenstrual Syndrome (PMS)

Etiology
Unknown
Cramping, mood changes, crying, etc.
Due to hormone fluctuation with cycle
Impact on family
If this lasts whole week and disrupts family life and job, it may be an issue that
needs to be checked
Especially with cramps
Management
Nursing considerations

PMS calendar to track symptoms

Elective Termination of Pregnancy (Abortion)

Methods of medical termination (depends on size of fetus

Drugs
 Used between 7-9 weeks
Induces termination
Surgical
Over 7 weeks
Vacuum and curettage to get out fetal parts
Medical methods
Used in the second trimester
Involve labor
Nursing considerations
Emotional support for any decision
Drugs at 7-9 weeks and the fetus does not actually get terminated
Follow-up appointments to make sure all products are expelled
RhoGam for Rh- moms in case the baby was positive

Menopause

Age of menopause
Average age for natural menopause is 51.5
Cessation of menstrual cycle
Reproduction is over
Physiologic changes
Takes place over a few years
Hormone changes
Hot flashes, etc.
May have trouble with intercourse due to vaginal dryness
Psychological responses
Therapy for menopause
Hormone replacement
Risk
Give estrogen to lessen symptoms
Complementary/alternative therapy
Nursing considerations
Teach comfort medications
Encourage to check alternative medicines with doctor
Box 34.6 (CAM)
Just because it’s “natural” doesn’t mean that it is safe
High risk of UTI
Hygiene, front to back wiping, hydration, etc.

Osteoporosis

Risk factors
Starts young (if you don’t have what you need by 23-24, calcium levels start
decreasing early)
23-25 has peak bone density
Late menarch… late menopause
 Early menarch… early menopause
Small, petite, caucasian women at higher risk
Signs and symptoms
Very silent
History and physical after menopause may include bone scans
Older ladies may develop a hunch, kyphosis
May seem to shrink
Prevention and medical management
Drug therapy
Calcium vitamin D
Exercise
Nursing consideration

Pelvic Floor Dysfunction

Vaginal wall prolapse

Cystocele
Anterior wall and bladder
Bladder goes into vaginal area
Causes stress incontinence
From uterus sagging down and pushing bladder down
Enterocele
Upper posterior part of uterus sagging into vagina and adding pressure
Rectocele
Rectum can protrude out
Put pressure in vagina to have a bowel movement
Uterine prolapse
Symptoms
Uterine ligaments are stretched from pregnancy and don’t return to
normal
Uterus itself sags into vagina
Less common due to less traumatic childbirths
Stress incontinence
Tampon might fall out and not stay in
Might be bent since it doesn’t go where it usually sits
Management
A & P repair
Takes tissue to tack things back up where it belongs
Hysterectomy
Nursing considerations
Pelvic exercises
Kegel’s
Medication for overactive bladder

Disorders of the Reproductive Tract: Benign Disorders

 Cervical polyps
Small tumors, usually only a few millimeters in diameter
See dysplasia of cervical tissue in Pap smear
Scrape out in LEEP procedure
Caused by proliferation of cervical mucosa
More likely to happen with STD history
Uterine leiomyomas (fibroids)
Develop from uterine smooth muscle cells
Are estrogen dependent
Grow more with estrogen
Why there are less fibroids after menopause
Ovarian cysts
Painful
Can rupture
Cyst usually goes away with cycle and gets sloughed out
Can use a needle to aspirate fluid
Treatment depends on size, location, and how many

Malignant Disorders

Signs/symptoms
May not be diagnosed until it is advanced
Few symptoms experienced in the early stages
Symptoms often nonspecific
Risk factors
Diagnosis
Pap smears
Ultrasound
Management
Depends on where it is
Could be cervical or uterine tumors (fibroids can turn into worse issues)

Infectious Disorders

Candidiasis
Mot common form of vaginitis
Not an STD
Yeast infection
Happens when normal flora/pH is changed
ex. antibiotics
Symptoms
Itching, burning
Treatment
OTC or prescription medicines or creams
STI (need to make sure partner is treated, too!)
WILL BE QUESTIONS ON NEXT TEST
 Trichomoniasis
Flagyl (no alcohol or you get very, very sick)
Bacterial vaginosis
Chlamydial infection
Gonorrhea
Syphilis
Herpes genitalis
Human papillomavirus
Acquired immunodeficiency syndrome
Nursing considerations
Teach
Know how to follow-up
Know how to protect against
Ensure partner and person are treated to prevent reinfection

Pelvic Inflammatory Disease

Etiology
Most cases caused by C. Trachomatis and N. Gonorrheoeae infections
Remainder caused by a variety of aerobic and anaerobic organisms
Symptoms
Pelvic pain, nausea, vomiting, discharge
Could be untreated STD
Infection of upper reproductive tract
1 million women get this every year
Can cause ectopic pregnancy
Management
Urinalysis
Fever or increased WBC may need IV antibiotics
Usually can be outpatient
Considerations
Education
STD prevention

Toxic Shock Syndrome

Rare but potentially fatal

Caused by toxin producing strains of staph. aureus
Good handwashing
Tampon use
Diaphragm or cervical cap use