1.

Anatomy and Physiology Reproduction Female: myometrium, External: protective (vulva) endometrium Internal: o Fallopian Tube: connect o Vagina: birth canal, fornix peritoneal cavity c vagina (where sperm collect) and uterus Protect against trauma Isthmus o Uterus: implantation site Ampule- fertilization Cervix= external Fimbria- funnel like opening, protective enlargement entrance to uterus Transport ovum Corpus = uterine body o Ovaries: produce female = perineum, gametes and hormones Male: o Epididymis External: penis and scrotum o Vas deferens Internal: o Urethra o Testes Female reproductive structures: support weight of uterus Bony pelvis o Directs presenting part o Support and protect o Form axis of birth canal True pelvis: below pelvic brim o Size and shape must be Ischial spines: reference point adequate during labor o Female = gynecoid o Evaluate descent Breast False pelvis: above pelvic brim, o Nourishment and antibodies 2. Family Centered Address whole family Family at center Family-professional collaboration Family professional communication Cultural diversity 3. Culture Norms: Care Coping differences and support Family-centered peer support Specialized service and support systems Holistic perspective

Value of children Number desired Gender and status Influenced by: status of family unit and role of extended family

View of pregnancy Taboos o Sitting in doorways, hot vs cold, bad air Discipline Prenatal care (natural state) Cultural competence o Self awareness, Understand and respond to understanding of different individual needs from a different cultures, ability to adapt background Biological: Identify and integrate family beliefs o Genetic, physical, disease Requires:

pattern (B: sickle cell anemia, H: DM and lactose intolerance, W: CF, celiac, Crohns) Communication: o Language

o Nonverbals Time orientation Nutrition/food: o Rituals, special occasions, fasting, value large children (H)

4. Legal and Ethical Issues Legal Scope of practice Informed consent: protect patients rights Standards of care o Emancipated minor <18; self o Protect public, judge quality support o ANA, AWHONN o Mature minor: 14-15; o Clinical practice guidelines understand treatment risks Client/Patient safety Right to privacy: o JCAHO; infant at high risk due o HIPPA to: dosage calculations, o Patient self-determination dilutions, communication act: advance directives, living barriers will, DNR Ethical: religionshape views Maternal-fetal conflict: fetus = separate client IU fetal surgery: therapeutic o Forced c/s, coercion of high research for anatomic lesions risk behaviors Reproductive assistance: ART; IVFET; surrogate Abortion: period of viability (20 weeks) Embryonic stem cell o Personal beliefs, cultural Cord blood banking norms, life experiences, 5. Dysmenorrhea vs. PMS Dysmenorrhea o NSAIDS (prostaglandin Painful period inhibitor) Primary= craps s underlying o Self care (exercise, rest, disease heat, good diet) o Uterine contractility, Vitamin B and E decrease uterine artery blood flow S2: a/c pathology of reproductive tract Tx: oral contraceptives (inhibit o Endometriosis; residual PID, ovulation) fibroids, cysts, IUD PMS prostaglandin inhibitors a/c Luteal phase (2weeks prior to o Diuretics, COCs menses) o Vitamin B and E, calcium, s/s repeat at same stage avoid Na and caffeine Tx: progesterone agonists and 6. Methods of Contraception Fertility Awareness methods: Natural family planning Free safe, acceptable- religious

believs A: natural, non invasive D: extensive initial counseling; requires abstinance periods +: cheap, easy to get -: apply prior to sex, messy

E: may be less reliable o Ex: basal body temp, calander/rhythm; ovualtion method, symptothermal e: minimally effective when alone

Spermicides:

Barrier: male and female condoms, cervical cap, diaphragm, IUD +: easy; no side effects, prevent spread of STIs IUD: +: up to 5 years (Mirana) or 10 years (ParaGuard) -: cramps/bleeding 1st 3-6months; Hormonal: +: menstrual sx decrease; predictable -: increase risk of blood clot; no Sterilization: +: permanent; no added cost after -: nonreversible; requires gen

-: some fitted by doctor, placed prior to sex, spermicide e: excellent when used correctly check placement after every period; not protect against STIs e: very while in place smoking; no heart condition e: highly effective when used correctly anesthesia for women; local for men e: completely

7. Endometriosis o Surgical removal of uterus cells found in endometrium travel and ovaries outside endometrial cavity o Hormonal therapy (through fallopian tube, embedded outside uterus o Min sx: tx c observation, analgesics, NSAIDS Women 20-45 Implication s/s o Infertility o pelvic pain o dyspareuria May have difficulty; o abnormal uterine bleeding seek help, find out endometriosis, tx c Tx: surgical removal COCs and hormone o Relieves pain therapy 8. Toxic Shock Syndrome o Rash on trunk Causes: o Hypotension o Toxin released by o Dizziness Staphylococcus auerus o V/D Risk factors: o Myalgia o Superabsorbent tampons o Cervical cap or diaphragm Tx: o Colonization of staph aureus o Hydration o Broad spectrum antibiotics S/S: o Fever ( >102) NI:

o Educate about prevention Correct use of

tampons, diaphragm, no tampons 6-8 weeks postpartum

9. Sexually Transmitted Diseases Prevention Limit sexual contacts Decrease high risk behaviors Protection Trichomoniasis Yellow-green, frothy, odorless d/c Tx: METRONIDAZOLE Vaginal itching Chlamydia prophylactic antibiotic: Asymptomatic, thin, pulrulent d/c, ERYTHROMYCIN dysuria, lower abdominal pain Tx: DOXYCYCLINE/ AZITHROMYCIN May cause disease in NB: o If pregnant: AMOXICILLIN Gonorrhea urinary frequency May cause PID, asymptomatic Tx: ANTIBIOTICSL CEFIXIME AND Purulent green-yellow d/c, dysuria, DOXYCYCLINE Herpes Blister-like vesicles on genitals; flu Tx: antiviral: ACYLOVIR, like sx VALACYCLOVIR No cure Syphilis Primary: flu-like, chancre sores Tx: BENZATHINE PENICILLIN G Secondary: chancre sores ***BLOOD TEST ON EVERY disappear, wart like PREGNANT WOMANS Condylomata acuminata: HPV genital warts, cauliflower like tx: cryotherapy, surgical removal, lesions cuttrettage/laser AIDS fatal profound implications to fetus Nurse: provide information about: fertility, general health, treatment infection, methods of transmission, of both partners implications on pregnancy, future 10. Yeast infection vs. Bacterial Vaginosis Bacterial Vaginosis: Cause: o Diagnosis: clue cells seen on wet mount alteration on normal o Tx: METRONIDAZOLE bacterial flora S/S: Alternate use of Clindamycin vaginal thin, white/gray d/c (w cream; oral fishy smell) clindamycin Vulvovaginal Candidiasis: Most common form of vaginitis Cause: r/t use of COCs, immunosuppressants, Candida albicans

o o

antibiotics o S/S: Thick, curdy, white vaginal d/c Severe itching, dysuria, dyspareuria o Diagnosis: hyphae and spores seen on wet mount

o Tx: antifungal drugs Intravaginal butoconazole, miconozole Nystatin suppository, cream, tablets o Recurrence: monitor glucose (for glycosuria)

11. PID Cause Chlamydia or gonorrheausually tubal infection o Infection may cause: scarring of fallopian tubes; prevention of union b/t sperm and ova; prevention of mobility of fertilized ova through fallopian tube; problems with fertility Risk factors: o sexually active females (15o early onset of sex 29) o recent gynecologic procedure o multiple sex partners o IUD S/S: o chills and fever o Purulent d/c and irregular o Bilateral cramping of lower vaginal bleeding o Malaise, N, V abdomen Tx: o Iv fluids o Tx of partner o Antibiotics o Removal of IUD 24-48h after start of antibiotics 12. Pap Smear Cervical cytology testing Herpes or trich detection o Yearly Bethesda system o Examine cells from cervix Inflammation of IUD can cause and endocervical canal Tx: repeat in 3-6mo o Detects cellular abnormalities o Colposcopy Abnormal: o Endocervical biopsy o Abnormal cervical cells or o Cryotherapy malignancy o Laser conization Best indicator of cervical cancer 13. Cystitis vs. Pyelonephritis Cystitis: lower UTI S/S: Dx: urine culture o Dysuria, urgency, frequency, Tx: PO antibiotics (SEPTRA DS) low grade fever Pyelonephritis: upper UTI o May have N, V, malaise Less common, more severe Tx: S/S: sudden onset: o Hospitalization o Chills, increased temp, flank o IV antibiotics or oral pain, dysuria, urgency, frequency antibiotics

14. Signs of Pregnancy Subjective (presumptive) changes: veins more visable Amenorrhea: absense of period st Quickening NVP: in 1 trimester o Fluttering sensation in o Morning sickness abdomen Excess fatigue o Occurs ~18-20weeks after Urinary frequency LMP (as early as 16wks) Breast changes o Gradually increase in o Increased pigmentation, intensity and frequency Objective (probable) changes: body of uterus against cervix Change in pelvic organs (only st physical change in 1 3mo) Enlargement of abdomeno Caused by increase vascular especially if continuous and a/b amnorrhea congestion Braxton Hicks contractions Goodells sign: softening of cervix o Palpated after 28th week Chadwicks sign: blue/purple discoloration Change in skin pigmentation Hegars sign: softening of isthmus Positive pregnancy test (detect of uterus hCG) McDonalds sign: easy in flexing Diagnostic (+) changes: Fetal heartbeat Visualization by US: o Doppler: 10-12 wks o Gestational sac: 4-5wks o Transvaginal o Fetal parts and fetal mvt: 8wks Fetal movements o Transvag-gest-sac- 10 days o Quickening after implant o 20th week 15. Prenatal History and Care Initial Prenatal history: o Illicit drug use and drug Current pregnancy st allergies o 1 day of LMP o Presence of disease Past pregnancy conditions o # of pregnancies, # of living o Immunizations children, # of abortions o Presence of abnormal sx Hx of previous pregnancies: length Occupation hx: physical demands of pregnancy, length of L&D, type of job of birth, anesthesia used, complications, neonatal Partners history: presence of complications genetic conditions, blood type, Hx of chronic illness, attitude Current medical history o Blood type and Rh factor Social history: for teaching o Age, educational background o Medications (herbals: o Ethnic background contraindicated b/c not regulated by FDA o Housing (stability) o Use of alcohol, tobacco, o Emotional problems caffeine o SES- nutrition

Subsequent Prenatal History: o Mcdonalds method Discomforts o Edema Danger signs: vaginal bleeding, o Uterine size and FHB abdominal pain, pain >101F, V, HA, o Urinalysis edema, oliguria, dysuria o Blood type of AFP (16Antepartal visits: o 0-28wks: q4wks 18wks), glucose (GTT: 2428wks) o 28-36wks: q2wks o Vaginal swab for GBS o 36+: every week (36wks) Assessment: o Expected psychological stage o VS/Wt 16. Common Obstetric Terms pregnant Gestation: #weeks since 1st day of LMP Primigravida: pregnant for 1st time Abortion: birth <20weeks gestation Multigravida: in 2nd or subsequent or weighs <500g pregnancy Term: normal duration of Para: birth after 20 weeks pregnancy; 38-42wks regardless if born dead or alive Antepartum: time between Nullipara: no births at >20wks conception and onset of labor; gestation prenatal Primipara: 1 birth at >20weeks Intrapartum: time from onset of gestation, regardless of alive or true labor until birth of placenta dead Postpartum: time from delivery of Multipara: woman c 2+ births at placenta and membranes until >20 weeks gestation womans body returns to Stillbirth: infant born dead after prepregnant state 20weeks Preterm: labor after 20 weeks but TPAL: before completion of 37 weeks o T: # of term infants Postterm: labor after 42 weeks o P: # of preterm Gravida: any pregnancy (g) o A: # of abortions o L: # of living children Nulligravida: woman never been 17. Normal physiological changes of Pregnancy o Recommendations VS (CV) o Pulse may increase by Normal wt: 25-35lbs 10bpm Under wt: up to 40lbs o R increase; thoracic Over wt: limit to 15lbs breathing Skin o Supine Hypotensive o Linea nigra syndrome o Striae gravidarum o Temp an BP: WNL o Mask of pregnancy o Pseudoanemia: Hgb: <10; o Spider nevi Hct: <30 Nose WT o Nosebleeds, stuffiness o Varies but should be Mouth proportional c gestational o Gingival hypertrophy age Chest/lungs

o Transverse diameter > anteroposterior diameter Abdomen: o Progressive enlargement o FHR heard by Doppler ~12 weeks Extremeties o Possible edema late: H20 retention Spine o Lordosis Pelvic area: o Vagina s d/c o Cervix closed o Growth of uterus Lab tests: o Physiologic edema (Hct) o Small degree of glycosuria

Uterus: enlargement; Braxton Hicks ~4mo Cervix: mucous plug o Increased cervical vascularity also causes: Goodells and Chadwicks sign Vagina: acidic secretions; susceptible to Candida infection Breasts: more nodular; nipples more erectile; areolae darken o Montgomerys tubercles enlarge o Colostrum: antibody rich yellow secretion N/V: due to elevated hCG Constipation Slow peristalsis and motility: Miralax

18. Commonly used methods to determine EDC Naeles Rule 280 days = mean pregnancy accurate if menses q28 days begin c 1st day of LMP delay in ovulation effects formula o subtract 3months o irregular cycle o add 7 days o birth control Physical exam fundus uterine size in 1st 10-12 weeks o FH in cm correlates well c Fundal height wks gestation o McDonalds method: o Increase lag in progression From top of symphysis M2M or W2W may pubis to top of uterine signal IUGR Ultrasound head visualized Measure fetal parts o Biparietal diameter (BPD) o C-R measurement 12/13 weeks, but most Fetal age until fetal accurate 20-30weeks 19. Abnormal signs during pregnancy 20. Discomforts of pregnancy (and nursing interventions) 1st trimester: N/V: avoid odors, fluids before Breast tenderness: well supporting meals; no greasy foods bra Urinary frequency: decrease intake Increased vaginal d/c: bathe daily; at night cotton underwear Fatigue: plan rest; ask for help Nasal stuffiness: cool mist vaporizer

2nd and 3rd Trimester: pelvic tilt exercises Heartburn: eat small, frequent meals; avoid overeating and lying leg cramps: heat; dorsiflex feet down after meals dyspnea: good posture to sit/stand; ankle edema: elevate legs; sleep: semi-fowlers dorsiflex feet flatulence: chew food completely; varicose veins: elevate, support avoid gas-forming foods hose Carpal Tunnel: avoid repetitive hemorrhoids; avoid constipation; hand movements; increase arm use ice packs PRN backache: good body mechanics; 21. Illicit drug use during Alcohol: CNS depressant, potent tetratogen Maternal: o malnutrition, BM suppression (anemic); increased incidence of infection, liver disease, w/d seizures, Cocaine: Maternal: o Seizures/hallucinations, Pulmonary edema, cerebral hemorrhage, increased risk of spontaneous abortion, abruptio placenta, preterm birth, stillbirth Fetal: o Increased risk for IUGR, small HC, cerebral infarctions, altered brain development, Marijuana Associated with impaired coordination, memory and critical thinking Risks r/t dose Ecstasy MDMA Produce euphoria and empathy Death Critical issue during fetal brain Heroin CNS depressant narcotic Alters perception; euphoria IV administration; highly addictive a/c malnutrition Pregnancy delirium tremens (PP) Fetal: o Mental retardation, microcephaly, midface hypoplasia, cardiac anomalies, IUGR; FAS, FAE shorter body length, malformations of GU tract o Lower APGAR (breathing and CV problems) o Marked irritability, exaggerated startle reflex Exposed in utero o Increased risk for SIDS o Breast milk o Extreme irritability and V, D, dialated pupils, apnea Increased risk of IUGR SIDS born to heavy users Withdrawal sx: o Trembling, excessive crying development Possibility w other amphetamines Withdrawal sx: o Drowsiness, jitteriness, breathing problems fetus: o high risk for IUGR and mech aspiration o hypoxia o restlessness/shrill; high

pitched cry o irritability and fist sucking, V Methadone used for opioid dependents blocks withdrawal symptoms decreases or eliminates cravings

and seixures o seizures = ~72 hours a/c pregnancy complications and abnormal fetal presentation prenatal exposure: o reduced HC and LBW

22. Diabetes Mellitus in Pregnancy endocrine dx: inadequate insulin, glucose metabolism impaired, cells breakdown stores of fat and protein for energy, result: nitrogen balance and keytones (fat metabolism) S/S o Polyuria o Polyphagia o Polydipsia o Weight loss Classification o Type 1: absolute insulin defect, insulin resistance o Gestational DM: glucose deficiency, beta cells destroyed intolerance, 1st diagnosed o Type 2: insulin secretory during pregnancy Influence of pregnancy on diabetes: o Difficult to control, insulin impairment, retinopathy may develop, N, V, decreased requirements vary, risk for ketoacidosis, nephropathy renal threshold glycosuria may result from renal Influence of DM on pregnancy: Maternal risks Major cause of death in o Hydraminos: increased infants amniotic fluid; result of Most involve heart, excessive urination b/c of CNS, skeletal system fetal hyperglycemia Sacral agenies: sacrium PROM and onset of and L spine fail to labor can occur develop and LE may o Preeclampsia-eclampsia develop imcompletely o Macrosomia Diabetic pregnancy b/c of vascular changes Excessive growth o Ketoacidosis: o IUGR o RDS Increase in keytone bodies released in Increased levels of fetal blood from metabolism insulin; prevent of fatty acids production of If untreated, lead to surfactant coma and death o Polycythemia o Infections Decreased ability of Monilial vaginitis and glycosylated Hgb to UTI because of release O2 increased glycosuria o Hyperbilirubinema (favor bacterial growth) Inability of liver Fetal risks enzymes to metabolize o Congenital anomalies the increased billirubin

resulting from Client Therapy Goal: maternal plasma glucose control Screenings: o 1 hour GTT at 24-28 weeks; 1 hour, 50g o 3 hour GTT; increase carbs for 3 days, 100g o blood gluecose monitoring o Assessment of LT gluecose control: HbA1c

polycythemia Measure RBC and glucose over 120 days (RBC life) HbA1c: 5 = WNL assessment: US at 18 weeks Repeat at 28 weeks (growth for IUGR or macrosomia) BPP

o Fetal

23. Anemia a/c pregnancy destruction of inherited dx Hb < 10g/dL o 8-12 weeks Hb/Hct test S/S o Fatigue due to insufficient Hb production r/t o Paleness nutritional deficiency in iron or folic o Lack of energy acid during pregnancy or Types: o Infant: NTD Iron deficiency o Want green leafy vegetables Sickle cell o Fetal: LBW, preterm, hypoxic o Bring on a vaso-occlusive crisis, Autosomal recessive Folic Acid deficiency o F: abortion, fetal death, o Multivitamin/prenatal vitamin IUGAR o Take with OJ (increases Thalassemia absorption of iron) o Blood disorder 24. Gestational Trophoblastic Disorder (molar pregnancy) o Vaginal bleding Pathologic proliferation of o Hyperemesis gravidarum (b/c trophoblastic cells hCG levels so high) Hydratidiform mole o Abnormal development of Therapy: o Suction evacuation placenta occurs resulting in hydropic vesicles Cutterage to remove o Trophoblastic tissure placental fragments proliferates Hysterectomy for Classic sign: uterine enlargement > excess bleeding gestational age 25. Incompetent Cervix multiple gestation a/c repeated 2nd trimester abortions Dx: positive history of repeated 2nd possible causes trimester abortions o cervical trauma Tx: o congenital cervical/uterine o Shirodkar procedure anomalies (cerclage) o increased uterin volume (as c

Reinforces weakened cervix by encircling it at the levels of the internal os c suture material Purse-string suture: places in 1st trimester or early in 2nd c/s may be planned

NI:

suture may cut at term and vaginal birth

o Monitor for premature labor o Monitor for premature rupture o Teach client signs of both o Contact HCP immediately

26. Hyperemesis gravidarum o Correct dehydration: IV fluids Excessive vomiting during o Improve nutritional status pregnancy Increased hCG may play role Vitamin supplements Severe cases dehydration Total paranteral o Fluid-electrolyte imbalance, nutrition alkalosis, metabolic acidosis, Nuring care: supportive decreased urinary output o Maintain relaxed Tx: environment o Control vomiting: Antiemetics o Maintain oral hygiene (ZOFRAN) Acidic state o Control F&E imbalance: o Monitor weight (qd) POTASSIUM CHLORIDE o Monitor signs of (prevent Hypokalemia) complications 27. Placenta Previa covered Cause of bleeding during 2 half o Marginal: edge of placenta (last 20 weeks) covered Placenta implants in lower uterine o Low-lying: close proximity segment rather than upper portion but not covering os As the lower uterine segment Monitor FHR closely contracts/dilates later, placental o Fetus may develop villi torn from wall exposing uterine sinuses at placental site Hypoxia o Complete: internal os Anemia completely covered Never vaginal exam if suspected o Partial: internal os partially
nd

28. Ectopic Pregnancy Implantation of fertilized ovum in other site than uterus o Positive hCG present in blood and urine Chorionic villi grow into tube wall or Tx: implantation site o Rupture and bleeding into abdominal cavity o o Results in sharp unilateral pain and syncope (fainting)

Only on site she ovulated from Referred shoulder pain, lower abdominal pain, vaginal bleeding METHOTREXATE IM if future pregnancy is desired Surgical therapy: salpingostomy or sapingectomy

29. Abruptio Placenta Premature separation May result in severe hemorrhage o Death to mother, fetus, or both May lead to clotting dx of mother Frequent assessment of uterine tone and measurement of abdominal girth NI: o Assess bleeding, monitor BP and P, observe signs of shock, amount of bleeding over time, prepare for IV therapy Nursing responsibilities: o Assess FHR, prepare equipment, O2 available, collect/organize data, obtain order to type and cross match for blood, assess coping of woman in crisis

30. Polyhydraminos and Oligohydraminos Polyhydraminos >2000mL amniotic fluid Fetal Implications o Malformations, preterm, swallow and inspire fluid and prolapsed cord (when ROM) urinate Therapy: a/c malformations and neuro dx o Supportive, fluid removed o anencephaly; diabetes; Rh sensit, NDD, large placenta Vaginally: (danger of prolapsed cord and Maternal implications inability to do it slowly) o SOB; edema in LE from vena cava compression Amniocentesis (sterile o Fundal height > gestational technique) weeks Care: monitor for complications, support Oligohydraminos: Approx < 500mL Causes: o Postmaturity, hypertensive disorder, IUGR r/t placental insufficiency, renal malformations Fundal height < gestational weeks Fetus easily palpated Fetus not blottable Maternal Implications: o Dysfunctional labor, slow progress Fetal implications o Abnormalities, pulmonary hypoplasia, cord compression (variable decels) Therapy: o if term: induction o fetal monitoring, amnioinfusion c ROM, monitor for expulsion of fluid o left tilt semilfowlers or side lying o 2 belts: tocodynamometer (holds device of detection; 2 holds US transducer that detects FHR Interpretation

31. Non-stress Test at 30-32 weeks gestation assess fetal status using electronic fetal monitor basis: when fetus has adequate O2 and intact CHS, there are acels of FHR and FM procedure:

o Reactive >/=2 accels of FHR c FM of 15bpm lasting >/= 15 seconds, over 20 minutes

o Nonreactive Reactive criteria not met; not good o Unsatisfactory Cannot be interpreted

32. Contraction Stress test quality lasting 40+ Demonstrates reaction of FHR to seconds in 10minutes s stress of uterin contraction evidence of late decels Enables identification of fetal risk indicates fetus for asphyxia can handle FHR response to contractions hypoxic stress of If placental reserve is insufficient: UC o Fetal hypoxia o Positive o Depression of myocardium Shows repetitive o Decrease in FHR persistent late decels Procedure with >50% of the o Contractions: spontaneous or contractions induced with Pitocin o Eqivocal or suspicious: Interpretation: Nonpersistent late o Negative: decels or decels r/t 3 contractions of good hyperstimulation 33. Bipophysical profile test Comprehensive assessment of 5 FT >/= 1 episode of biophysical variables extension and flexion o Fetal breathing movement AFV: single vertical o Fetal movements posket >2cm o Fetal tone AFI >/= 5cm o Amniotic fluid volume NST >/= 2 accels of o Reactive FHR c activity >/= 15bpm for >/= 15 seconds in 20 min Interpretation: o Max score: 10; no partial o Normal findings credit FBM >/=1 episode o Combination of US and NST lasting >/= 30 seconds o Help id healthy or within 30 minutes compromised fetus FM >/= 3 movements o Indicated when risk of in 30 minutes placental insufficiency Lecithin/sphingomyelin 34. L/S ratio 2:1 @ 35 weeks = normal fetus o low risk of RDS

35. Aminocentesis the 3rd trimester procedure to obtain amniotic fluid for genetic testing (early: 15/16 weeks) for fetal abnormalities or to may be used to screen for: determine fetal lung maturity in o down syndrome

o trisomy 18 and neural tube defects 36. PROM spontaneous rupture before labor preterm PROM: before 37 weeks maternal risk for infection increases o chorioamnionitis: intraamniotic infection r/f bacterial infection before birth o endometriosis: postpartal infection of endometrium o risk for abruptio placenta Fetal risks: o Risk of RDS o Sepsis o Malpresentation and prolapse of umbilical cord Prevention of infection: o Sterile spectrum to detect amniotic fluid o Limit vaginal exams o Maternal infection present: Antibiotics asap; depends on what infection is caused by Macrolids and penicillins o Absence of fetal infection: gestational age <37

o information about fetal lung maturity Hospitalization and bedrest CBC C-reactive protein and urinalysis Continuous and intermittent fetal monitoring Regular NST or BPP Look for color/odor VS q4h Fetal fibermectinswab to determine if going into preterm labor Fetal lung maturity studies: o Maternal corticosteroid administration BETAMETHASONE (CELESTONE) IM x 2 doses 24h apart (12 mg each) SE: increased blood sugar S/S: HTN, thromboembolis m

37. Preterm labor o assess cervical length via US Occurs between 20-36 weeks o obtain Hx of previous PTL Diagnosis: o asses presence of infections, o Documented uterine educate clients, assess early contractions S/S, maternal lab studies 4 in 20 minutes or 8 in Management: 1 hour o IV infusion---promotes o documented cervical changes maternal hydration o cervical dilation >1cm and o Tocolyticsmedication to cervical effacement of 80% stop PTL or more Nursing: Management: o Id woman at risk o Assess cervicovaginal o Assess progress of labor fibronectin o Administer medications +fFN test b/t 22 and 37 weeks = at risk Possible causes and risk factors:

o Excess contractions, too ,uch AFI, extra babies, ischemia, placental abruption, cervical

factor, PPROM, hormonal permissions, bacterial infection

39. Tocoyltics excitability Uterine relaxants: STOP PRETERM o NI to watch: LABOR contraction pattern (4 INMT (ITS NOT MY TIME) in 20min, 8 in 1hr) Indomethecin respirations (before o NSAID; helps stop PTL adm) o Can only stay on 72h (NI and DTRs/Clonus SE) o Monitor; causes problems for Seizures st o 1 use: PTL baby; decreased AFI o 2nd use: PIH Nifedipine (Procardia) o Antihypertensive Terbutaune: o Calcium-channel blocker; o Commonly used (Adrenergic blocks calcium from getting Agonist) to uterus o Given subQ 2/5mg; take HR o Watch to see if slows before contractions o When P increases, BP Magnesium Sulfate decreases o Anticonvulsant o NI to watch: o LAST LINE, IV only Increase heart rate o Stops threshold and CNS assess for tachycardia, educate 38. PIH Pregnancy induced hypertension o Gestational or transient HTN, preeclampsia-eclampsia, Chronic PIH o Cannot start before 20weeks gestation o Resolves within 72 hours after placenta releases o Resolves by itself o Any BP above 140/90 Pathophysiology o Decreased levels of vasodilators o Less of normal vadodilation capability o Increase level of vasoconstrictors o Concurrent vasospasm o BP begins to rise after 20 weeks Maternal risks: o Hyperreflexia and HA, seizures, renal failure, abruptio placenta o DIC o Ruptured liver and PE o HELLP syndrome Fetal risks o SGA, Premature, hypermagnesemia, increased morbidity and mortality Management: o Bed rest, high protein diet, anticonvulsants o Corticosteroids: (Betamethasone (enhance babys lungs) o Antihypertensive: Procardia: stops calcium from getting to the heart= slows down HR = not contracting as much = less pressure on arteries

NI: o VS q4h (respirations) o Auscultate lungs q shift o NST daily, Monitor I and O, daily weight o Check proteinuria once daily (urine dipstick) o Assess DTR and clonus 4+ hyperactive; jerly, clonic respirations;

abnormal 3+ brisker than average 2+average response 1+ diminished response, low normal 0 no response, abnormal sudden weight gain, high bp, edema = PIH

40. HELLP syndrome and DIC HELLP: Thrombycytopenia rd o 3 stage of cascade of DIC waterfall o 4th stage of cascade of o Hemolysis waterfall; after DIC = death o all clotting factors used up; Destruction of RBC o Elevated Liver enzymes cannot be used for RBC; pressure from high BP From blood flow artery bursts obstructed by fibrin o bleed from every orphus deposits (LFT) o very hard to stop o Low platelet count 41. Rh Imcompatibility measure of mothers Rh negative women carries Rh blood; measures positive baby number of Rh positive Fetal blood cells cross into antibodies; if not maternal circulation sensitized, 2nd test o Result in production of Rh done at 28weeks; antibodies If positive: 1st child not affected 300mcg RhoGam subsequent preg: at 28 weeks and o Rh antibody enters fetal 12h after delivery circulation o Give RhoGam when Result: hemolysis of Pregnant Rh- women fetal RBC and fetal with no antibody titer anemia At 28 week gestation Fetal risks Mother whose FOB is o Rh hemolytic disease st Rh positive or unknown o Anemia (1 ) After each abortion and o Erythoblastosis fetalis 72h PP Marked fetal edema Amniocentesis and (hydrops fetalis); CHF, placenta previa marked jaundice (anytime mixture of Prevention blood) o Screen for Rh incompatibility Invasive procedure and sensitization Anemia marked fetal edema o Antibody screen: CHF marked jaundice Indirect Coombs test:

neurologic damage (Kernicterus) 42. Methods for recording fetal activity Dr Maternal assessment o Kick counts ALONE o Amniocentesis o NST o L/S ratio o CST o Oxytocin test o Count FM at same time of o Non-stress test day o Estriol level If <10 in 3 hours, notify 43. False and True labor True labor o Contractions at regular intervals o Increase in duration and intensity o Interval b/t contractions shorten o Pain in back- radiates to front o Intensity increase c walking o Dilation and effacement are False o o o o o o progressive labor Irregular contractions Do not increase in duration and intensity No change in interval b/t contractions Pain in abdomen No effects with walking No change on cervix

44. Leopolds maneuver Indicates probably location of FHR Prep o o Empty bladder, lie on back; feet on bed o Purpose: o Evaluate maternal abdomen o Evaluate position, presentation, lie of fetus o Methods o 1: palpate abdomen w both hands

note shape, consistency, mobility 2: move hands on pelvis back feels smooth 3: 1 hand just above symphysis head? Breach? Engaged? 4: facing feet; both hands gently down on pubis cephalic prominence or brow

45. Dilatiation and Effacement

46. stages of labor 1st stage o cervical dilation onset of true labor cervix dilated 10cm

o 3 phases: Latent (0-3cm): regular mild contractions, increase in intensity; E&D begin; increased anxiety/excitement Active (4-7cm): Contractions increase in intensity, frequency and duration; no turning back, fetal descent Transition (8-10cm): painful, intense contractions, Fetus descents rapidly, Rectal pressure, N, V 2nd stage

o expulsion o complete dilation end of birth o urges to push o sense of purpose rd 3 stage o placental separation and delivery hormones released rush of blood, uterus cramps th 4 stage Hemostatic stabilization o Increase pulse, decrease BP (tachycardia) o Uterus remains contracted o Thirsty and hungry

47. Induction or Augmentation of Labor (23) Amniotomy: o Descent and indirect Induction of labor pressure on uterus AROM, accelerates labor Allows assessment of color, Manipulates hormones and composition, odor mechanical factors Delayed until engagement o Prostaglandins Labor Induction Methods: Cervical Ripening:

Softening and effacing Medications: o Prostaglandin agents (CERVIDIL) Intravaginally When induced is indicated but not emergent GDM, postdates, Stripping of membranes: Mechanical method Internal os rotation 360 degrees 2x o Separating amniotic membranes Pitocin: initiating uterine contractions enhance ineffective contractions (augmentation) assess FHR and contractions prior begin primary IVF o mixed in 500-1000mL of IVF (LR) o piggybank Pitocin into primary IVF at closes port control/titrate at IV pump

LGA +: sent home -: SE: hyperstimulation, Nonreassuring fetus (1st hour) o Misoprostol (CYTOTEC) Stimulate onset of contractions Various routes o +: no required monitoring o -: uncomfortablecramping, contractions, bleeding o may not induce labor goal: stable contractions q2-3min lasting 40-60 seconds o changes in effacement, dilation and station Monitor for: o BP and P changes; hypertonicity (not soft) o FHR and rhythm Stop if: o Contractions >90seconds o Contractions <2min apart o Fetal late decels

48. SROM vs AROM SROM Spontaneous rupture AROM: Artificial- labor induction Cause fetal head to move down Contractions become stronger cause ROM At full term +: shortened labor, determine presence of meconium (distress), FHR monitoring -: increased risk of umbilical cord prolapse, increased risk of infection

49. Internal and External FHR monitoring (18) Progress of labor assessment o preterm labor indications: o decreased FM o previous hx of stillborn at o Nonreassuring fetal status 38+ weeks o presence of complication of o Meconium staining pregnancy o TOL for VBAC o induction of labor External: Ultrasound sound waves) placed on abdomen Transducer (emits continuous

o Sound waves bounce off the Toco fetal heart and are picked up by electronic monitor Moment by moment FHR displayed on screen Internal: Internal spiral electrode Screws into occipit Must: o Membranes ruptured o cervix dilated 2cm o presenting part down against cervix IUCP: replaces TOCO; rest between fetus and side of uterine wall Signs: variations from normal heart rate pattern and decreased fetal movement Meconium-stained amniotic fluid and presence of ominous FHR pattern o Persistant late decels Nursing Interventions: Optimize maternal position (L side) Begin IV infusion or increase flow rate o Or if cord prolapse is suspected Assume knee chest position

(Tocodynamometer) Telemetry system: battery operated transmits signal to receiver connected to monitor Placed over uterine fundus o know presenting part provides more accurate continuous data than external o signal is clearer o movement does not interrupt it 2cm and ROM

50. NI for non-reassuring FHR patterns o Persistant and severe variable decels o Prolonged decles Intrauterine resuscitation o Corrective measures used to optimize O2 exchange within maternal-fetal circulation should start without delay Perform vaginal exam o Detect prolapsed cord Decrease uterin activity by d/c IV Pitocin or administer a tocolytic (terbutaline) to decrease contraction frequency and intensity Administer O2 via facemask

51. FHR Bradycardia, Tachycardia and BL (18) Baseline: normal: 110-160bpm Bradycardia: ominous if a/b: <110 o decreased LT variability o late decels causes: o profound hypoxia o = Nonreassuring o maternal HTN Tachycardia: o cord compression o fetal arrhythmias >160bpm o uterine hyperstimulation causes o early hypoxia o abruptio placenta o maternal fever (accel fetal o uterine rupture

o o o o

metabolism maternal dehydration maternal HTN amnionitis Maternal hyperthyroidism

o Brethezine (cardiac stimulant) o Fetal anemia Ominous if a/b: o Late decels, severe variable decels, decreased variability

52. Episiotomies and Lacerations (23) Episiotomy: 2 types: Preventative measures o midline (heal faster; less o Perineal massage for pain, 3-4th degree laceration) nulligravida o mediolateral (larger, avoid o Natural pushing during labor rectal; pain) o Side-lying for pushing o Warm/hot compress additional complications: o blood loss, infection, pain, o Controlled breathing pattern perineal discomforts (gradual expulsion o Supportive, distraction, comfort measures, evaluate REEDA Laceration: use Vaginal, cervical, perineal o Precipitous birth (<3hours) Trickle of blood o Macrosomia Risk factors: o Pitocin o Forceps or vacuum assisted o nulliparity 53. Crowning

54. Systemic pain medications during labor vs regional pain medications Systemic pain medication: relaxation Goal: provide max pain relef at min o 7-10cm (transition) min use risk to mom and fetus to woman and may lead to All systemic meds cross placental resp depression of newborn barrier by simple diffusion Opioid analgesics Med action in the body depends on o Stadol or Neubain rate metabolized by liver enzymes and excreted by kidneys Most common in active phase of 1st stage High med doses may remain in fetus for long periods of time Less SE than Demerol because fetal liver enzymes and or morphine kidney excretion are inadequate for Stadol: IV, 0.5-2mg metabolizing analgesic agents q4h; rapid onset Timing: Neubain: IV, 10-20mg, o <4cm (latent)prolong labor q3h PRN and depress fetus Advantages: rapid onset, short duration o 4-7cm (active) may aid

reverses narcotic Disadvantages: cross depression placenta RD, may o Fentanyl not be adequate 50-100mcg over 1o Narcan 2min Counteracts RD effects SE: brady, HTN, N, V, Se: tachy, HTN, tremors RD Considerations: Regional analgesia and anesthesia: Anesthesia May produce breakthrough pain, Temporary loss of sensation sedation, RD produced by injecting local Hot spots anesthesia directly into nervous SE: itching, HTN tissue Spinal Block: Block conduction of nerve impulses Directly into cerebral spinal fluid Absorption depends on vascularity Mostly for c/s of area +: immediate onset; east of adm; Agents contribute to increase blood smaller med volume flow (vasodilation) -: blockade of sympathetic nerve Analgesia fibers = increased rate of HTN Pain relief to body region alt. of FHR and hypoxia Injecting opioidfentanylalong Nursing care: with anesthesia o Bolus Nursing care: void, position, o BP monitoring monitor VS, resp. status o Monitor contractions and tell Epidural block: woman when to bear down Entire pelvis Pudendal Block: +: fully awake, no RD, relief during Transvaginalintercepts signal at prolonged labor and PP; rest and pudendal nerve regain strength; can be combined o Anesthesia to lower vagina, with opioids vulva, perineum -: numbness of LE, decreased Pain relief for latter part of 1st uterine contractions; little/no urge stage, 2nd stage, birth and to push; hypotension; bladder episiotomy repair Nursing care: +: ease of adm/absense of o Monitor BP q1-2min for maternal HTN; decreased 15min; then q15min discomforts of low forceps or o Continuous FHR monitor vacuum o Bladder (cath) -: possible broad ligament o Side lying to maximize hematoma, perforation of rectum, Uteroplacental blood flow trauma to sciatic nerve, must inject Continuous Epidural Block: along with presenting part Less N, increased ability to cough 55. Forceps and Vacuum extraction (23) Forceps-assisted birth: of labor, heavy regional block indications: Newborn risks: o maternal exhaustion, fetal o Bruising, edema, facial distress, premature placental lacerations, separation, shorten 2nd stage cephalohematoma, transient

facial paralysis, cerebral hemorrhage Maternal risks: o Lacerations of birth canal; infection s2 lacerations, increased bleeding, bruising, perineal edema Vacuum Extraction: Facilitate birth by suction to fetal head

In coordination with contractions, descent occurs, fetal head is born Progressive descent with 1st 2 pushes Procedure limited to prevent (risks): o Cephalohematoma o Brain injury o Jaundice (reabsoprtion of bruising at attachment site)

56. Cesarean Birth (23) Most common Indications: o Nonreassuring fetal status o Cephalopelvic disproportion o Lack of labor progression o Placenta previa o Maternal infection o Previous c/s Preparation: o Informed consent, IV lines, positioning, FOB at head, lap sponge count, assess cath, abdominal prep, adm. systems, promote bonding Antacid, fundal checks, care o Displace uterus 15 degrees of incision, post op meds, adm antibiotics, assist Nursing care: o Routine postpartal care system and returning bowel sound including fundal checks o Assessment of maternal pain o Care of incision level and provision of pain o Monitoring I and O relief o Assessment of respiratory Most common risks: o Hemorrhage o Infant death o Uterine rupture Care: o Continuous EFM o IV fluid o Internal monitoring Prostaglandin agents induction should be avoided if possible 57. Newborn Reflexes (25)

Protective: Blinking Yawning Coughing Others: Rooting o Adequate for nutritional intake o Turns head and opens mouth to suck when one side of face is stroked Sucking

Sneezing Drawing back from pain o Object inserted in mouth, automatically sucks Tonic neck o Fencing position o Head to one side, arm and leg on same side extend while opposite side flexed

o Persists until 3 months Plantar grasp o Pressure on ball of foot elicits curiling of toes Palmar grasp: o Pressure on palm elicits grasp Moro o Sudden disturbance = startled o Response: flexion of knees, stiffen body, arms in tense extension Finger spread forming C, may cry

Disappears by 6months

Babinski o Stroke sole upward and across ball of foot o Elicits fanning and extension of toes o Disappears by 12months Stepping o Held upright with one foot on flat surface, will step Trunk incurature (Galant reflex) o Stroking spine cause pelvis to turn to one side o Newborn is prone

58. Newborn assessment (25) reflex Time of birth Epstein pearls = small APGAR white specks on gum VS lines o Temp o Ears: hearing test, attention o Heartrate to sound; moro reflex o Respirations o Chest: clavicles straight and o Bp intact; barrel shaped o Cry o Breasts: engorgement Measurements: o Abdomen: soft, dome shaped o Weight Umbilical cord: o Length White, gelantious o Head circumference with 2 arteries 1 o Chest circumference vein General: Clamp removed o Head: 1/4th of body size; may before d/c appear asymmetrical d/t Falls off within 1molding 2 weeks o Fontanelles o Genitourinary: Anterior: diamond; May not void 12-24 close at 18months hours after birth Posterior: triangle; Void pale yellow and closes at 8-12 weeks urine 6-10x a day o Hair o Hips o Face Abduct to >60 degrees o Eyes with no clicks or snaps True color change at Ortolanis maneuver: 6mo spine and knees flexed Blocked tear duct and hip is abducted opens at 2mo Barlows maneuver o Nose: sneeze a lot; pug nose Adduct thigh, o Mouth: gag, swallowing press down.. coordinated with sucking

dislocation felt as femoral head slips out of acetabulum o Feet Creases on soles; positional clubfoot o Spine: C shaped; may have small dimple at base but without connection to spinal cord o Skin Acryocyanosis: bluish discoloration of hands and feet Mottling: pattern of dilated blood vessels caused by fluctuation in circulation Milia: baby acne

Mongolian spots: dark flat bluish pigments on lower back and butt On asian afrian and Hispanic Lanugo Begins to decrease 3640weeks Vernix caseosa Decreases with increased gestational age st o Anus: 1 stool: black and tarry 12-24h after delivery becomes greenishbrown for 203 days formula: pale yellow Brease: loose golden

59. Ballard Gestational age assessment Evaluates 6 neuromuscular and 6 physical characteristics performed 6 neuromuscular 1st few hours after birth o posture o square window sign Score of 1-5 assigned to each o arm recoil Total is related to gestational age o popliteal angle (degree of Ratings marked on graph with knee flexion) weight, length, and HC to classify o scarf sign newborn based on maturity and IUG o heal to ear extension SGA 6 physical characteristics: o <10% o skin o lanugo AGA o 10-90% o plantar surface (creases should cover at least 2/3rds LGA foot surface) o >90% o breasts SGA and LGA: frequent glucose o eyes/ears monitoring and early feedings o genitalia 60. Postpartum Assessment.

BUBBLE-HEB Breasts o Engorgement/tenderness? o Nonnursing Suppress lactation Tight bra, ice

packs, cabbage, no hot showers o Nursing Support lactation Dependent on infant sucking, successful

Uterus o Fundal height: position Height: when placenta is expelledgoes down to umbilicus, then 1finger breadth each day for 10 days Firm or boggy: Boggy = soft/spongy = not good o Can cause hemorrhag e Midline or deviated: Always deviated to the right Midline = good R = bladder is full o Afterpains o Involution Enhancing: uncomplicated L&D, BF, early ambulation, complete expulsion of placenta and membranes Slow: subinvolution: prolonged L&D,, anesthesia, grand multiparas (>6), retained placental fragments, full urinary bladder, infection, overdistension of uterus Bladder o Should void 6-8hours after delivery o Assess frequency, urgency, burning o Evaluate ability to empty o Palpate for bladder distension o Postpartum diuresis (output

production and delivery of milk Assess nipples (redness, cracks, erectility) Avoid soaps on nipples

> input) o Routine I &O Bowel o Perineum: sims position: REEDA, hemorrhoids o Flatus, constipation, auscultate bowel sounds x 4 o Bowels sluggish o NI: stool softeners, encourage ambulation and encourage fluids o c/s: hypoactive Lochia o Amount, odor, character, clots Foul odor = infection o d/c of blood and debris after delivery o c/s: less Lochia higher risk of PP hemorrhage o no large clots o 3 types Rubra: day 1-3 dark red Serosa: day 4-9, pink/brown Alba: day 10+; yellowwhite (creamy o BF mom speed up involution so more Lochia in beginning Get to Alba quickly Episotomy or perineal lacerations o Inspect perineum for REEDA o Inspect for hemorrhoids o NI: observe s/s infection Manage ice packs, topical anesthesia, sitz bath; analgesic (Ibuprofen) Teach peri-care o must look at from back Homans sign o Pain in calf on dorsi-flexion of food is recorded as positive o Indicates thrombophlebitis Deep pain = DVT st o 1 line predictor; not diagnostic Emotional Status

o Determine phase of Bonding psychological adjustment o Emotional relationship with o Postpartum blues: infant st 1 14 days Other assessments o Pulse: 50-90 bpm Vital signs o R: 18-24 o Temp elevations (only 24 hours) Education o BP remains consistant with o Self care BL during pregnancy 61. Postpartum Hemorrhage (32)

Blood Loss Vaginal: >/= 500mL C/S: >/= 1000mL Cause uterine atony (boggy uterus) lacerationsespecially forceps subinvolution: start involution then stops o usually fragments Risk for uterine atony: relaxation of uterus overdistension of uterus d/t large baby, multiple gestation, multiparity o polyhydraminos o grand multiparity Nursing Interventions: Assess vaginal bleeding Assess uterus for bogginess o If boggy fundal massage Assess hg and hct Assess for bladder distension Late Hemorrhage Frequent result of subinvolution or retention of placental fragments Subinvolution: o Fundal height > expected

10pt drop in Hct

uterine rupture: placental abruption uterine inversion: top of fundus comes in on itself and does not contract o macrosomia retained placental fragments (main reason) low platelet count d/t PIH Meds: Pitocin, Mag Sulfate If uterus is firm and still bleeding suspect laceration (firm = constricted Q15min x 4 Every labor gets 2 units cross matched blood waiting o Lochia flow fails to progress from rubra to serosa to alba normally o Tx with Methergine

62. Rubella Routine screening of pregnant women for rubella immunity is recommended 63. RhoGAM Given IM to prevent immuniological o Vaccination in case of susceptible pregnant women is often given immediately after giving birth. condition: hemolytic disease of

newborn Prevents sensitization of maternal immune system Prevents Rh imcompatability o Prevent development of antibodies against Rh+ blod If Rh negative:

o Women receive injection: Every pregnancy, miscarriage or abortion, after prenatal tests, after injury to abdomen Given at 28 weeks and 72 hours postpartum

64. Late Decles after contraction onset, nadir, recovery of decel follow beginning, peak and end insufficient blood flow to uterus UTEROPLACENTAL INSUFFICIENCY 65. Early Decels headed down, cervix dilated, GOOD Before contraction Onset to nadir > 30 seconds Nadir of decel matches peak of contraction HEAD COMPRESSION Baby head presses on cervix Umbilical cord compression 66. Variables Abrupt onset to nadir </= 30 seconds with drops of 15bpm below baseline for >/= 15 seconds but <2 minutes o < 5 bpm Moderate: amplitude 6-25 bpm Marked: not great, all over the place o > 25 bpm

Variability: Average long term variability Absent: o Amplitude undetectable o No variability (hypoxic) Minimal: amplitude detectable r/t fetal movement

67. Accelerations reassuring sign = accompany with contractions

68. Prolapsed Cord (22) cord precedes presenting part If loop is discovered o Firm pressure on head fetus not fully engaged o Administer O2 via face mask prevention preferred o Determine presence of o confirmed ROM: horizontal, pulsation bedrest until fetal head is o Immediate c/s well engaged o FHR monitoring o FHR measured 1 min at o Trendelenburg or knee-chest beginning and end of contractions 69. Cephalopelvic Disproportion (22) pelvis Fetal head too large to pass bony o No descent

Maternal risks o Prolonged labor o Hemorrhage Fetal risks: o Hypoxia o Birth trauma At 1 min and 5 min Evaluate neonate condition 5 signs: o heartbeat, respiratory effort, muscle tone, reflex Heart rate Respiratory effort Muscle tone Reflexes Color 0 Absent Absent Flaccid No response Blue/pale

TOL o When boarderline or dubious Increase pelvic diameter by: o Squatting, sitting, rolling side to side, knee chest, labor ball Avoid lithotomy irritability, color 0-2 score 7-10 good 4-6 fair 0-3 extremely poor 2 Normal (>100) Good cry Active Vigerous cry All pink

70. APGAR score (19) each o o o

1 Slow (<100) Slow, irregulat Slow, some flexion Weak cry Acrocyanosis

71. Breastfeeding and Bottle feeding (27) Breastfeeding: Advantages: no preparation immuonologic protection min 6mo prefer 1 year digest and absorb easier speeds up involution more vitamins Disadvantages: mother burns more calories making pain milk leaking milk (let down) maternal-infant attachment embarrassment, unequal feeding o hormone changes responsibilities o skin to skin (> physiologic diet restriction stability, < cry, sleep longer, medications BF better) o most pass to breast milk no additional cost Bottle feeding Advantages: Disadvantages: good nutrition May need to try different formulas before finding one well tolerated father can participate Proper preparation necessary for AAP recommends formula until 12 nutrition adequacy months o Especially so dont grow bacteria 100. Meds, Meds, Meds