3 Genetics, Conception, Fetal Development, and Reproductive Technology

OB NURS 306 Chapter 3 Genetics, Conception, Fetal Development, and Reproductive Technology, Chapter 4 Physiological Aspects of Antepartum Care Chapter 12 Postpartum Physiological Assessments and Nursing Care (Chap 1 to 18) Deeply elab Chapter 3 Genetics, Conception, Fetal Development, and Reproductive Technology o  30,000 genes in the human genome (organism’s complete set of DNA)  46 chromosomes; 22 homologous pairs of chromosomes and one pair of sex chromosomes  recessive genetic disorders  sickle cell anemia, cystic fibrosis, thalassemia, Tay-Sachs disease  carrier testing  identify individuals who carry one copy of a gene mutation that, when present in two copies causes a genetic disorder; used when there is a family history of genetic disorder  preimplantation testing/preimplantation genetic diagnosis  used to detect genetic changes in embryos that are created using assisted reproductive techniques  prenatal testing  early detection of genetic disorders  risks for conceiving child with genetic disorder  maternal age older than 35, man/woman who has genetic disorder; family history of genetic disorder, history of previous pregnancy resulting in a genetic disorder or newborn  sickle cell anemia o most common of African ancestry o sickle-cell hemoglobin forms rigid crystals that distort and disrupt RBCs; oxygen-carrying capacity of blood is diminished  cystic fibrosis o most common genetic disease of European ancestry o production of thick mucus clogs in bronchial tree and pancreatic ducts o most severe effects are chronic respiratory infections and pulmonary failure  Tay-Sach disease o Most common among Jewish ancestry o Degeneration of neurons and nervous system results in death by the 2 years old  PKU o Lack of enzyme to metabolize the amino acid phenylalanine  leads to severe mental and physical retardation  Huntington’s Disease o Uncontrollable muscle contractions between 30-50 years followed by memory loss and personality o No treatment that can delay mental deterioration  Hemophilia (X-linked) o Lack of factor 8 o Can be controlled with factor 8 from donated blood  Duchenne’s Musclular Dystrophy o Replacement of muscle by adipose or scare tissue with progressive loss of muscle function; often fatal before age 20 due to involvement of cardiac muscle  teratogens  any drugs, viruses, infections, or other exposures that can cause embryonic/fetal developmental abnormality  degree or types of malformation vary on length of exposure, amount of exposure, and when it occurs during human development  exposure after 13 weeks may cause fetal growth restriction or reduction of organ size  toxoplasma is a protozoan parasite found in cat feces and uncooked/rare beef and lamb o can cause fetal demise, mental retardation, blindness when fetus is exposed  rubella  increased risk for heart defects, deafness and/or blindness, mental retardation, fetal demise  cytomegalovirus  increased risk for hydrocephaly, microcephaly, cerebral calcification, mental retardation, hearing loss  herpes varicella/chicken pox  increased risk for hypoplasia of hands and feet, blindness/cataracts, mental retardation  syphilis  increased risk for skin, bone and/or teeth defects, fetal demise  cocaine  increased risk for heart, limbs, face, GI/GU tract defects, cerebral infarctions, placental abnormalities Chapter 4 Physiological Aspects of Antepartum Care  G/P System o Gravida: # times a woman has been pregnancy including current pregnancy o Para: # of births after 20 weeks’ gestation whether live or stillbirths o Abortions are not accounted for in this system  GTPAL o G: # times pregnancy o T: # of term infants born after 37 weeks o P: # of preterm infants between 20 and 37 weeks o A: # of abortions either spontaneous or induced before 20 weeks o L: # of living children  Nulligravida: woman who has never been pregnant or given birth  Primigravida: woman who is pregnant for the first time  Multigravida: someone who is pregnant for at least the second time  Prenatal period  entire time period during which a woman is pregnant through birth of baby  Nurse places emphasis on health education and health promotion  Family-centered maternity care is a model of obstetrical care based on a view of pregnancy and childbirth as a normal life event, a life transition that is not primarily medical but rather developmental  First trimester o Woman learns frequency of follow-up visits and what to expect from pregnancy visits as pregnancy progresses during initial visit o Comprehensive health and risk assessment; currently pregnancy history; complete physical and pelvic examination; nutrition assessment; psychosocial assessment; assessment for intimate partner violence o Assessment of uterine growth after 10-12 weeks is measured by height of fundus with centimeter measuring tape; zero point of tape is placed on the symphysis pubis and tape is extended to top of fundus; MEASUREMENT SHOULD EQUAL # OF WEEKS PREGNANT o Certain types of fish (king mackerel, shark, swordfish, tilefish) should be avoided due to high levels of methylmercury o Chart review; interval history; focused physical assessment; pelvic exam/sterile vaginal exam if indicated; confirm EDD o Triple/quad screen (neural tube defect); US; screening for gestational diabetes; hemoglobin and hematocrit; antibody screen if Rh-negative (Administration of RhoGAM if Rh-negative and anti-body screen negative)  Administered prophylactically at 28 weeks to prevent isoimmunization from potential exposure to Rh- positive fetal blood during normal course of pregnancy  Adverse reaction  pain at IM site; fever o Slight lower body edema is normal due to decreased venous return o At 20 weeks, fetus is 8 inches long and weights 1 pound o Chart review; interval history; nutrition follow-up; focused physical assessment; pelvic exam/sterile vaginal exam if indicated o Group B Strept at 35-37 weeks; H&H if not done in second trimester; repeat GC, chlamydia, RPR, HIV HbSAg; 1- hour glucose challenge test at 24-28 weeks o At term, fetus is 17-20 inches long, 6-8 pounds Chapter 6 Antepartal Tests   aspiration of a small amount of placental tissue for chromosomal, metabolic, or DNA testing o to detect fetal abnormalities caused by genetic disorders o Supine position for transabdominal aspiration with US to guide placement o Lithotomy for transvaginal aspiration with US to guide placement o Small biopsy of chorionic (placental) tissue is removed o Assess fetal and maternal well-being post-procedure; FHR is auscultated twice in 30 minutes o Instruct woman to report abdominal pain/cramps, leaking of fluid, bleeding, fever, chills o Results within 1 week  o Needle is inserted through maternal abdominal wall into uterine cavity to obtain amniotic fluid o Genetic testing, fetal lung maturity, assessment of hemolytic disease in fetus or for intrauterine disease o Results within 2 weeks  Delta OD 450 o Evaluation of amniotic fluid obtained via amniocentesis to predict life-threatening anemia in fetus during second and third trimester o Used in a lab to determine if there is a deviation of optical density at 45 nm  Fetal blood sampling/percutaneous umbilical blood sampling (CORDOCENTESIS) o Removal of fetal blood from umbilical cord  used to test for metabolic and hematological disorders, fetal infection, fetal karyotyping o may be done as early as 11 weeks but usually done in second trimester o results within 48 hours o POSITION WOMAN IN LATERAL/WEDGED POSITION TO AVOID SUPINE HYPOTENSION DURING FETAL MONITORING TESTS o Have terbutaline ready as ordered in case uterine contractions occur during procedure o Assess fetal well-being post-procedure 1-2 hours via external fetal monitoring o Done at 15-20 weeks gestation o Assessed in maternal blood to screen for certain developmental defects in the fetus (NTD, ventral abdominal wall defects) o Abnormal findings require additional testing  amniocentesis, VNS, US  Multiple marker screen o Combination of AFP, human chorionic gonadotropin (hCG), estriol levels o Detects for some trisomies and NTDs o done at 15-16 weeks gestation o maternal blood is drawn and sent to lab o low levels of maternal serum alpha-fetoprotein and unconjugated estriol levels suggest an abnormality o Instruct woman to palpate abdomen and track fetal movements daily for 1-2 hours o 10 distinct fetal movements within 2 hours is normal  once movement is achieved, counts can be d/c for the day o FEWER THAN 4 FETAL MOVEMENTS IN 2 HOURS SHOULD BE REPORTED o Uses electronic fetal monitoring to assess fetal condition/well-being o Looking for accelerations; baby is nice and active o Used in women with complications such as HTN, diabetes, multiple gestation, trauma and/or bleeding, woman’s report of lack of fetal movement, placental abnormalities o Monitored with external FHR until reactive (up to 40 minutes) while running FHR contraction strip for interpretation o In fetuses less than 32 weeks, two accelerations peaking at least 10 bpm above baseline and lasting 10 seconds in a 20-minute period is reactive o Nonreactive NST is one without sufficient FHR accelerations in 40 minutes  followed up for further testing o Presence of repetitive variable decelerations that are >30 seconds requires further assessment of amniotic fluid  Vibroacoustic stimulation o Uses auditory stimulation to assess fetal well-being with EFM when NST is nonreactive  Used to elicit a change in fetal behavior, fetal startle movements, increased FHR variability o Used only when baseline rate is determined to be within normal limits o Conducted by activating an artificial larynx on the maternal abdomen near the fetal head for 1 second in conjunction with NST;  Contraction stress test o Assess fetal well-being and uteroplacental function with EFM in women with nonreactive NST at term gestation o Identify a fetus that is at risk for compromise through observation of the fetal response to intermittent reduction in utero placental blood flow associated with stimulated uterine contractions o Monitor FHR and fetal activity for 20 minutes o If no spontaneous UCs, initiate contractions by having woman brush nipples for 10 minutes  Unsuccessful  oxytocin via IV until 3 UCs in 10-20 minutes lasting 40 seconds  Amniotic fluid index o Measures volume or amniotic fluid with ultrasound to assess fetal well-being and how well the placenta is working o AFI above 24 cm is indicative of polyhydramnios  May indicate fetal malformation  NTDs, obstruction of fetal GI tract, fetal hydrops o One or more episodes of rhythmic breathing movements of 30 seconds or movement within 30 minutes is expected o Three or more discrete body/limb movements within 30 minutes are expected o One or more fetal extremity extension with return to fetal flexion or opening and closing of hand is expected o Pocket of amniotic fluid that measures at least 2 cm in 2 planes perpendicular to each other is expected o Score of 2 is assigned to each component  6/10 is equivocal and may indicate need for delivery depending on gestational age  4/10 delivery is recommended because of a strong correlation with chronic asphyxia  2/10 or less prompts immediate delivery  modified biophysical profile o combines NST as an indicator of short term fetal well-being and AFI as indicator of long-term placental function o considered normal when NST is reactive and AFI is greater than 5cm Chapter 8 Intrapartum Assessment and Interventions  true labor o occur at regular intervals and increase in frequency, duration and intensity o bring about changes in cervical effacement and dilation  false labor o irregular contractions with little or no cervical changes  spontaneous rupture of the membranes can occur before onset of labor but typically occurs during labor o woman should deliver within 24 hours to reduce risk of infection  confirmation of rupture of membranes (ROM) o speculum exam to asses for fluid in the vaginal vault o Nitrazine paper  paper turns blue when in contact with amniotic fluid o Ferning  ferning pattern confirms ROM o AmniSure testing kit  Normal amniotic fluid is clear/cloudy with normal odor (similar to ocean water or loam of a forest floor) Stages of labor and childbirth  Labor/parturition is the process in which the fetus, placenta and membranes are expelled  First stage  begins with onset of labor and ends with complete cervical dilation o Longest stage, typically lasting 12 hours for primigravidas and 8 hours for multigravidas 0%-40% effacement; contractions lasting 30-45 seconds and mild intensity  Average length of 9 hours for primiparous and 5 hours for multiparous  Order CBC, UA, possible drug screening; start IV/insert saline lock  Intrapartum GBS prophylaxis ; 40%-80% effacement; contractions every 2-5 min with duration 45-60 seconds  Cervix dilates 0.5 cm/hr for primiparous and 1.5 cm for multiparous  Averages 3-6 hours; typically shorter for multigravidas  Women usually come to birthing center at this time  Monitor v/s every 2 hours; every 1 hour if ROM with complete effacement; intense contractions every 1-2 minutes lasting 60-90 seconds  Assess FHR and UCs every 15 minutes  begins with complete dilation of cervix and ends with delivery of baby o Typically lasts 50 minutes for primigravidas and 20 minutes for multigravidas; although several hours is normal o Contractions are intense occurring every 2 minutes and lasting 60-90 seconds and is usually characterized by expiratory grunting or vocalizations o benefits of upright position (head of bed at 45 degrees)  pelvic diameter may be increased by 30%, shortened duration of the second stage, pain may be decreased, perineal trauma may be decreased o delayed pushing  laboring down/passive pushing/rest and descent  may be appropriate for women with epidural anesthesia who do not feel the urge to push o perform episiotomy if necessary  incision in the perineum to provide more space for presenting part at delivery  mediateral episiotomy is cut at 45 degree angle to left/right; used in large infants; heals more slowly, causes greater blood loss and more painful o first-degree laceration -- > involves perineal skin and vaginal mucous membrane o second-degree laceration  involves skin, mucous membrane, fascia of perineal body o third-degree laceration  involves skin, mucous membrane, muscle of the perineal body and extends to rectal sphincter o fourth-degree laceration  extends into rectal mucosa and exposes the lumen of rectum o monitor FHR every 5-15 minutes or after each contraction o encourage rest between contractions by breathing wit patient/therapeutic touch o Placenta usually separates within a few minutes after delivery, but continues to contract until expelled which can take 5-30 minutes  active management of placental delivery consists of the use of uterotonics, controlled cord traction, uterine massage o Assess maternal v/s every 15 minutes o Uterotonics • Stimulates uterine smooth muscle that produces intermittent contractions • Directly stimulates smooth and vascular smooth muscles causing sustaining uterine contractions • Contraction of uterine muscle  Misoprostol (Cytotec) • Acts as a prostaglandin analogue causes uterine contractions  Fourth stage (immediate postpartum period)  begins after delivery of placenta and completed 4 hours later o Primary mechanism by which hemostasis is achieved at the placental site is vasoconstriction produced by a well- contracted myometrium o This stage also begins the postpartum period o Assess uterus/lochia; administer medications as order; assess maternal v/s every 15 minutes; monitor newborn every 30 minutes o IMPORTANT GOAL IS NEWBORN-FAMILY ATTACHMENT o BEST TIME TO INSTITUTE BREASTFEEDING Sign 0 1 2 Respiratory effort Absent Slow, irregular Good cry Heart rate Absent Slow, below 100 bpm Above100 bpm Muscle tone Flaccid Some flexion of ext. Active motion Reflex activity None Grimace Vigorous cry color Pale, blue Body pink, blue ext. Completely pink  Apgar scores should be obtained at 1 minute and 5 minutes after birth  If five 5 minute Apgar score is less than 7, additional scores should be assigned every 5 minutes up to 20 minutes  Should be recorded every 30 minutes until newborn’s condition is stable for at least 2 hours  initial steps of newborn resuscitation  provide warmth by placing baby under radiant heat source, positioning the head in a “sniffing” position to open the airway, clearing the airway if necessary with bulb syringe/suction catheter, drying baby, stimulating breathing  erythromycin ointment is administered to the eyes as prophylaxis to prevent gonococcal and Chlamydia infections  vitamin K is administered via IM injection to prevent hemorrhagic disease caused by vitamin K deficiency  hepatitis B virus vaccine is recommended for all newborns Chapter 9 Fetal Heart Rate Assessment Terminology related to fetal heart rate assessment  baseline FHR  mean FHR rounded to increments of 5 bpm during a 10-minute window, excluding accelerations and decelerations  baseline variability  fluctuations in the baseline FHR that are irregular in amplitude and frequency. Fluctuations are visually quantified as the amplitude of the peak to trough in bpm. Determined in a 10-minute window, excluding accelerations and decelerations. Reflects the interaction between the fetal sympathetic and parasympathetic nervous system. o Absent  amplitude range is undetectable o Minimal  amplitude range is visually undetectable ≤ to 5 bpm o Moderate  amplitude from peak to trough 6 bpm to 25 bpm o Marked  amplitude range > 25 bpm  Accelerations  visually apparent, abrupt increase in FHR above the baseline. The peak of the acceleration is ≥ 15 bpm over the baseline FHR for ≥ 15 seconds and > 2 minutes. o Before 32 weeks gestation acceleration is ≥ 10 beats over the baseline FHR for ≥ 10 seconds. o Prolonged accelerations are ≥ 2 minutes, but ≤ 10 minutes  deceleration  transitory decrease in the FHR from the baseline o early deceleration  visually apparent gradual decrease in FHR below baseline. The nadir (lowest point) of the deceleration occurs at the same time as the peak of the UC. In most cases the onset, nadir, and recovery of the deceleration are coincident or mirror the contraction. o variable deceleration  visually apparent abrupt decrease in the FHR below baseline; decrease in FHR is ≥ 15 bpm lasting ≥ 15 seconds and < 2 minutes in duration o late deceleration  visually apparent gradual decrease of FHR below the baseline. Nadir (lowest point) of the deceleration occurs after the peak of the contraction. In most cases the onset, nadir, and recovery of the deceleration usually occurs after the respective onset peak, and end of UC. o prolonged deceleration  visually apparent abrupt decrease in FHR below baseline that is ≥ 15 bpm lasting ≥ 2 minutes but ≤ 10 minutes o sinusoidal pattern  having a visually apparent smooth sine-like wave like undulating pattern in FHR baseline with a cycle frequency of 3-5/min that persists for ≥ to 20 minutes  tachycardia  baseline FHR of > 160 bpm lasting 10 minutes or longer  bradycardia  baseline FHR of <110 bpm lasting for 10 minutes or longer  normal FHR  FHR pattern that reflects a favorable physiological response to the maternal fetal environment  abnormal FHR  FHR pattern that reflects an unfavorable physiological response to the maternal fetal environment Modes or types of fetal and uterine monitoring  auscultation o use of fetoscope/Doppler to hear the FHR by externally listening without the use of a paper recorder o fetoscope  allows practitioner to hear sounds associated with opening/closing of ventricular valves via bone conduction o Doppler  uses ultrasound technology, using sound waves deflected from fetal heart movements  Converts information into a sound that represents cardiac events  palpation of contractions o assesses for frequency, tone, duration, intensity o nurse places fingertips on the fundus of uterus and assess for degree of tension as contractions occur o intensity of contractions is measured at peak of the contraction  mild or 1+ feels like tip of nose (easily indented)  moderate or 2+ feels like chin (can slightly indent)  strong or 3+ feels like forehead (cannot indent uterus) o resting tone is measured between contractions and listed as either soft or firm uterine tone  external electronic fetal and uterine monitoring o uses ultrasound device to detect FHR and a pressure device to assess uterine activity o external EFM detects FHR baseline, variability, accelerations, decelerations o erratic FHR recordings or gaps on paper recorder may be due to inadequate conduction of US signal displacement of transducer, fetal/maternal movement, inadequate US gel, fetal arrhythmia o contractions are measured via tocodynamometer; cannot measure pressure/intensity o uses f o involves using contractions that is applied to presenting part of fetus to detect FHR placed in the uterine cavity to directly measure uterine o Contraindications  chorioamnionitis, active maternal genital herpes, HIV, conditions that preclude vaginal exams o May be used due to maternal obesity or lack of progress in labor when quantitative analysis of uterine activity is needed for clinical decision making; treat worsening category II tracing o Contractions are measured via an intrauterine pressure catheter  contractions measured in mm Hg o Peak pressure  maximum uterine pressure during a contraction measured with IUPC o Resting tone/baseline pressure  uterine pressure between contractions and should be about 5-25 mm Hg  Telemetry o Continuous electronic fetal monitoring which involves connecting patient to a radio frequency transmitter that allows patient to walk/take bath without being connected to monitor  monitor paper used for the electronic fetal monitor o paper speed is 3 cm per minute; each dark vertical line is 1 minute and each lighter vertical line is 10 seconds o FHR on top grid; UC on lower grid FHR and contraction pattern interpretation  Baseline fetal heart rate  assess over 10-minute period o Mean FHR rounded to increments of 5 bpm during 10-minute window excluding accelerations, decelerations, or marked variability o Normal range  110-160 bpm o If above 200-220 bpm, fetal demise may occur o Fetal tachycardia  maternal fever, dehydration, anxiety, exposure to medications (terbutaline); may be sign of early fetal hypoxemia o Fetal bradycardia  maternal dehydration, hypotension, medications such as anesthetics, rupture of uterus/vasa previa  Sudden profound bradycardia (less than 80 bpm ) is obstetrical emergency  Fetal response related to hypoxia, umbilical cord occlusion  Assess for prolapsed cord o Fluctuations in the baseline FHR that are irregular in amplitude and frequency o Absent – not good (flat line) o Minimal – beat to beat fluctuation of 5 beats or less  Predicts well-oxygenated fetus with normal acid-base balance at the time o Marked – greater than 25 beats per minute  Periodic and episodic changes o Periodic changes accelerations/decelerations in FHR that are in relation to uterine contractions and persist over time o Episodic changes  acceleration and deceleration patterns NOT associated with contractions; accelerations most common  Fetal heart rate accelerations o Visually abrupt, transient increases (onset to peak <30 seconds) in the FHR above the baseline  if fetus is less than 32 weeks  10 x10  if fetus is greater than 32 weeks  15 x 15 o Predicative of adequate central fetal oxygenation and reflects absence of fetal academia o Identifies well-oxygenated fetus and requires no intervention  Fetal heart rate decelerations o Transitory decreases in the FHR baseline o Classified according to shape, timing and duration in relationship to contraction o Recurrent if occurs with at least 50% of UCs over a 20 minute period o Intermittent if occurs fewer than 50% of UCs over 20 minute period o Variable – cord compression o Early – head compression o Acceleration o Late o Cord o Head o Oxygenation o Placenta  Early decelerations o Visually apparent, usually symmetrical, with a gradual decrease and return of FHR associated with a UC o Lowest point of deceleration occurs at peak of contraction o Fetal head compression resulting in increased intracranial pressure, decreased transient cerebral blood flow, corresponding decreased in Po2 with stimulation of cerebral chemoreceptor o BENIGN AND NO INTERVENTION IS NEEDED  Variable decelerations o Visually apparent abrupt decrease in the FHR o MOST COMMON DECELERATIONS SEEN IN LABOR o Decrease in FHR is ≥ 15 bpm lasting ≥ 15 seconds and < 2 minutes in duration o Can be U, W, or V shaped  Late decelerations o Slowing of FHR after contraction has started with return of FHR to baseline well after contraction has ended o Sign of fetal intolerance to labor o Uteroplacental insufficiency causing inadequate fetal oxygenation, maternal hypotension, abruption placentae, uterine hyperstimulation with oxytocin o Place in side-lying position; D/C oxytocin, administer oxygen 8-10 L/min via mask, increase rate of fluid administration  Prolonged decelerations o Visually apparent abrupt decrease in FHR below baseline that is ≥ 15 bpm, lasting ≥ 2 minutes but < 10 minutes o Can be caused by interruption of uteroplacental perfusion, interruption of umbilical blood flow, vagal stimulation o Change maternal position; D/C oxytocin and consider Terbutaline to decrease UCs, administer oxygen 8-10 L/min via mask, increase rate of fluid administration  Uterine activity and contraction patterns o Frequency of contractions  counting number of contractions in a 10-minute period, from start of one contraction to start of next contraction in minutes o Duration of contractions  measure by counting from the beginning to end of one contraction and measured in seconds o Intensity strength of the contraction and measured by palpation or internally by IUPC in mm Hg; measured at the peak  mild, moderate, strong o Resting tone  pressure in the uterus between contractions; described as the number of mm Hg when uterus is not contracting when IUPC is being used and as “soft” if uterus feels relaxed by palpation o Normal  5 or fewer contractions in 10 minutes averaged over 30 minute window o Tachysystole  more than 5 contractions in 10 minutes over 30 minute window  Tachysystole/hyperstimulation o Excessive uterine activity o More than 5 contractions in 10 minutes, contractions lasting 2 minutes or longer, occurring within 1 minute of each other, increasing resting tone greater than 20-25 mm Hg, peak pressure greater than 80 mm Hg or Montevideo units greater than 400 o Most commonly caused by medications used for cervical ripening, induction, augmentation of labor Chapter 12 Postpartum Physiological Assessments and Nursing Care  Postpartum period – 6 weeks following delivery  Involution – 14 days; uterus to go back to pre-pregnant size “grapefruit” shape  bladder is full if uterus is deviated to left/right  Boggy uterus – first nursing intervention, massage it with the palm of hand in a circular motion until firm and reevaluate in 30 minutes o Risk for postpartum hemorrhage  Oxytocin gets uterus nice and firm; stimulates uterine smooth muscle to produce uterine contractions o Adverse reactions with IV use: coma, seizures, hypotension, water intoxication o Monitor for signs of water intoxication (drowsiness, headache, anuria) o Route and doses: 10 units in a liter of IV solution or 10 units IM  After delivery, uterus is at level of the umbilicus  Every day postpartum, will drop 1 cm  1 fingerbreadth o By day 14, the uterus has descended into the pelvis and is not palpable  Lochia: bloody discharge from the uterus that contains sloughed off necrotic tissue, undergoes changes that reflect the healing stages of the uterine placental site o Lochia rubra  Days 1-3  VERY RED, bloody with small clots, moderate to scant amount, increased flow on standing or breastfeeding, fleshy odor o Lochia serosa  Days 4-10  Pink or brown color, scant amount, increased flow during physical activity, fleshy odor light o Lochia alba  Days 10+  Yellow to white in color, scant amount, fleshy odor  Scant: blood only on tissue when wiped or 1- to 2-inch stain  Light: 4-inch or less stain  Moderate: less than 6-inch stain  Heavy: saturated pad  REEDA o Redness o Edema o Ecchymosis o Discharge o Approximation o applies to any lacerations o use ice packs within first 24 hours; ice causes local vasoconstriction and provides numbing effect o after 24 hours, warm use sitz bath  promotes circulation, healing, and comfort o use proper hand hygiene o lay patient on side; assess for lacerations and how it is healing; decreases pressure on the perineum  colostrum: clear, yellowish fluid, precedes milk production; high in protein, low in carbs, immunoglobulins G and A that provide protection for the newborn during the early weeks of life  primary engorgement: around day 3; ALL WOMEN BREASTFEEDING AND NON-BREASTFEEDING o become larger, firm, warm, and tender, and throbbing pain o relieve this pain by breastfeeding or applying ice packs  subsequent breast engorgement: feed every 2 -3 hours to empty the breasts and to prevent milk stasis  mastitis: usually occurs 3-4 weeks post birth; infection of the breast; usually unilateral; occurs if there is an opening in the nipple  can be caused by if baby is not latching on properly Cardiovascular System  average blood loss of 200-500 mL  pregnancy is naturally hypervolemic state  increased risk for orthostatic hypotension  assist to bathroom first 24 hours o instruct to rise slowly to a standing position  check CBC  hemoglobin decreases by 1.0 to 1.5 g/dL and hematocrit decreases 3%-4% per 500 mL blood loss  postpartum chills can be caused by blood loss  assess for venous thrombosis, postpartum chills  elevated temperature over 100.4F on two occasions that are 6 hours apart is a symptom of infection  do not cross legs, apply TED hose for woman who have history of blood clots Endocrine System : prolactin levels continue to decline throughout first 3 postpartum weeks; menses begin 7-9 weeks : prolactin levels increase in response to infant’s suckling; lactation suppresses menses, therefore return of menses depends on length and amount of breastfeeding  diaphoresis occurs in response to decreased estrogen levels o wear cotton nightwear; report signs of infection Discharge Teaching  report complications  excessive bleeding, foul smelling lochia, blurry vision, thoughts of harming self/infant, breasts tender, warm, reddened; key an eye on temperature: if below 100.4, nothing to be concerned about  lasting effects of epidural: should wear off within 8-12 hours  Weight loss: 12 pounds (including baby and placenta)  Lactating women: increase caloric intake by 500 calories per day and fluid intake of 2 liters per day  * * Contraception * *  sexual activity resumption: comfort of patient, encourage open communication with partner Chapter 16: only on newborn care  Abusive head trauma (shaken baby syndrome): infant is violently shaken; brain bounces back and forth against the skull, causing bruising, swelling, and bleeding within the brain tissue  mimic uterine environment  uterus was nice and tight  bathing: daily bathing is not necessary  cause skin irritation o mild soap that has neutral pH and is preservative free to decrease risk of skin irritation o encourage parents to clean off chin area/neck folds (milk often collects) o wipe front to back to decrease risk of cystitis  bulb syringe o cleaned with soapy water and rinsed after each use o mouth before nose  circumcision: do not need to know different types; know nursing care  doctor will place gauze with petroleum over penis o apply protective lubricant over circumcision site after each diaper change for the first week o baby needs to void within 24 hours of circumcision o teach parents not to remove gauze and let fall off on own  Colic: uncontrollable crying in healthy infants younger than 5 months of age o has to occur more than 3 hours a day, 3 times a week, for more than 3 weeks  cord care o cord clamp is removed after 24 hours of life o discourage use of alcohol o while umbilical cord is intact, do sponge bath; do not dip baby in tub of water o falls off and site heals within 10-14 days o diaper is placed below the cord to facilitate drying of the cord  infants should have at least 6 wet diapers a day after breastfeeding or bottle feeding has been established o any less can indicate dehydration o bowel movement: breastfed every other day is normal; formula  one to two stools per day more  feeding: every 2-4 hours  pediatrician office visit: within 3-4 days after discharge for well baby check; 2 week visit, then every month  prevention of dental decay: discourage use of baby going to sleep with bottle, clean infant’s gums with clean gauze after each feeding  nonnutritive sucking: kind of sucking babies use with pacifiers, is comforting to babies, if breastfeeding: do not let baby use until 1 month of age  diaper dermatitis is common  change diapers frequently (8 times a day)  soothing technique: select all that apply o feed if crying is related to hunger o reposition the newborn/infant to a more comfortable position when it is sleep time o swaddle the newborn/infant o hold the newborn/infant close to the body so she can feel the warmth of the parent’s body and hear the parent’s heartbeat o hold the newborn/infant and rock back and forth or walk around the house or dance with the infant in the parent’s arms o place the newborn/infant in a stroller and go for a walk  do rectal temperatures for newborn o insert no further than ½ inch into the rectum; use lubricant o anything higher than 100.4 needs to be brought to doctor’s attention  uncircumcised babies: do not force skin back  will retract around age 3 o can cause fibrosis Chapter 15 Physiological and Behavioral Components of the Neonate  Neonatal period: first 28 days of life  Biggest change occurs in respiratory system o Triggers changes in rest of the other systems  Mechanical stimuli – remove amniotic fluids from lungs o 30 cc amniotic fluids from vaginal delivery; more aggressive after c-sections  Chemical stimuli – drop in oxygen level after cord is clamped  Sensory stimuli – sensory changes newborn experiences immediately after birth o Changes in touch (biggest one), temperature  Surfactant – helps keep alveoli opened; developed closer to term  Amniocentesis – test for genetic issues early in pregnancy; closer to term  check for lung maturity  Signs of respiratory distress – cyanotic, retractions (extra effort to keep respirations going), flaring of nostrils o 30 – 60 breaths per minute is within normal range  ↓ Pulmonary resistance  ↑ pulmonary blood flow  ↑ systemic vascular resistance  Ductus venosus  turns into a ligament after 3 days  Foramen ovale – connects right and left atrium  Ductus arteriosus - connects pulmonary artery and aorta; can take couple of months to close  PDA – taking a bit longer for DA to close; will hear murmur  Neutral thermal environment – helps maintain body temperature in delivery room; use of radiant warmer  Brown fat – newborns rely this to maintain temperature; helps transfer heat; axillary, thoracic area; highly dense vascular fat tissue  Loss of heat from convection (heat loss through a draft; near open window/vent), radiation (indirect heat loss through a cold item; walls of isolet) , conduction (heat loss through direct contact; weighing baby through cold weighing scale), evaporation (delaying newborn bath; wait closer to 12 hours after delivery)  Cold stress occurs when  ↓ environmental temperature  ↓ body temperature  ↑ heart and respiratory rates  ↑ O2 consumption, depletion of glucose, and ↓ surfactant  respiratory distress o When glucose drops, surfactant levels drop  SGA (small for gestational age) babies usually born to hypertensive mothers  Skin to skin contact is more effective in maintaining baby’s temperature rather than radiant warmer  * * stocking/newborn cap as soon as hair is dry * *  Newborns will store large levels of glycogen in preparation for delivery  May be hypoglycemic 1 hour after delivery; should stabilize 2-3 hours after o Below 40 mg/dl is hypoglycemic o s/s – jittery, hypotonic o avoid sugar water to bring glucose levels up; encourage breast feeding at this time  bilirubin – broken down RBCs o indirect bilirubin (unconjugated)  fat-soluble; CANNOT be excreted through urine/stool o direct bilirubin (conjugated)  water-soluble; CAN be excreted through urine/stool  newborns have higher levels of RBCs, decreased RBC lifespan (60-90 days), immature liver  if bilirubin is slightly elevated, try to correct it through breast feeding  vitamin K shot IM help prevent babies from bleeding out; 25 G 5/8 needles (similar to insulin needles); 90 degrees in the thigh o synthesized in intestinal flora which is absent in neonates  GI system in newborns are slow; bowel sounds can be hypoactive  Characteristics of stools o Meconium – sticky, thick, black, odorless; may take up to 2 days for newborn to pass o Transitional – little bit of meconium and little bit of how stool will look like in the future; day 3-4 of life o Breastfeed – pasty stool, golden yellow, semi-formed stool o Formula feed – pale yellow, formed stool o DIARRHEA IS NEVER NORMAL  loose and green o * * BREASTFED NEONATES TEND TO HAVE MORE STOOLS PER DAY THAN FORMULA-FED NEONATES * *  glomerular filtration rate is initially low but doubles by 2 weeks of age  Delay/decrease urinary output  mothers received magnesium sulfate during labor (blocks neuromuscular transmissions and can cause urinary retention)  Will lose 5%-10% of birth weight within first week of life; will regain weight within 10 days  Active immunity – acquired type through vaccinations; body produces antibodies  Natural immunity– exposure to antigens after which the individual produces antibodies (flu)  Passive immunity – obtain from mothers via uterine  Lymphocytes function at immature level  Colostrum – IGA  Head to toe assessment in newborn –latex gloves, measuring tape, thermometer, weighing scale, stethoscope, warm environment, 14 French catheter o Mother’s history – Magnesium sulfate(baby will be sleepy) o How long did bag of water rupture – would like to deliver within 12 hours o Normal for newborns to have irregular breathing, apnea (under 15 seconds is normal), O2 sat can stay under 90% for first 10 minutes o Flexed posture, best time to do assessment is after feeding when baby is more calm o Assess skin for color, birthmarks, birth trauma  Swollen eyes for chemical pressure o Hypertonic, can be hypoglycemic o Head circumference : above ears and eyebrows (33 cm – 35.5 cm)  Microcephaly: head circumference is below the 10th percentile  Macrocephaly: head circumference is above 90th percentile o Chest circumference – across nipple line (2 cm – 3 cm lesser than head circumference  30.5 cm - 33 cm) o Length (19-21 inches; 45 cm – 53 cm) o Weight ( g is normal) o Thermoregulation – assessed in 15 minutes interval for first hour o Respirations may be irregular; can hear crackles due to amniotic fluids; 30-60 normal range o Blood pressure is usually never done in postpartum setting; usually in NICU o Milia will go away on its own o Lanugo – fine downy hair; usually seen mostly in premature babies o Mongolian spots – similar to a bruise; will go away within couple of years o Pilonidal dimple - right dimple above the sacrum; associated with sinus problems o Molding o Fontanels – anterior (diamond)/posterior(triangle); anterior takes longer to close  Will be sunken if dehydrated  Bulging may indicate intracranial bleeding o Caput succedaneum  Crosses suture lines  Takes couple of days to heal o Cephalohematoma  Does not cross suture lines; more severe  Vacuum applied to baby’s head during delivery  Takes couple of months to heal o Neck – lift up skin; check for webbing (Turner’s syndrome) o Eyes – VERY IMPORTANT to assess for Red Reflex (may indicate cataract); should respond to anything within 12 inches  PERRLA o Low set ears associated with Down’s Syndrome o Mouth – use gloved finger with pinky; check for sucking reflex, teeth o Epsin Pearls along gum lines (will go away with time) o PMI – 3rd and 4th ICS o Assess for peripheral pulses and should be present and equal; femoral pulses may be difficult to palpate (absent is associated with coarctation of aorta) o Pseudomenstruation – associated with hormonal imbalance; normal in first couple of days o Hypospadias – urethral opening on ventral surface of penis o Epispadias - Dorsal side o Hydrocele – fluid in testes o Syndactyly – webbed digits o Barlow – start with legs fanned out; assess for hip dysplasia  Click is not a good sign  head of femur is in acetebulum o Ortolani o Check for all reflexes in newborn o Dubowitz neurological examination WILL NOT BE ON EXAM o Ballard Maturational Score – done within first 12 hours of life  Know general trends for test purposes; 0 vs 5 o Need 2 out of the normal to be SGA/LGA o Periods of reactivity – first 15 to 30 minutes of life  Initial period of reactivity  Period of relative inactivity  Second period of reactivity o Brazelton’s Neonatal Behavioral Assessment Scale (BNBAS) DO NOT NEED TO KNOW o Go to NICU if PPV is used (Positive Pressure Ventilation) o APGAR scores are done at 1 min and 5 min of life; if less than 7 at 5 min, do at 5 min intervals o Give erythromycin ointment first then vitamin K; start at inner canthus  apply ¼ inch bead to lower eyelid of each eye o Bathing with neutral pH soap during first 4 hours is being phased out o Mother and baby’s vital signs should be done at the same time o Use barrier ointment for diaper changes o DO NOT NEED TO REMEMBER WHAT CALIFORNIA SCREENS FOR; TESTS WILL VARY FROM STATE TO STATE o Newborn hearing screening – will be done prior to discharge  Otoacoustic emissions (OAEs) – do when baby is asleep/lying still; look for movement of hair; flexible tube placed in ear; referral is made when there is no recorded response  Automated auditory brainstem response (ABR) – electrodes placed on baby’s mastoid, head, and neck; measuring electrical activity; referral is made when neonate does not have a positive response o Contraindications for circumcision - GU issues/premature babies  DO NOT NEED TO KNOW THREE DIFFERENT KINDS  KNOW PRE/POST OP • 1 hour before procedure, administer pain medication, make sure baby has not eaten right before circumcision to prevent aspiration • Teach parents not to remove petroleum gauze • Make sure babies void within 24 hours  Neonatal reflexes o Moro: present at birth; disappears by 6 months  Jar the crib or hold the baby in a semi-sitting position and let the head slightly drop back  Symmetrical abduction and extension of arms and legs, and legs flex up against trunk  The neonate makes a “C” shape with thumb and index finger  Slow response might occur with preterm/sleepy infants  Asymmetrical response may be related to temporary/permanent birth injury to clavicle, humerus, brachial plexus o Startle: present at birth; disappears by 4 months  Make a loud sound near the neonate  Same as Moro response  Slow response when sleeping; possible deafness/neuro deficit o Tonic neck: present between birth and 6 weeks; disappears by 4-6 months  With the neonate in a supine position, turn the head to the side so that the chin is over the shoulder  The neonate assumes a “fencing” position with arms and legs extended in the direction in which the head was turned  Response after 6 months may indicate cerebral palsy o Rooting  Present at birth; disappears between 3 and 6 months  Brush the side of a cheek near the corner of the mouth  Neonate turns head toward the direction of the stimulus and opens mouth  May not respond if recently fed; prematurity/neuro defects may cause weak/absent response o Sucking: present at birth; disappears at 10-12 months  Placed gloved finger or nipple of a bottle in the neonate’s mouth  Sucking motion occurs  May not respond if recently fed; prematurity/neuro defects may cause weak/absent response o Palmer grasp: present at birth; disappears at 3-4 months  Places finer in the palm of neonate’s hand  Neonate grasps fingers tightly; if neonate grasps the examiner’s fingers with both hands, neonate can be pulled to a sitting position  Absent/weak response indicates possible CNS defect; nerve/muscle injury o Plantar grasp: present at birth; disappears at 3-4 months  Place a thumb firmly against the ball of infant’s foot  Toes flex tightly down in a grasping motion  Weak/absent may indicate possible spinal cord injury o Babinski: present at birth; disappears at 1 year  Stroke the lateral surface of the sole in an upward motion  Hyperextension and fanning of toes  Absent/weak may indicate possible neuro defect o Stepping or dancing: present at birth; disappears at 3-4 weeks  Hold the neonate upright with feet touching a flat surface  Neonate steps up and down in place  diminished response may indicate hypotonia Chapter 7 • Gestational complications • Diabetes mellitus • Pregnancy hypertension • Placental abnormalities and hemorrhagic complications (as with exam 3, the final will not cover material after placental abruption) Chapter 7 High-Risk Antepartum Nursing Care Gestational diabetes  metabolic changes during pregnancy lower glucose tolerance  any degree of glucose intolerance with the onset or first recognition in pregnancy  insulin resistance during pregnancy stems from a variety of factors, including alterations in growth hormone and cortisol secretion (insulin antagonists), human placental lactogen secretion (which is produced by the placenta and affects fatty acids and glucose metabolism, promotes lipolysis, and decreases glucose uptake) and insulinase secretion (which is produced by the placenta and facilitates metabolism of insulin)  ESTROGEN AND PROGESTERONE ALSO CONTRIBUTE TO A DISRUPION OF THE GLUCOSE INSULIN BALANCE  Two main contributors to insulin resistance  increased maternal adiposity and insulin desensitizing hormones produced by the placenta  Routine screening 24-28 weeks of gestation with a nonfasting 1 hour 50 g oral glucose tolerance test  NEONATES NOT AT RISK FOR CONGENTIAL ANOMALIES  Insulin is the only safe medication to give during pregnancy  Test glucose 4 times a day; one fasting and three postprandial checks o Fasting less than 95 mg/dL and 12-135 mg/dL postprandial  Exercise has been shown to improve glycemic control Pregnancy Hypertension  Preelampsia is accompanied by proteinuria (measurement of 3.0 g or more protein in a 24-hour urine collection) after the 20th week o Delivery of placenta and fetus is the only cure o Oliguria is a sign of severe preeclampsia and kidney damage o Platelet count below 100,000 cells/mm3 is an indication of severe preeclampsia o Assessment finding: proteinuria is 1+ or greater o Antihypertensives are used to control elevated BP  Hydralazine, labetalol, methyldopa are first line drugs of choice o Magnesium sulfate during labor and delivery to prevent seizures o Antidote for magnesium sulfate is calcium gluconate or calcium chloride  Eclampsia is the occurrence of seizure activity in the presence of preeclampsia o Warning signs of potential eclampsia: severe persistent headaches, epigastric pain, n/v, hyperreflexia with clonus, restlessness o After seizure, administer oxygen at 10L/min via mask  Gestational hypertension > 140/90 for the first time after 20 weeks without proteinuria  Chronic hypertension >140/90 before conception or before the 20th week of gestation or hypertension first diagnosed after 20 weeks gestation that persists after 12 weeks postpartum  HELLP o Hemolysis is a result of red blood cell destruction as the cells travel through constricted vessels o Elevated liver enzymes result from decreased blood flow and damage to liver o low platelets result from platelets aggregating at the site of damaged vascular endothelium causing platelet consumption and thrombocytopenia ONLY DEFINITIVE TREATMENT IS DELIVERY Preterm labor  onset of labor before 37 weeks’ gestation  late preterm infant: born between 34-37 weeks gestation  very preterm infant: born before 32 weeks gestation  low birth weight: less than 2500 grams regardless of gestational age  very low birth weight: less than 1500 grams  extremely low birth weight: less than 1000 grams  contributing factors: uterine overdistention, decidual activation  risk factors: prior preterm birth, history of second trimester loss, history of incompetent cervix, multiple gestation, IVF pregnancy, infection, PROM, short pregnancy interval (less than 9 months), inadequate nutrition, low BMI, younger than 17 or older than 35 years old, pregnancy associated problems, lack of social support, smoking, alcohol  cervical change: cervix > 1 cm dilated or 80% effaced  check FHR  medical management o progesterone supplementation  useful to prevent preterm birth for women with a history of spontaneous preterm birth o tocolytics to suppress uterine contractions; may prolong for 2-7 days o IV hydration  increases vascular volume and help decrease contractions o Magnesium sulfate  Maternal effects  flushing, lethargy, headache, muscle weakness, diplopia, dry mouth, pulmonary edema, cardiac arrest o Calcium channel blockers  Nifedapine, Nicardipine  Maternal effects  flushing, headache, nausea, transient tachycardia, hypotension, o Beta-adrenergic agonists  Terbutaline  Maternal effects  cardiac or cardiopulmonary arrhythmias, pulmonary edema, myocardial ischemia, hypotension, tachycardia o Glucocorticoids  betamethasone  Accelerate fetal lung maturity  12 mg IM every 24 hours x 2 doses  adverse reactions: will raise blood sugar  Labs: urine and cervical cultures o WBC may be elevated due to corticosteroids (not indicative of infection) o Check fetal heart rate Preterm Premature Rupture of Membranes/Chorioamnionitis  Rupture of membranes with a premature gestation (before 37 weeks)  Premature rupture of membranes: rupture of the chorioamniotic membranes before the onset of labor but at term  Once the membranes rupture preterm, most women go into labor within a week  Latency  time from membrane rupture to delivery  Previable PROM  rupture of membranes before 23-24 weeks  Preterm PROM  24-32 weeks  Preterm PROM near term  31-36 weeks  Patients with PROM at 34-36 weeks should be managed as if they were at term with induction of labor and treatment for group B strept prophylaxis  The earlier the fetal gestation at ROM, the greater the risk for infection  Confirmed rupture of membranes with speculum exam and positive ferning exam  Delivery is recommended when preterm PROM occurs at or beyond 34 weeks  A single course of antenatal corticosteroids should be administered to women with preterm PROM before 32 weeks of gestation to reduce the risks of respiratory distress syndrome, perinatal mortality and other morbidities  Digital cervical examinations should be avoided in patients with PROM unless they are in active labor or imminent delivery is anticipated Incompetent cervix  Mechanical defect in the cervix that results in painless cervical dilation in second trimmest that can progress to ballooning of the membranes into the vagina and deliver of a premature fetus  can result in repeated second trimester abortions if undiagnosed  can be related to previous cervical trauma  treatment is cerclage  type of purse string suture placed cervical to reinforce a weak cervix  remove sutures if membranes rupture, infection occurs or labor develops  postop  administer tocolytics to suppress uterine activity Hyperemesis Gravidarum  severe vomiting that leads to dehydration, electrolyte, acid-base imbalance, starvation ketosis, weight loss  related to rapidly rising serum levels of pregnancy related hormones  first-line for n/v  vitamin B6 or vitamin B6 plus doxylamine  laboratory studies to monitor kidney/liver function, monitor I&O, daily weight  nonpharmalogical  ginger  minimize fluid intake with meals Placenta previa  placenta attaches to the lower uterine segment of the uterus, near or over the internal cervical os instead of in the body of fundus of the uterus  total  placenta complete covers the internal cervical os  partial  partially covers the internal cervical os  marginal  edge of the placenta is at the margin of the internal cervical os  low-lying  placenta is implanted in the lower uterine segment in close proximity to the internal cervical os  bright red blood, painless  bleeding usually occurs near the end of the second trimester or in the third trimester of pregnancy  emergency cesarean delivery is necessary when maternal/fetal status is compromised  ultrasound to determine placental location  VAGINAL EXAM IS CONTRAINDICATED  Monitor CBC, platelets, clotting studies Placental Abruption (abruptio placentae)  Premature separation of a normally implanted placenta  s/s  severe sudden onset of intense abdominal pain, uterine contractions, uterine tenderness, dark vaginal non- clotting bleeding may or may not be present, signs of hypovolemia, abnormal FHR  unstable/deteriorating maternal/fetal status, cesarean delivery is indicated  give corticosteroids to accelerate fetal lung maturity  DARK RED BLOOD WITH SEVERE ABDOMINAL PAIN  Grade 1 (mild) o Less than 1/6th of placenta separates prematurely o Total blood loss <500 mL o Normal FHR pattern  Grade 2 (moderate) o 1/6th to ½ of placenta separates prematurely o total blood loss mL o FHR shows signs of fetal compromise  Grade 3 (severe) o More than ½ of placenta separates prematurely o More than 1500 mL blood loss o FHR shows signs of fetal compromise and death can occur Placenta Accrete  Abnormality of implantation defined by degree of invasion into uterine wall of trophoblast of placenta o Typically diagnosed after delivery when placenta is retained o If placenta does not separate readily, rapid surgical intervention is needed  Placenta accreta: invasion of the trophoblast is beyond the normal boundary  Placenta increta: invasion of the trophoblast extends into uterine myometrium  Placenta percreta: invasion of the trophoblast extends into the uterine musculature and can adhere to other pelvic organs Chapter 10: High-Risk Labor and Birth * * FIRST THREE PERTAIN TO DYSTOCIA – abnormal labor that results from abnormalities of the power, passenger, or the passage  most common reason for primary cesarean sections * *  Five “P’s” o Powers: uterine contractions o Passenger: fetal aspect/position o Passage: pelvis o Position of the woman o Psychological response of the woman  Dysfunctional labor: abnormal UCs that prevent the normal progress of cervical dilation or descent of the fetus o Hypertonic uterine dysfunction  Uncoordinated uterine activity; contractions are frequent and painful but ineffective in promoting dilation and effacement  Risk factors: first time mothers  Concerned with maternal exhaustion  evaluate labor progress, hydrate (IV or PO fluids) to improve uterine perfusion and coordination of UCs, pain management (Demerol/morphine decreases labor contractions and allows the uterus to rest), assess FHR and UCs, PROMOTE REST o Hypotonic uterine dysfunction  Pressure of the UC is insufficient to promote cervical dilation and effacement  UCs become weaker and less effective during active phase  IUPC < 25 mm Hg  Common in multiparous women  augment (helping woman out when she’s already in labor) using oxytocin  amniotomy: break the water  cesarean birth  Stimulate uterine activity to achieve a normal labor pattern  precipitous labor: labor that lasts less than 3 hours from onset of labor to birth o risk factors: grand multiparity  more than 5 deliveries o provide comfort measures o more than 5 contractions in 10 minutes, uterine contractions lasting greater than 60 seconds o medical management  inadequate expulsive forces: occurs in the second stage of labor when the woman is not able to push or bear-down o risk factor: epidural anesthesia because woman may not feel the urge to push o medical management: augment with oxytocin, assists birth with vacuum or forceps, cesarean birth o can wait up to 4 hours to push after dilated to 10 cm  fetal dystocia may be caused by excessive fetal size, malpresentation, multifetal pregnancy or fetal anomalies o fetus can move through birth canal most effectively when head is flexed and is presenting anterior to woman’s pelvis (occiput anterior position) o risk factors: fetal macrosomia (greater than 4500 grams), abnormal fetal presentation (breech) o main concern with mom having excessive lacerations o FHR may be heard above umbilicus  breech  Cephalopelvic disproportion: size, shape or position of the fetal head prevents it from passing through the lateral aspect of the maternal pelvis or when the pelvis is of a size or shape that prevents the descent of fetus through the pelvis o most common type of pelvis: gynecoid  Pelvic dystocia o Inlet contraction occurs the widest part of the pelvis is small o midpelvis contraction related to ischial spines, convergent pelvic side walls, and a narrow sacrosciatic notch may result in arrest of descent of the vertex o outlet contraction: past 0 station  risk factors: petite moms, abnormal pelvic shape  maternal obesity o BMI greater than 30 o Risks at delivery: abnormal progress of labor, fetal macrosomia, shoulder dystocia, higher rates of operative vaginal birth and cesarean birth, epidural and spinal anesthesia may be problematic, increased postoperative complications  Labor interventions  Induce = initiate  Augment = strengthen  Induction of labor is the deliberate stimulation of UC’s before the onset of spontaneous labor to facilitate a vaginal delivery  Oxytocin induction: most common o ALWAYS INFUSED VIA A PUMP o Administer low-dose oxytocin starting at 0.5 mU/min and increase the dose by 1-2 mU/min every 30-60 min o Monitor strength, frequency and duration of UCs as an indicator of oxytocin efficacy every 30 minutes o Goal is to promote cervical dilation of about 1cm/hr once in active labor o Endogenous  peptide synthesized by the hypothalamus that is transported to the posterior lobe of the pituitary gland where it is released in the maternal circulation in response to vaginal and cervical stretching o Synthetic  identical to endogenous o Uterine response occurs in 3-5 minutes with half-life of 10 minutes o Contraindication: previous “classical” o Primary complication  tachysystole leading to category II or III FHR o Common side effects  tachysystole and subsequent FHR decelerations o Elective induction = 39 weeks gestational or more  Critical ripening is the process of physical softening and opening of the cervix in preparation for labor and birth o Favorable: Bishop score of 6 or more; easier to induce o Unfavorable: Bishop score of 6 or less; will take a lot longer o COOK balloon: 2 balloons; 60-80 cc of NaCl (more common) o FOLEY balloon: only 1 balloon in utero o Pharmacological : use of hormonal preparations in or near the cervix  Cervidil  10 mg controlled released vaginal insert with string for removal after 12 hours  Misoprostol  25 mcg inserted in the posterior vaginal fornix (will absorb)  Tachysystole  Excessive uterine activity and is the most concerning side effect of oxytocin  UCs cause an intermittent decrease in blood flow in the intervillous space where oxygen exchange occurs  Defined as (REQUIREMENT IS ONE OF THE THREE) o Five or more UCS in 10 minutes over 30-minute window o A series of single UCs lasting 2 minutes or longer o UCs occurring within 1 minute of each other  Nursing Actions for Category I o Maternal repositioning o IV fluid bolus of at least 500 mL of LR solution o Decrease rate of oxytocin infusion by at least half if no response to above measures o D/c oxytocin if the pattern persists  Nursing Actions for Category II/ III o d/c oxytocin o maternal reposition (left or right) o IV fluid bolus of at least 500 mL of LR solution o Consider oxygen at 10 L/min by nonbreather mask o Notify provider of actions taken and maternal fetal response o Consider terbutaline if no response to above measures (slows down the contractions; s/s may increase mom’s HR; fetal tachycardia as well)  Amniotomy o artificial rupture of membranes to induce/augment labor with an amnihook o Contraindications: maternal infection  HIV and active genital herpes  Labor augmentation o Stimulation of ineffective UCs after the onset of spontaneous labor to manage labor dystocia o Lower doses of oxytocin are required for augmentation of labor because cervical resistance is lower in women in labor who have some cervical effacement and dilation o Contraindications: previous classical uterine scar or prior transfundal uterine scar o MONITOR FHR AND UCs  Operative vaginal delivery o Use of only one method, either forceps or vacuum is recommended o Vacuum-assisted delivery:  vacuum cup on fetal head o maximum of three attempts for a period of 15 minutes  c-section  pop offs: cup detachment; warning sign that too much pressure or ineffective force; not to exceed 500-600 mm Hg  should not be on head for more than 15-20 min  fetus at 36 weeks gestation and head is engaged at least 0 at station  empty bladder to decrease risk of trauma o Forceps  Outlet: used when fetal head is visible on the perineum and skull has reached the pelvic floor, and rotation is less than 45 degrees  Low: used when the skull is at +2 station or lower in the maternal pelvis and not on the pelvic floor and rotation is greater than 45 degrees  Used only on fetus that is at least 36 weeks gestation  Vaginal birth after cesarean (VBAC) o Shorter recovery time, less blood loss, fewer infections/thromboembolic problems  Post-term pregnancy o Prolonged pregnancy after 42 weeks o As placenta deteriorates, there are increased areas of infarction and deposition of calcium and fibrin within its tissue o Fetus increases in size 1 ounce per day after term o Babies are more prone to pass meconium in utero  meconium aspiration syndrome  Obstetrical emergencies o Shoulder dystocia refers to difficulty encountered during delivery of the shoulders after the birth of the head  turtle sign  retraction of the fetal head against the maternal perineum after delivery of head • five minute window  fetal hypoxemia and acidosis  Maneuvers • McRoberts: sharply flexing the thigh onto the maternal abdomen to