NR 327 final maternal exam (The Hours, Discomfort, CS C-Section) | 100% verified | Download To Score A+

Postpartum Hemorrhage (PPH) • From delivery up to 6wks postpartum • SVD Spontaneous vaginal delivery: greater than 500ml (considered PPH) o Estimated blood loss o Quantitative blood loss (weig hing everything) • CS C-Section: greater than 1000ml Two main reasons for PPH • Full bladder • Retained placenta What you will assess when you walk into a patient’s room for PPH 1. Assess Fundus -should always be right at umbilicus If it feels like your cheek: boggy; (massage it) Don’t stop unless it firms up 2. Call for help 3. Call Dr. 4. Meds 5. VS and O2 stat 6. Weigh under pads (add this amount of blood loss to what she lost at delivery 7. Change under pads 8. Empty bladder (foley) 9. Start 2nd IV; may need to give patient blood o Once you start to feel the fundus firm up you can stop massaging o Only thing that can misplace the fundus is a full bladder • The uterus has to contract to stop bleeding Meds (all usually standing orders) • Pitocin: usually IV sometimes IM every patient after they deliver will get this drug (immediately) o If there is a fetus in the uterus; has to be on pump and is piggybacked o If not given wide open • Methergine: given IM; if patient has HTN CANNOT be given this drug • Hemabate: given IM; CANNOT give if patient has asthma (can cause explosive diarrhea) • Cytotec: rectally; given 800-1000 mcg *Methergine and Hemabate: work within 2-3 minutes If all of this doesn’t work then back to the OR • Should be dark brown • Firm w/ Bright red blood- laceration • After delivery check every 15 minutes x 4 • Every 30 minutes x 4 Oxygen • 8-10L • Non-rebreather mask • Never nasal cannula Menstrual cycle • 28, 32, or 36-day cycle • 36-day cycle, go back 14 days, she will ovulate on day 22 (can get pregnant on this day) • Have sex on the 17th and the 27th • Ovulation: go back 14 days from very last day of cycle • Sperm lives 3-5 days (200,000,000-800,000,000 per ejaculation) • Ova can only be penetrated for the first 24 hrs • If you want to get pregnant start intercourse 5 days before or 5 days after ovulation • Should have sex every 6 hrs during that time period • Progesterone levels decrease signals hypothalamus to anterior pituitary gland to stimulate the follicle stimulating hormone and luteinizing hormone; which increase estrogen and progesterone (~36 hours) • Corpus luteum: hole where egg left. increases/produces progesterone; you need increase in progesterone to carry a pregnancy • Progesterone levels have to go up in order to hold a pregnancy • Placenta takes over hormone level regulation after 6 - 7 weeks * Naegele’s Rule (estimated due date) • 1st day of last period (minus) 3 months (plus) 7 days -3 months + 7 days 30 days has September, April, June & November 1st Trimester • Conception – 13 6/7 weeks (13 weeks & 6 days) 2nd trimester • 14 weeks -26 6/7 weeks (26 weeks & 6 days) 3rd Trimester • 27 weeks-40 6/7 weeks (40 weeks & 6 days) Term: 37 weeks or greater 20 weeks gestation when the organs are done being formed G- # of pregnancies T- # of term deliveries P- # of preterm deliveries (20- 36 6/7 weeks) A- # of abortions (less than 20 weeks) L- # of living children Fetus cannot survive before 20 weeks Antepartum o fetus in uterus Prenatal Visit (1st things that need to be checked) • Vital signs • Estimated Date of Confinement (Estimated Due Date) • Medical hx • CBC • Hep B • HIV • VDRL- STI • Blood type- Rh factor • Rubella titters; drawn at prenatal visit (if nonimmune she needs Rubella titters w/in 72hrs after delivery) • TB skin test • Pap smear • Weight • UA- urinalysis • Fetal heart tones (can be heard at 6 weeks) If mother is Rh-(negative), she needs Rhogam (26-28wks), she needs that because negative antigens may try to fight off pregnancy • If mom is negative and baby blood positive; mom needs Rhogam within 72hrs after delivery to protect next pregnancy *Only run babies cord blood to find out blood type if moms blood type is negative Next visits • VS • Weight • UA • Fetal heart tones • Measure abdomen Office Visits- doctor for normal pregnancies • 1 week (conception) - 28 6/7 weeks: o Mom will visit Dr. every 4 weeks • 29 weeks- 36 6/7 weeks: o Mom will visit Dr. every 2 weeks • 37 weeks and greater: o Mom will visit Dr. every week Changes in Body Systems: Reproductive • Uterus o F • Cervix o Chadwick signs: bluesish/purplish o Goodell’s sign: cervix softening o Mucus plug: keeps the uterus safe from any germs getting into uterus; can cause some spotting as separating from cervix wall o Hrg’s sign: softening of lower segment of the uterus • Vagina and vulva o Increased vascularity o Vaginal mucosa thickens o Vaginal rugae becomes prominent o Increased roiduction • Breast o Grow larger o Areola gets darker o Colostrum- thick yellow discharge; body getting ready for breast home • Heart • Blood o Blood volume increase o Plasma volume increases: o Cardiac output increase • Relaxin: o body releases during pregnancy; smooth muscle relaxer; keeps BP normal - Has clotting factors in it • Oxygen needs increase o RR will go up about 20% • Appetite o increase after 1st trimester • Mouth o gums may bleed, can get gingivitis, ptyalism • Esophagus o acid reflux; heart burn • Large and small intestines o everything slows down; constipation (moms need to increase fluid intake and fiber) • Liver and gallbladder o gall stones • Bladder o 1st and 3rd trimester: frequent urination o 2nd trimester: slows down • Kidneys and ears o formed at the same time: around 16 weeks; if ear is deformed they will look further at the kidney function of the baby • Increase in nutrients in urine o can increase the risk of UTI in mom • Hair and nails o grow rapid and thicker • Ear o cornea becomes thicker o diminished hearing; increased wax • Autoimmune conditions o decrease during pregnancy o after pregnancy condition becomes worst • Pituitary gland o Prolactin o Oxytocin: after 36 weeks oxytocin levels go up progesterone starts to go down *Normal for pregnant women to have a trace of glucose in urine o Moms become insulin resistant to make more glucose for baby Conformation of pregnancy: • Presumptive (subjective) o Amenorrhea o N/V o Fatigue o Urinary frequency o Breast changes o Vaginal & cervical color changes o Quickening (fetal movement)- flutter of gas • Probable (objective) o Abdominal enlargement o Goodell’s sign softening of the lower part of the cervix-soft like your cheek. o Hagar’s sign (softening of the lower uterine segment) o Ballottement- Dr. does a dig vag exam & can push up on cervix. Fetus will go up & come back down o Braxton Hicks pre-contractions ATI o Palpation of fetal outline- Enlarged abdomen o Positive pregnancy test o Chadwick sign-- bluish purple color of the cervix • Positive o Fetal heart sounds o Fetal movement detected by provider o Visualization of the embryo or fetus First Trimester • Uncertainty Second Trimester • Physical evidence of pregnancy • Fetus as the primary • Narcissism and introversion • Body image • Changes in sexuality; changes in sex drive Third Trimester • Vulnerability • Increasing dependence • Preparation for birth o Nesting behavior (happen later on; just before labor) Maternal Role Transition • Three stages of attachment o Accepts pregnancy o Baby becomes real; she loves it o Increasing love and vulnerability; mom will do anything she has to do Couvade: where the father goes through the same symptoms as the mom • Things to know: o Mom needs 600mcg/day of folic acid o Mom: needs extra calcium o hCG: levels go up when pregnant o Moms should gain 25-35lbs: normal weight gain o Should drink 6-8liters/day o DO NOT ovulate during pregnancy o Never lie a pregnant women supine/flat on back; always needs to have a pillow wedged behind her back Week 2 Notes Effects of the birth process: Maternal Response Variability- (goes up & down) when we look at a fetal monitor strip. We’re always going to look for variability It’s the babies hear beat from beat to beat Absent- 0 BPM Minimal 0-5 BPM Moderate 5-25 BPM—Always want Marked 25 BPM Characteristics of contractions: • Coordinated o Frequency ▪ Beginning of one uterine contraction to the beginning of the next ▪ Range in minutes; how often (ex. 1.5- 2 minutes) ▪ Don’t want a frequeny to be any more than 2 min’s lasting about 60-90 sec’s o Duration ▪ Beginning of a uterine contraction to the end of the same contraction when it comes back to baseline ▪ Range in seconds; how long is last (ex. 60-90 sec’s) • Involuntary • Intermittent- relaxation of the contraction (we must have this relaxation period, because if not. That means the uterus is not contracting & it’s where the fetus is getting most nutrients & oxygen. During that resting tone) Contraction Cycle o Increment ▪ Period of increasing strength o Acme ▪ Period during which the contraction is most intense o Decrement ▪ Period of decreasing intensity as the uterus relaxes *In-between contractions is where baby gets it oxygen and blood supply that is being sent through the umbilical cord. Want contractions to be about 2 mins apart lasting 60- 90 secs Skinniest to fattest.. shortest to longest.. contraction Fetal Heart Tones • Baseline o Where the baby’s heart rate hits the most • Accelerations • Decelerations o Variable o Early- head compression- close to delivery- they mirror the contractions o Late Variability: BPM (beats per minute)- V Shape or W shape • 0-5: absent -minimal • 5-25: moderate (what we want) • 25: marked • 3 Ss (reasons for absent to moderate variability will vary) o Sleeping o Sedated- mom may have been given fentanyl or stadol or any narcotic o Sick (neonates temp will drop) If baby is not any of these- notify HCP Fetal Heart strip • Baby heart tone always at top • Mom contractions at the bottom Variable (type of deceleration) Cord Compression -Sudden drop with a quick return to baseline -Reposition mom w/in 30 seconds. V or W appearance Early (starts right w/contraction) Head Compression (usually est. 8cm) -mirrors mom contraction -Sterile vaginal exam (find out dilation) - reposition mom Acceleration (above baseline)-lack of baseline Oxygenated -Baby is saying he is ok Late (declaration and contraction don’t match) Placental insufficiency -Baby suffering -Not getting enough oxygen & nutrients Characteristics of late- beginning, middle, & end are off LATE deceleration (what to do) 1. Reposition mom 2. Shut off Pitocin (causes contractions) 3. Increase IV fluids 4. o2 via nonrebreather mask (8-10/L) 5. Sterile vaginal exam- 6. Call provider *Anything goes below baseline; deceleration *Want to see lots & lots of acceleration (when baby moves HR should go up) *NEVER nasal cannula in L&D Accelerated Increase in fetal heart rate • 15 beats by 15 beats above baseline (32+weeks) • 10 beats by 10 beats above baseline (under 32 weeks) Fetus well oxygenated Uterine body • Upper two thirds of the uterus contracts actively to push fetus down • Lower one third remains less active Cervical changes • Effacement (thinning and shortening: cervix) • Dilation (opening) • Effacement and dilation occur concurrently during labor bur at different rates *the only soft tissue that can hold a baby up from delivering is a full bladder Placental circulation • Most placenta exchange occurs during the interval b/w contractions Components of the Birth Process Five major factors that interact • Powers o Contractions o Maternal pushing • Passage o Pelvis • Passenger o Baby o Placenta o Membranes Baby can’t come out if it’s extended or hyperextended • Psyche (how mom feels about pushing) o Anxiety o Culture and expectation o Birth as an experience o Support o Impact of technology • Position o Fetal head position o Want baby to be in an anterior position (occipital) OA o OT- occipital transverse Presentation • Fetal part that first enters the pelvis • Cephalic o Vertex, military, brow, face • Breech o Frank, full, footling • Shoulder • Cephalic Presentation • The cephalic presentation is more favorable than others for the following reasons: • • The fetal head is the largest single fetal part, although the breech (buttocks), with the legs and feet flexed on the abdomen, is collectively larger than the head. After the head is born, the smaller parts follow easily as the extremities unfold. • • During labor, the fetal head can gradually change shape, molding to adapt to the size and shape of the maternal pelvis. • • The fetal head is smooth, round, and hard, making it a more effective part to dilate the cervix, which is also round. • Cephalic presentation has the following four variations (Fig. 12.8): • • Vertex—This is the most common type of cephalic presentation, in which the fetal head is fully flexed. It is called a vertex or occiput presentation and is the most favorable for normal progress of labor because the smallest suboccipitobregmatic diameter is presenting. • • Military—The head is in a neutral position, neither flexed nor extended. The longer occipitofrontal diameter is presenting. • • Brow—The fetal head is partly extended. The brow presentation is unstable, usually converting to a vertex presentation if the head flexes or to a face presentation if it extends. The longest supraoccipitomental diameter is presenting. C-section • • Face—The head is extended, and the fetal occiput is near the fetal spine. The submentobregmatic diameter is presenting. C-section • Breech Presentation • A breech presentation occurs when the fetal buttocks or legs enter the pelvis first, which happens in approximately 3% to 4% of births. Breech presentation is more common in preterm births, hydrocephaly (enlargement of the head with fluid), multiple gestations, abnormalities of the maternal uterus and pelvis, and with placenta previa (placenta in the lower uterus) (Cunningham et al., 2014). • Breech presentations are associated with the following disadvantages: • • The buttocks are not smooth and firm like the head and are less effective at dilating the cervix. • • The fetal head is the last part to be born. By the time the fetal head is deep in the pelvis, the umbilical cord is outside the mother’s body and is subject to compression between the fetal head and the maternal pelvis. • • Because the umbilical cord can be compressed after the fetal chest is born, the head should be delivered quickly to allow the infant to breathe. This does not permit gradual molding of the fetal head as it passes through the pelvis. • The breech presentation has the following three variations, depending on the relationship of the legs to the body (Fig. 12.9): • • Frank breech—This is the most common variation, occurring when the fetal legs are extended across the abdomen toward the shoulders. • • Complete breech—This is a reversal of the usual cephalic presentation. The head, knees, and hips are flexed, but the buttocks are presenting. Full breach- tucked in & flexed but upside down • • Footling breech—This occurs when one or both feet are presenting. • Shoulder Presentation • The shoulder presentation is a transverse lie and accounts for only 0.3% of births (Cunningham et al., 2014). It occurs more often with preterm birth, high parity, prematurely ruptured membranes, hydramnios, and placenta previa. A cesarean birth is necessary when the fetus is viable (one of a gestational age that might survive). ● Fetal lie Orientation of the long axis of the fetus to the long axis of the woman (baby’s spinal cord to mom’s spinal cord) In more than 99% of pregnancies, the lie is longitudinal and parallel to the long axis of the woman ● There are 3 lies: vertex, oblique, and transverse. Transverse lie is immediate c-section-horizontal Normal Labor: Premonitory Signs • Braxton Hicks contractions • Lightening • Increased vaginal mucus secretion • Cervical changes o Softening o Possible dilation o Bloody show- associated w/ cervical dilation & effacement expected finding Brownish vaginal discharge True Labor • Contractions w/cervical change • Increased contractions • Increased discomfort • Cervical change: progressive effacement and dilation most important False labor • Contractions inconsistent • Discomfort is more annoying than truly painful • Cervix does not change • Cervix has not shortened • Membranes still intact Labor Mechanism- cardinal movements • Descent o Movement of fetus through the birth canal • Engagement- fetal positioning o Fetal presenting part reaches 0 station o Baby’s head has to be at ischial spine to be considered 0 station o Station- where is babies head according to mom’s pelvis • Flexion • Internal rotation • Extension • External rotation • Expulsion Stages of Labor • 1st stage: 3 phases o Latent phase: 0-3 cm (putting on make-up, doing hair) o Active phase: 4-7 cm (starting to ask for pain meds) o Transition phase: 8-10 cm (no epidural; wants to be left alone, epidural: feeling ok) • 2nd stage o 10 cm: delivery of baby • 3rd stage o Delivery of placenta (usually happens 20-30mins after) • 4th stage o First 1-4hrs post delivery The cervix usually hangs down 2cm from the uterus this is 0% effaced. When we can no longer feel the cervix(paper thin) this is 100%. Don’t push until completely dilated and 100% effaced. During labor dilation and effacement occur at different rate Ex. 90% and 5cm A preceptor will have a new nurse close her eyes and put fingers into a plactic mold. The contraction starts at the top of the uterus or fundus- only the top 2/3 of the uterus is active. The lower1/3 is passive. Push ball through the sock to show how the cervix opens. ● Blood flow to the placenta decreases during a contraction. The muscle fibers of the uterus constrict around the maternal spiral arteries, which supply the placenta. There is a relative increase in the woman’s blood volume. This temporary change increases her blood pressure slightly and slows her pulse rate. • Vital signs are best assessed during the interval between contractions. ● Supine hypotension (aortocaval depression) may occur during labor if the woman lies on her back. The woman should be encouraged to rest in positions other than supine to promote blood return to her heart. Supine hypotensive syndrome is characterized by severe supine symptoms and hypotension in late pregnancy, which compel the unconstrained subject to change position. Rarely, it may manifest even from the fifth month of pregnancy or postpartum, as well as in the pelvic tilt or sitting positions. Inferior vena cava compression, influenced primarily by the size of the uterus and exact maternal and fetal position, is the major determinant in its development Aortocaval compression is thought to be the cause of supine hypotensive syndrome. Supine hypotensive syndrome is characterized by pallor, tachycardia, sweating, nausea, hypotension and dizziness, and occurs when a pregnant woman lies on her back and resolves when she is turned on her side Maternal resp system ● Increase depth and rate of respirations (deeper and faster) ● Hyperventilation It may occur with rapid and deep breathing. Respiratory alkalosis occurs as she exhales too much carbon dioxide. She may feel tingling of her hands and feet, numbness, and dizziness. ● The nurse should help her slow her breathing and breathe into a paper bag or her cupped hands to restore normal blood levels of carbon dioxide and relieve these symptoms. Umbilical Cord • 2 arteries 1 vein Characteristic s First Stage Second Stage Third Stage Fourth Stage Work accomplish ed Effacement and dilation of cervix Expulsion of fetus Separation of placenta Physical recovery and bonding with newborn Forces Uterine contractions Uterine contractions and voluntary bearing-down efforts Uterine contraction s Uterine contraction to control bleeding from placental site Cervical dilation Latent phase∗ : 0-3cm Active phase∗ : 4-7 cm Transition phase: 8- 10 cm 10cm (complete dilation) Not applicable Not applicable Uterine contraction s Latent phase: Initially mild and infrequent; progress to moderate strength, every 5min with a regular pattern; duration increases to 30- 40sec by end of latent phase Active phase: Increase in frequency, duration, and intensity until every 2-3 min, 40- 60 sec, and moderate to Strong, every 2- 3min, lasting 40-60sec; may be slightly less intense than during transition phase of first stage; may pause briefly as second stage begins Firmly contracted Firmly contracted Characteristic s First Stage Second Stage Third Stage Fourth Stage strong intensity Transition phase: Strong, every 1½-2 min, 60-90 sec Discomfort† Often begins with a low backache and sensations similar to those of menstrual cramps; back discomfort gradually sweeps to lower abdomen in a girdle-like fashion; discomfort intensifies as labor progresses Urge to push or bear down with contractions, which becomes stronger as fetus descends; distention of vagina and vulva may cause a stretching or splitting sensation Little discomfort; sometimes slight cramp is felt as placenta is passed Discomfort varies; some women have afterpains, more common in multigravidas or those who have had a large baby; as anesthesia wears off, perineal discomfort may become noticeable Maternal behaviors† Sociable, excited, and somewhat anxious during early labor; becomes more inwardly focused as labor intensifies; may lose control during transition Intense concentration on pushing with contractions; often oblivious to surroundings and appears to doze between contractions Excited and relieved after baby’s birth; usually very tired; often cries Tired, but may find it difficult to rest because of excitement; eager to become acquainted with her newborn Nursing Care During Labor and Birth Issues for New Nurses • Pain associated with birth • Inexperience and negative experiences • Unpredictability • Intimacy Cyclic pain: only hurts with contraction May have experienced negative things Labor follws it’s own course # of labor patients change from one minute to minute Admission to Birth Facility: • Number & duration of previous labors • Distance from the hospital • Available transportation • Childcare needs • Risk status FIRST PRIORITY IS FETAL WELL BEING!! Nursing Responsibility During Admission • Make family feel welcome • Determine family expectations • Convey confidence • Assign a primary nurse • Use touch for comfort • Respect cultural values Ultrasound transducer for FHT- goes over the fetal back Toco transducer for contractions- goes over the fundus Focus assessment • Fetal heart rate o FHR 110-160 o Regular rhythm: presence of acceleration; absence of deceleration • Maternal vital signs o Identify signs of HTN and infection o Impending birth o Grunting sounds- tell her to pant- breathe o Bearing down- we don’t want her to push because the doctor is not there o Urgency to push Fern- test that shows if mom has truly ruptured • Admission Procedure o Notify the birth attendant ▪ Give report ▪ Obtain orders o Consent forms- vaginal, c-section, & epidural o Lab tests- CBC & T&S o IV access- for Pitocin after delivery Nursing Responsibility After Admission: Fetal Assessment • FHR • Amniotic fluid: spontaneous rupture of membranes (SROM) or artificial rupture of membranes (AROM)-looks like a crochet hook Maternal Assessment • Vital signs • Contractions • Labor progress • Intake & Output • Response to labor Support person’s response- check on them & see if they’re pale or freezing (give blanket) Nursing Care During the Late Intrapartum Period: • Responsibilities during birth o Preparation of a delivery table with sterile gowns, gloves, drapes, solutions, and instruments o Perineal cleansing preparation o Supporting the woman and partner with final pushing efforts o Initial care and assessment of the newborn o Administration of medications (usually oxytocin) to contract the uterus and to control blood loss • Responsibilities after birth o Care of the infant ▪ Maintaining cardiopulmonary function (Apgar) ▪ Support thermoregulation ▪ Identify infant o Care of the mother ▪ Observe for hemorrhage ▪ Promote comfort o Promote early family attachment *Patients water breaks spontaneously: very first thing to do is check fetal heart rate Then we’ll look at the time, color & consistency. We do not want to meconium *Once patients’ water is broken: temp taken q2hr Postpartum Physiologic Adaptations Postpartum Assessment: Initial assessments • Vital signs • Skin color • Location and firmness of fundus • Amount and color of lochia • Perineum o Edema o Episiotomy o Lacerations o Hematoma • Presence, degree, and location of pain • Intravenous (IV) infusions o Type of fluid o Rate of administration o Type and amount of added medications o Patency of IV line o Redness, pain, edema of the site • Urinary Output o Time and amount o Presence of a catheter o Color and character of urine • Status of abdominal incision and dressing • Level of feeling and ability to move if regional anesthesia was administered *Pudendal block: numbing of vaginal area; only numbs one area; doesn’t last look Moms at risk for PPH • one that has a macrosomia baby; weighs 8.8lbs or more • very quick delivery; precipitous labor *Breastfeeding delays return of ovulation and menstruation Focused Assessments After Vaginal Birth • Every 15mins first hr. • Every 30mins for the sec hr. • Every 4 hrs. for the 24hrs • Every 8-12 hrs. thereafter Know BUBBLE HE • Breast • Uterus • Bowel • Bladder • Lochia • Episiotomy • Homan’s Sign • Emotions Fundus • Usually at umbilicus day of birth • Should go down 1 fingerbreadth a day Involution • going from a pregnant state (uterus) back down to non-pregnant state; uterus should be size of women’s fist (3 finger breaths below the umbilicus) *If mom wants epidural: gets bolus of LR first (1000ml) *Mom needs to void at least 150ml for it to be counted as a void; count (measure) the first three voids *If moms not voiding, will need bladder scan • Straight Cath if: ▪ She is unable to void ▪ The amount voided is less than 150 mL, and the bladder can be palpated ▪ The fundus is elevated or displaced from the midline Changes in color • Lochia rubra: first 3 days (ruby red like period blood) • Lochia serosa: days 4 -10 (pinkish color) • Lochia alba: after day 10 (clearish, creamy) *Bright red blood means laceration somewhere-obtain H&H Episiotomy • where doc cuts (makes incision) to allow more room for baby to deliver Episiotomy Healing evaluation (Perineum) • R-redness • E-edema • E-ecchymosis • D-discharge, drainage • A-approximation * lacerations in skin; from tears Care in immediate postpartum: providing comfort measure Ice packs • Used to soothe lacerations or episiotomy o can only be on perineum: 15-20 mins; off for 1 full hr. o cold pack can be left on: up to 4 hrs. o put on right after delivery Sitz bath • Cool water for 1st 24hrs • Warm water after 24hrs Perineal care Topical medications Sitting measures Analgesics Discomfort ● Assessment ● Analysis ● Planning ● Interventions Provide choices to enhance client control Determine whether anxiety is contributing to discomfort Pain relief is NOT a realistic goal Goal is for positive birth experience Comfort measures ● Lighting ● Temperature ● Cleanliness ● Mouth care ● Bladder ● Positioning *Every pt gets ibuprofen q6hrs around the clock; unless allergic *Encourage to drink 2500ml per day Examine for signs/symptoms of thrombophlebitis • Palpate pedal pulses • Assess Homan sign • Assess for edema • Assess deep tendon reflexes Preventing Thrombophlebitis • Early ambulation • Frequent trips to the bathroom Nursing Care Following Cesarean Birth Assessment • Pain relief • Respirations • Abdomen • I&O Interventions: The First 24 hours • Pain relief o Offer pain medication if not in PCA o Assess respiratory status if epidural • Overcoming effects of immobility • Provide Comfort Interventions: After 24 hours • Resume normal activities • Assist mother with infant feeding • Prevent abdominal distention • Teaching for discharge Postpartum Psychosocial Adaptations Process of Maternal Adaptation: Puerperal Phases Taking-in phase • Focused on own need for fluid, food, and sleep • Allows other to make decisions • Mother is integrating her birth experience into reality Taking-hold phase • Mother becomes more independent • Assumes responsibility for own self-care • Begins to shift attention to infant • Welcomes information about newborn behavior Letting-go phase • Couple relinquishes role as a childless couple • Gives up idealized expectations of birth experience • Relinquishes infant of their fantasy; accepts real infant Postpartum blues • 50-85% mothers in 1st 2 weeks postpartum • Symptoms: Irritability, anxiety, fluctuating mood, & increased emotional reactivity • Mild & spontaneous remits, not considered psychiatric disorder • Mom irritable, anxious • Can care for baby, self • She functions well, just kind of down and out • Should go away around 6 wks. Postpartum depression • Hits about 13% of mothers in first yr. • Symptoms Excessive guilt. Anxious, depressed mood, anhedonia, insomnia/hypersomnia, suicidal ideation, & fatigue • Doesn’t know the last time she fed baby, she ate, or slept • Moderate to severe symptoms, prolonged course Postpartum psychosis • 0.01% mothers in 1st 3 months postpartum • Symptoms: Mixed or rapid cycling, agitation, delusions, hallucinations, disorganized behavior, cognitive impairment, & low insight. • Severe, considered psychiatric emergency often necessitates hospitalization • Diseases that went away while pregnant: schizo, bipolar Diseases come back w/a vengeance Augmentation- Pitocin Action- rupture the membranes Normal Newborn: Processes of Adaptation Neonate • 0-28 days Neonates when sick: • Low temp- (priority) if you can’t get the babies temp up, check the glucose because it’s probably low. Babies with low temp- feed them w/ breast milk or formula. 30 after he eats, you’ll do another BS • Low glucose • Increase 02 consumption • Bilirubin same If baby temp low, can’t get it up check glucose, its prob low, resp increase, HR not infected When mom is going through later stage 1 & 2: also painful for baby When baby is in utero left lung: hypertensive Ductus arteriosa: must close after delivery; if not will hear a heart murmur Neurologic Adaptation: Thermoregulation • Methods of heat loss o Evaporation o Conduction o Convection ▪ Don’t put baby near fan or any type of air condition o radiation When baby comes out of womb, DRY • so, they don’t lose heat from evaporation-thermoregulation • to stimulate babies to cry • to expand the lungs Sites of brown fat • around heart and kidneys IntraUGR and premature babies • don’t have brown fat We do not want our babies to use up their brown fat. Place a hat, socks, & blanket for the 1st 24hrs. We want to keep them nice & warm. Heat is transferred through the blood Hematologic Adaptation • Newborn o 60-70% for hematocrit Vitamin K is given- because GI tract is sterile • To help with blood clotting • Prevent intracranial hemorrhage • Given in the vastus lateralis GI system: Stomach- digestive tract is sterile- need bacteria & need early feeding • Stomach will start to stretch as baby grows o Capacity expands within first few days of life • First feeding:15-20ml Q3-4hrs (bottle feeding) • Rapid peristalsis • Gastrocolic reflux o colic can be caused by overfeeding GI system: Intestines • Bowel sounds are present within the first hour. • The digestive tract is sterile until feeding begins • Infants are more prone to rapid water loss with diarrhea. GI system: Digestive Enzymes • Breast milk more easily digested • Saliva production limited until third month of life GI system: Stools • Meconium is the first stool excreted o Greenish black with a thick, sticky, tarlike consistency o First stool is usually passed within 12 hours o Consists of particles from amniotic fluid • Transitional stool is the second type • Breastfed infant- poop more often than bottle fed o Stools are seedy and mustard colored. o Stools are more frequent than with formula. o Stools have a sweet-sour smell. • Formula-fed infant o Stools are pale yellow to light brown. o Stools are firmer in consistency-never should have a formed stool o Stools have the characteristic odor of stools. o Stools smell like formula RBCs- live in newborn 100 days, premie- 80 dyas • Iron • Bilirubin • other stuff Conjugation of Bilirubin • Unconjugated bilirubin: albumin picks up unconjugated and takes to liver (enzyme in liver conjugates it) • Then, transported to GI and baby poops it out; early feeds are important • If baby isn’t fed enough an enzyme in the GI track will unconjugate and put back into blood stream Physiologic jaundice becomes visible when the serum bilirubin reaches 5 to 7 mg/dL, which occurs when the baby is approximately 3 days old. This finding is within normal limits for the newborn. Pathologic jaundice occurs during the first 24 hours of life. Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of erythrocytes, and must be investigated. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids. Hepatic System: Hyperbilirubinemia- crosses the BBB can cause brain damage • Physiologic jaundice o Caused by transient hyperbilirubinemia o Never present during first 24 hours of life o Jaundice is visible when bilirubin level is greater than 5 mg/dL o Rate of rise and fall of bilirubin level is important o EARLY frequent FEEDS so we can introduce good bacteria. o Breastfeed 1st then bottle feed for phototherapy Babies with jaundice need frequent feeds • start to feed them within an hour How to get rid of bilirubin: • Frequent feeds • Breastfeed: feed q2-3hrs • Formula babies: fed q3-4 hours • phototherapy Urinary system • If ear deformed or hole outside ear o kidney looked at Immune System • Less effective at fighting off infection • Immunoglobulin G (IgG) o Crosses placenta and provides temporary immunity • Immunoglobulin M (IgM) o First immunoglobulin produced when exposed to infection • Immunoglobulin A (IgA) o Receive some from colostrum and breast milk o Must be produced by the infant Psychosocial Adaptation • Periods of reactivity- o First period of reactivity o Period of sleep o Second period of reactivity • Behavioral states o Quiet sleep state o Active sleep state o Drowsy state o Quiet alert state o Active alert state o Crying state Assessment of the Normal Newborn Early Focused Assessment • Do VS before you assess the baby o while their sleep • HR and RR (40-60): listen full minute • First things we check: Fontanels Early Focused Assessment: Assessment of Cardiorespiratory Status • Airway o Respiratory rate o Breath sounds o Signs of respiratory distress o Choanal atresia • Color • Heart sounds • Brachial and femoral pulses • Blood pressure • Capillary refill Early Focused Assessment: Thermoregulation • Take temperature soon after birth. • Set warmer controls to regulate the amount of heat produced. • Reassess every 30 minutes until stable. Early Focused Assessment: Hepatic System • Blood glucose o At-risk newborns o Signs o Screening • Bilirubin o At-risk newborns o Jaundice o Phototherapy-babies eyes are covered Assessment of Gestational Age: Ballard Score • Scoring • Gestational age and infant size o Small for gestational age o Large for gestational age o Appropriate for gestational age • Monitor for complications common to age and size of infant. Care of the Normal Newborn • Vitamin K – to prevent intracranial problems o Administer within 1 hour of birth o Give intramuscularly- we do not aspirate o One dose prevents bleeding problems • Eye treatment- given to every newborn o Erythromycin ophthalmic ointment (given to all babies)- given once in the eyes- start from cornea to the outside corner of the eye o Administer within 1 hour of birth Thermoregulation • Assessment o Temperature shortly after birth o Assess every 30 min. until stable o More frequent if abnormal temperature Blood Glucose • Assessment o Risk factors ▪ Really big babies ▪ Diabetic mother: GD, type 1 or 2 • Interventions o Maintain safe glucose levels o Repeating glucose tests (after 30 mins of eating) levels below 40 o Provide other care Bilirubin • Assessment o Assess for jaundice • Interventions o Identify infants at risk for hyperbilirubinemia o Explain importance of adequate feedings o Explain significance of skin color changes o Continue to monitor during home or clinic visits Ongoing Assessments and Care • Assess every 8 hours • Provide skin care • Bathing once while in the hospital • Cord care • Cleansing the diaper area • Feedings • Positioning- babies sleep on their backs • Protecting the infant- ID bands & baby by the window Bathing • Cord care o make sure it is dry; but do nothing to it • Cleansing the diaper area o use baby wipe w/q diaper change • Feedings • Positioning • Protecting the infant Cord • Takes 7-10 days to fall off • Do not immerse baby in water until it falls off Circumcision • Babies given Tylenol • Consideration: o Less likely to develop HPV o Women who have regular intercourse with an uncircumcised man ▪ Higher risk of developing cervical cancer • Take 4x4 gauze with vaseline and put directly over penis • Yellowy crusty discharge will appear around head of penis (Gomco & Mogen only) ▪ normal, leave alone ▪ 1 week- 10 days to heal NEVER wipe (it’s the healing process) 3 methods of circumcision: • Mogen clamp- must put Vaseline over penis- put diaper loose • Plastibell device- no vaseline • Gomco clamp- must put Vaseline over penis- put diaper loose Bathing- DO not submerge baby in water until • have to wait 7-10 before bathing for circumcision healed • if baby wasn’t circumcised, will have to wait till the cord falls off NEVER USE LOTION (can clog baby pores) OR TALCUM POWDER ON BABIES If mom is Hep B positive: • Cannot refuse baby getting Hep B vaccine • Baby will get Hep B vacine and Hep B immune globulin o Give globulin within 12hrs of birth Hepatitis B • Included with routine childhood vaccinations Newborn Screening Tests • Hearing o any loss?; doing for early treatment • Phenylketonuria (PKU) o checks for 60+ diseases; done after 24hrs of life; must have PKU drawn on NB before d/c. Make sure the physician information is correct because they’re the only person that will be notified • Hypothyroidism • Galactosemia • Hemoglobinopathies • Congenital adrenal hyperplasia Discharge and Newborn Follow-Up Care: • Early discharge o Appropriate for gestational age o Vital signs within normal limits o Feeding successfully o Making transition from fetal to neonatal life o Passed urine and stool o Mother able to care for infant • Follow-up care o Professional follow-up care recommended with early discharge o Can be provided in a number of ways Nutritional Needs of Newborn: • Calories o Breastfed 85 to 100 kcal/kg daily o Formula fed 100 to 110 kcal/kg daily o May lose less than 10% of birth weight Breast Milk: Nutrients • Protein • Carbohydrates • Fat • Vitamins • Minerals • Enzymes (can have 1cp of caffeine (chocolate has caffeine in it) Colostrum • Thick yellow (rich in everything baby needs); o First form of milk produced from the breast o Colostrum until milks comes in Maternal Diet • Increase calories 500/day Premature Babies • Need high caloric diet Prolactin • Produces milk Oxytocin • Stimulate the release of milk through the nipple Start back feeding where you left off • Alternate breast Engorgement- do not skip feedings to prevent • Happens 1 time before milk comes in; gets hard as a rock (baby may slip off) Have the mom hand express her milk (massage the breast to make softer) • Pump milk to relieve pain so it can soften up so baby can latch on to it • Cold compress • If mom is NOT breastfeeding, tell mom to put cabbage leaves on breast, then their bra on, & it will dry up & they will have to keep changing cabbage leaves. Breast milk • can be frozen up to 6 months Newborn Assessment • Axillary temp • HR taken for 1 full minute. VS when sleeping • Blood pressure & VS will be taken on all 4 extremities on a newborn if heart murmur is heard. • Are there bleeding coming form the cord? 2 arteries & 1 veins at delivery, but once the cord starts to dry up, you won’t be able to see those anymore because it will turn into scab. Any discharge Apgar Score∗ Points Assessment 0 1 2 Heart rate Absent Below 100 beats per minute (bpm) 100 bpm or higher Respiratory effort No spontaneous respirations Slow respirations or weak cry Below 40 Spontaneous respirations with strong, lusty cry. Vigorously cry. RR 40-60 Muscle tone Limp Minimal flexion of extremities; sluggish movement Flexed body posture; spontaneous and vigorous movement Points Assessment 0 1 2 Reflex response No response to suction or gentle slap on soles Minimal response (grimace) to suction or gentle slap on soles Responds promptly to suction or gentle slap to sole with cry or active movement Color Pallor or cyanosis Whole body blue Bluish hands and feet only (acrocyanosis) Pink (light skinned) or absence of cyanosis (dark skinned); pink mucous membranes 0 1 2 3 4 5 6 7 8 9 10 Infant needs resuscitation.† Gently stimulate by rubbing infant’s back while administering oxygen. Determine whether mother received narcotics, which may have depressed infant’s respirations. Provide no action other than support of infant’s spontaneous efforts and continued observation. * The Apgar score is a method for rapid evaluation of the infant’s cardiorespiratory adaptation after birth. The nurse scores the infant at 1 minute and 5 minutes in each of five areas. The assessments are arranged from most important (heart rate) to least important (color). The infant is assigned a score of 0 to 2 in each of the five areas, and the scores are totaled. Resuscitation should not be delayed until the 1-minute score is obtained. However, general guidelines for the infant’s care are based on three ranges of 1-minute scores: 0 to 2, 3 to 6, 7 to 10. † Note: Neonatal resuscitation measures, if needed, do not await 1-minute Apgar scoring but are instituted at once. Skin-to-skin contact with a parent also maintains the infant’s temperature and promotes bonding between the infant and parent. Delaying the first bath for several hours allows the temperature to stabilize. Avoid positioning yourself between the infant and the radiant heat source in the warmer. The infant should be wrapped in dry, warm blankets when not in the warmer or making skin-to-skin contact. Remove wet linens, replacing them with warm and dry ones. A stockinette cap further reduces heat loss if it is placed on the baby’s dry head. A cap is not worn while the infant is in the radiant warmer because the cap slows transfer of heat to the baby. Assessing for Anomalies Head • Fontanels- anterior fontanelle is diamond shape, posterior triangular shape There are little lines that come from these fontanels that are called sutures. The sutures are what allows the baby’s head to squish down & mold to come through the birth canal. • Caput succedaneum- is what’s delivered 1st. It’s swelling and maybe some clear fluid build up between the skull and the scalp. It’s from being in the birth canal too long. It will go away in 1-2 days. Caput cross those sutures lines (cone head) • Cephalohematoma- caused by trauma, it does not cross those suture lines. It’s in one area of the scalp. Buildup of blood & takes 3-4 weeks for that blood to be absorbed into the baby’s peripheral system. Low set ears- sign of down syndrome Neural Defect Spina Bifida o Sacral Dimple- spread those cheeks o If you see a hole, notify HCP Observe for hip click Check for anal patency Assessing Neurologic System Reflexes Sensory assessment Other neurologic signs • Jitteriness (tremors) signs of hypoglycemia • Seizures- baby straightening out extremities w/ tiny shakes (rigid) • Irritability Facial bruising is probably from a quick delivery • Baby may have a lot of petechia or facial bruising • If the baby was covered up to his neck, you would think the baby was blue • 1st action- uncover him • Then see if his mucous membranes are pink. Oral Cavity Take your gloved finger & make sure his pallet is closed Gonna see if he can suck on his finger. Check his neck & abdomen & make sure it’s not distended & that it’s soft Baby should have bowel sounds 3 hours after birth Umbilical hernia- baby will have to have surgery Babies that are stretched out are more premature Flexed babies are termed Feet • Creases in feet are termed babies • Smooth feet are premature Legs • Creases on back of legs should be equal • They should go straight across. 1 leg creases should be equal w/ the other leg creases. • If not equal, there may be a little hip displacement Little girls • The more term the baby is, the labia majora is going to cover everything • The more preterm, the clitoris is going to be more prominent than anything else. Little boys Look at genitals • Check scrotum to make sure both testes are down in the scrotum • They’ll feel like tiny peas. You have to check each side. • Hypospadias- if you notice part of his skin is gone & he did not have a circumcision. This baby was born this way. He doesn’t have all of the foreskin. We do not do a circumcision on them. They need to see a urologist. Because maybe the meatus is not at the tip of the penis. It might be at the side. May need some of the foreskin to do reconstructive surgery. So do not do circumcisions. Newborn Pearl- White spot at end of penis. Nothing to worry about. Floppy Tone • Baby is not flexed • Pick up baby arm & falls back down • Full term baby, you could pull up arm & he will pull it back -Jittery- sign of low BS- heel stick on outer part of foot. -Rigid- could be sign of seizure -Absence of startle reflex • Take babies wrist. Pull him up by his arms & his body off the bed & let go & he should startle & if he doesn’t then we’re worried. • This floppy tone is not normal Reflex Moro or startle reflex • Take babies wrist. Pull him up by his arms & his body off the bed & let go & he should startle & if he doesn’t then we’re worried. Palmer grass reflex- • putting your finger in the baby’s palm. He should grab your finger The plantar reflex- • Put your finger at the base of the baby’s toes & it should flex, it should grab your finger. The Babinski reflexes • is elicited by stroking the lateral sole of the infant’s foot from the heel forward & across the ball of the foot. This causes the toes to flare outward & the big toe to dorsiflex. Sucking reflex • You put your finger in the baby’s mouth & he starts sucking on your finger Integumentary System Color Lanugo-hair on the baby (peach fuzz) Milia-little white dots on the baby’s nose. Leave them alone. Don’t touch them Marks from delivery- if the baby is forceps or vacuum baby. Check for trauma Breast, hair & nails- just document. Expected findings Mongolian spots • dark area on buttocks they do get lighter with age. (not a bruise) Stork bites • eyelids. appears when baby gets really upset. They get real dark. They will fade w/ time. Port wine stain- • these babies that are born w/ this does not go away. Permanent birth mark on face. Face is asymmetrical EXAM 1 Need to know the stages of labor Apgar 5p’s Prenatal visits Nageals rule Frequency, labor & contractions Involution Why do we feed babies with hyperbillirubin Make priority when babies come into the hospital Remember different stations Fundal height, fundal measurements Signs of pregnancy Different ways to prevent heat loss How do we pt’s truly in labor GTPAL How much folate acid How to care for circumcision PPH BUBBLE HE Be familiar with generic & Psychosis, blues, etc. Cephalohematoma & caput Labs during prenatal visit Prenatal Care and Expected Findings in Pregnancy Prenatal care is a vital component of a healthy pregnancy. Adequate, routine care will increase the likelihood of a safe birth for mother and child. To ensure adequate care, the pregnant woman must select from a variety of prenatal healthcare providers to manage her pregnancy. The individualized needs of the woman, her family, and the unborn baby will determine the best source of healthcare during the pregnancy. After selecting a prenatal care provider, prenatal care visits will begin as soon as possible, if not prior to conception. During the initial visits, a health history and physical will be conducted, gestational age of the fetus will be determined, and laboratory and diagnostic tests will be evaluated. Below is a table illustrating many of these common laboratory values explored during prenatal visits. Laboratory and Diagnostic Tests and Pregnancy Findings Preterm Labor: ( 37 weeks) Lower backache, increased vaginal discharge, bloody show, leaking amniotic fluid, contractions, pelvic pressure Term Labor: ( 37 weeks) Gross rupture of membranes, progressive cervical change, contractions continuing to get closer and stronger regardless of maternal activity Report to provider • Decreased fetal movement • Pelvic pressure • Bleeding • Contractions that are regular and coming closer together (more than 6 noted in an hour) • Rupture of membranes Obstetrical Procedures Stages of Labor Stage One Phase Dilation Contractions Duration Latent 0–3 cm Frequency 5–10 minutes 30–45 seconds Active 4–7 cm Frequency 2–5 minutes 40–60 seconds Transition 8–10 cm Frequency 1.5–3 minutes 45–90 seconds Stage Two Phase Dilation Contractions Duration Expulsion (birth of baby) 10 cm Stage Three Phase Contractions Frequency 2–3 minutes Duration 60–90 seconds Delivery of Placenta Strong 5 minutes to 20 minutes Stage Four Phase Vaginal Cesarean Section Recovery 2 hours minimum 4 hours minimum • General • Adjunct IV sedation Adjunct IV sedation is often applied via a nurse anesthetist or anesthesia provider to complement the patient's relaxation of the prior provided anesthesia. • Epidural • Spinal Spinal anesthesia is frequently utilized for scheduled C/S. Antepartum Fetal Assessment Indications for Fetal Diagnostic Testing • To detect congenital anomalies • To evaluate the condition of the fetus • The woman has the right to refuse antepartum • Nurses must respect the woman’s personal decisions Ultrasound- positive pregnancy signs (1st diagnostic test) • It is directed through tissues of the abdomen or vagina to provide two-dimensional images • High-frequency sound waves are aimed at body tissues • The amount of energy returned as an echo depends on the properties of the tissues. • It is deflected by tissues in their path & returned as echoes. • Three-dimensional ultrasound images have greater detail o They provide more accurate identification of the extent and size of abnormalities • Real-time scanning o Shows movement as it happens o Allows the observer to see fetal heart motion, fetal breathing activity, and fetal body movement o Can distinguish between moving tissues of the fetus and maternal tissues *By the 5th week of gestation, the U.S. tech can see the baby’s heartbeat Ultrasound: Emotional Response • Some parents are excited • Some parents report anxiety • Many couples expect to know the gender of the fetus • Others do not want to know the gender • Sonographers often give a still image *Mom may exhibit postpartum blues if wrong gender was given & was prepared to have the other gender. Postpartum blues • Hits mom in first couple weeks • Mom irritable, anxious • Can care for baby, self • She functions well, just kind of down and out Should go away around 6 wks ATI EXPECTED FINDINGS of postpartum blues: • Feelings of sadness • Lack of appetite • Sleep pattern disturbances • Feeling of inadequacies • Crying easily for no apparent reason • Restlessness, insomnia, fatigue • Headache • Anxiety, anger, sadness Nursing Care for postpartum blues • monitor interactions between client & baby. Encourage bonding activities • Monitor for mood & effect • Reinforce that feeling down in the postpartum period is expected & self-limiting. Encourage client to notify HCP if feeling persist • Reinforce the importance of compliance w/ any prescribed medications regimen • Contact a community resource to schedule a follow up visit after discharge for clients who are high risk for postpartum depression • Ask client if she has thoughts of self-harm, suicide, or harming the infant. Provide for the safety of the infant as the priority care. Levels of Obstetric Ultrasound • Standard (basic) o General survey ▪ Example: anatomy scan • Specialized (comprehensive) o Specific ▪ Example: looking for abnormalities to diagnose what the screening test said • Limited o Address a specific question ▪ Example: fetal presentation (scanned by symphysis pubis to see if there’s a head down there) usually a breech if you don’t feel the head Ultrasound: First Trimester • Purpose o Confirm pregnancy (checking how many baby’s); o Verify the location of the pregnancy (checking to see where embryo implanted) o Detect multifetal gestations o Determine gestational age o Identify markers o Determine the locations of the uterus, cervix, and placenta for procedures such as chorionic villus sampling (CVS) • Procedure o Transvaginal for 1st trimester An invasive procedure in which a probe is inserted vaginally to allow for more accurate evaluation Ultrasound: Second and Third Trimester • Purpose o Confirm viability searching for FHT (ex. Mom maybe 29wks hasn’t felt her baby in days) worse o Evaluate fetal anatomy o Determine gestational age- crown to rump- is 1 twin growing faster than the other. Is 1 getting all of the nourishment o Assess serial fetal growth o Compare growth of fetuses in multifetal gestations o Evaluate four of five markers in a biophysical profile o Locate the placenta when placenta previa is suspected o Determine fetal presentation o Guide needle for amniocentesis or percutaneous umbilical cord sampling (PUBS) • Specialized ultrasound for abnormal findings o Hydramnios (excessive amniotic fluid) o Oligohydramnios (insufficient amniotic fluid) o Abnormal levels of maternal serum alpha-fetoprotein (MSAFP) or other tests in multiple-marker testing o Neural tube defects (NTDs) (failure of the bony encasement of spinal cord or skull to close) • Procedure o Transabdominal for 2nd & 3rd trimester Doppler Ultrasound Blood Flow Assessment • Purpose o Identify abnormalities in the diastolic flow o Enhances detail about the degree of resistance to normal blood flow in the growth- restricted fetus Alpha-Fetoprotein Screening MSAFP (Maternal Serum Alpha-Fetoprotein) blood draw • Alpha-fetoprotein (AFP) is the predominant protein in fetal plasma. • AFP crosses placental membranes into the maternal circulation • AFP can be measured in maternal serum (MSAFP) and amniotic fluid (AFAFP) *All we do is draw some blood from mom Purpose • Abnormal concentrations of AFP are associated with serious fetal anomalies • Low levels of MSAFP suggest chromosomal abnormalities such as trisomy 21 ATI: down syndrome • Elevated MSAFP levels are associated with open NTDs (neural tube defects) and body wall defects. ATI: open abdominal defect o Anencephaly o Spina bifida *every single pregnant woman gets a MSAFP drawn Procedure • Initial screening (every pregnant woman gets this) is offered at 16 and 18 weeks of gestation- (can have an abortion up to 20 weeks gestation) • RISK FACTORS: Gestational age, maternal weight, multifetal pregnancy, race, maternal diabetes, and ethnicity must be considered when evaluating the levels • The mother is informed that MSAFP is a screening test rather than a diagnostic test Multiple-Marker Screening (everybody gets it)-consent does not need to be obtained • MSAFP (1st test for screening if AFP is abnormal) o Elevated levels used to detect open body wall defect o Low levels linked to chromosome defects • Triple-screen (done if MSAFP is abnormal) o Unconjugated estriol and hCG have been added to routine MSAFP evaluation. • Quad-screen (if additional screening is needed if triple screen still show abnormalities) o A fourth marker, the placental hormone inhibin A (protein produced by the ovaries & placenta), improves the accuracy of the triple-screen. o If all these screening come back abnormal then we can do a specialized ultrasound to diagnose what the MSAFP was alluding to Chorionic Villus Sampling (only if you have a history if chromosomal abnormalities in family) • Diagnostic test (2nd) o Checks for fetal chromosomal, metabolic, or DNA abnormalities • Procedure o Use Ultrasound to guide, go in with needle right into placenta & withdraw it, as needle comes out collects sample. IFMOM IS RH NEGATIVE: Rhogam given if mom is negative &/or indication of blood mixing when after needle was withdrawn & blood may have been mixed o Usually performed between 10 and 12 weeks sooner than MSAFP-advantage: done earlier to allow parents to see what they want to do o Transcervical or the transabdominal approach- mom supine o Genetic counseling o Counseling about the procedure • Advantages o Results are known earlier than early amniocentesis o CVS offers prenatal diagnosis to women who find later procedures unacceptable • Risks o Rate of pregnancy loss after CVS is similar to that of amniocentesis o More than two attempts or bleeding during the week before the procedure increases the risk for fetal loss. o Reports of limb reduction defects Amniocentesis- (3rd diagnostic test) which will be done to confirm chromosome abnormalities. HCP wants to avoid hitting any other products of conception (no fetus, no cord, no placenta) • The aspiration using a long needle to draw amniotic fluid from the amniotic sac or examination. • Also done by a guided ultrasound • Purpose: Mid-trimester to determine MSAFP o Examine fetal cells present in amniotic fluid to identify chromosome abnormalities o Evaluate the fetal condition when the woman is sensitized to Rh-positive blood o Diagnose intrauterine infections o Investigate amniotic fluid AFP when the multiple-marker test done on maternal serum is not normal • Purpose: Third Trimester-Because MSAFP is not done until 16-18 wks o Tests to determine fetal lung maturity ▪ Lecithin/sphingomyelin (L/S)ratio-takes 20mls to analyze the fluid o Test for fetal hemolytic disease ▪ Determine fetal bilirubin concentration (Rh sensitized) • Monitored after amniocentesis procedure o Baby: 1 hour after- make sure fetus is good Monitor fetal HR o Mom: 1 hour after-because we wanna make sure mom doesn’t contract • Disadvantage o Must wait until 16 weeks after MSAFP is drawn o Gives little time for decisions about additional tests or whether to terminate pregnancy before 20wks ATI: Indications Potential diagnoses from amniocentesis • Previous birth w/ a chromosomal anomaly • A parent who is a carrier of a chromosomal anomaly • Family history of neural tube defects • Prenatal diagnosis of a genetic disorder or congenital anomaly of the fetus • AFP level for fetal abnormalities • Lung maturity assessment • Fetal hemolytic disease • Meconium in the amniotic fluid Percutaneous umbilical blood sampling- very dangerous test • Aspiration of fetal blood from the umbilical cord for prenatal diagnosis or therapy • Procedure o High-resolution ultrasound is used to locate the fetus, placenta, and umbilical cord and guide needle insertion o Needle is inserted into the umbilical cord near the site at which the cord meets the placenta o Rho(D) immune globulin (RhoGAM) is given to Rh-negative women because of guided ultrasound Fetal Nonstress test-looking for acceleration (NST) eval for fetal well being (what does the HR do with fetal movement.) • Nursing action ATI & instructor: • Make sure mom voids • Have her nice & comfy sitting up in bed place in high or semi-fowler’s position or left lateral position or seat client in a reclining chair next to the bed. • Place toco & transducers. Toco (monitor uterine contractions) doppler transducer (monitor FHR) • Give mom a button-each time mom feels baby moving, she will push button • Have something to drink sitting next to her • Put her on a fetal monitor • Checking fetal wellbeing; not causing baby any stress-just placing mom on monitor • Observes the fetal heart rate response to fetal movement • MUST be on the monitor for minimum of 40 minutes-looking fetal well-being o Looking for minimum 2 accelerations a 15*15 in a 20min block (ATI: 20-30min’s to complete) • To be considered an acceleration ▪ 32 weeks or greater: (2-15x15 accelerarions) in a 20 min’s period ▪ under 32 weeks: (2x10x10) acceleration • 2-15x15: called reactive and reassuring ▪ min go up 15 beats from baseline and last a min 15 seconds ▪ ex. Baby hr 130 then goes up 15 & last for 15 sec’s that’s good to be considered an acceleration • Test is good for 1 week • Nonreactive and non-reassuring: Fetal movement but no increase in HR • Not routine must have Dr. order • Procedure o Women should void, baseline BS should be taken o Women may be seated in a reclining chair or have her head elevated at least 45° *Babies heart rate should go up with fetal movement Get mom something to eat & something cold (something that’s going to wake the baby up just in case he’s sleep). If still no movement, move on to vibroacoustic stimulation on if mom is not contracting o (ATI you might be asked to drink orange juice for stimulation) Advantage of NST • Noninvasive • Painless • Believed to be w/o risk to mother or fetus • Easily administered • Results immediately available Disadvantage of NST • High false-positive rate (ATI: fetal movement response blunted by sleep cycles of the fetus, fetal immaturity, maternal medications, and nicotine use disorder) • Additional testing related to a nonreactive NST Vibroacoustic Stimulation Test (used for if we have nonreactive & non-reassuring) find where the fetus head is located & zap • Uses sound stimulation to elicit fetal movement- o Stimulate fetal movement that results in a reactive NST o Confirm nonreactive NST • 3 seconds, 3 minutes in a row, only 3 times Risks • Appears to be safe for the fetus in terms of hearing at 33 wks Call physician if all has failed Contraction Stress test - we’re causing stress to the babies by inducing contractions. We’re looking for decelerations. Want to see if baby can handle stress during vaginal labor. If baby has decelerations, baby can’t handle stress of labor. • Negative CST: reassuring • Positive CST: non-reassuring-if baby has decelerations • Making mom contract o we don’t want baby to have HR accelerations o we need 3 contractions in 10 minutes. Once we get mom to get 3 contractions in 10 minutes, we’re looking for decelerations. If there is no decelerations, it is NEGATIVE (means no) which is reassuring for CST *we get our mothers to contract by either nipple stimulation or Pitocin • Start Pitocin to have mom contract (Pitocin is time consuming) • Test is good for 1 week • If mom doesn’t have decelerations. It is negative for decelerations & it’s reassuring. • If mom has decelerations. It is positive for decelerations (late) & non reassuring because the baby will not be able to handle that pregnancy & will need a C-section when it’s time for mom to deliver baby • Stimulate baby & feed mom if there’s no acceleration (stimulate ATI: nipple stimulation in order to receive uterine contraction) Procedure • EFM-transducer applied to abdomen to monitor FHR patterns during labor & birth • Oxytocin/nipple stimulation • 3 contractions in 10 minutes Interpretation • Negative (reassuring) • Positive (non-reassuring) Biophysical Profile (BPP)- (good for 1wk) if the HCP doesn’t order CST, he will order BPP • Done by US • Assesses 5 different parameters of fetal status o FHR Reactive=2 nonreactive=0 o Fetal breathing movements At least 1 episode 30sec’s=2, Absent or 30sec’s duration=0 o Gross fetal movements At least 3 body or limb extensions w/ return to flexion=2, 3 limb=0 o Fetal muscle tone At least 1 episode of slow extension w/ return to flexion=2 Slow extension & flexion. Lack of flexion, or absent movement=0 o Amniotic