Nur-254 Childbearing / maternity

▪ Categorizing signs/symptoms of pregnancy • Presumptive: subjective (Patient says they experience), least reliable – not definitive signs of pregnancy, COULD be caused by something other than pregnancy, QUICKENING o Breast changes, amenorrhea, nausea and vomiting, urinary frequency, fatigue, quickening • Probable: objective, (practitioner can see) “more than likely” pregnant o Positive pregnancy test, (false), (cervical softening), Chadwick’s sign (increased cervical vascularization), (softening of lower uterine segment), enlarging uterus, ballottement (pushing of the uterus – do you feel a fetus move and come back?) • Positive: visualization, hearing fetus HR, feel the fetus, VISUAL ULTRA SOUND; practitioner feels kicking ▪ What is considered normal or expected? • Effects on body systems o Breasts: increase in size, fullness, heaviness, tingling, darkening of the areola, lactation can occur as early as 18 weeks o GI: delayed GI motility, constipation, heartburn, nausea and vomiting, hemorrhoids, increased vascularity of gums, increased saliva o GU: increased urination; NORMAL o Cardio: pulse increase, increased blood volume, increased cardiac output o Respiratory: increased O2 consumption, nasal and sinus congestion, increased vascularity o Musculoskeletal: center of gravity shifts, unsteady gait o Sensory: sciatica, restless legs, muscle cramps, syncope, tension headache o Integumentary: melasma mask (hyperpigmentation), striae gravidarum (stretch marks), vascular malformation (spider veins) • Vital signs o HR: slight increase o BP: should not change dramatically from baseline o RR: SOB is common, difficulty breathing is NOT o O2: remains stable o Temp: can slightly increase ▫ Page 187 Calculating GTPAL • Number of pregnancies, regardless of the outcome – including current • Delivery at 37-42 weeks • Delivery between 20 weeks and 36 weeks 6 days • Before 20 weeks, including miscarriage • Number of children that are still living ▪ REMEMBER! With multiples, they count as one pregnancy! ▫ Page 178 Calculating Naegele’s Rule/EDD (expected date of delivery) – two ways to calculate ▪ First day of last menstrual period • Add 7 days + 9 months OR • ▪ EXAMPLE: • LMP: 1/12/22 • + 7 days = 1/19/22 • + 9 months = 10/19/22 ▫ Analyzing labs ▪ Blood work • CBC ▪ Live vaccines are contraindicated (page 193) o No booster while pregnant, can offer postpartum o Toxoplasma- Don’t not clean cat litter, eat raw meat or touch dirt What in yellow was on this exam o Goodell’s sign o H&H will increase ( normal Hemoglobin for PG 11) o Monitor for anemia • Coombs screening: Rh factor and antibodies o Rh negative mom, Rh positive baby o ( rh+ fetal blood crosses into maternal blood stimulating maternal antibodies) ▪ Rhogam UP to 72hr after birth or any instance when blood may become mixed • Blood type • STI screening: HIV, syphilis, chlamydia, gonorrhea ▫ Therapeutic communication ▪ Speaking with patients about common symptoms of pregnancy • Current exercise can continue, unless uncomfortable • HYDRATE • Careful in HOT weather • Sleep 8 hours every day if possible • Change bra, shoes and other clothing to ensure comfort • Sleep on side after 1st trimester Providing culturally competent careo Priority Actions ▪ What to do first? ▫ Page 198 Relieving discomforts of PG signs/symptoms ▪ Breast changes= wear supportive maternity bra ▪ Urgency frequency- empty bladder, kegel exercises, limit fluid before bed, avoid coffee ▪ N/V= avoid empty overload stomach; dry carb and hot tea, Avoid fried, spicy food; ▪ Bleeding gums= go to dentist; eat fresh fruit & veggies and soft toothbrush ▪ Constipation= Drink 2L of water; no stool softner, no laxative, only w/ Dr order ▪ Not preventable=mask of pg, spider nevi, pruritis, palpitations, food craving, carpal tunnel • Education o Page 208 Dietary management ▪ Weight gain of 25-35lbs is normal • First trimester: no increase in calories • 2nd and 3rd: 300 calorie increase ▪ Iron-deficiency anemia • Organ meats, green veggies, nuts, beans; PeanutButter; cereal, ▫ Page 200 • Take supplements on an empty stomach – mild nausea is common • Vitamin C will increase absorption= orange , broccoli • Stools can turn dark green to black and cause constipation • No calcium blocks absorption of Iron; can take 2hrs before and 2 hours after > no milk, yogurt, butter ▪ Folic acid • Low levels linked to fetal neural tube defects • Leafy greens ▪ 1st trimester • Severe vomiting= hyperemesis gravida • Chills, fever; burning upon urination; diarrhea= infection • Abd cramps; vag bleeding= miscarriage, ectopic pg ▪ 2nd & 3rd Trimester ▪ Persistent severe vomiting= hyperemesis gravida, HTN, Preclampsia ▪ Sudden discharge fluid from vag before 37w= Preterm Pre labor rupture of membranes ▪ Vag bleed, severe abd pain=miscarriage, placenta previa, abruptio placental ▪ Chills, fever, burning on urination, diarrhea= infection ▪ Severe backache or flank pain= kidney infection or stones, preterm labor ▪ Change in fetal movements = absence after quickening, any usual pattern or amt=fetal jeopardy, intrauterine fetal death ▪ Absence of FHR=intrauterine fetal death ▪ Uterine contractions, pelvic pressure; cramping before 37w= preterm labor ▪ Epigastric / abd pain = htn , preeclampsia, placenta abruption ▪ Glycosuria, + glucose tolerance reaction= gestational DM o Knowing if teaching is effective/ineffective • Fluid from vagina that is not leukorrhea (thin, white, scant vaginal discharge) • Abdominal or pelvic pain • Epigastric pain or severe heartburn • Sudden or severe edema in face and hands omelet Signs of possible complications of PG ▪ Red flag /warning pregnancy symptoms whole wheat, spinach, eggs don’t offend, always ask about preferences of food/ pain ect; check chart for previous • Severe or continuous headache • Dizziness, blurred vision, seeing spots • Persistent vomiting • Dysuria, oliguria • No fetal movement for over 12 hours • Leg edema with pain or redness • Chest pain or dyspnea (not just shortness of breath) ▫ Page 183 Preparing siblings for new baby o Take child on Prenatal visit. Let them listen to FHR o Involve child in preparations; help decorate o If child in crib move to bed 2 months before baby due o Read books, videos, dvd and hospital tour o Answer questions about birth. Babies are like o Take to homes of friends who have babies (realistic expectations) o With baby doll show sibling how to hold • Fundal height- measuring from pubic symphysis to highest part of uterus) o 12 weeks o 16-36 fundal hieght = weeks of pg o 20 weeks @ umbilicus o 36 weeks o 36-38 weeks lightening o 40 weeks Unit 2: High-Risk Childbearing • Nursing management o Priority actions ▪ Recognizing signs/symptoms that should be reported • Page 294 Miscarriage/ spontaneous abortion: spontaneous loss of pregnancy before 20th week o Risk factors: maternal age, previous miscarriages, uterine or cervical problems, smoking, alcohol, drugs o TYPES: ▪ Threatened abortion: showing signs but cervix hasn’t opened, light bleeding and cramping- treatment complete bedrest ..only one baby can be safed ▪ Inevitable: vaginal bleeding, strong lower stomach cramps, dilated cervix, fetus is expelled with bleeding ▪ Complete: all pregnancy tissues leaves uterus ▪ Incomplete: some pregnancy tissue remains (D&C might be indicated) ▪ Missed: placental and embryonic tissues remain in uterus but the embryo has died or never formed – brownish vaginal discharge • Page 299 Ectopic pregnancy: pregnancy develops/implants anywhere outside of the uterus o s/s: light vaginal bleeding with abdominal or pelvic pain referred to shoulder o if blood from fallopian: shoulder pain, urge to have a BM; pink tinge o if ruptured: stabbing pain in lower quadrant, can radiate to leg or chest, – followed by lightheadedness, fainting or shock o GOPHER- gush of blood; one sided pain, pain stops, hemorrhage, Emergency for Rupture o Treatment – methotrexate if only stretched; if bleeding sur remove part of fallopian tube • Page 297 Incompetent cervix: painless dilation of the cervix without labor or contractions of the uterus o Risk factors: congenital conditions, exposure to DES (synthetic estrogen), cervical trauma, excessive cervical dilation = repeated D&C o Starts between weeks 14 and 20: pelvic pressure, backache, mild abdominal cramps, light bleeding or spotting o Treatment- abd Cerclage (tie cervix) tocolytics, bedrest for a few days after procedure, progesterone, anti inflammatory drugs, antibiotics, hydration o I need Cerclage because my cervix is weak ▪ Recognizing signs/symptoms that require follow-up • Pregnancy complications o Hyperemesis gravidarum: severe nausea, vomiting, weight loss and dehydration ▪ Tx: IV hydration, control vomiting, stabilize mom ▪ Monitor for metabolic alkalosis • Physician orders that contradict patient conditions o NO vaginal exam if a mom is bleeding o Don’t give Pitocin to Patient w/ Abruption placenta they need c-section ▪ Who to see first? ▪ Patient priorities based on signs/symptoms • Immediate stabilization • End goal is to have mom and baby safe, that being said… o Stabilize mom first! ABCs o o o o o o Now, is baby still alive? o Medication management for high-risk conditions ▪ Page 280 after 20 weeks> seizure related • Risk factors: family history, multiple pregnancy, African-American, obesity, younger than 19yo, older than 40yo, pre-existing medical or genetic conditions • Decreased placental perfusion, generalized vasospasm, vasoconstriction, capillary leaking, reduced organ perfusion, can affect liver and brain function o Page 282 HELLP syndrome: lab diagnosis for a variant of preeclampsia that involves hepatic dysfunction – starts because of hypertension ▪ H: hemolysis: breakdown of RBCs ▪ EL: elevated liver enzymes – AST, LST, LFTs ▪ LP: low platelets (normal 400,00-150,000) ▪ Increased risk for: pulmonary edema, renal failure, liver hemorrhage or failure, DIC, placental abruption, acute respiratory distress syndrome, sepsis, stroke, fetal and maternal death • Mild Preeclampsia : BP 140/90 or greater, urine dipstick > 1+ • Moderate Preclampsia: BP 160/110, urine dipstick > 3+, persistent or severe headache, blurred vision, photophobia, epigastric pain, intrauterine growth restriction of fetus • S/S: independent edema (edema in lower extremities is normal, NOT in upper extremities or face), deep tendon reflexes = hyperreflexia, clonus = jerky spasms, rhythmic and involuntary (over 3) Severe preeclampsia: BP126/110 prevent seizures, control blood pressure o Assess respirations, level of consciousness, intake/output o Pregnancy-safe medications: methyldopa or hydralazine o ▪ Keep calcium gluconate bedside ▪ Monitor Mg levels (can also stop them) ▪ Page 289 Eclampsia: onset of seizure activity or coma in a woman with preeclampsia and no prior history ▪ Page 242 Diabetes: can be pregestational or gestational (management is pretty much the same) • Monitor comorbidities, preterm labor, macrosomia (big baby), C-section, polyhydramnios, hyper/hypoglycemia, increased risk for postpartum hemorrhage, sudden or unexplained stillborn, congenital malformations • Insulin needs: change throughout pregnancy o 1st trimester: reduced o Birth: decrease o Breastfeeding: decrease • At 24-28 weeks: glucose tolerance test o Negative = less than 130-140 o Positive = more than 140 (requires further testing) o Recognizing signs/symptoms low lying placenta classified by where egg implants and how much of the cervix is covered (total, partial, marginal) o placenta covers some or all of the cervix o Dx – with/ ultrasound ▪ usually occurs towards ends of 2nd trimester or later o Tx: bed rest, monitoring, possible C-section depending on degree of cervical coverage • Page 306 Abruptio placenta: partial or complete separation of the placenta from the uterine lining o MEDICAL EMERGENCY : C-section is necessary o causes/risk factors: hypertension, abdominal trauma, cigarette smoking, alcohol or cocaine use, blood clotting disorders, diabetes, previous history ▪ DIC (disseminated intravascular coagulation): “excessive clotting and bleeding at the same time” • can be triggered by abruptio placentae, serious infection or trauma, escape of amniotic fluid into bloodstream • Tx: replace blood and clotting factors, treat the cause, support vital functions pain,amopnitic fluid port wine color Magnesium sulfate: manage and prevent seizures • Preeclampsia: hypertension AND proteinuria ▪ Placenta abnormalities • Page 303 Placenta previa: Leopold's manuever ( Position: 2nd ▪ O = occiput= head ▪ UTI (urinary tract infection) • If untreated, infection can move and induce preterm labor • Treatment- antibiotics • Definitive diagnosis: 20-36 weeks gestation, uterine activity = true uterine contractions, progressive cervical change (effacement and/or dilation) , s/s: contractions every 10 minutes or less for 1hr or more (6 or more in an hour), lower abdominal menstrual-like cramps, dull and intermittent lower back pain, suprapubic pain or pressure, pelvic pressure or heaviness, membranes, signs of UTI, , rupture of amniotic • Education • Tx: bedrest, decreased activity and lifting, hydrate, tocolytic medications (relax smooth muscle) • We want to prolong pregnancy as long as possible (2-7 days) o Once “water” breaks, increased risk of infection o Managing pregnancy symptoms ▪ Recognizing signs/symptoms that should be reported o Knowing if teaching is effective/ineffective ▪ Complications of pregnancy Unit 3: Intrapartum (cervix dilation definite sign) • Nursing management o Factors affecting labor – the five P’s ▪ Passenger (fetus) ▪ Passageway (birth canal) ▪ Powers (contractions) ▪ Position of mother ▪ Psychological response Factor affect times- augmentation( Pitocin), maternal / infant size, maternal age, gravida status, elective induction, persistent posterior, victim of SA, maternal movement, maternal hydration o Fetal assessment ▪ Page 319 Fetal position (passenger) • Presentation (enter into birth canal) o Vertex: head down o Transverse: shoulder- cannot be delivered vaginally o Breech: butt or feet first • Lie: alignment to mother’s spine o Longitudinal or vertical o Horizontal (transvers) • Attitude: flexion (hands tight, head rest on chest) o Relaxed (not normal) • relation of fetal head to maternal pelvis (BEST start is LOA) o Divide pelvis to R and L o 4 steps) ▪ Find the back vs front of baby o Head up or head down, what is the presenting part? ▪ S = sacrum = butt or feet o Is baby looking up or down? Where is back of head of baby? ▪ where the presenting part of baby is in the birth canal (cm) ▪ Fetal heart patterns o Powers (changing of ▪ Primary powers • Effacement: thinning cervix(%) • Dilation: opening (cm) 10cm completely dialated • Ferguson reflex: baby is placing pressure on pelvic floor, mom feels she “HAS” to push” o If not ready not dialted completely mom change positions ▪ Secondary powers • Mom pushing- Bear-down