OB
Green = Very Important
Bold = Important
High Risk Pregnancies: *No prenatal care, pre-existing illness, pregnancy induced disease, risk for infertility *Low educational level background – don’t utilize resources as they should, scared *Lot more teenage pregnancy – sick, immature bodies, immature uterus (ideal age for pregnancy is 25) *Unwanted pregnancy – hangers, etc, anything to get rid of the pregnancy, people will do many different things, usually end up in the ED no matter what Reminders: Nagels Rule [to find the estimated date of confinement] + 7 days, - 3 months (don’t include the month you are in), + 1 year Ex. November 7th, 2008 [the 14th and August plus 1 year, August 14th 2009] High Risk Newborn – Apgar chart Score of 0
Score of 1
blue at Skin color blue all over extremities body pink Heart rate absent <100 grimace/feeble no response Reflex irritability cry when to stimulation stimulated Muscle tone none some flexion Breathing absent weak or irregular
Score of 2
Component of Acronym
no cyanosis body and extremities Appearance pink >100 Pulse sneeze/cough/pulls Grimace away when stimulated active movement strong
Activity Respiration
1st trimester: 1 to 13 weeks 2nd trimester: 14 to 26 weeks 3rd trimester: 27 to 40 weeks GTPAL [Gravity is # of pregnancies, parity is # of pregnancies in which the fetus or fetuses reach viability (approx 20 to 24 weeks or fetal weight of more than 500 g [2 lbs] regardless of whether the fetus is born alive or not) Gravidity number of pregnancies Term [full] births (38 weeks or more) Preterm (from viability up to 37 weeks) Abortions/miscarriages (prior to viability)/stillborns Living Children Early – fetal head compression (just monitor; when baby gets really low, most benign) Variable – cord compression (u, v, w shapes on fetal monitor), get Mommy on 8-10 L O2 and reposition Mommy on left side
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Late De-cels – placental/uteral insufficiency [O2]; HR drops and no re-oxygenation happens to baby and HR still decreases after contraction has ended Tocolytics – inhibit uterine contraction by suppressing smooth muscle contractions Contraindications: >34-35 weeks, fetal distress (at any gestational age), severe PIH, eclampsia, vaginal bleeding, cervical dilation > 6 cm [page 778] RN Closely Monitor 1. Pulmonary function 2. daily weights 3. I & O 4. S/S of pulmonary edema Yutopar/ritodrine – which is a beta adrenergic agonist, relaxes smooth muscle, inhibiting uterine activity and causes bronchodilation Adverse Reactions – SOB, tachy for both mommy and baby, hypotension, tachypnea, chest pain, pulmonary edema, n/v diarrhea Nursing Management – Maternal pulse >120-140, BP <90/40, pulmonary edema – to reverse effects, give Indural which will reverse these adverse effects Brethine/tertbutaline – is a beta adrenergic agonist, relaxes smooth muscle, inhibiting uterine activity and causes bronchodilation Tachy is a normal s/e of this drug (subQ or PO); SOB; *If given subQ, watch for infection at the site Interventions – VS, resp, skin Magnesium Sulfate (MgSO4) – IV uterine toco, CNS depressant; relaxes smooth muscle including uterus *most common **Monitor Q hr for lethargy, weakness, H/A, blurred vision, N/V, assess respiratory rate, deep tendon reflex, decreased urine output, watch for cardiac arrest -Hot, sweaty, dizzy –NormalRN Intervention – urine output <25 ml/hr, loss deep tendon reflex, RR <12, pulmonary edema, Mg lab <10 mg/dl [4.8 to 9.6 is normal] GIVE CALCIUM GLUCONATE AS AN ANTIDOTE FOR MAG OVERDOSE!!!!!!!! Procardia/Nifedipine – Ca+ channel blocker; relaxes smooth muscle including the uterus by blocking calcium entry ***NEVER, EVER give MgSO4 and Procardia together!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Research has demonstrated that a gain of 48 hours to several days is best outcome that can be expected with the use of tocolytics ■ Best reason to use tocolytic therapy is to achieve sufficient time to administer glucocorticoids in an effort to accelerate fetal lung maturity and reduce severity of respiratory complications in preterm infants
Pregnancy At Risk Hyperemesis Gravidarum -Excessive vomiting in the first trimester that leads to dehydration (5% weight loss), acidosis, starvation, and ultimately death of mother and fetus.
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HCG- hormone that is a biological marker in pregnancy tests; with hyperemesis, the levels are found to be really high, these are the Mommy’s with bad morning sickness Estrogen also can contributes to the hyperemesis Treatment -Hospitalize -NPO (1st until hydration resolved; usually 48 hours) -IV Hydration -Gradual diet – clear, full, soft, regular [or modified] -Anti emetic -TPN if necessary -Reglan, phergan, unisom, B6 *Small frequent meals/snacks *Increase protein and decrease fat (peanut butter and crackers) -Can never feel full because they will throw up -Morning/afternoon – don’t do well; evening or late night best time to get in a meal [around 6-7 pm] tend to do better to get in calories by having a small meal Nursing Responsibility -Strict I & Os [have them keep a diary of food] -Monitor fetus at all times -Emotional support – well being of baby and include rest of family Hydatidiform Mole (Moler Pregnancy) page 747 -Abnormal formation of the placenta into fluid filled, grape like clusters. -Fertilization of egg, but no nucleus because it has been lost -Will give increase levels of HCG -No prenatal care, Mommy can carry for full term -5 – 6 weeks usually start prenatal care, but will find out around 10 – 11 weeks -Happens 1 in 1200 pregnancies
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At Higher Risk for Mole -Early teen and women over 40 years old -Any defect of ovulation -Inadequate nutrition (anorexia, bulimia, drug use) Signs and Symptoms -Vaginal bleeding – brownish looking prune juice color -Passage of hydropic vesicles (grape like vesicle) -Uterine enlargement greater than expected gestational age -Doughy, soft abdomen -Spontaneous abortion 12 to 16 weeks -Spotting -Absence of fetal heart tones (no activity; NORMALLY can hear FHT on Doppler 10 -12 weeks and with a vaginal ultrasound heart can be heard 5 – 6 weeks, but not with Mole) -Hyperemesis Gravidarum [from the very beginning because HCG levels are so high] -PIH in second trimester [will happen before 20 weeks which is unusual and not good] Management -Ultrasound [will show Moler pregnancy] -Evacuation of the mole – D&C [dilate and clean] -Type and Cross for possible transfusion -Emotional support and bereavement care -*Follow up for at least one year following; Beta – HCG levels from blood, need to see decline of HCG
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-20% end up with chorio carcinoma because of the proliferative cells, which could lead to hysterectomy -CXR (lungs) 75% is the site of metasis -Don’t get pregnant for 1 year because could have cancer, follow ups is so important -Weekly for 3 weeks (want to see drastic drop in HCG levels), then monthly for 6 months, then Q 2 months x 3 -IF HCG still increased, D & C [again], tissue biopsy, chemo and possible hysterectomy -Don’t have them take pill contraceptives [will feed bad tissue with hormones], for birth control use condom Abortion -Expulsion of the fetus prior to viability, 20 weeks gestation -24 – 25 weekers can survive in NICU -23 and under – probably won’t make it… -20 weeks and less than 500 grams -15% of all 1st pregnancies, end up in miscarriage (80% of those happen under 12 weeks) Two Types: (page 739) -Spontaneous abortion: occurring naturally -Induced abortions: as a result of artificial or mechanical intervention. (D & C) Types of Spontaneous Abortions: -Threatened abortion – slight spotting, cervix does not dilate -Imminent abortion – inevitable, can NOT be prevented, cervix dilated Complete abortion – everything comes out fetus and tissue all comes out Incomplete abortion – heavy bleeding, haven’t seen any thing expelled from fetus (will have to D & C) -Missed abortion – could or not have bleeding, products of conception that remain in uterus, no cervical dilation, fetus is not alive 12 – 16 weeks, ultrasound confirm, give uterus time to rest before Mommy gets pregnant again -Habitual abortion – 3 – 6 abortions consecutively, for known reason, although common cause is Mommy with HTN and hx of abruptio placenta Signs and Symptoms -Unexplained bleeding – sudden spotting and tissue passage (products of conception) -Cramping – lower abdomen, dull, constant pain; pain is very different from ‘a growing fetus pain’ -Backache – [fever, bones hurt, n/v] -Assessment: LMP (know); gravida, para [full term, abortion, premie], VS, amount and color of bleeding (pad counts, frequency, bright red, fetal parts), pain (contraction verses cramps), level of comfort, and pt’s understanding of what is going on (they will leave hospital with NO baby), understanding of the loss, possible D & C Management
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-Ultrasound, lab work (H/H, CBC, Type and Cross), observe cervix and if dilated – bed rest, abstinence from sex, IV/ transfusion, D & C – dilation and curettage (if point of no return), if beyond 12 weeks induction of labor by oxytocin, pit, and prostaglandins may be used [missed abs common], emotional support and bereavement care [guilt, punishment, give support [support groups], fetal heart tones (120 – 16- bpm) is best indication for fetal well being Bleeding Disorders [page 744] Ectopic Pregnancy: implantation of the blastocyst in a site other than the endometrial lining of the uterus. Most common site is the fallopian tube (tubal pregnancy) -2% of all pregnancy in the US -Leading cause of maternal deaths (because of the rupture, bleeding/septic) -Fear is always the possibility of a rupture -Can see with ultrasound [vaginal] within 5 weeks -9 – 10 % of all maternal deaths -Leading cause of infertility -1 – 50 pregnancies, found usually in about 8 weeks
Risk Factors -STDs -Use of IUD (intra uterine device) -PID (pelvic inflammatory disease) Signs and Symptoms -Vaginal bleeding
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-Lower abdominal pain; sharp and one sided -Fainting or dizziness -Constant pain on the side of ectopic (usually right side) -Hypovolemia -Pt’s usually miserable -Rigid, tender abdomen -Palpable mass on vaginal exam – extreme pain! Complications -Hemorrhage, shock, peritonitis Management -Pelvic examination -Blood replacement -Culdocentesis (back in the day, now use ultrasound) -Laparoscopy/Laparotomy (small key holes in abdomen) -Methrotrexate – give if un-ruptured and it measures less than 0.35 cm, then can give Methr – will spot for week or 2 -Return weekly up to 12 weeks for Beta HCG draw (to watch for decline) -If it ruptures, the pt will go to OR to matter what Placenta Previa -Placenta implantation in the lower uterine segment -Abnorm implanted placenta, in the lower uterine segment -Classified into three types by the degree the cervical os is being covered
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*Marginal aka low laying is the most common and all of these are delivered by c-sect Predisposing Factors -Prior history of placenta previa -Multiple pregnancies -History of multiple births or closely spread pregnancies -Prior uterine scars [by c-sect] -After age of 35 Symptoms -Painless -Quiet onset bright red bleeding -Abdomen soft, palpable -Labor pains-cramping -Come in to get FHT and stat ultrasound -Stable VS, even after blood loss -Unless complete [type 3], loss lots of blood – hypovolemia shock -Shock, anemia -Infection **Vaginal bleeding = NO SVE & bright red blood and pregnancy does NOT go together Nursing Responsibility -Late 2nd to 3rd trimester, is when this happens [30 -32 weeks, if late 3rd trimester hospital and deliver baby] -Bed rest -Monitor blood loss (pad count) Q hr -Perineal care -Education re: s/s of labor, condition, degree of placenta previa and what is going on -Have current lab date eg T/S [Type and Cross] -Emotional support -Find FHT -Doppler and stat ultrasound -Monitor VS -Watch for hypovolemia (16 to 18 gauge) 8
-If “complete” placenta previa, c-sect and baby coming out -Prepare for emergency c-sect -Celestone-Bethamentone for fetal lung maturity to Mom IM; need 48 to 72 hrs at least for it to work Cause of P-previa: PIH, trauma, cig smoking, drug use, cocaine, induction via pit, maternal malnutrition, uterine fibroids, any maternal vascular disease, vena cava syndrome (Mommy never to lay on back!) [Type and Cross and H&H] Placenta Abruptio -Premature separation of the placenta -1-200 births -Emergency*** -Leading cause of maternal death extend of detachment or degree – D/C -Trauma leading cause of abruptio Symptoms -Dark venous blood -Abdomen rigid, hard -Severe pain, extreme -Sudden onset-trauma, fall, lifted -Shock, hemorrhage (IV) Nursing Responsibility -Prepare for emergency C/S -Time between abruption and delivery of baby Management -FHT, ultrasound, IV (fluid replacement), extremely late decals [reposition Mommy on left side and 8 to 10 L of O2, uterine irritability, tonicity]; fetal monitor with previa = late decels
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Amniotic Fluid Purpose (sticky and white normally) 1. cushions fetus 2. regulates temperature 3. equalizes pressure 4. allows fetus to move freely -Oligohydraminos-absence of or small amount [causes renal issues in fetus] -Polyhydraminos-too much fluid [causes baby can have IUGR] Premature Rupture of Membrane (PPROM – before 37 weeks)) -Spontaneous ROM prior to onset of labor at the end of 37 weeks [high risk] Full term = PROM [38 weeks] Fetal Risk: Pre-maturity, infection *Prevention of infection -Monitor temp -Monitor amniotic fluid, you want white and sticky – not black, green, smelly -Antibiotic within 24 hours and have c-sect Management -Hospitalized – pre term, NICU, lungs, intubation (will be in NICU until Mommy expected date of delivery) -Limit sterile vaginal exam -Antibiotics -Bed rest -Trendelenberg position- to get pressure off perineum -Daily CBC
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-Fetal well being tests – NST, which is FHT with fetal movement: baseline FHR, fetus must keep FHT 15 bpm above baseline for 15 seconds, twice in 20 mins for 40 mins total [then the result is considered a ‘reactive NST’] - Fetal well being tests – BPP, which is bio physical profile done the 3rd trimester, more specific ultrasound, HR, breathing, body movement, fetal tone, amniotic fluid volume and each of these gets 2 points and you want a score of 8 to 10 pts; done weekly every 3 to 4 days -Medication – Celestone (if anticipate delivery, give X 2 more) for fetal lung maturity -L/S ratio – premie lung maturity; 2 to 1 check fetal lung development Incompetent Cervix [recurrent premature dilation of the cervix] -Premature dilation of the cervix associated with repeated second trimester spontaneous abortions -Cervix and dilates -Possible from cervical trauma -Congenitally short cervix -Increase in maternal age Signs and Symptoms -Painless, bloodless, second trimester abortion -Minimal uterine contractions -Pelvic exam shows dilation and effacement -Educate Mommy to inform you if she feels funny, sit and call 911 and get them in so we can get them checked out Management -Cervical cultures for Gonorrhea Clamedia for STDs, Gram Beta Strep in first trimester -GBS lies dormant in vagina, but will flare up with pregnancy/stress -Bed rest, hydration, progesterone [helps endometrium attach to placenta] -Trendelenberg position -Antibiotics (triple abx on board before delivery) -Prevent/inhibit cramping and contractions (eg tocolytics [to inhibit contractions]) -Shirodkar suture/cerclage [page 743] -Draw baby’s blood and give antibiotic for 48 – 72 hours -Cerclage = purse string around the cervix to strengthen it
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Preterm Labor -Onset of labor between 20 and 37 completed weeks of pregnancy -Etiology unknown (dehydration) Reasons: pre-mature contractions, multiple fetus in one gestation, infections (UTI – dehydration, fetus become tachy – compensates, then Mommy contracts), abdominal surgeries in the past Symptoms -Cramping -Backache -Spontaneous contractions Management -Bed rest *** -Hydration *** -Empty bladder -Tocolysis – Terbutaline, MgSo4 [Mag sulfate FDA approved anticoagulant] – these are used to inhibit uterine contractions by relaxing smooth muscle of the uterus -Educate Mommy that normally – contractions go from front to back and belly gets hard; let them know how pre-term labor feels and the differences -Braxton Hicks – have Mommy drink water and lay on left side (will go away) Pregnancy Induced Hypertension (PIH) [Gestational HTN] -An increase in systolic blood pressure > 30 mmHg from baseline or an increase in diastolic blood pressure > 15 mmHg from baseline on at least two occasions > 6 hours apart. If no baseline data available – 140/90
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-Categories: Preeclampsia and Eclampsia Mild Preeclampsia -Characterized by: HTN with proteinuria -Increased BP -Proteinuria- + 1 and + 2 on dip stick -Edema (of hands and face) -Wt gain [“normal” 2nd trimester = 2.2 lbs] Severe Preeclampsia -Characterized by BP 160/110 on two occasions -Proteinuria which is > 5 g/L in 24 hours, oliguria which is < 400 mL/24 hours -Other symptoms like headache, blurred vision, scotomata (seeing stars in eyes), pitting edema, N/V, epigastric pain Labs – increased serum creatinine Eclampsia -Characterized by -Convulsions [can give MgSO4 for this] -Coma Treating Preeclampsia -Home management -Bed rest -Check BP, UA daily -Bi weekly NSTs -24 hour urine collection -Check fetal movement -Hospital Management -High protein, low sodium diet -24 hour urine collection for protein and creatinine -Fetal well being tests BPP, NST -Anti-convulsant therapy – MgSO4 -Anti hypertensive eg aldomet, Procardia, Labetelol [beta blocker] they are very common and safe antihypertensives Managing Eclampsia [page 725 for PIH info] -Safety, Safety, Safety, Safety…you get the idea. ;-) -Seizure management -MgSO4 -Safety precautions Gestational Diabetes -Carbohydrate intolerance with onset first recognized during pregnancy Lack of maternal glycemic control before conception and in first trimester of pregnancy may be responsible for fetal congenital malformations
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Maternal insulin requirements increase as pregnancy progresses and may quadruple by term as a result of insulin resistance created by placental hormones, insulinase, and cortisol
At birth, levels decrease dramatically; breastfeeding will affect insulin needs Poor glycemic control before and during pregnancy can lead to maternal complications such as miscarriage, infection, and dystocia caused by fetal macrosomia Careful glucose monitoring, insulin administration when necessary, and dietary counseling are used to create a normal intrauterine environment for fetal growth and development in pregnancy complicated by diabetes mellitus Because gestational diabetes mellitus is asymptomatic in most cases, many women undergo routine screening during pregnancy Maternal Risks [page 688] need to have blood glucose level the same at ALL times -Maternal hypotension causes IUGR -Polyhydraminos – increase of 2000 cc amniotic fluid from hyperglycemia -Hyperglycemia – dystocia [difficult labor dysfunction, uncoordinated] -PIH-risk -Large placenta -16 to 18 weeks AFP, tube screen Fetal Risks -Fetal demise d/t DKA -Macrosomia- big juicy babies, perineal laceration or c-sect -Shoulder displacment 14
-IUGR because of maternal hypotension -Premie, respiratory distress [under developed lungs and check L/S ratio] ->30 years, obesity, family history of diabetes or previous deliveries of large, juicy babies Screening -Blood drawn -50 g random glucose test at 24 – 28 weeks; results > 140 require further testing -Three hour GTT [glucose tol test] -Normal blood glucose level is 60 to 120 -Educate pt to avoid caffeine before test -Fasting >95 blood sugar (draw fasting bs) Screening sugar levels: -1st hour >180 -2nd hour >155 to 165 -3rd hour >140 to 145 ~Gestational Diabetes if 2 or more valves are high
Postpartum Complications Postpartum Hemorrhage -A blood loss greater than 500 mL in the first 24 hours after vaginal delivery -A blood loss greater than 1000 mL in the first 24 hours after C/S Postpartum hemorrhage is most common and most serious type of excessive obstetric blood loss Hemorrhagic (hypovolemic) shock is an emergency situation in which perfusion of body organs may become severely compromised, leading to significant morbidity or mortality rates for mothers Causes -Uterine atony [uterus forgets to contract] -Lacerations -Retained Placental Fragments -DIC Symptoms -Increased, thready and weak pulses -Decreased blood pressure -Increased shallow respirations -Pale clammy skin -Increasing anxiety Medical Management -LOTS AND LOTS of fluid *Early recognition is critical -1st = massage fundus and empty bladder
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-Pitocin (10 -40 units in 1000 D5W) -Methergine IM QID (this is to wake up uterus, can’t give to HTN pt) -OR-Prostaglandin administration – hemoabate, then -Bimanual compression – literally go in vagina with knuckles and a 4 x 4, press against uterus and clean out uterus -Blood replacement -Hysterectomy is worst case scenario -Pad change every 3 hours Nursing Considerations -Fundal massage -Measure fundal height, consistency and lochia Q 4 hours -Offer bedpan Q 4 hours -Position pt in supine -VS Q 15 mins -O2 by face mask if RDS -Don’t ever leave to, stay at bedside
Subinvolution -Incomplete return of the uterus to its pre-pregnant size and shape Symptoms -Late post partum hemorrhage 1 – 2 weeks after childbirth [about 3 to 6 weeks for it to stop] -Excessive blood loss -Lochia fails to progress from rubra-serosa-alba -Lochia Rubra persists after 2 weeks Management -Methergin or hemobate
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-Antibiotics -Frequent voiding -Lots of fluids -Breastfeed -D & C if necessary Risk factors -Endometritis -Placental fragments still left in uterus Deep Vein Thrombosis Symptoms Edema of ankle and leg, change in LOC, low grade fever followed by chills and high fever, pain, Homans sign + or negative, peripheral pulses decreased, dyspnea and chest pain; watch mommy if she says her legs hurt; pain lower legs and or lower abdomen
Three types of DVT -Superficial Thrombophlebitis swelling on effected leg, redness -Femoral Thrombophlebitis -Pelvic Thrombophlebitis (VS important, will have temp, chills, first sign is them saying I can’t breathe) Management and Nursing Considerations -Prevention -Early ambulation -Assess peripheral pain -Check hypotensive, chest pain -Monitor signs of bleeding 17
-Warm, moist soaks while maintaining legs elevated -Obtain clotting times -Increase fluid intake -Generalized petchie -Heavy vaginal bleeding Endometritis Definition - Refers to an infection of the endometrium, the lining of the uterus. Bacteria gains access to the uterus thru the vagina and enters the uterus either at the time of birth or during the post-partum period.
Causes Mommy had c/s, prolonged ROM, multiple sterile vag exams, prolonged labor, placental fragments Symptoms -WBCs 20,000 to 30,000 -A rise in temperature 24 hours postpartum -Starts 2 to 5th day post partum but before discharge -Chills, malaise, loss of appetite -Abdominal tenderness and strong after pains -Lochia is dark brown and it smells, culture lochia if endometritis is suspected -Will have delayed involution Management and Nursing Considerations -Antibiotics IV, broad spectrum [penicillin, gent] 18
-Analgesics -Anti pyretic -Lots of fluid -Frequent perineal care -Positioning, sit or lay Fowler or Semi-Fowlers to promote drainage Urinary Tract Infection Cystitis – infection in the lower urinary tract caused by E Coli Pylonephritis – infection in the upper urinary tract that causes damage to the kidney and impairs function Causes -Decreased bladder sensitivity -Frequent caths -Frequent vaginal exams -Increased bladder capacity -Bladder trauma at birth -Increased diuresis Symptoms -Over distention of the bladder -Frequent urination of small amounts, burning, dysuria -Hematuria -Elevated temperature (low grade – cystitis and high pyelonephritis) -Flank pain/CVT (costoverterbral flank pain) -Chills and N/V Management and Nursing Considerations -Culture and Sensitivity -Admin ABX (Bactrim) -Increase in fluids -Monitor VS and bladder Mastitis -Infection of the breast connective tissue, primarily in women who are lactating -Almost always uni-lateral -From blocked milk duct and creates abscess -Established after 2-3 weeks post partum -Usual causative organisms are: Staph a, E coli, Strep
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Symptoms -Affected breast show localized pain, swelling, and redness -Fever -Breast milk becomes scant -Pain -Tender axillary lymph nodes Management -Broad spectrum antibiotics -Breastfeeding continued or pumping (Q 2 -3 hrs) to promote that abscess to drain -Cold or ice compresses, supportive bra until pain subsides [45 minutes on 45 minutes off] -Frozen cabbage leaves [45 on 45 off] -Warm compresses right before mommy breastfeeds Complications of Childbirth Stress Factors = reduction of myometrial activity Nursing Plan -Comfort measures -Relaxation/Breathing techniques -Reassurance [always] and rapport [let her know what is going on every step of the way] Episiotomy
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Midline straight down 1-2 cm -Advantages: less blood loss, less painful, heals quickly -Disadvantages: may extend to anus (mommy has a big baby, cut straight down and can go down to anus) Midiolateral about 3-5 cm, these are big, big babies (like 8.5 lb –ers) -Advantages: more room -Disadvantages: more painful, more blood loss, takes longer to heal Precipitate Labor Labor that is completed in less than three hours. More common with multiparous woman. Poses risk of trauma to the fetus as well as trauma to the maternal soft tissue. Management -Early preparation for labor -Support the perineum in case of delivery [all RN in L&D are ready to delivery baby if have to] Risks for Mom – if mom is delivery too fast, uterine rupture is a risk, cervical – vaginal – rectal lacerations For neo-nate – hypoxia – caused by uterus placenta insufficiency by hypertonic contractions/uterus, intra-cranial hemorrhage Nursing considerations: -Don’t leave mommy alone! -Have her pant to buy some time or have her blow and distract her to decrease urge to push -Be sure to get sterile gloves prepared -Support the perineum -Look at monitor for baby’s well being (O2 like 8-10 L of oxygen for fetal distress) Lacerations First - perineal skin and the vaginal mucosa - extends through the skin and most common Second – perineal skin, vaginal mucosa, fascia, muscles of the perineal body 21
Third – Perineal skin, vaginal mucosa, fascia, muscles of the perineal body involving the anal sphincter Fourth – a third degree laceration but goes thru the rectal mucosa
Considerations -Put mom in stir-up if see trickle of blood post partum to check sutures and pat to see where it is coming from, can even come from vaginal laceration Nursing Considerations -Ice -Pain meds -Epi foam and derma plast to put on pad for perineal care (front to back, wipe from front to back and PAT dry) -Tucks Perineal Hematomas Collection of blood in the subQ layer of perineal tissue characterized by: purplish discolored area, swelling (2 to 8 cm), and feeling of pressure or tightness; usually from vacuum out baby -Mommy will say severe pain in her perineum and may not be able to close her legs Interventions -VS (hypovolemia) -Monitor for abnormal pain (use of vacuum and or forceps) -Monitor mommy’s bottom -Ice [15 minutes on 15 off] -Pain meds -I & O -Cath mommy if she is unable to void
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-Antibiotics (becomes infected, broad spectrum, prophylactic) -If bubble is clear, it is just edema – leave alone; if black and blue, will have to do I & D to evacuate hematoma so prepare for that Now, time for passenger… Mal-position Persistent occiput posterior cause: severe back pain, increased use of forceps/vacuum, increased risk of lacerations; posteriorly presenting head does not fit the cervix as snugly as the one in the anterior position
Risks -Sacral nerve compression = severe back pain -Increased risk of forceps and vacuum = increase risk of lacerations -FHT are heard on lateral side on the abdomen Nursing Plan -Position change – knee chest -Back rub
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Mal-presentation -Breech
-Face, brow -Transverse
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-Shoulder Treatment -Manual rotation [there is risk involved like where cord is located; doctor goes in and internally try to move the baby] -External version [page 789; ultrasound and move baby from the outside] -C-sect Macrosomia (large gestational age babies, big juicy babies); maternal diabetes or post term pregnancy – more than 42 weeks -Shoulder dystocia – shoulders are too broad to be delivered thru the pelvic outlet
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Nursing Responsibilities -McRoberts maneuver – [page 811] -Prep for c-sect -Check infant shoulders after delivery
Cesarean Birth
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Reasons for c-sect: -Mal-presentation [breech, etc] -Placenta previa or abruption -Fetal distress -Failure to progress [Mommy has been labor for 12 to 14 hrs] -Prior uterine scar [doesn’t want to go to a VBAC] Types of incision -Classic or vertical -Low transverse or prannestiel Nursing Responsibilities -Prepare client – shave, Foley, pre op meds [mommy – bicitra – neutralize stomach acid so she won’t feel like throwing up or aspirate] -Pre op and post op teaching [monitor vs, assess fundus, assess vaginal bleeding, assess abd dressing, foley cath and urine output, turn/cough and deep breath] page 800 Cord Prolapse [page 812] Occurs when a loop of the umbilical cord gets in front of the presenting part [see variable decals]
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Nursing Plan -Avoid cord compression -Trendelenberg position -Knee chest position -NEVER press the cord back in; what you do is put pressure on baby’s coconut so baby’s not putting pressure on cord and do NOT let this baby be delivered, will have to go to csect Causes -PROM -Placenta previa -Tumors -Cephalic Pelvic Disproportion [CPD] -Small baby -Multiple gestations Symptoms -Cord is felt on vaginal exam -Presence of FHR with variable decals Management -Ensure reassuring FHT -Vaginal exam to push up presenting part (not the cord)
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-8 to 10 L of O2 -Poss c-sect or rapid delivery -Positioning like Trendelenberg position or Knee chest position Dysfunctional Labor -Hypertonia – seen in early labor; painful d/t uterine muscle cell anoxia [not enough oxygenation; no normal resting phase that goes on – give analgesics, O2, positioning]; ineffective and doesn’t even allow cervix to dilate -Hypotonia – seen in active labor; caused by medication, epidural, over stretching of uterus, or mal-position (will have to rule out CPD – cephalic pelvic disproportion) – will give pit to jump start uterus, ultrasound to check positioning, vacuum assisted birth and csect is worst case Dysfunctional labor occurs as a result of: ■ Hypertonic uterine dysfunction ■ Hypotonic uterine dysfunction ■ Inadequate voluntary expulsive forces-not doing what is supposed to do Functional relations among uterine contractions, fetus, and mother’s pelvis are altered by maternal positioning, which is why ultrasound done at bedside Risk factors -Mommy over 40 -Uterine abnormalities -Fetal macrosomia -Fetal mal presentation -Multi fetal pregnancy Uterine Rupture May be as a result of VBAC, trauma, excess pitocin administration, fetal lie -Symptoms: excruciating pain [sharp, abrupt, sudden], cessation of contractions [uterus won’t contract anymore], drastic decrease in fetal heart rate [immediately], late decals, may have bleeding or may not have bleeding
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Treatment- emergency cesarean -O2 and fluids -Positioning How baby compensates: Brady late decalstachy Causes -Separation of scar from previous c/s -Intensive uterine contractions -Over stimulation of labor with Oxytocin -Difficult forceps assisted birth Uterine rupture management -Complete uterine rupture – extension thru entire uterine wall tx: shock, replace fluid and hysterectomy -Incomplete uterine rupture – laparotomy, repair tear, blood replacement
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Amniotic Fluid Embolism Occurs when amniotic fluid gets into maternal circulation; leading cause of death during labor or the first few hours post partum, first case was in 1926; leak in amniotic fluid and goes to lungs; unpreventable situation; pt can’t breath; may have meconium; maternal mortality rate is about 61% and if happens, permanent damage; baby will usually have permanent hypoxia problems [like CP] about 50%; via the endocervical veins
Symptoms -Respiratory distress – SOB, cyanosis -Chest pain [abrupt onset] -Tachycardia -Acute hemorrhage -Pale to bluish/cyanosis, dyspnea, respiratory distress Treatment = maintain oxygenation and support Cardio Vascular Support Management -Oxygen by mask or cannula [8 – 10 L] -CPR if needed -Avoid moving pt -Death may be imminent if not caught on time -Intubate DIC Over stimulation of the coagulation process triggered by underlying disease and vascular injury Management by treating underlying cause; will see in L & D process and part of childbirth Causes
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-Abruptio Placentae -Amniotic fluid embolism -Dead fetus syndrome [retained in utero usually about 5 to 6 weeks] -Severe Preeclampsia -Septicemia -Hemorrhage Management -Assess vaginal bleeding -Observe for clots -Place pt in a left lateral side lying position -Palpate fundus -Low platelets, low fibrogin, low protrombin, and low Factors 5 and 6 S/S -Bleeding from the nose -Bleeding from IV site or other areas HELLP Syndrome -Hemolysis -Elevated liver enzymes [AST more than 72 [5 and 40 is normal for AST] and increase in LDH [norm 0 to 250] of more than 600] -Low platelets [less than 100,000] Treatment -Improve platelet count -Close observation -Prevent bruising or bleeding -Once baby is out, HELLP is gone -HELLP mommies are very sick Symptoms -Usually more than 34 weeks, but can be under 34 weeks -N/V -Right upper quadrant pain or epigastric pain -H/A -Diarrhea
Newborn Complications Risk factors that causes newborn complications -Prenatal or intrapartal, diabetes, narcotics analgesics, anesthesia, fetal asphyxia, difficult or prolonged labor, multiple gestation, pre term baby, post term baby, congenital anomalies, maternal infection, neonatal infection, SGA or large for gestational age Preterm Newborn
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Definition – gestational age (under 37 weeks of gestation) as well as weight less than 2500 grams (5lbs 8oz) Preterm births can be attributed to many causes including: -Gestational HTN -Multiple pregnancies -Adolescent pregnancy -Lack of pre natal care -Substance abuse -Smoking Complications -Respiratory distress syndrome (RDS) - decrease in surfactant in alveoli regardless of birth weight -Aspiration – don’t have an intact gag reflex, inability to suck, swallow and breathe -Apnea of prematurity -Intraventricular hemorrhage (IVH) – bleeding in or around ventricles -Retinopathy of prematurity -Patent ductus arteriosus (PDA) -Necrotizing enterocolitis (NEC) - very common, acute inflammatory bowel d/o in pre term or low birth weight babies; as soon as baby gets to NICU, get baby on breastmilk and that will help NEC which leads to perf and peritonitis -Neonatal sepsis -Hypoglycemia – especially for macrocosmic babies -Hyperbilirubenmia – some babies are just born with this -12 to 15 bilirubin levels with bilirubin encephalopathy, kernicterus -Delayed growth and development Ballard assessment – assessment for premies and what they do before they go into the NICU, neuro and physical assessment Symptoms -Periodic breathing – watch for retraction and color change, that is not normal, but periodic breathing is normal -Apnea –pause longer than 10 to 15 seconds -Low birth weight -Minimal subcutaneous fat deposits -Head large in comparison to body -Lanugo over body -Minimal creases in the soles and palms (premies have minimal) -Flat areola without breast buds -Heels fully moveable to the ears – they are super flexible -Inability to coordinate suck and swallow -Skin is thin, smooth, skin and the smaller they are the more translucent -Ear cartilage is very soft, in the unit, watch to make sure that they cartilage is in alignment
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-Eyes may still be close -Un descended testies -Weak grasp reflex -Hypotonic muscle Nursing Interventions -Perform resuscitative measures -Ensure thermoregulation - can’t not regulate their own temp, radiant warmers, incubators -Administer respiratory support measures – surfactant and oxygen -Administer nutrition and fluids -Administer medications as prescribed -Minimize stimulation -Provide for non nutritive sucking -Keeps parents informed/educated about care of their pre term newborn -Less than 34 weeks, going to establish IV and oral gavage (when they get to 34 weeks, will start one PO 5 cc feed) -Clustered nursing care, Q 4, 6, 8 hrs -Provide non nutritive sucking -Inform and keep parents up to date -Blanket rolls, swaddling, secure holding -Goal in NICU is meeting infants growth and development needs, anticipate and manage complications in the NICU especially respiratory distress and sepsis (and cardiac system) Discharge Planning Home care needs of the infant’s parents are assessed Information is provided about infant care Referrals for appropriate resources Referrals for home health assistance Management -Bowel function -VS -Urinalysis -CXR -Arterial blood gas -Head U/S = ultrasound (for IVH) -Echo -Eye exams -Serum glucose -Calcium -Bilirubin Small for gestational [SGA] age newborn Describes an infant whose birth weight is at or below the 10th percentile Complications -Perinatal asphyxia – hypoxia
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-Meconium aspiration -Hypoglycemia -Instability of body temperature Symptoms -Weight – below 10th percentile -Reduced subQ fat -Loose, dry skin -Scalp hair sparse -Wide skull sutures **inadequate bone growth (IUGR) -Wide eyed and alert – prolonged fetal hypoxia that is their compensation -Sign of meconium aspiration, hypoglycemia and hypothermia Post term newborn Definition – an infant that is born after 42nd week of pregnancy Risks -Decrease effectiveness of placenta – increase asphyxia – increase in meconium passage in uterus – increase risk of meconium aspiration (MAS) – inhalation of meconium into the lungs = meconium is a BIG fear -Birth injury r/t shoulder dystocia -First pregnancies; gravida 1 -Etiology is unknown why mommy goes post term -Mommy had a previous post term, may happen again Symptoms -SGA or large birth weight -What happens depends on the placenta -Absence of vernix (younger they are the more vernix they have), minimal lanugo -Dry, cracked skin r/t metabolism of fat to energy need in utero -Hypoglycemia (metabolism of glycogen to meet energy needs in utero) -Minimal subcutaneous fat because baby has to compensate on their own -Skin and cord stained yellow/green (caused by meconium) -Long fingernails, scratches on the face, trunk Nursing Management -Blood sugar levels -Hemocrit -Complete Blood Panel -Obtain VS -Complete blood count -ABG -CXR Hypothermia -Increased consumption of calories = loss of weight
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-Increased oxygen consumption – hypoxia - acidosis – pulmonary construction -Utilization of fat for energy – lack of surfactant – RDS -Increased glucose consumption – hypoglycemia …Hypothermia is a good indication for sepsis Management -Wrap and dry baby after ensuring airway, have to dry baby up! -Reduce or eliminate heat lost thru drafts and contact with cold objects -Postpone initial bath until temp has stabilized -Dry infant immediately after birth and bathing -Keep axillary temp between 97.6 and 99.2 F Management complications -If axillary temp is less than 97.6 F -Put hat on infant’s head -Wrap newborn with warm blankets -Assess O2 and hypoglycemia status -Re warm infant slowly (hypotension and apnea) -Hypothermia is an early sign of sepsis Hypoglycemia Definition – blood glucose less than 40 mg/dl in an term infant [30 to 80 mg/dl is normal blood glucose in baby]; all stressed babies have a risk for being hypoglycemic Causes -Infants of diabetic mommy’s, SGA, premies, experiencing cold stress, hypothermia, delayed feedings, respiratory distress Symptoms -Tremors, jitteriness -Lethargy -Decreased muscle tone -Apnea -Anorexia -Weak cry -Can lead to seizures Management -Check blood glucose on all infants by one hour of age and 30 mins on infant’s with IDM mom’s -Treat hypoglycemia by breast feeding immediately or administering D5W, D10W PO or IV (Don’t attempt to feed po an infant who is lethargic at risk for aspiration) -If treatment has been started, recheck blood glucose level before the next feeding Neonatal sepsis
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Definition – is a generalized infection that has spread through the blood stream Pathophysiology -Immature immune system (inability of the body to localize infection) -Lack of IgM immunoglobin (protects against bacteria and does not cross the placenta) -Manifests itself 24 hours after birth Causes -Prolonged ROM -Difficult, long labor -Resuscitation, invasive procedures -Maternal infection (UTI and GBS) -Beta hemolytic strep causes (meningitis and sepsis) -Aspiration of amniotic fluid, formula or mucus -Nosocomial infections -Meconium -HIV mommies -Low birth weight babies Symptoms -Temperature instability (hypothermia) -Feeding intolerance (weak suck and low intake) -Behavioral changes ex. lethargy, pallor or seizures -Respiratory distress (grunting, flaring, retractions) -Hyperbilirubenmia -Jaundice -Tachycardia – apnea – bradycardia [because of compensation] -Drainage [eyes, umbilical stump] -Loose stool -Vomiting -Abdominal distention -Oral gavage –large residual Management -Obtain cultures, blood urine, and CSF, before starting antibiotic therapy [complete septic work up] -Administer antibiotics -Obtain VS and temp -Observe for changes in physical assessment -Will probably have fluid/electrolyte imbalance [Usually will be poly-microbial, usually steph, E coli, Hem influenza, group B strep] Hyperbilirubenmia Definition – term refers to excessive bilirubin in the blood characterized by jaundice; give yellow to their urine and brown to their stool
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Lab Values -Normal Values for Newborns Birth to 24 hours = 6 mg/dl Day 1 to 2 = 8 mg/dl Day 3 to 5 = 12 mg/dl Types -Un conjugated/indirect – fat soluble, physiologic jaundice [can turn into karnictus] Most commonly seen in newborns; from trauma at birth -Conjugated/direct – water soluble, pathologic in origin [this is the bad one!] Suggests hepatic problems ex biliary astresia, tumors, damaged liver cells Management -Conjugated hemolytic disease fo the newborn -Un conjugated – 50 – 80% babies have this **Look at eyeballs first! If below nipple line, not quite a concern as eyeballs Jaundice Management -Phototherapy -Exchange transfusion – used to treat infants who has raised levels (above 20), used when bili can’t be controlled by phototherapy (replacement of 75 to 80% infants blood of recipients blood by donor blood) Phototherapy Management -Cover infant’s eyes and remove covers Q 2 hrs -Change position q2hrs and assess skin -Assess stools (green stools are indicative of bilirubin being excreted thru the stools) -Increase fluid intake to prevent dehydration -Assess temp Q 2 hrs (hyperthermia) -Monitor bilirubin levels prescribed Respiratory Distress Syndrome Causes/Risks -Lack of surfactant -Surfactant is a phospholipids that keeps/assist alveoli from collapsing and allowing gas to be exchanged ex cervanta -Preterm infants -Meconium aspiration (term or post term) -Transient tachypnea of the newborn (TTN) cause from delayed absorption of fluid in the lungs from delivery; typically preterm and post term infant Symptoms -Grunting -Cyanosis
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-Tachypnea (more than ro RR/min) -Nasal flaring -Respiratory acidosis -Retractions: sternal and subcostal Newborn of addicted mother Symptoms -Withdrawal symptoms may occur as early 12 to 24 hours after birth or as late as up to 7 to 10 days post delivery S/S -High pitched cry -Irritable (difficult to console) -Decreased sleep pattern -Hyperflexia -Tachypnea -Vomiting and diarrhea -Uncoordinated suck Management -Position of infant on side (facilitates drainage) -Burp them a lot to prevent aspiration, LOTS of patients -Maintain sats -O2 -Suction prn -Decrease environmental stimuli and swaddle for comfort -Obtain meconium and urine (drug screening) -Monitor I & O and weight -Administer meds eg methadone and Phenobarbital -Control seizures -Offer pacifier for non-nutritive sucking -Assess: RR, weight, reflexes, CNS hyper-irritability **There is no breastfeeding from addicted mommy to baby Fetal alcohol syndrome (FAS)/ETOH Related Birth Defects S/S -Craniofacial anomalies – short eyelid openings, flat forehead, upper lip grove flat -Microcephaly – small head -Hyperactivity -Developmental delays -Poor sucks -Congenital heart defects -Mental disorders -Attention deficits
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*Education is key! Management -Position of infant on side (facilitates drainage) -Burp them a lot to prevent aspiration, LOTS of patients -Maintain sats -O2 -Suction prn -Decrease environmental stimuli and swaddle for comfort -Obtain meconium and urine (drug screening) -Monitor I & O and weight -Administer meds eg methadone and Phenobarbital -Control seizures -Offer pacifier for non-nutritive sucking -Assess: RR, weight, reflexes, CNS hyper-irritability Metabolic Conditions Phenylketonuria (PKU) -An inherited disorder that affects the body’s protein utilization caused by abnormal metabolism of the amino acid “phenylalanine” -If the disease is not detected early the infant can loose 10 pts in IQ in the first month and can lead to mental retardation Management -Protein restricted diet -Formula modified protein – hydrolysate and limited phenylalanine or free phenylalanine Assessment 40
-Obtain PKU after 48 hours of birth and no later than 7 days (infant’s need at least 24 hours of feeding to show adequate protein level) -Normal levels are <2mg/dl, if greater than 4mg/dl, test need to be repeated -S/S: FTT, vomiting, irritability, urine with musty odor, myoclonic or grand mal seizures, eczema type rash Metabolic Disorders Galactosemia (Maple syrup disease) Definition – is a disorder of carbohydrate metabolism characterized by abnormal amounts of galactose in the blood Assessment -S/S: lethargy, hypotonia, diarrhea, vomiting, jaundice, and cirrhosis -Cataracts and brain damage -Child may die after 3 days if no treatment is started Management -Beutier test is used to detect this disease (cord blood) -Diet free of galactose -Milk substitutes like casein hydrolysates (Nutramigen) Hypothyroidism Definition – a problem where the thyroid gland does not produce enough thyroid hormones to meet metabolic needs Assessment -Obtain T4 levels @ 2nd to 6th day after birth from a heel stick sample -Measure height, weight, HC, and developmental milestones S/S -Lethargy -Hoarse cry -Large, protruding tongue -Hypotonia, puffy and pale -Distended abdomen -Prolonged jaundice -Constipation -Feeding problems -Cold to touch -Excessive sleepiness Management -On thyroid medication for life Anticipatory Grief Experienced when told of the impending death of infant
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Prepares and protects parents who are facing a loss Parents who have an infant with a debilitating disease, but one that may not threaten the life of the child, also may experience anticipatory grief Loss of an infant Health care professionals can help by: Involving family in the infant’s care Providing privacy Answering questions Preparing the family for the inevitability of the death Growing emphasis on hospice and palliative care for infants and their families Key Points Preterm infants are at risk for problems stemming from the immaturity of their organ systems Nurses who work with preterm and other high risk infants observe them for respiratory distress and other early symptoms of physiologic disorders Adaptation of parents to preterm or high risk infants differs from that of parents to normal term infants Nurses can facilitate the development of a positive parent-child relationship Nurses’ skills in interpreting data, making decisions, and initiating therapy in newborn intensive care units are crucial to ensuring infants’ survival Parents need special instruction before they take home a high risk infant CPR Oxygen therapy Suctioning Developmental care SGA infants are considered at risk because of fetal growth restriction High incidence of nonreassuring fetal status among postmature infants is related to progressive placental insufficiency that can occur in a postterm pregnancy Specially trained nurses may transport high risk infants to and from special care units Parents need assistance coping with anticipatory loss and grief Regardless of infant’s disorder or condition, care provider must remember that infant belongs to a family that also has many needs Infection in neonate may be acquired: In utero During birth During resuscitation From within the nursery Nurse often is first to observe signs of newborn drug withdrawal Providing high-quality perinatal care to a varied population with multiple conditions is complicated by special needs of high risk, drug-dependent clients 42
Signs and symptoms of infant withdrawal vary in time of onset depending on type and dose of drug involved Most widespread use of postnatal testing for genetic disease is routine screening of newborns for inborn errors of metabolism Curative and rehabilitative problems of an infant with a congenital disorder are often complex and require a multidisciplinary approach to care Test Break Down: High risk pregnancy, high risk newborn, and high risk L&D (post partum) spread out evenly between all of the packets
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