NURSING 222 LECTURE NOTES                             TOPIC                                            PAGE                           2   10   34   41   53   69   88  107  129  140  158  168  190   

Lecture 1  Lecture 2  Lecture 3 

Introduction to Maternity Nursing    Uncomplicated Labor & Delivery  Analgesia & Anesthesia     

Lecture 4    Lecture 5   

Nursing in the Normal Puerperium    Nursing Care of the Normal Newborn  High Risk Newborn           

Lecture 6    Lecture 7   

Uncomplicated Pregnancy 

Lecture 8    Lecture 9    Lecture 10    Lecture 11    Lecture 12    Lecture 13   

Fetal Assessment & Pregnancy at Risk  Pregnancy at Risk #2       

Complications of Labor & Delivery    Complications of the Puerperium   

Disorders of the Female & Male Reproductive     System  Infertility & Genetics           



CSM Maternity Nursing Lecture 1 I. Intro to Maternity Nursing A. Role of the Perinatal Nurse
I. The Registered Nurse a. Scope of nursing practice determined by: -Calif State Nursing Practice Act-BRN -Community standards -Policy and Procedure of facility -JCAHO-Joint Commission on Accreditation of Healthcare Organizations -Dept. of Health Services Nurses held legally responsible for practicing within scope of practice Specialty Organization: AWHONN -Association of Women’s Health, Obstetrics, and Neonatal Nurses Orientation Period/Specialization -Labor and Delivery -Nursery/Level II Nsy/NICU -Postpartum/Mother-Baby-↑ since 1990’s -Occasional problems with comprehensive care-territorial -Differences in opinions lead to pt confusion

b. c.



Expanding roles in Perinatal Nurses a. Nurse Practitioners -Defined by ANA as: provide comprehensive health assessments, determine diagnoses plan/prescribe treatment manage healthcare regimens for the individual, families, and the community -In 1960’s, shortage of MD’s lead to 1


2 creation of the RNP -May provide family care or specialize -Take part in a certificate program or Master’s Degree program -Need at certification for third-party reimbursement -Requires documentation of continued education and practice b. Clinical Nurse Specialists -Defined by ANA: Clinical expert who provides direct pt care services --health assessments --health promotion --preventative interventions -MSN -Expertise in planning, supervising, and delivery of nursing care to families in childbearing period -Case managers -Consultant -Family and staff educator -Coordination of delivery of nursing care to families requiring intensive nursing support -Research activities/articles -May work specifically with high risk pts -Traditionally worked in hospitals but now found in nursing homes, schools, home care settings and hospice. Certified Nurse Midwife -Defined by ACNM: independent management of women’s health care especially R/T pregnancy, childbirth, PP period, and care of the newborn -Graduate from a certificate or MSN program -Also provide family planning services, other gynecological needs, and peri/ postmenopausal care -One of the oldest professions -1925-Mary Breckenridge establishes 2


and minorities who don’t seek out regular health care -lower rates of cesarean sections in facilities where CNM’s practice d. medications -Minimum 24 month programs/MSN with --45 hrs professional aspects --135 hrs anatomy/physiology/ pathophysiology --45 hrs chemistry --90 hrs anesthetic principles --45 hrs clinical/literature review --knowledge of at least 450 anesthetics -80 % practice in an anesthesia care team -20 % practice independent at solo providers Nurse Consultants -experts in a specific area of nursing -fee for service -may act as expert witnesses -used by corporations R/T developing products/equipment -consult to texts. airway. local.4 3 Frontier Nursing Services-first NurseMidwife to practice in the US -American College of Nurse Midwives was incorporated in 1955 -provide care to women with low incomes. and periodicals 3 e. and sedative anesthesia --manage pt’s airway/pulmonary status --facilitate emergence/recovery from anesthesia --provide follow-up evaluation and care --respond to emergency situations to asst with ACLS. electronic media. Certified Nurse Anesthetists -Defined by AANA: provide --pre-anesthetic assessment --develop and implement plan of care --perform general. uninsured. regional. .

a. Litigious nature of this specialty ↑ number of malpractice cases involving childbirth issues -OB/Gyn cases 2nd only to surgeries Minimum standard of care: -care that a reasonable. c.5 4 B. d. h. f. Legal and Ethical Issues I. g. prudent nurse would provide in the same or similar circumstances Predominant theory of Liability-negligence -4 elements duty exists breech of duty-standard of care violated injury connection between violation of the standard and the injury Malpractice lawsuits are based on the assumption that the health care provider failed to meet the professional standard of care and resulted in injury Alleged injury to fetus. or mother Families expecting a healthy child-bad outcome means mistake must have been made Attribute problem to one or more members of the health care team -frequent unavailability of physician -time frame to communicate may be short To support expert opinion. e. neonate. need evidence: -hospital procedures -nursing policies -guidelines established by professional organizations -state nurse practice acts -JCAHO b. 4 .

f. risks and consequences of no further tx. battery. Informed Consent a. 5 . g. Process by which a pt decides to have a certain medical or surgical procedure -includes knowing and understanding what health care treatment is being undertaken More than just signing a form Process by which the physician. or a combination of actions types of consent: -expressed-oral or written -implied: nurse states here to draw blood and the pt extends her arm --may be used in emergency cases --when pt continues to take tx without objection --during surgery. uncoerced. d. provider could be the subject of a lawsuit alleging assault. additional surgery is indicated Informed refusal -can take place at initiation of tx or any time after start of tx -refusal is valid even after informed consent is given -refusal must be voluntary. nurse. and not made under fraudulent circumstances -pt must refuse tx with knowledge and understanding of the refusal -chart should include signed refusal form by pt and nursing notes should include time left. left with whom.6 5 II. and who will be notified b. c. negligence . and possibly other health care professionals convey to pt the information for them to decide whether or not to proceed with the course of tx Without proper consent.

g. Standardized procedures/policies supervision of unlicensed asst. #1 allegation: birth of neurologically-impaired infant reporting/recording errors: -incomplete initial H & P -failure to observe & take appropriate action -failure to communicate changes in a pt’s condition in a timely manner -incomplete and/or inadequate documentation -failure to use or interpret fetal monitoring appropriately -inappropriate pitocin monitoring/usage -improper sponge/instrument count almost ¾ of OB/Gyn’s have been sued -most cases will not go trial but be settled out of court 30% have had 3 or more law suits rising costs of liability insurance ↑ demands for accountability created by expanding the scope of practices cost containments -shorter hospital stays -use of unlicensed asst personnel -decrease in hospital staff changes in technology mean needed continued education: EFM c. b. h. b. IV. f.7 6 III. d. personnel KNOW your facility’s Scope of Practice 6 . e. Common Legal Pitfalls a. Standards of Care a.

Reproductive Technology -IVF-ET -GIFT. b. Ethical Dilemmas Unique to Perinatal Nursing a. Wade (1973) -morning-after pill Plan B-levonorgestrel -lack of estrogen ↓ nausea -medical abortion US: mifepristone + misoprostol France: RU-486 artificial insemination -AIH-husband’s sperm-problem with mother -AID-donor sperm -legal problems-donor relinquishes rights surrogate childbirth -buying a child-$$$$ -biological mother may refuse to give up the newborn ART-Asst. fetal research-laws vary by state fetal surgery -i. 7 . g.e. f. congenital diaphragmatic hernia -what if mother refuses tx abortion-Roe vs.8 7 VI. d.: bilateral hydronephrosis. e. ZIFT embryonic stem cell research/cord blood banking c.

9 8 h. V. and deprivation? -who decides if major intervention is used -what kind of care do you give or deny the infant to allow him to die with dignity and comfort The Mother -use life support in irreversible conditions? i. (Review books) Review of Conception/Fetal Development 01/13 8 . no ↓ in rate of CP -is partially responsible for ↑ in C/S rate -ordinary part of Intrapartum careconstant threat of legal action b. Communication -interactions between MD’s. less use of litigation -earlier discharges home mean more educational responsibilities for the RN Use of EFM -first introduced at Yale University in 1958 -In last 25 yrs of use. disability. C. Nursing Role a. The Neonate -iatrogenic procedures prolonged use of ventilators O2 therapy -problem: should we save the lives of infants only to have them lead lives of pain. & nurses -was a clear line of communication used -was the chain of command followed -was there informed consent -the better the communication between nurse and pt. CNM’s.

Maternal response 1. CV a. WBC’s 25-30. hematopoietic 1. dehydration. Increase in cardiac output 10-15% Stage I 30-50% Stage II c.10 1 Uncomplicated Labor and Delivery Lecture 2 (2 days) I. hypovolemia d. blood flow ↓ in the uterine artery during contractions and is redirected to the peripheral vessels 2.000 mm secondary to stress. Stage II-↑ BP further 5. ↑ plasma fibrinogen→ ↓ blood coag time→ ↑ clotting factors to protect against hemorrhage but ↑ risk for thrombophlebitis (inflammation of vein in conjunction with formation of a thrombus (blood clot of a vessel or a cavity in the heart) . During U/C-300-500 ml blood from uterus to vascular system b. peripheral resistance occurs with an ↑ in BP and ↓ of pulse 3. Physiological effects of the birth process A. Blood pressure changes 1. trauma e. hydramnios. Supine hypotension-risk factors multifetal.↑ 30 mm Hg systolic ↑ 25 mm Hg diastolic 4. desire Hgb at least 11 g/dl Hct 33% or higher 2. Stage I. obesity.

NPO status. Breakdown of proteins may lead to proteinuria-albumnin in the urine 5. Proteinuria-↑ in amino acids may exceed capacity of renal tubules to absorb -may be renal damage caused by vasospasms of tubules GI a. hypocapnia (↓CO2) c. 4. ↑ in resp. Voiding may be difficult r/t anesthesia or Pressure from presenting part-↓ sensation of a full bladder c. and ↑ temp b. Fatigue of muscles/strain b.11 2 2. Fluids at tolerated r/t ↓ GI motility and absorption with delay in stomach emptying N & V with diarrhea in labor 3. Respiratory a. . hyperventilation →respiratory alkalosis ↑ in pH. hypoxia. alkalosis Muscular/skeletal a. ↑ insensible water loss through respirations. Fluids/electrolytes a. 2nd Stage-O2 consumption ↑ → metabolic acidosis uncompensated by resp. b. Diaphoresis. and softens the cervix) c. inhibit uterine contractions. ↑ O2 consumption. rate b. Separation of pubis symphysis -May be related to pregnancy or delivery process (relaxin-polypeptide hormone-secreted in corpus luteum during pregnancy-can relax the symphysis.

Neurological a. partial to total amnesia in 2nd stage Integumentary a. ∆ in fetal heart rate (FHR) -maternal hydration N&V ↑ maternal temp insensible water loss -maternal position -medications to mother -placental issues post dates-calcifications smoker/↑ BP-↓ placental size velamentous insertion (umbilical cord attached to the membrane a short distance from the placenta cord compresson -maternal anxiety . exacerbation of pruritusmay be related to cholestasis (arrest of the flow of bile) in pregnancy 7. diaphoresis b. B. ↑ anxiety c.12 3 6. ↑ temperature-may be R/T to maternal efforts or infection c. Fetal Response 1. Euphoria-believe it or not! endorphins-↑ pain threshold and produce sedation b. CV a.

False pelvis-the upper pelvis -portion above the inlet . Pulmonary a. Passageway 1. thoracic cavity squeezed -not as much in C/S cases -precipitous deliveries (swift progression of 2nd stage of labor marked by rapid descent/expulsion of the fetus) -may need extra suction b. 4 bones -2 innominate (nameless) bones -made up of 3 bones -ilium-iliac crest -ischium-ischial tuberosity -spines-shortest diameter -pubis-symphysis pubis -the sacrum -the coccyx b.13 4 2. maternal pelvis a. and smooth muscle b. metabolic rate. passing of meconium (1st feces of neonate) may need resuscitation effort Catecholamines a. II. change R/T ↑ stress of labor speed clearance of fluid 3.. temp. Essential Components of the Birth Process A. neuro. epinephrine & norepinephrine-active amines (nitrogen-containing organic compounds) -have effect on CV.

5-2 cm less than diagonal -midpelvis-cavity. anthropoid-oval shaped -24% of women -usual mode of birth-vaginal spontaneous or asst. android-heart shaped -23% of women -usual mode of birth-cesarean possible forceps-difficult c.5 cm or greater -obstetric conjugate. platypelloid-flat shaped -3% of women -not favorable for vaginal delivery . gynecoid-round -50% of women -most favorable -usual mode of birth-vaginal b. True pelvis -inlet -diagonal conjugate-lower border of symphysis pubis-sacral promontory -usually 12.5 cm -outlet -transverse diameter-intertuberous diameter-> 8 cm 2. midplane -transverse diameter-interspinous diameter-10. Pelvic shapes a. -may lead to OP position d.14 5 c.also called anterior/posterior diameter -measurement that determines whether presenting part can engage superior strait -usually 1.

fontanels-where membranes intersect -anterior (bregma)-diamond-shaped-2cm by 3 cm -closes by 18 months -posterior-triangle-shaped-1cm by 2 cm -closes by 8-12 weeks e. Fetal Presentation a. Fetal skull a.15 6 B. overlapping of bones to pass thru pelvis c. factors that influence presentation -fetal lie -fetal attitude -extension/flexion of fetal head . sutures-membranes -frontal -sagittal -lambdoidal -coronal d. Passenger 1. landmarks -mentum-chin -sinciput-brow -vertex-between anterior/posterior fontanel -occiput-beneath the posterior fontanel 2. made up of 6 bones -frontal -2 parietal -2 temporal -occipital b. not fused together-allow for molding. fetal part entering the pelvis first -cephalic (head)-96% -breech (buttock)-3% -transverse (shoulder)-1% b.

general flexion -back is rounded -chin flexed onto chest -thighs flexed on the abdomen -legs flexed at the knees -arms crossed over the thorax -umbilical cord lies between arms/legs c. relationship of long axis (spine) of fetus to long axis (spine) of mother b. primary lies: -longitudinal (vertical)-cephalic. diagnosed using -Leopold’s maneuvers -verify with ultrasound external version-MD attempts to manually rotate the fetus into a cephalic presentation -done in L &D -ultrasound to check fetal/placental position -may use medications to relax uterine muscle -frequently uncomfortable for mother 3. relationship of fetal parts to one another b. Fetal Lie a.25 cm -suboccipitobregmatic-9. . d.5 cm 4. breech -transverse (horizontal or oblique)-shoulder Fetal Attitude a.5 cm -occipitofrontal-12 cm -occipitomental-13.16 7 c. head flexion -biparietal diameter-9.

P.T) Station a. involuntary uterine contractions -start at fundus-thickened uterine muscle layer of upper uterine segment -upper segment thicker so more active -lower segment has less muscle -contractions move down muscle in waves -assessed by: reports from mother RN palpating fundus monitor b. Fetal position a.S. Primary Powers a. negative stations-higher in the pelvis c. relationship of presenting fetal part to 4 quadrants of maternal pelvis b. positive stations-lower in the pelvis 6. primarily responsible for dilation of cx and descent of fetus -drawing upward of the musculofibrous components of the cervix with fetal head compression lead to dilation (opening) -full dilation (10 cm) marks the end of .M) -3rd letter-location of presenting part in relationship to maternal pelvis (A. indicated using a 3-letter abbreviation -1st letter-location of part in pelvis (R or L) -2nd letter-presenting part of fetus (O.17 8 5. Powers 1. C. relationship of presenting fetal part to an imaginary line at the maternal ischial spines: 0 station is at the spines b.

acme. Secondary Powers a. better results when await maternal need . the first stage of labor effacement (thinning) -cx usually 3 cm long. decrement -involuntary. intermittent -frequency-beginning of one to the beginning of the next -regularity-usually start irregular then becomes more regular as labor progresses -duration-start to end of contraction -intensity-mild. bearing down effort at 10 cm -contraction of diaphragm and abdominal muscles while pushing b.18 9 c. 1 cm thick -taken up by shortening of uterine muscle bundles -usually expressed in % uterine contractions -3 phases-increment. d. usually no effect on dilation-important R/T expulsion of fetus and placenta d. rhythmic. ↑ intraabdominal pressure that compresses uterus on all sides c. moderate. strong or strength can be measured with internal monitor (IUPC) with resting tone usually 15-25 mm Ferguson’s reflex -presenting fetal part reaches perineal floor -mechanical stretching of cervix occurs -stretch receptors in vagina trigger exogenous (originating outside an organ) oxytocin release -triggers maternal urge to bear down 2. e.

Placenta 1. Structure a.19 10 e. structure is completed by 12 week e. f. breaks may occur in placental membrane allowing mixing of maternal and fetal blood-Rh sensitization f. formed at implantation b. position problems -previa-implanted in lower uterine segment-covers internal cx os -abruptio-separation of placenta from uterine wall -accreta-cotyledons invaded uterine musculature -increta-invasion into the myometrium -percreta-invasion to the serosa of the peritoneum covering of the uterus can lead to uterine rupture . cotyledon-mass of villi on the chorionic surface of the placenta -15-20 in number d. to bear down rather than start pushing at 10 cm debate over how to push -valsalva-closed glottis. prolonged push -open glottis pushing -mini pushes prolonged pushing efforts can lead to fetal hypoxia/acidosis and severe maternal perineal lacerations D. decidua (endometrium during pregnancy) basalis-with the chorion (extraembryonic membrane) forms the placenta c.

Function a. umbilical cord insertion problems -battledore-insertion into the margin of the placenta-resembles a paddle -velamentous-attached to membrane a short distance to placenta 2.20 11 g. endocrine gland-produces hormones to maintain pregnancy -hCG-human chorionic gonadotropin -basis for pregnancy test -preserves function of corpus luteum -ensures continued supply of estrogen/progesterone -reaches max level at 50-70 days -hPL-human placental lactogen -similar to growth hormone -stimulates maternal metabolism -↑ resistance to insulin and facilitates glucose transport across placental membrane (GDM?) -estrogen (estriol) -stimulates uterine growth -stimulates uteroplacental blood flow -progesterone -maintains endometrium -decreases contractility of uterus -stimulates development of breast alveoli and maternal metabolism metabolic functions b. -respiration -nutrition -excretion -storage .

social/economic responsibility 2. trust in staff-medical and nursing j. Factors associated with birth experience a. not being left alone i. partner’s commitment d. attendance at childbirth classes c. cultural/religious influences f. factors which could effect function -smoking -drug use -poor nutrition -↑ BP -maternal position -infection -trauma E. accomplishment of tasks of pregnancy b. self-confidence/self-esteem e. + relationship with partner f. sense of competency/mastery d. preparation for childbirth e. maintaining control during labor g. motivation for pregnancy b. pain management k. ↑ anxiety. support during the delivery h. ↑ for medical interventions .21 12 c. length of labor process-exhaustion. usual coping mechanisms in response to stress c. support system-esp. Factors influencing woman’s reaction to physical/emotional crisis of labor a. Psyche 1.

cortisol-(adrenocorticcal hormone) -slows production of progesterone -stimulates prostaglandin precursors Uterine Distention Theory a. promotes prostaglandin synthesis (also stimulates muscle) Progesterone Withdrawal Theory a. keeps estrogen in check) c. 5. . produced by posterior pituitary c. Estrogen Stimulation Theory a. ↑ response to oxytocin as nears term 2. usually relaxes muscle b. estrogen stimulates smooth uterine muscle to contract b. oxytocin stimulates smooth uterine muscle contractions d. ↓ progesterone (prog. 4. ↑ estrogen. stretching of cervical os causes ↑ in exogenous oxytocin b. stretching uterine muscles causes irritability leading to contractions b. Oxytocin Stimulation Theory a. at term-↓ in effectiveness Fetal Cortisol Theory a. fetus produces more cortisol b. stimulates production of prostaglandins 3.22 13 F. as approaches term. III. at term. Position (maternal)-See book Labor Physiology A. Labor Onset Theories 1.

occasionally bloody show noted with dark brown or light pink-tinged mucus noted Persistent low back ache a. and warm showers/baths help 3. 4. Signs of Labor 1. ↑ need to void Cervical and vaginal changes a. 2-3 weeks in primigravidas closer to onset of labor in multiparas c. 4-6 weeks before onset of labor b. Braxton-Hicks contractions a. may be strong and frequent but usually are irregular in pattern 2. Lightening a. Prostaglandins a. easier to breathe. cervix ripens (softens) and may begin to dilate and efface b. R/T relaxation of pelvic joint and descent of fetus b. fetal descent into the true pelvis b. 1day. change of position. can have production stimulated by various methods -↑ synthesis of PGE2 in amnion c. . vaginal mucus ↑ with mucus plug being released 1hr.23 14 6. stimulate smooth muscle to contract b. warm packs. research varies whether concentration of prostaglandins ↑ in amniotic fluid and maternal blood just before labor onset B. or even 1 week before start of labor c. uterine muscle workout before labor c.

R/T GI upset with N & V and diarrhea b. Effacement a. effaces. dilates Fetus starts descent into pelvis vary milder ↓ with walking felt in back or pelvis ↓ with relaxation techniques no significant changes no change in position D. Effacement. Weight Loss a. usually starts 1-2 days before onset Nesting a. C. thinning of cervix (shortening from usual length of 2-3 cm) b. have a need to get everything in order for arrival of baby 6. True vs. and station 1.24 15 5. have a burst of energy b. False Labor True False Uterine contractions regular irregular close together stronger ↑ with walking felt in low back then radiates to abdomen not stopped by bath or fluid Cervix softens. dilation. documented either in %’s or cm’s .

documented from –4 to +4 c. E. both dilation and effacement are measured by fingertip palpation or visual inspection with sterile speculum Station a. opening of cervical os from closed to 10 cm b.25 16 2. using imaginary line at ischial spines. note location of presenting fetal part b. may need oral/IM medication for rest 2. 50-90%. Stages and Phases of Labor 1. Stage 1 (0-10 cm)-has 3 phases a. ballottable-when presenting part is floating in and out of the pelvis 3. strong regular contractions without cervical change b. Prodromal phase a. -3to -1 -able to walk and talk -able to eat light meals -may be home for most of this phase -involves more cx effacement and less change in fetal position -U/C’s may be 2-10 minutes apart -U/C’s mild by palpation -lasts an average 8 hours for primips -multiparas may have cx dilate to 3 cm days prior to onset of labor . Early/Latent phase-0-3 cm. Dilatation a. leads to exhaustion R/t inability to sleep c. due to retraction of cervix into the lower uterine segment R/T uterine contractions and pressure from amniotic sac and fetus c.

100%. MD will need to manually remove-consider pain meds for mom Stage 4-Recovery a.5 hrs Transition phase-8-10 cm. 5. multiparas-15 min-1 hour without epid. mom-1-4 hours b. if retained. moderate by palpation -U/C’s last approx 60 sec -may start to have nausea/vomiting -may ask for enema if impacted to speed descent of fetus -may ask for pain medications -provider may decide to AROM to help speed labor -expect cx to change 1cm every 1-1.26 17 b. 1-2 hours with epidural Stage 3-birth of neonate to expulsion of Placenta a. -2 to 0 -U/C’s every 3-5 minutes. -ROM may occur during this time Active phase-4cm-7cm. usually lasts 20 minutes to 1 hour b. . -1 to +1 -U/C’s every 1-3 minutes with ↑ intensity -U/C’s last 45-90 sec long -using breathing techniques not to push too early -may ask for more pain medication -shortest phase-usually 15 min-3 hours with delays R/T medications/infections 3. c. baby-6 hours 4. Stage 2-10 cm (pushing) to delivery of neonate a. 3-4 hours with epidural b. 80-100%. nulliparas-2 hours on average-no epid.

shoulders rotate to anteroposterior b. Flexion a. natural attitude of fetus b. extension/straightening of fetus 2. fetal head rotates further to one side Expulsion a. fetal head begins to crown External Rotation a. uterine pressure on the breech c. . to go thru transverse diameter b. Engagement and Descent-occurs r/t: a. Mechanisms of Labor (Cardinal Movements) 1. posterior shoulder and body is then delivered 3. 5. fetal head flexes as it meets resistance Internal Rotation a. contractions of abdominal muscles d.27 18 F. rotates to occiput anterior Extension a. 4. pressure of amniotic fluid b. resistance of pelvic floor with vulva opening forward and anterior b. anterior shoulder slips under symphysis pubis b. 6.

ask why she came in b. any other symptoms? . 2nd stage-5 minutes-2 hours c. any complications of pregnancy c. blood type/RH factor 2. 1st stage-13 hours (1. urinalysis 8. Labor Duration 1. 3rd stage-10-20 minutes 2. any bleeding? e. 2nd stage-5 minutes to 1 hour c. HbsAG-surface antigen 4. any U/C’s? d. primary language 2.2 cm/hr) b. HIV test e. any high risk behaviors d. assess attendance to PN appts b. + FM recently? f. culture for GBS 7. VDRL/RPR-syphilis screen 3. Nulliparas a. Rubella immunity 6.28 19 G. 1st stage-7 hours (1. abnormal lab/ultrasound reports 1. prenatal record a. Plan of Care A.5 cm/hr) b. Assessment-Data Collection 1. Primi/multiparas a. CBC 5. status of BOW c. 3rd stage-5-20 minutes IV. initial interview a.

cultural/religious needs clinical evaluation of labor status a. ck for med allergies i. head to toe assessment h. Leopold’s maneuver e. palpate strength of U/C’s d. ultrasound if needed g. ck fetal lie/AFI with ultrasound expressed psychosocial and cultural factors/needs a. social support -family near by -friends who can pitch in d. CBC b. . history of depression/suicide attempts c. vaginal exam f. ask about classes taken 4. RBS (sure step or lab draw) d. PIH panel c. ck nitrazine paper or ferning d. if ROM. CBC and urine test c. sign consent forms b.29 20 3. 5. maternal vital signs b. FHR tracing c. history of sexual/physical abuse b. assess cervical dilation/effacement lab reports/ultrasound results a. physical exam a. 6. assess fetal presentation e.

Nursing Diagnoses 1. 4. discuss progress of labor e. and expectations of labor d. experiences. administer medications to aid in contraction of uterus e. possible type and screen/cross match if transfusion needed 3. orient parents to unit b.30 21 B. encourage frequent voiding c. Pain R/T increasing frequency and intensity of contractions a. encourage use of relaxation techniques d. assist to BRP or use catheter prn Risk for fluid volume deficit R/T ↓ fluid intake and blood loss during birth a. . administer oral/parenteral fluid prn c. palpate the bladder superior to symphysis b. Anxiety R/T labor and birthing process a. assess level of pain b. monitor fundus for firmness d. encourage support people to aid in comfort measures c. assess woman’s knowledge. explain when and why analgesics may be used Risk for altered pattern of urinary elimination R/T sensory impairment secondary to labor a. monitor fluid loss b. explain admission protocol c. involve woman and partner in care decisions during labor 2.

Fetal monitoring a. . 4. compression of umbilical cord a. Vital signs a. use of support people 3. assess FHR at least once hourly in early phases b. Interventions-Priority Setting 1. possible need for amnioinfusion C. maintain adequate hydration c. may need continuous monitoring c. consider internal monitoring for poor tracing.31 22 5. ck oxygen saturation if decels noted Comfort measures a. breathing/focal points/distractions -labor shakes are normal b. lack of progress. notify provider if BP above 140/90 b. shut off pitocin e. oxygen via mask if O2 below 90% d. or meconium Hydration/oxygenation a. encourage po fluids or start IV if N & V b. keep mother off her back b. fatigue. Impaired gas exchange R/T maternal ↓ BP. hydrotherapy/massage c. ck temp q 4 hrs if ROM 2. introspection -8-10 cm: irritable. excitement -4-7 cm: seriousness. amnesia d. active listening R/T maternal behaviors -0-3 cm: anticipation.

assess maternal VS and FHR tracings per hospital policies e. oral medications d. keep Provider aware of pt’s progress f. room prepped for delivery -warmer for neonate -delee suction if meconium present -possible need for Pedi -keep up NRP/BLS skills b.32 23 5. assess need for addition oxygen R/T FHR tracing d. . showers/warm or cool packs b. provider should be in LDR before head is crowning to provide support for perineum h. clean perineum if requests by provider i. Pain management a. asst partner with cutting of umbilical cord 6. IV or IM medications e. asst mother with a variety of positions while pushing -short pushes 6-7 seconds -consider open-glottis pushing -squatting can open the pelvis an addition ¼ inch c. Epidurals 2nd stage interventions a. consider lessening epidural dose if pushing effort less than adequate g. at delivery. massage c.

immediate newborn care -dry off fluids. observe for need for pitocin/methergine d. VI. Electronic Fetal Monitoring-skills lab Related Pharmacology-medication administration cards 01/13 . ice pack to peri/VS q 15 min/pain meds f. prepare for possible trip to OR if placenta is retained (↑ 1 hr) g. promote bonding/breastfeeding even during repair e. fundal rub post delivery of placenta -watch for trickle/spurt of blood and change in uterine shape to herald expulsion of placenta c. asst provider with lidocaine/suture if perineal/vaginal repair is needed -episiotomies: median or mediolateral -lacerations: 1st degree-skin.33 24 7. skin to skin. superficial 2nd degree-muscles of perineum 3rd degree-to anal sphincter muscle 4th degree-anterior rectal wall b. suction mucus -ck for 3-vessel cord -ck physical assessment/wt./length -APGAR score and infant ID tags V. 3rd and 4th stage interventions a.

breathing techniques 6. First Stage 1. massage/counterpressure 3. Transcutaneous Electrical Nerve Stimulation unit (TENS) 7. Early phase-0-3 cm a. Anxiety and fear of the unknown might heighten their level of pain 4. focal points 2. Be aware of cultural differences in response to pain -Asian populations may not exhibit pain or ask for pain medications -Hispanic women may be very stoic until just before the delivery of the baby -Middle Eastern groups may be very vocal in requesting early use of medications for pain 3. heat/cold packs 8. music 5. nonpharmacological methods 1. Ask patient comfort level and current pain level -0-10 scale or coping scale -comfort level is when they can participate in ADL’s without the need of pain meds 2. hypnosis 9. Data Collection and Assessment 1. Previous experiences with childbirth or other painful procedures may lead to higher levels of concern about pain management needs 5. changing positions/walk/rocker . Labor Pain A.34 1 Analgesia and Anesthesia Lecture 3 I. Attendance to childbirth classes may aid in the patient’s ability to cope through contractions B. hydrotherapy/aromatherapy 4.

usually orals: percocet vicodin/norco benadryl acetaminophen 3. C. encourage position changes if possible d. may want to be out of bed and push on toilet to relieve backache c. Second Stage 1. should be discouraged as they could slow the labor process 2. usually requests IV medications for fast action -fentanyl -nubain -stadol c. may receive a pudendal block which relieve pain in the vagina. may use many of the same non-medication choices as above b. vulva.35 2 2. If no epidural is in place. 3. May receive local anesthesia for repair of perineal laceration or episiotomy 3. occasionally IM: morphine with phenergan Active phase-4-7 cm a. short acting IV narcotics still ok but have Narcan available for infant resuscitation b. May continue pushing with epidural pump on if efforts are affective 2. when pain is more intense. may request epidural b. may also request and receive an epidural at this stage in labor Transitional phase-8-10 cm a. and perineal regions . pain medications 1.

Teens and Older Primigravidas B. may receive IV pain medications or be moved to OR for twilight sleep 2. use of local anesthetics or pudendal block (less common) II. For laceration/episiotomy repairs. Inability to relax back muscles and do deep breathing may lead to difficulty placing epidural catheter B. Psychological effects 1. Support person E. Tensing up against the pain leads to muscle and ligament strains in other parts of the body 3. may become hostile to staff/family R/T inability to cope III. If placenta is retained.: OP presentation .e. Effect on cervical change-more in pain. Preparatory classes F. Fetal position-i. less able to relax and let the labor progress 2. Cultures/Religions C. Previous experiences with pain D. “I can’t do it”-ineffective pushing due to fear of pain 2. inability to make decisions R/T pain 3. Factors Influencing Perception of Discomfort A. Physiological effects 1. May not keep properly hydrated and nourished R/T the intensity of the pain 4. Adverse Effects of Excessive Pain A. Third Stage 1.36 3 D.

encouraging resting between U/C’s 6. Pain R/T physiologic response to labor 1. Other possible nursing diagnoses 1. keep pt. will pain med even be effective 5. Anxiety R/T pain 5. assess patient’s knowledge of labor and relaxation techniques 2. Ineffective airway 2. encourage support people to aid in comfort measures 3. Pertinent Nursing Diagnoses A. If previous abuser of medications. and family notified of labor progress 7. Maternal concerns that she wasn’t “strong enough” to make it thru without pain meds 3. Cultural beliefs . offer possible choices for pain medications if all other methods have been unsuccessful B. assess need to void/defecate 5. Fetal oxygenation 4. Need to taper dosage to the patient 4.37 4 IV. Considerations for the Pregnant Patient 1. etc. Fluid volume deficit 3. What medications you give the mom you give the fetus 2. teach alternative non-pharmacological methods of pain relief 4. (see others in book) V. Pharmacological Pain Management A.

.38 5 B. Vistaril) -decrease anxiety and apprehension -helps reduce the amount of narcotic needed for relief Anesthetics (Regional and General) 1. may decrease ability to bear down R/T lack of sensation c. epinephrine may be added to intensify anesthetic and decrease bleeding 2. Analgesics a. goal to anesthetize the pudendal nerve located near the ischial spines b. Local block a. 1% lidocaine used c. Sedatives may be given in early labor to aid With sleep and anxiety but can lead to a Slowing of the labor progress and noted respiratory depression in the patient along with vasomotor depression of both mom and fetus. Pudendal block a. and adjuncts 1. analgesic potentiators -usually antiemetics (Phenergan. injected into skin and subcutaneous d. IV is preferred over IM due to rapid onset but IM medications last longer c. Analgesics. usually used on perineal region b. doesn’t provide pain relief for manual C. 2. sedatives. narcotic compounds -Demerol-meperidine -Sublimaze-fentanyl -Stadol-butorphanol -Nubain-nalbuphine -respiratory depression -tachy/bradycardia d. can be systemic crossing the blood/brain barrier as well as the placental barrier b.

pt. awake for procedure/delivery d. or L5 interspace→subarachnoid space 4. and narcotic antagonists should be handy to treat possible side effects of epidural n. may increase labor time and need for pitocin augmentation m. needs IV bolus before insertion R/T maternal hypotension due to vasodilation b. be prepared for possible severe adverse reactions such as bronchospasms. dyspnea.39 6 3. sitting up for placement e. antipruritics. done by CRNA or MD c. possibility of spinal headache if needle placement is not correct i. may need frequent position changes side to side to keep anesthetic level equal f. usually a local anesthetic alone or mixed with a narcotic (fentanyl. . saturates pain receptors but not motor one j. L4. sudden ↓ in BP.) l. pt. may need to use Ephedrine (a vasopressor) if maternal BP ↓ k. antiemetics. or convulsions-crash cart should be available on unit Spinal block a. extraction of placenta or uterine exploration Epidural block/PCEA a. as with any medication. local anesthetic into the L3. preferred block T10-S1 g. after insertion. etc. need Foley cath in bladder due to inability to feel when to void h.

c. oral sodium citrate before start c. general anesthesia may be needed during manual placenta removal or D & C 01/13 . IV maintained. wedge should be placed under mom’s R hip to displace uterus to the L g. pulse. resp. General anesthesia a. ↓ CO. IV. normally recovered in PACU (recovery rm) so bonding with infant delayed e. may be needed for C/S if unable to access regional block or in emergency cases b. besides C/S. as with all anesthesias used during C/S. d. RN may be asked to give cricoid pressure to aid anesthesiologist in tube placement d. e. e. and placental perfusion maternal BP.40 7 b. and FHR are assessed every 5 minutes for the first 15-30 post injection 5. medication mixes with CSF-saturates pain and motor receptors used for cesarean sections risk of spinal headache due to leak of CSF-may need to remain supine post delivery. effort. NPO. regional blocks-mother unconscious during birth of infant f. while rarely used. higher risk of complications vs. and possible blood patch IV bolus given prior to procedure R/T risk of maternal hypotension.

white l. 6 months for return of pelvic musculature 2. CO remains elevated for 2 weeks-12 wks before ↓ to prepregnancy values b. Cardiovascular a.41 1 Nursing in the Normal Puerperium (the period of 42 days post childbirth and expulsion of the placenta) Lecture 4 I. fundus descends 1-2 cm/24 hrs d. soft. placental site regeneration complete at 6 wks k. within 12 hours. vagina-returns to prepregnancy state by 6-8 wks n. fundus at U/U c. EBL 300-500 ml-vaginal birth 500-1000ml –C/S . complete within 4-6 months -Red -Edema -Ecchymosis -Drainage -Approximation o. oxytocin released from pituitary gland helps uterus to contract-↑ with BF i. brown alba-10 dys-2 wks-yellow. Alterations in the body systems as a result of the birth process 1. ↓ in estrogen/progesterone=autolysis f. involution of uterus-return to non-pregnant state-caused by contractions of uterine muscles (size of a grapefruit after 3rd stage) b. uterus not palpable after the 9th PP day e. change in lochia-rubra-1-3 days-bright red serosa-3-10 days-pink. afterbirth pains ↑ in multiparas j. cervix-bruised. Reproductive system a. subinvolution-failure of uterus to return to non-pregnant state-usually involves retained POC or infection g. Physiology of the puerperium A. perineum-healing start by 2-3 wks. inner layer becomes new endometrium h. outer decidua sloughs off as lochia. swollen-closes by 2 wks -external os-appears as jagged slit m.

blood volume increased by: -elimination of uteroplacental circulation -loss of placental endocrine function which removes stimulus for vasodilatation -mobilization of extravascular water stored Vital signs: -Temp-↑ to 380 C/1004 F R/T dehydration -Pulse-↑ 1st hr-return to pre-preg.42 2 c. . etc c. pitocin. d. excessive vaginal bleeding may be noted if bladder is allowed to get distended with urine Musculoskeletal a.e. tx hemorrhoids-ice packs. tucks. e. may have permanent increase in shoe size c. diuresis-from fluid retention. 3. returns to normal function 1 month after birth -bladder tone returned by 5-7 days b. no BM for 2-4 days post delivery -encourage ambulation -hydration -fiber -medications. crm -no pr meds if 3rd-4th degree laceration d. i. f.: stool softeners c. g. 5. joints stabilize 6-8 weeks post birth b.000/mm3 Coag factors-hypercoagulable state may lead to possible thromboembolism Gastrointestinal a. ↑ appetite b. 8-10 wks -Resp-↓ by 8-10 wks -BP-may have orthostatic hypotension Hgb/Hct: -1st 72 hrs-↑ loss of plasma volume compared to RBC’s -↑ in H & H by day 7 WBC’s may ↑ to 25-30. may have separation of symphysis pubis or rectus abdominis 4. Kegel exercises to strengthen pelvic floor Renal a.

8.43 3 6. appearance. . mutuality-infant’s behaviors stimulate mom’s f. responsive infant and repelled by irritable. hyperpigmentation of areolae and linea nigra may continue c. voice. cortisol progesterone. interaction d. Integumentary a. identify infant as an individual yet part of the whole family e. and sex fit parent’s expectations h. chloasma (mask of pregnancy) usually fades by end of pregnancy b. behaviors -entrainment-moving in time with adult speech -biorhythmicity-soothed by mom’s heartbeat -reciprocity-responds to cues -synchrony-mutually rewarding -engrossment-interest in baby by father 7. attachment occurs more readily with the infant whose temperament. and hPL (hCS) [human placental lactogen/human chorionic somatomammotropin] -reverse diabetogenic effect-lower BS level b. social capabilities. Expulsion of placenta=↓ in estrogen. parent’s acceptance of infant’s needs and abilities b. need to assess mother-infant communication i. may feel attracted to alert. need to learn cues. disinterested infant g. if BF-↑ prolactin levels for 6 weeks if bottle-fed-↓ -usually means later ovulation in lactating women Psychosocial a. touch. understand emotional states c. may note perfuse diaphoresis post delivery Endocrine a. bonding-proximity.

Fundus a. depression. soreness. anger. passive -taking hold-last 10 days to several weeks-focus on care of baby and competent mothering-dependent -letting go-focus on forward movement of the family unit PP blues. Data collection/Assessment 1. Situational low self-esteem 7. weepiness (resolves in 10-14 days) PP depression-7-30%-more severe syndrome -depression. loneliness II. Ineffective breast feeding 6. insomnia. note any redness. lochia b. k. Nursing Process A. assess site for intactness. feeling of failure overwhelming guilt. maternal adjustments -taking in-first 24 hrs-focus on self and basic need Dependent. measure first voids until 500 ml (voided out) c. Anxiety due to lack of knowledge base 8. Breasts a. Fatigue 5. ck fundal location. l.70% of women-mood swings. . edema. or drainage (REEDA) b.44 4 j. etc. letdown. assess for distention b. hematomas. Bladder a. Pain 4. fatigue. if repair done. Perineum a. cracking of nipples B. have pt empty bladder before exam 3. Risk for fluid volume deficit 2. assess for presence of hemorrhoids 5. tone. Alteration in urinary elimination 3. Vital signs 2. note if breast are filling-palpate b. Nursing Diagnoses 1. redness. catheterize if needed 4. H/A’s.

Newborns’ and Mothers’ Health Protection Act of 1996 a. warm packs before breast feeding. Tdap-Pertussisq.45 5 C. voiding c. pt and doctor may agree on earlier D/C 2. change linens c. instructions on self-care . Hgb >10 d. wear good supportive bra k. orientation to unit c. squeeze buttocks together when sitting or rising from a chair to help keep repair intact j. Interventions 1. teach pt about fundal massage g. use lanolin crm to prevent cracking of nipples l. no bleeding e. rhogam given to Rh – moms who had Rh+ babies III. Candidates and criteria 1. take pain meds prn o. Maternal criteria for early D/C a. proper hygiene d. encourage rubella vaccine if non-immune pt should prevent getting pregnant for at least 4 weeks post vaccination p. staff picture ID’s d. 48 hours minimum post vaginal delivery b. cool packs post m. wiping front to back f. VSS b. use of ice packs for the first 12 hours post repair of peri then instruct on use of sitz bath i. use of peppermint or running water to aid in voiding to prevent urinary retention h. Standard precautions a. walk as soon as possible-helps with gas pains n. Safety a. 96 hours minimum post C/S c. wash hands before handling baby b. move infant in crib 2. Early Discharge A. infant ID bands b. use of squeeze bottle for peri care e.

Pain 3. shock. emboli 6. at least 1 void and 1 defecation f. Risk for infection 4. Assessment/Interventions 1. C & DB-may use inspirometer B. tone. normal physical assessment d. GU-renal failure. VS every 15 min X 1hour. GI-paralytic ileus 4. dvt 2. assess fundal location. Care of the Cesarean Birth Patient A. CV-hemorrhage. then per hospital protocol 2. Situational low self-esteem Possible post-op complications 1. oliguria 5. newborn blood/hearing screenings done i. no jaundice g. Fluid volume deficit 2. UTI. Anxiety R/T surgery.46 6 3. ambulate asap 7. term infant b. VSS c. circ site ok h. 30 min X 1 hour. fetal well-being 6. Reprod-endometritis. Infant criteria for early D/C a. Nursing diagnoses 1. pnemothorax 3. hematuria. at least 2 successful feedings e. monitor I & O’s-need UO at least 30 ml/hr 3. Skin-wound infection. assess abdominal dressing for drainage 4. Pulm-embolus. dehiscence C. assess need for pain medication 5. follow-up in 1 week j. and lochia (still have 3 distinct lochia stages) 6. . assess for passage of gas-advance diet as tolerated 8. Risk for injury 5. maternal/infant teaching cklist completed IV.

continue on PN Vitamins and iron as directed C. Care of the Lactating Woman A. Female breast has 15-20 lobes containing alveoli (the milk producing cells) 2. Other hormone changes/reflexes 1. rich in immunoglobins b. add addition 200-500 calories/dy while breastfeeding 2.47 7 V. higher concentration of protein and minerals to mature milk but less fat c. . Oxytocin responsible for let-down reflex nipple stimulation→pituitary produces oxytocin→ makes cells around the alveoli contract→sends milk to nipple 2. Nipple erection reflex infant cries or rubs against the breast→nipple becomes erect→propulsion of milk Supply/demand 1. drink 2-3 liters of fluid daily 3. If infant is well nourished. Prolactin: -highest level at day 10 -is produced in response to infant’s sucking -promotes milk production by stimulating alveolar cells B. watch for infant growth spurts -10 days -3 weeks -6 weeks -3 months -4. promotes growth of Lactobacillus bifides in GI 2.5-6 months Maternal nutrition/considerations 1. ↓ estrogen & progesterone post delivery=↑ prolactin levels which remain above baseline thru duration of lactation (highest level is at day 10) 4. alveoli→ductules→lactiferous ducts→nipple 3. will see 6-8 wet diapers and 3 stools in 24 hours at day 5 of breastfeeding 3. First milk called colostrum a. Incomplete emptying can lead to ↓ milk supply 4. Physiology of Lactation 1. D.

Methods (failure rates listed within 1st year of use) 1. maternal medications C. usually feed every 2-4 hours 3. propping-don’t leave infant unattended while feeding Nutritional requirements 1. resumption of sexual activities should wait 2-3 weeks to decrease risk from infection 2. positioning-need to make sure milk covers nipple area 2. warming-never microwave bottle 3.48 8 4. mastectomies. Common problems 1. VII. first day-only give 7. Contraception Education A. concentrated. or ready to eat B. Considerations for Choosing a Method 1. commercial formulas primarily cow-milk based but soy and other specialty formulas available 2.5-15 ml formula at one time -their eyes are bigger than their stomachs 2. watch for engorgement/plugged milk ducts/ sore nipple/monilial (yeast) infections/mastitis Care of the Woman/Neonate Formula-fed A. +HIV. VI. Formula types 1. by 1 week of age. best to use condoms/foam at this time 3. when discussing contraception with your doctor. adopted infant. babies will be drinking 700-900 ml in 24 hours *bottle fed because-returning to work. Coitus interruptus (withdrawal) -action-prevents fertilization -safety-no protection from STI’s -convenience/availability-good -expense-N/A . -action -safety -effectiveness -convenience -availability -expense -personal preference B. some infants swallow air as they feed-burp them! 4. may be in powdered.

050C) then ↑ 0. diaphragm -action-mechanical barrier to sperm -safety-see condoms. condoms -action-physical barrier to sperm -safety-protect against STI’s/HIV if used properly -effectiveness-can ↓ failure rate with use of spermicides -vaginal sheath/condom c.49 9 2.3-0. cervical cap/sponges -cervical cap needs fitting -must ck position of cap before intercourse -failure rate in parous women-40% -sponge-moisten with water before insertion -have spermicide 3. . ↓ temp before ovulation (0.60C -cervical mucus-ck for changes-amt. spermicides -action-physical/chemical barrier to sperm -safety-may provide some protection from STI’s -convenience-needs to placed before act -availability-good if thought of in advance -expense-cheap b. 12-24 hours before ovulation Barrier methods a. small amt of cases with TSS-toxic shock syndrome -effectiveness-needs to be fitted to woman’s anatomy. and consistency -symptothermal-combo of BBT and cervical mucus -ovulation kits-detect surge in LH that occurs approx. needs to be used with spermicide -convenience-may be placed 6 hours before intercourse but must be left in for 6 hours post act. additional spermicide each time -availability-MD appt -expense-affordable d. Fertility awareness methods -periodic abstinence-no sex 4 days before and 4 days after ovulation -rhythm-based on 3-4 cycles-use shortest and longest -BBT-sl.

mini pill (progestin-only) -problems with irregular menses h. over 30 different formulations b. Emergency contraception Plan B-levonorgestrel -needs to used within 72 hours of unprotected intercourse -prevents ovulation/implantation -90% effective -OTC-must be at least 17 years old to purchase Ella-non-hormonal -needs to used within 120 hours -needs Rx -90% effective IUD insertion -99% effective if inserted within 5-7 days . c. may have estrogen/progestin or only prog. injectable progestin-Depo Provera -injected q 11-13 weeks-may need appt. Hormones a. vaginal d. -↑ risk of venous thrombosis i. not recommended for some women -h/o thromboembolic -smoker -h/o estrogen dependent tumors -h/o CAD -h/o impaired liver -over the age of 35 -HTN g. subdermal implantation. implanted progestin-Nexplanon -good for 3 years -implanted in arm -no STI protection j. do not protect against STI’s f. prevent pregnancy by stopping ovulation or prevention of implantation e.50 10 -risk of TSS if not removed after 24 hours 4. may be oral. IM.

crushed. Mirena (hormone IUD)-helps to diminish menses f. loaded with either copper or levonorgestrel c. or plugged -no protection against STI’s -should be considered permanent -informed consent needed at least 72 hours before procedure -eSSURE -done in clinic or OR -uses water to visualize fallopian tube meatus -coil placed and tissue collects on coil creating a blockage -HSG performed at 3 months to establish closure -back-up BC method used during this period b. . h/o CAD. banded. HTN g. Copper “T”-good choice for women over 35.bilateral tubal ligation -surgical procedure -expense usually higher than vasectomy -electrocoagulation. not recommended for women with: -h/o PID -suspected pregnancy -teens -h/o distorted uterine cavity -h/o multiple partners Sterilization a.51 11 5. smokers. prevents fertilization e. usually T-shaped b. females . ligation. Intrauterine Devices a. males-vasectomies -done in clinics under local anesthetic -vas deferens are ligated/cauterized -takes multiple ejaculations to clear remaining sperm from vas deferens 6. may be used for 5 yr (hormone)-10 yrs (copper) d.

5 4 0.05 0. For example.3 0.8 0.6 0. many clinicians recommend that when using condoms.3 0.3 0.1 0 85 29 15 21 16 14 16 32 22 16 12 ++++ ++++ ++++ ++++ ++++ ++++ ++++ +++ +++ +++ + + + + + + + + + + ++ ++ ++++ ++++ 51 43 68 68 68 56 59 80 80 + ++ ++ + + + + 42 53 49 57 57 57 46 51 51 Sponge w/o prior pregnancy Sponge w/ prior pregnancy Ovulation Method Sympto-Thermal Standard Days Method Calendar Method Lactation (LAM) Withdrawal Ortho Evra Patch Nuva Ring Shot (DepoProvera) Shot (Lunelle) IUD (ParaGard Copper) IUD (Mirena) Abstinence 13-20 +++ 6 27 8 8 8 3 3 0. If a woman is allergic to spermicides she can use a natural method and a condom and for extra protection.52 12 BIRTH CONTROL COMPARISONS FAILURE RATES MECHANISM OF ACTION STD USER method of birth control No Method Spermicides Male Condoms Female Condoms Diaphragm Cervical FemCap w/o prior pregnancy perfect actual prevents prevents postpone protection continuation use use fertilization implantation sex rates 85 18 2 5 6 4 9 20 3 2.3 For added protection against pregnancy. you can use more than one method of contraception at a time.1 0 ++++ ++++ +++ +++ +++ +++ +++ ++ ++ ++++ Oral Contraceptives 0. spermicides be used as well. Any of these combinations will reduce the predicted failure rate .5 5 5 0.

mature lung produces surfactant-no surfactant leads to alveoli collapsing with exhalation -sufficient surfactant by 34-36 weeks 2. lights. . Initiation of respiratory effort a. tract produces fetal lung fluid that expands alveoli b. 4. in medulla c. ctr. causes air into lungs—also helped with tactile stimulation. circulatory and lymphatic systems absorb moved fetal lung fluid c. as term approaches. pressure released. Chemical-carotid and aortic chemoreceptors respond to changes in blood chemistries: ↓pH. ↓pO2. Transition to extrauterine life A. complete absorption of fluid by 24 hrs-delayed absorption noted in C/S deliveries d. ↑pCO2—stimulate respiratory ctr. rate is usually between 30-60 breaths/min-may be irregular Respiratory Distress-reverse of the above 3. once alveoli opened. fluid starts to move to the interstitial spaces c. Mechanical-chest compression forces fluid out into upper airways-expelled with birth. resp. Respiratory changes at birth 1. noises Normal Respiratory Effort a. shift of fluid helps to ↓ pulmonary resistance to blood flow-present before birth and enhanced with breathing of air d. after initial tachypnea. Thermal-skin sensors respond to sudden change in temperature-impulses that stimulate resp. Development of the Lungs a. d. while a fetus. surfactant helps to keep them open b. first breathes require greater pressure to open alveoli b. resp.53 1 Nursing Care of the Normal Newborn Lecture 5 I.

newborn’s ability to produce heat is often = to adults but have a tendency towards rapid heat loss 2. umbilical vein. pO2 ∆ to 50 mm Hg in the arterial blood→constricture of the ductus arteriosus—functional closure in 10-24 hrs -permanent closure in 3-4 weeks pulmonary blood vessels dilate in response to O2 fetal lung fluid moves into the interstitial spaces (any ↓ O2-ductus dilates. Thermoregulation 1. pulmonary vessels constrict) clamping of the umbilical cord closes the umbilical arteries. 5. blood vessels close to surface. Neurological adaptation A. 4. heat easily transferred from internal to skin 3x the body surface than adults=4x heat loss flexed position helps preserve heat—problem with premies is poor muscle tone leads to less flex evaporation-heat loss thru wet skin exposed to air -dry baby immediately at birth conduction-loss of heat from body surface to cooler surface in direct contact -warm blanket. and ductus venosus which convert into ligaments-fibrosis within 2 months 3. little sub Q fat. II. fetal pO2 is 27 mm HG—after birth. . in utero. skin-to-skin contact 3. Cardiovascular transition 1. heat loss from: thin skin. 6. anatomically closed-30 months 2. 4.54 2 B. air inflates the lungs→↓ pulmonary vascular resistance→ ↓ pulmonary artery pressure→↓ in pressure in the R atrium→↑ pulmonary blood flow to L side of heart→ ↑ the pressure in the L atrium=functional closing of the foramen ovale (functionally closed-1-2 hrs.

55 3 7. sternum and intrascapulary region)→heat produced by lipid metabolic activity → warm baby (preterm infants lack brown fat) b. ↑ metabolism = ↑ need for O2 and glucose regardless of gestational age or condition b. Moro (startle) Usually present for first 3-4 months 2. and heart c. found at neck. if prolonged-leads to resp. adrenals. shivering begins when thermal receptors in skin detect a drop in the skin temp-rare in neonates cold stressa. secondarily thru increased metabolic activity in liver. brain. Nonshivering thermogenesis (NST) primarily thru brown fat ( highly vascular fat found only in infants with abundant supply of blood vessels/nerve endings. wrap in blanket with hat on head radiation-transfer of heat to cooler object not in direct contact with infant -keep cribs away from outer windows Thermogeneis a. convection-heat transferred to cooler ambient air -keep out of drafts. fatty acids released = metabolic acidosis g. plantar grasp Fingers/toes curl around examiner’s fingers palmar lessens by 3-4 months plantar by 8 months . kidneys. decreased pulmonary perfusion may lead to an open ductus arteriosus e. O2 consumption diverted from maintaining brain/heart function to thermogenesis d. 10. hypoglycemia f. difficulty c. 8. Palmar. Reflexes 1. B. fatty acids in blood can interfere with bilirubin transport = risk for jaundice 9.

by 6 months. tear glands developed by 2-8 weeks g. muscles in eye area are immature (transient strabismus) b. loud sounds make baby have startle reflex c. can differentiate their mother’s breast milk by smell 3. hearing loss is a common major abnormality 1-3/1000 normal term infants have bilateral hearing loss Touch a. decrease motor activity in presence of low frequency sounds such as a heartbeat d. C.56 4 3. prefer patterns to plain surfaces i. at 5 days old. clearest vision within 10-20 inches c. soles being most sensitive Taste a. eye color will not be set until 3-12 months 2. Hearing a. face. hands. at birth. prefer glucose water to plain water Smell a. like an adult’s after draining of amniotic fluid b. sensitive to light d. responses to touch on all parts of the body b. react to strong odors by turning head away b. their visual acuity is ½ of adults h. 5. can distinguish tastes b. . Vision a. Sensory adaptation 1. Tonic neck fencing position complete response gone by 3-4 months Sucking and rooting head turns towards stimulus and sucks 4. attracted to black/white patterns e. able to see colors at 2 months f. 4.

000/mm3 b. preterms have greater blood volume due to a greater plasma volume.000 per mm3 is normal at birth b. infection not well tolerated in infants with sepsis usually accompanied by a loss in WBC Platelets a. factors II. Neonatal differences 1.500 c. at birth. 80-85 ml/kg b. 300 ml c. blood volume approx.57 5 III. Hematological adaptation A. 5. VII.000-300. and X decreased due to lack of Vitamin K-not adult level until ≥ 9 months Blood Groups a. will rise then decline to a level of 11. delay of cord clamping shifts plasma to extravascular spaces with ↑ lab results 2. IX. RBC’s and H & H a. not RBC mass Heart rate and BP a. PMI (point of maximal impulse) left chest (apical pulse) e. ½ of heart murmurs heard at birth disappear by 6 months f. . HR averages at140 beats/min at birth b. levels are higher than adults -Hgb—14-24 g/dl -Hct—44-64% if > 65% = polycythemia -RBC—5. rises just after birth c. full term infants HR between 120-160 bt/min d.3/mm3-1st 24-48 hrs of life (neonatal RBC’s have a lower survival rate compared to adults)→physiological anemia c. cord blood sample taken to determine infant’s blood group and Rh status b. 6. WBC 9-30. 200. Rh neg mom’s receive Rhogam if Rh + baby Blood Volume a. at birth. Leukocytes a. 4.1-5. BP averages 50-80/35-50 mm Hg 3.

anterior closes at 12-18 months b. collection of blood between the skull bone and the periosteum-doesn’t cross suture lines b. 6. B. resolves in 2-4 weeks d. Musculoskeletal System A. disappears in 1-4 dys Cephalohematoma a. may cross suture lines c. arms a. may lead to jaundice neck/shoulders a. may be spontaneous or due to vacuum or forceps delivery c. more cartilage than bone 2. 7. Extremities 1. bulging fontanelles mean ↑ ICP d.58 6 IV. Head and upper body 1. shoulder dystocia→ brachial plexus injury -fx of scapula or clavicle (clavicle is the most commonly fx bone during delivery process) -immobilize in a sling 4. 5. edema of the scalp b. Erb’s palsy-injury to brachial plexus = paralysis of affected arm/shoulder -flaccid arm with absence Moro on affected side -immobilize arm but follow exercise regimen . face looks small in relationship to skull R/T molding (overlapping of the skull bones) fontanelles a. posterior closes at 8-12 weeks c. 3. sunken fontanelles mean dehydration craniostenosis-contracted skull due to premature closure of the cranial sutures-need surgery Caput succedaneum a. at birth.

. C. question possible tooth (more common in some cultures) may note sucking blisters (calluses) sucking behavior is influenced by neuromuscular maturity. Gastrointestinal A. d. maternal medications at birth. Activity and Muscle Tone 1. R/O any birth injuries 2.59 7 2. feet a. simian crease found on palms (and soles of feet)→frequently present in children with Down’s hips a. polydactyl-extra fingers b. hands a. Mouth/throat 1. transient motor function -if flaccid. c. and type of initial feeding 4. 3. check for intactness of hard and soft palates may find Epstein’s pearls-retention cysts-small white areas at gum margins and junction of palates -if area very hard to touch. syndactyl-fused fingers c. may be pathological watch for flexion and extension of all extremities V. b. spontaneous. 5. transient tremors normal but if persistent. can have congenital hip dysplasia-head of the femur slips out of the acetabulum Ortolani’s/Barlow’s maneuver-listen/feel for a click breech deliveries-higher risk may need to double or triple diaper poly/syndactyl club foot-positional or casted to help rotate 3. 3. b. 4. mucous membranes of mouth moist and pink if adequately hydrated 2.

metabolizing. and fats are present by 36-38 weeks amylase-not produced until 3 months-salivary glands 6 months-pancreas -unable to convert starch to maltose . K. digestive enzymes necessary to digest simple CHO. Intestines 1. 4. volume can decrease regurg by avoiding overfeeding. 3. infant unable to move food from lips to pharynxneed to place nipple deep inside mouth check for tongue-tied-may need frenulum cut peristaltic activity of esophagus is uncoordinated at birth Stomach 1. burping after eating. folate. digesting. 3. 3. Digestive Enzymes 1. 5. 4. no bacteria in intestines at birth 2. 8. and emulsifying fats 2. B.60 8 6. 7. absorbing proteins and simple carbs. air and bacteria enter the orifices highest bacterial content in lower intestine normal colon bacteria established in 1st week which helps synthesize Vit. and biotin D. full term newborns capable of swallowing. temperature of food. and infant positioning C. usually hear bowel sounds after 1 hour of life after birth. cardiac sphincter is immature-may have regurg gastric emptying times vary-effected by type of of feeding. capacity varies from 30-90 ml depending on size of infant 2. proteins.

odorous VI. 1/3 of stores as glycogen in liver b. 3. and odor like sour milk b. 60-70 mg/dl e. blood glucose levels stabilize at 50-60 mg/dl after delivery d. maintenance of blood sugar b. coagulation 2. meconium-first stools a. E. lipase-needed for digestion of fat-needs to be produced by pancreas Stool patterns 1. intestinal mucus (bilirubin). firmer. 4. # of stools vary-early feedings = sooner stool transitional stools-greenish brown→yellowish brown thick→thin. iron storage c. initiation of feeding assist in stabilizing newborn’s glucose levels f. filled with amniotic fluid and its constituents. watery milk stools a. breastfed-yellow to golden.61 9 4. newborn’s increased energy needs in first 24 hours of life can rapidly deplete glycogen stores . pasty. initially sterile then contains bacteria d. greenish black-may have occult blood c. drug metabolism d. Liver function alterations 1. bilirubin conjugation e. by day 3. hepatic system responsible for a. Hepatic System A. need constant supply for brain c. glucose a. and cells b. bottlefed-yellow-light brown. usually fully passed in 24 hours 2.

in the liver→enzyme glucuronyl transferase→ conjugates bilirubin (now called direct bili) -soluble. bound to circulating albumin-can permeate to other areas (also called indirect bilirubin) d. i. coag factors synthesized in liver←Vit. K b. excreted from liver cells→bile e. 3. unconjugated bilirubin-insoluble. excreted thru urine and feces f. 5. bilirubin-yellow pigment derived from Hgb released with breakdown of RBC’s/myoglobin b. Vit. prenatal dilatin/phenobarb→abnormal clotting conjugation of bilirubin a. total bili is the sum of both levels of conjugated and unconjugated bili g. Hgb is converted to bilirubin in unconjugated form (non-excretable form)-potential toxin c. at birth. K injection helps prevent clotting problems d. premies-lack adequate brown fat and glycogen stores -traumatic deliveries -asphyxia s/s of hypoglycemia -jitteriness -respiratory distress tx of hypoglycemia -feedings -IV therapy h. iron storage a.62 10 g. have enough iron stored for 4-6 months coagulation a. fetal liver begins storing iron in utero b. proportional to total body Hgb content and gestation age c. factors that ↑ bili -excess production of RBC’s -RBC’s life shorter-more breakdown -liver immature -poor/delayed feedings-breastfeeding jaundice 4. . risk for hypoglycemia -LGA’s-excess insulin uses up glucose -SGA’s. transient blood coagulation deficiency days 2-5 c.

6. at term. epilepsy. 3. and mental retardation 3. can lead to kernicterus-precipitation of bilirubin in neuronal cells leading to cerebral palsy. Eskimos neonatal jaundice is considered benign unless ↑ levels lead to pathological conditions it’s physiological jaundice if: a. Native Americans c. infant is well b. have a full complement of functioning nephrons . Asians b. serum concentration of unconjugated bili -less than 12 mg/dl in term baby -less than 15 mg/dl in premie d. wall 2. jaundice appears after 24 hours and ends by the end of day 7 c. 5.63 11 -traumatic delivery -fatty acids-bind with albumin instead of bili B. almost exclusively unconjugated bili -direct bili doesn’t exceed 1-1. incidence is increased in certain nationalities a. Occurs 50% in full terms. daily increments in bili doesn’t surpass 5 mg/dl Feed early to keep serum bili low if hyperbilirubinemia is not reversed. 80% in premies 2. VII. kidneys take up area of the posterior abd. Anatomy 1. Genitourinary system A.5 mg/dl e. 4. bladder close to anterior abdominal wall lying in both the abdomen and the pelvis at term. Hyperbilirubinemia/physiological jaundice 1.

and organic acids D. 4. phosphates. 4. frequency of voiding varies from 2-6 times/24 hours to 5-25 times during the 3rd day limited capability to concentrate urine -able to concentrate urine by age 3 months urine usually straw-colored and almost odorless may see pink stains from pseudomenses or uric acid crystals loss of fluid thru urine. Fluid and Electrolyte Balance 1. 3.6-44 mLs at term 2. 5. in preterm girls . lungs. increased metabolism. is extracellular fluids (adults are 20%) 2. Cl. 5.64 12 B. bladder capacity. 6. Genitals 1. 40% body wt. Females a. Voiding 1. feces. newborns intake and excrete 600-700 ml water =50% of extracellular fluid GFR is 30-50% of an adults ↓ GFR = ↑ wastes and nitrogenous in system ↓ Na reabsorption = ↑ levels of Na. and limited fluid intake can result in wt. in full term girls -labia majora large and cover labia minora -may be dark in pigment -vaginal or hymenal tags are common -vernix may be present between labia -may have mucousy discharge -may have false period (pseudomenses) b. loss of 5-10% normally C. 3.

65 13 -clitoris is prominent -labia majora are small and widely separated 2. Desquamation 1. by year 1. Birthmarks 1. helps the skin retain moisture present more in premies Lanugo 1. 3. Males a. cheese-like substance 2. fine. peeling of the skin 2. Vernix caseosa 1. infection VIII. more common on lower back and buttocks . smegma may be found under foreskin -teach boys at 3-4 years old to retract and clean under foreskin e. scrotum more deeply pigmented and with deep rugae in post term infants g. circumcision-personal decision -may reduce UTI’s -may reduce STI’s -may reduce penile CA -done on 8th day under Jewish faith -complications-hemorrhage. tight prepuce (foreskin) is common d. white. Mongolian spots a. evaluate for hypo or epispadias f. incidence of cryptorchidism is < 1% c. Integumentary system A. testes in scrotum in 90% of males b. B. 3. blue-black areas of pigmentation b. helps keep moisture in skin seen less in full to post term infants C. downy-like hair 2. seen more in post date infants D.

and nape of neck -usually fade between 1-2 years b. IX. upper lip. Immune system A. and location -do not blanch nor fade with time -if neurological problems exist-√ for Sturge-Weber syndrome Erythema toxicum a. IgA -can’t cross placenta -not produced in utero -colostrum is high in IgA -start producing about 4 weeks of age b. IgG -can cross placenta -passive immunity from mom-passed in 3rd ∆ -very active against bacterial toxins c. Nevus vasculosus. 3. size. IgM -produced by fetus in utero -reach adult levels at 9 months old .Strawberry mark -may be raised and be bright or dark red -may last thru childhood c. Telangiectatic nevi-Stork bites -are pink and easily blanched -appear on upper eyelids. passive immunity from mother immunoglobulins a.Port-wine stain -red to purple. thought to be a inflammatory response c. lower occiput bone. nonelevated -varies in shape. d.66 14 c. cells that provide infant with immunity are present but not activated for the first several months of life 2. Nevus flammeus. usually no clinical significance and needs no tx 3. Neonatal considerations 1. more common in dark skinned nationalities may fade over months or be permanent Nevia. nose. for first 3 months of life. transient rash also known as ‘flea-bite rash” b. 2.

IgA. skin color. rate with crackles c. synchrony to voices -watch & respond to their parents’ faces -active alert -crying Purposeful behaviors a. . tachycardia. passage of meconium Sleep/wake states a. awake and alert b. decrease in body temp g. flaring. IgD. X. Infants differ in their activity levels. grunting. 4. may be prolonged in term infants with abnormal labor or birth traumas Sleep period-unresponsiveness-2-4 hours a. Behavioral states 1. and IgE gradually produced colostrum and breast milk carry immunity Psychosocial Adaptation A. push away with hands/feet c. ↓ sensitivity by falling asleep 3.67 15 d. 5. ↑ muscle tone. increase in motor function h. feeding/sleep patterns. 4 wake states -drowsy -quiet alert/wide awake -smile. vocalize. 6. withdrawal by ↑ physical distance b. HR ↓ 100-120 b. 2 sleep states -deep sleep -light sleep-REM b. may have irregular resp. and responsiveness 2. e. retractions d. startle easily f. RR slow-irregular 2nd period of reactivity-4-6 hours a. may have periods of apnea e. mucus production c. 1st period of reactivity-first 30 minutes of life a. tachypnea b.

at 3 months. get fussy or cry as a signal term infants better at self-quieting abilities Care of the Newborn A. 7. Vit. K IM c. 10. XI. b. after procedure. R/O h/o substance abuse Newborn nutrition a. B vaccine-IM d. neonates need 110 kcal/kg/dy b. auscultate lungs and suction if moist 2. Hep. Assessment 1. ? infection at time of delivery b. Assess vital signs. 9. minor surgical procedure-sterile tech. Length-usually 18-22 inches c. 6. assess apical pulse c. 5. assign apgar scores a. 4. weight in pounds and grams b. Measurements a.68 16 d. temp-taken axillary b. HBIG IM-if needed Assess mother’s ability to breast feed Full head to toes assessment after bonding Review maternal chart a. 100 kcal/kg/dy c. erythromycin ointment-OU b. 8. head circumference-usually 33-36 cm Chart if voiding or passing meconium Administer medications a. e. infant to mother c. want to see 6-10 wet diapers/dy Assist with circumcision if requested a. medications given to mother c. teach parents care of circ site Home care instructions 01/13 3. .

69 1 The High Risk Newborn Lecture 6 I. MD’s b. Levels of Care for the High Risk Newborn A. RT’s 2. diabetes. may feel insecure with change in staff 3. etc maternal age and parity . 4. before 37 weeks. II. notify supervisor of need for transfer team b. if unable to transport before delivery: a. Risk Factors 1. I. 6. decreases neonatal morbidity/mortality b. may be frightened to move baby again b. transfer team consists of: a. teach about equipment helping baby b. start discharge teaching early get mother and infant together ASAP talk about possibility of return to primary center of care a. maternal transport with fetus in utero preferred a. 3. lack adequate reserves of bodily nutrients low SES of the mother exposure to environmental dangers. mother and infant not separated at birth 2. Transfer/multidisciplinary approach 1. The Preterm Neonate A.E. RN’s c. lack sufficient organ maturity 2. 4. toxic chemical pre-existing maternal conditions-heart disease. 5. Assessment for need of NICU/tertiary care center 1. keep parents undated on infant’s condition a. have emergency personnel to stabilize baby B.

8. d. 34-36 weeks-mature alveoli. c. decreased tissue perfusion g. b. . PIH. 29-30 weeks-growth of alveoli and surfactant level e. B. Respiratory a. infection obstetrical complications-cord prolapse. posture of extension e. swallow-coordinated after 34 weeks incompetent cardiac sphincter small stomach capacity 4. medical conditions R/T the pregnancy-GDM. noticeable cyanosis. surfactant begins production b. 24-26 weeks-inadequate alveolar size and surfactant c. ↓ pulmonary arteriole musculature ↓ pulmonary vascular resistance→↑ L→ R shunting thru ductus arteriosus→ into lungs ↓ BP. Thermoregulation a. ↑ resp. at 22 weeks gestation. abruptio placenta Physical characteristics and system alterations 1. apneic episodes-15-20 cessation of breathing 2. grunting. c.70 2 7. poor gag. suck. ↓ brown fat c. CV a. distress 3. b. larger body surface d. retractions. surfactant inadequate d. lack glycogen stores in liver-created in 3rd Δ b. surfactant level adequate (surfactants-surface-active phospholipids lecithin-increases after 24 weeks sphingomyelin-constant amount when L/S ratio is 2:1=lungs mature) f. less able to ↑ metabolism for heat GI a. 27-28 weeks-alveoli start to open. ↓ cap refill time.

malabsorption nutritional loss associated with vomiting/diarrhea work of sucking = ↑ BMR. blood loss from frequent lab work d. friable blood vessels c. fragile vessel walls b. don’t receive passive immunity b. may have been exposed to recurrent anoxic episodes Risk of infection a. 5. ↓ iron stores c. pancreatic lipase = ↓ absorption of nutrients. 8. ↓ storage of immunoglobulins d. up to 34 weeks. 7. thin. birth damage to immature structures d. at risk for edema (overhydration) or dehydration d. longer to excrete drugs from the system Hepatic a. the germinal matrix lines the ventricles c. 9. e. at 35 weeks. ↑ O2 usage feeding intolerance Renal a. ↓ buffering = acidosis e. g. ↓ glycogen stores = hypoglycemia b. ↓ production of RBC’s CNS a. f. increased capillary friability b. fragile skin b. 10.71 3 d. ↓ bile acids. ↓ GFR secondary to renal blood flow c. inability to make antibodies 6. IgG-not until last trimester Hematologic a. tendency to bleed c. kidneys have limited ability to dilute or concentrate urine b. . impaired conjugation of bilirubin Immunologic a. high risk of brain hemorrhage from thin.

Common complications of Preterm 1. Apnea a. Patent Ductus Arteriosus a. K d.2 mg/kg -stimulates closure of ductus surgery 2. RDS improves c.5g c. cessation of breathing > 20 seconds b. need addition iron. pulmonary edema g. noticeable by Day 3 b. CHF -S & S continuous/systolic murmur bounding pulses tachycardia tachypnea hepatomegaly -Tx echocardiogram restrict fluid-give diuretics indomethacin-0. R/T immature nervous system d. usually occurs < 36 weeks gestation c. E (multi vitamin) C. L ventricular failure f. calcium.72 4 11. Fluid/electrolytes a. L→R d. need 80-150 kcal/kg/dy-↑ than term infants b. usually get supplemental Vit. may be R/T temp instability maternal drugs in labor h/o maternal drug abuse infection metabolic disorders asphyxia abdominal distention . need protein 3-4 g/kg/dy-term 2-2. increases pulmonary blood flow e.

cyanosis. Tx -tx the symptoms -phenobarb-sedative. PPV. f. Intraventricular Hemorrhage-most common type of intracranial hemorrhage a. hood. ET tube Danger-excessive oxygen can lead to retinopathy of prematurity or bronchopulmonary dysplasia -report ABG changes -theophylline-CNS stimulant-stimulates resp ctr relaxes smooth muscle of bronchial airway and pulmonary blood vessels -surfactant administration -ECMO NOT used with premies due to risk of intraventricular hemorrhage 3. triggered by hypoxia no venous pressure changes ↑ osmolarity in blood-overuse of volume expanders c. < 34 weeks b. assessment -observe breathing pattern -stimulate-slap soles of feet -suction-use with free-flow oxygen watch for dusky. S &S -hypotonia -hypotension -lethargy -metabolic acidosis -temp instability -seizures -nystagmus -low Hct -bulging fontanelles -apnea -decerebrate posturing d. bradycardia -prepare for possible intubation -think possible septic workup tx -oxygen per order-usually started if PaO2<92% warmed and humidified nasal cannula. most susceptible-< 1500 gms.73 5 e. ↓ seizure activity -serial spinal taps -VP shunt -mainly observational and supportive care .

S&S -tachypnea -retractions -nasal flaring -↑ work to breath -tachycardia d. E therapy -decrease ambient light -circumferential cryopexy Bronchopulmonary Dysplasia a. causes unknown-up to 25-30% mortality rate c. . inflammatory disease of GI mucosa b. higher risk-<1000 gms c. Tx -oxygen -nutrition -fluid restriction -medications: diuretics. < 1500 gms b. steroids. caused by barotraumas from pressure ventilation and oxygen toxicity b. etiology is multifactorial c. Retinopathy of Prematurity (ROP) a. bronchodilators e. 6. contributing factors -asphyxia -UAC -infection -PDA -RDS -anemia/ischemia -congenital heart disease -early enteral feedings 5. at risk at < 36 weeks. Tx -laser photocoagulation -Vit. assessment -ophalmoscope exam-4-6 weeks -some damage may spontaneously heal f. key management is thru prevention f. if untreated-can lead to death from cardiorespiratory failure Necrotizing Enterocolitis a.74 6 4. oxygen tensions too high may lead to vasoconstriction d. at the end of oxygen therapy: vascularization of retina→constriction of vessels→ disintegration of vessels→new vessels→rupture→ retinal hemorrhage→scar tissue→detachment→ blindness e.


7 d. e. breastfed babies have lower risk of NEC S&S -hypotonia -decreased activity -recurrent apnea -pallor -decreased perfusion -hypotension -temp instability -cyanosis -abdominal distention -diarrhea -vomiting blood/bile Dx -x-ray -lab reports -abnormal electrolyte levels Tx -mainly supportive -no feedings-rest the gut-trying probiotics -use of TPN -tx of infection -surgical dissection of perforated/deteriorated area




Other neurological concerns a. hearing-1:50 loss of hearing -↑ risk R/T congenital virus -perinatal asphyxia -birth trauma -certain medications-gentamycin b. speech impairments c. cerebral palsy d. hydrocephalus e. seizure disorders f. lower IQ’s h. learning disabilities


Nursing Care 1. Methods of feeding a. depend on gestational age, physical condition, neuro status b. nipple feeding-34 weeks ok -need coordinated suck and swallow -needs to have gag reflex, RR < 60, and steady wt. gain


8 c. gavage-< 34 weeks gestation -used if infant has poor gag/swallow neuro insult losing wt. due to energy expenditure TPN-central or peripheral lines lipids-peripheral, no filter fluid requirements -80-100 ml/kg/dy-Day 1 -100-120 ml/kg/dy-Day 2 -150 ml/kg/dy-Day 3 -gradually increase

d. e. f.


Assessments a. vital signs-watch for temp for heat loss b. urine-ck protein, glucose, SG c. strict I & O -watch for vomiting, diarrhea -watch IV site for infiltration d. watch for gastric residual ↑ 2 ml e. guaiac stools f. assess for abdominal distention Goals a. maintenance of respiratory function b. maintenance of neutral thermal environment c. maintenance of fluid/lytes d. prevention of infection e. prevention of fatigue f. adequate nutrition g. promotion of attachment i. promotion of sensory stimulation



Dysmature Neonates A. Care of the Post Term Neonate 1. Problems a. post maturity syndrome b. hypoglycemia-depleted glycogen stores c. meconium aspiration-stress d. polycythemia-↑ RBC production R/T hypoxia e. congenital anomalies-unknown f. seizure activity-R/T hypoxia g. cold stress-R/T less sub Q fat


9 2. Assessment a. post maturity syndrome -dry, crackling skin -mec staining -long fingernails -profuse scalp hair -wasted appearance b. meconium aspiration syndrome -watch for mec stained infant -may not show signs of resp. depression at birth -if mec migrates to terminal airways-becomes meconium aspiration syndrome mechanical obstruction -if mec aspirated in utero→chemical pneumonitis c. persistent pulmonary HTN (PPHN) -pulmonary artery hypertension -R to L shunting -may need ECMO (extracorporeal membrane oxygenation therapy) Tx -tx the S & S-ECMO, inhaled nitric oxide, etc

3. B.

Care of the SGA/IUGR neonate 1. Causes a. maternal -smoker -heart disease -poor nutrition -PIH -substance abuse -chronic HTN -advanced DM -toxic chemical -infection exposure -small stature -<16, >40 yrs old -lack of PN care -low SES b. placental -infarcts -single umbilical artery -abnormal cord insertion -calcifications c. fetal -multiple gestation -TORCH-toxoplasmosis other infections, i.e. hepatitis rubella cytomegalovirus herpes (type II)


10 2. Problems a. perinatal asphyxia -associated with h/o smoker low SES preeclampsia multifetal gestation infections DM -watch for respiratory depression at birth b. hypoglycemia -higher metabolic rate -RBS < 40 mg/dl in term infant <25 mg/dl in premie -poor feeders, jittery, hypothermic -watch for lethargy, floppy, seizures c. heat loss -less muscle and brown fat mass -little ability to control skin capillaries -need to maintain thermoneutrality d. hypocalcemia-R/T birth asphyxia e. polycythemia-R/T ↑ RBC’s R/T stress Tx a. b. c. d. e. maintain clear airway prevent cold stress feeding per hospital protocol stabilize temperature nursing support similar to premies



Care of the LGA Neonate 1. Causes a. IDM/GDM b. genetics c. multips d. ethnic grps e. obesity 2. Problems a. CPD-↑ risk for C/S birth b. birth traumas-vacuum, forceps, asphyxia shoulder dystocias, fx clavicle c. hypoglycemia/polycythemia Tx-tx the S & S



11 IV. Common Respiratory Complications A. Respiratory Distress Syndrome(hyaline membrane disease) 1. Lung disorder usually affecting premies a. infants <1500 gms = 56% risk of RDS b. caused by lack of surfactant 2. Causes a. ↓ risk of incidence/severity -African-Americans -maternal steroid therapy -stressors such as PIH -PROM -IUGR -maternal drug use b. ↑ risk of incidence/severity -↓ in gestation age -maternal hypotension -Caucasians -maternal diabetes -C/S birth without labor -second-born twin -males -perinatal asphyxia Problems a. lack sufficient surfactant b. weak respiratory muscles g. epithelial debris in airways h. leads to ↓ oxygenation, cyanosis, and resp./ metabolic acidosis i. can lead to R to L shunting and opening of foramen ovale and ductus arteriosus S&S a. b. c. d. e. f. tachypnea grunting/nasal flaring retractions hypotension cyanosis self-limiting disease -usually abates in 72 hours -disappearance coincides with production of surfactant in type 2 cells of alveoli




12 5. Tx a. b. c. d. e. f. g. h.

supportive-adequate ventilation/oxygenation surfactant administration oxygen therapy per orders monitoring of acid/base balance prevent cold stress abx therapy for infection proper nutrition and I & O’s possible need for blood transfusion R/T frequent lab work


Transient Tachypnea of the Newborn 1. similar to RDS 2. 3. 4. 5. R/T asphyxia in utero-fluid in lungs x-ray shows over expansion/hyperinflation of lungs Tx-oxygen, ck for possible acidosis usually improves in 24-48 hrs, well in 2-5 days

C. V.

Meconium Aspiration-see post term neonate

Neonate with Sepsis A. Risk factors 1. maternal -low SES -poor nutrition 2.

-poor PN care -substance abuse

intrapartum -PROM -maternal fever -chorioamnionitis -prolonged labor -premature labor -maternal UTI neonatal -twins -birth asphyxia -galactosemia -LBW/premie -male -mec aspiration -absence of spleen -prolonged hospitalization


after birth b. maternal fever. TORCH 2. higher mortality rate-10-25% 2. Haemophilus influenza c. at birth c. Coli e. stillbirth. environmental. group B strep b. Listeria d. may need isolation from other neonates 3.81 13 B. vertical a. Staph aureus c. Pneumoniae f. may cause miscarriage. more common with PROM. group B strep Viral infections a. Psedomonas e. . intrauterine infections. Causes of susceptibility 1. horizontal a. i. Early onset-within 24 hours of birth a. and congenital malformations b. in utero b. may cause chronic infection with subtle manifestations c. 3. Causes of infection 1. may be from birth canal or environment b. Strep. and premature labor g. Mode of transmission 1. phagocytosis less efficient dysmaturity D. Acquired infections-seen after 2 weeks of age a. Staph epidermidis d. E. lack immunity 2.e. chorio. Staph C.

4. -abdominal distention -residuals > 50% -pallor 5. . S&S 1. Location of infection 1.82 14 4. greatest concern to immuno-compromised or premature neonates b. Pneumonia-most common form of neonatal infection -one of the leading causes of perinatal death Bacterial meningitis affect 1 in 2500 live births Gastroenteritis not as common F. Fungal infections a. thrush may be present in otherwise healthy kids E. -tachypnea -nasal flaring -decreased O2 sat CV -bradycardia -decreased CO -tachycardia -hypotension -decreased perfusion CNS -temp instability -hypotonia -seizures GI -vomiting -diarrhea Skin -jaundice -petechiae -lethargy -irritability 3. 4. Septicemia is infection in the blood system 2. 3. Respiratory -apnea -grunting -retractions 2.

occurs in 60-70% of term infants. oxytocin in labor e. serum bili > 15mg/dl at any time B. chest x-ray Tx the symptoms-i. ↑ bands(immature WBC) -urine -CSF -gastric aspiration -culture nose. drugs .e. VI. abx. throat. 2. Pathologic jaundice a. lab work -blood (CBC with diff) looking for ↓ neutrophils. Sepsis workup 1. 3. infection c. Types 1. Tx 1. 80% preterm b. diabetes d. umbilical cord 2. apparent within 24 hours of birth c. O2. isolation Assess handwashing techniques of the staff Encourage breastfeeding-passive immunity H.83 15 G. Physiologic jaundice a. arises 24 hours after delivery 2. serum bili of > 5mg/dl in cord blood d. Rh/ABO incompatibility -fetal antigen crosses placenta -maternal antibodies cross placenta -cause hemolysis of fetal RBC’s (erythroblastosis fetalis→hydrops fetalis) b. Maternal factors a. The Neonate with Hyperbilirubinemia A. hyperbilirubinemia→kernicterus (bilirubin encephalopathy) b. Causes 1. skin.

serum bili level 2. intestinal obstruction e. biliary atresia (absent or closed bile ducts) g. pyloric stenosis f. The Neonate born to a diabetic mother A. direct comb-ck for maternal antibodies in infant’s blood b. Tx a. Fetal/newborn factors a. Lab work a.84 16 2. Problems 1. blood swallowed by fetus C. ck infant’s blood type c. macrosomia/birth trauma . hepatic cell damage c. early. b. c. polycythemia d. premies b. frequent feedings phototherapy exchange transfusions -if Rh incompatibility-use O neg blood VII. Nursing care 1. congenital anomalies -believed to be caused by fluctuation in glucose & episodes of ketoacidosis -congenital heart lesions coarctation of the aorta transposition of the greater vessel atrial/ventricular septal defects -CNS anacephaly hydrocephaly encephalocele meningomyelocele -MS caudal regression syndrome-problems of the lower extremities 2.

B. 4. Maternal acidosis: ↓ in gas exchange Goal: Maternal control of BS thru pregnancy with PN care C. Pediatric staff at delivery 2. hypocalcemia. Nursing care 1. eyes -epicanthal folds -strabismus -ptosis-drooping lid -hypoplastic retinal vessels . Normally: maternal blood more alkaline pH than CO2-rich fetal blood→exchange of O2 & CO2 across placenta 2. cephalohematoma 3. Implement neonatal glucose testing per protocol If RBS < 40 mg/dl. 3. Fetal alcohol syndrome a. hypomagnesemia -hypocalcemia present in 50% of IDM’s -hypomagnesemia from maternal renal loss R/T DM hyperbilirubinemia/polycythemia -excess RBC production leads to ↑ bili 5. supplement with formula or IV prn Check serum bilirubin and calcium levels Reduce adverse environmental factors VIII.85 17 -excessive glucose in blood = ↑ fetal insulin production -enlargement of internal organ except brain -high risk for fx of clavicle/scapula. RDS -4-6X more likely to develop than in normal infants hypoglycemia. 6. 3. 4. Pathophysiology 1. Common characteristics 1. The Neonate born to a Substance Abusing Mother A.

4. h. infections -immune deficiencies tumors-nonspecific neoplasms skin -abnormal palmar -irregular hair f. e. congenital anomalies Heroin a. g.86 18 b. poor wt. mouth -poor suck -cleft lip -cleft palate -small teeth ears-deafness skeleton -fusion of cervical vertebrae -restricted bone growth heart -atrial/ventricular septum defects -Tetralogy of Fallot -patent ductus arteriosus kidney -renal hypoplasia -hydronephrosis -urogenital sinus liver -hepatic fibrosis immune system -increase infections -otitis media -upper resp. hyperactivity/difficult to console e. lethargy Tobacco a. 5. risk for SIDS c. j. Cocaine a. SGA/LBW/premie b. LBW b. prematurity/SGA b. Premie/LBW/IUGR b. 2. . risk for bronchitis/pneumonia 3. i. gain c. poor feeder/diarrhea d. d. microcephaly/developmental delays c. SGA c. c. neonatal withdrawal issues Amphetamines a.

Needs multidisciplinary approach for both neonate and parents 2. Supportive care a. developmental delays Marijuana a. paregorics (tincture of opium). diazepam. infection control d. phenobarb. respiratory care Quiet. Hypoxic Ischemic Encephalopathy (HIE) in Newborns→Article 01/13 . IX. Nursing Care 1. soothing environment during withdrawal period Pharmacological tx-morphine. 4. fluid and electrolyte balance b. 6. & methadone vs buprenorphine (article) 3. nutrition c. LBW B. possible neonatal tremors b.87 19 d.

Physiological Changes during Pregnancy A. hyperplasia-new muscle fibers/tissue c. Reproductive system and breasts 1. Hegar’s sign-6 weeks-softening of lower uterine segment . development of the decidua e. 1/6 of total blood volume within the vascular system of uterus m.88 1 Normal Pregnancy Lecture 7 I. altered center of gravity as enlarging uterus tilts against the anterior abdominal wall k. hypertrophy-enlargement of pre-existing fibers d. increased vascularity/dilation of blood vessels -60 gm(2oz) to 1100 gm(2. Uterus a. lightening -nulliparas-2 weeks before term -multiparas-when labor starts i. shape changes -7 weeks-egg size -10 weeks-orange size -12 weeks-grapefruit size -initially pear shaped -2nd trimester-globular -term-ovoid g. growth changes R/T stimulation from high levels of estrogen/progesterone f. ballottement-palpate floating structure j.2 lb) b. position -12 weeks-at or above the symphysis pubis -16 weeks-between SP and umbilicus -20 weeks-at the umbilicus -36 weeks-almost to the xiphoid process h. uteroplacental blood flow -uterine blood flow increases -more oxygen is extracted from the blood in the latter part of the pregnancy -at end of pregnancy. Braxton-Hicks contractions -start around 4 months -irregular -painless -help to facilitate blood flow l.

coag times -circulation time decreases by week 32 near normal at term -↑ in clotting factors leads to ↑ tendency for blood to coagulate -↑ risk for thrombosis-esp. Heart a. Goodell’s sign-softening of cx-6 weeks b. striae gravidarum (stretch marks) may appear g. Cervix a. start to change by week 6 R/T hormone surge b. Chadwick’s sign-bluish cast-8 weeks c. Blood a. cardiac output -increased 30-50% by week 32 -only 20% increase by week 40 -R/T increased stroke volume and heart rate e. B. heaviness. vessels beneath the skin dilate-more visible f. pulse rate increases 10-15 bt/min 2. position change R/T diaphragm position c. Hct under 35% c. breast and nipple size c. nipple erect d. physiological anemia-hemodilution of cells -anemic if Hgb under 10g/dl. may leak colostrum as early as 16 weeks 3. increased vascularity b. with C/S . slight hypertrophy R/T increase blood flow b. nipples and areola become more pigmented e. 4. Breasts a.89 2 2. Cardiovascular system 1. increase in sensitivity. leukorrhea-thick white vaginal discharge c. increase in blood volume 40-50% (1500ml) -plasma-1000 ml -RBC’s-450 ml b. operculum-mucus plug-endocervical glands Vagina a. friability increases d. transient murmurs may be auscultated d. change in pH leads to higher risk for yeast inf. increase in WBC’s d. increase in feeling firm.

alkalosis compensated by mild metabolic acidosis b.90 3 3. acceleration in metabolic rate b. facilitates maternal-fetal O2-CO2 transfer 4. reflex bradycardia -CO ↓ by half -woman feels faint C. . Blood Pressure a. 3rd trimester-BP returns to 1st trimester values d. epistaxis (nosebleeds) c. pregnancy is a state of resp. flaring of the rib cage 2. sensitivity in medulla to CO2-↑ depth. 6. nasal and sinus stuffiness-(estrogen-induced) b. 1st trimester-no change in BP b. the need to add to the tissue mass of uterus c. may experience heat intolerance R/T excess heat from ↑ BMR acid-base balance a. supine hypotensive syndrome -if they lie on their backs -at 5 minutes. tract a. 2nd trimester-BP ↓ 5-10 mm Hg c. ↑ 15-20% by term b. 3. resp rate ↑ 2 breaths/min d. Respiratory system 1. deep breathing-↓ airway resistance-Progesterone b. ↑ awareness to breath e. 5. changes in the voice pulmonary function a. rate basal metabolic rate a. fetal needs ↑ vascularity of the upper resp. shift from abdominal to thoracic breathing elevated maternal oxygen requirements a. ↑ tidal volume c. 7. reflects ↑ in oxygen demand c.

of urine c. may be overstressed by excessive Na intake c. pooling of fluids in legs = less blood flow to kidneys-better to elevate legs than diuretics d.91 4 D. bladder pulled up into the abdomen g. urethra lengthens-possible problem with cath 2. thighs d. striae gravidarum-stretch marks -on abdomen. ↑ estrogen and progesterone = ↑ uterus size and blood volume b. ↑ in GFR b. 2nd trimester. urine flow rate slowed→stasis/stagnation→ medium for bacteria d. breasts. anatomic changes a. linea nigra=dark vertical line from symphysis pubis to fundus -starts as linea alba-before pigmentation -not present in all pregnant women e. tubular reabsorption impaired→glucose ↑ in urine →more alkaline urine e. vulva. functional changes a. ↑ tubular reabsorption to maintain needed Na level b. thighs -separation of collagen -50-90% of women will have this . darkening of nipple. most efficient in L lateral-↑ perfusion to kidneys fluid and electrolyte balance a. caused by stimulation of anterior pituitary hormone melanotropin b. urinary frequency from ↑ in bladder sensitivity and compression from uterus f. Integumentary 1. chloasma=brownish facial pigmentationintensified by sun -usually fades after pregnancy c. Renal system 1. dilations of ureters. slight protein leakage +1 ok 3. renal calyces→ large amt. hyperpigmentation a. areola. E. pelvis.

bleeding of gums/problems of the mouth a. paresthesia b. . ptyalism-excessive salivation 15-20% will have problem with hiatal hernia ↑ estrogen = ↓ secretion of HCl acid ↑ progesterone = ↓ stomach emptying time=heartburn 3. helps with relaxation and increased mobility of pelvic joints -waddling gait diastasis recti abdominis-persistent separation of muscles of the abdominal wall 3. Neurologic system 1. Gastrointestinal 1. angiomas-vascular spiders b. radiating to the elbow ↑ tension headaches syncope common in early pregnancy 3. other changes a. Musculoskeletal 1. gum hypertrophy-bleeding gums e. H.92 5 2. burning. an ovarian hormone. 4. edema on peripheral nerves-carpal tunnel syndrome a. compression of pelvic nerves may cause sensory changes in legs -sciatica 2. ↑ blood supply = ↑ perspiration F. G. ↑ lordosis-center of gravity is more forward 2. pruritus d. N & V 2. hirsutism-excessive hair growth g. pain in the hand. caused by rising level of estrogen b. 5. palmar erythema-blotches on hands c. ↓ peristalsis→constipation. accelerated nail growth f. 4. relaxin.


6 6. 7. 8. ↑ gallbladder distention→prolonged emptying time and thickening of bile→development of gall stones pruritus gravidarum-may be R/T accumulation of bile change in appetite/food consumption a. change in CHO, protein, fat metabolism b. pica-craving for non-food material c. morning sickness-usually ends by 2nd trimester


Endocrine system 1. ↑ secretions of pituitary hormones: a. thyrotropin b. FSH/LH c. prolactin d. vasopressin (antidiurectic hormone) e. oxytocin 2. ↑ secretions of thyroid hormones: a. thyroxine b. triiodothyronine ↑ secretion of parathyroid hormones ↑ secretion of the adrenal hormones: a. cortisol-r/t ↑ estrogen-regulates CHO/prot meta. b. Aldosterone-protective response to Na excretion ↑ secretion of insulin from the pancreas

3. 4.

5. II.

Diagnosis of Pregnancy A. Gravidity and Parity 1. gravida-woman who is pregnant a. nulligravida-never been pregnant b. multigravida-2 or more pregnancies c. primigravidas-first pregnancy 2. parity-number of births after 20 weeks gestation a. doesn’t matter if born alive or stillborn b. nullipara-never completed a pregnancy c. multipara-completed 2 or more births at more than 20 weeks gestation d. primipara-completed one birth > 20 weeks e. not the number of fetuses born


7 3. 4. 5. preterm-before 37 weeks gestation postdates-after 42 week of gestation viability-capacity to live outside the uterus a. somewhere between week 22-24 b. fetus greater than 500 gms 5-digit system a. gravida b. term-para c. preterm d. abortions-spontaneous or therapeutic e. living children



Pregnancy tests 1. hCG-human chorionic gonadotropin a. production starts with implantation b. found in blood 6 days after conception c. in urine by day 26 d. level rises until peak at day 60-70 in pregnancy then falls-lowest level at 100-130 days 2. ELISA-enzyme linked immunosorbent assays a. color change with hCG bonding b. result as fast as 5 minutes c. detect hCG in 7-9 after conception

C. D.

Nagele’s Rule 1. First day of LMP→subtract 3 months→add 1 week Classic indicators 1. presumptive a. amenorrhea-week 4 b. quickening-weeks 16-20 c. breast changes-weeks 3-4 d. N & V-weeks 4-14 e. urinary frequency-weeks 6-12 f. fatigue-week 12 2. probable a. Goodwell’s sign-week 5 b. Chadwick’s sign-weeks 6-8 c. Hegar’s sign-weeks 6-12


8 d. e. f. g. h. i. 3. + pregnancy test (serum)-weeks 4-12 + pregnancy test (urine)-weeks 6-12 Braxton-Hicks contractions-week 16 abdominal enlargement ballottement-weeks 16-28 palpable fetal outline

positive a. visualization of fetus on U/S-weeks 5-6 b. fetal heart tones by U/S-week 6 c. fetal heart tones by Doppler-weeks 10-17 d. FHT by stethoscope-weeks 17-19 e. fetal movements palpated-weeks 19-22 f. visibility-late pregnancy


First Trimester A. History taking 1. reasons for seeking care a. may have other concerns besides the preg. b. use open ended questions 2. current pregnancy a. review signs and symptoms b. evaluate how pt is coping OB/Gyn history a. menstrual history b. contraceptive history c. any infertility concerns d. any Gyn concerns e. ck last Pap and cultures for STI’s medical history a. pre-existing medical conditions/concerns b. history of surgical procedures nutritional history a. assess for food allergies b. any special dietary concerns history of drug use a. past and present use of legal medications b. h/o illegal drug use





assess for aggravating/alleviating factors C.96 9 7. blood type and Rh factor c. need immediate clinical intervention 9. urinalysis with culture b. HbsAG screen f. Physical examination 1. 4. cultures for STI’s TB skin test 3. situational factors b. any previous care of infants c. abuse may increase during pregnancy b. . 4. vital signs 2. HIV screen e. urine screen a. 3. CBC b. assess each sign/symptom for onset. rubella titer d. Pap smear b. coping mechanisms history of physical/verbal abuse a. blood work up a. UDAP pelvic a. family history psychosocial history a. 8. character. and course b. Laboratory tests 1. glucose tolerance test 2. RPR/VDRL g. Tay-Sachs h. B. head to toe assessment pelvic exam with vaginal/abdominal U/S review of systems a. Sickle-cell i.

1 lb per week past 1st trimester b. Priority patient education topics 1. serum testing for free beta hCG and PAPP-A c.97 10 5. abruption tips to help with fatigue. ↑ NT. assess breasts/nipples f. no ok if live-measles. rabies (Tdap-after 20 wks) b. schedule of visits 2. polio alcohol. ask about quickening-approx 20 weeks . C Pox. glucose d. screening for fetal chromosome anomalies a. IV. 4. 6. iron tabs prn anemia immunizations a. weight-approx. Ongoing care 1. Hep B. MMR. review birth plan g. rationale for labs Kegel exercises for pelvic floor review nutritional needs ok to travel and continue exercise as comfortable ck all use of medications with your provider-even OTC a. 3. Second trimester A. and ↓ PAPP-A can suggest aneuploidy D. physical examination a. mumps. 8. N & V 7. ↑ free beta hCG. tobacco usage→ PROM. NT-nuchal translucency (fetal nuchal fold) b. 9. auscultate FHT e. ok if killed-DT. will start on PN vitamins with folic acid b. BP-watch for ↑ 140/90 or ↑ systolic 30>baseline ↑ diastolic 15>baseline c. dip urine for protein. 5. PTL.

pertinent laboratory tests a. exercise. hCG 3. headaches-rest. MSAFP 2. and pregnancy test results b. inhibin-A 5. hydration. Quad Screen-done between 15-20 weeks: 1. PROM -amniotic fluid discharge e.98 11 2. UE-unconjugated estriol 4. 4. Assessing for possible spina bidifa. hydramnios gestational age a. . decreased fetal activity c. PIH/GHTN -headache -swelling of face/fingers -epigastric pain -muscular irritability -visual disturbance d. or other chromosomal defects b. constipation-hydration. fundal height (from symphysis pubis to top of uterus) # in cm = weeks of gestation (weeks 18-36) b. assess skin changes b. prune juice 3. 5. 6. Down syndrome. bleeding b. follow-up on any prior test results c. stable or decreased fundal height-? IUGR c. amniocentesis potential complications a. acetaminophen c. determined from LMP. infections -chills -fever -burning with urination fundal height a. excessive increase-multifetal gestation. contraceptive history. usually confirmed with U/S interventions for discomforts a.

need for support garments V. Group Beta strep culture-35-37 weeks 2. e. rhogam injection-26-28 weeks for Rh . support stockings food cravings-6 small meals-keep BS level even heartburn-small meals. warning signs b. PIH. 4.e. breast shields for inverted nipples -too much stimulation can lead to PTL f. varicose veins-elevate legs.99 12 d. vaginal exams may begin in the last month 2. dealing with rapid mood changes . travel-if not high risk. g. confidence d. 7. cigarettes k. ↓ spicy foods. B. ok j. D. assess nutrition status c. risk factors at work-i. Voids e. caustic agents i. dental care g. assess for S & S of PTL. avoid alcohol. R&R h. 3. antacids joint/ligament pain-support garments education topics a. if happy about pregnancy-usually have higher self-esteem. accept the concept of being pregnant b. History and physical 1. may dislike pregnancy but love child c. freq. GDM Laboratory tests 1. Third Trimester A. f. hygiene-R/T increase perspiration d. Interventions for discomforts (same as 2nd trimester) Family adjustments 1.moms glucose tolerance test may retest for STI’s C. maternal tasks a. UTI prevention-hydration. sit up after eating.

sibling classes 3.100 13 e. j. establish relationship with fetus -kiss or rub abdomen -talk to fetus -assist with preparing baby’s room sibling adjustment a. c. f. paternal tasks a. may feel replaced c. couvades -observance of rituals = transition to fatherhood -may have psychosomatic symptoms of preg. identify with father role -may be influenced by how their father was e. may have feelings of ambivalence prepare for childbirth practice of mothering role may need to work on communication with family members work on relationship with her mother trust and share with the partner work on sexual relationship with spouse 3 phases of developmental pattern -accept biological fact-“I am pregnant” -accepts need to nurture fetus-“I am going to have a baby” -prepares for role of parent-“I am going to be a mother” 2. i. instrumental g. l. g. expressive vs. . reordering personal relationships -may see fetal as a rival -may feel wife is too dependent on MD/CNM f. participate in childbirth education d. observer vs. k. first crisis for a child b. h. acceptance of pregnancy -may express joy or dismay -unwanted vs. unplanned -affairs/battery of spouse b. need to prepared to become the big sister or brother d.

prenatal breast feeding d. most see the pregnancy as a renewal of their youth d. PTL/PROM c. may be non-supportive-try to decrease new mother’s self esteem c. 4. PIH b. prenatal yoga b. African-Americans -most unmarried. 3. preparation for childbirth classes a.101 14 4. ↓ FM . bleeding d. now have classes on being a grandparent other psychosocial issues a. E. if only in 30’s or 40’s-may not be as interested b. nutritional guidelines. adolescent mothers -most pregnancies unintended-80% -40% will end in abortion-EABs & SABs -higher rates for Hispanics. low SES -more likely not to receive PN care -RN needs to encourage PN visits. grandparent responses a. Education topics 1. Lamaze c. older mothers -multips-pregnancy may be surprise-thought to have started menopause -may feel separated from younger moms -nullips-pregnancy is a chosen event -may feel isolated from older friends -usually seek genetic counseling and PN care -higher risk for adverse perinatal outcomes 5. and social service consult b. continuity of past and present e. may help bridge a previous estrangement f. review warning signs signs and symptoms of labor other potential complications a. cesarean information 2.

B. VII.102 15 VI. blood volume ↑→↑ strain on CV system 2. alcoholism-risk of fetal alcohol syndrome. walk around the plane during long trips 2. abruption b. should avoid air travel after the 7th month MVA-most common cause of fetal death-seatbelts continue with non-weight bearing exercises Substance abuse 1. abortion -problem with using antabuse-suspected teratogenic smoking-retards fetal growth and development a. C. no such thing as a safe level of drugs 2. Maternal concerns 1. Preventing Preterm labor Multifetal pregnancies A. Travel/exercise 1. with social services/women’s shelters E. stop the car every few hours for stretch 2. second-hand smoke just as bad caffeine-since it’s a stimulant. 4. PROM. risk of SAB b. ↑ risk for PTL. no prolonged use of hot tubs b. 3. Vaccinations-ok if not a live vaccine Battering 1. 3. ↑ anemia . D. risk of growth restriction 4. best to limit-300 mg/day a. use common sense a. may increase with enlargement of abdomen 2. high risk for clots in legs if not moving around 1. Ongoing safety issues A. must be reported hook up pt. 3.

4. PROM types of twins a. monochorionic-monoamniotic -if division 7-13 days after fertilization -rarest c. ↑ uterine distention→separation of abdominal muscles ↑ risk for placenta previa ↑ for separation of placenta lack of emotional preparement a. Examples of cultural variations 1. belief of whether pregnancy is state of illness/health 2. Fetal concerns 1. 2 placentas 2. dichorionic-diamniotic twins (20-30%) -if division 3 days after fertilization -may have separate or fused placentas 2. ↑ risk of congenital malformations-in monozygotic twins d. twin to twin shunting e. behavioral expectations of mother/provider . workload. 3. monochorionic-diamniotic -if division 5 days after fertilization 3. Cultural variations during the prenatal period A. risk of prematurity 2. 2 amnions b.103 16 3. dizygotic-from 2 fertilized ova/2 spermatozoa 1. 6. and relationships 7. two-vessel cord delivery complications 4. possible need for selective reduction ↑ strain on finances. 2 chorions 3. space. B. 5. monozygotic-originating from one fertilized ovum 1. VIII. will need additional education and support b.

inevitable. amulets. warm vs. dietary prescriptions/restrictions a. Middle Eastern -only female attendants -FOB usually not at delivery c. c. 5. 7. like to like c. no tying of knots-leads to knot in umbilical cord knife under bed to cut the pain specific groups a. to be endured can be avoided completely punishment for sin can be controlled 4. encourage patients to participate in medical decisions . d. Mexicans -stoic until just before delivery -avoid eclipse of moon-cleft palate -everybody present at delivery b. pica activity restrictions availability of advice/if advice is sought at all consideration of modesty/religion a. clothing b. 6. Nursing care 1. cold b. 9. beads pain a. Asian -prefer warm fluid -natural childbirth -labor in silence -may eat during labor -FOB may or may not be present B. b. 8.104 17 3. support cultural belief-offer alternatives 2. 10.

iron -needed for fetus and expansion of maternal RBC mass -poor iron intake/absorption = iron deficiency -if diagnosed with anemia-extra iron supplements and iron-rich diet -iron deficiency can lead to: -maternal: cardiac failure. low-birth weight infant -deficiencies more common in teen moms and African-Americans b. protein a. b. d. death -fetal: PTL. milk. Maternal Nutrition A. cheese-complete proteins c. Nutritional requirements 1. c. needed for growing fetus b. energy needs-additional 300 kcal greater than pre-pregnancy 2. meat. calcium -no change in DRI for calcium -1000 mg daily if 19 yrs or older -1300 mg daily if under 19 -if lactose-intolerant. eggs. recommend 8-10 glasses (2-3 liters) caffeinated drinks don’t count-diuretic may be good to avoid artificial sweeteners proper hydrations helps prevent headaches. poor wound healing. PP infections. only slightly higher need than non-pregnancy fluids a. and uterine cramping 3.105 18 IX. seeks non-dairy sources of calcium -may need dietary supplement containing 600 mg calcium -helps prevent leg cramps from imbalance of calcium/phosphorus ratio c. sodium -slight increase in need -essential for maintaining water balance . minerals and vitamins a. constipation. 4.

D. Anorexia/Bulimia 01/13 .5 kg (15-25 lbs) obese-7 kg (≤ 15 lbs) 1st trimester-development of fetal tissues 2nd and 3rd trimester-growth of fetal tissues 3. f. K -chronic overdoses can lead to toxic levels -Accutane-if used for cystic acne.5-18 kg (28-40 lbs) overweight-7-11. B. C. C -readily excreted in urine so needs frequent intake -Folic acid -need 50% more folic acid than nonpregnancy -400-800 mcg daily -CDC-50-70% of NTD (neural tube defect) & anaencephaly ↓ with adequate folate d. Vegetarian 2. Pica 3.106 19 -restriction only needed in women with HTN. e.-for synthesis of prothrombin water-soluble vitamins-B. normal BMI-11.44 kg/week) 2. K.5-16 kg (25-35 lbs) underweight-12. may cause multiple birth defects -neonatal hypocalcemia noted in areas where mother’s skin lacked access to sunlight -Vit. E. renal or liver failure zinc -deficiency associated with CNS malformations -needed for protein metabolism -if pt on high-dose iron supplements. 1st trimester-5 lbs (1-2 kg) 2nd-3rd trimester-1 lb/week (0. Cultural differences Nutritional risk factors 1. D. Weight gain 1. Lactose Intolerant 4. needs additional zinc supplement fat-soluble vitamins-A.

Indications for fetal diagnostic testing 1. genetics -defective genes -inherited disorders -chromosomal anomalies -multiple pregnancies -ABO incompatibility b. biophysical-risk factors that originate within the mother or fetus-affect the development or function of either or both a. caffeine c. alcohol d. The High Risk Pregnancy A. smoking b. psychosocial-risks comprised of maternal behaviors and adverse lifestyle that have a negative effect on the health of the mother and/or fetus a. psychologic status -h/o physical/verbal abuse -inadequate support systems -noncompliance with cultural norms -situational crises . nutritional status -teen moms -3 pregnancies in last 2 years -tobacco.107 1 Fetal Assessment Lecture 8 I. alcohol. drugs e. fetal death -sickle cell -heart disease -HIV -bleeding problems 2. medical or obstetric -chronic HTN -PIH -GDM or IDDM -h/o PTL -AMA -h/o stillborn. or drug use -inadequate or excessive weight gain -Hct less than 33% c.

done at home b. illegal drugs f.108 2 -unsafe cultural. 5. follow up with NST. CALL MD e. diet 3. Offer access to services for health promotion Discuss reasons for health diet and lifestyle practices Emphasize need to keep PN visits and do lab work Educate patient/partner to play an active role in health of the mother and fetus II. CST. 3. ethnicity environmental-risks include hazards of the workplace and the woman’s general environment a. low income b. therapeutic drugs e. Complete PN interview with history 2. simple. stress. residence g. 4. industrial pollutants g. B. presence of fetal movement is generally a sign of good health d. radiation c. < 10 movements in 3 hours. ethical. age d. Daily fetal movement count a. Biophysical Assessment 1. or religious practices sociodemographic-risks arise from the mother and her family and place the mother and fetus at risk a. marital status f. lack of PN care c. Nursing Interventions 1. CALL MD f. can be affected by fetal sleep cycle or maternal drug use c. noninvasive. 4. infections b. parity e. smoke. or biophysical profile . 2 hours after a meal and still < 4. chemicals d. Fetal diagnostic tests A.




ultrasound a. indicators -gestational age -multiple gestations -fetal growth patterns -fetal congenital anomalies -placental position and maturity -affects of disease process on the fetus -assess fetal responses to intrauterine environ. -assist with amniocentesis, CVS, fetoscopy, etc. b. data -reflections of echoes that are produced when sound waves are dispersed to and absorbed by tissues being scanned -no recognizable risks to mother or baby -full bladder helps to lifts up the uterus -transvaginal probe 1. allows for better visualization of pelvis 2. good to use on obese patients 3. allows pregnancy to be determined earlier 4. well tolerated, no full bladder 5. helps detect ectopic pregnancies 6. used in adjunction with abdominal scan to R/O PTL in 2nd & 3rd trimesters -abdominal scan 1. full bladder helps move uterus up 2. may be hard to use on obese pts. 3. more useful after 1st trimester -fetal heart activity by 6-7 week by echo scanner -gestational age 1. gestational sac dimensions-8 weeks 2. crown-rump length-7-14 weeks 3. biparietal diameter (BPD)-12+ weeks 4. femur length-12+ weeks -amniotic fluid volume (AFV or AFI) 1. ck fluid-filled pockets without fetal parts or cord 2. AFI-depth of fluid in all 4 quads -< 5cm=oligo -5-19 cm=normal -over 20 cm=poly



3. 4. 3.

decreased AFV-largest pocket of fluid is <2 cm increased AFV-multiple large pockets of fluid > 12 cm

MRI-magnetic resonance imaging a. noninvasive, no known effect on fetus b. evaluate fetal growth c. evaluate fetal structure d. evaluate placental growth, position e. AFV f. maternal structures g. biochemical status h. soft tissue, metabolic, or functional malformations


Biochemical Assessment 1. Amniocentesis a. transabdominal insertion of a needle into uterus b. done after week 14 when uterus is in the abd. c. indications for: -PN diagnosis of genetic disorders collection of fetal cells in fluid karyotype done ↑ AFP level-possible neural tube defect -congenital anomalies -assessment of lung maturity L/S ratio of 2:1 or +PG or LBC >50,000 cts/UL -dx fetal hemolytic disease d. complications -less than 1% of cases -PTL/miscarriage -infection -hemorrhage(Rh – moms get Rhogam) -amniotic fluid embolism -injury to fetus/fetal death 2. PUBS-percutaneous umbilical blood sampling a. also known as cordocentesis b. used during 2nd or 3rd trimester c. used for blood sampling or transfusion d. insert needle into fetal vessel using U/S e. used to dx fetal blood disorders, karyotype, blood type, and coombs


5 f. 3. assess FHR for 1 hour and rescan in 1 hour

CVS-chorionic villus sampling a. done at 10-12 weeks b. remove small tissue from fetal portion of placenta c. indicative of fetal genetic makeup d. use transcervical or transabdominal approach e. complications -abortion -infection -bleeding f. Rhogam given to Rh – moms g. 90% of procedures done on women > 35 yrs old h. because done early, can’t detect neural tube defects maternal blood sampling a. California Prenatal Screening Program -see booklet for blood test and U/S offered b. Coombs -test for Rh incompatibility -indirect=amt. of Rh+ antibodies in mom’s blood -direct=presence of antibody-coated Rh+ RBCs in baby’s blood -determine severity of fetal anemia from hemolysis



Electronic fetal monitoring 1. Nonstress test-(NST) a. healthy fetus with intact CNS, 90% will have FHR accelerations with gross body movements b. blunted by hypoxia, acidosis, drugs, fetal sleep c. reactive if: -normal baseline rate -2 or more accelerations (15X15) in 20 min. -moderated variability d. nonreactive or unsatisfactory -need further monitoring, consider CST/BPP 2. contraction stress test-(CST) a. provides a warning of fetal compromise earlier than NST b. U/C’s decrease uterine blood flow/placental perfusion-hypoxia to fetus=deceleration in FHR c. FHR is monitored for at least 15 minutes d. nipple-stimulated CST

f. reactive fetal heart rate -normal (2)-2 or more accels with +FM/20 min -abnormal (0)-less than requirement e. FSpO2 may be helpful in differentiating fetal hypoxia b. fetal breathing movements -normal (2)-one or more episodes in 30 min lasting > 30 seconds -abnormal (0)-absent or no episode matching requirement above b. gross body movements -normal (2)-3 or more movements/30 min -abnormal (0)-none or less than 3/30 min c. or too much vernix f. fetal oxygen saturation a.112 6 -massage nipple until contraction is elicited -desire 3 U/C’s/10 minutes/lasting 40-60 sec oxytocin-stimulated CST -IV infusion of oxytocin to start U/C’s -increased in 0. Biophysical profile 1. 3. normal FSpO2 may prevent unnecessary interventions when a nonreassuring FHR pattern is identified d. noninvasive dynamic assessment of fetus/environment 2. qualitative amniotic fluid volume -normal (2)-1 or more pockets of fluid > 1 cm in . g.5 mU/min increments negative results -no late decels positive results -persistent and consistent late decels with more than half the contractions e. too hairy. signal error if improperly placed. assessing 5 variables a. fetal tone -normal (2)-1 or more active extension with return to flexion -abnormal (0)-slow extension with return d. normal FSpO2 during labor is between 30-70% D. ROM is needed e. adjunct to EFM c.

equivocal = 6 c.113 7 2 perpendicular planes -abnormal (0)-pockets absent or below needed 3. baseline -range of FHR in a 10 minute period in the absence of or between U/C’s -110-160 bpm b. interpreting the findings d. preparation for procedure b. tachycardia -FHR over 160 bpm for 10 minutes or more -marked tachycardia > 180 bpm -prematurity -mild hypoxia -tocolytic agents -maternal fever . 3. the RN will perform the NST. maternal analgesics. Role of the Nurse in Fetal Assessment Testing 1. and basic U/S patient teaching a. Electronic FHR assessment 1. congenital anomalies -decrease in variability-possible sign of fetal distress or profound compromise c. CVS. PUBS. etc 2. prematurity. bradycardia -FHR below 110 bpm for 10 minutes or more -indicative of fetal hypoxia d. FHR tracing-assessment and interpretation a. abnormal = <4 E. providing psychosocial support PRN F. amnio. score a. variability -98% accuracy in predicting fetal well-being -result of fetal sympathetic/parasympathetic nervous systems -can be affected by fetal sleep cycle. CST. in some settings. support person when the woman is undergoing exams such as U/S. normal = 8-10 if AFI ok b. BPP.

oxygen via mask g. record information on strip if unable to chart b. 2. mirror image of U/C b. variable -U or V shaped -with or without U/C -R/T cord compression -usually transient. early-rarely below 110 bpm -periodic decels R/T intense fetal head compression -uniform shape. changeable -action change to side lying oxygen external fetal manipulation SVE knee-chest position amnioinfusion if ROM 3. medications h. vaginal exams c. late -uniform-reflects shape of contraction -onset after peak of U/C -repetitious -cause-uteroplacental insufficiency -hypotension -PIH -hypertonic contractions -abruptio -postmaturity -IUGR -DM -action -oxygen -position change -stop pitocin drip -IV hydration -assess other S & S c.114 8 -maternal anemia -fetal activity changes in FHR -accelerations-usually assoc. nursing role a. with + FM -decelerations-early. assess if ROM d. position changes when needed f. emesis control i. variable e. late. . VS assessments e. assess need for internal monitors deceleration patterns a.

molar or incompetent cx during the second half-usually placenta previa. placenta abruptio risk for maternal exsanguination with 8-10 minutes r/t uterine blood flow is 650 ml/min (15% of CO) spontaneous abortion 1. 4. ectopic. bacteruria) -systemic disorders (lupus) -genetic factors late-12-20 weeks a. pregnancy that ends before 20 weeks 2. hemorrhage during pregnancy 1. or fetal weight less than 500 gms incidence-10-15% of all pregnancies early-occurring prior to 12 weeks a. 3. B.115 9 Pregnancy at Risk IV. Disorders Causing Bleeding in Early Pregnancy A. 80% occur within the first 12 weeks c. 50% causation from chromosomal abnormalities b. 3. 4. during the first half-usually result of SAB. . usually r/t maternal causes -AMA -parity -chronic infections -premature dilation of cx -reproductive tract anomalies -chronic diseases -inadequate nutrition -recreational drug use/abuse 5. emergent situation-complicates 1 in 5 pregnancies 2. other causes -endocrine imbalance (IDDM) -immunological factors (antiphospholipid antibodies) -infections (chlamydia.

threatened-spotting. some scant dark discharge 1-2 weeks post c. D&E d. inevitable-open cervix. assess for infection plan of care a. cramping b. 6-12 weeks-moderate discomfort. 8. may need prostaglandins. 12 weeks-severe pain assessment a. recurrent-3 or more clinical manifestations a. refer to support group 7. closed cervix. age increases b. no vaginal insertions until bleeding stops d. mod-severe cramping c. take entire course of abx if prescribed e. report heavy or bright red bleeding b. C. 9. missed-death in utero without obvious S & S diagnosed by U/S f. or pitocin for fetal demise teaching a. before 6 weeks-increased flow like heavy menses c. U/S c. therapeutic-for maternal/fetal health or disease . CBC d. rest and supportive care b. increasingly severe as gest. mod-heavy bleeding. check PN history and hCG level b. blood type and Rh factor e. induced abortion 1. IV. blood loss d. incomplete-some POC retained d. complete-all POC removed e. grief counseling if needed f. elective-by request 2. D&C c. types a.116 10 6. 10.

may use methotrexate IM with vaginal misoprostol complications a. 3% abdominal cavity c. 4. tenderness d. 6. 5. accounts for 2% of all pregnancies 95% occur in the fallopian tubes a. may use PG gel to ripen cx c. and bleeding d. Ectopic pregnancy 1. need to monitor temp. Cullen’s sign-ecchymotic blueness around the umbilicus indicating hematoperitoneum 4. colicky pain c.117 11 3. 3. dull. 1% ovary b. clots d. bleeding 5. primarily done in 1st trimester assessment a. laminaria then vacuum aspiration (D & E ) b. informed consent b. shock if ruptured f. fertilized ovum outside the uterus 2. infection b. 1% cervix responsible for 10% of all maternal mortality & leading cause of infertility assessment a. D. retained POC c. bleeding b. options explored c. . discuss conflicts/fears procedure a. may use RU486 (Mifepristone) e. referred shoulder pain r/t diaphragmatic irritation e.

membranes. ruptured-laparotomy with salpingectomy plan a. c. or 69 xy -fetus with multiple anomolies etiology unknown risk factors: clomid. and choriocarcinoma 2. SAB. or fluid -avascular vesicles -associated with choriocarcinoma b. CBC. and U/S d. Rh administration of IV fluids/blood transfusion frequent vital signs administration of Rhogam PRN post-op teaching support groups/grief counseling 7. hCG. hydatidiform mole. g. 8. congenital anomalies -karyotype of 69 xxy.118 12 6. placenta. need to r/o appendicitis. Gestational trophoblastic disease 1. unruptured-methotrexate to dissolve residual tissue b. c. results in ambiguous parts. etc. teenagers. . women over 40 4. d. invasive mole. f. 5. slightly higher in Asians types of hydatidiform moles: a. progesterone ≥25ng/mL=intrauterine progesterone <5ng/mL=dead fetus/ectopic procedure a. √ beta hCG. blood type. salpingostomy c. b. incidence: 1:1200. clinical picture sounds like other infections or diseases b. 3. teaching concerning possible procedures monitor labs-CBC. diagnosis a. F. 69 xxx. complete-fertilized egg whose nucleus is lost -intrauterine contents resemble bunch of white grapes-grow and enlarge uterus -no fetus. partial-2 sperm fertilized normal ovum. e.

16 weeks-passage of vesicles labs/tests a. hyperemesis gravidarum. manifestations a. implantation of placenta in lower uterine segment near or over internal cervical os 2. Rhogam if needed nursing plan a. therapeutic communication c. early part of pregnancy uncomplicated b. serial hCG b. return for serial hCG protocol for 1 year & baseline chest x-ray to detect lung metastasis e. . low-lying-implanted in lower uterine segmentdoesn’t reach os incidence: 0. monitor hCG and increasing fundal height for possible choriocarcinoma-chemo/methotrexate 7. total-os totally covered when cervix dilated b. associated with anemia. V. induction with pitocin/prostaglandins NOT recommended r/t increase risk of embolization of trophoblastic tissue c. care for grief/loss b.119 13 6. PIH-9-12 weeks f. 8. partial-incomplete c. Placenta previa 1.5% of all births 3. abdominal cramps e. types a. suction curettage of tissue b. U/S plan a. higher than expected fundal height (50%) d. Disorders Causing Bleeding in Later Pregnancy A. dark brown vaginal discharge or bright red c. marginal-edge extends to os but may increase during dilation d. 9.

cocaine c. B. vaginal bleeding. ck NST. e. ethnic-African-American. f. detachment of part or all of placenta from implantation site after 20 weeks gestation 2. premature separation of placenta. 7. previous C/S c. smoking i. MVA d. Asians h. AMA g. fetal monitoring monitor bleeding and vital signs monitor CBC give Betamethasone no vaginal exams do C/S later if stable 5. g. previous placenta previa (12X risk) b. if term and in labor with bleeding-C/S if before 36-37 weeks-rest/observation NST. h. 70% painless bleeding b. cocaine manifestations a. associated risk factors a. b. c.120 14 4. smoking . observation for FHR. significant perinatal mortality for both fetus/mother risk factors a. 20% uterine activity diagnosis a. d. multifetal e. transabdominal ultrasound b. HTN b. blunt trauma-battering. closely spaced pregnancies f. requires C/S c. 6. 3. Abruptio placenta 1. fetal lung maturity d. bed rest PRN e. VS plan a. BPP. induced abortion d.

infection j. fibrinogen. 6. Grade 1-mild separation-10-20% b. monitor CBC. c. vaginal bleeding c. blood administration PRN e. 9. monitor FHR f. couvelaire uterus-R/T blood trapped between placenta and uterine wall→hysterectomy h. SGA. malnutrition risk of recurrence significant classification a. I & O. IV fluids. status. PTT h.121 15 e. therapeutic communication for anxiety. Grade 2-moderate-20-50% c. 4. betamethasone if applicable usually requires C/S-may have problems with uncontrollable bleeding 5. foley catheter c. monitor for pain g. fetal monitoring. blood admin. grief . Grade 3-severe->50% clinical a. watch for decrease in urinary output d. PT. hypovolemic shock f. b. perinatal mortality-hypoxia in utero. and mom VS. coagulopathy g. may have no bleeding e. shock. depends on gestation age. DIC-disseminated intravascular coagulation i. f. contractions d. large bore IV’s b. neurological deficits diagnosis-U/S plan a. PTL. 7. d. significant uterine tenderness/pain b. complications-hemorrhage. nursing care a.

psych consult PRN 2. 3. daily weight d. Hyperemesis Gravidarum A. keep NPO b. HTN is the most common medical complication of pregnancy-1-5% 2. admit. 5. multifactorial-may be associated with transient hyperthyroidism or elevated levels of estrogen Priority nursing care 1. I&O c. plan a. therapeutic communication b. obesity. Hypertensive disorders of pregnancy A. molar 2. place IV. rest e. preeclampsia complicates 2-7% of all pregnancies -14% in twin pregnancies women with chronic HTN or renal disease=25% risk for preeclampsia rate has risen since early 1990’s 2nd only to emboli as cause of maternal mortality . diet as tolerated f. etiology-obscure. Background 1. decrease fats and protein if not tolerated h.122 16 VI. small. medications: according to need -Zofran-ondansetron HCl -Reglan-metoclopramide -Benadryl-diphenhydramine -Inapsine-droperidol -corticosteroids d. less than 20 yrs old. 4. multifetal. monitor IV site VII. diet-advance as tolerated c. Risk factors 1. frequent meals g. nursing care a. B.

123 17 6. CHTN-predates the pregnancy or HTN that continues beyond 42 weeks postpartum b. 2 basic types-chronic HTN and pregnancy-induced a. cerebral hemorrhage maternal and perinatal morbidity and mortality are highest when eclampsia is seen early in gestation (before week 28). hepatic failure. and chronic HTN or renal disease fetus at risk from abruptio placentae. and acute hypoxia 7. preeclampsia a. 8. DIC. 5. Classification/assessment 1. multisystem vasopastic disease-HTN with Proteinuria (1-2+) . >35 yrs diabetes Rh incompatibility obesity C. PTL. moms over the age of 35. pregnant specific b. Risk factors 1. abruptio. multigravidas. predisposes mother for eclampsia. PIH/GHTN-onset of HTN generally after the 20th week may occur independently or simultaneously 2. B. HTN after week 20 c. 10. 7. 8. 4. chronic renal disease 2. ARDS. 3. IUGR. 6. chronic hypertension family h/o PIH multifetal gestation primigravida maternal age <19 yrs.

maternal mortality-as high as 24% d. considered mild if diastolic remains below 110 d. g. ↓ platelets-thrombocytopenia g. can be normotensive and without proteinuria h. hands. endothelial damage. seen more frequently in older women. low PLT a. HTN before pregnancy or diagnosed before week 20 b. thought to be caused by arterial vasospasms. hepatic involvement f. visual disturbances/headaches/altered LOC e. characterized mild or severe ↑ BP is first warning sign-↑140/90 pathologic edema in face. 6. BP ↑ 160/110 b. and multiparous women e. oliguria-<400-500 ml/dy d. appears in 2-12% of women with severe preeclampsia c. 5. f. drug of choice: Aldomet (methyldopa) 4. > 3+ or 4+ on dipstick: 5g≥ 24 hr urine collection c. 3. elevated liver enzymes. Caucasians. or abdomen or weight gain >2 kg/week urine and BP checks need 2 + results to be classified preeclampsia severe preeclampsia a. may be initial sign patient has PIH HELLP-hemolysis.124 18 d. 50% will have N & V g. 65% will have c/o epigastric/RUQ pain f. . also considered chronic if HTN lasts longer than 6 weeks PP c. development of HELLP syndrome i. onset of seizure activity in the woman diagnosed with PIH with no neurologic pathology b. and platelet aggregation chronic HTN a. severe fetal growth retardation eclampsia a. e. variant of severe preeclampsia b. pulmonary/cardiac involvement h.

diastolic 15 mm Hg b. decreased colloid osmotic pressure main pathogenic factor is not ↑ BP but poor perfusion as a result of vasospasm 3.000/mm3 b. Pathophysiology/etiology ↑ BP→vasospams ↓ ↓ placental perfusion ↓ endothelial cell activation ↓ ↓ ↓ vasoconstriction activation of intravascular coagulation fluid cascade redistribution ↓ decreased organ perfusion 1. vasodilation c.125 19 7. 2. ↑ liver enzymes -AST-aspartate aminotransferase ↑ -ALT-alanine aminotransferase ↑ c. diagnosis a. is a laboratory. BP with ↑ systolic 30 mm Hg. increase blood plasma volume b. platelets < 100. elevated cardiac output e. no other S & S of preeclampsia 8. not clinical. D. chronic HTN with superimposed preeclampsia a. with proteinuria and generalized edema transient HTN a. E. some evidence of hemolysis . development of HTN during pregnancy or in the first 24 hours post partum b. decreased systemic vascular resistance d. mild preeclampsia→severe preeclampsia→HELLP→ or eclampsia reflects alterations in normal adaptations of pregnancy a. HELLP syndrome 1.

chem panel: uric acid.126 20 -elevated bili level & burr cells on smear unlike DIC. 6. √ for clonus fetal assessment uterine tonicity vaginal exam lab tests a. creatinine. anxiety b. DIC e. coagulation panel normal d. risk for impaired gas exchange e. Nursing process 1. clotting factors c. pulmonary edema c. complications reported with HELLP include: a. epigastric pain c. edema. wt. and DTR’s a. RBS e. recognized risk factors 2. 7. 8. risk for ↓ CO 3. abruptio placentae F. 5. proteinuria. 4. edema on a scale of 0-+4 b. BUN. DTR-patella and bicep. knowledge deficit d. altered tissue perfusion c.. visual disturbances assess BP. urinalysis or 24 hr proteinuria nursing diagnoses a. . history a. 2. headache b. ruptured liver hematoma d. liver enzymes d. CBC b. type and screen f. renal failure b.

severe PIH or HELLP a. labs as directed c. dark room. immediate birth or conservative management b. possible frequent NST’s d. abd. G. wt. exam. IM is more painful -diuresis within 24 hours is an + prognostic sign 3. ↓ reflexes.127 21 f. and muscle weakness -may be given IM for transport yet absorption rate isn’t controlled. teach mom to assess BP. dip urine. g. no visitors f. magnesium sulfate -helps prevent or treat convulsions -interferes with acetylcholine at synapses -↓ neuromuscular and CNS irritability -↓ cardiac conduction -increases blood flow in uterus to protect the fetus -increases prostracylins to prevent uterine vasoconstriction -secondary infusion loading dose-4-6 gms over 20-30 min maintenance-1-3 gms/hr -mag level in 4-6 hrs (therapeutic level 4-8 mg/dl) -frequently ck RR. fetal kick count c. continue to monitor during the intra to postpartum pharmacology a. slurred speech. may want to encourage low Na diet 2. . EFM e. padded side rails g. toxemia box in room-resuscitation meds i. rest at home. suction equipment at bedside h. flushing. vag. on L side when possible b. UO.. bed rest. strict I & O. mild PIH a. foley. DTR’s -have calcium gluconate at bedside (antidote) -toxicity-nausea. palpation d. quiet. risk of injury to fetus or mother ineffective coping R/T powerlessness Pharmacology and related nursing interventions 1.

d. c.128 22 -if eclampsia develops-2-6 gms MgSO4 IV push over 3-5 minutes amobarbital sodium-sedative -250 mg slow push over 3-5 min diazepam-occasionally used -may cause phlebitis. venous thrombosis -if given too rapidly-apnea. methyldopa. 01/13 . or nifedipine b. cardiac death antihypertensives -IV hydralazine (Apresoline) -labetalol HCl.

129 1 Pregnancy at Risk. age. action. increase risk if obese or fat around abdomen c. Part 2 Lecture 9 VIII. IX. nephropathy. 5. previous GDM d. etiology unknown a. develops gradually. 3. may or may not be insulin dependent b. 6. or both 2. Pathophysiology 1. may miss S & S (polydipsia. 4. relative insulin deficiency most prevalent form of DM. Beta cells→insulin→moves glucose into adipose and muscle cells to be used for energy ↓ or ineffective insulin→hyperglycemia→ hypersosmolarity→↑ intracellular fluid into the vascular system→ ↑ blood volume→ excess UO with glycouria cells burns proteins/fats for energy=ketoacidosis weight loss from breakdown of fat and muscle tissues complications: retinopathy. runs in families Pregestational: Type 1 or 2 that exists before preg. Classifications 1. Gestational: any degree of glucose intolerance with onset or recognition during pregnancy a. Group of metabolic diseases characterized by hyperglycemia R/T defects in insulin secretion. Maternal-fetal blood incompatibilities (See High Risk Neonates) Diabetes mellitus A. should be reclassified 6 weeks PP 3. neuropathy. and premature atherosclerosis 4. B. polyphagia) b. polyuria. HTN. sedentary lifestyle. Type 1: pancreatic cell destruction-insulin deficient prone to ketoacidosis (acidosis R/T excessive ketones) 2. Type 2: insulin resistant. .

estrogen. 3. cortisol. ↑ risk for polyhydramnios→overdistention of uterus which can lead to PTL or PROM e. Risk factors 1. IUGR R/T vascular disease e. ↑ tissue glycogen stores=↓ hepatic glucose production (this can affect insulin needs) c. progesterone. congenital anomalies (6-10% chance) -cardiac most common c. volume depletion. ketoacidosis (DKA)→fatty acids move from fat to circulation→oxidized→ketone bodies into circulation→↑ blood glucose and ketones=osmotic diuresis=↓ fluids/electrolytes. prolactin. maternal insulin requirements may double or quadruple by 36 weeks of pregnancy (leaves abundant supply of glucose for fetus) C. and insulinase = ↑ insulin resistance (they are insulin antagonists) (antagonists-counteract the action of another) (synergists-enhances the action of another) d. . macrosomia/birth traumas d. best predictor of pregnancy outcome=degree of maternal control of glucose levels 2. ↓ glycemic control in early pregnancy=SAB ↓ glycemic control late in pregnancy = a. ↑ macrosomic fetus = ↑ risk birth trauma b. infections f. 2nd & 3rd trimesters-↑ levels of hPL. ↑ for PIH or preeclampsia d. metabolic factors: a.130 2 7. 1st trimester-↑ estrogen/progesterone=↑ insulin production=↑ peripheral glucose utilization b. RDS 4. ↑ risk for C/S c. ?chronic hypoxia b. stillborn-etiology unk. cellular dehydration= maternal and fetal death fetal risks a.

. BPP’s. U/S. insulin dosage may decrease b.131 3 f. Educate to test glucose at home-dietary changes Dietary management based on blood sugar tests -1st trimester-2200 kcal/dy -2nd and 3rd trimester-2500 kcal/dy -40-45% CHO. 6. MSAFP c. oral agents may be viable solution -Glyburide (sulfonylurea) ↑ insulin secretion -doesn’t cross the placenta c. 2nd and 3rd trimesters→↑ insulin resistance = ↑ insulin dosage d. hypomagnesemia. 3. hypocalcemia. euglycemia=65-130 mg/dl b. hypoglycemia. urine screen for UTI. NST’s. creatinine clearance d. proteinuria. various regimens followed f. thyroid function screening 2. kick counts b. Lab work a. Some insulin can cross the placenta e. Fetal echocardiogram (18-22 weeks) 4. see California Diabetes and Pregnancy Program -CDAPP -Sweet Success Fetal surveillance to monitor well-being a. 5. 1st trimester. insulin pump may be used during pregnancy g. 12-20% protein. Nursing Process 1. assessment of glycosylated hemoglobin A1c -helps assess level of hemoglobin saturated with glucose caused by hyperglycemia -good control 7% ->10 % = ↑ risk for fetal anomalies (20-25%) c. and polycythemia D. hyperbilirubinemia. 35-40% fats -need bedtime snack to maintain BS level thru night Exercise after meals to prevent drop in BS Insulin therapy a.

Urine testing at home a. complications -preeclampsia -eclampsia -hemorrhage -infection d. or BS > 200mg/dl c. test first morning urine b. Gestational Diabetes 1. hypo/hyperglycemia c. 9. NPO Postpartum a. sched C/S in morning-hold AM insulin.132 4 7. insulin needs drop dramatically with removal of placenta b. several days before CHO homeostasis c. breastfeeding encouraged -helps use up CHO in milk production -risk for hypoglycemia -risk for mastitis -may reduce infants risk for DM -may need to recalculate insulin dose e. spilling large amounts of ketones-CALL MD Intrapartum a. follow hospital’s P & P b. less common in Caucasians . E. spilling small amounts of ketones ok d. watch for dehydration. discuss contraceptive methods -barrier method safest -OC’s have risk of thromboembolic/vascular complications -use of IUD risks infection -tubal ligation if completed family 8. ill. mainline usually D5LR with insulin on secondary infusion d. recheck if meal missed. 4% of all pregnancies/90% of diabetic pregnancies 2.

congenital heart defects. Preexisting cardiac disease A. i. 1 hour glucola-50 gram oral glucose load -considered + if >140 mg/dl b. septal defect d. 3-hour glucose tolerance test -fasting glucose -drink a 100 gm loading dose -ck serum and urine every hour -+GDM if 2 or more of the results are elevated fasting = 95 1 hour = 180 2 hour = 155 3 hour = 140 4. leading cause of non-OB maternal mortality b. change in intravascular volume postpartum 2. 4th ranking cause of maternal death some of the more common cardiac diseases a. mitral stenosis b. over age 30 c. unexplained stillbirth f. Overview 1. CV changes that occur normally with pregnancy can affect women with cardiac disease a. ↓ systemic vascular resistance c. X. risk factors a. family history d. h/o macrosomic infant e. periparum cardiomyopathy -dysfunction of the L ventricle -seen in last month of preg or 1st 5 months PP 3. mitral valve prolapse -use Inderal if symptomatic. cardiac disease complicates 1% of all pregnancies a.133 5 3. miscarriage g. obese b. ie: chest pain -use abx if having regurgitation c.e. . change in CO d. ↑ intravascular volume b. having an infant with congenital anomalies screening a.

mitral stenosis (class I. over 100 -progressive. C.134 6 -mortality rate of 25-50 % -tx-treat the symptoms B. aortic coarctation (complicated) b. feet. subjective -increasing fatigue -difficulty breathing -frequent cough -palpitations -swelling of face. rapid pulse. Class I: Asymptomatic at normal levels of activity mortality = 1% a. Nursing Process 1. aortic stenosis Class III: Symptomatic with ordinary activity mortality = 25-50% a. objective -irregular. legs. Marfan’s syndrome d. artificial heart valves c. educated R/T S & S of cardiac decompensation a. septal defects 2. Classifications 1. generalized edema -crackles at base of lungs . medical care is multidisciplinary 2. Class II: Symptomatic with increased activity mortality = 5-15% a. corrected Tetralogy of Fallot b. myocardial infarction c. II) d. pulmonic/tricuspid disease c. 4. mitral stenosis with atrial fibrillation b. uncorrected Tetralogy of Fallot e. true cardiomyopathy e. fingers b. aortic coarctation (uncomplicated) f. IV) d. weak. mitral stenosis (class III. pulmonary HTN Class IV: Symptomatic at rest 3.

14. 11.135 7 -orthopnea -tachypnea. over 25 -moist. 4. digitalis for arrhythmias and heart failure intrapartum a. O2 via mask 8. side lying or semi-fowlers b. heparin for anticoagulation-doesn’t cross placenta b. redness b. 13. frequent cough -increasing fatigue -cyanosis of lips and nail beds 3. chem panel b. 10. coumadin-contradindicated-teratogenic c. . 9. 12. ECG c. may be put on prophylactic abx labs/studies a. chest x-rays d. 6. 5. 7. abx-↓ risk of bacterial endocarditis d. pain avoid constipation and straining for BM report any S & S of infection keep all PN appts. diuretics to treat CHF e. swelling c. CBC. EFM medications a. tenderness e. identify areas that may lead to stress identity coping mechanisms support groups consultation with dietician watch for S & S of thromboembolism a.

preterm c. 3. d. metabolized better with Vit. C risk to fetus a. B. < 11 g/dl in 3rd ∆ 2. Iron deficiency anemia 1. Folic acid deficiency anemia→megaloblastic anemia 1. increases risk for neural tube defect. breastfeeding may be contraindicated in higher classifications of disease XI. asst. Sickle cell anemia-recessive autosomal disease .136 8 c. iron for fetus comes from maternal serum oral iron supplements-30-60mg/dy a. f. with ADL’s as needed c. < 11 g/dl in 1st ∆ b. e. LBW b. cleft lip/palate 2. 3.5 g/dl in 2nd ∆ c. ↑ perinatal mortality-maternal Hbg < 6g/dl 4. recommended daily intake 400 microgram/day “enriched foods” have additional folic acid C. diuretics to ↓ fluid retention prophylactic abx encourage pain meds to decrease stress-Epid. Anemias A. 1st 24-48 hours most important for hemodynamic stability b. most common a. prevent constipation d. clinical-325 mg ferrous sulfate tablets b. bed rest. monitor FHR and maternal may use vacuum to shorten 2nd stage no ritodrine/terbutaline for tocolysis -may cause myocardial ischemia no methergine postpartum a. 15. i. h. < 10. g.

glaucoma. pain in abdomen. associated with jaundice. schizophrenia. R-rubella-DM. c. bone infection c. heart disease d. and implications for pregnancy and fetus…such as: T-toxoplasmosis-retinochoroiditis. Preexisting psychiatric illness-effect on pregnancy 1. hereditary. convulsions. abnormal hemoglobin in the blood recessive. syphilis-infection. seizures Psychosocial problems during pregnancy A. 5. b. and demonstrated abnormal hemoglobin maternal/fetal risks a.137 9 1. hearing loss. d. PIH e. tx. jaundice. XII. Mediterranean ancestry crisis: fever. normochromic anemia. women with bipolar disorder. folic acid-1mg/day abx as needed O2 and IV’s SCD’s postpartum 3. microcephaly O-others-Hepatitis. and organ failure b. tissue hypoxia. pyelonephritis b. edema. HIV. 4. encephalitis C-cytomegalovirus-90% of survivors have neurological problems H-herpes simplex-hyper/hypothermia. S/S. reticulocytosis. . extremities a. Maternal infections Pages 352-357 KNOW: Type of organism. SAB. 2. attacks R/T vascular occlusion. RBC destruction. or chronic depression may be on psychotropic meds that can cross the placenta or be found in breast milk XIII. fetal loss due to impaired oxygen supply tx: a. + sickle cell test. African-Americans (10% have trait) b. familial hemolytic a.

find out about pt. g. poor sucking B. b. convulsions speed-PTL. microencephaly heroin-PTL. AIDS. respiratory dysfunction caffeine-IUGR. C. barriers to tx a. risk to unborn may = criminal charges to mom b. 3.’s environment. past drug use. housed in psychiatric hospital for rest of the pregnancy c. 3. altered sleep patterns smoking-SIDS. tremors c. and support systems b. hypertonicity d. 352 Substance abuse-pg. c. IUGR. Abuse-pp. ↓ head circumference. current drug use. preterm birth. LBW 3. d.138 10 2. legal considerations a. fetal and maternal death alcohol-FAS cocaine-a. congenital anomalies b. little understanding how drug effects fetus or pregnancy b. conceal abuse 2. LBW. SAB. pediatric allergies. drug testing-blood and urine -alcohol can go undetected in urine . IUGR. neonatal neurobehavioral handicaps. e. case management a. 302 1. 108. PTL. PROM. weakness e. shame. delay seeking PN care c. SGA. may be arrested. f. IUGR. guilt d. stigma. baby may be give to child protective services risks a. placenta. jailed. need to weigh the benefits of therapy to risks to mom and fetus fetal risks to medications a. neonatal addiction.

can test neonate’s hair or meconium to analyze past drug usage screen for h/o physical abuse or psychosocial problems determine need for women’s health services. d. i. f. e. 01/13 .139 11 c. social services.e. g. and education for family support groups. AA alcohol withdrawal tx -benzodiazepines (psychotropic-sedative) -nutritional follow-up -psychotherapy methadone (synthetic opioid) controversial -impaired blood flow to placenta -detrimental fetal effects -stronger withdrawal symptoms for neonate compared to heroin h.

before 4 cm b. assessment -↓ in U/C frequency and intensity -during the active phase of stage 1 -uterus easily indentable between U/C’s c. Dysfunctional Labor A.140 1 Complications of Labor and Delivery Lecture 10 I. Alterations in contraction patterns and quality 1. risk to mom -infection -exhaustion d. tx -analgesia -rest for mom g. Hypertonic Uterine Dysfunction a. maybe R/T anxiety/fear c. risk to fetus -asphyxia -passage of meconium f. tx -r/o CPD -labor augmentation -amniotomy -change position. causes -pelvic contracture -fetal malpresentation -overdistention of uterus -unknown b. after 4-6 hours rest. assessment -pain out of proportion to intensity of U/C -U/C’s ↑ in frequency but uncoordinated d. risk to mom -loss of control -exhaustion e. Hypotonic Uterine Dysfunction a. shower . usually in latent phase. cause unknown. usually awaken in normal labor pattern 2. ambulation. risk to fetus -infection -death e.

3. causes -regional anesthesia -analgesia -exhaustion -lack of urge to push b. R/T macrosomic infants b.141 2 Inadequate expulsive effort (secondary powers) a. usually persistent OP (LOP or ROP) b. may be able to change fetal position -knee chest position -squats -lunges -pelvic rocking -rolling side to side 3. . -C/S ***See Table 18-1 for a list of complications B. usually c/o severe back pain d. risk to mom -surgery (C/S) c. anomalies a. risk to fetus -asphyxia d. maternal causes -pelvis too small -pelvis abnormally shaped -pelvic deformity malpositions a. Fetal malpositions and malpresentations 1. prolonged second stage c. CPD-cephalopelvic disproportion a. affect relationship of fetal anatomy to the maternal pelvic capacity 2. tx -change position -coaching -lower epidural strength or D/C -vacuum-asst.

malpresentation a.142 3 4. knees extended -complete-thighs and knees flexed -incomplete one foot below the buttock or one knee below the buttock b. deformities from MVA. breech most common -frank-thighs flexed. soft tissue dystocia a. immature pelvis in teens 2. pelvic dystocia a. Pelvic alterations 1. risk of prolapsed cord d. fascia. stress can slow or stop dilatation -pain and lack of support ↑ stress level -confinement in bed may make pt feel trapped 2. muscle. placenta previa b. breech presentations associated with: -multifetal gestations -preterm birth -fetal and maternal anomalies -hydramnios c. stress can increase pain perception . contractures (fibrosis of connective tissue in skin. cervical edema e. might attempt vaginal delivery in multiparas e. face/brow presentations -uncommon -associated with fetal anomalies or pelvic contractures -may need forcep delivery f. or a joint capsule) of the pelvis b. traumas c. if external version fails to rotate a breech or shoulder presentation = C/S C. Psychological alterations 1. leiomyomas (fibroids) c. full bladder or rectum d. Bandl’s ring (pathologic retraction ring) at the junction of the lower and upper uterine segments D.

risk to fetus -hypoxia -intracranial hemorrhage -bruising of head/face nullips >20 hrs <1. cortisol. CPD b. stress-related hormones act on smooth muscle a. decrease uterine contractility E. labor less than 3 hours from start of U/C’s b.5 cm/hr >2 hrs <2 cm/hr >1/2 hr 3. ineffective U/C’s c. Alterations in the length of labor 1. epinephrine.2 cm/hr >2 hrs <1 cm/hr >1 hr multips >14 hrs <1.143 4 3. analgesia/anesthesia f. pelvic contractures d. malpresentation of fetus e. beta-endorphins. anxiety/stress precipitous labor/delivery a. prolonged labors more frequent with moms over 40 2. pattern prolonged latent phase protracted active phase dilation secondary arrest: no change protracted descent arrest of descent failure of descent precipitous labor No change in second stage >5 cm/hr 10 cm/hr . maternal complications -uterine rupture -lacerations -amniotic fluid embolism -PP hemorrhage c. abnormal labor patterns can occur because of: a. etc b.

Preterm labor-cervical change and U/C’s between 20-37 wks Preterm birth-completion of pregnancy before wk37-pg 347 1. d. life threatening to fetus and mom -mom-sepsis. ROM 1 hour before onset of labor 2.144 5 F. ck GBS status r/o prolapsed cord 4. Premature rupture of membranes (PROM) 1. support mother and family 2. Related nursing interventions 1. 3. monitor mother/fetus pitocin augmentation/vacuum/C/S Complications of the labor process A. medical risks with pregnancy -multiple gestation -infection -incompetent cervix -UTI’s -short interval between pregnancies -bleeding -anemia -placenta previa/abruptio -fetal anomalies -PROM . II. meningitis discuss ROM protocol a. 3. kick counts/EFM c. chorioamnionitis b. sepsis. ck AFI b. PPROM-occurs before 37 weeks gestation cause unknown-possibly R/T infection a. medical risks predating pregnancy -h/o PTL-triples the risk -multiple abortions -uterine anomalies -parity-0 or >4 -low prepregnancy weight -diabetes -HTN c. B. death -fetus-pneumonia. risk factors a. demographic -African-American -<17 yrs old. >34 yrs old -low SES -unmarried -low level of education b.

is an indicator for PTL -negative predictive value=95% -positive predictive value=25-40% -easier to predict who will not have PTL -expense=$180-215 b. 2. predicting PTL a. 25% R/T PROM followed by labor e. infection major etiological factor c. behavioral/environmental risks -DES (diethylstilbestrol) exposure -smoking -poor nutrition -substance abuse -late on no PN care other risks -anxiety/stress -uterine irritability -long working hours -inability to rest e. pressure in vagina or low back 3. clear. 4. 50% idiopathic (conditions without recognizable cause) preterm births assessment a. 25% are iatrogenic-intentionally delivery of fetus -R/T health of fetus/mom d. pink. -appearance between 24-34 weeks gest. fetal fibronectin-biochemical marker -glycoproteins-found in plasma -appear in cervical canal early/late in preg. salivary estriol-biochemical marker -form of estrogen produced by fetus and present in plasma by 9 weeks -levels have been shown to ↑ before PTL -negative predictive value=98% -positive predictive value=7-25% -expense=$90 each test c. or brownish discharge d. unknown and thought to be multifactorial b. persistent cramping c.145 6 d. endocervical length -lengths less than 30 mm in singleton may predict risk for PTL causes of PTL a. contractions <10 minutes apart in frequency b. .

palpitations fetal tachycardia -nifedipine calcium channel blocker headache. diarrhea cervical effacement >80% 1 cm dilated pt. f. education a. . home uterine activity monitoring d. tocolytics -magnesium sulfate CNS depressant can cause respiratory depression flushing. hypotension -indomethacin prostaglandin inhibitor risk of closure of ductus arteriosus risk of NEC or IVH 6. bed rest-no studies have proven its efficacy -wt. ↓ DTR’s and BP -terbutaline/ritodrine beta-adrenergic receptor stimulant helps with hypertonic contractions tachycardia. N & V. g. notify MD of changes in S & S c. 5.146 7 e. discuss lifestyle adaptations-need to ↓ -sexual activity -heavy lifting -long drives -standing more than 50% of the time -climbing stairs -not stopping when tired pharmacology a. loss -loss of muscle tone -calcium loss -fatigue -depression -constipation b.

5. placenta percreta -invasion of myometrium to the serosa of the peritoneum covering of uterus -can lead to rupture of uterus 2. palpation of vessels succenturiate -accessory lobes of fetal villi developed -vessels supported only by membranes ↑ risk of retained POC -fetal blood loss if vessel nicked battledore -insertion at or near placental margin rather than center -increased risk of fetal hemorrhage 4. Intrapartum emergencies A. antenatal glucocorticoids -betamethasone-12 mg IM X 2 doses 24 hrs apart -dexamethasone-6 mg IM 2 doses 12 hrs apart stimulate lung maturity promote release of enzyme to induce surfactant production can cause maternal infection. abruptio placenta vasa previa -velamentous insertion-cord attached to membranes -no Wharton’s jelly -vessels exposes to laceration -high incidence of fetal mortality -Dx with U/S. placenta increta -chorionic villi invade the myometrium c. Placental abnormalities 1. pulmonary edema can worsen HTN or GDM III. adherent retained placenta a. . placenta accreta -cotyledons invaded uterine muscle b. 3.147 8 b.

classifications a. Death care management a. hyperstimulation of uterine muscle g. intense spontaneous U/C’s f. 6. congenital uterine anomalies d. may be occult and occur even with intact BOW frank prolapse occurs with SROM-1 out of 400 births contributing factors a. external/internal version j. overdistented uterus h. hold presenting part off cord b. complete -extends through the entire uterine wall into the peritoneal cavity/broad ligament . malpresentation c. C. knee-chest or Trendelenburg position c. malpresentation i. transverse lie d. causes of rupture a. multiparas e. umbilical cord lies below the presenting part 2. CNS damage c. previous uterine scar -classical C/S -myomectomy b. uterine trauma c. 3. Uterine rupture 1.148 9 B. hypoxia b. delivery -possible forcep/vacuum if 10 cm -usually stat C/S 5. 4. Prolapsed umbilical cord 1. unengaged presenting part risk to fetus a. forceps 2. long cord->100 cm b.

sharp shooting pain f. lack of progress i. leiomyomas c. assess woman’s risk factors c. vomiting c. D. fundal implantation of placenta b. nonreassuring FHR b. fainting d. incomplete -rupture extends to peritoneum but not into the peritoneal cavity/broad ligament 3. ↑ uterine tenderness e. palpable fetal parts prevention a. hypotonic U/C’s h. 5. abnormally adherent placental tissue S&S a. use of tocolytic drugs case management a. vigorous fundal pressure d. S & S-may be silent or dramatic a. prevent hyperstimulation d. shock & pain b. classifications a. sudden. shoulder pain j. type and cross for possible blood transfusion d.149 10 b. IV/oxygen c. incomplete-smooth mass palpated thru cervix 2. maternal mortality-50-75% 4. possible hysterectomy b. . Uterine inversion 1. risk factors a. therapeutic communication/support e. hypovolemic shock g. complete-protrudes b. hemorrhage (loss of 800-1800 ml) 3. no VBAC’s with classical uterine scar b. prepare pt for surgery-C/S. fetal mortality>80% f.

3. intubate/bag with 100% oxygen e. multiparity b. meconium passage case management a. CPR-30 degree angle of uterus f. Amniotic fluid embolism 1. fetal death in utero g. tumultuous labor c. emotional support/counseling if death occurs 5. fetal macrosomia f. blood transfusion/tx coagulation defects h. need for surgery is rare E. manual replacement b. IV’s g. oxytocin c. amniotic fluid with particles enters maternal circulation and obstructs pulmonary vessels 2. foley catheter i. abruptio placenta d.150 11 4. interventions a. oxygenate-10 L d. caused by opening in amniotic sac or maternal uterine vein with intrauterine pressure forcing fluid into vein maternal mortality=85%/fetal mortality=50% risk factors a. . assess for shock -hypotension -tachycardia -cardiac arrest -hemorrhage -uterine atony c. 4. assess for manifestations of RDS -restlessness -dyspnea -cyanosis -pulmonary edema -respiratory arrest b. prepare for possible C/S j. oxytocin induction e.

physical observation less reliable b. stab wound -direct fetal injury from bullet. . C/S within 20 minutes other causes of trauma: burns. 4. requires surgery -fetal injury from stab wound -better chances if injury occurs in upper maternal abdomen c. 6. 7. Trauma 1. C/S needed in most cases b. leading nonobstetric reason for maternal mortality 2. clinical signs don’t appear until 30% of loss of circulating volume e. CO can tolerate 1000ml blood loss c. falls. all female victims of childbearing age to be considered pregnant until proven otherwise 70% R/T MVA’s (lack of seatbelt)-head injuries and shock physiological differences with pregnant women experiencing trauma a. maternal pulse over 100 bpm=abnormal types of trauma a. 3. assaults complicates 8% of all pregnancies 5.151 12 F. if maternal death occurs. exsanguination -fetal skull fx or ICH -ck for abrupted placenta -pelvic fx can cause injury to fetus -uterine rupture rare b. thoracic trauma-25% of trauma deaths -maternal life threatened by pulmonary contusion -can cause pneumo/hemothorax fetal death R/T maternal death or abrupted placenta a. 8. no indicators until blood loss > 1500-2000 ml d. blunt abdominal trauma -MVA. battering. penetrating abdominal trauma -bullet.

Obstetrical Instrumentation and Procedures A.3 ml for every 1 am EBL over 30-60 minutes g. lateral positioning i. most frequently used method of labor induction 2. peritoneal lavage-ck for blood. assess Glasgow coma scale j. insert NG tube l. LR infused thru cath/fluid ck for cell count o. LR or NS 3:1 ratio. Shoulder dystocia 1. fetal assessment testing-U/S n. oxygen 10-12 liters c. large bore IV’s-14-16 gauge f. assess newborn for fx of clavicle/humerus c. tx: supportive care a. focus on abdomen k. may give O negative if type unknown h. if +.152 13 9. 4. increase risk of maternal/fetal morbidity/mortality 2. induces labor when cervix is favorable or augments a slowing labor progress . 5. fetal head is born but anterior shoulder can’t pass under pubic arch fetopelvic disproportion or maternal pelvic abnormalities may be the cause may use McRoberts maneuver-legs flexed. 6. Rh negative women get Rhogam G. 3. assess mom for hemorrhage IV. check for abrupted placenta m. laparotomy -if -. ABC’s b. knees on abdomen may use Gaskin maneuver-all-fours-hands and knees may use Mazzanti or Rubin techniques to deliver shoulder a. Amniotomy-AROM (artificial rupture of membranes) 1. RN assists with the suprapubic pressure b.

hyperstimulation of uterus fetal passage of meconium b.153 14 3. cord prolapse. N & V. diarrhea. transverse lie nonreassuring FHR placenta previa or vasa previa classical uterine incision active genital herpes invasive CA of the cx . oxytocin -hormone produced by posterior pituitary gland -stimulates uterine contractions -used to induce or augment labor -indications for use suspected fetal jeopardy dystocia postdates maternal medical problems fetal demise -contraindications for use CPD. can lead to infection-Ck temp q 2 hours can be used in combination with oxytocin explain to pt that procedure is painless but might feel increase in vaginal pain R/T movement of fetus presenting fetal part must be engaged in pelvis and applied to cervix to prevent cord prolapse assess color. 6. 5. 7. labor usually begins 12 hours post rupture-if prolonged. chemical agents a. odor. PG gel-prostaglandin gel Cervidil/Prepidil/Prostin E2-dinoprostone -helps to ripen (soften and thin) cervix -may initiate labor without further medications -may be used to terminate pregnancy -adverse reactions headaches. 4. Cytotec (misoprostol)-synthetic prostaglandin E1 -not FDA approved for cervical ripening c. B. fever hypotension. consistency and quantity of fluid Induction and augmentation of labor 1.

amniotomy C. 2. external a. internal a. Version 1. U/S scanning before to ck fetus and placenta d. e. attempt to rotate fetus from a malpresentation b. may be used in multifetal pregnancies to rotate second fetus c. types a. constant pressure to abdomen to rotate presenting fetal part g. Rh – moms may receive Rhogam due to the risk of fetomaternal bleeding 2. f. incision in the perineum to enlarge the vaginal outlet 2.154 15 d. obtain informed consent-usually done in L & D due to risk of complications f. median-midline -most commonly used -effective. mediolateral -prevents 4th degree laceration -repair most difficult -more pain to mom . easily repaired -can possibly extend into rectum b. MD or CNM give gentle. dilators b. may use a tocolytic agent like terbutaline e. Episiotomy 1. maternal/fetal injury possible d. MD inserts hand into the uterus and changes position or presentation b. usually done at or after 37 weeks c. RN role to monitor FHR and support mother D. infusion done on IV pump watch for hyperstimulation assess fetal well being and maternal pain level mechanical methods a.

less rate of episiotomies with CNM vs. No CPD care management a. indications/conditions the same as use of forceps follow hospital’s P & P R/T method. suction pressure. palsy 3.155 16 3. fully dilated b. uses paired curved blades to asst. cardiac moms c. delivery of head during breech delivery conditions a. E. Vacuum 1. Pedi MD at delivery c. distress b. 4. poor pushing effort/fatigue/anesthesia fetal indications for use a. F. ROM f. assess baby for facial bruising. 3. 5. assess FHR before and after delivery b. abnormal presentation-asynclitic c. assess mother for lacerations. attachment of vacuum cup and use of negative pressure 2. urinary retention d. engaged presenting fetal part d. MD Forceps 1. duration. and charting . pros prevents tearing decreases stage 2 enlarges vagina cons lacerations can occur ↑ pain/discomfort lateral position can control head 4. abrasions. maternal indications for use a. vertex e. empty bladder c. second stage arrest b. delivery of head 2.

. multiple gestation g. may attempt VBAC with next pregnancy 7. less likely to rupture. dysfunctional labor pattern/first stage arrest f. and horizontal (low transverse) -classical-faster to perform. CPD/malpresentation/malposition c. 5. 3. 4. placental abnormalities d. low vertical. contraindication for VBAC -transverse-easier. uncontrolled HTN i. decrease risk for infections. AMA moms f. scalp laceration Surgical Birth 1. newborns-ck for caput. active genital herpes h. umbilical cord prolapse e. uterus-vertical (classical).156 17 4. ↑ of repeat C/S e. 6. epidural use d. 8. birth of the fetus thru a transabdominal incision in the uterus 2. less blood loss. G. cephalohematoma. skin-vertical or horizontal (Pfannenstiel. bikini) b. moms with high SES indications for C/S a. term cesarean from Latin “caedo”-to cut C/S rate-20-30%-higher in women over the age of 35 ↑ rate of VBAC’s had lead to ↓ C/S’s but might Δ purpose to preserve health or life of mom or baby ↑ in C/S rate R/T a. increased EFM b. fetal distress/intolerance of labor b. PIH/preeclampsia type of incisions a. private insurance/private hospitals g. is performed in other countries.

risks/complications a. increase financial expense m. wound infection d. anesthesia complications j. injury to bladder or bowel or fetus i. pulmonary embolism c. decreased satisfaction with the birth process k. 11. UTI h. aspiration b. loss of ability to accomplish vaginal deliveries l. wound dehiscence e. longer hospital stay n.157 18 9. hemorrhage g. 01/13 . regional blocks -epidural-most common. bonding and breastfeeding may be delayed types of anesthesia a. thrombophlebitis f. general -higher risk of complications pre/intra/postoperative care-in the textbook 10. feel pressure. no pain -spinal-no pain or pressure b.

5. 1000ml or more blood loss after a C/S delivery 10% change in Hct from admission to PP or need for transfusion early PP hemorrhage-in the first 24 hours a. uterine rupture e. Definition/Risk factors 1.158 1 Complications of the Puerperium Lecture 11 1. 3. Sulfate trauma anesthesia infections prolonged oxytocin usage rapid/prolonged labor b. 4. swollen veins) . lower genital tract lacerations -cervix. uterine atony -marked hypotonia -90% of PPH cases R/T atony -associated with overdistended uterus mag. retained placenta c. placenta accreta d. Postpartum Hemorrhage A. 500 ml or more blood loss after a vaginal delivery 2. perineum 1st-4th degree laceration of perineum -associated with precipitous delivery operative birth congenital anomalies contracted pelvis infection varicosities (distended. vagina. uterine inversion f.

O2 10-12L/min via mask if oxygen saturation low g. if unsuccessful-prostaglandin F2a (Hemabate) given IM or intramyometrially . express clots-1 gm=1ml (weigh pads) c. Δ in LOC.2 mg IM-produces sustained U/C -elevates BP. excessive bleeding palpable boggy uterus. B. 6. hematomas-collection of blood in connective tissue -vulvar-most common. i. pale cool skin. with uterine artery branches/vessels in the broad ligament -cervical-usually shallow. fundal height greater than expected b. if hypotonic uterus a. N & V e. bleeding infections coagulopathies late PP hemorrhage-after 24 hrs to 6 weeks PP a. retained POC c. painful -vaginal-assoc. massage b. h. bright red blood-arterial-deep laceration of cx 7. Complication-Hypovolemic shock Care management 1. headache -may exacerbate cardiac disease h. C. episiotomy -subperitoneal-life threatening-assoc. large bore IV’s-LR 1000 ml with 10-40 units pitocin -watch for water intoxication. empty bladder or place Foley cath f. assess for tachycardia. lethargy d. ↓ BP. retained placenta -S & S: prolonged lochia. with forceps. visible. endometritis dark blood-probably venous-varices/superficial lac. Methergine 0. tachypnea. N & V. 8. subinvolution of the uterus -delayed return of the enlarged uterus to normal size -caused by infection.159 2 g. min.

Teaching 1. inspection of vagina. D. review factors associated with hemorrhage check for bladder distention inspect perineum/vaginal pads assess fundus . suture bleeding lacerations d. assess for clots in lower uterine segment b. perineum c. oxytocin d. 3. D & C if placenta fragments retained 3. oxytocin/ergonovine b. 5. normal lochia progression 2. 4. 2. vasocontrictive -blue cohosh-oxytocic -nettle-↑ available Vit. diarrhea. cervix. reposition uterus b. ↑ Hgb -Shepard’s purse-promotes U/C -red raspberry leaves-promotes U/C follow-up with labs -CBC -coag panel -type and cross match i.160 3 -headache. j. for hematoma -cold packs -ligation of bleeding vessel uterine inversion a. fever -may aggravate asthmatics herbal remedies -witch hazel -motherwort-promotes U/C. 4. N & V. bleeding with contracted uterus a. tx shock c. K. broad spectrum abx e. NG tube if concerned R/T paralytic ileus subinvolution a.

e. h/o DVT. superficial-pain/tenderness/warmth/redness 2. most common type PP b. most common type during pregnancy b. pulmonary arteriogram 2. diagnosing a. venography-less common-exposes mom/fetus to radiation d. obesity. deep-unilateral leg pain/calf tenderness/swelling pulmonary-dyspnea/tachypnea/apprehension/cough tachycardia/hemoptysis/pleuritic chest pain D. deep vein thrombosis a. involves superficial saphaneous vein 2.161 4 6. analgesic-antiinflammatory agent (i. 3. smoker. superficial venous thrombosis-1 out of 500-750 women 2. 3. hypercoagulation. declined R/T early ambulation causes: venous stasis. Motrin) . call MD immediately Thromboembolic disorders A. 4. occludes vessel-obstruct blood flow to lungs 3. II. & injury to blood vessel risk factors: C/S. involves veins from foot to iliofemoral pulmonary embolism a. varicose veins C. Homan’s sign-can be false positive b. Case management 1. DM. superficial venous thrombosis a. B. Clinical manifestations 1. Classifications 1. Incidence/etiology 1. Doppler U/S (VUS) c. if S & S change. blood clot dislodged-carried to pulmonary artery b. AMA over 35 yrs.

abortion. most frequent culprit: E. if spreads to peritoneum=peritonitis c.162 5 3. 5. 4. C/S c. occur in 2-4% of PP women b. chlamydia parametritis (pelvic cellulitis) a. often develops at home b. endometritis-infection of the lining of the uterus a. 5. elevation. . supportive care if Coumadin ordered-need OC therapy -teratogenic to fetus Infections A. 6. -PPROM -multiple vaginal exams -FSE/IUPC -chorioamnionitis -vacuum/forceps delivery -lapse in aseptic technique Classifications 1. may be result of pelvic vein thrombophlebitis wound infection a. exams. broad-spectrum abx may be used UTI’s a. rest. 4. freq. Risk Factors -C/S -prolonged labor -poor health status -OB trauma -pre-existing vag. epidural. coli 3. laceration site c. episiotomy. higher incidence with C/S d. most common PP infection b. usually starts at placental site c. risk factors: Foley. elastic stockings (TEDS) DVT-tx with anticoagulants-IV heparin→po Warfarin PE-IV heparin therapy. infection -manual removal of placenta B. warm packs. C/S site. III. puerperal sepsis-any infection of genital canal within 6 weeks of miscarriage. involves connective tissue of broad ligament b. most frequent culprits: GBS. or birth 2.

5. pain. usually ends day 10 . supportive care a. emotionally labile. 3. Tucks pads d. sitz bath c. profuse foul-smelling lochia. usually Staph aureus. if organism is Candida→oral thrush in babies C. chills. coli. IV. 5. ↑ sed rate wound separation. 6. 4. urgency redness. warm blankets b. 7. encourage proper perineal hygiene rest. 50-80% of women experience the baby blues 2. frequency. E. leukocytosis.163 6 6. PP Blues 1. cry often and for no reason peaks day 5. mastitis a. tenderness 2. dehiscence dysuria. Manifestations 1. ↑ pulse. fever. Psychiatric disorders A. fatigue. develops unilaterally c. warmth D. Case management 1. Streptococcus d. lethargy. abx appropriate for organism-improve hydration 2. most first-time mothers b. analgesics. 3. cool compresses to peri continue breastfeeding or pumping breasts reinforce good handwashing techniques consider I & D for wound if needed assist with ADL’s or baby care 4. affects 5-10%. 3.

sleeping heavily distinguishing feature: irritability prominent feature: rejection of the infant R/T jealousy may have thoughts about harming the baby/self with tx. B. b. 3. severe/labile mood swings 2. 7. symptoms rarely disappear without help feel intense fear. 9. intense. poor concentration. 10. 9. fatigue. 4. 8. psychotherapy antidepressants anxiolytic agents electroconvulsive therapy . anger. 8. 7. pervasive sadness. binge eating. gradually improves in 6 months Tx a.164 7 4. H/A etiology unknown feeling overwhelmed with parental responsibility let-down feeling. d. 5. mild depression. 5. anxiety. and despondency feelings of guilt/inadequacy fuel worry of being incompetent parent odd food cravings. 6. lack connection of mom to fetus needs to learn coping strategies. 6. seek support grps 5-30% of this group will experience PP depression PP depression-PP Major Mood Disorder 1. c.

7. 14. restlessness. 9. irrational statements. and thoughts of harming infant or self 2. depression. hallucinations in 25% severe delusions/hallucinations will command mom to kill infant or have her believe the baby is possessed by the devil nursing staff should be on alert for mothers who are agitated. meet with mental health therapist c. 4. 6. 13. .165 8 C. incoherence. 5. fatigue. 3. occurs in 1-2 of 1000 births/up to 50% chance to reoccur with subsequent births behavior evident within 1-3 months PP initial complaints: agitation. confused. delusions. confusion. insomnia. 10. home visits b. overactive. PP depression with psychotic features (PP psychosis) 1. or suspicious course of syndrome similar to that seen in people with mood disorders psychiatric emergency: antidepressants and lithium mother may not be able to breastfeed on certain medications will probably need psychiatric hospitalization use screening tools: PP depression-pp 851-853 follow-up with advanced practice psychiatric RN a. and obsessive concerns R/T infant’s health delusions in 50% of cases. 12. 11. support groups 8. emotionally labile-inability to move or work then suspiciousness.

depression. have to return to work-possibly meet insensitive coworkers/family d. state of shock/numbness d. anger b. loneliness. 5. loss of identity as parent b.000 women fetal death-6. premature labor/birth C/section loss of control during birth process birth of a boy when expecting a girl/visa versa birth of a handicapped child maternal death-7-8 out of 100. loss of a dream/hope c. intense grief a. 4. responses: anger. Loss and Grief A. clothes c. denial e. have to accommodate the changes the loss has created-i. disbelief. acceptance) 1. 9.166 9 V. bargaining. guilt feelings may intensify if mother thinks she is being punished for a prior bad act f. 6. may have outburst of emotion or lack affect f. 8. need to accept the loss g. may need help with funeral arrangements 2. Situational life crises 1. anger. normal functioning impeded/hard to make decisions h. difficulty handling leakage of breast milk-a reminder of loss e. emptiness. guilt.000 yearly Phases of grief-(denial. resentment . infertility 2. confusion. bitterness. the nursery.e. 7. acute distress a. B. yearning. 3.8 out of 1000 births neonatal death-27.

privacy d. visitation for other family/friends e. religious rituals f. 6. 5. bath and dress the baby c. see and hold the baby b. start to enjoy simple pleasures without guilt d. “bittersweet grief”-grief response occurring with reminders of the loss f. provide time to grieve interpret normal feelings/allow for individual differences provide for the cultural/spiritual needs of parents assist with their physical comfort offer options a. 4. Communication and caring 1. 3. h. grief can also be triggered by subsequent births C. backaches reorganization a. improved function at home and work c. actualize the loss 2. special memorials/pictures 01/13 . search for a meaning to the tragedy b.167 10 g. fatigue. 3. reestablishing relationships e. dizziness. focused anger on health care team for not saving the infant’s life physical symptoms: H/A.

lump may be tender during menses g. Breast self exams a. occurs in women from puberty to menopause b. lumps e. may also do while standing/in the shower g. may need surgical excision if lump suspicious or symptoms are severe . U/S. Exam by clinician a. risk factors -nulliparity -low parity -later menopause -estrogen therapy -family h/o of brst CA c. while on back. direction. MRI h. usually done with yearly pelvic exam b. rashes. ulcerations. vary with woman’s age. and heredity i. use finger pads to ck for indentations. contour should be smooth without puckering or dimpling j. best if done 5-7 days after menses has stopped b. and discharge k. Fibroadenoma a. assess nipples for shape. if periods are not regular. palpate each breast in a circular or vertical motion to cover whole breast d. usually solitary lump < 1cm to 15 cms in diameter f. note size and shape usually equal but not always symmetrical h. Breast Masses A. chose the same day each month c. masses are solid and made of connective tissue d. 90% of brst lumps found by women -20-25% will be malignant 2. may request mammogram for women with dense breast tissue or palpable changes -mammograms-ACS guidelines annually age 40 and over if healthy and with no risk factors-sooner if risk factors present B. Screening for breast masses 1. cause unknown e.168 1 Disorders of the Female/Male Reproductive Systems Lecture 12 I. compress nipple to ck for discharge f. should not be on period at time of exam c. Benign Breast Disorders 1. change in contour/texture. nutritional status. diagnosed by mammogram. doesn’t respond to changes in diet/hormones i.

deeper cysts may not be differentiated from carcinomas k. well differentiated. management -dietary changes-↓ caffeine -↓ Na intake -Vit. do fluid Pap smear of nipple discharge e. Tx: excision 3. aspiration. occurs most often in perimenopausal women d. . Tx: symptomatic -no stimulation -good breast hygiene -I & D if abscess develops -abx -may need affected duct excised Intraductal papillomas a. usually in both breasts but may be singular h. B. or purple in color e. mammogram followed by fine needle aspiration (FNA) or core biopsy m. S & S develop one week before menses -dull. etiology-unknown-possibly R/T imbalance of hormones g. benign lesion in the terminal nipple ducts -may be too small to palpate (2-3 cm) c. ↑ risk of brst CA with relative having brst CA f. rare. found in women 30-50 years of age b. inflammation of ducts behind nipple b. characterized by lumpiness. etiology-unknown c. characterized by thick. if solid. and E supplements -use NSAIDS -some relief with ↓ smoking/alcohol intake -supportive bra -heat packs to breasts Ductus ectasia a. workup: mammo. movable j. may note nipple discharge-serosanguinous d. and may be associated with changes in menstruation c. Fibrocystic breast condition a. green. most common breast problem-mostly found in upper. sticky nipple discharge either white. cysts are usually soft. itching.169 2 2. 70% nonproliferative (benign growing cells) d. inner quadrant of breast b. brown. culture of fluid g. others are proliferative lesions with atypical hyperplasia (↑ risk of brst CA) e. 4. C. with/without tenderness. U/S to determine if fluid filled-if so-aspirate l. heavy pain -sense of fullness -increasing tenderness i. other S & S: burning pain. palpable mass behind nipple f.

. noninvasive if stays in duct (ductal carcinoma in situ or DCIS) c. most common infiltrating ductal carcinoma -abnormal cells grow in the epithelial cells which line the mammary ducts -needs 5-9 years to be palpable b. invasion of lymphatic channels/lymph ducts carry abnormal cells to lymph and to metastatic sites e. exact cause unclear b. liver 2. brain. colon. especially axillary nodes f. or thyroid CA -early menarche (before age 12) -later menopause (after age 55) -nulliparity -first preg. other risk factors-family history -previous h/o brst CA -family history -h/o ovarian. Etiology/risk factors/incidence a.org (American Cancer Society) 1. 1 out of 8 women will develop brst CA -risk factors help identify less than 30% of women -5% of brst CA attributed to heredity -↑ risk for women with abnormal BRCA1/BRCA2 genes -testing expensive -often not covered by insurance -debate R/T prophylactic mastectomies or Tamofixen use -↑ risk of brst CA with use of HRT -occurs in men < 1 % Clinical manifestations a. ↑ risk with ↑ of woman’s age c. Pathophysiology a. staging of disease must include lymph node examination. endometrial. incidence -in US.170 3 C. Breast cancer-Cancer. invasive if penetrates the tissue around the duct d. soft and spongy -well-defined or irregular borders -may cause dimpling due to fixed to skin (orange peel) -may have nipple discharge-bloody or clear 3. physical -most lumps in upper outer quadrant -may feel lump or thickening of brst -hard and fixed. ≥ age 3 -HRT -obesity -h/o benign breast disease with hyperplasia -Caucasians -African-Americans have a higher mortality rate due to late diagnosis -sedentary lifestyle -high SES d. lungs. metastatic sites include bone.

contrast media injected. g. . pain R/T surgical procedure b. partial mastectomy) -removal of tumor -removal of small surrounding area -sampling of axillary lymph node -doesn’t effect pectoral muscle -may follow-up with 6-7 weeks of radiation -modified radical mastectomy -removal of entire breast -sample of lymph nodes -spares pectoral muscle -risks: infections. hematoma lymphadema. no other organs -Stage 4-metastasis to distant-bones. h. M=metastases -Stage 0-ductal carcinoma (in situ)-earliest form -Stage 1-2 cm tumor/hasn’t spread -Stage 2-tumor >2 cm-in axillary nodes on same side -Stage 3-tumor >5 cm-spread to lymph nodeslocalized spread. body-image disturbance R/T loss of body part Management a. assess duct FNA biopsy-aspiration or core-may use guide wire Triple test-physical exam. lungs. risk for infection c. FNA -if any benign-98% of lesion being benign staging-TNM-T=size. surgery -lumpectomy (tylectomy. i. mammogram. Nursing diagnoses a. f. e. limitation of arm/shoulder mobility -sentinel lymph node biopsy (SLNB) -radioactive tracer/dye injected -carried by lymph to sentinel node which is first node to receive lymph from tumor -most likely to contain metastasis if CA has spread -if sentinel node is cancerous. N=nodes. d.171 4 b. psychosocial -denial -grief and loss behaviors mammogram/U/S/MRI nipple discharge exam-culture/specimen to lab ductogram-fine plastic tube placed into duct. liver lymph nodes not local 4. more nodes are excised 5. c.

Infections associated with ulcers 1. kissing. indurated h. 120. hematoma. primary-chancre appears day 5-90 post infection-nontender. CV.000 new cases each year e. can cross the placenta d. c. secondary-occurs 6 weeks-8 months -wide spread maculopapular rash on palms/soles -fever. oral-genital sex c. hair loss b. higher rates in young African-Americans f. malaise -may have condylomata lata i. attributed to use of sex for drugs/money g. anemia. refill.172 5 -reconstructive surgery -goal is achievement of symmetry with preservation of body image -3 types of autologous flap reconst. Sexually Transmitted Diseases/Infections A. -latissimus dorsi -TRAM-transverse rectus abdominis myocutaneous -inferior gluteus free -monitor skin flap for ↓ cap. GI problems. infection. transmission thru abrasion of tissue. neutropenia. screening: . Discharge planning -resources ACS Reach for Recovery program NCCN-National Comprehensive Cancer Network ACS home page II. headache. Syphilis a. 6. thromobocytopenia. necrosis -may also receive breast expanders→ implants adjuvant therapy-radiation -after lumpectomy in non/microinvasive cases -any invasive ductal carcinoma <1 cm diameter -interstitial or balloon brachytherapy -intraoperative radiation adjuvant therapy-drug therapies -chemotherapy started soon after dx -most useful in premenopausal women with brst CA with + nodes -can increase time without CA -may be given alone or with HRT -tamoxifen attaches to hormone receptor on CA cell-cell unable to grow -side effects-leukopenia. biting. caused by treponema pallidum-spirochete b. tertiary-neurologic. MS. shallow. or multiorgan system complications j.

reoccurring episodes not as severe k. B. chills. lesions may progress from macule→papule→ vesicle→pustule→ulcer that crusts→scar i. secondary. zinc. and calcium -kelp powder. sunflower seed oil -relaxation techniques -support groups -condoms to prevent transmission to new partner -C/section delivery if primary outbreak -counseling to deal with shame. estimated 1 out of 4 women will get HSV-2 g. reoccurring ulcers b.173 6 -microscopic exam of lesions -serology-VDRL/RPR-may have false + -MHA-TP-microhemagglutination assays for antibody to T. malaise -severe dysuria -painful lesions-may last 2-3 weeks h. initial infection: -fever. purulent vaginal vaginal discharge and urinary retention j. results in painful. 20% Americans infected with virus-over 50 million people f. valacyclovir. weekly shots for 3 wks -alternatives: doxycycline. not a reported disease e. HSV-2-transmitted during oral/genital sex d. management: -chronic/reoccurring -proper hygiene -systemic antiviral medications -acyclovir. anger Lymphogranuloma venereum-CDC. HSV-2 can have adverse effects on mom/fetus -viremia -congenital infection -60% infant mortality if infant contracts HSV l. C. HSV-1-usually nonsexually transmitted -oral labial ulcers -gingivostomatitis c.gov-look for Facts Sheets 3. can cause cervical problems. screening: -physical exam with complete H & P -viral culture of ulcer n. association between cervical CA and HSV-2 m. guilt. Genital herpes simplex a. .erythromycin-unlikely to cure fetal infection j. 2. and early latent -if syphilis older than 1 year. pallidum used to confirm + tests -seroconversion takes 6-8 weeks post exposure management: -PCN G IM -treats primary. tetracycline -not used in pregnancy . famiciclovir -sitz bath with baking soda -oral analgesics -diet rich in Vit.

Prevention-vaccine Gardisil-start at age 9-26 -killed vaccine -give prior to sexual debut or early after -not given after >5 partners -series of 3 injections/6 mo -$$$. podophyllin. screening: -S & S-dyspareunia. Tx-no treatment can eradicates HPV-only symptoms -imiquimod.174 7 4. Diagnosis -cervical exam to include Pap smear & HPV test -pap only 30-60% sensitive -HPV screen is 90% sensitive -cervical screening guidelines-start at age 21 (whether or not sexually active) -intervals-every 2-3 yrs 21-29 if pap neg -every 3 yrs 30-65 if pap/HPV neg -age 30-HPV neg-1% risk (99% cx CA from HPV-low progression-8. rarely transmitted to neonate at birth g. unaffordable to uninsured -lifetime immunity but still needs paps since not all strains covered k.8% 25-29yrs old→27.8% 20-24yrs old→44. B. a. 90% of cases cleared by immune system in 2 years c. if not cleared. discharge. podofilox-topical -cryotherapy .1 to 12.6 yrs) -age 65 w/ 3 consequential neg paps in last 10 yrs -stop needing paps -colposcopy to view growth with biopsy i.4% e. need to differentiate between HPV &: -molluscum contagiosum-white papules -condylomata lata-secondary syphilis j. can lead to genital warts. itching. 5. Chancroid Granuloma inguinale Infections of Epithelial surfaces Human papilloma virus-HPV 1. 100+ HPV types. bumps -may need to change gloves between vaginal and rectal exams to prevent spread h. cervical cancer d. 40 known mucosal serotypes b. ages at risk for HPV 14-19yrs old→26. warts in the throat. may look like a cauliflower-mass f.

transmission: oral. higher incidence in women under age 20 3. most common/fast spreading STI in women c. higher incidence in African-Americans g. may caused ulcers on the cervix increasing risk to acquire HIV e. people are frequently coinfected-should be tested for other STI’s l. rectum. 45% women will also have chlamydia so should have concomitant tx Chlamydia a. caused by Chlamydia trachomatis b. caused by Neisseria gonorrhoeae-bacteria b. and possibly pharynx k. 600. Gonorrhea a. genital. vaginal discharge. . screening: cultures taken from endocervix. women most often asymptomatic h. management: usually single dose antibiotic: ceftriaxone m. untreated leads to PID and acute salpingitis d. higher incidence in people under 20 years old f.175 8 2. men may c/o pain with urination and yellowish discharge from penis i. rising incidence of drug-resistance d. low back pain h.000 contract gonorrhea each year c. may present with pain/burning with urination. may take up to 3-10 days before symptoms present j. anal e.

infertility. caused by multiple organisms and occasionally caused by more than one c. leads to: risk for ectopic pregnancy. PID-Pelvic Inflammatory Disease a. l. history of PID. ↑ sed rate. k. need to screen asymptomatic women with history of risky behavior n. adnexal tenderness.3 0 C. screening: good history taking to r/o other causes. microorganisms spread from vagina to upper genital tract-usually occurring at the end of or just after menses f. j. chronic pelvic pain. during menses. pyosalpinx. lab documentation of chlamydia or gonorrhea l. abscesses.176 9 f. most commonly caused by C. sexually active individuals ≤ 25 yrs old-screen for chlamydia yearly all pregnant women should be screened at first PN visit repeat cultures if woman was previously + or has multiple partners may have spotting. or severe pelvic pain. and blood used as a medium for growth g. cervical discharge. g. . and possibly ovaries and peritoneal surfaces b. dyspareunia. postcoital bleeding. new partners. i. also caused by gonorrhea and other aerobic and anaerobic bacteria e. abnormal cervical/vaginal discharge. bilateral pelvic tenderness k. 1 million women will experience symptomatic PID h. bleeding. adhesions j. uterus (endometritis). or dysuria dx thru culture management-doxycycline or azithromycin if pregnant-erythromycin/amoxicillin since usually asymptomatic. pain with cervical movement (Chandelier sign). use of IUD i. risk factors: teens. h. tx: usually broad-spectrum abx. must encourage completion of all the medication women tx with erythromycin need to be retested in 3 weeks due to poor validity of tx 4. n. involves fallopian tubes (salpingitis). spread supported by open cx. need to teach prevention of causes to help prevent disease m. m. multiple partners. temp ↑38. S & S: dull. each year. cramping. use analgesics. decrease cervical mucus. trachomatis d.

must individualized to pt’s S & S . new studies proving that HRT may lead to ↑ risk for brst CA g. low calcium intake sedentary lifestyle use of steroids. lifestyle. for polyps-removal c. bleed easily b. ↓ HDL. problem with adding progesterone. polyps-masses in/on the cervix c. atrophic vaginitis-tissues more sensitive. q. p. for vaginitis-use of creams to protect tissues b. proper nutrition. Management a. short term HRT (1-5 years)-no protections against osteoporosis or CVD -risk factors for osteoporosis family history short. thin European or Asian descent early menopause smoker. Postmenopausal bleeding-bleeding 12 months post menses cessation 1. Gynecologic Disorders A. diuretics -risk factors for CVD ↑ LDL. 5-10X risk of endometrial CA e. alcohol use caffeine use. follow-up pelvic exams. HRT Discussion regarding HRT a. . and efficacy c. endometrial problems -endometrial hyperplasia may be a precursor to endometrial CA-need a D & C to evaluate d. III.177 10 semi-fowlers position while resting encourage rest. synthyroid. Related factors a. most studies show ↑ risk factors and adverse reactions R/T dose and length of tx b. and medical history -need to deal with philosophy/beliefs regarding exohormones d. ↑ total serum cholesterol ↑ risk of atherosclerosis 3. and other contraceptive methods other than IUD’s o. controversy R/T method of administration. doses. ↓ ovarian function → ↓ estrogen/progesterone 2. bleeding f. and hydration will need follow-up lab work to confirm cure teaching to include use of barrier methods. if ERT alone. no sexual relations until completion of meds.

possible reasons why some women develop the condition -individual immune system fails to destroy tissue -differences in genetic make-up -environmental challenges n. surgical scars. S&S -pain (dysmenorrhea)-possibly prior to menses -lower abdomen pain -dyspareunia -painful defecation -hypermenorrhea -sacral back pain -infertility . may remain asymptomatic and disappear after menopause j. Endometriosis 1. perineum. uterine ligaments. and other sites such as thoracic cavity.000 hysterectomies i. may worsen with repeated cycles k. each year account for almost 50. cervix. tissue bleeds during or after menses causing inflammatory response by adjacent organs/tissues f. cul-de-sac. gallbladder and heart d. found across all SES levels l. can lead to scars and adhesions g. and inguinal area c. bladder. B. pelvic peritoneum. benign disease characterized by implantation of endometrial tissue outside the uterus b. most widely accepted cause-retrograde menstruation -estimated to occur in 96% of women who menstruate m. vulva. tissue responds to hormonal stimulation e. implanted on the ovaries. incidence -10% in women of reproductive age -25-35% infertile women -28% of women with chronic pelvic pain h. rectovaginal septum.178 11 MI emboli thromboses long term-may use estrogen alone or in combination with progesterone or testosterone -may be continuous or cyclic h. sigmoid colon. Assessment a. endometrial lesions can be found in the vagina.

pregnancy-related-SAB c. Possible causes a. menorrhagia b. Lupron. mifepristone (RU-486) being used with success e. vaginal dryness limited to 6 months R/T bone loss potential teratogen -androgen derivatives Danocrine (danozol) suppress FSH/LH secretion produces anovulation regression of endometrial tissues may produce masculinizing traits weight gain edema deepening of voice oily skin hirsutism ↓ in brst size other side effects H/A hot flashes vaginal dryness ↓ libido insomnia fatigue dizziness ↓HDLs ↑ LDLs contraindicated-h/o liver disease use with caution if h/o heart or renal disease fetus-pseudohermaphroditism c. 40% reoccurrence-except in TAH-BSO cases C. NSAIDs b.179 12 2. a. surgery-nd to consider age. Dysfunctional uterine bleeding-abnormal uterine bleeding Wide variety of menstrual irregularities 1. genital infections-chlamydial cervicitis d. location of disease -TAH-BSO -laser surgery to remove adhesions/tissue f. suppression of endogenous estrogen production medically induced menopause -GnRH agonists (gonadotropin-releasing hormone) i. may use OC’s with low E to P ratio to shrink endometrial tissues SE: N & V.e. anovulation-polycystic ovary syndrome b. desire for children. Synarel ↓pituitary gonadotropin secretion→ ↓FSH/LH stimulation of ovaries→ ↓ovarian function→hot flashes. edema d. irregular cycles 2. bleeding. neoplasms-CA of cx . Management a.

D. trauma-foreign body systemic diseases-DM iatrogenic-herbal preparations-ginseng Severe bleeding with Hgb ↓8g/100ml=hospitalization a. estrogen X 21 days with progesterone (medroxyprogesterone-Provera) added for the last 7-10 days b. oral cong. teens-20% b. g. 3. hysterectomy 4. DM. low dose OCP c. endometrial biopsy to r/o endometrial CA Incidence a. 5. burning. infections -candidiasis-yeast causes-abx.180 13 e. causes -infections -lack of hormone estrogen -irritants/allergies chemicals medicines latex condoms spermicides diaphragm/cervical cap scented/colored toilet paper bubble baths douches laundry detergents hot tubs horseback riding wearing tight garments rubbing on a bicycle seat d. urinary frequency -spotting c. women under 50-50% Management a. Inflammations and Infections 1. estrogen (Premarin) b. Vaginitis/Vulvitis a. given IV cong. possible D & C c. inflammation of vagina and/or vulva b. problems immune system thick white odorless discharge in the mouth-called thrush tx-antifungal agents -bacterial vaginosis-BV caused by a variety of bacteria including gardnerella associated with PTL and birth . pregnancy. S&S -irritation. ablation of endometrium d. malodorous abnormal discharge -itching. f.

SGPT. barrier devices left in place. recent delivery -S & S-fever >102 F. ↓ platelets b. Problems R/T Pelvic Support Structures 1. widespread macular rash. SGOT.181 14 etiology unknown heavy gray frothy malodorous D/C tx-oral metronidazole-Flagyl antiprotozoal/antibacterial contraindicated in women who breast feed may affect the CNS and hematopoietic systems with alcohol-can cause abdominal distress. aureus→produces toxin TSST-1 -risk factors-retained tampons. management -mainly supportive -antibiotics-limited value -need to teach prevention. 2. N & V. assessment -primarily a disease of the reproductive age -caused by S. hypotension. reoccurrence E. Uterine Prolapse a. radiation tx -estrogen creams restore lubrication and decrease soreness/irritation e. N & V. Toxic Shock Syndrome a. round ligaments hold uterus in anteversion uterosacral ligaments pull cx up and back b. dizziness. 38. bilateral oophorectomy. urinary urgency tx-Flagyl-treat both partners since a STI-should screen for other STIs atrophic vaginitis-irritation without discharge -lack of estrogen due to childbirth. uterus remains retroverted c. 2 months PP.9 C. inflamed mucous membranes -lab tests-↑ BUN. causes: congenital or acquired pelvic relaxation -pregnancy -perimenopausal period -pelvic surgery -pelvic radiation . Cr. ligaments should return to normal length-1/3 of women. surgery. H/A -trichomoniasis-anaerobic protozoan may be asymptomatic or have frothy musty-smelling discharge itching on or around the vagina spotting. menopause. diarrhea myalgia.

irregular bleeding -may resolve on own -use of OC’s -diagnostic laparoscopy with possible laparotomy b.182 15 d. F. hemorrhoids. ovarian masses -70-80% benign -S & S-asymptomatic -mass may be palpated on pelvic exam -may have a feeling of fullness. vaginal fullness bulge in vaginal wall d. fullness. tx: -pessaries -estrogen creams -abdominal/vaginal hysterectomy education: use of Kegel exercises to strengthen pelvic floor muscles Cystocele a. cramping -can lead to dyspareunia. advanced age c. herniation of anterior rectal wall b. causes: genetics. hysterectomy . follow surgery with low residue diet 3. S & S: urinary incontinence. feeling of vaginal/rectal fullness c. childbirth. tx: vaginal pessary or surgical repair colporrhapy (anterior repair)-shortens pelvic muscles to better support bladder Rectocele a. dysmenorrhea -metrorrhagia (intermenstrual bleeding) -may shrink with menopause -myomectomy. uterine masses -fibroids-leiomyomas -minimal CA risk -S & S-frequently asymptomatic -low abdominal pain. pressure -menorrhagia. Common Benign Neoplasms 1. downward displacement of bladder-bulge in anterior vaginal wall b. surgery-posterior colporrhaphy or A & P repair f. D & C. 2. obesity. Types/Management a. need to promote bowel elimination e. may lead to constipation. e. fecal impaction. complete emptying of bladder difficult R/T the cystocele sags below the bladder neck e. found by rectal exam or barium enema d.

questionable reasons for surgery e. and colorectal c. testing -Pap smear -colposcopy -punch biopsy -ECC d. S &S-postmenopausal bleeding f. IV. removal of uterus and cervix thru abdominal incision b. BE. chest x-ray. late menopause >age 52 Caucasians g. tests: CBC. Total abdominal hysterectomy a. pre-op: lab work. Cervicala. f. may want to consider alternatives LAVH-laparoscopic assisted vaginal hyster. abdominal prep. liver function. found by endometrial biopsy h.183 16 2. Reproductive cancers 1. unopposed ERT. liver and bone scan. 5th most common after skin. 3rd most common CA of reproductive tract b. Endometrial a. may include removal of fallopian tubes/ovaries BSO-bilateral salpingo-oophorectomy castration in females c. breast. lung. informed consent-must understand means sterility g. nulliparity. renal function. risk factors -age (50-55) -early childbearing -non-Caucasians -smoking -multiple sexual partners -HPV→Gardasil vaccine c. tx: radiation-intracavity (brachytherapy) -external beam chemo surgery-TAH/BSO 2. CA-125 j. endometrial cancers are nearly all adenocarcinomas (80%) -cancer of glandular cells e. advanced age. ECG. Foley cath h.000+ are done yearly d. staging: Stage 0-carcinoma in situ-superficial Stage 1-invaded the cervix without spreading Stage 2-CA has spread but remains in pelvis -5 year survival rate 65-80% . need to deal with psychosocial issues G. post-op care similar to post-op C/section i. CT. asymptomatic in early development d. most frequently occurring reproductive cancer b. risk factors: obesity. 600. shave.

most often occurs in 5th decade (age 45-65) b. most occur after menopause c. cone biopsy. risk factors -fertility drugs -early menstruation -nulliparity -high fat diet -smoking -alcohol st -1 child after age 30 -h/o breast. in 75% of cases. 90% squamous cell carcinomas b. usually localized. more than 50% of cases occur in postmenopausal women (age 65-70) d. hysterectomy (loop electrosurgical excision procedure) Stage 1-simple hysterectomy if cancer is more than 3mm-may want radical hysterectomy with removal of lymph nodes in the pelvis Stage 2-hysterectomy with high-dose radiation and chemo Stage 3 & 4-treatment and predictive prognosis varies on severity of spread and response e. LEEP/LEETZ. accounts for 4% of Gyn malignancies c.184 17 Stage 3-CA spread to lower wall of vagina -5 year survival rate as low as 20-40% Stage 4-CA spread to distant organs tx: Stage 0-cryosurgery. . dx: transvaginal U/S. laparotomy i. Ovariana. CA 125-associated with various epithelial CA may be used to assess response to tx in women with known ovarian CA Vulvar a. tx: -TAH/BSO -tamoxifen -chemo -radiation j. 10% (Stage IV) -discovery of CA not until advanced stage f. slow-growing. laparoscopy. S&S -irregular menses -PM tension -menorrhagia -breast tenderness -early menopause -abdominal discomfort -dyspepsia -pelvic pressure -↑ abdominal girth -urinary frequency g. 5 year survival rate-90% (Stage 1). 3. colon. laser surgery. ↓ risk -use of OC’s -h/o BTL -BSO e. and marked 4. CA had metastasized before dx -60% beyond the pelvis h. or endometrial CA -family h/o breast or ovarian CA d.

pain. CA most commonly dx-solid tumor-age 15-40 e. Leading cause of cancer deaths in men 15-35 yrs old a. radiation. pruritus tx: excision.185 18 by late metastasis to regional lymph nodes risk factors: HTN. rarely bilateral d. laser. Pathophysiology a. most often in Caucasians. stromal-hormone producing -interstitial cell tumors(arise from Leydig cells) ↑ androgenic hormone secretions rare. DM S & S: bleeding. malodorous D/C. Testicular Cancer 1. rare in African-Amer. vulvectomy e. highly treatable b.(40%) -occur in men late 30’s to early 50’s -localized-grow slow -metastasized later -response well to radiation -5 year survival rate-95% with surgery and radiation nonseminomas-not sensitive to radiation -occur in men late teens to early 40’s -need surgery or chemo -embryonal carcinomas common in men 19-26 yrs old may spread via bloodstream -teratomas rarely occur often mixed with other tumors -choriocarcinomas lethal. 2. IV. obesity. germinal-sperm-producing cells-95%of cases -2 types seminomas. fast spreading initial dx often in metastatic stage -25%-teratocarcinomas b. usually benign may secrete estrogen-feminization gynecomastia . f. Male Reproductive DisordersA. usually benign -androblastomas rare. g. usually curable-over 90% in all stages combined c.

75% will be in the undescended testis (assoc. radical retroperitoneal lymph node dissection -helps to stage the disease and reduce tumor Post-op teaching a. may be R/T cryptorchidism -if develops CA. Causes a.186 19 3. inguinal Nursing diagnosis a. lymphangiography to ck retroperitoneal lymph nodes Physical exam a. CT scan. mainly unknown b. may see painless enlargement c. dragging sensation d. watch for fever. Chest x-ray to r/o metastasis d. palpate for lump b. chemo c. risk for sexual dysfunction R/T disease/surgery b. 7. increasing tenderness. anxiety R/T dx of cancer Management a. markers should fall b. radiation-seminomas -used after orchiectomy -external beam therapy →nonseminomas-radical lymph node dissection saves sympathetic ganglia d. drainage. no stair climbing or heavy lifting (>20 lbs) c. tumor marker study -benign tumors never elevate marker proteins -AFP and HCG-for nonseminoma -in seminomas-↑ hCG/LDH but not AFP if ↑ AFP. U/S c. may be R/T trauma. disturbance of body image R/T dx and tx d. acute/chronic pain e. pain around the incision. stem cell transplantation-used with chemo to help prevent infection/anemia e. think mixed tumor-diff. with seminomas) c. heaviness. chills. resume normal activities 1 week after discharge 4. 8. 5. sperm banking-before radiation and chemo b. dull ache in abdomen. or dehiscence of the incision b. dysfunctional/anticipatory grieving c. unilateral orchiectomy f. infection Testing a. . Tx -if tx effective. 6.

may be excised thru small incision in scrotum Varicocele a. B. can cause infertility by ↑ scrotal temperature Scrotal trauma a.187 20 d. cystic mass with straw-colored fluid forming around the testis b. orchidopexy-surgical placement of testis into the scrotum Cancer of the Penis a. 80% will spontaneously descend d. ice. . torsion of testes-twisting of spermatic cord -considered a surgical emergency -S & S-pain. avoid heavy lifting. if painful-surgically removed -inguinal incision -may need to elevate scrotum with towel when in bed to help with drainage e. penectomy-partial (glans only) or total -with total-need a perineal urethrotomy for urinary drainage 3. small areas may be excised or cured with radiation d. 6. sperm-containing cystic mass on the epididymus alongside the testicle b. cluster of dilated veins posterior/above testis b. mainly a pediatric problem -3% full term males -20% male premies c. may need surgical drain and hospitalization f. N & V b. Spermatocele a. uni or bilateral c. 5. no tx necessary unless compromises testis circulation d. disorder of lymphatic drainage of scrotum c. scrotal support Cryptorchidism a. needs follow-up studies/TSE Other Reproductive Disorders 1. less than 1% of male malignancies b. elevate. directed to wear scrotal support 2. wartlike growth/ulcer c. 4. usually small/asymptomatic-no intervention c. aspirated or surgically removed e. usually asymptomatic-no tx d. carcinoma is a painless. Hydrocele a. undescended testis b.

prepuce constricted-can’t retract over glans b. men under 35 yrs. with STI -also called prostatodynia c. hard. Proteus. dysuria. 11. penis remains large. Phimosis a. may have pain and swelling of the scrotum f. scrotal elevation. caused by bacteria from urethra or other sources d. 10. chills. coli. tender prostate d. warm enemas. urologic emergency e. with urethritis -common bad guys-E. causes -neurological -vascular -pharmacological d. analgesics. Enterobacter and group D streptococci -S & S-fever. tx-circumcision Priapism a. may be uni or bilateral e. urethral discharge. pyuria and bacteriuria may develop g. if untreated. c/o pain along inguinal canal and vas deferens e. need to improve venous drainage to corpora cavernosa f. chlamydia trachomatis d. may come from infection of the prostate c. aspiration of corpora cavernosa Epididymitis a. can lead to inflammation of the bladder and epididymus e. bacterial-assoc. may be bacterial or abacterial (more common) b. abscess may form necessitating an orchiectomy Orchitis a. and boggy. ice. . catheter. acute testicular inflammation b. and antibiotics g.188 21 7. infection of the epididymis-tx with abx b. uncontrolled. mumps orchitis-20% of males who have mumps after puberty-given gamma globulins -childhood vaccination is a good preventative measure Prostatitis a. results from infection or trauma c. abacterial-after a viral illness or assoc. risk for sterility R/T testicular atrophy f. Cipro g. tx: antimicrobials-Geocillin. tx: Demerol. tx: bedrest. 9. prolonged erection b. encourage sitz baths and completion of meds 8. sexual dysfunction may occur R/T pain f. and becomes painful c.

i.189 22 h. use analgesics prn if UTI develops. j. may be put on Septra instructions on activities to drain prostate -sexual activities -masturbation -prostatic massage 01/13 .

mumps f. inflammation within the tube i. hypospadias c. abnormal external genitals b.190 1 Infertility and Genetics Lecture 13 I. marijuana. Problem for 10-15% of reproductive-aged couples Women over age 35-21% chance of infertility Risk Factors 1. change in sperm -smoking. heroin. Asherman’s syndrome-uterine adhesions/scars 2. The Couple Experiencing Infertility A. exposure to hazardous substances j. amyl nitrate. 3. methaqualone 1 . varicocele d. Males a. Primary-never pregnant b. Females a. B. Incidence 1. abnormal internal reproductive structures c. tubal adhesions j. amenorrhea after stopping OCP e. early menopause f. testicular damage-trauma. low testosterone levels e. Definition: Inability to conceive and carry a pregnancy to viability after at least one year of regular sexual intercourse without contraceptive use a. genetic disorders h. endometrial/myometrial tumors k. undescended testes b. Secondary-had been pregnant in the past 2. butyl nitrate. anovulation -pituitary/hypothalamus hormone disorders -adrenal gland disorders d. STI’s i. tubal motility reduced h. increased prolactin levels g. endocrine disorders g.

C.191 2 k. decrease in sperm -hypopituitarism -chronic disease -gonadotropic inadequacy obstruction of the vas deferens or epididymis decreased libido impotency Components of Fertility 1. l. physical exam -assess endocrine systems for abnormalities -visualize secondary sex characteristics -tests to evaluate uterus and fallopian tubes -bimanual exam of organ mobility -lab tests c. complete history -duration of infertility -past obstetrical events -sexual history -review medical/surgical history -assess exposure to hazardous substances b. unexplained factors-15% Assessment of female infertility a. . male problems-35% b. 4. n. 3. Sperm viable in female reproductive tract for up to 48+ hours -fertility potential-24 hrs 2. m. testing -HSG-hysterosalpingogram -postcoital test Sims-Huhner test-ck cervical mucus abstain from intercourse for2-3 days performed several hours after ejaculation examine cervical mucus/sperm under 2 5. Ova viable for about 24 hours -optimum time for fertilization may be only 1-2 hours Blastocyst must implant within 7-10 days into the hormonally prepared endometrium Women account for 50% of infertility cases a.

use of condoms if woman has immunologic 3 .00 rise=surge of LH. Psychosocial a. progesterone ova released 24-36 hrs before ↑ temp intercourse-3-4 days prior to 2-3 after -endometrial biopsy -laparoscopy -U/S 6. dx of infertility may lead to problems with couple’s personal relationship c. adoption 2. i. Infertility management 1. change to boxer shorts c. Assessment of male infertility a.192 3 microscope -sperm immobilization antigen-antibody reaction -assessment of cervical mucus spinnbarkeit-the formation of thread by mucus from the cervix when spread on a glass slide and drawn out by a cover glass -U/S dx of follicular collapse -serum assay of plasma progesterone -hormone analysis estrogen.5-1.e. H&P b. discuss alternatives. progesterone FSH. LH thyroid -basal body temperature (BBT) biphasic-↑ temp 12-14 days before menses ck temp before rising 0. semen analysis -sperm density-20-200 million cells/ml -may vary day to day-collect over a month -effects of cervical mucus on sperm’s motility and survival -ck sperm’s ability to penetrate an ova D. water soluble lubricants b. may need counseling to deal with issues of loss or inadequacy b. Nonmedical therapies a.

if uterine cavity too small to carry pregnancy. 4 . hysterosalpingography-may unblock tubes d. chemo/thermocautery to eliminate chronic inflammation and infection 4. may be able to reconstruct uterus R/T bicornuate f. Medical therapies a. estrogen and medroxyprogesterone c. Menopur (human menopausal gonadotropin) extremely potent requires daily monitoring daily IM for 7-14 days-first half of cycle incidence of multifetal > 25% -HCG-may be given to induce ovulations after ovaries stimulated with HMG -GnRH (gonadotropin-releasing hormone) used with hypothalamic-pituitary dysfunction or failure to respond to clomiphene b. male tx -thyroid/adrenal gland correction -abx for STI -clomiphene-unsure effectiveness -HCG-stimulates androgens-↑ spermatogenesis Surgical treatments a. removal of adhesions c. ovulatory stimulants -Clomid (clomiphene) stimulates the ovarian follicle -multifetal rates-less than 10% -Parlodel (bromocriptine) inhibits release of prolactin (elevated levels of prolactin have an amenorrhea effect on the body) -Bravelle. excise ovarian tumors b. myomectomy g. hormone replacement therapy -use conj.193 4 reaction to sperm-will reduce antisperm antibody production 3. no medical tx available-each successive pregnancy enlarges uterus e.

194 5 5. ova and sperm moved into tube -ZIFT-zygote intrafallopian transfer -ovum transfer (oocyte donation) -embryo adoption -intracytoplasmic sperm injection -assisted hatching -TDI-therapeutic donor insemination b. Decisional conflict Altered patterns of sexuality Risk for social isolation II. initial sequencing complete 06/00 c. and Social Implications Program-sentinel to prevent discrimination or use of material for eugenic purposes (selective breeding) b. goal-to facilitate study of hereditary diseases and provide potential for altering genes to treat and/or prevent occurrence 5 . Reproductive alternatives a. Human Genome Project-1990-international effort to map and sequence the genetic makeup of humans a. ELSI-Ethical. The Family Experiencing a Genetic Disorder A. Legal. assisted reproductive alternative (higher risk for ectopic) -IVF-ET-in vitro fertilization-embryo transfer -GIFT-gamete intrafallopian transfer *after ovulation. Body image disturbance 2. surrogate mothers -use surrogate’s ova and husband’s sperm -use mother’s ova and husband’s sperm d. Nursing diagnoses 1. Chromosomal abnormalities 1. preimplantation genetic diagnosis -eliminate defect embryos before implantation c. 4. 3. adoption E.

autosomal chromosomes-22 pairs control traits of the body c. sex chromosome abnormalities -45X-Turner’s juvenile external genitalia undeveloped ovaries short in stature webbing of the neck 6 3. occurs during meiosis when pair fails to separate c. sex chromosomes-pair 23 determines sex controls some other traits XX-female XY-male d. karyotype-pictorial analysis of chromosomesusually from peripheral blood but may come from any body tissue b. usually caused by nondisjunction b. lack of an autosomal chromosome (45)=death of embryo e. mosaicism-some cells have normal #.195 6 2. others missing/having an additional chromosome f. . Chromosomes a. terms-allele-gene that determines a specific trait each trait has a pair of alleles genotype-genetic makeup of an individual phenotypephenotype-expression of gene’s function either measurable or observed homozygoushomozygous-has identical alleles on each chromosome in the same locus hetrozygoushetrozygous-2 different alleles at a given locus Abnormalities in chromosomal numbers (aneuploidy) a. trisomy-additional autosomal chromosome -21-Down Syndrome -18-Edwards Syndrome -13-Patau Syndrome (18 & 13-poor prognosis: cardiac & respiratory problems) d. recessive gene-only expressed when another another recessive is present (aa) f. dominant gene-their trait is expressed over another (AA or Aa) e.

one gene controls a particular trait. psychiatric disorders 2. tend to occur in families d. Multifactorial a. malformation may be mild to severe depending on # of genes affected c.196 7 impaired intelligence most affected embryos SAB -47XXY-Klinefelter’s poorly developed secondary sexual characteristics small testes-infertile tall.e. autosomal dominant inheritance -abnormal gene with trait is expressed even with a normal member of the pair-no carriers -mutation of the gene-spontaneous. polygenic.: cleft lip/palate. Patterns of Inheritance 1. obesity. multifactorial diseases: coronary artery disease. additions/deletions gamete produced has too many/too few gene-effect may be mild→severe B. or defect b.000 genes in 23 chromosomes c. # of unifactorial abnormalities exceed the # of chromosomal abnormalities -50-100. Unifactorial-Single-gene disorders a. translocation-genetic material moved from one chromosome to another-may create an imbalance of materials no problem if all information present b. neural tube defects b. effeminate subnormal intelligence usually present 4. disorder. combination of genetic and other factors such as environment i. some malformations more common in one sex e. Abnormality of chromosome structure a. HTN. permanent change -affected individual comes from a family with generations of the disorder-50% chance of have mutant allele if parent was affected 7 .

197 8 -ex: Marfan’s-disorder of connective tissue achondroplasia-dwarfism polydactyly-extra digits Huntington disease autosomal recessive inheritance -both genes in the pair carry the abnormality -heterozygous-carriers of the recessive trait -ex: Tay-Sachs sickle cell anemia cystic fibrosis -phenylketonuria X-linked dominant inheritance -occur in males and heterozygous females -ex: Fragile X syndrome-mental retardation X-linked recessive inheritance -no male to male transmission -50% chance that carrier mother will pass abnormal gene to each son who will be affected (therefore. congenital adrenal hyperplasia-electrolytes 8 . Newborn testing-see booklet a. C. e. PKU-mental retardation b. MSAFP b. father must be affected and mother be a carrier or affected as well -ex: hemophilia-defect in clotting factor VIIIc Duchenne muscular dystrophy d. f. maple syrup urine disease-neurologic e. blood tests for: -Tay-Sachs -Sickle Cell Anemia -Thalassemia -Cystic Fibrosis d. homocystinuria-neurologic f. 50% of males will be unaffected) -50% chance that carrier mother will pass abnormal gene to each daughter who will become carriers -for daughters to be affected. congenital hypothyroidism-retardation c. Prenatal testing-see booklet a. Testing 1. U/S-fetoscopy 2. galactosemia-dehydration/sepsis d. CVS/amniocentesis c.

aware of options e.198 9 g. correct misconceptions f. understand how heredity contributes c. biotinidase deficiency-neurologic Clinical management 1. assess need for referral d. course of action f. demonstrate support and sensitivity g. explain typical outcomes 01/13 9 . D. prepare for genetic counseling e. Genetic counseling a. identify risk factors b. understand rate of recurrence d. identify physical/developmental abnormalities c. understand facts about the disease-cause and treatment b. Nursing roles a. use of coping mechanisms/support systems 2.

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master Your Semester with a Special Offer from Scribd & The New York Times

Cancel anytime.