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Lecture1 IntroductiontoMaternityNursing 2
Lecture2 UncomplicatedLabor&Delivery 10
Lecture3 Analgesia&Anesthesia 34
Lecture4 NursingintheNormalPuerperium 41
Lecture5 NursingCareoftheNormalNewborn 53
Lecture6 HighRiskNewborn 69
Lecture7 UncomplicatedPregnancy 88
Lecture8 FetalAssessment&PregnancyatRisk 107
Lecture9 PregnancyatRisk#2 129
Lecture10 ComplicationsofLabor&Delivery 140
Lecture11 ComplicationsofthePuerperium 158
Lecture12 DisordersoftheFemale&MaleReproductive 168
Lecture13 Infertility&Genetics 190
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

b. Nurses held legally responsible for practicing
within scope of practice

c. Specialty Organization: AWHONN
-Association of Womens Health,
Obstetrics, and Neonatal Nurses

d. Orientation Period/Specialization
-Labor and Delivery
-Nursery/Level II Nsy/NICU
-Postpartum/Mother-Baby- since 1990s
-Occasional problems with
comprehensive care-territorial
-Differences in opinions lead to pt

II. 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
-In 1960s, shortage of MDs lead to
creation of the RNP
-May provide family care or specialize
-Take part in a certificate program or
Masters Degree program
-Need at certification for third-party
-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
-Expertise in planning, supervising, and
delivery of nursing care to families in
childbearing period
-Case managers
-Family and staff educator
-Coordination of delivery of nursing care
to families requiring intensive nursing
-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.

c. Certified Nurse Midwife
-Defined by ACNM: independent
management of womens health
care especially R/T pregnancy,
childbirth, PP period, and care of the
-Graduate from a certificate or MSN
-Also provide family planning services,
other gynecological needs, and peri/
postmenopausal care
-One of the oldest professions
-1925-Mary Breckenridge establishes
Frontier Nursing Services-first Nurse-
Midwife to practice in the US
-American College of Nurse Midwives
was incorporated in 1955
-provide care to women with low
incomes, uninsured, and minorities who
dont seek out regular health care
-lower rates of cesarean sections in
facilities where CNMs practice

d. Certified Nurse Anesthetists
-Defined by AANA: provide
--pre-anesthetic assessment
--develop and implement plan
of care
--perform general, regional, local,
and sedative anesthesia
--manage pts airway/pulmonary
--facilitate emergence/recovery from
--provide follow-up evaluation and care
--respond to emergency situations
to asst with ACLS, airway, medications
-Minimum 24 month programs/MSN with
--45 hrs professional aspects
--135 hrs anatomy/physiology/
--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

e. Nurse Consultants
-experts in a specific area of nursing
-fee for service
-may act as expert witnesses
-used by corporations R/T developing
-consult to texts, electronic media, and
B. Legal and Ethical Issues
I. Litigious nature of this specialty

a. number of malpractice cases involving
childbirth issues
-OB/Gyn cases 2
only to surgeries

b. Minimum standard of care:
-care that a reasonable, prudent nurse would
provide in the same or similar circumstances

c. Predominant theory of Liability-negligence
-4 elements
duty exists
breech of duty-standard of care violated
connection between violation of the
standard and the injury

d. Malpractice lawsuits are based on the
assumption that the health care provider
failed to meet the professional standard of
care and resulted in injury

e. Alleged injury to fetus, neonate, or mother

f. Families expecting a healthy child-bad
outcome means mistake must have been

g. Attribute problem to one or more members
of the health care team
-frequent unavailability of physician
-time frame to communicate may be short

h. To support expert opinion, need evidence:
-hospital procedures
-nursing policies
-guidelines established by professional
-state nurse practice acts

II. Informed Consent

a. Process by which a pt decides to have a
certain medical or surgical procedure
-includes knowing and understanding
what health care treatment is being

b. More than just signing a form

c. Process by which the physician, nurse, 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

d. Without proper consent, provider could be the
subject of a lawsuit alleging assault, battery,
negligence , or a combination of actions

f. 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
--during surgery, additional surgery is

g. Informed refusal
-can take place at initiation of tx or any time
after start of tx
-refusal is valid even after informed consent is
-refusal must be voluntary, uncoerced, 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, risks and
consequences of no further tx, and
who will be notified

III. Common Legal Pitfalls

a. #1 allegation: birth of neurologically-impaired

b. reporting/recording errors:
-incomplete initial H & P
-failure to observe & take appropriate action
-failure to communicate changes in a pts
condition in a timely manner
-incomplete and/or inadequate documentation
-failure to use or interpret fetal monitoring
-inappropriate pitocin monitoring/usage
-improper sponge/instrument count

c. almost of OB/Gyns have been sued
-most cases will not go trial but be settled
out of court

d. 30% have had 3 or more law suits

e. rising costs of liability insurance

f. demands for accountability created by
expanding the scope of practices

g. cost containments
-shorter hospital stays
-use of unlicensed asst personnel
-decrease in hospital staff

h. changes in technology mean needed
continued education: EFM

IV. Standards of Care

a. Standardized procedures/policies

b. supervision of unlicensed asst. personnel
KNOW your facilitys Scope of Practice


VI. Ethical Dilemmas Unique to Perinatal Nursing

a. fetal research-laws vary by state

b. fetal surgery
-i.e.: bilateral hydronephrosis, congenital
diaphragmatic hernia
-what if mother refuses tx

c. abortion-Roe vs. Wade (1973)
-morning-after pill
Plan B-levonorgestrel
-lack of estrogen nausea
-medical abortion
US: mifepristone + misoprostol
France: RU-486

d. artificial insemination
-AIH-husbands sperm-problem with
-AID-donor sperm
-legal problems-donor relinquishes rights

e. surrogate childbirth
-buying a child-$$$$
-biological mother may refuse to give up
the newborn

f. ART-Asst. Reproductive Technology

g. embryonic stem cell research/cord blood


h. 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,
disability, 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

i. The Mother
-use life support in irreversible conditions?

V. Nursing Role

a. Communication
-interactions between MDs, CNMs, &
-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, less use of litigation
-earlier discharges home mean more
educational responsibilities for the

b. Use of EFM
-first introduced at Yale University in 1958
-In last 25 yrs of use, no in rate of CP
-is partially responsible for in C/S rate
-ordinary part of Intrapartum care-
constant threat of legal action

C. Review of Conception/Fetal Development
(Review books)

Uncomplicated Labor and Delivery
Lecture 2 (2 days)

I. Physiological effects of the birth process
A. Maternal response
1. CV
a. During U/C-300-500 ml blood from uterus
to vascular system
b. Increase in cardiac output
10-15% Stage I
30-50% Stage II
c. Blood pressure changes
1. blood flow in the uterine artery
during contractions and is redirected
to the peripheral vessels
2. peripheral resistance occurs with an
in BP and of pulse
3. Stage I- 30 mm Hg systolic
25 mm Hg diastolic
4. Stage II- BP further
5. Supine hypotension-risk factors
multifetal, hydramnios, obesity,
dehydration, hypovolemia
d. WBCs 25-30,000 mm secondary to stress,
e. hematopoietic
1. desire Hgb at least 11 g/dl
Hct 33% or higher
2. 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)
2. Fluids/electrolytes
a. Diaphoresis, insensible water loss through
respirations, NPO status, and temp
b. Voiding may be difficult r/t anesthesia or
Pressure from presenting part- sensation
of a full bladder
c. Proteinuria-
- in amino acids may exceed capacity
of renal tubules to absorb
-may be renal damage caused by
vasospasms of tubules

3. GI
a. Fluids at tolerated r/t GI motility and
absorption with delay in stomach
b. N & V with diarrhea in labor

4. Respiratory
a. O2
consumption, in resp. rate
b. hyperventilation respiratory alkalosis
in pH, hypoxia, hypocapnia (CO
c. 2
consumption metabolic
acidosis uncompensated by resp. alkalosis

5. Muscular/skeletal
a. Fatigue of muscles/strain
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, inhibit uterine
contractions, and softens the cervix)
c. Breakdown of proteins may lead to
proteinuria-albumnin in the urine
6. Neurological
a. Euphoria-believe it or not!
endorphins- pain threshold and produce
b. anxiety
c. partial to total amnesia in 2

7. Integumentary
a. diaphoresis
b. temperature-may be R/T to maternal
efforts or infection
c. exacerbation of pruritus-
may be related to cholestasis (arrest of
the flow of bile) in pregnancy

B. Fetal Response
1. CV
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
2. Pulmonary
a. thoracic cavity squeezed
-not as much in C/S cases
-precipitous deliveries (swift progression of
stage of labor marked by rapid
descent/expulsion of the fetus)
-may need extra suction
b. passing of meconium (1
feces of
neonate) may need resuscitation effort

3. Catecholamines
a. epinephrine & norepinephrine-active
amines (nitrogen-containing organic
-have effect on CV, neuro, metabolic
rate, temp., and smooth muscle
b. change R/T stress of labor
speed clearance of fluid

II. Essential Components of the Birth Process
A. Passageway
1. maternal pelvis
a. 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. False pelvis-the upper pelvis
-portion above the inlet

c. True pelvis
-diagonal conjugate-lower border
of symphysis pubis-sacral
-usually 12.5 cm or greater
-obstetric conjugate- also called
anterior/posterior diameter
-measurement that determines
whether presenting part can
engage superior strait
-usually 1.5-2 cm less than
-midpelvis-cavity, midplane
-transverse diameter-interspinous
diameter-10.5 cm
-transverse diameter-intertuberous
diameter-> 8 cm

2. Pelvic shapes
a. gynecoid-round
-50% of women
-most favorable
-usual mode of birth-vaginal
b. android-heart shaped
-23% of women
-usual mode of birth-cesarean
possible forceps-difficult
c. anthropoid-oval shaped
-24% of women
-usual mode of birth-vaginal
spontaneous or asst.
-may lead to OP position
d. platypelloid-flat shaped
-3% of women
-not favorable for vaginal delivery
B. Passenger
1. Fetal skull
a. made up of 6 bones
-2 parietal
-2 temporal
b. not fused together-allow for molding,
overlapping of bones to pass thru pelvis
c. sutures-membranes
d. 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. landmarks
-vertex-between anterior/posterior
-occiput-beneath the posterior fontanel

2. Fetal Presentation
a. fetal part entering the pelvis first
-cephalic (head)-96%
-breech (buttock)-3%
-transverse (shoulder)-1%
b. factors that influence presentation
-fetal lie
-fetal attitude
-extension/flexion of fetal head

c. diagnosed using
-Leopolds maneuvers
-verify with ultrasound
d. external version-MD attempts to manually
rotate the fetus into a cephalic
-done in L &D
-ultrasound to check fetal/placental
-may use medications to relax uterine
-frequently uncomfortable for mother

3. Fetal Lie
a. relationship of long axis (spine) of fetus
to long axis (spine) of mother
b. primary lies:
-longitudinal (vertical)-cephalic, breech
-transverse (horizontal or oblique)-shoulder

4. Fetal Attitude
a. relationship of fetal parts to one another
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. head flexion
-biparietal diameter-9.25 cm
-suboccipitobregmatic-9.5 cm
-occipitofrontal-12 cm
-occipitomental-13.5 cm

5. Fetal position
a. relationship of presenting fetal part to
4 quadrants of maternal pelvis
b. indicated using a 3-letter abbreviation
letter-location of part in pelvis (R or L)
letter-presenting part of fetus (O,S,M)
letter-location of presenting part in
relationship to maternal pelvis (A,P,T)

6. Station
a. relationship of presenting fetal part to an
imaginary line at the maternal ischial
spines: 0 station is at the spines
b. negative stations-higher in the pelvis
c. positive stations-lower in the pelvis

C. Powers
1. Primary Powers
a. involuntary uterine contractions
-start at fundus-thickened uterine
muscle layer of upper uterine
-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
b. 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
the first stage of labor
c. effacement (thinning)
-cx usually 3 cm long, 1 cm thick
-taken up by shortening of uterine
muscle bundles
-usually expressed in %
d. uterine contractions
-3 phases-increment, acme, decrement
-involuntary, rhythmic, intermittent
-frequency-beginning of one to the
beginning of the next
-regularity-usually start irregular then
becomes more regular as labor
-duration-start to end of contraction
-intensity-mild, moderate, strong or
strength can be measured with
internal monitor (IUPC) with
resting tone usually 15-25 mm
e. Fergusons reflex
-presenting fetal part reaches perineal
-mechanical stretching of cervix occurs
-stretch receptors in vagina trigger
exogenous (originating outside an
organ) oxytocin release
-triggers maternal urge to bear down

2. Secondary Powers
a. bearing down effort at 10 cm
-contraction of diaphragm and
abdominal muscles while pushing
b. intraabdominal pressure that
compresses uterus on all sides
c. usually no effect on dilation-important
R/T expulsion of fetus and placenta
d. better results when await maternal need
to bear down rather than start pushing
at 10 cm
e. debate over how to push
-valsalva-closed glottis, prolonged push
-open glottis pushing
-mini pushes
f. prolonged pushing efforts can lead to
fetal hypoxia/acidosis and severe
maternal perineal lacerations

D. Placenta
1. Structure
a. formed at implantation
b. decidua (endometrium during
pregnancy) basalis-with the chorion
(extraembryonic membrane) forms the
c. cotyledon-mass of villi on the chorionic
surface of the placenta
-15-20 in number
d. structure is completed by 12 week
e. breaks may occur in placental
membrane allowing mixing of maternal
and fetal blood-Rh sensitization
f. position problems
-previa-implanted in lower uterine
segment-covers internal cx os
-abruptio-separation of placenta from
uterine wall
-accreta-cotyledons invaded uterine
-increta-invasion into the myometrium
-percreta-invasion to the serosa of the
peritoneum covering of the uterus
can lead to uterine rupture

g. 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. Function
a. endocrine gland-produces hormones to
maintain pregnancy
-hCG-human chorionic gonadotropin
-basis for pregnancy test
-preserves function of corpus luteum
-ensures continued supply of
-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
-maintains endometrium
-decreases contractility of uterus
-stimulates development of breast
alveoli and maternal
b. metabolic functions


c. factors which could effect function
-drug use
-poor nutrition
- BP
-maternal position

E. Psyche
1. Factors influencing womans reaction to
physical/emotional crisis of labor
a. accomplishment of tasks of pregnancy
b. usual coping mechanisms in response to
c. support system-esp. partners
d. preparation for childbirth
e. cultural/religious influences
f. social/economic responsibility

2. Factors associated with birth experience
a. motivation for pregnancy
b. attendance at childbirth classes
c. sense of competency/mastery
d. self-confidence/self-esteem
e. + relationship with partner
f. maintaining control during labor
g. support during the delivery
h. not being left alone
i. trust in staff-medical and nursing
j. pain management
k. length of labor process-exhaustion,
anxiety, for medical interventions

F. Position (maternal)-See book

III. Labor Physiology
A. Labor Onset Theories
1. Oxytocin Stimulation Theory
a. stretching of cervical os causes in
exogenous oxytocin
b. produced by posterior pituitary
c. oxytocin stimulates smooth uterine muscle
d. response to oxytocin as nears term

2. Estrogen Stimulation Theory
a. estrogen stimulates smooth uterine muscle
to contract
b. as approaches term, estrogen,
progesterone (prog. keeps estrogen in
c. promotes prostaglandin synthesis (also
stimulates muscle)

3. Progesterone Withdrawal Theory
a. usually relaxes muscle
b. at term- in effectiveness

4. Fetal Cortisol Theory
a. at term, fetus produces more cortisol
b. cortisol-(adrenocorticcal hormone)
-slows production of progesterone
-stimulates prostaglandin precursors

5. Uterine Distention Theory
a. stretching uterine muscles causes
irritability leading to contractions
b. stimulates production of prostaglandins
6. Prostaglandins
a. stimulate smooth muscle to contract
b. can have production stimulated by
various methods
- synthesis of PGE2
in amnion
c. research varies whether concentration
of prostaglandins in amniotic fluid and
maternal blood just before labor onset

B. Signs of Labor
1. Braxton-Hicks contractions
a. 4-6 weeks before onset of labor
b. uterine muscle workout before labor
c. may be strong and frequent but usually
are irregular in pattern

2. Lightening
a. fetal descent into the true pelvis
b. 2-3 weeks in primigravidas
closer to onset of labor in multiparas
c. easier to breathe, need to void

3. Cervical and vaginal changes
a. cervix ripens (softens) and may begin to
dilate and efface
b. vaginal mucus with mucus plug being
released 1hr, 1day, or even 1 week before
start of labor
c. occasionally bloody show noted with
dark brown or light pink-tinged mucus

4. Persistent low back ache
a. R/T relaxation of pelvic joint and descent
of fetus
b. change of position, warm packs, and
warm showers/baths help
5. Weight Loss
a. R/T GI upset with N & V and diarrhea
b. usually starts 1-2 days before onset

6. Nesting
a. have a burst of energy
b. have a need to get everything in order
for arrival of baby

C. True vs. False Labor
True False
Uterine contractions
regular irregular

close together vary

stronger milder

with walking with walking

felt in low back then felt in back or pelvis
radiates to abdomen

not stopped by bath with relaxation
or fluid techniques

softens, effaces, dilates no significant changes

starts descent into pelvis no change in position

D. Effacement, dilation, and station
1. Effacement
a. thinning of cervix (shortening from usual
length of 2-3 cm)
b. documented either in %s or cms

2. Dilatation
a. opening of cervical os from closed to
10 cm
b. due to retraction of cervix into the lower
uterine segment R/T uterine contractions
and pressure from amniotic sac and fetus
c. both dilation and effacement are
measured by fingertip palpation or visual
inspection with sterile speculum

3. Station
a. using imaginary line at ischial spines,
note location of presenting fetal part
b. documented from 4 to +4
c. ballottable-when presenting part is
floating in and out of the pelvis

E. Stages and Phases of Labor
1. Prodromal phase
a. strong regular contractions without
cervical change
b. leads to exhaustion R/t inability to sleep
c. may need oral/IM medication for rest

2. Stage 1 (0-10 cm)-has 3 phases
a. Early/Latent phase-0-3 cm, 50-90%, -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/Cs may be 2-10 minutes apart
-U/Cs mild by palpation
-lasts an average 8 hours for primips
-multiparas may have cx dilate to 3 cm
days prior to onset of labor
-ROM may occur during this time
b. Active phase-4cm-7cm, 80-100%, -2 to 0
-U/Cs every 3-5 minutes, moderate by
-U/Cs 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 1-1.5 hrs
c. Transition phase-8-10 cm, 100%, -1 to +1
-U/Cs every 1-3 minutes with intensity
-U/Cs 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. Stage 2-10 cm (pushing) to delivery of neonate
a. nulliparas-2 hours on average-no epid.
3-4 hours with epidural
b. multiparas-15 min-1 hour without epid.
1-2 hours with epidural

4. Stage 3-birth of neonate to expulsion of
a. usually lasts 20 minutes to 1 hour
b. if retained, MD will need to manually
remove-consider pain meds for mom

5. Stage 4-Recovery
a. mom-1-4 hours
b. baby-6 hours


F. Mechanisms of Labor (Cardinal Movements)
1. Engagement and Descent-occurs r/t:
a. pressure of amniotic fluid
b. uterine pressure on the breech
c. contractions of abdominal muscles
d. extension/straightening of fetus

2. Flexion
a. natural attitude of fetus
b. fetal head flexes as it meets

3. Internal Rotation
a. to go thru transverse diameter
b. rotates to occiput anterior

4. Extension
a. resistance of pelvic floor with vulva
opening forward and anterior
b. fetal head begins to crown

5. External Rotation
a. shoulders rotate to anteroposterior
b. fetal head rotates further to one side

6. Expulsion
a. anterior shoulder slips under
symphysis pubis
b. posterior shoulder and body is then


G. Labor Duration
1. Nulliparas
a. 1
stage-13 hours (1.2 cm/hr)
b. 2
stage-5 minutes-2 hours
c. 3
stage-10-20 minutes

2. Primi/multiparas
a. 1
stage-7 hours (1.5 cm/hr)
b. 2
stage-5 minutes to 1 hour
c. 3
stage-5-20 minutes

IV. Plan of Care
A. Assessment-Data Collection
1. prenatal record
a. assess attendance to PN appts
b. any complications of pregnancy
c. any high risk behaviors
d. abnormal lab/ultrasound reports
1. blood type/RH factor
2. VDRL/RPR-syphilis screen
3. HbsAG-surface antigen
4. CBC
5. Rubella immunity
6. culture for GBS
7. urinalysis
8. HIV test
e. primary language

2. initial interview
a. ask why she came in
b. status of BOW
c. any U/Cs?
d. any bleeding?
e. + FM recently?
f. any other symptoms?

3. physical exam
a. maternal vital signs
b. FHR tracing
c. palpate strength of U/Cs
d. assess fetal presentation
e. assess cervical dilation/effacement

4. lab reports/ultrasound results
a. CBC
b. PIH panel
c. RBS (sure step or lab draw)
d. ck fetal lie/AFI with ultrasound

5. expressed psychosocial and cultural
a. history of sexual/physical abuse
b. history of depression/suicide attempts
c. social support
-family near by
-friends who can pitch in
d. cultural/religious needs

6. clinical evaluation of labor status
a. sign consent forms
b. CBC and urine test
c. if ROM, ck nitrazine paper or ferning
d. Leopolds maneuver
e. vaginal exam
f. ultrasound if needed
g. head to toe assessment
h. ck for med allergies
i. ask about classes taken


B. Nursing Diagnoses
1. Anxiety R/T labor and birthing process
a. orient parents to unit
b. explain admission protocol
c. assess womans knowledge,
experiences, and expectations of
d. discuss progress of labor
e. involve woman and partner in care
decisions during labor

2. Pain R/T increasing frequency and intensity of
a. assess level of pain
b. encourage support people to aid in
comfort measures
c. encourage use of relaxation techniques
d. explain when and why analgesics may be

3. Risk for altered pattern of urinary elimination R/T
sensory impairment secondary to labor
a. palpate the bladder superior to symphysis
b. encourage frequent voiding
c. assist to BRP or use catheter prn

4. Risk for fluid volume deficit R/T fluid intake
and blood loss during birth
a. monitor fluid loss
b. administer oral/parenteral fluid prn
c. monitor fundus for firmness
d. administer medications to aid in
contraction of uterus
e. possible type and screen/cross match
if transfusion needed


5. Impaired gas exchange R/T maternal BP,
compression of umbilical cord
a. keep mother off her back
b. maintain adequate hydration
c. oxygen via mask if O2
below 90%
d. shut off pitocin
e. possible need for amnioinfusion

C. Interventions-Priority Setting
1. Vital signs
a. notify provider if BP above 140/90
b. ck temp q 4 hrs if ROM

2. Fetal monitoring
a. assess FHR at least once hourly in
early phases
b. may need continuous monitoring
c. consider internal monitoring for poor
tracing, lack of progress, or meconium

3. Hydration/oxygenation
a. encourage po fluids or start IV if N & V
b. ck oxygen saturation if decels noted

4. Comfort measures
a. breathing/focal points/distractions
-labor shakes are normal
b. hydrotherapy/massage
c. active listening R/T maternal behaviors
-0-3 cm: anticipation, excitement
-4-7 cm: seriousness, introspection
-8-10 cm: irritable, fatigue, amnesia
d. use of support people


5. Pain management
a. showers/warm or cool packs
b. massage
c. oral medications
d. IV or IM medications
e. Epidurals

6. 2
stage interventions
a. room prepped for delivery
-warmer for neonate
-delee suction if meconium present
-possible need for Pedi
-keep up NRP/BLS skills
b. 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 inch
c. assess need for addition oxygen R/T FHR
d. assess maternal VS and FHR tracings per
hospital policies
e. keep Provider aware of pts progress
f. consider lessening epidural dose if
pushing effort less than adequate
g. provider should be in LDR before head is
crowning to provide support for perineum
h. clean perineum if requests by provider
i. at delivery, asst partner with cutting of
umbilical cord


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

V. Electronic Fetal Monitoring-skills lab

VI. Related Pharmacology-medication administration cards


Analgesia and Anesthesia
Lecture 3
I. Labor Pain
A. Data Collection and Assessment
1. Ask patient comfort level and current pain level
-0-10 scale or coping scale
-comfort level is when they can participate in
ADLs without the need of pain meds
2. Be aware of cultural differences in response to
-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. Anxiety and fear of the unknown might
heighten their level of pain
4. Previous experiences with childbirth or other
painful procedures may lead to higher levels of
concern about pain management needs
5. Attendance to childbirth classes may aid in the
patients ability to cope through contractions

B. First Stage
1. Early phase-0-3 cm
a. nonpharmacological methods
1. focal points
2. massage/counterpressure
3. hydrotherapy/aromatherapy
4. music
5. breathing techniques
6. Transcutaneous Electrical Nerve
Stimulation unit (TENS)
7. heat/cold packs
8. hypnosis
9. changing positions/walk/rocker

b. pain medications
1. should be discouraged as they
could slow the labor process
2. usually orals:
percocet vicodin/norco
benadryl acetaminophen
3. occasionally IM:
morphine with phenergan
2. Active phase-4-7 cm
a. may use many of the same
non-medication choices as above
b. when pain is more intense, usually
requests IV medications for fast
c. may also request and receive an epidural
at this stage in labor

3. Transitional phase-8-10 cm
a. may request epidural
b. may want to be out of bed and push on
toilet to relieve backache
c. encourage position changes if possible
d. short acting IV narcotics still ok but have
Narcan available for infant resuscitation

C. Second Stage
1. May continue pushing with epidural pump on if
efforts are affective
2. May receive local anesthesia for repair of
perineal laceration or episiotomy
3. If no epidural is in place, may receive a
pudendal block which relieve pain in the
vagina, vulva, and perineal regions

D. Third Stage
1. If placenta is retained, may receive IV pain
medications or be moved to OR for twilight
2. For laceration/episiotomy repairs, use of local
anesthetics or pudendal block (less common)

II. Adverse Effects of Excessive Pain
A. Physiological effects
1. Effect on cervical change-more in pain, less
able to relax and let the labor progress
2. Tensing up against the pain leads to muscle
and ligament strains in other parts of the body
3. May not keep properly hydrated and nourished
R/T the intensity of the pain
4. Inability to relax back muscles and do deep
breathing may lead to difficulty placing
epidural catheter

B. Psychological effects
1. I cant do it-ineffective pushing due to fear
of pain
2. inability to make decisions R/T pain
3. may become hostile to staff/family R/T
inability to cope

III. Factors Influencing Perception of Discomfort
A. Teens and Older Primigravidas
B. Cultures/Religions
C. Previous experiences with pain
D. Support person
E. Preparatory classes
F. Fetal position-i.e.: OP presentation

IV. Pertinent Nursing Diagnoses
A. Pain R/T physiologic response to labor
1. assess patients knowledge of labor and
relaxation techniques
2. encourage support people to aid in comfort
3. teach alternative non-pharmacological
methods of pain relief
4. assess need to void/defecate
5. encouraging resting between U/Cs
6. keep pt. and family notified of labor progress
7. offer possible choices for pain medications if
all other methods have been unsuccessful

B. Other possible nursing diagnoses
1. Ineffective airway
2. Fluid volume deficit
3. Fetal oxygenation
4. Anxiety R/T pain
5. etc. (see others in book)

V. Pharmacological Pain Management
A. Considerations for the Pregnant Patient
1. What medications you give the mom you give
the fetus
2. Maternal concerns that she wasnt
strong enough to make it thru without
pain meds
3. Need to taper dosage to the patient
4. If previous abuser of medications, will pain med
even be effective
5. Cultural beliefs

B. Analgesics, sedatives, and adjuncts
1. 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.
2. Analgesics
a. can be systemic crossing the blood/brain
barrier as well as the placental barrier
b. IV is preferred over IM due to rapid onset
but IM medications last longer
c. narcotic compounds
-respiratory depression
d. analgesic potentiators
-usually antiemetics (Phenergan, Vistaril)
-decrease anxiety and apprehension
-helps reduce the amount of narcotic
needed for relief

C. Anesthetics (Regional and General)
1. Local block
a. usually used on perineal region
b. 1% lidocaine used
c. injected into skin and subcutaneous
d. epinephrine may be added to intensify
anesthetic and decrease bleeding
2. Pudendal block
a. goal to anesthetize the pudendal nerve
located near the ischial spines
b. may decrease ability to bear down R/T
lack of sensation
c. doesnt provide pain relief for manual
extraction of placenta or uterine
3. Epidural block/PCEA
a. needs IV bolus before insertion R/T
maternal hypotension due to
b. done by CRNA or MD
c. pt. awake for procedure/delivery
d. pt. sitting up for placement
e. after insertion, may need frequent
position changes side to side to
keep anesthetic level equal
f. preferred block T10-S1
g. need Foley cath in bladder due to
inability to feel when to void
h. possibility of spinal headache if needle
placement is not correct
i. saturates pain receptors but not motor
j. may need to use Ephedrine
(a vasopressor) if maternal BP
k. usually a local anesthetic alone or
mixed with a narcotic (fentanyl, etc.)
l. may increase labor time and need for
pitocin augmentation
m. antiemetics, antipruritics, and narcotic
antagonists should be handy to treat
possible side effects of epidural
n. as with any medication, be prepared for
possible severe adverse reactions such
as bronchospasms, sudden in BP,
dyspnea, or convulsions-crash cart should
be available on unit

4. Spinal block
a. local anesthetic into the L
, L
, or L

interspacesubarachnoid space
b. medication mixes with CSF-saturates
pain and motor receptors
c. used for cesarean sections
d. risk of spinal headache due to leak
of CSF-may need to remain supine post
delivery, IV maintained, and possible
blood patch
e. IV bolus given prior to procedure R/T
risk of maternal hypotension, CO,
and placental perfusion
e. maternal BP, pulse, resp. effort, and FHR
are assessed every 5 minutes for the first
15-30 post injection

5. General anesthesia
a. while rarely used, may be needed for C/S
if unable to access regional block or in
emergency cases
b. NPO, IV, oral sodium citrate before start
c. RN may be asked to give cricoid pressure
to aid anesthesiologist in tube placement
d. normally recovered in PACU (recovery rm)
so bonding with infant delayed
e. higher risk of complications vs. regional
blocks-mother unconscious during birth
of infant
f. as with all anesthesias used during C/S,
wedge should be placed under moms
R hip to displace uterus to the L
g. besides C/S, general anesthesia may be
needed during manual placenta removal
or D & C

Nursing in the Normal Puerperium (the period of 42 days post
childbirth and expulsion of the placenta)
Lecture 4

I. Physiology of the puerperium
A. Alterations in the body systems as a result of the birth process
1. Reproductive system
a. involution of uterus-return to non-pregnant
state-caused by contractions of uterine
muscles (size of a grapefruit after 3
b. within 12 hours, fundus at U/U
c. fundus descends 1-2 cm/24 hrs
d. uterus not palpable after the 9
PP day
e. in estrogen/progesterone=autolysis
f. subinvolution-failure of uterus to return to
non-pregnant state-usually involves retained
POC or infection
g. outer decidua sloughs off as lochia, inner layer
becomes new endometrium
h. oxytocin released from pituitary gland helps
uterus to contract- with BF
i. afterbirth pains in multiparas
j. placental site regeneration complete at 6 wks
k. change in lochia-rubra-1-3 days-bright red
serosa-3-10 days-pink, brown
alba-10 dys-2 wks-yellow, white
l. cervix-bruised, soft, swollen-closes by 2 wks
-external os-appears as jagged slit
m. vagina-returns to prepregnancy state by 6-8 wks
n. perineum-healing start by 2-3 wks, complete
within 4-6 months
o. 6 months for return of pelvic musculature

2. Cardiovascular
a. CO remains elevated for 2 weeks-12 wks before
to prepregnancy values
b. EBL 300-500 ml-vaginal birth
500-1000ml C/S


c. blood volume increased by:
-elimination of uteroplacental circulation
-loss of placental endocrine function which
removes stimulus for vasodilatation
-mobilization of extravascular water stored
d. Vital signs:
-Temp- to 38
F R/T dehydration
-Pulse- 1
hr-return to pre-preg. 8-10 wks
-Resp- by 8-10 wks
-BP-may have orthostatic hypotension
e. Hgb/Hct:
72 hrs- loss of plasma volume compared to
- in H & H by day 7
f. WBCs may to 25-30,000/mm

g. Coag factors-hypercoagulable state may lead
to possible thromboembolism

3. Gastrointestinal
a. appetite
b. no BM for 2-4 days post delivery
-encourage ambulation
-medications, i.e.: stool softeners
c. tx hemorrhoids-ice packs, tucks, crm
-no pr meds if 3
degree laceration
d. Kegel exercises to strengthen pelvic floor

4. Renal
a. returns to normal function 1 month after birth
-bladder tone returned by 5-7 days
b. diuresis-from fluid retention, pitocin, etc
c. excessive vaginal bleeding may be noted if
bladder is allowed to get distended with urine

5. Musculoskeletal
a. joints stabilize 6-8 weeks post birth
b. may have permanent increase in shoe size
c. may have separation of symphysis pubis or
rectus abdominis


6. Integumentary
a. chloasma (mask of pregnancy) usually fades
by end of pregnancy
b. hyperpigmentation of areolae and linea nigra
may continue
c. may note perfuse diaphoresis post delivery

7. Endocrine
a. Expulsion of placenta= in estrogen, cortisol
progesterone, and hPL (hCS)
[human placental lactogen/human chorionic
-reverse diabetogenic effect-lower BS level
b. if BF- prolactin levels for 6 weeks
if bottle-fed-
-usually means later ovulation in lactating

8. Psychosocial
a. parents acceptance of infants needs and
b. need to learn cues, understand emotional
c. bonding-proximity, touch, voice, interaction
d. identify infant as an individual yet part of the
whole family
e. mutuality-infants behaviors stimulate moms
f. may feel attracted to alert, responsive infant
and repelled by irritable, disinterested infant
g. attachment occurs more readily with the
infant whose temperament, social capabilities,
appearance, and sex fit parents expectations
h. need to assess mother-infant communication
i. behaviors
-entrainment-moving in time with adult speech
-biorhythmicity-soothed by moms heartbeat
-reciprocity-responds to cues
-synchrony-mutually rewarding
-engrossment-interest in baby by father


j. maternal adjustments
-taking in-first 24 hrs-focus on self and basic need
Dependent, passive
-taking hold-last 10 days to several weeks-focus
on care of baby and competent
-letting go-focus on forward movement of
the family unit
k. PP blues- 70% of women-mood swings, anger,
depression, letdown, fatigue, insomnia,
H/As, weepiness (resolves in 10-14 days)
l. PP depression-7-30%-more severe syndrome
-depression, feeling of failure overwhelming
guilt, loneliness

II. Nursing Process
A. Data collection/Assessment
1. Vital signs
2. Fundus
a. ck fundal location, tone, lochia
b. have pt empty bladder before exam
3. Bladder
a. assess for distention
b. measure first voids until 500 ml (voided out)
c. catheterize if needed
4. Perineum
a. if repair done, assess site for intactness, edema,
hematomas, redness, or drainage (REEDA)
b. assess for presence of hemorrhoids
5. Breasts
a. note if breast are filling-palpate
b. note any redness, soreness, cracking of

B. Nursing Diagnoses
1. Risk for fluid volume deficit
2. Alteration in urinary elimination
3. Pain
4. Fatigue
5. Ineffective breast feeding
6. Situational low self-esteem
7. Anxiety due to lack of knowledge base
8. etc.

C. Interventions
1. Safety
a. infant ID bands
b. orientation to unit
c. staff picture IDs
d. move infant in crib
2. Standard precautions
a. wash hands before handling baby
b. change linens
c. proper hygiene
d. use of squeeze bottle for peri care
e. wiping front to back
f. teach pt about fundal massage
g. use of peppermint or running water to aid in
voiding to prevent urinary retention
h. use of ice packs for the first 12 hours post
repair of peri then instruct on use of sitz bath
i. squeeze buttocks together when sitting or rising
from a chair to help keep repair intact
j. wear good supportive bra
k. use lanolin crm to prevent cracking of nipples
l. warm packs before breast feeding, cool packs
m. walk as soon as possible-helps with gas pains
n. take pain meds prn
o. encourage rubella vaccine if non-immune
pt should prevent getting pregnant for at least
4 weeks post vaccination
p. Tdap-Pertussis-
q. rhogam given to Rh moms who had Rh+ babies

III. Early Discharge
A. Candidates and criteria
1. Newborns and Mothers Health Protection Act of 1996
a. 48 hours minimum post vaginal delivery
b. 96 hours minimum post C/S
c. pt and doctor may agree on earlier D/C
2. Maternal criteria for early D/C
a. VSS
b. voiding
c. Hgb >10
d. no bleeding
e. instructions on self-care

3. Infant criteria for early D/C
a. term infant
b. VSS
c. normal physical assessment
d. at least 2 successful feedings
e. at least 1 void and 1 defecation
f. no jaundice
g. circ site ok
h. newborn blood/hearing screenings done
i. follow-up in 1 week
j. maternal/infant teaching cklist completed

IV. Care of the Cesarean Birth Patient
A. Assessment/Interventions
1. VS every 15 min X 1hour, 30 min X 1 hour, then per
hospital protocol
2. monitor I & Os-need UO at least 30 ml/hr
3. assess abdominal dressing for drainage
4. assess need for pain medication
5. assess fundal location, tone, and lochia
(still have 3 distinct lochia stages)
6. ambulate asap
7. assess for passage of gas-advance diet as tolerated
8. C & DB-may use inspirometer

B. Nursing diagnoses
1. Fluid volume deficit
2. Pain
3. Risk for infection
4. Risk for injury
5. Anxiety R/T surgery, fetal well-being
6. Situational low self-esteem

C. Possible post-op complications
1. CV-hemorrhage, shock, dvt
2. Pulm-embolus, pnemothorax
3. GI-paralytic ileus
4. GU-renal failure, hematuria, UTI, oliguria
5. Reprod-endometritis, emboli
6. Skin-wound infection, dehiscence


V. Care of the Lactating Woman
A. Physiology of Lactation
1. Female breast has 15-20 lobes containing alveoli
(the milk producing cells)
2. alveoliductuleslactiferous ductsnipple
3. estrogen & progesterone post delivery= prolactin
levels which remain above baseline thru duration of
lactation (highest level is at day 10)
4. Prolactin:
-highest level at day 10
-is produced in response to infants sucking
-promotes milk production by stimulating alveolar cells

B. Other hormone changes/reflexes
1. Oxytocin responsible for let-down reflex
nipple stimulationpituitary produces oxytocin
makes cells around the alveoli contractsends milk to
2. Nipple erection reflex
infant cries or rubs against the breastnipple becomes
erectpropulsion of milk

C. Supply/demand
1. First milk called colostrum
a. rich in immunoglobins
b. higher concentration of protein and minerals to
mature milk but less fat
c. promotes growth of Lactobacillus bifides in GI
2. If infant is well nourished, will see 6-8 wet diapers and
3 stools in 24 hours at day 5 of breastfeeding
3. Incomplete emptying can lead to milk supply
4. watch for infant growth spurts
-10 days
-3 weeks
-6 weeks
-3 months
-4.5-6 months

D. Maternal nutrition/considerations
1. add addition 200-500 calories/dy while breastfeeding
2. drink 2-3 liters of fluid daily
3. continue on PN Vitamins and iron as directed
4. watch for engorgement/plugged milk ducts/
sore nipple/monilial (yeast) infections/mastitis

VI. Care of the Woman/Neonate Formula-fed
A. Formula types
1. commercial formulas primarily cow-milk based but
soy and other specialty formulas available
2. may be in powdered, concentrated, or ready to eat

B. Common problems
1. positioning-need to make sure milk covers nipple area
2. warming-never microwave bottle
3. propping-dont leave infant unattended while feeding

C. Nutritional requirements
1. first day-only give 7.5-15 ml formula at one time
-their eyes are bigger than their stomachs
2. usually feed every 2-4 hours
3. some infants swallow air as they feed-burp them!
4. by 1 week of age, babies will be drinking 700-900 ml
in 24 hours
*bottle fed because-returning to work, +HIV, mastectomies,
adopted infant, maternal medications

VII. Contraception Education
A. Considerations for Choosing a Method
1. resumption of sexual activities should wait 2-3 weeks
to decrease risk from infection
2. best to use condoms/foam at this time
3. when discussing contraception with your doctor,
-personal preference

B. Methods (failure rates listed within 1
year of use)
1. Coitus interruptus (withdrawal)
-action-prevents fertilization
-safety-no protection from STIs

2. 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. temp before ovulation (0.05
C) then
-cervical mucus-ck for changes-amt. and consistency
-symptothermal-combo of BBT and cervical mucus
-ovulation kits-detect surge in LH that occurs approx.
12-24 hours before ovulation

3. Barrier methods
a. spermicides
-action-physical/chemical barrier to sperm
-safety-may provide some protection from STIs
-convenience-needs to placed before act
-availability-good if thought of in advance
b. condoms
-action-physical barrier to sperm
-safety-protect against STIs/HIV if used properly
-effectiveness-can failure rate with use
of spermicides
-vaginal sheath/condom
c. diaphragm
-action-mechanical barrier to sperm
-safety-see condoms, small amt of cases with
TSS-toxic shock syndrome
-effectiveness-needs to be fitted to womans
anatomy, needs to be used with
-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
d. 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
-risk of TSS if not removed after 24 hours

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


5. Intrauterine Devices
a. usually T-shaped
b. loaded with either copper or levonorgestrel
c. may be used for 5 yr (hormone)-10 yrs (copper)
d. prevents fertilization
e. Mirena (hormone IUD)-helps to diminish menses
f. Copper T-good choice for women over 35,
smokers, h/o CAD, HTN
g. not recommended for women with:
-h/o PID
-suspected pregnancy
-h/o distorted uterine cavity
-h/o multiple partners

6. Sterilization
a. females
- bilateral tubal ligation
-surgical procedure
-expense usually higher than vasectomy
-electrocoagulation, ligation, banded,
crushed, or plugged
-no protection against STIs
-should be considered permanent
-informed consent needed at least 72
hours before procedure
-done in clinic or OR
-uses water to visualize fallopian tube
-coil placed and tissue collects on coil
creating a blockage
-HSG performed at 3 months to establish
-back-up BC method used during this
b. males-vasectomies
-done in clinics under local anesthetic
-vas deferens are ligated/cauterized
-takes multiple ejaculations to clear
remaining sperm from vas deferens


method of
birth control
No Method 85 85
Spermicides 18 29 ++++ + 42
Male Condoms 2 15 ++++ ++ 53
Female Condoms 5 21 ++++ ++ 49
Diaphragm 6 16 ++++ + 57
Cervical FemCap
w/o prior pregnancy
4 14 ++++ + 57
w/o prior pregnancy
9 16 ++++ + 57
w/ prior pregnancy
20 32 ++++ + 46
Ovulation Method 3 22 +++ + 51
Sympto-Thermal 2.5 16 +++ + 51
Standard Days
5 12 +++ +
Calendar Method 5 13-20 +++ + 51
Lactation (LAM) 0.5 6 ++++
Withdrawal 4 27 ++++ + 43
Oral Contraceptives0.3 8 +++ + 68
Ortho Evra Patch 0.3 8 +++ + 68
Nuva Ring 0.3 8 +++ + 68
Shot (Depo-
0.3 3 +++ + 56
Shot (Lunelle) 0.05 3 +++ + 59
IUD (ParaGard
0.8 0.6 ++ ++ 80
IUD (Mirena) 0.1 0.1 ++ ++ 80
Abstinence 0 0 ++++ ++++ ++++
For added protection against pregnancy, you can use more than one method of
contraception at a time. For example, many clinicians recommend that when using
condoms, spermicides be used as well. If a woman is allergic to spermicides she can use
a natural method and a condom and for extra protection. Any of these combinations will
reduce the predicted failure rate
Nursing Care of the Normal Newborn
Lecture 5

I. Transition to extrauterine life
A. Respiratory changes at birth
1. Development of the Lungs
a. while a fetus, resp. tract produces fetal lung
fluid that expands alveoli
b. as term approaches, fluid starts to move to the
interstitial spaces
c. shift of fluid helps to pulmonary resistance to
blood flow-present before birth and enhanced
with breathing of air
d. mature lung produces surfactant-no surfactant
leads to alveoli collapsing with exhalation
-sufficient surfactant by 34-36 weeks

2. Initiation of respiratory effort
a. first breathes require greater pressure to open
b. Chemical-carotid and aortic chemoreceptors
respond to changes in blood chemistries:
pH, pO
, pCO
stimulate respiratory ctr.
in medulla
c. Thermal-skin sensors respond to sudden change
in temperature-impulses that stimulate resp. ctr.
d. Mechanical-chest compression forces fluid out
into upper airways-expelled with birth, pressure
released, causes air into lungsalso helped with
tactile stimulation, lights, noises

3. Normal Respiratory Effort
a. once alveoli opened, surfactant helps to keep
them open
b. circulatory and lymphatic systems absorb moved
fetal lung fluid
c. complete absorption of fluid by 24 hrs-delayed
absorption noted in C/S deliveries
d. after initial tachypnea, resp. rate is usually
between 30-60 breaths/min-may be irregular

4. Respiratory Distress-reverse of the above


B. Cardiovascular transition
1. 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,
anatomically closed-30 months

2. in utero, fetal pO
is 27 mm HGafter birth, pO
50 mm Hg in the arterial bloodconstricture of the
ductus arteriosusfunctional closure in 10-24 hrs
-permanent closure in 3-4 weeks

3. pulmonary blood vessels dilate in response to O

fetal lung fluid moves into the interstitial spaces
(any O
-ductus dilates, pulmonary vessels constrict)

4. clamping of the umbilical cord closes the umbilical
arteries, umbilical vein, and ductus venosus which
convert into ligaments-fibrosis within 2 months

II. Neurological adaptation
A. Thermoregulation
1. newborns ability to produce heat is often = to adults
but have a tendency towards rapid heat loss

2. heat loss from: thin skin, little sub Q fat, blood vessels
close to surface, heat easily transferred from internal
to skin

3. 3x the body surface than adults=4x heat loss

4. flexed position helps preserve heatproblem with
premies is poor muscle tone leads to less flex

5. evaporation-heat loss thru wet skin exposed to air
-dry baby immediately at birth

6. conduction-loss of heat from body surface to cooler
surface in direct contact
-warm blanket, skin-to-skin contact

7. convection-heat transferred to cooler ambient air
-keep out of drafts, wrap in blanket with hat on head

8. radiation-transfer of heat to cooler object not in
direct contact with infant
-keep cribs away from outer windows

9. Thermogeneis
a. Nonshivering thermogenesis (NST)
primarily thru brown fat ( highly vascular fat
found only in infants with abundant supply of
blood vessels/nerve endings, found at neck,
kidneys, adrenals, sternum and intrascapulary
region)heat produced by lipid metabolic
activity warm baby (preterm infants lack
brown fat)
b. secondarily thru increased metabolic activity in
liver, brain, and heart
c. shivering begins when thermal receptors in skin
detect a drop in the skin temp-rare in neonates

10. cold stress-
a. metabolism = need for O
and glucose
regardless of gestational age or condition
b. if prolonged-leads to resp. difficulty
c. O
consumption diverted from maintaining
brain/heart function to thermogenesis
d. decreased pulmonary perfusion may lead to an
open ductus arteriosus
e. hypoglycemia
f. fatty acids released = metabolic acidosis
g. fatty acids in blood can interfere with
bilirubin transport = risk for jaundice

B. Reflexes
1. Moro (startle)
Usually present for first 3-4 months

2. Palmar, plantar grasp
Fingers/toes curl around examiners fingers
palmar lessens by 3-4 months
plantar by 8 months

3. Tonic neck
fencing position
complete response gone by 3-4 months

4. Sucking and rooting
head turns towards stimulus and sucks

C. Sensory adaptation
1. Vision
a. at birth, muscles in eye area are immature
(transient strabismus)
b. clearest vision within 10-20 inches
c. sensitive to light
d. at 5 days old, attracted to black/white patterns
e. able to see colors at 2 months
f. tear glands developed by 2-8 weeks
g. by 6 months, their visual acuity is of adults
h. prefer patterns to plain surfaces
i. eye color will not be set until 3-12 months

2. Hearing
a. like an adults after draining of amniotic fluid
b. loud sounds make baby have startle reflex
c. decrease motor activity in presence of low
frequency sounds such as a heartbeat
d. hearing loss is a common major abnormality
1-3/1000 normal term infants have bilateral
hearing loss

3. Touch
a. responses to touch on all parts of the body
b. face, hands, soles being most sensitive

4. Taste
a. can distinguish tastes
b. prefer glucose water to plain water

5. Smell
a. react to strong odors by turning head away
b. can differentiate their mothers breast milk by

III. Hematological adaptation
A. Neonatal differences
1. RBCs and H & H
a. at birth, levels are higher than adults
-Hgb14-24 g/dl
-Hct44-64% if > 65% = polycythemia
24-48 hrs of life
(neonatal RBCs have a lower survival rate
compared to adults)physiological anemia
c. delay of cord clamping shifts plasma to
extravascular spaces with lab results

2. Leukocytes
a. WBC 9-30,000 per mm
is normal at birth
b. will rise then decline to a level of 11,500
c. infection not well tolerated in infants with
sepsis usually accompanied by a loss in WBC

3. Platelets
a. 200,000-300,000/mm

b. factors II, VII, IX, and X decreased due to lack
of Vitamin K-not adult level until 9 months

4. Blood Groups
a. cord blood sample taken to determine infants
blood group and Rh status
b. Rh neg moms receive Rhogam if Rh + baby

5. Blood Volume
a. 80-85 ml/kg
b. at birth, blood volume approx. 300 ml
c. preterms have greater blood volume due to
a greater plasma volume, not RBC mass

6. Heart rate and BP
a. HR averages at140 beats/min at birth
b. rises just after birth
c. full term infants HR between 120-160 bt/min
d. PMI (point of maximal impulse) left chest
(apical pulse)
e. of heart murmurs heard at birth disappear by
6 months
f. BP averages 50-80/35-50 mm Hg

IV. Musculoskeletal System
A. Head and upper body
1. at birth, more cartilage than bone

2. face looks small in relationship to skull R/T molding
(overlapping of the skull bones)

3. fontanelles
a. anterior closes at 12-18 months
b. posterior closes at 8-12 weeks
c. bulging fontanelles mean ICP
d. sunken fontanelles mean dehydration

4. craniostenosis-contracted skull due to premature
closure of the cranial sutures-need surgery

5. Caput succedaneum
a. edema of the scalp
b. may cross suture lines
c. disappears in 1-4 dys

6. Cephalohematoma
a. collection of blood between the skull bone and
the periosteum-doesnt cross suture lines
b. may be spontaneous or due to vacuum or
forceps delivery
c. resolves in 2-4 weeks
d. may lead to jaundice

7. neck/shoulders
a. shoulder dystocia brachial plexus injury
-fx of scapula or clavicle (clavicle is the most
commonly fx bone during delivery process)
-immobilize in a sling

B. Extremities
1. arms
a. Erbs palsy-injury to brachial plexus = paralysis of
affected arm/shoulder
-flaccid arm with absence Moro on affected side
-immobilize arm but follow exercise regimen

2. hands
a. polydactyl-extra fingers
b. syndactyl-fused fingers
c. simian crease found on palms (and soles of
feet)frequently present in children with Downs

3. hips
a. can have congenital hip dysplasia-head of the
femur slips out of the acetabulum
b. Ortolanis/Barlows maneuver-listen/feel for a
c. breech deliveries-higher risk
d. may need to double or triple diaper

4. feet
a. poly/syndactyl
b. club foot-positional or casted to help rotate

C. Activity and Muscle Tone
1. spontaneous, transient motor function
-if flaccid, R/O any birth injuries

2. transient tremors normal but if persistent, may be

3. watch for flexion and extension of all extremities

V. Gastrointestinal
A. Mouth/throat
1. mucous membranes of mouth moist and pink if
adequately hydrated

2. check for intactness of hard and soft palates

3. may find Epsteins pearls-retention cysts-small white
areas at gum margins and junction of palates
-if area very hard to touch, question possible tooth
(more common in some cultures)

4. may note sucking blisters (calluses)

5. sucking behavior is influenced by neuromuscular
maturity, maternal medications at birth, and type
of initial feeding

6. infant unable to move food from lips to pharynx-
need to place nipple deep inside mouth

7. check for tongue-tied-may need frenulum cut

8. peristaltic activity of esophagus is uncoordinated at

B. Stomach
1. capacity varies from 30-90 ml depending on size of

2. cardiac sphincter is immature-may have regurg

3. gastric emptying times vary-effected by type of
of feeding, temperature of food, volume

4. can decrease regurg by avoiding overfeeding,
burping after eating, and infant positioning

C. Intestines
1. no bacteria in intestines at birth

2. usually hear bowel sounds after 1 hour of life

3. after birth, air and bacteria enter the orifices

4. highest bacterial content in lower intestine

5. normal colon bacteria established in 1
which helps synthesize Vit. K, folate, and biotin

D. Digestive Enzymes
1. full term newborns capable of swallowing, digesting,
metabolizing, absorbing proteins and simple carbs, and
emulsifying fats

2. digestive enzymes necessary to digest simple CHO,
proteins, and fats are present by 36-38 weeks

3. amylase-not produced until 3 months-salivary glands
6 months-pancreas
-unable to convert starch to maltose

4. lipase-needed for digestion of fat-needs to be
produced by pancreas

E. Stool patterns
1. meconium-first stools
a. filled with amniotic fluid and its constituents,
intestinal mucus (bilirubin), and cells
b. greenish black-may have occult blood
c. initially sterile then contains bacteria
d. usually fully passed in 24 hours

2. # of stools vary-early feedings = sooner stool

3. transitional stools-greenish brownyellowish brown
thickthin, watery

4. milk stools
a. breastfed-yellow to golden, pasty, and odor like
sour milk
b. bottlefed-yellow-light brown, firmer, odorous

VI. Hepatic System
A. Liver function alterations
1. hepatic system responsible for
a. maintenance of blood sugar
b. iron storage
c. drug metabolism
d. bilirubin conjugation
e. coagulation

2. glucose
a. 1/3 of stores as glycogen in liver
b. need constant supply for brain
c. blood glucose levels stabilize at
50-60 mg/dl after delivery
d. by day 3, 60-70 mg/dl
e. initiation of feeding assist in stabilizing
newborns glucose levels
f. newborns increased energy needs in
first 24 hours of life can rapidly deplete
glycogen stores

g. risk for hypoglycemia
-LGAs-excess insulin uses up glucose
-SGAs, premies-lack adequate brown fat
and glycogen stores
-traumatic deliveries
h. s/s of hypoglycemia
-respiratory distress
i. tx of hypoglycemia
-IV therapy

3. iron storage
a. fetal liver begins storing iron in utero
b. proportional to total body Hgb content
and gestation age
c. at birth, have enough iron stored for 4-6 months

4. coagulation
a. coag factors synthesized in liverVit. K
b. transient blood coagulation deficiency days 2-5
c. Vit. K injection helps prevent clotting problems
d. prenatal dilatin/phenobarbabnormal clotting

5. conjugation of bilirubin
a. bilirubin-yellow pigment derived from Hgb
released with breakdown of RBCs/myoglobin
b. Hgb is converted to bilirubin in unconjugated
form (non-excretable form)-potential toxin
c. unconjugated bilirubin-insoluble, bound to
circulating albumin-can permeate to other
areas (also called indirect bilirubin)
d. in the liverenzyme glucuronyl transferase
conjugates bilirubin (now called direct bili)
-soluble, excreted from liver cellsbile
e. excreted thru urine and feces
f. total bili is the sum of both levels of conjugated
and unconjugated bili
g. factors that bili
-excess production of RBCs
-RBCs life shorter-more breakdown
-liver immature
-poor/delayed feedings-breastfeeding jaundice
-traumatic delivery
-fatty acids-bind with albumin instead of bili

B. Hyperbilirubinemia/physiological jaundice
1. Occurs 50% in full terms, 80% in premies

2. incidence is increased in certain nationalities
a. Asians
b. Native Americans
c. Eskimos

3. neonatal jaundice is considered benign unless levels
lead to pathological conditions

4. its physiological jaundice if:
a. infant is well
b. jaundice appears after 24 hours and ends by
the end of day 7
c. serum concentration of unconjugated bili
-less than 12 mg/dl in term baby
-less than 15 mg/dl in premie
d. almost exclusively unconjugated bili
-direct bili doesnt exceed 1-1.5 mg/dl
e. daily increments in bili doesnt surpass 5 mg/dl

5. Feed early to keep serum bili low

6. if hyperbilirubinemia is not reversed, can lead to
kernicterus-precipitation of bilirubin in neuronal cells
leading to cerebral palsy, epilepsy, and mental

VII. Genitourinary system
A. Anatomy
1. at term, kidneys take up area of the posterior abd.

2. bladder close to anterior abdominal wall lying in both
the abdomen and the pelvis

3. at term, have a full complement of functioning


B. Voiding
1. bladder capacity- 6-44 mLs at term

2. frequency of voiding varies from 2-6 times/24 hours
to 5-25 times during the 3

3. limited capability to concentrate urine
-able to concentrate urine by age 3 months

4. urine usually straw-colored and almost odorless

5. may see pink stains from pseudomenses or uric acid

6. loss of fluid thru urine, feces, lungs, increased
metabolism, and limited fluid intake can result in
wt. loss of 5-10% normally

C. Fluid and Electrolyte Balance
1. 40% body wt. is extracellular fluids (adults are 20%)

2. newborns intake and excrete 600-700 ml water
=50% of extracellular fluid

3. GFR is 30-50% of an adults

4. GFR = wastes and nitrogenous in system

5. Na reabsorption = levels of Na, phosphates, Cl,
and organic acids

D. Genitals
1. Females
a. 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. in preterm girls
-clitoris is prominent
-labia majora are small and widely separated

2. Males
a. testes in scrotum in 90% of males
b. by year 1, incidence of cryptorchidism is < 1%
c. tight prepuce (foreskin) is common
d. smegma may be found under foreskin
-teach boys at 3-4 years old to retract and clean
under foreskin
e. evaluate for hypo or epispadias
f. scrotum more deeply pigmented and with deep
rugae in post term infants
g. circumcision-personal decision
-may reduce UTIs
-may reduce STIs
-may reduce penile CA
-done on 8
day under Jewish faith
-complications-hemorrhage, infection

VIII. Integumentary system
A. Vernix caseosa
1. white, cheese-like substance

2. helps the skin retain moisture

3. present more in premies

B. Lanugo
1. fine, downy-like hair

2. helps keep moisture in skin

3. seen less in full to post term infants

C. Desquamation
1. peeling of the skin

2. seen more in post date infants

D. Birthmarks
1. Mongolian spots
a. blue-black areas of pigmentation
b. more common on lower back and buttocks
c. more common in dark skinned nationalities
d. may fade over months or be permanent

2. Nevi-
a. Telangiectatic nevi-Stork bites
-are pink and easily blanched
-appear on upper eyelids, nose, upper lip,
lower occiput bone, and nape of neck
-usually fade between 1-2 years
b. Nevus vasculosus- Strawberry mark
-may be raised and be bright or dark red
-may last thru childhood
c. Nevus flammeus- Port-wine stain
-red to purple, nonelevated
-varies in shape, size, and location
-do not blanch nor fade with time
-if neurological problems exist- for Sturge-Weber

3. Erythema toxicum
a. transient rash also known as flea-bite rash
b. thought to be a inflammatory response
c. usually no clinical significance and needs no tx

IX. Immune system
A. Neonatal considerations
1. cells that provide infant with immunity are present but
not activated for the first several months of life

2. for first 3 months of life, passive immunity from mother

3. immunoglobulins
a. IgA
-cant 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 3

-very active against bacterial toxins
c. IgM
-produced by fetus in utero
-reach adult levels at 9 months old
d. IgA, IgD, and IgE gradually produced
e. colostrum and breast milk carry immunity

X. Psychosocial Adaptation
A. Behavioral states
1. Infants differ in their activity levels, feeding/sleep
patterns, and responsiveness

2. 1
period of reactivity-first 30 minutes of life
a. awake and alert
b. may have irregular resp. rate with crackles
c. grunting, flaring, retractions
d. may have periods of apnea
e. startle easily
f. decrease in body temp
g. increase in motor function
h. may be prolonged in term infants with abnormal
labor or birth traumas

3. Sleep period-unresponsiveness-2-4 hours
a. HR 100-120
b. RR slow-irregular

4. 2
period of reactivity-4-6 hours
a. tachycardia, tachypnea
b. muscle tone, skin color, mucus production
c. passage of meconium

5. Sleep/wake states
a. 2 sleep states
-deep sleep
-light sleep-REM
b. 4 wake states
-quiet alert/wide awake
-smile, vocalize, synchrony to voices
-watch & respond to their parents faces
-active alert

6. Purposeful behaviors
a. withdrawal by physical distance
b. push away with hands/feet
c. sensitivity by falling asleep
d. get fussy or cry as a signal
e. term infants better at self-quieting abilities

XI. Care of the Newborn
A. Assessment
1. Assess vital signs, assign apgar scores
a. temp-taken axillary
b. assess apical pulse
c. auscultate lungs and suction if moist

2. Measurements
a. weight in pounds and grams
b. Length-usually 18-22 inches
c. head circumference-usually 33-36 cm

3. Chart if voiding or passing meconium

4. Administer medications
a. erythromycin ointment-OU
b. Vit. K IM
c. Hep. B vaccine-IM
d. HBIG IM-if needed

5. Assess mothers ability to breast feed

6. Full head to toes assessment after bonding

7. Review maternal chart
a. ? infection at time of delivery
b. medications given to mother
c. R/O h/o substance abuse

8. Newborn nutrition
a. neonates need 110 kcal/kg/dy
b. at 3 months, 100 kcal/kg/dy
c. want to see 6-10 wet diapers/dy

9. Assist with circumcision if requested
a. minor surgical procedure-sterile tech.
b. after procedure, infant to mother
c. teach parents care of circ site

10. Home care instructions
The High Risk Newborn
Lecture 6

I. Levels of Care for the High Risk Newborn
A. Assessment for need of NICU/tertiary care center
1. maternal transport with fetus in utero preferred
a. decreases neonatal morbidity/mortality
b. mother and infant not separated at birth

2. if unable to transport before delivery:
a. notify supervisor of need for transfer team
b. have emergency personnel to stabilize baby

B. Transfer/multidisciplinary approach
1. transfer team consists of:
a. MDs
b. RNs
c. RTs

2. keep parents undated on infants condition
a. teach about equipment helping baby
b. start discharge teaching early

3. get mother and infant together ASAP

4. talk about possibility of return to primary center of care
a. may be frightened to move baby again
b. may feel insecure with change in staff

II. The Preterm Neonate
A. Risk Factors
1. before 37 weeks, lack sufficient organ maturity

2. lack adequate reserves of bodily nutrients

3. low SES of the mother

4. exposure to environmental dangers, I.E. toxic chemical

5. pre-existing maternal conditions-heart disease,
diabetes, etc

6. maternal age and parity

7. medical conditions R/T the pregnancy-GDM, PIH,

8. obstetrical complications-cord prolapse, abruptio

B. Physical characteristics and system alterations
1. Respiratory
a. at 22 weeks gestation, surfactant begins
b. 24-26 weeks-inadequate alveolar size and
c. 27-28 weeks-alveoli start to open, surfactant
d. 29-30 weeks-growth of alveoli and surfactant
e. 34-36 weeks-mature alveoli, surfactant level
(surfactants-surface-active phospholipids
lecithin-increases after 24 weeks
sphingomyelin-constant amount
when L/S ratio is 2:1=lungs mature)
f. noticeable cyanosis, retractions, grunting,
decreased tissue perfusion
g. apneic episodes-15-20 cessation of breathing

2. CV
a. pulmonary arteriole musculature
b. pulmonary vascular resistance L R
c. shunting thru ductus arteriosus into lungs
d. BP, cap refill time, resp. distress

3. Thermoregulation
a. lack glycogen stores in liver-created in 3

b. brown fat
c. larger body surface
d. posture of extension
e. less able to metabolism for heat

4. GI
a. poor gag, suck, swallow-coordinated after
34 weeks
b. incompetent cardiac sphincter
c. small stomach capacity
d. bile acids, pancreatic lipase = absorption
of nutrients, malabsorption
e. nutritional loss associated with vomiting/diarrhea
f. work of sucking = BMR, O
g. feeding intolerance

5. Renal
a. at 35 weeks, kidneys have limited ability to dilute
or concentrate urine
b. GFR secondary to renal blood flow
c. at risk for edema (overhydration) or dehydration
d. buffering = acidosis
e. longer to excrete drugs from the system

6. Hepatic
a. glycogen stores = hypoglycemia
b. iron stores
c. impaired conjugation of bilirubin

7. Immunologic
a. dont receive passive immunity
b. IgG-not until last trimester

8. Hematologic
a. increased capillary friability
b. tendency to bleed
c. blood loss from frequent lab work
d. production of RBCs

9. CNS
a. high risk of brain hemorrhage from thin, fragile
vessel walls
b. up to 34 weeks, the germinal matrix lines the
c. birth damage to immature structures
d. may have been exposed to recurrent anoxic

10. Risk of infection
a. thin, fragile skin
b. friable blood vessels
c. storage of immunoglobulins
d. inability to make antibodies

11. Fluid/electrolytes
a. need 80-150 kcal/kg/dy- than term infants
b. need protein 3-4 g/kg/dy-term 2-2.5g
c. need addition iron, calcium, K
d. usually get supplemental Vit. E (multi vitamin)

C. Common complications of Preterm
1. Patent Ductus Arteriosus
a. noticeable by Day 3
b. RDS improves
c. L R
d. increases pulmonary blood flow
e. L ventricular failure
f. pulmonary edema
g. CHF
-S & S
continuous/systolic murmur
bounding pulses
restrict fluid-give diuretics
indomethacin-0.2 mg/kg
-stimulates closure of ductus

2. Apnea
a. cessation of breathing > 20 seconds
b. usually occurs < 36 weeks gestation
c. R/T immature nervous system
d. may be R/T
temp instability
maternal drugs in labor
h/o maternal drug abuse
metabolic disorders
abdominal distention


e. assessment
-observe breathing pattern
-stimulate-slap soles of feet
-suction-use with free-flow oxygen
watch for dusky, cyanosis, bradycardia
-prepare for possible intubation
-think possible septic workup
f. tx
-oxygen per order-usually started if PaO
warmed and humidified
nasal cannula, hood, PPV, 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 NOTused with premies due to risk of
intraventricular hemorrhage

3. Intraventricular Hemorrhage-most common type of
intracranial hemorrhage
a. most susceptible-< 1500 gms, < 34 weeks
b. triggered by
no venous pressure changes
osmolarity in blood-overuse of volume
c. S &S
-hypotonia -hypotension
-lethargy -metabolic acidosis
-temp instability -seizures
-nystagmus -low Hct
-bulging fontanelles -apnea
-decerebrate posturing
d. Tx
-tx the symptoms
-phenobarb-sedative, seizure activity
-serial spinal taps
-VP shunt
-mainly observational and supportive care

4. Retinopathy of Prematurity (ROP)
a. at risk at < 36 weeks, < 1500 gms
b. higher risk-<1000 gms
c. oxygen tensions too high may lead to
d. at the end of oxygen therapy:
vascularization of retinaconstriction of vessels
disintegration of vesselsnew vesselsrupture
retinal hemorrhagescar tissuedetachment
e. assessment
-ophalmoscope exam-4-6 weeks
-some damage may spontaneously heal
f. Tx
-laser photocoagulation
-Vit. E therapy
-decrease ambient light
-circumferential cryopexy

5. Bronchopulmonary Dysplasia
a. caused by barotraumas from pressure ventilation
and oxygen toxicity
b. etiology is multifactorial
c. S & S
-tachypnea -retractions
-nasal flaring - work to breath
d. Tx
-oxygen -nutrition
-fluid restriction
-medications: diuretics, steroids, bronchodilators
e. key management is thru prevention
f. if untreated-can lead to death from cardio-
respiratory failure

6. Necrotizing Enterocolitis
a. inflammatory disease of GI mucosa
b. causes unknown-up to 25-30% mortality rate
c. contributing factors
-asphyxia -UAC -infection
-PDA -RDS -anemia/ischemia
-congenital heart disease
-early enteral feedings
d. breastfed babies have lower risk of NEC
e. S & S
-hypotonia -decreased activity
-recurrent apnea -pallor
-decreased perfusion -hypotension
-temp instability -cyanosis
-abdominal distention -diarrhea
-vomiting blood/bile
f. Dx
-lab reports
-abnormal electrolyte levels
g. Tx
-mainly supportive
-no feedings-rest the gut-trying probiotics
-use of TPN
-tx of infection
-surgical dissection of perforated/deteriorated

7. 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 IQs
h. learning disabilities

D. 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

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

2. 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

3. 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

III. 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

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 uterochemical pneumonitis
c. persistent pulmonary HTN (PPHN)
-pulmonary artery hypertension
-R to L shunting
-may need ECMO (extracorporeal membrane
oxygenation therapy)
3. Tx
-tx the S & S-ECMO, inhaled nitric oxide, etc

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
-single umbilical artery
-abnormal cord insertion
c. fetal
-multiple gestation
other infections, i.e. hepatitis
herpes (type II)

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 RBCs R/T stress

3. Tx
a. maintain clear airway
b. prevent cold stress
c. feeding per hospital protocol
d. stabilize temperature
e. nursing support similar to premies

C. Care of the LGA Neonate
1. Causes
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

4. Tx-tx the S & S

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
-maternal steroid therapy
-stressors such as PIH
-maternal drug use
b. risk of incidence/severity
- in gestation age
-maternal hypotension
-maternal diabetes
-C/S birth without labor
-second-born twin
-perinatal asphyxia

3. 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

4. S & S
a. tachypnea
b. grunting/nasal flaring
c. retractions
d. hypotension
e. cyanosis
f. self-limiting disease
-usually abates in 72 hours
-disappearance coincides with production of
surfactant in type 2 cells of alveoli

5. Tx
a. supportive-adequate ventilation/oxygenation
b. surfactant administration
c. oxygen therapy per orders
d. monitoring of acid/base balance
e. prevent cold stress
f. abx therapy for infection
g. proper nutrition and I & Os
h. possible need for blood transfusion R/T frequent
lab work

B. Transient Tachypnea of the Newborn
1. similar to RDS

2. R/T asphyxia in utero-fluid in lungs

3. x-ray shows over expansion/hyperinflation of lungs

4. Tx-oxygen, ck for possible acidosis

5. usually improves in 24-48 hrs, well in 2-5 days

C. Meconium Aspiration-see post term neonate

V. Neonate with Sepsis
A. Risk factors
1. maternal
-low SES -poor PN care
-poor nutrition -substance abuse

2. intrapartum
-PROM -maternal fever
-chorioamnionitis -prolonged labor
-premature labor -maternal UTI

3. neonatal
-twins -male
-birth asphyxia -mec aspiration
-galactosemia -absence of spleen
-LBW/premie -prolonged hospitalization


B. Mode of transmission
1. vertical
a. in utero
b. at birth

2. horizontal
a. after birth
b. environmental, i.e. Staph

C. Causes of susceptibility
1. lack immunity

2. phagocytosis less efficient

3. dysmaturity

D. Causes of infection
1. Early onset-within 24 hours of birth
a. group B strep
b. Haemophilus influenza
c. Listeria
d. E. Coli
e. Strep. Pneumoniae
f. more common with PROM, maternal fever,
chorio, and premature labor
g. higher mortality rate-10-25%

2. Acquired infections-seen after 2 weeks of age
a. may be from birth canal or environment
b. Staph aureus
c. Staph epidermidis
d. Psedomonas
e. group B strep

3. Viral infections
a. may cause miscarriage, stillbirth, intrauterine
infections, and congenital malformations
b. may cause chronic infection with subtle
c. may need isolation from other neonates


4. Fungal infections
a. greatest concern to immuno-compromised
or premature neonates
b. thrush may be present in otherwise healthy kids

E. Location of infection
1. Septicemia is infection in the blood system

2. Pneumonia-most common form of neonatal infection
-one of the leading causes of perinatal death

3. Bacterial meningitis affect 1 in 2500 live births

4. Gastroenteritis not as common

F. S & S
1. Respiratory
-apnea -tachypnea
-grunting -nasal flaring
-retractions -decreased O

2. CV
-bradycardia -decreased CO
-tachycardia -hypotension
-decreased perfusion

3. CNS
-temp instability -lethargy
-hypotonia -irritability

4. GI
-vomiting -abdominal distention
-diarrhea -residuals > 50%

5. Skin
-jaundice -pallor


G. Sepsis workup
1. lab work
-blood (CBC with diff)
looking for neutrophils, bands(immature WBC)
-gastric aspiration
-culture nose, throat, skin, umbilical cord

2. chest x-ray

H. Tx
1. Tx the symptoms-i.e. abx, O

2. Assess handwashing techniques of the staff

3. Encourage breastfeeding-passive immunity

VI. The Neonate with Hyperbilirubinemia
A. Types
1. Physiologic jaundice
a. occurs in 60-70% of term infants, 80% preterm
b. arises 24 hours after delivery

2. Pathologic jaundice
a. hyperbilirubinemiakernicterus
(bilirubin encephalopathy)
b. apparent within 24 hours of birth
c. serum bili of > 5mg/dl in cord blood
d. serum bili > 15mg/dl at any time

B. Causes
1. Maternal factors
a. Rh/ABO incompatibility
-fetal antigen crosses placenta
-maternal antibodies cross placenta
-cause hemolysis of fetal RBCs
(erythroblastosis fetalishydrops fetalis)
b. infection
c. diabetes
d. oxytocin in labor
e. drugs


2. Fetal/newborn factors
a. premies
b. hepatic cell damage
c. polycythemia
d. intestinal obstruction
e. pyloric stenosis
f. biliary atresia (absent or closed bile ducts)
g. blood swallowed by fetus

C. Nursing care
1. Lab work
a. direct comb-ck for maternal antibodies in
infants blood
b. ck infants blood type
c. serum bili level

2. Tx
a. early, frequent feedings
b. phototherapy
c. exchange transfusions
-if Rh incompatibility-use O neg blood

VII. The Neonate born to a diabetic mother
A. Problems
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
caudal regression syndrome-problems of the
lower extremities

2. macrosomia/birth trauma
-excessive glucose in blood = fetal insulin production
-enlargement of internal organ except brain
-high risk for fx of clavicle/scapula, cephalohematoma

3. RDS
-4-6X more likely to develop than in normal infants

4. hypoglycemia, hypocalcemia, hypomagnesemia
-hypocalcemia present in 50% of IDMs
-hypomagnesemia from maternal renal loss R/T DM

5. hyperbilirubinemia/polycythemia
-excess RBC production leads to bili

B. Pathophysiology
1. Normally:
maternal blood more alkaline pH than CO
-rich fetal
bloodexchange of O
& CO
across placenta

2. Maternal acidosis:
in gas exchange

3. Goal:
Maternal control of BS thru pregnancy with PN care

C. Nursing care
1. Pediatric staff at delivery

2. Implement neonatal glucose testing per protocol

3. If RBS < 40 mg/dl, supplement with formula or IV prn

4. Check serum bilirubin and calcium levels

6. Reduce adverse environmental factors

VIII. The Neonate born to a Substance Abusing Mother
A. Common characteristics
1. Fetal alcohol syndrome
a. eyes
-epicanthal folds -strabismus
-ptosis -drooping lid
-hypoplastic retinal vessels

b. mouth
-poor suck -cleft lip
-cleft palate -small teeth
c. ears-deafness
d. skeleton
-fusion of cervical vertebrae
-restricted bone growth
e. heart
-atrial/ventricular septum defects
-Tetralogy of Fallot
-patent ductus arteriosus
f. kidney
-renal hypoplasia -hydronephrosis
-urogenital sinus
g. liver
-hepatic fibrosis
h. immune system
-increase infections -otitis media
-upper resp. infections -immune deficiencies
i. tumors-nonspecific neoplasms
j. skin
-abnormal palmar -irregular hair

2. Cocaine
a. prematurity/SGA
b. microcephaly/developmental delays
c. poor feeder/diarrhea
d. hyperactivity/difficult to console
e. congenital anomalies

3. Heroin
a. LBW
b. SGA
c. neonatal withdrawal issues

4. Amphetamines
a. SGA/LBW/premie
b. poor wt. gain
c. lethargy

5. Tobacco
a. Premie/LBW/IUGR
b. risk for SIDS
c. risk for bronchitis/pneumonia
d. developmental delays

6. Marijuana
a. possible neonatal tremors
b. LBW

B. Nursing Care
1. Needs multidisciplinary approach for both neonate
and parents

2. Supportive care
a. fluid and electrolyte balance
b. nutrition
c. infection control
d. respiratory care

3. Quiet, soothing environment during withdrawal period

4. Pharmacological tx-morphine, phenobarb, diazepam,
paregorics (tincture of opium), &
methadone vs buprenorphine (article)

IX. Hypoxic Ischemic Encephalopathy (HIE) in NewbornsArticle

Normal Pregnancy
Lecture 7

I. Physiological Changes during Pregnancy
A. Reproductive system and breasts
1. Uterus
a. increased vascularity/dilation of blood vessels
-60 gm(2oz) to 1100 gm(2.2 lb)
b. hyperplasia-new muscle fibers/tissue
c. hypertrophy-enlargement of pre-existing fibers
d. development of the decidua
e. growth changes R/T stimulation from high levels
of estrogen/progesterone
f. shape changes
-7 weeks-egg size
-10 weeks-orange size
-12 weeks-grapefruit size
-initially pear shaped
g. 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. lightening
-nulliparas-2 weeks before term
-multiparas-when labor starts
i. ballottement-palpate floating structure
j. altered center of gravity as enlarging uterus tilts
against the anterior abdominal wall
k. Braxton-Hicks contractions
-start around 4 months
-help to facilitate blood flow
l. 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, 1/6 of total blood volume
within the vascular system of uterus
m. Hegars sign-6 weeks-softening of lower uterine
2. Cervix
a. Goodells sign-softening of cx-6 weeks
b. Chadwicks sign-bluish cast-8 weeks
c. friability increases
d. operculum-mucus plug-endocervical glands

3. Vagina
a. increased vascularity
b. leukorrhea-thick white vaginal discharge
c. change in pH leads to higher risk for yeast inf.

4. Breasts
a. start to change by week 6 R/T hormone surge
b. increase in sensitivity, breast and nipple size
c. increase in feeling firm, heaviness, nipple erect
d. nipples and areola become more pigmented
e. vessels beneath the skin dilate-more visible
f. striae gravidarum (stretch marks) may appear
g. may leak colostrum as early as 16 weeks

B. Cardiovascular system
1. Heart
a. slight hypertrophy R/T increase blood flow
b. position change R/T diaphragm position
c. transient murmurs may be auscultated
d. cardiac output
-increased 30-50% by week 32
-only 20% increase by week 40
-R/T increased stroke volume and heart rate
e. pulse rate increases 10-15 bt/min

2. Blood
a. increase in blood volume 40-50% (1500ml)
-plasma-1000 ml
-RBCs-450 ml
b. physiological anemia-hemodilution of cells
-anemic if Hgb under 10g/dl, Hct under 35%
c. increase in WBCs
d. 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. with C/S

3. Blood Pressure
a. 1
trimester-no change in BP
b. 2
trimester-BP 5-10 mm Hg
c. 3
trimester-BP returns to 1
trimester values
d. supine hypotensive syndrome
-if they lie on their backs
-at 5 minutes, reflex bradycardia
-CO by half
-woman feels faint

C. Respiratory system
1. flaring of the rib cage

2. shift from abdominal to thoracic breathing

3. elevated maternal oxygen requirements
a. acceleration in metabolic rate
b. the need to add to the tissue mass of uterus
c. fetal needs

4. vascularity of the upper resp. tract
a. nasal and sinus stuffiness-(estrogen-induced)
b. epistaxis (nosebleeds)
c. changes in the voice

5. pulmonary function
a. deep breathing- airway resistance-Progesterone
b. tidal volume
c. resp rate 2 breaths/min
d. awareness to breath
e. sensitivity in medulla to CO
- depth, rate

6. basal metabolic rate
a. 15-20% by term
b. reflects in oxygen demand
c. may experience heat intolerance R/T excess
heat from BMR

7. acid-base balance
a. pregnancy is a state of resp. alkalosis
compensated by mild metabolic acidosis
b. facilitates maternal-fetal O
D. Renal system
1. anatomic changes
a. estrogen and progesterone = uterus size and
blood volume
b. dilations of ureters, pelvis, renal calyces large
amt. of urine
c. urine flow rate slowedstasis/stagnation
medium for bacteria
d. tubular reabsorption impairedglucose in urine
more alkaline urine
e. urinary frequency from in bladder sensitivity
and compression from uterus
f. 2
trimester, bladder pulled up into the
g. urethra lengthens-possible problem with cath

2. functional changes
a. in GFR
b. most efficient in L lateral- perfusion to kidneys

3. fluid and electrolyte balance
a. tubular reabsorption to maintain needed Na
b. 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. slight protein leakage +1 ok

E. Integumentary
1. hyperpigmentation
a. caused by stimulation of anterior pituitary
hormone melanotropin
b. chloasma=brownish facial pigmentation-
intensified by sun
-usually fades after pregnancy
c. darkening of nipple, areola, vulva, thighs
d. linea nigra=dark vertical line from symphysis
pubis to fundus
-starts as linea alba-before pigmentation
-not present in all pregnant women
e. striae gravidarum-stretch marks
-on abdomen, breasts, thighs
-separation of collagen
-50-90% of women will have this
2. other changes
a. angiomas-vascular spiders
b. palmar erythema-blotches on hands
c. pruritus
d. gum hypertrophy-bleeding gums
e. accelerated nail growth
f. hirsutism-excessive hair growth
g. blood supply = perspiration

F. Musculoskeletal
1. lordosis-center of gravity is more forward

2. relaxin, an ovarian hormone, helps with relaxation and
increased mobility of pelvic joints
-waddling gait

3. diastasis recti abdominis-persistent separation of
muscles of the abdominal wall

G. Neurologic system
1. compression of pelvic nerves may cause sensory
changes in legs

2. edema on peripheral nerves-carpal tunnel syndrome
a. burning, paresthesia
b. pain in the hand, radiating to the elbow

3. tension headaches

4. syncope common in early pregnancy

H. Gastrointestinal
1. peristalsisconstipation, N & V

2. bleeding of gums/problems of the mouth
a. caused by rising level of estrogen
b. ptyalism-excessive salivation

3. 15-20% will have problem with hiatal hernia

4. estrogen = secretion of HCl acid

5. progesterone = stomach emptying time=heartburn
6. gallbladder distentionprolonged emptying time
and thickening of biledevelopment of gall stones

7. pruritus gravidarum-may be R/T accumulation of bile

8. 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 2

I. Endocrine system
1. secretions of pituitary hormones:
a. thyrotropin
c. prolactin
d. vasopressin (antidiurectic hormone)
e. oxytocin

2. secretions of thyroid hormones:
a. thyroxine
b. triiodothyronine

3. secretion of parathyroid hormones

4. secretion of the adrenal hormones:
a. cortisol-r/t estrogen-regulates CHO/prot meta.
b. Aldosterone-protective response to Na excretion

5. secretion of insulin from the pancreas

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. doesnt 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
3. preterm-before 37 weeks gestation

4. postdates-after 42 week of gestation

5. viability-capacity to live outside the uterus
a. somewhere between week 22-24
b. fetus greater than 500 gms

6. 5-digit system
a. gravida
b. term-para
c. preterm
d. abortions-spontaneous or therapeutic
e. living children

B. 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. Nageles Rule
1. First day of LMPsubtract 3 monthsadd 1 week

D. 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. Goodwells sign-week 5
b. Chadwicks sign-weeks 6-8
c. Hegars sign-weeks 6-12
d. + pregnancy test (serum)-weeks 4-12
e. + pregnancy test (urine)-weeks 6-12
f. Braxton-Hicks contractions-week 16
g. abdominal enlargement
h. ballottement-weeks 16-28
i. palpable fetal outline

3. 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

III. 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

3. OB/Gyn history
a. menstrual history
b. contraceptive history
c. any infertility concerns
d. any Gyn concerns
e. ck last Pap and cultures for STIs

4. medical history
a. pre-existing medical conditions/concerns
b. history of surgical procedures

5. nutritional history
a. assess for food allergies
b. any special dietary concerns

6. history of drug use
a. past and present use of legal medications
b. h/o illegal drug use

7. family history

8. psychosocial history
a. situational factors
b. any previous care of infants
c. coping mechanisms

9. history of physical/verbal abuse
a. abuse may increase during pregnancy
b. need immediate clinical intervention

B. Physical examination
1. vital signs

2. head to toe assessment

3. pelvic exam with vaginal/abdominal U/S

4. review of systems
a. assess each sign/symptom for onset, character,
and course
b. assess for aggravating/alleviating factors

C. Laboratory tests
1. blood work up
a. CBC
b. blood type and Rh factor
c. rubella titer
d. HIV screen
e. HbsAG screen
g. Tay-Sachs
h. Sickle-cell
i. glucose tolerance test

2. urine screen
a. urinalysis with culture

3. pelvic
a. Pap smear
b. cultures for STIs

4. TB skin test
5. screening for fetal chromosome anomalies
a. NT-nuchal translucency (fetal nuchal fold)
b. serum testing for free beta hCG and PAPP-A
c. NT, free beta hCG, and PAPP-A can
suggest aneuploidy

D. Priority patient education topics
1. schedule of visits

2. rationale for labs

3. Kegel exercises for pelvic floor

4. review nutritional needs

5. ok to travel and continue exercise as comfortable

6. ck all use of medications with your provider-even OTC
a. will start on PN vitamins with folic acid
b. iron tabs prn anemia

7. immunizations
a. ok if killed-DT, Hep B, rabies (Tdap-after 20 wks)
b. no ok if live-measles, MMR, C Pox, mumps, polio

8. alcohol, tobacco usage PROM, PTL, abruption

9. tips to help with fatigue, N & V

IV. Second trimester
A. Ongoing care
1. physical examination
a. weight-approx. 1 lb per week past 1
b. BP-watch for 140/90 or systolic 30>baseline
diastolic 15>baseline
c. dip urine for protein, glucose
d. auscultate FHT
e. assess breasts/nipples
f. review birth plan
g. ask about quickening-approx 20 weeks

2. pertinent laboratory tests
a. Quad Screen-done between 15-20 weeks:
2. hCG
3. UE-unconjugated estriol
4. inhibin-A
5. Assessing for possible spina bidifa, Down
syndrome, or other chromosomal defects
b. follow-up on any prior test results
c. amniocentesis

3. potential complications
a. bleeding
b. decreased fetal activity
-swelling of face/fingers
-epigastric pain
-muscular irritability
-visual disturbance
-amniotic fluid discharge
e. infections
-burning with urination

4. fundal height
a. fundal height (from symphysis pubis to top of
uterus) # in cm = weeks of gestation
(weeks 18-36)
b. stable or decreased fundal height-? IUGR
c. excessive increase-multifetal gestation,

5. gestational age
a. determined from LMP, contraceptive history, and
pregnancy test results
b. usually confirmed with U/S

6. interventions for discomforts
a. assess skin changes
b. headaches-rest, hydration, acetaminophen
c. constipation-hydration, exercise, prune juice
d. varicose veins-elevate legs, support stockings
e. food cravings-6 small meals-keep BS level even
f. heartburn-small meals, sit up after eating, spicy
foods, antacids
g. joint/ligament pain-support garments

7. education topics
a. warning signs
b. assess nutrition status
c. hygiene-R/T increase perspiration
d. UTI prevention-hydration, freq. Voids
e. breast shields for inverted nipples
-too much stimulation can lead to PTL
f. dental care
g. R & R
h. risk factors at work-i.e. caustic agents
i. travel-if not high risk, ok
j. avoid alcohol, cigarettes
k. need for support garments

V. Third Trimester
A. History and physical
1. vaginal exams may begin in the last month

2. assess for S & S of PTL, PIH, GDM

B. Laboratory tests
1. Group Beta strep culture-35-37 weeks

2. rhogam injection-26-28 weeks for Rh - moms

3. glucose tolerance test

4. may retest for STIs

C. Interventions for discomforts (same as 2

D. Family adjustments
1. maternal tasks
a. accept the concept of being pregnant
b. may dislike pregnancy but love child
c. if happy about pregnancy-usually have
higher self-esteem, confidence
d. dealing with rapid mood changes
e. may have feelings of ambivalence
f. prepare for childbirth
g. practice of mothering role
h. may need to work on communication with
family members
i. work on relationship with her mother
j. trust and share with the partner
k. work on sexual relationship with spouse
l. 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

2. paternal tasks
a. acceptance of pregnancy
-may express joy or dismay
-unwanted vs. unplanned
-affairs/battery of spouse
b. couvades
-observance of rituals = transition to fatherhood
-may have psychosomatic symptoms of preg.
c. participate in childbirth education
d. identify with father role
-may be influenced by how their father was
e. reordering personal relationships
-may see fetal as a rival
-may feel wife is too dependent on MD/CNM
f. observer vs. expressive vs. instrumental
g. establish relationship with fetus
-kiss or rub abdomen
-talk to fetus
-assist with preparing babys room

3. sibling adjustment
a. first crisis for a child
b. may feel replaced
c. need to prepared to become the big sister or
d. sibling classes

4. grandparent responses
a. if only in 30s or 40s-may not be as interested
b. may be non-supportive-try to decrease new
mothers self esteem
c. most see the pregnancy as a renewal of their
d. continuity of past and present
e. may help bridge a previous estrangement
f. now have classes on being a grandparent

5. other psychosocial issues
a. adolescent mothers
-most pregnancies unintended-80%
-40% will end in abortion-EABs & SABs
-higher rates for Hispanics, African-Americans
-most unmarried, low SES
-more likely not to receive PN care
-RN needs to encourage PN visits, nutritional
guidelines, and social service consult
b. 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

E. Education topics
1. preparation for childbirth classes
a. prenatal yoga
b. Lamaze
c. prenatal breast feeding
d. cesarean information

2. review warning signs

3. signs and symptoms of labor

4. other potential complications
a. PIH
c. bleeding
d. FM
VI. Ongoing safety issues
A. Travel/exercise
1. use common sense
a. no prolonged use of hot tubs
b. high risk for clots in legs if not moving around
1. walk around the plane during long trips
2. stop the car every few hours for stretch

2. should avoid air travel after the 7

3. MVA-most common cause of fetal death-seatbelts

4. continue with non-weight bearing exercises

B. Substance abuse
1. no such thing as a safe level of drugs

2. alcoholism-risk of fetal alcohol syndrome, abortion
-problem with using antabuse-suspected teratogenic

3. smoking-retards fetal growth and development
a. risk for PTL, PROM, abruption
b. second-hand smoke just as bad

4. caffeine-since its a stimulant, best to limit-300 mg/day
a. risk of SAB
b. risk of growth restriction

C. Vaccinations-ok if not a live vaccine

D. Battering
1. may increase with enlargement of abdomen

2. must be reported

3. hook up pt. with social services/womens shelters

E. Preventing Preterm labor

VII. Multifetal pregnancies
A. Maternal concerns
1. blood volume strain on CV system

2. anemia

3. uterine distentionseparation of abdominal muscles

4. risk for placenta previa

5. for separation of placenta

6. lack of emotional preparement
a. will need additional education and support
b. possible need for selective reduction

7. strain on finances, space, workload, and relationships

B. Fetal concerns
1. risk of prematurity


3. types of twins
a. dizygotic-from 2 fertilized ova/2 spermatozoa
1. 2 placentas
2. 2 chorions
3. 2 amnions
b. monozygotic-originating from one fertilized ovum
1. dichorionic-diamniotic twins (20-30%)
-if division 3 days after fertilization
-may have separate or fused placentas
2. monochorionic-diamniotic
-if division 5 days after fertilization
3. monochorionic-monoamniotic
-if division 7-13 days after fertilization
c. risk of congenital malformations-in monozygotic
d. twin to twin shunting
e. two-vessel cord

4. delivery complications

VIII. Cultural variations during the prenatal period
A. Examples of cultural variations
1. belief of whether pregnancy is state of illness/health

2. behavioral expectations of mother/provider

3. dietary prescriptions/restrictions
a. warm vs. cold
b. like to like
c. pica

4. activity restrictions

5. availability of advice/if advice is sought at all

6. consideration of modesty/religion
a. clothing
b. amulets, beads

7. pain
a. inevitable, to be endured
b. can be avoided completely
c. punishment for sin
d. can be controlled

8. no tying of knots-leads to knot in umbilical cord

9. knife under bed to cut the pain

10. specific groups
a. Mexicans
-stoic until just before delivery
-avoid eclipse of moon-cleft palate
-everybody present at delivery
b. Middle Eastern
-only female attendants
-FOB usually not at delivery
c. Asian
-prefer warm fluid
-natural childbirth
-labor in silence
-may eat during labor
-FOB may or may not be present

B. Nursing care
1. support cultural belief-offer alternatives

2. encourage patients to participate in medical

IX. Maternal Nutrition
A. Nutritional requirements
1. energy needs-additional 300 kcal greater than

2. protein
a. needed for growing fetus
b. milk, meat, eggs, cheese-complete proteins
c. only slightly higher need than non-pregnancy

3. fluids
a. recommend 8-10 glasses (2-3 liters)
b. caffeinated drinks dont count-diuretic
c. may be good to avoid artificial sweeteners
d. proper hydrations helps prevent headaches,
constipation, and uterine cramping

4. minerals and vitamins
a. 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, PP infections,
poor wound healing, death
-fetal: PTL, low-birth weight infant
-deficiencies more common in teen moms and
b. calcium
-no change in DRI for calcium
-1000 mg daily if 19 yrs or older
-1300 mg daily if under 19
-if lactose-intolerant, seeks non-dairy sources of
-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
-restriction only needed in women with
HTN, renal or liver failure
d. zinc
-deficiency associated with CNS malformations
-needed for protein metabolism
-if pt on high-dose iron supplements, needs
additional zinc supplement
e. fat-soluble vitamins-A, D, E, K
-chronic overdoses can lead to toxic levels
-Accutane-if used for cystic acne, may cause
multiple birth defects
-neonatal hypocalcemia noted in areas where
mothers skin lacked access to sunlight
-Vit. K.-for synthesis of prothrombin
f. water-soluble vitamins-B, C
-readily excreted in urine so needs frequent
-Folic acid
-need 50% more folic acid than non-
-400-800 mcg daily
-CDC-50-70% of NTD (neural tube defect)
& anaencephaly with adequate folate

B. Weight gain
1. 1
trimester-5 lbs (1-2 kg)
trimester-1 lb/week (0.44 kg/week)

2. normal BMI-11.5-16 kg (25-35 lbs)
underweight-12.5-18 kg (28-40 lbs)
overweight-7-11.5 kg (15-25 lbs)
obese-7 kg ( 15 lbs)

3. 1
trimester-development of fetal tissues
and 3
trimester-growth of fetal tissues

C. Cultural differences

D. Nutritional risk factors
1. Vegetarian
2. Pica
3. Lactose Intolerant
4. Anorexia/Bulimia
Fetal Assessment
Lecture 8

I. The High Risk Pregnancy
A. Indications for fetal diagnostic testing
1. biophysical-risk factors that originate within the mother
or fetus-affect the development or function of either
or both
a. genetics
-defective genes
-inherited disorders
-chromosomal anomalies
-multiple pregnancies
-ABO incompatibility
b. nutritional status
-teen moms
-3 pregnancies in last 2 years
-tobacco, alcohol, or drug use
-inadequate or excessive weight gain
-Hct less than 33%
c. medical or obstetric
-chronic HTN
-h/o PTL
-h/o stillborn, fetal death
-sickle cell
-heart disease
-bleeding problems

2. psychosocial-risks comprised of maternal behaviors
and adverse lifestyle that have a negative effect on
the health of the mother and/or fetus
a. smoking
b. caffeine
c. alcohol
d. drugs
e. psychologic status
-h/o physical/verbal abuse
-inadequate support systems
-noncompliance with cultural norms
-situational crises
-unsafe cultural, ethical, or religious practices
3. sociodemographic-risks arise from the mother and her
family and place the mother and fetus at risk
a. low income
b. lack of PN care
c. age
d. parity
e. marital status
f. residence
g. ethnicity

4. environmental-risks include hazards of the workplace
and the womans general environment
a. infections
b. radiation
c. chemicals
d. therapeutic drugs
e. illegal drugs
f. industrial pollutants
g. smoke, stress, diet

B. Nursing Interventions
1. Complete PN interview with history

2. Offer access to services for health promotion

3. Discuss reasons for health diet and lifestyle practices

4. Emphasize need to keep PN visits and do lab work

5. Educate patient/partner to play an active role in
health of the mother and fetus

II. Fetal diagnostic tests
A. Biophysical Assessment
1. Daily fetal movement count
a. simple, noninvasive, done at home
b. can be affected by fetal sleep cycle or maternal
drug use
c. presence of fetal movement is generally a sign
of good health
d. < 10 movements in 3 hours, CALL MD
e. 2 hours after a meal and still < 4, CALL MD
f. follow up with NST, CST, or biophysical profile

2. 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
4. well tolerated, no full bladder
5. helps detect ectopic pregnancies
6. used in adjunction with abdominal
scan to R/O PTL in 2
& 3
-abdominal scan
1. full bladder helps move uterus up
2. may be hard to use on obese pts.
3. more useful after 1
-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. decreased AFV-largest pocket of
fluid is <2 cm
4. increased AFV-multiple large
pockets of fluid > 12 cm

3. 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

B. 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
-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 2
or 3
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
f. assess FHR for 1 hour and rescan in 1 hour

3. 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, cant detect neural tube

4. 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 moms blood
-direct=presence of antibody-coated Rh+ RBCs
in babys blood
-determine severity of fetal anemia from

C. 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/Cs 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
-massage nipple until contraction is elicited
-desire 3 U/Cs/10 minutes/lasting 40-60 sec
e. oxytocin-stimulated CST
-IV infusion of oxytocin to start U/Cs
-increased in 0.5 mU/min increments
f. negative results
-no late decels
g. positive results
-persistent and consistent late decels with more
than half the contractions

3. fetal oxygen saturation
a. FSpO
may be helpful in differentiating fetal
b. adjunct to EFM
c. normal FSpO
may prevent unnecessary
interventions when a nonreassuring FHR pattern
is identified
d. ROM is needed
e. signal error if improperly placed, too hairy, or
too much vernix
f. normal FSpO
during labor is between 30-70%

D. Biophysical profile
1. noninvasive dynamic assessment of fetus/environment

2. assessing 5 variables
a. 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. fetal tone
-normal (2)-1 or more active extension with
return to flexion
-abnormal (0)-slow extension with return
d. reactive fetal heart rate
-normal (2)-2 or more accels with +FM/20 min
-abnormal (0)-less than requirement
e. qualitative amniotic fluid volume
-normal (2)-1 or more pockets of fluid > 1 cm in
2 perpendicular planes
-abnormal (0)-pockets absent or below needed

3. score
a. normal = 8-10 if AFI ok
b. equivocal = 6
c. abnormal = <4

E. Role of the Nurse in Fetal Assessment Testing
1. support person when the woman is undergoing exams
such as U/S, amnio, PUBS, CVS, etc

2. in some settings, the RN will perform the NST, CST,
BPP, and basic U/S

3. patient teaching
a. preparation for procedure
b. interpreting the findings
d. providing psychosocial support PRN

F. Electronic FHR assessment
1. FHR tracing-assessment and interpretation
a. baseline
-range of FHR in a 10 minute period in the
absence of or between U/Cs
-110-160 bpm
b. variability
-98% accuracy in predicting fetal well-being
-result of fetal sympathetic/parasympathetic
nervous systems
-can be affected by fetal sleep cycle, maternal
analgesics, prematurity, congenital
-decrease in variability-possible sign of fetal
distress or profound compromise
c. bradycardia
-FHR below 110 bpm for 10 minutes or more
-indicative of fetal hypoxia
d. tachycardia
-FHR over 160 bpm for 10 minutes or more
-marked tachycardia > 180 bpm
-prematurity -mild hypoxia
-tocolytic agents -maternal fever
-maternal anemia -fetal activity
e. changes in FHR
-accelerations-usually assoc. with + FM
-decelerations-early, late, variable

2. nursing role
a. record information on strip if unable to chart
b. vaginal exams
c. assess if ROM
d. VS assessments
e. position changes when needed
f. oxygen via mask
g. medications
h. emesis control
i. assess need for internal monitors

3. deceleration patterns
a. early-rarely below 110 bpm
-periodic decels R/T intense fetal head
-uniform shape, mirror image of U/C
b. late
-uniform-reflects shape of contraction
-onset after peak of U/C
-cause-uteroplacental insufficiency
-hypotension -PIH
-hypertonic contractions
-abruptio -postmaturity
-oxygen -position change
-stop pitocin drip -IV hydration
-assess other S & S
c. variable
-U or V shaped
-with or without U/C
-R/T cord compression
-usually transient, changeable
change to side lying oxygen
external fetal manipulation SVE
knee-chest position
amnioinfusion if ROM
Pregnancy at Risk

IV. Disorders Causing Bleeding in Early Pregnancy
A. hemorrhage during pregnancy
1. emergent situation-complicates 1 in 5 pregnancies

2. during the first half-usually result of SAB, ectopic, molar
or incompetent cx

3. during the second half-usually placenta previa,
placenta abruptio

4. risk for maternal exsanguination with 8-10 minutes
r/t uterine blood flow is 650 ml/min (15% of CO)

B. spontaneous abortion
1. pregnancy that ends before 20 weeks

2. or fetal weight less than 500 gms

3. incidence-10-15% of all pregnancies

4. early-occurring prior to 12 weeks
a. 50% causation from chromosomal abnormalities
b. 80% occur within the first 12 weeks
c. other causes
-endocrine imbalance (IDDM)
-immunological factors (antiphospholipid
-infections (chlamydia, bacteruria)
-systemic disorders (lupus)
-genetic factors

5. late-12-20 weeks
a. usually r/t maternal causes
-chronic infections
-premature dilation of cx
-reproductive tract anomalies
-chronic diseases
-inadequate nutrition
-recreational drug use/abuse

6. types
a. threatened-spotting, closed cervix, cramping
b. inevitable-open cervix, mod-heavy bleeding,
mod-severe cramping
c. incomplete-some POC retained
d. complete-all POC removed
e. missed-death in utero without obvious S & S
diagnosed by U/S
f. recurrent-3 or more

7. clinical manifestations
a. increasingly severe as gest. age increases
b. before 6 weeks-increased flow like heavy
c. 6-12 weeks-moderate discomfort, blood loss
d. 12 weeks-severe pain

8. assessment
a. check PN history and hCG level
b. U/S
c. CBC
d. blood type and Rh factor
e. assess for infection

9. plan of care
a. rest and supportive care
b. D & C
c. D & E
d. may need prostaglandins, IV, or pitocin for
fetal demise

10. teaching
a. report heavy or bright red bleeding
b. some scant dark discharge 1-2 weeks post
c. no vaginal insertions until bleeding stops
d. take entire course of abx if prescribed
e. grief counseling if needed
f. refer to support group

C. induced abortion
1. elective-by request

2. therapeutic-for maternal/fetal health or disease

3. primarily done in 1

4. assessment
a. informed consent
b. options explored
c. discuss conflicts/fears

5. procedure
a. laminaria then vacuum aspiration (D & E )
b. may use PG gel to ripen cx
c. need to monitor temp. and bleeding
d. may use RU486 (Mifepristone)
e. may use methotrexate IM with vaginal

6. complications
a. infection
b. retained POC
c. clots
d. bleeding

D. Ectopic pregnancy
1. fertilized ovum outside the uterus

2. accounts for 2% of all pregnancies

3. 95% occur in the fallopian tubes
a. 1% ovary
b. 3% abdominal cavity
c. 1% cervix

4. responsible for 10% of all maternal mortality &
leading cause of infertility

5. assessment
a. bleeding
b. dull, colicky pain
c. tenderness
d. referred shoulder pain r/t diaphragmatic
e. shock if ruptured
f. Cullens sign-ecchymotic blueness around the
umbilicus indicating hematoperitoneum

6. diagnosis
a. clinical picture sounds like other infections or
b. need to r/o appendicitis, SAB, etc.
c. beta hCG, CBC, and U/S
d. progesterone 25ng/mL=intrauterine
progesterone <5ng/mL=dead fetus/ectopic

7. procedure
a. unruptured-methotrexate to dissolve residual
b. salpingostomy
c. ruptured-laparotomy with salpingectomy

8. plan
a. teaching concerning possible procedures
b. monitor labs-CBC, hCG, blood type, Rh
c. administration of IV fluids/blood transfusion
d. frequent vital signs
e. administration of Rhogam PRN
f. post-op teaching
g. support groups/grief counseling

F. Gestational trophoblastic disease
1. hydatidiform mole, invasive mole, and

2. incidence: 1:1200, slightly higher in Asians

3. types of hydatidiform moles:
a. complete-fertilized egg whose nucleus is lost
-intrauterine contents resemble bunch of white
grapes-grow and enlarge uterus
-no fetus, placenta, membranes, or fluid
-avascular vesicles
-associated with choriocarcinoma
b. partial-2 sperm fertilized normal ovum, results
in ambiguous parts, congenital anomalies
-karyotype of 69 xxy, 69 xxx, or 69 xy
-fetus with multiple anomolies

4. etiology unknown

5. risk factors: clomid, teenagers, women over 40

6. manifestations
a. early part of pregnancy uncomplicated
b. dark brown vaginal discharge or bright red
c. higher than expected fundal height (50%)
d. associated with anemia, hyperemesis
gravidarum, abdominal cramps
e. PIH-9-12 weeks
f. 16 weeks-passage of vesicles

7. labs/tests
a. serial hCG
b. U/S

8. plan
a. suction curettage of tissue
b. induction with pitocin/prostaglandins NOT
recommended r/t increase risk of embolization
of trophoblastic tissue
c. Rhogam if needed

9. nursing plan
a. care for grief/loss
b. therapeutic communication
c. return for serial hCG protocol for 1 year &
baseline chest x-ray to detect lung metastasis
e. monitor hCG and increasing fundal height for
possible choriocarcinoma-chemo/methotrexate

V. Disorders Causing Bleeding in Later Pregnancy
A. Placenta previa
1. implantation of placenta in lower uterine segment
near or over internal cervical os

2. types
a. total-os totally covered when cervix dilated
b. partial-incomplete
c. marginal-edge extends to os but may increase
during dilation
d. low-lying-implanted in lower uterine segment-
doesnt reach os

3. incidence: 0.5% of all births

4. associated risk factors
a. previous placenta previa (12X risk)
b. previous C/S
c. induced abortion
d. multifetal
e. closely spaced pregnancies
f. AMA
g. ethnic-African-American, Asians
h. smoking
i. cocaine

5. manifestations
a. 70% painless bleeding
b. 20% uterine activity

6. diagnosis
a. transabdominal ultrasound
b. requires C/S
c. ck NST, BPP, fetal lung maturity
d. bed rest PRN
e. observation for FHR, vaginal bleeding, VS

7. plan
a. if term and in labor with bleeding-C/S
b. if before 36-37 weeks-rest/observation
c. NST, fetal monitoring
d. monitor bleeding and vital signs
e. monitor CBC
f. give Betamethasone
g. no vaginal exams
h. do C/S later if stable

B. Abruptio placenta
1. premature separation of placenta, detachment of part
or all of placenta from implantation site after 20 weeks

2. significant perinatal mortality for both fetus/mother

3. risk factors
a. HTN
b. cocaine
c. blunt trauma-battering, MVA
d. smoking
e. malnutrition
f. risk of recurrence significant

4. classification
a. Grade 1-mild separation-10-20%
b. Grade 2-moderate-20-50%
c. Grade 3-severe->50%

5. clinical
a. significant uterine tenderness/pain
b. vaginal bleeding
c. contractions
d. may have no bleeding
e. hypovolemic shock
f. coagulopathy
g. couvelaire uterus-R/T blood trapped between
placenta and uterine wallhysterectomy
h. DIC-disseminated intravascular coagulation
i. complications-hemorrhage, shock, infection
j. perinatal mortality-hypoxia in utero, PTL, SGA,
neurological deficits

6. diagnosis-U/S

7. plan
a. depends on gestation age, status, and mom
b. VS, fetal monitoring, I & O, IV fluids, blood admin.
c. betamethasone if applicable
d. usually requires C/S-may have problems with
uncontrollable bleeding

9. nursing care
a. large bore IVs
b. foley catheter
c. watch for decrease in urinary output
d. blood administration PRN
e. monitor FHR
f. monitor for pain
g. monitor CBC, fibrinogen, PT, PTT
h. therapeutic communication for anxiety, grief

VI. Hyperemesis Gravidarum
A. Risk factors
1. less than 20 yrs old, obesity, multifetal, molar

2. etiology-obscure, multifactorial-may be associated with
transient hyperthyroidism or elevated levels of estrogen

B. Priority nursing care
1. plan
a. admit, place IV, keep NPO
b. diet-advance as tolerated
c. medications: according to need
-Zofran-ondansetron HCl
d. psych consult PRN

2. nursing care
a. therapeutic communication
b. I & O
c. daily weight
d. rest
e. diet as tolerated
f. small, frequent meals
g. decrease fats and protein if not tolerated
h. monitor IV site

VII. Hypertensive disorders of pregnancy
A. Background
1. HTN is the most common medical complication of

2. preeclampsia complicates 2-7% of all pregnancies
-14% in twin pregnancies

3. women with chronic HTN or renal disease=25% risk for

4. rate has risen since early 1990s

5. 2
only to emboli as cause of maternal mortality

6. predisposes mother for eclampsia, DIC, abruptio,
hepatic failure, ARDS, cerebral hemorrhage

7. maternal and perinatal morbidity and mortality are
highest when eclampsia is seen early in gestation
(before week 28), moms over the age of 35,
multigravidas, and chronic HTN or renal disease

8. fetus at risk from abruptio placentae, PTL, IUGR, and
acute hypoxia

B. Risk factors
1. chronic renal disease

2. chronic hypertension

3. family h/o PIH

4. multifetal gestation

5. primigravida

6. maternal age <19 yrs, >35 yrs

7. diabetes

8. Rh incompatibility

10. obesity

C. Classification/assessment
1. 2 basic types-chronic HTN and pregnancy-induced
a. CHTN-predates the pregnancy or HTN that
continues beyond 42 weeks postpartum
b. PIH/GHTN-onset of HTN generally after the 20

may occur independently or simultaneously

2. preeclampsia
a. pregnant specific
b. HTN after week 20
c. multisystem vasopastic disease-HTN with
Proteinuria (1-2+)
d. characterized mild or severe
e. BP is first warning sign-140/90
f. pathologic edema in face, hands, or abdomen
or weight gain >2 kg/week
g. urine and BP checks need 2 + results to be
classified preeclampsia

3. severe preeclampsia
a. BP 160/110
b. > 3+ or 4+ on dipstick: 5g 24 hr urine collection
c. oliguria-<400-500 ml/dy
d. visual disturbances/headaches/altered LOC
e. hepatic involvement
f. platelets-thrombocytopenia
g. pulmonary/cardiac involvement
h. development of HELLP syndrome
i. severe fetal growth retardation

4. eclampsia
a. onset of seizure activity in the woman diagnosed
with PIH with no neurologic pathology
b. may be initial sign patient has PIH

5. HELLP-hemolysis, elevated liver enzymes, low PLT
a. variant of severe preeclampsia
b. appears in 2-12% of women with severe
c. maternal mortality-as high as 24%
d. seen more frequently in older women,
Caucasians, and multiparous women
e. 65% will have c/o epigastric/RUQ pain
f. 50% will have N & V
g. can be normotensive and without proteinuria
h. thought to be caused by arterial vasospasms,
endothelial damage, and platelet aggregation

6. chronic HTN
a. HTN before pregnancy or diagnosed before
week 20
b. also considered chronic if HTN lasts longer than
6 weeks PP
c. considered mild if diastolic remains below 110
d. drug of choice: Aldomet (methyldopa)


7. chronic HTN with superimposed preeclampsia
a. BP with systolic 30 mm Hg, diastolic 15 mm Hg
b. with proteinuria and generalized edema

8. transient HTN
a. development of HTN during pregnancy or
in the first 24 hours post partum
b. no other S & S of preeclampsia

D. Pathophysiology/etiology

placental perfusion

endothelial cell activation

vasoconstriction activation of intravascular
coagulation fluid
cascade redistribution

decreased organ perfusion

1. mild preeclampsiasevere preeclampsiaHELLP
or eclampsia

2. reflects alterations in normal adaptations of pregnancy
a. increase blood plasma volume
b. vasodilation
c. decreased systemic vascular resistance
d. elevated cardiac output
e. decreased colloid osmotic pressure

3. main pathogenic factor is not BP but poor perfusion
as a result of vasospasm

E. HELLP syndrome
1. is a laboratory, not clinical, diagnosis
a. platelets < 100,000/mm
b. liver enzymes
-AST-aspartate aminotransferase
-ALT-alanine aminotransferase
c. some evidence of hemolysis
-elevated bili level & burr cells on smear
d. unlike DIC, coagulation panel normal

2. complications reported with HELLP include:
a. renal failure
b. pulmonary edema
c. ruptured liver hematoma
d. DIC
e. abruptio placentae

F. Nursing process
1. recognized risk factors

2. history
a. headache
b. epigastric pain
c. visual disturbances

3. assess BP, wt., edema, proteinuria, and DTRs
a. edema on a scale of 0-+4
b. DTR-patella and bicep, for clonus

4. fetal assessment

5. uterine tonicity

6. vaginal exam

7. lab tests
a. CBC
b. clotting factors
c. liver enzymes
d. chem panel: uric acid, creatinine, BUN, RBS
e. type and screen
f. urinalysis or 24 hr proteinuria

8. nursing diagnoses
a. anxiety
b. altered tissue perfusion
c. knowledge deficit
d. risk for impaired gas exchange
e. risk for CO
f. risk of injury to fetus or mother
g. ineffective coping R/T powerlessness

G. Pharmacology and related nursing interventions
1. mild PIH
a. rest at home, on L side when possible
b. teach mom to assess BP, dip urine, fetal
kick count
c. possible frequent NSTs
d. may want to encourage low Na diet

2. severe PIH or HELLP
a. immediate birth or conservative management
b. labs as directed
c. wt., foley, strict I & O, vag. exam, abd. palpation
d. EFM
e. bed rest, quiet, dark room, no visitors
f. padded side rails
g. suction equipment at bedside
h. toxemia box in room-resuscitation meds
i. continue to monitor during the intra to

3. pharmacology
a. 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
-increases prostracylins to prevent uterine
-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, UO, DTRs
-have calcium gluconate at bedside (antidote)
-toxicity-nausea, flushing, reflexes, slurred
speech, and muscle weakness
-may be given IM for transport yet absorption
rate isnt controlled, IM is more painful
-diuresis within 24 hours is an + prognostic sign
-if eclampsia develops-2-6 gms MgSO
IV push
over 3-5 minutes
b. amobarbital sodium-sedative
-250 mg slow push over 3-5 min
c. diazepam-occasionally used
-may cause phlebitis, venous thrombosis
-if given too rapidly-apnea, cardiac death
d. antihypertensives
-IV hydralazine (Apresoline)
-labetalol HCl, methyldopa, or nifedipine

Pregnancy at Risk, Part 2
Lecture 9

VIII. Maternal-fetal blood incompatibilities
(See High Risk Neonates)

IX. Diabetes mellitus
A. Classifications
1. Type 1: pancreatic cell destruction-insulin deficient
prone to ketoacidosis (acidosis R/T excessive ketones)

2. Type 2: insulin resistant, relative insulin deficiency
most prevalent form of DM, etiology unknown
a. develops gradually, may miss S & S
(polydipsia, polyuria, polyphagia)
b. increase risk if obese or fat around abdomen
c. age, sedentary lifestyle, HTN, previous GDM
d. runs in families

3. Pregestational: Type 1 or 2 that exists before preg.

4. Gestational: any degree of glucose intolerance with
onset or recognition during pregnancy
a. may or may not be insulin dependent
b. should be reclassified 6 weeks PP

B. Pathophysiology
1. Group of metabolic diseases characterized by
hyperglycemia R/T defects in insulin secretion, action,
or both

2. Beta cellsinsulinmoves glucose into adipose and
muscle cells to be used for energy

3. or ineffective insulinhyperglycemia
hypersosmolarity intracellular fluid into the vascular
system blood volume excess UO with glycouria

4. cells burns proteins/fats for energy=ketoacidosis

5. weight loss from breakdown of fat and muscle tissues

6. complications: retinopathy, nephropathy, neuropathy,
and premature atherosclerosis

7. metabolic factors:
a. 1
trimester- estrogen/progesterone= insulin
production= peripheral glucose utilization
b. tissue glycogen stores= hepatic glucose
production (this can affect insulin needs)
c. 2
& 3
trimesters- levels of hPL, estrogen,
progesterone, prolactin, cortisol, and insulinase
= insulin resistance (they are insulin antagonists)
(antagonists-counteract the action of another)
(synergists-enhances the action of another)
d. maternal insulin requirements may double or
quadruple by 36 weeks of pregnancy
(leaves abundant supply of glucose for fetus)

C. Risk factors
1. best predictor of pregnancy outcome=degree of
maternal control of glucose levels

2. glycemic control in early pregnancy=SAB

3. glycemic control late in pregnancy =
a. macrosomic fetus = risk birth trauma
b. risk for C/S
c. for PIH or preeclampsia
d. risk for polyhydramniosoverdistention of uterus
which can lead to PTL or PROM
e. infections
f. ketoacidosis (DKA)fatty acids move from fat to
circulationoxidizedketone bodies into
circulation blood glucose and
ketones=osmotic diuresis= fluids/electrolytes,
volume depletion, cellular dehydration=
maternal and fetal death

4. fetal risks
a. stillborn-etiology unk, ?chronic hypoxia
b. congenital anomalies (6-10% chance)
-cardiac most common
c. macrosomia/birth traumas
d. IUGR R/T vascular disease
e. RDS
f. hypocalcemia, hypoglycemia,
hypomagnesemia, hyperbilirubinemia, and

D. Nursing Process
1. Lab work
a. euglycemia=65-130 mg/dl
b. assessment of glycosylated hemoglobin A

-helps assess level of hemoglobin saturated
with glucose caused by hyperglycemia
-good control 7%
->10 % = risk for fetal anomalies (20-25%)
c. urine screen for UTI, proteinuria, creatinine
d. thyroid function screening

2. Educate to test glucose at home-dietary changes

3. Dietary management based on blood sugar tests
trimester-2200 kcal/dy
and 3
trimester-2500 kcal/dy
-40-45% CHO, 12-20% protein, 35-40% fats
-need bedtime snack to maintain BS level thru night

4. Exercise after meals to prevent drop in BS

5. Insulin therapy
a. 1
trimester, insulin dosage may decrease
b. oral agents may be viable solution
-Glyburide (sulfonylurea) insulin secretion
-doesnt cross the placenta
c. 2
and 3
trimesters insulin resistance =
insulin dosage
d. Some insulin can cross the placenta
e. various regimens followed
f. insulin pump may be used during pregnancy
g. see California Diabetes and Pregnancy Program
-Sweet Success

6. Fetal surveillance to monitor well-being
a. NSTs, BPPs, U/S, kick counts
c. Fetal echocardiogram (18-22 weeks)

7. Urine testing at home
a. test first morning urine
b. recheck if meal missed, ill, or BS > 200mg/dl
c. spilling small amounts of ketones ok
d. spilling large amounts of ketones-CALL MD

8. Intrapartum
a. follow hospitals P & P
b. watch for dehydration, hypo/hyperglycemia
c. mainline usually D5LR with insulin on secondary
d. sched C/S in morning-hold AM insulin, NPO

9. Postpartum
a. insulin needs drop dramatically with removal of
b. several days before CHO homeostasis
c. complications
d. 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. discuss contraceptive methods
-barrier method safest
-OCs have risk of thromboembolic/vascular
-use of IUD risks infection
-tubal ligation if completed family

E. Gestational Diabetes
1. 4% of all pregnancies/90% of diabetic pregnancies

2. less common in Caucasians

3. risk factors
a. obese
b. over age 30
c. family history
d. h/o macrosomic infant
e. unexplained stillbirth
f. miscarriage
g. having an infant with congenital anomalies

4. screening
a. 1 hour glucola-50 gram oral glucose load
-considered + if >140 mg/dl
b. 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

X. Preexisting cardiac disease
A. Overview
1. CV changes that occur normally with pregnancy can
affect women with cardiac disease
a. intravascular volume
b. systemic vascular resistance
c. change in CO
d. change in intravascular volume postpartum

2. cardiac disease complicates 1% of all pregnancies
a. leading cause of non-OB maternal mortality
b. 4
ranking cause of maternal death

3. some of the more common cardiac diseases
a. mitral stenosis
b. mitral valve prolapse
-use Inderal if symptomatic, ie: chest pain
-use abx if having regurgitation
c. congenital heart defects, i.e. septal defect
d. periparum cardiomyopathy
-dysfunction of the L ventricle
-seen in last month of preg or 1
5 months PP
-mortality rate of 25-50 %
-tx-treat the symptoms

B. Classifications
1. Class I: Asymptomatic at normal levels of activity
mortality = 1%
a. corrected Tetralogy of Fallot
b. pulmonic/tricuspid disease
c. mitral stenosis (class I, II)
d. septal defects

2. Class II: Symptomatic with increased activity
mortality = 5-15%
a. mitral stenosis with atrial fibrillation
b. artificial heart valves
c. mitral stenosis (class III, IV)
d. uncorrected Tetralogy of Fallot
e. aortic coarctation (uncomplicated)
f. aortic stenosis

3. Class III: Symptomatic with ordinary activity
mortality = 25-50%
a. aortic coarctation (complicated)
b. myocardial infarction
c. Marfans syndrome
d. true cardiomyopathy
e. pulmonary HTN

4. Class IV: Symptomatic at rest

C. Nursing Process
1. medical care is multidisciplinary

2. educated R/T S & S of cardiac decompensation
a. subjective
-increasing fatigue
-difficulty breathing
-frequent cough
-swelling of face, feet, legs, fingers
b. objective
-irregular, weak, rapid pulse, over 100
-progressive, generalized edema
-crackles at base of lungs
-tachypnea, over 25
-moist, frequent cough
-increasing fatigue
-cyanosis of lips and nail beds

3. identify areas that may lead to stress

4. identity coping mechanisms

5. support groups
6. consultation with dietician

7. watch for S & S of thromboembolism
a. redness
b. swelling
c. tenderness
e. pain

8. avoid constipation and straining for BM

9. report any S & S of infection

10. keep all PN appts.

11. may be put on prophylactic abx

12. labs/studies
a. CBC, chem panel
b. ECG
c. chest x-rays
d. EFM

13. medications
a. heparin for anticoagulation-doesnt cross
b. coumadin-contradindicated-teratogenic
c. abx- risk of bacterial endocarditis
d. diuretics to treat CHF
e. digitalis for arrhythmias and heart failure

14. intrapartum
a. side lying or semi-fowlers
b. O2 via mask
c. diuretics to fluid retention
d. prophylactic abx
e. encourage pain meds to decrease stress-Epid.
f. monitor FHR and maternal
g. may use vacuum to shorten 2
h. no ritodrine/terbutaline for tocolysis
-may cause myocardial ischemia
i. no methergine

15. postpartum
a. 1
24-48 hours most important for hemodynamic
b. bed rest, asst. with ADLs as needed
c. prevent constipation
d. breastfeeding may be contraindicated in higher
classifications of disease

XI. Anemias
A. Iron deficiency anemia
1. most common
a. < 11 g/dl in 1

b. < 10.5 g/dl in 2

c. < 11 g/dl in 3

2. iron for fetus comes from maternal serum

3. oral iron supplements-30-60mg/dy
a. clinical-325 mg ferrous sulfate tablets
b. metabolized better with Vit. C

4. risk to fetus
a. LBW
b. preterm
c. perinatal mortality-maternal Hbg < 6g/dl

B. Folic acid deficiency anemiamegaloblastic anemia
1. increases risk for neural tube defect, cleft lip/palate

2. recommended daily intake 400 microgram/day

3. enriched foods have additional folic acid

C. Sickle cell anemia-recessive autosomal disease
1. abnormal hemoglobin in the blood

2. recessive, hereditary, familial hemolytic
a. African-Americans (10% have trait)
b. Mediterranean ancestry

3. crisis: fever, pain in abdomen, extremities
a. attacks R/T vascular occlusion, tissue hypoxia,
edema, RBC destruction, and organ failure
b. associated with jaundice, normochromic
anemia, reticulocytosis, + sickle cell test,
and demonstrated abnormal hemoglobin

4. maternal/fetal risks
a. pyelonephritis
b. bone infection
c. heart disease
d. PIH
e. fetal loss due to impaired oxygen supply

5. tx:
a. folic acid-1mg/day
b. abx as needed
c. O2 and IVs
d. SCDs postpartum

XII. Maternal infections
Pages 352-357
KNOW: Type of organism, S/S, tx, and implications for pregnancy
and fetussuch as:
T-toxoplasmosis-retinochoroiditis, convulsions, microcephaly
O-others-Hepatitis, HIV, syphilis-infection, SAB,
R-rubella-DM, hearing loss, glaucoma, encephalitis
C-cytomegalovirus-90% of survivors have neurological problems
H-herpes simplex-hyper/hypothermia, jaundice, seizures

XIII. Psychosocial problems during pregnancy
A. Preexisting psychiatric illness-effect on pregnancy
1. women with bipolar disorder, schizophrenia, or
chronic depression may be on psychotropic meds
that can cross the placenta or be found in breast

2. need to weigh the benefits of therapy to risks to mom
and fetus

3. fetal risks to medications
a. congenital anomalies
b. tremors
c. hypertonicity
d. weakness
e. poor sucking

B. Abuse-pp. 108, 352

C. Substance abuse-pg. 302
1. barriers to tx
a. little understanding how drug effects fetus or
b. delay seeking PN care
c. stigma, shame, guilt
d. conceal abuse

2. legal considerations
a. risk to unborn may = criminal charges to mom
b. may be arrested, jailed, housed in psychiatric
hospital for rest of the pregnancy
c. baby may be give to child protective services

3. risks
a. SAB, preterm birth, IUGR, neonatal addiction,
neonatal neurobehavioral handicaps, AIDS,
fetal and maternal death
b. alcohol-FAS
c. cocaine-a. placenta, PTL, SGA, microencephaly
d. heroin-PTL, PROM, IUGR, convulsions
e. speed-PTL, IUGR, head circumference, altered
sleep patterns
f. smoking-SIDS, LBW, pediatric allergies, respiratory
g. caffeine-IUGR, LBW

3. case management
a. find out about pt.s environment, past drug use,
current drug use, and support systems
b. drug testing-blood and urine
-alcohol can go undetected in urine
c. can test neonates hair or meconium to analyze
past drug usage
d. screen for h/o physical abuse or psychosocial
e. determine need for womens health services,
social services, and education for family
f. support groups, i.e. AA
g. alcohol withdrawal tx
-benzodiazepines (psychotropic-sedative)
-nutritional follow-up
h. methadone (synthetic opioid) controversial
-impaired blood flow to placenta
-detrimental fetal effects
-stronger withdrawal symptoms for neonate
compared to heroin

Complications of Labor and Delivery
Lecture 10

I. Dysfunctional Labor
A. Alterations in contraction patterns and quality
1. Hypertonic Uterine Dysfunction
a. usually in latent phase, before 4 cm
b. cause unknown, maybe R/T anxiety/fear
c. assessment
-pain out of proportion to intensity of U/C
-U/Cs in frequency but uncoordinated
d. risk to mom
-loss of control
e. risk to fetus
-passage of meconium
f. tx
-rest for mom
g. after 4-6 hours rest, usually awaken in normal
labor pattern

2. Hypotonic Uterine Dysfunction
a. causes
-pelvic contracture
-fetal malpresentation
-overdistention of uterus
b. assessment
- in U/C frequency and intensity
-during the active phase of stage 1
-uterus easily indentable between U/Cs
c. risk to mom
d. risk to fetus
e. tx
-r/o CPD
-labor augmentation
-change position, ambulation, shower

3. Inadequate expulsive effort (secondary powers)
a. causes
-regional anesthesia
-lack of urge to push
b. risk to mom
-surgery (C/S)
c. risk to fetus
d. tx
-change position
-lower epidural strength or D/C
***See Table 18-1 for a list of complications

B. Fetal malpositions and malpresentations
1. anomalies
a. affect relationship of fetal anatomy to the
maternal pelvic capacity

2. CPD-cephalopelvic disproportion
a. R/T macrosomic infants
b. maternal causes
-pelvis too small
-pelvis abnormally shaped
-pelvic deformity

3. malpositions
a. usually persistent OP (LOP or ROP)
b. prolonged second stage
c. usually c/o severe back pain
d. may be able to change fetal position
-knee chest position
-pelvic rocking
-rolling side to side

4. malpresentation
a. breech most common
-frank-thighs flexed, knees extended
-complete-thighs and knees flexed
one foot below the buttock or
one knee below the buttock
b. breech presentations associated with:
-multifetal gestations
-preterm birth
-fetal and maternal anomalies
c. risk of prolapsed cord
d. might attempt vaginal delivery in multiparas
e. face/brow presentations
-associated with fetal anomalies or pelvic
-may need forcep delivery
f. if external version fails to rotate a breech or
shoulder presentation = C/S

C. Pelvic alterations
1. pelvic dystocia
a. contractures (fibrosis of connective tissue in skin,
fascia, muscle, or a joint capsule) of the pelvis
b. deformities from MVA, traumas
c. immature pelvis in teens

2. soft tissue dystocia
a. placenta previa
b. leiomyomas (fibroids)
c. full bladder or rectum
d. cervical edema
e. Bandls ring (pathologic retraction ring) at the
junction of the lower and upper uterine segments

D. Psychological alterations
1. stress can slow or stop dilatation
-pain and lack of support stress level
-confinement in bed may make pt feel trapped

2. stress can increase pain perception

3. stress-related hormones act on smooth muscle
a. beta-endorphins, epinephrine, cortisol, etc
b. decrease uterine contractility

E. Alterations in the length of labor
1. prolonged labors more frequent with moms over 40

2. abnormal labor patterns can occur because of:
a. CPD
b. ineffective U/Cs
c. pelvic contractures
d. malpresentation of fetus
e. analgesia/anesthesia
f. anxiety/stress

3. precipitous labor/delivery
a. labor less than 3 hours from start of U/Cs
b. maternal complications
-uterine rupture
-amniotic fluid embolism
-PP hemorrhage
c. risk to fetus
-intracranial hemorrhage
-bruising of head/face

pattern nullips multips
prolonged latent phase >20 hrs >14 hrs

protracted active phase dilation <1.2 cm/hr <1.5 cm/hr

secondary arrest: no change >2 hrs >2 hrs

protracted descent <1 cm/hr <2 cm/hr

arrest of descent >1 hr >1/2 hr

failure of descent No change in second stage

precipitous labor >5 cm/hr 10 cm/hr

F. Related nursing interventions
1. support mother and family

2. monitor mother/fetus

3. pitocin augmentation/vacuum/C/S

II. Complications of the labor process
A. Premature rupture of membranes (PROM)
1. ROM 1 hour before onset of labor

2. PPROM-occurs before 37 weeks gestation

3. cause unknown-possibly R/T infection
a. chorioamnionitis
b. life threatening to fetus and mom
-mom-sepsis, death
-fetus-pneumonia, sepsis, meningitis

4. discuss ROM protocol
a. kick counts/EFM b. ck GBS status
c. ck AFI d. r/o prolapsed cord

B. Preterm labor-cervical change and U/Cs between 20-37 wks
Preterm birth-completion of pregnancy before wk37-pg 347
1. risk factors
a. demographic
-African-American -<17 yrs old, >34 yrs old
-low SES -unmarried
-low level of education
b. medical risks predating pregnancy
-h/o PTL-triples the risk -multiple abortions
-uterine anomalies -parity-0 or >4
-low prepregnancy weight
-diabetes -HTN
c. medical risks with pregnancy
-multiple gestation -infection
-incompetent cervix -UTIs
-short interval between pregnancies
-bleeding -anemia
-placenta previa/abruptio
-fetal anomalies -PROM

d. behavioral/environmental risks
-DES (diethylstilbestrol) exposure
-smoking -poor nutrition
-substance abuse -late on no PN care
e. other risks
-anxiety/stress -uterine irritability
-long working hours -inability to rest

2. predicting PTL
a. fetal fibronectin-biochemical marker
-glycoproteins-found in plasma
-appear in cervical canal early/late in preg.
-appearance between 24-34 weeks gest. is
an indicator for PTL
-negative predictive value=95%
-positive predictive value=25-40%
-easier to predict who will not have PTL
b. 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. endocervical length
-lengths less than 30 mm in singleton may
predict risk for PTL

3. causes of PTL
a. unknown and thought to be multifactorial
b. infection major etiological factor
c. 25% are iatrogenic-intentionally delivery of fetus
-R/T health of fetus/mom
d. 25% R/T PROM followed by labor
e. 50% idiopathic (conditions without recognizable
cause) preterm births

4. assessment
a. contractions <10 minutes apart in frequency
b. persistent cramping
c. clear, pink, or brownish discharge
d. pressure in vagina or low back
e. diarrhea
f. cervical effacement >80%
g. 1 cm dilated

5. pt. education
a. bed rest-no studies have proven its efficacy
-wt. loss
-loss of muscle tone
-calcium loss
b. notify MD of changes in S & S
c. home uterine activity monitoring
d. discuss lifestyle adaptations-need to
-sexual activity
-heavy lifting
-long drives
-standing more than 50% of the time
-climbing stairs
-not stopping when tired

6. pharmacology
a. tocolytics
-magnesium sulfate
CNS depressant
can cause respiratory depression
flushing, N & V, DTRs and BP
beta-adrenergic receptor stimulant
helps with hypertonic contractions
tachycardia, palpitations
fetal tachycardia
calcium channel blocker
headache, hypotension
prostaglandin inhibitor
risk of closure of ductus arteriosus
risk of NEC or IVH

b. 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, pulmonary
can worsen HTN or GDM

III. Intrapartum emergencies
A. Placental abnormalities
1. adherent retained placenta
a. placenta accreta
-cotyledons invaded uterine muscle
b. placenta increta
-chorionic villi invade the myometrium
c. placenta percreta
-invasion of myometrium to the serosa of the
peritoneum covering of uterus
-can lead to rupture of uterus

2. abruptio placenta

3. vasa previa
-velamentous insertion-cord attached to membranes
-no Whartons jelly
-vessels exposes to laceration
-high incidence of fetal mortality
-Dx with U/S, palpation of vessels

4. succenturiate
-accessory lobes of fetal villi developed
-vessels supported only by membranes
risk of retained POC
-fetal blood loss if vessel nicked

5. battledore
-insertion at or near placental margin rather than
-increased risk of fetal hemorrhage

B. Prolapsed umbilical cord
1. umbilical cord lies below the presenting part

2. may be occult and occur even with intact BOW

3. frank prolapse occurs with SROM-1 out of 400 births

4. contributing factors
a. long cord->100 cm
b. malpresentation
c. transverse lie
d. unengaged presenting part

5. risk to fetus
a. hypoxia
b. CNS damage
c. Death

6. care management
a. hold presenting part off cord
b. knee-chest or Trendelenburg position
c. delivery
-possible forcep/vacuum if 10 cm
-usually stat C/S

C. Uterine rupture
1. causes of rupture
a. previous uterine scar
-classical C/S
b. uterine trauma
c. congenital uterine anomalies
d. multiparas
e. intense spontaneous U/Cs
f. hyperstimulation of uterine muscle
g. overdistented uterus
h. malpresentation
i. external/internal version
j. forceps

2. classifications
a. complete
-extends through the entire uterine wall into
the peritoneal cavity/broad ligament
b. incomplete
-rupture extends to peritoneum but not into
the peritoneal cavity/broad ligament

3. S & S-may be silent or dramatic
a. nonreassuring FHR
b. vomiting
c. fainting
d. uterine tenderness
e. sudden, sharp shooting pain
f. hypovolemic shock
g. hypotonic U/Cs
h. lack of progress
i. shoulder pain
j. palpable fetal parts

4. prevention
a. no VBACs with classical uterine scar
b. assess womans risk factors
c. prevent hyperstimulation
d. use of tocolytic drugs

5. case management
a. prepare pt for surgery-C/S, possible hysterectomy
b. IV/oxygen
c. type and cross for possible blood transfusion
d. therapeutic communication/support
e. fetal mortality>80%
f. maternal mortality-50-75%

D. Uterine inversion
1. classifications
a. complete-protrudes
b. incomplete-smooth mass palpated thru cervix

2. risk factors
a. fundal implantation of placenta
b. leiomyomas
c. vigorous fundal pressure
d. abnormally adherent placental tissue

3. S & S
a. shock & pain
b. hemorrhage (loss of 800-1800 ml)
4. interventions
a. manual replacement
b. oxytocin
c. need for surgery is rare

E. Amniotic fluid embolism
1. amniotic fluid with particles enters maternal circulation
and obstructs pulmonary vessels

2. caused by opening in amniotic sac or maternal uterine
vein with intrauterine pressure forcing fluid into vein

3. maternal mortality=85%/fetal mortality=50%

4. risk factors
a. multiparity
b. tumultuous labor
c. abruptio placenta
d. oxytocin induction
e. fetal macrosomia
f. fetal death in utero
g. meconium passage

5. case management
a. assess for manifestations of RDS
-pulmonary edema
-respiratory arrest
b. assess for shock
-cardiac arrest
-uterine atony
c. oxygenate-10 L
d. intubate/bag with 100% oxygen
e. CPR-30 degree angle of uterus
f. IVs
g. blood transfusion/tx coagulation defects
h. foley catheter
i. prepare for possible C/S
j. emotional support/counseling if death occurs

F. Trauma
1. leading nonobstetric reason for maternal mortality

2. all female victims of childbearing age to be considered
pregnant until proven otherwise

3. 70% R/T MVAs (lack of seatbelt)-head injuries and

4. physiological differences with pregnant women
experiencing trauma
a. physical observation less reliable
b. CO can tolerate 1000ml blood loss
c. no indicators until blood loss > 1500-2000 ml
d. clinical signs dont appear until 30% of loss
of circulating volume
e. maternal pulse over 100 bpm=abnormal

5. types of trauma
a. blunt abdominal trauma
-MVA, battering, falls, exsanguination
-fetal skull fx or ICH
-ck for abrupted placenta
-pelvic fx can cause injury to fetus
-uterine rupture rare
b. penetrating abdominal trauma
-bullet, stab wound
-direct fetal injury from bullet, requires surgery
-fetal injury from stab wound
-better chances if injury occurs in upper maternal
c. thoracic trauma-25% of trauma deaths
-maternal life threatened by pulmonary
-can cause pneumo/hemothorax

6. fetal death R/T maternal death or abrupted placenta
a. C/S needed in most cases
b. if maternal death occurs, C/S within 20 minutes

7. other causes of trauma: burns, assaults

8. complicates 8% of all pregnancies

9. tx: supportive care
a. ABCs
b. oxygen 10-12 liters
c. large bore IVs-14-16 gauge
f. LR or NS 3:1 ratio- 3 ml for every 1 am EBL over
30-60 minutes
g. may give O negative if type unknown
h. lateral positioning
i. assess Glasgow coma scale
j. focus on abdomen
k. insert NG tube
l. check for abrupted placenta
m. fetal assessment testing-U/S
n. peritoneal lavage-ck for blood, if +, laparotomy
-if -, LR infused thru cath/fluid ck for cell count
o. Rh negative women get Rhogam

G. Shoulder dystocia
1. increase risk of maternal/fetal morbidity/mortality

2. fetal head is born but anterior shoulder cant pass
under pubic arch

3. fetopelvic disproportion or maternal pelvic
abnormalities may be the cause

4. may use McRoberts maneuver-legs flexed, knees on

5. may use Gaskin maneuver-all-fours-hands and knees

6. may use Mazzanti or Rubin techniques to deliver
a. RN assists with the suprapubic pressure
b. assess newborn for fx of clavicle/humerus
c. assess mom for hemorrhage

IV. Obstetrical Instrumentation and Procedures
A. Amniotomy-AROM (artificial rupture of membranes)
1. most frequently used method of labor induction

2. induces labor when cervix is favorable or augments
a slowing labor progress

3. labor usually begins 12 hours post rupture-if prolonged,
can lead to infection-Ck temp q 2 hours

4. can be used in combination with oxytocin

5. explain to pt that procedure is painless but might feel
increase in vaginal pain R/T movement of fetus

6. presenting fetal part must be engaged in pelvis and
applied to cervix to prevent cord prolapse

7. assess color, odor, consistency and quantity of fluid

B. Induction and augmentation of labor
1. chemical agents
a. 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, N & V, diarrhea, fever
hypotension, hyperstimulation of uterus
fetal passage of meconium
b. Cytotec (misoprostol)-synthetic prostaglandin E1
-not FDA approved for cervical ripening
c. oxytocin
-hormone produced by posterior pituitary gland
-stimulates uterine contractions
-used to induce or augment labor
-indications for use
suspected fetal jeopardy
maternal medical problems
fetal demise
-contraindications for use
CPD, cord prolapse, transverse lie
nonreassuring FHR
placenta previa or vasa previa
classical uterine incision
active genital herpes
invasive CA of the cx
d. infusion done on IV pump
e. watch for hyperstimulation
f. assess fetal well being and maternal pain level

2. mechanical methods
a. dilators
b. amniotomy

C. Version
1. external
a. attempt to rotate fetus from a malpresentation
b. usually done at or after 37 weeks
c. U/S scanning before to ck fetus and placenta
d. may use a tocolytic agent like terbutaline
e. obtain informed consent-usually done in L & D
due to risk of complications
f. MD or CNM give gentle, constant pressure to
abdomen to rotate presenting fetal part
g. Rh moms may receive Rhogam due to the risk
of fetomaternal bleeding

2. internal
a. MD inserts hand into the uterus and changes
position or presentation
b. may be used in multifetal pregnancies to rotate
second fetus
c. maternal/fetal injury possible
d. RN role to monitor FHR and support mother

D. Episiotomy
1. incision in the perineum to enlarge the vaginal outlet

2. types
a. median-midline
-most commonly used
-effective, easily repaired
-can possibly extend into rectum
b. mediolateral
-prevents 4
degree laceration
-repair most difficult
-more pain to mom

3. pros cons
prevents tearing lacerations can occur
decreases stage 2 pain/discomfort
enlarges vagina lateral position can
control head

4. less rate of episiotomies with CNM vs. MD

E. Forceps
1. uses paired curved blades to asst. delivery of head

2. maternal indications for use
a. second stage arrest
b. cardiac moms
c. poor pushing effort/fatigue/anesthesia

3. fetal indications for use
a. distress
b. abnormal presentation-asynclitic
c. delivery of head during breech delivery

4. conditions
a. fully dilated
b. empty bladder
c. engaged presenting fetal part
d. vertex
e. ROM
f. No CPD

5. care management
a. assess FHR before and after delivery
b. Pedi MD at delivery
c. assess mother for lacerations, urinary retention
d. assess baby for facial bruising, abrasions, palsy

F. Vacuum
1. attachment of vacuum cup and use of negative

2. indications/conditions the same as use of forceps

3. follow hospitals P & P R/T method, suction pressure,
duration, and charting

4. newborns-ck for caput, cephalohematoma, scalp

G. Surgical Birth
1. birth of the fetus thru a transabdominal incision in the

2. term cesarean from Latin caedo-to cut

3. C/S rate-20-30%-higher in women over the age of 35

4. rate of VBACs had lead to C/Ss but might

5. purpose to preserve health or life of mom or baby

6. in C/S rate R/T
a. increased EFM
b. epidural use
d. of repeat C/S
e. AMA moms
f. private insurance/private hospitals
g. moms with high SES

7. indications for C/S
a. fetal distress/intolerance of labor
b. CPD/malpresentation/malposition
c. placental abnormalities
d. umbilical cord prolapse
e. dysfunctional labor pattern/first stage arrest
f. multiple gestation
g. active genital herpes
h. uncontrolled HTN
i. PIH/preeclampsia

8. type of incisions
a. skin-vertical or horizontal (Pfannenstiel, bikini)
b. uterus-vertical (classical), low vertical, and
horizontal (low transverse)
-classical-faster to perform, is performed in other
countries, contraindication for VBAC
-transverse-easier, less blood loss, decrease risk
for infections, less likely to rupture, may
attempt VBAC with next pregnancy

9. risks/complications
a. aspiration
b. pulmonary embolism
c. wound infection
d. wound dehiscence
e. thrombophlebitis
f. hemorrhage
g. UTI
h. injury to bladder or bowel or fetus
i. anesthesia complications
j. decreased satisfaction with the birth process
k. loss of ability to accomplish vaginal deliveries
l. increase financial expense
m. longer hospital stay
n. bonding and breastfeeding may be delayed

10. types of anesthesia
a. regional blocks
-epidural-most common, feel pressure, no pain
-spinal-no pain or pressure
b. general
-higher risk of complications

11. pre/intra/postoperative care-in the textbook

Complications of the Puerperium
Lecture 11

1. Postpartum Hemorrhage
A. Definition/Risk factors
1. 500 ml or more blood loss after a vaginal delivery

2. 1000ml or more blood loss after a C/S delivery

3. 10% change in Hct from admission to PP

4. or need for transfusion

5. early PP hemorrhage-in the first 24 hours
a. uterine atony
-marked hypotonia
-90% of PPH cases R/T atony
-associated with
overdistended uterus
mag. Sulfate
prolonged oxytocin usage
rapid/prolonged labor
b. retained placenta
c. placenta accreta
d. uterine rupture
e. uterine inversion
f. lower genital tract lacerations
-cervix, vagina, perineum
degree laceration of perineum
-associated with
precipitous delivery
operative birth
congenital anomalies
contracted pelvis
varicosities (distended, swollen veins)


g. hematomas-collection of blood in connective
-vulvar-most common, visible, painful
-vaginal-assoc. with forceps, episiotomy
-subperitoneal-life threatening-assoc. with
uterine artery branches/vessels in the
broad ligament
-cervical-usually shallow, min. bleeding
h. infections
i. coagulopathies

6. late PP hemorrhage-after 24 hrs to 6 weeks PP
a. subinvolution of the uterus
-delayed return of the enlarged uterus to
normal size
-caused by infection, retained placenta
-S & S: prolonged lochia, excessive bleeding
palpable boggy uterus, fundal
height greater than expected
b. retained POC
c. endometritis

7. dark blood-probably venous-varices/superficial lac.

8. bright red blood-arterial-deep laceration of cx

B. Complication-Hypovolemic shock

C. Care management
1. if hypotonic uterus
a. massage
b. express clots-1 gm=1ml (weigh pads)
c. assess for tachycardia, BP, tachypnea, pale
cool skin, in LOC, lethargy
d. large bore IVs-LR 1000 ml with 10-40 units pitocin
-watch for water intoxication, N & V
e. empty bladder or place Foley cath
f. O
10-12L/min via mask if oxygen saturation low
g. Methergine 0.2 mg IM-produces sustained U/C
-elevates BP, N & V, headache
-may exacerbate cardiac disease
h. if unsuccessful-prostaglandin F
given IM or intramyometrially
-headache, N & V, diarrhea, fever
-may aggravate asthmatics
i. herbal remedies
-witch hazel
-motherwort-promotes U/C, vasocontrictive
-blue cohosh-oxytocic
-nettle- available Vit. K, Hgb
-Shepards purse-promotes U/C
-red raspberry leaves-promotes U/C
j. follow-up with labs
-coag panel
-type and cross match

2. bleeding with contracted uterus
a. assess for clots in lower uterine segment
b. inspection of vagina, cervix, perineum
c. suture bleeding lacerations
d. for hematoma
-cold packs
-ligation of bleeding vessel

3. uterine inversion
a. reposition uterus
b. tx shock
c. oxytocin
d. broad spectrum abx
e. NG tube if concerned R/T paralytic ileus

4. subinvolution
a. oxytocin/ergonovine
b. D & C if placenta fragments retained

D. Teaching
1. normal lochia progression

2. review factors associated with hemorrhage

3. check for bladder distention

4. inspect perineum/vaginal pads

5. assess fundus

6. if S & S change, call MD immediately

II. Thromboembolic disorders
A. Classifications
1. superficial venous thrombosis
a. most common type PP
b. involves superficial saphaneous vein

2. deep vein thrombosis
a. most common type during pregnancy
b. involves veins from foot to iliofemoral

3. pulmonary embolism
a. blood clot dislodged-carried to pulmonary artery
b. occludes vessel-obstruct blood flow to lungs

B. Incidence/etiology
1. superficial venous thrombosis-1 out of 500-750 women

2. declined R/T early ambulation

3. causes: venous stasis, hypercoagulation, & injury to
blood vessel

4. risk factors: C/S, obesity, AMA over 35 yrs, h/o DVT, DM,
smoker, varicose veins

C. Clinical manifestations
1. superficial-pain/tenderness/warmth/redness

2. deep-unilateral leg pain/calf tenderness/swelling

3. pulmonary-dyspnea/tachypnea/apprehension/cough
tachycardia/hemoptysis/pleuritic chest pain

D. Case management
1. diagnosing
a. Homans sign-can be false positive
b. Doppler U/S (VUS)
c. venography-less common-exposes mom/fetus
to radiation
d. pulmonary arteriogram

2. analgesic-antiinflammatory agent (i. e. Motrin)

3. rest, elevation, warm packs, elastic stockings (TEDS)

4. DVT-tx with anticoagulants-IV heparinpo Warfarin

5. PE-IV heparin therapy, supportive care

6. if Coumadin ordered-need OC therapy
-teratogenic to fetus

III. Infections
A. Risk Factors
-prolonged labor -multiple vaginal exams
-poor health status -FSE/IUPC
-OB trauma -chorioamnionitis
-pre-existing vag. infection -vacuum/forceps delivery
-manual removal of placenta -lapse in aseptic technique

B. Classifications
1. puerperal sepsis-any infection of genital canal within
6 weeks of miscarriage, abortion, or birth

2. endometritis-infection of the lining of the uterus
a. most common PP infection
b. usually starts at placental site
c. higher incidence with C/S
d. most frequent culprits: GBS, chlamydia

3. parametritis (pelvic cellulitis)
a. involves connective tissue of broad ligament
b. if spreads to peritoneum=peritonitis
c. may be result of pelvic vein thrombophlebitis

4. wound infection
a. often develops at home
b. C/S site, episiotomy, laceration site
c. broad-spectrum abx may be used

5. UTIs
a. occur in 2-4% of PP women
b. risk factors: Foley, epidural, freq. exams, C/S
c. most frequent culprit: E. coli

6. mastitis
a. affects 5-10%, most first-time mothers
b. develops unilaterally
c. usually Staph aureus, E. coli, Streptococcus
d. if organism is Candidaoral thrush in babies

C. Manifestations
1. fever, chills, pulse, fatigue, lethargy, pain, tenderness

2. profuse foul-smelling lochia, leukocytosis, sed rate

3. wound separation, dehiscence

4. dysuria, frequency, urgency

5. redness, warmth

D. Case management
1. abx appropriate for organism-improve hydration

2. encourage proper perineal hygiene

3. rest, analgesics, supportive care
a. warm blankets
b. sitz bath
c. Tucks pads
d. cool compresses to peri

4. continue breastfeeding or pumping breasts

5. reinforce good handwashing techniques

6. consider I & D for wound if needed

7. assist with ADLs or baby care

IV. Psychiatric disorders
A. PP Blues
1. 50-80% of women experience the baby blues

2. emotionally labile, cry often and for no reason

3. peaks day 5, usually ends day 10

4. mild depression, fatigue, poor concentration, H/A

5. etiology unknown

6. feeling overwhelmed with parental responsibility

7. let-down feeling, lack connection of mom to fetus

8. needs to learn coping strategies, seek support grps

9. 5-30% of this group will experience PP depression

B. PP depression-PP Major Mood Disorder
1. intense, pervasive sadness, severe/labile mood swings

2. symptoms rarely disappear without help

3. feel intense fear, anger, anxiety, and despondency

4. feelings of guilt/inadequacy fuel worry of being
incompetent parent

5. odd food cravings, binge eating, sleeping heavily

6. distinguishing feature: irritability

7. prominent feature: rejection of the infant R/T

8. may have thoughts about harming the baby/self

9. with tx, gradually improves in 6 months

10. Tx
a. psychotherapy
b. antidepressants
c. anxiolytic agents
d. electroconvulsive therapy

C. PP depression with psychotic features (PP psychosis)
1. depression, delusions, and thoughts of harming
infant or self

2. occurs in 1-2 of 1000 births/up to 50% chance to
reoccur with subsequent births

3. behavior evident within 1-3 months PP

4. initial complaints: agitation, fatigue, insomnia,
restlessness, emotionally labile-inability to move or work

5. then suspiciousness, confusion, incoherence, irrational
statements, and obsessive concerns R/T infants health

6. delusions in 50% of cases, hallucinations in 25%

7. severe delusions/hallucinations will command mom to
kill infant or have her believe the baby is possessed by
the devil

8. nursing staff should be on alert for mothers who are
agitated, overactive, confused, or suspicious

9. course of syndrome similar to that seen in people
with mood disorders

10. psychiatric emergency: antidepressants and lithium

11. mother may not be able to breastfeed on certain

12. will probably need psychiatric hospitalization

13. use screening tools: PP depression-pp 851-853

14. follow-up with advanced practice psychiatric RN
a. home visits
b. meet with mental health therapist
c. support groups

V. Loss and Grief
A. Situational life crises
1. infertility

2. premature labor/birth

3. C/section

4. loss of control during birth process

5. birth of a boy when expecting a girl/visa versa

6. birth of a handicapped child

7. maternal death-7-8 out of 100,000 women

8. fetal death-6.8 out of 1000 births

9. neonatal death-27,000 yearly

B. Phases of grief-(denial, anger, bargaining, depression,
1. acute distress
a. loss of identity as parent
b. loss of a dream/hope
c. state of shock/numbness
d. confusion, disbelief, denial
e. may have outburst of emotion or lack affect
f. need to accept the loss
g. normal functioning impeded/hard to make
h. may need help with funeral arrangements

2. intense grief
a. loneliness, emptiness, guilt, yearning, anger
b. have to accommodate the changes the
loss has created-i.e. the nursery, clothes
c. have to return to work-possibly meet
insensitive coworkers/family
d. difficulty handling leakage of breast milk-a
reminder of loss
e. guilt feelings may intensify if mother thinks she
is being punished for a prior bad act
f. responses: anger, bitterness, resentment
g. focused anger on health care team for not
saving the infants life
h. physical symptoms: H/A, fatigue, dizziness,

3. reorganization
a. search for a meaning to the tragedy
b. improved function at home and work
c. start to enjoy simple pleasures without guilt
d. reestablishing relationships
e. bittersweet grief-grief response occurring with
reminders of the loss
f. grief can also be triggered by subsequent births

C. Communication and caring
1. actualize the loss

2. provide time to grieve

3. interpret normal feelings/allow for individual differences

4. provide for the cultural/spiritual needs of parents

5. assist with their physical comfort

6. offer options
a. see and hold the baby
b. bath and dress the baby
c. privacy
d. visitation for other family/friends
e. religious rituals
f. special memorials/pictures

Disorders of the Female/Male Reproductive Systems
Lecture 12

I. Breast Masses
A. Screening for breast masses
1. Breast self exams
a. best if done 5-7 days after menses has stopped
b. if periods are not regular, chose the same day
each month
c. while on back, palpate each breast in a circular
or vertical motion to cover whole breast
d. use finger pads to ck for indentations, change in
contour/texture, lumps
e. compress nipple to ck for discharge
f. may also do while standing/in the shower
g. note size and shape usually equal but not always
h. vary with womans age, nutritional status, and
i. contour should be smooth without puckering
or dimpling
j. assess nipples for shape, direction, rashes,
ulcerations, and discharge
k. 90% of brst lumps found by women
-20-25% will be malignant

2. Exam by clinician
a. usually done with yearly pelvic exam
b. should not be on period at time of exam
c. 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. Benign Breast Disorders
1. Fibroadenoma
a. occurs in women from puberty to menopause
b. risk factors
-low parity
-later menopause
-estrogen therapy
-family h/o of brst CA
c. masses are solid and made of connective tissue
d. cause unknown
e. usually solitary lump < 1cm to 15 cms in diameter
f. lump may be tender during menses
g. diagnosed by mammogram, U/S, MRI
h. doesnt respond to changes in diet/hormones
i. may need surgical excision if lump suspicious or
symptoms are severe

2. Fibrocystic breast condition
a. most common breast problem-mostly found in upper,
inner quadrant of breast
b. characterized by lumpiness, with/without tenderness, and
may be associated with changes in menstruation
c. 70% nonproliferative (benign growing cells)
d. others are proliferative lesions with atypical hyperplasia
( risk of brst CA)
e. risk of brst CA with relative having brst CA
f. etiology-unknown-possibly R/T imbalance of hormones
g. usually in both breasts but may be singular
h. S & S develop one week before menses
-dull, heavy pain
-sense of fullness
-increasing tenderness
i. cysts are usually soft, well differentiated, movable
j. deeper cysts may not be differentiated from carcinomas
k. U/S to determine if fluid filled-if so-aspirate
l. if solid, mammogram followed by fine needle aspiration
(FNA) or core biopsy
m. management
-dietary changes- caffeine - Na intake
-Vit. B, C, and E supplements -use NSAIDS
-some relief with smoking/alcohol intake
-supportive bra -heat packs to breasts

3. Ductus ectasia
a. inflammation of ducts behind nipple
b. etiology-unknown
c. occurs most often in perimenopausal women
d. characterized by thick, sticky nipple discharge either white,
brown, green, or purple in color
e. other S & S: burning pain, itching, palpable mass
behind nipple
f. workup: mammo, aspiration, culture of fluid
g. Tx: symptomatic
-no stimulation -good breast hygiene
-I & D if abscess develops -abx
-may need affected duct excised

4. Intraductal papillomas
a. found in women 30-50 years of age
b. rare, benign lesion in the terminal nipple ducts
-may be too small to palpate (2-3 cm)
c. may note nipple discharge-serosanguinous
d. do fluid Pap smear of nipple discharge
e. Tx: excision

C. Breast (American Cancer Society)
1. Pathophysiology
a. 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. noninvasive if stays in duct (ductal carcinoma in situ or
c. invasive if penetrates the tissue around the duct
d. invasion of lymphatic channels/lymph ducts carry
abnormal cells to lymph and to metastatic sites
e. staging of disease must include lymph node examination,
especially axillary nodes
f. metastatic sites include bone, lungs, brain, liver

2. Etiology/risk factors/incidence
a. exact cause unclear
b. risk with of womans age
c. other risk factors-family history
-previous h/o brst CA -family history
-h/o ovarian, endometrial, colon, or thyroid CA
-early menarche (before age 12)
-later menopause (after age 55)
-nulliparity -first preg. age 3
-HRT -obesity
-h/o benign breast disease with hyperplasia
-African-Americans have a higher mortality rate due to late
-sedentary lifestyle -high SES
d. incidence
-in US, 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 %

3. Clinical manifestations
a. physical
-most lumps in upper outer quadrant
-may feel lump or thickening of brst
-hard and fixed, 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

b. psychosocial
-grief and loss behaviors
c. mammogram/U/S/MRI
d. nipple discharge exam-culture/specimen to lab
e. ductogram-fine plastic tube placed into duct,
contrast media injected, assess duct
f. FNA
g. biopsy-aspiration or core-may use guide wire
h. Triple test-physical exam, mammogram, FNA
-if any benign-98% of lesion being benign
i. staging-TNM-T=size, N=nodes, M=metastases
-Stage 0-ductal carcinoma (in situ)-earliest form
-Stage 1-2 cm tumor/hasnt spread
-Stage 2-tumor >2 cm-in axillary nodes on same
-Stage 3-tumor >5 cm-spread to lymph nodes-
localized spread, no other organs
-Stage 4-metastasis to distant-bones, lungs, liver
lymph nodes not local

4. Nursing diagnoses
a. pain R/T surgical procedure
b. risk for infection
c. body-image disturbance R/T loss of body part

5. Management
a. surgery
-lumpectomy (tylectomy, partial mastectomy)
-removal of tumor
-removal of small surrounding area
-sampling of axillary lymph node
-doesnt effect pectoral muscle
-may follow-up with 6-7 weeks of
-modified radical mastectomy
-removal of entire breast
-sample of lymph nodes
-spares pectoral muscle
-risks: infections, hematoma
lymphadema, 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, more
nodes are excised

-reconstructive surgery
-goal is achievement of symmetry with
preservation of body image
-3 types of autologous flap reconst.
-latissimus dorsi
-TRAM-transverse rectus
abdominis myocutaneous
-inferior gluteus free
-monitor skin flap for cap. refill,
hematoma, infection, necrosis
-may also receive breast expanders implants
b. adjuvant therapy-radiation
-after lumpectomy in non/microinvasive cases
-any invasive ductal carcinoma <1 cm diameter
-interstitial or balloon brachytherapy
-intraoperative radiation
c. 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, neutropenia, anemia,
thromobocytopenia, GI problems, hair loss

6. Discharge planning
ACS Reach for Recovery program
NCCN-National Comprehensive Cancer Network
ACS home page

II. Sexually Transmitted Diseases/Infections
A. Infections associated with ulcers
1. Syphilis
a. caused by treponema pallidum-spirochete
b. transmission thru abrasion of tissue, kissing,
biting, oral-genital sex
c. can cross the placenta
d. 120,000 new cases each year
e. higher rates in young African-Americans
f. attributed to use of sex for drugs/money
g. primary-chancre appears day 5-90 post
infection-nontender, shallow, indurated
h. secondary-occurs 6 weeks-8 months
-wide spread maculopapular rash on palms/soles
-fever, headache, malaise
-may have condylomata lata
i. tertiary-neurologic, CV, MS, or multiorgan system
j. screening:
-microscopic exam of lesions
-serology-VDRL/RPR-may have false +
-MHA-TP-microhemagglutination assays
for antibody to T. pallidum used to confirm + tests
-seroconversion takes 6-8 weeks post exposure
j. management:
-treats primary, secondary, and early latent
-if syphilis older than 1 year, weekly shots for 3 wks
-alternatives: doxycycline, tetracycline
-not used in pregnancy
- erythromycin-unlikely to cure fetal infection

2. Genital herpes simplex
a. results in painful, reoccurring ulcers
b. HSV-1-usually nonsexually transmitted
-oral labial ulcers
c. HSV-2-transmitted during oral/genital sex
d. not a reported disease
e. 20% Americans infected with virus-over 50 million people
f. estimated 1 out of 4 women will get HSV-2
g. initial infection:
-fever, chills, malaise
-severe dysuria
-painful lesions-may last 2-3 weeks
h. lesions may progress from maculepapule
vesiclepustuleulcer that crustsscar
i. can cause cervical problems, purulent vaginal
vaginal discharge and urinary retention
j. reoccurring episodes not as severe
k. HSV-2 can have adverse effects on mom/fetus
-congenital infection
-60% infant mortality if infant contracts HSV
l. association between cervical CA and HSV-2
m. screening:
-physical exam with complete H & P
-viral culture of ulcer
n. management:
-chronic/reoccurring -proper hygiene
-systemic antiviral medications
-acyclovir, valacyclovir, famiciclovir
-sitz bath with baking soda -oral analgesics
-diet rich in Vit. C, B, 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, guilt, anger

3. Lymphogranuloma for Facts Sheets
4. Chancroid
5. Granuloma inguinale

B. Infections of Epithelial surfaces
1. Human papilloma virus-HPV
a. 100+ HPV types, 40 known mucosal serotypes
b. 90% of cases cleared by immune system in 2 years
c. if not cleared, can lead to genital warts, warts in the throat,
cervical cancer
d. ages at risk for HPV
14-19yrs old26.8%
20-24yrs old44.8%
25-29yrs old27.4%
e. may look like a cauliflower-mass
f. rarely transmitted to neonate at birth
g. screening:
-S & S-dyspareunia, itching, discharge, bumps
-may need to change gloves between vaginal
and rectal exams to prevent spread
h. 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-8.1 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. need to differentiate between HPV &:
-molluscum contagiosum-white papules
-condylomata lata-secondary syphilis
j. 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
-$$$, unaffordable to uninsured
-lifetime immunity but still needs paps since not all
strains covered
k. Tx-no treatment can eradicates HPV-only symptoms
-imiquimod, podophyllin, podofilox-topical


2. Gonorrhea
a. caused by Neisseria gonorrhoeae-bacteria
b. 600,000 contract gonorrhea each year
c. rising incidence of drug-resistance
d. transmission: oral, genital, anal
e. higher incidence in people under 20 years old
f. higher incidence in African-Americans
g. women most often asymptomatic
h. may present with pain/burning with urination,
vaginal discharge, low back pain
h. men may c/o pain with urination and yellowish
discharge from penis
i. may take up to 3-10 days before symptoms present
j. screening: cultures taken from endocervix,
rectum, and possibly pharynx
k. people are frequently coinfected-should be
tested for other STIs
l. management: usually single dose antibiotic:
m. 45% women will also have chlamydia so should
have concomitant tx

3. Chlamydia
a. caused by Chlamydia trachomatis
b. most common/fast spreading STI in women
c. untreated leads to PID and acute salpingitis
d. may caused ulcers on the cervix increasing
risk to acquire HIV
e. higher incidence in women under age 20
f. sexually active individuals 25 yrs old-screen for chlamydia
g. all pregnant women should be screened at first PN visit
h. repeat cultures if woman was previously + or has multiple
i. may have spotting, postcoital bleeding, cervical
discharge, or dysuria
j. dx thru culture
k. management-doxycycline or azithromycin
l. if pregnant-erythromycin/amoxicillin
m. since usually asymptomatic, must encourage
completion of all the medication
n. women tx with erythromycin need to be retested
in 3 weeks due to poor validity of tx

4. PID-Pelvic Inflammatory Disease
a. involves fallopian tubes (salpingitis), uterus
(endometritis), and possibly ovaries
and peritoneal surfaces
b. caused by multiple organisms and occasionally
caused by more than one
c. most commonly caused by C. trachomatis
d. also caused by gonorrhea and other aerobic
and anaerobic bacteria
e. microorganisms spread from vagina to upper
genital tract-usually occurring at the end
of or just after menses
f. during menses, spread supported by open cx,
decrease cervical mucus, and blood used
as a medium for growth
g. each year, 1 million women will experience
symptomatic PID
h. risk factors: teens, multiple partners, new
partners, history of PID, use of IUD
i. leads to: risk for ectopic pregnancy, infertility,
chronic pelvic pain, dyspareunia,
pyosalpinx, abscesses, adhesions
j. S & S: dull, cramping, or severe pelvic pain,
bleeding, adnexal tenderness, pain
with cervical movement (Chandelier
sign), bilateral pelvic tenderness
k. screening: good history taking to r/o other
causes, temp 38.3
C, abnormal
cervical/vaginal discharge, sed rate,
lab documentation of chlamydia or
l. need to teach prevention of causes to help
prevent disease
m. need to screen asymptomatic women with
history of risky behavior
n. tx: usually broad-spectrum abx, use analgesics,
semi-fowlers position while resting
o. encourage rest, proper nutrition, and hydration
p. will need follow-up lab work to confirm cure
q. teaching to include use of barrier methods, no
sexual relations until completion of meds,
follow-up pelvic exams, and other
contraceptive methods other than IUDs

III. Gynecologic Disorders
A. Postmenopausal bleeding-bleeding 12 months post menses
1. Related factors
a. atrophic vaginitis-tissues more sensitive, bleed
b. polyps-masses in/on the cervix
c. endometrial problems
-endometrial hyperplasia may be a precursor to
endometrial CA-need a D & C to evaluate
d. ovarian function estrogen/progesterone

2. Management
a. for vaginitis-use of creams to protect tissues
b. for polyps-removal
c. HRT

3. Discussion regarding HRT
a. most studies show risk factors and adverse
reactions R/T dose and length of tx
b. controversy R/T method of administration,
doses, and efficacy
c. must individualized to pts S & S , lifestyle,
and medical history
-need to deal with philosophy/beliefs regarding
d. if ERT alone, 5-10X risk of endometrial CA
e. problem with adding progesterone, bleeding
f. new studies proving that HRT may lead to
risk for brst CA
g. 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, alcohol use
caffeine use, low calcium intake
sedentary lifestyle
use of steroids, synthyroid, diuretics
-risk factors for CVD
LDL, HDL, total serum cholesterol
risk of atherosclerosis
h. long term-may use estrogen alone or in
combination with progesterone or
-may be continuous or cyclic

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

2. Management
b. suppression of endogenous estrogen production
medically induced menopause
-GnRH agonists
(gonadotropin-releasing hormone)
i.e. Lupron, Synarel
pituitary gonadotropin secretion
FSH/LH stimulation of ovaries
ovarian functionhot flashes, vaginal
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
c. may use OCs with low E to P ratio
to shrink endometrial tissues
SE: N & V, bleeding, edema
d. mifepristone (RU-486) being used with success
e. surgery-nd to consider age, desire for children,
location of disease
-laser surgery to remove adhesions/tissue
f. 40% reoccurrence-except in TAH-BSO cases

C. Dysfunctional uterine bleeding-abnormal uterine bleeding
1. Wide variety of menstrual irregularities
a. menorrhagia
b. irregular cycles

2. Possible causes
a. anovulation-polycystic ovary syndrome
b. pregnancy-related-SAB
c. genital infections-chlamydial cervicitis
d. neoplasms-CA of cx
e. trauma-foreign body
f. systemic diseases-DM
g. iatrogenic-herbal preparations-ginseng

3. Severe bleeding with Hgb 8g/100ml=hospitalization
a. given IV cong. estrogen (Premarin)
b. possible D & C
c. endometrial biopsy to r/o endometrial CA

4. Incidence
a. teens-20%
b. women under 50-50%

5. Management
a. oral cong. estrogen X 21 days with progesterone
(medroxyprogesterone-Provera) added for the
last 7-10 days
b. low dose OCP
c. ablation of endometrium
d. hysterectomy

D. Inflammations and Infections
1. Vaginitis/Vulvitis
a. inflammation of vagina and/or vulva
b. S & S
-irritation, malodorous abnormal discharge
-itching, burning, urinary frequency
c. causes
-lack of hormone estrogen
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. infections
causes-abx, pregnancy, DM, 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
etiology unknown
heavy gray frothy malodorous D/C
tx-oral metronidazole-Flagyl
contraindicated in women
who breast feed
may affect the CNS and
hematopoietic systems
with alcohol-can cause abdominal
distress, N & V, H/A
-trichomoniasis-anaerobic protozoan
may be asymptomatic or have frothy
musty-smelling discharge
itching on or around the vagina
spotting, urinary urgency
tx-Flagyl-treat both partners
since a STI-should screen for other STIs
e. atrophic vaginitis-irritation without discharge
-lack of estrogen due to childbirth, menopause,
bilateral oophorectomy, radiation tx
-estrogen creams restore lubrication and
decrease soreness/irritation

2. Toxic Shock Syndrome
a. assessment
-primarily a disease of the reproductive age
-caused by S. aureusproduces toxin TSST-1
-risk factors-retained tampons, barrier devices left in place,
surgery, recent delivery
-S & S-fever >102 F, 38.9 C, hypotension,
widespread macular rash, dizziness, N & V, diarrhea
myalgia, inflamed mucous membranes
-lab tests- BUN, Cr, SGOT, SGPT, platelets
b. management
-mainly supportive
-antibiotics-limited value
-need to teach prevention, reoccurrence

E. Problems R/TPelvic Support Structures
1. Uterine Prolapse
a. round ligaments hold uterus in anteversion
uterosacral ligaments pull cx up and back
b. 2 months PP, ligaments should return to normal
length-1/3 of women, uterus remains
c. causes: congenital or acquired pelvic
-perimenopausal period
-pelvic surgery
-pelvic radiation

d. tx: -pessaries -estrogen creams
-abdominal/vaginal hysterectomy
e. education: use of Kegel exercises to strengthen
pelvic floor muscles

2. Cystocele
a. downward displacement of bladder-bulge
in anterior vaginal wall
b. causes: genetics, obesity, childbirth, advanced
c. S & S: urinary incontinence, vaginal fullness
bulge in vaginal wall
d. complete emptying of bladder difficult R/T the
cystocele sags below the bladder neck
e. tx: vaginal pessary or surgical repair
colporrhapy (anterior repair)-shortens
pelvic muscles to better support bladder

3. Rectocele
a. herniation of anterior rectal wall
b. may lead to constipation, hemorrhoids, fecal
impaction, feeling of vaginal/rectal fullness
c. found by rectal exam or barium enema
d. need to promote bowel elimination
e. surgery-posterior colporrhaphy or A & P repair
f. follow surgery with low residue diet

F. Common Benign Neoplasms
1. Types/Management
a. ovarian masses
-70-80% benign
-S & S-asymptomatic
-mass may be palpated on pelvic exam
-may have a feeling of fullness, cramping
-can lead to dyspareunia, irregular bleeding
-may resolve on own
-use of OCs
-diagnostic laparoscopy with possible
b. uterine masses
-minimal CA risk
-S & S-frequently asymptomatic
-low abdominal pain, fullness, pressure
-menorrhagia, dysmenorrhea
-metrorrhagia (intermenstrual bleeding)
-may shrink with menopause
-myomectomy, D & C, hysterectomy

2. Total abdominal hysterectomy
a. removal of uterus and cervix thru abdominal
b. may include removal of fallopian tubes/ovaries
BSO-bilateral salpingo-oophorectomy
castration in females
c. 600,000+ are done yearly
d. questionable reasons for surgery
e. may want to consider alternatives
LAVH-laparoscopic assisted vaginal hyster.
f. pre-op: lab work, ECG, chest x-ray, informed
consent-must understand means sterility
g. IV, shave, abdominal prep, Foley cath
h. post-op care similar to post-op C/section
i. need to deal with psychosocial issues

G. Reproductive cancers
1. Endometrial
a. most frequently occurring reproductive cancer
b. 5
most common after skin, lung, breast, and colorectal
c. asymptomatic in early development
d. endometrial cancers are nearly all
adenocarcinomas (80%)
-cancer of glandular cells
e. S &S-postmenopausal bleeding
f. risk factors: obesity, advanced age,
unopposed ERT, nulliparity,
late menopause >age 52
g. found by endometrial biopsy
h. tests: CBC, liver function, renal function, BE,
CT, liver and bone scan, CA-125
j. tx: radiation-intracavity (brachytherapy)
-external beam

2. Cervical-
a. 3
most common CA of reproductive tract
b. risk factors
-age (50-55) -early childbearing
-non-Caucasians -smoking
-multiple sexual partners -HPVGardasil vaccine
c. testing
-Pap smear -colposcopy
-punch biopsy -ECC
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%
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
e. tx:
Stage 0-cryosurgery, laser surgery, LEEP/LEETZ,
cone biopsy, 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

3. Ovarian-
a. most often occurs in 5
decade (age 45-65)
b. most occur after menopause
c. risk factors
-fertility drugs -early menstruation
-nulliparity -high fat diet
-smoking -alcohol
child after age 30
-h/o breast, colon, or endometrial CA
-family h/o breast or ovarian CA
d. risk
-use of OCs -h/o BTL
e. 5 year survival rate-90% (Stage 1), 10% (Stage IV)
-discovery of CA not until advanced stage
f. S & S
-irregular menses -PM tension
-menorrhagia -breast tenderness
-early menopause -abdominal discomfort
-dyspepsia -pelvic pressure
- abdominal girth -urinary frequency
g. in 75% of cases, CA had metastasized before dx
-60% beyond the pelvis
h. dx: transvaginal U/S, laparoscopy, laparotomy
i. tx:
-TAH/BSO -tamoxifen -chemo -radiation
j. CA 125-associated with various epithelial CA
may be used to assess response to tx
in women with known ovarian CA

4. Vulvar
a. 90% squamous cell carcinomas
b. accounts for 4% of Gyn malignancies
c. more than 50% of cases occur in
postmenopausal women (age 65-70)
d. usually localized, slow-growing, and marked
by late metastasis to regional lymph nodes
e. risk factors: HTN, obesity, DM
f. S & S: bleeding, malodorous D/C, pain, pruritus
g. tx: excision, laser, radiation, vulvectomy

IV. Male Reproductive Disorders-
A. Testicular Cancer
1. Leading cause of cancer deaths in men 15-35 yrs old
a. highly treatable
b. usually curable-over 90% in all stages combined
c. rarely bilateral
d. CA most commonly dx-solid tumor-age 15-40
e. most often in Caucasians, rare in African-Amer.

2. Pathophysiology
a. germinal-sperm-producing cells-95%of cases
-2 types
seminomas- (40%)
-occur in men late 30s to early 50s
-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 40s
-need surgery or chemo
-embryonal carcinomas
common in men 19-26 yrs old
may spread via bloodstream
rarely occur
often mixed with other tumors
lethal, fast spreading
initial dx often in metastatic
b. stromal-hormone producing
-interstitial cell tumors(arise from Leydig cells)
androgenic hormone secretions
rare, usually benign
rare, usually benign
may secrete estrogen-feminization

3. Causes
a. mainly unknown
b. may be R/T cryptorchidism
-if develops CA, 75% will be in the undescended
testis (assoc. with seminomas)
c. may be R/T trauma, infection

4. Testing
a. tumor marker study
-benign tumors never elevate marker proteins
-AFP and HCG-for nonseminoma
-in seminomas- hCG/LDH but not AFP
if AFP, think mixed tumor-diff. Tx
-if tx effective, markers should fall
b. CT scan, U/S
c. Chest x-ray to r/o metastasis
d. lymphangiography to ck retroperitoneal
lymph nodes

5. Physical exam
a. palpate for lump
b. may see painless enlargement
c. heaviness, dragging sensation
d. dull ache in abdomen, inguinal

6. Nursing diagnosis
a. risk for sexual dysfunction R/T disease/surgery
b. dysfunctional/anticipatory grieving
c. disturbance of body image R/T dx and tx
d. acute/chronic pain
e. anxiety R/T dx of cancer

7. Management
a. sperm banking-before radiation and chemo
b. chemo
c. radiation-seminomas
-used after orchiectomy
-external beam therapy
nonseminomas-radical lymph node
dissection saves sympathetic ganglia
d. stem cell transplantation-used with chemo to
help prevent infection/anemia
e. unilateral orchiectomy
f. radical retroperitoneal lymph node dissection
-helps to stage the disease and reduce tumor

8. Post-op teaching
a. watch for fever, chills, increasing tenderness,
pain around the incision, drainage, or
dehiscence of the incision
b. no stair climbing or heavy lifting (>20 lbs)
c. resume normal activities 1 week after discharge
d. needs follow-up studies/TSE

B. Other Reproductive Disorders
1. Hydrocele
a. cystic mass with straw-colored fluid forming
around the testis
b. disorder of lymphatic drainage of scrotum
c. no tx necessary unless compromises testis
d. aspirated or surgically removed
e. may need surgical drain and hospitalization
f. directed to wear scrotal support

2. Spermatocele
a. sperm-containing cystic mass on the epididymus
alongside the testicle
b. usually small/asymptomatic-no intervention
c. may be excised thru small incision in scrotum

3. Varicocele
a. cluster of dilated veins posterior/above testis
b. uni or bilateral
c. usually asymptomatic-no tx
d. if painful-surgically removed
-inguinal incision
-may need to elevate scrotum with towel when
in bed to help with drainage
e. can cause infertility by scrotal temperature

4. Scrotal trauma
a. torsion of testes-twisting of spermatic cord
-considered a surgical emergency
-S & S-pain, N & V
b. ice, elevate, avoid heavy lifting, scrotal support
5. Cryptorchidism
a. undescended testis
b. mainly a pediatric problem
-3% full term males
-20% male premies
c. 80% will spontaneously descend
d. orchidopexy-surgical placement of testis
into the scrotum

6. Cancer of the Penis
a. less than 1% of male malignancies
b. carcinoma is a painless, wartlike growth/ulcer
c. small areas may be excised or cured with radiation
d. penectomy-partial (glans only) or total
-with total-need a perineal urethrotomy for urinary

7. Phimosis
a. prepuce constricted-cant retract over glans
b. tx-circumcision

8. Priapism
a. uncontrolled, prolonged erection
b. penis remains large, hard, and becomes painful
c. causes
-neurological -vascular -pharmacological
d. urologic emergency
e. need to improve venous drainage to corpora
f. tx: Demerol, warm enemas, catheter, aspiration
of corpora cavernosa

9. Epididymitis
a. infection of the epididymis-tx with abx
b. may come from infection of the prostate
c. men under 35 yrs, chlamydia trachomatis
d. c/o pain along inguinal canal and vas deferens
e. may have pain and swelling of the scrotum
f. if untreated, pyuria and bacteriuria may develop
g. abscess may form necessitating an orchiectomy

10. Orchitis
a. acute testicular inflammation
b. results from infection or trauma
c. caused by bacteria from urethra or other
d. may be uni or bilateral
e. risk for sterility R/T testicular atrophy
f. tx: bedrest, scrotal elevation, ice, analgesics,
and antibiotics
g. mumps orchitis-20% of males who have mumps
after puberty-given gamma globulins
-childhood vaccination is a good preventative

11. Prostatitis
a. may be bacterial or abacterial (more common)
b. abacterial-after a viral illness or assoc. with STI
-also called prostatodynia
c. bacterial-assoc. with urethritis
-common bad guys-E. coli, Proteus, Enterobacter
and group D streptococci
-S & S-fever, chills, dysuria, urethral discharge,
and boggy, tender prostate
d. can lead to inflammation of the bladder and
e. sexual dysfunction may occur R/T pain
f. tx: antimicrobials-Geocillin, Cipro
g. encourage sitz baths and completion of meds
h. use analgesics prn
i. if UTI develops, may be put on Septra
j. instructions on activities to drain prostate
-sexual activities -masturbation
-prostatic massage


Infertility and Genetics
Lecture 13

I. The Couple Experiencing Infertility
A. Incidence
1. Definition: Inability to conceive and carry a pregnancy
to viability after at least one year of regular
sexual intercourse without contraceptive use
a. Primary-never pregnant
b. Secondary-had been pregnant in the past

2. Problem for 10-15% of reproductive-aged couples

3. Women over age 35-21% chance of infertility

B. Risk Factors
1. Females
a. abnormal external genitals
b. abnormal internal reproductive structures
c. anovulation
-pituitary/hypothalamus hormone disorders
-adrenal gland disorders
d. amenorrhea after stopping OCP
e. early menopause
f. increased prolactin levels
g. tubal motility reduced
h. inflammation within the tube
i. tubal adhesions
j. endometrial/myometrial tumors
k. Ashermans syndrome-uterine adhesions/scars

2. Males
a. undescended testes
b. hypospadias
c. varicocele
d. low testosterone levels
e. testicular damage-trauma, mumps
f. endocrine disorders
g. genetic disorders
h. STIs
i. exposure to hazardous substances
j. change in sperm
-smoking, heroin, marijuana, amyl nitrate, butyl
nitrate, methaqualone

k. decrease in sperm
-chronic disease
-gonadotropic inadequacy
l. obstruction of the vas deferens or epididymis
m. decreased libido
n. impotency

C. Components of Fertility
1. Sperm viable in female reproductive tract for up to
48+ hours
-fertility potential-24 hrs

2. Ova viable for about 24 hours
-optimum time for fertilization may be only 1-2 hours

3. Blastocyst must implant within 7-10 days into the
hormonally prepared endometrium

4. Women account for 50% of infertility cases
a. male problems-35%
b. unexplained factors-15%

5. Assessment of female infertility
a. complete history
-duration of infertility
-past obstetrical events
-sexual history
-review medical/surgical history
-assess exposure to hazardous substances
b. 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. testing
-postcoital test
Sims-Huhner test-ck cervical mucus
abstain from intercourse for2-3 days
performed several hours after ejaculation
examine cervical mucus/sperm under
-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
-U/S dx of follicular collapse
-serum assay of plasma progesterone
-hormone analysis
estrogen, progesterone
-basal body temperature (BBT)
biphasic- temp 12-14 days before menses
ck temp before rising
rise=surge of LH, progesterone
ova released 24-36 hrs before temp
intercourse-3-4 days prior to 2-3 after
-endometrial biopsy

6. Assessment of male infertility
a. H & P
b. semen analysis
-sperm density-20-200 million cells/ml
-may vary day to day-collect over a month
-effects of cervical mucus on sperms motility and
-ck sperms ability to penetrate an ova

D. Infertility management
1. Psychosocial
a. may need counseling to deal with issues of loss
or inadequacy
b. dx of infertility may lead to problems with
couples personal relationship
c. discuss alternatives, i.e. adoption

2. Nonmedical therapies
a. water soluble lubricants
b. change to boxer shorts
c. use of condoms if woman has immunologic
reaction to sperm-will reduce antisperm
antibody production

3. Medical therapies
a. ovulatory stimulants
-Clomid (clomiphene) stimulates the ovarian
-multifetal rates-less than 10%
-Parlodel (bromocriptine) inhibits release of
prolactin (elevated levels of prolactin have
an amenorrhea effect on the body)
-Bravelle, Menopur (human menopausal
extremely potent
requires daily monitoring
daily IM for 7-14 days-first half of
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. hormone replacement therapy
-use conj. estrogen and medroxyprogesterone
c. male tx
-thyroid/adrenal gland correction
-abx for STI
-clomiphene-unsure effectiveness
-HCG-stimulates androgens- spermatogenesis

4. Surgical treatments
a. excise ovarian tumors
b. removal of adhesions
c. hysterosalpingography-may unblock tubes
d. if uterine cavity too small to carry pregnancy,
no medical tx available-each successive
pregnancy enlarges uterus
e. may be able to reconstruct uterus R/T bicornuate
f. myomectomy
g. chemo/thermocautery to eliminate chronic
inflammation and infection

5. Reproductive alternatives
a. assisted reproductive alternative
(higher risk for ectopic)
-IVF-ET-in vitro fertilization-embryo transfer
-GIFT-gamete intrafallopian transfer
*after ovulation, 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. preimplantation genetic diagnosis
-eliminate defect embryos before implantation
c. surrogate mothers
-use surrogates ova and husbands sperm
-use mothers ova and husbands sperm
d. adoption

E. Nursing diagnoses
1. Body image disturbance

2. Decisional conflict

3. Altered patterns of sexuality

4. Risk for social isolation

II. The Family Experiencing a Genetic Disorder
A. Chromosomal abnormalities
1. Human Genome Project-1990-international effort to
map and sequence the genetic makeup of
a. ELSI-Ethical, Legal, and Social Implications
Program-sentinel to prevent discrimination
or use of material for eugenic purposes
(selective breeding)
b. initial sequencing complete 06/00
c. goal-to facilitate study of hereditary diseases
and provide potential for altering genes
to treat and/or prevent occurrence

2. Chromosomes
a. karyotype-pictorial analysis of chromosomes-
usually from peripheral blood but may
come from any body tissue
b. autosomal chromosomes-22 pairs
control traits of the body
c. sex chromosomes-pair 23
determines sex
controls some other traits
d. dominant gene-their trait is expressed over
another (AA or Aa)
e. recessive gene-only expressed when another
another recessive is present (aa)
f. terms-allele-gene that determines a specific trait
each trait has a pair of alleles
genotype-genetic makeup of an individual
phenotype phenotype- -e ex xp pr re es ss si io on n o of f g ge en ne e s s f fu un nc ct ti io on n
e ei it th he er r m me ea as su ur ra ab bl le e o or r o ob bs se er rv ve ed d
homozygous homozygous- -h ha as s i id de en nt ti ic ca al l a al ll le el le es s o on n
e ea ac ch h c ch hr ro om mo os so om me e i in n t th he e s sa am me e l lo oc cu us s
hetrozygous hetrozygous- -2 2 d di if ff fe er re en nt t a al ll le el le es s a at t a a g gi iv ve en n
l lo oc cu us s

3. Abnormalities in chromosomal numbers (aneuploidy)
a. usually caused by nondisjunction
b. occurs during meiosis when pair fails to separate
c. trisomy-additional autosomal chromosome
-21-Down Syndrome
-18-Edwards Syndrome
-13-Patau Syndrome
(18 & 13-poor prognosis: cardiac &
respiratory problems)
d. lack of an autosomal chromosome (45)=death of
e. mosaicism-some cells have normal #, others
missing/having an additional chromosome
f. sex chromosome abnormalities
juvenile external genitalia
undeveloped ovaries
short in stature
webbing of the neck
impaired intelligence
most affected embryos SAB
poorly developed secondary sexual
small testes-infertile
tall, effeminate
subnormal intelligence usually present

4. Abnormality of chromosome structure
a. translocation-genetic material moved from
one chromosome to another-may
create an imbalance of materials
no problem if all information present
b. additions/deletions
gamete produced has too many/too few
gene-effect may be mildsevere

B. Patterns of Inheritance
1. Multifactorial
a. combination of genetic and other factors such
as environment
i.e.: cleft lip/palate, neural tube defects
b. malformation may be mild to severe depending
on # of genes affected
c. tend to occur in families
d. some malformations more common in one sex
e. polygenic, multifactorial diseases: coronary
artery disease, obesity, HTN, psychiatric disorders

2. Unifactorial-Single-gene disorders
a. one gene controls a particular trait, disorder, or
b. # of unifactorial abnormalities exceed the # of
chromosomal abnormalities
-50-100,000 genes in 23 chromosomes
c. autosomal dominant inheritance
-abnormal gene with trait is expressed even with
a normal member of the pair-no carriers
-mutation of the gene-spontaneous, permanent
-affected individual comes from a family with
generations of the disorder-50% chance of
have mutant allele if parent was affected
-ex: Marfans-disorder of connective tissue
polydactyly-extra digits
Huntington disease
d. 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
e. X-linked dominant inheritance
-occur in males and heterozygous females
-ex: Fragile X syndrome-mental retardation
f. X-linked recessive inheritance
- -n no o m ma al le e t to o m ma al le e t tr ra an ns sm mi is ss si io on n
- -5 50 0% % c ch ha an nc ce e t th ha at t c ca ar rr ri ie er r m mo ot th he er r w wi il ll l p pa as ss s
a ab bn no or rm ma al l g ge en ne e t to o e ea ac ch h s so on n w wh ho o
w wi il ll l b be e a af ff fe ec ct te ed d ( (t th he er re ef fo or re e, , 5 50 0% % o of f
m ma al le es s w wi il ll l b be e u un na af ff fe ec ct te ed d) )
- -5 50 0% % c ch ha an nc ce e t th ha at t c ca ar rr ri ie er r m mo ot th he er r w wi il ll l p pa as ss s
a ab bn no or rm ma al l g ge en ne e t to o e ea ac ch h d da au ug gh ht te er r
w wh ho o w wi il ll l b be ec co om me e c ca ar rr ri ie er rs s
- -f fo or r d da au ug gh ht te er rs s t to o b be e a af ff fe ec ct te ed d, , f fa at th he er r m mu us st t
b be e a af ff fe ec ct te ed d a an nd d m mo ot th he er r b be e a a c ca ar rr ri ie er r
o or r a af ff fe ec ct te ed d a as s w we el ll l
-ex: hemophilia-defect in clotting factor VIIIc
Duchenne muscular dystrophy
C. Testing
1. Prenatal testing-see booklet
b. CVS/amniocentesis
c. blood tests for:
-Tay-Sachs -Sickle Cell Anemia
-Thalassemia -Cystic Fibrosis
d. U/S-fetoscopy

2. Newborn testing-see booklet
a. PKU-mental retardation
b. congenital hypothyroidism-retardation
c. galactosemia-dehydration/sepsis
d. maple syrup urine disease-neurologic
e. homocystinuria-neurologic
f. congenital adrenal hyperplasia-electrolytes

g. biotinidase deficiency-neurologic

D. Clinical management
1. Genetic counseling
a. understand facts about the disease-cause
and treatment
b. understand how heredity contributes
c. understand rate of recurrence
d. aware of options
e. course of action
f. use of coping mechanisms/support systems

2. Nursing roles
a. identify risk factors
b. identify physical/developmental abnormalities
c. assess need for referral
d. prepare for genetic counseling
e. correct misconceptions
f. demonstrate support and sensitivity
g. explain typical outcomes