OB Green = Very Important Bold = Important

High Risk Pregnancies:

*No prenatal care, pre-existing illness, pregnancy induced disease, risk for infertility
*Low educational level background – don’t utilize resources as they should, scared
*Lot more teenage pregnancy – sick, immature bodies, immature uterus (ideal age for
pregnancy is 25)
*Unwanted pregnancy – hangers, etc, anything to get rid of the pregnancy, people will do
many different things, usually end up in the ED no matter what

Reminders:
Nagels Rule [to find the estimated date of confinement]
+ 7 days, - 3 months (don’t include the month you are in), + 1 year
Ex. November 7th, 2008 [the 14th and August plus 1 year, August 14th 2009]

High Risk Newborn – Apgar chart

Component
Score of 0 Score of 1 Score of 2
of Acronym
blue at no cyanosis
Skin color blue all over extremities body and extremities Appearance
body pink pink
Heart rate absent <100 >100 Pulse
grimace/feeble
no response sneeze/cough/pulls
Reflex irritability cry when Grimace
to stimulation away when stimulated
stimulated
Muscle tone none some flexion active movement Activity
Breathing absent weak or irregular strong Respiration

1st trimester: 1 to 13 weeks

2nd trimester: 14 to 26 weeks
3rd trimester: 27 to 40 weeks

GTPAL [Gravity is # of pregnancies, parity is # of pregnancies in which the fetus or

fetuses reach viability (approx 20 to 24 weeks or fetal weight of more than 500 g [2 lbs]
regardless of whether the fetus is born alive or not)
Gravidity number of pregnancies
Term [full] births (38 weeks or more)
Preterm (from viability up to 37 weeks)
Abortions/miscarriages (prior to viability)/stillborns
Living Children

Early – fetal head compression (just monitor; when baby gets really low, most benign)
Variable – cord compression (u, v, w shapes on fetal monitor), get Mommy on 8-10 L O2
and reposition Mommy on left side

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Late De-cels – placental/uteral insufficiency [O2]; HR drops and no re-oxygenation
happens to baby and HR still decreases after contraction has ended

Tocolytics – inhibit uterine contraction by suppressing smooth muscle contractions

Contraindications: >34-35 weeks, fetal distress (at any gestational age), severe PIH,
eclampsia, vaginal bleeding, cervical dilation > 6 cm [page 778]

RN Closely Monitor
1. Pulmonary function 2. daily weights 3. I & O 4. S/S of pulmonary edema

Yutopar/ritodrine – which is a beta adrenergic agonist, relaxes smooth muscle,

inhibiting uterine activity and causes bronchodilation
Adverse Reactions – SOB, tachy for both mommy and baby, hypotension, tachypnea,
chest pain, pulmonary edema, n/v diarrhea
Nursing Management – Maternal pulse >120-140, BP <90/40, pulmonary edema – to
reverse effects, give Indural which will reverse these adverse effects

Brethine/tertbutaline – is a beta adrenergic agonist, relaxes smooth muscle, inhibiting

uterine activity and causes bronchodilation
Tachy is a normal s/e of this drug (subQ or PO); SOB;
*If given subQ, watch for infection at the site
Interventions – VS, resp, skin

Magnesium Sulfate (MgSO4) – IV uterine toco, CNS depressant; relaxes smooth

muscle including uterus *most common
**Monitor Q hr for lethargy, weakness, H/A, blurred vision, N/V, assess respiratory rate,
deep tendon reflex, decreased urine output, watch for cardiac arrest
-Hot, sweaty, dizzy –Normal-
RN Intervention – urine output <25 ml/hr, loss deep tendon reflex, RR <12, pulmonary
edema, Mg lab <10 mg/dl [4.8 to 9.6 is normal] GIVE CALCIUM GLUCONATE AS
AN ANTIDOTE FOR MAG OVERDOSE!!!!!!!!

Procardia/Nifedipine – Ca+ channel blocker; relaxes smooth muscle including the uterus
by blocking calcium entry
***NEVER, EVER give MgSO4 and Procardia together!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

 Research has demonstrated that a gain of 48 hours to several days is best outcome
that can be expected with the use of tocolytics
■ Best reason to use tocolytic therapy is to achieve sufficient time to
administer glucocorticoids in an effort to accelerate fetal lung maturity and
reduce severity of respiratory complications in preterm infants

Pregnancy At Risk
Hyperemesis Gravidarum
-Excessive vomiting in the first trimester that leads to dehydration (5% weight loss),
acidosis, starvation, and ultimately death of mother and fetus.

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HCG- hormone that is a biological marker in pregnancy tests; with hyperemesis, the
levels are found to be really high, these are the Mommy’s with bad morning sickness
Estrogen also can contributes to the hyperemesis

Treatment
-Hospitalize
-NPO (1st until hydration resolved; usually 48 hours)
-IV Hydration
-Gradual diet – clear, full, soft, regular [or modified]
-Anti emetic
-TPN if necessary
-Reglan, phergan, unisom, B6
*Small frequent meals/snacks
*Increase protein and decrease fat (peanut butter and crackers)
-Can never feel full because they will throw up
-Morning/afternoon – don’t do well; evening or late night best time to get in a meal
[around 6-7 pm] tend to do better to get in calories by having a small meal

Nursing Responsibility
-Strict I & Os [have them keep a diary of food]
-Monitor fetus at all times
-Emotional support – well being of baby and include rest of family

Hydatidiform Mole (Moler Pregnancy) page 747

-Abnormal formation of the placenta into fluid filled, grape like clusters.
-Fertilization of egg, but no nucleus because it has been lost
-Will give increase levels of HCG
-No prenatal care, Mommy can carry for full term
-5 – 6 weeks usually start prenatal care, but will find out around 10 – 11 weeks
-Happens 1 in 1200 pregnancies

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At Higher Risk for Mole
-Early teen and women over 40 years old
-Any defect of ovulation
-Inadequate nutrition (anorexia, bulimia, drug use)

Signs and Symptoms

-Vaginal bleeding – brownish looking prune juice color
-Passage of hydropic vesicles (grape like vesicle)
-Uterine enlargement greater than expected gestational age
-Doughy, soft abdomen
-Spontaneous abortion 12 to 16 weeks
-Spotting
-Absence of fetal heart tones (no activity; NORMALLY can hear FHT on Doppler 10 -12
weeks and with a vaginal ultrasound heart can be heard 5 – 6 weeks, but not with Mole)
-Hyperemesis Gravidarum [from the very beginning because HCG levels are so high]
-PIH in second trimester [will happen before 20 weeks which is unusual and not good]

Management
-Ultrasound [will show Moler pregnancy]
-Evacuation of the mole – D&C [dilate and clean]
-Type and Cross for possible transfusion
-Emotional support and bereavement care
-*Follow up for at least one year following; Beta – HCG levels from blood, need to see
decline of HCG

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-20% end up with chorio carcinoma because of the proliferative cells, which could lead to
hysterectomy
-CXR (lungs) 75% is the site of metasis
-Don’t get pregnant for 1 year because could have cancer, follow ups is so important
-Weekly for 3 weeks (want to see drastic drop in HCG levels), then monthly for 6
months, then Q 2 months x 3
-IF HCG still increased, D & C [again], tissue biopsy, chemo and possible hysterectomy
-Don’t have them take pill contraceptives [will feed bad tissue with hormones], for birth
control use condom

Abortion
-Expulsion of the fetus prior to viability, 20 weeks gestation
-24 – 25 weekers can survive in NICU
-23 and under – probably won’t make it…
-20 weeks and less than 500 grams
-15% of all 1st pregnancies, end up in miscarriage (80% of those happen under 12 weeks)

Two Types: (page 739)

-Spontaneous abortion: occurring naturally
-Induced abortions: as a result of artificial or mechanical intervention. (D & C)

Types of Spontaneous Abortions:

-Threatened abortion – slight spotting, cervix does not dilate
-Imminent abortion – inevitable, can NOT be prevented, cervix dilated
Complete abortion – everything comes out fetus and tissue all comes out
Incomplete abortion – heavy bleeding, haven’t seen any thing expelled from fetus
(will have to D & C)
-Missed abortion – could or not have bleeding, products of conception that remain in
uterus, no cervical dilation, fetus is not alive 12 – 16 weeks, ultrasound confirm, give
uterus time to rest before Mommy gets pregnant again
-Habitual abortion – 3 – 6 abortions consecutively, for known reason, although common
cause is Mommy with HTN and hx of abruptio placenta

Signs and Symptoms

-Unexplained bleeding – sudden spotting and tissue passage (products of conception)
-Cramping – lower abdomen, dull, constant pain; pain is very different from ‘a growing
fetus pain’
-Backache – [fever, bones hurt, n/v]
-Assessment:
LMP (know); gravida, para [full term, abortion, premie], VS, amount and color of
bleeding (pad counts, frequency, bright red, fetal parts), pain (contraction verses cramps),
level of comfort, and pt’s understanding of what is going on (they will leave hospital with
NO baby), understanding of the loss, possible D & C

Management

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-Ultrasound, lab work (H/H, CBC, Type and Cross), observe cervix and if dilated – bed
rest, abstinence from sex, IV/ transfusion, D & C – dilation and curettage (if point of no
return), if beyond 12 weeks induction of labor by oxytocin, pit, and prostaglandins may
be used [missed abs common], emotional support and bereavement care [guilt,
punishment, give support [support groups], fetal heart tones (120 – 16- bpm) is best
indication for fetal well being

Bleeding Disorders [page 744]

Ectopic Pregnancy: implantation of the blastocyst in a site other than the endometrial
lining of the uterus. Most common site is the fallopian tube (tubal pregnancy)
-2% of all pregnancy in the US
-Leading cause of maternal deaths (because of the rupture, bleeding/septic)
-Fear is always the possibility of a rupture
-Can see with ultrasound [vaginal] within 5 weeks
-9 – 10 % of all maternal deaths
-Leading cause of infertility
-1 – 50 pregnancies, found usually in about 8 weeks

Risk Factors
-STDs
-Use of IUD (intra uterine device)
-PID (pelvic inflammatory disease)

Signs and Symptoms

-Vaginal bleeding

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-Lower abdominal pain; sharp and one sided
-Fainting or dizziness
-Constant pain on the side of ectopic (usually right side)
-Hypovolemia
-Pt’s usually miserable
-Rigid, tender abdomen
-Palpable mass on vaginal exam – extreme pain!

Complications
-Hemorrhage, shock, peritonitis

Management
-Pelvic examination
-Blood replacement
-Culdocentesis (back in the day, now use ultrasound)
-Laparoscopy/Laparotomy (small key holes in abdomen)
-Methrotrexate – give if un-ruptured and it measures less than 0.35 cm, then can give
Methr – will spot for week or 2
-Return weekly up to 12 weeks for Beta HCG draw (to watch for decline)
-If it ruptures, the pt will go to OR to matter what

Placenta Previa
-Placenta implantation in the lower uterine segment
-Abnorm implanted placenta, in the lower uterine segment
-Classified into three types by the degree the cervical os is being covered

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*Marginal aka low laying is the most common and all of these are delivered by c-sect

Predisposing Factors
-Prior history of placenta previa
-Multiple pregnancies
-History of multiple births or closely spread pregnancies
-Prior uterine scars [by c-sect]
-After age of 35

Symptoms
-Painless
-Quiet onset bright red bleeding
-Abdomen soft, palpable
-Labor pains-cramping
-Come in to get FHT and stat ultrasound
-Stable VS, even after blood loss
-Unless complete [type 3], loss lots of blood – hypovolemia  shock
-Shock, anemia
-Infection

**Vaginal bleeding = NO SVE & bright red blood and pregnancy does NOT go together
Nursing Responsibility
-Late 2nd to 3rd trimester, is when this happens [30 -32 weeks, if late 3rd trimester 
hospital and deliver baby]
-Bed rest
-Monitor blood loss (pad count) Q hr
-Perineal care
-Education re: s/s of labor, condition, degree of placenta previa and what is going on
-Have current lab date eg T/S [Type and Cross]
-Emotional support
-Find FHT
-Doppler and stat ultrasound
-Monitor VS
-Watch for hypovolemia (16 to 18 gauge)

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-If “complete” placenta previa, c-sect and baby coming out
-Prepare for emergency c-sect
-Celestone-Bethamentone for fetal lung maturity to Mom IM; need 48 to 72 hrs at least
for it to work

Cause of P-previa: PIH, trauma, cig smoking, drug use, cocaine, induction via pit,
maternal malnutrition, uterine fibroids, any maternal vascular disease, vena cava
syndrome (Mommy never to lay on back!) [Type and Cross and H&H]

Placenta Abruptio
-Premature separation of the placenta
-1-200 births
-Emergency***
-Leading cause of maternal death extend of detachment or degree – D/C
-Trauma leading cause of abruptio

Symptoms
-Dark venous blood
-Abdomen rigid, hard
-Severe pain, extreme
-Sudden onset-trauma, fall, lifted
-Shock, hemorrhage (IV)

Nursing Responsibility
-Prepare for emergency C/S
-Time between abruption and delivery of baby

Management
-FHT, ultrasound, IV (fluid replacement), extremely late decals [reposition Mommy on
left side and 8 to 10 L of O2, uterine irritability, tonicity]; fetal monitor with previa = late
decels

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Amniotic Fluid
Purpose (sticky and white normally)
1. cushions fetus
2. regulates temperature
3. equalizes pressure
4. allows fetus to move freely
-Oligohydraminos-absence of or small amount [causes renal issues in fetus]
-Polyhydraminos-too much fluid [causes baby can have IUGR]

Premature Rupture of Membrane (PPROM – before 37 weeks))

-Spontaneous ROM prior to onset of labor at the end of 37 weeks [high risk]
Full term = PROM [38 weeks]
Fetal Risk: Pre-maturity, infection
*Prevention of infection
-Monitor temp
-Monitor amniotic fluid, you want white and sticky – not black, green, smelly
-Antibiotic within 24 hours and have c-sect

Management
-Hospitalized – pre term, NICU, lungs, intubation (will be in NICU until Mommy
expected date of delivery)
-Limit sterile vaginal exam
-Antibiotics
-Bed rest
-Trendelenberg position- to get pressure off perineum
-Daily CBC

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-Fetal well being tests – NST, which is FHT with fetal movement: baseline FHR,
fetus must keep FHT 15 bpm above baseline for 15 seconds, twice in 20 mins for 40
mins total [then the result is considered a ‘reactive NST’]
- Fetal well being tests – BPP, which is bio physical profile done the 3rd trimester,
more specific ultrasound, HR, breathing, body movement, fetal tone, amniotic fluid
volume and each of these gets 2 points and you want a score of 8 to 10 pts; done
weekly every 3 to 4 days
-Medication – Celestone (if anticipate delivery, give X 2 more) for fetal lung
maturity
-L/S ratio – premie lung maturity; 2 to 1 check fetal lung development

Incompetent Cervix [recurrent premature dilation of the cervix]

-Premature dilation of the cervix associated with repeated second trimester spontaneous
abortions
-Cervix and dilates
-Possible from cervical trauma
-Congenitally short cervix
-Increase in maternal age

Signs and Symptoms

-Painless, bloodless, second trimester abortion
-Minimal uterine contractions
-Pelvic exam shows dilation and effacement
-Educate Mommy to inform you if she feels funny, sit and call 911 and get them in so we
can get them checked out

Management
-Cervical cultures for Gonorrhea Clamedia for STDs, Gram Beta Strep in first trimester
-GBS lies dormant in vagina, but will flare up with pregnancy/stress
-Bed rest, hydration, progesterone [helps endometrium attach to placenta]
-Trendelenberg position
-Antibiotics (triple abx on board before delivery)
-Prevent/inhibit cramping and contractions (eg tocolytics [to inhibit contractions])
-Shirodkar suture/cerclage [page 743]
-Draw baby’s blood and give antibiotic for 48 – 72 hours
-Cerclage = purse string around the cervix to strengthen it

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Preterm Labor
-Onset of labor between 20 and 37 completed weeks of pregnancy
-Etiology unknown (dehydration)

Reasons: pre-mature contractions, multiple fetus in one gestation, infections (UTI –

dehydration, fetus become tachy – compensates, then Mommy contracts), abdominal
surgeries in the past

Symptoms
-Cramping
-Backache
-Spontaneous contractions

Management
-Bed rest ***
-Hydration ***
-Empty bladder
-Tocolysis – Terbutaline, MgSo4 [Mag sulfate FDA approved anticoagulant] – these are
used to inhibit uterine contractions by relaxing smooth muscle of the uterus
-Educate Mommy that normally – contractions go from front to back and belly gets hard;
let them know how pre-term labor feels and the differences
-Braxton Hicks – have Mommy drink water and lay on left side (will go away)

Pregnancy Induced Hypertension (PIH) [Gestational HTN]

-An increase in systolic blood pressure > 30 mmHg from baseline or an increase in
diastolic blood pressure > 15 mmHg from baseline on at least two occasions > 6 hours
apart. If no baseline data available – 140/90

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-Categories: Preeclampsia and Eclampsia

Mild Preeclampsia
-Characterized by: HTN with proteinuria
-Increased BP
-Proteinuria- + 1 and + 2 on dip stick
-Edema (of hands and face)
-Wt gain [“normal” 2nd trimester = 2.2 lbs]

Severe Preeclampsia
-Characterized by BP 160/110 on two occasions
-Proteinuria which is > 5 g/L in 24 hours, oliguria which is < 400 mL/24 hours
-Other symptoms like headache, blurred vision, scotomata (seeing stars in eyes), pitting
edema, N/V, epigastric pain
Labs – increased serum creatinine

Eclampsia
-Characterized by
-Convulsions [can give MgSO4 for this]
-Coma

Treating Preeclampsia
-Home management
-Bed rest
-Check BP, UA daily
-Bi weekly NSTs
-24 hour urine collection
-Check fetal movement
-Hospital Management
-High protein, low sodium diet
-24 hour urine collection for protein and creatinine
-Fetal well being tests BPP, NST
-Anti-convulsant therapy – MgSO4
-Anti hypertensive eg aldomet, Procardia, Labetelol [beta blocker] they are
very common and safe antihypertensives

Managing Eclampsia [page 725 for PIH info]

-Safety, Safety, Safety, Safety…you get the idea. ;-)
-Seizure management
-MgSO4
-Safety precautions

Gestational Diabetes
-Carbohydrate intolerance with onset first recognized during pregnancy
 Lack of maternal glycemic control before conception and in first trimester of
pregnancy may be responsible for fetal congenital malformations

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  Maternal insulin requirements increase as pregnancy progresses and may
quadruple by term as a result of insulin resistance created by placental hormones,
insulinase, and cortisol

 At birth, levels decrease dramatically; breastfeeding will affect insulin needs

 Poor glycemic control before and during pregnancy can lead to maternal
complications such as miscarriage, infection, and dystocia caused by fetal
macrosomia
 Careful glucose monitoring, insulin administration when necessary, and dietary
counseling are used to create a normal intrauterine environment for fetal growth
and development in pregnancy complicated by diabetes mellitus
 Because gestational diabetes mellitus is asymptomatic in most cases, many
women undergo routine screening during pregnancy

Maternal Risks [page 688] need to have blood glucose level the same at ALL times
-Maternal hypotension causes IUGR
-Polyhydraminos – increase of 2000 cc amniotic fluid from hyperglycemia
-Hyperglycemia – dystocia [difficult labor dysfunction, uncoordinated]
-PIH-risk
-Large placenta
-16 to 18 weeks AFP, tube screen

Fetal Risks
-Fetal demise d/t DKA
-Macrosomia- big juicy babies, perineal laceration or c-sect
-Shoulder displacment

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-IUGR because of maternal hypotension
-Premie, respiratory distress [under developed lungs and check L/S ratio]
->30 years, obesity, family history of diabetes or previous deliveries of large, juicy babies

Screening
-Blood drawn
-50 g random glucose test at 24 – 28 weeks; results > 140 require further testing
-Three hour GTT [glucose tol test]
-Normal blood glucose level is 60 to 120
-Educate pt to avoid caffeine before test
-Fasting >95 blood sugar (draw fasting bs)
Screening sugar levels:
-1st hour >180
-2nd hour >155 to 165
-3rd hour >140 to 145
~Gestational Diabetes if 2 or more valves are high

Postpartum Complications

Postpartum Hemorrhage
-A blood loss greater than 500 mL in the first 24 hours after vaginal delivery
-A blood loss greater than 1000 mL in the first 24 hours after C/S
 Postpartum hemorrhage is most common and most serious type of excessive
obstetric blood loss

 Hemorrhagic (hypovolemic) shock is an emergency situation in which perfusion

of body organs may become severely compromised, leading to significant
morbidity or mortality rates for mothers

Causes
-Uterine atony [uterus forgets to contract]
-Lacerations
-Retained Placental Fragments
-DIC

Symptoms
-Increased, thready and weak pulses
-Decreased blood pressure
-Increased shallow respirations
-Pale clammy skin
-Increasing anxiety

Medical Management
-LOTS AND LOTS of fluid
*Early recognition is critical
-1st = massage fundus and empty bladder

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-Pitocin (10 -40 units in 1000 D5W)
-Methergine IM QID (this is to wake up uterus, can’t give to HTN pt)
-OR-
-Prostaglandin administration – hemoabate, then
-Bimanual compression – literally go in vagina with knuckles and a 4 x 4, press against
uterus and clean out uterus
-Blood replacement
-Hysterectomy is worst case scenario
-Pad change every 3 hours

Nursing Considerations
-Fundal massage
-Measure fundal height, consistency and lochia Q 4 hours
-Offer bedpan Q 4 hours
-Position pt in supine
-VS Q 15 mins
-O2 by face mask if RDS
-Don’t ever leave to, stay at bedside

Subinvolution
-Incomplete return of the uterus to its pre-pregnant size and shape

Symptoms
-Late post partum hemorrhage 1 – 2 weeks after childbirth [about 3 to 6 weeks for it to
stop]
-Excessive blood loss
-Lochia fails to progress from rubra-serosa-alba
-Lochia Rubra persists after 2 weeks

Management
-Methergin or hemobate

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-Antibiotics
-Frequent voiding
-Lots of fluids
-Breastfeed
-D & C if necessary

Risk factors
-Endometritis
-Placental fragments still left in uterus

Deep Vein Thrombosis

Symptoms
Edema of ankle and leg, change in LOC, low grade fever followed by chills and
high fever, pain, Homans sign + or negative, peripheral pulses decreased, dyspnea and
chest pain; watch mommy if she says her legs hurt; pain lower legs and or lower
abdomen

Three types of DVT

-Superficial Thrombophlebitis swelling on effected leg, redness
-Femoral Thrombophlebitis
-Pelvic Thrombophlebitis (VS important, will have temp, chills, first sign is them saying I
can’t breathe)

Management and Nursing Considerations

-Prevention
-Early ambulation
-Assess peripheral pain
-Check hypotensive, chest pain
-Monitor signs of bleeding

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-Warm, moist soaks while maintaining legs elevated
-Obtain clotting times
-Increase fluid intake
-Generalized petchie
-Heavy vaginal bleeding

Endometritis
Definition - Refers to an infection of the endometrium, the lining of the uterus. Bacteria
gains access to the uterus thru the vagina and enters the uterus either at the time of birth
or during the post-partum period.

Causes
Mommy had c/s, prolonged ROM, multiple sterile vag exams, prolonged labor, placental
fragments

Symptoms
-WBCs 20,000 to 30,000
-A rise in temperature 24 hours postpartum
-Starts 2 to 5th day post partum but before discharge
-Chills, malaise, loss of appetite
-Abdominal tenderness and strong after pains
-Lochia is dark brown and it smells, culture lochia if endometritis is suspected
-Will have delayed involution

Management and Nursing Considerations

-Antibiotics IV, broad spectrum [penicillin, gent]

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-Analgesics
-Anti pyretic
-Lots of fluid
-Frequent perineal care
-Positioning, sit or lay Fowler or Semi-Fowlers to promote drainage

Urinary Tract Infection

Cystitis – infection in the lower urinary tract caused by E Coli
Pylonephritis – infection in the upper urinary tract that causes damage to the kidney and
impairs function

Causes
-Decreased bladder sensitivity
-Frequent caths
-Frequent vaginal exams
-Increased bladder capacity
-Bladder trauma at birth
-Increased diuresis

Symptoms
-Over distention of the bladder
-Frequent urination of small amounts, burning, dysuria
-Hematuria
-Elevated temperature (low grade – cystitis and high pyelonephritis)
-Flank pain/CVT (costoverterbral flank pain)
-Chills and N/V

Management and Nursing Considerations

-Culture and Sensitivity
-Admin ABX (Bactrim)
-Increase in fluids
-Monitor VS and bladder

Mastitis
-Infection of the breast connective tissue, primarily in women who are lactating
-Almost always uni-lateral
-From blocked milk duct and creates abscess
-Established after 2-3 weeks post partum
-Usual causative organisms are: Staph a, E coli, Strep

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Symptoms
-Affected breast show localized pain, swelling, and redness
-Fever
-Breast milk becomes scant
-Pain
-Tender axillary lymph nodes

Management
-Broad spectrum antibiotics
-Breastfeeding continued or pumping (Q 2 -3 hrs) to promote that abscess to drain
-Cold or ice compresses, supportive bra until pain subsides [45 minutes on 45 minutes
off]
-Frozen cabbage leaves [45 on 45 off]
-Warm compresses right before mommy breastfeeds

Complications of Childbirth
Stress Factors = reduction of myometrial activity
Nursing Plan
-Comfort measures
-Relaxation/Breathing techniques
-Reassurance [always] and rapport [let her know what is going on every step of the way]

Episiotomy

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Midline straight down 1-2 cm
-Advantages: less blood loss, less painful, heals quickly
-Disadvantages: may extend to anus (mommy has a big baby, cut straight down and can
go down to anus)

Midiolateral about 3-5 cm, these are big, big babies (like 8.5 lb –ers)
-Advantages: more room
-Disadvantages: more painful, more blood loss, takes longer to heal

Precipitate Labor
Labor that is completed in less than three hours. More common with multiparous woman.
Poses risk of trauma to the fetus as well as trauma to the maternal soft tissue.
Management
-Early preparation for labor
-Support the perineum in case of delivery [all RN in L&D are ready to delivery baby if
have to]
Risks for Mom – if mom is delivery too fast, uterine rupture is a risk, cervical – vaginal –
rectal lacerations
For neo-nate – hypoxia – caused by uterus placenta insufficiency by hypertonic
contractions/uterus, intra-cranial hemorrhage

Nursing considerations:
-Don’t leave mommy alone!
-Have her pant to buy some time or have her blow and distract her to decrease urge to
push
-Be sure to get sterile gloves prepared
-Support the perineum
-Look at monitor for baby’s well being (O2 like 8-10 L of oxygen for fetal distress)

Lacerations
First - perineal skin and the vaginal mucosa - extends through the skin and most common
Second – perineal skin, vaginal mucosa, fascia, muscles of the perineal body

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Third – Perineal skin, vaginal mucosa, fascia, muscles of the perineal body involving the
anal sphincter
Fourth – a third degree laceration but goes thru the rectal mucosa

Considerations
-Put mom in stir-up if see trickle of blood post partum to check sutures and pat to see
where it is coming from, can even come from vaginal laceration

Nursing Considerations
-Ice
-Pain meds
-Epi foam and derma plast to put on pad for perineal care (front to back, wipe from front
to back and PAT dry)
-Tucks

Perineal Hematomas
Collection of blood in the subQ layer of perineal tissue characterized by: purplish
discolored area, swelling (2 to 8 cm), and feeling of pressure or tightness; usually from
vacuum out baby
-Mommy will say severe pain in her perineum and may not be able to close her legs

Interventions
-VS (hypovolemia)
-Monitor for abnormal pain (use of vacuum and or forceps)
-Monitor mommy’s bottom
-Ice [15 minutes on 15 off]
-Pain meds
-I & O
-Cath mommy if she is unable to void

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-Antibiotics (becomes infected, broad spectrum, prophylactic)
-If bubble is clear, it is just edema – leave alone; if black and blue, will have to do I & D
to evacuate hematoma so prepare for that

Now, time for passenger…

Mal-position
Persistent occiput posterior cause: severe back pain, increased use of forceps/vacuum,
increased risk of lacerations; posteriorly presenting head does not fit the cervix as snugly
as the one in the anterior position

Risks
-Sacral nerve compression = severe back pain
-Increased risk of forceps and vacuum = increase risk of lacerations
-FHT are heard on lateral side on the abdomen

Nursing Plan
-Position change – knee chest
-Back rub

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Mal-presentation
-Breech

-Face, brow
-Transverse

24
-Shoulder

Treatment
-Manual rotation [there is risk involved like where cord is located; doctor goes in and
internally try to move the baby]
-External version [page 789; ultrasound and move baby from the outside]
-C-sect

Macrosomia (large gestational age babies, big juicy babies); maternal diabetes or post
term pregnancy – more than 42 weeks
-Shoulder dystocia – shoulders are too broad to be delivered thru the pelvic outlet

25
Nursing Responsibilities
-McRoberts maneuver – [page 811]
-Prep for c-sect
-Check infant shoulders after delivery

Cesarean Birth

26
Reasons for c-sect:
-Mal-presentation [breech, etc]
-Placenta previa or abruption
-Fetal distress
-Failure to progress [Mommy has been labor for 12 to 14 hrs]
-Prior uterine scar [doesn’t want to go to a VBAC]

Types of incision
-Classic or vertical
-Low transverse or prannestiel

Nursing Responsibilities
-Prepare client – shave, Foley, pre op meds [mommy – bicitra – neutralize stomach acid
so she won’t feel like throwing up or aspirate]
-Pre op and post op teaching [monitor vs, assess fundus, assess vaginal bleeding, assess
abd dressing, foley cath and urine output, turn/cough and deep breath] page 800

Cord Prolapse [page 812]

Occurs when a loop of the umbilical cord gets in front of the presenting part [see variable
decals]

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Nursing Plan
-Avoid cord compression
-Trendelenberg position
-Knee chest position
-NEVER press the cord back in; what you do is put pressure on baby’s coconut so baby’s
not putting pressure on cord and do NOT let this baby be delivered, will have to go to c-
sect

Causes
-PROM
-Placenta previa
-Tumors
-Cephalic Pelvic Disproportion [CPD]
-Small baby
-Multiple gestations

Symptoms
-Cord is felt on vaginal exam
-Presence of FHR with variable decals

Management
-Ensure reassuring FHT
-Vaginal exam to push up presenting part (not the cord)

28
-8 to 10 L of O2
-Poss c-sect or rapid delivery
-Positioning like Trendelenberg position or Knee chest position

Dysfunctional Labor
-Hypertonia – seen in early labor; painful d/t uterine muscle cell anoxia [not enough
oxygenation; no normal resting phase that goes on – give analgesics, O2, positioning];
ineffective and doesn’t even allow cervix to dilate
-Hypotonia – seen in active labor; caused by medication, epidural, over stretching of
uterus, or mal-position (will have to rule out CPD – cephalic pelvic disproportion) – will
give pit to jump start uterus, ultrasound to check positioning, vacuum assisted birth and c-
sect is worst case
 Dysfunctional labor occurs as a result of:
■ Hypertonic uterine dysfunction
■ Hypotonic uterine dysfunction
■ Inadequate voluntary expulsive forces-not doing what is supposed to do
 Functional relations among uterine contractions, fetus, and mother’s pelvis are
altered by maternal positioning, which is why ultrasound done at bedside

Risk factors
-Mommy over 40
-Uterine abnormalities
-Fetal macrosomia
-Fetal mal presentation
-Multi fetal pregnancy

Uterine Rupture
May be as a result of VBAC, trauma, excess pitocin administration, fetal lie
-Symptoms: excruciating pain [sharp, abrupt, sudden], cessation of contractions [uterus
won’t contract anymore], drastic decrease in fetal heart rate [immediately], late decals,
may have bleeding or may not have bleeding

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Treatment- emergency cesarean
-O2 and fluids
-Positioning

How baby compensates: Brady late decalstachy

Causes
-Separation of scar from previous c/s
-Intensive uterine contractions
-Over stimulation of labor with Oxytocin
-Difficult forceps assisted birth

Uterine rupture management

-Complete uterine rupture – extension thru entire uterine wall tx: shock, replace fluid and
hysterectomy
-Incomplete uterine rupture – laparotomy, repair tear, blood replacement

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Amniotic Fluid Embolism
Occurs when amniotic fluid gets into maternal circulation; leading cause of death during
labor or the first few hours post partum, first case was in 1926; leak in amniotic fluid and
goes to lungs; unpreventable situation; pt can’t breath; may have meconium; maternal
mortality rate is about 61% and if happens, permanent damage; baby will usually have
permanent hypoxia problems [like CP] about 50%; via the endocervical veins

Symptoms
-Respiratory distress – SOB, cyanosis
-Chest pain [abrupt onset]
-Tachycardia
-Acute hemorrhage
-Pale to bluish/cyanosis, dyspnea, respiratory distress

Treatment = maintain oxygenation and support Cardio Vascular Support

Management
-Oxygen by mask or cannula [8 – 10 L]
-CPR if needed
-Avoid moving pt
-Death may be imminent if not caught on time
-Intubate

DIC
Over stimulation of the coagulation process triggered by underlying disease and vascular
injury
Management by treating underlying cause; will see in L & D process and part of
childbirth

Causes

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-Abruptio Placentae
-Amniotic fluid embolism
-Dead fetus syndrome [retained in utero usually about 5 to 6 weeks]
-Severe Preeclampsia
-Septicemia
-Hemorrhage

Management
-Assess vaginal bleeding
-Observe for clots
-Place pt in a left lateral side lying position
-Palpate fundus
-Low platelets, low fibrogin, low protrombin, and low Factors 5 and 6

S/S
-Bleeding from the nose
-Bleeding from IV site or other areas

HELLP Syndrome
-Hemolysis
-Elevated liver enzymes [AST more than 72 [5 and 40 is normal for AST] and increase in
LDH [norm 0 to 250] of more than 600]
-Low platelets [less than 100,000]

Treatment
-Improve platelet count
-Close observation
-Prevent bruising or bleeding
-Once baby is out, HELLP is gone
-HELLP mommies are very sick

Symptoms
-Usually more than 34 weeks, but can be under 34 weeks
-N/V
-Right upper quadrant pain or epigastric pain
-H/A
-Diarrhea

Newborn Complications

Risk factors that causes newborn complications

-Prenatal or intrapartal, diabetes, narcotics analgesics, anesthesia, fetal asphyxia, difficult
or prolonged labor, multiple gestation, pre term baby, post term baby, congenital
anomalies, maternal infection, neonatal infection, SGA or large for gestational age

Preterm Newborn

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Definition – gestational age (under 37 weeks of gestation) as well as weight less than
2500 grams (5lbs 8oz)

Preterm births can be attributed to many causes including:

-Gestational HTN
-Multiple pregnancies
-Adolescent pregnancy
-Lack of pre natal care
-Substance abuse
-Smoking

Complications
-Respiratory distress syndrome (RDS) - decrease in surfactant in alveoli regardless of
birth weight
-Aspiration – don’t have an intact gag reflex, inability to suck, swallow and breathe
-Apnea of prematurity
-Intraventricular hemorrhage (IVH) – bleeding in or around ventricles
-Retinopathy of prematurity
-Patent ductus arteriosus (PDA)
-Necrotizing enterocolitis (NEC) - very common, acute inflammatory bowel d/o in pre
term or low birth weight babies; as soon as baby gets to NICU, get baby on breastmilk
and that will help NEC which leads to perf and peritonitis
-Neonatal sepsis
-Hypoglycemia – especially for macrocosmic babies
-Hyperbilirubenmia – some babies are just born with this
-12 to 15 bilirubin levels with bilirubin encephalopathy, kernicterus
-Delayed growth and development

Ballard assessment – assessment for premies and what they do before they go into the
NICU, neuro and physical assessment

Symptoms
-Periodic breathing – watch for retraction and color change, that is not normal, but
periodic breathing is normal
-Apnea –pause longer than 10 to 15 seconds
-Low birth weight
-Minimal subcutaneous fat deposits
-Head large in comparison to body
-Lanugo over body
-Minimal creases in the soles and palms (premies have minimal)
-Flat areola without breast buds
-Heels fully moveable to the ears – they are super flexible
-Inability to coordinate suck and swallow
-Skin is thin, smooth, skin and the smaller they are the more translucent
-Ear cartilage is very soft, in the unit, watch to make sure that they cartilage is in
alignment

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-Eyes may still be close
-Un descended testies
-Weak grasp reflex
-Hypotonic muscle

Nursing Interventions
-Perform resuscitative measures
-Ensure thermoregulation - can’t not regulate their own temp, radiant warmers, incubators
-Administer respiratory support measures – surfactant and oxygen
-Administer nutrition and fluids
-Administer medications as prescribed
-Minimize stimulation
-Provide for non nutritive sucking
-Keeps parents informed/educated about care of their pre term newborn
-Less than 34 weeks, going to establish IV and oral gavage (when they get to 34 weeks,
will start one PO 5 cc feed)
-Clustered nursing care, Q 4, 6, 8 hrs
-Provide non nutritive sucking
-Inform and keep parents up to date
-Blanket rolls, swaddling, secure holding
-Goal in NICU is meeting infants growth and development needs, anticipate and manage
complications in the NICU especially respiratory distress and sepsis (and cardiac system)
Discharge Planning
 Home care needs of the infant’s parents are assessed
 Information is provided about infant care
 Referrals for appropriate resources
 Referrals for home health assistance

Management
-Bowel function
-VS
-Urinalysis
-CXR
-Arterial blood gas
-Head U/S = ultrasound (for IVH)
-Echo
-Eye exams
-Serum glucose
-Calcium
-Bilirubin

Small for gestational [SGA] age newborn

Describes an infant whose birth weight is at or below the 10th percentile

Complications
-Perinatal asphyxia – hypoxia

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-Meconium aspiration
-Hypoglycemia
-Instability of body temperature

Symptoms
-Weight – below 10th percentile
-Reduced subQ fat
-Loose, dry skin
-Scalp hair sparse
-Wide skull sutures **inadequate bone growth (IUGR)
-Wide eyed and alert – prolonged fetal hypoxia that is their compensation
-Sign of meconium aspiration, hypoglycemia and hypothermia

Post term newborn

Definition – an infant that is born after 42nd week of pregnancy

Risks
-Decrease effectiveness of placenta – increase asphyxia – increase in meconium passage
in uterus – increase risk of meconium aspiration (MAS) – inhalation of meconium into
the lungs = meconium is a BIG fear
-Birth injury r/t shoulder dystocia
-First pregnancies; gravida 1
-Etiology is unknown why mommy goes post term
-Mommy had a previous post term, may happen again

Symptoms
-SGA or large birth weight
-What happens depends on the placenta
-Absence of vernix (younger they are the more vernix they have), minimal lanugo
-Dry, cracked skin r/t metabolism of fat to energy need in utero
-Hypoglycemia (metabolism of glycogen to meet energy needs in utero)
-Minimal subcutaneous fat because baby has to compensate on their own
-Skin and cord stained yellow/green (caused by meconium)
-Long fingernails, scratches on the face, trunk

Nursing Management
-Blood sugar levels
-Hemocrit
-Complete Blood Panel
-Obtain VS
-Complete blood count
-ABG
-CXR

Hypothermia
-Increased consumption of calories = loss of weight

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-Increased oxygen consumption – hypoxia - acidosis – pulmonary construction
-Utilization of fat for energy – lack of surfactant – RDS
-Increased glucose consumption – hypoglycemia

…Hypothermia is a good indication for sepsis

Management
-Wrap and dry baby after ensuring airway, have to dry baby up!
-Reduce or eliminate heat lost thru drafts and contact with cold objects
-Postpone initial bath until temp has stabilized
-Dry infant immediately after birth and bathing
-Keep axillary temp between 97.6 and 99.2 F

Management complications
-If axillary temp is less than 97.6 F
-Put hat on infant’s head
-Wrap newborn with warm blankets
-Assess O2 and hypoglycemia status
-Re warm infant slowly (hypotension and apnea)
-Hypothermia is an early sign of sepsis

Hypoglycemia
Definition – blood glucose less than 40 mg/dl in an term infant [30 to 80 mg/dl is normal
blood glucose in baby]; all stressed babies have a risk for being hypoglycemic

Causes
-Infants of diabetic mommy’s, SGA, premies, experiencing cold stress, hypothermia,
delayed feedings, respiratory distress

Symptoms
-Tremors, jitteriness
-Lethargy
-Decreased muscle tone
-Apnea
-Anorexia
-Weak cry
-Can lead to seizures

Management
-Check blood glucose on all infants by one hour of age and 30 mins on infant’s with IDM
mom’s
-Treat hypoglycemia by breast feeding immediately or administering D5W, D10W PO or
IV (Don’t attempt to feed po an infant who is lethargic at risk for aspiration)
-If treatment has been started, recheck blood glucose level before the next feeding

Neonatal sepsis

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Definition – is a generalized infection that has spread through the blood stream

Pathophysiology
-Immature immune system (inability of the body to localize infection)
-Lack of IgM immunoglobin (protects against bacteria and does not cross the placenta)
-Manifests itself 24 hours after birth

Causes
-Prolonged ROM
-Difficult, long labor
-Resuscitation, invasive procedures
-Maternal infection (UTI and GBS)
-Beta hemolytic strep causes (meningitis and sepsis)
-Aspiration of amniotic fluid, formula or mucus
-Nosocomial infections
-Meconium
-HIV mommies
-Low birth weight babies

Symptoms
-Temperature instability (hypothermia)
-Feeding intolerance (weak suck and low intake)
-Behavioral changes ex. lethargy, pallor or seizures
-Respiratory distress (grunting, flaring, retractions)
-Hyperbilirubenmia
-Jaundice
-Tachycardia – apnea – bradycardia [because of compensation]
-Drainage [eyes, umbilical stump]
-Loose stool
-Vomiting
-Abdominal distention
-Oral gavage –large residual

Management
-Obtain cultures, blood urine, and CSF, before starting antibiotic therapy [complete septic
work up]
-Administer antibiotics
-Obtain VS and temp
-Observe for changes in physical assessment
-Will probably have fluid/electrolyte imbalance

[Usually will be poly-microbial, usually steph, E coli, Hem influenza, group B strep]

Hyperbilirubenmia
Definition – term refers to excessive bilirubin in the blood characterized by jaundice;
give yellow to their urine and brown to their stool

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Lab Values
-Normal Values for Newborns
Birth to 24 hours = 6 mg/dl
Day 1 to 2 = 8 mg/dl
Day 3 to 5 = 12 mg/dl

Types
-Un conjugated/indirect – fat soluble, physiologic jaundice [can turn into karnictus]
Most commonly seen in newborns; from trauma at birth
-Conjugated/direct – water soluble, pathologic in origin [this is the bad one!]
Suggests hepatic problems ex biliary astresia, tumors, damaged liver cells

Management
-Conjugated hemolytic disease fo the newborn
-Un conjugated – 50 – 80% babies have this
**Look at eyeballs first! If below nipple line, not quite a concern as eyeballs

Jaundice
Management
-Phototherapy
-Exchange transfusion – used to treat infants who has raised levels (above 20), used when
bili can’t be controlled by phototherapy (replacement of 75 to 80% infants blood of
recipients blood by donor blood)

Phototherapy Management
-Cover infant’s eyes and remove covers Q 2 hrs
-Change position q2hrs and assess skin
-Assess stools (green stools are indicative of bilirubin being excreted thru the stools)
-Increase fluid intake to prevent dehydration
-Assess temp Q 2 hrs (hyperthermia)
-Monitor bilirubin levels prescribed

Respiratory Distress Syndrome

Causes/Risks
-Lack of surfactant
-Surfactant is a phospholipids that keeps/assist alveoli from collapsing and allowing gas
to be exchanged ex cervanta
-Preterm infants
-Meconium aspiration (term or post term)
-Transient tachypnea of the newborn (TTN) cause from delayed absorption of fluid in the
lungs from delivery; typically preterm and post term infant

Symptoms
-Grunting
-Cyanosis

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-Tachypnea (more than ro RR/min)
-Nasal flaring
-Respiratory acidosis
-Retractions: sternal and subcostal

Newborn of addicted mother

Symptoms
-Withdrawal symptoms may occur as early 12 to 24 hours after birth or as late as up to 7
to 10 days post delivery

S/S
-High pitched cry
-Irritable (difficult to console)
-Decreased sleep pattern
-Hyperflexia
-Tachypnea
-Vomiting and diarrhea
-Uncoordinated suck

Management
-Position of infant on side (facilitates drainage)
-Burp them a lot to prevent aspiration, LOTS of patients
-Maintain sats
-O2
-Suction prn
-Decrease environmental stimuli and swaddle for comfort
-Obtain meconium and urine (drug screening)
-Monitor I & O and weight
-Administer meds eg methadone and Phenobarbital
-Control seizures
-Offer pacifier for non-nutritive sucking
-Assess: RR, weight, reflexes, CNS hyper-irritability
**There is no breastfeeding from addicted mommy to baby

Fetal alcohol syndrome (FAS)/ETOH Related Birth Defects

S/S
-Craniofacial anomalies – short eyelid openings, flat forehead, upper lip grove flat
-Microcephaly – small head
-Hyperactivity
-Developmental delays
-Poor sucks
-Congenital heart defects
-Mental disorders
-Attention deficits

39
*Education is key!

Management
-Position of infant on side (facilitates drainage)
-Burp them a lot to prevent aspiration, LOTS of patients
-Maintain sats
-O2
-Suction prn
-Decrease environmental stimuli and swaddle for comfort
-Obtain meconium and urine (drug screening)
-Monitor I & O and weight
-Administer meds eg methadone and Phenobarbital
-Control seizures
-Offer pacifier for non-nutritive sucking
-Assess: RR, weight, reflexes, CNS hyper-irritability

Metabolic Conditions
Phenylketonuria (PKU)
-An inherited disorder that affects the body’s protein utilization caused by abnormal
metabolism of the amino acid “phenylalanine”
-If the disease is not detected early the infant can loose 10 pts in IQ in the first month and
can lead to mental retardation

Management
-Protein restricted diet
-Formula modified protein – hydrolysate and limited phenylalanine or free phenylalanine

Assessment

40
-Obtain PKU after 48 hours of birth and no later than 7 days (infant’s need at least 24
hours of feeding to show adequate protein level)
-Normal levels are <2mg/dl, if greater than 4mg/dl, test need to be repeated
-S/S: FTT, vomiting, irritability, urine with musty odor, myoclonic or grand mal seizures,
eczema type rash

Metabolic Disorders
Galactosemia (Maple syrup disease)
Definition – is a disorder of carbohydrate metabolism characterized by abnormal amounts
of galactose in the blood

Assessment
-S/S: lethargy, hypotonia, diarrhea, vomiting, jaundice, and cirrhosis
-Cataracts and brain damage
-Child may die after 3 days if no treatment is started

Management
-Beutier test is used to detect this disease (cord blood)
-Diet free of galactose
-Milk substitutes like casein hydrolysates (Nutramigen)

Hypothyroidism
Definition – a problem where the thyroid gland does not produce enough thyroid
hormones to meet metabolic needs

Assessment
-Obtain T4 levels @ 2nd to 6th day after birth from a heel stick sample
-Measure height, weight, HC, and developmental milestones

S/S
-Lethargy
-Hoarse cry
-Large, protruding tongue
-Hypotonia, puffy and pale
-Distended abdomen
-Prolonged jaundice
-Constipation
-Feeding problems
-Cold to touch
-Excessive sleepiness

Management
-On thyroid medication for life

Anticipatory Grief
 Experienced when told of the impending death of infant

41
  Prepares and protects parents who are facing a loss
 Parents who have an infant with a debilitating disease, but one that may not
threaten the life of the child, also may experience anticipatory grief

 Loss of an infant
 Health care professionals can help by:
 Involving family in the infant’s care
 Providing privacy
 Answering questions
 Preparing the family for the inevitability of the death
 Growing emphasis on hospice and palliative care for infants and
their families

Key Points
 Preterm infants are at risk for problems stemming from the immaturity of their
organ systems
 Nurses who work with preterm and other high risk infants observe them for
respiratory distress and other early symptoms of physiologic disorders
 Adaptation of parents to preterm or high risk infants differs from that of parents to
normal term infants
 Nurses can facilitate the development of a positive parent-child relationship
 Nurses’ skills in interpreting data, making decisions, and initiating therapy in
newborn intensive care units are crucial to ensuring infants’ survival
 Parents need special instruction before they take home a high risk infant
 CPR
 Oxygen therapy
 Suctioning
 Developmental care
 SGA infants are considered at risk because of fetal growth restriction
 High incidence of nonreassuring fetal status among postmature infants is related
to progressive placental insufficiency that can occur in a postterm pregnancy
 Specially trained nurses may transport high risk infants to and from special care
units
 Parents need assistance coping with anticipatory loss and grief
 Regardless of infant’s disorder or condition, care provider must remember that
infant belongs to a family that also has many needs
 Infection in neonate may be acquired:
 In utero
 During birth
 During resuscitation
 From within the nursery
 Nurse often is first to observe signs of newborn drug withdrawal
 Providing high-quality perinatal care to a varied population with multiple
conditions is complicated by special needs of high risk, drug-dependent clients

42
  Signs and symptoms of infant withdrawal vary in time of onset depending on type
and dose of drug involved
 Most widespread use of postnatal testing for genetic disease is routine screening
of newborns for inborn errors of metabolism
 Curative and rehabilitative problems of an infant with a congenital disorder are
often complex and require a multidisciplinary approach to care

Test Break Down:

High risk pregnancy, high risk newborn, and high risk L&D (post partum) spread out
evenly between all of the packets

43