103- Final Exam Master Study Guide

Newborn Adaptation

- Lung development
● Fetal lung fluid (amniotic fluid)
● Surfactant (34-36 weeks)
○ Reduces alveolar surface tension
○ Prevents the alveoli from sticking together when your baby exhales
○ If not adequate surfactant → will be in respiratory distress
○ Given in NG tube or airway
● Requires negative pressure
● C section baby has harder time

Chemical → oxygen (hypoxia)

Mechanical → most common (recoil from birth/squeeze)

Thermal → warm to cold air

Sensory → touch/rubbing/stimulating

- Cardiovascular
● Ductus venosus
○ a shunt that allows oxygenated blood in the umbilical vein to bypass the
liver and is essential for normal fetal circulation
○ Closes 1-3 days
○ Blood AWAY FROM LIVER
● Foramen Ovale
○ opening before birth that allows blood to bypass the lungs
○ away from right atria to left atria
○ Cord clamping causes left heart pressure to be greater than right
heart
○ Closes within minutes
● Ductus Arteriosus**
○ Shunts blood away from lungs by connecting pulmonary artery to
descending aorta
○ Baby may have murmur, BP all 4 extremities, early cardiac testing
○ Infants with asphyxia at birth may have patent ductus arteriosus (PDA)
and may take longer
Thermoregulation
Evaporation: sweat from the capillaries of the skin (water of sorts)

- DRY BABY

Conduction: losing heat through physical contact with another object or body

- Cold scale hands

Convection: losing heat through the movement of air or water molecules across the skin.

- Fan, close doors/windows/vents, trafficked areas

Radiation: heat loss through infrared rays. transfer of heat from one object to another, with no
physical contact involved.

- Near walls and windows

Nonshivering Thermogenesis (NST): increase in metabolic heat production that is not
associated with muscle activity.

Uses Brown fat → develop in 3rd trimester (26 weeks)

Cold Stress: vasoconstriction to minimize heat losses, followed by a rise in metabolic rate to
increase heat production (temp less than 97.7 approx)

- Increase metabolic rate

- Increased O2
- Increase acid production (from decreased glucose)
- Increase Fatty acids (jaundiced)
- Decreased surfactant
- Decrease in Glucose
- GFR (grunting, flexing/flaring, retracting)
- Interventions
- SKIN to SKIN
- Baby in blanket/Hats
- Warmers/incubators
- Assessment in baths
Hematologic
● Timing of cord clamping
○ provide safety net in case; more RBCs and O2 in baby
○ Can cause jaundice (benefit outweigh risk)
○ 30-60 seconds until cord stops pulsating
● Babies carry more O2 and have more RBCs than adults
● Vitamin K → helps clotting
Gastrointestinal
● Stomach (6ml/kilo)
○ size of marble at birth and grows rapidly
○ Rapid peristalsis (why need to eat more often)
○ Gastrocolic reflex stimulated when stomach fills (reflux, spit up if overfeed)
● Intestines
○ Long in proportion to size-- more surface area for absorption
○ More prone to rapid water loss (dehydration)
○ Bowel sounds present within first hour
○ Digestive tract is sterile until feeding begins
○ Deficient in amylase and lipase (abundant in breast milk)
● Meconium-first stool(s)
○ Greenish-black, sticky, thick, tarlike
○ Usually within 12 hours
○ Can be in utero → INFECTION
■ long/hard delivery
■ Past due date
■ Diabetic or high blood pressure
■ smoked /drugs
○ Meconium aspiration
■ Stained fluid/cord
■ Respiration problems/limp
■ Slow HR
■ Interventions → O2 and Suction @ birth
● Transitional stool
○ Dark green-yellow
○ Combination of meconium and milk stools
○ Can take up to 3 days
● Milk stools
○ Breastfed infant
■ Seedy, mustard color
■ More frequent (2-5 by 4th day)
■ Sweet-sour odor
○ Formula-fed infant
■ Pale yellow to light brown
■ Firmer consistency
■ More characteristic odor of stool
Urinary System
- Unable to dilute or concentrate urine
- May see uric crystals if intake decreased (brick red dust; pinkish)
- Parents may think baby bleeding (common in breastfed babies)
- Diuresis of extracellular fluid--5-10 % weight loss
- I & O → measure diapers
- Low intake = low output
- Start ½ oz - 1 oz
- Diarrhea = WATER RING in diaper

Bilirubin

- Liver responsible for conjugation of bilirubin

- Hemolysis of RBCs
- Conjugated- liver converts into a soluble form (direct)
- Unconjugated- in blood stream causes jaundice (indirect)
- Bilirubin encephalopathy (brain)
- Kernicterus (chronic neuro damage)

Risk factors for Hyperbilirubinemia

● Premature babies**
● Shorter red blood cell life (NB= 80-100 days)**
● Liver immaturity
● Blood incompatibility** (ABO ; rH factors)
● Gestation*
● Delayed feeding
● Trauma (resuscitation)

Physiologic jaundice

● Transient hyperbilirubinemia (will correct itself)

● Never present in first 24 hours, usually 2-3 days
● Usually visible when levels greater than 5 mg/dL
● 5 or less at 24 hours= low risk, 8 or greater = high risk
● Bruised babies more likely to have jaundice (birth trauma)
● Good lighting is needed to assess color
● Will blanch, can see yellow if newly starting
● Jaundice babies are SLEEPY (not feeding/pooping)
Pathologic jaundice

● May occur in first 24 hours

● May rise higher and last longer
● Typically will need phototherapy/exchange transfusion
● Causes:
○ excessive rbc destruction
○ problem with conjugation of bili
○ Infection, hypothyroid, diabetic mom, ABO/rh incompatibility

Hyperbilirubinemia (Pathologic jaundice)

● Hemolytic Disease of Newborn (HDN- destruction of fetal RBCs by maternal
antibodies)--> Rh or ABO incompatibility
● Bilirubin elevated in first 24 hours of life-
● Prevention
○ Identify incompatibilities- cord blood for type, Rh and DAT (Coombs)
○ Rhogam when appropriate
● Routine TCB screening
● Phototherapy- changes bili into water soluble substance for excretion
○ Eye protection
○ May room -in
○ Educate parents
● Exchange transfusion to replace blood supply (Hydrops-Rh incompatibility)
○ Complications- electrolyte imbalance, infection, dysrhythmias, air embolism
○ Nurse’s role- prepare equipment, cardiac monitor, monitor vital signs and fluid
status, provide warmth, educate parents
Breastfeeding jaundice → Inadequate intake (pump/feed asap)

True breast milk jaundice → can last up to 3 mo (phototherapy needed)

Immune system → less effective in newborn

● Immunoglobulin G (IgG)- maternal to fetus ( “GO” from mom to fetus)
○ Crosses placenta
○ Temporary immunity
● Immunoglobulin M (IgM)- produced by fetus (“mine mine mine”)
○ Produced when exposed to sources of infection
○ Don't cross placenta
● Immunoglobulin A (IgA)- mostly by baby
○ Some from colostrum and breast milk
○ Must be produced by the infant to build immunity
○ Don't cross placenta
● Signs of infection → lethargy, not feeding as well, temp DROP
Periods of reactivity

● First period (birth - 30 min.)- bonding, feeding, skin-to-skin, elevated vitals

● Sleep period- pulse and respiratory rates decreased, infant sleeps
○ Not interested in feeding (Deep sleep)
● Second period of reactivity (4-6 hours )- again interested in feeding
○ Awake, alert, bonding

Behavioral states

● Deep or quiet sleep state- no feeding

● Light or active sleep state- moving around a little, will feed*
● Drowsy state- better luck feeding during this*
● Quiet alert state - feeding, bonding *
● Active alert state- fussy, feed quickly or dont feed
● Crying state- not interested in feeding

Newborn Assessment (every 8 hours AT LEAST)

Tone, HR, Breathing 3 most important assessment after birth

What do we need to know ?

- Pregnancy, labor and delivery information

- Gestational age (preterm vs term babies)
- Maternal risk factors (Magnesium sulfate/ Narcotics)
- Rupture of membranes (how long?)
- Group B strep status
○ Every mother gets checks @ 35 weeks
○ If positive, antibiotics during labor + prenatally
○ Vitals every 4 hours
- Maternal blood type and Rh status
- Delivery trauma (vacuum? Pushing long? Shoulders stuck?)
- Apgar scores (1 min and 5 min)
Group B Strep
- Bacteria on skin
- Can cause life threatening infection for baby
- ALL pregnant women tested 35-37 weeks gestation
- Tests: vaginal/rectal swab
- Treatment: antibiotics during birth (penicillin or ampicillin)
- If no prenatal care → give as precaution
- Can have problems after birth →
- Maternal: sepsis, chorioamnionitis
- Baby: meningitis, sepsis, pneumonia

Apgar scores*** ( Completed at delivery)

- At 1 and 5 minutes (0-10 score)
- Snapshot in time for how baby is doing
- Every 5 minutes until greater than 7
- Scores of 8 or above- no resuscitation needed
- 3 or less; baby in trouble

Initial assessments (Reassess every 30 minutes)

- ABCS
- Respiratory distress
 - tachypnea, grunting, flaring, retractions, cyanosis, asymmetry, seesaw
- GFR: grunting flaring, retracting
- Heart sounds- greater than 100 (typically higher than that)
- Color- cyanosis, acrocyanosis, pallor, ruddiness
- Pulses-brachial and femoral
- Thermoregulation (temperature soon after birth)
- Initiate skin to skin
- Warmer pre-warmed

Assessment 1 hour of age

● Measurements
● Growth Charts- weight vs gestational age
○ SGA (small for gestational age)- below 10%
○ AGA (appropriate for gestational age)-between 10% and 90%
○ LGA (large for gestational age)-greater than 90%
● Medications
○ Erythromycin eye ointment: required (Infection)
○ Vitamin K: required (clotting)
○ Hepatitis B: Need consent
Ballard score-- higher score =greater gestational age (10-50)

Vital signs
every 30 minutes X 4

every 1 hr X 2-4

4 hr X 24 hrs

then every 8 hrs (dependent on facility policy)

EVERY 4 hours regardless if mom is step B +

BP not standardly taken (80/50 normal average)

Systems Normal Physiological Variations
Variations
Vital Signs HR- 110-160 bpm --apical (one
full min)
Resp- 30-60 breaths/ min
Temp-- axillary preferred
36.5-37.5
Skin Smooth, elastic turgor and
subcutaneous fat, peeling after 24hrs
Milia (small white bumps on skin),
vernix in creases
Lanugo (hair)
Erythema toxicum (newborn rash)
Mongolian Spots (blue spots) usually
on butt and bruising
Telangiectatic nevi (stork bites)
Acrocyanosis (first 24 hrs) normal for
infants (blue hands and feet)
Head Round or slightly molded
Caput succedaneum (swelling)
Open soft, flat anterior and
posterior fontanels (can bulge
when crying)
sutures may be slightly separated
or overlapping due to molding
Posterior fontanelle usually
closes 2 mo(triangular), anterior
fontanelle longer (18 mo;
diamond shaped front of head)
Eyes Sclera white or bluish-white
Transient strabismus (eyes not
aligned)
Abnormal Physiological
out of normal range
Extreme desquamation, many
visible veins - postmaturity
Meconium staining-- fetal
distress
Cyanosis/ persistent mottling
- Heart disease, asphyxia /
perfusion issues/chromosomal
abnormality
Jaundice (within 24hrs) -
blood incompatibilities, sepsis,
drug reactions,
Vesicles-- herpes, syphilis
Bulging/sunken fontanel--
increased ICP/ dehydration
Widely separated
sutures--Hydrocephalus
Premature suture
closure--Genetic disorders
Cephalohematoma-- blood
under periosteum due to
trauma-only on one side (does
not cross suture lines; 1-3mo to
resolve)
Sclera yellow → jaundice
Sclera blue → osteogenesis
imperfecta
 Pupils = and reactive
Nose Midline
Appears Flattened
Occasional Sneezing
Ears Pinna at or above level of line
drawn from outer canthus of eye
Well formed and firm with instant
recoil if folded against head
Face Awake
Flexed extremities
Moves all extremities
Strong lusty cry
Obvious presence of
subcutaneous fat
White spots on lens =
cataracts?
Short, upturned, small philtrum
(creases under nose)-- fetal
alcohol syndrome
Nasal flaring-- respiratory distress
Grunting--respiratory distress,
choanal atresia (bone blocking
nasal passage)
Snuffles-- Syphilis
Excessive sneezing-- drug
withdrawal
Low-set-- Down Syndrome
Unformed, soft-- Prematurity
Preauricular sinus-- Possible
renal anomaly
Little subcutaneous fat
Frog position
Flaccid
Hard to arouse
High-pitched cry
Intrauterine growth problems/stress
Prematurity
Asphyxia (lack of O2), Prematurity
Sepsis, CNS problems, Asphyxia
CNS damage, Hypoglycemia,
withdrawal
Mouth Symmetrical movement
Intact lip and palate (finger in back of
mouth to feel for openings that
shouldn't be there)
Epstein pearls (white spots on roof of
mouth)
Mobile tongue (tongue tie?) trouble
with breastfeeding
Sucking pads in cheeks
Reflexes: rooting, sucking,
swallowing, and gagging
Neck Short
Full range of motion
Ability to lift head momentarily
Chest Symmetric excursion
Breath sounds clear and equal
(usually crackly and moist initially)
Transient rales at birth
Round
Breast engorgement/ white discharge
Transient murmurs
Abdomen Rounded, soft
BS present x 4 quadrants--stool X 1
by 24 hrs (first 15-30min)
Two arteries and one vein in cord:
white cord with wharton jelly (AVA)
Asymmetry-- facial nerve injury
Cleft lip-/ palate- genetic disorder
White plaques on cheeks, tongue--
Monilia infection/ thrush
Excessive drooling-- esophageal
atresia
Limited range of motion-- torticollis
Nuchal rigidity-- meningitis
Enlarged thyroid--Hyperthyroid
Crepitus-- fractured clavicle
Large fat pad--chromosomal
abnormality
Persistent murmur-- abnormal blood
flow through the heart
Visible activity over
precordium--Congenital heart
anomaly
Retractions-- Respiratory distress
Asymmetrical chest-- Pneumothorax
Scaphoid/sunken-- diaphragmatic
hernia
Distention/ visible loops of bowel--
meconium ileus, GI obstruction
Hepatosplenomegaly-- Sepsis
Purulent discharge from cord/ foul
odor-- infection
 One artery-- Renal or heart
anomalies

Omphalocele-- Abdominal content

in umbilicus

Gastroschisis-- Abdominal
content on outside

Genitalia Normal Female Labia minora and clitoris visible

-- Prematurity
- Slightly edematous labia covering
clitoris and labia minora Undescended testes--
Prematurity
- Pseudomenstruation/white mucus
vaginal discharge Meatus on dorsal surface
penis--Epispadias (wont
Male circumcised)

Penis with foreskin (won't retract all Meatus on ventral surface

the way for several years) penis--Hypospadias (wont
circumcised)
Meatus in middle of tip of penis
Fluid in scrotum around
Descended testes testis--Hydrocele

Slight edema of scrotum Intestine in inguinal canal--

Inguinal hernia
Rugae on scrotum

Extremities Arms, hands, fingers, legs, feet, toes Polydactyly/Syndactyly--extra/w

ebbed digits
Flexion
Difference in pulses
Symmetrical movement upper/lower--coarctation of aorta

Palpable brachial and radial pulses Absence of plantar

(equal and symmetrical) creases--prematurity

Reflexes: Moro (startle), palmar Rigid fixation of ankle--clubfoot

(hand), plantar grasp (foot), babinski
(stroke foot) Absent Babinski-- CNS injury

Multiple palmar and plantar creases flapping tremors-- Down Syndrome

Slight bowed legs = good tone single transverse palmar crease

(simian)
Femoral pulses present
Incurving little finger
 Jittery → glucose (hold down for
difference between seizure;
rhythmic?)

Back Spine intact Pilonidal dimple or sinus--CNS

Symmetrical gluteal folds
Equal limb lengths
Dimple? Can you see the bottom?
anomaly, covert spina bifida
Hip click, unequal limb lengths,
asymmetrical gluteal folds--
Congenital hip dysplasia

Anus Patent anus GI obstruction, Imperforate anus

Stool meconium (first stool) Absence of stools after 24 hrs

Reflexes

Cephalhematoma
Nursing Care: Ongoing
- Vital Signs per protocol
- Head to toes assessment every 8 hours
- Infant bathing
- Delayed bathing if parents with
- Check TEMP before and after bath
- Cover parts not being washed (TEMP REGULATION)
- Involve parents + Skin to Skin post bath!
- Cord care
- Fall off 10-14 days
- NO tub baths until healed
- DRY and diaper BELOW
- Infection symptoms
- Circumcision
- Consent needed
- Contraindications: infection, meatus displaced, have not voided
- Pain management: lidocaine, sucrose on tongue; PRN tylenol afterwards
- Methods--Gomco Clamp, Mogen clamp, PlastiBell Ring
- Circ care: going to look red, heals within days, put a lot of vaseline, check every
15 min for bleeding (Vaseline)
- Baby needed to have at least one void before circumcision
- Intake and output
- Record number of wet diapers (uric crystals = dehydration)
 - Record number of stools (type and size)
- Emesis (spit up)
- 1 day → 1 void and 1 stool
- Monitor for Jaundice
- Visual → blanch nose and chest
- Transcutaneous Bilirubin (TCB) (routine at 24 hours)
- Bilitool (don't need order for this)
- Total Serum Bilirubin (TSB) ( if TCB is abnormal (blood draw))
- Combination of indirect (unconjugated; not soluble) and direct(conjugated;
what can be excreted).
- Prevention/Treatment
- Frequent feeding
- Exposure to sunlight
- Phototherapy
- Monitor for blood glucose changes
- Infants at risk--Pre/post mature, Late Preterm infant, IUGR, LGA or SGA,
Asphyxia, Birth trauma, Cold Stress, Maternal diabetes
- Signs and Symptoms -- Jittery, Tremors, Low Temp, Lethargy, Irritability
- Hypoglycemia-- BS less than 45 mg/dL initially, the 50mg/dL by heel stick
- baby can seize and develop brain damage
- Can be asymptomatic, poor sucking bc lack of energy

***SGA, LGA, and infants of Mothers with Diabetes are routinely screened (checking at 90
min weather fed or not)

- Try feeding first, then use glucose gel

- Check 90 min after birth, and if low, refeed and check again in 30 min to see if worked
(x3)
Infant screening tests (24 hour tests)

● Critical congenital heart defects (CCHD) → after 24 hours

● Hearing Screening (can be done before 24 hours but usually not)
● Newborn Screen (after 24 hours)
Rh Incompatibility (28 weeks + 72 hrs after delivery)

mother is RH negative and Infant is RH positive (autosomal recessive)

RoGAM → shot to affect future fetus (so body doesn't attack itself)

Done following delivery, pregnancy termination, following any abdominal trauma, ectopic
pregnancy, version, or after procedures such as amniocentesis or chorionic villus sampling.

ABO Incompatibility

mother's Blood type is O and the infant is A, B, or AB

Cord blood is tested.

Infants in these situations are at high risk for Jaundice

Infant Feeding; Matches stool

Breast Milk (ideal for baby)

Lactogenesis I--Colostrum (immunoglobulins)

Lactogenesis II--Transitional milk

Lactogenesis III--Mature milk (3-5 days)

- Estrogen and progesterone start milk production

- Prolactin → Milk production
- Oxytocin → Milk let down/release
- May add iron after 6 mo
- Extra 300 calories for breastfeeding moms

Fewer GI problems, less obesity, less necrotizing colitis, less ear infections, asthma, SIDS, less
allergic reactions
Breastfeeding Teaching
● Identifying hunger cues (reflexes)
● Position of mother and infant
● Latching-on
○ Lips flared out
○ Tongue down
○ Deep latch (should see not a lot of the areola)
● Suckling pattern
● Removal from breast → Finger in mouth
● Frequency and length of feedings (2-3 hrs)

Common Breastfeeding Concerns

Maternal

● Breast problems → Prenatal breast exams

● Nipple shape → everted, flat, inverted, retracts
● Illness in mother → antibodies for baby
● Medications → can't with drug use, methotrexate, lithium
● Breast surgery → mastectomy
● Employment → embarrassed
● Milk expression → Hand expression
● Storing milk → Fridge (4 days) or freezer (6 mo)
● Multiple births
Infant

● Sleepy
● Nipple confusion (bottles vs breast)
● Latch problems
● Infant complications
○ Jaundice
○ Prematurity
○ Illness and congenital defects

Formulas
●Modify cow’s milk to compare with breast milk

- No cow milk until 12 mo of age

- Reduce protein content
- Remove saturated fat

●Formulas for infants with special needs

- Soy/protein hydrolysate
- Protein hydrolysate
- Low phenylalanine

Teaching

● Frequency/ Amount (1.5 - 3oz every 2-3 hours)

● Types of formulas + how to mix them
○ Powder
○ Concentrate
○ Ready to feed
● Explaining feeding techniques - not propped, no microwaved, Burping
● Engorgement- no stimulation, snug fitting bra, cabbage leaves in bra
○ Can lead to mastitis (infection of breast)
 High Risk Newborn (Gestational Age and Development)
Preterm Infants (Born before 37 weeks)
● Extremely preterm (<28 wk)
● Moderately preterm (28-33+6 wk)
● Late preterm ( 34-36+6)
● Prevention if possible (prenatal care)
● Appearance- frail, weak, red translucent skin,larger head, decrease tone, more vernix
and lanugo,
● Behavior- tire easily, flaccid, increased need for sleep, feeding challenges
● CONTINUOUS MONITORING FOR ALL THINGS

Preterm Respiratory

● Poor cough
● Low surfactant levels (helps keep alveoli open)
● Apneic spells (> 20 seconds). May require stimulation
● Respiratory distress syndrome (RDS)
○ Low surfactant levels
● Use of respiratory equipment
● side-lying, prone- supine when tolerated
● Suction secretions only when necessary (only 5-10 seconds)
● Maintain hydration (thins secretions)

Preterm Thermoregulation

● Thin skin, blood vessels close to the surface, little subQ & brown fat, larger body surface
area
● Assess for hypoglycemia, resp. Distress, irritability, poor muscle tone, mottled skin
● Low temp may indicate infection/hypoglycemia
● Neutral thermal environment
○ Warm delivery room
○ Saran wrap or plastic bag
○ Incubator vs. warmer
○ Caution against overheating
○ Warmed oxygen if necessary

Preterm Fluid and electrolyte balance

● Rapid fluid loss (immature kidney)

● Sodium loss
● Strict I&O - diapers, emesis, IVs/ meds, blood draws, drainage tubes
● Weight- same time everyday (Indicates water loss)
● Careful monitoring of IV fluids and sites every hour
Preterm Skin

● Minimal adhesives, remove carefully

● Specially designed devices
● Minimal bathing
● NO soap <32 wks
● Chlorhexidine instead of alcohol
● No betadine
● Disinfectants removes with sterile water

Preterm Infection

● 3-10x greater risk → Transmission in utero, at birth, after birth

● Maternal infection, immature immune system, no IgG in third trimester
● Invasive procedures
● Assess for S/S of sepsis →Sepsis neonatorum : bacteria in the bloodstream early
onset (1st wk), late onset (7-30 days)
○ Conduct blood tests, possible antibiotics)
○ Temp low, breathing problems, decreased bowel movements, low blood sugar,
reduced movements, reduced sucking, seizures
● Strict handwashing
● TORCH infections increase risk of anomalies
○ Toxoplasmosis (No cat litter)
○ Other (GC, Hep B , varicella zoster, syphilis, parvovirus, HIV, etc. )
○ Rubella
○ Cytomegalovirus (CMV)
○ Herpes simplex virus

Preterm Pain

● Infants DO feel pain with negative effects

○ Increased ICP ( risk for hemorrhage)
○ hypoxia/ increased metabolic rate
● S/S of infant pain
○ increased/decreased VS
○ Decreased O2 sat
○ High-pitched cry
○ “Cry face”- eyes squeezed shut,grimace, open mouth, furrowed or bulging brow
○ Tense tone- rigid
○ Changes in sleep-wake patterns
● PIPP tool
● Skin-to-skin or nursing (esp. for procedures)
● Sucking/sucrose
● Opioids pre-procedure, Tylenol
 Preterm Infants: Common complications
Respiratory Distress Syndrome- due to insufficient surfactant

● During first hour after birth

○ Tachypnea
○ Tachycardia
○ Nasal flaring, Retractions
○ Cyanosis
● Therapeutic management
○ Surfactant administration
○ CPAP/mechanical ventilation
○ fluids

Chronic lung disease (Bronchopulmonary Dysplasia)- O2 still required after 28 days/unable

to wean

● Prevention- steroids before birth, minimal O2 amounts and pressures

Intraventricular Hemorrhage (IVH) -bleeding in brain, fragile blood vessel, increased or

decreased pressure-- many causes

○ May develop Hydrocephalus (spinal fluid in brain)

○ Minimal handling
○ Reduce pain and environmental stressors
○ Daily head circumference
○ Observe for neuro changes
Retinopathy of prematurity- Injury to blood vessels in eyes. May lead to visual impairment or
blindness

○ Risk with high levels of oxygen administration

○ Also associated with prolonged ventilation,acidosis, sepsis, shock, IVH,
fluctuating blood oxygen levels
○ Now Titrate oxygen to O2 sat levels

Necrotizing enterocolitis (NEC)- inflammatory condition of GI tract, possibly from intestinal

hypoxia and feeding too soon or increased too fast

○ Breast Milk may have preventative effect, recognize early- withhold feeds and
notify provider
○ Monitor abdominal girth, manage parenteral feeds, I&O, positioning, antibiotics
as ordered
○ Feeding too fast or too much

Short Bowel Syndrome-bowel shorter than normal due to congenital malformation or

surgery-malabsorption, nutritional deficiencies

○ Nutritional/ fluid support- monitor TPN and enteral feeds

○ Not going to absorb nutrition normally
Late Preterm Infants ( 34-36+6)
● Born between 34 0/7 weeks and 36 6/7 weeks gestation
● often look full term
● Behavior-experience challenges
○ Thermoregulation
○ Hypoglycemia
○ Respiratory disorders
○ Feeding
● Thermoregulation-lack of brown fat
○ More frequent temperature assessment
○ Skin-to-skin contact (kangaroo care)
● Hypoglycemia- glucose checks before feedings
● Hyperbilirubinemia → jaundice / dehydration
● Respiratory problems
● Feedings- immature suck/swallow reflexes, shorter wake periods
○ Feeds every 2-3hrs
○ Monitor weight carefully
● Car Seat Challenge test

Preterm Labor (After 20th week but before 37 weeks)

● Uterine contractions that cause cervical changes 20-37 weeks gestation
● Risk: Infection, diabetes, smoking, hypertension, multifetal pregnancy, PROM, placenta
previa, early gestation
● Signs: cervical dilation, discharge of amniotic fluid, uterine contractions/cramping,
pressure, backache, vaginal pain
● Labs: Fetal fibronectin (amniotic enzyme)
● Treatment: magnesium (risk toxicity) (calcium gluconate reverses), nifedipine (help relax
uterine muscle), trobutiline (tocolytic), indomethacin (NSAID), betamethasone (lung
maturity)

Postterm Infants
● Born after 42 weeks-
○ May be large (time for increased growth) or smaller (less perfusion through an
aging placenta)
● Assessment:
○ Size for gestational age
○ Hypoglycemia, hypothermia
○ Dry, wrinkly or peeling skin, little to no vernix, hair on head, long nails
○ May have meconium fluid at delivery

Postterm Pregnancy
 ● Complications: placental insufficiency (potential fetal compromise), oligohydramnios,
late growth restriction, meconium aspiration, large fetus (Dysfunctional labor- , operative
delivery, postpartum hemorrhage, shoulder dystocia, trauma), increased risk of fetal
mortality
● Management: accurate determination of gestation, tests for fetal well-being-NST,
biophysical profile, amniotic fluid index, stripping membranes, induction

Small for Gestational Age (SGA) Infants

● Below 10th percentile for weight
● Ultrasound and fetal surveillance to determine when delivery becomes necessary
● Nursing considerations:
○ Monitor hypoglycemia- glucose checks begin at 90 minutes after birth, then q3
hrs X 24 hrs prior to feeds
○ ??? hr feeds and vital signs
○ Monitor temp and signs of jaundice

Large for Gestational Age Infants (LGA)

● Weight above 90th percentile
● Observe for hypoglycemia and respiratory problems
● Assess carefully for S/S of injury →
● Monitor Glucose beginning at 90 minutes after birth, then q 3 hrs prior to feeds X 12
hrs

Asphyxia- LACK OF O2 in utero, at birth, in infancy

● Primary apnea → Come out of it

● Secondary apnea →continues; need resuscitation
● All infants at risk

Neonatal resuscitation (NRP)

● Therapeutic hypothermia - neuroprotection for Hypoxic -Ischemic Encephalopathy (HIE)

Transient Tachypnea of the Newborn (TTN)- usually from inadequate reabsorption of lung
fluid

● Tachypnea within 6 hours of birth, S/S of respiratory distress

● Fluid in lungs on imaging
● GFR (grunting, flaring, retracting
● Therapeutic management-supportive
 ○ O2, sometimes CPAP (to get rid of fluid)
○ Gavage feeds

Meconium aspiration syndrome -meconium passed in utero enters lungs causing

obstruction--S/S respiratory distress

● Preparation at birth- Respiratory therapist ,SCN, resuscitation equipment ready

● Watch for S/S of infection
● Persistent Pulmonary Hypertension of the Newborn (PPHN)
○ Tachypnea, respiratory distress and progressive cyanosis- usually within 12 hrs
of birth
○ Treat cause of poor oxygenation
○ Manage thermoregulation, glucose levels and minimize stressors-handling, noise

Birth Trauma
● Soft tissue, skeletal, peripheral or central nervous system (Hematoma, fractures)
● Risk Factors
○ Maternal
■ Age < 16 or > 35 (extreme ages)
■ Primipara (giving birth first time)
■ Uterine Dysfunction (causes prolonged labor)
■ Preterm/ Post Term labor
■ Cephalopelvic disproportion (CPD): baby's head is too big for pelvis
■ Oligohydramnios (decreased amniotic fluid)
○ Fetal
■ Macrosomia (larger than average baby)
■ Malpresentation (shoulder dystocia)
■ Multifetal pregnancy (more than one baby)
■ Hydrocephalus/ Congenital anomalies
○ Procedures
■ Fetal scalp electrode
■ Fetal scalp blood sampling
■ Vacuum/ forceps***
■ Cesarean birth (breech baby)

Infant of a diabetic mother

● Risks: Congenital anomalies, macrosomia (bigger babies), birth trauma, respiratory
distress syndrome (delay surfactant production), hypoglycemia, hyperbilirubinemia and
polycythemia, hypocalcemia and hypomagnesemia, and cardiomegaly.
○ Macrosomia
○ Round face, red skin. Body is obese, poor muscle tone at birth
 ● Therapeutic management
○ Respiratory management as needed
○ Control hypoglycemia (Glucose does not pass placenta; insulin does)
● Nursing considerations
○ Assess glucose beginning at 90 minutes of life and q 3 hrs before feeds X 12 hrs
○ Early and adequate feeding, glucose gel

Prenatal drug exposure

● Neonatal Opioid Withdrawal Syndrome (NOWS)/ Neonatal Abstinence Syndrome
(NAS)
○ Eat- Sleep-Console
● Therapeutic management
○ Observe signs of withdrawal- irritability, hyperactivity, high-pitched cry, poor feed,
nasal congestion (finnegan score)
○ Medications as ordered (urine test reportable)
● Nursing considerations
○ Maternal urine collection
○ Fetal urine and meconium collection (longer term than urine specimen)
○ Encourage bonding- feeding, cuddling, rest, decreased stimulation
○ Social services consult- plan of safe care

Gastro Congenital Anomalies

● Cleft lip and palate
○ Assessment- inspection and palpation of mouth
○ Interventions - altered feeding strategies (Surgical repair)
● Esophageal Atresia and Tracheoesophageal Fistula
○ Assessment- Distended abdomen, gastric secretions aspirated into lungs causing
respiratory S/S
■ Frothy drooling
■ Unable to pass catheter into stomach
■ Imaging best
○ Interventions
■ Observe for feeding difficulty
■ Prevent
■ Suctioning and gastrostomy tube
■ Surgical intervention
● Omphalocele and Gastroschisis- anomalies in the abdominal wall
○ Omphalocele- intestines protrude into the base of the umbilical cord
○ Gastroschisis- intestines protrude out of the body
○ Assessment: inspection
 ○ Interventions: gastric tube and suction,parenteral nutrition, antibiotics, place torso
in a bag with saline (decrease water and heat loss), surgery

Respiratory Anomalies

● Diaphragmatic Hernia- abdominal contents protrude into chest cavity through a hole in
the diaphragm, may hinder lung development
○ Pressure on heart and lungs
○ Assessment- Respiratory S/S, heart sounds displaced to the right, scaphoid
abdomen (concave), bowel sounds in the chest
○ Interventions: ET tube for ventilation, gastric tube to decrease air in the stomach,
position on affected side, elevate head, surgery
● Choanal atresia- obstruction of posterior nares
○ Respiratory distress/color changes at rest that improve with crying
○ Snorting respirations, nasal discharge
○ Difficulty eating and breathing at the same time
○ Oral airway, prone position, supportive care
● Laryngeal web- incomplete separation of sides of larynx
○ tube, Surgical emergency
○ Respiratory distress, weak or high-pitched cry

Musculoskeletal Disorders

Developmental Dysplasia of the Hip (Congenital Hip dysplasia) → check hip clicks

Risks → Intrauterine positioning, oligohydramnios, genetic /family history

Splinting with Pavlik harness (goes up to shoulders)

Clubfoot-abnormal curve to foot and ankle (feet turned in; can you reposition?)

- Serial casting

Inborn Errors of Metabolism

Newborn Screen tests for 50 IEM

Phenylketonuria (PKU)-screen 24 hours after beginning of feedings

- Need special diet (low phenylalanine diet) → low protein

Galactosemia- breastfeeding contraindicated due to lactose

 - Don't recommend breastfeed

Congenital Anomalies Cont. - Central Nervous System

Neural Tube defects*

● Spina Bifida Occulta, (dimple back of spine)- failure to close

● Meningocele, protrusion of meninges and spinal fluid through the spina bifida
● Myelomeningocele- protrusion of membrane covered sac through the spina bifida
● Folic acid helps prevent neural tube defects (600 mcg)
○ Higher doses if already has baby with neural tube defect (4,000 mcg)
● Assessment: Elevated alpha-fetoprotein level, ultrasound
○ Note level of paralysis by observing movement
○ Observe for dribbling of stool /urine (cleaning baby well)
● Intervention:
○ Positioning (prone or side lying)
○ Cover protrusions with sterile,moist, non adherent dressing but prevent irritation
(no clothes/ blankets)
○ Assess size
○ Keep clean with diaper changes
○ Antibiotics
○ Surgery

Hydrocephalus- abnormal absorption or obstructed flow of CSF in the ventricles of the brain

● Assessment
○ Bulging fontanels
○ Separated sutures
○ Large head
○ Irritability, feeding difficulty
 ● Intervention- Surgical repair-placement of shunt with revision as child grows
○ Head circumference daily
○ Prevent pressure areas
○ Prevent increased ICP
○ Monitor for S/S of infection

Microcephaly- smaller than normal head size (often with other problems-neurological, growth)

Congenital Anomalies: Cardiac defects

Acyanotic defects- increased blood flow to the lungs and those that cause obstruction of blood
flow from the ventricles (Left to right shunting of blood)

- PDA-Patent Ductus Arteriosus- increased pulmonary blood flow

- ASD- Atrial Septal Defect- increased pulmonary blood flow
- VSD- Ventral Septal Defect- increased pulmonary blood flow
- Coarctation of the aorta/ aortic stenosis- obstruction of blood flow from ventricles
- Manifestations:
● Cyanosis or gray color, pallor, motling
● Heart murmurs
● Tachycardia and tachypnea
● Feeding difficulty- cyanosis, fatigue, diaphoresis
- Therapeutic management:
● Support until surgical repair- oxygen and medication
- Nursing considerations:
● Screening
○ CCHD screening (normal > 95% and <3 difference btw upper and lower
extremities)
● Assessment
○ Color, breathing, pulses, heart (rate, rhythm, sounds), feeding tolerance
(breathing and suck, swallow coordination), poor weight gain, diaphoresis
● Interventions- Careful monitoring and support
○ O2, meds,I & O, daily weights, nutrition, skin care, positioning, minimize
demands on heart-restlessness, crying), Neutral thermal environment
Assessment

- Cyanosis increased with crying - pallor/mottling

- Murmur - Tachycardia/ Tachypnea
- Dyspnea - Choking spells
- Poor intake - Falling asleep
- Diaphoresis → sweating - Poor growth
- Tire easily

Nursing Intervention

- Assess for changes -Decrease O2 need

- O2 titrated to saturation levels
- Neutral thermal environment
- Allow rest/cluster care
- Feeds with increased calories
- Surgery (based on status)
- I&O
- Evaluate response to activity
- Gavage feeds if tachypnea
- Meds as ordered
- CCHD before discharge

Cyanotic defects- decreased blood flow to the lungs and those that cause mixing of
oxygenated and deoxygenated blood systemically in the body

- Right to left shunting of blood

- Tetralogy of Fallot ( decreased pulmonary flow)
- VSD
- Overriding Aorta
- Pulmonary Stenosis
- Right Ventricular Hypertrophy
- Transposition of the Great Vessels (mixed blood flow)
 Part 2- Postpartum Mother

Gravida- # of pregnancies

Para- # of pregnancies that have ended at 20 or more weeks

GTPAL- Gravida, Term, Preterm, Abortions, Living

Gravida-# of pregnancies

Term- # of pregnancies ending at term

Preterm- # of deliveries prior to 37 week (< 37-0/7)

Abortions- # Spontaneous and Induced

Living- # of living children (twins individual)

Laboratory data

●CBC → anemia

●WBC- can be up to 25,000 (can have increased if in labor) → infection

●H/H- Drop

●Blood type and Rh factor → rhogam

●Hepatitis B → antibiotics, consent for vaccine

●Rubella - MMR → cannot get in pregnancy

●Syphilis screen- RPR → prenatal screening

●Group B strep status (35-36 weeks testing) → antibiotics

●Varicella status / TDAP status

Vital Signs

Q15 min for 2 hours, Q 4 hours x3, Every 8-12 hours thereafter

Respirations hourly X 12-24 hours after epidural/spinal duramorph

Head-to-Toe → BUBBLE-HE

Breasts → nipple shape, trauma, breastfeeding, mastitis, engorgement

- Cracks, fissures, blisters, redness, and/or tenderness

- Lansinoh ointment, colostrum on edge of nipple
- Engorgement- cool compresses/ cabbage leaves

Uterus → firm/boggy, fundal height

- Involution: 1-2 cm/day

- Contraction of uterine muscle, decreases size of uterus (constantly checking)
- Controls bleeding from site of placental attachment
- Location-- Umbilicus or 1-2 cm above Umbilicus
- Day 14: no longer palpable

Bowels → constipation?

- Iron levels
- Increase fluids
- Stool softener per order (Colace)
- I&Os

Bladder → empty!! Catheter if needed

● Color, quantity, pain/burning, difficulty

● Presence of indwelling catheter (take out during delivery)
● Diuresis- up to 3000 mL per day
● Diaphoresis (sweating)
● Lost muscle tone in bladder
● Traumatized meatus
● Over distended bladder
○ Urinary retention
○ UTI
○ Hemorrhage (uterine atony)
● Bladder elimination--Must void within 6 hours of delivery or catheter removal
○ Ensure Emptying
■ Bladder Scan
 ■ Catheterization may be necessary (until edema goes away)

Lochia → amount, color, oder, clots

- Scant: Less than a 2.5-cm (1-inch) stain on the peripad

- Light: Less than 10-cm (4-inch) stain
- Moderate: Less than 15-cm (6-inch) stain
- Heavy: Saturated peripad in 1 hour
- Excessive: Saturated peripad in 15 minutes
- Constant trickle, dribble, or oozing indicate excessive bleeding and require immediate
attention.
- Lochia rubra: Days 1 to 3--Blood tinge, may be shreds of tissue
- Lochia serosa: Days 3 to 10--Pale pinkish to brownish
- Lochia alba: After day 10--Thicker, whitish-yellowish (contains leukocytes)
- Foul odor suggests infection.

Episiotomy → bleeding? Infection?

- 3rd/4th degree extension/laceration = NO ENEMAS or SUPPOSITORIES

- REEDA
- ○Redness
- ○Edema
- ○Ecchymosis → discoloration
- ○Discharge
- ○Approximation
- Position patient on her side for Perineum Assessment
Homan’s Signs → dorsiflex foot (calf cramping) ASK ONLY

Signs and symptoms of a DVT

○Pain in calves → gently palpate

○Red/ Heat

○Swelling (one leg more swollen than other)

Edema (pitting or generalized)

Pulses, Sensation, Strength, and Capillary Refill

Emotions → baby blues/ PP depression

Reva Rubin

●Taking in: passive and dependent

- Willing to let the nurse do whatever, mom is exhausted.

- Nurse Role: Facilitate rest for mom, listen as she tells the details of her labor/delivery,
identify readiness (or not) to learn infant care and self care.

●Taking hold: autonomous, seeks information, confidence in caretaking builds but feeling
inadequate is normal

- Autonomous, energy, asking questions, start guiding her than doing it for her
- Nurse Role: Avoid taking over mom’s role, empower, praise for efforts, great time for
teaching

●Letting go: total separation of newborn from self, confident in caretaking abilities

-Returning to work, renewing relationship with partner

The uterus will not contract with clots present!

Oxytocin

- Oxytocin in IV after delivery

- Body will produce on their own
- Helps milk production and uterus contraction after birth
- Causes afterpains to be stronger

Abdomen will return to normal position by 6 weeks postpartum

Nursing Care –
- Perineum
- Ice packs
- Sitz bath (cool water for the first 24 hrs)
- Pericare
- Topicals- Dermoplast, Nupercainal, Tucks pads
- Sitting measures
- Analgesics (Motrin, Percocet, Tylenol)

Incision

- Splinting
- Analgesia → pain meds (Motrin , Toradol, Percocet, Tylenol, Morphine)
- Ambulation- 6 hours post op

Nursing Care: Psychosocial

“Baby Blues”

- Mild depression is a frequently expressed concern.

- Condition has an early onset.
- Usually lasts no longer than 2 weeks
- Characterized by fatigue, weeping, mood instability, and anxiety
- Does not usually affect ability of mother to care for infant
- Direct cause unknown
- Self limiting

After 2 weeks → postpartum depression

Edinburgh Postnatal Depression Screen at 6 week pp visit (Over 10 → calling provider )

Discharge Topics (starts at admission)

- Birth certificate
- 24 hr testing
- Rogham shot

Sudden infant death syndrome (SIDS)

- Nothing in crib/ no padding

- No sleeping in bed with parents
- Back sleeping/ no blankets/pillows

Newborn Education

- Follow up with Pediatrician within 1-2 days

- When to call the Doctor
- Temp
- Vomiting/Watery stools
- Rashes/blisters sores
- Changes in behavior: sleeping, irritability
- Coughing, sneezing, runny nose
- Difficulty with feeding
- Any Questions or concerns at anytime

High Risk Postpartum: Risk Assessment

Hemorrhage (MUCH TOE)

>500 ml vaginal delivery - Stage 1

>1000ml for cesarean delivery

Tone-Trauma-Tissue- Thrombin !!!!!

● Risk Factors
○ Grand multiparity (over 5 pregnancies)
○ Overdistention of the Uterus (with large babies, multiples, excessive amniotic
fluid)
○ Precipitous labor (fast labor)
 ○ Prolonged labor (more than fast) (induction, augmentation)
○ Retained placenta (within 30 min) (manual removal, previous Csection)
○ Placenta previa, accreta, abruption
○ Drugs (cocaine)
○ Operative procedures (Csection, vacuum, forceps)
○ infection
● Prevention
○ Assessment of type and amount of lochia per protocol.
○ Assessment for presence of clots/tissue.
○ Fundal massage per protocol and as needed.
○ Frequent and full emptying of bladder.
○ Identification of risk factors.
○ Breastfeeding; stimulates Oxytocin
○ Put in a second IV in as precaution
● Uterine atony (not contracting efficiently) TONE
○ Predisposing factors-
■ Overdistention (polyhydramnios, multifetal pregnancy, large baby)
■ Multiparity
■ Prolonged labor or prolonged oxytocin administration
■ Obesity
○ Clinical manifestations
■ Boggy uterus-difficult to find, unable to maintain tone
■ Fundus above expected level
■ Excessive lochia /clots (check underneath patient)
○ Therapeutic management
■ Oxytocin (first line of defence)
■ Uterine massage
■ Empty bladder
■ Methergine ( contraindicated with elevated BP) (IM, or PO 12-24 hrs)
■ Cytotec (misoprostol) 25mcg (rectally, 800-1000mcg for hemorrhage)
■ Hemabate (carboprost)-not given if history of asthma (not common, may
increase moms temp)
■ TXA (tranexamic Acid) (antifibroinlytic; prevents breakdown of blood
clots)(1g IV)
■ Check underneath the patient !
■ Start pitocin low before placenta delivers, once out crank pitocin up
○ Bimanual compression, Bakri balloon ( uterine balloon tamponade), vacuum
hemorrhage control (Jada)
● Trauma
○ Predisposing factors
■ Same as for atony but add--Induction, augmentation, vacuum, forceps
○ Lacerations- look for these if fundus is firm but bleeding continues
■ Saturating pads
■ May or may not be visible
 ○ Hematoma- Bleeding into tissues
■ Vulvar hematomas (can be seen)
■ Vaginal hematomas (cant be seen)
■ Retroperitoneal hematoma (most serious; csection scar, rupture of artery)
■ Small hematoma will usually resolve
■ Large may need surgery (possible at bedside)
○ Therapeutic management
■ Surgical repair
■ Incision and evacuation of large hematoma, small hematomas usually
resolve
● Late hemorrhage-- can occur up to 12 weeks postpartum
○ Subinvolution
● Retained placental fragments- Tissue
○ Predisposing factors- manual removal of placenta, placenta accreta, previous
cesarean
○ Clinical manifestations
■ Excessive bleeding
■ Pelvic pain/ heaviness
■ Backache
■ Clots*
○ Therapeutic management
■ Same as with early hemorrhage
■ D & C if bleeding persists
■ Education
● Thrombin- possible coagulation disorder
○ Looking at platelets
○ Von Willebrand disease (on anticoagulants during preg; cut off 36 weeks;
desmopressin after delivery)
● Code Magenta - staged response (alters a lot of people, all with jobs assigned)
○ Postpartum hemorrhage cart (notifies blood bank)
○ Identify roles
○ Postpartum hemorrhage protocol
○ Medications-- Pitocin, cytotec, methergine, hemabate
■ More than 2 meds stage 1 → stage 2
○ Continued assessment of blood loss- quantified
○ Foley **
○ IV access
○ Vital signs every 5 min
○ Careful not to put into pulmonary edema (oxytocin 2 L max)

Hypovolemic shock → Shunting of blood to central circulation

● Clinical manifestation
 ○ Tachycardia (usually earliest sign but may not occur until 25% loss)
○ Low BP -late sign
○ Pallor, cool to touch
○ Increased respiratory rate
○ Anxiety→ confusion→ lethargy
● Therapeutic management
○ Second IV line (fluid replacement, transfusion)
○ Foley
○ Vasopressors to maintain BP
● Nursing considerations → Rapid response

DIC → Disseminated Intravascular Coagulation (all coagulation factors used up)

● Secondary condition involving trauma to tissues
○ Placental abruption
○ Preeclampsia/eclampsia/HELLP
○ Retained Intrauterine Fetal Demise
○ Massive hemorrhage
○ Sepsis, etc.
● Life-threatening
● Increased bleeding occurs/ brusing
● Look for excessive or bleeding from unusual places, bruising, petechiae, purpura,
hematuria (blood in urine, blood at IV sites)
● S/S of shock
● Aggressive replacement therapy/ Mass transfusion Protocol
● Thromboelastometry (ROTEM) and Thromboelastography (TEG)-assess clot formation
● dimer and INR not helpful in pregnancy
● Safety Bundles (BE PREPARED: RECOGNIZE EARLY)
○ Readiness (supplies, protocols, staff education/drills)
○ Recognition/ Prevention (risk assessments, quantify blood loss, early oxytocin
administration)
○ Response (emergency plan)
○ Reporting/Learning (review, debrief, practice changes)
○ Ask for help
● Code situation:Team responsibilities-multiple members working simultaneously
○ Fundal checks/ massage
○ Vital signs/O2 sat monitoring q3-5 min
○ Oxygen
○ medication administration
○ Scribe (for any CODE)
Thromboembolic Disorders
● Thrombus - blood clot on vessel wall
● Thrombophlebitis - inflammation of vessel wall due to thrombus
● Embolus - thrombus or amniotic fluid released into bloodstream
● Pulmonary embolism- pulmonary artery obstruction
● Pregnant women clotting factors ENHANCED (body knows what's to come)
● What do we look for
○ Redness
○ Warmth
○ Swelling
○ Pain
● Incidence and etiology
○ Venous stasis
○ Hypercoagulation
○ Blood vessel injury

Superficial Venous Thrombosis

● Clinical manifestations → Not only in calves
● Therapeutic management
○ Analgesics/anti inflammatories (dont recommend NSAIDS)
■ IV or piclines
○ Rest until symptoms gone
○ Elastic support
○ Elevation of lower extremities
○ Ted hose

Deep Venous Thrombosis (DVT)

● Signs and symptoms- absent in most women affected
● Diagnosis
○ Venous ultrasound, Doppler study
○ Magnetic Resonance Imaging (MRI)
● Therapeutic management
○ Prevention of thrombus formation
○ Treatment- Anticoagulants coumadin (but not while pregnant), bedrest, moist
heat application, analgesics
■ Monitor for excessive bleeding
■ Can go on coumadin AFTER but not during pregnancy
■ After symptoms, up and moving to prevent clots
○ Monitor for signs of PE- frequent vital signs and respiratory assessment
 ■Looking for chest pain, hypoxic, tachy, blood with sputum, crackles,
cough, low grade fever
■ Head elevated, Heparin, going to ICU, administer O2
○ Lovenox or Heparin (has to be off 24 hours before epidural or C Section)

Pulmonary Embolism*
● Clinical manifestations
○ Dyspnea,chest pain, tachycardia, tachypnea, hypoxemia
○ Hemoptysis ( expectoration of blood or bloody sputum)
○ Pulmonary crackles, cough
○ Low-grade fever
● Therapeutic management
○ O2, bedrest /elevate head of bed, analgesics, heparin therapy, O2 sat monitoring

Risks- Infection
● Risk Factors
○ Operative procedures
○ Multiple cervical exams in labor (especially if ruptured)
○ Prolonged Labor
○ Prolonged Rupture of membranes (more than 24 hours, prominent risk)
○ Manual removal of the placenta or placental fragments or sweep uterus
■ Usually give antibiotics
○ Diabetes
○ Catheterization
● Prevention
○ Manage Engorgement
○ Incision care
○ Peri care
○ Hand Washing
○ Teaching

Puerperal Infection → Bacterial infection after childbirth

○ Temp ≥ 38°C (100.4°F) after the first 24 hours and occurring on at least 2 of the
first 10 days (on phone to physician)
○ Following childbirth
● Normal anatomy/physiology effects on infection (predisposing factors)
○ Alkaline environment, necrotic tissue, presence of lochia
■ Peripads not changed = bacteria LOVE
● Nursing Considerations
- Identify S/S
- Monitor response to treatment
- Educate- S/S of worsening condition
 ○ Self-care
○ May be treated inpatient or outpatient
- Pumping if separated from infant (mastitis prevention)
- Proper hand hygiene

Endometritis
● Infection/inflammation of endometrium (lining of uterus)
● Very painful
● Risks: C section, coreoamioitis, retained placental fragments, PROM, Prolonged labor,
Internal fetal monitoring, multiple cervical exams
● Signs: FEVER, suprapubic/abd pain, excessive odor lochia, tachycardia, hypotension
● Treatment: IV/oral antibiotics (ampicillin, gentamicin) , analgesics
● Monitor VS Q2-4 hrs

Wound infection
● Includes: abdominal incision, episiotomy, lacerations
● Clinical manifestations
○ Warmth/ Redness/ Edema/ Pain
○ Edges of wound may not be approximated
○ Purulent drainage
● Therapeutic management
○ Cultures
○ Antibiotic therapy
○ Incision and drainage
○ Education- hand hygiene, frequent peri care, S/S to report

Urinary tract Infection

● Etiology
○ Trauma of vaginal delivery, foley placement
○ Urinary distension often (empty bladder frequently)
● Clinical manifestations
○ Urgency
○ Frequency
○ pain/burning with urination
○ Hematuria
● Therapeutic management
○ Antibiotics
○ Encourage increased fluids (esp. acidic drinks such as cranberry, apricot,plum
and prune juices; avoid carbonated and grapefruit)
○ Encourage frequent urination and peri care (peribottle)
Mastitis → Breast infection
● maternal skin or newborn mouth/nose enter through a crack or blister in nipple
● Infection/inflammation of breast
● Common with breastfeeding moms
● Risk: infrequent feeding, clogged milk duct, nipple damage (improper latching), poor
hand hygiene
● Signs: flu like symptoms, FEVER, pain in breast (unilateral), palpable lump, redness,
warmth, enlarged nodes
● Treatment: antibiotics, analgesics, heat prior to feeding, manual milk
expression/pumping
● CONTINUE BREASTFEEDING

Sepsis** (sneaky)
● Widespread infection resulting in organ dysfunction/failure, shock
● Hypovolemia, hypotension, decreased tissue perfusion, potential DIC
● This is a medical emergency!! -early recognition and treatment are key
○ Fluid resuscitation (LOTS)
○ Manage hypotension (checking very often)
○ Antibiotics (broad spectrum)
○ Cultures (before antibiotics)
○ Lactate levels
○ VTE prophylaxis - SCDs, LMWH or unfractionated heparin (worried about
clotting)

Intrapartum Nursing Care

Labor: cervix opening, thinning, baby coming down birth canal

Uterine muscle upper ⅔ most active (bottom more passive)

Contractions

- Coordinated, involuntary, intermittent (will go away)

- Frequency → how far apart? Beginning to beginning (min)
- Duration → how long will it last? (count small boxes (seconds))
- Intensity → how strong?
 - External monitor → must palpate uterine tone (doesn't tell you how strong)
- Internal monitor → counts and charts pressure unit (more invasive)
- Rest → tone and time
- Uterus should be SOFT to palpation between contractions for at least 60 seconds
- Time to recover O2
- Normal contractions → 2-3 min apart in active labor (60 seconds, intensity 60)
- Tachysystole → over 5 contractions in 10 min
Uterus is SMOOTH MUSCLE

Cervix (starts inch thick)

● Mothers will mostly do thinning before dilating (especially multipara)

● Complete = 5cm and 100% thin
● Dilation-opening (gets bigger and thinner) (doughnut reference)
● Effacement-thinning
○ Nullipara-has not completed a pregnancy to at least 20 weeks gestation
■ More cervical effacement before dilation
○ Para (multipara)- has given birth after a ≥ 20 wks gestation pregnancy
■ Cervix usually remains thicker during dilation than that of a nullipara

Fetal Descent (Station)

● Presenting part in relation to pelvic ischial spines

○ Level = 0 (zero) station
○ Above- negative numbers (-1,-2, -3, -4, -5) FURTHER FROM BIRTH
○ Below- positive numbers (+1, +2, +3, +4, +5) CLOSER TO BIRTH
Cardiovascular changes IN LABOR - maternal

● Placental blood flow decreased during a contraction

○ Relative increase in woman’s blood volume- causes slight BP increase, slow
pulse rate
○ Vital signs best assessed between contractions**
● Supine hypotension when lying on back
○ Alternate positions promote blood return to the heart
○ Put hip role under right hip, shift weight and prevent hypotension**
○ Can affect placental perfusion (increased when mom lying down)

Respiratory changes - maternal

● Increased rate and depth of respirations during contractions
● Hyperventilation
○ Rapid, deep breathing
○ Numbness, tingling sensations; dizziness
○ Encourage controlled breathing to maintain normal blood levels of CO2
○ Hands together and up to mouth to help (instead of paper bag)

Gastrointestinal /Urinary changes- maternal

● Gastric motility reduced
○ Ice chips
○ Clear liquid (jello, popsicles)
○ If given anesthesia, can aspirate if eating full meals
● Reduced sensation of full bladder
○ Urinate every hour - 2 hours (ambulate if can to progress labor)
 ○ Full bladder inhibits fetal descent

Hematopoietic system changes-maternal

● Levels of clotting factors elevated before, during and after delivery (body preparing for
delivery)
○ Especially fibrinogen (increased)
○ Protection from hemorrhage
○ Increased risk for DVTs
● Expected Blood loss at delivery
○ ≤ 1000ml (for both vag and C)
○ Approaching 500ml worried

Fetal Response
● Placental circulation
○ Exchange of O2, nutrients and waste products
○ Most placental exchange occurs between contractions*
○ Placental perfusion diminished during contractions
● Cardiovascular system
○ Responds to stress
○ Heart rate between 110-160 bpm (as baseline throughout labor)
● Pulmonary system
○ Lungs produce fluid to allow normal airway development
○ Surfactant

Components of the Birth Process

Powers → contractions, maternal pushing efforts

Passage→ bony structures especially

Passenger→ fetus, membranes, placenta, position, presentation

Psyche→ anxiety,culture, birth experience, support

Descent → Movement of fetus through the birth canal

Engagement → Fetal presenting part reaches 0 station

Passenger--Presentation (Fetal part that first enters the pelvis)
● Cephalic
○ Vertex → baby is taught (smallest part of baby head coming first)
○ Military → head down, straight
○ Brow →
○ Face → full extended face (don't come out well)
○ Breech
○ Shoulder
● Sutures
○ Frontal bones
○ parietal bones-sides
○ Occipital bone- back
● Fontanels → Anterior vs Posterior
Fetal Lie
Orientation of the long axis of the fetus in relation to the long axis of the woman

Longitudinal/ Transverse/ Oblique

99% of pregnancies are longitudinal

Position
Location of fixed reference point on the presenting part in relation to the four quadrants of the
maternal pelvis

● Right (R) or left (L)

● Occiput (O) (back of head), Mentum (M) (chin), Sacrum (S)(butt)
● Anterior (A) (front), Posterior (P (back)) or Transverse (T)

External cephalic version (ECV) or internal

- Turn baby or attempt to turn baby

- Provider usually does
- stress test prior
- Prepare for C section
- Monitor for at least an hour
- Contraindications (anything that puts RISK)
● Uterine malformations or previous uterine surgery
● Placenta abnormalities
● Third trimester bleeding
● Cephalopelvic disproportion
● Multifetal gestation
● Oligohydramnios
● Intrauterine growth restriction
● Uteroplacental insufficiency
- Risks
● FHR alterations- usually return to normal
● More severe fetal risks
○ Cord entanglement
○ Fetal hypoxia
○ Abruptio placentae
● Maternal sensitization to fetal blood type
- Procedures
● Nonstress test (NST) to evaluate fetal well-being
● Determine gestational age > 37 weeks
● Prepared as a possible cesarean (NPO, IV, consents, education)
● Tocolytic drugs as ordered to relax uterus
● Ultrasound to monitor FHR and guide manipulation
 ● RHO(D) immune globulin (RhoGAM) given if indicated
● FHR monitoring for at least 1 hour after procedures
- Nursing Care
● Educate + help prepare
● Reduce anxiety
● Assess maternal and fetal well-being
● May induce her or C section schedule

Normal Labor: Premonitory Signs

● Braxton Hicks contractions → Practice contractions (sometimes painful)
○ Irregular, don't last too long
○ Help to soften and ripen cervix
○ Doesn't mean need to rush to hospital (some women thing need to)
● Lightening – “Drop down low”
○ Baby engages and moves down pelvis
○ More significant in multips
● Increased vaginal mucus secretion → Loss of mucus plug
○ Bloody show (spotting)
○ Bleeding is ALWAYS a reason to call HCP or go to hospital
● Cervical changes
○ softening/ripening
○ Possible dilation
○ Bloody show
● Energy spurt (nesting instinct)
○ 1-2 days before labor
○ Cleaning, rearranging, focus on baby coming
● Weight loss (could lose a pound of two before labor)
● Loose stools (common complaint of diarrhea before labor)

True labor

- Increased contractions
- Increased discomfort
- Progressive cervical change*
- 20-30 min contractions at first and gradually get stronger
- Open and thin cervix

False labor (prodromal labor)

- Inconsistent contractions (irregular; braxton hicks)

- Discomfort does not increase
- Cervix does not progressively change*
Normal Labor: Stages of Labor
● First stage → effacement and dilation (0-10 cm)
○ Latent phase → 0- 6cm (excited, talking)
○ Active phase → 6-10cm (1 cm every hour or two until 10cm) (faster than latent)
(emotional support needed)
● Second stage → pushing (10 cm → birth of baby)
- (bulging perineum/rectum + increase in bloody show) Imminent Birth
● Third stage → Birth to placenta (half hour or so )
- Gush of blood and uterus changes shape from oval to globular
- Fundus should be at umbilicus
- Shiny side of placenta → schultze mechanism baby side
● Fourth stage → recovery/ postpartum (2 hours after delivery)
● Duration varies! → Longer for first time moms
● Just because fully dilated; doesn't mean pushing (labor down )

Effacement → thinning of cervix (%)

- As contractions occur, stretching upwards of cervix

Dilation → Opening of cervix (cm)

Nursing responsibilities during birth

- Prepare delivery equipment and infant warmer
- Support with pushing efforts
- Initial care and assessment of newborn (stabilize mom and baby )
- Circulate delivery room- assist provider as needed, document
- Administer medications as ordered

OPEN GLOTTIS PUSHING (low deep vibration of throat)

- Shoulder dystocia → CALLING EXTRA BODIES

Labor Dystocia
- Prolonged or difficult birth
 - Causes: fetal macrosomia (Large baby), maternal fatigue, uterine abnormalities
(structure, weakness), cephalopelvic disproportion (head too big for pelvis), fetal
malpresentation (babys not in a good position), anesthetic/NSAIDS (too strong)
- Signs: not progressing (dilation, effacement, fetal station/position)
- Treatment: ambulate, change positions (hands and knees → posterior to anterior
position), assist with amniotomy, administer oxytocin, prep for surgery
- Shoulder dystocia → shoulder gets stuck (EMERGENCY)
- Nurse puts pressure on suprapubic region of mom
- Help to perform Mcroberts maneuver

Electronic fetal monitoring --Low technology

Intermittent Auscultation : is fine as long as low risk and everything is ok

Uterine contractions- frequency, duration and strength, rest period (PALPATE TO MONITOR
INTENSITY)

- 60 sec of rest between contractions (resting period)

- Performed in a consistent manner
- Hand-held doppler ultrasound

Benefits
● Less invasive & More comfortable
● Less restrictive, more freedom of movement
● More 1;1 care (“doula effect”)
● Easier with hydrotherapy

Limitations

● Difficult to perform in some situations

● Patient may prefer not to be touched at times
● Does not provide a permanent, visual record of FHR or Uterine activity (UA)
● Significant events can be missed
● May not allow early detection of FHR changes reflecting fetal hypoxemia
● Cannot visually assess patterns, variability, periodic or non periodic changes
● Not recommended for high-risk pregnancies
● Unable to determine intensity of contractions

Electronic fetal monitoring -- Continuous (High technology)

Bedside fetal monitor

● External (NON INVASIVE )

○ SONO or ultrasound for BABY (fetus HR)
 ■ Palpated to find PMI (between baby shoulder blades)
■ Cephalic (lower abd)
■ Breech (upper abd)
○ TOCO → moms uterine activity (fundus; strength of contractions)
- Benefits
● Noninvasive; Easy to apply
● Does not require cervical dilation or ruptured membranes
● known fetal or maternal risks
● Provides continuous recording of FHR and UA
● Contraction monitor higher on moms abd
- Limitations
■ Limits maternal mobility
■ Often requires repositioning of transducers to maintain tracing
■ May record maternal heart rate
■ Unable to assess intensity of contractions
● Internal
- Fetal Scalp Electrode (FSE) Head screw
- Benefits
● Accurately displays FHR between 30 and 240bpm
● Maternal position changes don’t usually affect quality of tracing
● Capable of displaying some fetal cardiac arrhythmias when linked
to an ECG recorder
- Limitations
● Requires ruptured membranes and cervical dilation for placement
● Can cause maternal trauma (i.e. vaginal lacerations)
● Fetal presenting part must be accessible and identifiable
● May record maternal heart rate
● May have inadequate ECG conduction when excessive fetal hair
is present
● Possible infection risk
● PROVIDER WILL PUT ON
- Intrauterine Pressure Catheter (IUPC)
- Benefits
● Only true accurate measure of uterine activity
● Allows assessment of contraction intensity
● Allows use of amnioinfusion
- Limitations
● Requires rupture of membranes
● Cervix must be sufficiently dilated to allow placement
● Improper insertion can cause maternal or fetal trauma ( i.e. uterine
perforation or placental abruption)
● Maternal position may change hydrostatic pressure resulting in
inaccurate readings
● Possible infection risk
 - Wouldn't want to do this on HIV/AIDS patient
● Telemetry → remote monitor (free to walk)
● Central monitor → big screen (all momas; in nursing station)

Fetal Monitor Tracing

Normal → 110-160 bpm
- Baseline between contractions

Accelerations → FHR increase from baseline (15 bpm for 15 seconds)

- Response to FETAL MOVEMENT
- Good, normal, reassuring
- Good Oxygentation

Decelerations → EARLY Decelerations (normal)

- In relation to contractions (during contractions)
- MIRROR IMAGE
- NO intervention needed
- Likely head compression (baby ready for delivery)
Variability → how does HR change second by second
- 6-25 bpm around baseline
- Moderate variability → good nervous system

—-------------------------------------------
ABNORMAL

Fetal Bradycardia → Lack of 02 to baby

- <110 and lasts 10 min
 - Causes:
- Prolonged cord compression ( Increase BP, decrease HR)
- Umbilical cord prolapse (uteroplacental insufficiency)
- Anesthetic meds
- Maternal hypotension
- Fetal heart abnormalities
- Interventions
- Side lying
- Notify provider
- IV fluids
- O2/discontinue Oxytocin

Fetal Tachycardia
- >160 bpm for 10 min
- Early signs of fetal distress
- Causes:
- MATERNAL FEVER/Infection
- Trauma to mom (broken bone)
- Fetal hypoxia
- maternal hypothyroidism
- Cocaine/stimulants
- Tachy with DECREASED variability = SEVERE fetal distress
- Interventions → O2, IV fluids, antipyretics (fever)

Late Deceleration
- Base LOW will be AFTER peak of contraction
- Prolonged return to baseline
- Causes:
- Uteroplacental insufficiency
- Fetal hypoxia (decrease HR)
- Interventions
- L - Left lying
- I - IV fluids
- O - Oxygen/ discontinue Oxytocin
- N - Notify provider
- S - Surgery prep
Variable Deceleration (v)
- Sharp, dramatic drop (15 sec for 2 min)
- Recovers fast to baseline
- Causes → Umbilical cord compression ( increase BP, decrease HR in fetus) and
decreased amniotic fluid
- NEED baby off cord
- Mom in trendelenburg position
- Knee chest position
- Interventions
- O2
- Reposition (side lying)
- Call provider
- Discontinue oxytocin
- Amnioinfusion possibly (if position changes doesn't help) (sterile saline)
VEAL CHOP

V: Variable C: Cord Compression M- Maternal repositioning

E: Early H: Head Compression I - Identify Labor Progress

A: Accelerations O: OKAY N- NO interventions

L: Late P: Placental Insufficiency E- Execute interventions

Baby either sleeping or in trouble; concerning

BABY needs to come out right now via Csection

Marked Variability
- Exceeds 25 BPM.
- acute hypoxia or mechanical compression of the umbilical cord
- second stage of labor (typically seen)
- When coupled with decelerations, this pattern is considered non reassuring and should
warn the physician to search for, and correct, potential causes of hypoxia
- Causes:
- Fetal stimulation
- Mild, transient hypoxemia
- Drugs

Calculating MVUs
- IUPC used
- Where baseline is
- Every contraction look at change (baseline to peak and count boxes)
- Tells us how strong contraction (10 min period)(subtract baseline (20))
- Want around 200
- Want to see if contractions efficient for progressing labor

Categorization of FHR patterns

Category 1: normal (moderate variability, HR within parameters, do NOT see D cell)

Category 2: Indeterminate (inbetween) (back and forth between categories)

 - Everyone is made aware of category 2 strips (DR, nurse, midwife, etc)

Category 3: Abnormal (baseline may not be normal, NO moderate variability, SEEING D

cellerations)

Leopold Maneuvers

- Where baby is in utero

- Step 1 = palpate fundus (feet or head?)
- Step 2 = feel along both sides or uterus (where is the baby's back?)
- Step 3 = palpate above pubic bone
- Step 4 = if cephalic → use fingers to feel where is babies face

Corrective Measures
● Maternal repositioning ( want on left side) increase parental profusion
● Intravenous fluid boluses (helps with circulatory volume)
● Administering oxygen 10 L → non rebreather mask and document
● Reducing uterine activity (more rest period for baby)
● Correcting maternal hypotension ( BP will drop with epidural )
- AVOID SUPINE HYPOTENSION
● Performing amnioinfusion-(putting fluid into uterus) (cushion cord) (variable
decelerations; will try this)
- PROVIDER ORDER
● Modifying second stage pushing efforts (more O2 to baby if push every 2-3 contractions.
Give mom time to breath)
- CAN DO WITHOUT ORDER

Cord Blood Sampling ( AVA)

● Completed at delivery to determine the oxygenation status of the infant at birth
● Sample artery and vein and send to lab
● Arterial samples are more commonly used.
● LOOKING FOR PH * (if lower, what's going on with baby) looking for acidosis (HIE)
● Respiratory, metabolic, mixed can be determined

Nurses role on admission

● Establish a therapeutic relationship
● Contractions every 5 min, can't walk talk or laugh, for at least an hour*
● Focused assessment (Baby first then mom) (baby not good, moms not good)
○ FHR- Regular? Accels? Decels?
○ Maternal Vital signs
 ○ Baseline history-Concerns during pregnancy? (from her perspective) also
prenatal records (what does the provider think?)
○ Impending birth?
○ By themselves → ask if safe at home, questions that shouldn't be asked around
others
● Data Collection
○ Basic information- prenatal record, interview, birth plan
○ Physical exam
○ Fetal assessment- FHR, Leopold’s maneuvers (palpate abdomen) (helps to
determine where to place FHM), Presentation, Position
■ Back of shoulder blades best for FHR
○ Labor status- contraction pattern, membrane status (water broken??), vaginal
bleeding, vaginal exam? (depends on what's going on)
■ History of placenta previa, bleeding, impending birth → call provider, no
vag exam
● Admission procedures
○ Notify provider and obtain orders
○ Consent forms + paperwork
■ Consent for: blood products, vag delivery, admission, admission of baby,
Hep B
○ IV access/ laboratory tests
■ Most women will have IV access
■ CBC, syphilis, typing screen?

Fetal membranes
● Oligohydramnios - (lower amount of fluid)
○ See variable decelerations
○ Amnioinfusion (IV) more fluid in = more cushion
○ PROM, uteroplacental insufficiency, fetal abnormalities
● Polyhydramnios- higher amount of fluid)
○ Lots of amniotic fluid
○ Gestational diabetes, fetal abnormalities
○ Amniocentesis → remove amniotic fluid
● Chorioamnionitis
○ Infection of amniotic sac
○ Common in women that have UTI or infection
○ Cause elevated WBC, odor discharge, fever, uterine pain
○ Treatment: antibiotics

● Intact or Ruptured? (leaking?)-- Time, amount, color, clarity, odor? TACO

■ Cloudy/odor = infection
■ Green = meconium stain
○ Spontaneous rupture of membranes (SROM) → Rupture on OWN
PPROM → preterm premature rupture of membranes

PROM → premature rupture of membrane

● Associated with: Infection/ Triple I, weak sac structure, history of preterm birth,fetal
anomalies/malpresentation, incompetent or short cervix, uterine overdistention, maternal
hormones,stress, nutrition,diabetes, low socioeconomic status
● Complications: Infection (risk increases with longer time since rupture, frequent vag
exams), oligohydramnios, cord compression, reduced lung volume, RDS (if preterm)
● Management: Verify rupture, steroids if preterm, limited vag exams, antibiotics,
possible induction if term and labor does not begin, home management if far from term
(pelvic rest, no breast stimulation, frequent temperature monitoring, possible activity
restrictions, instruct when to call provider)

Artificial rupture of membranes (AROM)

● Amnihook with vaginal exam (used to break membranes; pic below)

● If fetal station HIGH → only ROM if NEEDED
○ If have to → KEEP IN BED
● Indications
○ Induction of labor
○ Augmentation of labor (get it movin better)
○ Internal monitoring
● Risks
○ Prolapsed Cord- most immediate risk
○ Infection- Chorioamnionitis
○ Abruptio placenta → placenta away/detach from uterine wall prematurely
○ Decrease amount of fluid and volume
○ If uterus shrinks, can cause abruptio
● Nursing role
○ FHR assessment before and after
○ Temp every 2 hours
○ Limit vag exams → risk of infection (call provider)
○ Assist - absorbent pads. Equipment
○ Identify complications
○ Provide comfort
- Coming in tests to see ROM → speculum, fluid swab under microscope (ferning),
swab to lab to determine if water broken, looking for pooling
- Nitrazine test → check PH of fluid

Induction & Augmentation of Labor*

- Post dates, diabetic, hostile uterine environment, chronic hypertension, preeclampsia, or
if baby is deceased
- Indications
 - Hostile intrauterine environment
- Spontaneous ROM
- Postterm pregnancy
- Chorioamnionitis
- Hypertension
- Maternal medical conditions
- Fetal demise
- Contraindications
- Placenta previa
- Umbilical cord prolapse
- Abnormal fetal presentation
- Herpes
- Breech Presentation
- Overdistended uterus due to multifetal pregnancy or polyhydramnios
- Risks
- Excessive uterine activity
- Uterine rupture
- Maternal water intoxication
- Chorioamnionitis
- Cesarean birth
- Postpartum hemorrhage
- Techniques → Determine whether induction is indicated
- Cervical assessment (Bishop’s score)
- Ripening → softening of cervix (25 mcg)**
- Prostaglandins (uterine tachysystole risk) , misoprostol
- Cytotec (not recommended if previous cesarean) 25mcg
- Cervidil (flat tampon; inset behind cervix on vag exam)
- Overnight ripening process (12 hours can stay in)
- Balloon catheters, dilators and membrane stripping
- Amniotomy → puncturing the amniotic sac (AROM) (risk of infection and
cord prolapse)
- Nursing: presenting part engaged, monitor HR and checking moms temp
more often
- Oxytocin → naturally occurring (15 units of pitocin) High risk med (2RNS
check)
- Pitocin → artificial oxytocin
- Hook to secondary port → closes to HUB (same with Mag Sulfate)
- Increase strength, frequency and intensity or contractions
- Can also be used to control postpartum bleeding, firm uterus after
delivery
- Want to constantly be monitoring baby and moms contractions
- Uterine tachysystole → DISCONTINUE, O2, fluids and reposition
- Terbutaline (tocolytic; relax uterus) → decrease contractions
- Nursing Care
 - Close observation– ANY CONCERNS = stop pitocin (then call provider)
○ Tachysystole (> 5 cont in 10 min averaged over 30 min)****
● Nonreassuring FHR or tachysystole
○ Reduce or stop oxytocin infusion, maternal position change, hydration, O2
● Maternal response
○ Assess uterine activity
○ Assess vital signs
○ Assist with pain management techniques
○ Record intake & output
○ Observe for signs of water intoxication
○ Assess for uterine atony in postpartum period

Bishop Score
- Maternal readiness for induction
- 0-3 scale
- Can indicate ready to have a baby, or not ready
- Multiparous = ready is higher than 8
- Nulliparous = score of 10 or higher
- “I wish my bisssh op score was high enough to induce labor”

- High Bishop score = not gonna have to work hard for it

- Lower bishop score = more cervical ripening NEEDED
Operative Vaginal Birth: Vacuum Extraction
To shorten second stage due to:

○ Maternal indications
■ Exhaustion (too tired)
■ Inability to push effectively
■ Infection (uterus is sick → won't contract as well)
■ Cardiac or pulmonary disease (may not want mom to push)
○ Fetal indications
■ Partial separation of the placenta
■ Nonreassuring FHR pattern (repetitive Decels)
● Contraindications (Cesarean birth preferable)
○ Severe fetal compromise
○ Acute maternal conditions
○ High fetal station
○ Cephalopelvic disproportion (baby not fitting through pelvis)
● Risks-trauma to maternal and fetal tissues
○ Maternal- lacerations/hematoma, pelvic floor disorders, anal sphincter disruption,
infection
○ Fetal- ecchymosis, lacerations, facial nerve injury, cephalhematoma, subgaleal
hemorrhage, intracranial hemorrhage, scalp edema (monitor for bleeding)
● Preparation
○ Cervix fully dilated
○ Membranes ruptured
○ Adequate anesthesia
○ Empty bladder
○ Make sure mom is COMFORTABLE
○ May or may not do episiotomy (to make more room for baby)
● Procedure--Kiwi or Mushroom cup applied to fetal head and traction applied
○ 3 “pop-offs” only
○ Document suction on and off and “pop-offs” and alert provider
○ Sometimes focused on other things, look out for # of pop offs and remind
provider
● Nursing considerations- Observe and monitor for signs of trauma (mother and newborn)

Episiotomy
- Indications
● Shoulder dystocia
● Vacuum or forceps assisted births
● Face presentation
● Breech delivery
● Macrosomic fetus
 - Risks
● Infection
● Perineal pain
- Nursing Considerations
● Promote gradual perineal stretching in second stage
- May use perineal massage
● Delay pushing until mom feels the urge
● Open-glottis pushing
● Observe for edema, hematoma or infection
● Pain relief as indicated-meds, cold/ heat therapy
● does not heal faster than lacerations per research
● Lidocaine for repair of lacerations (mom may not even know she has them
bc amount of pressure)

Cesarean Birth 22-25%

- Indications
○ Dystocia
○ Cephalopelvic disproportion
○ Hypertension
○ Maternal diseases
○ Active genital herpes
○ Previous uterine surgical procedures
○ Fetal intolerance of labor
○ Prolapsed umbilical cord
- Risks
● Maternal
○ Infection
○ Hemorrhage
○ Urinary tract trauma
○ Thrombophlebitis/ Thromboembolism (clotting factors increased)
○ Bowel dysfunction
○ Atelectasis
○ Endometritis
○ Anesthesia complications
○ Wound complications
● Fetal (usually around 39 weeks)
○ Inadvertent preterm birth-- lung immaturity
○ Transient tachypnea (no big squeeze)
○ Persistent pulmonary hypertension of the newborn
○ Traumatic injury (incision can slightly cut baby)
● Preparation
 ○ Alert necessary staff- OR, anesthesia, OB staff, pediatrician and/ or respiratory
therapy as needed
○ Laboratory studies: type and cross (if higher risk for hemorrhage)
○ Fetal surveillance
○ Iv status 18 gage
○ Foley catheter
○ Prophylactic antibiotics (as she goes into OR to prevent infection and decrease
stomach acids)
○ Hip roll (avoid supine hypotension), safety belt, BP cuff, check if numb, support
person by head
○ Timeout → checking materials and equipment. RIGHTS and RISKS
○ Incision: skin/uterine (low transverse, low vertical, classical)
- Nursing Care
- Circulate, infant care roles in OR (documents, calling people, counts, etc)
- 2 RNS for 2 hours (one for mom and one for baby)
- Treatment: Patent IV, Foley, IV fluids, Pre op meds (antibiotics), analgesia
(duramorph given with spinal), assessing incision site
- Low transverse incision = BEST to see uterus
Provide emotional support

Promote safety

Postoperative care- 2 hour recovery and ongoing

Most of time low transverse (best to see uterus)

Classic → emergency to get to fetus fast

VBAC → Classical incision will be EXCLUDED from vag births ***

 Pain Management During Childbirth

Labor Pain
- Self-limiting, ends with birth
- Intermittent
- Physiologic- pain cycle
- Psychological- interpretation, perceptions

Variables in Childbirth Pain

- Sources of pain
- Tissue ischemia
- Cervical dilation
- Pressure and pulling on pelvic structures
- Distention of the vagina and perineum
- Pain tolerance
- Psychosocial factors

Pain tolerance/ Perception

- Labor intensity
- Cervical readiness
- Fetal position
- Pelvic anatomy
- Fatigue and hunger
- Caregiver interventions

Pain management

Nonpharmacologic

● Relaxation/ meditation
● Breathing → technique (FOCAL PT)
● Cutaneous stimulation
○ Gate control theory (all different “gates” to block pain from brain)
● Hydrotherapy → tub/shower
● Mental stimulation /distraction
● Changing position
● Taking into consideration PTSD, anxiety
● Guide them into things and communicate
● Focal point → something else to concentrate on
- Advantages
 ● Does not slow labor
● side effects or allergy risks
● May be only option in rapid, advanced labor
- Limitations
● Not always able to achieve desired level of pain control
● Difficult labors may still require analgesia/ anesthesia

Pharmacologic

● Systemic medications
● Regional analgesia
● General anesthesia → emergency c sections
● Everything that goes into mom will go to fetus
● Effects on fetus- decreased FHR/variability (EXPECTED)
● Maternal physiologic alterations- respiratory capacity decreased (esp. general)
● Effects on the course of labor → dont want to give too many meds at beginning of
labor bc can slow things down
● Effects of complications- FVE, hypotension
● Interactions with other substances

Local infiltration → into perineum

- Lidocaine (episiotomy, forceps, suturing lacerations)

Regional: Pudendal block, epidural, spinal

Pudendal block injection of local anesthetic into pudendal nerves

- Anesthetizes lower vagina and part of perineum

- Anesthesia for episiotomy and vaginal birth
- No relief from contraction pain
- Still feel pressure
- Vacuum delivery or forceps

Sadol, morphine, smaller doses. → Not want to give early in labor

Regional Pain Management: Epidural Block (MOST OFTEN)

● Injection of local anesthetic agent, often combined with an opioid into epidural space
● Provides substantial relief of pain
● Adequate pain relief without complete motor block
● Technique
○ Hunch over bed in a C shape
○ Poke at back to find epidural space
○ Chlorhexidine sponge clean and local anesthetic
○ Test dose → checking moms pulse (if increases wrong place)
 ○ Catheter put in for CONTINUOUS dose during labor
● What to do before
○ Vaginal exam → anesthesia will want to know how effaced and dilated
○ 1000ml bolus of IV NEEDED FOR EPIDURAL (prehydration)
○ Gather equipment and give report to anesthesia team
○ Mom signs consent (we witness)
● Risk of Dural Puncture → Potential need for blood patch
○ CSF can leak out and cause headache (spinal headache; better if she lies down)
● Contraindications and precautions
○ ICP
○ coagulation problems (platelets below 100)
○ infection at insertion area or systemic infection
○ Allergy
○ fetal emergency
○ sometimes spinal surgery, scoliosis
○ Moms BP decreases, placental perfusion compromised (hypoxia) (baby may feel
it first before BP taken on FHRM)
● Adverse effects
○ Maternal hypotension
○ Bladder distention
○ Catheter migration
○ Prolonged second stage
○ Maternal fever

Regional Pain Management: Spinal (Subarachnoid Block)

- Used for quick C section birth if no epidural
- Similar to local infiltration and pudendal block
- Performed just before birth - NO pain relief for most of labor
- SINGLE DOSE (no catheter)
- Give duramorph → long acting (watch for respiratory depression)
- ITCHING
- RR assessed hourly
- Lasts 24 hours at least
- Loss of sensory and motor function below level of injection
- Contraindications: similar to epidural
- Adverse effects:
- Hypotension
- Bladder distension
- Post-dural puncture headache (more of a risk than epidural)

Systemic Drugs for Labor

● Parenteral Analgesia-takes the edge off, careful use after 6cm
○ Opioid agonists
 ■ Fentanyl
■ Morphine
■ Remifentanil
○ Mixed agonist-antagonist-avoid with opiate-dependant client
■ butorphanol (Stadol)
■ nalbuphine (Nubain)
○ Opioid Antagonists
■ Naloxone (Narcan)- not with opiate-dependant client or newborn (will be
in withdrawal)
● Adjunctive drugs Reglan, Zofran → N/V (normal)
● Sedatives- Vistaril (take at night to sleep if needed)
- Nitrous Oxide
● Self-administered
● Need good ventilation!
● Early labor to second stage
● Inhaled at peak of contraction
● Short half-life
● Continuous monitoring
● One to one nursing care

General anesthesia - EMERGENCY C SECTIONS ONLY

- Systemic pain control
- Loss of consciousness
- Rarely used for vaginal births
- Used for some cesarean births
- Unexpected emergency procedures
- Adverse effects
- Failed intubation
- Aspiration
- Reaction to medications: anaphylaxis, malignant hyperthermia, respiratory
depression, uterine relaxation (esp if magnesium sulfate)
- Miss birth of a baby :(

Intrapartum Emergencies
● Placental abnormalities- placenta embeds into uterine tissue
○ ultrasound or MRI
○ Major hemorrhage risk (3000-5000ml)
○ Hysterectomy may be necessary
■ Placenta Accreta- uterine wall
■ Placenta Increta-into the myometrium
■ Placenta Percreta-through uterus into adjacent organs
● Uterine Rupture- tear in uterine wall
 ○ Causes: previous uterine surgery (esp. Classical uterine incision), high parity,
abdominal trauma, intense contractions
○ Signs and symptoms depend on extent of rupture- pain (abdominal, chest &/or
shoulder), hemorrhage/shock, fetal heart rate concerns, absent Fetal heart
sounds, cessation of uterine contractions, Palpate fetus outside the uterus, loss
of station
○ Management: Stabilize mom for cesarean, manage blood loss, potential
hysterectomy
○ Nursing Considerations: situational awareness of increased risk, careful
monitoring for s/s, diligent caution when administering uterine stimulants
● Uterine Inversion
○ Causes: Excessive cord traction, fundal pressure, increased intraabdominal
pressure, placental implantation or adherence abnormalities, weak uterine wall
○ Signs/ Symptoms: Fundal indentation, visible protrusion
○ Management:rapid replacement, (manual or via laparotomy), blood replacement
○ Nursing considerations: assessment, be sure uterus is contracted before
applying fundal pressure, hemorrhage management
● Prolapsed cord - cord slips down after membranes rupture, becomes compressed
interrupting blood flow to fetus
○ Cord is coming out of cervix before baby
○ After ROM
○ Risk: High fetal station, small fetus, breech/transverse, polyhydramnios, AROM
○ Lead to: cord compression and fetal hypoxia/distress/compromised circulation
○ Signs: we can see it, or we feel it (LATE DECELS, BRADYCARDIA)
○ Nursing treatment:
■ CALL FOR ASSISTANCE, but don't leave patient
■ apply sterile gloves and insert fingers (V shape) and lift fetus off cord
■ Position mom in trendelenburg
■ Make sure cord is covered (warm sterile towel)
■ O2
■ Prepare for birth (C section)
■ Terbutaline → decrease contractions

Placenta Previa vs. Abruptio Placentae

Previa-implantation of the placenta in the lower uterus

● Can cause bleeding - sudden onset

● RISKS: maternal age over 35, multiples, drug use (cocaine, smoking), scarring, c
sections
● Signs: PAINLESS bright red bleeding
○ Abnormal fetal positioning, normal FHR
● Diagnose with ultrasound, usually seen early
● NO cervical checks/ vag exam
 ● Treatment: iv fluids and blood if needed, corticosteroids to improve lung maturation
● Monitor vitals, side lying position, monitor pad count, monitor CBC and clotting levels
● Hemorrhage precautions , probable C Section
● Pelvic rest and kick counts

Abruption-separation of a normally implanted placenta before the fetus is born

● HIGH RISK of maternal fetal mortality

● Lack of blood flow → baby not getting blood
● Mom at risk for hemorrhage
● DARK RED vaginal bleeding and SEVERE abdominal pain (wine colored amniotic
fluid)
● Pt may have a RIGID board/firm like abdomen (blood accumulating)
● Signs: tachycardia, hypotension, tachypnea, pallor
○ Hard abdomen, tender uterus, fetal distress, increase fundal height
● Risks: smokers, hypertension, trauma, multiparity, cocaine/stimulants
● Treatment → emergency C section, O2, IV fluids, avoid vag exams
○ Report any bleeding (IV SITES) anywhere on body to physician (Entering DIC;
clotting levels depleted and thromboplastin)
○ Kleihauer-Betke blood test → determines amount of rhogam
○ Rhogam

Hypertensive Disorders of pregnancy

Hypertension: BP≥ 140 systolic, and/ or ≥90 diastolic

Severe Hypertension: BP≥160 and/or ≥110 for ≥ 15 minutes Hypertensive emergency

- Get meds→ Labetalol

- Can stroke/seizure
- BP every 10 min taken

Gestational hypertension: onset after 20 weeks gestation without proteinuria or signs of

preeclampsia

- BP greater than 140-90

- At least 2 BPs taken

Eclampsia- Seizures in a woman with preeclampsia

● Potentially preventable
● Maternal blood volume severely reduced*
○ Decreased placental perfusion
○ Fluid shifts-potentially causing pulmonary edema or heart failure
○ Severely reduced renal blood flow- oliguria/ potential renal failure
 ○ Potential cerebral hemorrhage
○ Stimulation of uterine irritability- potential ROM,labor or abruption
○ Potential aspiration of gastric contents
○ Won't give diuretics or ace inhibitors

HELLP Syndrome- Hemolysis, Elevated Liver enzymes, Low Platelets

● Hemolysis, Elevated Liver enzymes, Low Platelets

● All women who have HELLP have preeclampsia
● Signs: epigastric/RUQ pain, elevated ALT/AST, low platelets (thrombocytopenia), N/V,
severe Edema
● Treatment: antihypertensive medications (hydralazine and lobatorol), give MAGNESIUM
monitor reflexes and respiratory; calcium gluconate to reverse), DELIVERY (vaginal
preferred)

Chronic Hypertension- Present before conception ,prior to 20 weeks, Persistent 12 weeks

after delivery

● Hypertension identified prior to 20 weeks gestation or persisting beyond 12 weeks

postpartum
● Associated with :
○ Advanced maternal age
○ Obesity
○ comorbidities(i.e. diabetes)
○ Heredity
● May have chronic hypertension with superimposed preeclampsia

Preeclampsia - systemic disease with hypertension, with or without proteinuria after 20 weeks
gestation, On 2 occasions at least 4 hours apart

**Generalized vasoconstriction and vasospasm resulting in multisystem organ failure**

- Hypertension often with proteinuria ( kidney involvement)

- Edema nonspecific
- Can occur antepartum, intrapartum or postpartum
- Risk factors:
- Obesity
- Pre pregnancy diabetes
- First pregnancy
- Advanced maternal age (AMA)
- Paternal factors
- vitro fertilization
- History of preeclampsia
 - Multifetal pregnancy
- Prevention
- Early detection to minimize morbidity and mortality: weight gain, BP, urinary
protein
- consensus on the reliability of prevention measures that have been tried
- Low-dose aspirin (ACOG still recommends for mod and high risk patients over 12
weeks gestation)
- Calcium and magnesium supplements
- Signs and symptoms
- Decreased renal perfusion reduces GFR.
- BUN, creatinine and uric acid increase
- Protein loss from kidneys allows fluid to shift into interstitial spaces (often
generalized edema)
- Reduction of intravascular volume (increased blood viscosity, increased Hct)
- Increased liver enzymes, epigastric pain
- Vasoconstriction of cerebral vessels, headaches, visual disturbances and
hyperactive deep tendon reflexes
- pulmonary edema: Dyspnea
- Decreased placental circulation causes infarct increasing the risk of abruption
and HELLP syndrome, uterine growth restriction, persistent fetal hypoxemia, and
acidosis
- Clinical manifestations (Diagnostics):
● Hypertension ≥140/90
● Proteinuria-may or may not be present
○ Clean catch 1+ or above
○ 24Hr≥300 mg
○ Protein-to- creatinine ratio (random sample) ≥ 0.3 mg
● Proteinuria is not detected one of the following is also required for diagnosis:
○ Thrombocytopenia
○ Renal Insufficiency
○ Impaired liver function
○ Pulmonary edema
○ Cerebral or vision problems
- Clinical manifestations: ( RAPID Symptoms)
○ Headache
○ Drowsiness or mental confusion
○ Visual disturbances → floaters/blurry
○ Numbness or tingling of hands/feet → edema
○ Hyperactive reflexes → hyperactive (greater than 2+)
○ Epigastric pain → liver not getting enough blood flow
○ Decreased urine output*******
● Therapeutic management → Delivery is the only cure
○ Timing depends on gestation and severity of the disorder
○ wks recommended without severe features
 ● Home care
○ Activity restrictions
○ Blood pressure monitoring
○ Daily weights
○ Urinalysis
○ Fetal Kick counts
○ Diet
○ Education on what to report

Severe Preeclampsia (Preeclampsia with severe features)

● **Diagnostic criteria
○ Hypertensive emergency- BP≥ 160/110 x2 15-60 min apart
○ Thrombocytopenia (< 100,000)
○ Impaired liver function LFTs, > 2x normal, epigastric pain
○ Progressive renal insufficiency ( creatinine levels)
○ Pulmonary edema
○ Cerebral or visual disturbances
○ Oliguria (<500mL in 24 hours)
● Management- hospitalization and progression toward delivery
○ Antepartum-maximize fetal oxygenation and prevent seizures/ stroke
○ Bedrest (low stimulation) and fetal monitoring
○ Antihypertensive medications
■ Labetalol
■ Hydralazine
■ Nifedipine
○ Anticonvulsant medication
■ Magnesium sulfate** (IV)
■ Intrapartum
■ Low stimulation (neurological irritability)
■ (frequently 2 IV sites)
■ Hourly checks (vitals, reflexes)
■ Labs CBC, CMP, Uric acid, Magnesium levels PRN
■ Foley catheter
■ Hourly: Vitals, checks for CNS depression- with DTRs/clonus, I &
O
■ Magnesium sulfate management (1-2 g /hr) (4g load) → relax
muscles and neuroprotectant for baby (seizure preventing; NOT
decrease BP)
■ Oxytocin management
■ Continuous EFM
■ Postpartum
■ Continue to monitor for at least 48 hours., magnesium
infusion X 24 hours
HELLP syndrome is associated with severe preeclampsia

Coagulation abnormalities of severe preeclampsia or eclampsia may lead to DIC

Magnesium Sulfate
● High-risk medication
● Anticonvulsant- CNS depression
● Settings/ orders verified by 2 RNs
● IVPB
● Hourly checks
● Monitor for pulmonary edema
● Monitor for magnesium toxicity (CNS depression)
● Magnesium levels as ordered ( 4.8-8.4 mEq/L therapeutic)
● Have ready access to calcium gluconate

Prenatal and Antenatal Nursing Care Unit 3

Ovaries → 2 of them. Fluid filled sacs that contain immature eggs. Body releases hormones that
cause eggs to mature and then egg released during ovulation

Ovary Phases: FOL (fuck off Lily)

- Follicular → day 1-13
- Ovulation → day 14
- Luteal → day 15-28

Follicular phase ( BEFORE OVULATION)

Hormones in Ovarian cycle in order

FSH → anterior pituitary senses FSH release, and causes GROWING follicles. Only one of the
follicles will release a mature egg. Other follicles will die. Follicle will keep growing and
INCREASING estrogen.

Estrogen released from maturing egg (NEGATIVE FEEDBACK LOOP) with hypothalamus;-->
causing dip/decrease in FSH and LH. (signals that the egg is maturing and dont need so much
of it anymore).

Peak of estrogen → egg is fully matured. (Positive feedback loop). Causes LH surge! (egg
released 24-36 hours after)

LH → causes eggs to be released and break the wall holding the egg in place to roam freely.

Causes follicle to turn into CORPUS LUTEUM → secretes estrogen and progesterone
Progesterone and estrogen → make endometrium receptive to fertilize egg (gets thicker for
better chance)

Best chance at conceiving → days 9-15

Sperm can live inside tract for 5 days

Ovulation Phase

Ovum (mature egg) released into peritoneal cavity

Swept into fallopian tube (cilia help move egg down into uterus)

Egg only lives for 24 hours, then disintegrates

- DECREASE IN BODY TEMP

- Increased FSH, LH and Estrogen
- Endometrium THICK

If sperm is present → most common site of implantation is AMPULLA of fallopian tube

***Spinnbarkeit- cervical mucus is elastic during ovulation, raw egg consistency

***Mittelschmerz- pain with ovulation

Luteal Phase (AFTER OVULATION)

Prepare for fertilization/implantation

Corpus Luteum has formed from empty follicle that released egg (supports pregnancy)
(secretes progesterone and estrogen)

Corpus Luteum will stay in place for 14 days (if no pregnancy → will disintegrate)

Once corpus luteum is gone → progesterone and estrogen DECREASE and cycle starts again

If fertilization DOES happen, corpus luteum will STAY in place and continue to secrete estrogen
and progesterone

Because fertilized → corpus luteum will start to release HcG hormone (prevents corpus
luteum from dying)
- Estrogen and Progesterone DROP
- FSH and LH will rise again if no implantation
Corpus Luteum will stay in place until placenta takes over (placenta will secrete
estrogen/progesterone to support pregnancy) ( about 8 weeks time) (corpus luteum will die
after)

Uterine Changes → MPSI (my period still intense)

- Menstrual → days 1-6 (during Follicular phase)
- Shedding stratum (bleeding)
- Last cycle pregnancy did not occur, causing body to DROP estrogen and
progesterone
- Proliferative →days 7-14
- Rebuild
- Estrogen secreted (from growing follicle) (getting ready to thicken endometrium
in case egg implants this cycle)
- Affect cervical mucus (thinning) (more sperm friendly)
- Secretory → days 15-28
- Release of progesterone from corpus luteum supports implantation
- Ischemic phase-- 3 days prior to menstruation ( if no fertilization)
- Decrease in progesterone and estrogen
- Blood supply to endometrium is blocked and necrosis occurs

Signs of Pregnancy
- Presumptive
- Probable
- Positive

Presumptive (means speculation/ unconfirmed)

- Subjective
- Only things the woman will say TO YOU

P - Period Absent (amenorrhea)

R- Really Tired
E- Enlarged breast
S- Sore breast
U- Urination ⬆
M- movement perceived (quickening)
E- Emesis & Nausea
Bluish color vulva, vagina, cervix ( Chadwick’s Sign) (4 weeks gestation)
Probable (likely)
- Able to observe and document
- Has all the “signs”

P- Positive pregnancy test

R- Returning of fetus when uterus pushed with fingers (Ballottement Sign)
O- Outline of fetus palpated
B- Braxton hicks contractions
A- A softening of cervix (Goodell’s Sign)
B- Bluish color vulva, vagina, cervix ( Chadwick’s Sign) (4 weeks gestation)
L- Lower uterine segment soft (Hegar’s Sign) (6-12 weeks gestation)
E- Enlarged uterus

Positive
- Absolute, definite, conclusive
- Fetus is presenting symptoms

F- Fetal Movement felt by DR/RN

E- Electronic device detects (heart tones)
T- The delivery of the baby
U- Ultrasound detects baby
S- See visible movement by DR/RN

Discomforts of Pregnancy

Round ligament pain

Cause → Ligaments are stretched by enlarging uterus
Teaching → Avoid quick movements, support abdomen w/pillow, don't bend over/squat down

Leg Cramps
Cause → pressure of uterus on blood vessels + imbalance of calcium/phosphorus
Teaching → stand with feet FLAT + adjust Ca+ intake

Edema in LE
Cause → Congestion of the blood vessels of the LA. Increase in fluid volume
Teaching → Elevate legs, avoid tight clothing, don't sit/stand for long periods of time

Dizziness
Cause → Compression of Inferior vena cava (supine hypotension) and postural hypertension
Teaching → move slowly and lie on LEFT side

Urinary Frequency
Cause → Hormones (HcG and progesterone) or pressure of baby on bladder
Teaching → decrease fluid intake (mostly before bed), avoid caffeine
Morning Sickness
Cause → research is showing HcG and low blood sugar but not definitive
Treatment → Small frequent meals, avoid spicy, greasy and fatty foods

Constipation? → fiber

Naegele’s Rule

Estimate delivery date

Add 7 days to first day of LMP and count back 3 months

Example: LMP March 23rd, EDD would be December 30th

Prenatal Labs

HcG → pregnancy test (released by corpus luteum)

Rh → rhogam (28 weeks; within 72 hours after delivery)

MSAFP → genetic abnormalities (not reliable)

- If Increased → neural tube defects

- If decreased → down syndrome
- If abnormal may consider amniocentesis

Glucose tolerance test → response to glucose (1hr) (gestational diabetes)

- 24-48 weeks
- No fasting needed
- 50g glucose solution → Wait 1 hour → Draw blood
- Above 140 → 3 hr glucose test (fasting test; 100g glucose drink)
- 2 or more high scores → gestational diabetes

Estrogen → Stimulates uterine growth, increase uterine blood supply

- From ovary (corpus luteum) and placenta

- Prepare breasts for lactation

Progesterone → Stimulates thickening and maintains uterine lining for implantation

- From ovary (corpus luteum) and placenta

- Suppresses FSH and LH during pregnancy

Human placental lactogen (hPL) → Made by placenta

 - Nutrition for the fetus
- Prepares for breastfeeding

- - - - - - - - - - - - -

Key times of Fetal Development

4 weeks → ♥️ beat

8 weeks → All organs are formed (teratogens**)

8-12 weeks → ♥️ tones via doppler

- N/V
- Goodell’s sign
- NO noticeable weight gain
- Chadwick’s sign
- Breast tenderness/ darkening of areola
- Estrogen- growth of mammary ductal tissue
- Progesterone- growth of lobes, lobules, alveoli

12 weeks → sex can be seen, looks like a baby

- Kidneys produce urine (amniotic fluid increasing)

- Braxton Hicks
- Placenta fully functional
- Round ligament pain

20 weeks → Viability (could possibly survive outside womb)

- Vernix present
- Lanugo
- Activity: sleep, suck and kicks
- Fundus at level of umbilicus (Relaxin hormone)
- Nasal stuffiness/ ears clogged → Presence of estrogen
- Leg cramps
- Varicose veins
- Constipation → Decreased peristalsis

24 weeks → fetal respiratory movement starts

28 weeks → surfactant production

- breathe, swallow, and regulate temp

- Able to hear
- Fundus halfway between umbilicus and xiphoid process
 - Striae gravidarum (stretch marks)
- Diastasis recti → abdominal muscles spread apart
- Heartburn
○ Progesterone decreases tone of esophageal sphincter
○ Baby higher in abdomen
- Hemorrhoids → pressure and constipation

32 weeks → sucking develops

- Brown fat development

- Storage of iron, calcium, and phosphorus
- Fundus at xiphoid process
- Breasts full and tender
- Urinary frequency- weight of uterus on bladder
- Swelling, Difficulty sleeping, Shortness of breath

40 weeks → full term

- Activity more subtle

- Maternal antibodies transferred to fetus (IgG)
- Brain development
- Lightening, Burst of energy, Backache, Urinary frequency
- Braxton Hicks contractions intensify

- - - - - - - - - - - - -

Prenatal Care: Trimesters

1st Trimester Visit (every 4 weeks) 1st day of LMP until 14 weeks

- Before 12 weeks gestation

- Ultrasound → only way bc baby too small
- Labs/diagnostic testing → CBC (anemia/infection), STI testing, PAP test, Blood typing
(Rh factor), hepatitis B, HcG pregnancy test
- Maternal teaching

2nd Trimester 14 weeks until 27 weeks

- MSASP → genetic testing (14-18 weeks)

- Gestational diabetes testing (HIGH RISK; 14-18 weeks)
- Ultrasound/ Anatomy scan, Fundal height assessment (cm) (18-22 weeks)
- Routine gestational diabetes (1hr oral glucose test), transvaginal ultrasound (measure
length of cervix) (22-24 weeks)

3rd Trimester 27 weeks until 40 weeks (2 week visits)

 - Rh- patient → rhogam (28 weeks)
- Education → kick counts (assess wellbeing) (30-32 weeks)
- TDAP, NSTs (30 weeks)
- Vaginal /rectal swab → group B strep (35-37 weeks) will treat will antibiotics weekly & at
time of birth
- 36 weeks → weekly visits with provider

- - - - - - - - - - - - -

Diagnostic Testing

Nonstress test (NST) (lasts 20 min)

- Not stress on mom or baby during procedure

- Monitoring baby inside mom
- Put tocometer (measure uterine stress) and FHR ultrasound transducer/doppler
- Usually Mom also given button to push → when mom feels baby moves
- What are we looking for?
- Reactive → want (accelerations x2)
- Non reactive → don't want (not accelerating; need more testing)
- If non reactive → move to Biophysical profile (BPP) test
- Can be done routinely if high risk

Biophysical Profile (BPP) test (0 or 2 score)

- NST and ultrasound to assess baby wellbeing

- FHR → based on NST (reactive/non reactive)
- Fetal breathing movements (1 or more in 30 seconds)
- Gross body movements (3 body movements or more)
- Fetal tone (extension or flexion)
- Amniotic fluid volume (measure; if greater /= 1 pocket)
- 6 = more monitoring (fetal hypoxia)
- 8 = adequate

Contraction Stress Test (CST)

- If failed NST (NOT COMMON)

- 3 contractions in 10 minutes (No late decelerations; WANT NEGATIVE TEST)
- Stressing baby by inducing contractions (NOT LABOR)
- Putting tocometer and doppler on → watching babies HR when contractions
- Nipple stimulation → release oxytocin or GIVE OXYTOCIN
- Risk → preterm labor

- - - - - - - - - - - -

Prenatal Nutrition
 - Folic Acid → increase
- 400-800 mg prior to conception (@3mo decrease to 600mg)
- Helps prevent neural tube defects
- If H/O neural tube defect → increase up to 4,000mg
- Iron → blood volume increases; need enough hemoglobin to transport O2
- 27mg/day
- Take with Vit C
- Protein → building blocks of life
- 60 g per day
- Calcium
- PKU → low protein diet
- Food iversions and cravings normal (1st trimester N/V)
- Eat SMALLER meals
- 340 calories (2nd trimester) 452 (3rd trimester) per day in
- Wash raw veggies very well- toxoplasmosis
- NO raw or undercooked meats/ poultry- cook to well done
- lunch meat- must be heated ( prevent Listeriosis (foodborne bacterial infection)-
can cause fetal death)
- Pica (weird food cravings)
- Drink a total of 10 cups per day (mostly water)
- Limit caffeine to 8 oz per day
- Drink LOTS of fluids (mostly water)
- Avoid large fish due to mercury (shark, swordfish, mackerel)
- Limit tuna to 6 oz per week
- NO soft cheese (Brie, Feta Gorgonzola)
- Avoid hot tubs, saunas and steam rooms for more than 10-15 min (hyperthermia)
- Travel is acceptable up to 36 weeks (no airlines after then)
- Stop every 2 hours, seat belt across lap below belly (circulation; prevent blood
clots)
- 6 hours or less in a day travel
- Intercourse is safe unless contraindicated
- Previa, incompetent cervix, risk of preterm labor
- No smoking, alcohol or illicit use (don't quit cold turkey)
- No NSAIDs (no aspirin/motrin)
- No douching
- Breast care → avoid soap on nipples, assessed early for nipple type
- Clothing → supportive bra

Lbs for Pregnancy (look in book chart)

- 28-40 lbs for underweight women (BMI less than 18)

- 25-35 lbs for normal weight women (BMI 18-24)
- 15-25 lbs for overweight women
 - 11-20 lbs for obese women (BMI over 30)
- 1st trimester → 2.2-4.4 lbs (1-2kg)
- 2nd and 3rd trimesters → 1 lbs per week

Warning signs

- Diarrhea, fever, chills

- Severe abdominal cramping (normal for little cramps)
- Severe N/V → hypovolemic
- Decreased fetal activity**

Unpleasant Side Effects (normal)

- Congestion
- Constipation (uterus pressure; increase fluid and fiber)
- Epistaxis (nosebleed → humidifier)
- Fatigue
- Heartburn
- Gingivitis
- Decreased immune response (to protect baby)
- Hemorrhoids → fiber and fluids, witch hazel or warm sitz baths
- N/V → eat crackers, carbs before getting out of bed, frequent small meals, bland foods
- Urinary frequency → more blood = more fluid, uterine pressure
- Varicose veins → compression socks

Maternal Psychological Response-1st trimester **

Uncertainty - shock

- pregnancy tests taken; sometimes a lot

Ambivalence- questioning everything

The self as primary focus - (1st/2nd trimester)

- Uncomfortable feeling, tired, self care

Changes in sexuality - don't feel attractive, COMMUNICATION important, cultural

Value
Nonpregnant Pregnant
Red blood cell count 4.0-5.2 2.71-4.55

Hgb 12-15.8 Decreased slightly because of

hemodilution

9.5-15

Anemia- <11 in 1st or 3rdtrimester

< 10.5 2nd trimester

Hct 35.4-44.4 28-41

WBC 3500-9100 5600-16,9000

Platelets 165,000-415,000 146,000-429,000

Fasting Blood glucose 70-100 95 or less

Creatinine 0.5-0.9 0.4-0.9

Creatinine Clearance 91-130 50-166

Fibrinogen 233-496 244-696

Prothrombin time (s) 12.7-15.4 9.5-13.5

Aptt 26.3-39.4 sec 22.6-38.9 sec

D-dimer 0.22-0.74 0.05-1.7

 Uncertainty

Ambivalence
Ist trimester
Self as primary focus

Changes in sexuality

2nd trimester Physical evidence of pregnancy

Fetus as primary focus

Narcissism and introversion

Body image concerns

Changes in sexuality

3rd trimester Vulnerability

Increasing dependence

Preparation for birth

—-----------------------------------------------------

Complications of Pregnancy

TORCH infections (teratogenic) → Toxoplasmosis, other, rubella, cytomegalo, herpes

Toxoplasmosis → parasitic infection

- NO CAT LITTER/ raw meat

Rubella → contagious
- MMR vaccine (live vaccine) can't administer while pregnant
- Wait before getting pregnant or postpartum

Herpes → can be transmitted during birth

- Antiviral given during pregnancy
- C section usually
STIs
- gonorrhea/chlamydia → asymptomatic
- Erythromycin on eyes when baby is born
- Syphilis → given penicillin

HIV/AIDS
- Can be passed through breastmilk (NO BREASTFEEDING) and body fluids
- Plan for C section around 38 weeks if HIV viral is high
- Don't do any invasive procedures
—----------------------------------------------------------

Bleeding in Early Pregnancy

Molar pregnancy → gestational trophoblastic disease (placenta problem)

- Occurs because of chromosomal abnormalities
- HCG levels high
- Non invasive = Hydatidiform mole
- Risk factors → previous molar pregnancy, extremes of age, asians
- Clinical features → bleeding, rapid growth, cysts and N/V (from increase HCG),
preeclampsia, hyperthyroidism

Hydatidiform Mole (Gestational trophoblastic disease)

- Abnormal growth of embryo
- Clinical manifestations
- hCG levels higher than expected for gestation and large uterus
- Bleeding (Dark purple color)
- May develop Preeclampsia prior to 24 weeks
● Diagnostic ultrasound--Fluid-filled grape-like clusters “snowstorm”-
○ NO fetal sac/heart activity
○ Will evacuate clusters
○ Can become malignant
● Management
○ Evacuation
○ Continuous follow-up to detect possible malignant changes in tissue esp with
repeated molar pregnancies
○ Delay pregnancy for 1 year
○ Serial HcGs and D&C
● Nursing considerations- support, psychological , education, RhoGAM
○ Monitor for bleeding complications
○ Pain control
○ Educate regarding precautions and follow-up
○ Emotional support
○ Rhogam as required
 -

Miscarriage → Spontaneous abortion BEFORE 20 WEEKS

- D&C → cervix dilated (lidocaine) and uterus scrapped (cramping normal)
 ● Abortion -Loss before viability (< 20 weeks)
○ Spontaneous (also known as miscarrhage)
■ Nothing that the woman did wrong to cause this; SUPPORT needed
■ Threatened -bleeding in first half of pregnancy (always needs to be
assessed)
● Pelvic rest
● Ultrasound (transvaginal)
● Serial HCGS
● Watch, wait and see
■ Inevitable- rupture of membranes , cervical dilation
● Can't stop it
● Pregnancy will be lost
■ Incomplete-Not all products expelled, usually requires D&C or D&E
● If products retained, if fetal demise, dead cells → infection
● Cells will release products related to inflammation →
thrombus//microcirculation → DIC
■ Complete- all products of conception expelled
■ Missed - Fetus dies, not expelled- may require D&C, D&E or
prostaglandin/misoprostol induction or may lead to infection or DIC
■ Recurrent- 3 or more spontaneous abortions- genetic or chromosomal
abnormalities, uterine anomalies, incompetent cervix, research
regarding other causes (endocrine, autoimmune, hemophilias

Ectopic Pregnancy
- Not growing in uterus (Most likely fallopian tubes )
- Unilateral, severe pain
- Can be FATAL
 - Clinical manifestations- early pregnancy transvaginal ultrasounds may allow diagnosis
prior to onset of symptoms
- Missed menstrual period
- Positive pregnancy test
- Abdominal pain (may be severe if rupturing or include shoulder pain)
- Hypovolemic shock may occur due to internal bleeding
- Weakness, dizziness, fainting
- Vaginal “spotting”
- Signs and symptoms- early ultrasounds may catch it before these occur
- Diagnosis hCG levels and transvaginal ultrasound
- Methotrexate → medication to end pregnancy
- Surgery → remove pregnancy
- Salpingostomy -salvage the tube
- Salpingectomy - remove the tube

Hyperemesis Gravidarum
● Persistent , uncontrollable vomiting; Begins in early pregnancy, may last throughout
● May cause: Weight loss, dehydration, acidosis (starvation), elevated ketones, alkalosis
(oss of gastric hydrochloric acid),hypokalemia
● May also lead to short-term hepatic dysfunction, elevated liver enzymes, Vitamin K
deficiency, Thiamine deficiency Etiology; Unknown
● Therapeutic management : medications for vomiting, IV fluids , enteral nutrition , TPN,
Labs- H & H, electrolytes
● Nursing considerations:
○ Assess and monitor I & O,, IV / nutritional therapy, medications PRN for nausea
and vomiting,support and educate
○ Nausea/vomiting: Small meals, low-fat foods and easily digested carbs, food and
drinks at different times,
■ upright position after meals, ginger
○ Nutrition/ fluid balance: eat every 1-2 hours, Increase salt, potassium and
magnesium rich foods

Multifetal Pregnancy (concentrate more on twins)

- Can be detected @ 6 weeks
- More common in women over 35
- Fundal height 4cm or more greater than expected
- BV increased 500ml or more
- Increased workload on body (more fatigue)
- Supine hypotension on WHOLE NEW LEVEL
- Higher risk in monozygotic twins
 ● Monozygotic Twins can be higher risk
○ Single ovum and sperm that later divides
○ Identical genetic components/ same gender
○ Random- no genetic predisposition
○ May share a placenta and/or amniotic sac (or even be conjoined)- less risk if
different placentas and different sacs
○ More of a risk if they share placenta (could be conjoined) (watch them carefully)
● Dizygotic Twins (seen more often)
○ Two ova that are fertilized by different sperm
○ Different placentas - less risk
○ NOT identical/ may be same or different genders
○ May be hereditary ( run in family)
○ More common with conception over age 40

Antepartum assessment and Care: Multifetal pregnancy

● Maternal physiologic change is greater with multiple fetuses
● Increased workload for the heart
● Increased respiratory difficulty
● Higher levels of HCG and AFP→ (16-18 weeks)
● Early diagnosis
● Special antepartum classes
● More frequent visits/ ultrasounds
● More frequent NSTS
● Teach signs of preterm labor (more likely to have preterm)
○ If not both head down → c section
● Nutritional needs increased

Maternal role transition: Steps in maternal role taking**

Mimicry- observation and copying of maternal behaviors

- Watching other people and how they mother their children

Role play → “let me change their diaper” practice and get used to it

Fantasy- dreaming of what infant will look like, how being a parent will be

Search for a role fit- plan for parenting/ what a “good’ mother

Grief work- realize changes that will occur and grieve loss of certain aspects

- Shouldn't affect their life to interfere with daily life

Maternal role transition: maternal tasks of pregnancy**
● Seeking safe passage
○ Seeking the care of a physician or nurse- midwife
○ Following recommendations about diet, vitamins, rest and attending visits for
care
○ LOOK FOR ADVICE
● Securing acceptance
○ Family and partner
○ Increased closeness with own mother
● Learning to give of herself
○ Body changes accepted, proud to be sustaining life, derive pleasure from giving
● Committing yourself to the unknown child
○ Attachment
■ Development of strong affection usually begins in early pregnancy
■ May be delayed until pregnancy is considered viable (prior loss may
impact)

Pregnancy Education***
● Exercise
○ Regular exercise (not more than previous exercise routine)
■ 30 min everyday
○ Avoid activities that could cause abdominal trauma (skiing, water skiing, contact
sports)
○ Walking, swimming, jogging and yoga acceptable

Classes available
● Preconception- nutrition, healthy lifestyle, signs of pregnancy, choosing a caregiver,
effect of pregnancy on relationships and career
● Ist trimester- adapting to pregnancy, what to expect
● 2nd trimester- high risk pregnancies may require extra instruction
● 3rd trimester- coping with fears and vulnerabilities
○ All 3 trimesters may be provided together
● Childbirth preparation- coping techniques- relaxation, breathing, conditioning, labor
partner support
● Breastfeeding

Diabetes Mellitus
Disorder of carbohydrate metabolism

- Complete or partial lack of insulin secretion from pancreas

- Control BEFORE GET PREGNANT
 - Glucose unable to enter cells and accumulates in the blood-hyperglycemia
○ Symptoms-Polydipsia, Polyuria, Polyphagia
○ Classifications
■ Type 1- insulin deficient
■ Type 2- insulin resistant
■ Gestational Diabeties (GDM)- onset of glucose intolerance in pregnancy
■ GDMA-1 (diet controlled)
■ GDMA-2 (diet and insulin controlled)
■ 72% chance of getting type 2 diabetes after pregnancy
- Fetal effects
○ Congenital malformations→esp neural tube and cardiac defects
○ Variations in fetal size (SGA,LGA)
○ Hypoglycemia
○ Hypocalcemia
○ Hyperbilirubinemia
○ Respiratory distress syndrome
- Neonatal effects--Hypoglycemia, Hypocalcemia, Hyperbilirubinemia
○ Early pregnancy
■ Little change in metabolic rate and energy needs
■ Insulin release increases
■ May have more hypoglycemia—> esp. if nausea and vomiting
○ Late pregnancy
■ Fetal growth accelerates
■ Rising placental hormones create insulin resistance in maternal cells
(lactogen, cortisol, progesterone)
■ More glucose in blood to go to the fetus
■ Hormones cause diabetogenic effect for mom- needs more insulin - not
enough insulin causing hyperglycemia
■ Most of the time pancreas increases insulin to prevent hyperglycemia
○ Labor and Birth*** → adequate glucose control related to extent of neonatal
hypoglycemia
■ NPO with insulin drip, LR and D5 titrated to hourly glucose checks
during active labor
○ Postpartum → insulin requirements fall
■ Usually no insulin for GDM
■ Increased risk of Type 2 in future
■ Breastfeeding encouraged- mom uses more calories decreasing insulin
needs

Gestational Diabetes
● Gestational Diabetes Risk Factors
○ Overweight
○ Maternal age over 25 years
 ○ Previous birth outcome associated with GDM (i.e. macrosomia, maternal
hypertension)
○ GDM with previous pregnancy
○ History of abnormal glucose tolerance
○ History of diabetes in a close relative
○ History of pre diabetes
○ History of polycystic ovary syndrome (PCOS)
○ Member of high-risk ethnic group
● Identification of gestational diabetes (screening)
○ Glucose Challenge Test (24-28 weeks)
■ 1 hour test-drink 50 gram glucose solution- lab draw in 1 hr
■ Normal < 140 mg/dL
■ No fasting
■ 3 hour test, 100 gram solution--Lab draws- diagnosed if 2 or more results
meet or exceed threshold
■ Fasting 95 mg/dL (8-12 hrs) (draw fasting blood)
■ 1 hour-180 mg/dL
■ 2 hours-155 mg/dL
■ 3 hours-140 mg/dL
■ If don't pass 2 or more → has GB

More frequent NSTS (2-3 times a week), Biophysical profiles done, glucose testing, labs, kick
counts (MORE TESTS)

● Therapeutic management
○ Diet→ Registered Dietician, diabetes educator
■ Limit weight gain
○ Exercise
○ Blood glucose monitoring
○ Pharmacologic treatment
■ Glyburide (micronase), metformin (glucophage)
■ Insulin
○ Fetal surveillance → LGA, macrosomic, birth injury risk
○ Placental circulation compromised → IUGR possible

Cardiac Disease
● Congenital (since birth)
○ Atrial septal defect
○ Ventricular septal defect
○ Patent Ductus Arteriosus
○ Tetralogy of Fallot
○ Transposition of the great vessels
○ Mitral valve prolapse
○ Coarctation of the aorta
● Acquired
○ Rheumatic heart disease and Endocarditis
● Ischemic
○ MI and Acute coronary syndrome
● Other → Cardiomyopathy
● Risks and assessment
○ Risk assessment tools (CARPREG, ZAHARA, mWHO)
○ Increased CO, BV, decreased Vascular resistance, Increased Clotting factor
○ Depends on:
■ Specific cardiac lesion
■ Function and ability to adapt to physiologic changes
■ Development of pregnancy related complications
● Classified -Class I (unrestricted physical activity) to Class IV (no activity allowed)
● Prenatal and antepartum care
○ Team approach to plan of care
○ NYHA functional assessment every visit
○ Assess ability to tolerate physiologic changes of pregnancy
○ Monitor weight gain and fetal growth
○ Fetal echo btw 18 & 22 wks
○ Begin fetal surveillance testing at 32 wks
○ Avoid beta agonist drugs
○ Cardiac meds as ordered
○ Biophysical profiles, NSTS, echo on baby, monitor meds, avoid beta
agonist drugs (no coumadin), educate on S/s,
- Antepartum considerations
● Encourage 8-10 hours of sleep and rest periods during the day
● Self- administration of heparin as ordered
○ NO NSAIDs
○ Monitor for bleeding
● Report S/S of infection promptly
○ adequate sleep (8-10 hours), know how to administer drugs, NO
NSAIDs, infection risks
● Teach pt and assess for signs/ symptoms of decompensation
○ Subjective- *
■ dyspnea, syncope (fainting) with exertion
■ Fatigue
■ Racing heart
■ Dry, hacking cough
■ Orthopnea or dyspnea
■ Chest pain with exertion
○ Objective*
■ Pulse > 100
■ Crackles in lung bases
■ Respirations > 25
 - Intrapartum concerns
● Determine need for continuous ECG or invasive hemodynamic monitoring
(increased level of care?)
● Continuous fetal and uterine monitoring
● Lateral positions → helps supine hypotension and placental perfusion
● Frequent vitals- avoid tachycardia
● I & O → hydration vs fluid overload
● Cardiac workload (300 to 500 mL of blood is shifted from the uterus and
placenta into the central circulation with every contraction)
● Observe carefully for signs of pulmonary edema
● Effective pain control → keep comfortable
● Vaginal delivery is recommended for a woman with heart disease unless there
are specific indications for cesarean birth.
○ Minimize maternal pushing and use of the valsalva maneuver.
○ Limit prolonged labor.
○ May need vacuum, labor down more
- Postpartum concerns
● Even with no evidence of distress during pregnancy, labor, and childbirth, may
have cardiac decompensation during the postpartum period
○ Close observation for signs of infection, hemorrhage, and
thromboembolism.
○ Extended high- acuity monitoring
○ Effective pain control
○ Avoid methergine
○ Stool softeners
○ Quantitative blood loss measurement/prevent hypovolemia
○ Monitor crackles
○ Breastfeeding → increase demand on heart (lactation consult usually
needed)

Anemias
Iron Deficiency

● Decrease in the oxygen carrying capacity of blood

○ Iron-deficiency anemia
○ Folic acid deficiency anemia- Needs in pregnancy double
● Increases- Miscarriage, preterm labor, infections, preeclampsia, pp hemorrhage, IUGR
● Assessment
○ Fatigue / Pallor
○ PIKA can be a sign
○ Become more winded
○ Easy bruising
○ Poor nutritional intake, Noncompliance with prenatal vitamins/ iron
supplementation
 ○ Low H/H
■ < 11/37 in first trimester (lower than 11 bad)
■ < 10.5/35 in second trimester
■ < 11/ 32 in third trimester (lower than 10 bad)
● Treatment- Supplementation of iron (ferrous sulfate) or folic acid
○ May depend on symptoms

Megaloblastic (folic acid and vitamin B12)

● Deficiency in either cause large, immature erythrocytes

● Increased risk of preterm birth, low birth weight, NTDs
● Treatment: folic acid supplements and/or IM vitamin injections

Sickle-cell Disease- autosomal recessive

- Shape of erythrocytes (RBCs) won’t allow passage thru small blood vessels causing
occlusions
- Changes in pregnancy may lead to crisis with multiple facets
- Watch for pain, extremity pallor, signs of cardiac failure
- Increased risk for spontaneous abortion / preterm labor/ IUGR
- Treatment
- Pre and early prenatal care
- Folic acid
- Appropriate immunizations to prevent infection
- Fetal surveillance
- Intrapartum hydration and continual oxygen administration

Thalassemia- also genetic (uncommon in pregnancy)

- Thalassemia Minor -Mild anemia but overall problems during pregnancy healthy with
minimal
- Fetus may inherit more serious Thalassemia major if both parents carry gene
- Look for abnormal hemoglobin

Autoimmune

Systemic lupus- increased risk for complications ( hypertensive disorders, Preeclampsia,

preterm birth, IUGR, etal loss/stillbirth, neonatal heart block)
Antiphospholipid syndrome

- Possible risks: stroke, preeclampsia, placental insufficiency

- Low dose aspirin and prophylactic anticoagulants, lovenox
- Thrombus formation → difficulty with preg (more likely for spontaneous abortion,
preterm)
- Monitored carefully

Graves Disease → increased thyroid (same risks as below)

Hashimoto’s Thyroiditis → decrease thyroid

- Preeclampsia, HF, thyroid storm

- LGA baby
- Increased risk of preterm, stillbirth
- Can take levothyroxine

Rheumatoid arthritis → chronic inflammatory

- May actually feel better during pregnancy

- Fewer symptoms while pregnant, worse before and after

Neurologic Disorders
● Seizure disorders
○ Increased risk for miscarriage, antepartum and postpartum hemorrhage,
hypertensive disorders, abruption, preterm birth, teratogenic effects of some
anti-seizure medications
○ Preconception care, close monitoring, attempt to minimize seizure risk
○ Discharge planning
● Bell’s Palsy
○ Sudden unilateral neuropathy causing facial paralysis
○ Unknown cause
○ Result of viral infection

Infections During Pregnancy

● STDs (STIs) (test at first prenatal visit)
○ Syphilis (also tested when get into hospital)
○ Gonorrhea
○ Chlamydia
○ Trichomoniasis
○ Condyloma Acuminatum (HPV)
○ Increase risk for preterm and giving this to baby
○ Safe sec, good hygiene
 ● Vaginal infections
○ Candidiasis (yeast infection)
○ Bacterial Vaginosis (BV)
● Viral infections
○ Cytomegalovirus → herpes, hearing loss (if does not pass screening test)
○ Rubella (can cross placenta → IUGR, deafness; can't get vaccine in pregnancy)
■ Don't get pregnancy for 28 days after vaccine
■ Signed consent
○ Varicella Zoster (biggest risk 13-20 weeks)
■ If mom contracts 5 days before delivery → big risk bc no antibodies to
baby
■ Vaccine they would give baby within 96 hours after birth
○ Herpes Simplex → depends on if active outbreak
■ If active → c section bc want NO contact
■ Give meds at 36 weeks to mom to prevent
■ If no lesions on breast → breastfeeding OK
○ Parvovirus B19 → 5ths disease
■ Fetal death if during pregnancy could happen
■ Fetal RBC production → anemia → HF (1st trimester risk)
○ Hepatitis B
■ OK in pregnancy
■ If mom pos → antibiotics, Hbig
■ Bathe baby before injection
○ Human immunodeficiency virus (HIV)
■ Testing all clients
■ If known → start on antiviral therapy prior to pregnancy
■ >1000 OK for vag birth
■ If higher C section at 36 weeks
■ No fetal scalp electrodes, any risk of bleeding
■ Bath ASAP after birth
■ Breastfeeding → NO breastfeeding
○ Covid-19
● Nonviral
○ Toxoplasmosis → raw meats, NO CAT LITTER
○ Group B streptococcus→ treated in labor
■ Antibiotics (every 4 hours) (penicillin preferred)
○ Tuberculosis

Obesity → Determined by BMI

● Risks- pregnancy may exacerbate many comorbidities (i.e. hypertension, diabetes,
asthma)
○ Less fertile
 ○ Increased risk for spontaneous abortions/ stillbirth
○ Maternal Increased risk for : GDM, preeclampsia, venous
thrombosis,cesarean delivery, wound infection, respiratory complications,
preterm birth, birth trauma, postpartum anemia
○ Infant increased risk for: Neural tube defects, hydrocephalus and cardiac defects,
macrosomia, hypoglycemia, birth injury from shoulder dystocia
● Antenatal- less weight gain recommended during pregnancy
○ Encourage proper nutrition, behavior modification and exercise
○ Screen prenatally and at 24-28 weeks for diabetes
○ Follow fetal growth with ultrasounds
● Intrapartum-appropriate sized equipment necessary
○ Monitoring challenges may require one-to-one care
○ Increased risk for dysfunctional labor/cesarean
● Postpartum- increased risk for complications-pneumonia, postpartum
hemorrhage, infection, DVTs, wound dehiscence
● Special consideration to possible vitamin and nutritional deficiencies if post bariatric
surgery

UNIT 4

Health Maintenance and disease prevention

● Health history / Physical assessment / Preventive counseling
● Immunizations
● Screening and self-examinations
○ Breast exam-self-awareness
○ Mammography- annually at 45-55, then every other year. will pick up
much earlier than a self breast exam.
○ Vulvar self-exam-monthly > 18 or sexually active
○ Pelvic exam/ Pap smear
■ every 3 years (21-29)
■ Add HPV test every 5 years (30-35)
■ Over 65 none if normal tests for last 10 years
○ Rectal exam- done with physical exam.
○ SUPPLEMENTS IMPORTANT TO NOTE

Women’s Health Problems

● Cardiovascular disease → Leading cause of death for females
- Leading cause of death→ heart attack, heart failure, arrhythmia, stroke
- Often go undiagnosed- atypical symptoms (arm pain)
- Risk factors-
 - Hypertension
- Inadequate physical activity
- overweight/obesity
- Diet and glucose control
- Age, family history
- Smoking
● Hypertension
● Disorders of the breast
● Menstrual cycle disorders
● Abortion
● Menopause → decreased E/P = more risk for these problems
● Pelvic floor dysfunction
● Disorders of the reproductive tract
● Infectious disorders of the reproductive tract

Benign Disorders of the breast

Fibrocystic breast changes - tissue thickens = cysts

● (20s to 50s)
● Lumps may or may not be painful (pain with menstrual cycle)
● Most common in 20-30s
● Not associated with breast cancer risk
● Ultrasound to diagnose
● May aspirate cyst to relieve pain
● Good support bra/ avoid caffeine/ oral contraceptives help
● If severe → longer 6 mo = meds
● Risk factors
○ Premenstrual abnormalities
○ Nulliparity
○ History of spontaneous abortion
○ use of oral contraceptives
○ Early menarche
○ Late menopause
● Signs/symptoms
○ Thickening of breast tissue
○ Palpable round, well-delineated, freely movable lumps, tenderness (size
may fluctuate with menstrual cycle)
○ Green, dark-brown, non bloody nipple discharge
● Treatment
 ○ Support bra
○ Avoid stimulants-coffee, tea,etc.
○ Oral contraceptives
○ Severe breast pain >6 months- tamoxifen, bromocriptine or danazol

Fibroadenoma- fibrous & glandular tissue

● Teens through 20s**

○ Firm, mobile nodules-”marbles”
○ changes with menstrual cycle
○ Monitor and biopsy if size increases
○ Ultrasound/MRI to diagnose
○ May remove to biopsy for malignancy

Mammary Duct Ectasia- dilation of collecting ducts, distends and fills with cellular
debris

● Women approaching menopause (45-55), inflammatory response

○ Mass near areola, firm/ irregular (MASTITIS LIKE)
○ Enlarged axillary node
○ Nipple retraction
○ White cheesy discharge
● Biopsy, Duct may need to be excised
● Antibiotics
● ANY NIPPLE DISCHARGE → PROVIDER CHECKS

Intraductal papilloma- “wart-like” tumor forms in a milk duct in the breast, glandular
and fibrous tissue as well as blood vessels

● Just before or during menopause

○ Often under the areola-solitary
○ May be several farther from nipple-multiple papillomas (slight increased
cancer risk)
○ Clear or bloody nipple discharge
○ Erosion of the ducts
● Diagnosis- (X ray) Ductogram, ultrasound, mammogram
● Treatment
○ Excise mass and ducts → if large enough
○ Analysis of discharge to rule out malignancy
Diagnostics for breast disorders
● Ultrasound- fluid -filled cysts vs. solid tissue
● Fine- needle aspiration biopsy- removes fluid or small cells
● Core biopsy-larger needle- cylinder of tissue
● Open biopsy (surgical)- lumpectomy if:
○ Suspicious mass that persists through menstrual cycle
○ Bloody fluid aspirated from a cyst
○ Cyst recurrence after 1 or 2 aspirations
○ Solid dominant mass not diagnosed a fibroadenoma
○ Serous or serosanguineous nipple discharge
○ Nipple ulceration or persistent crusting
○ Skin edema and erythema suspicious for inflammatory breast carcinoma
○ Suspicious mammography or ultrasound findings
○ Genetic abnormality that increases risk

Malignant Tumors of the Breast

● Incidence- 1 in 8 biologic female, 1 in 1000 biologic male
○ Highest in non-hispanic white
○ death rate highest for African-American
● Risk factors- cause unknown
○ Gene mutations/ genetic links
○ BRACA 1&2
● Pathophysiology
○ Infiltrating ductal carcinoma- begins in lining of mammary ducts and
spreads to breast tissue
○ Infiltrating lobular -originates in milk-secreting pockets of breast tissue
○ Inflammatory breast carcinoma (IBC) cutaneous with involvement of the
dermis- skin rash,dimpling of skin, tenderness, itching
■ Often mistaken for infection
○ Cancer cells carried by lymph channels, metastasis through blood and
lymph systems
● Staging- Tumor, node and metastasis system (TNM)
○ Stages used to guide treatment
○ Stages I-4
■ Stage 1- small tumor, no lymph involvement or metastasis
 ■ Stage 4-spread to lymph, metastasis to distant organs
■ Look also at hormone receptors and rate of proliferation

Malignant Tumors of the Breast: Management

● Usually combination of therapies
● Surgery- depends on stage, type and location
○ Curative → completely remove tumor (with chemo/rad)
○ Debulking → decrease size of tumor (too close to other organs
○ Palliative → treat symptoms but not tumor itself (remove pain)
○ Supportive → insert port (to give meds)
○ Restorative/Reconstruction → mastectomy/ partial or full
○ Preventive/ prophylactic → decrease risk (if family history) screenings
○ Adjuvant therapy - supportive or additional therapy usually
recommended after surgery (chemo/radiation)
○ Based on age, stage, preferences and hormone receptor status of the
lesion
○ Radiation high-energy rays to destroy cancer cells remaining (May be
used to reduce tumor size before surgery)
○ Chemotherapy-- drugs to kill cancer cells
■ May be used before or after tumor removal
■ May also kill normal cells*
■ Bleeding tendencies,increase susceptibility to infection, hair
loss, menstrual irregularities, anemia, fatigue, nausea
possible
○ Hormone therapy - Medications given to reduce estrogen production to
treat tumors with growth stimulated by estrogen
■ Tamoxifen-estrogen blocking
■ Aromatase inhibitors-hinder production of estrogen
■ Raloxifene-estrogen modifier
○ Immunotherapy
■ Trastuzumab: REDUCE cancer growth

Malignant Tumors of the Breast → Psychosocial concerns

● Stress- surgery, treatment options, loss of control
● Fear : death,quality of life,
● Body image/ sexuality
○ Side effects of therapy
 ● Communication/ relationships
● Nursing considerations: support, provide accurate information about what to
expect with treatments, exercise
○ Lymphedema- more with extensive lymphatic tissue removal
■ Compression arm sleeves
■ Usually no BPs, IVs, blood draws in affected side
○ Discharge teaching self-care , S/S to report

Menstrual Cycle Disorders* KNOW FOR EXAM

● Amenorrhea (absence of menses)
○ Primary- has not reached menarche
○ Secondary- cessation of 3 months or more in a woman with an
established cycle or irregular menstruation for 6 months
■ PCOS is a very common cause but occasionally associated with
primary amenorrhea
■ hypothalamic/endocrine disorders may relate
● Abnormal uterine bleeding***
○ menorrhagia-prolonged / heavy bleeding
○ Metrorrhagia- irregular
○ Menometrorrhagia-irregular and more frequent
● Cyclic Pelvic pain-repetitive/predictable
○ Mittelschmerz
○ Primary dysmenorrhea-painful periods
○ Endometriosis- endometrial tissue outside the uterine cavity
■ May have infertility issues, dyspareunia,rectal
pressure/urgency
■ Oral contraceptives may suppress tissue proliferation
■ May need surgery will try laparoscopic
● Premenstrual Syndrome
○ Physical and psychological symptoms
○ Cause unknown,? Fluctuating hormones
○ Supportive measures/ small,frequent meals

Treatment depends on the cause

- Hormone administration, D&C, Laparoscopy, Hysterectomy

Elective Termination of Pregnancy
● Methods of termination
○ Medical-up to 7 weeks of LMP
■ Mifepristone followed by cytotec (misoprostol)
■ Methotrexate followed by cytotec
○ Surgical- over 7 weeks or if medical abortion failed
■ Through 12 weeks vacuum aspiration with curettage
○ Surgical- 2nd trimester
■ Greater cervical dilation and larger aspirator for fetal contents
■ Induction/labor--laminaria (seaweed like) , Prostaglandin E2
● Nursing considerations
○ Support
○ RhoGam
○ Bleeding
○ Infection
○ Follow up
○ contraception
Menopause (climacteric)
Ovaries no longer respond to FSH and LH

● Onset- average- 51.5 years

● Physiologic changes
○ Ovulation and menstruation irregular and sporadic
○ decrease estrogen = increase cardiac risks
○ Hot flashes
○ Painful intercourse
○ Uncomfortable
○ Dyspareunia,frequent vaginal infections, cystitis
● Psychological responses
○ Pursue personal Development
○ Mood swings/depression / irritability/ insomnia/ fatigue
● Therapy-- hormone replacement therapy (HRT)
○ Descuse Risks vs Benefits

Osteoporosis - decreased bone density

● more susceptible to fracture
● Risk increases with age
○ Family history
○ Late menarche
○ Early menopause
○ Sedentary lifestyle
○ Medications
● May lose bone mass for years without symptoms
○ Height decreases
○ Vertebral changes- “Dowager’s hump”
● Diagnosis-- history, physical exam and bone density (DEXA scan)
● Treatment/ Prevention
○ Estrogen
○ Medications-Calcitonin, bisphosphonates, Raloxifene, Teriparatide,
Denosumab
○ Calcium/Vitamin D
○ Physical activity-weight bearing
Disorders of the Reproductive Tract:

Benign disorders

● Cervical Polyps
● Uterine Leiomyomas
● Ovarian Cysts
● Cervical Polyps
○ Small tumors ( usually only a few millimeters in diameter)
○ Caused by proliferation of the cervical mucosa
○ Intermittent vaginal bleeding
○ Surgically removed

Uterine Leiomyomas (fibroids)

● Develop from uterine smooth muscle cells

● Estrogen dependent
● Grow rapidly during reproductive years/ shrink with menopause
● Can be asymptomatic depending on size, number and location
● Signs/symptoms- may be asymptomatic
○ Bleeding
○ Pelvic pressure
○ Urinary frequency
● Treatment
○ Myomectomy
○ Uterine embolization
○ Hysterectomy
○ Medications- contraceptives, GnRH agonists
Ovarian cysts

● Follicular--Ovarian follicle fails to rupture

○ Asymptomatic
○ Regress naturally
● Luteal--if the corpus luteum cystic and fails to regress
○ Painful
○ Delay in menstrual cycle ( hormones continue, positive HCG)
○ Differentiate from solid malignant tumor (transvaginal ultrasound,
laparoscopy,laparotomy)
● Hemorrhagic cyst-- any cyst that ruptures and bleeds

Malignant disorders

● Signs and Symptoms- often asymptomatic in early stages or S/S nonspecific

○ Irregular vaginal bleeding/ bleeding after menopause
○ Unusual vaginal discharge
○ Dyspareunia
○ Persistent vulvar or vaginal itching
○ Vulvar lesions
○ Persistent abdominal bloating/ constipation
○ Persistent anorexia or vomiting
○ Blood in stools
● Risk factors-depend on site
○ Cervical- STIs, esp. HPV, multiple partners (risky sexual practices)
,multiple pregnancies,Obesity, diet lacking fruits/veggies, low
socioeconomic status, Smoking
 ○ Uterine-prolonged unopposed estrogen (ERT), obesity, nulliparity, age,
late menopause,diabetes, other cancers,,african-american
○ Ovarian- menarche<12, No children or first child after 30, late
menopause, infertility, infertility drugs, family history of cancers, personal
breast cancer history

Cervical Cancer, Endometrial Cancer, Ovarian Cancer

● Diagnosis- early diagnosis associated with long-term survival

○ Screening
■ pelvic exams
■ Pap tests Ultrasound
■ serum testing for tumor markers/ genes (CA-125, BRCA1, BRCA2)
■ Biopsies
● Management- depends on location, progression of disease, age, desire for
children
○ Tumor size may start with chemo to decrease size, than surgery.
○ Degree of malignancy and metastases
○ Chemotherapy, radiation, surgery
- Cervical-biopsy, endocervical curettage (if not pregnant)
○ Early treatment-cryosurgery, laser, LEEP (electrosurgical excision
procedure), or cervical conization
■ Regular surveillance
○ Advanced cancer--surgery ((Total abdominal hysterectomy /bilateral
salpingectomy-TAH/BSO)
■ Sentinel Lymph Node (SLN) Biopsy ****
■ Radiation and Chemotherapy

(https://www.acog.org/womens-health/videos/cervical-cancer-screening)

Endometrial- TAH/BSO, chemotherapy and/or radiation

Ovarian- may be asymptomatic CA125 test (blood)

Surgery- TAH/ BSO

Chemotherapy- before to shrink tumor or after surgery

Hysterectomy
● Post-op management
○ Pain management
○ Ambulation
○ Intake and output
○ Incision site(s)
○ Vaginal discharge → more than 1 pad in 4 hours

Pelvic Floor Dysfunction

Vaginal wall prolapse- feeling of fullness or “organs falling out”, pelvic pressure, low
backache

● Cystocele- relaxation of anterior vagina with bladder prolapse

○ Incontinence, Urinary retention, Bladder infections
● Enterocele-prolapse of upper posterior vaginal wall between vagina and rectum
○ Often found with uterine prolapse
● Rectocele-weak posterior vaginal wall leads to rectum protruding into vagina
○ Difficulty with bowel elimination- pressure frequent feeling of need to
defecate

Uterine Prolapse-stretched ligaments don’t return to normal after childbirth

- more common after multiple vaginal deliveries or large babies

- If cervix protrudes from vagina may have cervical ulceration and bleeding
- Management- depends on extent, age, physical condition, sexual activity
- Surgery- A & P repair (anterior and posterior colporrhaphy, may also have
vaginal hysterectomy
- Pessary
- Topical or systemic estrogen
- Nursing considerations: encourage pelvic floor muscle exercises (Kegels***),
bladder training to decrease incontinence, caution against fluid restriction
irritation of bladder by alcohol and caffeine, link to obesity
Infectious Disorders of the Reproductive Tract
Sexually transmitted diseases/ infections

○ Most common among adolescents and young adults

○ May be asymptomatic
○ Protection with barrier contraceptive methods but not others
○ Birth control will NOT protect against STi/STDs *****
○ Treat BOTH partners or will just pass back and forth

Bacterial Vaginosis- organisms replace lactobacilli

● Associated with multiple partners, douching, lack of vaginal lactobacilli,

sometimes but not always sexual activity
● thin, grayish-white vaginal discharge with fishy odor
● Diagnosis: wet mount to identify cells
● Treatment: reestablish vaginal flora, metronidazole, clindamycin
● Avoid sexual intercourse until cured or use condom

Human Papillomavirus (HPV)- Condylomata Acuminata-- genital warts

● Wart-like growths, clusters may resemble cauliflower

● Found on labia, vagina cervix, perineum
● Associated with cervical cancer
● Diagnosis:visually, more frequent Pap testing and colposcopy recommended to
evaluate for abnormal cervical tissue
● Treatment: no treatment except removing cells but does not remove the virus
○ Topical- podophyllin, trichloroacetic acid, bichloroacetic acid
 ○ Cryotherapy, laser, LEEP, conization (does not REMOVE VIRUS)
○ Interferon if not responsive to other therapies
○ sexual contact until lesions are healed, condoms recommended to reduce
transmission

Syphilis- divided into stages

● Primary- local up to 90 days post exposure

○ Painless Chancre- geniatalia, anus or lips/ oral cavity
○ Highly infectious
○ Can identify spirochetes under microscope but serologic tests usually
negative
● Secondary- if untreated -chancre heals in approx 6 weeks but spread in the
blood throughout body
○ About 2 months after initial exposure symptoms include: headache,
anorexia, enlarged liver and spleen, generalized maculopapular rash
○ May develop vulvar condylomata lata (resemble warts)- highly contagious
○ Serologic tests positive
● Tertiary- latent phase may last for years followed by tertiary phase
○ Heart, blood vessels and central nervous system involvement
○ General paralysis and psychosis
○ Serology positive- VDRL, RPR, FTA-ABS
● Treatment: Penicillin G parenterally

Chlamydia- antibiotics: Doxycycline. Azithromycin or Levofloxacin

● Females: asymptomatic or s/s of infection

● Males: urethritis

Genital Herpes (HSV)-

● HSV type 2 -usually genital lesions

● HSV type 1 → oral lesions
● Blisters- usually in 2-12 days after infection, rupture and form ulcers 1-7 days
then heal in 7-10 days
○ Pain, tenderness, dyspareunia
○ Virus is dormant and periodically reactivates (stress, fever,
menstruation)
 ● Contagious even when asymptomatic (lesions → spread)
● Diagnosis: S/S, culture
● Treatment: NO cure , antiviral drugs reduce symptoms ,shedding and
recurrence (acyclovir, famciclovir, valacyclovir)
○ sexual contact while lesions are present)

Gonorrhea

● Females asymptomatic or purulent discharge, dysuria, dyspareunia

● Males- dysuria, yellow-green discharge, urinary frequency
● Diagnosis: positive culture
● Treatment: cefixime, ceftriaxone, ciprofloxacin
○ Frequently associated with PID- treat both
○ Treat both partners**
○ Avoid intercourse**, use condom until cure confirmed

Acquired Immunodeficiency Syndrome (AIDS)- caused by HIV

- HIV found in blood semen, vaginal secretions,urine, saliva, tears, cerebrospinal

fluid, amniotic fluid and breast milk
- Routine testing for all pregnant women to treat and possibly avoid transmission
to fetus
- NO cure but meds improve length and quality of life
- Can have a vag. Birth but will wash the baby earlier. NO BREASTFEEDING

Vaginitis

Candidiasis-(moniliasis or yeast infection)-most common

- Changes in vaginal pH and flora- often with pregnancy, diabetes, oral

contraceptives, systemic antibiotic therapy
- S/S: perineal/ vaginal itching, burning on urination, white “cottage -cheese -like”
discharge
- Diagnosis: Identification of candida albicans spores
- Treatment: see provider for first sign of infection
- OTC meds: butoconazole, miconazole, clotrimazole, terconazole, tioconazole
- Vaginally for 3-7 days
- Prescription: Oral fluconazole- single dose, may need to be repeated
Infectious Disorders of the Reproductive Tract
** Nursing Considerations**

● Non Judgemental, straightforward approach

● Sexual history
○ Partners- male, female, number
○ Practices
○ Protection
○ Previous history of STIs
● Education → Prevention of spread-barrier methods

Pelvic Inflammatory Disease (PID)

- Most cases caused by repeated infections by C. Trachomatis and N. Gonorrhea-
pockets of infection

Risk factors: history of STI/repetitive STIs, multiple partners, douching, under 25

Chronic infection can scar tubes/ peritubal adhesions-fertility issues, ovum transport
thru tubes affected

- Signs
○ Asymptomatic
○ Pain
○ Fever
○ Purulent discharge
○ Bleeding
○ Nausea
○ Anorexia
○ Adnexal, uterine,cervical tenderness
● Diagnosis: increased WBCs, increased sedimentation rate, UA (rule out
UTI),cultures
● Management- may be cyclic
○ IV antibiotics
○ If abscesses present may require surgical intervention
● Prevention
○ Decrease exposure
○ DO not spread
Toxic Shock Syndrome
Rare but potentially fatal

● Caused by toxin-producing strains of Staphylococcus aureus

○ Alters capillary permeability, hypovolemia and hypotension
■ Effects coagulation- can lead to DIC
■ Hypovolemic shock
■ Septic shock
● Tampon use
○ Wash hands
○ Change every 4 hrs, pads during sleeping hours
● Diaphragm or cervical cap use-wash hands, don’t use during
menstruation,remove as recommended
● History of nasal surgery or staph aureus wound infection
● Signs: flu-like symptoms, sudden fever, hypotension, sunburn-like rash, skin
peeling on palms and soles of feet
● Treatment: Fluid replacement, vasopressor meds, antibiotics

Family Planning Role of the nurse → provide facts

Methods: Sterilization
● Female- Tubal Ligation
○ Use alternative method for 3 months
○ Follow up with hysterosalpingogram
● Male: Vasectomy
○ Use alternative method for at least 3 months
○ Submit specimen for analysis 8-16 weeks following procedure

No STD protection

Reversal is expensive

Surgical risks
Long-acting Reversible Contraceptives
● Intrauterine devices (IUDs)-Para Gard, Mirena,Skyla, Liletta
○ years effectiveness, depends on specific type
○ Inserted anytime not pregnant or with active STDs or infection
○ Immediate action and reversal once removed
○ Hostile uterine environment for conception
○ Considered safe, convenient and highly effective
○ Complications: perforation with insertion, expulsion
○ Side effects: cramping, irregular bleeding after insertion, ectopic
pregnancy,infection
○ Teaching: bleeding expectations based on type, see provider if unable to
feel the string, report signs of infection or pregnancy, can have ectopic
pregnancy
● Contraceptive implant- Nexplanon
○ Releases progestin over 3 years, inhibits ovulation, thickens cervical
mucus, thins endometrium
○ Side effects: , acne, minimal weight gain, Irregular bleeding
○ Fertility returns immediately upon removal
● Hormone injections
○ Depo-Provera
■ Progestin injection scheduled every 13 weeks
■ not rub site after injection
■ Not recommended for longer than 2 years
■ Side effects: Irregular bleeding, headaches, depression, hair loss,
nervousness, decreased libido, breast discomfort
■ Decreased bone density reversed after discontinued
■ May be a delay in return of fertility after stopping

Oral Hormonal Contraceptives-inhibit ovulation

● Combination (estrogen/progestin)
○ Decreases FSH and LH, suppresses ovulation, Thickens cervical mucus
○ Shorter, lighter withdrawal bleeding
● Progestin only- women who can’t take estrogen, usually breastfeeding mothers
○ Thickens cervical mucus, Unfavorable uterine lining, less effective in
inhibiting ovulation
● Benefits: Regulates cycle, highly effective, amenorrhea, Fertility usually returns
within 3 months, Improves acne, endometriosis, premenstrual symptoms,
 dysmenorrhea, bleeding from leiomas, decreased incidence of PID, salpingitis,
ectopic pregnancy, Ovarian, endometrial and colorectal cancer
● Risks: NO protection from STIs, may increase cervical cancer risk, increased
incidence of VTE, pulmonary embolism, MI, stroke, hypertension, migraines,
chlamydial infection, gallbladder disease
● Side effects: nausea, breast tenderness, breakthrough bleeding, weight gain
● Teaching: when to start and how to take (consistency), side effects, missed
doses, avoid for 21-28 days after birth, interactions with other meds (
anticonvulsants, antiretroviral, rifampin, OTC (St. John’s Wort See text pg. 745
● Follow-up: annual BP monitoring, plans and potential changes

Emergency Contraception “morning after pill”

Prevent pregnancy after unprotected intercourse or contraceptive failure

Most effective within 72 hrs

Should receive counseling regarding a regular contraceptive method

Plan B One-Step- available without prescription

- Delay ovulation, thicken cervical mucus, interfere with function of corpus luteum
- Ineffective after implantation has already occurred , not harmful to fetus

Ella -prescription required-delays or blocks luteinizing hormone and ovulation

Transdermal Contraceptive Patch

Ortho Evra

● Releases small amounts of estrogen and progestin

● Regulates menstrual cycles
● effective as oral contraceptives
● Hormone levels return to normal in 1 month
● Application
○ Weekly, rotating sites (left off for 1 week)
○ Attempt to reattach if falls off, no tape
● Contraindications and side effects
○ VTE, greater direct estrogen delivery
○ Spotting, headaches, breast tenderness
Contraceptive Vaginal Ring
● Soft, flexible, vinyl ring inserted into vagina and left in place for 3 weeks
● Week 4 withdrawal bleeding occurs, then a new ring inserted
● Estrogen and progesterone prevent ovulation
● Removal - can be removed for up to 3 hours without change in effectiveness
● Prescription required, no fitting necessary
● Side effects: headache, breast tenderness, nausea, vaginitis, increased vaginal
discharge, discomfort

Barrier Methods
● Chemical barriers
○ Spermicides
■ Messy
■ Placed for 15 minutes prior to intercourse
■ Easy to obtain, cheap
● Mechanical barriers
○ Male condom- STD protection
○ Female condom- STD protection, not to be used with male condoms
○ Sponge- traps sperm, non hormonal, leave in place for 6 hours after
intercourse
○ Diaphragm- used with spermicide, new product is one size fits most
○ Cervical cap- similar to diaphragm but smaller, used with spermicide,
check placement

Natural Family Planning

Using physiological cues to predict ovulation to prevent or become pregnant

● Calendar- timing of ovulation approximately 14 days prior to menstruation

● Standard days-string of color coded beads or digital platform/ fertile days 8-19
after first day of menses
● Symptothermal method
○ Cervical mucus
○ Basal body temperature
● Abstinence → best way to prevent
Least reliable contraceptive methods
● Lactational amenorrhea
○ Breastfeeding - inhibits ovulation
● Coitus Interruptus
○ Also called withdrawal

Infertility
Approximately 20 % of infertile couples have no identified problem

Evaluation of both partners helps to identify therapies most likely to be successful

Male factors: sperm, erection, ejaculation or seminal fluid abnormalities

Female factors: Disorders of ovulation, cervical, fallopian tube abnormalities

Recurrent loss factors: abnormalities of fetal chromosomes, cervix, uterus,endocrine

function, immunologic or thrombotic factors, environmental agent exposure, infections

Evaluation: preconception counseling, history and physical, diagnostic tests

Facilitating pregnancy: Pharmacologic, surgery, therapeutic insemination, egg donation,

surrogacy, Assisted Reproductive Technologies (ART) - in vitro fertilization, intrafallopian
transfer, zygote intrafallopian transfer, intracytoplasmic sperm injection, preimplantation
genetic testing
MEDS
vistaril - anxiety
Antibiotics - pen g (step B +)
Methergine→ uterine contraction (contradicted w/BP)
Nubain → pain med opioid
Cytotec → uterine contraction/cervical ripening/missed abortion
Enoxaparin → prevent DVT
Hemabate → uterine contraction (contradicted with asthma)
Percocet → mix opioid and acetaminophen
Stadol, Nubain → mixed opioids
Naloxone → narcan
Fentynal, Morphine, Remifentanil → painkiller Opioids
Milk of magnesia → helps constipation, also given before C sections
Percolone → no tylenol
Terbutaline → stops uterine contractions/ Increased HR / also give corticosteroids
Lanolin → nipple cream
Erythromycin → infection
Lidocaine → local pain
Mag sulfate → prevent seizures in preeclampsia (can decrease RR)
Calcium gluconate → antidote for mag
Misoprosol /cytotec→ thins cervix
Methotrexate → chemo drug for ectopic preg (urine toxic 72 hours) -
Corticosteroids → not given to diabetics
Betamethasone → lung maturity (34-36 weeks)
Prostaglandins → cervical ripening agent
Cervidil → overnight ripening
Tamoxifen-estrogen blocking (hormone therapy)

Aromatase inhibitors-hinder production of estrogen (hormone therapy)

Raloxifene-estrogen modifier (hormone therapy)

Trastuzumab: REDUCE cancer growth (immunotherapy)

laminaria (seaweed like): induction/labor 2nd trimester termination of pregnancy

Calcitonin, bisphosphonates, Raloxifene, Teriparatide, Denosumab: osteoporosis

medications

contraceptives, GnRH agonists: treatment for fibroids

metronidazole, clindamycin: treatment of BV

podophyllin, trichloroacetic acid, bichloroacetic acid: treatment for HPV

Penicillin G: treatment of syphilis

Doxycycline. Azithromycin or Levofloxacin: treatment of chlamydia (antibiotic)

acyclovir, famciclovir, valacyclovir: Treatment for Herpes (antiviral)

cefixime, ceftriaxone, ciprofloxacin: treatment for gonorrhea

butoconazole, miconazole, clotrimazole, terconazole, tioconazole: OTC meds for yeast

infection

Oral fluconazole: Prescription med for yeast infection