LABOR AND DELIVERY SKILLS

Bloodborne pathogens / Standard Precautions
The Center for Disease Control (CDC) defines Standard Precautions as a set of precautions designed to prevent or reduce the risk of transmission of HIV, HBV, HCV and other blood-borne pathogens from both recognized and unrecognized sources of infection in health-care workers (HCWs). HCWs are defined as persons, including students and trainees, whose activities involve contact with patients or with blood or other body fluids from patients in a health-care setting. Nurses employed in labor and delivery are exposed to blood, vaginal secretions and amniotic fluid, which are carriers of infectious diseases. Blood is the single most important source of HIV, HBV and other bloodborne pathogens. The blood does not have to be visible to the human eye to be capable of transmitting disease. Handwashing Wash the hands thoroughly, with soap and water, after contamination with blood or other body fluids, between patients and immediately after gloves are removed. Gloves do not replace the need to wash the hands. There may be minuscule puncture marks on the gloves that can aid in spreading infectious diseases. Gloves In labor and delivery, gloves must always be worn when touching body fluids that contain blood or when handling items or surfaces with blood or body fluids what are potentially infectious. (CDC, 1999) Non sterile gloves can be used when starting the intravenous, phlebotomy, washing used instruments, cleaning a patient before or after a vaginal delivery, obtaining various body fluids for diagnostic purposes (peritoneal or amniotic fluids), handling the placenta and umbilical cord, and when handling the infant after the delivery until blood and amniotic fluid is washed off. Non-sterile gloves can also be used for procedures involving contact with mucous membranes and other non sterile examination, for example: digital examination of mucous membranes or when performing heel sticks on infants. Sterile gloves must be used for procedures that involve contact with normally sterile areas of the body. In obstetrics this includes the use of sterile gloves during vaginal examinations to protect the transmission or introduction of infection into the vagina. Gloves should be changed between each patient contact. Never wash gloves for reuse. Protective Barriers The Center for Disease Control (CDC) states that all health care workers who participate in invasive procedures must use appropriate barrier precautions. (CDC, 1999).The CDC recommends that for both vaginal and cesarean deliveries gloves, gown (with protective front), plastic disposable overshoes, eyeguard and mask be worn. Both in a vaginal or cesarean section, the floor or ground is likely to be contaminated and when the placenta is delivered, the blood may splatter. Human Milk Although HIV and outer surface antigens (HBsAg) have been found in the milk of mothers infected with HIV and HBV, health care workers do not have the same type of exposure as the infant. Therefore, universal precautions do not apply to breast milk. Source: The Center for Disease Control (CDC) the prevention of transmission of blood-borne diseases in the health-care setting 1999.

HISTORY AND INITIAL ASSESSMENT As with any evaluation the first and perhaps most essential component is the history. The patient should be specifically queried about the presence or absence of leaking or ruptured membranes and the presence or absence or vaginal bleeding. A history of recent illnesses should be sought and any prenatal complications should be reviewed. Finally, an inquiry should be made about the patient's expectations and preparation for the labor and delivery process (childbirth classes, preferred pain management, plans for infant feeding). A careful review of the prenatal record should be supplemented by the patient interview with regard to recent illnesses and obstetrical complications.

PHYSICAL EXAMINATION OF THE LABORING WOMAN

Steps you should take to prepare for the examination: Ask woman to empty bladder (collect urine for testing). Prepare to follow a logical order. Prepare to chart logically immediately after exam (make notes). Remember to use all your senses during assessment. Remember to explain everything you are doing. Exam should be carried out immediately and as quickly as possible.

Urine tests used during intrapartum

Ph Measures acidity/alkalinity of the urine, Levels below normal indicate high fluid intake, levels above the norm indicate inadequate fluids & dehydration. Protein Normal = Negative, Small amounts may be in urine from vaginal secretions & dehydration, Amounts of 2+ to 4+ may indicate be one indicator of possible UTI, Kidney Infection or PIH. Glucose Normal = Negative or + I. High levels of glucose may be one indicator of high blood sugar, gestational diabetes or diabetes mellitus. Always ask what woman has recently eaten if her BS is high. Ketones Normal = Negative. Ketones are products of the breakdown of fatty acids caused by fasting. The body breaks down fats because there are not enough carbohydrates and proteins available. Ketones may be deleterious to fetus.

Techniques to be used in performing a physical examination: Inspection Palpation Auscultation...

For more information go to:
The Auscultation Assistant - Hear Breath Sounds, Heart Murmurs, Heart Sounds, and ...

Perform Examination:

General appearance: Edema, skin color, hygiene, pain, distress, mood

Measure vital signs: Blood pressure, pulse, respiration, temperature

Blood pressure Take blood pressure with woman in sitting or side lying position Compare blood pressure with prenatal blood pressure

At what point would you determine if the patient were hypertensive? What additional assessments and interventions would you take if patient were hypertensive? Test for proteinuria. Assess for facial and general edema. Test for hyperreflexia. Ask if patient is having headaches, blurred vision, spots in vision. Notify provider of any pathologic results

Pulse Rate: 60 - 90 Increased pulse can be dehydration, anxiety. Always question possibility of cardiac problems. What is the most common cardiac problem in a young female?

Respiration Don’t count during a contraction

Temperature Think about infection and dehydration

Abdominal examination

An abdominal examination should include a measurement of fundal height as well as an assessment of fetal size (estimated fetal weight), presentation and position using Leopold's maneuvers. Inspect: Scars, linea, striae, symmetry Palpate: fundal height, fetal position Osculate: fetal heart tones Determine and palpate contractions

Inspect and palpate lower extremities Press firmly with thumbs about 5 seconds over shin If any signs of elevated blood pressure, elicit DTR If reflexes are hyperactive, check for clonus

Measuring fundal height

Place the zero line of the tape measure on the anterior border of the symphysis pubis and stretch tape over midline of abdomen to top of fundus. The tape should be brought over the curve of the fundus. The height of the fundus in centimeters equals the number of weeks gestation plus or minus 2. After 32 weeks the relationship is less accurate. Perform Leopold maneuver.

fluctuating amniotic fluid. While locating fetal position and heart tones. The presenting part (head or breech) is palpated above the symphysis and degree of engagement determined. The monitors are great but do remove that human touch. presentation. engagement and size by abdominal examination. 3. Palpation of the uterine fundus to determine which fetal pole "head or breech" is present in the fundus. The fetal occipital prominence and flexion of the vertex is determined. You should always assess for position. If the fetal vertex is flexed. The examiner uses the thumb the fingers of one hand in the suprapubic region (similar to palming a basketball) and attempts to move the presenting part from side to side. Always remember there is a human being . indefinite outlines and baby’s small knobby parts. Using two hands and compressing the maternal abdomen. Leopold's maneuvers are used to determine the orientation of the fetus through abdominal palpation. Palpating the fundus (top) of the abdomen along with the symphysis pubis area (bottom) of the abdomen. the cephalic prominence may be palpable on a same side as the fetal small parts. The purpose of this maneuver is to determine whether the fetal back is left or right. Sometimes just taking those few minutes to touch. Use Leopold's to locate fetal back and as a reason to "lay hands" on your patient. talk to and listen to the patient goes a long way to establishing the tone of the whole labor. 2. The purpose of this maneuver is to determine the pelvic position of the presenting part.. 4. With warm hands and gentle pressure palpate the abdomen for soft consistency. a sense of fetal direction is obtained (vertical or transverse). If little movement occurs or only the fetal neck is palpable the presenting part is engaged.Leopold's Maneuver Abdominal Examination for Position and Presentation and Size Hands have an acute sense of touch especially when attached to a well-trained mind. The fetal spine will palpate as firm. talk to the patient. the hands will be feeling for the firm irregular buttocks of baby or baby’s even firmer regular and smooth head as you ‘visualize’ the size of baby. Assess abdominal tenderness as well as contractions and ascertain fetal movement. slowly “walk” fingers over the abdomen looking for the resistance of baby’s back. flat and linear. If a distinct cephalic prominence is noted on the same side as the spine and head the vertex is not very well flexed. 1. which may be in the center of the abdomen or deflected off to either side. The fetal extremities are palpable by their varying contour and movements. The lateral sides of the fundus are palpated to determine the position of the fetal back and small parts.

These examinations should be done only often enough to ensure the safe conduct of labor. She has a lot of information to impart if you ask the right questions and make astute observations Leopold's maneuvers just are a part of a whole-person assessment. The progress of labor is followed by abdominal or vaginal examination to note the position of the baby. the patient should be impressed with the important of relaxing with the contractions. since a full bladder impedes progress.. the station of the presenting part. Help the couple as much as possible to work with the contractions and compliment them for a good job. q 2 hours if ROM. ROA is best heard in mother's right lower quadrant. • • • • Ausculate fetal heart tones. It just makes it all much more personal. The passage of meconium stained fluid in a cephalic presentation is a possible sign of fetal distress and if present. Technology is a wonderful thing but NEVER takes the place of this touch and YOUR assessment skills. If the patient is unable to take enough orally. and the dilatation of the cervix. The maternal temp is taken q 4 hrs. in second stage.e. in active phase. catheterization may be necessary. It CAN help you determine a lot of things and help establish a warmer relationship with a mom-to-be--especially if you provide her with the information you find. FHT's are checked q 30 min in latent phase. The patient's condition and progress is checked periodically. the presentation normal. to determine that the rate of dilatation is within the normal range or to evaluate the patient if she is requesting medication. Adequate amounts of fluids and nourishment are essential. During the first stage. The American Journal of Maternal/Child Nursing September / October 2003 . the patient should be continually monitored during active labor. a intravenous of Lactated Ringers solution may be given. Over distension of the bladder is obviated by urging the patient to void every few hours. and the fetus in good condition. i.attached to that monitor and treat her as such. Monitoring the Mother and Fetus During Labor • • • A 20 minute fetal monitor strip is done for all patients on admission. and q 5min. If she is not able to do so. For more information go to: Should Women be Given a Choice About Fetal Assessment in Labor? MCN. q 15min. the woman may walk about or be in bed as she wishes.. Develop a skill for this by practicing and learn it well. the presenting part well engaged. Variations to this timing depend on the maternal-fetal situation. ROP or LOP is best heard in mother’s left side. As long as the patient is healthy.

the mother’s abdomen should be regularly palpated by hand.Abdominal Examination for Contractions An initial abdominal examination is carried out on admission by laying a hand on the uterus and palpating. Montevideo units are calculated by totaling the peak uterine pressures (in mm/Hg) minus the baseline pressures over a ten minute period. The actual amount of intrauterine pressure generated with each contraction must be measured by internal devices. at least 200 Montevideo units are required before the forces of labor can be considered adequate (i.e.. The traditionally used measure of uterine work is called the Montevideo method. Uterine Contractions . The uterus should always feel softer between contractions. noting the degree of hardness during a contraction and timing its length. The external tocodynamometer can generally provide reliable information about the frequency of uterine contractions and their approximate duration. strength and frequency of contractions and the descent of the presenting part. This should be repeated at intervals throughout labor in order to assess the length. Uterine contractility can be quantified subjectively by palpation or objectively by the use of an external tocodynamometer or an intrauterine pressure catheter (IUPC). when a protraction or arrest disorder is noted measures should be taken to ensure that contractions at least 200 Montevideo units exist before a cesarean delivery is undertaken). such as the intrauterine pressure catheter. The monitor should never be relied on.

Lie and presentation Lie and Presentation Engagement .Vaginal examination A fetal heart check and an abdominal palpation for fetal position and presentation should always precede initial vaginal examination.g. effacement. Purpose of exam is to assess the status of membranes. engagement. herpes. The vulva should be carefully inspected for lesions (e. cervical dilatation and station. etc). fetal presentation and position. prominence of the iliac spine and size of the pelvis in relation to the fetal head should be made.. some assessment of the superpubic angle.

Inspect vaginal opening (introitus).uvm. especially during a contraction. . Syphilis Examinations are done with aseptic technique (sterile gloves and antiseptic solution). Observe for: Amount of bloody show: advanced labor Ruptured membranes Discharge that is malodorous Discharge that is deep yellow or greenish brown: Meconium Ulcerated areas on perineum: Herpes.dcr Procedure Prepare client the same way as for a speculum examination. This may be uncomfortable.edu/cats_teachingmod/ob_gyn/teaching_modules/normal_delivery/movies/expulsion1.med. Lubricate index and middle finger of examining hand generously.Engagement Effacement Effacement Station Station http://cats. You insert two fingers into the vagina and feel the cervix and the top of the baby’s head to gather information about the dilation and the presentation of the baby. Separate the labia with gloved fingers.

Excessive vaginal examinations carry with it the risk of increased infection. . Vaginal examination should only be done when there is doubt about the clinical situation or symptoms.There is no place for routine vaginal examinations in any labor. and the information gathered is necessary or likely to be of use in making a clinical decision. You should rely on behavior and emotional responses and physical sensations rather than vaginal exams.

5 cm. (2) Presence of placenta previa. Questions to ask yourself as you perform a Vaginal Examination Status of amniotic membranes: Are they intact.Reasons to defer or avoid digital vaginal examination: The vaginal examination should be avoided or deferred in certain circumstances. (4) Presence of active HSV lesions in a patient with ruptured membranes. anterior or posterior? (the cervix must be anterior before it can really start to dilate) How much effacement? 0%/long and thin to 100%/completely thinned out. . (3) Ruptured membranes in patients who are not in labor and for whom immediate induction of labor is not anticipated. In most of these situations a careful speculum examination is acceptable: (1) Significant vaginal bleeding of unknown etiology (delay examination until placenta previa has been ruled out by ultrasonography). Dilatation chart (actual size) Cervical dilation: 1 finger represents aprox 1. Bulging through the cervix? Status of cervix: Is it soft or firm (the cervix must be soft before it can efface and dilate).

palpate for sagital suture. . follow to anterior or posterior fontanel If what you feel is soft it may be breech or face. (dilation complete). Fetal presentation: What is the presenting part? (head. breech. anterior/posterior/transverse) Fetal station: What is the presenting part in relation to the ischial spines? Engagement: Is the presenting part engaged and well applied to the cervix? stabilized in the middle of the pelvis below the level of the ischial spine [zero station]. other fetal part) What is the fetal position? (left/right.How much dilation? 0 (closed) to 10 cm. How to palpate presenting part: Palpate the hard skull.

To determine station estimate in centimeters. normal cervix about 1 inch thick How to determine station: Station is the relationship of the presenting part to the ischial spines.Assessing Cervical effacement Cervical effacement: Palpate degree of thickness. Locate the lowest portion of presenting part. the tip of presenting part is above the ischial spine. then sweep the fingers deeply to one side of pelvis to feel for ischial spines. Tell the mother your findings. .

Keep a downward pressure on blade to avoid upward pressure on sensitive bladder and top of vaginal wall. feet resting either flat on table or in stirrups. Drape client’s legs. Have client empty bladder. Place a minimum amount of lubricant on speculum. place 2 fingers just inside the introitus and gently press down on base of vagina. With other hand. Assist client to bend legs. The presence of "leaking" or ruptured membranes can be confirmed by performing a nitrazine test.Speculum examination A speculum examination will be necessary in cases of suspected "leaking" or ruptured membranes. Place pillow under her head and under her hip. inspecting the posterior fornix for pooling of fluid and by obtaining a sample of the fluid with a sterile applicator and applying the fluid to a glass slide. Sterile water may be used as lubricant. The glass slide is allowed to air dry and is subsequently inspected for an arborization pattern ("ferning"). . Procedure: Select speculum Speculum is made of 2 blades and a handle There is a thumb piece attached to top blade The bottom blade is fixed The top blade is hinged and thumb piece controls movement Comes in both metal and plastic Explain what you will do. Using dominant hand. introduce the closed speculum past your fingers at about 45-degree angle downward.

. Touch applicator to nitrazine paper or glass slide. Lie. When cervix in view. or longitudinal (parallel). The normal fetal attitude when labor begins is with all joints in flexion. Position. LOT: the occiput is transverse and to the left). Point of Reference or Direction. This references the presenting part to the level of the ischial spines measured in plus or minus centimeters. This describes that part on the fetus lying over the inlet of the pelvis or at the cervical os. This is an arbitrary point on the presenting part used to orient it to the maternal pelvis [usually occiput. If drops of fluid are spread on glass slide. If membranes are ruptured. Turn blades into a horizontal plane while keeping moderate downward pressure. mentum (chin) or sacrum].g.e. This refers to the posturing of the joints and relation of fetal parts to one another. Rotate the blades to a sideways position.. Place sterile cotton tipped applicator in pool of fluid. i. Gently and slowly remove. . tighten the thumbscrew to keep blades open. transverse. Station.After speculum in vagina. Move your thumb to the thumb piece and press to open blades so that the cervix is in view. This occurs when the biparietal diameter is at or below the inlet of the true pelvis. Engagement. Release thumb screw. Hold blades apart by pressing on thumb piece and begin withdrawing the speculum until cervix is released. you will see fluid leaking from cervix. This describes the relation of the point of reference to one of the eight octanes of the pelvic inlet (e. Mechanisms of Labor The following definitions must be mastered to be able to discuss and understand the mechanism of labor: Attitude. a characteristic fern pattern can be seen. Sweep the blades upward and gently press on the handle. Fern testing for ruptured membranes Amniotic fluid contains a high amount of salt. remove finger. This refers to the longitudinal axis of the fetus in relation to the mother's longitudinal axis. exert downward pressure. allowed to dry and examined through microscope. oblique. Release pressure on thumb piece and allow blades to close. Presentation.

Extension: With further descent and full flexion of the head. nose.the inlet is a transverse oval. walls of the pelvis or the pelvic floor. brow. and the rest of the body. External Rotation: While the head has been descending to the pelvic floor. it untwists. the nucha (the base of the occiput) becomes impinged under the symphysis. With the descent.) Internal Rotation: After engagement. the lowermost portion of the head (usually the occiput) meets resistance from one side or the other of the pelvic floor and is rotated about 45 degrees anteriorly to the midline under the symphysis. The sagittal suture has now resumed its normal right angeled relationship to the transverse (bisacromial) diameter of the shoulders. posterior shoulder. o o o o Expulsion . contractions of abdominal muscles (2nd stage) and extension and straightening of the fetal body. to the transverse position. Restitution: When the head is free of resistance. as the head descends. The head usually enters the pelvis in the transverse or oblique . the leading (anterior)shoulder meets the resistance of the side of the pelvic floor and is rotated anteriorly toward the midline under the symphysis. flexion results. Upward resistance from the pelvic floor causes the head to extend. Internal rotation brings the AP diameter of the head in line with the AP diameter of the pelvic outlet. The movement of the shoulders causes the occiput to rotate another 45 degrees. The chin is brought into contact with the fetal thorax and the resenting diameter is changed from occipitofrontal to suboccipitobregmatic (9. the shoulders have entered the pelvis and engaged with the bisacromial diameter in the transverse or in an oblique diameter.5 cms. mouth and chin being born successively. direct pressure of the fundus upon the breech.Normal mechanisms of labor/Cardinal Movements . Descent: This occurs intermittently with contractions and is brought about by one or more forces: Pressure of the amniotic fluid. with the bregma. Related factors o Passage: Size and morphology of the pelvis o Passenger: Size of the baby and moldability of the fetal skull o Powers: Quality (efficiency) of uterine contractions and voluntary expulsive forces and quality and direction of soft tissue resistance. adaptive movements of the fetal head and shoulders through the birth canal.Occiput anterior positions • • Definition: A mechanism of labor is a series of passive. causing the occiput to move about 45 degrees back to its original left or right position. especially of the levator ani muscles o Psyche: Mom’s attitude Cardinal Movements of Labor o o o o Engagement: Mechanism by which the greatest transverse diameter of the head in vertex (biparietal diameter) passes through the pelvic inlet (usually 0 station). This movement brings the long axis of the shoulders in line with the long axis of the pelvic outlet. Flexion: As soon as the vertex meets resistance from the cervix. Expulsion: Delivery of the anterior shoulder.

Flexion and Molding The fetal head rotates. flexion. The diagnosis of labor progression may be dependent upon the patient's history of uterine contractions as well as information gathered from abdominal palpation and vaginal examination. By the active part of labor the cervix will be completely effaced and be paper-thin. Cervical Position The cervix moves from a posterior to an anterior position. molding. • Cervical dilatation and fetal descent are the only indicators that labor is progressing.The Six Steps of Labor Progression Labor can be defined as regular. Evidence of progressive cervical effacement and/or dilation is necessary in order to distinguish true labor from false labor. Remember. Cervical Effacement The cervix effaces About two inches in length is average size. . Fetal Head Rotation. Not much dilatation can occur until the cervix has completed the above three processes. duration and intensity of contractions cannot be relied upon as measures of progression in labor. During most of the pregnancy. The uterus may contract for several days intermittently before true labor begins to accomplish these first two things. This causes the cervix to soften from the consistency of rubber to something that feels like a marshmallow. but that pre-labor contractions are accomplishing the important job of pre-paring the cervix to dilate. Labor progresses in six ways and all are equally important. the cervix points toward the back (posterior). but in early labor. and anterior movement of the cervix). Cervical Ripening The cervix ripens or softens. it moves forward (anterior). effacement. move to an anterior position and get paper-thin before it will dilate much past 3-4 centimeters. The head begins to change shape to fit through the pelvis. more in the multipara) rarely occurs). Remember the cervix needs to get very soft. It is vital to understand that when the cervix has not undergone the first three steps (ripening. flexes. Cervical Dilatation The cervix dilates and active labor begins. painful uterine contractions that result in progressive cervical change. As a woman’s body gets ready to labor it produces prostaglandin. Frequency. and molds. but during the last few weeks of pregnancy or in early labor. this is called molding. the cervix begins to get shorter and thinner (effacement). Rotation. significant dilation (beyond 3-4 cm in the nullipara. softening the cervix and bringing the cervix from the back of the vagina to the front of the vagina.

Remember. descent is measured in terms of "stations. The second stage involves descent of the fetus and its eventual expulsion from the vagina. It begins with complete cervical dilation (10 cm) and ends with delivery of the infant. The third stage of labor involves delivery of the placenta." Stages of Labor Chart The first stage of labor begins when uterine contractions of sufficient frequency.and descent of the fetal head take place in active labor and second stage Fetal Descent and Birth The fetus descends and is born. Descent occurs as the baby lowers itself into your pelvis. intensity and duration result in effacement and dilation of the cervix. The first stage is completed when the cervix reaches 10 cm. It begins with the completion of the infants' delivery and ends with delivery of the placenta and membranes. .

back pain.) (4-8 cm. -Birth) THIRD STAGE Delivery of the Placenta Pre-labor ♥ Ripening and Contractions: effacement of the cervix ♥ 5-20 minutes apart Contractions: ♥ 2-5 minutes apart Contractions: ♥ 1 -2 minutes apart Contractions: ♥ 3-5 minutes apart Contractions: ♥ Irregular ♥ 30-45 seconds long ♥ 45-60 seconds long ♥ 45-90 seconds long ♥ 60-120 seconds long ♥ A feeling of fullness and cramping as placenta separates ♥ Mild. in vagina as baby moves down . more aware of urge ♥ A time for mom to hold and enjoy to push and fullness baby.FIRST STAGE LABOR LATENT LATENT-EARLY ACTIVE LABOR LABOR (0-3 cm. feel like cramps.) TRANSITION LABOR (8-10 cm) SECOND STAGE LABOR (10 cm. pressure ♥ Stronger and more intense ♥ The strongest they will get ♥ Less aware of contractions.

. narcotic analgesia or oxytocin augmentation of labor. Appleton and Lange. CT) plotted the labor curves of over 10.e. Additionally. E. Most center's begin oxytocin at 1-2 mL per minute and increase the dose by 1/2 to 1 mL every 20-40 minutes. labor: clinical evaluation and management. Norwalk.Diagnosis of Abnormal Labor Review Friedman Curve Cervical dilation usually follows a sigmoid curve over time. In most instances the laboring patient has a relatively normal pelvis d fetus but uterine contractile forces are found to be inadequate. false labor would be diagnosed and the patient would be subsequently discharged to home. Typically. In cases where the fetal heart rate tracing is normal and the patient is at low risk a large dose of narcotic plus antihistamine may be administered in order to allow the patient to rest for several hours.000 normal pregnant women. The power refers to the adequacy of labor. In these cases labor augmentation with oxytocin is indicated. When addressing active phase labor abnormalities most Obstetricians refer to "the three P's". In the later case. Friedman (Friedman EA 1978. This disorder is associated with a higher incidence of occiput posterior and occiput transverse fetal positions. placing an intrauterine pressure catheter and determing the number of Montevideo units).2 cm an hour in nulliparous patients and less than 1. the size of the fetus in relation to the pelvis must also be determined. Patients whose labor is excessively long in duration or slow in rate of progress require special attention and may be treated with various forms of intervention aimed at improving the progress of labor. when the parturient awakens she will either find that she has entered the active phase or the contractions will completely dissipate during the hours of sleep. It may also be indicative of true cephalopelvic disproportion or it may result from inhibitory effects of narcotics anagelsia. . Prolonged or Protracted Active Phase A protracted active phase is defined as progression at less than 1. In addition to noting that cervical dilation progressed on a sigmoid curve. This diagnosis may be difficult to make since the onset of labor is very often dependent upon the patient's perception of when labor actually began. In the 1970s. Friedman Curve For more information go to: Diagnosis of Abnormal Labor Prolonged or Protracted Latent Phase: A prolonged latent phase is present when the active phase of labor is not achieved after 14 hours in multiparous patients and 20 hours in nulliparous patients.5 cm and hour in parous patients during the active phase. Generally this condition is treated by first assessing the adequacy of labor (i. he noted that labor progressed faster in parous women. There are two basic methods for prolonged latent phase. passenger refers to the size and attitude of the fetus and the pelvis refers to the size and shape of the maternal boney pelvis.

However. Reducing the risk of maternal morbidity and mortality by reducing stomach contents.Active Phase Arrest: This is the most common abnormality of labor in women who are ultimately delivered by cesarean section. is given as the rationale. The reasons for this disorder are the same as Protracted Descent. Pregnancy hormones decrease intestinal motility and gastroesophageal barrier pressure. juices (less acidic are preferable. Arrested Descent: Arrested Descent occurs when there is no advancement of the presenting part for more than an hour. and hydrating fluids such as Gatorade. Additionally. popsicles. Intravenous Hydration . The criteria are the same in both the nulliparous and multiparous patients. a well-established routine in many hospitals. the three P's must be assessed and in most cases a trial of oxytocin augmentation given. These times may be significantly increased in patients who have epidural anesthesia. Reducing the level of maternal epidural anesthesia may be helpful in some cases. laboring women are considered to have a full stomach. Protracted Descent: Common causes of protracted descent include poor maternal expulsive effort and excessive fetal size relative to the maternal pelvis. despite adequate uterine contractions (> 200 Montevideo units). It is defined as a lack of cervical progress over 2 or more hours. When the fetal vertex reaches a +2 station or more a forceps or vacuum delivery may be used. In the presence of an epidural anesthetic the second stage may last as long as three hours in a nulliparous patient and as long as 1-1/2 hours in a parous patient. The enlarged gravid uterus physically obstructs gastric emptying and increases intragastric pressure. Choices for fluids in labor include water or ice. may be frozen in ice cubes). regrettably. changes in maternal position such as having the mother assume the "squatting" position may be helpful. A common management approach to protracted descent is to simply allow a longer period of time for the patient to push. The policy of NPO (nothing by mouth) is. Fluids As part of the altered anatomy and physiology during pregnancy. thus eliminating the acidic contents for pulmonary aspiration. Second Stage Disorders: The average primigravida can expect to spend one to two hours in the second stage of labor while the multiparous women will typically have a second stage of 30 minutes duration or less. as evidenced by the common complaints of constipation and acid reflux or heartburn. Alternatively. expectant management can be undertaken while the patient is allowed to relax for the first 1 to 1-1/2 hours after becoming completely dilated (laboring down). As with Protracted Active Phase. in a patient with epidural anesthesia who has poor effort initially. surveys of literature from anesthesia and obstetrics show no compelling scientific basis for maintaining NPO policies (although aspiration can be a complication of inadvertently high spinal or epidural blocks).

October / December 2003 Slow-Paced Breathing Every woman beginning labor should be taught this simple technique for coping with labor. Routine IV fluid administration can induce fluid overload. Change soiled and damp linen promptly. Rest and sleep between contractions is important. quiet and privacy. hyperglycemia in the fetus. Do not leave alone in active labor. uncluttered. and can alter plasma sodium levels. IV therapy is not needed routinely. especially in the first hours of labor. Ensuring a steady. Provide mouth care. who already has approximately 2 L of stored body water in extravascular spaces. . Keep room cool. Ice chips. Begin the Breathing Technique This technique is done only during contractions. adequate intake of oxygen. The use of a specific breathing pattern during labor contractions has two objectives: Helping the woman relax by distracting her from the intense contraction sensations. A normal healthy woman.IV fluids (usually dextrose and water or lactated Ringer's solution) are indicated when the mother is NPO status and should be run at a rate of 125 mL per hour. lubricate lips. Promote participation of coach. and hypoglycemia in the newborn. which ensures that the mother receives 1.000 mL of fluid every 8 hours. Instruct the laboring woman to do the following: Assume a comfortable position. Comfort Measures for the Laboring Woman. For more information go to: Therapeutic Choices for the Discomforts of Labor Journal of Perinatal and Neonatal Nursing.

Close her eyes or Concentrate on a focal point while doing the breathing (e. Maintain a steady rate of approximately 6 to 9 breaths during a 60-second contraction (the cleansing breaths do not count).g. a button on someone's shirt). 2. Breathe slowly and deeply in through the nose and out through slightly pursed lips or the nose over the duration of the contraction. For some women. 3. For more information go to: AWHONN Clinical Position Statement Professional Nursing Support of Laboring Women Epidural Anesthesia . Slow-Paced Breathing This technique can be used in early labor and for as long as the mother is comfortable with it. like a big sigh.. Take a cleansing breath as soon the contraction begins. this may last throughout the entire first stage of labor.Try to maintain a relaxed state throughout the contraction. This is simply a deep quick breath. Inhalation is through the nose. a pretty picture. exhalation is through slightly pursed lips. 1. Cleansing Breath Begin and end each breathing technique with a cleansing breath.

when a bolus dose is administered.Pain management options for woman in labor have changed dramatically over the last decade. Blood pressures are recorded prior to the start of the epidural. FHR and contractions are recorded at these intervals also. After one hour of stable BP's. The anesthesiologist gives BP parameters to be notified if abnormal. L&D RN's assist with patient positioning during the procedure. Neuraxial analgesia is defined as intrathecal or epidural administration of opioids and/or local anesthetics for treatment of postoperative pain or other acute pain problems. The fluid bolus potentially alleviates any precipitous drops in the patient’s blood pressure. January/March 2003 . and an oral antacid (Bicitra) prior to the placement of the epidural. spinal and combined spinal-epidural techniques. Neuraxial analgesia includes epidural. Patients receive a 1000cc Lactated Ringers IV bolus (unless on a fluid restriction). BP's can be recorded q 30 min until delivery. complications of neuraxial analgesia. A standardized educational program should be established for initial training and certification of nurses caring for patients receiving neuraxial analgesia and for maintenance of competence. when a test dose is administered. Patients are kept NPO or ice chips only after placement. but catastrophic. For more information go to: Nursing Responsibilities in Preventing. including delayed respiratory depression when hydrophilic opioids are used Assessment and management of respiratory depression Assessment of motor and sensory blockade Assessment and management of hypotension in patients receiving neuraxial analgesia Signs and symptoms of the rare. Preparing for. have become more popular. and Managing Epidural Emergencies Journal of Perinatal and Neonatal Nursing. Nursing personnel should understand • • • • • The risk of respiratory depression. and q 5-15 minutes until stable per the RN's and anesthesiologists discretion. with minimal motor blockade. Education and certification of nurses. Systemic analgesia and densemotor-blockade regional analgesia/anesthesia have become less common for childbirth while the use of newer neuraxial and regional techniques.

Nursing Care of the Woman Receiving Regional Analgesia/Anesthesia in Labor. . Document informed consent by the woman The nurse clarifies and elaborates on information regarding the purpose. the desired effect. and episiotomy repair. This allows perineal tone to be maintained to avoid interfering with internal rotation of the fetal head to the occiput anterior position. Evidence is lacking regarding the safety of nurses administering bolus medications during labor. Intrathecal. When Stage II labor is reached. anesthetic dosages are given to limit the block to the lower thoracic (T10) and upper lumbar segments. Spinal. such as maternal fear Sympathetic blockade worsens some of these. the block can be extended to the sacral area to promote perineal relaxation. The purpose of these guidelines is to provide principles of management. so that neuraxial analgesia is provided in a fashion that maximizes its benefit-risk ratio. anesthesiologist. Adequate nursing support is essential to the safe provision of an epidural. Actions Before the Procedure Remarks Consult with anesthesia and obstetric providers The physician. possible side effects. The AWHONN position statement maintains that the insertion of epidural catheters and injection or rebolus of regional analgesic/anesthetic agents remains within the scope of the licensed. Note contraindications. or nursewhen epidural anesthesia is requested by client anesthetist is responsible for explaining complications.The Role of the Registered Nurse (RN) in the Care of Pregnant Women Receiving Analgesia/Anesthesia by Catheter Techniques (Epidural. the significance of potential side effects has necessitated standards that preclude this activity from nursing functions currently. PCEA Catheters) Guidelines for the Epidural Procedure Adapted from the AWHONN's Evidence-Based Clinical Practice Guideline. Special techniques include the following: • • Patient-controlled epidural anesthesia (PCEA): allows the patient to self-titrate periodic amounts of anesthetic So called walking epidural: patients who have intentional motor function and semi-mobility with a bolus or continuous infusion via an indwelling epidural catheter preceded by an injection of local anesthetic into the subarachnoid space. and recovery. delivery. During the first stage of labor. However. the procedure itself. credentialed anesthesia care provider.

The epidural block can reduce or eliminate bladder sensation. and feet supported on a chair. local infection at the injection site. and maternal hypotension or shock. Assist the woman to a side-lying position with legs slightly flexed or to a sitting position with the mother's head flexed forward. Confirm a reassuring fetal heart tracing before the procedure. pulse rate. pulse. Thereafter. Repeat at least every 5 minutes throughout administration of the anesthetic dose and for 15 minutes afterwards. Avoid maternal hypotension by promoting Promote and maintain uterine displacement.000 ML A preprocedure bolus will help prevent balanced saline or lactated Ringer's solution 10 hypotension caused by vasodilatation from the to 30 minutes before the epidural procedure. Administer an IV fluid bolus of 500 to 1. anesthetic. Note maternal BP and pulse rate before and after the test dosage. uterine displacement with a pillow/wedge or Avoid the supine position. respiratory rate. and respiration rate regularly based on institutional protocol and patient's status. Epinephrine is added to the test dosage. Ensure that all connections along the epidural route are secure. Breathing techniques appropriate to the phase of labor can be encouraged to promote relaxation. A high-pressure volumetric pump is required for continuous epidural infusion. Have the woman void before the procedure. elbows resting on her knees. This provides for any emergency. Remarks This is a normal preanesthetic effect. maternal pulse rate will increase 20% to 30%. Obtain maternal baseline BP. coagulation defects. Check frequently to ensure that the proper hourly rate is according to the prescribed orders. with the head of the bed .or refusal. and fetal baseline heart rate and variability. Support the mother throughout the procedure of local infiltration and catheter threading. Move the crash cart to an area nearby. NOTE: IV glucose solutions are not recommended because of the potential impact of fetal hyperglycemia with subsequent and rebound newborn hypoglycemia. placing the mother in a full lateral position or in a supine position. This is important to overcome catheter resistance. Actions Following the Procedure You need to reassure the mother if she feels a warm tingling sensation down her legs when the initial bolus loading dose is given. Systolic drops below 90 mm Hg are considered inadequate to maintain uterine blood flow for fetal oxygenation. Anesthetic effects include vascular vasodilatation. and possible fetal heart rate accelerations that could exacerbate a preexisting problem. record BP. Never leave a mother unattended during the first 20 minutes following administration of the initial anesthetic or any bolus dose. decreased BP. If the catheter is misplaced and is in the dilated epidural vein. This promotes moderate spinal flexion to assist in locating the appropriate site. A normal rate reflects that the drug was not injected intravascularly.

(One way to do this is to move an ice cube from the mother's groin area upward. Under the influence of epidural anesthesia. If fetal heart rate decelerations occur. types. Evaluate the mother's bladder every 30 minutes. . vomiting. Nausea. Periodically assess for level of anesthesia before administration of any bolus dose. Mark with a skin marker the level at which the mother becomes aware of the cold.elevated. This documentation is placed on the fetal monitor strip and becomes part of the medical record. repeat on other side. a prolonged Stage.Avoid excessive pressure in one area. This is also done to assess the fading of anesthesia. II is greater than 2 hours with regional anesthesia and Document the same information in the nursing notes. assist the mother to a semi-upright position. Continually monitor for maternal complications. Nausea and vomiting can occur in up to 50% of women having epidural anesthesia.) Determine the level of pain relief using institutional pain assessment scales. The woman can lose the sensation to void. a lateral position optimizes blood flow to the fetus. or a sidelying position. Document the following per institutional policy: Times. and urinary retention are possible. Can be rapidly reversed by administering naloxone hydrochloride (Narcan). and amounts of anesthetic Maternal BP and pulse rates Position changes Oxygen administration IV rate changes Maternal response Use of oxygen Other supportive interventions. in preparation for delivery. Stage II of labor is sometimes delayed. This is important to avoid potentially high levels of anesthesia. including description of the following: The woman's responses to the procedure Any complications A semi-upright position allows the anesthetic to migrate into the sacral area. itching. Assist the mother in turning every hour. The American College of Obstetricians and Gynecologists (ACOG) defines a prolonged Stage II as being greater than 3 hours in a nullipara with regional anesthesia and greater than 2 hours without regional anesthesia. A full bladder not only is subject to trauma but also can impede descent of the fetus. Avoid anesthesia receding too far bfore a (bolus dose) is needed. should they be necessary During Stage II of labor. an upright position. This allows the drug to defuse bilaterally. For the multipara.

Diphenhydramine or naloxone is used for treatment. Continue to monitor for maternal complications and evaluate and document maternal pain levels using standard assessment tools such as visual and verbal analog scales Actions to Respond to Complication Maternal Hypotension Remarks Maternal hypotension is defined as a systolic Maternal hypotension may result in a fetal blood pressure less than 100 mm Hg or a 20% hypotensive response showing fetal bradycardia decrease from preanesthesia levels. usually begins within 10 to 30 minutes of epidural initiation and medication administration. Assessment of bladder status is critical to avoid overdistension of the bladder. This is the vasopressor of choice because it targets cardiac muscle. Less than 20% of women require medication to alleviate it. Urinary retention Urinary retention is a side effect of epidural anesthesia in a large percentage of women. Urinary displacement relieves pressure on the vena cava and aorta. Urinary catheterization will be necessary in some women High Spinal Inadvertent intravenous catheter placements can . and/or late decelerations. Pruritus Pruritus is a common and mild reaction to anesthetic. which the mother cannot feel. The use of opioids may increase the risk of pruritus by 40% to 90%. Usually. If vasopressors are needed. Place the mother in a full lateral or upright position. These supportive measures are intended to restore uterine blood flow. promoting better venous return to the heart. 5 to 10 mg IV ephedrine is recommended. the pruritus resolves within an hour of onset. Give oxygen by face mask Give 250 to 500 ML IV bolus of non-glucosebalanced saline solution. thus increasing uterine blood flow by enhancing cardiac output.greater than 1 hour with anesthesia.

Manually push the gravid uterus to one side. women may experience spinal headaches 24 to 48 hours after the puncture. Give 100% oxygen at a high flow rate. Spinal Headaches If the dura is accidentally punctured. including cardiopulmonary resuscitation. or metallic taste Loss of consciousness. . Take steps to do the following: Establish a patent airway. and assisted ventilation. Headaches develop in 1% to 3% of women who receive epidural anesthesia. Intravascular Injection of Local Anesthetic Signs of this include the following: Change in maternal heart rate (tachycardia or bradycardia) Maternal hypertension Dizziness. Intubate if necessary. 02 administration.Prevailing symptoms: Profound motor and sensory block within 1 to 5 minutes of the epidural injection Severe hypotension Cessation of respirations Cardiac arrest occur in up to 5% of pregnant women. tinnitus. Intravascular injection of a local anesthetic may result in seizure or cardiac arrest and requires an immediate response. Administer vasopressors. Inadvertent dural punctures occur in approximately 2% of pregnant women.

Assess for motor and sensory return by asking the mother to move her legs up and down and side to side. Inspect the catheter carefully to make sure it is intact. Actions to Respond to Neonatal Remarks . The mother must be able to support her knees in an upright position. Remarks Remove the catheter once the placenta has been delivered and the mother begins her recovery period. Actions During Recovery From Epidural/Delivery During the mother's recovery. alert the anesthesiologist immediately. and an abdominal binder and administering analgesics.It is preferable to remove the catheter with the mother in the same position used during placement. keep the side rails up and the bed in a low position. The maternal position increases the intervertebral space. If you suspect breakage. As the blood clots. pressure is diminished throughout that compartment and the brain descends somewhat. it "patches" the area. Always save the catheter for the anesthesiologist's inspection. A registered nurse with training may remove the catheter.Conservative treatment involves: Maintaining a flat position. especially when the mother is in an upright position. usually affording quick relief As cerebrospinal fluid is lost. as in a standing position. hydration. A blood patch is used to seal the puncture site. perform plantar flexion and dorsiflexion of the feet. using 15 mL of the patient's unanticoagulated blood.

[2003] Do epidurals increase risk of C/S? No. Narcan Monitor all neonates for signs of neurobehavioral change associated with the use of epidurals For more information go to: American Family Physician The Nature and Management of Labor Pain: Part II. Nonpharmacologic Pain Relief [2003] Contemporary OB/GYN Do epidurals increase risk of C/S? Yes. Pharmacologic Pain Relief [2003] The Nature and Management of Labor Pain: Part I. [2003] Epidural analgesia: 2002 update [2002] Cochrane Reviews Types of intra-muscular opioids for maternal pain relief in labour (Cochrane Review) [2004] Spinal versus epidural anaesthesia for caesarean section (Cochrane Review) [2004] Prophylactic intravenous preloading for regional analgesia in labour (Cochrane Review) [2004] Epidural versus non-epidural analgesia for pain relief in labour (Cochrane Review) [2004] Complementary and alternative therapies for pain management in labour (Cochrane Review) [2004] Combined spinal-epidural versus epidural analgesia in labour (Cochrane Review) [2004] Amnioinfusion .Complication Neonatal respiratory depression as a result of opioids can be treated with narcotic antagonists i.e.

New-generation pressure catheters are equipped with dual lumens. insert a fetal scalp electrode and an intrauterine pressure catheter. Double-lumen uterine catheters permit monitoring of uterine activity while amnioinfusion is being performed.Guidelines for the Amnioinfusion Procedure Adapted from the AWHONN's Evidence-Based Clinical Practice Guideline. . Determine cervical dilatation. station. if 250 mL infuses with no evidence of return. Do not use a microwave oven to warm the fluid • Infuse the stipulated infusate at the rate determined by protocols and by primary care provider orders. effacement. use a separate uterine catheter to monitor uterine activity throughout the procedure. Otherwise. NOTE: A literature survey revealed no demonstrable benefits using infusion pumps or solution warmers during amnioinfusion. Nursing Care of the Woman Receiving Amnioinfusion in Labor. and amnioports (sites for injecting the amnioinfusion fluid). An initial bolus of 250 to 600 mL and an hourly maintenance rate of 150 to 180 mL has been suggested. Extremes of temperature should be avoided. including purpose. Infusion rates vary among recent reports in the literature. • • Observe for fluid return. Recent studies show initial bolus ranges from 250 to 600 mL followed by a maintenance infusion rate of 150 to 180 mL per hour. and presentation. Ask the woman to position herself on her side. With the mother's permission. internal transducers. Connect the catheter to the amnioinfusion system. • • • Obtain informed consent. discontinue the infusion and wait to see fluid. perform a vaginal examination to rule out cord prolapse. Resolution of variable decelerations might not occur. by either gravity flow or an infusion pump. • Prepare the infusion (an initial bolus of normal saline or lactated Ringer's). risks. Warming is accomplished by using a standard blood-warming unit. With the mother's consent. status of membranes. The woman's primary care provider should be contacted if resolution is not achieved within the time frame stipulated in nursing protocols. and benefits. and explain the procedure to the mother. Continue the infusion until either the variable decelerations cease or 800 mL of normal saline or lactated Ringer's infuse.

Iatrogenic polyhydramnios can occur if the fetal head is pressed closely against the cervix. Signs and symptoms of abruptio placentae include a hard. Too much retained fluid may result in maternal symptoms of shortness of breath. Abruptio Placentae. • • Document the procedure on the fetal monitor tracing and in nursing progress notes.• • • Reduce the infusion rate to the hourly maintenance rate designated by nursing and institutional protocols. NOTE: Vaginal bleeding does not always occur with abruptions of the placenta. • Carefully calculate fluid output during the amnioinfusion. Umbilical cord prolapse can occur if the cord is carried down with fluid output. Carefully monitor uterine activity throughout the procedure. hypotension. Watch uterine resting tone. all vaginal fluid should be captured in whatever padding is kept under the mother. Be attentive to other possible complications associated with amnioinfusion. Artificially increased uterine resting pressures higher than the preinfusion baseline can occur. or tachycardia. A resting baseline pressure of less than 25 mm Hg should be maintained. Intrauterine Resuscitation . Fluid output can be evaluated by comparing a dry-weight item with a wet-weight item. Therefore. vaginal bleeding. 1 mL of fluid is equal to 1 g of weight. board like abdomen. and pain.

These are empirically designed to overcome uteroplacental insufficiency or to decrease cord compromise. and are displayed on the electronic fetal monitoring strip providing continuous real-time data. The normal range of fetal oxygenation in labor is between 30% and 70%. and fetus to improve placental and fetal oxygenation. placenta. cheek.g. as measured by differences in light absorption. Fetal oxygen saturation monitoring provides a continuous measure of fetal oxygenation and is used to evaluate peripheral tissue perfusion to provide additional information when a nonreassuring fetal heart rate pattern occurs and a management decision cannot be made without benefit of additional information regarding fetal oxygenation. Measurements are based on a fraction that represents the rate of hemoglobin that is oxygenated (oxyhemoglobin). Values greater than 30% provide reassurance. These include the following: • • • • • • • Positioning the mother to right/left side lying recumbent or knee-chest to improve blood flow to the uterus Repositioning the mother to alleviate cord compression Discontinuing oxytocin Tocolysis with subcutaneous Terbutaline to decrease/moderate uterine activity and improve blood flow Increasing intravenous (IV) fluids to enhance maternal blood flow volume Administering oxygen to the mother in an effort to promote oxygen flow across the placental membrane Performing amnioinfusion-fluid instillation into the amniotic cavity through a catheter. Fetal Pulse Oximetry Current techniques for evaluating fetal status in labor are limited in their ability to predict outcome. usually performed transcervically during the intrapartum period. cord. . forehead). temple.What is intrauterine resuscitation? Interventions undertaken to attempt to change the relationship of the uterus.. Procedure A sensor is inserted into the uterus and placed next to a fetal vascular bed (e.

HIV. C.Indications Single fetus at term Vertex presentation Nonreassuring fetal heart rate pattern Ruptured membranes Cervix dilated at least 2 cm with station -2 or below Contraindications Placenta previa Nonreassuring fetal heart rate pattern necessitating immediate delivery Infectious diseases that preclude internal fetal heart rate monitoring (e. hepatitis B.g. The technique involves perforation of the fetal membranes with a sterile plastic instrument (amnihook) or by applying a fetal scalp electrode through the membranes onto the fetal scalp.. Amniotomy results and local release of arachidonic acid from the membranes and the subsequent prostaglandin formation is thought to be one of the mechanisms responsible for labor augmentation and induction. The procedure may be associated with changes in . and E) Amniotomy Artificial rupture of membranes is a commonly used practice in obstetrics performed at or beyond 3 cm dilation. active herpes virus.

For more information go to: Amniotomy and Placement of Internal Fetal Spiral Electrode AWHONN Clinical Position Statement Amniotomy and Placement of Internal Fetal Spiral Electrode through Intact Membranes Induction of Labor Induction of labor is the deliberate starting of uterine contractions before they begin on their own. For more information go to: Methods for Cervical Ripening and Induction of Labor http://www. Augmentation is the administration of synthetic oxytocin to enhance existing labor.html http://www.g. accelerations or bradycardia) secondary to prolonged uterine contraction.aafp.org/afp/20030515/editorials.aafp.html Indications The benefits of delivering the fetus at a specific point in time must outweigh the benefits of permitting the pregnancy to continue. Induction is appropriate when delivery is indicated but immediate delivery by cesarean is not necessary Indications include. secondary to release of a large quantity of fluid or in some cases prolapse of the umbilical cord..the fetal heart rate (e. .org/afp/20030515/2123.

Pregnancy induced hypertension (PIH) Fetal demise PROM, with or to prevent chorioamnionitis Suspected fetal jeopardy Macrosomia Relative contraindications include. Previous classical uterine incision Placenta previa Active genital herpes Fetal malposition; abnormal lie Cephalopelvic disproportion Invasive cervical carcinoma

Pre-requisites Accurate estimation of gestational age Favorable Bishop score Available personnel and resources for observation and immediate intervention

Methods Cervical ripening Hygroscopic dilators Prostaglandin gel Amniotomy Oxytocin

Oxytocin Pharmacology

Posterior pituitary hormone/ Half life = 3-6 minutes /Causes uterine contractions/Antidiuretic/Causes milk ejection reflex

Policy and prerequisites Physician availability Nursing personnel Monitoring ACOG guidelines

Induction Procedure Intravenous LR infusion Use volumetric pump Piggy back oxytocin solution

Dosage Induction -start at 0.5-1.0 mU/min, increasing every 15-4(minutes by 1-2 mU/min Augmentation- start at 0.5 mU/min Active management (nulliparous patients) -start at 4.0-6.0 mU/min, increasing every 15 minutes by 4.0-6.0 mU/min

Indications for reducing or discontinuing oxytocin include: Non-reassuring fetal heart rate Uterine hyperstimulation Persistent uterine hypertonus

Nursing responsibilities Assess and document fetal presentation Explain procedure to patient; obtain consent

Document maternal and fetal assessment at the time of each change in infusion rate Notify physician of abnormal FHR, abnormal contraction pattern, or discontinuance Monitor Intake and Output

For more information go to: Active management of labor

Vacuum Extraction

In vacuum extraction, a properly sized silastic cup is attached to a source of suction (manual or electric). The physician determines the position of the fetal head, and places the cup on the head of the fetus in the area of the posterior fontanel. The practitioner then uses gentle downward traction to deliver the fetal head. Continuous or intermittent suction is used. Once the baby's head is delivered, the suction is discontinued and the cup removed. The nurse's involvement in vacuum extraction is primarily on the side of patient education. The nurse is responsible for assessing the patient's level of pain, assisting the physician and reassuring the patient throughout the procedure. Additionally, the nurse must be prepared to resuscitate the newborn if necessary and explain any marks that may be caused by either forceps delivery or vacuum extraction.

For more information go to: Vacuum Extraction

Shoulder Dystocia

Most of the time, an infant's shoulders present in the proper alignment across the mother's pelvic outlet. However, occasionally the shoulders present transverse to the pelvic outlet. As a result, shoulder dystocia may occur. In shoulder dystocia, the baby's shoulder becomes lodged under the mother's symphysis pubis, making delivery difficult. In such cases, the nurse-midwife or obstetrician will require assistance. When the physician identifies a shoulder dystocia, the nurse's first response is to call for additional assistance. The nurses help the physician with either the McRobert's maneuver or applying suprapubic pressure, if required.

The McRobert's Maneuver First try the McRobert's maneuver. In this maneuver, one nurse stands on each side of the patient and help her to hyperflex her legs. If possible, the patient must keep her knees bent back to her abdomen. When the patient's legs are hyperflexed, the birth canal opens to its maximum, facilitating the delivery of her baby's anterior shoulder.

Suprapubic Pressure In applying suprapubic pressure, the nurse must feel the infant's shoulder above the symphysis pubis and press directly down on it with the heel of her hand. This action can help to dislodge the baby's shoulder to facilitate easier delivery of the baby.

Perineal Skin Prep

Crowning and birth of the baby and placenta .

.

Father or SO Cuts the Cord .

The caregiver will inspect to see if the umbilical cord is wrapped around the neck. and slipped over the infant’s head. If it is impossible to slip . If the cord is around the infant’s neck. the mouth is suctioned first and then the nose to reduce the risk of aspiration. it is loosened.Hand baby to mom: if baby is stable For more information go to: Management of the Third Stage of Labor Newborn Management Review of Newborn ABC Management A Airway When the head is delivered.

the cord is clamped in two places and cut between the clamps. If baby is stable placing the infant on the mother’s abdomen is a warm and appropriate place. Good flexion Good motion Strong cry 2 If breathing is not spontaneous. Administer a 25% solution at 0. C Clamp the Cord C Cover C Continue the assessment CPR Neonatal Resuscitation Continue to dry the baby. Determine the Apgar score at delivery and then again 5 minutes after delivery. Do not hyperextend the neck. Provide oxygen. and cut between the clamps. Add them together. When the cord has stopped pulsating. establish effective ventilation with a bag-valve mask or endotracheal intubation. and put in a warm environment. Reassess the airway. Then the body of the baby is delivered and the mouth and nose are suctioned again. pulse. 0 to 3 is severely depressed. the caregiver gently rubs the baby’s back with a towel to stimulate breathing. Medications are infrequently needed. Some flexion Some motion Weak cry Pink > 100 beat/min. If breathing is absent or heart rate is < 80 beats/min.the cord over the head. 4 to 6 is depressed. the caregiver clamps the cord in two places.. Assign a score to appearance. and respiratory. If the baby is not stable the baby must be transferred to the radiant warmer. Continue the assessment. activity. cover and keep warm. reposition the newborn. . cover. B Breathing C Circulation Dry the baby. pink body < 100 beats/min. suction the nose and then the mouth. again if baby is stable the mother’s abdomen is a warm and appropriate place. and perform a slight chin lift. grimace. A score 7 to 10 is good. begin resuscitation. encourage the mother to breastfeed the infant. Breastfeeding stimulates the uterus to contract. A blood glucose level of 40 mg/dl is critical in a newborn. If the airway is not clear.5 g/kg. and perform chest compressions. Apgar Score 0 Appearance Pulse Grimace Activity Respiratory Blue Absent Limp Absent Absent 1 Blue limbs.

For more information go to: Ultrasound of Placental Abruption Abruptio placentae: Fetal tracing Abruptio Placentae Gross: abruptio placenta Microscopic: abruptio placenta . A frank breech is presentation with the infant's hips flexed and the legs extended. Diagnostic tests include hemogram and crossmatch of 4 units of PRBC. fetal monitoring. Management includes fluid resuscitation with normal saline. An incomplete breech is presentation with one or both of the infant’s feet or knees first. For more information go to: Breech Presentation Abruptio placentae Abruptio placenta is premature separation of the placenta. Symptoms may include vaginal bleeding and abdominal pain or contractions. and STAT C-section. The cause is unknown.Obstetrical Complications Breech Breech presentations are categorized into three types: A complete breech is presentation with the infant’s knees and hips flexed.

Symptoms may include profound hypotension. cover it with saline moistened sterile gauze. placenta previa. STAT C-section is performed. The goal is prevention of fetal anoxia. The cord may not be visual but is felt in the vaginal canal. Management may include rapid endotracheal intubation. fluid resuscitation with normal saline and blood products. If the cord is exposed. For more information go to: Umbilical Cord Complications "Velamentous" insertion of the umbilical cord . and cases of fetal demise. The cord is protruding from the vagina.Abruptio placenta Characteristic findings of placental abruption (list) Risk factors for placental abruption (list) . Amniotic fluid embolism An amniotic fluid embolism is amniotic fluid that leaks into the mother’s vascular system and is associated with abruptio placentae. Management includes positioning the mother on the left side in trendelenberg or in a knee-chest position and administering 100% oxygen. and evaluation of coagulopathy. Cord prolapse There are three variations of cord prolapse: • • • The cord is compressed by the fetus and not visible externally. mechanical ventilation. cardiopulmonary comprise and/or cardiac arrest.

Diagnostic tests may include hemogram. May/June 2004 Eclampsia . blood replacement. intravenous access. and proteinuria. The amount of coverage of the os is used to determine the type of placenta previa: total completely covers the os. type and crossmatch for four units of PRBC. sudden weight gain with generalized edema. Eclampsia symptoms may include seizures and coma. and transfer to labor and delivery. and marginal is beside the os. Management may include fluid resuscitation with normal saline. Hydralazine and nitroprusside sodium may be used to control hypertension. and ultrasound.Placenta previa Placenta previa is a disorder where the placenta presents before the fetus. Magnesium sulfate is used to control seizures. partial partially covers the os. Pelvic examination is contraindicated. but can occur up to two months post delivery. For more information go to: Placenta Previa Total Placenta previa: schematic of complete placenta previa Total Placenta previa: placenta accreta in uterine specimen Partial placenta previa Low lying posterior placenta previa Pre-Eclampsia/Eclampsia Cardinal signs of pre-Eclampsia are elevated blood pressure. and fetal monitoring. Symptoms may include hemorrhage not accompanied by labor. and renal disease. The problem commonly occurs in primagravida women and is associated with diabetes. Signs and symptoms usually occur in the third trimester. hypertension. decreased urine volume. Treatment includes oxygen. The American Journal of Maternal/Child Nursing. For more information go to: Obstetrical Accidents Involving Intravenous Magnesium Sulfate: Recommendations to Promote Patient Safety MCN. clotting studies.

The anesthesiologist is then called. the resuscitation team may arrive in the OR after the patient is taken to the OR. • • The labor and delivery nurse is responsible for informing the physician of complications and calling the anesthesiologist. .R. the time from decision to delivery is ideally within 30 minutes For more information go to: Cesarean Delivery Nursing Responsibilities in the O. he will order the C-section. If the physician is present.Edema Risk factors for preeclampsia (table) PIH is a multi-organ pathologic state with various subsets: (list) Signs and symptoms of mild and severe pregnancy induced hypertension (table) Cesarean Section In the case of severe obstetric emergencies. If the C-section is not immediate. who confirms the necessity of the C-section. Notifying the pediatrician and resuscitation team (usually an RN from the nursery and a respiratory therapist). the nurse phones the physician. If he is not present.

The nurse also answers questions the patient may have about the procedure at this point.• • • • • • • • • • • • Informed consent must be obtained. explaining to the patient what is happening to the extent that time allows just prior to emergency surgery. The number of each item must be determined with utmost certainty. In preparing equipment for delivery. For more information go to: Common Areas of Litigation Related to Care During Labor and Birth: Recommendations to Promote Patient Safety and Decrease Risk Exposure Journal of Perinatal and Neonatal Nursing. Abdominal prep varies from institution to institution and from physician to physician. it is imperative for the nurse to explain what is happening and reassure the patient as much as possible. Placing a grounding pad under her thigh and attaching the electrocautery unit. as in a crash c-section.R. Obtaining a fetal heart rate (unless the C-section is a critical emergency). It is important not to place the grounding pad over a wet surface. This may occur before leaving the birthing room or when patient arrives at the OR. the nurse turns the infant warmer on. and prior to skin closure. The circulating nurse is responsible for making sure the counts of these items are accurate. The nurse can then prepare the patient appropriately. sponges and sharps prior to surgery. the instrument count is forgone. The JCAHO states that this is to be obtained by the physician. Take patient to the OR and transfer to the operating table. when a body cavity is closed. Inserting a Foley catheter. April/June 2003 CRITICAL THINKING: Labor and Delivery . Administering ordered meds. It is important to remember that an emergency C-section can be very frightening for the patient and her birth partner. In a crash C-section. Under normal circumstances. Assuring Infant resuscitation equipment is present and in good operating condition prior to delivery. or sprayed. The grounding pad or return electrode for the electrocautery unit must be placed on the patient's thigh and attached to the unit before being turned on. The labor and delivery nurse witnesses the patient's signature and asks the patient if she understands what the physician has told her. their application process is consistent. During emergency surgeries. It is important for the circulating nurse and scrub tech to count instruments aloud and simultaneously. the circulating nurse informs the physician of the results. even while preparations are being made. and the physician verbally acknowledges this information. one of several types of prep solutions is applied. Positioning the patient with a wedge under the patient's right hip to keep the weight of the uterus off of her large blood vessels. according to emergency and timing. A post op x-ray is then taken to confirm the absence of any instrument or foreign body left in the abdominal cavity. Providing patient education. Once preparations are complete. That's why. while attempts are usually made to count sponges and needles. Although these solutions differ. the prep does not include a shave and the solution is poured over the belly. Working from the side of the patient tilted toward the nurse. Prepping the patient's abdomen for surgery. Then. the area directly over and immediately surrounding the surgical site is shaved or clipped. the surgeon(s) and anesthesiologist are called to the O. These counts occur at the beginning of the surgery. the nurse starts at the incision site and works outward (cleanest area to dirtiest) in a circular motion. The nurse must be careful to assure that the prep solution does not run down over the area where the pad will be placed. This occurs as soon as the patient arrives at the OR. who is also responsible for explaining the procedure as well as the risks and benefits. If the patient has had an epidural. The scrub tech or nurse and circulating nurse counts the instruments together. never going back over a previously prepped site with a used applicator. as well as the sources for oxygen and suction. Counting instruments. she may already have a Foley in place. At the end of each count.

What data support your suspicion that Mary is a substance abuser? What common pain meds should be avoided in drug addicted persons? CRITICAL THINKING: Labor Mary has an emergency cesarean section for abruptio placenta. I don’t know what is going to happen next and if it will be painful to me or harmful to my baby. Her monitor pattern reveals fetal heart rate of 180 and decreased variability. How can you make the coach feel more welcome and comfortable? Take a minute and draw a fetus inside a uterus. Mary is slow to respond to questions and appears weak and diaphoretic. . Describe Mary’s obstetrical history? What emergency obstetrical complication do you suspect Mary has? Support your choice with clinical findings. Her fundal height measures 30cm. What should you do if you discover fetal bradycardia? What are common causes of early decelerations? What are common causes of late decelerations? What are common causes of variable decelerations? What are the nursing responsibilities for a patient receiving Terbutaline? CRITICAL THINKING: Labor and Delivery • • A childbirth coach can sometimes feel "in the way". BP 100/60. Her abdomen is rigid and a hypertonic pattern appears on the monitor. What symptoms will you look for in Mary’s baby due to Mary’s use of drugs? CRITICAL THINKING: Labor Sarah is at 42 weeks’ gestation. She is very upset and tells the nurse: "All my doctor told me is that the test will see if my baby is O. Explain why these babies are prone to hypothermia. Her physician has ordered a biophysical profile (BPP). G3. CRITICAL THINKING: Unknown Obstetrical Complication Mary.• • • • • • • • • IV Nubain/Stadol is ordered for pain to the mother in active labor. She appears reluctant to answer questions. hypoglycemia and hyperbilirubinemia. extended attitude. What measures do you need to take before giving pain medication to a laboring woman? When should an IV medication be given in relation to her contractions? List four possible causes of fetal tachycardia. She is 38 weeks pregnant with a history of no prenatal care. List three possible causes of fetal bradycardia. She is in the recovery room and you notice bloody urine in the Foley catheter and a 2cm area of bright red blood on her abdominal dressing. What should you do. cephalic lie. R 24.K. P 120. and what serious complication would Mary be at risk for? Mary’s baby weighs 3 pounds and is severely growth restricted. P0 presents to L&D complaining of vaginal bleeding and abdominal pain." Sarah receives a score of 8 for the BPP. Draw the fetus in a longitudinal lie.

Describe how you would be respond to Sarah’s concerns. Specify the meaning of Sarah’s test result of 8. List the factors that were evaluated to obtain this score. Thermoregulation Using a Radiant Warmer .

or signs of infection.4° and 37. Assess skin integrity. or leave infant in crib and gently pick up head. leaving a diaper on. drainage. peeling. Place infant under the heater Place thermal skin probe on the abdomen and attach by an aluminum heat deflector patch.Assessment • • Assess infant's axillary temperature. Hold the infant in a "football" hold over the washbasin.6° F). Set the radiant warmer controls according to agency protocol. may lead to cold stress. A soft washcloth may be used to wash the scalp if there is excess soiling. Place in an open crib. Length of time under the warmer. Assess the infant's temperature if at high risk for hypothermia. Assess infant's axillary and skin probe temperature every 30 minutes or according to agency protocol.8° and 98. supporting it in one hand.2° C (97. Recheck axillary temperature in 1 hour.5° F). Lather scalp with a small amount of mild soap. . dress and wrap in prewarmed blankets with a dry cap on head. Condition of skin after warming process Infant Bathing || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities | Assessment • • • • • • • Assess the infant's skin for dryness. Implementation • • • • • Prewarm the radiant warmer to between 36° and 37° C (96. If below 36. prewarm blankets. Shampooing infant's hair: Wrap the infant in the blanket using a swaddling technique. Evaluation • • • • • • • Evaluate axillary temperature to verify stability between 36. When the infant's temperature reaches 37° C (98° F). Remove shirt from infant. Inspect infant's skin for absence of redness and irritation. Identify Unexpected Outcomes and Nursing Interventions …Report and Record • • • • Temperature of infant before and after warming. As the infant's temperature stabilizes. and intactness. Assess the site of the umbilical cord for redness.5° and 99° F). Temperature of infant 1 hour after removing from the warmer.4176C (97. drying.

Use separate portions of the washcloth for each wipe. Place infant in crib or bassinet with sides and have all supplies within reach. Cleanse the face and neck with plain water. Thoroughly rinse the rest of the upper body and dry completely by using a patting motion. Cleanse the legs and outer buttocks with soap and water. Rinse and dry thoroughly.8° C (98° to 100° F). handle. and along upper and lower gum pads. Dry the area. with attention to areas behind ears and creases in neck. Document parent teaching and response. roof of mouth. Comb or brush infant's hair gently. Dry face and neck with a towel using a gentle patting motion. Apply a moistened washcloth for 1 to 2 minutes before cleansing to soften crusts if present. Change this dressing with each diaper change. cleanse the infant's mouth. Cleanse the abdomen around the umbilicus with soap and water. Cleanse infant's upper body with soap and washcloth. and dry. rinsing well after washing. Keep infant covered with a blanket to maintain warmth. Cover the upper body with a dry towel or blanket. Apply clean diaper. In uncircumcised newborns. dorsal surface of tongue. Identify Unexpected Outcomes and Nursing Interventions Record and Report • • Temperature on the graphic sheet. Implementation Prepare washbasin with warm water at about 36. Incorporate specific bathing techniques important to their family or culture.• • • • • • • • • • • • • • • • • • • • • • • • Rinse the scalp thoroughly by pouring water from a small cup over the infant's scalp into the washbasin. Apply cord care product according to agency protocol until area is healed. Use clean gloves for first newborn bath or if in contact with body secretions during any bath. • • • Evaluate parents' ability to bathe. Cleanse anal area with soap. Parent Teaching and Evaluation Communication Tip: Assess parents' knowledge of how to give a bath and any cultural deviations that may alter the care of the infant. cleanse the genitalia with plain water. Cover infant's lower body with blanket. Replace the damp blankets. Quickly rinse soap from the infant's hands. Observe parents' interactions with infant in relation to sensory and social stimulation. and dress the infant during a return demonstration. For a female infant: Gently retract labia and wash from front to back toward the anus. the foreskin may be adhering to the glans and should not be retracted. In a circumcised newborn. Cleanse the area gently with warm tap water and cotton gauze or cotton balls. A small amount of soap may be used for soiled creases. rinse. With fresh washcloth dampened with plain water. Wash scrotum and folds of the groin. Assess area for bleeding. Dry thoroughly with a towel. . including inside lips. which is comfortably warm. keeping the cord dry. Description of skin condition. With a fresh washcloth. Place sterile gauze dressing with sterile petroleum jelly added between the penis and diaper. circumcision care is done. For an uncircumcised male infant: Wash from the urethra outward and down toward the scrotum. Cleanse the external ears with plain water and a twisted end of the washcloth. Wash the other portions of the labia and the folds in the groin. cheeks. Cleanse the eyes with plain water from the inner to the outer canthus. using a clean portion of the washcloth with each wipe.6° to 37.

After the breast has softened. When the mouth is open wide and the tongue is down. bringing the baby to the breast and not the breast to the baby. . Position the infant: cradle head in one hand or on one arm. Assist the mother to position the infant in one of four positions (The football hold. If there is pain. Assess for the following evidence of success: After the milk comes in at least one breast softens with each feeding. Encourage the mother to begin feedings on the opposite breast each time. Assess for tolerance of last feeding of formula. The baby has bursts of 10 or more sucks and swallows at the beginning and slows down to 2 to 3 sucks and swallows as the breast softens. Have the mother lightly touch the baby's lower lip and the tip of the tongue with her nipple. Lying down) and encourage her to to use a variety of positions Assist the baby to latch on effectively. The swallowing can be heard. continue nursing on the opposite breast. Prepare the infant by providing clean diaper and clothing and wrap snugly. encourage the mother to burp the infant and. Implementation • • • Identify the infant using identification bracelet. Touch the corner of infant's mouth with nipple. have the mother pull the baby quickly to the breast. As the let-down reflex occurs. support body on the other. Assisting with Breast-Feeding • • • • • • • • • • • • • • Assist the mother to a comfortable position supported with pillows in the bed or chair. The mother feels a firm tug on her nipple and no pinching or sliding sensation. Across the lap. Encourage mother to implement thorough hand washing before infant feeding. Assisting with Formula Feeding • • • • Identify and prepare the appropriate type and amount of formula. and the quality of that feeding time. Have the mother support the breast in one hand with the fingers underneath and the thumb on top. Place bib or small cloth under infant's chin. Evaluate for a proper latch on.Infant Feeding || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities | Assessment • • • • Assess for feeding readiness cues Determine when the infant was last fed. if possible or desired. there may be leaking from the other breast. Ask if nursing hurts after the first few sucks. Assess physical development of infant and suck reflex. The cradle hold. have her release the suction with her finger and remove the infant from the breast and start over.

Positive/negative bonding response of parents. Evaluation • • • • Evaluate the amount of formula or. or regurgitation during feeding. gagging. the time in minutes and note if infant softens at least one breast each feeding. Identify Unexpected Outcomes and Nursing Interventions Record and Report • • • • • Amount of formula infant drank. observing for suck-swallow-breathe reflex. Dispose of bottle and unused formula in an appropriate container. never on the abdomen. gagging. Length of feeding. Observe infant's face for signs of choking or vomiting. Newborn Exam Physical Assessment of the Newborn || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities | . Place infant in bed on right side. The infant may also be placed on the shoulder of the caregiver or in a sitting position. if breast-feeding. Observe for choking. Infant's tolerance of formula.• • • • • • • • • • Insert nipple into mouth and hold bottle so that nipple is completely filled with formula. The infant is content for at least 2 to 2½ hours between feedings. Burp infant at the end of the feeding. or regurgitation after feeding. Place infant in prone position across lap and gently pat infant's back. The infant has at least six wet diapers and two bowel movements each 24 hours by 4 days of age. The infant regains birth weight in 7 to 10 days and doubles the birth weight in 6 months. Observe for choking. Check diaper and change if needed. Continue to feed remainder of formula. How infant sucked. Allow infant to suck. Burp infant about halfway through feeding.

which should be done within 24 hours after birth. generalized neurofibromatosis. Reflexes Reflexes must be symmetrical.Measure and record height.associated with low hemoglobin Cyanosis . generally present at birth. The exam is divided into two parts: an external characteristics score. with fingers covering the thumb.associated with methemoglobinemia NEUROLOGICAL EXAM || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities | State of alertness Check for persistent lethargy or irritability. Miliaria . Posture In term infant. Should not have more than 10% head lag when moving from supine to sitting position.small vesicopustules. Clear within 1 week.if large numbers suspect tuberous sclerosis. weight.associated with hypoxemia Plethora . Pallor .suspect neurofibromatosis if there are many large spots. Pinpoint vesicles on forehead scalp and skinfolds. The neck extensors should be able to hold the head in line for 3 seconds. SKIN Color • • • • • Lesions • • • • • • Milia .Most common newborn rash. xeroderma pigmentosus. Erythema toxicum . Cafe au lait spots . Biceps jerk test C5 and C6 . The fists are often clenched. cheeks and forehead. which is best done at birth. containing WBCs and no organisms.Elevated bilirubin Slate grey colour . Tone Support the infant with one hand under his chest.pinpoint white papules of keratogenous material usually on nose. Transient neonatal pustular melanosis . irregular macular patches. perform a Dubowitz/Ballard exam to assess gestational age (see Dubowitz/Ballard scoring grid). Variable. Arms are adducted and flexed at the elbow. Lasts a few days. and a neuromuscular score. normal position is one with hips abducted and partially flexed and with knees flexed. and head circumference. last several weeks. If the infant appears premature or is unusually large or small.obstructed eccrine sweat ducts. Junctional nevi .associated with polycythemia Jaundice .

S2 Truncal incurvation reflex tests T2 through S1 Anal wink test S4. DOLL'S EYE While manually turning baby's head. and the asymmetric tonic neck reflex (ATNR).Knee jerk tests L2-L4 Ankle jerk tests S1. Reflex may be seen up to age one. if it reappears later. **** **** Absence may Absence or weakness of this reflex may Absence or indicate spinal suggest a severely disturbed CNS. while the others fan out. then swiftly baby's back to lowered a few inches. his eyes will stay fixed. hands open then clutch. The big toe should lift up. BABINSKI Baby's foot is stroked from heel toward the toes. **** While stroking Baby is held horizontally.. mouth will open and her head will turn to one side. her eyes will close. or other problems. sucking and rooting reflexes. instead of moving with the head. or the head may one side. weakness of injury or this reflex . Neonatal Primitive Reflexes Newborn and infant reflex tests and behaviors. defective spinal chord. palmer and planter grasps. S5 Other primitive reflexes include the Moro. **** **** Absence of reflex may suggest immaturity of the CNS. her be lowered a few inches. While normally vanishing around one month of age. or a loud spine and trunk sudden noise will make baby's arms will arch toward fling out and then come together as that side. then reaction will be reversed with the toes curling downward. there may be damage to the CNS. GALANT MORO PALMAR GRASP By pressing just one of baby's palms. fingers should grasp the object. **** Absence of this reflex or if it reappears after vanishing around 3-4 mos. it may signify a malfunctioning CNS. BABKIN When both of baby's palms are pressed.

will make her cry out and head will rise. **** **** **** Absence of this reflex could indicate a damaged sciatic nerve. make sucking motions. **** PEREZ Firmly stroking baby's spine from tail to head. Depressed If this reflex doesn't vanish sucking may be in 3-4 months. could reflect an injured spinal chord or depressed CNS. rhythmical toward finger and she will sucking.depression of the CNS. **** STEPPING Holding baby upright with feet touching a solid surface and moving him forward should elicit stepping movements. SUCKING ROOTING WITHDRAWAL A finger or nipple When baby's cheek is A pinprick to the sole of placed in baby's stroked at the corner of her baby's foot will make mouth will elicit mouth. this reflex not vanish in 4-6 the spinal chord. PLANTERS GRASP Pressing thumbs against the balls of baby's feed will make his toes flex. **** Absence of this reflex If this reflex does may indicate damage to After 3-4 months. the CNS due to may be malfunctioning. should vanish. baby's reappears. her head will turn baby's knee and foot flex. there may be an CNS may be injury of the upper spinal severely chord. medication given during childbirth When reflexes appear and disappear: Reflex Moro Grasp LE crossed extensors Extensor plantar Placing/stepping ATNR Appears Newborn Newborn Birth Newborn Birth Newborn Disappears 3 months 3 months 1 month 8-12 months 1-2 months 3 months . If it months. depressed.

000 births. Palate Check for cleft lip and palate. irregular shapes. A whitish color may be suggestive of retinoblastoma. Silver nitrate prophylaxis can cause a chemical conjunctivitis. heterochromia. Ears Check for asymmetry. Microstomia . or skin tags.Inspect for erythema.small bluish white swellings of variable size on the floor of the mouth representing benign mucous gland retention cysts. Ranulas .seen in Trisomy 18 and 21. Black dots may represent cataracts.seen in fetal alcohol syndrome. Look for hyper. Check for choanal atresia (CA) as manifested by respiratory distress (neonates are obligate nose breathers). Check for encephalocoeles.Hold the ophthalmoscope 6-8" from the eye. exudate. Risk of aspiration if loosely attached. A soft NG tube should be passed through each nostril to confirm patency if choanal atresia is suspected. Mouth • • • • • • Observe the size and shape of the mouth. the number of fontanelles and their size.Hypothyroidism. edema.seen in mucopolysaccharidoses. Measure the head circumference.Check for cloudiness. Check for abnormal shape of head.occur in 1/2.small white cysts that contain keratin. Conjunctiva . Macrostomia .HEAD AND NECK || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities | Head Check for overriding sutures. jaundice and hemorrhage. Use the +10 diopter lens. Cornea . fleshy appendages. Fish mouth . lipomas. Look for auricular or pre-auricular pits. frequently found on either side of the median raphe of the palate. Red Reflex . . Mostly lower incisors. Epstein pearls . Tongue Macroglossia .or hypo-telorism. mucopolysaccharidoses Teeth Natal teeth . Check for pupillary size and reactivity to light. Nose Look for flaring of the alae nasi as a sign of increased respiratory effort. The normal newborn transmits a clear red colour back to the observer. • • • • • Eyes Check for colobomas.

Neck Palpate over all muscles. Before birth. or other thoracic problem. Treacher-Collins syndrome. Locate PMI with single finger on chest. Cardiovascular System Measure heart rate. Lymph nodes are unusual at birth and their presence usually indicates congenital infection. Web neck found in Turner's and Noonan's syndromes. and plethora. Note that there may be some enlargement of the breasts secondary to maternal hormones. respiratory pattern (periodic breathing. PDA occurs when this opening fails to close. Torticollis usually secondary to sternocleidomastoid hematoma. surgery is performed. grunting. diaphragmatic hernia. Hallerman Streiff syndrome. CHEST AND LUNGS Observe respiratory rate. Inspection Check baby's color for pallor. If the ductus fails to close on its own or with indomethacin. cyanosis. Patent Ductus Arteriosis . Palpation Check capillary refill. situs inversus. The ductus is either ligated (tied off) or cut. periods of true apnea). respiratory rate. Listen for stridor.occurs with Pierre-Robin syndrome. A small incision is made on the left side of the chest. palpate clavicles for possible fractures. note character of pulses (bounding or thready).Chin Micrognathia . abnormal location of PMI can be clue to pneumothorax. Auscultation Note rhythm and presence of murmurs that may be pathologic. PDA is often treated initially with a medication called indomethacin. PDA occurs in about 10% of infants. there is a natural opening between the aorta (the main artery to the body) and the pulmonary artery (the main artery to the lungs) called the ductus arteriosus. note any decrease in femoral pulses or radio-femoral delay as a sign of possible coarctation of the aorta. Observe chest movements for symmetry and for retractions. This opening usually closes shortly after birth. Cystic hygromas most common neck mass. blood pressure in upper and lower extremities. Check pulses.

This opening usually closes about the time the baby is born. omphalocoele. be alert for congenital infection or extramedullary hematopoeisis. Inspect anal area for patency and/or presence of fistulas. abdominal contents in chest. In fetal circulation there is normally an opening between the two atria (the upper chambers of the heart) to allow blood to bypass the lungs. or a VSD. They will have no symptoms. Flat abdomens signify decreased tone. Note abdominal distension. • • • Auscultate for bowel sounds. Genitourinary Exam || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities | .g. blood continues to flow from the left to the right atria. or abnormalities in abdominal musculature. the hole is small. The spleen is not usually palpable.umbilical or inguinal. and the hole will close spontaneously as the muscular wall continues to grow after birth. Examine for hernias . Note color of cord.Atrial septal defect (ASD) is a congenital heart defect. It is estimated that up to 1% of babies are born with this condition. Atrial Septal Defect Before a baby is born. a hole remains. As the fetus grows. If the ASD is persistent. then too much blood will be pumped to the lungs. This is called a shunt. palpate for any abnormal masses. After locating these organs (checking for situs inversus). a muscular wall forms to separate these lower heart chambers. Observe for diastasis recti. the right and left ventricles of its heart are not separate. Palpate liver and spleen. Examine umbilical cord and count the vessels. leading to congestive heart failure. These babies are often have symptoms related to the problem and may need medicine or surgery to close the hole. if the spleen is felt. Observe for any obvious malformations e. If the hole is large. It may be normal for the liver to be about 2 cm below the right costal margin. Ventricular Septal Defect ABDOMEN Note shape of abdomen. An omphalocoele has a membrane covering (unless it has been ruptured during the delivery) whereas a gastroschisis does not. In the vast majority (80-90%) of babies born with this condition. This is what is known as a ventricular septal defect. If the wall does not completely form.

Male genitalia Term normal penis is 3. this is normal.6±0. clitoris. The kidneys should be about 4. Inspect creases and fingers. urethral opening. Hymenal tags may be present normally. Often a whitish discharge is present. Full term infant should have brownish pigmentation and fully rugated scrotum. Female genitalia Inspect the labia. March/April 2004 Newborn Behavioral and Psychological Responses to Circumcision MCN. meningomyelocoeles. Problems in the Neonate Cueing Into Infant Pain MCN. The American Journal of Maternal/Child Nursing. The technique for palpation is either a) one hand with four fingers under the baby's back. Inspect circumcised penis for edema. Inspect glans.5-5. Lower extremity See posture above. Extremities and Skeletal System || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities | Spine Scoliosis. incision. Do Ortolani maneuver to check for congenital hip dislocation. Check toes. Palpate the testes. Normally difficult to completely retract foreskin. lordosis. absence of radius or ulna. spinal defects. bleeding. The American Journal of Maternal/Child Nursing. kyphosis. urethral opening and external vaginal vault. September/October 2003 . Upper extremity Look for clavicular fracture. prepuce and shaft.0 cm vertical length in the full term newborn. as is a small amount of bleeding. or b) palpate the left kidney by placing the right hand under the left lumbar region and palpating the abdomen with the left hand (do the reverse for the right kidney).Kidneys Examined by palpation.7 cm stretched length. epispadias. which usually occurs a few days after birth and is secondary to maternal hormone withdrawal. palpation by rolling the thumb over the kidneys. Observe for hypospadias.

55% of SGA infants • Uteroplacental insufficiency -. velamentous insertion. Wt <10 %) -. 18. malaria) Inborn errors of metabolism o Hypophosphatasia o Leprechaunism o Some amino acidurias Environmental o Drugs (heroin. diphenylhydantoin) o X-rays (therapeutic) o Smoking • • • Small for gestational age (SGA) Asymmetric (HC = L > Wt. CMV. multiple gestation. ethanol. Large for gestational age (LGA) • • • • Infants of diabetic mothers Beckwith-Wiedemann syndrome Hydrops fetalis Large mother . multiple gestation. varicella.onset usually after 24 weeks o Chronic hypertension o Preeclampsia o Renal disease o Cyanotic heart disease o Hemoglobinopathies o Placental infarcts or chronic abruption. methadone. velamentous insertion. and Turner's syndrome) o Congenital abnormalities Intrauterine infections o Viruses (rubella. all <10 %) -.33% of SGA infants • Genetic o Small maternal size o Chromosomal abnormalities (Trisomies 13. circumvallate placenta. 21. HIV) o Bacteria (tuberculosis) o Spirochete (syphilis) o Protozoan (toxoplasmosis. circumvallate placenta. o Altitude Small for gestational age (SGA) Combined (symmetric or asymmetric) -.12% of SGA infants • • Environmental o Drugs (including ethanol) o Smoking Placental unit insufficiency o Placental infarcts or chronic abruption.Small for gestational age (SGA) Symmetric (HC = Wt = L.

fundal height and firmness. March/April 2003 .POSTPARTUM PHYSICAL ASSESSMENT: VS. status of perineum. bladder distension First hour: every 15 minutes Second hour: every 30 minutes First 24 hours: every 4 hours After 24hours: every 8 hours Postpartum Beliefs and Practices Among Non-Western Cultures MCN. amount of lochia. The American Journal of Maternal/Child Nursing. presence of edema.

presence of colostrum or breastmilk. bruised. bleeding.uterus B . tenderness.lochia E . engorged.DELIVERY HISTORY /ADMISSION/TRANSITION ASSESSMENT: Gravida.bowels B . everted.breast U . filling. cracked.episiotomy BREAST ASSESSMENT Breasts – Soft.bladder L . redness. swelling. parity / Time and type of delivery Anesthesia or medications / Risk factors for PPH Medical history / Routine medications / Allergies Infant status / Breast/bottle Rho (D) / Rh-? (72h) / Rubella immune? VITAL SIGNS Heart Rate Respiratory Blood Pressure Temperature dehydration . Nipples – Inverted. DAY 1 40-70 BPM Normal DAY 2 AND AFTER Bradycardia or normal Normal Normal Norma 100. POSTPARTUM PHYSICAL ASSESSMENT B . .4 is considered normal for first 24 hours due to muscular exertion.KNOW YOUR PATIENT --.

.AWHONN Clinical Position Statements Breastfeeding The Role of the Nurse in the Promotion of Breastfeeding Drugs in Nursing Mothers FUNDAL ASSESSMENT Location in relation to umbilicus Degree of firmness Midline or deviated to one side ASSESSING THE UTERINE FUNDUS The uterus is best evaluated with the patient in a supine position and with an empty bladder. Fundal descent is measured in relationship to the umbilicus in fingerbreadths or centimeters. The nurse should support the lower uterine segment just above the symphysis pubis with the nondominant hand and palpate the uterine fundus for degree of involution.

ecchymosis.21 . Day 1.3 .lochia serosa Day 11. approximation of edges of episiotomy) to guide assessment. Hemorrhoids ? LOCHIA ASSESSMENT Assessment of lochia includes noting color. presence of clots and foul odor. Unusual perineal discomfort may be a symptom of impending infection or hematoma.PERINEAL ASSESSMENT Assessment of the episiotomy/perineum should occur with the woman in lateral Sims (side lying) position. discharge. the perineum should still be assessed.lochia rubra Day 4-10 . Even if there is no episiotomy. Use the acronym REEDA (redness. edema.lochia alba .

incomplete emptying of bladder. . retention of residual urine and increased risk of UTI and postpartum hemorrhage. Postpartum diuresis is a reversal of that process and occurs post delivery. UTERINE ATONY Normal pregnancy is associated with an increase in extracellular H20. This leads to over-distension of the bladder.BLADDER ASSESSMENT Voiding pattern. complete emptying. pain burning on urination Record first three voids with the amount and times voided A full bladder displaces the uterus upwards and laterally and prevents contraction of the uterus = UTERINE ATONY = > risk of postpartum hemorrhage. The bladder has increased capacity and decreased muscle tone.

combine palpation and pain management measures. if the fetus is Rh+ the material blood may cross the placenta and destroy fetal cells. . When the factor is present a person is designated Rh+ (positive). POSTPARTUM CESAREAN Incision site…approximated redness swelling. Rh Factor The Rh factor is blood group present on the surface of erythrocytes of the rhesus monkey. If lochia indicates excessive bleeding. In subsequent pregnancies.UTERINE INVOLUTION –at delivery fundus at umbilicus –1-2 hours midway between umbilicus and symphysis pubis --12 hours 1 cm above or at umbilicus After that the height of the uterine fundus decreases (involutes) by approximately 1 cm per day. It is found in variable degrees in the human population. The blood of an Rh+ fetus can sensitize a pregnant female and form anti-Rh agglutinin. A person without the factor is Rh(negative). discharge.

Clotting factors are consumed before the liver can replace them. lethargy Made from human plasma. platelets. peak and duration unknown Irritation at injection site. fever. Postpartum hemorrhage Postpartum hemorrhage is excessive bleeding of more than 1000 ml within 24 hours of delivery. RhoGAM Rho (d) immune globulin. RhoGAM 300 mcg is the standard dose. human Indications Prevention of isoimmunization in Rh. Diagnostic monitor is the fibrinogen level.mother within 72 hours after delivery of an Rh+ infant or if the Rh is unknown. fetal demise.RhoGAM immune globulin is prepared from the plasma of a person with high Rh antibodies. The dose must be repeated after each subsequent delivery. Hemorrhage ensues.females after delivery of an Rh+ infant or if the Rh is unknown. and abruptio placentae. The cause is often failure of the uterus to return to normal size. Adult dose Onset Side effects Precautions Postpartum Emergencies Postpartum DIC (disseminated intravascular coagulation) DIC is characterized by the increase of clotting mechanisms. Causes may include amniotic fluid embolus. Heparin may be used. fresh frozen plasma. and cryoprecipitate. 1 vial IM given within 72 hours of termination of pregnancy IM onset rapid. Products made from human plasma may contain infectious agents. Management may include replacement of clotting factors. retrained products . It is given to an Rh.

may be required. sleep. type and cross. includes a period of at least 2 weeks of depressed mood or loss of interest in almost all activities. and correction of the underlying cause. and psychomotor activity. fluid resuscitation with normal saline and blood. Postpartum depression AWHONN Clinical Position Statement The Role of the Nurse in Postpartum Depression Postpartum depression is a nonpsychotic depressive episode that begins in the postpartum period. decreased energy. STUDY GUIDE . and vaginal or cervical lacerations. Management may include CBC. diagnosis. feeling of worthlessness or guilt. difficulty thinking. Postpartum depression prevalence rates are estimated to be 10-15%. vaginal examination. plans. or attempts.of conception. and at least four of the following symptoms: *changes in appetite or weight. concentrating or making decisions. Complete pelvic examination under anesthesia and/or surgical repair. sedimentation rate. or recurrent thoughts of death or suicidal ideation.

containing WBCs and no organisms. which is best done at birth. • • NEUROLOGICAL EXAM State of alertness Check for persistent lethargy or irritability. Junctional nevi .associated with hypoxemia Plethora .Elevated bilirubin Slate grey colour . Cafe au lait spots . | Skin | Neurological Exam | Head & Neck | Chest & Lungs | Abdomen | | Extremities & Skeletal | Neonatal Primitive Reflexes | Exam for Gestational Age | | Physical Maturity | Maturity Rating | Administering & Enema | Urinary Catheterization | SKIN Color • • • • • Pallor . last several weeks. and a neuromuscular score. and head circumference. cheeks and forehead. xeroderma pigmentosus.associated with polycythemia Jaundice . Pinpoint vesicles on forehead scalp and skinfolds.associated with methemoglobinemia Lesions • • • Milia . The exam is divided into two parts: an external characteristics score. Variable. Transient neonatal pustular melanosis .Most common newborn rash.small vesicopustules.if large numbers suspect tuberous sclerosis. Lasts a few days.associated with low hemoglobin Cyanosis . generalized neurofibromatosis. which should be done within 24 hours after birth.NEWBORN EXAMINATION Physical Assessment of the Newborn Measure and record height. generally present at birth. weight.suspect neurofibromatosis if there are many large spots. perform a Dubowitz/Ballard exam to assess gestational age (see Dubowitz/Ballard scoring grid). Erythema toxicum . Clear within 1 week. If the infant appears premature or is unusually large or small.obstructed eccrine sweat ducts. Posture .pinpoint white papules of keratogenous material usually on nose. irregular macular patches. Miliaria .

Check for cloudiness. Mouth • • • • • • Observe the size and shape of the mouth.Inspect for erythema. Check for pupillary size and reactivity to light. Tongue . Palate Check for cleft lip and palate. edema. The normal newborn transmits a clear red colour back to the observer. The neck extensors should be able to hold the head in line for 3 seconds. Check for choanal atresia (CA) as manifested by respiratory distress (neonates are obligate nose breathers). see below) Head Check for overriding sutures. Cornea . Fish mouth . fleshy appendages. Tone Support the infant with one hand under his chest. Black dots may represent cataracts. with fingers covering the thumb.seen in mucopolysaccharidoses. Nose Look for flaring of the alae nasi as a sign of increased respiratory effort. Macrostomia . Microstomia . or skin tags. Conjunctiva . Check for encephalocoeles.seen in fetal alcohol syndrome. Measure the head circumference. Should not have more than 10% head lag when moving from supine to sitting position. normal position is one with hips abducted and partially flexed and with knees flexed. Red Reflex .small white cysts that contain keratin. lipomas. Eyes • • • • Check for colobomas. the number of fontanelles and their size. Epstein pearls . irregular shapes. Arms are adducted and flexed at the elbow. exudate. Reflexes Reflexes must be symmetrical. The fists are often clenched. A soft NG tube should be passed through each nostril to confirm patency if choanal atresia is suspected. Use the +10 diopter lens. Look for auricular or pre-auricular pits. A whitish color may be suggestive of retinoblastoma.Hold the ophthalmoscope 6-8" from the eye.seen in Trisomy 18 and 21. Ears Check for asymmetry.or hypo-telorism. Check for abnormal shape of head. jaundice and hemorrhage.In term infant. Look for hyper. Ranulas . heterochromia. frequently found on either side of the median raphe of the palate. Silver nitrate prophylaxis can cause a chemical conjunctivitis.small bluish white swellings of variable size on the floor of the mouth representing benign mucous gland retention cysts.

occurs with Pierre-Robin syndrome.Hypothyroidism. Listen for stridor. periods of true apnea). grunting. Palpation Check capillary refill.occur in 1/2. CHEST AND LUNGS Observe respiratory rate. Note that there may be some enlargement of the breasts secondary to maternal hormones. abnormal location of PMI can be clue to pneumothorax. cyanosis. Web neck found in Turner's and Noonan's syndromes. respiratory pattern (periodic breathing. Check pulses. note any decrease in femoral pulses or radio-femoral delay as a sign of possible coarctation of the aorta.000 births. ABDOMEN . Lymph nodes are unusual at birth and their presence usually indicates congenital infection. Cardiovascular System Measure heart rate. Inspection Check baby's color for pallor. Cystic hygromas most common neck mass. Treacher-Collins syndrome. Mostly lower incisors. palpate clavicles for possible fractures. Hallerman Streiff syndrome. and plethora. mucopolysaccharidoses Teeth Natal teeth . note character of pulses (bounding or thready). Auscultation Note rhythm and presence of murmurs that may be pathologic. or other thoracic problem. situs inversus. Neck Palpate over all muscles.Macroglossia . Risk of aspiration if loosely attached Chin Micrognathia . respiratory rate. Torticollis usually secondary to sternocleidomastoid hematoma. blood pressure in upper and lower extremities. Observe chest movements for symmetry and for retractions. diaphragmatic hernia. Locate PMI with single finger on chest.

Full term infant should have brownish pigmentation and fully rugated scrotum. The spleen is not usually palpable. Male genitalia Term normal penis is 3. or abnormalities in abdominal musculature. Observe for hypospadias. Auscultate for bowel sounds. Examine for hernias .6±0. The kidneys should be about 4. prepuce and shaft. Often a whitish discharge is present. GENITOURINARY EXAM Kidneys Examined by palpation.umbilical or inguinal. incision. abdominal contents in chest. urethral opening and external vaginal vault. or b) palpate the left kidney by placing the right hand under the left lumbar region and palpating the abdomen with the left hand (do the reverse for the right kidney). Inspect creases and fingers. bleeding. An omphalocoele has a membrane covering (unless it has been ruptured during the delivery) whereas a gastroschisis does not.g. EXTREMITIES AND SKELETAL SYSTEM Spine Scoliosis. Inspect glans. Female genitalia Inspect the labia. Examine umbilical cord and count the vessels. Inspect anal area for patency and/or presence of fistulas. Palpate liver and spleen.0 cm vertical length in the full term newborn. The technique for palpation is either a) one hand with four fingers under the baby's back. Note color of cord. as is a small amount of bleeding. Palpate the testes. absence of radius or ulna. Flat abdomens signify decreased tone.5-5. be alert for congenital infection or extramedullary hematopoeisis. After locating these organs (checking for situs inversus). Observe for any obvious malformations e. if the spleen is felt. meningomyelocoeles. epispadias. Upper extremity Look for clavicular fracture. Observe for diastasis recti.• • • • • • Note shape of abdomen. Normally difficult to completely retract foreskin. urethral opening. spinal defects. . Note abdominal distension. It may be normal for the liver to be about 2 cm below the right costal margin. which usually occurs a few days after birth and is secondary to maternal hormone withdrawal. this is normal.7 cm stretched length. palpate for any abnormal masses. lordosis. Inspect circumcised penis for edema. kyphosis. Hymenal tags may be present normally. clitoris. palpation by rolling the thumb over the kidneys. omphalocoele.

or the head may one side.Lower extremity See posture above. fingers should grasp the object. NEONATAL PRIMITIVE REFLEXES | TOP | Skin | Neurological Exam | Head & Neck | Chest & Lungs | Abdomen | | Extremities & Skeletal | Neonatal Primitive Reflexes | Exam for Gestational Age | | Physical Maturity | Maturity Rating | Administering & Enema | Urinary Catheterization | Newborn and infant reflex tests and behaviors. there may be damage to the CNS.. hands open then clutch. it may signify a malfunctioning CNS. MORO PALMAR GRASP By pressing just one of baby's palms. The big toe should lift up. **** Absence of this reflex or if it reappears after vanishing around 3-4 mos. DOLL'S EYE While manually turning baby's head. BABINSKI Baby's foot is stroked from heel toward the toes. if it reappears later. mouth will open and her head will turn to one side. **** **** Absence may Absence or weakness of this reflex may Absence or indicate spinal suggest a severely disturbed CNS. injured spinal chord or depressed CNS. his eyes will stay fixed. instead of moving with the head. BABKIN When both of baby's palms are pressed. defective spinal chord. Reflex may be seen up to age one. . or other problems. weakness of injury or this reflex depression of could reflect an the CNS. her be lowered a few inches. **** **** Absence of reflex may suggest immaturity of the CNS. Check toes. then reaction will be reversed with the toes curling downward. GALANT While normally vanishing around one month of age. Do Ortolani maneuver to check for congenital hip dislocation. while the others fan out. or a loud spine and trunk sudden noise will make baby's arms will arch toward fling out and then come together as that side. then swiftly baby's back to lowered a few inches. her eyes will close. **** While stroking Baby is held horizontally.

this reflex not vanish in 4-6 the spinal chord. her head will turn baby's knee and foot flex. **** Absence of this reflex If this reflex does may indicate damage to After 3-4 months. **** STEPPING Holding baby upright with feet touching a solid surface and moving him forward should elicit stepping movements. **** **** **** Absence of this reflex could indicate a damaged sciatic nerve. will make her cry out and head will rise. **** PLANTERS GRASP Pressing thumbs against the balls of baby's feed will make his toes flex. depressed. Depressed If this reflex doesn't vanish sucking may be in 3-4 months. should vanish. the CNS due to may be malfunctioning. If it months. medication given during childbirth Dubowitz/Ballard Exam for Gestational Age Neuromuscular Maturity . SUCKING ROOTING WITHDRAWAL A finger or nipple When baby's cheek is A pinprick to the sole of placed in baby's stroked at the corner of her baby's foot will make mouth will elicit mouth. there may be an CNS may be injury of the upper spinal severely chord. baby's reappears. make sucking motions.PEREZ Firmly stroking baby's spine from tail to head. rhythmical toward finger and she will sucking.

fully flex the forearm for 5 seconds. 90-100 degrees = 3 Brisk return to full flexion. Assistance to the elbow is permissible by lifting it across the body. take the infant's hand and draw it across the neck and as far across the opposite shoulder as possible. score as follows: • • • • • Arms and legs extended = 0 Slight or moderate flexion of hips and knees = 1 Moderate to strong flexion of hips and knees = 2 Legs flexed and abducted. 140-180 degrees = 1 Small amount of flexion.Posture: With the infant supine and quiet. The angle between the hypothenar eminence and the anterior aspect of the forearm is measured and scored: • • • • • • >90 degrees = -1 90 degrees = 0 60 degrees = 1 45 degrees = 2 30 degrees = 3 0 degrees = 4 Arm Recoil: With the infant supine. or random movements = 0 Minimal flexion. then fully extend by pulling the hands and release. <90 degrees = 4 Popliteal Angle: With the infant supine and the pelvis flat on the examining surface. . the leg is flexed on the thigh and the thigh fully flexed with the use of one hand. Score the reaction: • • • • • Remains extended 180 degrees. hold the infant's foot with one hand and move it as near to the head as possible without forcing it. Exert pressure sufficient to get as much flexion as possible. Score as shown in the diagram above. Score according to the location of the elbow: • • • • • • Elbow reaches or nears level of opposite shoulder = -1 Elbow crosses opposite anterior axillary line = 0 Elbow reaches opposite anterior axillary line = 1 Elbow at midline = 2 Elbow does not reach midline = 3 Elbow does not cross proximate axillary line = 4 Heel to Ear: With the infant supine. With the other hand the leg is then extended and the angled scored: • • • • • • • 180 degrees = -1 160 degrees = 0 140 degrees = 1 120 degrees = 2 100 degrees = 3 90 degrees = 4 <90 degrees = 5 Scarf Sign: With the infant supine. arms slightly flexed = 3 Full flexion of arms and legs = 4 Square Window: Flex the hand at the wrist. Keep the pelvis flat on the examining surface. 110-140 degrees = 2 Moderate flexion.

rare cracking. Full areola. 5-10 1-2 mm bud 3-4 mm bud mm bud Formed and firm. Majora cover minora small clitoris and minora Genitals. small labia minora Maturity Rating Add up the individual Neuromuscular and Physical Maturity scores for the twelve categories. veins vessels wrinkled Bald areas Mostly bald Creases over entire sole Lanugo Plantar Creases Breast Heel-toe 40-50 Heel-toe >50 Faint red marks Anterior Creases over mm = -1. Prominent female labia flat clitoris. tightly = -2 flat. no cracked. no bud Stippled areola. stays folded pinna. few veins Thinning 3 4 5 Gelatinous red.PHYSICAL MATURITY | TOP OF PAGE | Sign Skin -1 Sticky. soft but slow recoil ready recoil Genitals. Weeks -10 -5 0 5 10 15 20 25 30 35 40 45 50 20 22 24 26 28 30 32 34 36 38 40 42 44 . with instant recoil Thick cartilage. Scrotum flat. Raised areola. minora equally enlarging minoraprominent Majora large. <40 mm mm. friable. pale Parchment. transparent None 0 1 2 Superficial peeling and/or rash. few good rugae pendulous. soft with pinna. deep rugae rugae rugae Prominent Majora and clitoris. no creases transverse crease anterior 2/3 = -2 only Imperceptible Barely perceptible Flat areola. pinna Slightly curved Well-curved = -1. Clitoris prominent. loosely Lids open. deep Leathery. Testes faint rugae cannal. Testes in upper Testes Testes down. then obtain the estimated gestational age from the table below. areas. Smooth pink. Total Score Gestational Age. male smooth Scrotum empty. rare descending. ear stiff Eye & Ear Lids fused. translucent visible veins Sparse Abundant Cracking.

___ ___ ___ ____________ Assess client's understanding of procedure. . ___ ___ ___ ____________ 2. Use Standard Protocol. ___ ___ ___ ____________ Assist client to side-lying (Sims') position with right knee flexed. 6. __ ___ ___ ____________ Assess ability to control external sphincter. 3. 2. ___ ___ ___ ____________ Assess client's mobility status.ADMINISTERING AN ENEMA | TOP OF PAGE | Skin | Neurological Exam | Head & Neck | Chest & Lungs | Abdomen | | Extremities & Skeletal | Neonatal Primitive Reflexes | Exam for Gestational Age | | Physical Maturity | Maturity Rating | Administering & Enema | Urinary Catheterization | Assessment 1. 5. ___ ___ ___ ____________ Implementation 1. ___ ___ ___ ____________ Determine presence of hemorrhoids. Determine last bowel movement and presence of bowel sounds or abdominal pain. ___ ___ ___ ____________ Assess abdominal pain. 4.

Explain to client that a feeling of distention is expected. Instruct client to take deep breaths through mouth. applying more lubricant to cap if needed. Instruct clients with history of cardiovascular disease to exhale during defecation (Valsalva maneuver can cause cardiac arrest). ___ ___ ___ ____________ 10. ___ ___ ___ ____________ Squeeze bottle continuously until all fluid is expelled. ___ ___ ___ ____________ Insert tip of tube slowly. 9. ___ ___ ___ ____________ 11. ___ ___ ___ ____________ Gently separate buttocks and locate anus. H. ___ ___ ___ ____________ Lower height of container if client experiences cramping. for 3 to 4 inches (adult). ___ ___ ___ ____________ Hold tubing until fluid is instilled. 5. ___ ___ ___ ____________ 13. Check temperature of water. C. ___ ___ ___ ____________ B. ___ ___ ___ ____________ Raise height of container to 12 to 18 inches above anus and hang on IV pole. D. ___ ___ ___ ____________ Insert lubricated tip into rectum 3 to 4 inches (adult). F. and clamp. B. ___ ___ ___ ____________ Cover client with bath blanket. G. C. ___ ___ ___ ____________ Add soap to water if ordered. Assist client with perineal care as necessary. 7. Lubricate 3 to 4 inches of tip of tubing. 4. ___ ___ ___ ____________ Clamp tubing after solution instilled and inform client that tubing will be removed. Ask client to retain solution as long as possible (5 to 10 minutes). 6. Remove plastic cap from rectal tip. exposing only rectal area.3. ___ ___ ___ ____________ Prepackaged container: A. Instruct client to call for nurse to inspect results before discarding. ___ ___ ___ ____________ With container at hip level. E. or commode. ___ ___ ___ ____________ . bedpan. Place waterproof pad under hips and buttocks. pointing tip toward umbilicus. ___ ___ ___ ____________ 8. ___ ___ ___ ____________ A. open clamp and begin instillation. D. ___ ___ ___ ____________ 14. Discard enema container (and tubing). removing air. bedpan. Enema bag: Fill enema bag with 750 to 1000 ml warm tap water. ___ ___ ___ ____________ 12. ___ ___ ___ ____________ Ensure that toilet. Assist client to use bathroom. Fill tubing with solution. or commode is available. ___ ___ ___ ____________ Gently separate buttocks and locate anus.

erythema. ___ ___ ___ ____________ Ask client the time of last voiding and to describe urine (if nurse did not observe). palpate abdomen). 7. ability to cooperate. URINARY CATHETERIZATION: FEMALE | TOP OF PAGE | Skin | Neurological Exam | Head & Neck | Chest & Lungs | Abdomen | | Extremities & Skeletal | Neonatal Primitive Reflexes | Exam for Gestational Age | | Physical Maturity | Maturity Rating | Administering & Enema | Urinary Catheterization | Assessment 1. ___ ___ ___ ____________ Assess any pathological condition that may impair passage of catheter ___ ___ ___ ____________ Review client's medical record. Note previous catheterization. 3. . 5. ___ ___ ___ ____________ Assess client's knowledge and prior experience with catheterization. response of client. Type of enema given ___ ___ ___ ____________ Results (color. Assess client's weight. and mobility of lower extremities. including physician's order and nurse's notes. age. Use Completion Protocol. ___ ___ ___ ____________ Inspect perineal region. Evaluate results of enema (decreased abdominal discomfort. observing for perineal landmarks. ___ ___ ___ ____________ Ask client and check chart for allergies. Check I&O flow sheet. amount. and time of last catheterization. 6. ___ ___ ___ ____________ 2. 3. ___ ___ ___ ____________ Palpate for bladder over symphysis pubis. ___ ___ ___ ____________ Identify Unexpected Outcomes and Intervene as Necessary Report and Record 1. including catheter size. 2. __ ___ ___ ____________ Observe characteristics of stool. level of consciousness. or discharge. 8. ___ ___ ___ ____________ Evaluation 1. 4.15. and appearance of stool) ___ ___ ___ ____________ Subjective response 2. drainage.

2. place bag over edge of bottom bed frame and bring tube up between siderail. 8. maintaining sterility of gloves. ___ ___ ___ ____________ Place catheter kit on overbed table and open outer wrap using sterile technique. moving anterior to posterior. ___ ___ ___ ____________ Put on sterile gloves. B. taking care not to contaminate sterile gloves. ___ ___ ___ ____________ Open package containing drainage system. 7. and slip drape under buttocks. ___ ___ ___ ____________ Pour antiseptic solution over all but one cotton ball. ask client to lift buttocks. Allow top edge of sterile drape to form cuff over both gloved hands. ___ ___ ___ ____________ B. 3. ___ ___ ___ ____________ Lubricate catheter 1 to 2 inches. ___ ___ ___ ____________ Place drape on bed between thighs. ___ ___ ___ ____________ Prepare equipment: A. down the center. then on opposite side. C. ___ ___ ___ ____________ Open specimen container if needed. D. E. ___ ___ ___ ____________ Organize supplies on sterile field. If balloon leaks. . ___ ___ ___ ____________ Position and drape client in dorsal recumbent position with soles of feet together and knees abducted as far as possible. 5. ___ ___ ___ ____________ Cleanse labia and meatus using forceps to hold cotton balls and one cotton ball for each stroke. C. 6. 9. ___ ___ ___ ____________ Cleanse perineal area with soap and water. Withdraw fluid if no leakage is noted. Draping and Cleansing: A. Check bag clamp. (Option: if unable to lie supine. The first stroke is on one side of meatus. ___ ___ ___ ____________ Place sterile tray and contents on sterile drape between thighs. E. ___ ___ ___ ____________ Position overhead light to illuminate perineum. Use Standard Protocol. ___ ___ ___ ____________ Test balloon by injecting saline solution into balloon port. use side-lying position with upper leg flexed at knee and hip and supported by another caregiver). rinse and dry. replace with another catheter set. D.Implementation 1. This hand remains in this position for remainder of the procedure. 10. ___ ___ ___ ____________ 4. ___ ___ ___ ____________ Separate labia with fingers on nondominant hand (now contaminated).

Holding catheter with dominant hand near tip. slowly insert catheter until urine flows. ___ ___ ___ ____________ 12. it is collected during this drainage process. ___ ___ ___ ____________ EVALUATION 1. ___ ___ ___ ____________ 16. Cleanse and dry perineal area. For straight catheterization. ___ ___ ___ ____________ Identify Unexpected Outcomes and Nursing Interventions Record and Report 1. while continuing to hold catheter in place with nondominant hand. 2. ___ ___ ___ ____________ 14. Secure catheter to inner thigh with nonallergenic tape or catheter strap. Position drainage bag with tubing coiled on the bed (not in dependent loops). Observe urine in catheter bag for amount. Position for comfort. 2. 4. then advance another 1 to 2 inches. If specimen is needed. Use Completion Protocol. ___ ___ ___ ____________ 17. place end of catheter in urine tray and allow to drain until bladder is empty. For indwelling catheter. allowing some slack to prevent tension of the balloon on the internal sphincter. pulling slowly but evenly after drainage stops. 5. and clarity. noting color and clarity. Remove catheter. 3. ___ ___ ___ ____________ 13. secure catheter to drainage bag. Type and size of catheter inserted ___ ___ ___ ____________ Amount of fluid used to inflate balloon ___ ___ ___ ____________ Characteristics of urine and amount of urine ___ ___ ___ ____________ Reasons for catheterization and specimen collection ___ ___ ___ ____________ Client's response to procedure ___ ___ ___ ____________ . Measure urine.11. ___ ___ ___ ____________ 15. color. ___ ___ ___ ____________ Palpate bladder and determine client's comfort level. ___ ___ ___ ____________ 19. (Some sets come pre-attached). ___ ___ ___ ____________ 18. use prefilled syringe to inflate balloon. If necessary.

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