Maternal Health/ OB Final Exam Study Guide

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OB FINAL STUDY GUIDE

OB DRUGS
 RUBELLA VACCINE:
• Given sub-Q before discharge in patients that are not immune.
• Give when titer is lower than 1:8
• SIDE EFFECTS: transient rash ***
• NURSING INTERVENTION
• Teach patient to avoid getting pregnant for 1-3months after
immunization.
 RhoGAM
• Given to pregnant women who are Rh- but carry an Rh+ fetus
• Intramuscular injection * don’t give intravenously.
• Prevents antibody reaction
• Should be given at 28weeks gestation then 72hours after the
delivery of the fetus.
• *watch for temp increase after giving this shot
OB DRUGS
 BETHAMETHASONE
• Corticosteroid that increases the production of
surfactant.
• Intramuscular injection given 24hours before
delivery of the infant.
• USED IN PRETERM LABOR * when the labor
cannot be inhibited and the woman is likely to
deliver in 48hours.
• Prevents RDS in the preterm neonate.
• ADVERSE EFFECTS: pulmonary edema *** (watch
for crackles, wheezing and chest pain).
OB DRUGS
 MAGNESIUM SULFATE
• CNS depressant and anticonvulsants
• Tocolytic Used to STOP PRETERM LABOR by relaxing
the smooth muscle and prevent seizures during
eclampsia.
• ADVERSE REACTIONS:
• Decreased DEEP TENDON REFLEX ***
• Decreased resps
• Muscle weakness
• Decreased urine output
• Flushing
• Pulmonary edema
• * contraindicated in women with cardiac iddues because it
can cause heart block
OB DRUGS
• NURSING INTERVENTIONS:
• Test patellar reflex before giving the med.
• Use infusion pump
• Assess deep tendon reflexes every hour *
decrease = sign for toxicity.
• Watch magnesium levels *4-7.5 is therapeutic
range.
• CALCIUM GLUCONATE = antidote for toxicity
• Call doc if resps are less than 12  sign for resp
depression.
• Monitor input and output.
OB DRUGS: MEDS THAT PREVENT HEMORRHAGE:
METHERGINE:
• stimulates uterus contractions and increases the
force, intensity and duration of contractions.
• Also produces vasoconstriction of the coronary artery.
• INDICATION: post partum hemorrhage
• ADVERSE EFFECTS: bradycardia, dysrrythmia,
*severe hypertension.
• NURSING INTERVENTIONS:
• Monitor blood pressure closely
• Vital signs
• Watch for chest pain, SOB, itchiness, pale cold hands
and feet.
OB DRUGS: PITOCIN

PITOCIN
• Stimulate the uterus and causes contractions
of the myocardium.
• Oxytocin promotes milk let down.
• ADVERSE EFFECT:
• Water intoxication *** big one
• NURSING INTERVENTIONS:
• Monitor vital signs closely.
CONTRACEPTION
• CONTRACEPTION= deliberate prevention of conception
using a method or device that avoids the fertilization of the
ovum.
• TWO TYPES OF CONTRACEPTION:
• NATURAL FAMILY PLANNING METHODS
• Rhythm method
• BBT
• Cervical mucus
• Symptothermal
• Ovulation awareness
• Coitus interruptus.
• PHARMACOLOGICAL METHODS
• Condom
• Diaphragm
CONTRACEPTION:PHARMACOLOGICAL METHODS
• Hormonal contraception contains estrogen and progestin or
in some cases progestin alone.
• The Estrogen-progestin combination suppress ovulation and
change the cervical mucus making it difficult for sperm to
enter.
• The Hormones containing Progestin alone are less effective
• Taken for 21days then stopped for 7 days during which the
patient will get her period.
• Useful in controlling irregular periods.
• Factors that increase the adverse risks of contraceptives are
Obesity, smoking and hypertension.
• Contraceptives are contraindicated in people with
hypertension, thromboembolitic diseases, estrogen
dependent cancers and pregnancy.
CONTRACEPTION:PHARMACOLOGICAL METHODS
• Contraceptives increase the toxicity of tricyclic
antidepressants, may alter glucose levels, and
antibiotics decrease the absorption and effectiveness
of oral contraceptives.
• Side Effects: break through bleeding (spotting),
excessive cervical mucus production, breast
tenderness, hypertension, nausea and vomiting.
• ADVANTAGE:
– 99.9% effective
– You can be spontaneous
– May reduce the risk of ovarian cancer, ecptopic
pregnancy, ovarian cysts and non cancerous breast
tumors.
CONTRACEPTION:PHARMACOLOGICAL METHODS
• DISADVANTAGES:
– Don’t protect against STD’s
– Must be taken daily
– Expensive
– Illnesses that cause one to vomit may reduce the effectiveness of the
pills.
• PATIENT TEACHING:
• Reinforce the need to take the medication every day at the
same time if they are pills.
• Keep yearly pap smear exams
• Instruct the patients to do a breast self exam
• When the patient now wants to conceive she may not be able
to do so for 8months after stopping the oral contraceptives
because the pituitary gland requires a recovery period to
begin to stimulate the cyclic gonadotropins FSH & LH (these
regulate ovulation).
CONTRACEPTION
• PATIENT TEACHING …
• Increase vitamin B6 foods in diet (wheat, corn, liver, meat) and folic acid
(liver, greens, leafy vegetables). Because the hormonal contraceptives
have dietary deficiencies in Vitamin B6 and folic acid.
• Use another form of contraception for the first 7 days of using the
contraceptive because the contraceptives don’t take effect for 7 days.
• If you miss one pill , take one as soon as you remember
• Use another form of contraception if you miss two pills in a row.
• If you miss 3 pills in a row, then discard the pack and start a new pack
• ADVERSE REACTIONS:
• Fluid retention
• Weight gain
• Breast tenderness
• Break through bleeding
• Fatigue
• Headache
• Nausea and vomiting
CONTRACEPTION
• TRANSDERMAL PATCH:
• Weekly birth control patch that contains estrogen and
progestin and is worn on the skin,
• The hormones are absorbed into the skin and
transferred into the blood stream.
• The patch remains attached to the sin.
• ADVANTAGES:
• 99.9% effective
• DISADVANTAGES:
• Does not protect against STD’s
• Some patients may react to the adhesive on the patch.
CONTRACEPTION
• PARENTAL AGENTS : DEPO PROVERA
• These are I.M injections administered every 12weeks
• They stop ovulation from occurring by supressing the release of
gonodotropin hormones
• They also change the cervical mucus to prevent the sperm from
entering the uterus.
• ADVANTAGES:
• Long lasting
• Breast feeding patients can use them
• DISADVANTAGES:
• Invasive
• Expensive
• Don’t protect against STDs
• Their effects can be reversed
• * report shortness of breath, chest pain, swelling of the extremities
or heavy vaginal bleeding.
CONTRACEPTION: MORNING AFTER PILL
• MORNING AFTER PILL: EMERGENCY CONTRACEPTION
• Taken 72hours after unprotected sex.
• Antiemetic taken 1hour prior to taking the morning
after pill to overcome the feeling of nausea that can
occur with high doses of estrogen and progesterone.
• If a period does not come in 21days then the woman
should be evaluated for pregnancy.
• DISADVANTAGE:
• Doesn’t provide long term contraception
• Must be taken within that 72hour window but this
does not guarantee 100% protection.
CONTRACEPTION: BARRIER METHODS
• MALE CONDOMS:
• Synthetic sheath placed over the penis before intercourse.
• Prevents pregnancy by colleting sperm in the tip of the
condom, preventing it from entering the vagina.
• ADVANTAGES:
• Prevents STD’s and pregnancy
• DISADVANTAGE:
• Must be put on before any genital contact because pre
ejaculation may contain spermatozoa.
• There may be an allergic reaction to the latex.
• May beak during intercourse
• Cant be reused
• Sexual pleasure may be affected.
CONTRACEPTION: BARRIER METHODS
• DIAPHRAGM AND SPERMICIDE:
• Dome shaped cup that fits over the cervix with spermicide cream or gel in the cup
and around the rim.
• Its fitted by the primary care giver and must be refitted every 2years.
• The diaphragm must remain in place 6 hours after intercourse and more
spermicide must be applied after each sexual activity.
• Empty the bladder prior to inserting the diaphragm.
• ADVANTAGES:
• Gives the woman control over the contraception.
• DISADVANTAGE:
• Inconvinient
• You cannot be spontaneous
• Requires reapplication of spermicide with each sex act.
• TEACHING:
• Not recommended for patients that have had Toxic Shock Syndrome (caused by a
bacteria S/S high fever, watery diarrhea, drop in blood pressure, nausea and
vomiting, muscle aches) *prevented by proper hand washing and removing the
diaphragm 6 hours after sex, frequent UTI.
CONTRACEPTION
• IMPLANTABLE PROGESTIN LEVONORGESTREL
(NORPLANT):
• 6 rods implanted subdermally on the inner arm.
• They contain levonorgestrel
• PATIENT TEACHING: avoid trauma to the area of
implantation
• ADVANTAGE:
• Effective for 5 years
• Reversible when the woman now wants to concieve.
• DISADVANTAGE:
• Can cause irregular menstrual bleeding
• Does not protect against STD’s
• Use condoms to protect against STD’s.
CONTRACEPTION: INTRAUTERINE METHOD
• INTRAUTERINE DEVICE (IUD)
• T shaped device inserted in the vagina to the cervix
and placed in the uterus.
• Releases chemicals that damage sperm when they are
moving up to the uterine tubes, preventing
fertilization.
• Patient must monitor that the small string that hangs
from the device into the vagina is still there to make
sure the IUD has mot migrated or slipped out during
menstrual cycle.
• ADVANTAGE:
• Provides protection for 1-10 years
• DISADVANTAGES:
CONTRACEPTION:SURGICAL METHODS
• TUBAL LIGATION:
• Female’s fallopian tubes are tied
• NPO after midnight prior to surgery
• Permanent
• Sex is not affected.
• Disadvantage:
• Infection
• Hemorrhage
• Trauma
• There is a risk of an ectopic pregnancy
• The procedure is irreversible.
CONTRACEPTION:SURGICAL METHODS
• VASECTOMY:
• Ligation and severance of the vas deferens
• The male is not sterile until the proximal portion
of the vas deferens is cleared of all sperm (this
will take approximately 20 ejaculations).
• Use another form of birth control until the vas
deferens is cleared of all sperm.
• permanent,, but irreversible when the man finally
decides he would like to conceive.
• Complications are: bleeding, infection and
anesthesia reaction.
ANTEPARTUM PERIOD
NORMAL PHYSIOLOGICAL CHANGES DURING
PREGNANCY
• SYMPTOMS OF PREGNANCY:
• Divided into 3 groups
• PRESUMPTIVE SIGN =
– subject, what the woman says about why she thinks she’s
pregnant e.g missing her period, breast tenderness.
– No periods for an unknown reason
– urinary frequency
– breast enlargement or tenderness
– fatigue
– Quickening = feeling like there's a baby moving in you.
• Multigravida (woman who has had previous pregancies can feel
quickening at 16weeks
• Primigravida ( woman who is pregnant for the first time) feels
quickening at 18weeks.
NORMAL PHYSIOLOGICAL CHANGES DURING
PREGNANCY
• PROBABLE SIGNS = test findings that suggests the woman is
pregnant but not 100% guarantee.
• Hegars sign: softening of the uterus
• Chadwicks sign: when the vaginal mucosa are a bluish-
purplish tint
• Goodells sign = softening of the cervix
• Braxton hicks = contractions that the woman feels through
out the pregnancy. These are painless and irregular
• Positive pregnancy test
• POSITIVE SIGN = confirm pregnancy.
• FHR
• Fetal movement when you palpate the abdomen
• Visualization of the fetus by ultrasound.
NORMAL PHYSIOLOGICAL CHANGES DURING
PREGNANCY
NAGELE’S RULE
• Determines the estimated date of delivery
• 1ST DAY OF LAST MENSES – 3MONTHS + 7
DAYS.

• Gravida = number of pregnancies


• Para = number of pregnancies that reach
viability 20-24weeks or fetal weight of more
than 2lbs regardless of weather the baby is
born alive or dead.
NORMAL PHYSIOLOGICAL CHANGES DURING
PREGNANCY
• REPRODUCTIVE
• Enlargement of the uterus
• Change in the cervix (thinnning and bluish-purplish tint).
• CARDIOVASCULAR
• Increase in cardiac output
• Increased blood volume to meet metabolic needs
• Increased HR
• Blood pressure remains the same within the first trimester, decreases
by 5-10mmhg in second trimester then should return to normal within
20weeks.
• Supine Hypotensive Syndrome = aka supine vena cava syndrome.
Woman gets hypotension when laying down in supine position
because weight and pressure is applied on the vena cava decreasing
blood flow to the heart  maternal hypotension and fetal S/S =
dizziness, light headedness, pale clammy skin.
• * tell the patient to potion herself of the lateral position.
NORMAL PHYSIOLOGICAL CHANGES DURING
PREGNANCY
• RESPIRATORY:
• Increased oxygen demand
• GI
• Displacement of the stomach and intestines due to increases in the
abdominal cavity
• Nausea and vomiting
• RENAL
• Increased filtration rate  urinary frequency
• ENDOCRINE
• Increased production of progesterone, estrogen and Human Chorionic
Gonadotropin (hCG this is whats dictated in pregnancy test)
• SKIN
• CHLOASMA = increased facial pigmentation (mask of pregnancy)
• LINEA NIGRA = long dark line that goes across the umbilicus to the
pubic area
• STRIAE GRAVIDARUM = stretch marks
NUTRITION DURING PREGNANCY
• Recommended weight gain:
– 11-14kg (25-35lb)
– Gain about 4lb in the first trimester then 1-2lb/week for the next 2
trimesters.
– Excessive weight gain  macrosomia & labor complications.
• Poor weight gain  low birth weight of the newborn.
• Increase protein intake
• Increase the intake FOLIC ACID INTAKE * important for neurological
development and preventing neural tube defects.
 Foods high in folic acid – leafy vegetables, beans, seeds, orange
juice.
• Iron to increase the martenal RBC
• Calcium- for the developing fetus.
• AVOID TOO MUCH CAFFEINE – increases the risk of spontaneous
abortion.
CULTURAL ISSUES DURING PREGNANCY
 CULTURAL COMPETENT NURSING = care that respects and is
compatible with each clients culture, and shows respect to their
values and beliefs of others.
• NATIVE AMERICANS
• Indians
• Private and don’t like to share private information. * be patient
with these patients.
• No person has a right to speak for another so they may not give you
any patient information.
• Eye contact is seen as rude.
• Strong handshake may be seen as offensive and prefer light greet.
• Father of the baby may be absent during the delivery
• Female family and friends attend to the patient during the labor
and delivery.
• They may want to have the placenta.
CULTURAL ISSUES DURING PREGNANCY
• AFRICAN AMERICANS
• Don’t disclose more information than whats asked.
• Communicate loudly, lots of hand movements and animated body
language.
• Fathers are active during the labor.
• Express pain openly.

• LATINOS
• Admiring the child without touching it is considered giving the CHILD
THE EVIL EYE.
• Direct eye contact is respectful
• The man is usually in charge of all the decision making
• The fathers prefer not to play an active role in the birthing process.
• The woman prefer to keep their bodies covered during labor
• Some mexican women may wear a cord around their waist because
they believe it prevents morning sickness and ensures a safe birth.
CULTURAL ISSUES DURING PREGNANCY
• ASIAN AMERICANS
• Prolonged eye contact is disrespectful.
• More comfortable with arms length distance
• The head of the baby is considered sacred (gate way to
the soul) so it can only be touched by the relatives
only. * touching the baby’s head when you are a non-
family member is considered bad omen.
• May not want a male physician because the womans
waist and between the knees area is private.
• Modesty is important.
• Father usually does not participate in the delivery of
the infant.
CULTURAL ISSUES DURING PREGNANCY
• FOODS PREFERRED DURING PREGNANCY:
• Asian Families – warm foods during the
pregnancy and after delivery.
• Muslim – halal meats
• Jewish – Kosher foods
ANTERPARTUM PERIOD

COMPLICATIONS OF PREGANCY
COMPLICATIONS DURING PREGNANCY
ABORTION:
• ABORTION = pregnancy ending before 20weeks
gestation
• S/S: spontaneous vaginal bleeding, clots may be
seen through the vagina, lower uterine
contractions, can lead to hemorrhage and shock.
• NURSING INTERVENTIONS: bed rest
• vital signs
• count the # of pads to evaluate blood loss, IV fluids
• Avoid vaginal exams
• Avoid sex with threatened abortions.
COMPLICATIONS DURING PREGNANCY: ABORTIONS
 TYPES OF ABORTIONS:
• SPONTANEOUS
• Just occurs naturally before 20weeks gestation
• INDUCED
• Elective choice to terminate pregnancy.
• THREATENED
• Patient may have slight or no cramping at all
• Moderate spotting
• No tissue passes
• The cervical opening is closed
• INEVITABLE
• Spotting and cramping
• Cervix begins to dilate and efface
COMPLICATIONS DURING PREGNANCY: ABORTION
 TYPES OF ABORTIONS
• INCOMPLETE
• Severe cramping
• Continuous and severe bleeding
• Partial fetal tissue or placenta
• Dilated with tissue in cervical canal or passage of the tissue.
• COMPLETE
• Loss of all uterine contents (conception products).
• MISSED
• Patient may have a brownish discharge
• The products of conception are retained in utero after fetal
death
• HABITUAL
• Spontaneous abortions in 3 or more pregnancies
 PLACENTA PREVIA
• PLACENTA PREVIA = improper implantation of the uterus. Its
implanted on the lower segment or near the internal cervical os.
• TYPES OF PLACENTA PREVIA :
– Total = the placenta covers the cervical os
– Partial = covers the cervical os partially.
– Marginal =
• SIGNS AND SYMPTOMS ?
– Painless, bright red vaginal bleeding
– Uterus is soft, relaxed and nontender.
– Fundal height may be more expected than the gestational age.
• NURSING INTERVENTIONS:
– Fetal heart rate and maternal vital signs should be assessed first.
– There may be a need for a c-section if bleeding is heavy.
– No vaginal exam or anything that will stimulate the uterus.
– Position the patient in side lying position.
 ABRUPTIO PLACENTAE
• ABRUPTIO PLACENTAE: this is premature separation of the
placenta from the uterus wall after the 12th week of gestation and
before the fetus is delivered.
• SIGNS AND SYMPTOMS:
– Dark red vaginal bleeding
– Uterine pain and tenderness
– Uterine rigidness
– Severe abdominal pain
– Signs of fetal distress.
– There may be signs of shock
• NURSING INTERVENTIONS:
– Vital signs and FHR
– Bed rest, oxygen, IV fluids and blood products
– Trendelenburg position to decrease the pressure of the fetus on the
placenta.
 GESTATIONAL DIABETES, PRE-ECLAMPSIA
AND ECLAMPSIA
• Hypertension that occurs during pregnancy.
• PREECLAMPSIA:
– Non convulsive form
– Occurs after 20weeks gestation.
• ECLAMPSIA:
– Convulsive form
– Occurs at 24weeks gestation or the first postpartum week.
• SIGNS AND SYMPTOMS
– Blood pressure higher than 140/90mmHg.
– Weight gain of more than 5lbs (2.3 kg)/week.
– Protein uria *this is the also the diagnostic finding.
• TREATMENT:
– MAGNESIUM SULFATE (neuromuscular sedative that reduces
the amount of actelycholine  preventing seizures).
MAGNESIUM SULFATE
 MAGNESIUM SULFATE
• CNS depressant and anticonvulsants
• Tocolytic Used to STOP PRETERM LABOR by relaxing
the smooth muscle and prevent seizures during
eclampsia.
• ADVERSE REACTIONS:
• Decreased DEEP TENDON REFLEX ***
• Decreased resps
• Muscle weakness
• Decreased urine output
• Flushing
• Pulmonary edema
• * contraindicated in women with cardiac iddues because it
can cause heart block
MAGNESIUM SULFATE
• NURSING INTERVENTIONS:
• Test patellar reflex before giving the med.
• Use infusion pump
• Assess deep tendon reflexes every hour * decrease = sign
for toxicity.
• Assess for ANKLE CLONUS but dorsing flexing the patients
ankle 3times if the foot stops moving when you move your
hand then there is no ankle clonus, if the foot doesn’t stop
moving this is a (+) sign for ankle clonus.
• Watch magnesium levels *4-7.5 is therapeutic range.
• CALCIUM GLUCONATE = antidote for toxicity. Keep tab at
bedside.
• Call doc if resps are less than 12  sign for resp
depression.
• Monitor input and output.
 HELLP SYNDROME
• HELLP SYNDROME = HEMOLYSIS ELEVATED LIVER ENZYMES & LOW
PLATELETS
• A category of gestational hypertension that involves the changes in
blood components and liver function
• CONTRIBUTING RISK FACTOR: pre- eclampsia.
• Hemolysis due to damage of erythrocytes.
• Elevated liver enzymes caused by the obstrcution in the liver due to
the fibrin deposits.
• SIGNS AND SYMPTOMS:
• *pain in the upper right quadrant due to distended liver, epigastric
area and lower chest pain
• INTERVENTIONS:
• Don’t palpate the abdomen because this increases intra abdominal
pressure which could lead to a rupture and liver hematoma
 ECTOPIC PREGNANCY
• Implantation of a fertilized egg outside the uterus
• Usually the abnormal implantation is in the fallopian
tubes  tubal rupture.
• TESTING WILL SHOW:
– High hCG levels
– The ultrasound will show an empty uterus
• SIGNS AND SYMPTOMS
– Unilateral stabbing pain
– Missing two periods.
– Dark red or brown vaginal spotting if the ruptures have
ruptured.
– Referred shoulder pain *common symptoms.
– Hemorrhage and shock (hypotension, tachycardia, pallor)
 ECTOPIC PREGNANCY
• THERAPEUTIC MEASURES:
– METHOTREXATE = to inhibit cell division and
enlarge the embryo
– Avoid alcohol and folic acid to prevent a toxic
response to the meds
– Laproscopic salpingostomy = removal of the tube
if the tube ruptured
– Linear Salpingostomy = a section is cut to remove
the contents if the tube is not ruptured
 MOLAR PREGNANCY
• Aka GESTATIONAL TROPHOBLASTIC DISEASE
• Proliferation and degeneration of trophoblastic villi in the
placenta which become swollen and fluid filled then look
like grape like clusters.
• THERE ARE TWO TYPES OF MOLAR GROWTHS:
• COMPLETE MOLE
– No fetus, placenta and amniotic membranes or fluid.
– Theres no placenta to receive the maternal blood 
hemorrhage into the uterus  vaginal bleeding.
– COMPLICATION = CHORIOCARCINOMA 
• PARTIAL MOLE
• Contains abnormal embryoninc or fetal parts an amniotic
sac and fetal blood.
• COMPLICATIONS = CHORIOCARCINOMA
 MOLAR PREGNANCY
• DIAGNOSTIC
– High hCG levels
– Ultra sound shows growths and vesicles but theres no fetus in utero.
– Urine analysis shows proteinuria.
• SIGNS AND SYMPTOMS:
– Rapid uterus growths
– Dark brown vaginal bleeding
– Hyperemesis gravidarum due to high hCG levels
• INTERVENTIONS
– Bring any clots to the physician for testing
– RhoGAM if the woman is Rh –
– Not get pregnant for up to a year (so use contraception).
– Testing of hCG levels for every 1-2weeks until the levels are normal ,
then every 2-4weeks for 6months & 2months for 1 year. * INCREASE
IN HCG LEVELS IS A SIGN FOR MALIGNANT TRANSFORMATION.
– Chemotherapy is done choriocarcinoma.
 HYPEREMESIS GRAVIDARUM
• Excessive nausea and vomiting in the first trimester
• Most common in young pregnant ,20yrs; first pregnancy, multifetal
gestation, GTD, Vitamin B6
• HYPEREMESIS CAUSES: weight loss, electrolyte imbalance,
dehydration, ketosis.
• RISKS IT HAS TO THE FETUS: intrauterine growth restriction or pre-
term birth.
• DIAGNOSTICS: *most important lab results shows Ketones and
Acetones (protein & fat breakdown ; hematocrit concentration is
elevated because of the inability to retain fluid leads to hematocrit
concentration.
• NURSING INTERVENTIONS:
• NPO for 24-48hours
• IV fluids of lacated ringers for dehydration
• Vitamin B6
 HYPEREMESIS GRAVIDARUM
• Excessive vomiting that lasts for more than 12weeks and causes 5%
weight loss.
• RISK TO THE FETUS: Intrauterine Growth Restriction (IUGR) and
preterm births.
• RISK FACTORS: younger than 20yrs, first pregnancy, multiple
gestation, gestational trophoblastic disease, Vitamin B deficiency.
• S/S: excessive vomiting, electroltye imbalance, dehydration, poor
skin turgor.
• Diagnostics: Urine analysis for Ketones and acetones (protein and
fat break down) is the most important lab; increased hematocrit
concentration.
• NURSING INTERVENTIONS: NPO for 24-48hours, IV fluids of
lacteted ringersm Vitamin B6 or vitamin supplements, if severe
TPN.
 GESTATIONAL DIABETES
• Diabetes that starts during pregnancy . Normal glucose levels are
60mg/dl-120mg
• Should be screened for gestational diabetes between 24-28weeks
pregnancy.
• DIAGNOSTIC: 3 hour oral glucose tolerance test (GTT) *confirms
gestational diabetes. (NPO after midnight then 100g oral glucose given,
then serum glucose test done in 1, 2, 3hrs after the dose).
• PREDISPOSING/RISK FACTORS: older than 35years, obesity, family
history of diabetes.
• RISK TO THE FETUS: spontaneous abortions (big one) ; UTI because of the
increased glucose in the urine; Ketoacidosis (increased resistance to
insulin caused by untreated hyperglycemia).
• S/S: excessive thirst, hunger, weight loss, frequent urination, excessive
weight gain during pregnancy, blurred vision.
• NURSING INTERVENTIONS:
– Watch for hypoglycemia (clammy pale skin, shaking, tingling of mouth and
extremities, weak, shallow resps, nervousness).
– Watch for hyperglycemia : excessive thirst and urination,flushed dry skin,
acetone (fruity breath.
 TORCH
• TORCH= group of infections that are teratogenes and can cross the placenta to the
fetus.
• TOXOPLASMOSIS = infection caused by the protozoa Toxoplasma gondii.
– s/s: rash and flu like symptoms
– Transmission: eating raw meats or handling cat liter.
– RISK: causes spontaneous abortions.
• OTHER INFECTIONS = GBS most dangerous, transmitted during delivery usually
occurs within 48Hours can cause meningitis, permanent neurological defects,
sepsis and pneumonia.
• RUBELLA =
– Teratogenic during the first semester
– Causes congenital defects of the eyes, heart, ears and brains
– If not immune (has a titer of 1:8 or less) then the mother must be vaccinated
and wait 3months before getting pregnant.
 TORCH
• CYTOMEGALOVIRUS=
– Transmitted through droplets, semen vaginal secretions, breast milk, urine
*body secretions.
– There's no treatment
– PREVENT EXPOSURE BY FREQUENT HANDWASHING BEFORE EATING,
AVOIDING CROWDS OF YOUNG CHILDREN.
• HERPES SIMPLEX VIRUS =
– If the woman has herpes then vaginal exams are contraindicated
– Can cause death or permanent neurological defects.
– C-section indicated if the woman has lesions to avoid transmission to the fetus
during delivery.
INTRAPARTUM PERIOD
INTRAPARTUM PERIOD

LABOR AND DELIVERY


BIRTHING ASSISTANT PROCEDURES
 NORMAL LABOR AND DELIVERY
• PROCESS OF LABOR: 4 P’S

• PASSENGER
• PASSAGEWAY
• POWERS
• PSYCHE
 NORMAL LABOR AND DELIVERY
• PASSENGER: the fetus
• Consider the fetal head, presentation, lie, attitude. All
these affect the fetus ability to pass through the birth
canal.
• PRESENTATION= part of the fetus that enters the
pelvic inlet first.
– Occiput (back of the head)
– Mentum (chin)
– Scapula (shoulder)
– Sacrum (breech)
• LIE = relationship of the moms spine to the fetus spine.
– Longitudinal (cephalic or breech presentation.
– Transverse = lying across/horizontally. C-section needed.
 NORMAL LABOR AND DELIVERY
• FETAL POSITIONING: relationship between the
presenting part of the fetus to the direction its
facing in the maternal pelvis.
– Maternal pelvis divided into four quadrants (anterior,
posterior, left, right)
– Example: ROP (first letter is the side of the maternal
pelvis , 2nd letter is the presenting part, 3rd the
direction the presenting part is facing, anterior,
posterior or transverse part of the maternal pelvis.

– The occiput is facing the Left and its


Anterior so its LOA.
 NORMAL LABOR AND DELIVERY
• PASSAGEWAY: the birth canal
• POWERS:
– Contractions- force to push out the fetus *involuntary.
– Effacement- thinning and shortening of the cervix
– Dilation- enlargement of the cervix
• PSYCHE
• Emotional state
• Maternal stress, tension and anxiety can produce physiological
changes that impair progress of labor.
• STATION
• Measures the progress of descent in cm
• Station 0 = at the ischial spine
• (-) station = above the ischial spine
• (+) station = below the ischial spine
• ENGAGEMENT = when the presenting part has passed the pelvic
inlet.
 MECHANISM OF LABOR
• LIGHTENING = when the fetus descends into
the pelvis.
• Braxton hicks contractions
• Brownish or blood tinged cervical mucus.
• Cervix ripens = softening, thinning of the
cervix leading to dilation.
• NESTING = this is when the woman has a
sudden burst of energy. Usually occurs 24-
48hours before the onset of labor.
• Spontaneous rupture of membranes.
 FALSE LABOR VS. TRUE LABOR
• FALSE LABOR
– No dilation effacement or descent occurs
– Irregular contractions that don’t progress in intensity,
– Discomfort relieved by position change and walking.
• TRUE LABOR
– Contractions may present as back pain.
– Regular contractions
– Contractions last longer, more intense and close together
e.g 4mins apart.
– Leads to cervical dilation, effacement and engagement.
– Bloody show
– Mucus plug expelled
– Rupture of the membranes * assess the color of the
amniotic fluid *meconium stained amniotic fluid is a sign
of fetal distress.
TRUE SIGNS OF LABOR
• RUPTURE OF THE FETAL MEMBRANES:-
• The membrane sac that contains and supports the fetus and amniotic fluid
ruptures.
• May occur spontaneously at the start of labor or main remain intact till the
health care provider ruptures it.
• May occur as a sudden gush or slow leakage.
• May cause the fetal head to descend into the pelvis shortening the labor
process.
• Labor usually starts 24hours after the rupture in most patients
• The fluid should be clear and odorless, any variations from this report them
to the physician.
• THE NITRAZINE TEST is used to test the amniotic fluid to make sure that the
membrane ruptured.
• The nitrazine test uses litmus paper to detect the Ph of the secretions  (+)
= when the paper turns into blue (this is fluid from the amniotic sac.
• A MEMBRANE THAT RUPTURES 24HOURS BEFORE LABOR BEGINS IS CALLED
PREMATURE RUPTURED MEMBANES.
FETAL ASSESSMENT DURING LABOR
• LEOPOLDS MANEUVER: helps determine the
fetal presentation.
• If the head is the in fundus = hard and round,
movable object will be felt
• The buttocks feel soft and irregular shape,
difficult to move.
• Palpate the sides of the abdomen to feel for
the back. The back will feel smooth and hard,
irregular bumps are the hands, elbows, knees.
 FETAL ASSESSMENT DURING LABOR:
MONITORING
• Monitors FHR (120-160 beats/min).
• FHR monitored in relation to maternal contractions.
• EXTERNAL FETAL MONITORING:
• Tocotransducer or doppler ultrasound used.
• Tocotransducer is placed over the fundus where the
contractions are the strongest.
• Non invasive.
• INTERNAL FETAL MONITORING:
• Electrodes placed on the presenting part of the fetus.
• REQUIREMENTS: ruptured membranes, woman must
be dilated for 2-3cm.
• invasive
 FETAL HEART RATE PATTERNS
• VARIABILITY = fluctuation in baseline FHR
• ACCELERATION;
– Brief increase in FHR by 15beats more than the baseline
lasting longer than 15seconds.
– Usually occur with fetal movement
– Usually a positive (+) shows fetal responsiveness.
– Can happen with uterus contractions, vaginal exams, cord
compressions or when the fetus is in breech presentation.
• EARLY DECELERATIONS:
– Normal don’t need intervention
– Caused by head compression on the pelvis or cervix.
– Decrease in FHR below the baseline (lower than 100
beats/min).
– Occurs during contractions and returns to the baseline
FHR by the end of contractions.
 FETAL HEART RATE PATTERNS
• LATE DECELERATIONS
– Not normal
– Start AFTER the contraction begins and returns to
baseline when the contraction ends. (early
decelerations start when the contraction starts).
– Sign of UTEROPLACENTAL INSUFFICIENCY, or
impaired placental exchange.
• NURSING INTERVENTION:
– Change the patient position to side lying
– 8-10L/min oxygen
 FETAL HEART RATE PATTERNS
• VARIABLE DECELERATIONS:
• Caused by restricted airflow to the umbilical cord.
• SIGN OF COMPRESSED CORD, prolapsed cord,
nuchal cord (cord that’s around the fetus neck).
• Do not occur at times of the contractions.
• FHR decreases to less than 70beats/min and lasts
for 6seconds before returning to the baseline HR.
• NURSING INTERVENTIONS
• Change position
• 8-10l/min oxygen mask
• Vaginal exam
• Amnioinfusion if ordered.
 HYPERTONIC UTERINE CONTRACTIONS
• In hypertonic contractions = the resting tone
of contractions is high  reduces blood flow
to the uterus and decreases fetal oxygen
supply.
• The uterus should relax between contractions.
• Resting time should be 60seconds or longer
• The resting tone of the uterus is 5-15mmhg.
 4 STAGES OF LABOR
• STAGE 1
• LATENT PHASE
• Cervical dilation 1-4cm
• Contractions shorter in duration and 15-30mins apart.
• INTERVENTION: position change and voiding q1-2hours.
• ACTIVE
• Cervical dilation 4-7cm
• Uterus contractions lasting 30-60secondsoccuring every 3-
5mins
• TRANSITIONAL PHASE
• Cervical dilation 8-10cm
• Contractions every 2-3cm, duration lasting 45-90seconds
• Woman may feel like she is losing control, and becomes
restless.
STAGES OF LABOR: STAGE 2
• STAGE 2 OF LABOR
• Starts from complete cervical dilation to the delivery
• Occurs in 7 cardinal movements = this is POSITION CHANGES as the
fetus moves along the birth canal.
• Cardinal movements are necessary because of the size of the fetus
head in relation to the irregular shaped pelvis.
• The movements change to allow the smallest diameter of the fetus to
pas through the diameter of the patients pelvis.
• THE 7 MOVEMENTS THAT OCCUR ARE :-
• Engagement
• Descent
• Flexion
• Internal rotation
• Extension
• External rotation
• expulsion
STAGES OF LABOR: STAGE 2
• ENGAGEMENT = the presenting part of the fetus is inline with
the mothers ischial spines.
• DESCENT = the downward movement of the fetus.
- This is when the fetal head moves into the pelvic inlet.
- Full descent is when the the fetal head passes beyond the
cervix and comes in contact with the posterior vaginal floor.
• FLEXION = movement of the fetal head forward so that the chin
is pressed against the chin.
- The pressure from the abdominal muscles and the contractions
causes the fetus head so that the chin is pressed forward
against the chest.
STAGES OF LABOR: STAGE 2
• INTERNAL ROTAION = rotation of head making it easier for it to
pass through the ischial spines.
• EXTENSION=
- As the head passes the pelvis, the occiput emerges from the
vagina and the back of the neck is stopped by the symphis
pubis,
- Further descent is halted temporarily because the shoulders
are too wide to pass through the pelvis or under the pubic arch
in this position
- Upward resistance from the pelvic floor causes the head to
extend against the pubic arch & as this happens the brow,
mouth and chin appear
STAGES OF LABOR : STAGE 3
• This is the time from the delivery of the baby to the delivery of
the placenta.
• Last about 5-30mins
• After the baby is delivered the uterus contractions stop for a
while.
• Can be divided into 2 phases:-
- Placenta separation
- Placenta expulsion
- SIGNS THAT THE PLACENTA IS READY TO BE DELIVERED ARE:-
- Lengthening of the umbilical cord
- Sudden gush of vaginal blood
- Change in the shape of the uterus.
STAGES OF LABOR : STAGE 3
• PLACENTA SEPARATION :-
• Occurs after the uterus starts contractions again
• After the baby is delivered the uterus contractions allow the placenta
to fold and separate because there is no baby to exert pressure on
the placenta preventing it from separating prematurely.
• As the placenta pulls away from the uterus wall bleeding begins and
pushes the placenta further away.
• The placenta falls to the upper part of the vagina or lower uterine
segment.
• Most placentas start separating in the middle/ center then folds onto
itself  this leads to delivery with the FETAL SURFACE EXPOSED =
SCHULTZE PLACENTA.
• If the placenta separates from the edges first its delivered with the
maternal surface exposed = DUNCAN PLACENTA.
STAGES OF LABOR : STAGE 3
• THE SCHULTZE PLACENTA IS shiny and glistening
• THE DUNCAN PLACENTA IS red and appears raw with irregular
ridges.
• The outer lining of the uterus (endometrium / decidua ) is
expelled at the same time as the placenta.
• The remaining layer of the uterus is shed in two layers:
- The superficial layer is shed a lochia
- The basal layer remains to regenerate a new endothelium.

- SIGNS THAT THE PLACENTA IS READY TO BE DELIVERED ARE:-


- Lengthening of the umbilical cord
- Sudden gush of vaginal blood
- Change in the shape of the uterus.
STAGES OF LABOR : STAGE 3
- PLACENTA EXPULSION :-
- The mother bears down and gentle pressure is applied on the
fundus of the contracting uterus ( CREDE’S MANUEVER).
- If the plecenta doesn’t deliver spontaneously then it needs to
be removed manually.
- * pressure should never be applied on a NON CONTRACTING
UTERUS to avoid the possibility of hemorrhage.
STAGES OF LABOR: STAGE 4
• Time immediately after the delivery of the placenta
• This is usually the first hour after delivery – recovery period
• The main activity is getting the neonate stabilized and getting
used to the environment outside the uterus.
• Fundus is two fingers below the umbilicus.
• Lochia may be red.
• The focus is on promoting maternal – neonate bonding.
MATERNAL PSYCHOLOGICAL RESPONSES TO LABOR
• RESPONSE DURING FIRST STAGE:-
- Feeling of anticipation, excitement or apprehension.
- During active phase the mother becomes concerned about the
progress of the labor and may want pain medications.

• RESPONSE DURING STAGE 2 OF LABOR:


- Feeling of exhaustion as the patient is now actively pushing

• RESPONSE DURING STAGE 3 OF LABOR:


- Focus is on the condition of the neonate

• RESPONSE DURING STAGE 4 OF LABOR:


- Focus is on the neonate
- The patient starts adjusting to their new role as a mother
- The primary activity is promoting maternal- neonate bonding
 ANESTHESIA
• LOCAL ANESTHESIA
• Done just before the birth of the baby
• Blocks the pain during an episiotomy
• Does not affect the fetus.
• PUDENDAL BLOCK
• Injected through the pudendal nerve through
transvaginal block.
• Indicated for the perineal area for an episiotomy.
• Lasts for 30mins
• No effect on the contractions and fetus.
OB PROCEDURES:
• FETAL BLOOD SAMPLING
- Method of monitoring the fetal blood ph when indefinite FHr occur
- Indicated when fetal hypoxia is suspected
- Sample is usually taken from the scalp ( Or the presenting part if the fetus is
in breech position).
- The membranes must be ruptured, the cervix dilated to 2cm and -2cm
station.
- The fetal scalp blood has a ph of 7.25 or higher *this is normal. Any value
less than 7.20 = severe acidosis or fetal distress.
• AMNIOINFUSION = replacement of the amniotic fluid volume through an
interuterine infusion of an isotonic solution, using a pressure catheter.
- Indicated when repetitive variable decelerations are not being resolved by
interventions such as changing the position and oxygen
- Helps relieve the umbilical cord compression.
- Usually about 500ml is administered of warm solution to avoid chilling.
- Assess the temp every 1hour to assess to infection
- * tell the DOC if the fluid suddenly stops because this is a sign that the fetal
head is engaged and fluid is collecting in the uterus  hydramnions or
uterus rupture.
OB PROCEDURES: EPISIOTOMY

• EPISIOTOMY = surgical incision of the perineum used to enlarge


the vaginal outlet.
- Prevents tearing and relieved the pressure of the fetal head
during birth.
- 2 types: midline & Mediolateral

- MIDLINE = the middle of the perineum is cut, allos for easier


healing, decreased blood loss and decreased postpartum
discomfort
- MEDIOLATERAL = the cut starts of in the middle then its angled
one side away from the rectum. The advantage to this method is
it reduces the risk of rectal mucosal tears, but it may be more
uncomfortable, and make the patient hesitant to use the
bathroom for bowel movement.
 OB PROCEDURES: AMNIOTOMY
• This is the artificial rupturing of the amniotic sac to induce labor
- Allows for access to the fetal monitoring and blood sampling.
- Can only be done if : the membranes are intact, the fetus is in
vertex position, the fetal head is at +2 station or lower, bishop
score is 8 and the cervical dilation is 3cm.
- The patient is placed in dorsal recumbent position then the
membranes are torn using an Amniohook inserted in the
vagina.
- If done correctly then the fluid will gush out.
- ADVANTAGE: you can access the fetus and induces labor
- DISADVANTAGE: increased risk of umbilical cord prolapse,
increases the risk for infection, abruptio placenta may occur 
placenta unable to fit in the implantation site  decrease in
surface area for fetal oxygenation  affecting the fetus oxygen
consumption (possibly hypoxia).
BIRTH RELATED PROCEDURES-
VERSION
• VERSION = aka turning the patient
• Used to turn change the fetal position/presentation by abdominal
or intrauterine manipulation.

• TYPES OF VERSION:
• EXTERNAL CEPHALIC VERSION (ECV)
- Done by manipulating the abdomen.
- Pressure is applied to the fetal head and the buttocks so that the fetus
completes a backward flip or a forward roll. (the baby is flipped from
breech to vertex position by applying pressure on the belly).
- The fetus is changed from breech , transverse or oblique to the
CEPHALIC POSITION.
- If this is successful this reduces the chance of non-vertex and cesarean
births.
- Best results are seen in baby’s that are in transverse position.
BIRTH RELATED PROCEDURES-
VERSION
• PODALIC VERSION:
- Used with only a second twin during a vaginal delivery.
- The obstetrician places a hand in the uterus, grabs the feet of the fetus
and turns the fetus from transverse (or any non-vertex positions) to
BREECH.
- The baby is born in breech position
- Better than ECV because it causes fewer decelaration.
- Some obstetricians may choose to do a C-section that use this method.

• ECV = EXTERNAL CEPHALIC VERSION


- Done after 36-37 weeks gestations because before this time most fetuses
still in breech at this time will not spontaneously switch to vertex
presentation.
- The stress of this procedure may increase the risk of intrapartum birth.
BIRTH RELATED PROCEDURES-
VERSION
• BREECH FETUSES
- Have a smaller head circumference from cephalic baby’s.
- Lower birth weights
- Fetuses that were previously breech tend to have higher
rates of none reassuring fetal status and dystocia.
• MOTHERS OF BREECH BABY’S:
- Tend to have small pelvis.
• SUCCESS OF ECV IS INFLUENCED BY:
- High parity
- Adequate amniotic fluid
- Lack of fetal enlargement
- Transverse lie
BIRTH RELATED PROCEDURES-
VERSION
• FAILURE OF ECV IS LINKED TO:
- Nulliparity
- Advanced dilation
- Fetal weight less than 2500g
- Anterior placenta
- Low station
- Maternal obesity
- Anterior and posterior positioning of the fetal spine.
• CRITERIA FOR EXTERNAL VERSION:
- Single fetus ( if its multiples then they might get twisted during the ECV).
- Enough amniotic fluid
- The fetus must not be engaged (you cant do it if the fetus is engaged).
- None Stress Test must be done immediately before.
- The fetus must be 36-37 weeks. If less than 37weeks then the baby may
be born preterm.
BIRTH RELATED PROCEDURES- VERSION

• CONTRAINDICATIONS FOR ECV:-


- fetal anomalies
- Suspected intrauterine growth restriction = the fetus has been stressed
and amniotic fluid may be low at this time (you need an adequate amount
of amniotic fluid for you to have an ECV done).
- Presence of an abnormal FHR =because this means that the fetus is
already stressed.
- Rupture of the membranes – because it causes a low supply of amniotic
fluid.
- Cesarean birth that’s indicated anyway – cesarean may be indicated for a
mother with placenta previa. If ECV is done instead of a cesarean then it
will cause bleeding.
- Maternal problems – e.g gestational diabetes, cardica probs, pre-
eclampsia.
- Amniotic fluid abnormalities - OLIGOHYDRAMNIOS (amniotic fluid less
than 5cm) makes the baby difficult to manuever and increases the
chances of umbilical cord compression; HYDRAMNIOS (amniotic fluid
greater than 25cm ) this stretches the uterus decreasing he chances that
the fetus will remain in cephalic position if ECV is done.
BIRTH RELATED PROCEDURES- VERSION

- Previous lower uterine C- section because it increases the risk of


uterine rupture or tear
- Nuchal cord because it will tighten around the fetus and choke
it.
- Signs of uteroplacental insufficiency
- 3rd trimester bleeding
- Uterine malformation.

• ECV PROCEDURE:-
- Woman must fast for 8 hours prior
- Ultra sound to confirm that theres only one fetus, amount of
amniotic fluid, position of the uterus, position of the umbilical
cord and that the baby is still in breech position.
- Maternal and Fetal vital signs taken external FHR monitor is
used.
- CBC, NST, blood typing and antibody screening.
BIRTH RELATED PROCEDURES- VERSION

ECV PROCEDURE CONTINUED…..


- Doc explains the procedure and gets consent.
- Terbutaline or Magnesium sulfate if terbutaline is
contraindicated to RELAX THE UTERUS.
- Woman placed in supine or trenderlinberg position.
- Womans belly is covered with ultrasound gel to decrease friction
during the manipulation.
- The fetal breech and head are moved in opposite directions
(rotating the baby)
- If the woman is RH – then Rh immune globulin must always be
given after the version because there is a risk of Fetal- maternal
hemorrhage.
- The version is stopped if the woman is in great pain or if the
fetal vital signs are not reassuring. The doctor will resume in a
week if the version was not successful the first time.
BIRTH RELATED PROCEDURES- VERSION

• ECV NURSING CARE

- Start by making sure the woman understands the procedure and that she
can tell the doctor to stop if she becomes in too much pain.
- If the EVC fails there is a chance that cesarean birth will need to be done.
(this prepares the woman).
- Explain the the version while the version is being done and answer any
questions.
- Monitor blood pressure and pulse every 2mins throughout the time the
terbutaline (beta mimetic) is being used and for 30mins after.
- Monitor the FHR for 1-2hours after the ECV.
- Assess the response of both the fetus and the mother to the med give
(terbutaline)
- Teach the mother how to monitor the uterine contractions, fetal
movement (a kick) and ways to recognize signs of reversion (excessive
movement which most women describe as “the baby is turning round”).
- RhoGAM shoud be given to all Rh- women.
BIRTH RELATED PROCEDURES- CARE DURING RIPENING

• RIPENING = softening and effacing of the womans


cervix.
• If induced labor has been indicated then
PROSTAGLANDIN E2 gel (PGE2) is used for cervical
ripening.
• The two common gels used are: PREPIDIL &
CERVIDIL
• PREPIDIL contains 0.5mg of dinoprostone ( a form
of prostaglandin E 2) is placed intracervically
• Cervidil is placed in the posterior vagina and is left
in place to slow release at a rate of 0.3mghr over
10hours.
BIRTH RELATED PROCEDURES- CARE DURING RIPENING

• DINOPROSTONE (CERVIDIL VAGINA INSERT)


- Naturally occurring prostaglandin E2
- Used for ripening and can stimulate smooth muscle uterus
contractions.
- One vaginal insert is used, the oxytocin is used 30mins later.
- The insert is placed transversely in the posterior fornix of the
vagina.
- Patient is kept in supine for 2hours.
- The insert is removed by pulling on the retrieval string when the
contractions start or after 12hours.
- CONTRAINDICATIONS: nonreassuring fetal status, sensitivity to
prostaglandins, unexplained vaginal bleeidng, a client already on
oxytocin, client who has had 6 or more previous pregancies,
client who will give birth vaginally.
- CAUTION: in breech, ruptured membranes.
BIRTH RELATED PROCEDURES- CARE DURING RIPENING
• SIDE EFFECTS OF CERVIDIL :-
- Hyperstimulation
- Fever
- Nausea
- Vomiting
- Diarrhea
- Abdominal pain.
- Non reassuring FHR.
- Increased chance of postpartum hemorrhage.
- Uterine rupture (especially in women that have had a previous incision).
- * should not be used on women with compromised Cardiac, hepatic,
renal, glaucoma, asthma.
• NURSING CONSIDERATIONS
- Assess the fetal status prior to administering
- Report uterine stimulation , non reassuring fetal status to the DOC or the
CNM.
BIRTH RELATED PROCEDURES- CARE DURING RIPENING

• PROSTAGLANDIN AGENT INSERTION:


• PREPIDIL: a prefilled syringe attached to a catheter is
inserted into through the vagina into the endocervix
where the gel is injected.
- The catheter has a small shield on top so gel cannot spill
out into the internal OS.
- DINOPROSTONE : available in a gel form that can be
applied on a diaphragm and inserted into the cervix or
as a suppository that is inserted into the posterior fornix
of the vagina.
- CERVIDIL: the vaginal insert is placed in the posterior
vagina. * call the nurse if it is discharged. If
hyperstimulation occurs then the cervidil can be
removed. If active labor occurs Cervidil should also be
removed.
BIRTH RELATED PROCEDURES- CARE DURING RIPENING

• CYTOTEC (MISOPROSTOL): synthetic PGE1 used to soften and ripen


the cervix and to induce labor.
- Available in a tablet form that can be taken orally or inserted into the
vagina.
- Women usually deliver in 24hours.
- Contraindicated in the 1990’s because it increased the chances of Uterine
Rupture.
- Drug manufacture instructions say it should not be use to induce labor.
- Some research has shown that its more effecttive than oxytocin and
prostaglandins & its associated with low cesasrean births.
- Used in the 3rd trimester
- One fourth of the full dose should be used at first (25mcg).
- Keep the following doses consistant do not allow 3-6hours pass without
giving the next dose.
- Pitocin should not be administered less than 4hours after the last dose of
CYTOTEC has been given.
BIRTH RELATED PROCEDURES- CARE DURING RIPENING

- CONTRAINDICATIONS FOR CYTOTEC:


- Uterine contractions 3times in 10mins
- Asthma
- Previous C-section or uterine scarring
- Placenta previa
- Non reassuring fetal status.
• TRANSCERVOCAL CATHETER
- balloon catheter is used for cervical ripening and
mechanical dilation.
- Foley catheter balloon with 25-80ml of water is inserted
into the undilated cervix and then inflated.
- The balloon applies pressure on the inetrnal os of the
cervix and ripens the cervix.
BIRTH RELATED PROCEDURES- CARE DURING RIPENING

• NURSING INTERVENTIONS:
- Delivery nurses with special training give ripening agents.
- Maternal and fetal vital signs taken for baseline.
- External Fetal Heart rate monitor is used for 30mins.
- The woman must remain lying down with a rolled
blanket or hip wedge under her right hip to tip the
uterus slightly to the left for the first 30-60mins to
maintain the cervical ripening agent in place.
- Monitor for hyperstimulation and FHr variations.
- If TACHYSYSTOLE = hyperstimulation of the uterus occurs
(5 contractions in 10mins) POSITION THE WOMNA IN
THE LEFT SIDE AND ADMINISTER OXYGEN IF THERE IS
FETAL DISTRESS.
BIRTH RELATED PROCEDURES- CARE DURING RIPENING

- NURSING INTERVENTIONS FOR CERVICAL RIPENING


CONTINUED…
- 0.25mg subcutaneous injection of Terbutaline should be
considered if the hyperstimulation continues.
- The cervical ripening gel may be removed if the patient
experiences nausea, vomiting or tachysystole develops * don’t
give antiemetics though.
- Women using the transcervical technique for cervical ripening
and dilation does not need continous fetal monitoring.
- Mark the caheter tubing at the point that’s outside the insertion
point as a way to determine if the catheter at any point gets
displaced.
- A woman who receives the catheter method should remain in
the recumbent position * don’t perform any vaginal exams.
- Avoid ambulation and use a bedpan.
BIRTH PROCEDURES- AUGMENTATION & INDUCED LABOR
• INDUCED LABOR = deliberately initiating uterus contractions to stimulate
labor.
• LABOR AUGMENTATION= stimulation of uterus contractions when
spontaneous contractions have failed to result in cervical dilation or
descent of the fetus.
• INDICATIONS OF INDUCED LABOR OR AUGMENTATION:
- Diabetes
- Renal disease
- Preeclampsia
- Hypertension
- PROM
- Post term gestation
- Intrauterine growth restriction (IUGR)
- Isoimmunization
- History of precipitous labor
- Abruptio placentae
- olighydramnios.
BIRTH PROCEDURES- AUGMENTATION & INDUCED LABOR

• CONTRAINDICATIONS TO LABOR INDUCTION OR


AUGMENTATION:-
- Abnormal fetal heart rate
- Breech presentation
- Unknown fetal presentation
- Multiple gestations
- Polyhyamnios
- Presenting fetal part is above the pelvic inlet
- Severe hypertension
- Maternal heart disease.
• BISHOP SCORING SYSTEM IS USED TO EVALUATE OF THE
WOMAN IS READY TO BE INDUCED.
• Assessment is key before the induction is done, amniotic fluid
tests and phosphatidylglycerol to assess the fetal lung maturity
must also be done.
BIRTH PROCEDURES- AUGMENTATION & INDUCED LABOR
• WAYS OF INDUCING LABOR:
• STRIPPING MEMBRANES: aka sweeping.
- Non pharm method of inducing labor
- as an Augmentation method it can be done in the birthing room to
attempt to strengthen the contractions without the need for oxytocin.
BUT if the contractions are still not strong enough then Oxytocin might
need to be given.
- This is stripping of the amniotic membranes.
- The physician uses his finger, inserts it into the the vagina as far as
possible into the cervix and rotates his finger 360 degrees twice  this
separates the amniotic membranes.
- Sweeping is believed to release PGE2 from the cervix.
- Women who have this procedure done tend to have shorter pregnancy.
- Uterine contractions, bleeding and abdominal cramping can occur from
this procedure.
- If successful then labor occurs within 24-48hours
BIRTH PROCEDURES- AUGMENTATION & INDUCED LABOR

• OXYTOCIN INFUSION
- Given through IV to create uterine contractions & INDUCE
LABOR.
- THE GOAL IS TO HAVE contractions lasting in about 40-
60seconds in 10mins with good uterus relaxation and return to
the baseline tone when between contractions.
- Oxytocin is also given during augmentation when the labor is not
progressing as it should, the fetus is not descending so Oxytocin
will be given in this case to create the desired uterus contraction
pattern with strong contractions  cervical dilation  fetal
descent.
• Before administering oxytocin for induced labor or
augmentation the nurse should assess for:
- Assess the mothers pelvis * contraindicated in cephalopelvic
disproportion
- Fetal positioning and fetal station
BIRTH PROCEDURES- AUGMENTATION & INDUCED LABOR

• HOW OXYTOCIN IS ADMINISTERED:


- Should be given using a device that allows precise
control of the IV flow rate.
- A primary line of IV fluid is started first this avoids the
risk of large dose of oxytocin being given. * let the line
run.
- Oxytocin is then piggybacked into the primary tubing
*use the port closest to the catheter insertion (this
allows only a small amount of oxytocin to back flow into
the tubing creating greater dosage accuracy.
- Oxytocin should not be given Intramuscularly and
without an IV PUMP.
- To reduce pulmonary edema
 BIRTH PROCEDURES- VACUUM ASSISTED BIRTH

• Cup like suction device placed on the fetal heal to


help with delivery.
• INDICATED WHEN: the woman is having a difficult
labor, labor not progressing, fetal distress during
second stage of labor.
• CONDITIONS FOR VACUUM EXTRACTION: vertex
presentation, ruptured membranes.
• Don’t apply for longer than 25mins.
• Watch for lacerations and cephalohematoma.
• Capput succedeneum is normal will resolve in
24hours.
 OB PROCEDURES: FORCEP USE

• FORCEPS = spoon like blades used to assist with the


delivery of the fetal head.
• RISK FOR USE: face nerve palsy and laceration of the cervix
and vagina.
• INDICATED WHEN: fetal distress and when the fetus is in
breech presentation and the head needs to be delivered.
INTRAPARTUM PERIOD:

COMPLICATIONS OF LABOR AND


BIRTH
PRETERM LABOR
• PRETERM LABOR = uterus contractions and cervical
changes occurring between 20-37weeks gestation.
• RISK FACTORS THAT INCREASE CHANCES: infection,
hydramnios (excess amniotic fluid), below the age of 17yrs
or above, diabetes, incompetent cervix (cervix that’s unable
to remain closed to carry the pregnancy to term).
• SIGNS AND SYMPTOMS: low back pain, pain on the pelvis
and cramping, increased vaginal discharge blood may be
present, regular contractions lasting longer than an hour,
PROM.
• NURSING INTERVENTIONS:
• Priority is to stop the contractions. Done by: *restrict
activity, keep patient hydrated, give tocolytic meds,
glucocorticoids for fetal lung maturity. Treating the
infection if the patient has one.
PRETERM LABOR:tocolytics
• Contraindicated when the woman is 34weeks
or more, fetal ditress, vaginal bleeding,dilation
greater than 6cm.
• WATCH FOR PULMONARY EDEMA (chest pain,
SOB, resp distress, wheezing and crackles,
blood tinged sputum.
PRETERM BIRTH
• PRETERM BIRTH: birth occurring at 20weeks
gestation but before 37weeks
• COMPLICATION TO THE FETUS: RDS (watch
for nasal flaring, retraction of the chest wall
during inspiration, grunting).
• GIVE THE WOMAN BETHAMETHOSONE FOR
24HOURS PRIOR TO DELIVERY TO PROMOTE
LUNG DEVELOPMENT AND PREVENT RDS.
PREMATURE RUPTURE OF MEMBRANES
• PROM= sudden rupture of membranes 1 hour or more
prior to the onset of true labor.
• PPROM = PRETERM PREMATURE RUPTURE OF
MEMBRANES = the rupture of membranes after
27weeks but before 37weeks.
• Biggest risk when PROM occurs = INFECTION
• NURSING INTERVENTIONS:
– Nitrazine test to test that its amniotic fluid (ph 6.5-7.5 is
positive).
– Check for PROLAPSED UMBILICAL CORD.
– Tell patient to wipe from front to back to avoid infection,
no sex, no inserting anything vaginally.
– Take temp at home every 4hours , report increase.
– Avoid bath tubs.
PROLAPSED UMBILICAL CORD
• The umbilcal cord appears/falls or before the presenting part of the
fetus.
• Can cause cord compression & compromise circulation.
• SIGNS AND SYMPTOMS:
– VARIABLE DECELERATIONS ***** BIGGIE
– Woman reports that she feels something coming through her vagina.
– The umbilical cord is protruding.
• FACTORS INCREASING THE RISK:
– Fetus is in abnormal presentation
– SGA
– Cephalopelvic disproportion because if theres a loose fit between the
presenting part and the pelvis this leaves room for the fetus to pass
through.
– The presenting part is not engaged when the membranes rupture
PROLAPSED UMBILICAL CORD
• NURSING INTERVENTIONS:
– Change position to side lying with towel rolled
under the hip, knee-chest.
– Using sterile gloved hands insert two fingers into
the vagina and apply finger pressure to relieve the
pressure of the cord
– Monitor FHR
– Oxygen 8-10L
– Amnioinfusion of normal saline to relieve
compression if its been caused by
oligohydramnios (too little amniotic fluid).
PRECIPITATE LABOR
• PRECIPITATE LABOR: labor lasting 3hours or less from the time of
contractions to the time of birth.
• CONTRIBUTING RISK FACTORS:
• HYPERTONIC UTERUS CONTRACTIONS
• HYPERTONIC CONTRACTIONS
– Non-cordinated
– Non productive
– Painful uterus contractions
– Don’t allow for relaxation of the uterus between contractions  decrease in
fetal oxygenation supply.
• NURSING INTERVENTIONS.
– Don’t leave the mother unattended
– Side lying position for fetal circulation and oxygenation
– Don’t stop the delivery.
– Control rapid delivery by applying pressure on the perineal area and fetal
head. *this helps prevent rapid expulsion preventing CEREBRAL DAMAGE &
PERINEAL LACERATIONS FOR THE MOTHER.
PRECIPITATE LABOR
• COMPLICATIONS OF PRECIPITATE LABOR:
• TO THE FETUS:
– INTERCRANIAL HEMORRHAGE *** resulting from
the trauma during the rapid delivery.
– Hypoxia due to the uteroplacental insufficiency
caused by the hypertonic uterine contractions.
• TO THE MOTHER:
– Cervical, vaginal and perineal lacerations.
MECONIUM STAINED AMNIOTIC FLUID
• Can be caused by fetal cord compression  fetal
hypoxia  vagus nerve which is responsible for
HR and GI peristalsis is stimulated  peristalsis of
the fetus GI  relaxation of the anal sphincter 
meconium released (the first stool of the fetus)
• SIGN OF FETAL DISTRESS if accompanied by
variable or late decelerations, acidosis which is
confirmed by scalp blood sampling.
• NURSING INTERVENTIONS:
– Suction the nasopharynx at the time of birth to prevent
meconium aspiration syndrome.
POST TERM PREGNANCY
• POST TERM PREGNANCY = pregnancy going beyond 42weeks gestation.
• RISK TO THE MOTHER:
– Birth canal trauma because the fetal bones have matured and the skull has
hardened.
– Post partum hemorrhage and infection.
• RISK TO THE FETUS:
– Dystocia and prolonged labor  fetal distress meconium in amniotic fluid
– Macrosmonia (large for gestational age)
– Polycythemia
• CONTRIBUTING FACTORS:
– Decrease in estrogen  decrease in oxytocin production  decreased
contractions.
• SIGNS AND SYMPTOMS:
– Weight loss of 3lbs/week and decrease in the size of the uterus which is
caused by the decrease in amniotic fluid.
• NURSING INTERVENTIONS
– AMNIOINFUSION
DYSTOCIA
• Difficult labor
• Related to the 4 powers of labor (power, passenger, passage,
psyche, position).
• Related to abnormal uterus contractions (hypertonic or hypotonic
contractions).
• CONTRIBUTING RISK FACTORS:
• *LGA
• Older than 40yrs, fetal head is larger than the pelvis, uterine
abnormalities, maternal fatigue and fear.
• SIGNS AND SYMPTOMS:
• Fetal distress
• Lack of progress in labor*** (hypotonic contractions can be
indented during contractions, hypertonic contractions cant).
• SHOULDER DYSTOCIA IS :
• When the fetus anterior shoulders cannot pass under the symphysis
pubis after the delivery of the fetal head.
RUPTURE OF THE UTERUS
• Complete or incomplete separation of the uterus caused by a tear
in wall of the uterus from the stress of labor.
• Complete- rupture goes into the peritoneum
• Incomplete –
• SIGNS AND SYMPTOMS
• The fetus may be palpated outside the uterus *in complete rupture
• Absent FHR
• Contractions can stop or fail to progress.
• Rigid abdomen.
• INTERVENTIONS:
• Monitor for shock
• IV fluids and oxygen
• Prepare for C-section and hysterotomy.
 PLACENTA PREVIA
• PLACENTA PREVIA = improper implantation of the uterus. Its
implanted on the lower segment or near the internal cervical os.
• TYPES OF PLACENTA PREVIA :
– Total = the placenta covers the cervical os
– Partial = covers the cervical os partially.
– Marginal =
• SIGNS AND SYMPTOMS ?
– Painless, bright red vaginal bleeding
– Uterus is soft, relaxed and nontender.
– Fundal height may be HIGHER more expected than the gestational
age.
• NURSING INTERVENTIONS:
– Fetal heart rate and maternal vital signs should be assessed first.
– There may be a need for a c-section if bleeding is heavy.
– No vaginal exam or anything that will stimulate the uterus.
– Position the patient in side lying position.
 ABRUPTIO PLACENTAE
• ABRUPTIO PLACENTAE: this is premature separation of the
placenta from the uterus wall after the 12th week of gestation and
before the fetus is delivered.
• SIGNS AND SYMPTOMS:
– Dark red vaginal bleeding * DARK RED
– Uterine pain and tenderness *PAINFUL
– Uterine rigidness
– Severe abdominal pain
– Signs of fetal distress.
– There may be signs of shock
• NURSING INTERVENTIONS:
– Vital signs and FHR
– Bed rest, oxygen, IV fluids and blood products
– Trendelenburg position to decrease the pressure of the fetus on the
placenta.
 PLACENTA ABNORMALITIES
• PLACENTA ACCRETA = abnormal attachment of
the placenta
• PLACENTA INCRETA = placenta penetrates the
uterus muscle itself
• PLACENTA PARCRETA = the placenta goes all the
way through the uterus.
• SIGNS AND SYMPTOMS:
• Hemorrhage immediately after birth because the
placenta will not separate as one would normally.
• INTERVENTIONS:
• Monitor for shock and hemorrhage
 UTERUS INVERSION
• UTERUS INVERSION= the uterus is completely
turned inside out.
• Occurs during delivery of the placenta
• SIGNS AND SYMPTOMS:
– Depression in the fundal area
– The uterus may be seen protruding through the cervix
or through the vagina
– Woman is in severe pain.
• NURSING INTERVENTIONS:
– Watch for signs and hemorrhage and shock *
interventions to meet these.
 AMNIOTIC FLUID EMBOLISM
• This is when amniotic fluid escapes into maternal circulation.
• The debri which is found on the amniotic fluid enters the mothers
pulmonary arteries and deposits there.
• SIGNS AND SYMPTOMS:
– RD and chest pain
– Cyanosis
– Seizures
– Pulmonary edema
– Bradycardia.
• NURSING INTERVENTIONS:
– Oxygen 8-10L/min
– Position on side
– IV fluids and blood products
– Prepare for emergency delivery and monitor the fetal status.
POSTPARTUM PERIOD

 NEONATE POSTPARTUM PERIOD


NEW BORN POSTPARTUM PERIOD

 NEWBORN ASSESSMENT
 NEWBORN DRUG NEEDS
 CIRCUMSICION
 NEWBORN NUTRIONAL REQUIREMENTS
 POSTPARTUM NEWBORN COMPLICATIONS
APGAR SCORING
• Done 1-5mins after birth
• Assesses the extrauterine adjustment of the neonate.
• Scoring based from 0-2
• 0 = poor / absent
• 2 = excellent
• 5 categories assessed
• Heart rate ( 1= less than 100 bpm; 2= more than 100bpm).
• Respirations (1= slow or weak cry ; 2= good vigorous cry)
• Muscle tone
• Reflex irritability (0= absent ;1 = minimal ; responds promptly)
• Skin color (0 = pallor and cyanosis ;1= normal coloring with blue
extremities; 2= body and extremity coloring is normal)
• When total is added up:
• 0-3 = severe distress
• 4-6 = moderate distress
• 7-10 = no distress
GESTATIONAL ASSESSMENT
• Done within 2-12hours after birth
• Measurements of the newborn and New Ballard
Scale is used to estimate gestational aging & its
used as a baseline to assess growth and
development.
• PHYSICAL MEASUREMENTS :
• WEIGHT = 2500g – 4000g
• LENGTH =45cm- 55cm. Measurement from top of the
head to the heal of the foot.
• HEAD CIRCUMFERENCE= 32cm- 36.8cm (18-22inch)
• CHEST CIRCUMFERENCE = 30 – 33cm (12.6 – 14.5inch)
GESTATIONAL ASSESSMENT
• New ballard scale assesses the neuromuscular and physical
maturity to find the infants gestational age.
• NEUROMASCULAR MATURITY:
• Posture – fully extended and fully flexed
• Square window formation of the wrist
• Arm recoil (the babys arms are extended then just let go and allows it
to spontaneously return to flexion.
• Popliteal angel – degrees to which the knees can extend.
• Scarf sign – crossing the neonates arms over the chest.
• Heel to ear – how far the heels reach the ears.
• PHYSICAL MATURITY
• Skin texture
• Lanugo
• Plantar surface creasess
• Breast tissue
• Genitalia (testes and labia)
INFANT VITAL SIGNS
• RESPIRTIONS
• 30 – 60/ min may have short periods of apnea lasting
15seconds
• Apnea periods occur mostly during REM
• Apnea lasting longer than 15seconds may be a sign for
resp distress.
• Crackles and wheezing can be a sign for fluid in the
lungs or infection
• Grunting and nasal flaring = Respiratory distress.
• HEART RATE
• 120- 160/min
• Listen to apical pulse for full min
INFANT VITAL SIGNS
• BLOOD PRESSURE
• Systolic = 60-80mmhg
• Diastolic = 40-50mmhg
• TEMPERATURE
• 36.5 – 37. 2 degrees celcius (97.7 – 98.9 F)
• High risk for hypothermia and hyperthermia
because of the infants inability to thermoregulate.
• If the baby becomes CHILLED (COLD STRESS) 
increased oxygen demands  acidosis
• Fetal hypoxia  depressed respirations
BODY ASSESSMENT OF THE NEW BORN
• POSTURE: must be flexed and resistant to extension.
• SKIN: pink or acrocyanotic, no jaundice on the first day but it may
appear a day later.
• Texture: dry, soft and smooth. * full term babys may be peeling
*DESQUAMATION.
• SKIN DEVIATIONS:
• Milia= small white spots * don’t pop
• MONGOLIAN SPOTS: bluish purple spots, usually on the neonates
back, shoulder and buttocks.
• TELANGIECTATIC NEVI = * stork bite. flat and pink or red marks
found on the babys upper eyelids or the middle of the forehead.
They fade by the time the baby is 2.
• NEVUS FLAMMEUS: port wine stain. Red or purplish mark, does
not blanch or disappear.
• ERYTHEMA TOXICUM = erythema nenatorum. Rash that appears
suddenly.
BODY ASSESSMENT OF THE NEW BORN
• THE HEAD:
• Should be larger than the chest circumference.
• If the head is greater or equal to 4cm larger than
the chest this could be a sign for
HYDROCEPHALUS.
• LESS THAN OR EQUAL TO THE CHEST
CIRCUMFERENCE = MICROCEPHALY (abnormally
small head).
• BULGING FONTANELS = Increased intercranial
pressure, infection or hemorrhage
• DEPRESSED FONTANELS = dehydration.
CAPUT SUCCEDANEUM & CEPHALOHEMATOMA
• CAPUT SUCCEDANEUM
• Localized swelling of the soft tissue on the scalp. (the
swelling is over the bone)
• The swelling cross over the suture line
• Caused by pressure on the head during labor
• Usually resolves within 3-4days .
• CEPHALOHEMATOMA:
• Swelling caused by bleeding into an area between the bone.
*collection of blood between the periosteum and the skull
bone.
• Absorbed within 6 weeks with no treatment.
• Caused by trauma during birth for instance pressure of the
fetal head against the maternal pelvis in a prolonged
difficult labor or the use of forcep delivery.
• Appears within 1-2days after birth.
NEW BORN ASSESSMENT
• EYES:
• Permanent eye color is established in 3-12months.
• Immature lacrimal glands so there is tearless crying.
• EARS:
• The upper tip of the pina should be In line with the outer canthus of
the eye.
• Low set ears could be a sign for downs syndrome.
• Lack of cartilage = sign for immaturity.
• NOSE:
• Babys are nose breathers
• They get the skill to breath with their mouths at 3weeks.
• MOUTH
• EPSTEIN PEARLS = white spots found in the palate and gums.
Caused by accumulation of epithelial cells * normal.
• Tongue: if its large and protruding this is a sign for downs
syndrome.
NEW BORN ASSESSMENT
• REFLEXES:
• MORO = you act like you are going to let go of the
baby or strike the surface that they are sleeping on. *
the baby will extend the body and form a C with the
hands (act like they are griping onto something).
• Palmar grasp = you touch the palm of the baby and
they will try to grasp the object.
• Plantar grasp = the baby’s toes curl downward when
the sole of the foot is touched.
• Stepping = you pick up the baby as if you are making
them stand and they respond by dancing or stepping.
• Startle = loud noise * the baby will abduct his arms and
flex his elbows.
NEW BORN ASSESSMENT
• Most important adjustments to extrauterine life are
Respiratory and Circulatory. They must occur rapidly.
• Respirations established by the cutting of the umbilical
cord *most important extrauterine adjustment
because the infant now has to breath by themselves.
Air enters the lungs with that first breath.
• ASSESSMENT OF THE NEONATE ARE:
• Initial assessment immediately after birth (APGAR
SCORE)
• GESTATIONAL AGING ASSESSMENT WITHIN 2HOURS
• COMPLETE IN DEPT PHYSICAL EXAM WITHIN 24HOURS
NURSING CARE OF THE NEWBORN
• CARE OF THE NEWBORN IS DIVIDED INTO THREE PHASES:
• PHASE 1: STABILIZATION
• Stabilize or resuscitate to relieve airway obstructions if there's any
• Thermoregulation to maintain body temperature.
• PHASE 2: ASSESSMENT COMPLETION
• Apgar score, physical exam, measurements and monitoring the
infants labs).
• PHASE 3: NURSING INTERVENTIONS AND FAMILY TEACHING
• Umbilical cord care
• Prophylatic measures
• New born screening
• Infant feeding and bathing
• Helping parent – infant attachment.
NURSING CARE OF THE NEWBORN
• Highest priority is the abduction safety * use identification
bracelets for bothe the mother and the infant.
• Anyone coming in contact with the infant should be wearing an
indentification bracelet.
• Children with respiratory distress are at risk for HYPOTHERMIA
• Infants of mothers with diabetes are at highest risk for
HYPOGLYCEMIA
• Infants delivered by c-section are at highest risk of FLUID IN THE
LUNGS.
• NURSING ASSESSMENTS:
• Vital signs q30mins x2; q1hr x2 then every 8hours.
• Weight, length and chest circumference
• Chest the umbilical cord
• Watch periods of reactivity
NURSING CARE OF THE NEWBORN

• PERIODS OD REACTIVITY :
• 1st period: the infant is exploring the world
making sucking noises, rapid resps and heart
Rate which stabilize in 15-30mins.
• Period of relative inactivity: the infant is
resting and sleeping.
• 2nd period of reactivity : the infant awakens
and becomes alert again. Baby may be
choking on their saliva and mucus this may
last from 10mins to
NURSING CARE OF THE NEWBORN: THERMOREGULATION

• NEWBORN KEEPS WARM BY METABOLIZING BROWN FAT.


• When the baby is chilled  oxygen demand increases  more
brown fat is used.
• HYPOTHERMIA SIGNS: cyanosis,increased resps , temp of 36.5
degrees celsius.
• CONDUCTION: loss of body heat from direct contact with a cooler
surface. * place the baby on the mothers stomach skin to skin then
cover with a blanket.
• CONVECTION: flow of heat from the body to a cooler air. (so with a
fan the heat moves away from you towards the cooler air which is
being blown by the fan). *place the baby stuff out of the direct line
of a fan.
• RADIATION: loss of heat from the body surface to a cool and solid
surface that is close but not in direct contact like with conduction.
*keep the examining tables away from stuff like windows.
NURSING CARE OF THE NEWBORN:

• ELIMINATION:
• The newborn should void at least once in the 24hours after birth ,
then 6-10 days the day after or 4 days after.
• Meconium should be passed in the first 24hours
• Poo for breast fed infants is yellow and seedy
• Formular fed babies have lighter and looser stool.

• BATHING THE BABY:


• Done when the baby’s temperature stabilizes at 36.5 degrees.
• Done after 1-2 hours after birth.
• Should be done under the radiant heat warmer to prevent heat
loss.
• After the initial bath, just clean the areas like the face, perineal and
skin folds daily , but do a complete bath 2-3 times a week.
NEWBORN MEDS
NURSING CARE OF THE NEWBORN: DRUGS
• GLUCOSE for hypoglycemia
• NEW BORN GENETIC SCREENING:
• Capillary heel stick test done within 24hours after birth.
• For accurate results the infant must have had breast milk or
formula within that 24hours.
• If the newborn is discharged before the baby is 24hours old
then the test should be done again in 1-2weeks.
• The genetic testing is assessing PKU (PHENYLKETONURIA) which
is a defect in protein metabolism.
• The accumulation of the amino acid phenylalanine can result in
MENTAL RETARDATION.
• Treatment in the first 2months of life can prevent mental
retardation.
• Other genetic tests are: cystic fibrosis, maple syrup urine
disease, sickle cell disease.
NURSING CARE OF THE NEWBORN: DRUGS
• NEWBORN HEARING SCREENING:
• To detect deafness early
• PROPHYLACTIC EYE CARE:
• Antibiotic ointment is placed in the eyes to prevent OPTHALAMIA
NEONATORUM.
• Baby’s eyes can get infected when the baby is passing down the birth
canal.
• OPTHALAMIA NEONATORUM = is caused by N. gonorrhoeae or
Chlamydia trachomatis which can cause blindness.
• ERYTHROMYCIN (E-MYCIN) 0.5% ointment is used.
• Applied in the lower conjuctiva sac (start inner canthus and move
outwards).
• Close the eye for 5 seconds to allow the ointment to spread. Wipe the
excess ointment after 1min.
• Adverse reaction = chemical conjuctivitis which is seen as redness,
swelling, drainage and temporarily blurred vision for 24-48hours.
• Teaching = the chemical conjuctiva is a normal reaction and will pass in
24-48hours. This is normal.
NURSING CARE OF THE NEWBORN: DRUGS

• HEPATITIS B VACCINE
• Given at birth , 1 month then at 6months if the
woman is Hep B –
• If the mother is Hep B positive then they should
get Hep B immuno globulin and the Hep B vaccine
in addition within 12hours of birth.
• The Hep B vaccine is then given at 1month,
2months and 12months
• Do not give the vitamin k and Hep B vaccine on
the same thigh.
NEW BORN CARE DRUGS: VITAMIN K
• VITAMI K (AQUAMEPHYTON) injection
• Used to prevent hemorrhagic disorders
• Infants don’t priduce Vitamin K is not produced in
the GI tract of the newborn until Day 8.
• Vitamin K is produced in the colon by the bacteria
that forms once formula or breast milk is
introduced into the the GI system of the newborn.
• Shot is given IM into the VASTUS LATERALIS
because this is where the muscle is most
developed within 2hours after birth.
NEWBORN CARE: UMBILICAL CORD
• Should have 1 vein 2 arteries. LESS = ABNORMALITY
• Odorless and have not intestinal structures
• Small thin cord = poor fetal growth.
• Should be clamped for 24hours until the the cord is dry and occluded.
• Clean with alcohol.
• Signs of umbilical cord infection = moistness, oozing, discharge and
reddened base.
• Bleeding umbilical cord = due to a cord that was pulled or loosened cord
clamp.
• Foul smelling drainage = infection *treat immediately to prevent
septicimia.
• Umbilical cord hernia is caused by patent omphalomesentric duct *
common in african infants.
• Serous or serosanguineous drainage that continues after the cord falls off
is a sign for GRANULOMA (you will see a small red button deep in the
umbilicus). TREATMENT = SILVER NITRATE STICK.
• MOISTNESS OR DRAINING URINE AT THE BASE OF THE UMBILICAL CORD IS
A SIGN FOR PATENT URACHUS (abnormal connection between the
umbilical cord and the bladder)
NEWBORN CARE: CIRCUMSICION
• CIRCUMCISIONS = removal of the foreskin
• Jewish = do this 8days after birth
• NOT DONE IMMEDIATELY AFTER BIRTH BECAUSE:
• Low levels of Vitamin K so theres increased risk for bleeding
• Danger of cold stress.
• CONTRAINDICATIONS:
• Congenital abnormalities (hypospadias, Epispadias).
• Hypospadias = abormal positioning of the urethra on the ventral
under surface of the penis.
• EPISPADIAS = urethral canal terminates at the dorsum of the
penis
• History of bleeding in the family
• Ambiguous genitalia (both male and female parts)
• Illness or infection
NEWBORN CARE: CIRCUMSICION
• TYPES OF PROCEDURES:
• YELLEN, MOGEN, GOMCO CLAMP PROCEDURES:
• Clamp is applied to the penis, foreskin is loosened and a
cone is inserted under th foreskin to provide a cutting
surface.
• The wound is covered with a petroleum gauze to prevent
infection and bleeding.
• PLASTIBELL METHOD:
• Plastibell is placed between the foreskin and the glans of
the penis.
• The physician ties a suture tightly around the foreskin at
the coronal edge of the glans.
• The suture becomes ischemic and atrophies
• 5-8 days later the foreskin drops off with the plastibell
attached leaving the clean well healed incision.
NEWBORN CARE: CIRCUMSICION
• POSSIBLE COMPLICATIONS OF CIRCUMCISIONS:
• BLEEDING:
• Apply gentle pressure with gelfoam powder or sponge to
stop bleeding.
• Tell the physician if the bleeding continues, continue to
apply pressure until the physician arrives.
• COLD STRESS/HYPOGLYCEMIA
• Watch for excessive heat loss from increased respirations
and lower body temp.
• Use a radiant warmer during this procedure during the
procedure and swaddle the baby after.
• OTHER COMPLICATIONS:
• Monitor for infections, urethra fistula, delayed healing,
scarring.
POSTPARTUM: NEWBORN NUTRIONAL
NEEDS
NEWBORN CARE: CIRCUMSICION
NURSING INTERVENTIONS AND TEACHINGS:
• Tell the parents anesthesia will be given
• Do not bottle feed 4hours prior the procedure to prevent the vomiting
and aspiration.
• Breast feeding infants may nurse until the procedure.
• Signed consent should be in the chart prior to the procedure.
• Keep the area clean (change diaper q4hrs and clean the penis with
warm water with ach diper change, with clamp procedures apply
petrolium jelly with each diaper change for at least 24hours after the
circumcision)
• Fan fold the diaper to prevent pressure on the circumcised area.
• Don’t wrap the penis in tight gauze
• No tub bath until its completely healed
• Tell the physician if there is any rednessm swelling, strong odor,
tenderness, decreased urination, excessive crying of the infant
• There may be a yellowish mucus over the penis by day 2 * do not
wash it off
• No baby wipes because they have alcohol.
NEWBORN CARE: NUTRITIONAL NEEDS
• Normal Weight Loss and Weight Gain:
• 5-10% weight loss immediately after birth gained after 10-
14days.
• 110- 200g/week weight gain for the first 3months.
• Breast feeding the best nutritional source of food for the first
6months.
• COLOSTRUM =contains immunoglobulins providing passive
immunity. Secreted 1-3days.
• FEEDING FREQUENCY:
• Q2-3hours for breast feeding
• Q 3-4hours for bottle feeding
• Feed Q4hours at night
• Healthy newborn fluid intake 100-10mml/kg/24hours
• They receive enough water from breast milk so no need to
supplement with water.
NEWBORN CARE: NUTRITIONAL NEEDS
• CALORIE INTAKE :
• 110/kg/day for the first 3months
• 100/kg/day when they are now 3-6months
• Baby’s cannot digest fat from cows as easily this is why cow
milk is not given.
• They may be a need for vitamin D supplementation (especially
in dark skinned women who have limited exposure to the sun,
vegetarian mothers who exclude meat from their diert, fish
and dairy products.
• Iron = after 6 months the babys need to be given iron fortified
cereal; babys that are bottle fed should receive iron fortified
formula until they are 12months.
• Fluoride low in breast milk too so should be supplemented.
• SOLIDS should be given at 6months
NEWBORN CARE: NUTRITIONAL NEEDS
• BENEFITS OF BREASTFEEDING:
• Reduce infection by providingantibodies, leukocytes
• Large amounts of lactose provides rapid brain growth
• Has electrolytes and minerals
• Sucking associated with breastfeeding reduces dental
problems.
• Colostrum provides IgA antibodies.
• NEWBORN FACTORS THAT COULD CAUSE FAILURE TO
THRIVE:
• Inadequate breastfeeding
• Illness
• Infection
• Malabsorption
NEWBORN CARE: NUTRITIONAL NEEDS
• MATERNAL FACTORS THAT CAN CAUSE FAILURE TO THRIVE:
• Pain when feeding
• Inappropriate timing of feeding
• Inadeqaute breast tissue
• Maternal hemorrhage
• Illness
• Infections
• Breasts are not emptying well
• THINGS TO ASSESS FOR :
• Growth and weight gain
• Weigh daily while I nursery
• Weigh when 2weeks for breast fed infants
• Weigh at 6 weeks for formula fed infants.
• Adeqaute wieght gain is within the 10th to 90th percentile
• Monitor length and head circumference
• Calculate the newborns 24hour intake
NEWBORN CARE: NUTRITIONAL NEEDS
• NURSING INTERVENTIONS:
• Feed when the infant is showing signs of hunger rather than waiting
for the infant to start crying.
• Signs of hunger (hand to mouth, or hand to hand movements,
sucking motions, rooting, mouthing.
• SUCCESSFUL BREASTFEEDING:
• Get comfortable, wash hands before holding the breast and have
fluids to maintain hydration and allow let down
• Stimulation of the nipple releases oxytocin  let down.
• Uterine cramps are normal during breastfeeding (they care cuased
during oxytocin).
• Show proper latch position (support the breast with one hand and
compress the breast, stimulate the infant by rubbing our nipple on
the baby's mouth, the mouth should cover the areola as well as the
nipple.
• Squeeze some colostrum and spread it over the nipple to lubricate
the nipple
NEWBORN CARE: NUTRITIONAL NEEDS
• Teach the mother to breastfeed for at least 15mins each breast
• Insert the finger in the mouth to break the suctioning from the nipple this prevents
nipple trauma.
• Burp between births.
• Start the next feeding with the breast that she stopped the infant with in the last
feeding.
• To make sure that the infant is receiving enough feeding the infant will gain weight,
void 6-8 times a day
• Loose pale, yellow stools are normal with breast feeding
• Place the baby in supine position after feeding
• STORAGE OF BREAST MILK:
• If the mother is using a breast pump store the milk in the fridge for up to 48hr after
being pumped.
• Throw away after 48hours
• Label the containers so you know the dates and time the milk was expressed.
• Can be stored in the freezer for up to 1 year.
• If kept in the freezer thaw the milk in the fridge for 24hours ( this preserves the
immunoglobulins.
• Do not thaw by microwave.
NEWBORN CARE: NUTRITIONAL NEEDS
• SUCCESSFUL BOTTLE FEEDING:
• Prepared formular can be kept in the fridge for 48hours
• Cradle the baby in a semi-upright position when holding the baby *
don’t feed the baby while in supine position this will cause
aspiration.
• The nipple of the bottle must be kept filled to prevent the newborn
from swallowing air if partially filled.
• Throw away any unused formula as it can cause bacterial
contamination
• FAILURE TO THRIVE
• This is slow weight gain
• The baby falls in the 5th percentile
• Evaluate the latch during breast feeding
• Massage the breast during feeding to encourage let down
• If the baby is formula feeding evaluate how much they feeding
• Vomiting a lot if they are bottle feeding may be a sign that they are
allergic to cow milk and they may need to be moved to soy milk.
POSTPARTUM: NEW BORN
COMPLICATIONS
CARE OF THE NEWBORN: COLD STRESS

• Complication of poor thermoregulation


• Can lead to hypoxia, acidosis and hypoglycemia.
• SYMPTOMS OF COLD STRESS: cyanotic trunk,
depressed respirations.
• PREVENTION: avoid any heat loss (cover the babys
head with the hat to prevent heat loss, place the baby
under the heating bed. * keep the baby warm.
• INTERVENTION FOR COLD STRESS:
• Slowly warm the baby over 2-4hours
• If the baby has hypoxia give oxygen
• Correct the acidosis and hypoglycemia
NEWBORN COMPLICATIONS: RDS
• RDS = RESPIRATORY DISTRESS SYNDROME
• Caused by not enough surfactant (phospholipid that helps
in the expansion of the lungs) in the lungs
• Characteristics = poor gas exchange and ventilation failure.
• Poor gas exchange  ATELECTASIS (collapsing of the
portion of the lungs)  increased breathing effort 
respiratory acidosis and hypoxemia.
• COMPLICATIONS OF RDS:
• Pneumothorax
• Pneumomediastinum
• Retinopathy
• Bronchopulmonary dysplasia
• Infection
• Intraventricular hemorrhage
NEWBORN COMPLICATIONS: RDS
• FACTORS INCREASING THE RISK OF RDS:
• PRETERM * biggest one (but birth weight alone is not an
indicator).
• Perinatal asphyxia (e.g meconium statining, cord prolapse,
nuchal cord).
• Maternal diabetes
• PROM
• Mother who uses barbituates, and narcotics close to birth.
• C- section birth
• Hydrops fetalis = massive edema of the fetus caused by
hyperbilirubinemia.
• DIAGNOSTICS :
• ABG’s will show hypercapnia (too much CO2 in the blood)
and respiratory or mixed acidosis.
NEWBORN COMPLICATIONS: RDS
• SIGNS AND SYMPTOMS OF RDS:
• Tachypnea
• Intercoastal and substernal retractions
• Labored breathing
• Rales when auscultation
• Nasal flaring
• Cyanosis
• LATE SIGNS= infant is unresponsive, flaccid, apneic, decreased breath
sounds.
• NURSING INTERVENTIONS
• Suction mouth, trachea and nose
• Thermoregulation
• Give meds (NARCAN AND exogenous surfactant).
• Give mouth and skin care
• Give SODIUM BICARBONATE FOR METABOLIC ACIDOSIS
• Oxygen
• Decrease stimulation
NEWBORN COMPLICATIONS: LGA/MACROSMNIA
• LGA = weighing more than 4000g (8lbs 12oz).
• Macrosmic infants are at high risk for birth injuries:
Clavicle fracture, hypoglycemia and polcythemia
• Most common cause for Lga is uncontrolled
hyperglycemia during pregnancy. This can lead to
congenital defects (most common congenital heart
defects, CNS abnormalities).
• CONTRIBUTING FACTORS TO LGA INFANT:
• Post term infant *
• Maternal diabetes*
• Genetics
• Obesity
• Multiparous mother
NEWBORN COMPLICATIONS: LGA/MACROSMNIA
• SIGNS AND SYMPTOMS OF LGA
• More than 4000g
• Plump and full faced(cushingoid appearance from increased
fat).
• Signs of hypoxia
• Birth traumas (fractures, intercranial hemorrhage, CNS injury).
• Hypotonic muscles
• Tremors caused by HYPOCALCEMIA
• Signs of HYPOGLYCEMIA.
• Signs of RD from immature lungs or meconium aspiration.
• NURSING INTERVENTIONS:
• Heel stick for glucose testing
• Early feeding or IV therapy to maintain normal glucose levels
• Thermoregulation
• Identify any injuries and treat.
NEWBORN COMPLICATIONS: LGA/MACROSMNIA
• DIAGNOSTICS & THERAPEUTIC INTERVENTIONS:
• C- section
• Chest x- ray to rule out meconium aspiration
syndrome.
• Blood glucose level monitoring for hypoglycemia (less
than 40mg/dl)
• ABG may show hypoxia
• CBC may show POLYCYTHEMIA (hematocrit greater
than 65%) due to the utero hypoxia.
• HYPERBILIRUBINEUMIA caused by polycythemia as
excess RBC break down after birth.
• Hypocalcemia due to the long birth.
NEWBORN COMPLICATIONS: SGA
• SMALL FOR GESTATIONAL AGE INFANT = SGA infant below the 10th
percentile.
• COMPLICATIONS OF SGA:
• Perinatal asphyxia
• Meconium aspiration
• Hypoglycemia
• Polycythemia
• Instability of body temp
• CONTRIBUTING FACTORS TO SGA:
• Genetic
• Maternal infections, disease, malnutrition
• Gestational hypertension or diabetes
• Smoking alcohol, drug use
• Multiple gestations
• Placental factors (small placenta, placenta previa, decreased placental
perfusion).
• Fetal infections (rubella and toxoplasmosis).
NEWBORN COMPLICATIONS: SGA
• SIGNS AND SYMPTOMS OF SGA:
• Weight below the 10th percentile
• Normal skull but reduced body dimensions
• Reduced subcutaneous fat
• Loose dry skin
• Drawn abdomen *not well rounded.
• Scalp hair sparse
• Wide skull sutures from inadequate bone growth.
• Wide eyed and alert which may be cause by prolonged
fetal hypoxia
• Signs of meconium aspiration, hypoglycemia hypothermia
• Thin, dry and yellow umbilical cord rather than grey,
glistening and moist.
• Signs of respiratory distress and hypoxia.
NEWBORN COMPLICATIONS: SGA
• NURSING INTERVENTIONS:
• Maintain open airway
• Maintain thermoregulation
• Parenteral nutrition
• Hydration
• Prevent skin break down
• Protect from infection
• Conserve the newborns energy level
• Partial exchange transfusion to reduce the
viscosity of the blood if prescribed.
NEWBORN COMPLICATIONS: HYPOGLYCEMIA
• HYPOGLYCEMIA = glucose levels less than 40mg/dl
• Watch for hypoglycemia especially in infants with LGA.
• It differs in preterm and term newborn.
• Hypoglycemia that occurs in the first 3 days in a term born
newborn = glucose level <40mg/dl.
• Hypoglycemia in pre-term newborn = blood glucose
<25mg/dl.
• If left untreated can lead to mental retardation.
• CONTRIBUTING FACTORS :
• Maternal diabetes
• Pre term infant
• LGA
• Stress at birth Like cold stress and asphyxia
• Maternal epidural.
NEWBORN COMPLICATIONS: HYPOGLYCEMIA
• SIGNS AND SYMPTOMS:
• Poor feeding
• Jitteriness and tremors
• Hypothermia
• Diaphoresis
• Weak shril cry
• Lethargic
• Flaccid muscle tone
• Seizures and comas
• NURSING INTERVENTIONS:
• Heel stick for glucose monitoring
• Frequent oral or guavage feeding to treat the hypoglycemia.
• COMPLICATIONS
• Seizures, brain damage and death if left untreated.
NEWBORN COMPLICATIONS: HYPERBILIRUBINEMIA
• HYPERBILIRUBINEMIA = increased bilirubin levels  jaundice.
• Jaundice usually happens in cephalocaudal manner ( starts at the
head the sclera and mucous membranes then progresses down to
the thorax, abdomen, extremities).
• JAUNDICE CAN BE PHYSIOLOGICAL OR PATHOLOGICAL.
• PHYSIOLOGICAL JAUNDINCE :
• caused by increased bilirubin production due to the shortened
lifespan and breakdown of fetal breakdown of fetal RBC and liver
immaturity.
• Normal
• The baby shows no other symptoms of jaundice fater 24hours.
• PHATHOLOGICAL JAUNDICE:
• Appears after 24hours of birth and persists 7 days after.
• Caused by blood group incompatibility or an infection OR RBC
disorder.
• Will occur if the mothers blood group is incompatible with the fetus
blood type.
NEWBORN COMPLICATIONS: HYPERBILIRUBINEMIA
• KERNICTERUS:
• Caused by untreated hyperbilirubinemia
• The bilirubin levels will be higher or equal to 25mg/dl.
• Neurological syndrome caused by bilirubin depositing in the
brain cells.
• May lead to cerebral palsy, epilepsy, mental retardations
• The infant may develop learning disorders or perceptual motor
disorders.
• RISK FACTORS:
• Increased RBC production and breakdown
• Rh or ABO incompatibility.
• Decreased liver function
• Maternal enzymes in breast milk
• Hypoglycemia and hypothermia
• Anoxia
• Ineffective breast feeding
NEWBORN COMPLICATIONS: HYPERBILIRUBINEMIA
• DIAGNOSTIC PROCEDURES:
• Elevated serum bilirubin level (monitor the infants bilirubin levels
q4hrs until the levels return to normal).
• DIRECT COOMBS TEST shows antibody- coated (sensitized) Rh positive
RBCs in the newborns.
• Electrolyte levels for dehydration from phototherapy.
• SIGNS AND SYMPTOMS OF JAUNDICE:
• Yellowish tint to the skin, sclera and mucous membranes
• Verify that the infant has jaundice (press the infants skin cheek,
abdomen with one finger then release and watch the skin color for a
yellowish tint when the skin is blanched).
• Note when the jaundice started (this will help tell whether someone
has physiological or pathological jaundice).
• SIGNS AND SMPTOMS OF KERNICTERUS
• Yellowish ski
• Lethargy, hypotonic, poor suck, backward arching of the back and
neck if left untreates, high pitched cry, fever.
NEWBORN COMPLICATIONS: HYPERBILIRUBINEMIA
• TREATMENT:
• Phototherapy
• Cover the babys eyes with an eye mask
• Keep the new born undressed with the exception of males.
*surgical mask should be placed over the male (like a bikini over
the genitals to prevent testicular damage from the heat and
light waves).
• Remove any metal
• Do not apply any lotions and ointments because this will cause
burns.
• Remove the newborn from phototherapy every 4hours and
remove the eye mask for signs of inflammation and injury.
• REPOSITION the baby every 2hours to prevent pressure sores
and expose all body surfaces.
• Turn off phototherapy lights before drawing blood for testing.
NEWBORN COMPLICATIONS: HYPERBILIRUBINEMIA
• SIDE EFFECTS OF PHOTOTHERAPY:
• Bronze discoloration
• Maculopapular skin rash
• Pressure areas
• Dehydration
• Poor skin turgor.
• Elevated temperature.
• NURSING INTERVENTIONS DURING PHOTOTHERAPY:
• Monitor elimination daily watching for dehydration
• Temperature monitoring because the temp will
become elevated.
NEWBORN COMPLICATIONS: HYPERBILIRUBINEMIA
• NURSING INTERVENTSIONS FOR
HYPERBILIRUBINEMIA:
• Feeding early and frequently q3-4hrs to promote
bilirubin excretion in the stools.
• Adequate fluid intake to prevent dehydration
• Reassure the parents that some level of jaundice
does occur.
• Teach the parents that the stool will be containing
bile so the stool will look loose and green.
• Explain the test and treatment procedures to the
parents.
NEWBORN COMPLICATIONS: SEPSIS
• INFECTION:
• Babys are more susceptible because of the
immaturity of their immune system.
• NEONATAL SEPSIS:
• Micro- organisms or toxins in the blood or tissues of
the infant during the first month after birth
• Presence of more than one micro-organism shows
infection.
• PREVENTION OF INFECTION AND NEONATAL
SEPSIS:
• Use asceptic technique during delivery
• Care of the umbilical cord
• Prophylatic eye treatment (erythromycin)
NEWBORN COMPLICATIONS: SEPSIS
• RISK FACTORS CONTRIBUTING TO INFECTION
OR SEPSIS:
• PROM
• TORCH (toxoplasmosis, rubella, cytomegalovirus,
herpes)
• Premature birth
• Low birth weight
• Substance abuse
• Maternal UTI
• Meconium
• HIV
NEWBORN COMPLICATIONS: SEPSIS
• SIGNS AND SYMPTOMS OF INFECTION/ SEPSIS:
• Temp instability
• Drainage in the eyes and umbilical cords
• Poor feeding
• Vomitting and diarrhea
• Poor weight gain
• Abdominal distention
• Large amounts of residual if the infant was feeing by
gavage
• Apnea, grunting, nasal flaring and sternal retractions
• Low oxygen saturations
• Color changes : jaundice, pallor, petechae
• Tachycardia or bradycardia
• Poor muscle tone and lethargic
NEWBORN COMPLICATIONS: SEPSIS
• NURSING INTERVENTIONS:
• Specimens (blood, urine and stool to identify the
causative organisms).
• Maintain temperature
• Give meds
• Iv therapy for electrolyte replacement
• Hand washing, don’t store left over formula,
breast hygeine.
NEW BORN DISCHARGE TEACHINGS
NEWBORN CARE TEACHING DISCHARGE
• TEACH:
• causes of crying, quieting techniques, sleeping patterns,
feeding, bathing and clothing the infant.
• Following infant check ups and immunization schedules
• Signs of illness and When to call the physician.
• Infant safety and proper car seat use.
• CRYING:
• Baby cries when they are hungry, wet, cold, hot, tired,
bored, over stimulated.
• Do not feed the baby every time the baby cries.
• QUIETING TECHNIQUES:
• Warm the crib sheets with hot water bottle.
• Swaddle the infant
• Comfort the baby by rocking and listening
NEWBORN CARE TEACHING DISCHARGE
• SLEEPING
• Don’t sleep with the baby – risk of suffocation
• Place baby in supine position – reduces SIDS.
• Babys sleep 16-24hours in 2-3hours at a time
• Bathe before bedtime
• Last feeding at 11p.m
• Ro reduce day/night confusion bring the baby into the living
room (centre of the action during the day).
• ORAL AND NASAL SUCTIONING:
• Bulb syringe to suction nose and mouth
• Start with the mouth first
• Squeeze bulb first before inserting it into the nose or mouth.
• When suctioning the mouth, place the bulb at the sides of the
mouth not the middle
NEWBORN CARE TEACHING DISCHARGE
• HOLDING THE NEWBORN
• support the head ***
• BATHING THE NEWBORN:
• Teach by demonstration then have the parents
demonstrate it back.
• Start from eyes, face, head, chest, arms, legs ,groin last.
• The soap used must not have HEXACHLOROPHENE.
• Clean the face and perineal area daily but complete bath
2-3times a week.
• Should be done before feeding to prevent vomiting and
spitting.
• Sponge bath until the umbilical cord falls off.
• Do not use any lotions, oils or powders because they
create an area for bacterial growth.
NEWBORN CARE TEACHING DISCHARGE
• FEEDING AND ELIMINATION:
• Feeding = on demand or every 2-3hours
• Breast feed 20-30mins per breast
• Bottle fed infants should be fed every 3-4hours
• 6-8 wet diapers/day
• 3-4 stool diapers/day
• Burp between breasts. Prevents gas and chances of the infant
vomiting.
• Keep the infant upright for a few mins after feedings because
thee are chances they may want to spit up.
• CORD CARE:
• Report any foul odor, drainage or redness
• Avoid water on the cord until it falls off
• CIRCUMCISION CARE:
• Petroleum jelly on the penis for the first 24hours so it doesn’t
stick to the diaper.
NEWBORN CARE TEACHING DISCHARGE
• SAFETY:
• No small objects – choking hazard
• Never leave the infant unattended with pets or other
small children or on the bed alone.
• Don’t place on stomach
• Eliminate potential fire hazards by keeping the baby
crib and stuff away from radiators, heat vents. *they
can catch fire.
• INFANT WELLNESS CHECK UPS:
• Check ups at 2-6weeks of age then every two months
until 6months of age.
• Its important to get immunizations on time to protect
against diptheria, tetanus, pertussis, Hep B, flu, polio,
measles, mumps, rubella and varicella.
NEWBORN CARE TEACHING DISCHARGE
• ILLNESSES OR SIGNS TO REPORT:-
• Fever above 38 degrees celcius
• Poor feeding or little interest in food
• Frequent vomiting
• Diarrhea or decreased bowel movements
• Decreased urination
• Labored breathing
• Cyanosis
• Jaundice
• Lethargy
• Difficulty walking
• Inconsolable crying
• Bleeding or purulent bleeding around the umbilical cord or
circumcision
• Drainage around the eyes.
MATERNAL POSTPARTUM PERIOD

 PHYSIOLOGICAL CHANGES
 POST PARTUM MATERNAL
COMPLICATIONS
POSTPARTUM PHYSIOLOGICAL
CHANGES
 DIC
• DIC = DISSEMINATED INTRAVASCULAR COAGULATION is a clotting
disorder in which the clotting and anticlotting mechanism is
activated at the same time.
• Increased clotting consumes and destroys the amounts of clotting
factor (platelets, fribinogen, prothrombin and factors V & VII).
• The decrease in clotting factor  external and Internal bleeding 
formation of small clots in the microcirculation triggering vascular
occlusion of the small vessels  ischemia.
• FIRST SIGN OF COAGGULATION PROBLEMS ?
• When the ways usually used to stimulate uterus contractions and
contractions fails to stop vaginal bleeding.
• COMPLICATIONS OF DIC ?
• Hemorrhage ; renal failure; organ ischemia  tissue death 
major organ failure.
 DIC
• RISK FACTORS OF DIC ?
• Abruptio placenta
• Amniotic fluid embolism
• Missed abortion
• Fetal death in utero
• Septicimia
• Gestational hypertension
• SIGNS AND SYMPTOMS OF DIC ?
• Unusual spontaneous bleeding from the clients gums or nose
• Oozing or trickling of blood from the incision, lacerations and
episiotomy
• Hematuria, hematemesis or vaginal bleeding
• Presence of blood in stools.
• Increase in Pt and PTT, clotting time fibrinogen degeneration
products.
 DIC
• NURSING INTERVENTIONS ?
• The focus should be on assessing for the
correction of the underlying cause (removal of
the dead fetus, treatment of infection,
preclampsia or removal of placenta abruption).
• Monitor vital signs and signs for shock
• Oxygen, volume replacement, blood component
therapy and possibly heparin.
• Monitor for signs of complications associated
with the fluid and blood replacement.
• Monitor urine output and maintain at 30ml/hr
(because renal failure is a complication of DIC).
CHP 34: POSTPARTUM PHYSICAL ADAPTATION
• POST PARTUM STAGE:
• 4th stage of labor.
• Starts after the delivery of the placenta to when the body returns to its
nonpregnant state.
• Usually takes about 6weeks
• The initial dangers are = hemorrhage, shock and infection.
• The body starts to satbilize the internal organs returning to the non-
pregnant state.
• Parent-infant bonding starts at this stage.
• POSTPARTUM ASSESSMENT IMMEDIATELY AFTER DELIVERY SHOULD
LOOK AT :
• Vital signs
• Uterus : firmness, location in relation to the umbilicus, uterus position in
relation to the midline of the abdomen and the amount of vaginal
bleeding.
• Cervix, vaginal and perineal healing
• Bladder functions
POSTPARTUM PHYSICAL ADAPTATION: FUNDUS
• WHAT IS INVOLUTION OF THE UTERUS ?
• Involution = decrease in the size of the uterus returning to its non
pregnant state.
• Immediately after breastfeeding the fundus is found midline at
approximately the level of the umbilicus. 12hours postpartum its 1cm
above the umbilicus
• Breast feeding stimulates the release of Oxytocin from the pituitary gland
which strengthens uterus contractions  rapid involution. 8 encourage
early breast feeding
• the uterus decreases in weight from 2.2lbs to 2oz in 6weeks.
• The fundal height decreases about 1cm (1 finger breadth) per day.
• By day 10 the uterus is now within the true pelvis & cannot be palpated
abdominally.
• Tender fundus = infection
• Boggy (non firm uterus )= uterine atony massage till firm.
• NURSING INTERVENTION ?
• Document the consistency (firm or boggy), location & height of the fundus
• Give Pitocin or methergene to promote uterine contractions.
POSTPARTUM PHYSICAL ADAPTATION: LOCHIA

• WHAT IS LOCHIA ?
• Blood flow from the uterus during the postpartum stage
• Lochia is made up of ?
• Blood from the vessels of the placenta attachment site to the
uterus, debris from the exfoliation of the decidua (thickening
lining of uterine endometrium during pregnancy).

• WHAT ARE THE 3 STAGES OF LOCHIA ?


• LOCHIA RUBRA =bright red bloody consistency may have small
clots. Lasts 1-3days after delivery.
• LOCHIA SEROSA= pinkish/brown color contains old blood,
leukocytes, tissue debris. Lasts day 4-10 after delivery
• LOCHIA ALBA= yellowish/white creamish color. Contains
decidua, mucus, serum, bacteria, leukocytes. Lasts from day 11-
week 6 postpartum
POSTPARTUM PHYSICAL ADAPTATION: LOCHIA

• ASSESSMENT OF LOCHIA ?
• Color, amount and consistency
• Usually trickles down but may gush down on
ambulation or massaging the uterus.
• SIGNS OF ABNORMAL LOCHIA ?
• Excessive spurting of bright red blood from the
vagina. Could be a sign of a tear.
• Numerous large clots
• Persistent lochia rubra beyond 3 days *this is a sign
that they are retained placenta fragments.
• Continued flow of lochia for more than the
expected days with a fever or abdominal
tenderness.
POSTPARTUM PHYSICAL ADAPTATION: LOCHIA

• NORMAL AND ABNORMAL AMOUNTS OF LOCHIA ?


• Scant = less than 2.5cm/1in on the pad in 1hour
• Light = less than 10cm/4inch
• Moderate = less than 15cm/6inches
• Heavy = saturated pad in an hour
• Excessive = pad saturated in less than 15mins
• CHANGES IN THE CERVIX, VAGINA & PERINEUM ?
• CERVIX = soft after delivery but 2-3days postpartum
becomes firm again with the os gradually closing.
• VAGINA= no rugae and thin mucosa due to the low
estrogen immediately after. But It gradually returns to its
normal size with the reappear, thickening of the vaginal
mucosa but the muscle tone is never fully regained.

POSTPARTUM PHYSICAL ADAPTATION: LOCHIA

• ASSESSMENT, NURSING INTERVENTIONS & COMFORT


MEASURES FOR CERVICAL, VAGINAL & PERINEAL
HEALING:
• Assess the episiotomy for drainage quality and quantity.
Bright red blood early postpartum period is normal.
• Watch for edema, hematoma and erythema.
• NURSING INTERVENTIONS
• Stool softeners
• Proper cleaning (from front to back each time you void)
• COMFORT MEASURES:
• Ice packs to the perineum for the first 24-48hours to
reduce edema.
• Sitz bath at least twice a day.
• Witch hazel (tucks) to the rectal area for hemorrhoids.
POSTPARTUM PHYSICAL ADAPTATION: BREASTS

• Secret colostrum for 48-72hours after delivery.


• Decrease in estrogen and progesterone after delivery stimulates
increase in prolactin  stimulating the production of breast
milk.
• Breasts become distended with milk on the third day.
• Engorged nipples usually occur in the 4th day in non-breast
feeding mothers.
• Teach proper latch on techniques to prevent nipple soreness.
• Breastfeeding  releasing oxytocin  promoting uterine
contractions.
• HOW SHOULD NON BREAST FEEDING MOTHERS CARE FOR
THEIR BREASTS ?
• Avoid nipple stimulation
• Wear a tight fitting bra
• Ice pack compress
• Usually resolves 24-36hours after it begins.
POSTPARTUM: CARDIOVASCULAR

• blood loss during childbirth = 500ml vaginal birth, 1000ml c-


section. Diaphoresis and diuresis occurs within the first 2-3days
postpartum.
• Increase in WBC for the first 10-14days without and infection.
• Coaggulation factors increased for 2-3weeks postpartum.
Venous stasis of the lower extremities during the last part or
pregnancy and the client immobility during recovery  risk for
thrombus formation.
• VITAL SIGNS:
• Temp= rises due to dehydration. Higher than 100.4 degrees is an
infection.
• Pulse = bradycardia may decrease to 50 beats/min
• Blood pressure = normal * if hypotension  it may be
hypovolemia
• RESPS= remain unchanged. * if they increase suspect pulmonary
embolism
POSTPARTUM: URINARY & GI CHANGES

• URINARY TRACT:
• Urinary retention is the major issue due to the lack of
elasticity and tone and loss of sensation in the bladder
from trauma, meds, anesthesia,
• Diuresis usually starts within the first 12hours after
delivery.
• GI TRACT
• Hunger
• *constipation
• Hemorrhoids are common (tuck is the herb for
hemorrhoids).
• Eat high fiber diet
• Encourage ambulation
• Give stool softner.
POSTPARTUM: BONDING & INTERGRETING THE INFANT INTO THE
FAMILY
• FACTORS AFFECTING INFANT BONDING ?
• Mothers emotional and physical condition: unwanted
pregnancy, teen pregnancy, depression, difficult pregnancy and
delivery infants physical conditions.
• Separation of the mother and infant after birth due to
complications this delays the bonding process.
• Culture, age and socioeconomic status.

• BEHAVIOUS THAT FACILITATE AND INDICATE MOTHER-INFANT


BONDING ?
• EN FACE = holding the infant face to face maintaining eye
contact.
• Considers the infant a family member
• Maintains close proximity with the infant.
• Smiles and coos at the infant
• Communicates with pride to the infant.
POSTPARTUM: BONDING & INTERGRETING THE INFANT INTO THE
FAMILY
• SIGNS SHOWING LACK OF MOTHER-INFANT BONDING ?
• Apathy when infant cries
• Disgust when the infant voids, stools or spits up.
• Expressing disappointment in the infant
• Doesn’t want to be close to the infant
• Does not talk about the infants unique features.
• Ignores the infant totally
• Views the infants behavior as deliberately unco-operative.
• NURSING INTERVENTIONS TO ENCOURAGE BONDING ?
• Allow skin to skin contact as soon as the infant is born
• Encourage the mother when she is doing stuff like changing
diapers.
• Encourage the mother to do stuff with the infant that will help
with bonding, for instance, bathing, feeding and talking to the
baby.
POSTPARTUM: BONDING & INTERGRETING THE INFANT INTO THE
FAMILY
• PATERNAL ADAPTATION = father becoming engrossed with the infant and
transitioning to fatherhood & developing infant-parent bond.
• ENGROSSMENT = father being absorbed and preoccupied with the infant.
• SIGNS OF ENGROSSMENT ?
• Talking to the infant
• Finding features in the infant that look like his (validating that its his)
• Touching, holding and maintaining good eye contact with the infant.
• STAGES OF TRANSITIONING INTO FATHERHOOD
• Occurs in 3 stages
• Stage 1: expectation =the father has ideas of what he thinks it will be like
when the infant comes home

• Stage 2: reality = the expectations may be different from reality. May have
some sadness, jealousy of the infant, ambivalence, feeling of surprise at
the reward of parenting.

• Stage 3: transition to mastery = father is more determined to be an active


father.
POSTPARTUM: BONDING & INTERGRETING THE INFANT INTO THE
FAMILY
• 3 STAGES OF FATHER INFANT BONDING PROCESSING ?
• MAKING A COMMITMENT = having a sense of duty and
responsibility.
• BECOMING CONNECTED= feeling of excitement, joy at the first
meeting with the infant. Will start to see the infant as
predictable.
• MAKING ROOM FOR THE INFANT = starts to change his schedule
to accommodate the infant.
• NURSING INTERVENTION TO HEP WITH FATHER-INFANT
BONDING ?
• Educate the father on infant care
• Assist the father in activities that will help the father become
more involved rather than just a helper.
• Encourage the couple to discuss their expectations and division
of labor
POST PARTUM MATERNAL
COMPLICATIONS
POST PARTUM HEMORRHAGE
• Leading cause of mortality in the U.S
• WHAT IS POSTPARTUM HEMORRHAGE ?
– Bleeding of more than 500ml after a vaginal delivery
– Bleeding of more than 1000ml after a c-section birth.
– EARLY HEMORRHAGE = occurs in less than 24hours after
delivery
– LATE HEMORRHAGE = occurs after 24hours from delivery
– 10% change in hematocrit values from the baseline values
(values taken during the admission from the postpartum
values).
• WHAT COMPLICATION CAN HEMORRHAGE LEAD TO ?
– Hypovolemic shock.
– Anemia (so watch for hemoglobin & hematocrit levels plus
educate the patient on folic acid and iron dietary source).
POST PARTUM HEMORRHAGE
• WHAT ARE THE SIGNS OF HYPOVOLEMIC SHOCK ?
– Hypotension
– Tachycardia
– Weak thready pulse
– Rapid shallow breaths
– Oliguria
• WHAT ARE THE CAUSES OF POSTAPARTUM
HEMORRHAGE ?
– uterine atony (poor muscle tone) * MOST COMMON
CAUSE.
– Vaginal laceration
– Cervix, perineum or labia hematoma
– Placenta fragments that remained.
POST PARTUM HEMORRHAGE
• WHAT ARE THE CONTRIBUTING RISK FACTORS
FOR HEMORRHAGE ?
– Dystocia
– Pre-longed labor
– Operative delivery – (c-section, forcep delivery, intra-
uterine manipulation).
– Overdistention of uterus – polyhydramnios, multiple
gestations or large neonates.
– Abruptio placentae
– Previous history of postpartum hemorrhage
– Infection
– Placenta previa
POST PARTUM HEMORRHAGE
• WHAT ARE THE SIGNS AND SYMPTOMS OF
POSTPARTUM HEMORRAHGE ?
– Uterine atony
– Blood clots larger than a quarter
– Pad saturation in less than 15mins
– Rising pulse rate & decreasing pulse rate (often the
first warning of decrease in blood volume).
– The skin is cool and clamy with poor skin turgor
– Oliguria
– Constant oozing or flowing of bright red blood from
the vagina
– When the lochia changes back from lochia serosa or
alba to lochia Rubra.
POST PARTUM HEMORRHAGE
• WHAT ARE THE NURSING INTERVENTIONS
WHEN YOU SUSPECT POSTPARTUM
HEMORRAHGE?
– Assess the patient for the location of the bleeding
– Assess the fundus for height, firmness and
position. * you are massaging the fundus for
uterine atony.
– Check the lochia (it will be lochia rubia).
– Check for signs of lacerations, the episiotomy sign
or a hematoma
– Vital signs (tachycardia, hypotension).
POST PARTUM HEMORRHAGE
• NURSING INTERVENTIONS FOR HEMORRHAGE ?
• Massage the fundus for uterine atony
• Notify the physician
• Monitor the vital signs and the fundus every 5mins-
15mins.
• Remain with the patient.
• Stop the site of the blood loss if possible.
• IV fluids (volume expanders albumin, NS, PRBC)
• Oxygen 2-3L per nasal cannula to increase the RBC
saturation of oxygen.
• Catheter to get an accurate measurement of output.
• Elevate legs to increase venous return.
INFECTION
• Postpartum infection Aka puerperal infection
• WHAT IS IT ?
• Infection of the genital birth canal tht occurs after childbirth, abortion or
miscarriage.
• WHAT ARE THE SIGNS OF INFECTION ?
• Fever of 100 degrees (38 degrees Celsius) for 2 days or more during the
first 10days
• Fever in the first 24hours is normal
• WHAT IS THE MAJOR COMPLICATION OF POSTPARTUM INFECTION ?
• Septicemia
• WHAT ARE THE TYPES OF INFECTION ?
• ENDOMETRITIS = infection of the endometrial lining, decidua, and
myometrium of the uterus. * most common infection, usually starts in the
2nd to 5th postpartum day
• PARAMETRITIS = infection spread by the lymphatic system through the
uterine wall or pelvis
• PERITONITIS = infection of the peritoneum.
INFECTION
• WHAT IS THE CAUSE OF INFECTION/PATHOPHYSIOLOGY ?
• Introduction of the vaginal micro-organisms into the the
sterile uterine area through:
• Premature rupture membranes
• Operation incisions
• Hematoma
• Damaged tissue
• Not using sterile technique
• Retained placenta fragments because this allows for tissue
necrosis providing an area for bacterial growth.
• Postpartum hemorrhage
• Prolonged labor (one lasting more than 24hours. because it
opens up the cervix into the uterus with exposure to the
external environment through the vagina.
INFECTION
• WHAT ARE THE FINDING ASSESSMENTS WHEN ONE HAS A
POSTPARTUM INFECTION ?
• Fever of 100 degrees for 2 consecutive days during the first
10-28days postpartum
• Fever in the first 24hours is normal because of dehydration.
• The fever usually comes with chills, backache, malaise,
restlessness & anxiety.
• Foul smelling lochia
• Lethargy
• Abdominal pain
• Anorexia
• Pelvic discomfort.
• Elevated WBC
INFECTION
• NURSING INTERVENTIONS FOR POSTAPRTUM INFECTION ?
• Monitor vital signs every 2-4hours
• Closely monitor intake and output
• Place the mother in a position that promotes drainage
• If the patient has chills keep her warm
• If theres a chance of spreading the infection to the infant then
keep them separate but give constant updates on the infants
well being
• Increase intake to 3000-4000ml unless contraindicated.
• Encourage frequent voiding
• Closely monitor intake and output.
• Frequently check the perineum assessing the fundus to palpate
it for tenderness (subinvolution may be a sign for endometritis).
• Note the color odor of the vaginal drainage and document your
observations.
MASTITIS
• WHAT IS MASTITIS ?
– Inflammation of the breast due to infection.
– Usually seen as a tender localized hard mass with redness
in that area.
– Usually on one breast.
– Usually occurs in breast feeding women 2-3weeks after
delivery but may occur anytime during lactation.
– Usually occurs in primiparas
• WHAT IS THE CAUSE ?
– Staphylococcus aureus from the neonates throat or nose
– The bacteria usually enters through a crack or fissure in
the nipples.
– The bacteria enters travels through the milk ducts.
MASTITIS
• WHAT ARE THE RISK FACTORS THAT CAN CONTRIBUTE TO MASTITIS
?
– Fissure or crack in the nipple
– Blocked milk ducts (from wearing restrictive bras, or waiting too long
to breast feed)
– Incomplete let down
– Milk stasis from blocked milk ducts
– Poor breast feeding technique with improper lacthing of the infant
onto the breast leading to sore cracked nipples.
– Decrease in breast feeding when the mother is supplimenting with
bottle feeding.
– Poor hand hyegeine

• HOW CAN MASTITIS BE PREVENTED?


– Good breast and hand hygiene
– Washing your hands before holding your breasts.
MASTITIS
• WHAT ARE THE SIGNS AND SYMPTOMS OF MASTITIS ?
– Localized heat and swelling
– Pain, tender axillary lymph nodes (axillary adenopathy)]
– Elevated temp
– Complaints of flu like symptoms (malaise and headache).

• WHAT ARE THE NURSING INTERVENTIONS FOR MASTITIS ?


• Teach good hand washing and breast hygiene techniques.
• Wash hands before touching your breast.
• Apply heat or cold compress to the site
• Encourage the use of a breast pump every 4hours
• Give analgesic and antibiotics as prescribed.
UTERINE ATONY
• WHAT IS UTERINE ATONY ?
• Aka hypotonic uterus
• Hypotonic uterus that is not firm
• Boggy uterus
• IF LEFT UNTREATED WHAT IS THE COMPLICATION?
• Postpartum hemorrhage (because the myometrium of the uterus are
unable to contract and stay contracted  so the blood vessels of the
uteroplacenta implantation site are left open  post partum hemorrhage.
• Uterine inversion
• RISK FACTORS FOR UTERINE ATONY ?
• Retained placenta fragments
• Prolonged labor
• Macrosomic fetus (fetus large for gestational age)
• Trauma during the labor and birth during C-section, forcept assisted births
and vaccum assisted births.
• Use of oxytocin or magnesium sulfate or anesthesia
UTERINE ATONY
• WHAT ARE THE SIGNS FOR UTERINE ATONY ?
• Larger than usual uterus
• Prolonged lochia
• Irregular or excessive bleeding
• The uterus feels boggy and may be laterally displaced

• WHAT ARE THE THERAPEUTIC PROCEDURES FOR UTERINE ATONY ?


• All done by the physician
• BIMANUAL COMPRESSION = fist inserted into the vagina then using
the knuckles pressure is applied on the anterior side of the uterus
while the other hand is on the abdomen and massaging the posterior
uterus.
• MANUAL EXPLORATION = physician manually removes the retained
placenta fragments from the uterine cavity.
• HYSTERECTOMY
UTERINE ATONY
• NURSING INTERVENTIONS FOR UTERINE ATONY ?
• Make sure the bladder is empty (because this can distend and
displace the uterus).
• Massage the boggy fundus until its firm
• Remove clots that have accumulated in the uterus. * do not do
this unless the uterus is firm because if the uterus is still boggy
then this can cause uterine inversion and cause hemorrhage.
• Give OXYTOCIS :
• PITOCIN : but watch for water intoxication (lightheadedness,
nausea, vomiting, headache, malaise. Can become SERIOUS:
cerebral edema, seizures, coma, death).
• Q: METHERGINE : watch for Hypertension, N/V, headache
• ERGOTRATE: watch for Hypertension, N/V, headache
• PROSTAGLANDIN F (prostin 15M) : watch for fever, chills,
headache, N/V and diarrhea.
SUBINVOLUTION OF THE UTERUS
• WHAT IS SUBINVOLUTION ?
• Failure of the uterus to return to its normal size/pre-pregnant state.
• The uterus remains enlarged with lochia.
• May lead to postpartum hemorrhage.
• WHAT MAY BE THE CAUSE/ RISK FACTORS?
• Pelvic infection = endometritis
• Incomplete removal of placental fragments
• Retained fragments or infection interferes with the ability of the
uterus to contract effectively so the uterus remains enlarged and
soft.

• WHAT IS THE TREATMENT ?


• Methergine
• Patient teaching about methergine: will cause menstrual cramps.
SUBINVOLUTION OF THE UTERUS
• WHAT ARE THE SIGNS AND SYMPTOMS OF THE
SUBINVOLUTION?
• Uterus pain when you palpate
• Uterus that is larger than expected
• More than normal vaginal bleeding
• WHAT ARE THE NURSING INTERVENTIONS ?
• Assess the vital signs
• Monitor vaginal bleeding
• Assess the uterus and fundus for firmness
• Elavate the legs to encourage venous return
• Encourage frequent voiding
• Monitor the hemoglobin and hematocrit values (if low=
blood loss).
Chp 38 : HEMATOMA
• WHAT IS IT ?
• Collection of 250ml-500ml of clotted blood in the soft tissue of the
perineum
• Usually seen in the vulva and vagina
• Vulvar hematomas are the most common.
• Usually look like a buldging blue mass.
• Usually results from the breakage of blood vessels in the soft tissue
of the vagina and the perineum.
• An lead to postpartum hemorrhage of infection of the laceration.

• SIGNS AND SYMPTOMS ?


• Severe vulva pain *most significant sign
• Purplish discoloration
• Feeling of fullness/pressure in the vagina.
HEMATOMA
• RISK FACTORS FOR LACERATIONS ?
• Assisted Vaginal birth (forcep or vaccum assisted
births)
• Precipitate birth
• Cephalopelvic disproportion
• Macrosmic infant
• Prolonged pressure of the fetal head on the vaginal
mucosa
• Damage is pronounced in NULLIPAROUS WOMEN
because their tissue is firm, more resistant and less
distensible.
• Light skin women especially those with RED HAIR
because they have less distensible tissue
HEMATOMA
• WHAT ARE THE SIGNS AND SYMPTOMS FOR A
HEMATOMA OR LACERATION?
• Most significant sign is SEVERE VULVAR PAIN.
• firm contracted uterus despite vaginal bleeding
• Constant oozing ot trickling of bright red blood from
the vagina (hematoma blood = bright red; lochia
blood = dark red).
• Blood oozing from the laceration or episiotomy.
• Inability to void due to the pressure on the urethra
from the hematoma.
• Feeling you need to defecate because of hematoma
pressure on the rectum
• Decreased hemoglobin or hematocrit levels.
THROMBOPHLEBITIS AKA DVT
• WHAT IS DVT ?
• THROMBOSIS = Formation of a blood clot in the vessel
walls due to inflammation
• Partial obstruction of the blood vessel can occur.
• THROMBOPHLEBITIS = inflammation of a vessel wall caused
by the attachment of a blood clot to the wall with partial
blockage of the blood vessel.
• Superficial venous thrombosis = involves the surface veins
and saphenous veins.
• Deep Vein Thrombosis = involves the deep venous system.
Can extend from the foot to the iliofemoral region.
• WHAT COMPLICATION CAN THROMBOPHLEBITIS LEAD TO ?
• Pulmonary embolism
THROMBOPHLEBITIS AKA DVT
• WHAT ARE THE SIGNS AND SYMPTOMS OF THROMBOPHLEBITIS ?
• TENDERNESS, HEAT & PAIN ON PALPATION.
• POSITIVE HOMANS SIGN (pain in the calf when you dorsiflex).
• Localized redness and enlarged superficial hardened vein = sign for superficial vein
thrombosis.
• One sided leg pain (pain on one leg) that travels up to the knees, tender calfs,
swelling, extermity coolness and pale color = deep vein thrombosis
• Low grade fever and chills.

• WHAT ARE THE RISK FACTORS THAT LEAD TO POSTPARTUM THROMBOEMBOLIC


DISEASE:
• Immobility postpartum
• C-section
• Prolonged sitting and standing
• Smoking
• Multiparity
• History of thrombosis
• Obesity
• Women over 35yrs
THROMBOPHLEBITIS AKA DVT
• SIGNS AND SYMPTOMS OF THROMBOPHLEBITIS BASED ON TYPES:
• SUPERFICIAL THROMBOPHLEBITIS
• Palpable thrombus that feels bumpy and hard
• Pain and tenderness of the lower extremities.
• Warm and pinkish-red color over the thrombus area.
• Redness along the vein
• FEMORAL THROMBOPHLEBITIS:
• Malaise
• Chills and fever
• Positive homans sign (pain on the calf when dorsiflexing)
• Shiny skin over the affected area
• Pain, stiffness and swelling of the affected leg
• Decreased peripheral pulses.
• PELVIC THROMBOPHLEBITIS
• Severe chills
• Dramatic body temp changes
• Pulmonary embolism may be the first sign
THROMBOPHLEBITIS AKA DVT
• NURSING INTERVENTIONS BASED ON THE TYPE OF THROMBOPHLEBITIS:
• assess the lower extremity for edema, tenderness, varices and increased
skin temperature.
• Maintain bed rest
• Elevate the affected leg
• Never massage the leg
• SUPERFICIAL THROMBOPHLEBITIS:
• Bed rest
• Apply hot packs to the affected site
• TED hose stockings
• Analgesics.
• FEMORAL THROMBOPHLEBITIS
• Elevate leg
• Apply moist heat continously
• Prepare to give heparin
THROMBOPHLEBITIS AKA DVT
• NURSING INTERVENTIONS FOR PELVIC THROMBOPHLEBITIS ?
• Bed rest
• Give meds as ordered
• Avoid crossing the legs or sitting for long periods of time
• Avoid pressure behind the knees (so no pillows under the knees)
• TED hose
• Anticoaggulants
• TEACH THE PATIENTS SIGNS OF ADVERSE EFFECTS OF
ANTICOAGGULANTS:
• Bleeding from gums and nose
• Increased vaginal bleeding
• Blood in urine
• Bruising easily
THROMBOPHLEBITIS AKA DVT
• WHAT IS THE PATIENT TEACHING WHEN
SOMEONE IS TAKING THE ANTICOAGGULANTS ?
• Heparin and Coumadin will be given
• Avoid asprin
• Use an electric razor when shaving
• Avoid the use of alcohol because it inhibits the
action of anticoaggulation med coumadin.
• Brush teeth gently
• Avoid the massaging of the legs
• Avoid sitting for long time and crossing legs
THROMBOPHLEBITIS AKA DVT
• WHAT ARE THE WAYS IN WHICH ONE CAN AVOID
THROMBOPHLEBITIS ?
• Ambulate early
• Avoid sitting, standing or any immobility for long
periods at a time
• Elevate legs when sitting
• Avoid crossing legs because it reduces circulation
• Maintain fluid intake at 2500ml/day to prevent
dehydration which leads to sluggish/slowed circulation
• Stop smoking
• Use of TED hose.
PULMONARY EMBOLISM
• WHAT IS AN EMBOLI?
• When a clot dislodges and moves into circulation.
• WHAT IS PULMONARY EMBOLISM ?
• Movement of a clot usually originating from the uterine or pelvic vein into
the lungs were it disrupts the circulation of the blood.
• WHAT ARE THE SIGNS AND SYMPTOMS OF PULMONARY EMBOLISM ?
• Dyspnea, tachycardia, tachypnea
• Pleuritic chest pain
• Cough and lung crackles
• Hemoptysis
• Pleuritic chest pain
• Hypotension
• Peripheral edema
• Distended neck veins
• High temp, hypotension
• *feeling of impending doom /apprehension
PULMONARY EMBOLISM

• WHAT ARE THE NURSING INTERVENTIONS


FOR PULMONARY EMBOLISM:
• Lace the patient in semi fowlers position
• IV heparin
• Oxygen
:UTI
• WHAT IS A UTI ?
• Infection of the bladder
• Common infection postpartum due to the bladder trauma due to
delivery or break in septic technique during catheterization.

• WHAT IS THE COMPLICATION OF UTI ?


• Pyelonephritis with permanent renal damage or renal failure.
• WHAT ARE THE RISK FACTORS OF UTI IN POSTPARTUM PEROD ?
• Postpartal hypotonic bladder
• Urinary stasis or retention
• Catheters
• Epidural anesthesia
• History of UTI
UTI
• WHAT ARE THE SIGNS AND SYMPTOMS FOR UTI ?
• Burning and pain on urination
• Lower abdominal pain
• Increased frequency on urination
• Fever
• Proteinuria, hematuria, bacteruria, WBC in urine
• Pain at the costovertebral angle (pyelonephritis)
• Elevated temp

• WHAT IS THE NURSING INTERVENTIONS FOR A UTI ?


• Urine sample
• Proper perineal hygiene = wipe from front to back
• Increase fluid to 3000ml/day to dilute the bladder and flush out the
bladder.
POST PARTUM BLUES
• POST PARTUM “blues” DEPRESSION :
• Usually starts a few days after the birth and continues for 10days.
• SIGNS AND SYMPTOMS OF POSTPARTUM DEPRESSION:
• Tearfulness
• Insomnia
• Lack of appetite
• Feeling of let down
• Ambivalence toward the infant and family
• Mother has an intense fear or anxiety, anger and inability to cope with the
slightest problems and become despondent.
• Can progress to postpartum psychosis,
• WHAT IS POSTPARTUM PSYCHOSIS?
• Characterized by delusional thinking and possible hallucinations.
• Monitor the patient for suicidal or delusional thoughts and monitor the
infant for failure to thrive secondary to the mother being unable to care
for her newborn.
POST PARTUM BLUES
• WHAT IS THE PRIORITY ?
• Safety of the newborn
• Get psychiatric supervision
• Involve outreach programs concerned with self care and parent
child interactions, child injuries and failure to thrive.

• WHAT ARE THE CONTRIBUTING FACTORS TO POSTPARTUM BLUES ?


• Hormonal changes with decline in estrogen and progesterone levels
• Postpartum physical discomfort and pain
• Fatigue from the work and labor and demand of the new role as a
mother
• Decreased social support
• Anxiety and being a new mother
• History of depression
• Low self esteem
POST PARTUM BLUES
• WHAT IS THE NURSING INTERVENTION FOR
POSTPARTUM BLUE’S ?
• Teach the patient to sleep when the infant is
sleeping
• Encourage communication of feelings
• Reschedule follow up visit in 6weeks postpartum
for women at risk of postpartum depression.
• Reinforce that feeling down is normal but if the
condition persists then to notify the physician.
RUBINS STAGES
• TAKING IN STAGE: first 3 days
- The mother focuses on her own primary needs (sleep and food),
- Nurses role is to listen and help the mother interpret the events of the
delivery
- Excited and talks about the experience of labor and birth
- Teach the mother about baby care
• TAKING HOLD PHASE: DAY 3-10
- The woman starts to assume the roles of mothering
- Becomes more independent and focuses on caring for her newborn
- May verbalizes feelings of incompetence in new role.
- Best time for patient teaching.
• LETTING GO PHASE:
- Feeling of loss from separation of the fetus from her body.
- Feeling of being caught in dependent-independent role (she wants to feel
safe and secure but at the same time wanting to make decisions).
- Increased demand from home and newborn care may lead to depression.
OTHER ISSUES: FIBROIDS
- FIBROIDS = aka leiomyomas
- Common in african americans and women over
40yrs.
- SIGNS AND SYMPTOMS:
- Lower abdominal pain
- The woman may feel pressure or fullness
- Dysmenorrhea or menorrhagia may occurs.
- Diagnosis when masses are felt on the pelvic exam.
- GnRH used to reduce the size of the fibriods. * no
meds to prevent them.
- Majority of the masses will shrink after
menopause.
OTHER ISSUES: MENORRHAGIA
- MENORRHAGIA = frequent heavy bleeding.
- Commonly seen in pre-menopausal women
due benign causes (like cysts).
- Also seen as heavy bleeding in menopausal
women.
- can lead to iron deficiency anemia (heavy
period  excess blood loss  excess loss of
iron found on RBC lost  iron deficiency
anemia
OTHER ISSUES: DOMESTIC VIOLENCE
- DOMESTIC VIOLENCE = forceful behaviors and methods used to
gain and maintain power and control by one individual over
another.
- This involves physical abuse, psychological abuse and sexual
assault.
- TYPES OF PSYCHOLOGICAL ABUSE:
- EMOTIONAL: putting her down
- ISOLATION: controlling who she sees
- OBFUSCATION : denying responsibility for his actions and blaming her
for his actions.
- USING OTHERS: using children against the woman
- MALE PRIVILEGE: treating the woman like a servant
- ECONOMIC ABUSE : controlling the money or preventing her from
getting a job so shes dependent on you.
- COERCISION THREATS: making or carrying out threats to harm her
family.
- INTIMIDATION: making her afraid through looks and gestures.
OTHER ISSUES: DOMESTIC VIOLENCE
- SEXUAL ABUSE IS WHEN = the husband/ spouse
forces the woman to have sex with him, includes
the forced use of objects or forcing the woman to
have sex with someone else against her will.
- CONTRIBUTING FACTORS TO DOMESTIC
VIOLENCE:
- Childhood experiences
- Male dominance in the family
- Marital conflict
- Unemployment and low socioeconomic status
- Traditional definitions of masculinity.
OTHER ISSUES: DOMESTIC VIOLENCE
- CYCLE OF VIOLENCE:
1. TENSION BUILD UP PHASE
• Batterer shows power and control
• Starts blaming the woman for external factors, minor battering
incidents starts to occur
• Woman senses growing danger.
2. ACUTE BATTERING INCIDENT
• Phase of acute violence triggered by an external event.
• The man blames the woman for the violence.
• The woman may go somewhere else but return when she feels its
cooled down.
3. TRANQUIL PHASE/ HONEYMOON PERIOD:
• The man is very kind and warm and tries to make it up to the
woman.
• The woman may accept the gifts and the word of the batterer and
take him back
OTHER ISSUES: DOMESTIC VIOLENCE
- COMMON CHARACTERISTICS OF BATTERERS:
- Have feelings of insecurity, inferiority,
powerlessness and helplessness.
- Tend to be emotionally immature
- Express their overwhelming feeling of inadequacy
through violence.
- Extreme jealousy and possessiveness are the
hallmark of abusers.
OTHER ISSUES: DOMESTIC VIOLENCE
- SIGNS THAT THE WOMAN IS BEING DOMESTIC
VIOLENCE:
- Woman shows hesitation about how she got hurt.
- Inappropriate affect
- Defensive injuries
- Delayed seeking of care for the injuries
- Explaining injuries as being an accident at home
- Vague complaints
- Lack of eye contact
- Anxiety when the batterer is in the room
OTHER ISSUES: INFERTILITY
- INFERTILITY= inability to get pregnant after one year of
trying without the use of contraception.
- PRIMARY INFERTILITY = the woman has never been
able to get pregnant at all.
- SECONDARY INFERTILITY = the woman was able to get
pregnant once but is not able to for a second time.
- PATHOPHYSIOLOGY:
- Hypothyroidism
- Genital tract obstruction *tubal obstruction.
- Cervical mucus is too thick
- Male sexual dysfunction
OTHER ISSUES: INFERTILITY
- DIAGNOSTIC EVAULATION FOR THE FEMALE:
- BBT monitoring
- Menstrual cycle mapping for 6months.
- CERVICAL MUCOSAL TEST to assess the
elasticity.
- FERN TEST = done before ovulation when
estrogen levels are the highest. The cervical
mucus is thin with low stretch ability.
- SPINNBARKEIT TEST = cervical mucus is highly
stretchable showing that ovulation is close.
OTHER ISSUES: INFERTILITY
- OPTIONS FOR INFERTILE COUPLES:
- ARTIFICIAL INSERMINATION: sperm from the partner
or donor is injected into the patients cervix or uterus
on a day after ovulation.
- In Vitro FERTILIZATION:
- Egg is removed from the woman, fertilized in the lab then
fertilized egg is reinserted into the woman's uterus.
- GAMETE INTRAFALLOPIAN TUBE TRANSFER:
- Egg and sperm are fertilized in a tube then inserted into
the woman's uterus.
- SURROGATE MOTHER
- ADOPTION.

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