1151 Parent Child Exam 1

Antepartum

1-3 trimesters

Antenatal care

• verify pregnancy

• evaluate health history and baseline

• evaluate physical health

• evaluate psychosocial needs

• assess fetal well being

• counseling and teaching

• plan of care

Presumptive

Subjective = women’s experience

Examples of presumptive

• amenorrhea

• nausea/vomiting

• fatigue

• urinary frequency

• breast changes

• skin hyperpigmentation

• fetal movement (quickening)

Probable

Objective = Physical exam

Examples of probable

• changes in cervical size and consistency

• vaginal and cervical color changes

• changes in uterine size and consistency

Positive

• visualization - ultrasound

• auscultation of

• fetal heart sounds

• fetal movements

• felt by examiner

• human chorionic gonadotropin hCG in serum or urine

Goodell’s

Changes in cervical size and consistency

Chadwick’s

Vaginal and cervical color changes

Hegar’s

changes in uterine size and consistency

Nagele’s rule

• LMP minus 3 months plus 7 days

• Ultrasound

• EDD/EDC

Nullipara

A patient who has not completed a pregnancy beyond 20 weeks of gestation

Multipara

A patient who has completed at least two pregnancies beyond 20 weeks of gestation

Primipara

A patient whose first time it is giving birth

What does obstetric history GTPAL stand for

• gravida: Total number of pregnancies

• term infants 37- 42 weeks

• preterm infants 20-36 weeks

• abortions

• living kids

Patient health history and baseline data

• medical/surgical history

  • including drug history

• family history

• psychosocial history

• lab data

• baseline physical exam

Evaluate physical health

• reproductive

• gastrointestinal

• cardiovascular

• respiratory

• urinary-Renal

• musculoskeletal

• integumentary

• endocrine

• immune

Placenta

• metabolic

• endocrine

• transfer functions

  • oxygen

  • waste products

  • nutrients

  • antibodies

Psychosocial adaptations & needs in the 1st trimester

• uncertainty

• ambivalence

• self is primary focus

• fear and guilt

• abuse

Psychosocial adaptations & needs in the 2nd trimester

• physical evidence of pregnancy

• acceptance >attachment

• fetus is primary focus

• narcissism and introversion

• body image

• changes in sexuality

Psychosocial adaptations & needs in the 3rd trimester

• vulnerability

• increasing dependence

• preparation for birth

Psychosocial adaptations & needs

• values

• beliefs

• practices

• information

Assess fetal well-being

• fundal height

• fetal movements

• fetal heart rate

  • auscultation of fetal heart rate

  • non-stress test

  • stress test

• ultrasound

  • biophysical profile

  • doppler ultrasound

Nonstress test

• assessing response of fetal heart to fetal movement

Reactive FHR

• two accelerations within 20 mins

• 15 bpm rise from baseline lasting at least 15 seconds

Biophysical profile (BPP)

• measures the health of the fetus

• nonstress test with and ultrasound

• heart rate reactivity

• muscle tone

• movement

• breathing

• amniotic fluid volume

What is the Ultrasound/ Doppler study

• S/D ratio = measurement of the umbilical cord artery that compares the sysolic with the diastolic flow

• identifies the amount of resistance in the placental vasculature

Assess fetal well-being

• screening vs. diagnostic

• informed consent

  • non-invasive prenatal testing (NIPT)

• amniocentesis

Amniocentesis

Amenorrhea

The absence of menstruation

Ethical issues

• Principles that govern right and wrong

  • abortion

  • substance abuse

  • refusal of care

  • father’s rights

Legal issues

• rules that govern right and wrong

  • HIPPA

  • documentation

  • rights of fetus/mother

What is stage 1 of labor?

• latent phase

• active phase

• transition

Latent phase

• labor onset and ends when the cervix reaches 6cm dilation

Active phase

• begins when the cervix is dilated to 6cm and ends with full dilation of 10cm

• amniotic membrane usually ruptures during this phase

What are the 4 stages of birth?

• Stage 1: Labor

• Stage 2: Birth

• Stage 3: Placenta

• Stage 4: Recovery (1-4hrs after birth)

What are the 4 P’s of labor?

• passage

• passenger

  • presentation

  • position

• powers

• psyche

Passage - pelvis

• floating

• ballottement

• engagement

• station -3 to +3

Passage - Cervix

• Passage

  • Cervical dilation 1 to 10cm

  • Cervical effacement 0 to 100%

Cervical effacement

• goes from 2.5cm to paper- thing

Presentation

• cephalic

• transverse

• breech

Cephalic presentation

• increase flexion > ease of birth

Cephalopelvic disproportion (CPD)

• when passage and passenger don’t match when babies head or body is too large to fit through the mother’s true pelvis

• Safest type of delivery is a cesarean birth

Cardinal movements of delivery

• engagement

• flexion

• internal rotation

• restitution (external rotation)

• expulsion

Vaginal exam (physical exam)

• cervical dilation (passage)

• cervical effacement (passage)

• station (passage)

• presentation (passenger)

• position (passenger)

Powers

• Contractions:

  • strength

  • frequency

  • duration

  • resting tone

  • resting interval

• Mom’s urge and ability to push

Psyche

• Birth as a developmental crisis

  • anxiety + fear + pain

  • cultural view

  • previous experiences

  • support

  • knowledge + preparation

  • perception of control

  • self confidence

  • trust level with care/caregivers

Pain management during birth

• pain during birth is unique

  • part of normal process

  • self-limiting

  • intermitten, not constant

  • positive outcome

• excessive pain has negative physiological and psychological effects

Variables in childbirth pain

• Source of pain

  • Tissue ischemia

  • cervical dilation

  • pressure and pulling on pelvis

  • distention of vagina and perineum

Labor

• progressive cervical change

• contractions

• show

• lightening

• rupture of membrane

• nesting

Status of membrane

• ferning

• time

• color

• amount/type

• odor

First stage: Lab tests

• CBC

• ABO-Rh status

• Group B strep (GBS)

Nursing assessments: fetus

• oxygenation status of fetus

• uteroplacental exchange

• fetal heart rate patterns/change

Fetal assessment: Baseline

FHR

• normal

• Bradycardia

• Tachycardia

Fetal assessment: Variability

FHR

• absent

• minimal

• moderate

• marked

Fetal assessment: Periodic patterns

• accelerations

• declarations

  • early (head compression)

  • late (uteroplacental insufficency)

  • variable (cord compression)

  • periodic patterns in FHR

Significance of FHR Patterns

• normal patterns (category 1)

• Indeterminate (category 2)

• abnormal patterns (category 3)

  • absent variability

    • recurrent late decels

    • recurrent variable decels

    • bradycardia

Intervention for abnormal FHR

• Increase placental perfusion

  • Mom on side

  • Increase primary (nonadditive) IV rate

  • Turn off or decrease pitocin if being used

• Increase maternal O2 saturation

  • O2 per mask 8-10L/min

• Reduce cord compression or prolapse

  • Reposition mom to get baby off cord

  • Amnioinfusion

  • Knee/chest position with vaginal exam

• Notify provider, document

Second stage of labor

• Pushing

• Crowning

  • Fetal head encircled by vaginal opening between contractions, fetal head recedes

  • Women may have an episiotomy at this time

  • Fetus changes positions to facilitate passage through birth canal

• Fetal resuscitation

  • Apgar

  • Bonding/attachment/breastfeeding

Crowning

• Fetal head encircled by vaginal opening between contractions, fetal head recedes

• Women may have an episiotomy at this time

• Fetus changes positions to facilitate passage through birth canal

Fetal resuscitation

• Apgar

• Bonding/attachment/breastfeeding

Third stage of labor

• Placental separation from uterus due to uterine contractions

• Occurs within 5-30min after birth

  • Avergage 10mins

  • Globular-shaped uterus, rise of fundus, sudden gush of blood, further protrusion of umbilical cord

  • Intermittent - continuous, firm contractions

  • May be given oxytocin (or methergine if BP not elevated)

  • If placenta is retained or is not intact = risk of postpartum hemorrhage/ uterine atony

Fourth stage of labor

• Physiological readjustment begins in mother’s body

• contracted uterus

• Bonding/attachment

• Infant

  • identification

Uterine decent

• The myometrium contracts, constricting blood vessels and decreasing blood flow to the placental site, which minimizes bleeding

• Assessed via palpation of the fundus

Lochia

• Discharge from the uterus that lasts up to six weeks following birth

• The discharge is red to reddish-brown in color, mimicking a heavy menstrual period