Maternity and Neonatology Mark K lecture 10

Naegele’s Rule

• Take the first day of the LMP, add 7 days and subtract 3 months from it.

• Edit year if passed December 31st.

Weight Gained During Pregnancy 1st trimester and 2nd and 3rd trimester

1st Trimester (12 weeks)

• 1lb per month = Today 3lbs

2nd and 3rd trimester

• Add 1lb every week

Ideal Weight Gained During Pregnancy

• 28 lbs plus or minus 3

• Between 25lbs to 31 lbs

If weight gain during pregnancy is within +/- 1 to 2lbs of the ideal weight for the gestation week

• Patient is WDL

If weight is gained +/- 3 lbs

• Assess patient

If weight gained is within +4lbs or -4lbs

• There is trouble

• Perform a Biophysical Profile (BPP)

Quick way to come up with the ideal weight gained during pregnancy is to?

• Take the number of weeks gestation and minus 9.

When can the fundus be palpated at the umbilicus?

• Between 20 and 22 weeks

Fundal Height

• Measurement from the top of the symphysis pubis to the top of the fundus.

Fundus height cannot be palpated until the second trimester true or false?

• TRUE

• Fundus cannot be palpated until the second trimester

Positive Signs of Pregnancy

• Fetal skeleton on X-ray

• Presence of fetus on ultrasound

• Auscultation of fetus on ultrasound

• EXAMINER palpates fetal movement (outline) NOT THE MOTHER.

In OB there are 3 types of questions regarding range values.

• When would you first? (Pick EARLIEST range)

• When would you most likely? (Pick MID range)

• When should you by? (Pick END range)

When can a fetal heart rate be heard?

• Fetal Heart rate can be heard first between 8 to 12 weeks of gestation

When would you first hear the fetal heart rate?

• 8 weeks

When would you most likely hear the fetal HR?

• 10 weeks

When should you hear the fetal heart beat?

• 12 weeks

When should quickening ( baby kicks) be first felt between?

• 16 to 20 weeks

• First 16 weeks

• Most likely 18 weeks

• By 20 weeks

Maybe signs of pregnancy

• Positive urine/blood hCG tests

• A positive pregnancy test may result from other conditions for instance, cancer.

• Chadwick sign- Cervical color change to cyanosis (Cs)

• Goodell sign- good and soft. Softening of the cervix.

• Hegar sign- uterine softening. Softening of the lower uterine segment.

Chadwick Sign

• Cervical Color Change to Cyanosis (Cs)

Goodell Sign

• Good and Soft

• Softening of the cervix

Hegar sign

• Uterine softening

• Softening of the lower uterine segment

Patient teaching for Prenatal visits during the first 28 weeks?

• Once a month until week 28

Prenatal Visits between week 28- week 36?

• Every other week between week 28-week 36.

Prenatal visits after week 36?

• Once a week after week 36 until delivery or week 42

• At week 42 delivery can be induced or by C-section.

Hemoglobin levels WILL FALL during pregancy. A pregnant woman can tolerate lower levels of hemoglobin.

• Normal hemoglobin Hb in females is 12-16

First Trimester Hemoglobin normal drop

• Hemoglobin can fall to 11 and be perfectly normal.

Second Trimester Hemoglobin normal drop

• Hb can fall to 11.5 and be perfectly normal.

Third trimester hemoglobin drop.

• Hb can fall to 10 and be perfectly normal

If Hemoglobin is < 9

• Anemia

• Evaluation

How do you treat morning sickness?

• Morning sickness usually seen during the 1st trimester.

• Treatment: Dry Carbohydrates- not before breakfast but BEFORE PATIENT GETS OUT OF BED.

How do you deal with urinary incontinence?

• Urinary Incontince is seen in the first and 3rd trimesters.

• Patient needs to void every 2 hours from the day she gets pregnant until 6 weeks postpartum.

Patient complains of difficulty breathing. What should you advise her to do?

• Difficulty breathing is a problem during the 2nd and 3rd trimesters

• Advise patient to assume TRIPOD position

• Tripod position is a physical stance often assumed by people experiencing respiratory distress.

• The patient will be leaning forward with hands on knees or the surface of a desk or table.

A pregnant patient complains of back pain. What should you advise her to do?

• Back pain is seen during 2nd and 3rd trimester

• Advise PELVIC TILT exercises to patient.

What is the truest most valid sign that she is in labor?

• The truest most valid sign of labor is the onset of regular/progressive contractions.

Dilation

• opening of the cervix from 0cm to 10cm

Effacement

• Thinning of the cervix. It goes from thick to 100% efface ( thin like paper)

Station

• Relation between fetal presenting part and the mother’s ischial spine.

Ischial Spine

• the narrowest part of the pelvis

• Positive numbers mean the baby has made it through the tight squeeze and is good to go.

What does it mean if the baby stays at -3, -2, -1?

• It can’t get through vaginally.

• It needs a C-section

What intervention needs to be done if the baby stays at +4, +2, +4, +2

• Vacuum/ Forceps

Engagement

• station zero this means the presenting part is at ischial spines.

Lie

• relationship between the spine of the mother and spine of the baby.

Vertical lie

• Compatible with vaginal birth

Parallel

• The mother’s spine and the baby’s spine is parallel- we got a baby.

Lie is Perpendicular

• Tranverse lie = Trouble… C-section

• If we got them perpendicular, we’ve got trouble T.

Most common presentations is ROA or LOA

• That’s the guess don’t bother memorizing.

• Pick ROA FIRST!

How many stages of labor are there?

• 4 stages

How many phases are there in labor?

• 3 phases in the first stage of labor

• LAT

• Latent, Active, Transitioning

Stage 1 of labor

• Onset of labor it has 3 stages.

Latent

• Phase 1 in stage 1

• Cervcal dilation from 0 to 4cm

• Contractions are 5 to 30 minutes apart, lasting 15-30 seconds

• Mild Intensity

Active

• Phase 2 of Stage 1

• Cervical dilation from 5-7 cm

• contractions are 3 to 5 minutes apart

• Lasting 30-60 seconds

• Moderate Intensity

Transition

• Phase 3 of Stage 1

• Cervical dilation from 8 to 10cm

• Contractions are 2 to 3 minutes apart, lasting 60 to 90 seconds.

• Strong Intensity.

A pregnant woman comes into L&D. She is 5cm dilated, with contractions 5 minutes apart, lasting 45 seconds. What PHASE of labor is the patient in?

• Active Phase

• She is in the First STAGE.

• Pay careful attention to wording phase vs stage!

Stage 1

• Onset of labor- Cervical Dilation and Effacement

  3 Phases in Stage 1

• Phase 1 Latent

• Phase 2 Active

• Phase 3 Transition

Stage 2

Delivery of the Baby

Stage 3

Delivery of the placenta

Stage 4

• Recovery: 2 hours until bleeding stops

What is the purpose of the uterine contraction in 1st stage?

• Dilation and Effacement

What is the purpose of the contactions in the 2nd stage?

Delivery of the baby

What is the purpose of contractions in the 3rd stage?

Delivery of the placenta

What is the purpose of contractions in the 4th stage?

• Stop Bleeding

When does postpartum technically begin?

• 2 hours after delivery of the placenta

What is the #1 priority of the 2nd phase?

• Pain Management

• 2nd phase the Active Phase is in the first stage of labor.

What is the #1 priority of second stage?

• Second Stage is the Delivery of the Baby so it would be

• Clearing Baby’s airway

What is the number one priority of the third phase?

• Third phase is in the first stage of Labor

• Checking Cervical Dilation, Helping Pregnant mother with breathing and pain management.

What is the #1 priority of the third stage?

• Third Stage is Delivery of the Placenta

• Assess the placenta for smoothness and intactness, and for 3-vessel (not 2) umbilical cord.

Uterine Contractions should be no longer than how many seconds and minutes?

• No longer than 90 seconds and no closer than 2 minutes

What is a sign of Uterine Tetany?

• No longer than 90 seconds and no closer than 2 minutes.

What parameters regarding uterine contraction would make you stop pitocin?

• No longer than 90 seconds and no closer than 2 minutes.

What is uterine hyperstimulation?

• No longer than 90 seconds and no closer than 2 minutes.

Frequency

• The beginning of one contraction and the beginning of the next.

• A,C

Duration

• Beginning to End of one contraction.

• A to B

• C to D

How do you teach a pregnant mom to palpate?

• Palpate with one hand over the fundus with the pads of the fingers.

Painful Back pain- OP = Oh Pain. What do you do?

• Position - Push

• What position?

• KNEE -CHEST POSITION

• Then PUSH fist into sacrum to use counter pressure

• Low priority

Fist into sacrum to relieve back pain in pregnant client

Position Knee to Chest then push fist into sacrum to relieve back pain.

Prolapsed Cord

• PUSH - POSITION

• PUSH HEAD off cord and position KNEE- Chest or Trendelenburg

• Prep for C-section

• THINK PUSH/POSITION

• Push head off the cord of the fetus and position mother to knee-chest.

• HIGH PRIORITY

Interventions for all other complications including

• Tetany

• Maternal Hypertension

• Vena Cava Syndrome

• Toxemia

• Uterine Rupture

  All treated with LION

LION

• Left side ( place mother on left side)

• IV

• Oxygen

• Notify HCP

• STOP PITOCIN (PIT) IF IT WAS RUNNING- FIRST THING YOU DO!!!

IN A OB CRISIS IF PITOCIN IS RUNNING YOU STOP IT BEFORE IMPLEMENTING LION.**

LION

• LEFT side

• IV

• Oxygen

• Notify HCP

When to administer systemic pain medication?

• DO NOT ADMINISTER a systemic pain medication if the baby is likely to be born when the med is at its peak.

You have a primigravida at 5cm dilated who wants her IV push pain med. What is the nursing intervention?

• Would give it because the patient is a primigravida and not likely to deliver in about 15-30 minutes when the medication PEAKS.

You have a multigravida at 8cm and she wants her IM pain med. What is the nursing intervention?

• Do not administer the pain medication because the client is likely to deliver when the medication would be at its peak.