Maternity Exam 3!

Accelerations

-abrupt, temporary increases in FHR

• >32 weeks- minimum of 15 bpm for 15+ seconds

• <32 weeks- minimum of 10 bpm for 10+ seconds (or more- if has larger accelerations, new standard is created even if <32 weeks)

• if occur for >10 minutes, could have a baseline change

Decelerations

-type determines severity

• early

• late

• varibale

• prolonged

-Reading

• Nadir- lowest point; very bottom of decel

• onset- start

• recovery- return to baseline

-Duration- start of it going down to when its back to baseline

-Frequency-

• recurrent if >50% of contractions in 20 minutes

• intermittent if <50% of contractions in 20 minutes

-*****LEARN VEAL CHOP MINE acronym*****

Early Decelerations

-gradual decrease and return to baseline FNH

• associated with uterine contractions

• mirror the contraction

• nadir occurs during peak of contraction

-caused by head compression

• not concerning as occurs with compression of head when baby is in vaginal canal during birth/labor

Variable Decelerations

-abrupt drop/decrease in FHR below baseline

• decrease >15 bpm lasting >15 seconds

• duration of < 2 minutes

• W, V, U shaped

• may or may not be associated with contractions

-caused by umbilical cord compression

-Nursing Interventions- try to relieve cord compression

• intrauterine resuscitation- if recurrent and causing baby stress with getting oxygen

• amnioinfusion- put fluid in to uterus to try to expand it off of cord compression

• tocolytics- medication to slow down labor

• prepare for delivery

Late Decelerations

-Gradual decrease and return to baseline FHR associated with contraction

• delayed timing- bad as sthere is slowed reoxygenation and hinderance of blood flow to baby

• nadir occurs after peak of contraction- no set time standard, anything that follows this pattern

-Caused by uteroplacental insufficiency

-Nursing Actions

• Intrauterine resuscitation- change mom position, increase IV fluids, give mom O2 if hers is low

• Tocolytics- slow down labor/contractions or induction stop oxytocin to decrease contractions

• Delivery- c/s or if close to delivery use vacuum/forceps to get baby out

Prolonged Decelerations

-Decrease in FHR

• Decrease > 15 bpm

• Lasts > 2 minutes but < 10 minutes- at 10 minutes is a baseline change

-Caused by significant change in fetal O²

• Interrupted uteroplacental perfusion

• Interrupted umbilical blood flow

• seen in cord prolapse and epidurals (hypotension)

-Vagal stimulation- if mom goes from ex. 6→9cm dilated, moves down in to pelvis in station and can cause baby as they move suddenly into vaginal canal

• Treat the underlying cause

• Intrauterine resuscitation- fluid, O2 levels, maternal resuscitation

• Delivery

Non-Stress Test (NST)

Results:

• reactive- 2 accelerations within 20 mintes

• non-reactice- insufficient accelerations or repetitive declerations >30 seconds

-put on monitor before labor to determine how baby’s oxygen status is

• want good variablility, at least 2 accelerations in 20 minutes window (reactive test results)

-do not have accelerations or there is any type of deceleration (non-reactive results)

• sometimes need PPP to add in US component

Vibroacoustic Stimulation

-Assess fetal well-being with non-reactive NST if FHR baseline normal

• put next to baby’s head and give baby a buzz/sounds

-Activate near fetal head for 1 sec.

-May repeat q1min x 3

                                       

Contraction Stress Test (CST)

-Term gestation non-reactive NST

• try to determine weather a baby will do good in labor or not (see how its HR reacts)

• rarely done

• done if had non-reactive NST, do this test to see if need to deliver

-Need 3 ctx/10-20 minutes

-Results:

• No variable or late decels = NEGATIVE/NORMAL

• Late decels with 50% of ctx= POSITIVE

• Intermittent late/variable decels= EQUIVOCAL

3 Tier FHR Interpretation System

-Category 1-normal

• FHR baseline 110-160

• moderate baseline variability

• no late or variable decelerations

• accelerations or early decelerations present or absent

• shows if baby is well oxygenated- idea is child will do well for next 3 days

-Category 2= indeterminate

• all FHR tracings not category 1 or 3

• probablly need to be watched more

-Category 3- abnormal

• absent variability with recurrent late declerations, recurrent varibale decelerations, or bradycardia

• OR sinusoidal pattern

  • sawtooth pattern that is completely symmetric

  • baby needs to go to OR- immediately out of mom from decreased oxygenation/neurological issues

EFM: Preterm Fetus (before 32 weeks)

-FHR baseline higher- sometimes still need intervention

-accelerations = 10bpmx10 sec (unless prove can do other minimum)

-decreased varibalilty

-variable decelerations common

-deteriorates more rapidly

-Multiple Gestations

• monitor each fetus separately

• check both babies at same time- 1 toco for contractions and 2 FHR monitors for each baby

• can also put moms HR on screen so know you are tracking baby

Maternal Adaptation Influencers

• Parity- how many children had before

• Age

• Relationship status

• Multigestational

• Previous abuse

• Military involvement

Childbearing Family Developmental Tasks

• Plan for needs & prepare to care for baby

• Adapting financial patterns- childcare is expensive

• Realigning tasks & responsibilities

• Adjusting sexual expression

• Expanding communication

• Reorienting relationships with relatives & friends/community

  • oversupportive, not enough, relationship boudnaries being set

Parental Developmental Tasks

-announcement phase- oftentimes happy but not always

• sometimes have ambivalence as dad does not yet have connection to the baby as mom does (feeling movement = earlier bonding)

• dad accepts that partner is pregnant and take on fatherly role

-moratorium phase- stop thinking about pregnancy for short amount of time

• do not see a lot of changes with pregnancy and partner

• sexual adaptation that can lead to feelings of rivalry between dad and child

-focusing phase- more active involvement

• can feel external movement and see changes so dad can start to think of relationship and bonding

• start to see themselves as a father

• tasks- manage L&D role and preparation roles

Sibling and Grandparents Adaptation

-siblings

• young children can have sense of jealousy for new baby- include them in the process

-grandparents

• typically excited

• role can sometimes bring some conflict

• setting bournaries is healthy, want to discuss them before the delivery

LGBTQ Childbrearing Considerations

-Lesbian family

• Donor insemination

use one partners eggs and then a donor set of sperm

• feels surrounding who’s baby it is biologically and who carries the child

-Gay family

• Surrogacy or adoption

-Transgender men- important to use correct pronouns

-Nursing considerations

• Social support concerns

• Healthcare barriers

• Health disparities

Social Support System

-Benefits of support

• helps to increase likelihood to show up to visits, compliant care, breastfeeding longer

-Challenges-what needs are for that women and if needs are different from what support person might need

• language and socioeconimic

• family in area? Speak English to get more support? Family willing to help?

-Sources of support

-Nurse’s role

• want to identify supports for them within family and more in community if needed/availability

• where community clinical rotations come in to place

Intimate Partner Violence

-can include economic or physical or psycho threatening to partner

• help educate them on the definition of this

-risk- unemplyed, lower eduation, low support (red flag), unplanned pregnancy, +

-Screening- want owmen alone when done, start with broad idea

-Cycle of Violence

-start- absense of tension- honeymoon phase

• tend to htink person has changed- making promises it won’t happen again, apologize

-tension-building

• abuse begins to escalate while victum tries to keep tension low and remove it

• abuser may threaten, start having mood changes, signs violence may occur again

• victum tries to calm situation; start to become isolated (either by themselves or be puleld away by partner)

-explosion

• phsyical violence and attack

• victum goal to maintain safety of themselves and children

• may reach out to help from family or police but do not always accept help after situation settles

-people often stay in these relationships…

• economics- if have children who rely on you for food

• isolation- abuser isolate victums so they have no where to go/turn to or someone who can say that is not okay

• complex relationships and emotions- still love that person and believe they can change

• trauma bonding related to entire cycle

• sometimes feel the abuse is deserved- this is puniished for past something and they deserve it

Sex Trafficking

• trade sex act for something else of value

• Coercion & control

• Red flags

  • Scripted or inconsistent history

  • Unusual dependence

  • Anxious, avoids eye contact

  • Fearful attachment to cell phone

  • Branding

-Nurses Role

• provide privacy

• education

• ask

• respect and respond

Substance abuse

-Maternal Effects

• Miscarriage

• Placental abruption

• Preterm labor

• Malnutrition

• Premature rupture of membranes

• Death

-Fetal Effects

• Low birth weight/growth restriction

• Developmental disabilities

• Neurological issues

• Birth defects

• Neonatal abstinence syndrome (NAS)

• Death

-universal screening in all pregnant women is essential

• want to identify mental health hx that can contribute

• identify patients and offer them options

Marijuana Use in Pregnancy

• Increased use

  • Legal in some states

  • Synthetic cannabinoids (“Spice”)

  • Medical marijuana

• Effect on pregnancy

  • Risks of low birth weight, preterm labor

  • Potential long term effect

  • Contraindicated for breastfeeding

Opioid Addiction Treatment in Pregnancy

-do not want to abruptly withdrawal opioid as it can harm mom and baby- need to have transition

-Methadone

• Opioid agonist

• Dispensed from licensed clinic

• PO

• Titrated doses- to slowly reduce over time

-Buprenorphine

• Opioid agonist-antagonist

• Prescribed by accredited physicians

• SL/buccal/PO/transdermal

• May be combined with naloxone- help to prevent abuse and taking more than necessary

Culutral and Religious Practices realted to Pregnancy

• Nutrition

• Breastfeeding

• Health practices

• Expressions of pain- willingness to take medications

• Contraception- if allowed in culture

• Family interactions

Female Genital Cutting

• ultural, religious, & social reasons

  • commonly done in Africa/Middle East (illegal in US) but can be seen here if moves to US/practice beliefs here and went home to have it done

  • idea is to promote modesty, viriginity, and cleanliness in

• Various degrees

• Role of the nurse

  • Nonjudgmental

  • Provide necessary care

  • Privacy & confidentiality

  • Assessment & adaptation

Pregnancy Hypertensive Disorders

-chronic hypertension (CHTN)

• if occurs at < 20 wks or previous diagnosis

• Medications for elevations that are significant

• deliver at 39 wks if controlled or 37 wks if uncontrolled

-gestational hypertension (GHTN)

• HTN w/o damage to organs (doing PET workup)

• anticipate as PET precursor

• antinatal testing 2x/wk

• weeksly labs

• delivery @ ~37 wks (max)

-preeclampsia

• w/ or w/o severe features

• eclampsia

• HELLP syndrome

Preeclampsia Patho and S/s

-increased permeability and capillary leakage

• edema

• proteinurea

• hemoconcetrated blood

-intravascular coagulation

• hemolysis of RBCs

• Platelet Adhesion and decrease in total PLT volume

-vasospams

• HTN

• decreased placental perfusion → IUGR

• glomerular damage → oliguria

• cortico brain spasms → headache, hyperreflexia, seizure

• retinal spasms → blurred vision

• liver ischemia → n/v, epigastric pain

Risk Factors for developing preeclampsia

-nulliparity

-age extremes: <19 or >35

-obesity

-multiple gestation

-family history or previous diagnosis

-CHTN or Renal Dx

-Diabetes

-COVID-19

-PREVENTION

• Aspirin 81 mg daily from 12+ weeks to delivery

Preeclampsia Criteria

-Hypertension

• after 20 weeks

• BP >140/90 (on or other)

• AND signs of damage

• proteinurea

  • radon urine 2+ (less preferred)

  • 24 hr urine: >300 mg)

  • protein:creatinine ratio >0.3 mg/dL

• severe features- new onset of systemic disease/end-organ dysfunction (only need one of these to be considered with this as the rest will follow)

  • thrombocytopenia (PLT <100,000)

  • renal insufficiency- creatinine > 1.1 mg/dL, oliguria

  • liver dysfunction- AST/ALT >70, n/v, RUQ epigastric pain

  • pulmonary edema (RR <10 or >30)

  • cerebral/vision- persistent headache and blurred vision

  • BP >160/110 (in one part)

-can develop antepartum or up to 6 weeks postpartum

Ecclampsia

-new onset of seizures

-warning signs (of pending seizure)

• severe, persistent headache

• epigastric pain

• n/v

• hyperreflexia with clonus

• restlessness

-Goal: Prevention

HELLP Snydrome

-Hemolysis- decreased RBC and H/H → increased bilirubin

-Elevated Liver enzymes- increase ALT/AST, LDH >600 u/L

-Low Platelets- <100,000/mm

-only need to have one as the rest will eventually follow

• need PET first

• can have HELLP with regular PET or with severe features

Preeclamspia Associated Complications

-Maternal

• hemorrhage/cerebral edema

• DIC (disseminated intravasulcar coagulation)

• pulmonary edema

• hepatic failure

• renal failure

• placental abruption

• increased risk for CV disease later in life

-Fetal

• PTL

• IUGR and LBW

• oligohydraminos

• stillbirth

• labor intolerance (increase c/s risk)

• CV and metabolic disease risk later in life

Preeclampsia Nursing Care

-Assessment

• DTR’s and clonus

• edema

• pain

• visual changes

• LOC (level of consciousness)

• vital signs with O2 sat

• weight

• I/O’s

• NST/BPP to monitor baby

-Interventions

• meds- Mag Sult and HTN med

• labs

• decreased activity and low stimulation environment

Eclampsia Nursing Care

-prevention is top priority

-fetal bradycardia- treat mom first to fix

-lateral positioning

-protect from injury

-medications

• Mag Sulfate (IV/10 g IM w/o IV)

• if no Mag Sulf- Loazepam or Diazepam

• HTN mgmt meds

Medication’s for HTN in Pregnancy: Magnesium Sulfate

-Magnesium Sulfate

• prevents calcium entry into cell and interferes with release of acetylcholine

• prevents seizures

• side effects

• Dose

  • 4-6g/100mL IV fluid bolus 15-20 min

  • 1-2 mg/dL IV drop as maintenance

• Assessment

  • therapeutic levels: 4-8 mEq/L

  • signs of toxicity: absent reflexes, respiratory depression (<12/minand decreased O2 sat), decreased LOC, oliguria (<30mL/hr)

  • antidote: Calcium gluconate (1g slow IV push over 3 minutes)

Medication’s for HTN in Pregnancy: Labetalol

-IV push for acute severe hypertension (crisis)

• administer slowly over 2 min

-PO for chonic HTN mgmt

-assessment

• BP monitoring (and HR)

• maternal SE: drowsiness, weakness

• fetal monitoring with EFM: bradycardia

-AVOID WITH ASTHMA

Medication’s for HTN in Pregnancy: Hydralazine

-IV for acute severe hypertension

• Administer slowly over 2 min.

• Repeat Q 20 min. until target BP reached

-Nursing assessment

• Blood pressure & HR monitoring

• Maternal side effects: headache, flushing, tachycardia, N/V

• EFM: fetal tachycardia, late decelerations

Medication’s for HTN in Pregnancy: Nifedipine

-First line treatment if no IV access

-Immediate release PO for acute, severe HTN

• May repeat in 20 min. X 2 doses

• If no effect, labetalol 2 mg IV

-Extended release PO for chronic HTN

-Nursing assessments

• Blood pressure & HR

• Maternal side effects: edema, hypotension, tachycardia, headache

Glucose Control in Normal (All) Pregnancy

-1st trimester

• nausea and vomiting common

• increased beta cell response

• low fetal needs

• increased fat storage

-2nd/3rd trimesters

• increased insulin production

• increased placental hormones (hPL/hCS, progesterone, GH, corticotropin-releasing hormone), insulin resistance

-maternal glucose transported through plcaenta BUT insulin does not

-Classificaitons

• pregrestational- T1 and T2 DM

• gestational- GDM A1 and A2

-Goals

• euglycemia

• decreased complications

• full term baby

Pregestational Diabetes Complications and Risks

-Maternal

• poly or oligohyraminos

• PTL and PPPROM

• PET/HTN

• DKA

• Dystocia, c/s

• infection

• PPH

-Fetal

• congential defects

• macrosomia/IUGR

• hypoglycemia

• respiratory distress syndrome

• hyperbilirubinemia

• prematurity

• birth injury

• death

• metabolic disease later in life

Pregestational Diabetes Prenatal Nursing Care

-maintain low HbA1C and consistent BG levels → start preconception

-office visits every 1-2 wks and weekly after 28 weeks

-self-monitoring of blood glucose and urine ketones

-healthy diet and exercise

-current ophthalmic exam

-accurate EDD and assess for anomalies

-monitor fetal status

-teaching is essntial

Glucose Goals and Monitoring

-self testing 4-8 times/day

• fasting <95 mg/dL

• AC <100

• 1hr postprandial <140

• 2 hr pp <120

• ideally 70-110

• critical values

  • hypoglycemia <70 mg/dL

  • hyperglycemia >200 mg/dL

Diabetes Pharmacologic Therapy

-Insulin- first choice

• replace or supplement natural supply

• requirements vary throughout pregnancy

  • 1st tri decreased needs

  • marked increased 28-32 wks

Intrapartum and Postpartum Care for Pregestational DM

-timing of delivery

• balance risks

-gluscose control in labor

• IV infusion of regular insulin titrated to maintain hourly blood glucose between 70 – 110 mg/dl

-Postpartum insulin needs decrease

-High risk for complications

Gestational Diabetes Complications

-Maternal

• hypoglycemia

• DKA

• Preeclampsia

• C/S

• Development of nongestational diabetes

-Fetal

• Macrosomia

• Neonatal hypoglycemia

• Hyperbilirubinemia

• Shoulder dystocia

• RDS

• No increased risk for congenital anomalies

GDM Screenings

-initial visit for women with high risk

• Early glucose tolerance test

-1 hour glucose screening (glucola) for all pregnant women between 24-28 weeks

• Test 1 hr after 50 g glucose solution

• BG > 140 mg/dl—abnormal

If do not pass… 3 hr glucose tolerance test (GTT)

• Fasting blood glucose

• 100 g glucose load

• Blood glucose levels at 1, 2, 3 hours

• diagnosis positive if 2+ elevated levels

Gestatoinal DM Management

-Strict monitoring of BG levels

-Control with diet & exercise

-Insulin needed sometimes

-PNC

• Well-controlled—usual care

• Poorly-controlled—follow recommendations for pregestational DM

-INtrapartum and Postpartum Management of GDM

• timing of delivery

• Monitor BG during labor

  • Insulin potentially

• Often resolves after delivery

• Recurrence

GDM Newborn Assessment and Care

• Prematurity and hyperglycemia → respiratory Distress Syndrome (RDS)

• Injury

• Hypoglycemia (hyperinsulemic)

• Polycythemia → Hyperbilirubinemia

Arrest of labor: 1st Stage

-during active phase with ROM

• 4+ hours of adequate contractions (decide if adequate with IUPC to measure intensity in quantifiable way)

• 6+ hours of inadequate contractions with oxytocin administration

• no cervical change

-Nursing

• want patient to be up and moving, change positions

• start to plan for c/s by pulling all supplies

Arrest of decent: 2nd stage

-adequate or inadequate pushing with little/no decent; pushing 4 hours without any change

• baby not coming down even with pushing

• could be stuck: in wrong position, shape of moms pevlis, size of baby head

-risk factors

• maternal exhaustion

• epidural anesthesia

-potential complications

• operative vaginal birth and perineal trauma

• fetal asphyxia

-Nurses

• coach mom to be able to push effectively

• change positions (to open pelvis- peanut ball)

• may need to prepare for vacuum/forceps if baby is low enough to see head

• c/s if cannot fix

Labor Dystocia Powers: Uterine Dysfunction

-underexcited: hypotonic

• low UC frequency, strength, and duration

• little or no cervical change

• stimulate labor (can be done with medical intervention of pharmacologic or ROM)

-overexcited: hypertonic/prodromal labor

• painful, frequent UC with little cervical change (so not benefit)

  • tachysystole (too many contractions)

  • can start before beginning of labor

• irregular tone and ineffective

  • can be irregular in strength

• Category II and III EFM

• promote hydration, relaxation, and rest

  • to allow for coping through labor (sleep as a break, with morphine) to give time for cervical change

-Potential Complications

• maternal: exhaustion, anxiety, infection

• fetal: intolerance of labor, hypoxia, infection

Labor Dystocia Powers: Passenger

-Potential Complications

• maternal:

  • cephalopelvic disproportion- head and pelvis not proportional (need c/s)

  • maternal lacerations- if head is really large, increases risk

• fetal: injuries, hypoxia

-Nursing

• assess fetal position/presentation: Leopold’s maneuvers, US, location of FHT’s, SVE (sterile vaginal exam)

• notify provider w/ SBAR

• often related to baby being too big, in wrong position, multiple gestation, fetal anomalies, labor intolerance

External Cephalic Version

-used to try to turn fetus that is in wrong position (breech/transverse) to try to delivery vaginally

• only attempted >/= 37 weeks gestation to get into vertex position

-Nursing Interventions

• NST/BPP prior to procedure

• tocolytic

• ThoGAM for Rh- mom

• prep for emergency delivery

• risk factors: rupture, blood misxing, placental abruption

• more successful in woman who have: had babies before, with baby of normal size, normal amount of amnioitic fluid

Non-reassuring Fetal Heart Tones (NRFHT)

-low baseline decelerations or variability

-Nursing action

• promote oxygenation (turn, fluid blous, check O2 levels)

• reduce uterine activity ( if tachsystolic- terbutalen injection)

• alleviate umbilical cord compression

• correct maternal hypotension

Labor Dystocia Powers: Passage

-incomplete or insufficient pelvic structure; can occur at three points in pelvis

• inlet- just not wide enough; funnel to narrow

• midplane- prominent ischial spines

• outlet- pelvis angled off or prominent sacral bones

-pelvic sytocia

• rediced capacity of boney pelvis

• r/t contraction of pelvic planes

• typically can see trial of labor but anticipate low threshold to think of next steps

Labor and Induction

-medical indications:

• promotion of delivery to address safety of mother and/or baby

• treat dystocia

-elective reasons

• convenience (ie. military family, insurance timing, single mom w/o support all the time)

• not before 39 weeks

Labor Induction

-chemical or mechanical initiation of uterine contractions before spontaneous onset of labor

• types: stripping membranes, mechanical cervical ripening, chemical cervical ripening, oxytocin, amniotomy

-Nursing

• ensure informed consent and awareness of risks

• assess maternal and fetal wellbeing

• understand indications, actions, expected results, and risks of methods

• educate mom through process

-Bishop’s Score

• rating system to assess favorability of cervix for labor

• induction more likely to be successful if score >/= 6 (higher scores = increased likelihood of induction resulting in vaginal delivery)

• if score is low, want to try some ripening

Induction: Stripping (Sweeping) Membranes

-done by a provider to possibly create prostaglandin and oxytocin release

• often done in the office (before L&D)

• wait until 39 wks

• cervix must be dilated to at least 1 finger and try to separate amniotic sac from uterine wall

-risks

• infection

• bleeding

• cramping

• ROM

Mechanical Cervical Ripening Agents

-no medication but forcing cervix open

-types:

• hygroscopic dilators (Laminaria, Lamicil, Dilapan)- seaweed that is rolled and dried → inserted into vagina and cervix (which must be slightly dilated) → rehydrates and expands → stretches cervix and releases prostaglandins

• baloon catheter (Foley Bulb or Cook’s catheter)- inflated to put gental pressure on cervix to open it even more (to act as pressure as baby’s head would)

Chemical Cervical Ripening Agents

-examples of meds that soften cervix and may stimulate contractions:

• Dinoprostone 10 mg controlled released insert into vagina or as a gel

• misoprostol 25 mcg (Cytotec) q3-6h

• contraindications: IUGR, previous uterine scar (c/s, fibroids)

-Nursing

• VS, EFM

• laterla position 2 hours after insert of 30 min after misoprostol

• if tahcysystole: remove inset or give terbutaline injection

• delay oxytocin for induciton until > 4hr after last dose misoprostol or 30-60min after removal of insert

Oxytocin

-for cervical ripening, induction, or augmentation of labor

• risk for tachysystole → FHR decelerations

-Nursing

• follow established protocol

• continuous EFM usually required

• careful titration based on maternal and fetal response (discontinue)

• notification w/ SBAR and documentation

• discontinue with tachysystole or FHR decelers (prolonged)

Amniotomy (AROM)

-AROM- artificial rupture of membranes (rupture mom before she does on her own)

-risks

• variable decelerations

• bleeding

• umbilical cord prolapse

• intraamniotic infection

-Nursing

• assess fluid for color, odor, amount, time (COAT)

• document time and FHR

• monitor infection s/s: temp q2hr, fould smelling amnioitc fluid, fetal tachycardia, uterine tenderness

Precipitous Labor

-labor that lasts < 3 hr total from onset of contractions to both

• can be tachysystole r/t

• strong uterine contractions < q 2 min and lasting > 60 seconds

-potential complications

• maternal: lacerations (higher degree), uterine rupture, amniotic fluid embolism, PPH

• fetal: hypoxia, CNS depression, trauma from rapid descent (increased bruising → higher jaundice likelihood)

-Nursing

• stay calm, call for help, do not leave!!

• equipment, wash hands, gloves

• maternal safety

• controlled delivery of head, check for nuchal cord/reduce

• dry infeant, suction, place on maternal abdomen or chest

• anticipate complications

• wait for placenta to separate and deliver placenta; funal massage

• note birth time and APGARS (so can be done correct times)

Operative Vaginal Delivery

-forceps or vacuum extrction

• improve outcomes by shortening 2nd stage

• risk for maternal and fetal injury

-Nursing

• assure maternal bladder is empty

• assess FHR

• document type, number of applications, time

• assess mother and newborn for trauma signs

Shoulder Dystocia

-impaction of fetal shoulders

• stuck behind moms shoulders

• usually after head is delivered

-turtle sign- mom pushes and head comes out a little → with stop in pushing, head goes back in some → keeps trying to go back in and out

• in normal delivery, once head is engaged, should stay there

-associated factors

• macrosomia

• history

• prolonged 2nd stage

-Newborn Assessment Afterwards

• neonatal: brachial plexus injuries (need PT to help get back dexterity), fractures

• maternal: trauma (mom need pelvic floor PT, high risk of PPH from potential laceractions), hemorrhage

Nursing Invterventions: Shoulder Dystocia

-McRoberts maneuver

• pull the legs back to try to open pelvis enough to let baby come out

• push on with suprapubic pressure (hurts mom) to try to curve the shoulder so it can pop underneath pubic bone

• never fundal pressure

-Other options (provider based)

• Gaskin maneuver- moving mother onto hands and knees with back arched (nurse helps to flip mom; not commonly done)

• Woods Corkscrew maneuver- provider tries to push posterior should and pull out an arm to create more space

• episiotomy- only usually done if tight band of tissue stopping it

• intentional fracture (clavicle, pubis, coccyx)

• Zavanelli maneuver: rotate and flex fetal head, push into vagina, delivery via c/s

Prolapsed Umbilical Cord

-risk factors:

• malpresentations: footling breech, transverse lie

• cephalopelvix disproportion

• unengaged presenting part

• polyhydramnios

• preterm fetus

• multiple gestation

-Nursing Interventions

• prompt recognition

• assist with positioning: on stomach with knee chest-position of Trendelenburg w/ hips elevated by pillows

• hold presenting part off cord (tap out HR from umbilical cord) keeping hand in vagina the entire time

• prepare for immediate delivery

Uterine Rupture

-tear in uterine muscle

• complete

• incomplete

-risk factors

• previous uterine scar

• uterine trauma

• tachysystole

• overdistended uterus

• external version

• extra fluid, multiple gestation

-s/s: pain always there, some have bleeding out via vagina, decomposition, fetal tachycardia/brady cardia, baby can leave if bad enough rupture

-Nursing Interventions

• prevention

• lateral position

• when indicated: IV fluids, blood replacement, O2

• insert foley

• prepare for immediate delivery via c/s

• patient and family support

Cesarean Birth

-birth of fetus through transabdomnial incision in uterus

-indications

• dystocia, CPD

• previous c/s or uterine surgery

• malpresentation

• fetal intolerance of labor

• placental abnormalities

• maternal health factors

• multiple gestation

-risks

• neonatal: respiratory morbidity (TTN- transitional typicnea of newborn- increased RR); injury

• maternal short-term: PP infection, PPH, thromboembolic dx, organ injury, death

• maternal long-term: adhesions, chronic pain, abdnormal plcentation (previa, accreta, abruption)

-Prevention

• allow women adequate time to labor!!

• reserve labor induction for medical reasons

• elective inductions only >39 weeks GA

• ripen cervix first

• allow adequate induction attempt

Cesarean Birth Types

-classical (usually only seen in emergency or preterm (no LUS thinning))

• certical incision into upper body of uterus

• must have repeat c/s with future births

-low transverse c/s (always the goal)

• tranverse incision into lower uterine segment

• may have VBAC (vagina birth after c/s) with future births

-T incision

• combination of the two

• typically done in emergency

-OUTER INCISION ON SKIN IS NOT ALWAYS UTERINE INCISION

Trial of Labor (VBAC)

-observance of patient and fetus in spontaneous labor to assess safety of vaginal birth

-Nursing

-Contraindications

• classical or T-shaped uterine incision

• previous uterine rupture

• high risk maternal or fetal conditions

-VBAC- vaginal birth after cesarean

• previous c/s w/ ½ low transverse incisions and no other uterine scares, adequate pelvis, or team immediately available

• risk of uterine ruptue <1% (aboid use of chemical ripening agents)

• nursing interventions

  • IV access

  • continuous EFM when in active labor

  • s/s uterine rupture: abnormal FHR, pain, blood loss

Preoperative Nursing Care

-Education!

-Antiseptic wash (CHG)

-Hair clipping/shave

-Sodium citrate (Bicitra)- 1 oz liquid taken just before entering Operating Room

• neutralizes stomach acids

-Fetal monitoring

-IV

-Foley catheter

-Antibiotic administration

• on call dose to prevent post-surg infection; given as go to OR

-VTE prophylaxis

• SCD’s, TED’s, anti-coagulants (enosparin as it is one time dose)

Postpartum PTSD

-diagnostic criteria

• stressor

• intrusion symptoms

• avoidance

• negative alterations in cognition and mood

• alternation in arousal and reactivity

• duration

• functional significane

-can affect both this and subsequent pregnancy

-rsk factors

• previous trauma or violence exposure

• history of mental illness

• pregnancy losses

• low social support

• high medical intervention/complications

-effect

• fear of childbirth

• breastfeeding difficulties

• detachment

• pregnancy complications

-Treatment

• prevention

• early recognition

• cognitive behavioral therapy

• eye movement desensitization and reprocessing

Nursing Support for Tranisition to Parenting/Bonding

-assess transition and bonding

-support adequate rest and self-care

-provide culturally sensitive care

• keep traditions in mind when assessing bonding

• some cultures rely on family members for infant care in pp

• how to promote bonding based on what parents need

-listen actively

-encourage parents to provide care with support

• education on care and then let them take over most of it- correct and support so they can be confident in care at home

-give feedback on paren’ts infant care behaviors

5 Rights of Teaching

-right time

-right context

• learn best when free from distractions (pain, visitors, tv)

-right goal

• line up with patient’s goals for ending

-right content

• at right educaitonal level

-right method

Bonding

-the emotions that begin during pregnancy or shortly after birth

• have lifelong impact

-multifactoral fo rif bodning occurs

• if pregnancy is wanted

• knowledge abse

• child experience

• support system

• maturity

• expectations of pregnancy and infant

• culture

-Undirectional: parent → infant

• en face

• call baby by name

• cuddling baby close to chest

• talk/sing to baby

• kisses baby

• beastfeeds baby or holds close to chest when bottle-feeding

-Bidirectional: parent ←→ infant

• parents respond to infant’s cry

• infant responds to parents comforting measures

• parents stimulate and entertain infant while awake

• parents become senstivie to cues in infant behavior

-Delayed Bonding

• maternal or neonatal illness

• exhaustion from labor or fatigue pp

• discomfort post birth

• maturity/developmental status

• outside stressors- paying for baby, take care of it, how other will react

Discharge Timing

-timing may differ based on insurance, hospital system, or birthing center guidelines

-usually

• with uncomplicated VD- 24-48 hours

• with uncomplicateed c/s ~72 hours

Bathing

-timing of first bath depends on hospital poliviy

-ensure neontatal temperature is stable and normal

-use mild spap and warm water

-saty away from drafts and fans

-sponge baths until cord comes off

-dry as you go

-include parents in the process

-parental education: bath baby every 2-3 days

Bulb Syringe

-use to clear mucous

-always have accessible

-use in nose or inner cheeks

-be aware of suction devices

-instruct parents to clean regularly or replace device so bacteria cannot be introduced to baby

-mouth first and then clear nose

Circumcision

-elective surgical removal of foreskin

• benefits ourweight risks but not reoutinely recommended

• personal preference, religious/tradition

• procedure uses local lidocaine and oral surcrose

  • method chosen bby provider: Gomco, Mogen, Plastibell

-Contraindicated for hypospadias

-Care

• lubricant on tip of penis at every diaper change until healed

• if plastibell used, leave alone

• watch for void within 12-24 hours

• check for bleeding every 4 hours

• yellow, granulation is normal healing of tissue- do not touch or wipe

• only wring wet washcloth on top if soiled- do not wipe

Clothing

-avoid overheating to reduce SIDS

-set temperature comfortable for adults and put one additional layer on baby

-hat if outside in cooler weather or A/C

Cord Care

-clamp can be removed after 24 hrs

-cord will fall off aorund 2 weeks

-place diaper below cord site

-monitor for s/s infection

-wash with plain water only if soiled

Diapers and Elimination

-thorough cleansing

• if female, wipe front to back to avoid feces in vagina

-stages of stool

• meconium- dark, tary, sticky

• transition- less sticky, more liquid

• milk

-diaper rash prevention

• frequently change

• cleanse with water or wipes

• use petroleum or zinc oxide ointments while avoiding powder

-Diaper amounts

• 1 in 1 day, 2 in 2 days up to 6 days

• 6+ days should have 6-8 wet diapers minimum

Non-nutritive sucking

-calms infants

-pacifier choice by patients

• not recommended for breastfeeding baby until well established

• may reduce SIDS risk

• one pirce pacifier

• don’t tie around neck or crib

• wash with warm, soapy water frequently

Crying

-period of PRUPLE crying

• P- peak of crying- baby increases every week until 2 months and then less 3-5 months

• U- unexpected crying and don’t know why

• R- resists soothing no matter what is tried

• P - pain-liek face even without pain

• L- long lasting crying for as long as 5 hours

• E- evening- might cry more in late afternoon/evening

-Colic

• greater than 5 months

• cry > 3 hours > 3 days a weeks > 3 weeks

-Handling Crying baby- 5 S’s

• swaffle

• side/stomach psotion

• swaying (really big)

• suck- pacifier

• SHHHHH -really loudly

Shaken baby Syndrome

-national initiative mandated discharge education

-babies who are colicky have higher liklihod for this syndrome

-babies highly susceptible bc of large heads and small neck muscles with immature brains that cannot withsatnd shaking

-brain moves with rocking and hits skull- blood vessels tear and cause bleeding → blood clots → swelling in brain

-weakened neck muscles → shake vertebrae → can crush spinal cord

-life altering results: brain damage, developmental delays, paralysis, deafness, blindness, death

-put baby in safe place if crying and your getting angry- need to get yourself space to calm down

-baby is not going to die from crying

Safe Sleep

-SIDS- sudden infant death syndrome

-do not always know cause

-sleep on back - only tightly fitted sleep and baby- nothing else that could suffocate/strangle baby

-free of all clutter in designated sleep space

-discourage co-sleeping or falling alseep with baby in a chair

-do not smoke around baby- SIDS increases when exposed to smoke

-overheating also increases SIDS

Car Seat Safety

• Rear facing, back seat until age 2

  •  Keep baby rearfacing until out grow weight and height requirement

• Assessment by certified technician

• Straps should not be “pinch-able”

• Chest clip at chest

  • should be across nipples

• No non-manufacturer accessories

  • do not have coats on in seat, cover with blanket, put jacket on when out of car

Follow-up care

-First visit within 48-72hours of discharge, or sooner for breastfeeding/weight checks

-Possible 2 week check-up

• one month check for development anything sooner for growth/feeding

-Assess growth, feeding, development, jaundice, immunizations, education

-S/S illness

• rectal temp >100.4 F or <97F

• decreased feedings or diapers

• lethary or rash

• looks funny, feels funny, smells funny something is probably off

• anything conerning, call to get advice