Maternity Exam 1

Apgar scores are done when?

at 1 and 5 minutes of life

Apgar scoring allows the nurse to rapidly assess ____ ____ and intervene with appropriate nursing actions.

extrauterine adaptation

Apgar score of 0-3 indicates

severe distress

Apgar score of 4-6 indicates

moderate difficulty

Apgar score of 7-10 indicates

minimal or no difficulty with adjusting to extrauterine life

Apgar score measures

heart rate

respiratory rate

muscle tone

reflex irritability

color

Apgar score: heart rate

0- absent

1- slow, <100 bpm

2- >100 bpm

Apgar score: respiratory rate

0- absent

1- slow, weak cry

2- good cry

Apgar score: muscle tone

0- flaccid

1- some flexion of extremities

2- well- flexed

Apgar Score: reflex irritability

0- none

1- grimace

2- cry

Apgar score: color

0- blue/ pale

1- pink body, cyanotic hands and feet (acrocyanosis)

2- completely pink

Ballard score is a newborn maturity rating score used to assess ____ and ____ maturity.

neuromuscular and physical maturtiy

Ballard score neuromuscular measures

posture

square window (wrist)

arm recoil

popliteal angle

scrap sign

heel to ear

Ballard score physical maturity measures

skin

lanugo

plantar surface

breast

eye/ ear

genitals (male)

genitals (female)

Ballard score maturity rating

-10: 20 weeks

-5: 22 weeks

0: 24 weeks

5: 26 weeks

10: 28 weeks

15: 30 weeks

20: 32 weeks

25: 34 weeks

30: 36 weeks

35: 38 weeks

40: 40 weeks

45: 42 weeks

50: 44 weeks

Leopold maneuvers determine

number of fetuses

presenting part, fetal lie, and fetal attitude

degree of descent of the presenting part into the pelvis

location of fetus’s back to assess for fetal heart tones

Vertex presentation: fetal heart tones should be assessed below the client’s ____ in either the right or left ___ quadrant of the abdomen.

umbilicus, lower

Breech presentation: fetal heart tones should be assessed ____ the client’s umbilicus in either the right or left ____ quadrant of the abdomen.

above, upper

Newborn vital signs are assessed in this order

1. RR

2. HR

3. BP

4. temperature

Normal newborn RR

30-60 breaths/min with short periods of apnea occurring most frequently during the rapid eye moment sleep cycle (<15 sec)

Normal newborn HR

110-160 bpm

Apical pulse is assessed for 1 min, preferably done when sleeping

Normal newborn BP

60-80 systolic

40-50 diastolic

Normal newborn temperature

97.7- 98.6 F

36.5-37.5 C

Lochia (PP uterine discharge) contents

amniotic fluid, WBCs, RBCs, blood, mucous, uterine tissue

Lochia rubra

1-3 days PP

dark red color, bloody consistency, fleshy odor, can contains small clots

transient flow increases during breastfeeding and upon rising

Lochia serosa

4-10 days PP

pinkish brown color, serosanguineous consistency

can contain small clots and leukocytes

Lochia alba

10 days- 8 weeks PP

yellowish white creamy color, fleshy odor

can consist of mucus and leukocytes

Scant bleeding

0-1in

Small bleeding

1-3in bleeding

Moderate bleeding

4-6in bleeding

Heavy bleeding

fully saturated pad in 1 hour

Homan’s sign: assesses for DVT in lower calf

check pedal pulse

have pt lift calf, flex and point feet

painful=positive

observe, dont touch

Oxytocin (Pitocin: synthetic form)

classification: uterine stimulant

promotes uterine contractions; labor induction

milk ejection/ let down

stimulation can lead to hypertonic uterine contractions

Oxytocin is released by

posterior pituitary

Prolactin

milk production

Prolactin is released by

anterior pituitary

Risk factors for shoulder dystocia

previous shoulder dystocia

cephalopelvic disproportion

fetal macrosomia

maternal diabetes mellitus

maternal obesity, short stature

uterine abnormalities

prolonged first stage of labor

maternal age > 40 years

pelvic soft tissue obstructions/ pelvic contracture

prolonged second stage

augmentation/ induction of birth

operative vaginal birth

Complications of shoulder dystocia

brachial plexus injury of neonate

neonatal fractures; humerus and/or clavicle

hypoxia & stillbirth

maternal trauma; ex. PPH and 3rd degree tears

Recognition of shoulder dystocia

slow & difficult delivery of fetal face and chin

when fetal head is born, it remains tightly applied to vulva

chin retraction “turtle sign”

anterior shoulder fails to deliver with ‘routine’ traction (diagnostic traction)

Shoulder dystocia management

McRoberts’ maneuver- thighs to chest, bottom lifted

suprapubic pressure- use palm/ fist, directly applying pressure over fetal anterior shoulder to dislodge it

Gaskin maneuver- hands and knees position. May be difficult to accomplish if mom has significant loss of motor function caused by regional anesthesia

Prolapse of the umbilical cord occurs when

the umbilical cord is displaced, preceding the presenting part of the fetus, or protruding through the cervix.

Results in cord compression and compromised fetal circulation.

Prolapsed umbilical cord is diagnosed by

seeing/ palpating the prolapsed cord, accompanied by the presence of abnormal FHR tracings

First stage of labor

lasts from onset of regular uterine contractions to full effacement and dilation of cervix (longer than second and third stage combined)

First stage; latent phase

onset of labor; contractions

• irregular, mild to moderate

• frequency: 5-30 min

• duration: 30- 45 secs

• dilation: 0-3cm

First stage; active phase

contractions

• more regular, moderate to strong

• frequency: 3-5 min

• duration: 40-70 sec

• dilation: 4-7cm

First stage; transition phase

contractions

• strong to very strong

• frequency: 2-3min

• duration: 45-90sec

Second stage of labor

full dilation

progresses to intense contractions every 1-2min

Third stage of labor

delivery of the neonate

Fourth stage of labor

delivery of placenta, then maternal stabilization of vital signs

MR SOPPA- NRP

1. Mask adjustment (consider 2- hand technique)

   Reposition (head neutral/ slightly extended

   • once seal is achieved, evaluate chest movement, air entry, then HR

2. Suction mouth (depth nose tip to earlobe)

   Open mouth

   • once seal is achieved, evaluate chest movement, air entry, then HR

3. Pressure increase to 25/ 5cm H2O

   • once seal is achieved, evaluate chest movement, air entry, then HR

4. Pressure increase to 30/ 5cm H2O

   • once seal is achieved, evaluate chest movement, air entry, then HR

5. Airway alternative (ETT or LMA)

   • once seal is achieved, evaluate chest movement, air entry, then HR

NRP; the most important indicator of successful PPV is

a rising HR

NRP; maximum recommended pressures

30/5 in preterm baby

40/5 in full term baby

NRP; assess the need for decreasing pressures when HR is above

100 bpm

Provide __ seconds of effective ventilation before progressing through the NRP algorithm. Ensure there is ____ before starting compressions; if not, consider increasing PIP if appropriate.

30 seconds, chest rise

*PIP= peak inspiratory pressure

Immature lungs in the newborn may need

surfactant (keeps alveoli open)

Amniotic fluid volume

700-1000mL

Amniotic fluid properties

watery, clear, slightly yellow tinge

nonodorous

alkaline; pH 6.5-7.5

Five Ps of labor

passenger (fetus & placenta)

passageway (birth canal)

powers (contractions)

position (of the woman)

physiological response

Expected blood loss; vaginal delivery

300-500mL (10% of blood volume)

Expected blood loss; c- section

500-1000mL (15%-30% of blood volume)

Possible orthostatic hypotension within the first __ hours PP can occur immediately after standing up.

48 hours

Maternal BP after birth is usually ___ but can have

unchanged

an insignificant slight transient increase

Significant decrease of maternal BP after birth could indicate

bleeding

Significant increase of maternal BP after birth could indicate

PP hypertension

What vital signs increase for the first hour PP, then gradually decreases to a pre pregnant baseline by _-_ weeks.

____ in the PP period should be evaluated.

pulse, stroke volume, cardiac output

6-8 weeks

tachycardia

Due to elevations in stroke volume during the first _ days PP, maternal HR can be as low as

2 days PP

40 bpm

Elevation of maternal temperature to __F (38C) resulting from ____ after labor during the first 24 hours can occur, but should return to normal after 24 hours PP.

Elevation after 24 hours or that persists after 2 days could indicate ____.

100F, dehydration

infection

PP hemorrhage is blood loss over

1000mL

Risk factors for PP hemorrhage (PPH)

#1 cause: uterine atony

history of uterine atony

grand multiparity/ high parity

fetal macrosomia

manual removal of placenta, retained placental fragments

trauma to perineum (lacerations), hematoma

polyhydramnios; buildup of increased amniotic fluid

multiple gestation (twins, triplets, etc)

complications during pregnancy (placenta previa; placenta attaches below uterus, placental abruption/ abruptio placentae)

precipitous/ rapid labor

administration of magnesium sulfate therapy during labor

ruptured uterus, inversion/ subinvolution of uterus

coagulopathies (DIC)

Uterine atony results from

the inability of the uterine muscle to contract adequately after birth

Grand multiparity

≥5 births (live or stillborn) at ≥20 weeks of gestation

4 Ts of PPH

tone; uterine atony

tissue; placenta

trauma; lacerations, use of forceps, etc

thrombus; bleeding disorders, client on blood thinners

Physical assessment findings of PPH

uterine atony

blood clots larger than a quarter

perineal pad saturation in 15min or less

constant oozing, trickling, or frank flow of bright red blood from vagina

tachycardia & hypotension

pallor of skin & mucous membranes; cool, and clammy with loss of turgor

oliguria (low urine output)

Lab tests for PPH

Hgb & Hct

coagulation profile (PT)

blood type and crossmatch

Nursing care for PPH

fundal massage

monitor vital signs

assess for source of bleeding

• assess fundus for height, firmness, position. If boggy, massage to increase muscle contraction

• assess lochia for color, quantity, clots

• assess for clinical findings of bleeding from lacerations, episiotomy site, or hematomas

assess bladder for distention; insert indwelling catheter to assess kidney function and obtain accurate measure of urinary output

maintain/ initiate IV fluids to replace fluid volume loss with IV isotonic solutions; LR or 0.9% sodium chloride; colloid volume expanders, such as albumin; and blood products (packed RBCs and fresh frozen plasma)

provide oxygen 2-3L/min per nasal cannula and monitor O2 sat

elevate client’s legs to 20-30 degree angle to increase circulation to essential organs

breastfeeding can stimulate uterine contractions

Medications for PPH

uterine stimulants

• oxytocin; promotes uterine contractions

• methylergonovine; controls PPH

• misoprostol; controls PPH

• carboprost tromethamine; controls PPH

Docusate sodium may be administered after birth to

prevent constipation

The position and location of the uterus after birth should be documented according to the number fingerbreadths.

If above umbilicus, document as

If below umbilicus, document as

above umbilicus +1, U+1, 1/U

below umbilicus -1, U-1, U/1

Location of fundus after delivery

Dday: at U

Dday 1: U-1

Dday 2: U-2, etc

(Dday= delivery day)

The fundus is located

at the top of the uterus

Gravidity

# of pregnancies

Nulligravida

a client who has never been pregnant

Primagravida

a client in their first pregnancy

Multigravida

a client who has had two or more pregnancies

Parity

# of births in which the fetus(es) reach 20 weeks of gestation

not affected whether the fetus is born stillborn or alive

Nullipara

no pregnancy beyond stage of viability

Primapara

has completed one pregnancy to stage of viability

Multipara

has completed two or more pregnancies to stage of viability

Viability

the point in time when an infant has the capacity to survive outside of the uterus

~20 to 25 weeks gestation

GTPAL

Gravidity; # of pregnancies

Term births; 37 weeks or more

Preterm births; viability- 37 weeks

Abortions/ miscarriages (prior to viability)

Living children

GTPAL

Gravidity; # times pregnant

GTPAL

Terms- # live/ still births at or passed 37 weeks (full term)

GTPAL

Preterm- # pregnancies delivered at less than 36 6/7 weeks

GTPAL

Abortion/ miscarriage less than/ before 20 weeks

GTPAL

Living- # living children

What is the GTPAL for a 27 y/o who is 16 weeks pregnant and has

2 y/o twins delivered at 39 weeks

5 y/o delivered at 40 weeks

no miscarriages or abortions

G3 T2 P0 A0 L3

What is the GTPAL for a 30 y/o woman who is 25 weeks pregnant with twins and has

5 living children

4/5 born at 39 weeks

1 born at 27 weeks

1 miscarriage at 10 weeks

G7 T4 P1 A1 L5

Naegele’s rule is used to calculate

the expected due date based on the birthing person’s last menstrual period.

Only used if the person is sure of their LMP.

How is Naegele’s rule calculated?

subtract 3 months from the date of their LMP and add 7 days. Usually the year remains the same unless the date calculated takes us into the next calendar year.

What is the expected due date of a woman whose LMP was May 21, 2023 using Naegele’s rule?

February 28, 2024