NURS 332-001 OB lec - units 3 & 4

Taylor Edwards

Informed consent of contraceptives

don’t get the info jaded, stay BRAIDED:

B:  Benefits

R:  Risks

A:  Alternatives

I:  Inquires

D:  Decisions

E:  Explanation

D:  Documentation

coitus interruptus

withdrawal- “pulling out”

sex is INTERRUPTED

• 22% failure rate

Fertility awareness-based (FAB) & Natural family planning (NFP) methods of birth control

(only contraception accepted by Catholics)

• Involves only having sex during the infertile phase (before and after ovulation)

• Fertile for 5-7 days around ovulation (avoid intercourse during this)

Calendar-based method:

• record menstrual cycles for 6 months, subtract shortest cycle by 18 and longest by 11. Then avoid intercourse the days in between

• Example: shortest 28 days, longest 32 days. 28-18=10; 32-11=21. So avoid intercourse from days 10 to 21.

Symptoms-based method:

• avoid sex when you have sx that suggest ovulation.

• Cervical mucus clear, wet, sticky, slippery. (intercourse can resume 4 days after last day of this)

• Basil body temp: slight drop and then slight increase.

Biologic marker method: l

• Luteinizing hormone increase 12 to 24 hours prior to ovulation

• Hcg (pregnancy test)

spermicides

Nonoxynol-9 (N-9)

• reduces sperm motility

• can be a gel, cream, film, etc

• Don’t use alone - use in conjunction with other methods

contraceptives - hormonal methods

Oral Contraceptives:

• take at same time each day (can be 100% effective if no doses are omitted)

• can’t take estrogen-based if cardiac hx, hypertensive or clotting disorders- it has side effects that can increase risk of hypertension & stroke.

Vaginal ring: 9% failure

• 3 weeks in and 1 week out: reusable for 1 year; wash with soap and water, dry and store in case

Transdermal:

• same, place on back of arm or shoulder. Replace patch each week

Progesterone-only

• Oral-Minipill

• Injections- Depo-Provera - administer every 11-13 weeks

• Implantable-Nexplanon (inserted in non-dominant arm- 3 years!

Emergency contraception

• Take oral Plan B (or copper IUD) ASAP but within 5 days of unprotected intercourse

complications of combined oral contraceptives (COCs)

they contain estrogen & progesterone

ACHES:

• A: Abdominal pain - liver or gallbladder problem

• C: Chest pain or SOB → clot problem within the lungs or heart.

• H: Headaches (sudden or persistent) → cardiovascular accident or hypertension.

• E: Eye problems → vascular accident or hypertension.

• S: Severe leg pain –> DVT

intrauterine device (IUD)

*extremely effective → 0.1% fail

• Check for string placement after each period – should feel it at cervical opening

• Potential Complications: PID, no protection of STI, ectopic pregnancy, infection, bleeding unpredictable

Watch for PAINS

• P- Period late, abnormal spotting

• A- abd pain, pain with intercourse

• I- infection exposure, abnormal vaginal discharge

• N- not feeling well, fever, or chills

• S- Strings missing, shorter or longer

sterilization

Extremely effective - 99%

• Female- tubal ligation. Must be 21+. Informed consent and 30-day waiting period. If c/s, tubal can be done in same surgery. If cardiac hx, must give body time to recover before this surgery

• Male- vasectomy: takes 30 ejaculations afterwards to fully clear sperm – needs re-evaluated to ensure no sperm present. No impact on hormone levels or sexual function

• NO protection against STIs

breastfeeding & contraception

Breastfeeding is a natural, TEMPORARY way to prevent pregnancy. The body is telling you to WAIT to get pregnant bc you’re already feeding one baby.

• Breastfeeding prevents ovulation → Lactational amenorrhea method (LAM)

• Effective for ~6 months, if breastfeeding / pumping in < 4-hr intervals with no more than 6-hr

• AKA - skipping breastfeeding or pumping for like 10 hrs can trigger ovulation & result in pregnancy

contraceptives - barrier methods

*Condoms

• watch with latex allergy! Only one that also protects against STIs

Diaphragms

• Covers cervical opening - 12% failure

• Apply spermicide in addition.

• Before inserting diaphragm - urinate, inspect before use.

• Insert diaphragm up to 6 hours before sex, leave in place for 6 - 24 hrs after sex.

• Need fitted, annual gyne exam; also-if 20% weight change, miscarriage, pelvic surgery, painful intercourse, recurrent UTI’s-follow up with provider

• Good for 2 years, wash after use with mild soap and water, dry, and then use cornstarch.

• *Risk of toxic shock

Cervical caps:

• similar to diaphragm but not as effective! Also do not use if there is abnormal PAP smear, vaginal infections, or latex allergy

Contraceptive sponges:

• same concept, but you moisten it with water!

*Toxic shock syndrome (TSS):

• high fever, dizzy, faint, weak, Skin appears to have sunburn, vomiting, muscle and joint pain

infertility

the inability to become pregnant after one year of unprotected intercourse.

• infertility: prolonged time to conceive

• Sterility: inability to conceive

Increases with age, particularly women older than 35 years

Less than 35 years: during each ovulation, 25%-30% chance of conceiving; within 6 months 80% chance of conceiving

causes of infertility:

• poor nutrition, obesity, substance use, thyroid or endocrine d/o (disorder), genetics, anxiety, depression, STIs, advanced age

women:

• Hormonal and ovulatory factors (Anovulation, amenorrhea, pituitary or hypothalamic hormones d/o (disorder), adrenal gland d/o, increased prolactin

• Tubal and peritoneal factors

• Uterine factors (Developmental anomalies, tubes: decreased motility, inflammation, adhesions. Endometrium: tumors, endometriosis, uterine adhesion

• Cervicitis, unfavorable mucus

men:

• Undescended testes or damage to testicles

• Hypospadias (urethra is under tip)

• Varicocele (varicose vein of the scrotum)

• Low testosterone levels

• Hypopituitarism

• Azoospermia: no sperm cells produced

• Oligospermia: few sperm cells produced

common s/s of newborn infections:

atypical:

• apnea, resp distress, irritability, seizures, bleeding, abnormal HR/ temp, lethargy, poor feeding, abnormal cry, bulging fontanels

dx

• lab studies (CRP, CBC, CSF, urine)

tx

• erythromycin, IV antibiotics

bacterial vaginosis (BV)

most common vaginal infection

• sx- fishy odor

• tx- antibiotic, NO SEX

contraction - douching, multiple partners

vaginal candidiasis (yeast infection)

contraction- prolonged moisture (sweaty undies, bathing suit)

• sx- thick, white, clumpy d/c. pruritus

• tx- antifungal (Monostat)

• urinate after intercourse

viral hepatitis

viral

Hep A

• fecal-oral transmission

• malaise, nausea, fever, RUQ pain (liver pain!)

• vaccine

Hep B

• transmitted thru bodily fluids

• arthritis, clay-colored stools & dark urine, n/v, h/a, jaundice

• dangerous for newborn- baby needs Hep B vaccine

Hep C

• sexual transmission

• can breastfeed unless cracks in nipples

• flu-like sx

Human Papillomavirus (HPV)

viral: once you contract it, it always remains in your body!

sx

• can cause warts or abnormal cervical cells to grow (cancerous!)

dx

• exam, screening, pap smear

tx

• can resolve on its own as it passes tu the body

• vaccine!

pelvic inflammatory disease (PID)

woman’s reproductive system is affected negatively by an organism (ex- untreated STI)

• can lead to infertility, pelvic pain, ectopic pregnancy (would need Methotrexate)

sx

• acute severe pain, cramping, hyperthermia, malaise, n/v

dx

• inflammatory markers (increased CRP)

tx

• analgesics, limit pelvic exams & intercourse

diagnosing infertility

Assessment of female infertility

• Detection of ovulation: Luteinizing hormone, basal body temperature, cervical mucus

• Hormone analysis

• Imaging (Transvaginal Ultrasound & MRI: pelvic structure abnormalities); Sonohysterography (fluid injected into uterine cavity and depth of lining and then viewed by ultrasound); Laparoscopy (view outer uterus -adhesion, endometriosis, occluded tubs, polycystic ovaries)

Assessment of male infertility

• Semen analysis (number, morphology, and motility)

• Abstain 2-5 days, Take specimen to the lab within 1 hour, Do not refrigerate

• Ultrasonography (scrotal and transrectal)

• Hormonal testing

Assisted Reproductive Therapy (ART)

• Intrauterine insemination (IUI): sperm placed into uterus

• In vitro fertilization: embryo transfer: fertilization of the egg takes place in the laboratory and transferred to woman during embryonic period

• Intracytoplasmic sperm injection: selection of 1 sperm that is injected into egg

• Preimplantation genetic diagnosis: cell is removed from embryo on day 3 or 4 and tested for genetic issues

• Gamete intrafallopian transfer (GIFT): egg and sperm placed in uterine tube where natural fertilization takes place

• Zygote intrafallopian transfer (ZIFT): fertilized then placed in tube (fertilization takes place in vitro)

STIs

mostly affect young ppl ages 15-25.

• if left untreated - can lead to infertility

the 5 Ps:

1. Partners (number, m/f)

2. Practices (type of sex)

3. Prevention of Pregnancy (condoms? bc?)

4. Prevention of STIs?

5. Past STIs?

postpartum hemorrhage (PPH)

Cumulative blood loss ≥1000 mL. (>500 ml for vag delivery; >1,000ml for c/s), or bleeding with signs/symptoms of hypovolemia. Problematic -> can be hard to recognize until late, & can cause death

• Early / acute / primary PPH: occurs within 24 hours of the birth

• Late / secondary PPH: occurs more than 24 hours (can be up to 12 weeks after the birth!)

Causes

• Uterine atony: hypotonia of uterus (soft & boggy)- leading cause of PPH

• Retained placenta fragments

• Unusual Adherent placenta (too much interwoven penetration into uterine lining)

  • Accreta: (A little) slight penetration into myometrium

  • INcreta: (rlly IN there) deep penetration into myometrium

  • PERcreta: PERforation thru myometrium and uterine serosa, possibly involving adjacent organs

• Lacerations of genital tract

• Hematomas

• Inversion of the uterus (turns inside out) – may give terbutaline to soften uterus, then manually push it back in, then give uterotonic to contract it back

• Subinvolution of the uterus (not contracting & shrinking normally)

• Prolonged lochial discharge

Who is at risk for PPH?

• Any woman who is overextending the uterus: High parity, Polyhydramnios, Macrosomia, Obesity, Multifetal gestation

• Any woman likely to bleed: aspirin, coagulation disorders, placental abruption / previa/ retained, uterine subinvolution, traumatic birth (c/s, forceps, manual placental removal, laceration)

• Anesthesia and Analgesia

• Long labor/ Pitocin induced

• Magnesium sulfate

• Chorioamnionitis

• Intrauterine fetal demise

• Hypertensive disorders 

PPH screen needs done:

On admission, 30-60 min. prior to anticipated delivery & Post-birth

Care management

• Early recognition and tx critical.

• The initial intervention is fundal massage, also voiding, may need to give large bore IV fluids or infusion of oxytocin (uterotonic to contract)

• Additional uterotonic medications (methergine- don’t give with hypertension, or cardiac hx. Cytotec- tablet dissolves. Hemabate- don’t give to asthmatics. Tranexamic acid- helps blood clot itself)

• Always quantify blood loss!

• Surgical Management: Bakri Balloon (balloon in uterus tamponades aka pushes pressure against vessels), Hysterectomy (remove uterus – can’t have future kids)

Special PPH considerations:

• These women may need longer recovery time, have lots of fatigue, anxiety, postpartum depression, Delayed lactogenesis bc of less fluids. If hysterectomy, lots of support. Watch for DIC

hemorrhagic / hypovolemic shock

Results from hemorrhage. Emergency situation in which perfusion of organs is severely compromised → Death may occur

• Restore circulating blood volume & eliminate the cause of the hemorrhage (give fluids or blood transfusion)

• Shock index: divide HR / systolic BP. Ratio 1:1+ is alarming. Normal should be 0.5-0.7. 

• Sx- *increased HR & decreased BP. Compensations → RR rapid and shallow, HR rapid, weak, irregular. Cool, clammy pale skin; urine output decreased; LOC-lethargic to coma.

• DON”T sit or stand up bc blood will drop from head. Lay them flat or Trendelenberg so blood flows to major organs

• O2 may be needed

Disseminated Intravascular Coagulation (DIC)

There’s an imbalance in blood stream, lots of micro clots. It pulls the blood away from perfusing the tissues normally. Can cause hemorrhaging from small cuts in body

• Triggered by other event (ex. Abruption, preeclampsia, IUFD, Sepsis, Amniotic Fluid Embolism)

• sx- Tachycardia, hypotension. bleeding from sites- hematomas, bruising, petechia, oozing at IV site, epistaxis, GI bleed, hematuria. Peripheral cyanosis, renal impairment. Can lead to LOC changes: drowsy, confused, coma

LABS:

• Platelets decreased (helps with blood clot formations)

• Fibrinogen decreased (essential for clot formation)

• Prothrombin time prolonged (amount of time blood takes to clot). normal= ~12 secs.

• Fibrin split products increased (breaks down clots)

• D-dimer increased (fibrin/ clot degradation product)

Tx= correct the cause, fluids, blood products

thromboembolic diseases

Superficial venous thrombosis:

• involvement of the superficial saphenous venous system

• sx- Pain and tenderness, warmth, redness, enlarged hardened vein

• tx- Rest, elevate leg, heat, compression stocking, NSAID

Deep venous thrombosis (DVT):

• affects lower extremities

• sx- Unilateral leg pain, calf tenderness, swelling, redness, warmth, positive homan’s sign

• tx- bed rest, elevate leg, analgesia, compression stocking (after swelling decreases); avoid rubbing the site bc it may dislodge clot; do not sit with the legs sharply flexed

Pulmonary embolism:

• blood clot dislodges and is carried to pulmonary artery / lungs

• sx- Dyspnea and tachypnea, tachycardia, apprehension, chest pain, cough, hemoptysis (pink frothy sputum), elevated temp, syncope

postpartum infections

Risks: prolonged ROM / labor (24+ hrs), chorioamnionitis, cath, retained placenta, PPH, perineal trauma, c-section, internal monitoring (fetal scalp electrode & IUPC goes up into uterus), amount of Vaginal exams, nutrition concerns, diabetes, pneumonia, history of infection, anemia

Puerperal: Genital tract infection post-birth

• fever of 38° C (100.4° F) after 24 hours or lasting 2+ days (right after birth a slight fever can be normal)

Mastitis: breast infection

• fever, malaise, flu-like symptoms, and a sore area in a breast.

• Continue breastfeeding

Endometritis: infection of uterus

• fever, increased pulse, chills, anorexia, nausea, fatigue, lethargy, pelvic pain, uterine tenderness, foul-smelling lochia

UTI

• dysuria, frequency, urgency, lower grade fever, urinary retention, hematuria, pyuria. 

Wound

• fever, erythema, edema, warmth, tenderness, pain, purulent drainage, wound separation

uterine rupture

EMERGENCY → a tear in the uterine wall! Could potentially cause the fetus to move into the mother’s abdomen, with so many complications.

Most frequent causes:

• Separation of scar of a previous c/s

• Uterine trauma (accidents, surgery)

• Congenital uterine anomaly

• During labor and birth

• Intense spontaneous uterine contractions

• Labor stimulation (oxytocin, prostaglandin)

• Overdistended uterus (multifetal gestation)

• Malpresentation, external or internal version

• Difficult forceps-assisted birth

• Occurs more in multigravidas

hyperbilirubinemia

dangerous buildup of broken-down RBCs in baby’s body

• Pathologic Jaundice: within 24 hours of birth (something VERY wrong)

• Physiologic jaundice: after 24 hours of birth

• bili level >12 = concern

Risks: Rh negative mother, ABO incompatibility, polycythemia (increased RBCs), bruising, history with other children, preterm, formula feeding (bc breastmilk is natural laxative), birth trauma (don’t dismiss petechiae)

Rh incompatibility

Happens when Mother is Rh-negative & Baby is Rh-positive. The mother becomes sensitized (exposed) to Rh+ blood → her immune system forms antibodies. These antibodies cross the placenta in future pregnancies and destroy the Rh+ baby’s red blood cells, causing hemolysis.

• Coombs test: (ex- 1:8, 1:16, 1: 32). Larger second number means that there are more antibodies present! We want NEG. If pos, differentiate direct or indirect:

• Indirect Coombs: antibodies are in blood stream that could attach

• Direct Coombs: antibodies are directly attached to blood, can cause hemolysis

ABO incompatibility

Usually an O mother who births an A, B, or AB infant. Type O mothers naturally have anti-A and anti-B IgG antibodies that can cross the placenta. These antibodies can attack the fetus’s red blood cells → hemolysis.

• Baby’s body has a hard time excreting so many broken-down RBCs → can lead to jaundice!

high risk newborn

High risk infants are classified according to:

1. Birth weight -> SGA neonates at high risk

2. Gestational age -> preemies are at high risk (Organ systems are immature and lack adequate reserves of bodily nutrients)

3. Predominant pathophysiologic problems

respiratory therapies for neonate

Oxygen therapy, Hood therapy, Nasal cannula, Continuous positive airway pressure (CPAP)

Mechanical ventilation- do NOT over-oxygenate (caution using 100% o2). SpO2 monitor must be constant, 90-95%. Needs titrated to maintain this

Arterial blood Gas (ABG) are needed for baseline but are painful procedures; do not do frequently unless necessary!

Surfactant administration: reduces surface tension and promotes gas exchange

Nitric oxide therapy- inhaled to relax lungs & improve blood flow & oxygenation

Extracorporeal membrane oxygenation (ECMO)!: basically heart/lung bypass for very critical infants. Blood leaves the baby → goes through ECMO machine → gets oxygenated and CO₂ removed → warmed → returned to the baby

*Wean from respiratory assistance

high-risk neonate’s care management

Skin-

• increased sensitivity and fragility

• Braden Q or Neonatal Skin Condition Scoring (NSCS) should be used daily.

• Avoid the use of soap.

• reposition frequently

environment

• avoid overstimulation

Kangaroo care

• skin to skin!

Parental support & education- anticipatory grief

common complications for high-risk neonates

Respiratory Distress Syndrome (RDS)

• Caused by a lack of pulmonary surfactant, which leads to progressive atelectasis. Apparent minutes after birth (retraction, nasal flaring, grunting, skin color, apnea)

Retinopathy of prematurity (ROP)

• Believed to occur from oxygen toxicity! → watch SpO2 closely

• Can cause blindness → consult ophthalmologist

Bronchopulmonary dysplasia (BPD)

• occurs when an infant has been on a mechanical ventilator and cannot tolerate being weaned off.

• May have tachypnea, retractions, nasal flaring, activity intolerance.

Patent ductus arteriosus (PDA)

• Fetal ductus arteriosus of heart fails to close after birth (hole in heart)

• Echocardiogram (ultrasound to visualize heart structure)

• Give Indomethacin or ibuprofen: helps with vasoconstriction to hopefully close on its own

• May have murmur, crackles, tachypnea, bounding pulses

necrotizing enterocolitis (NEC)

Acute inflammatory disease of the GI mucosa. Bacteria enter infant’s GI tract. Can lead to intestinal ischemia!

• Sx- abd distention, bloody stools, bile-stained residual, pale, apnea, hypotonia, decreased activity, bradycardia

• X-ray to confirm, then GI rest (NPO)! TPN, antibiotics, and possible surgery

common physiologic problems in high-risk newborn

Respiratory fxn:

• decreased alveoli, surfactant, absent gag reflex, capillaries immature. Give betamethasone before 34 weeks!

Cardiovascular fxn:

• watch for CV shock, low BP, poor cap refill, RDS

Central nervous system fxn:

• Can have trauma from birth, hypotonia (flaccid), decreased activity, weak cry, inability to suck and swallow

• Have an impaired coagulation process (Vit K needed)

Thermoregulation: 

• Maintain a neutral thermal environment (isolette, skin-to-skin, hat). Avoid cold stress- increased O2 needs → RR >60, hypoglycemia bc body burns glucose to warm up, resp distress, signs of poor perfusion.  Rapid changes in body temp may cause apnea.

Nutrition:

• gag reflex lacks, uncoordinated suck and swallow

Renal Function:

• monitor I and O

Hematologic Status:

• tendency to bleed, slow production of RBCs, low iron stores (they limit the amt of blood draws)

Prone to infections:

• s/s: glucose instability, feeding intolerance, lethargy, irritability, temp instability- usually hypothermia, tachypnea, apnea, RDS, jaundice, pale, cyanosis, vomiting, diarrhea, poor perfusion

growth & development of high-risk neonate

Corrected age

• Age of the preterm infant is corrected by adding gestational age and postnatal age

• Milestones are corrected until age 2½

• VLBW survivors: have increased risk for neurologic or cognitive disability

Discharge Criteria

• Neurologic responses appropriate for corrected age

• Appropriate weight gain (for VLBWs, it’s normal to lose up to 15% of birth weight)

• An ability to cry vigorously when hungry

• An ability to raise the head when prone

signs of newborn hypothermia vs hyperthermia

Hypothermia / cold stress:

• body temp < 36.5°C (< 97.7°F)

• skin pale, mottled (marbled), cyanotic, acrocyanosis, cold to touch, vasoconstriction → poor cap refill

• flexed position to conserve heat

• resp distress, apnea, bradycardia

• lethargy, poor feeding, decreased activity, weak cry

• hypoglycemia bc body burns glucose for warmth → can lead to metabolic acidosis

Hyperthermia:

• body temp >37.5°C (> 99.5°F)

• skin flushed & warm if environmental, or pale & cold if sepsis-related

• vasodilation

• extended position

• tachypnea, tachycardia

• Irritability initially, Lethargy (if severe)

• poor feeding, Increased oxygen demand

• risk for febrile seizures

preterm labor / birth

Occurs between 20 to 36 6/7 weeks: Regular contractions with cervical change (effacement, dilation or both), and regular uterine contractions

• Preterm birth has been decreased in recent yrs because fertility practices limit scheduled preterm births to only those with valid indications

Causes of spontaneous preterm labor:

• Infection

• Multifetal gestation (overdistention)

• Placental causes

• Structural abnormalities of the uterus, insufficiency

• Cervical shortening

• Maternal and fetal stress

• Decrease in progesterone

• Allergic reaction

Predicting spontaneous preterm labor and birth

• Cervical length: >30 mm unlikely to give birth prematurely

• Fetal Fibronectin (fFN) Test: fFN is a glycoprotein “glue” produced during fetal life. Women with a negative test have <1% chance of giving birth within 2 weeks (We WANT it to be fFN negative)

Preterm labor management

• If you recognize sx of preterm labor, stop what you are doing, lie on your L side, drink 2-3 glasses of water, wait 1 hour, call doc if sx persist

• Lifestyle modifications: not bedrest, but no vigorous lifting, minimize stairs, restrict sexual activity

External cephalic version (ECV)

An attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for vaginal birth

Done at 36-37 weeks

• Ultrasound, NST, and informed consent before procedure

• Terbutaline given to relax uterus

*Contraindications: previous c/s, oligohydramnios, multifetal pregnancy

induction & augmentation of labor

Elective induction of labor (I’m choosing this bc I want to get this baby out):

• should not be initiated until 39 weeks of gestation

• must have good Bishop’s score (dilation, effacement, station, cervical consistency, cervical position)

Cervical ripening agents:

• Cytotec- tablet into vagina, Cervidil- vaginal suppository, or Prepidil. 

• Given if cervix hasn’t made much change during pregnancy. Ripens cervix, causes cramps, jumpstarts labor

• Don’t give cervical ripening agents to previous c/s patients bc it can cause scar tissue to rupture! we’d just give Pitocin

• Urinate first before cervical ripening agents! (otherwise they’ll fall out)

Labor drugs

• Oxytocin: induce or augment labor. CANNOT be given with cervical ripening agent

• Pitocin med calc! max 40 milli units

Sweeping / stripping of membranes: in prenatal office, mom ready for labor, during cervical exam provider scrapes some cervix, which MAY jumpstart labor.

Amniotomy – AROM – artificial rupture of membranes, AKA breaking mom’s water. Baby should be at ischial spine

uterine tachysystole

more than 5 contractions in 10 minutes; a single contraction lasting >2 minutes , <1 min apart. Normally, good contractions last ~1 min, 2-3mins apart

Interventions vary according to FHR strip category:

• Reposition

• IV fluid bolus of lactated ringer

• decrease or d/c Pitocin (if category 2 or 3, d/c pit first! then reposition & LR)

• o2 if necessary

• Terbutaline if necessary- TERminates contractions

meconium-stained fluid

Dark green amniotic fluid indicates fetus has passed stool in utero

Possible causes:

• Breech presentation

• Hypoxia-induced peristalsis

• Umbilical cord compression

*We automatically notify NICU team for delivery, WORRIED AB MECONIUM ASPIRATION. Respiratory resuscitation possibly needed. Bulb suction needed to clear airway. If needed (decreased FHR, trouble breathing, etc) deep Deely suctioning

shoulder dystocia

Baby’s anterior shoulder cannot pass under maternal pubic arch

• Turtle sign – head crowns, but pops back in (like a turtle popping in & out of its shell)

Risks – diabetes or macrosomia (big baby), small maternal frame, previous shoulder dystocia

Suprapubic pressure – stand above on stool, push hard to roll baby’s shoulder forward

McRoberts Maneuver – More Room Maneuver- hyperflex mom’s knees to chest to straighten sacrum & give more room in uterus

Newborn risks: clavicle fracture, asphyxia, brachial plexus injury

Mother risks: operative injury, uterine rupture, hysterectomy, endometritis, death

prolapsed cord

Umbilical cord descends into birth canal before the baby does - it can get compressed (prolonged or variable decels!) - EMERGENCY

With sterile glove, push up on fetal head to alleviate compression! Literally holding pressure off cord until baby is delivered (usually c/s)

Risks: long cord (100+ cm), breech / malpresentation, multiple gestation, premature ROM or labor

1. Call for help & notify MD

2. reposition mom off cord

cesarean birth (c/s)

Birth of a fetus through a transabdominal incision of the uterus

• "Classic incision” (vertical) – much more traumatic, only done if anatomical abnormalities, transverse lie, emergency

Pre-operative-

• Hibiclens at home, arrive 2 hrs before time, CBC, type & screen, chlorhexidine prep, NST, FHM, compression stockings, foley cath to keep bladder empty

Immediate postoperative care –

• stork nurse & NICU team present - c/s doesn’t squeeze the baby out of birth canal, so they’re more likely to have respiratory distress from retained secretions

Nursing interventions –

• decrease gas pains – avoid drinking w/ straw so you don’t inhale air, give Mylicon – my Gas is Gone!

TOLAC- trial of labor after cesarean

VBAC-vaginal birth after cesarean

meds for intrapartum preterm labor

Suppressing uterine activity in preterm labor

• Betamethasone - (Breath Betta!) Promotes fetal lung maturity (before 34 weeks gestation)

• Antenatal glucocorticoids: reduce RDS, hemorrhage, NEC, and death in neonates

• Tocolytics (relax uterus):

• Terbutaline- TERminates contractions

• Magnesium Sulfate for fetal neuroprotection- their CNS system is underdeveloped, so we give this to decrease risk of cerebral palsy. Also used for relaxing uterus to slow contractions.

• Calcium Channel Blockers (Nifedipine)

rupture of membranes

• PROM: Prelabor rupture of amniotic sac and leakage of fluid (prior to the onset of labor)

• PPROM: premature prelabor rupture of membranes (before 37 weeks of gestation)

Often preceded by infection like chorioamnionitis

Care management

• PPROM <32 weeks is managed conservatively - too early to induce labor, so they’d just give antibiotics to decrease infection & wait longer

• Vigilance for signs of infections (fetal tachycardia, prophylactic antibiotics)

• Fetal assessment

• Antenatal glucocorticoids for all women with PPROM 24 - 34 weeks gestation

• Magnesium sulfate (fetal neuroprotection, prevent Pre-E, or  tocolytic in premature labor)

chorioamnionitis

Bacterial infection of the amniotic cavity

• Major cause of complications for mothers and newborns

• Diagnosed by the clinical findings: maternal fever, maternal and fetal tachycardia, uterine tenderness (sore, continuous pain), and foul odor of amniotic fluid

• Neonatal risks- prolonged ROM

post-term birth

42+ weeks gestation

• Maternal and Fetal Risks:  Dysfunctional labor (labor doesn’t progress as expected -> usual 1cm per hour dilation for primis), perineal injury, PPH, infection, birth interventions (forceps or vacuum), maternal morbidity, Fetal abnormal growth, cord compression, shoulder dystocia, fetal injury, placenta ages & calcifies, meconium stained fluid, post-maturity syndrome

• More frequent fetal assessment, NST, contraction stress test (CST), BPP

obesity in pregnancy

• <18.5 = underweight

• 18.5 – 24.9 = normal

• 25-29.9 = overweight

• 30-39.9 = obese

• 40+ = morbidly obese

Obese pregnant women are at increased risk for complications:

• Spontaneous abortion and stillbirth

• Pregnancy-associated hypertensive disorders

• Gestational diabetes

• Fetal congenital abnormalities

• Cesarean birth

• Venous thromboembolism

• Post-term pregnancy and longer labor

Interprofessional Care Challenges:

• Standard furniture often not large enough

• Fetal monitoring can be difficult – more likely to get internal fetal monitoring bc thick layer of fat blocks FHR signal

• Mobility is often a problem

Postoperative Challenges:

• Pannus (large roll of abdominal fat) causes area to remain moist

chlamydia

bacterial infection- STI

sx

• Usually asymptomatic

• spotting, post-sex spotting, purulent d/c, dysuria

dx

• screening, culture

tx

• antibiotics can cure it (doxycycline)

• Can lead to infertility if untreated

After tx, they need re-tested!

can cause conjunctivitis or pneumonia in newborn!

gonorrhea

Bacterial infection- STI

sx

• can be asymptomatic

• purulent d/c, bleeding between periods, swollen labia, abd pain, if rectal sex- pain and bleeding, stool changes

dx

• screening & re-screening

Tx

• antibiotics

• *If untreated, can lead to to PPROM, pelvic inflammatory disease (PID), or infertility

herpes simplex virus (Herpes / HSV)

No cure, lifelong infection!

sx

• Painful blisters on genitals or mouth

• dysuria, purulent d/c

tx

• antiviral to help decrease viral load

• avoid stress, sickness - triggers cause flare-ups of blisters

if active lesions & close to delivery of fetus, they MUST get a c/s!

Trichomoniasis

Sexually transmitted, caused by parasite: curable

• sx- Itching, burning, inflammation, d/c: yellow/ green/ frothy

• tx- antibiotic can kill it

HIV

Cannot be infected thru touching, spit, sweat, tears, urine, or feces -> only blood, semen, vaginal fluid, breast milk

• Flu-like sx (headache, malaise, fever, weight loss, rash)

• No cure bc it’s a virus, but Antiretroviral therapy -> slows the spread. Can decrease the viral load so it’s undetectable & not spreadable!

• HIV+ Pregnant woman:

• at 36 weeks, they will check viral load. If virus has <1000 copies / ml, pt is safe to deliver vaginally. If at >1000 copies / ml, a c/s is needed

• avoid fetal scalp electrodes, forceps, vacuum

• NO BREASTFEEDING

syphilis

bacterial STI

1. First sx- small, painless, red lesion where syph entered body (ex- on tip of penis)

2. Second - patchy hair loss, skin rashes on palms & soles, warts / lesions, malais

3. Third - latent, asx, then causing organ damage & neurosyphilis

we want pts to be syphilis RPR (non-reactive)

• tx- penicillin (antibiotic). ABSTINENCE during this

paternal postpartum depression (PPD)

• Can happen from birth to 6 months after birth

• The best predictor of paternal depression is having a partner with PPD

• Men are not routinely screened for PPD

Baby blues vs PPD vs Postpartum Psychosis

Baby blues

-should go away within a few days to a week

-Sad, anxious, overwhelmed, crying, loss of appetite, difficulty sleeping

Postpartum Depression (PPD)

-Irritability, crying, sleeping issues, sad, anxious, overwhelmed, loss of appetite (that persists and are more severe)

-Feelings of detachment toward the newborn / no interest in them

-Thoughts of harm

Postpartum Depression with Psychotic Features (Postpartum Psychosis)

-Commonly associated with bipolar disorder

-Symptoms: trying to harm self or baby, rapid mood swings, confusion, seeing or hearing things not there

-Need inpatient psychiatric care

caring for mom with PPD

To recognize symptoms of PPD as early as possible, the nurse should inquire directly, be an active listener, and demonstrate a caring attitude

• Refer to appropriate psychiatric provider when PPD screening is positive

• Risk of suicide, detachment from newborn

• Prevention! discuss feelings, rely on support system, purposefully relax, eat, exercise, sleep, get out of house

perinatal substance abuse

Universal screening for drug use in pregnant women is recommended.

• start w/ least invasive qs first - “prescribed meds? Caffeine? Tobacco? Illegal substances?”

Maternal and Fetal Effects of drug abuse

• Tobacco

• Alcohol – fetal alcohol syndrome (FAS)

• Opioids – neonatal abstinence syndrome (NAS)

• Cocaine – placental abruption

in PA, being on drugs doesn’t make the mom immediately at risk of being charged with CHAB. Only if the abuse affects the baby when it’s born, we must report to ChildLine

neonatal abstinence syndrome (NAS)

Finnegan Scoring- looks at poor feeding, trouble sleeping after feeds, projectile vomiting, diarrhea, loose stools, tremors, increased temp & rr, high-pitch cry, increased sucking, red excoriated skin patches, mottling / marbling, frequent yawning and sneezing, increased muscle tone (esp Moro)

• Recently changed to Eat Sleep Console

• Feeding q2-3 hrs – small amounts, don’t look baby in eyes during feeding bc it distracts them

• Give pacifier for sucking

• Swaddling, holding, rocking

• Reduce stimuli – dark environment

preterm labor / birth

Occurs between 20 to 36 6/7 weeks:
Regular contractions with cervical change (effacement, dilation or both), and regular uterine contractions

Preterm birth has been decreased in recent yrs:

• fertility practices reduce the risk for multiple gestations

• limit scheduled preterm births to only those with valid indications

• prevent recurrent preterm birth

Causes of spontaneous preterm labor / birth

• *Infection

• Placental / cervical insufficiencies

• Structural abnormalities of the uterus

• Maternal and fetal stress

• Decreased progesterone- “pregnancy hormone”

• Overdistension of uterus- multifetal gestation or polyhydramnios

• Allergic reaction

Predicting preterm labor

• Cervical shortening- not predictive, but cervical length >30 mm in the 2^nd and 3^rd trimester unlikely to give birth prematurely

• Fetal Fibronectin (fFN) Test- fFN is a glycoprotein “glue” produced during fetal life. We WANT it to be fFN negative - v unlikely to go into preterm labor within the next 2 weeks

Signs of preterm labor

• Change in vaginal discharge - increased amt; watery, mucus, bloody

• low back pain

• Pelvic or lower abdominal pressure

• abd cramps, uterine tightening

• ruptured membranes

Managing preterm labor

• Stop activity, lie on your side, drink 2-3 glasses of water, wait 1 hour, if symptoms get worse call provider or go to hospital

• Lifestyle modifications- Activity restriction: not bedrest, but no vigorous lifting, minimize stairs, Restriction of sexual activity

Meds given in preterm labor

• Betamethosone - Breath Better - Promotion of fetal lung maturity when <34weeks gestation.

• Tocolytics (incl Terbutaline) Terminate contractions & relax uterus

• Magnesium sulfate- can be used for preterm labor → neuroprotection of fetus- their CNS system is underdeveloped, so we give this to decrease risk of cerebral palsy. It slows things down so it can help slow contractions

• Prostaglandin Inhibitors (NSAIDs - Indomethacin) → block prostaglandin (a labor hormone)

• Calcium Channel Blockers (ex- Nifedipine) → blocks calcium activity which controls muscle contractions

Maternal cardiovascular changes during pregnancy

In a normal pregnancy,

• Increased intravascular volume (40-50% blood increase, CO increases)

• Intravascular volume changes after childbirth (blood loss, CO decreases)

In a pregnancy with cardiovascular issues,

• decompensation of maternal cardiac status can occur!

• maternal arrhythmias, heart failure, preterm birth, fetal growth restriction, and fetal death

Pre-conceptional and genetic counseling are essential components of care

cardiac decompensation

If mom has persistent cardiac decomp, high risk of mortality rate!

• Often triggered by an infection

Subjective:

• Increasing fatigue, Breathing difficulties​, Smothering feeling, Frequent cough​, Palpitations

Objective:

• Irregular, weak, rapid pulse, Crackles, Orthopnea, Increased respirations, Moist frequent cough​, Lip and nail bed cyanosis, Generalized edema (lower extremity edema in 3^rd trimester is normal)

antepartum care for cardiac patients

Heart surgery preferred before pregnancy, but if during, usually done in 3^rd trimester

• Warning signs to call doc: cardiac decomp, DVT, Chest pain, PE

• Daily weights (2-4 lbs overall in first trimester, 1 lb per week afterwards, 25-35 total gain during pregnancy)

• Prenatal appointments

• Activity: limit as instructed. Normal pregnancy- encourage activity, but with cardiac patients, be rlly careful not to increase CO demand too much

• Medications may be adjusted. Colace important bc we don’t want them to strain

• Infection prevention bc it can trigger cardiac decomp

intrapartum care for cardiac patients (during active L & D)!

• Monitor BP, SpO2

• Cardiac monitoring (HR >100 or RR > 25 concerning)​

• FHR monitoring ​

• Minimize anxiety​ and pain

• Positioning​: side-lying to help with perfusion, HOB elevated (avoid stirrups & closed glottis pushing- we always want OPEN glottis pushing- exhale so air moves thru vocal cords*)

• Pain management​: epidural

• Vaginal birth preferred to minimize blood loss. May have them “labor down” – wait at 10cm without pushing for a while, to limit pushing. Likely will use vacuum or forceps​

• Precautions: no methergine (increases contractions), no terbutaline (relaxes uterus if contracting too much- uterine tachysystole, or prolonged decels)

• If getting a tubal ligation, wait 2+ weeks after delivery until body stabilizes

postpartum care of cardiac patients

• Vital signs, SpO2

• Thorough respiratory and cardiac assessment​

• Monitor for edema​

• Bleeding​

• Uterine tone​

• Fundal height​

• Urinary output​

• Bowel movements ​- increase fiber, fluids, Colace

• Pain​

• Promote activity and rest

• Birth control: avoid estrogen (it increases blood clots, bp, & fluid retention). Use barrier-methods or progesterone-only** risk for complications. Wait to get pregnant again!

• 24-48 hours after delivery is most likely to decomp, but can happen 2 weeks after

Perinatal mood disorders

disorders that occur during pregnancy or in the first year postpartum. 

Mental health disorders affect women more, esp during childbearing years (ages 15-40)

• Depression (PPD)

• Bipolar disorder

• Postpartum psychosis

• Suicide

Diagnosis

• Rule out thyroid abnormalities and anemia first

• Sx of major depression: crying, depressed mood, sleep changes, weight changes, fatigue, worthlessness, guilt, inability to concentrate, suicidal ideation

Antidepressant Medications

• Selective serotonin reuptake inhibitors (SSRIs)- Zoloft

• Serotonin/norepinephrine reuptake inhibitors (SNRIs)

• Tricyclic antidepressants (TCAs)

• Monoamine oxidase inhibitors (MAOIs) contraindicated

• She can choose to go off meds if she’s stable enough. Risk-benefit analysis will be done to help decide this

anxiety disorders

Characterized by prominent symptoms of anxiety that impair functioning

• more common in women than men

• OCD, PTSD, Generalized anxiety disorder, Panic disorder, Social anxiety phobia

postpartum depression

Up to 85% of women experience a mild depression (“baby blues”) after the birth. Can get emotional, but it only lasts abt a week

Postpartum depression persists longer

• Complications of pregnancy and birth increase the risk for PPD