Nurs 319 – Nursing Care of the Childbearing Family Exam #2

Baseline

average rate duting a 10 minute period, at least 2 minutes of interpretable data, normal range 110-160bpm

· Tachycardia

> 160 bpm= early signs of hypoxia

· Bradycardia

< 110bpm (<80=omnious)= late sign of fetal hypoxia

Variability

described as irregular waves or fluctuations in the baseline FHR of two cycles per minute or greater

· Absent

· Minimal

· Moderate

· Marked

Absent variability

amplitude range undetected/ no change/flat

· Minimal variability

<5 BPM/ little squiggly

· Moderate variability

6 to 25 BPM/ ideal and most common

· Marked variability

>25 BPM

Accels

good for baby , indication of fetal well being (15bpm x 15secs)

Decels

· Early

· Late

· Variable

· Prolonged

· Early Decels

mirrors the contraction

o Associated with head compression(expected)

· Late Decels

peak of decel occurs after the peak of the contrction (starts and ends late- gradual)

o Associated with uteroplacental insufficiency- profusion issue

o Intrauterine resuscitation needed

· Variable Decels

abrupt drop from basleine(V,W, or U shaped)

o May okay at anytime (variable timing)

o Associated with umbilical cord compression

o Need to relieve cause of compression

· Prolonged Decels

greater than 2 minutes

o Intrauterine resuscitation needed!

Uterine components

· Frequency

· Duration

· Intensity

· Frequency

from beginning of the contraction to the start of the next contraction

· Duration

from start to end of the contraction

· Intensity

by palpation(resting tone, contraction, back to resting) or by internal monitoring (in mmHg)

· Tachysystole

greater than 5 contractions in 10 minutes/ closer than 2 minutes

· Hypertonic

single contraction lasting longer than 2 minutes

· Hyperstimulation

increase leads to nonreassuring fetal heart rate pattern

Sinusoidal Pattern

absent b/c its smooth and undulating

Category I: normal

· Baseline HR= 110-160

· Moderate variability

· No late or variable decels

· Eary or no decels

· Accels or no accels

Category III: abnormal

Absent variability with any of the following:

-recurrent late decelerations

-recurrent variable decelerations

-bradycardia

-sinusoidal pattern

Early dcels nursing intervention

document and continue to observe FHR

Variable decels nursing interventions

· Reposition the mother to relieve cord compression

· Increase IV fluids and apply O2

· Decrease/stop oxytocin

· Anticipate amnioinfusion/ increases space for baby to move

· Vaginal exam to assess for prolapsed cord

Late decels nursing intervention

· Focus on increasing profusion!!

· Position on lateral side(usually left)

· Apply O2 @ 10 L

· Increase IV fluids to improve blood volume and increase profusion

· Stop oxytocin

· Notify health care provider

Prolonged decel nursing intervention

· Same as late

Variable

Early

Accelerations

Late

Cord (umbilical compression

Head compression

Ok (fetus is doing well, enough O2)

Placental insufficiency

First stage of labor

Begind with uterine contractions

ends with full cervial effacement and dilation

Early/Latent phase (up to 5 cm of dilation)

UC irregular, 2-30 min apart, 30-40 sec

Active phase (6 to 10 cm of dilation)

UC regular, 1.5 - 5 min apart, 40-90 sec

First stage of labor Nursing Care

- Prenatal data

- Assessment and nursing diagnosis

~ determine if its true or false labor

~ obstetric triage

Admission to the labor unit

- Prenatal data

- Interview:

~ what brought the patient in?

~ what are the plans for labor/ birth plan?

psychosocial factors

~stress in labor

~cultural and religious preferences (get hospital interpreter, listen to concerns, explain procedure and rationales)

assessment on admission

Physical examination

- assessment of FHR and pattern

- Assessment of uterine contractions

- vaginal examination (cervial effacement, dilation, station)

- assessment of amniotic membranes: fluid characteristics (COAT/ TACO- color, odor, amount, time)

physical care during labor

general hygiene

nutrient and fluid intake

elimination (voiding at least every 2 hours)

nurses provide what during labor

emotional support

physical care

comfort measures

advice/info- advocate for your patient

Stage 2 of birth

Begins with full cervical dilation (10 cm) and complete effacement

Duration:

• Nulliparous - 50-60 minutes and up to 3 hours (4 hours w/epidural)

• Multiparous - 20-30 minutes and up to 2 hours (3 hours w/epidural)

Two phases:

Latent: relatively calm with passive descent of baby through birth canal "laboring down"

Active: pushing and urge to bear down

Ferguson reflex: the urge to "bear down"

Preparing for birth

Maternal Positions

Bearing Down Efforts(valsalva maneuver)

FHR monitoring

Support from family/partner

Pushing- encourage laboring patient to respond to the rhythmic nature

Birth in delivery room or birthing room

No fundal pressure!!

ritgen maneuver= hands on

hands-poised = hands off

immediate assessments and care of newborn

- time of birth

- dried and placed skin to skin or under radiant warmer

- ABCs and VS

- APGAR at 1 and 5 minutes

- postpone complete head to toe

perineal lacerations

- first degree- vaginal mucosa torn

- second degree- perineal muscles torn

- third degree- anal sphincter torn

- forth degree- rectum torn

episiotomy

an incision in the perineum to enlarge the vaginal outlet

3rd stage of labor

Birth of the baby until the placenta is expelled- shortest stage (average 10-15 minutes after birth)

Signs the placenta is separating:

- sudden gush of dark blood

- noticeable lengthening of the umbilical cord

- vaginal fullness

Once the placenta is removed

- oxytocin admin

- examination- intact or not, odd findings, cord blood collection

- disposal

4th stage of labor

first 1 to 2 hours after birth

- assessment of maternal physical status (get back to pre-pregnancy status)

- care of new patient

- care of the family

Postpartum recovery - cardiac changes

o Blood volume

- Pregnancy induced hypervolemia= 40-45% increase

- Can tolerate considerable blood loss

· Vaginal deliver= average 300-500 ml blood loss

· C- section = average 500-1000 ml blood loss

Postpartum recovery - cardiac changes

o Cardiac output

- CO up 60-80% afterbirth till 1 hour when it returns to pre-pregnancy state

- Drops 30% by 2 weeks

- Pre-pregnant levels by 6-8 weeks

Postpartum recovery - cardiac changes

o Blood components

- Hematocrit and hemoglobin drops for 3-4 days

- WBC increases for 4-7 days

- Coag factor- increased risk for venous thromboembolism

Postpartum recovery - uterine changes

o Involution process

- fundus contracting back to normal size

- 6 week=non-pregnant

- If placental fragments left will cause failure to contract

Postpartum recovery - uterine changes

o Contractions

- postpartum diuresis of extracellular fluid (3000ml or more in first 2-3 days)

Postpartum recovery - uterine changes

o fluid loss

- decreased urge to void due to anesthesia and/or perineal soreness

- distended bladder= excessive bleeding

- bladder tone back by 5-7 days

Interventions for postpartum period

Care management during postpartum - assessment and nursing interventions

· typically stay 1-2 days for vaginal, 2-4 for cesarean

· after the initial recovery after birth 1-2 hours -> move to post partum unit

· post anesthesia recovery (discharge after recovered from anesthesia (moving legs), nurses are ACLS certified)

· routine laboratory tests- Hmg & Hct, prenatal labs- rubella, ABO/Rh

· Promotion of normal bowel function & prevention of bladder distention( Encourage voiding, measure urine output, use of the peri bottle to prevent infection)

· Prevention of excess bleeding

· Maintenance of uterine tone

· Prevention of infection

· Promotion of comfort

· Promotion of ambulation

· Promotion of rest

o Postpartum fatigue (PPF)- can lead to PPD

· Promotion of breastfeeding

· Lactation supression

· BUBBLERS Assessment

o B- breast

o U- uterus

o B- bowel

o B- bladder

o L- lochia

o E- episiotomy/ perineal assessment

o R- emotional response

o S- skin

Commonly occurring situations in postpartum period - bleeding

· Spiled sanitary towel- 30 mL

· Soaked sanitary towel- 100mL

· Small soaked swab- 60mL

· Incontinence pad- 250mL

· Large soaked swab- 350 mL

· 100 cm diameter floor spill- 1500mL

· PPH on bed only- 1000mL

· PPH spilling on floow- 2000mL

· Full kidney dish- 500mL

Discharge teaching - what to teach and when

· Self management and signs of complications

· Sexual activity and contraception

o Follow up in 2-6 weeks

· Medications

· Follow up after discharge

- First period of reactivity

lasts up to 30 minutes after birth, HR increases to 160-180 BPM and decreases gradually after 30 minutes

- Second period of reactivity

occurs 2-8 hours after birth, lasts 10 minutes to several hours, tachycardia and tachypnea, increased muscle tone, improved skin color, mucous production, meconium typically passed

respiratory adaptions

- Chemical factors, mechanincal factors, thermal factors, and sensory factors all initiate breathing. Surfactant is a protein that lines the alveoli and lowers surface tension

- Nose breathers so suction mouth before nose

- Acrocyanosis is a normal finding with the first 24 hours of birth

cardiac adaptions

- Significant changes from FHR

- First breath-> alveolar capillary distention-> reduced pulmonary resistance

- 110-160 bpm, listen to apical for full min

- Blood pressure 60-80/40/50 average

- Blood volume: total volumes_ 300ml- can increase 100ml depending on cord clamping, >2 minutes helps premature babies

thermoregulation adaptions

- Balance between heat loss and heat production

- Thin layer of subq fat, blood vesssles close to surface, large body surface to weight ratio

- Non-shovering thermogenesis= using brown fat

- Hyperthermia 99.5 (over dressed or sepsis, sweat glands dont function well)

Assessment of newborn - birth trauma

ADD

Behavioral characteristics - assessment of six states

1. Temperament: behaviors vary according to each individual baby

2. Habituation: becoming accustomed to the environmental stimuli, equals cerebral organization but depends on hunger, fatigue, etc

3. Consolability: hands to mouth/sucking, held and rocked

4. Cuddliness: important to parents

5. Irritability: similar to temperment

6. Crying: newborns language, caregivers response= trust , amount and tone depends on gestational age, maternal milk lets down with cry, peak at 2nd month more in evening hours

Stabilization after birth and in the first 2 hours (vital signs)

- APGAR: heart rate, RR, muscle tone, reflex irritability, skin color

- Thermoregulation

- Airway management: drying helps stimulate crying

- Cardiovascular adaptation: feel base of umbilical cord, count for 6 seconds, multiple by 10= initial HR count

- Normal vital signs???? ADDweight at term" 2500-4000gms (5.5-8.5lbs) loss of 105 is normal for up to 4 days

- Length: 45-55cm (17.7-21.7in)

- Head circumference: 32-36.8cm

- Chest circumference: 30-35cm

New born weight catagpries

AGA: 10%-90%

SGA: <10%

LGA: >90%

Preterm

before 37 weeks gestation

increases risk fo hypoglycemia, respiratory problems, more chance of NICU, long term health issues such as learning difficulties

Late preterm

34 0/0 through 36 6/7 weeks

"the great imposters", often look like term babies, increased risk for respiratory distress, temperature instability, hypoglycemia, apnea, and feeding issues

Early term

37 0/7 through 38 6/7 weeks

Postertm

wasted physical appearance due to intrauterine deprivation, depletion of subq fat, long and thin, fetal distress in labor, meconium stained fluid leasing to aspiration pneumonia

Normal newborn interventions - medications, screening tests

- Airway maintenance: side lying position, bulb syringe (M before N), nasopharyngeal catheter if needed

- Maintain oxygen supply

- Maintain body temp (wait for bath for 8-24 hours)

- Eye prophylaxis: to prevent ophthalmia neonatorum or neonatal conjuctivitis

- Vitamin K to prevent hemmorrhagic disease

- Screening tests??? ADD

Common physiologic problems - jaundice

every 8-12 hours, commonly with VS, visual in natural light= blanch- if yellow= jaundice, lab draw, may need to replace infants books with RBC and FFP

Common physiologic problems - hypoglycemia

blood glucose less than 40 or 50 mg/dl, at risk of SGA, LGA, diabetic mother, late preterm, screened 1st 30 mins after feeing then before feds for 1st 12-24 hours. Symptoms: jitteriness, lethargy, poor feeding, abnormal cry, temp instability, respiratory distress, apnea, seizures. Treat with frequent feeds or IV dextrose, treat symptomatic infants

New born Lab and diagnostic tests - what, how, and why

- Univeral newborn screening mandated by US law, early detection of genetic diseases (sickle cell, hypothyroidism, SCID, PKU, Galactosemic

- Hearing screen: measure the echo in the earpiece of the baby's acoustic nerve

- CCHS: pulse ox to measure sat 95% with less than 3% difference between hand and foot

Neonatal pain

- Nervous system developed by 24 weeks

- Fight or flight is observable

- SANS reaction less mature and predictable

- When in pain: HR incease, rapid shallow RR, O2 sat decreased, BP increse, increased ICP, decreased vagal tone, increased cortisol

- Assess pain with each assessment and any painful procedure

Health impact (benefits) of breastfeeding

- Human milk provides the best nutrition for infants

- The AAP recommends exclusive breastfeeding for the first 6 months and continued for at least 2 months, during the second 6 months appropriate solid foods may be added

- Numerous short and long term impacts, there are risks of not breastfeeding

Barriers to breastfeeding

- Insufficient training and education of health care professionals regarding breastfeeding knowledge, skills, and attitudes

- Lack of social and family support for breastfeeding

- Widespread marketing of formula

- Lack of prenatal breastfeeding education and support

Lactogenesis process (hormones involved)

- Myoepithelial cells contract to send milk to ductules

- The size and shape of the breast are not accurate indications of ability to produce milk

- Mammogenesis

- Lactogenesis I

- Delivery of the placenta

- Lactogenesis II

- Lactogenesis III

- Lactogenesis

- Prolactin

- Oxytocin

- Nipple-erection reflex

- Mammogenesis

cellular changes in breast occur due to pregnancy

- Lactogenesis I

colostrum (first milk) production begins about 16-20 weeks in pregnancy

- Delivery of the placenta

change in hormones (drop in estrogen and progesterone, rise in oxytocin and prolactin)

- Lactogenesis II

onset of copious milk section (30-72 hours post delivery)

- Lactogenesis III

mature milk is established, maintenance of lactation

- Lactogenesis

delivery of the placenta drops progesterone levels with stimulate the release of prolactin

- Prolactin

causes milk production in response to sucking stimuli (supply-meets-demand system)

- Oxytocin

milk ejection reflex (MER) let down reflex, stimulates uterine contraction during labor, decreases risk for postpartum hemorrhage

- Nipple-erection reflex

nipples becomes erect with stimulation

Normal newborn feeding behaviors - feeding frequency, cues, intake & output

- Teach parents to watch for: hand to mouth or hand to hand movements, sucking motions, rooting relfex, and mouth

- Crying is a late sign of hunger

- Feed 8-12 times in 24 hours, cluster the feeds, wake at first then go to on demand feds

- Duration 30-40 minutes for a meal, snacks will be shorter

Basics of latch and positioning

- Latch is most important to increase milk flow and decrease pain

- Learned from mom and baby

- Use LATCH score

- Position: laid back, cradle, cross cradle

- Football/clutch

- Side-lying