Maternity Exam 1

Culture

religion, language, profession, age, gender identity, sexual orientation, disability, beliefs and traditions

Average maternal age

26\.3 years

non-high risk maternal age

20-34 years

why are pregnancies over 35 high risk?

diminished egg quality, increased risk of complications, and increased risk of preexisting health conditions

why are pregnancies under 20 high risk?

socioeconomic conditions

GTPAL

G - number of pregnancies

T - number of term pregnancies (37 weeks or more)

P - number of preterm pregnancies (20-37 weeks)

A - number of spontaneous or elective abortions before 20 weeks

L - number of living children

GP

G - number of pregnancies had

P - number of pregnancies carried to a viable term (20-24 weeks)

estimated date of delivery - naegeles rule

First day of last period; subtract 3 months; add 7 days

reccomended weight gain

Normal BMI (18.5 - 24.9) = 25 to 35 pounds

Underweight BMI (less than 18) = 28 to 40 pounds

Overweight (25-34.9) = 15 to 25 pounds

Obese (35 and greater) = 12 pounds or less

First trimester

conception - 12 weeks

second trimester

weeks 13 - 28

third trimester

weeks 29 - 40

presumptive signs of pregnancy

amenorrhea, breast tenderness, fatigue, nausea

probable signs of pregnancy

braxton hicks contractions, positive pregnancy test, increased HcG levels, softening of the cervix (goodells sign),

bluish discoloration of genitalia (chadwicks sign)

positive signs of pregnancy

fetal heartbeat, visualization of the fetus on ultrasound

cervical cancer screening

reduces rates of cancer, pap smear collects sample of cervical cells:

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* first screening at age 21, and then every 3 years until age 30, after 30 pap and HIV test every five years until age 65 or every three years if just pap

preembryonic stage

fertilized ovum becomes morula and then blastocyte

embryonic stage

weeks 2-8: implantation, neural tube fuses, respiratory & digestive tracts form, limb buds, heart is final, first brain waves

fetal stage

weeks 9-38+: fetal movement, oogenesis, blood vessels, toes/fingers, lungs form surfactant at 24, testes, subcutaneous fats

striae gravida

stretch marks

linea nigra

dark line

nevi

mole

macules

freckles

prenatal care

For low risk: every 4 weeks until 28 and then every 2 weeks between 28 & 36 and then weekly

Prenatal appointments include:

* physical assessment, history since last assessment, vital signs and weight assessment, fetal heart rate assessment, fundal height assessment (after 16 weeks), and any need pt education

five P’s of labor

power, passageway, passenger, psyche, and position

power

refers to uterine contractions and pushing efforts.

* Hypotonic uterine dysfunction -> uterine contractions are too uncoordinated or too weak to dilate the cervix, occurs in active phase, related to polyhydramnios, macrosomia, multiple pregnancy
* Ineffective pushing -> dystocia

passageway

refers to the maternal bony pelvis and soft tissues. Soft tissue due to bladder or bowel being full, small maternal pelvis & scar tissue on cervix -> dystocia

passanger

refers to the fetus:

Cephalopelvic disproportion

Occiput posterior position -> low back pain

Breech presentation (frank, footling, or complete)

psyche

refers to the maternal state of mind

position

refers to maternal position:

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Upright positions such as sitting, kneeling, squatting, or standing can shorten the first stage of labor by 90 minutes.

signs of labors

contractions are regular (4-1-1), bloody show, decent of fetus into the birth canal, nesting impulse, GI distress, and weight loss

how many stages of labor are there

4

1st stage of labor

dilation and effacement of cervix; divided into three phases:

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* latent: 0-3cm
* active: 3-7 cm
* transition 8-10cm

2nd stage of labor

starts with pushing when cervix is fully dilated and effaced, and ends with the birth of the baby (can range 20 min to 2 hrs)

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* Engagement: Fetal head reaches level of the ischial spines.
* Descent: Fetus moves past the ischial spines.
* Flexion: Fetal chin touches chest in response to pressure from maternal tissue.
* Extension: Fetal chin comes off the chest and the neck arches as the head is born.
* External rotation: Fetal head rotates as the shoulders move into position for delivery.
* Expulsion: Body of the fetus is born

3rd stage of labor

delivery of the placenta (5-30 minutes)

4th stage of labor

4 hours later or once mother becomes stable

PCOS

most common cause of infertility and subinfertility

Endocrine disorder that causes ovulatory dysfunction & hyperandrogenism

Associated with obesity & insulin resistance

true labor

contractions in lower back & abdomen, pressure in pelvis, at least 60 seconds long and every 4 minutes, stronger and closer, rest or hydration don’t resolve

false labor

contractions in abdomen, may be regular for short periods of time, often stop, resolved with rest or hydration

FHR Variablity

– absent, minimal (less than 5), moderate (6-25), marked (>25)

contractions

duration, frequency, & strength

lochia

problem if there is foul order or saturated pad in 15 minutes or large blood clots

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* rubra: dark red 3-4 days
* serosa: lighter red/pink/brown 10-14 days
* alba: yellow or white 2-4 weeks

measured in scant, light, moderate, or heavy

boggy uterus

uterine atony

perineal pain

tylenol, ibuprofen, ice packs, peri bottle, colace, and sitz bath

maternal infection signs

burning/pain/frequency of urination, localized firm areas of redness on breast especially with flu symptoms, pelvic pain, elevated temperature, and foul smelling lochia

family structures

* 40 percent of children are born to women who are not marries


* 27% female same sex couples and 11% males are raising children - more likely to adopt or foster and are at risk for feeling judged or marginalized


* 22% of children are being raised in blended families
* 26% of children are raised with only one parent and are at an increased risk of financial insecurity
* 4-5% are being raised without parents
* family structures are no indicative of avalible support

three main functions of the placenta

circulation, protection, and hormone production

umbilical cord

arises from the fetal side of the placenta

main function is transporting blood to and from the fetus

AVA

chloasma

aka the mask of pregnancy, darkens with sun exposure and disappears after pregnancy

endocrine system changes

thyroid hormones: mother supplies these hormones to the fetus until 12th week and is critical for neurological development; these hormones often increase during pregnancy

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blood glucose metabolism changes: during first half of the pregnancy insulin production increases leading to energy storage. during the second half insulin resistance increases and allows more glucose to pass through the placenta - women whos pancreas cant handle this can develop gestational diabetes

respiratory system changes

* oxygen consumption increases 15-20% during pregnancy
* Mild hyperventilation and sense of dyspnea results in a state of physiologic respiratory alkalosis.
* Diaphragm elevates approximately 5 cm during pregnancy, to accommodate this change, ribs expand and the subcostal angle increases.
* Increased estrogen causes congestion of mucus membranes. This congestion can cause swelling of pharynx, trachea, larynx, while engorged capillaries may cause frequent nose bleeds.

cardiovascular system changes

* cardiac output increases by as much as 50%
* heart rate increases
* hormones in pregnancy reduce peripheral vascular resistance to compensate for increased blood volume
* total blood volume increases to 40-50% while red blood cell count increases by 30% - results in physiologic anemia
* white blood cell count increases during pregnancy and may not indicate infection
* Rise in fibrinogen and other clotting factors thought to prevent excessive postpartum bleeding puts women at risk for blood clots, which could lead to pulmonary embolism or stroke.
* Temporary changes in heart sounds are common and benign in pregnancy.

urinary system changes

* blood flow to and through the kidneys increases by 80% during pregnancy
* glomerular filtration rate increases by 50%
* not uncommon for pregnant women to spill small amounts of glucose and protein into the urine
* In pregnancy, the threshold for hydration at which thirst \n is cued and the release of antidiuretic hormone is lower \n than for women who are not pregnant.
* More salt and water is reabsorbed in pregnant women \n than nonpregnant women

reproductive system changes

* in the breasts the ducts, lobules, and alveoli grow to prepare for breastfeeding. The breasts become fuller, nipples and alveoli become darker
* colostrum a yellowish form of early milk is produced and may leak from the nipple
* Between the 16th and 36th week of pregnancy, the size of the uterus (in centimeters) from the symphysis pubis to the fundus equals the number of weeks’ gestation.
* Braxton Hicks contractions occur throughout pregnancy.
* Mucus plug (operculum) forms inside the cervical canal to create a barrier against pathogens.
* increased vascularity of the vulva, vagina, and cervix.
* pH of the vagina is slightly more acidic and prevents bacterial pathogens.

musculoskeletal changes

* Lordosis, an exaggerated curve to the lumbar spine, \n causes a shift to the mother’s center of gravity and \n increases the risk of falls. (sway back)
* Relaxin and progesterone increases mobility of pelvis for \n delivery but makes joints less stable.
* Round ligaments, which position and stabilize the uterus, can stretch and cause pain.
* Abdominal walls separate at the midline (referred to as \n diastasis recti).
* Increased calcium reabsorption due to increased \n parathyroid hormone. Not usually problematic unless the woman has a large number of closely spaced \n pregnancies or poor nutrition.

gastrointestinal changes

* Reduced peristalsis in gastrointestinal tract causes \n delayed stomach emptying and results in heartburn, \n constipation, and gallstones.
* Metabolic rate increases 10% to 20% during pregnancy. \n To meet increased metabolic needs, the woman should \n consume 350 to 450 additional calories per day
* Too little weight gain in pregnancy may result in a small-for-gestational age infant.
* Too much weigh gain may result in complications such as pregnancy-induced hypertension or a greater risk for \n surgical delivery.

weight gain by trimester

First trimester: 1-5lbs

Second and third: 1 pound a week

gynecological history

* age of menses
* date of last menstrual period
* cycle length and regularity
* STIs
* gyneological surgeries and conditions

obstetrics history

\n Dates of prior deliveries \n o Gestational age at deliveries \n o Mode of delivery \n o Type of anesthesia \n o Location of delivery \n o Pregnancy outcome \n o Sex of the child \n o Length of labor \n o Birth weight and percentile according to gestational age \n o Length of labor \n o Past pregnancy complications

screening recommendations for genetic conditions

cystic fibrosis, tay-sachs, sickle cell anemia, Alpha and beta thalassemia, Blood and ultrasound screening for trisomies between 11 and 13 weeks (recommended for all women), Additional blood screening ideally between 15 and1 6 weeks for trisomy 21, trisomy 18, and neural tube \n defects such as spina bifida (recommended for all \n women)

common discomforts of pregnancy

* nausea and vomiting, heartburn, backache, round ligament pain, urinary frequency, varicosities, hemorrhoids, constipation, leg cramps, dyspnea, lightheadedness, fatigue, supine hypotension, edema, temporary carpal tunnel

danger signs in pregnancy

vaginal bleeding (with or without discomfort), rupture of membranes, swelling of fingers and puffiness of face or around eyes, continuous pounding headaches, visual disturbances, persistant or severe abdominal pain, chill or fever, painful urination, persistant vomiting, change in frequency or strength of fetal movements, signs of preterm labor

types of fetal assessments

nonstress test

kick counts

fetal heart rate monitoring

characteristics of fetal heart rate monitoring

* baseline hr assessed over 10 mins between 110-160
* Variability is the irregular fluctuations in the baseline fetal heart rate.
* Accelerations are an increase in baseline of at least \n 15 beats and lasting at least 15 seconds in a term \n fetus.
* Decelerations are decreases in the fetal heart rate \n from baseline.

labor pain

Pain is what the patient says it is. many things can play a role in pain tolerance and they include:

* fear, previous experiences with labor pain, support system, and fatigue

Manifestations of pain include:

* pain in abdomen, low back, or thighs with contraction.

labor pain management

opioids: fentynal short acting (1-2 hrs), can cause respiratory depression in the fetus

\n Mixed opioid agonist/antagonists:

* should not be used in patients with a dependence on opioids because may cause withdrawal; less risk of respiratory depression
* nubain (3-6 hrs) stadol (3-4 hrs)

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Nitrous oxide:

self administered gas that pt can put on during start of contractions

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Nonpharmacological pain management

newborn care immediately after birth

* skin to skin for 1 hr
* apgar score at 1 and 5 minutes
* vital signs within 30 minutes
* erythromycin and vitamin k (eyes and thighs)
* encourage breast feeding
* note urine and stool

BUBBLLEE

breasts

uterus

bladder

bowels

lochia

laceration

edema

emotions

indications for c-section

failure to progress

nonreassuring fetal heart rate

fetal malpresentation

umbilical cord prolapse

fetal macrosomia

Types of c-section incisions

* classical = vertical
* low vertical
* low transverse

When should Rh- mothers receive rhogam if needed

28 weeks

Typical amount of blood loss during a vaginal birth and c-section

* vaginal: 200-500ml
* c-section: up to 1,000ml

maternal adaptation phases

* taking in phase: where the mother recovers and takes a passive, dependent role
* taking hold phase: where the mother processes the \n birth experience and transitions to independent behavior.
* letting go phase: where she acknowledges her new \n normal and sees the baby as a person instead of an idea.

postpartum patients should be taught to report these issues before discharge

taught to report the following signs of infection:

* burning, pain, or frequency of urination
* localized firm areas of redness on the breasts, especially with flu like symptoms
* pelvic pain
* elevated temperature
* foul smelling lochia

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also taught to report:

* new onset leg pain and warmth (sign of a DVT)
* chest pain and shortness of breath (signs of PE)
* sustained depression or thoughts of hurting onself (signs of ppd and PPP)

infant feeding readiness cues

early:

* licking lips, sucking motions, smacking lips, and moving as if looking for the breast

Late:

* crying

infant feeding positions

cradle, football, cross-cradle, and side-lying

elements of a good latch

lips flanged outwards, chin and tip of nose pushed into breast, wide open mouth, full cheeks, asymmetry of exposed areola, and audible swallowing

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after eating the infant should appear satisfied

phases of infant transition to extrauterine life

transition period lasts 6-8 hrs

* first phase: phase of reactivity occurs 1-2 hrs after birth. The infant should be awake and alert. Optimal time to initiate breast feeding and bonding

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* second phase: time of transition and of sleep, may last several hours

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* third phase: second phase of reactivity. occurs between 2 and 8 hours after birth. meconium often passed during this time

signs of respiratory distress in a newborn

cyanosis, apnea, tachypnea, intercostal or subcostal retractions, grunting, nasal flaring, seesaw breathing, stridor, gasping

APGAR Score

each section given a score between 0-2

color = appearance

heart rate = pulse

irritability = grimace

tone = activity

respiratory effort = respirations

newborn assessment

* apgar score - done at one and five minutes of life
* Gestational age assessment—evaluation of an infants \n physical and neuromuscular maturity
* physical assessment
* newborn reflexes

Neonatal heat loss

* evaporation = through evaporation of liquid from the body
* conduction = transfer of heat by direct contact with a cooler object
* convection = heat transfer from the newborn to the surrounding air
* radiation = transfer of heat from or to the newborn from or to a nearby surface

cephlohematoma

a collection of blood between the skull and periosteum; swelling does not cross the suture line

caput succedaneum

Swelling under the skin of the scalp that does cross \n the suture line.

Subgaleal Hemorrhage

Swelling that does cross the suture line but is rare

newborn reflexes

* Rooting reflex—when the mouth or cheek is touched, the infant turns toward the stimulus and opens the mouth
* Sucking reflex—when fed, the neonate coordinates sucking, swallowing, and breathing.
* Extrusion—when the tip of the tongue is touched, the infant sticks out the tongue.
* Palmar reflex—the infant curls fingers around the object placed in the hand.
* Plantar reflex—the infant curls toes around the object placed at the base of the toes.
* Moro reflex—the infant abducts and extends arms when startled by a loud noise or if experiencing a dropping sensation.
* Babinski reflex—when an infant’s foot is stroked along the lateral aspect and then across the ball of the foot, the toes fan outward
* Stepping reflex—when held upright by the torso and held so the feet touch a surface, the infant makes a walking motion.
* Fencing reflex—turning an infant’s head to one side \n quickly causes the baby to extend the arm and leg on \n that side and flex the other side.

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post circumcision care

Assess for bleeding \n Teach parents how to care for circumcision \n o Cleaning \n o Signs of Infection \n  Greenish Discharge \n  Red stripes on penis \n o Use of Vaseline or gauze and Vaseline if plastiball is \n not used.

common newborn complications

hypoglycemia, hyperbilirubinemia (jaundice), hypothermia, transient tachypnea

hypoglycemic risk factors

SGA, LGA, infants of diabetic mother, infants who require resuscitation at birth, Infants whose mothers were one beta-blockers or terbutaline, and late pre-term babies

symptoms of hypoglycemia

newborns may be asymptomatic

* jittery
* pallor
* tachypnea
* poor tone
* poor feeding
* temperature instability

Hyperbilirubinemia Risk Factors

* ABO incompatibility Positive Combs Test
* Preterm and Late Preterm Infants
* Family history of Hyperbilirubinemia
* Bruising or Cephalhematoma
* Macrosomic Infant of Diabetic Mother
* Mother of East Asian ethnicity
* Poor feeding

assessment of hyperbillirubinemia

Visual (not reliable) \n Bili meter \n Serum blood levels \n Newborns at high risk may be assessed at 24 hours \n Acceptable level depends on hours of life and gestational \n age- bili tool

\n Treatment Hyperbilirubinemia

Increase feedings \n Phototherapy- converts bilirubin to lumirubin which is \n more easily excreted in the bile and cannot be \n reabsorbed in the intestine. \n Many different forms of phototherapy \n After desired bilirubin levels have been achieved and \n newborn is no longer receiving phototherapy and another \n blood level will be done 12 hours later to assure newborn \n has stabilized.

hypothermia

low temperatures can be caused by:

* environment (cold room, poorly swaddled)
* SGA baby
* sign of infection
* hypoglycemia

hypothermia treatment

Skin to skin care \n Warmer \n Wrap in warm blankets \n Assess for underlying cause

Transient Tachypnea

Excess fluid in the lungs- rapid vaginal birth or c/section \n Late preterm infants more at risk \n Infants of diabetic mothers more at risk \n Grunting Flaring Retracting \n Cyanosis circumoral \n May be sign of infection or hypoglycemia \n Treatment depends on severity of symptoms. \n Late Preterm Infants

Group B Streptococcus

GBS colonization is often asymptomatic for women but \n can be devastating for infants. \n Signs and symptoms of GBS infections in neonates \n include sepsis, pneumonia, or meningitis. \n Women should be screened for GBS at 35 to 37 weeks of \n gestation. \n GBS-positive women are treated in labor with antibiotics \n that must be started at least 4 hours before delivery. \n Women with preterm labor are treated for GBS without \n screening.

placental abruption

Placental abruption is the premature detachment of the placenta from the decidua of the uterus and is often classified as mild or severe.

Causes of placental abruption include:

Often unknown cause \n o Trauma \n o Smoking \n o Cocaine

placental abruption prognosis

\n A mild abruption may have limited impact. \n

A severe abruption may result in complete detachment of \n the placenta and risk the life of the mother and the fetus.