328-maternity final

patient family centered care / both / trauma informed care

• focus on respect and dignity for pt and family

• explicit attention to their values and preferences

• shared decision making

both

• share info w pt and family

• encourage family presence

• provide with choose and give sense of control

• consider needs and family strengths

• cultural competence

trauma informed care

• minimize potentially traumatic / dressing aspects

• address distress; pain fear anxiety

• provide emotional support

indigenous ways of knowing

• community support; mothering as a collective responsibility

• elder guidance; honoring matriarchal knowledge

• cultural preservation

health promotion in maternity care

1. individual level

   • promoting physical, mental, psychosocial wellness (nutrition, substance abuse)

   • Healthy weight gain

   • promoting breastfeeding

2. systemic level

   • support for breast feeding

   • maternal leave

   • contraceptive access

   • availability of maternity care

3. community level

postpartum care

known as the 4th trimester

immediate-focused on recovery

early postpartum-first week; physiological changes occur

late postpartum-6wks to 6mo-gradual return to prepartum

episiotomy and lacerations

episiotomy indications

• fetal distress requiring delivery

• shoulder dystocia

• instrumental delivery

• prevention of severe laceration

laceration types

• first degree-skin/mucosa

• second degree-perineal muscles

• third degree- anals sphincter

• fourth degree rectal muscle

episiotomy and lacerations pain comparison

natural tears

• follow tissue planes

• less painful during healing

episiotomy

• cuts through multiple tissue layers at once

• cleaner edges for repair

extremeties assessment

a) hypercoagulability

• increased fibrinogen and blood clotting factors

b) clotting factors

• clot dissolving decreases

deep vein thrombosis (tmt, prevention, assessment) and whos at highrisk?

tmt

• heparin

• anticoag

prevention

• mobilize

• pneumatic compressions

• hydration

assessment

• homans sign

• calf measurement

• pain eval

high risk

• obesity

• >35 age

• c sec

• immobility

vital signs

vaginal

• q15 for 1 hr

• temp x1 hr

• at 2 hours

• qshift until discharge

csec

• q15 for 1 hr

• temp x1 hr

• resp rate q1h for 12h

• at 2 hr

• q4h/24h

• qshift til discharge

post partum complications

• hemorrhage

• infections

• cvd

• mood disorders

PPH risk factors

1. history of pph

   • grand multiparity

2. uterine factors - fibroids

   • can compromise contractions

3. labour characteristics

4. c section

4 t for pph

1. TONE

   • uterine atony causes 70/80%

2. TISSUE

   • retained placental fragments can impair contractions

3. TRAUMA

4. thrombin

PPH tmt

1- prevention

• admin uterotonic immediately

• imeeidate fundal massage

2-first line treatment

• empty bladder

• continue fundal massage

• initiate breast feeding

3- escalating med tmt

• more uterotonic; oxytocin, hemabate, ergot, misoprostol

• iv fluid resuscitation

• blood products

4-surgical

puerperium

6 weeks - 6 months til organs return to normal size

breast assessment: normal findings, lactation timeline, assessment techniques

normal findings

• symmetrical enlargement

• colostrum production

• decreasing firmness

lactation timeline

• 1-3 days; colostrum

• day 3-5; transitional milk

• day 10+ mature milk

assessment findings:

• visual assessment

• gentle palpation

• nipple assessment

uterine involution ( shrinking of an organ ) process

1- initial contraction

• immediate contraction after placental delivery

2-rapid contraction

• uterus descends 1cm daily into pelvis

3-complete involution

• back to normal

why assess tone In the fundus

• afterpain occurs In multipara and as the uterus contracts

bladder assessment

• encourage voiding q4h and expect increased urine output

bowel changes

• will return to normal in 2-3 days; encourage fluid and fiber

lochia progression

• day 1-3; lochia rubra

• day 3-10; lochia serous

• day 11-21; lochia alba

perineum assessment (inspection, REEDA, intervention)

inspection: edema, hematoma, bruising, hemorrhoids

REEDA= redness, edema, ecchymosis, discharge, apprx sutures'

intervention: cold packs; after 24 do sitz baths

neonatal care environment

• level 1-basic care for healthy full term babes

• level 2-care for moderately ill newborns

• level 3-critically ill or preterm

• level 4 - nicu

circulatory/respiratory transition

• fetal circulation

  • nutrients and blood delivered through placenta

• birth transition

  • first breath causes dramatic pressure changes

• pulmonary circulation

  • blood flow increases to lungs for gas exchange

• systemic circulation

  • shunts close - foramen ovale, ductus arteriosus

transition to extra uterine life

• cardio resp transition can be stimulated by

A) chemical

• cessation of the umbilical cord (decreased o2 and ph; increased co2)

• these changes stimulate the aortic and carotid chemoreceptors

B) mechanical

• chest compressions to remove fluid

• air replaces fluid during reexpansion

• crying

• increased intrathoracic pressure

newborn feeding assessment

• time- initiate in the first hour

• position; asymmetrical latch

• audible swallowing- rhythmic suck swallow breathe

• output-wet stool diapers

8-12 feeds in the first 24h

newborn chest assessment

• palpation points: clavicles, sternum, rib for fracture or deformities

• resps 40-60

• fhr-120-160

abdomen and umbilical assessment

• soft rounded countour

• umbilical cord

  • 2 arteries 1 vein

  • begins drying in 24 h

  • falls off in 5-10 days

  • clamping is good for iron storage

  • clamp can be removed after 24 h - 48 h

• warning signs

  • odor drainage

  • redness

newborn medications

• vitamin k for hemorrhagic diseases - IM in the first 6 hours

• erythromycin

routine newborn procedures

1- hearing

2- metabolic screening for 27 blood disorders can be done in 24-48h

3-cchd-pulse oximetry in r hand and foot

4-paim management

pulse ox screening

24-36h - ni more than 3%

extra new born pieces

• bath >24h

• weight loss 10%% acceptable

4 stages of labour

1. cervix dilation/thinning=longest stage of labour

   • active 0-3 cm

   • latent 3-8

   • transitional 8-10

2. pushing/expulsion

3. placental delivery

4. post partum

5 ps influencing labour

power

• uterine contractions

  • mild moderate firm

  • phases= increment, peak, decrement

  • effacement, dilation

• pushing effort

passage

• pelvis

• soft tissues

passenger

• fetal attitude, positioning

• fetal size macrosomia >4000g

  • shoulder dystocia

position

psyche

fetal station 0

• fetal vertex is aligned with ischial spine

pharm and non pharm methods to stimulate contractions

nonpharmacological

1. nipple stimulation during active labour releases oxytocin through pituitary gland

2. position change

3. acupunture

4. membrane sweeping

pharmacological

1. prostaglandin E2 - Cervadil

   • given intravaginally; sustained release

2. prostaglandin E1- misoprostol

   • po or ivag

oxytocin induction/augumentation

• baseline fhr then q15 in first stage active of labour

• q5mins in second stage

• temp q2

• vs q30-60 min

• monitor I/o

• monitor tachysystolic

intermittent auscultation IA

• preferred method of fetal health

• should be done q15 for active, q5 for second stage and one full min between contractions

• used to determine

  • baseline fhr

  • accelerations

  • deceleration

variability

• the up/down in the fhr cycles

• balance between the para and symp nervous system

• normal = neuro integrity

• abnormal may occur d/t sedative drugs or fetal sleep = decreased variability

• normal 6-25

acceleration vs deceleration

a

• 15×15

• sign of adequate oxygenation

d

• decrease in fhr

• early - ok

• late - bad

• variables - it varies

early vs late deceleration

early

• baroreceptor dt head compression

• normal

• early bc

  • smooth rounded

  • simultaneously with contractions

late

• chemoreceptors dt hypoxemia and uteroplacental deficiency

• accompanies w other warning signs such as decreased variability or tachycardia

• late bc

  • smooth rounded

  • AFTER contraction

GTPAL

• gravidity- number of pregnancies

• term- born at term - 37 weeks

• preterm - born 20-37wks

• abortion-including miscarriages

• living children

estimated date of birth calculation

• LMP-first day of last menstrual day

• then add 7 days, and then 9 months

OR

• count BACK 3 mo then add 7 days

hormone changes during pregnancies

• human chorionic gonadotropin (HCG)

  • Found very early in pregnancy in the fertilized egg-then later in the placenta

  • signals the body you’re pregnant

  • keeps corpus luteum working so it makes estrogen and progesterone early

• estrogen

  • found in corpus luteum (til day 14) then mainly placenta

  • responsible for enlarging uterus breasts and genitals

  • skin changes-veins more visible

  • relaxes pelvic muscles

  • decreases insulin maybe resulting in high bs

  • adds fat for breast feeding

• progesterone

  • found in corpus luteum til about day 14 then later in the placenta

  • prevents early contractions

  • prepares breasts for breast feedings

  • relaxes muscles ;

    • GI: constipation, heartburn, varicose veins

• relaxin

  • produced first by placenta and corpus luteum

  • softens pelvis joints and cervix

  • stops early contractions

• human chorionic somatotropin (HPL)

  • Placenta

  • metabolize glucose/protein

  • more glucose for baby

  • breast development

physiological changes - in relation to hormones

• vagina / cervix

  • change in color bluish/purple-chadwicks sign

  • softer cervix-goodwell sign vaginal secretions have more glycogen - risk of uti'

  • increase in ph to fight against scretions

• breast

  • estrogen and progesterone prepare for breastfeeding

  • increased pigmentation

  • colostrum antibodies end of pregnancies

• urinary

  • increased kidney filtration rate-water retention for. blood volume increases-may result in glycosuria and proteinuria

  • progesterone relaxes uterus and bladder

  • stasis of nutrient rich urine

• Gi

  • uterus displaces stomach and intestine

  • mouth tissues may become more tender and at risk for bleeding

  • slow digestive system (constipation and bloating) relaxed pyloric sphincter - pyrosis and heartburn

• respiratory

  • enlarged uterus-dyspna may occur

• MSK

circulatory changes during pregnancy

• cardiac output increases by 30-50%; pulse may increase

• bp normally does not increase due to decreased peripheral vascular resistance

• dilution anemia: where water component increases more than erythrocyte

• physiologic anemia

  • hct may drop from 0.37/47-0.33

  • wbc increase in 2nd/3rd trimester

  • blood volume increases bye 40-50% by 24-32 wks gestation

• coag factors increase in 2nd and third trimester

enlarged uterus

• thoracic breathing

• increased tidal volume

• dyspnea may occur

supine hypotension

• aortocaval compression

when lying on back

• uterus pushes on Inferior vena cava

• decreasing blood return to heart

• may cause fetal hypoxia

symptoms

• faintness

• agitation

• lightheadedness

• dizziness

relief

• reposition ; L side better

prenatal visit people

family physician

midwife

obsectritian

frequency of prenatal visits

• intake visit first trimester

• conception to 28 wks = every 4 weeks

• 29-36 weeks 2-3 weeks

• 37 weeks til birth weekly

fetal movements and fetal heart tones

need to monitor fetal movements after 26 weeks

heart tones tell the viability for baby

urinary dipstick

proteinuria is a classic symptom of preeclampsia

isoimmunization

where rh pos of baby leaks into rh neg into mom circulation creating antibodies that would destroy rh

• requires rhogam at 28 wks and within 72h post birth

  • also after amniocentesis, miscarriage or abortion, abdominal trauma

preeclampsia definition

• high bp with damage to organ; liver or kidney

dx of hDP and classificaiton

dx:

• bp readings of 140/90 or greater for 2 sep readings on 2 measurements at least 15 mins apart on the same arm

classification

• pre existing chronic htn before 20 wks

• gestational htn after 20 wks

preeclampsia= increased bp with proteinuria

• non severe 140/90

• severe 160/110

• eclampsia - seizures

  • magnesium sulfate and calcium gluconate for toxicity

severe complications of preeclampsia

blood clotting HELLP

• hemolysis

• Elevated liver enzymes

• low platelets

gestational diabetes: effect of pregnancy in glucose metabolism

estrogen/progesterone, insulinase and increased prolactin have 2 effects

• increased resistance of cells to insulin

• speed breakdown of Insulin

gestational diabetes: screening and dx

50 g glucose oral test

retest if over 7.8

3 hours

initial fasting 1 hour, 2 hour , if one is abnormal this is a dx