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OB ATI Study Guide

Initial Prenatal Visit: Estimated date of delivery based on LMP. Vaginal ultrasound may be done to establish DOD Medical & nursing hx including past med health, family hx, social supports, social hx, & review of systems (to determine risk factors) & past OB hx Physical assessment: baseline weight, vitals, pelvic exam Initial lab work: o Blood type o Urinalysis o RH factor o Pap o HIV status o Indirect Coombs test will o Hep B determine if client is sensitized o VDRL to RH+ blood o Rubella status Ongoing Prenatal Visits: Monitor weight, BP, & urine for glucose, protein, & leukocytes Present of edema Fetal development: o FHR heard by Doppler at 10-12 wks o Heard with ultrasound stethoscope at 16-20 wks. Listen at the midline, right above the symphysis pubis, holding stethoscope firmly on abd o Measure fundal height after 12 wks. Between 18 & 30 weeks, fundal height measured in cm should equal the week of gestation. Have pt empty bladder & measure from the level of the symphysis pubis to the upper border of the fundus o Begin assessing for fetal movement between 16 & 20 weeks gestation

Routine Lab Tests in Prenatal Care & Their Purpose Blood type, Rh factor, presence of irregular Determines risk for maternal-fetal blood antibodies incompatibility (erythroblastosis fetalis) or neonatal hyperbilirubinemia. For clients are are Rh(-) & not sensitized, the indirect Coombs test will be repeated b/t 24-28 weeks gestation CBC w/ differential, Hgb, Hct Hgb electrophoresis Urinalysis: pH, gravity, color, sediment, protein, glucose, albumin, RBCs, WBCs, casts, acetone, & HCG Detects infection & anemia Identifies hemoglobinopathies (sickle cell anemia & thalassemia) Identifies DM, gestational HTN, renal disease, & infection

2 1 hr Glucose Tolerance (oral/IV admin of concentrated glucose w/ venous sample taken 1 hr later. Fasting not necessary) 3 hr Glucose Tolerance (fasting overnight prior to oral or IV admin of concentrated glucose with a venous sample taken at 1, 2, & 3 hrs later) Pap Test Vaginal/Cervical Culture Identifies hyperglycemia; done at initial visit for atrisk clients, & at 24-28 wks for all pregnant women (>140 requires follow up) Used in clients w/ elevated 1-hr glucose tst as a screening tool for DM. A dx of GD requires 2 elevated blood-glucose readings Screens for cervical cancer, HSV II, &/or HPV Detects streptococcus B-hemolytic, Group B (routinely done at 35-37 wks), BV, STDS (gonorrhea, chlamydia) Determines immunity to rubella. If non-immune, give shot! Identifies exposure to TB Identifies carriers of hep B Syphilis screening mandated by law Detects HIV infection: recommended for all clients who are pregnant unless client refuses testing Screening for group of infections capable of crossing the placenta & adversely affecting fetal development Between 15-22 wks

Rubella Titer

PPD, chest screening after 20 weeks w/ + purified protein derivative Hep B Screen VDRL HIV

TORCH (Toxoplasmosis, other infections, rubella, cytomegalovirus, & herpes) when indicated

Maternal serum alpha-fetoprotein (MSAFP)

Rhogam Administration: IM around 28 weeks for clients who are Rh (-) For amniocentesis, car wreck, or any instance of possibility of fetal/maternal blood mixture

Health Promotion: Avoid all OTC meds, supplements, & rx meds unless OB who is supervising care has knowledge of this practice Alcohol (birth defects) & tobacco (low birth weight) contraindicated during pregnancy Substance abuse of any kind is to be avoid during pregnancy & lactation Encourage flu vaccine during the fall months

3 Treat current infections Ascertain maternal exposure to hazardous materials Avoid use of hot tubs/saunas Consume at least 2-3 L of h20 daily from food & beverage sources Exercise: moderate exercise (walking/swimming) consisting of 30 minutes; no new exercise during pregnancy

Third Trimester Childbirth Prep: Breathing & relaxation techniques o Deep cleansing breaths at the usual respiratory rate during ctxns can promote relaxation of the abd muscles, which lessens the discomfort of uterine ctxns. discussion regarding pain management during labor & birth (natural child birth, epidural) Fetal movement/kick counts to ascertain fetal well-being. Client should be instructed to count & record fetal movements or kicks daily o It is recommended that mothers count fetal activity 2-3 x/day for 60 mins each time o Fetal movements <3/hr or movements that cease entirely for 12 hours need further eval

Common Discomforts During Pregnancy: Morning sickness: eat cracker or dry toast to 1 hr before rising in the morning to prevent discomfort. Avoid an empty stomach & drink fluids between meals. UTIs are common due to renal changes & vaginal flora becoming more alkaline o Wipe front to back, avoid bubble baths, wear cotton panties, avoid tight-fitting pants, & consume 8 glasses of water/day o Urinate as soon as urge occurs Constipation may occur during 2nd & 3rd trimesters. Drink plenty of fluids, eat a diet high in fiber, exercise regularly Leg cramps may occur during 3rd trimester d/c compression of lower extremity nerves & blood vessels by the enlarging uterus o Homans sign should be checked o If negative, patient should extend the affected leg, keeping knee straight & dorsiflexing the foot (toes toward the head) o Massaging & applying heat over affected muscle or a foot massage while the leg is extended can help relieve cramping o Notify PCP if frequent cramping occurs Varicose veins & extremity edema during 2nd & 3rd trimesters o Rest w/ legs elevated o Avoid sitting w/ legs crossed at o Avoid constricting clothing knees o Wear support hose o Sleep in left lateral position o Avoid sitting or standing in one position for long periods of time

4 Gingivitis, nasal stuffiness, & epistaxis can occur Braxton Hicks ctxns o Should subside with change of position & walking

Danger Signs of Pregnancy: Gush of fluid from vagina (rupture of amniotic fluid) prior to 37 weeks of gestation Vaginal bleeding (placental problems such as abruption or previa) Abd pain (premature labor, abruption placenta, or ectopic pregnancy) Changes in fetal activity ( fetal movement may indicate fetal distress) Persistent vomiting (hyperemesis gravidarum) Severe HA (PIH) Elevated temp (infection) Dysuria (UTI) Blurred vision (PIH) Edema of face & hands (PIH) Epigastric pain (PIH) Concurrent occurrence of flushed dry skin, fruity breath, rapid breathing, thirst & urination, & HA (hyperglycemia) Concurrent occurrence of clammy pale skin, weakness, tremors, irritability, & lightheadedness (hypoglycemia)

Common birthing methods: prepare a pregnant woman for the l&d process & may anxiety: Dick-Read method- childbirth w/out fear. Uses controlled breathing & conscious & progressive relaxation of different muscle groups through the entire body. Instructs a woman to relax completely between contractions & keep all muscles except the uterus relaxed during ctxns Lamaze- promote a healthy, natural, & safe approach to pregnancy, childbirth, & early parenting by advocating & working w/ HCP, parents, & prof. childbirth instructors Leboyer- based on the idea of birth without violence. Environmental variables are stressed to ease the transition of the fetus from the uterus to the external environment (dim lights, soft voices, warm birthing room). Water births are based on this method. Bradley- emphasizes partners involvement as the birthing coach. Emphasizes increasing selfawareness & teaching the woman to deal w/ the stress of labor by tuning into her own body. Mother is encouraged to trust her body & use natural breathing, relaxation, nutrition, exercise, & education throughout pregnancy

Nutrition During Pregnancy: protein intake foods high in folic acid (leafy vegetables, dried peas & beans, seeds, orange juice. Breads, cereals, & other grains are fortified with folic acid). o 600 mcg during pregnancy

5 o 500 mcg during lactation Iron supplements facilitate an of the maternal RBC mass o Best absorbed between meals & when given w/ good source of Vit. C o Milk & caffeine interfere w/ absorption o Sources of iron: beef liver, red meats, fish, poulty, dried peas & beans, & fortified cereals & breads o Stool softener may be added to constipation experienced w/ iron Adolescents may have poor nutritional habits (a diet low in vitamins & protein, not taking prescribed iron supplements(

Potential Diagnoses for Ultrasound during Pregnancy: Confirm pregnancy, fetal viability, or death Confirm GA by biparietal diameter (side-to-side) measurement Identify multifetal pregnancy Site of fetal implantation (uterine or ectopic) Assessment of fetal growth & development Client presentation: o Vaginal bleeding eval o Questionable fundal height measurement in relationship to gestational weeks Assessing maternal structure Ruling out fetal abnormalities Locating site of placental attachment Determining amniotic fluid volume Fetal movement observation (FHR, breathing, & activity) Placental grading (evaluating placental maturation) Adjunct for other procedures o o o fetal movements Preterm labor Questionable rupture of membranes

Amniocentesis: Aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into clients uterus & amniotic sac under direct ultrasound guidance locating the placenta & determining position of fetus. May be performed after 14 weeks Indications: o Maternal age >35 years o Prenatal dx of genetic disorder o Previous birth w/ chromosomal or congenital anomaly of fetus anomaly o Alpha fetoprotein level for fetal o Parent who is carrier of abnormalities chromosomal anomaly o Lung maturity assessment o Family hx of neural tube defects o Fetal hemolytic disease dx o Meconium in amniotic fluid Interpretation of finding:

6 AFP (protein produced by fetus) can be measured from the amniotic fluid between 1618 weeks & may be used to assess for neural tube defects in fetus or chromosomal disorders. May be evaluated to follow up a high level of AFP in maternal serum: High level: associated w/ neural tube defects such as anencephaly (incomplete development of fetal skull & brain), spina bifida (open spine), or omphalocele (abd wall defect). May also be present with normal multifetal pregnancies Low levels: chromosomal disorders (Down syndrome) or gestational trophoblastic disease (hydratiform mole) o Tests for fetal lung maturity may be performed if gestation < 27 weeks in event of rupture of membranes, preterm labor, or for complication indicating C-section. Amniotic fluid tested to determine if the fetal lungs are mature enough to adapt to extrauterine life or if the fetus will likely have respiratory distress. Determination is made whether the fetus should be removed immediately or if the fetus requires more time in utero w/ the admin of glucocorticoids to promote fetal lung maturity Fetal lung tests Lecithin/sphingomyelin (L/S) ratio- a 2:1 indicating fetal lung maturity (2.5:1 or 3:1 for a client who has DM) Presence of phosphatidylglycerol (PG)- absence of PG is associated w/ respiratory distress Preprocedure for Amniocentesis o Explain procedure & obtain informed consent o Instruct client to empty bladder to reduce risk of inadvertent puncture Intraprocedure: o Assist client in supine position & place a wedge or rolled towel under right hip to displace uterus off vena cava & place drape over client exposing only abd o Prepare for ultrasound to locate placenta o Obtain baseline vitals & FHR & document prior to procedure o Cleanse abd w/ antiseptic solution prior to administration of a local anesthetic given by the PCP o Advise client that she will feel slight pressure as the needle is inserted for aspiration. However, she should continue breathing because holding her breath will lower the diaphragm against the uterus & shift intrauterine contents\ Postprocedure: o Monitor vitals, FHR, & uterine ctxns throughout procedure & 30 mins following o Have client rest for 30 mins o Administer Rhogam if Rh (-) o Advise client to report to PCP if she experiences fever, chills, leakage of fluid/bleeding from insertion site, d fetal movement, vaginal bleeding, or uterine ctxns after the procedure o Drink plenty of fluids & rest for next 24 hours post procedure Complications: o

7 Amniotic fluid emboli o Fetal death Maternal or fetal hemorrhage o Inadvertent maternal intestinal Fetomaternal hemorrhage w/ or bladder damage Rh isoimmunization o Miscarriage or preterm labor o Maternal or fetal infection o Premature rupture of o Inadvertent fetal damage or membranes anomalies involving limbs o Leakage of amniotic fluid Nursing Actions: o Monitor vitals, temp, respiratory status, FHR, uterine ctxns, vaginaly discharge o Provide med admin as prescribed, client education, & support o o o

Alpha-Fetoprotein Screening Abnormal finding should be referred for a quad marker screening, genetic counseling, ultrasound, & an amniocentesis Indications: all pregnant clients between 16 & 18 weeks Interpretation of findings: o High levels: neural tube defect or open abd defect o Low levels: Down syndrome Nursing actions: o Discuss testing w/ client o Draw blood sample o Offer support & education as needed Summary of Causes of Bleeding during Pregnancy Complication S/S Spontaneous abortion Vaginal bleeding, uterine cramping, & partial or complete expulsion of products of conception

Time

First Trimester Ectopic pregnancy Abrupt unilateral lower-quad pain w/ or w/out vag bleeding

Gestational trophoblastic disease Second Trimester

Uterine size increasing abnormally fast, abnormally high levels of hCG, nausea & emesis, no fetus present on ultrasound, scant/profuse dark brown or red vag bleeding

Placenta previa

Painless vaginal bleeding

Abruptio placenta Third Trimester

Vaginal bleeding, sharp abd pain, & tender rigid uterus

Vasa previa

Fetal vessel cross over the cervix abrupt red vaginal bleeding following ROM

Other Causes of Bleeding: Incompetent cervix o Painless bleeding w/ cervical dilation leading to fetal expulsion Preterm Labor o Pink-stained vaginal discharge, uterine ctxns becoming regular, cervical dilation & effacement

Spontaneous Abortion When a pregnancy is terminated before 20 weeks of gestation or a fetal weight <500 g Chromosomal abnormalities account for 50% Provide client education & emotional support Provide contacts for bereavement support groups

Gestational Diabetes Mellitus: Impaired tolerance to glucose w/ the first onset or recognition during pregnancy. Ideal blood glucose during pregnancy should be between 70 & 110 mg/dL. Sx may disappear a few weeks following delivery. Approximately 50% of women will develop DM w/ in 5 years GDM causes risks to fetus including: o Spontaneous abortion r/t poor glycemic control o Infections (urinary & vaginal) r/t glucose in urine & resistance because of altered carb metabolism o Hydramnios, which can cause overdistention of uterus, premature ROM, preterm labor, hemorrhage o Ketoacidosis from diabetogenic effect of pregnancy ( insulin resistance), untreated hyperglycemia, or inappropriate insulin dosing o Hypoglycemia, which Is caused by overdosing in insulin, skipped or late meals, or exercise o Hyperglycemia, which can cause excessive fetal growth (macrosomia) Risk Factors: o Obesity o Maternal age >35 y.o

9 o Family hx of DM o Previous delivery of infant that was large or stillborn

Subjective data o Hypoglycemia (nervousness, HA, weakness, irritability, hunger, blurred vision, tingling of mouth or extremities) o Hyperglycemia (thirst, nausea, abd pain, frequent urination, flushed dry skin, fruity breath) Objective Data o Hypoglycemia o Hyperglycemia o Shaking o Vomiting o Clammy pale skin o Excess weight gain during o Shallow respirations pregnancy o Rapid pulse Lab tests o Routine urinalysis w/ glycosuria o Glucola screening test/1 hour GTT Positive: 140 mg/dL or greater Additional testing w/ 3 hr GTT is indicated o 3-hr GTT Avoidance of caffeine & abstinence from smoking for 12 hour prior to testing 100 g glucose load given o Ketones tested to assess the severity of ketoacidosis Dx procedures o Biophysical profile to ascertain fetal well-being o Amniocentesis w/ alpha-fetoprotein o Nonstress test to assess fetal well-being Nursing Care: o Monitor clients blood glucose o Monitor fetus o Instruct client to perform daily kick counts o Administer insulin as prescribed Most oral hypoglycemic agents are contraindicated for GDM, but there is limited use of glyburide at this time. The provider will need to make the determination if these meds can be used o Educate client about diet, exercise, & self-administration of insulin o Desired client outcomes: effectively manage & control blood glucose level throughout her pregnancy to ensure maternal/fetal well-being

Gestational Hypertension/ Pregnancy Induced Hypertension (PIH)

10 Hypertensive disease in pregnancy is divided into clinical subsets of the disease based on endorgan effects & progresses along a continuum from mild gestational hypertension, mild & severe preeclampsia, eclampsia, & HELLP syndrome Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the s/s of pregnancy hypertensive disorders Gestational hypertension (GH), which begins after the 20th week of pregnancy, describes hypertensive disorders of pregnancy whereby the woman has: o an elevated BP at 140/90 or greater o or a systolic of 30 o or a diastolic of 15 from the prepregnancy baseline o no proteinuria or edema o clients bp returns to baseline by 12 weeks postpartum Mild preeclampsia: o GH w/ addition of proteinuria of 1 to 2+ o Weight gain of more than 2 kg (4.4 lbs) per week in the 2nd & 3rd trimesters o Mild edema will appear in the upper extremities or face Severe preeclampsia: o BP >160/100 o Hyperreflexia w/ possible ankle o Proteinuria 3 to 4+ clonus o Oliguria o Pulmonary or cardiac o Elevated serum creatinine >1.2 involvement mg/dL o Extensive peripheral edema o Cerebral or visual disturbances o Hepatic dysfunction (HA & blurred vision) o Epigastric & RUQ pain o Thrombocytopenia Eclampsia is severe preeclampsia symptoms along w/ onset of seizure activity or coma. o Usually preceded by HA, severe epigastric pain, hyperreflexia, & hemoconcentrations, which are warning signs of possible convulsions HELLP syndrome is a variant of GH in which hematologic conditions coexist w/ severe preeclampsia involving hepatic dysfunction. Diagnosed by lab tests, not clinically: o H- hemolysis resulting in anemia & jaundice o EL- elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), epigastric pain, n/v o LP- low platelets (< 100,000), resulting in thrombocytopenia, abn bleeding & clotting time, bleeding gums, petechiae, & possibly DIC Gestational hypertensive disease & chronic hypertension may occur simultaneously Gestational hypertensive diseases are associated w/ placental abruption, acute renal failure, hepatic rupture, preterm birth, & fetal & maternal death Risk Factors o No single profile identifies risks for GH disorders, but some high risks include:

11 Subjective Data Maternal age <20 or >40 First pregnancy Morbid obesity Multifetal gestation Chronic renal disease Chronic hypertension Assessment of Gestational Hypertensive Disorders Lab Findings Severe continuous HA Nausea HTN Proteinuria Periorbital, facial, hand, & abd edema Epigastric pain RUQ pain Dyspnea Seizures Jaundice Scotoma Diminished breath sounds Hgb Creatinine Thrombocytopenia Liver enzymes CBC Clotting studies Dipstick urine for proteinuria 24 hr urine collection for protein & creatinine clearance Familiar hx of preeclampsia DM Rh incompatibility Molar pregnancy Previous hx of GH

Blurred vision Flashes of lights or dots before the eyes Pitting edema of lower extremities Vomiting Oliguria Hyperreflexia Rapid weight gain (2 kg [4.4 lb]) per week in 2nd & 3rd trimesters Signs of progression of hypertensive disease w/ indications of worsening liver involvement, renal failure, worsening hypertension, cerebral involvement, & developing coagulopathies Plasma uric acid liver enzymes (LDH, AST) Hyperbilirubinemia Serum creatinine, BUN, uric acid, & Mg as renal function Chemistry profile Nonstress test, ctxn stress test, biophysical profile, & serial ultrasounds to assess fetal status Doppler blood flow analysis to assess fetal well-being

Objective

Lab Tests

Dx Procedures

Nursing Care: o Assess LOC o Pulse ox o Urine output & obtain cleancatch urine sample to assess for proteinuria o Daily weights Meds:

o o o o

Vitals Lateral positioning Perform NST & daily kick counts as prescribed Instruct client to monitor I&O

12 o Mag Sulfate Anticonvulsant Med of choice for prophylaxis or treatment. Lowers BP & depresses CNS Use infusion control device to maintain regular flow rate Inform client she may initially feel flushed, hot, & sedated w/ MgSO4 bolus Monitor BP, pulse, RR, DTRs, LOC, urinary output (indwelling cath for accuracy), presence of HA, visual disturbances, epigastric pain, uterine ctxns, & FHR & activity Fluid restriction of 100 to 125 ml/hr, maintain urinary output of 30 ml/hr or greater Monitor for signs of mag toxicity: Absence of patellar DTR Urine output <30 ml/hr Respirations <12/min LOC Cardiac Dysrhythmias If mag toxicity is suspected: Immediately d/c infusion Admin antidote calcium gluconate Prepare for actions to prevent respiratory or cardiac arrest Health Promotion/Disease Prevention Maintain bed rest & lie in side-lying position Promote diversional activities Avoid foods high in Na Avoid etoh & limit caffeine fluid intake to 8 glasses/day Dark quiet environment, avoid stimuli that may precipitate seizure Patent airway in event of seizure Admin antihypertensive meds as prescribed Client outcomes: Maintain BP w/in acceptable parameters Client & fetus will remain free of injury

Preterm Labor Nursing Care: focus on stopping uterine ctxns o Activity restriction Modified bed rest w/ bathroom privileges Rest in left lateral position to blood flow to uterus & uterine activity Avoid sex o Ensure hydration

13 Dehydration stimulates pituitary gland to secrete an ADH & oxytocin. Preventing dehydration will prevent release of oxytocin, which stimulates uterine ctxns o Identifying & treating any infection Client should report vag discharge, noting color, consistency, odor Monitor vitals & temp o Choroamnionitis should be suspected w/ occurrence of elevated maternal temp & tachycardia o Monitor FHR & ctxn pattern Fetal tachycardia (prolonged in FHR >160/min) may indicate infection, which is frequently associated w/ preterm labor Medications o Terbutaline (Brethine) o Mag sulfate Commonly used tocolytic that relaxes the smooth muscle of the uterus & thus inhibits uterine activity by suppressing ctxns Monitor closely. Therapy should be d/c immediately if the client exhibits s/s of pulmonary edema (chest pain, SOB, resp distress, audible wheezing & crackles, &/or productive cough containing blood-tinged sputum) Monitor for side effects Monitor for mag sulfate toxicity & d/c for any of the following adverse effects: Loss of DTR Urine output <30 ml/hr Respiratory depression <12/min Pulmonary edema Chest pain Admin calcium gluconate as antidote for mag sulfate toxicity Contraindications for tocolysis: Active vaginal bleeding Dilation of cervix > 6 cm Chorioamnionitis >34 weeks gestation Acute fetal distress Instruct client to notify nurse of blurred vision, HA, n/v, or difficulty breathing

Pain Management Safety for the mother & fetus must be first consideration of the nurse when providing pain management measures Nurse is responsible for helping client maintain the proper position during admin of pharmacological interventions Nonpharmacological pain management: seek to reduce anxiety, fear, & tension, which are major contributing factors of pain in labor

14 o Gate-control theory of pain- based on concept that the sensory nerve pathways that pain sensations use to travel to the brain will only allow a limited number of sensations to travel at any giving time. By sending alternate signals through these pathways, the pain signals can be blocked from ascending the neuro pathway & inhibit brains perception & sensation of pain Gate-control theory assists in the understanding of how nonpharm pain techniques can work to relieve pain Childbirth prep education, sensory & cutaneous strategies, & frequent position changes Lamaze, Bradley, Dick-Read methods Pattern breathing methods: nurse should assess for signs of hyperventilation (caused by low blood levels of PCO2 from blowing off too much CO2) such as light-headedness & tingling of the fingers If hyperventilation occurs, have the client breathe into a paper bag or cupped hands Sensory stimulation strategies: Aroma therapy Music Breathing techniques Use of focal points Imagery Cutaneous Strategies: Back rubs & massage Effleurage: Light, gentle circular stroking of clients abd w/ fingertips in rhythm w/ breathing during ctxns Sacral counterpressure Consistent pressure is applied by the support person using the heel of the hand or fist against clients sacral area to counteract pain in the lower back Heat or cold therapy Transcutaneous Intradermal water block electrical nerve Hypnosis stimulation (TENS) unit Acupressure Hydrotherapy (whirlpool or shower) s maternal endorphin levels Frequent maternal position changes: Semi-sitting Kneeling & rocking back Squatting & forth Kneeling Supine position only w/ the placement of a wedge under 1 of the clients hips to tilt the uterus & avoid supine hypotension syndrome

o o

Pharmacological Pain Management: avoid slowing the progress of labor.

15 Prior to administration, nurse should verify that labor is well established by performing a vag exam & evaluating uterine ctxn pattern Adverse effect of opioid analgesics: crosses the placental barrier; if given to the mother too close to the time of delivery, opioid analgesics can cause respiratory depression in neonate Epidural & spinal regional analgesia: fentanyl & sufentanil, which are short-acting opioids that are administered as a motor block into the epidural or intrathecal space w/out anesthesia o Produce regional analgesia providing rapid pain relief while still allowing client to sense ctxns & maintain ability to bear down o Adverse effects: gastric emptying Bradycardia or resulting in n/v tachycardia Inhibition of bowel & Hypotension bladder elimination Respiratory depression sensations Allergic rxn & pruritus Elevated temperature o Provide client w/ ongoing education r/t expectations for procedure o Institute safety precautions such as side rails up. Patient may experience dizziness & sedation, which s maternal risk for injury o Assess the client for n/v & admin antiemetics as prescribed o Monitor vitals per hospital protocol o Monitor for allergic rxn o Continue FHR pattern monitoring Epidural Block: local anesthetic bupivacaine along w/ analgesic Morphine or fentanyl injected into epidural space at 4th or 5th vertebrae. Eliminates all sensation from level of umbilicus to the thighs, relieving discomfort of perineum. o Admin when client is in active labor & dilated to at least 4 cm o Continuous infusion or intermittent injections may be admin through an indwelling epidural cath o Patient controlled epidural analgeis is a new technique o Adverse effects: Maternal hypotension Fetal bradycardia Inability to feel the urge to void Loss of the bearing down reflex o Nursing Actions: Admin bolus of IV fluids to help offset maternal hypotension as prescribed Help position client into either sitting or side-lying modified Sims w/ back curved to widen intervertebral space for insertion of the epidural cath Remain in side-lying position after insertion to avoid supine hypotension syndrome w/ compression of vena cava o

16 Coach pushing efforts & request evaluation of epidural pain mgmnt by anesthesia if pushing efforts ineffective Monitor maternal BP & pulse, observe for hypotension, resp depression, & o2 sats Assess FHR continuously Maintain IV line & have O2 & suction ready Assess for orthostatic hypotension. If present, prepare to admin IV vasopressor such as ephedrine, position laterally, IV fluids, initiate O2 Provide client safety: raise side rails. Dot not allow client to ambulate unassisted until all motor control has returned Assess bladder for distention at frequent intervals & catheterize if necessary Monitor the return of sensation in legs after delivery but prior to standing. Assist with standing & walking for the first time after delivery that included epidural anesthesia A nurse is caring for a client in active labor. The client reports lower back pain. The nurse suspects that this pain is persistent occiput posterior presentation. Which of the following nonpharmacological nursing interventions should best alleviate this pain? B. Sacral counterpressure.

Late Deceleration of FHR Slowing of FHR after ctxn has started w/ return of FHR to baseline well after ctxn has ended Causes/Complications: o Uteroplacental insufficiency causing inadequate fetal oxygenation o Maternal hypotension, abruption placentae, uterine hyperstimulation w/ oxytocin (Pitocin) Nursing interventions: o Side-lying position o Notify PCP o Start IV line or IV rate o Prepare for assisted vag birth or o D/C oxytocin if being infused C-section o Admin O2 8-10 L/min per mask Assessments R/T possible rupture of membranes: First assess FHR to assure there is no fetal distress from possible umbilical cord prolapse, which can occur w/ gush of amniotic fluid Nitrazine paper will turn blue in the presence of alkaline amniotic fluid (pH 6.5-7.5) Sample of fluid obtained & viewed on a slide under microscope o Amniotic fluid will exhibit frond-like ferning pattern Fluid should be a clear straw color & free of odor

Bishop Score Used to determine maternal readiness for labor by evaluating if cervix is favorable:

17 Cervical dilation o Position (posterior, Effacement midposition, or anterior) Consistency (firm, medium, or o Presenting part station soft) 5 factors are assigned a numerical value of 0-3, total score is calculated, & a score of 9 for nulliparas & 5 or more for multiparas indicates readiness for labor induction Indication: o Any condition in which augmentation or induction of labor is indicated o o o

Amniotomy Artificial rupture of amniotic membranes by PCP using an Amnihook or other sharp instrument Labor typically begins w/in 12 hrs after rupture Client is at risk for cord prolapse or infection Indications: o Labor progression too slow & augmentation/induction is indicated o Amnioinfusion is indicated for cord compression Outcomes: o Labor will progress w/out complications Nursing Actions: o Assure presenting part of fetus is engaged prior to an amniotomy to prevent cord prolapse o Monitor FHR prior to & following AROM to assess for cord prolapse AEB variable/late decelerations o Assess & document characteristics of amniotic fluid including color, odor, & consistency Interventions: o Document the time of rupture o Obtain temp q 2 hr

Cesarean Birth Incisions currently made horizontally into lower segment of uterus Previously made as classical vertical incision into muscular body of the uterus Indications: o Malpresentation, particularly Hypertensive disorders breech such as preeclampsia & o Cephalopelvic disproportion eclampsia o Fetal distress Maternal DM o Placental abn Active herpes outbreak Previa o Previous c-section Abruption placenta o Dystocia o High-risk pregnancy o Multiple gestations HIV + o Umbilical cord prolapse

18 Client outcome: free of injury during birthing process Preprocedure: o Assess/record FHR, vitals, BP o Obtain abd ultrasound to assess if c-section is indicated o Supine position w/ wedge under 1 hip to laterally tilt her & keep her off of the vena cava & descending aorta. This helps maintain optimal perfusion of oxygenated blood to the fetus during procedure o Insert indwelling cath o Admin preop meds o Prepare surgical site o Insert IV line o Obtain informed consent o Determine client has had NPO since midnight before procedure. If she has, notify anesthesiologist o Assure preop dx tests are complete including Rh-factor test Intraprocedure: o Assist in positioning client on operating table o Monitor FHR o Monitor vitals, IV fluids, urine output Postprocedure Assessments & Actions: o Signs of infection & excessive o S/s of thrombophlebitis bleeding (tenderness, pain, heat) o Uterine fundus for firmness or o I&O, vitals tenderness o Provide pain relief & o Lochia amount & characteristics antiemetics Tender uterus & foulo Turn, cough, & deep breath smelling lochia: o Splinting of incision w/ pillows endometritis o Ambulation to prevent o Productive cough or chills thrombus formation (pneumonia) o Sx of UTI Complications o Maternal: Aspiration Hemorrhage Amniotic fluid PE UTI Wound infection Injuries to Dehiscence bladder/bowel Severe abd pain Anesthesia assoc Thrombophlebitis complications o Fetal: Premature birth of fetus if GA is inaccurate Fetal injuries during surgery

19 Meconium-Stained Amniotic Fluid Typically associated w/ unfavorable fetal outcome Fetus has had an episode of loss of sphincter control, allowing meconium to pass into fluid Risk Factors: o >38 weeks gestation o Umbilical cord compression r/I fetal hypoxia that stimulates the vagal nerve in mature fetuses o Hypoxia stimulate vagal nerve, which induces peristalsis of fetal GI tract & relaxation of the anal sphincter, which r/I release of meconium as well as fetal bradycardia Objective Data: o Presence of meconium via visual inspection o Fluid may vary in color from black to greenish, yellow or brown, w/ thick fresh consistency o Criteria for evaluation of meconium-stained amniotic fluid: Consistency that is thick & fresh: indicates fetal stress Meconium is 1st passed in later labor w/ variable or late FHR decelerations (ominous sign) Meconium alone in the amniotic fluid isnt sign of fetal distress; it must be accompanied by variable or late FHR decelerations w/ or w/out acidosis, which is confirmed by scalp blood sampling to be considered ominous o Dx Procedures Intrapartal meconium requires further careful evaluation if birth is not imminent Electronic fetal monitoring Fetal scalp blood sampling Nursing Care: o Document meconium-stained amniotic fluid & its color o Amnioinfusion of 0/9% NaCl or LR should be instilled into the amniotic cavitiy through a transcervical cavity into the uterus to thin meconium-stained fluid o Nurse should be prepared to suction the nasopharynx of neonate o Suctioning reduces the incidence & severity of meconium aspiration syndrome in the neonate

Postpartum Period Greatest risks: hemorrhage, shock, & infection Oxytocin coordinates & strengthens uterine contractions o May be administered postpartum to improve quality of uterine ctxns o Firm & contracted uterus prevents excessive bleeding & hemorrhage o Uncomfortable uterine cramping: afterpains Assessments immediately following delivery: o Vitals

20 o Uterine firmness & location relative to umbilicus o Uterine position in relation to midline of the abd o Amount of vaginal bleeding Postpartum chill: occurs in first 2 hr puerperium. Uncontrollable shaking chills possibly r/t nervous system response, vasomotor changes, shift in fluid, &/or work of labor. o Normal occurrence unless accompanied by elevated temperature o Provide client w/ warm blankets & fluids Fundus: o Immediately after delivery: firm, midline w/ umbilicus, at level of umbilicus o At 12 hr postpartum: 1 cm above umbilicus o Q 24 hr, descends approximately 1-2 cm Should be halfway b/t symphysis pubis & umbilicus by 6th day o By day 10, uterus should lie within true pelvis & not palpable Comfort measures: o Apply ice packs to perineum for 1st 24-48 hrs to reduce edema & provide anesthetic o Encourage sitz baths at temp of 38-30 (100-104 F) or cooler at least BID o Admin analgesia such as nonopioids, NSAIDS,& opioids as prescribed o Opioid analgesia may be admin via PCA after c-section. Continuous epidural infusions may also be used for pain control after c-sections o Apply topical anesthetics to perineal area prn or witch hazel compresses to rectal area for hemorrhoids Immune System: o Review the Rh status All Rh(-) mothers w/ newborns who are Rh(+) must be given Rhogam administered w/in 72 hrs of delivery to suppress antibody formation in mother o Test client who receives both rubella vaccine & RhoGAM after 3 months to determine if immunity to rubella has been developed

Bonding & Integration of Infant into Family System Mothers emotional & physical condition (unwanted pregnancy, adolescent pregnancy, history of depression, difficult pregnancy & delivery) & infants physical condition (prematurity, congenital anomalies) after birth can affect familys bonding experience Culture, age, & socioeconomic level can influence bonding Bonding can be delayed secondary to maternal or neonatal factors Psychosocial adaptation & maternal adjustment begin during pregnancy as the client goes through commitment, attachment, & preparation for the birth of the newborn. o 1st 2-6 weeks after birth: acquaintance, physical restoration, focus on competently caring for newborn o 4 months following birth: achieving maternal identity o These stages may overlap & are variable based on maternal, infant, & environmental factors

21 Nursing interventions to assist w/ maternal-infant bonding: o Provide quiet & private environment o Place infant skin-to-skin w/ mother soon after birth in en face position o Encourage bonding via cuddling, feeding, diapering, & inspection o Provide frequent praise, support & reassurance to mother o Encourage mother/parents to express feelings, fears, & anxieties about care for infant

Client Education & Discharge Teaching Breast care: o Wear well-fitting bra continuously for 1st 72 hours after birth o Provide breast care for lactating women Emphasize importance of hand hygiene prior to breast feeding Breast engorgement: Completely empty breasts at each feeding Allow infant to nurse q 2 hr Massage breast during feeding Allow infant to feed 15-20 mins per breast or until breast softens If 2nd breast doesnt soften after feeding, it may be emptied w/ pump Apply cool compresses b/t feedings & warm compresses/warm shower prior to feeding ( milk flow & promotes letdown reflex) Cold cabbage leaves also swelling & relieve discomfort Flat nipples Suggest client roll nipples between fingers just before breastfeeding Sore nipples: Apply small amount of breast milk to nipple & allow to air dry after feeding Apply breast creams as prescribed & wear breast shields in bra to soften nipples Promote adequate fluid intake b/c its important to replace fluid lost from breastfeeding as well as produce an adequate amount of milk o Non-lactating Women: Suppression of lactation is necessary for women who are not breastfeeding Avoid breast stimulation & running warm water over the breast for prolonged periods until no longer lactating For breast engorgement, which may occur on 3rd or 5th postpartum day: Apply cold compresses 15 min on & 45 min off Fresh cabbage leaves inside bra Mild analgesics for pain & discomfort Rest/Sleep o Plan at least one daily rest period; rest when infant naps Activity o Dont perform housework that requires heavy lifting for at least 3 wks

22 o o o o o Dont lift anything heavier than the infant Avoid sitting for prolonged periods of time w/ legs crossed Limit stair climbing for 1st few weeks C-section clients should wait until 6 wk follow-up visit before performing strenuous exercise, heavy lifting, or excessive stair climbing Instruct client not to drive for 1st 2 weeks postpartum or while taking opioids

Postpartum Hemorrhage Assessment: o vaginal bleeding o Constant oozing, trickling, or o Uterine atony frank flow of bright red blood o Blood clots larger than quarter from vag o Perineal pad saturation in 15 o Tachycardia & hypotension min or less o Skin thats pale, cool, & clammy o Return of lochia rubra once w/ poor turgor & pale mucous lochia has progressed to serosa membranes or alba o Oliguria Nursing Care: o Monitor vitals o Assess for source of bleeding Fundus: height, firmness, & position Lochia: color, quantity, & clots Signs of bleeding from lacerations, episiotomy site, hematomas o Assess bladder for distention Insert indwelling cath to assess kidney function & obtain accurate measurement of urinary output o Maintain/initiate IV fluids w/ isotonic solutions (lactated Ringers or .9% NaCl), colloid volume expanders (albumin), and blood products o Provide O2 at 2-3 L per nasal cannula as prescribed to RBC sat o Monitor O2 sat o Elevate legs to 20-30 degree angle to venous return Uterine Stimulant Meds: o Oxytocin Promotes uterine ctxns Nurse should assess uterine tone & vag bleeding Monitor for adverse rxns of H2O intoxication (lightheadedness, n/v, HA, & malaise). These rxns can progress to cerebral edema w/ seizures, coma, & death o Methylergonovine (Methergine) Controls postpartum hemorrhage Nurse should assess uterine tone & vag bleeding.

23 Dont admin to clients w/ hypertension Monitor for adverse rxns: hypertension, n/v, HA o Misoprostol (Cytotec) Controls postpartum hemorrhage Nurse should assess uterine tone & vag bleeding o Carboprost tromethamine (Hemabate) Controls postpartum hemorrhage Assess uterine tone & vag bleeding Monitor for adverse rxns: fever, chills, HA, n/v, diarrhea Client education & Outcomes o Provide d/c instructions: Limit physical activity to conserve strength iron & protein intake to rebuild RBC volume o Outcomes: Vaginal bleeding will be controlled w/ employed interventions Vitals & lab results WNL No complications or injury r/t postpartum hemorrhage

Dilation & curettage (D&C): performed by PCP to remove retained placental fragments if indicated Infections Mastitis: infection of breast involving interlobular connective tissue; usually unilateral o May progress to abscess if untreated o Most commonly occurs in first time breastfeeding mothers & well after establishment of milk flow, which is usually 2-4 wks after delivery o Staphylococcus aureus is usually the infecting organism o Risk Factors: Milk stasis from blocked duct Nipple trauma, cracked/fissured nipples Poor technique w/ improper latching of infant onto breast breast feeding frequency due to supplementation w/ bottle Poor hygiene, inadequate hand hygiene b/t handling perineal pads & breasts o Client education: Hand hygiene prior to breastfreeding Maintain cleanliness of breasts w/ frequent changes of breast pads Allow nipples to air dry How to completely empty breasts Use ice packs/warm packs Continue breastfeeding frequently (at least q 2-4hr), especially on affected side. Manually express milk or use a breast pump if too painful Being breastfeeding on unaffected breast first to initiate the letdown reflex in the affected breast that is distended or tender

24 Rest, analgesics, fluid intake of at least 3,000 ml/day Report redness & fever Well-fitting bra Antibiotics; complete entire prescription The immediate postpartum period following birth is a time of risk for all women for microorganisms entering the reproductive tract & migrating into blood & other parts of the body, which could result in septicemia o Risk Factors Cervical dilation: provides uterus w/ exposure to external environment Well-supplied exposed blood vessels Wounds from lacerations, incisions, hematomas Alkalinity of amniotic fluid, blood, & lochia during pregnancy & early postpartum period, decreasing the acidity of the vagina Risk Factors for Endometritis: o C-section o Retained placental fragments & manual extraction of placenta o Prolonged labor o Prolonged rupture of membranes o Chorioamnionitis o Internal fetal/uterine pressure monitoring o Multiple vag exams after ROM o Postpartum hemorrhage

Newborn Assessment APGAR: done immediately following birth to rule out abn. Completed at 1 & 5 mins of life. Allows nurse to rapidly assess extrauterine adaptation & intervene w/ appropriate nursing actions 0 Absent Absent Flaccid None Blue, pale 1 < 100 Slow, weak cry Some flexion Grimace Pink body, cyanotic hands & feet (acrocyanosis) 0-3 4-6 7-10 Quick initial assessment by nurse: o External assessment: Severe distress Moderate distress No distress 2 100 Good Cry Well-flexed Cry Completely pink

Score Heart rate Respiratory Rate Muscle Tone Reflex Irritability Color

25 Chest: Skin color Peeling Birthmarks Foot creases Breast tissue Nasal patency Meconium staining

PMI location Respirations for Ease of breathing crackles, wheezes Auscultation for HR & Equality of bilateral quality breath sounds o Abdomen: Rounded abdomen Umbilical cord for 1 vein & 2 arteries o Neurologic: Muscle tone Fontanels: fullness or Reflex rxn (Moro) bulge Palpation of sutures o Other observations: inspection for gross structural malformations Gestational age assessment: o Performed w/in 2-12 hr of birth o Neonatal morbidity & mortality are r/t GA & birth weight o Involves measurements of newborn & New Ballard Scale o Normal Ranges: Weight: 2,500-4,000 g Length: 45-55 cm (1822 in) Head: 32-36.8 cm (12.6 Chest: 30-33 cm (12-13 14.5 in) in) o New Ballard Scale: newborn maturity rating scale that assesses neuromuscular & physical maturity. See images below. 6 ranges of development Totals: maturity rating in weeks gestation (a score of 35= 38 wks gestation)

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Following physical assessment, classification by GA & birth weight is determined: o Appropriate for gestational age (AGA) Weight b/t 10th & 90th percentile o Small for GA (SGA) Weight < 10th percentile o Large for GA (LGA) Weight > 90th percentile o Low birth weight (LBW) Weight 2,500 at birth o IUGR: growth rate doesnt meet expected norms o Term: Birth beginning of week 38 & prior to end of 42 wks o Preterm/Premature: Born prior to completion of 37 weeks o Posterm: Born after completion of 42 weeks o Postmature: Born after completion of 42 wks gestation w/ signs of placental insufficiency