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NURSING222LECTURENOTES TOPIC PAGE 2 10 34 41 53 69 88 107 129 140 158 168 190

Lecture1 Lecture2 Lecture3

IntroductiontoMaternityNursing UncomplicatedLabor&Delivery Analgesia&Anesthesia

Lecture4 Lecture5

NursingintheNormalPuerperium NursingCareoftheNormalNewborn HighRiskNewborn

Lecture6 Lecture7

UncomplicatedPregnancy

Lecture8 Lecture9 Lecture10 Lecture11 Lecture12 Lecture13

FetalAssessment&PregnancyatRisk PregnancyatRisk#2

ComplicationsofLabor&Delivery ComplicationsofthePuerperium

DisordersoftheFemale&MaleReproductive System Infertility&Genetics

CSM Maternity Nursing Lecture 1 I. Intro to Maternity Nursing A. Role of the Perinatal Nurse
I. The Registered Nurse a. Scope of nursing practice determined by: -Calif State Nursing Practice Act-BRN -Community standards -Policy and Procedure of facility -JCAHO-Joint Commission on Accreditation of Healthcare Organizations -Dept. of Health Services Nurses held legally responsible for practicing within scope of practice Specialty Organization: AWHONN -Association of Womens Health, Obstetrics, and Neonatal Nurses Orientation Period/Specialization -Labor and Delivery -Nursery/Level II Nsy/NICU -Postpartum/Mother-Baby- since 1990s -Occasional problems with comprehensive care-territorial -Differences in opinions lead to pt confusion

b. c.

d.

II.

Expanding roles in Perinatal Nurses a. Nurse Practitioners -Defined by ANA as: provide comprehensive health assessments, determine diagnoses plan/prescribe treatment manage healthcare regimens for the individual, families, and the community -In 1960s, shortage of MDs lead to 1

2 creation of the RNP -May provide family care or specialize -Take part in a certificate program or Masters Degree program -Need at certification for third-party reimbursement -Requires documentation of continued education and practice b. Clinical Nurse Specialists -Defined by ANA: Clinical expert who provides direct pt care services --health assessments --health promotion --preventative interventions -MSN -Expertise in planning, supervising, and delivery of nursing care to families in childbearing period -Case managers -Consultant -Family and staff educator -Coordination of delivery of nursing care to families requiring intensive nursing support -Research activities/articles -May work specifically with high risk pts -Traditionally worked in hospitals but now found in nursing homes, schools, home care settings and hospice. Certified Nurse Midwife -Defined by ACNM: independent management of womens health care especially R/T pregnancy, childbirth, PP period, and care of the newborn -Graduate from a certificate or MSN program -Also provide family planning services, other gynecological needs, and peri/ postmenopausal care -One of the oldest professions -1925-Mary Breckenridge establishes 2

c.

3 Frontier Nursing Services-first NurseMidwife to practice in the US -American College of Nurse Midwives was incorporated in 1955 -provide care to women with low incomes, uninsured, and minorities who dont seek out regular health care -lower rates of cesarean sections in facilities where CNMs practice d. Certified Nurse Anesthetists -Defined by AANA: provide --pre-anesthetic assessment --develop and implement plan of care --perform general, regional, local, and sedative anesthesia --manage pts airway/pulmonary status --facilitate emergence/recovery from anesthesia --provide follow-up evaluation and care --respond to emergency situations to asst with ACLS, airway, medications -Minimum 24 month programs/MSN with --45 hrs professional aspects --135 hrs anatomy/physiology/ pathophysiology --45 hrs chemistry --90 hrs anesthetic principles --45 hrs clinical/literature review --knowledge of at least 450 anesthetics -80 % practice in an anesthesia care team -20 % practice independent at solo providers Nurse Consultants -experts in a specific area of nursing -fee for service -may act as expert witnesses -used by corporations R/T developing products/equipment -consult to texts, electronic media, and periodicals 3

e.

B.

Legal and Ethical Issues


I. a.

Litigious nature of this specialty number of malpractice cases involving childbirth issues -OB/Gyn cases 2nd only to surgeries Minimum standard of care: -care that a reasonable, prudent nurse would provide in the same or similar circumstances Predominant theory of Liability-negligence -4 elements duty exists breech of duty-standard of care violated injury connection between violation of the standard and the injury Malpractice lawsuits are based on the assumption that the health care provider failed to meet the professional standard of care and resulted in injury Alleged injury to fetus, neonate, or mother Families expecting a healthy child-bad outcome means mistake must have been made Attribute problem to one or more members of the health care team -frequent unavailability of physician -time frame to communicate may be short To support expert opinion, need evidence: -hospital procedures -nursing policies -guidelines established by professional organizations -state nurse practice acts -JCAHO

b.

c.

d.

e. f.

g.

h.

5 II. Informed Consent a. Process by which a pt decides to have a certain medical or surgical procedure -includes knowing and understanding what health care treatment is being undertaken More than just signing a form Process by which the physician, nurse, and possibly other health care professionals convey to pt the information for them to decide whether or not to proceed with the course of tx Without proper consent, provider could be the subject of a lawsuit alleging assault, battery, negligence , or a combination of actions types of consent: -expressed-oral or written -implied: nurse states here to draw blood and the pt extends her arm --may be used in emergency cases --when pt continues to take tx without objection --during surgery, additional surgery is indicated Informed refusal -can take place at initiation of tx or any time after start of tx -refusal is valid even after informed consent is given -refusal must be voluntary, uncoerced, and not made under fraudulent circumstances -pt must refuse tx with knowledge and understanding of the refusal -chart should include signed refusal form by pt and nursing notes should include time left, left with whom, risks and consequences of no further tx, and who will be notified

b. c.

d.

f.

g.

6 III. Common Legal Pitfalls a. b. #1 allegation: birth of neurologically-impaired infant reporting/recording errors: -incomplete initial H & P -failure to observe & take appropriate action -failure to communicate changes in a pts condition in a timely manner -incomplete and/or inadequate documentation -failure to use or interpret fetal monitoring appropriately -inappropriate pitocin monitoring/usage -improper sponge/instrument count almost of OB/Gyns have been sued -most cases will not go trial but be settled out of court 30% have had 3 or more law suits rising costs of liability insurance demands for accountability created by expanding the scope of practices cost containments -shorter hospital stays -use of unlicensed asst personnel -decrease in hospital staff changes in technology mean needed continued education: EFM

c.

d. e. f. g.

h. IV.

Standards of Care a. b. Standardized procedures/policies supervision of unlicensed asst. personnel KNOW your facilitys Scope of Practice

VI.

Ethical Dilemmas Unique to Perinatal Nursing a. b. fetal research-laws vary by state fetal surgery -i.e.: bilateral hydronephrosis, congenital diaphragmatic hernia -what if mother refuses tx abortion-Roe vs. Wade (1973) -morning-after pill Plan B-levonorgestrel -lack of estrogen nausea -medical abortion US: mifepristone + misoprostol France: RU-486 artificial insemination -AIH-husbands sperm-problem with mother -AID-donor sperm -legal problems-donor relinquishes rights surrogate childbirth -buying a child-$$$$ -biological mother may refuse to give up the newborn ART-Asst. Reproductive Technology -IVF-ET -GIFT, ZIFT embryonic stem cell research/cord blood banking

c.

d.

e.

f.

g.

8 h. The Neonate -iatrogenic procedures prolonged use of ventilators O2 therapy -problem: should we save the lives of infants only to have them lead lives of pain, disability, and deprivation? -who decides if major intervention is used -what kind of care do you give or deny the infant to allow him to die with dignity and comfort The Mother -use life support in irreversible conditions?

i. V.

Nursing Role a. Communication -interactions between MDs, CNMs, & nurses -was a clear line of communication used -was the chain of command followed -was there informed consent -the better the communication between nurse and pt, less use of litigation -earlier discharges home mean more educational responsibilities for the RN Use of EFM -first introduced at Yale University in 1958 -In last 25 yrs of use, no in rate of CP -is partially responsible for in C/S rate -ordinary part of Intrapartum careconstant threat of legal action

b.

C.

(Review books)

Review of Conception/Fetal Development

01/13

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Uncomplicated Labor and Delivery Lecture 2 (2 days) I. Physiological effects of the birth process A. Maternal response 1. CV a. During U/C-300-500 ml blood from uterus to vascular system b. Increase in cardiac output 10-15% Stage I 30-50% Stage II c. Blood pressure changes 1. blood flow in the uterine artery during contractions and is redirected to the peripheral vessels 2. peripheral resistance occurs with an in BP and of pulse 3. Stage I- 30 mm Hg systolic 25 mm Hg diastolic 4. Stage II- BP further 5. Supine hypotension-risk factors multifetal, hydramnios, obesity, dehydration, hypovolemia d. WBCs 25-30,000 mm secondary to stress, trauma e. hematopoietic 1. desire Hgb at least 11 g/dl Hct 33% or higher 2. plasma fibrinogen blood coag time clotting factors to protect against hemorrhage but risk for thrombophlebitis (inflammation of vein in conjunction with formation of a thrombus (blood clot of a vessel or a cavity in the heart)

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2.

Fluids/electrolytes a. Diaphoresis, insensible water loss through respirations, NPO status, and temp b. Voiding may be difficult r/t anesthesia or Pressure from presenting part- sensation of a full bladder c. Proteinuria- in amino acids may exceed capacity of renal tubules to absorb -may be renal damage caused by vasospasms of tubules GI a. b. Fluids at tolerated r/t GI motility and absorption with delay in stomach emptying N & V with diarrhea in labor

3.

4.

Respiratory a. O2 consumption, in resp. rate b. hyperventilation respiratory alkalosis in pH, hypoxia, hypocapnia (CO2) c. 2nd Stage-O2 consumption metabolic acidosis uncompensated by resp. alkalosis Muscular/skeletal a. Fatigue of muscles/strain b. Separation of pubis symphysis -May be related to pregnancy or delivery process (relaxin-polypeptide hormone-secreted in corpus luteum during pregnancy-can relax the symphysis, inhibit uterine contractions, and softens the cervix) c. Breakdown of proteins may lead to proteinuria-albumnin in the urine

5.

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6.

Neurological a. Euphoria-believe it or not! endorphins- pain threshold and produce sedation b. anxiety c. partial to total amnesia in 2nd stage Integumentary a. diaphoresis b. temperature-may be R/T to maternal efforts or infection c. exacerbation of pruritusmay be related to cholestasis (arrest of the flow of bile) in pregnancy

7.

B.

Fetal Response 1. CV a. in fetal heart rate (FHR) -maternal hydration N&V maternal temp insensible water loss -maternal position -medications to mother -placental issues post dates-calcifications smoker/ BP- placental size velamentous insertion (umbilical cord attached to the membrane a short distance from the placenta cord compresson -maternal anxiety

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2.

Pulmonary a. thoracic cavity squeezed -not as much in C/S cases -precipitous deliveries (swift progression of 2nd stage of labor marked by rapid descent/expulsion of the fetus) -may need extra suction b. passing of meconium (1st feces of neonate) may need resuscitation effort Catecholamines a. epinephrine & norepinephrine-active amines (nitrogen-containing organic compounds) -have effect on CV, neuro, metabolic rate, temp., and smooth muscle b. change R/T stress of labor speed clearance of fluid

3.

II.

Essential Components of the Birth Process A. Passageway 1. maternal pelvis a. 4 bones -2 innominate (nameless) bones -made up of 3 bones -ilium-iliac crest -ischium-ischial tuberosity -spines-shortest diameter -pubis-symphysis pubis -the sacrum -the coccyx b. False pelvis-the upper pelvis -portion above the inlet

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c.

True pelvis -inlet -diagonal conjugate-lower border of symphysis pubis-sacral promontory -usually 12.5 cm or greater -obstetric conjugate- also called anterior/posterior diameter -measurement that determines whether presenting part can engage superior strait -usually 1.5-2 cm less than diagonal -midpelvis-cavity, midplane -transverse diameter-interspinous diameter-10.5 cm -outlet -transverse diameter-intertuberous diameter-> 8 cm

2.

Pelvic shapes a. gynecoid-round -50% of women -most favorable -usual mode of birth-vaginal b. android-heart shaped -23% of women -usual mode of birth-cesarean possible forceps-difficult c. anthropoid-oval shaped -24% of women -usual mode of birth-vaginal spontaneous or asst. -may lead to OP position d. platypelloid-flat shaped -3% of women -not favorable for vaginal delivery

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B.

Passenger 1. Fetal skull a. made up of 6 bones -frontal -2 parietal -2 temporal -occipital b. not fused together-allow for molding, overlapping of bones to pass thru pelvis c. sutures-membranes -frontal -sagittal -lambdoidal -coronal d. fontanels-where membranes intersect -anterior (bregma)-diamond-shaped-2cm by 3 cm -closes by 18 months -posterior-triangle-shaped-1cm by 2 cm -closes by 8-12 weeks e. landmarks -mentum-chin -sinciput-brow -vertex-between anterior/posterior fontanel -occiput-beneath the posterior fontanel 2. Fetal Presentation a. fetal part entering the pelvis first -cephalic (head)-96% -breech (buttock)-3% -transverse (shoulder)-1% b. factors that influence presentation -fetal lie -fetal attitude -extension/flexion of fetal head

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c. d.

diagnosed using -Leopolds maneuvers -verify with ultrasound external version-MD attempts to manually rotate the fetus into a cephalic presentation -done in L &D -ultrasound to check fetal/placental position -may use medications to relax uterine muscle -frequently uncomfortable for mother

3.

Fetal Lie a. relationship of long axis (spine) of fetus to long axis (spine) of mother b. primary lies: -longitudinal (vertical)-cephalic, breech -transverse (horizontal or oblique)-shoulder Fetal Attitude a. relationship of fetal parts to one another b. general flexion -back is rounded -chin flexed onto chest -thighs flexed on the abdomen -legs flexed at the knees -arms crossed over the thorax -umbilical cord lies between arms/legs c. head flexion -biparietal diameter-9.25 cm -suboccipitobregmatic-9.5 cm -occipitofrontal-12 cm -occipitomental-13.5 cm

4.

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5.

Fetal position a. relationship of presenting fetal part to 4 quadrants of maternal pelvis b. indicated using a 3-letter abbreviation -1st letter-location of part in pelvis (R or L) -2nd letter-presenting part of fetus (O,S,M) -3rd letter-location of presenting part in relationship to maternal pelvis (A,P,T) Station a. relationship of presenting fetal part to an imaginary line at the maternal ischial spines: 0 station is at the spines b. negative stations-higher in the pelvis c. positive stations-lower in the pelvis

6.

C.

Powers 1. Primary Powers a. involuntary uterine contractions -start at fundus-thickened uterine muscle layer of upper uterine segment -upper segment thicker so more active -lower segment has less muscle -contractions move down muscle in waves -assessed by: reports from mother RN palpating fundus monitor b. primarily responsible for dilation of cx and descent of fetus -drawing upward of the musculofibrous components of the cervix with fetal head compression lead to dilation (opening) -full dilation (10 cm) marks the end of

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c.

d.

e.

the first stage of labor effacement (thinning) -cx usually 3 cm long, 1 cm thick -taken up by shortening of uterine muscle bundles -usually expressed in % uterine contractions -3 phases-increment, acme, decrement -involuntary, rhythmic, intermittent -frequency-beginning of one to the beginning of the next -regularity-usually start irregular then becomes more regular as labor progresses -duration-start to end of contraction -intensity-mild, moderate, strong or strength can be measured with internal monitor (IUPC) with resting tone usually 15-25 mm Fergusons reflex -presenting fetal part reaches perineal floor -mechanical stretching of cervix occurs -stretch receptors in vagina trigger exogenous (originating outside an organ) oxytocin release -triggers maternal urge to bear down

2.

Secondary Powers a. bearing down effort at 10 cm -contraction of diaphragm and abdominal muscles while pushing b. intraabdominal pressure that compresses uterus on all sides c. usually no effect on dilation-important R/T expulsion of fetus and placenta d. better results when await maternal need

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10

e.

f.

to bear down rather than start pushing at 10 cm debate over how to push -valsalva-closed glottis, prolonged push -open glottis pushing -mini pushes prolonged pushing efforts can lead to fetal hypoxia/acidosis and severe maternal perineal lacerations

D.

Placenta 1. Structure a. formed at implantation b. decidua (endometrium during pregnancy) basalis-with the chorion (extraembryonic membrane) forms the placenta c. cotyledon-mass of villi on the chorionic surface of the placenta -15-20 in number d. structure is completed by 12 week e. breaks may occur in placental membrane allowing mixing of maternal and fetal blood-Rh sensitization f. position problems -previa-implanted in lower uterine segment-covers internal cx os -abruptio-separation of placenta from uterine wall -accreta-cotyledons invaded uterine musculature -increta-invasion into the myometrium -percreta-invasion to the serosa of the peritoneum covering of the uterus can lead to uterine rupture

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g.

umbilical cord insertion problems -battledore-insertion into the margin of the placenta-resembles a paddle -velamentous-attached to membrane a short distance to placenta

2.

Function a. endocrine gland-produces hormones to maintain pregnancy -hCG-human chorionic gonadotropin -basis for pregnancy test -preserves function of corpus luteum -ensures continued supply of estrogen/progesterone -reaches max level at 50-70 days -hPL-human placental lactogen -similar to growth hormone -stimulates maternal metabolism - resistance to insulin and facilitates glucose transport across placental membrane (GDM?) -estrogen (estriol) -stimulates uterine growth -stimulates uteroplacental blood flow -progesterone -maintains endometrium -decreases contractility of uterus -stimulates development of breast alveoli and maternal metabolism metabolic functions b. -respiration -nutrition -excretion -storage

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c.

factors which could effect function -smoking -drug use -poor nutrition - BP -maternal position -infection -trauma

E.

Psyche 1. Factors influencing womans reaction to physical/emotional crisis of labor a. accomplishment of tasks of pregnancy b. usual coping mechanisms in response to stress c. support system-esp. partners commitment d. preparation for childbirth e. cultural/religious influences f. social/economic responsibility 2. Factors associated with birth experience a. motivation for pregnancy b. attendance at childbirth classes c. sense of competency/mastery d. self-confidence/self-esteem e. + relationship with partner f. maintaining control during labor g. support during the delivery h. not being left alone i. trust in staff-medical and nursing j. pain management k. length of labor process-exhaustion, anxiety, for medical interventions

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F. III.

Position (maternal)-See book

Labor Physiology A. Labor Onset Theories 1. Oxytocin Stimulation Theory a. stretching of cervical os causes in exogenous oxytocin b. produced by posterior pituitary c. oxytocin stimulates smooth uterine muscle contractions d. response to oxytocin as nears term 2. Estrogen Stimulation Theory a. estrogen stimulates smooth uterine muscle to contract b. as approaches term, estrogen, progesterone (prog. keeps estrogen in check) c. promotes prostaglandin synthesis (also stimulates muscle) Progesterone Withdrawal Theory a. usually relaxes muscle b. at term- in effectiveness Fetal Cortisol Theory a. at term, fetus produces more cortisol b. cortisol-(adrenocorticcal hormone) -slows production of progesterone -stimulates prostaglandin precursors Uterine Distention Theory a. stretching uterine muscles causes irritability leading to contractions b. stimulates production of prostaglandins

3.

4.

5.

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Prostaglandins a. stimulate smooth muscle to contract b. can have production stimulated by various methods - synthesis of PGE2 in amnion c. research varies whether concentration of prostaglandins in amniotic fluid and maternal blood just before labor onset

B.

Signs of Labor 1. Braxton-Hicks contractions a. 4-6 weeks before onset of labor b. uterine muscle workout before labor c. may be strong and frequent but usually are irregular in pattern 2. Lightening a. fetal descent into the true pelvis b. 2-3 weeks in primigravidas closer to onset of labor in multiparas c. easier to breathe, need to void Cervical and vaginal changes a. cervix ripens (softens) and may begin to dilate and efface b. vaginal mucus with mucus plug being released 1hr, 1day, or even 1 week before start of labor c. occasionally bloody show noted with dark brown or light pink-tinged mucus noted Persistent low back ache a. R/T relaxation of pelvic joint and descent of fetus b. change of position, warm packs, and warm showers/baths help

3.

4.

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5.

Weight Loss a. R/T GI upset with N & V and diarrhea b. usually starts 1-2 days before onset Nesting a. have a burst of energy b. have a need to get everything in order for arrival of baby

6.

C.

True vs. False Labor True False Uterine contractions regular irregular close together stronger with walking felt in low back then radiates to abdomen not stopped by bath or fluid Cervix softens, effaces, dilates Fetus starts descent into pelvis vary milder with walking felt in back or pelvis with relaxation techniques no significant changes no change in position

D.

Effacement, dilation, and station 1. Effacement a. thinning of cervix (shortening from usual length of 2-3 cm) b. documented either in %s or cms

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2.

Dilatation a. opening of cervical os from closed to 10 cm b. due to retraction of cervix into the lower uterine segment R/T uterine contractions and pressure from amniotic sac and fetus c. both dilation and effacement are measured by fingertip palpation or visual inspection with sterile speculum Station a. using imaginary line at ischial spines, note location of presenting fetal part b. documented from 4 to +4 c. ballottable-when presenting part is floating in and out of the pelvis

3.

E.

Stages and Phases of Labor 1. Prodromal phase a. strong regular contractions without cervical change b. leads to exhaustion R/t inability to sleep c. may need oral/IM medication for rest 2. Stage 1 (0-10 cm)-has 3 phases a. Early/Latent phase-0-3 cm, 50-90%, -3to -1 -able to walk and talk -able to eat light meals -may be home for most of this phase -involves more cx effacement and less change in fetal position -U/Cs may be 2-10 minutes apart -U/Cs mild by palpation -lasts an average 8 hours for primips -multiparas may have cx dilate to 3 cm days prior to onset of labor

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b.

c.

-ROM may occur during this time Active phase-4cm-7cm, 80-100%, -2 to 0 -U/Cs every 3-5 minutes, moderate by palpation -U/Cs last approx 60 sec -may start to have nausea/vomiting -may ask for enema if impacted to speed descent of fetus -may ask for pain medications -provider may decide to AROM to help speed labor -expect cx to change 1cm every 1-1.5 hrs Transition phase-8-10 cm, 100%, -1 to +1 -U/Cs every 1-3 minutes with intensity -U/Cs last 45-90 sec long -using breathing techniques not to push too early -may ask for more pain medication -shortest phase-usually 15 min-3 hours with delays R/T medications/infections

3.

Stage 2-10 cm (pushing) to delivery of neonate a. nulliparas-2 hours on average-no epid. 3-4 hours with epidural b. multiparas-15 min-1 hour without epid. 1-2 hours with epidural Stage 3-birth of neonate to expulsion of Placenta a. usually lasts 20 minutes to 1 hour b. if retained, MD will need to manually remove-consider pain meds for mom Stage 4-Recovery a. mom-1-4 hours b. baby-6 hours

4.

5.

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F.

Mechanisms of Labor (Cardinal Movements) 1. Engagement and Descent-occurs r/t: a. pressure of amniotic fluid b. uterine pressure on the breech c. contractions of abdominal muscles d. extension/straightening of fetus 2. Flexion a. natural attitude of fetus b. fetal head flexes as it meets resistance Internal Rotation a. to go thru transverse diameter b. rotates to occiput anterior Extension a. resistance of pelvic floor with vulva opening forward and anterior b. fetal head begins to crown External Rotation a. shoulders rotate to anteroposterior b. fetal head rotates further to one side Expulsion a. anterior shoulder slips under symphysis pubis b. posterior shoulder and body is then delivered

3.

4.

5.

6.

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G.

Labor Duration 1. Nulliparas a. 1st stage-13 hours (1.2 cm/hr) b. 2nd stage-5 minutes-2 hours c. 3rd stage-10-20 minutes 2. Primi/multiparas a. 1st stage-7 hours (1.5 cm/hr) b. 2nd stage-5 minutes to 1 hour c. 3rd stage-5-20 minutes

IV.

Plan of Care A. Assessment-Data Collection 1. prenatal record a. assess attendance to PN appts b. any complications of pregnancy c. any high risk behaviors d. abnormal lab/ultrasound reports 1. blood type/RH factor 2. VDRL/RPR-syphilis screen 3. HbsAG-surface antigen 4. CBC 5. Rubella immunity 6. culture for GBS 7. urinalysis 8. HIV test e. primary language 2. initial interview a. ask why she came in b. status of BOW c. any U/Cs? d. any bleeding? e. + FM recently? f. any other symptoms?

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3.

physical exam a. maternal vital signs b. FHR tracing c. palpate strength of U/Cs d. assess fetal presentation e. assess cervical dilation/effacement lab reports/ultrasound results a. CBC b. PIH panel c. RBS (sure step or lab draw) d. ck fetal lie/AFI with ultrasound expressed psychosocial and cultural factors/needs a. history of sexual/physical abuse b. history of depression/suicide attempts c. social support -family near by -friends who can pitch in d. cultural/religious needs clinical evaluation of labor status a. sign consent forms b. CBC and urine test c. if ROM, ck nitrazine paper or ferning d. Leopolds maneuver e. vaginal exam f. ultrasound if needed g. head to toe assessment h. ck for med allergies i. ask about classes taken

4.

5.

6.

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B.

Nursing Diagnoses 1. Anxiety R/T labor and birthing process a. orient parents to unit b. explain admission protocol c. assess womans knowledge, experiences, and expectations of labor d. discuss progress of labor e. involve woman and partner in care decisions during labor 2. Pain R/T increasing frequency and intensity of contractions a. assess level of pain b. encourage support people to aid in comfort measures c. encourage use of relaxation techniques d. explain when and why analgesics may be used Risk for altered pattern of urinary elimination R/T sensory impairment secondary to labor a. palpate the bladder superior to symphysis b. encourage frequent voiding c. assist to BRP or use catheter prn Risk for fluid volume deficit R/T fluid intake and blood loss during birth a. monitor fluid loss b. administer oral/parenteral fluid prn c. monitor fundus for firmness d. administer medications to aid in contraction of uterus e. possible type and screen/cross match if transfusion needed

3.

4.

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5.

Impaired gas exchange R/T maternal BP, compression of umbilical cord a. keep mother off her back b. maintain adequate hydration c. oxygen via mask if O2 below 90% d. shut off pitocin e. possible need for amnioinfusion

C.

Interventions-Priority Setting 1. Vital signs a. notify provider if BP above 140/90 b. ck temp q 4 hrs if ROM 2. Fetal monitoring a. assess FHR at least once hourly in early phases b. may need continuous monitoring c. consider internal monitoring for poor tracing, lack of progress, or meconium Hydration/oxygenation a. encourage po fluids or start IV if N & V b. ck oxygen saturation if decels noted Comfort measures a. breathing/focal points/distractions -labor shakes are normal b. hydrotherapy/massage c. active listening R/T maternal behaviors -0-3 cm: anticipation, excitement -4-7 cm: seriousness, introspection -8-10 cm: irritable, fatigue, amnesia d. use of support people

3.

4.

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5.

Pain management a. showers/warm or cool packs b. massage c. oral medications d. IV or IM medications e. Epidurals 2nd stage interventions a. room prepped for delivery -warmer for neonate -delee suction if meconium present -possible need for Pedi -keep up NRP/BLS skills b. asst mother with a variety of positions while pushing -short pushes 6-7 seconds -consider open-glottis pushing -squatting can open the pelvis an addition inch c. assess need for addition oxygen R/T FHR tracing d. assess maternal VS and FHR tracings per hospital policies e. keep Provider aware of pts progress f. consider lessening epidural dose if pushing effort less than adequate g. provider should be in LDR before head is crowning to provide support for perineum h. clean perineum if requests by provider i. at delivery, asst partner with cutting of umbilical cord

6.

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7.

3rd and 4th stage interventions a. asst provider with lidocaine/suture if perineal/vaginal repair is needed -episiotomies: median or mediolateral -lacerations: 1st degree-skin, superficial 2nd degree-muscles of perineum 3rd degree-to anal sphincter muscle 4th degree-anterior rectal wall b. fundal rub post delivery of placenta -watch for trickle/spurt of blood and change in uterine shape to herald expulsion of placenta c. observe for need for pitocin/methergine d. promote bonding/breastfeeding even during repair e. ice pack to peri/VS q 15 min/pain meds f. prepare for possible trip to OR if placenta is retained ( 1 hr) g. immediate newborn care -dry off fluids, skin to skin, suction mucus -ck for 3-vessel cord -ck physical assessment/wt./length -APGAR score and infant ID tags

V. VI.

Electronic Fetal Monitoring-skills lab Related Pharmacology-medication administration cards

01/13

34

Analgesia and Anesthesia Lecture 3 I. Labor Pain A. Data Collection and Assessment 1. Ask patient comfort level and current pain level -0-10 scale or coping scale -comfort level is when they can participate in ADLs without the need of pain meds 2. Be aware of cultural differences in response to pain -Asian populations may not exhibit pain or ask for pain medications -Hispanic women may be very stoic until just before the delivery of the baby -Middle Eastern groups may be very vocal in requesting early use of medications for pain 3. Anxiety and fear of the unknown might heighten their level of pain 4. Previous experiences with childbirth or other painful procedures may lead to higher levels of concern about pain management needs 5. Attendance to childbirth classes may aid in the patients ability to cope through contractions B. First Stage 1. Early phase-0-3 cm a. nonpharmacological methods 1. focal points 2. massage/counterpressure 3. hydrotherapy/aromatherapy 4. music 5. breathing techniques 6. Transcutaneous Electrical Nerve Stimulation unit (TENS) 7. heat/cold packs 8. hypnosis 9. changing positions/walk/rocker

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2.

pain medications 1. should be discouraged as they could slow the labor process 2. usually orals: percocet vicodin/norco benadryl acetaminophen 3. occasionally IM: morphine with phenergan Active phase-4-7 cm a. may use many of the same non-medication choices as above b. when pain is more intense, usually requests IV medications for fast action -fentanyl -nubain -stadol c. may also request and receive an epidural at this stage in labor Transitional phase-8-10 cm a. may request epidural b. may want to be out of bed and push on toilet to relieve backache c. encourage position changes if possible d. short acting IV narcotics still ok but have Narcan available for infant resuscitation

b.

3.

C.

Second Stage 1. May continue pushing with epidural pump on if efforts are affective 2. May receive local anesthesia for repair of perineal laceration or episiotomy 3. If no epidural is in place, may receive a pudendal block which relieve pain in the vagina, vulva, and perineal regions

36

D.

Third Stage 1. If placenta is retained, may receive IV pain medications or be moved to OR for twilight sleep 2. For laceration/episiotomy repairs, use of local anesthetics or pudendal block (less common)

II.

Adverse Effects of Excessive Pain A. Physiological effects 1. Effect on cervical change-more in pain, less able to relax and let the labor progress 2. Tensing up against the pain leads to muscle and ligament strains in other parts of the body 3. May not keep properly hydrated and nourished R/T the intensity of the pain 4. Inability to relax back muscles and do deep breathing may lead to difficulty placing epidural catheter B. Psychological effects 1. I cant do it-ineffective pushing due to fear of pain 2. inability to make decisions R/T pain 3. may become hostile to staff/family R/T inability to cope

III.

Factors Influencing Perception of Discomfort A. Teens and Older Primigravidas B. Cultures/Religions C. Previous experiences with pain D. Support person E. Preparatory classes F. Fetal position-i.e.: OP presentation

37

IV.

Pertinent Nursing Diagnoses A. Pain R/T physiologic response to labor 1. assess patients knowledge of labor and relaxation techniques 2. encourage support people to aid in comfort measures 3. teach alternative non-pharmacological methods of pain relief 4. assess need to void/defecate 5. encouraging resting between U/Cs 6. keep pt. and family notified of labor progress 7. offer possible choices for pain medications if all other methods have been unsuccessful B. Other possible nursing diagnoses 1. Ineffective airway 2. Fluid volume deficit 3. Fetal oxygenation 4. Anxiety R/T pain 5. etc. (see others in book)

V.

Pharmacological Pain Management A. Considerations for the Pregnant Patient 1. What medications you give the mom you give the fetus 2. Maternal concerns that she wasnt strong enough to make it thru without pain meds 3. Need to taper dosage to the patient 4. If previous abuser of medications, will pain med even be effective 5. Cultural beliefs

38

B.

Analgesics, sedatives, and adjuncts 1. Sedatives may be given in early labor to aid With sleep and anxiety but can lead to a Slowing of the labor progress and noted respiratory depression in the patient along with vasomotor depression of both mom and fetus. 2. Analgesics a. can be systemic crossing the blood/brain barrier as well as the placental barrier b. IV is preferred over IM due to rapid onset but IM medications last longer c. narcotic compounds -Demerol-meperidine -Sublimaze-fentanyl -Stadol-butorphanol -Nubain-nalbuphine -respiratory depression -tachy/bradycardia d. analgesic potentiators -usually antiemetics (Phenergan, Vistaril) -decrease anxiety and apprehension -helps reduce the amount of narcotic needed for relief Anesthetics (Regional and General) 1. Local block a. usually used on perineal region b. 1% lidocaine used c. injected into skin and subcutaneous d. epinephrine may be added to intensify anesthetic and decrease bleeding 2. Pudendal block a. goal to anesthetize the pudendal nerve located near the ischial spines b. may decrease ability to bear down R/T lack of sensation c. doesnt provide pain relief for manual

C.

39

3.

extraction of placenta or uterine exploration Epidural block/PCEA a. needs IV bolus before insertion R/T maternal hypotension due to vasodilation b. done by CRNA or MD c. pt. awake for procedure/delivery d. pt. sitting up for placement e. after insertion, may need frequent position changes side to side to keep anesthetic level equal f. preferred block T10-S1 g. need Foley cath in bladder due to inability to feel when to void h. possibility of spinal headache if needle placement is not correct i. saturates pain receptors but not motor one j. may need to use Ephedrine (a vasopressor) if maternal BP k. usually a local anesthetic alone or mixed with a narcotic (fentanyl, etc.) l. may increase labor time and need for pitocin augmentation m. antiemetics, antipruritics, and narcotic antagonists should be handy to treat possible side effects of epidural n. as with any medication, be prepared for possible severe adverse reactions such as bronchospasms, sudden in BP, dyspnea, or convulsions-crash cart should be available on unit Spinal block a. local anesthetic into the L3, L4, or L5 interspacesubarachnoid space

4.

40

b. c. d.

e. e.

medication mixes with CSF-saturates pain and motor receptors used for cesarean sections risk of spinal headache due to leak of CSF-may need to remain supine post delivery, IV maintained, and possible blood patch IV bolus given prior to procedure R/T risk of maternal hypotension, CO, and placental perfusion maternal BP, pulse, resp. effort, and FHR are assessed every 5 minutes for the first 15-30 post injection

5.

General anesthesia a. while rarely used, may be needed for C/S if unable to access regional block or in emergency cases b. NPO, IV, oral sodium citrate before start c. RN may be asked to give cricoid pressure to aid anesthesiologist in tube placement d. normally recovered in PACU (recovery rm) so bonding with infant delayed e. higher risk of complications vs. regional blocks-mother unconscious during birth of infant f. as with all anesthesias used during C/S, wedge should be placed under moms R hip to displace uterus to the L g. besides C/S, general anesthesia may be needed during manual placenta removal or D & C

01/13

41

1 Nursing in the Normal Puerperium (the period of 42 days post childbirth and expulsion of the placenta) Lecture 4 I. Physiology of the puerperium A. Alterations in the body systems as a result of the birth process 1. Reproductive system a. involution of uterus-return to non-pregnant state-caused by contractions of uterine muscles (size of a grapefruit after 3rd stage) b. within 12 hours, fundus at U/U c. fundus descends 1-2 cm/24 hrs d. uterus not palpable after the 9th PP day e. in estrogen/progesterone=autolysis f. subinvolution-failure of uterus to return to non-pregnant state-usually involves retained POC or infection g. outer decidua sloughs off as lochia, inner layer becomes new endometrium h. oxytocin released from pituitary gland helps uterus to contract- with BF i. afterbirth pains in multiparas j. placental site regeneration complete at 6 wks k. change in lochia-rubra-1-3 days-bright red serosa-3-10 days-pink, brown alba-10 dys-2 wks-yellow, white l. cervix-bruised, soft, swollen-closes by 2 wks -external os-appears as jagged slit m. vagina-returns to prepregnancy state by 6-8 wks n. perineum-healing start by 2-3 wks, complete within 4-6 months -Red -Edema -Ecchymosis -Drainage -Approximation o. 6 months for return of pelvic musculature 2. Cardiovascular a. CO remains elevated for 2 weeks-12 wks before to prepregnancy values b. EBL 300-500 ml-vaginal birth 500-1000ml C/S

42

c.

d.

e.

f. g. 3.

blood volume increased by: -elimination of uteroplacental circulation -loss of placental endocrine function which removes stimulus for vasodilatation -mobilization of extravascular water stored Vital signs: -Temp- to 380 C/1004 F R/T dehydration -Pulse- 1st hr-return to pre-preg. 8-10 wks -Resp- by 8-10 wks -BP-may have orthostatic hypotension Hgb/Hct: -1st 72 hrs- loss of plasma volume compared to RBCs - in H & H by day 7 WBCs may to 25-30,000/mm3 Coag factors-hypercoagulable state may lead to possible thromboembolism

Gastrointestinal a. appetite b. no BM for 2-4 days post delivery -encourage ambulation -hydration -fiber -medications, i.e.: stool softeners c. tx hemorrhoids-ice packs, tucks, crm -no pr meds if 3rd-4th degree laceration d. Kegel exercises to strengthen pelvic floor Renal a. returns to normal function 1 month after birth -bladder tone returned by 5-7 days b. diuresis-from fluid retention, pitocin, etc c. excessive vaginal bleeding may be noted if bladder is allowed to get distended with urine Musculoskeletal a. joints stabilize 6-8 weeks post birth b. may have permanent increase in shoe size c. may have separation of symphysis pubis or rectus abdominis

4.

5.

43

6.

Integumentary a. chloasma (mask of pregnancy) usually fades by end of pregnancy b. hyperpigmentation of areolae and linea nigra may continue c. may note perfuse diaphoresis post delivery Endocrine a. Expulsion of placenta= in estrogen, cortisol progesterone, and hPL (hCS) [human placental lactogen/human chorionic somatomammotropin] -reverse diabetogenic effect-lower BS level b. if BF- prolactin levels for 6 weeks if bottle-fed- -usually means later ovulation in lactating women Psychosocial a. parents acceptance of infants needs and abilities b. need to learn cues, understand emotional states c. bonding-proximity, touch, voice, interaction d. identify infant as an individual yet part of the whole family e. mutuality-infants behaviors stimulate moms f. may feel attracted to alert, responsive infant and repelled by irritable, disinterested infant g. attachment occurs more readily with the infant whose temperament, social capabilities, appearance, and sex fit parents expectations h. need to assess mother-infant communication i. behaviors -entrainment-moving in time with adult speech -biorhythmicity-soothed by moms heartbeat -reciprocity-responds to cues -synchrony-mutually rewarding -engrossment-interest in baby by father

7.

8.

44

j.

k. l.

maternal adjustments -taking in-first 24 hrs-focus on self and basic need Dependent, passive -taking hold-last 10 days to several weeks-focus on care of baby and competent mothering-dependent -letting go-focus on forward movement of the family unit PP blues- 70% of women-mood swings, anger, depression, letdown, fatigue, insomnia, H/As, weepiness (resolves in 10-14 days) PP depression-7-30%-more severe syndrome -depression, feeling of failure overwhelming guilt, loneliness

II.

Nursing Process A. Data collection/Assessment 1. Vital signs 2. Fundus a. ck fundal location, tone, lochia b. have pt empty bladder before exam 3. Bladder a. assess for distention b. measure first voids until 500 ml (voided out) c. catheterize if needed 4. Perineum a. if repair done, assess site for intactness, edema, hematomas, redness, or drainage (REEDA) b. assess for presence of hemorrhoids 5. Breasts a. note if breast are filling-palpate b. note any redness, soreness, cracking of nipples B. Nursing Diagnoses 1. Risk for fluid volume deficit 2. Alteration in urinary elimination 3. Pain 4. Fatigue 5. Ineffective breast feeding 6. Situational low self-esteem 7. Anxiety due to lack of knowledge base 8. etc.

45

C.

Interventions 1. Safety a. infant ID bands b. orientation to unit c. staff picture IDs d. move infant in crib 2. Standard precautions a. wash hands before handling baby b. change linens c. proper hygiene d. use of squeeze bottle for peri care e. wiping front to back f. teach pt about fundal massage g. use of peppermint or running water to aid in voiding to prevent urinary retention h. use of ice packs for the first 12 hours post repair of peri then instruct on use of sitz bath i. squeeze buttocks together when sitting or rising from a chair to help keep repair intact j. wear good supportive bra k. use lanolin crm to prevent cracking of nipples l. warm packs before breast feeding, cool packs post m. walk as soon as possible-helps with gas pains n. take pain meds prn o. encourage rubella vaccine if non-immune pt should prevent getting pregnant for at least 4 weeks post vaccination p. Tdap-Pertussisq. rhogam given to Rh moms who had Rh+ babies

III.

Early Discharge A. Candidates and criteria 1. Newborns and Mothers Health Protection Act of 1996 a. 48 hours minimum post vaginal delivery b. 96 hours minimum post C/S c. pt and doctor may agree on earlier D/C 2. Maternal criteria for early D/C a. VSS b. voiding c. Hgb >10 d. no bleeding e. instructions on self-care

46

3.

Infant criteria for early D/C a. term infant b. VSS c. normal physical assessment d. at least 2 successful feedings e. at least 1 void and 1 defecation f. no jaundice g. circ site ok h. newborn blood/hearing screenings done i. follow-up in 1 week j. maternal/infant teaching cklist completed

IV.

Care of the Cesarean Birth Patient A. Assessment/Interventions 1. VS every 15 min X 1hour, 30 min X 1 hour, then per hospital protocol 2. monitor I & Os-need UO at least 30 ml/hr 3. assess abdominal dressing for drainage 4. assess need for pain medication 5. assess fundal location, tone, and lochia (still have 3 distinct lochia stages) 6. ambulate asap 7. assess for passage of gas-advance diet as tolerated 8. C & DB-may use inspirometer B. Nursing diagnoses 1. Fluid volume deficit 2. Pain 3. Risk for infection 4. Risk for injury 5. Anxiety R/T surgery, fetal well-being 6. Situational low self-esteem Possible post-op complications 1. CV-hemorrhage, shock, dvt 2. Pulm-embolus, pnemothorax 3. GI-paralytic ileus 4. GU-renal failure, hematuria, UTI, oliguria 5. Reprod-endometritis, emboli 6. Skin-wound infection, dehiscence

C.

47

V.

Care of the Lactating Woman A. Physiology of Lactation 1. Female breast has 15-20 lobes containing alveoli (the milk producing cells) 2. alveoliductuleslactiferous ductsnipple 3. estrogen & progesterone post delivery= prolactin levels which remain above baseline thru duration of lactation (highest level is at day 10) 4. Prolactin: -highest level at day 10 -is produced in response to infants sucking -promotes milk production by stimulating alveolar cells B. Other hormone changes/reflexes 1. Oxytocin responsible for let-down reflex nipple stimulationpituitary produces oxytocin makes cells around the alveoli contractsends milk to nipple 2. Nipple erection reflex infant cries or rubs against the breastnipple becomes erectpropulsion of milk Supply/demand 1. First milk called colostrum a. rich in immunoglobins b. higher concentration of protein and minerals to mature milk but less fat c. promotes growth of Lactobacillus bifides in GI 2. If infant is well nourished, will see 6-8 wet diapers and 3 stools in 24 hours at day 5 of breastfeeding 3. Incomplete emptying can lead to milk supply 4. watch for infant growth spurts -10 days -3 weeks -6 weeks -3 months -4.5-6 months Maternal nutrition/considerations 1. add addition 200-500 calories/dy while breastfeeding 2. drink 2-3 liters of fluid daily 3. continue on PN Vitamins and iron as directed

C.

D.

48

8 4. VI. watch for engorgement/plugged milk ducts/ sore nipple/monilial (yeast) infections/mastitis

Care of the Woman/Neonate Formula-fed A. Formula types 1. commercial formulas primarily cow-milk based but soy and other specialty formulas available 2. may be in powdered, concentrated, or ready to eat B. Common problems 1. positioning-need to make sure milk covers nipple area 2. warming-never microwave bottle 3. propping-dont leave infant unattended while feeding Nutritional requirements 1. first day-only give 7.5-15 ml formula at one time -their eyes are bigger than their stomachs 2. usually feed every 2-4 hours 3. some infants swallow air as they feed-burp them! 4. by 1 week of age, babies will be drinking 700-900 ml in 24 hours *bottle fed because-returning to work, +HIV, mastectomies, adopted infant, maternal medications

C.

VII.

Contraception Education A. Considerations for Choosing a Method 1. resumption of sexual activities should wait 2-3 weeks to decrease risk from infection 2. best to use condoms/foam at this time 3. when discussing contraception with your doctor, -action -safety -effectiveness -convenience -availability -expense -personal preference B. Methods (failure rates listed within 1st year of use) 1. Coitus interruptus (withdrawal) -action-prevents fertilization -safety-no protection from STIs -convenience/availability-good -expense-N/A

49

2.

Fertility awareness methods -periodic abstinence-no sex 4 days before and 4 days after ovulation -rhythm-based on 3-4 cycles-use shortest and longest -BBT-sl. temp before ovulation (0.050C) then 0.3-0.60C -cervical mucus-ck for changes-amt. and consistency -symptothermal-combo of BBT and cervical mucus -ovulation kits-detect surge in LH that occurs approx. 12-24 hours before ovulation Barrier methods a. spermicides -action-physical/chemical barrier to sperm -safety-may provide some protection from STIs -convenience-needs to placed before act -availability-good if thought of in advance -expense-cheap b. condoms -action-physical barrier to sperm -safety-protect against STIs/HIV if used properly -effectiveness-can failure rate with use of spermicides -vaginal sheath/condom c. diaphragm -action-mechanical barrier to sperm -safety-see condoms, small amt of cases with TSS-toxic shock syndrome -effectiveness-needs to be fitted to womans anatomy, needs to be used with spermicide -convenience-may be placed 6 hours before intercourse but must be left in for 6 hours post act, additional spermicide each time -availability-MD appt -expense-affordable d. cervical cap/sponges -cervical cap needs fitting -must ck position of cap before intercourse -failure rate in parous women-40% -sponge-moisten with water before insertion -have spermicide

3.

50

10 -risk of TSS if not removed after 24 hours 4. Hormones a. over 30 different formulations b. may have estrogen/progestin or only prog. c. may be oral, subdermal implantation, IM, vaginal d. prevent pregnancy by stopping ovulation or prevention of implantation e. do not protect against STIs f. not recommended for some women -h/o thromboembolic -smoker -h/o estrogen dependent tumors -h/o CAD -h/o impaired liver -over the age of 35 -HTN g. mini pill (progestin-only) -problems with irregular menses h. injectable progestin-Depo Provera -injected q 11-13 weeks-may need appt. - risk of venous thrombosis i. implanted progestin-Nexplanon -good for 3 years -implanted in arm -no STI protection j. Emergency contraception Plan B-levonorgestrel -needs to used within 72 hours of unprotected intercourse -prevents ovulation/implantation -90% effective -OTC-must be at least 17 years old to purchase Ella-non-hormonal -needs to used within 120 hours -needs Rx -90% effective IUD insertion -99% effective if inserted within 5-7 days

51

11

5.

Intrauterine Devices a. usually T-shaped b. loaded with either copper or levonorgestrel c. may be used for 5 yr (hormone)-10 yrs (copper) d. prevents fertilization e. Mirena (hormone IUD)-helps to diminish menses f. Copper T-good choice for women over 35, smokers, h/o CAD, HTN g. not recommended for women with: -h/o PID -suspected pregnancy -teens -h/o distorted uterine cavity -h/o multiple partners Sterilization a. females - bilateral tubal ligation -surgical procedure -expense usually higher than vasectomy -electrocoagulation, ligation, banded, crushed, or plugged -no protection against STIs -should be considered permanent -informed consent needed at least 72 hours before procedure -eSSURE -done in clinic or OR -uses water to visualize fallopian tube meatus -coil placed and tissue collects on coil creating a blockage -HSG performed at 3 months to establish closure -back-up BC method used during this period b. males-vasectomies -done in clinics under local anesthetic -vas deferens are ligated/cauterized -takes multiple ejaculations to clear remaining sperm from vas deferens

6.

52

12

BIRTH CONTROL COMPARISONS


FAILURE RATES MECHANISM OF ACTION STD USER

method of birth control No Method Spermicides Male Condoms Female Condoms Diaphragm Cervical FemCap
w/o prior pregnancy

perfect actual prevents prevents postpone protection continuation use use fertilization implantation sex rates 85 18 2 5 6 4 9 20 3 2.5 5 5 0.5 4 0.3 0.3 0.3 0.05 0.8 0.1 0 85 29 15 21 16 14 16 32 22 16 12 ++++ ++++ ++++ ++++ ++++ ++++ ++++ +++ +++ +++ + + + + + + + + + + ++ ++ ++++ ++++ 51 43 68 68 68 56 59 80 80 + ++ ++ + + + + 42 53 49 57 57 57 46 51 51

Sponge
w/o prior pregnancy

Sponge
w/ prior pregnancy

Ovulation Method Sympto-Thermal Standard Days Method Calendar Method Lactation (LAM) Withdrawal Ortho Evra Patch Nuva Ring Shot (DepoProvera) Shot (Lunelle) IUD (ParaGard Copper) IUD (Mirena) Abstinence

13-20 +++ 6 27 8 8 8 3 3 0.6 0.1 0 ++++ ++++ +++ +++ +++ +++ +++ ++ ++ ++++

Oral Contraceptives 0.3

For added protection against pregnancy, you can use more than one method of contraception at a time. For example, many clinicians recommend that when using condoms, spermicides be used as well. If a woman is allergic to spermicides she can use a natural method and a condom and for extra protection. Any of these combinations will reduce the predicted failure rate

53

1 Nursing Care of the Normal Newborn Lecture 5 I. Transition to extrauterine life A. Respiratory changes at birth 1. Development of the Lungs a. while a fetus, resp. tract produces fetal lung fluid that expands alveoli b. as term approaches, fluid starts to move to the interstitial spaces c. shift of fluid helps to pulmonary resistance to blood flow-present before birth and enhanced with breathing of air d. mature lung produces surfactant-no surfactant leads to alveoli collapsing with exhalation -sufficient surfactant by 34-36 weeks 2. Initiation of respiratory effort a. first breathes require greater pressure to open alveoli b. Chemical-carotid and aortic chemoreceptors respond to changes in blood chemistries: pH, pO2, pCO2stimulate respiratory ctr. in medulla c. Thermal-skin sensors respond to sudden change in temperature-impulses that stimulate resp. ctr. d. Mechanical-chest compression forces fluid out into upper airways-expelled with birth, pressure released, causes air into lungsalso helped with tactile stimulation, lights, noises Normal Respiratory Effort a. once alveoli opened, surfactant helps to keep them open b. circulatory and lymphatic systems absorb moved fetal lung fluid c. complete absorption of fluid by 24 hrs-delayed absorption noted in C/S deliveries d. after initial tachypnea, resp. rate is usually between 30-60 breaths/min-may be irregular Respiratory Distress-reverse of the above

3.

4.

54

B.

Cardiovascular transition 1. air inflates the lungs pulmonary vascular resistance pulmonary artery pressure in pressure in the R atrium pulmonary blood flow to L side of heart the pressure in the L atrium=functional closing of the foramen ovale (functionally closed-1-2 hrs, anatomically closed-30 months 2. in utero, fetal pO2 is 27 mm HGafter birth, pO2 to 50 mm Hg in the arterial bloodconstricture of the ductus arteriosusfunctional closure in 10-24 hrs -permanent closure in 3-4 weeks pulmonary blood vessels dilate in response to O2 fetal lung fluid moves into the interstitial spaces (any O2-ductus dilates, pulmonary vessels constrict) clamping of the umbilical cord closes the umbilical arteries, umbilical vein, and ductus venosus which convert into ligaments-fibrosis within 2 months

3.

4.

II.

Neurological adaptation A. Thermoregulation 1. newborns ability to produce heat is often = to adults but have a tendency towards rapid heat loss 2. heat loss from: thin skin, little sub Q fat, blood vessels close to surface, heat easily transferred from internal to skin 3x the body surface than adults=4x heat loss flexed position helps preserve heatproblem with premies is poor muscle tone leads to less flex evaporation-heat loss thru wet skin exposed to air -dry baby immediately at birth conduction-loss of heat from body surface to cooler surface in direct contact -warm blanket, skin-to-skin contact

3. 4. 5. 6.

55

3 7. 8. convection-heat transferred to cooler ambient air -keep out of drafts, wrap in blanket with hat on head radiation-transfer of heat to cooler object not in direct contact with infant -keep cribs away from outer windows Thermogeneis a. Nonshivering thermogenesis (NST) primarily thru brown fat ( highly vascular fat found only in infants with abundant supply of blood vessels/nerve endings, found at neck, kidneys, adrenals, sternum and intrascapulary region)heat produced by lipid metabolic activity warm baby (preterm infants lack brown fat) b. secondarily thru increased metabolic activity in liver, brain, and heart c. shivering begins when thermal receptors in skin detect a drop in the skin temp-rare in neonates cold stressa. metabolism = need for O2 and glucose regardless of gestational age or condition b. if prolonged-leads to resp. difficulty c. O2 consumption diverted from maintaining brain/heart function to thermogenesis d. decreased pulmonary perfusion may lead to an open ductus arteriosus e. hypoglycemia f. fatty acids released = metabolic acidosis g. fatty acids in blood can interfere with bilirubin transport = risk for jaundice

9.

10.

B.

Reflexes 1. Moro (startle) Usually present for first 3-4 months 2. Palmar, plantar grasp Fingers/toes curl around examiners fingers palmar lessens by 3-4 months plantar by 8 months

56

4 3. Tonic neck fencing position complete response gone by 3-4 months Sucking and rooting head turns towards stimulus and sucks

4. C.

Sensory adaptation 1. Vision a. at birth, muscles in eye area are immature (transient strabismus) b. clearest vision within 10-20 inches c. sensitive to light d. at 5 days old, attracted to black/white patterns e. able to see colors at 2 months f. tear glands developed by 2-8 weeks g. by 6 months, their visual acuity is of adults h. prefer patterns to plain surfaces i. eye color will not be set until 3-12 months 2. Hearing a. like an adults after draining of amniotic fluid b. loud sounds make baby have startle reflex c. decrease motor activity in presence of low frequency sounds such as a heartbeat d. hearing loss is a common major abnormality 1-3/1000 normal term infants have bilateral hearing loss Touch a. responses to touch on all parts of the body b. face, hands, soles being most sensitive Taste a. can distinguish tastes b. prefer glucose water to plain water Smell a. react to strong odors by turning head away b. can differentiate their mothers breast milk by smell

3.

4.

5.

57

5 III. Hematological adaptation A. Neonatal differences 1. RBCs and H & H a. at birth, levels are higher than adults -Hgb14-24 g/dl -Hct44-64% if > 65% = polycythemia -RBC5.1-5.3/mm3-1st 24-48 hrs of life (neonatal RBCs have a lower survival rate compared to adults)physiological anemia c. delay of cord clamping shifts plasma to extravascular spaces with lab results 2. Leukocytes a. WBC 9-30,000 per mm3 is normal at birth b. will rise then decline to a level of 11,500 c. infection not well tolerated in infants with sepsis usually accompanied by a loss in WBC Platelets a. 200,000-300,000/mm3 b. factors II, VII, IX, and X decreased due to lack of Vitamin K-not adult level until 9 months Blood Groups a. cord blood sample taken to determine infants blood group and Rh status b. Rh neg moms receive Rhogam if Rh + baby Blood Volume a. 80-85 ml/kg b. at birth, blood volume approx. 300 ml c. preterms have greater blood volume due to a greater plasma volume, not RBC mass Heart rate and BP a. HR averages at140 beats/min at birth b. rises just after birth c. full term infants HR between 120-160 bt/min d. PMI (point of maximal impulse) left chest (apical pulse) e. of heart murmurs heard at birth disappear by 6 months f. BP averages 50-80/35-50 mm Hg

3.

4.

5.

6.

58

6 IV. Musculoskeletal System A. Head and upper body 1. at birth, more cartilage than bone 2. 3. face looks small in relationship to skull R/T molding (overlapping of the skull bones) fontanelles a. anterior closes at 12-18 months b. posterior closes at 8-12 weeks c. bulging fontanelles mean ICP d. sunken fontanelles mean dehydration craniostenosis-contracted skull due to premature closure of the cranial sutures-need surgery Caput succedaneum a. edema of the scalp b. may cross suture lines c. disappears in 1-4 dys Cephalohematoma a. collection of blood between the skull bone and the periosteum-doesnt cross suture lines b. may be spontaneous or due to vacuum or forceps delivery c. resolves in 2-4 weeks d. may lead to jaundice neck/shoulders a. shoulder dystocia brachial plexus injury -fx of scapula or clavicle (clavicle is the most commonly fx bone during delivery process) -immobilize in a sling

4. 5.

6.

7.

B.

Extremities 1. arms a. Erbs palsy-injury to brachial plexus = paralysis of affected arm/shoulder -flaccid arm with absence Moro on affected side -immobilize arm but follow exercise regimen

59

7 2. hands a. polydactyl-extra fingers b. syndactyl-fused fingers c. simian crease found on palms (and soles of feet)frequently present in children with Downs hips a. b. c. d. 4. feet a. b. can have congenital hip dysplasia-head of the femur slips out of the acetabulum Ortolanis/Barlows maneuver-listen/feel for a click breech deliveries-higher risk may need to double or triple diaper poly/syndactyl club foot-positional or casted to help rotate

3.

C.

Activity and Muscle Tone 1. spontaneous, transient motor function -if flaccid, R/O any birth injuries 2. 3. transient tremors normal but if persistent, may be pathological watch for flexion and extension of all extremities

V.

Gastrointestinal A. Mouth/throat 1. mucous membranes of mouth moist and pink if adequately hydrated 2. 3. check for intactness of hard and soft palates may find Epsteins pearls-retention cysts-small white areas at gum margins and junction of palates -if area very hard to touch, question possible tooth (more common in some cultures) may note sucking blisters (calluses) sucking behavior is influenced by neuromuscular maturity, maternal medications at birth, and type of initial feeding

4. 5.

60

6. 7. 8. B.

infant unable to move food from lips to pharynxneed to place nipple deep inside mouth check for tongue-tied-may need frenulum cut peristaltic activity of esophagus is uncoordinated at birth

Stomach 1. capacity varies from 30-90 ml depending on size of infant 2. 3. 4. cardiac sphincter is immature-may have regurg gastric emptying times vary-effected by type of of feeding, temperature of food, volume can decrease regurg by avoiding overfeeding, burping after eating, and infant positioning

C.

Intestines 1. no bacteria in intestines at birth 2. 3. 4. 5. usually hear bowel sounds after 1 hour of life after birth, air and bacteria enter the orifices highest bacterial content in lower intestine normal colon bacteria established in 1st week which helps synthesize Vit. K, folate, and biotin

D.

Digestive Enzymes 1. full term newborns capable of swallowing, digesting, metabolizing, absorbing proteins and simple carbs, and emulsifying fats 2. 3. digestive enzymes necessary to digest simple CHO, proteins, and fats are present by 36-38 weeks amylase-not produced until 3 months-salivary glands 6 months-pancreas -unable to convert starch to maltose

61

4. E.

lipase-needed for digestion of fat-needs to be produced by pancreas

Stool patterns 1. meconium-first stools a. filled with amniotic fluid and its constituents, intestinal mucus (bilirubin), and cells b. greenish black-may have occult blood c. initially sterile then contains bacteria d. usually fully passed in 24 hours 2. 3. 4. # of stools vary-early feedings = sooner stool transitional stools-greenish brownyellowish brown thickthin, watery milk stools a. breastfed-yellow to golden, pasty, and odor like sour milk b. bottlefed-yellow-light brown, firmer, odorous

VI.

Hepatic System A. Liver function alterations 1. hepatic system responsible for a. maintenance of blood sugar b. iron storage c. drug metabolism d. bilirubin conjugation e. coagulation 2. glucose a. 1/3 of stores as glycogen in liver b. need constant supply for brain c. blood glucose levels stabilize at 50-60 mg/dl after delivery d. by day 3, 60-70 mg/dl e. initiation of feeding assist in stabilizing newborns glucose levels f. newborns increased energy needs in first 24 hours of life can rapidly deplete glycogen stores

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10 g. risk for hypoglycemia -LGAs-excess insulin uses up glucose -SGAs, premies-lack adequate brown fat and glycogen stores -traumatic deliveries -asphyxia s/s of hypoglycemia -jitteriness -respiratory distress tx of hypoglycemia -feedings -IV therapy

h. i.

3.

iron storage a. fetal liver begins storing iron in utero b. proportional to total body Hgb content and gestation age c. at birth, have enough iron stored for 4-6 months coagulation a. coag factors synthesized in liverVit. K b. transient blood coagulation deficiency days 2-5 c. Vit. K injection helps prevent clotting problems d. prenatal dilatin/phenobarbabnormal clotting conjugation of bilirubin a. bilirubin-yellow pigment derived from Hgb released with breakdown of RBCs/myoglobin b. Hgb is converted to bilirubin in unconjugated form (non-excretable form)-potential toxin c. unconjugated bilirubin-insoluble, bound to circulating albumin-can permeate to other areas (also called indirect bilirubin) d. in the liverenzyme glucuronyl transferase conjugates bilirubin (now called direct bili) -soluble, excreted from liver cellsbile e. excreted thru urine and feces f. total bili is the sum of both levels of conjugated and unconjugated bili g. factors that bili -excess production of RBCs -RBCs life shorter-more breakdown -liver immature -poor/delayed feedings-breastfeeding jaundice

4.

5.

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11 -traumatic delivery -fatty acids-bind with albumin instead of bili B. Hyperbilirubinemia/physiological jaundice 1. Occurs 50% in full terms, 80% in premies 2. incidence is increased in certain nationalities a. Asians b. Native Americans c. Eskimos neonatal jaundice is considered benign unless levels lead to pathological conditions its physiological jaundice if: a. infant is well b. jaundice appears after 24 hours and ends by the end of day 7 c. serum concentration of unconjugated bili -less than 12 mg/dl in term baby -less than 15 mg/dl in premie d. almost exclusively unconjugated bili -direct bili doesnt exceed 1-1.5 mg/dl e. daily increments in bili doesnt surpass 5 mg/dl Feed early to keep serum bili low if hyperbilirubinemia is not reversed, can lead to kernicterus-precipitation of bilirubin in neuronal cells leading to cerebral palsy, epilepsy, and mental retardation

3. 4.

5. 6.

VII.

Genitourinary system A. Anatomy 1. at term, kidneys take up area of the posterior abd. wall 2. 3. bladder close to anterior abdominal wall lying in both the abdomen and the pelvis at term, have a full complement of functioning nephrons

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12

B.

Voiding 1. bladder capacity- 6-44 mLs at term 2. 3. 4. 5. 6. frequency of voiding varies from 2-6 times/24 hours to 5-25 times during the 3rd day limited capability to concentrate urine -able to concentrate urine by age 3 months urine usually straw-colored and almost odorless may see pink stains from pseudomenses or uric acid crystals loss of fluid thru urine, feces, lungs, increased metabolism, and limited fluid intake can result in wt. loss of 5-10% normally

C.

Fluid and Electrolyte Balance 1. 40% body wt. is extracellular fluids (adults are 20%) 2. 3. 4. 5. newborns intake and excrete 600-700 ml water =50% of extracellular fluid GFR is 30-50% of an adults GFR = wastes and nitrogenous in system Na reabsorption = levels of Na, phosphates, Cl, and organic acids

D.

Genitals 1. Females a. in full term girls -labia majora large and cover labia minora -may be dark in pigment -vaginal or hymenal tags are common -vernix may be present between labia -may have mucousy discharge -may have false period (pseudomenses) b. in preterm girls

65

13 -clitoris is prominent -labia majora are small and widely separated 2. Males a. testes in scrotum in 90% of males b. by year 1, incidence of cryptorchidism is < 1% c. tight prepuce (foreskin) is common d. smegma may be found under foreskin -teach boys at 3-4 years old to retract and clean under foreskin e. evaluate for hypo or epispadias f. scrotum more deeply pigmented and with deep rugae in post term infants g. circumcision-personal decision -may reduce UTIs -may reduce STIs -may reduce penile CA -done on 8th day under Jewish faith -complications-hemorrhage, infection

VIII.

Integumentary system A. Vernix caseosa 1. white, cheese-like substance 2. 3. B. helps the skin retain moisture present more in premies

Lanugo 1. fine, downy-like hair 2. 3. helps keep moisture in skin seen less in full to post term infants

C.

Desquamation 1. peeling of the skin 2. seen more in post date infants

D.

Birthmarks 1. Mongolian spots a. blue-black areas of pigmentation b. more common on lower back and buttocks

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14 c. d. 2. more common in dark skinned nationalities may fade over months or be permanent

Nevia. Telangiectatic nevi-Stork bites -are pink and easily blanched -appear on upper eyelids, nose, upper lip, lower occiput bone, and nape of neck -usually fade between 1-2 years b. Nevus vasculosus- Strawberry mark -may be raised and be bright or dark red -may last thru childhood c. Nevus flammeus- Port-wine stain -red to purple, nonelevated -varies in shape, size, and location -do not blanch nor fade with time -if neurological problems exist- for Sturge-Weber syndrome Erythema toxicum a. transient rash also known as flea-bite rash b. thought to be a inflammatory response c. usually no clinical significance and needs no tx

3.

IX.

Immune system A. Neonatal considerations 1. cells that provide infant with immunity are present but not activated for the first several months of life 2. 3. for first 3 months of life, passive immunity from mother immunoglobulins a. IgA -cant cross placenta -not produced in utero -colostrum is high in IgA -start producing about 4 weeks of age b. IgG -can cross placenta -passive immunity from mom-passed in 3rd -very active against bacterial toxins c. IgM -produced by fetus in utero -reach adult levels at 9 months old

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15 d. e. X. IgA, IgD, and IgE gradually produced colostrum and breast milk carry immunity

Psychosocial Adaptation A. Behavioral states 1. Infants differ in their activity levels, feeding/sleep patterns, and responsiveness 2. 1st period of reactivity-first 30 minutes of life a. awake and alert b. may have irregular resp. rate with crackles c. grunting, flaring, retractions d. may have periods of apnea e. startle easily f. decrease in body temp g. increase in motor function h. may be prolonged in term infants with abnormal labor or birth traumas Sleep period-unresponsiveness-2-4 hours a. HR 100-120 b. RR slow-irregular 2nd period of reactivity-4-6 hours a. tachycardia, tachypnea b. muscle tone, skin color, mucus production c. passage of meconium Sleep/wake states a. 2 sleep states -deep sleep -light sleep-REM b. 4 wake states -drowsy -quiet alert/wide awake -smile, vocalize, synchrony to voices -watch & respond to their parents faces -active alert -crying Purposeful behaviors a. withdrawal by physical distance b. push away with hands/feet c. sensitivity by falling asleep

3.

4.

5.

6.

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16 d. e. XI. get fussy or cry as a signal term infants better at self-quieting abilities

Care of the Newborn A. Assessment 1. Assess vital signs, assign apgar scores a. temp-taken axillary b. assess apical pulse c. auscultate lungs and suction if moist 2. Measurements a. weight in pounds and grams b. Length-usually 18-22 inches c. head circumference-usually 33-36 cm Chart if voiding or passing meconium Administer medications a. erythromycin ointment-OU b. Vit. K IM c. Hep. B vaccine-IM d. HBIG IM-if needed Assess mothers ability to breast feed Full head to toes assessment after bonding Review maternal chart a. ? infection at time of delivery b. medications given to mother c. R/O h/o substance abuse Newborn nutrition a. neonates need 110 kcal/kg/dy b. at 3 months, 100 kcal/kg/dy c. want to see 6-10 wet diapers/dy Assist with circumcision if requested a. minor surgical procedure-sterile tech. b. after procedure, infant to mother c. teach parents care of circ site Home care instructions 01/13

3. 4.

5. 6. 7.

8.

9.

10.

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1 The High Risk Newborn Lecture 6 I. Levels of Care for the High Risk Newborn A. Assessment for need of NICU/tertiary care center 1. maternal transport with fetus in utero preferred a. decreases neonatal morbidity/mortality b. mother and infant not separated at birth 2. if unable to transport before delivery: a. notify supervisor of need for transfer team b. have emergency personnel to stabilize baby

B.

Transfer/multidisciplinary approach 1. transfer team consists of: a. MDs b. RNs c. RTs 2. keep parents undated on infants condition a. teach about equipment helping baby b. start discharge teaching early get mother and infant together ASAP talk about possibility of return to primary center of care a. may be frightened to move baby again b. may feel insecure with change in staff

3. 4.

II.

The Preterm Neonate A. Risk Factors 1. before 37 weeks, lack sufficient organ maturity 2. 3. 4. 5. 6. lack adequate reserves of bodily nutrients low SES of the mother exposure to environmental dangers, I.E. toxic chemical pre-existing maternal conditions-heart disease, diabetes, etc maternal age and parity

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2 7. 8. B. medical conditions R/T the pregnancy-GDM, PIH, infection obstetrical complications-cord prolapse, abruptio placenta

Physical characteristics and system alterations 1. Respiratory a. at 22 weeks gestation, surfactant begins production b. 24-26 weeks-inadequate alveolar size and surfactant c. 27-28 weeks-alveoli start to open, surfactant inadequate d. 29-30 weeks-growth of alveoli and surfactant level e. 34-36 weeks-mature alveoli, surfactant level adequate (surfactants-surface-active phospholipids lecithin-increases after 24 weeks sphingomyelin-constant amount when L/S ratio is 2:1=lungs mature) f. noticeable cyanosis, retractions, grunting, decreased tissue perfusion g. apneic episodes-15-20 cessation of breathing 2. CV a. b. c. d. pulmonary arteriole musculature pulmonary vascular resistance L R shunting thru ductus arteriosus into lungs BP, cap refill time, resp. distress

3.

Thermoregulation a. lack glycogen stores in liver-created in 3rd b. brown fat c. larger body surface d. posture of extension e. less able to metabolism for heat GI a. b. c. poor gag, suck, swallow-coordinated after 34 weeks incompetent cardiac sphincter small stomach capacity

4.

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3 d. e. f. g. 5. bile acids, pancreatic lipase = absorption of nutrients, malabsorption nutritional loss associated with vomiting/diarrhea work of sucking = BMR, O2 usage feeding intolerance

Renal a. at 35 weeks, kidneys have limited ability to dilute or concentrate urine b. GFR secondary to renal blood flow c. at risk for edema (overhydration) or dehydration d. buffering = acidosis e. longer to excrete drugs from the system Hepatic a. glycogen stores = hypoglycemia b. iron stores c. impaired conjugation of bilirubin Immunologic a. dont receive passive immunity b. IgG-not until last trimester Hematologic a. increased capillary friability b. tendency to bleed c. blood loss from frequent lab work d. production of RBCs CNS a. high risk of brain hemorrhage from thin, fragile vessel walls b. up to 34 weeks, the germinal matrix lines the ventricles c. birth damage to immature structures d. may have been exposed to recurrent anoxic episodes Risk of infection a. thin, fragile skin b. friable blood vessels c. storage of immunoglobulins d. inability to make antibodies

6.

7.

8.

9.

10.

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4 11. Fluid/electrolytes a. need 80-150 kcal/kg/dy- than term infants b. need protein 3-4 g/kg/dy-term 2-2.5g c. need addition iron, calcium, K d. usually get supplemental Vit. E (multi vitamin)

C.

Common complications of Preterm 1. Patent Ductus Arteriosus a. noticeable by Day 3 b. RDS improves c. LR d. increases pulmonary blood flow e. L ventricular failure f. pulmonary edema g. CHF -S & S continuous/systolic murmur bounding pulses tachycardia tachypnea hepatomegaly -Tx echocardiogram restrict fluid-give diuretics indomethacin-0.2 mg/kg -stimulates closure of ductus surgery 2. Apnea a. cessation of breathing > 20 seconds b. usually occurs < 36 weeks gestation c. R/T immature nervous system d. may be R/T temp instability maternal drugs in labor h/o maternal drug abuse infection metabolic disorders asphyxia abdominal distention

73

e.

f.

assessment -observe breathing pattern -stimulate-slap soles of feet -suction-use with free-flow oxygen watch for dusky, cyanosis, bradycardia -prepare for possible intubation -think possible septic workup tx -oxygen per order-usually started if PaO2<92% warmed and humidified nasal cannula, hood, PPV, ET tube Danger-excessive oxygen can lead to retinopathy of prematurity or bronchopulmonary dysplasia -report ABG changes -theophylline-CNS stimulant-stimulates resp ctr relaxes smooth muscle of bronchial airway and pulmonary blood vessels -surfactant administration -ECMO NOT used with premies due to risk of intraventricular hemorrhage

3.

Intraventricular Hemorrhage-most common type of intracranial hemorrhage a. most susceptible-< 1500 gms, < 34 weeks b. triggered by hypoxia no venous pressure changes osmolarity in blood-overuse of volume expanders c. S &S -hypotonia -hypotension -lethargy -metabolic acidosis -temp instability -seizures -nystagmus -low Hct -bulging fontanelles -apnea -decerebrate posturing d. Tx -tx the symptoms -phenobarb-sedative, seizure activity -serial spinal taps -VP shunt -mainly observational and supportive care

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4.

Retinopathy of Prematurity (ROP) a. at risk at < 36 weeks, < 1500 gms b. higher risk-<1000 gms c. oxygen tensions too high may lead to vasoconstriction d. at the end of oxygen therapy: vascularization of retinaconstriction of vessels disintegration of vesselsnew vesselsrupture retinal hemorrhagescar tissuedetachment blindness e. assessment -ophalmoscope exam-4-6 weeks -some damage may spontaneously heal f. Tx -laser photocoagulation -Vit. E therapy -decrease ambient light -circumferential cryopexy Bronchopulmonary Dysplasia a. caused by barotraumas from pressure ventilation and oxygen toxicity b. etiology is multifactorial c. S&S -tachypnea -retractions -nasal flaring - work to breath -tachycardia d. Tx -oxygen -nutrition -fluid restriction -medications: diuretics, steroids, bronchodilators e. key management is thru prevention f. if untreated-can lead to death from cardiorespiratory failure Necrotizing Enterocolitis a. inflammatory disease of GI mucosa b. causes unknown-up to 25-30% mortality rate c. contributing factors -asphyxia -UAC -infection -PDA -RDS -anemia/ischemia -congenital heart disease -early enteral feedings

5.

6.

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7 d. e. breastfed babies have lower risk of NEC S&S -hypotonia -decreased activity -recurrent apnea -pallor -decreased perfusion -hypotension -temp instability -cyanosis -abdominal distention -diarrhea -vomiting blood/bile Dx -x-ray -lab reports -abnormal electrolyte levels Tx -mainly supportive -no feedings-rest the gut-trying probiotics -use of TPN -tx of infection -surgical dissection of perforated/deteriorated area

f.

g.

7.

Other neurological concerns a. hearing-1:50 loss of hearing - risk R/T congenital virus -perinatal asphyxia -birth trauma -certain medications-gentamycin b. speech impairments c. cerebral palsy d. hydrocephalus e. seizure disorders f. lower IQs h. learning disabilities

D.

Nursing Care 1. Methods of feeding a. depend on gestational age, physical condition, neuro status b. nipple feeding-34 weeks ok -need coordinated suck and swallow -needs to have gag reflex, RR < 60, and steady wt. gain

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8 c. gavage-< 34 weeks gestation -used if infant has poor gag/swallow neuro insult losing wt. due to energy expenditure TPN-central or peripheral lines lipids-peripheral, no filter fluid requirements -80-100 ml/kg/dy-Day 1 -100-120 ml/kg/dy-Day 2 -150 ml/kg/dy-Day 3 -gradually increase

d. e. f.

2.

Assessments a. vital signs-watch for temp for heat loss b. urine-ck protein, glucose, SG c. strict I & O -watch for vomiting, diarrhea -watch IV site for infiltration d. watch for gastric residual 2 ml e. guaiac stools f. assess for abdominal distention Goals a. maintenance of respiratory function b. maintenance of neutral thermal environment c. maintenance of fluid/lytes d. prevention of infection e. prevention of fatigue f. adequate nutrition g. promotion of attachment i. promotion of sensory stimulation

3.

III.

Dysmature Neonates A. Care of the Post Term Neonate 1. Problems a. post maturity syndrome b. hypoglycemia-depleted glycogen stores c. meconium aspiration-stress d. polycythemia- RBC production R/T hypoxia e. congenital anomalies-unknown f. seizure activity-R/T hypoxia g. cold stress-R/T less sub Q fat

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9 2. Assessment a. post maturity syndrome -dry, crackling skin -mec staining -long fingernails -profuse scalp hair -wasted appearance b. meconium aspiration syndrome -watch for mec stained infant -may not show signs of resp. depression at birth -if mec migrates to terminal airways-becomes meconium aspiration syndrome mechanical obstruction -if mec aspirated in uterochemical pneumonitis c. persistent pulmonary HTN (PPHN) -pulmonary artery hypertension -R to L shunting -may need ECMO (extracorporeal membrane oxygenation therapy) Tx -tx the S & S-ECMO, inhaled nitric oxide, etc

3. B.

Care of the SGA/IUGR neonate 1. Causes a. maternal -smoker -heart disease -poor nutrition -PIH -substance abuse -chronic HTN -advanced DM -toxic chemical -infection exposure -small stature -<16, >40 yrs old -lack of PN care -low SES b. placental -infarcts -single umbilical artery -abnormal cord insertion -calcifications c. fetal -multiple gestation -TORCH-toxoplasmosis other infections, i.e. hepatitis rubella cytomegalovirus herpes (type II)

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10 2. Problems a. perinatal asphyxia -associated with h/o smoker low SES preeclampsia multifetal gestation infections DM -watch for respiratory depression at birth b. hypoglycemia -higher metabolic rate -RBS < 40 mg/dl in term infant <25 mg/dl in premie -poor feeders, jittery, hypothermic -watch for lethargy, floppy, seizures c. heat loss -less muscle and brown fat mass -little ability to control skin capillaries -need to maintain thermoneutrality d. hypocalcemia-R/T birth asphyxia e. polycythemia-R/T RBCs R/T stress Tx a. b. c. d. e. maintain clear airway prevent cold stress feeding per hospital protocol stabilize temperature nursing support similar to premies

3.

C.

Care of the LGA Neonate 1. Causes a. IDM/GDM b. genetics c. multips d. ethnic grps e. obesity 2. Problems a. CPD- risk for C/S birth b. birth traumas-vacuum, forceps, asphyxia shoulder dystocias, fx clavicle c. hypoglycemia/polycythemia Tx-tx the S & S

4.

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11 IV. Common Respiratory Complications A. Respiratory Distress Syndrome(hyaline membrane disease) 1. Lung disorder usually affecting premies a. infants <1500 gms = 56% risk of RDS b. caused by lack of surfactant 2. Causes a. risk of incidence/severity -African-Americans -maternal steroid therapy -stressors such as PIH -PROM -IUGR -maternal drug use b. risk of incidence/severity - in gestation age -maternal hypotension -Caucasians -maternal diabetes -C/S birth without labor -second-born twin -males -perinatal asphyxia Problems a. lack sufficient surfactant b. weak respiratory muscles g. epithelial debris in airways h. leads to oxygenation, cyanosis, and resp./ metabolic acidosis i. can lead to R to L shunting and opening of foramen ovale and ductus arteriosus S&S a. b. c. d. e. f. tachypnea grunting/nasal flaring retractions hypotension cyanosis self-limiting disease -usually abates in 72 hours -disappearance coincides with production of surfactant in type 2 cells of alveoli

3.

4.

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12 5. Tx a. b. c. d. e. f. g. h.

supportive-adequate ventilation/oxygenation surfactant administration oxygen therapy per orders monitoring of acid/base balance prevent cold stress abx therapy for infection proper nutrition and I & Os possible need for blood transfusion R/T frequent lab work

B.

Transient Tachypnea of the Newborn 1. similar to RDS 2. 3. 4. 5. R/T asphyxia in utero-fluid in lungs x-ray shows over expansion/hyperinflation of lungs Tx-oxygen, ck for possible acidosis usually improves in 24-48 hrs, well in 2-5 days

C. V.

Meconium Aspiration-see post term neonate

Neonate with Sepsis A. Risk factors 1. maternal -low SES -poor nutrition 2.

-poor PN care -substance abuse

intrapartum -PROM -maternal fever -chorioamnionitis -prolonged labor -premature labor -maternal UTI neonatal -twins -birth asphyxia -galactosemia -LBW/premie -male -mec aspiration -absence of spleen -prolonged hospitalization

3.

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13

B.

Mode of transmission 1. vertical a. in utero b. at birth c. TORCH 2. horizontal a. after birth b. environmental, i.e. Staph

C.

Causes of susceptibility 1. lack immunity 2. 3. phagocytosis less efficient dysmaturity

D.

Causes of infection 1. Early onset-within 24 hours of birth a. group B strep b. Haemophilus influenza c. Listeria d. E. Coli e. Strep. Pneumoniae f. more common with PROM, maternal fever, chorio, and premature labor g. higher mortality rate-10-25% 2. Acquired infections-seen after 2 weeks of age a. may be from birth canal or environment b. Staph aureus c. Staph epidermidis d. Psedomonas e. group B strep Viral infections a. may cause miscarriage, stillbirth, intrauterine infections, and congenital malformations b. may cause chronic infection with subtle manifestations c. may need isolation from other neonates

3.

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14

4.

Fungal infections a. greatest concern to immuno-compromised or premature neonates b. thrush may be present in otherwise healthy kids

E.

Location of infection 1. Septicemia is infection in the blood system 2. 3. 4. Pneumonia-most common form of neonatal infection -one of the leading causes of perinatal death Bacterial meningitis affect 1 in 2500 live births Gastroenteritis not as common

F.

S&S 1. Respiratory -apnea -grunting -retractions 2.

-tachypnea -nasal flaring -decreased O2 sat

CV -bradycardia -decreased CO -tachycardia -hypotension -decreased perfusion CNS -temp instability -hypotonia -seizures GI -vomiting -diarrhea Skin -jaundice -petechiae -lethargy -irritability

3.

4.

-abdominal distention -residuals > 50% -pallor

5.

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15

G.

Sepsis workup 1. lab work -blood (CBC with diff) looking for neutrophils, bands(immature WBC) -urine -CSF -gastric aspiration -culture nose, throat, skin, umbilical cord 2. chest x-ray Tx the symptoms-i.e. abx, O2, isolation Assess handwashing techniques of the staff Encourage breastfeeding-passive immunity

H.

Tx 1. 2. 3.

VI.

The Neonate with Hyperbilirubinemia A. Types 1. Physiologic jaundice a. occurs in 60-70% of term infants, 80% preterm b. arises 24 hours after delivery 2. Pathologic jaundice a. hyperbilirubinemiakernicterus (bilirubin encephalopathy) b. apparent within 24 hours of birth c. serum bili of > 5mg/dl in cord blood d. serum bili > 15mg/dl at any time

B.

Causes 1. Maternal factors a. Rh/ABO incompatibility -fetal antigen crosses placenta -maternal antibodies cross placenta -cause hemolysis of fetal RBCs (erythroblastosis fetalishydrops fetalis) b. infection c. diabetes d. oxytocin in labor e. drugs

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16

2.

Fetal/newborn factors a. premies b. hepatic cell damage c. polycythemia d. intestinal obstruction e. pyloric stenosis f. biliary atresia (absent or closed bile ducts) g. blood swallowed by fetus

C.

Nursing care 1. Lab work a. direct comb-ck for maternal antibodies in infants blood b. ck infants blood type c. serum bili level 2. Tx a. b. c. early, frequent feedings phototherapy exchange transfusions -if Rh incompatibility-use O neg blood

VII.

The Neonate born to a diabetic mother A. Problems 1. congenital anomalies -believed to be caused by fluctuation in glucose & episodes of ketoacidosis -congenital heart lesions coarctation of the aorta transposition of the greater vessel atrial/ventricular septal defects -CNS anacephaly hydrocephaly encephalocele meningomyelocele -MS caudal regression syndrome-problems of the lower extremities 2. macrosomia/birth trauma

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17 -excessive glucose in blood = fetal insulin production -enlargement of internal organ except brain -high risk for fx of clavicle/scapula, cephalohematoma 3. 4. RDS -4-6X more likely to develop than in normal infants hypoglycemia, hypocalcemia, hypomagnesemia -hypocalcemia present in 50% of IDMs -hypomagnesemia from maternal renal loss R/T DM hyperbilirubinemia/polycythemia -excess RBC production leads to bili

5. B.

Pathophysiology 1. Normally: maternal blood more alkaline pH than CO2-rich fetal bloodexchange of O2 & CO2 across placenta 2. 3. Maternal acidosis: in gas exchange Goal: Maternal control of BS thru pregnancy with PN care

C.

Nursing care 1. Pediatric staff at delivery 2. 3. 4. 6. Implement neonatal glucose testing per protocol If RBS < 40 mg/dl, supplement with formula or IV prn Check serum bilirubin and calcium levels Reduce adverse environmental factors

VIII.

The Neonate born to a Substance Abusing Mother A. Common characteristics 1. Fetal alcohol syndrome a. eyes -epicanthal folds -strabismus -ptosis-drooping lid -hypoplastic retinal vessels

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18 b. c. d. e. mouth -poor suck -cleft lip -cleft palate -small teeth ears-deafness skeleton -fusion of cervical vertebrae -restricted bone growth heart -atrial/ventricular septum defects -Tetralogy of Fallot -patent ductus arteriosus kidney -renal hypoplasia -hydronephrosis -urogenital sinus liver -hepatic fibrosis immune system -increase infections -otitis media -upper resp. infections -immune deficiencies tumors-nonspecific neoplasms skin -abnormal palmar -irregular hair

f. g. h. i. j. 2.

Cocaine a. prematurity/SGA b. microcephaly/developmental delays c. poor feeder/diarrhea d. hyperactivity/difficult to console e. congenital anomalies Heroin a. LBW b. SGA c. neonatal withdrawal issues Amphetamines a. SGA/LBW/premie b. poor wt. gain c. lethargy Tobacco a. Premie/LBW/IUGR b. risk for SIDS c. risk for bronchitis/pneumonia

3.

4.

5.

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19 d. 6. developmental delays

Marijuana a. possible neonatal tremors b. LBW

B.

Nursing Care 1. Needs multidisciplinary approach for both neonate and parents 2. Supportive care a. fluid and electrolyte balance b. nutrition c. infection control d. respiratory care Quiet, soothing environment during withdrawal period Pharmacological tx-morphine, phenobarb, diazepam, paregorics (tincture of opium), & methadone vs buprenorphine (article)

3. 4.

IX.

Hypoxic Ischemic Encephalopathy (HIE) in NewbornsArticle

01/13

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1 Normal Pregnancy Lecture 7 I. Physiological Changes during Pregnancy A. Reproductive system and breasts 1. Uterus a. increased vascularity/dilation of blood vessels -60 gm(2oz) to 1100 gm(2.2 lb) b. hyperplasia-new muscle fibers/tissue c. hypertrophy-enlargement of pre-existing fibers d. development of the decidua e. growth changes R/T stimulation from high levels of estrogen/progesterone f. shape changes -7 weeks-egg size -10 weeks-orange size -12 weeks-grapefruit size -initially pear shaped -2nd trimester-globular -term-ovoid g. position -12 weeks-at or above the symphysis pubis -16 weeks-between SP and umbilicus -20 weeks-at the umbilicus -36 weeks-almost to the xiphoid process h. lightening -nulliparas-2 weeks before term -multiparas-when labor starts i. ballottement-palpate floating structure j. altered center of gravity as enlarging uterus tilts against the anterior abdominal wall k. Braxton-Hicks contractions -start around 4 months -irregular -painless -help to facilitate blood flow l. uteroplacental blood flow -uterine blood flow increases -more oxygen is extracted from the blood in the latter part of the pregnancy -at end of pregnancy, 1/6 of total blood volume within the vascular system of uterus m. Hegars sign-6 weeks-softening of lower uterine segment

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2 2. Cervix a. Goodells sign-softening of cx-6 weeks b. Chadwicks sign-bluish cast-8 weeks c. friability increases d. operculum-mucus plug-endocervical glands Vagina a. increased vascularity b. leukorrhea-thick white vaginal discharge c. change in pH leads to higher risk for yeast inf. Breasts a. start to change by week 6 R/T hormone surge b. increase in sensitivity, breast and nipple size c. increase in feeling firm, heaviness, nipple erect d. nipples and areola become more pigmented e. vessels beneath the skin dilate-more visible f. striae gravidarum (stretch marks) may appear g. may leak colostrum as early as 16 weeks

3.

4.

B.

Cardiovascular system 1. Heart a. slight hypertrophy R/T increase blood flow b. position change R/T diaphragm position c. transient murmurs may be auscultated d. cardiac output -increased 30-50% by week 32 -only 20% increase by week 40 -R/T increased stroke volume and heart rate e. pulse rate increases 10-15 bt/min 2. Blood a. increase in blood volume 40-50% (1500ml) -plasma-1000 ml -RBCs-450 ml b. physiological anemia-hemodilution of cells -anemic if Hgb under 10g/dl, Hct under 35% c. increase in WBCs d. coag times -circulation time decreases by week 32 near normal at term - in clotting factors leads to tendency for blood to coagulate - risk for thrombosis-esp. with C/S

90

3.

Blood Pressure a. 1st trimester-no change in BP b. 2nd trimester-BP 5-10 mm Hg c. 3rd trimester-BP returns to 1st trimester values d. supine hypotensive syndrome -if they lie on their backs -at 5 minutes, reflex bradycardia -CO by half -woman feels faint

C.

Respiratory system 1. flaring of the rib cage 2. 3. shift from abdominal to thoracic breathing elevated maternal oxygen requirements a. acceleration in metabolic rate b. the need to add to the tissue mass of uterus c. fetal needs vascularity of the upper resp. tract a. nasal and sinus stuffiness-(estrogen-induced) b. epistaxis (nosebleeds) c. changes in the voice pulmonary function a. deep breathing- airway resistance-Progesterone b. tidal volume c. resp rate 2 breaths/min d. awareness to breath e. sensitivity in medulla to CO2- depth, rate basal metabolic rate a. 15-20% by term b. reflects in oxygen demand c. may experience heat intolerance R/T excess heat from BMR acid-base balance a. pregnancy is a state of resp. alkalosis compensated by mild metabolic acidosis b. facilitates maternal-fetal O2-CO2 transfer

4.

5.

6.

7.

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4 D. Renal system 1. anatomic changes a. estrogen and progesterone = uterus size and blood volume b. dilations of ureters, pelvis, renal calyces large amt. of urine c. urine flow rate slowedstasis/stagnation medium for bacteria d. tubular reabsorption impairedglucose in urine more alkaline urine e. urinary frequency from in bladder sensitivity and compression from uterus f. 2nd trimester, bladder pulled up into the abdomen g. urethra lengthens-possible problem with cath 2. functional changes a. in GFR b. most efficient in L lateral- perfusion to kidneys fluid and electrolyte balance a. tubular reabsorption to maintain needed Na level b. may be overstressed by excessive Na intake c. pooling of fluids in legs = less blood flow to kidneys-better to elevate legs than diuretics d. slight protein leakage +1 ok

3.

E.

Integumentary 1. hyperpigmentation a. caused by stimulation of anterior pituitary hormone melanotropin b. chloasma=brownish facial pigmentationintensified by sun -usually fades after pregnancy c. darkening of nipple, areola, vulva, thighs d. linea nigra=dark vertical line from symphysis pubis to fundus -starts as linea alba-before pigmentation -not present in all pregnant women e. striae gravidarum-stretch marks -on abdomen, breasts, thighs -separation of collagen -50-90% of women will have this

92

5 2. other changes a. angiomas-vascular spiders b. palmar erythema-blotches on hands c. pruritus d. gum hypertrophy-bleeding gums e. accelerated nail growth f. hirsutism-excessive hair growth g. blood supply = perspiration

F.

Musculoskeletal 1. lordosis-center of gravity is more forward 2. relaxin, an ovarian hormone, helps with relaxation and increased mobility of pelvic joints -waddling gait diastasis recti abdominis-persistent separation of muscles of the abdominal wall

3. G.

Neurologic system 1. compression of pelvic nerves may cause sensory changes in legs -sciatica 2. edema on peripheral nerves-carpal tunnel syndrome a. burning, paresthesia b. pain in the hand, radiating to the elbow tension headaches syncope common in early pregnancy

3. 4. H.

Gastrointestinal 1. peristalsisconstipation, N & V 2. bleeding of gums/problems of the mouth a. caused by rising level of estrogen b. ptyalism-excessive salivation 15-20% will have problem with hiatal hernia estrogen = secretion of HCl acid progesterone = stomach emptying time=heartburn

3. 4. 5.

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6 6. 7. 8. gallbladder distentionprolonged emptying time and thickening of biledevelopment of gall stones pruritus gravidarum-may be R/T accumulation of bile change in appetite/food consumption a. change in CHO, protein, fat metabolism b. pica-craving for non-food material c. morning sickness-usually ends by 2nd trimester

I.

Endocrine system 1. secretions of pituitary hormones: a. thyrotropin b. FSH/LH c. prolactin d. vasopressin (antidiurectic hormone) e. oxytocin 2. secretions of thyroid hormones: a. thyroxine b. triiodothyronine secretion of parathyroid hormones secretion of the adrenal hormones: a. cortisol-r/t estrogen-regulates CHO/prot meta. b. Aldosterone-protective response to Na excretion secretion of insulin from the pancreas

3. 4.

5. II.

Diagnosis of Pregnancy A. Gravidity and Parity 1. gravida-woman who is pregnant a. nulligravida-never been pregnant b. multigravida-2 or more pregnancies c. primigravidas-first pregnancy 2. parity-number of births after 20 weeks gestation a. doesnt matter if born alive or stillborn b. nullipara-never completed a pregnancy c. multipara-completed 2 or more births at more than 20 weeks gestation d. primipara-completed one birth > 20 weeks e. not the number of fetuses born

94

7 3. 4. 5. preterm-before 37 weeks gestation postdates-after 42 week of gestation viability-capacity to live outside the uterus a. somewhere between week 22-24 b. fetus greater than 500 gms 5-digit system a. gravida b. term-para c. preterm d. abortions-spontaneous or therapeutic e. living children

6.

B.

Pregnancy tests 1. hCG-human chorionic gonadotropin a. production starts with implantation b. found in blood 6 days after conception c. in urine by day 26 d. level rises until peak at day 60-70 in pregnancy then falls-lowest level at 100-130 days 2. ELISA-enzyme linked immunosorbent assays a. color change with hCG bonding b. result as fast as 5 minutes c. detect hCG in 7-9 after conception

C. D.

Nageles Rule 1. First day of LMPsubtract 3 monthsadd 1 week Classic indicators 1. presumptive a. amenorrhea-week 4 b. quickening-weeks 16-20 c. breast changes-weeks 3-4 d. N & V-weeks 4-14 e. urinary frequency-weeks 6-12 f. fatigue-week 12 2. probable a. Goodwells sign-week 5 b. Chadwicks sign-weeks 6-8 c. Hegars sign-weeks 6-12

95

8 d. e. f. g. h. i. 3. + pregnancy test (serum)-weeks 4-12 + pregnancy test (urine)-weeks 6-12 Braxton-Hicks contractions-week 16 abdominal enlargement ballottement-weeks 16-28 palpable fetal outline

positive a. visualization of fetus on U/S-weeks 5-6 b. fetal heart tones by U/S-week 6 c. fetal heart tones by Doppler-weeks 10-17 d. FHT by stethoscope-weeks 17-19 e. fetal movements palpated-weeks 19-22 f. visibility-late pregnancy

III.

First Trimester A. History taking 1. reasons for seeking care a. may have other concerns besides the preg. b. use open ended questions 2. current pregnancy a. review signs and symptoms b. evaluate how pt is coping OB/Gyn history a. menstrual history b. contraceptive history c. any infertility concerns d. any Gyn concerns e. ck last Pap and cultures for STIs medical history a. pre-existing medical conditions/concerns b. history of surgical procedures nutritional history a. assess for food allergies b. any special dietary concerns history of drug use a. past and present use of legal medications b. h/o illegal drug use

3.

4.

5.

6.

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9 7. 8. family history psychosocial history a. situational factors b. any previous care of infants c. coping mechanisms history of physical/verbal abuse a. abuse may increase during pregnancy b. need immediate clinical intervention

9.

B.

Physical examination 1. vital signs 2. 3. 4. head to toe assessment pelvic exam with vaginal/abdominal U/S review of systems a. assess each sign/symptom for onset, character, and course b. assess for aggravating/alleviating factors

C.

Laboratory tests 1. blood work up a. CBC b. blood type and Rh factor c. rubella titer d. HIV screen e. HbsAG screen f. RPR/VDRL g. Tay-Sachs h. Sickle-cell i. glucose tolerance test 2. urine screen a. urinalysis with culture b. UDAP pelvic a. Pap smear b. cultures for STIs TB skin test

3.

4.

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10 5. screening for fetal chromosome anomalies a. NT-nuchal translucency (fetal nuchal fold) b. serum testing for free beta hCG and PAPP-A c. NT, free beta hCG, and PAPP-A can suggest aneuploidy

D.

Priority patient education topics 1. schedule of visits 2. 3. 4. 5. 6. rationale for labs Kegel exercises for pelvic floor review nutritional needs ok to travel and continue exercise as comfortable ck all use of medications with your provider-even OTC a. will start on PN vitamins with folic acid b. iron tabs prn anemia immunizations a. ok if killed-DT, Hep B, rabies (Tdap-after 20 wks) b. no ok if live-measles, MMR, C Pox, mumps, polio alcohol, tobacco usage PROM, PTL, abruption tips to help with fatigue, N & V

7.

8. 9. IV.

Second trimester A. Ongoing care 1. physical examination a. weight-approx. 1 lb per week past 1st trimester b. BP-watch for 140/90 or systolic 30>baseline diastolic 15>baseline c. dip urine for protein, glucose d. auscultate FHT e. assess breasts/nipples f. review birth plan g. ask about quickening-approx 20 weeks

98

11 2. pertinent laboratory tests a. Quad Screen-done between 15-20 weeks: 1. MSAFP 2. hCG 3. UE-unconjugated estriol 4. inhibin-A 5. Assessing for possible spina bidifa, Down syndrome, or other chromosomal defects b. follow-up on any prior test results c. amniocentesis potential complications a. bleeding b. decreased fetal activity c. PIH/GHTN -headache -swelling of face/fingers -epigastric pain -muscular irritability -visual disturbance d. PROM -amniotic fluid discharge e. infections -chills -fever -burning with urination fundal height a. fundal height (from symphysis pubis to top of uterus) # in cm = weeks of gestation (weeks 18-36) b. stable or decreased fundal height-? IUGR c. excessive increase-multifetal gestation, hydramnios gestational age a. determined from LMP, contraceptive history, and pregnancy test results b. usually confirmed with U/S interventions for discomforts a. assess skin changes b. headaches-rest, hydration, acetaminophen c. constipation-hydration, exercise, prune juice

3.

4.

5.

6.

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12 d. e. f. g. 7. varicose veins-elevate legs, support stockings food cravings-6 small meals-keep BS level even heartburn-small meals, sit up after eating, spicy foods, antacids joint/ligament pain-support garments

education topics a. warning signs b. assess nutrition status c. hygiene-R/T increase perspiration d. UTI prevention-hydration, freq. Voids e. breast shields for inverted nipples -too much stimulation can lead to PTL f. dental care g. R&R h. risk factors at work-i.e. caustic agents i. travel-if not high risk, ok j. avoid alcohol, cigarettes k. need for support garments

V.

Third Trimester A. History and physical 1. vaginal exams may begin in the last month 2. B. assess for S & S of PTL, PIH, GDM

Laboratory tests 1. Group Beta strep culture-35-37 weeks 2. 3. 4. rhogam injection-26-28 weeks for Rh - moms glucose tolerance test may retest for STIs

C. D.

Interventions for discomforts (same as 2nd trimester) Family adjustments 1. maternal tasks a. accept the concept of being pregnant b. may dislike pregnancy but love child c. if happy about pregnancy-usually have higher self-esteem, confidence d. dealing with rapid mood changes

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13 e. f. g. h. i. j. k. l. may have feelings of ambivalence prepare for childbirth practice of mothering role may need to work on communication with family members work on relationship with her mother trust and share with the partner work on sexual relationship with spouse 3 phases of developmental pattern -accept biological fact-I am pregnant -accepts need to nurture fetus-I am going to have a baby -prepares for role of parent-I am going to be a mother

2.

paternal tasks a. acceptance of pregnancy -may express joy or dismay -unwanted vs. unplanned -affairs/battery of spouse b. couvades -observance of rituals = transition to fatherhood -may have psychosomatic symptoms of preg. c. participate in childbirth education d. identify with father role -may be influenced by how their father was e. reordering personal relationships -may see fetal as a rival -may feel wife is too dependent on MD/CNM f. observer vs. expressive vs. instrumental g. establish relationship with fetus -kiss or rub abdomen -talk to fetus -assist with preparing babys room sibling adjustment a. first crisis for a child b. may feel replaced c. need to prepared to become the big sister or brother d. sibling classes

3.

101

14 4. grandparent responses a. if only in 30s or 40s-may not be as interested b. may be non-supportive-try to decrease new mothers self esteem c. most see the pregnancy as a renewal of their youth d. continuity of past and present e. may help bridge a previous estrangement f. now have classes on being a grandparent other psychosocial issues a. adolescent mothers -most pregnancies unintended-80% -40% will end in abortion-EABs & SABs -higher rates for Hispanics, African-Americans -most unmarried, low SES -more likely not to receive PN care -RN needs to encourage PN visits, nutritional guidelines, and social service consult b. older mothers -multips-pregnancy may be surprise-thought to have started menopause -may feel separated from younger moms -nullips-pregnancy is a chosen event -may feel isolated from older friends -usually seek genetic counseling and PN care -higher risk for adverse perinatal outcomes

5.

E.

Education topics 1. preparation for childbirth classes a. prenatal yoga b. Lamaze c. prenatal breast feeding d. cesarean information 2. 3. 4. review warning signs signs and symptoms of labor other potential complications a. PIH b. PTL/PROM c. bleeding d. FM

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15 VI. Ongoing safety issues A. Travel/exercise 1. use common sense a. no prolonged use of hot tubs b. high risk for clots in legs if not moving around 1. walk around the plane during long trips 2. stop the car every few hours for stretch 2. 3. 4. B. should avoid air travel after the 7th month MVA-most common cause of fetal death-seatbelts continue with non-weight bearing exercises

Substance abuse 1. no such thing as a safe level of drugs 2. 3. alcoholism-risk of fetal alcohol syndrome, abortion -problem with using antabuse-suspected teratogenic smoking-retards fetal growth and development a. risk for PTL, PROM, abruption b. second-hand smoke just as bad caffeine-since its a stimulant, best to limit-300 mg/day a. risk of SAB b. risk of growth restriction

4.

C. D.

Vaccinations-ok if not a live vaccine Battering 1. may increase with enlargement of abdomen 2. 3. must be reported hook up pt. with social services/womens shelters

E. VII.

Preventing Preterm labor

Multifetal pregnancies A. Maternal concerns 1. blood volume strain on CV system 2. anemia

103

16

3. 4. 5. 6.

uterine distentionseparation of abdominal muscles risk for placenta previa for separation of placenta lack of emotional preparement a. will need additional education and support b. possible need for selective reduction strain on finances, space, workload, and relationships

7. B.

Fetal concerns 1. risk of prematurity 2. 3. PROM types of twins a. dizygotic-from 2 fertilized ova/2 spermatozoa 1. 2 placentas 2. 2 chorions 3. 2 amnions b. monozygotic-originating from one fertilized ovum 1. dichorionic-diamniotic twins (20-30%) -if division 3 days after fertilization -may have separate or fused placentas 2. monochorionic-diamniotic -if division 5 days after fertilization 3. monochorionic-monoamniotic -if division 7-13 days after fertilization -rarest c. risk of congenital malformations-in monozygotic twins d. twin to twin shunting e. two-vessel cord delivery complications

4. VIII.

Cultural variations during the prenatal period A. Examples of cultural variations 1. belief of whether pregnancy is state of illness/health 2. behavioral expectations of mother/provider

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17

3.

dietary prescriptions/restrictions a. warm vs. cold b. like to like c. pica activity restrictions availability of advice/if advice is sought at all consideration of modesty/religion a. clothing b. amulets, beads pain a. b. c. d. inevitable, to be endured can be avoided completely punishment for sin can be controlled

4. 5. 6.

7.

8. 9. 10.

no tying of knots-leads to knot in umbilical cord knife under bed to cut the pain specific groups a. Mexicans -stoic until just before delivery -avoid eclipse of moon-cleft palate -everybody present at delivery b. Middle Eastern -only female attendants -FOB usually not at delivery c. Asian -prefer warm fluid -natural childbirth -labor in silence -may eat during labor -FOB may or may not be present

B.

Nursing care 1. support cultural belief-offer alternatives 2. encourage patients to participate in medical decisions

105

18

IX.

Maternal Nutrition A. Nutritional requirements 1. energy needs-additional 300 kcal greater than pre-pregnancy 2. protein a. needed for growing fetus b. milk, meat, eggs, cheese-complete proteins c. only slightly higher need than non-pregnancy fluids a. b. c. d. recommend 8-10 glasses (2-3 liters) caffeinated drinks dont count-diuretic may be good to avoid artificial sweeteners proper hydrations helps prevent headaches, constipation, and uterine cramping

3.

4.

minerals and vitamins a. iron -needed for fetus and expansion of maternal RBC mass -poor iron intake/absorption = iron deficiency -if diagnosed with anemia-extra iron supplements and iron-rich diet -iron deficiency can lead to: -maternal: cardiac failure, PP infections, poor wound healing, death -fetal: PTL, low-birth weight infant -deficiencies more common in teen moms and African-Americans b. calcium -no change in DRI for calcium -1000 mg daily if 19 yrs or older -1300 mg daily if under 19 -if lactose-intolerant, seeks non-dairy sources of calcium -may need dietary supplement containing 600 mg calcium -helps prevent leg cramps from imbalance of calcium/phosphorus ratio c. sodium -slight increase in need -essential for maintaining water balance

106

19 -restriction only needed in women with HTN, renal or liver failure zinc -deficiency associated with CNS malformations -needed for protein metabolism -if pt on high-dose iron supplements, needs additional zinc supplement fat-soluble vitamins-A, D, E, K -chronic overdoses can lead to toxic levels -Accutane-if used for cystic acne, may cause multiple birth defects -neonatal hypocalcemia noted in areas where mothers skin lacked access to sunlight -Vit. K.-for synthesis of prothrombin water-soluble vitamins-B, C -readily excreted in urine so needs frequent intake -Folic acid -need 50% more folic acid than nonpregnancy -400-800 mcg daily -CDC-50-70% of NTD (neural tube defect) & anaencephaly with adequate folate

d.

e.

f.

B.

Weight gain 1. 1st trimester-5 lbs (1-2 kg) 2nd-3rd trimester-1 lb/week (0.44 kg/week) 2. normal BMI-11.5-16 kg (25-35 lbs) underweight-12.5-18 kg (28-40 lbs) overweight-7-11.5 kg (15-25 lbs) obese-7 kg ( 15 lbs) 1st trimester-development of fetal tissues 2nd and 3rd trimester-growth of fetal tissues

3. C. D.

Cultural differences Nutritional risk factors 1. Vegetarian 2. Pica 3. Lactose Intolerant 4. Anorexia/Bulimia 01/13

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1 Fetal Assessment Lecture 8 I. The High Risk Pregnancy A. Indications for fetal diagnostic testing 1. biophysical-risk factors that originate within the mother or fetus-affect the development or function of either or both a. genetics -defective genes -inherited disorders -chromosomal anomalies -multiple pregnancies -ABO incompatibility b. nutritional status -teen moms -3 pregnancies in last 2 years -tobacco, alcohol, or drug use -inadequate or excessive weight gain -Hct less than 33% c. medical or obstetric -chronic HTN -PIH -GDM or IDDM -h/o PTL -AMA -h/o stillborn, fetal death -sickle cell -heart disease -HIV -bleeding problems 2. psychosocial-risks comprised of maternal behaviors and adverse lifestyle that have a negative effect on the health of the mother and/or fetus a. smoking b. caffeine c. alcohol d. drugs e. psychologic status -h/o physical/verbal abuse -inadequate support systems -noncompliance with cultural norms -situational crises

108

2 -unsafe cultural, ethical, or religious practices sociodemographic-risks arise from the mother and her family and place the mother and fetus at risk a. low income b. lack of PN care c. age d. parity e. marital status f. residence g. ethnicity environmental-risks include hazards of the workplace and the womans general environment a. infections b. radiation c. chemicals d. therapeutic drugs e. illegal drugs f. industrial pollutants g. smoke, stress, diet

3.

4.

B.

Nursing Interventions 1. Complete PN interview with history 2. 3. 4. 5. Offer access to services for health promotion Discuss reasons for health diet and lifestyle practices Emphasize need to keep PN visits and do lab work Educate patient/partner to play an active role in health of the mother and fetus

II.

Fetal diagnostic tests A. Biophysical Assessment 1. Daily fetal movement count a. simple, noninvasive, done at home b. can be affected by fetal sleep cycle or maternal drug use c. presence of fetal movement is generally a sign of good health d. < 10 movements in 3 hours, CALL MD e. 2 hours after a meal and still < 4, CALL MD f. follow up with NST, CST, or biophysical profile

109

2.

ultrasound a. indicators -gestational age -multiple gestations -fetal growth patterns -fetal congenital anomalies -placental position and maturity -affects of disease process on the fetus -assess fetal responses to intrauterine environ. -assist with amniocentesis, CVS, fetoscopy, etc. b. data -reflections of echoes that are produced when sound waves are dispersed to and absorbed by tissues being scanned -no recognizable risks to mother or baby -full bladder helps to lifts up the uterus -transvaginal probe 1. allows for better visualization of pelvis 2. good to use on obese patients 3. allows pregnancy to be determined earlier 4. well tolerated, no full bladder 5. helps detect ectopic pregnancies 6. used in adjunction with abdominal scan to R/O PTL in 2nd & 3rd trimesters -abdominal scan 1. full bladder helps move uterus up 2. may be hard to use on obese pts. 3. more useful after 1st trimester -fetal heart activity by 6-7 week by echo scanner -gestational age 1. gestational sac dimensions-8 weeks 2. crown-rump length-7-14 weeks 3. biparietal diameter (BPD)-12+ weeks 4. femur length-12+ weeks -amniotic fluid volume (AFV or AFI) 1. ck fluid-filled pockets without fetal parts or cord 2. AFI-depth of fluid in all 4 quads -< 5cm=oligo -5-19 cm=normal -over 20 cm=poly

110

3. 4. 3.

decreased AFV-largest pocket of fluid is <2 cm increased AFV-multiple large pockets of fluid > 12 cm

MRI-magnetic resonance imaging a. noninvasive, no known effect on fetus b. evaluate fetal growth c. evaluate fetal structure d. evaluate placental growth, position e. AFV f. maternal structures g. biochemical status h. soft tissue, metabolic, or functional malformations

B.

Biochemical Assessment 1. Amniocentesis a. transabdominal insertion of a needle into uterus b. done after week 14 when uterus is in the abd. c. indications for: -PN diagnosis of genetic disorders collection of fetal cells in fluid karyotype done AFP level-possible neural tube defect -congenital anomalies -assessment of lung maturity L/S ratio of 2:1 or +PG or LBC >50,000 cts/UL -dx fetal hemolytic disease d. complications -less than 1% of cases -PTL/miscarriage -infection -hemorrhage(Rh moms get Rhogam) -amniotic fluid embolism -injury to fetus/fetal death 2. PUBS-percutaneous umbilical blood sampling a. also known as cordocentesis b. used during 2nd or 3rd trimester c. used for blood sampling or transfusion d. insert needle into fetal vessel using U/S e. used to dx fetal blood disorders, karyotype, blood type, and coombs

111

5 f. 3. assess FHR for 1 hour and rescan in 1 hour

CVS-chorionic villus sampling a. done at 10-12 weeks b. remove small tissue from fetal portion of placenta c. indicative of fetal genetic makeup d. use transcervical or transabdominal approach e. complications -abortion -infection -bleeding f. Rhogam given to Rh moms g. 90% of procedures done on women > 35 yrs old h. because done early, cant detect neural tube defects maternal blood sampling a. California Prenatal Screening Program -see booklet for blood test and U/S offered b. Coombs -test for Rh incompatibility -indirect=amt. of Rh+ antibodies in moms blood -direct=presence of antibody-coated Rh+ RBCs in babys blood -determine severity of fetal anemia from hemolysis

4.

C.

Electronic fetal monitoring 1. Nonstress test-(NST) a. healthy fetus with intact CNS, 90% will have FHR accelerations with gross body movements b. blunted by hypoxia, acidosis, drugs, fetal sleep c. reactive if: -normal baseline rate -2 or more accelerations (15X15) in 20 min. -moderated variability d. nonreactive or unsatisfactory -need further monitoring, consider CST/BPP 2. contraction stress test-(CST) a. provides a warning of fetal compromise earlier than NST b. U/Cs decrease uterine blood flow/placental perfusion-hypoxia to fetus=deceleration in FHR c. FHR is monitored for at least 15 minutes d. nipple-stimulated CST

112

6 -massage nipple until contraction is elicited -desire 3 U/Cs/10 minutes/lasting 40-60 sec oxytocin-stimulated CST -IV infusion of oxytocin to start U/Cs -increased in 0.5 mU/min increments negative results -no late decels positive results -persistent and consistent late decels with more than half the contractions

e. f. g.

3.

fetal oxygen saturation a. FSpO2 may be helpful in differentiating fetal hypoxia b. adjunct to EFM c. normal FSpO2 may prevent unnecessary interventions when a nonreassuring FHR pattern is identified d. ROM is needed e. signal error if improperly placed, too hairy, or too much vernix f. normal FSpO2 during labor is between 30-70%

D.

Biophysical profile 1. noninvasive dynamic assessment of fetus/environment 2. assessing 5 variables a. fetal breathing movements -normal (2)-one or more episodes in 30 min lasting > 30 seconds -abnormal (0)-absent or no episode matching requirement above b. gross body movements -normal (2)-3 or more movements/30 min -abnormal (0)-none or less than 3/30 min c. fetal tone -normal (2)-1 or more active extension with return to flexion -abnormal (0)-slow extension with return d. reactive fetal heart rate -normal (2)-2 or more accels with +FM/20 min -abnormal (0)-less than requirement e. qualitative amniotic fluid volume -normal (2)-1 or more pockets of fluid > 1 cm in

113

7 2 perpendicular planes -abnormal (0)-pockets absent or below needed 3. score a. normal = 8-10 if AFI ok b. equivocal = 6 c. abnormal = <4

E.

Role of the Nurse in Fetal Assessment Testing 1. support person when the woman is undergoing exams such as U/S, amnio, PUBS, CVS, etc 2. 3. in some settings, the RN will perform the NST, CST, BPP, and basic U/S patient teaching a. preparation for procedure b. interpreting the findings d. providing psychosocial support PRN

F.

Electronic FHR assessment 1. FHR tracing-assessment and interpretation a. baseline -range of FHR in a 10 minute period in the absence of or between U/Cs -110-160 bpm b. variability -98% accuracy in predicting fetal well-being -result of fetal sympathetic/parasympathetic nervous systems -can be affected by fetal sleep cycle, maternal analgesics, prematurity, congenital anomalies -decrease in variability-possible sign of fetal distress or profound compromise c. bradycardia -FHR below 110 bpm for 10 minutes or more -indicative of fetal hypoxia d. tachycardia -FHR over 160 bpm for 10 minutes or more -marked tachycardia > 180 bpm -prematurity -mild hypoxia -tocolytic agents -maternal fever

114

8 -maternal anemia -fetal activity changes in FHR -accelerations-usually assoc. with + FM -decelerations-early, late, variable

e.

2.

nursing role a. record information on strip if unable to chart b. vaginal exams c. assess if ROM d. VS assessments e. position changes when needed f. oxygen via mask g. medications h. emesis control i. assess need for internal monitors deceleration patterns a. early-rarely below 110 bpm -periodic decels R/T intense fetal head compression -uniform shape, mirror image of U/C b. late -uniform-reflects shape of contraction -onset after peak of U/C -repetitious -cause-uteroplacental insufficiency -hypotension -PIH -hypertonic contractions -abruptio -postmaturity -IUGR -DM -action -oxygen -position change -stop pitocin drip -IV hydration -assess other S & S c. variable -U or V shaped -with or without U/C -R/T cord compression -usually transient, changeable -action change to side lying oxygen external fetal manipulation SVE knee-chest position amnioinfusion if ROM

3.

115

9 Pregnancy at Risk IV. Disorders Causing Bleeding in Early Pregnancy A. hemorrhage during pregnancy 1. emergent situation-complicates 1 in 5 pregnancies 2. 3. 4. B. during the first half-usually result of SAB, ectopic, molar or incompetent cx during the second half-usually placenta previa, placenta abruptio risk for maternal exsanguination with 8-10 minutes r/t uterine blood flow is 650 ml/min (15% of CO)

spontaneous abortion 1. pregnancy that ends before 20 weeks 2. 3. 4. or fetal weight less than 500 gms incidence-10-15% of all pregnancies early-occurring prior to 12 weeks a. 50% causation from chromosomal abnormalities b. 80% occur within the first 12 weeks c. other causes -endocrine imbalance (IDDM) -immunological factors (antiphospholipid antibodies) -infections (chlamydia, bacteruria) -systemic disorders (lupus) -genetic factors late-12-20 weeks a. usually r/t maternal causes -AMA -parity -chronic infections -premature dilation of cx -reproductive tract anomalies -chronic diseases -inadequate nutrition -recreational drug use/abuse

5.

116

10 6. types a. threatened-spotting, closed cervix, cramping b. inevitable-open cervix, mod-heavy bleeding, mod-severe cramping c. incomplete-some POC retained d. complete-all POC removed e. missed-death in utero without obvious S & S diagnosed by U/S f. recurrent-3 or more clinical manifestations a. increasingly severe as gest. age increases b. before 6 weeks-increased flow like heavy menses c. 6-12 weeks-moderate discomfort, blood loss d. 12 weeks-severe pain assessment a. check PN history and hCG level b. U/S c. CBC d. blood type and Rh factor e. assess for infection plan of care a. rest and supportive care b. D&C c. D&E d. may need prostaglandins, IV, or pitocin for fetal demise teaching a. report heavy or bright red bleeding b. some scant dark discharge 1-2 weeks post c. no vaginal insertions until bleeding stops d. take entire course of abx if prescribed e. grief counseling if needed f. refer to support group

7.

8.

9.

10.

C.

induced abortion 1. elective-by request 2. therapeutic-for maternal/fetal health or disease

117

11 3. 4. primarily done in 1st trimester assessment a. informed consent b. options explored c. discuss conflicts/fears procedure a. laminaria then vacuum aspiration (D & E ) b. may use PG gel to ripen cx c. need to monitor temp. and bleeding d. may use RU486 (Mifepristone) e. may use methotrexate IM with vaginal misoprostol complications a. infection b. retained POC c. clots d. bleeding

5.

6.

D.

Ectopic pregnancy 1. fertilized ovum outside the uterus 2. 3. accounts for 2% of all pregnancies 95% occur in the fallopian tubes a. 1% ovary b. 3% abdominal cavity c. 1% cervix responsible for 10% of all maternal mortality & leading cause of infertility assessment a. bleeding b. dull, colicky pain c. tenderness d. referred shoulder pain r/t diaphragmatic irritation e. shock if ruptured f. Cullens sign-ecchymotic blueness around the umbilicus indicating hematoperitoneum

4. 5.

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12 6. diagnosis a. clinical picture sounds like other infections or diseases b. need to r/o appendicitis, SAB, etc. c. beta hCG, CBC, and U/S d. progesterone 25ng/mL=intrauterine progesterone <5ng/mL=dead fetus/ectopic procedure a. unruptured-methotrexate to dissolve residual tissue b. salpingostomy c. ruptured-laparotomy with salpingectomy plan a. b. c. d. e. f. g. teaching concerning possible procedures monitor labs-CBC, hCG, blood type, Rh administration of IV fluids/blood transfusion frequent vital signs administration of Rhogam PRN post-op teaching support groups/grief counseling

7.

8.

F.

Gestational trophoblastic disease 1. hydatidiform mole, invasive mole, and choriocarcinoma 2. 3. incidence: 1:1200, slightly higher in Asians types of hydatidiform moles: a. complete-fertilized egg whose nucleus is lost -intrauterine contents resemble bunch of white grapes-grow and enlarge uterus -no fetus, placenta, membranes, or fluid -avascular vesicles -associated with choriocarcinoma b. partial-2 sperm fertilized normal ovum, results in ambiguous parts, congenital anomalies -karyotype of 69 xxy, 69 xxx, or 69 xy -fetus with multiple anomolies etiology unknown risk factors: clomid, teenagers, women over 40

4. 5.

119

13

6.

manifestations a. early part of pregnancy uncomplicated b. dark brown vaginal discharge or bright red c. higher than expected fundal height (50%) d. associated with anemia, hyperemesis gravidarum, abdominal cramps e. PIH-9-12 weeks f. 16 weeks-passage of vesicles labs/tests a. serial hCG b. U/S plan a. suction curettage of tissue b. induction with pitocin/prostaglandins NOT recommended r/t increase risk of embolization of trophoblastic tissue c. Rhogam if needed nursing plan a. care for grief/loss b. therapeutic communication c. return for serial hCG protocol for 1 year & baseline chest x-ray to detect lung metastasis e. monitor hCG and increasing fundal height for possible choriocarcinoma-chemo/methotrexate

7.

8.

9.

V.

Disorders Causing Bleeding in Later Pregnancy A. Placenta previa 1. implantation of placenta in lower uterine segment near or over internal cervical os 2. types a. total-os totally covered when cervix dilated b. partial-incomplete c. marginal-edge extends to os but may increase during dilation d. low-lying-implanted in lower uterine segmentdoesnt reach os incidence: 0.5% of all births

3.

120

14 4. associated risk factors a. previous placenta previa (12X risk) b. previous C/S c. induced abortion d. multifetal e. closely spaced pregnancies f. AMA g. ethnic-African-American, Asians h. smoking i. cocaine manifestations a. 70% painless bleeding b. 20% uterine activity diagnosis a. transabdominal ultrasound b. requires C/S c. ck NST, BPP, fetal lung maturity d. bed rest PRN e. observation for FHR, vaginal bleeding, VS plan a. b. c. d. e. f. g. h. if term and in labor with bleeding-C/S if before 36-37 weeks-rest/observation NST, fetal monitoring monitor bleeding and vital signs monitor CBC give Betamethasone no vaginal exams do C/S later if stable

5.

6.

7.

B.

Abruptio placenta 1. premature separation of placenta, detachment of part or all of placenta from implantation site after 20 weeks gestation 2. 3. significant perinatal mortality for both fetus/mother risk factors a. HTN b. cocaine c. blunt trauma-battering, MVA d. smoking

121

15 e. f. 4. malnutrition risk of recurrence significant

classification a. Grade 1-mild separation-10-20% b. Grade 2-moderate-20-50% c. Grade 3-severe->50% clinical a. significant uterine tenderness/pain b. vaginal bleeding c. contractions d. may have no bleeding e. hypovolemic shock f. coagulopathy g. couvelaire uterus-R/T blood trapped between placenta and uterine wallhysterectomy h. DIC-disseminated intravascular coagulation i. complications-hemorrhage, shock, infection j. perinatal mortality-hypoxia in utero, PTL, SGA, neurological deficits diagnosis-U/S plan a. b. c. d. depends on gestation age, status, and mom VS, fetal monitoring, I & O, IV fluids, blood admin. betamethasone if applicable usually requires C/S-may have problems with uncontrollable bleeding

5.

6. 7.

9.

nursing care a. large bore IVs b. foley catheter c. watch for decrease in urinary output d. blood administration PRN e. monitor FHR f. monitor for pain g. monitor CBC, fibrinogen, PT, PTT h. therapeutic communication for anxiety, grief

122

16 VI. Hyperemesis Gravidarum A. Risk factors 1. less than 20 yrs old, obesity, multifetal, molar 2. B. etiology-obscure, multifactorial-may be associated with transient hyperthyroidism or elevated levels of estrogen

Priority nursing care 1. plan a. admit, place IV, keep NPO b. diet-advance as tolerated c. medications: according to need -Zofran-ondansetron HCl -Reglan-metoclopramide -Benadryl-diphenhydramine -Inapsine-droperidol -corticosteroids d. psych consult PRN 2. nursing care a. therapeutic communication b. I&O c. daily weight d. rest e. diet as tolerated f. small, frequent meals g. decrease fats and protein if not tolerated h. monitor IV site

VII.

Hypertensive disorders of pregnancy A. Background 1. HTN is the most common medical complication of pregnancy-1-5% 2. 3. 4. 5. preeclampsia complicates 2-7% of all pregnancies -14% in twin pregnancies women with chronic HTN or renal disease=25% risk for preeclampsia rate has risen since early 1990s 2nd only to emboli as cause of maternal mortality

123

17 6. predisposes mother for eclampsia, DIC, abruptio, hepatic failure, ARDS, cerebral hemorrhage maternal and perinatal morbidity and mortality are highest when eclampsia is seen early in gestation (before week 28), moms over the age of 35, multigravidas, and chronic HTN or renal disease fetus at risk from abruptio placentae, PTL, IUGR, and acute hypoxia

7.

8. B.

Risk factors 1. chronic renal disease 2. 3. 4. 5. 6. 7. 8. 10. chronic hypertension family h/o PIH multifetal gestation primigravida maternal age <19 yrs, >35 yrs diabetes Rh incompatibility obesity

C.

Classification/assessment 1. 2 basic types-chronic HTN and pregnancy-induced a. CHTN-predates the pregnancy or HTN that continues beyond 42 weeks postpartum b. PIH/GHTN-onset of HTN generally after the 20th week may occur independently or simultaneously 2. preeclampsia a. pregnant specific b. HTN after week 20 c. multisystem vasopastic disease-HTN with Proteinuria (1-2+)

124

18 d. e. f. g. 3. characterized mild or severe BP is first warning sign-140/90 pathologic edema in face, hands, or abdomen or weight gain >2 kg/week urine and BP checks need 2 + results to be classified preeclampsia

severe preeclampsia a. BP 160/110 b. > 3+ or 4+ on dipstick: 5g 24 hr urine collection c. oliguria-<400-500 ml/dy d. visual disturbances/headaches/altered LOC e. hepatic involvement f. platelets-thrombocytopenia g. pulmonary/cardiac involvement h. development of HELLP syndrome i. severe fetal growth retardation eclampsia a. onset of seizure activity in the woman diagnosed with PIH with no neurologic pathology b. may be initial sign patient has PIH HELLP-hemolysis, elevated liver enzymes, low PLT a. variant of severe preeclampsia b. appears in 2-12% of women with severe preeclampsia c. maternal mortality-as high as 24% d. seen more frequently in older women, Caucasians, and multiparous women e. 65% will have c/o epigastric/RUQ pain f. 50% will have N & V g. can be normotensive and without proteinuria h. thought to be caused by arterial vasospasms, endothelial damage, and platelet aggregation chronic HTN a. HTN before pregnancy or diagnosed before week 20 b. also considered chronic if HTN lasts longer than 6 weeks PP c. considered mild if diastolic remains below 110 d. drug of choice: Aldomet (methyldopa)

4.

5.

6.

125

19

7.

chronic HTN with superimposed preeclampsia a. BP with systolic 30 mm Hg, diastolic 15 mm Hg b. with proteinuria and generalized edema transient HTN a. development of HTN during pregnancy or in the first 24 hours post partum b. no other S & S of preeclampsia

8.

D.

Pathophysiology/etiology BPvasospams placental perfusion endothelial cell activation vasoconstriction activation of intravascular coagulation fluid cascade redistribution decreased organ perfusion 1. 2. mild preeclampsiasevere preeclampsiaHELLP or eclampsia reflects alterations in normal adaptations of pregnancy a. increase blood plasma volume b. vasodilation c. decreased systemic vascular resistance d. elevated cardiac output e. decreased colloid osmotic pressure main pathogenic factor is not BP but poor perfusion as a result of vasospasm

3. E.

HELLP syndrome 1. is a laboratory, not clinical, diagnosis a. platelets < 100,000/mm3 b. liver enzymes -AST-aspartate aminotransferase -ALT-alanine aminotransferase c. some evidence of hemolysis

126

20 -elevated bili level & burr cells on smear unlike DIC, coagulation panel normal

d.

2.

complications reported with HELLP include: a. renal failure b. pulmonary edema c. ruptured liver hematoma d. DIC e. abruptio placentae

F.

Nursing process 1. recognized risk factors 2. history a. headache b. epigastric pain c. visual disturbances assess BP, wt., edema, proteinuria, and DTRs a. edema on a scale of 0-+4 b. DTR-patella and bicep, for clonus fetal assessment uterine tonicity vaginal exam lab tests a. CBC b. clotting factors c. liver enzymes d. chem panel: uric acid, creatinine, BUN, RBS e. type and screen f. urinalysis or 24 hr proteinuria nursing diagnoses a. anxiety b. altered tissue perfusion c. knowledge deficit d. risk for impaired gas exchange e. risk for CO

3.

4. 5. 6. 7.

8.

127

21 f. g. G. risk of injury to fetus or mother ineffective coping R/T powerlessness

Pharmacology and related nursing interventions 1. mild PIH a. rest at home, on L side when possible b. teach mom to assess BP, dip urine, fetal kick count c. possible frequent NSTs d. may want to encourage low Na diet 2. severe PIH or HELLP a. immediate birth or conservative management b. labs as directed c. wt., foley, strict I & O, vag. exam, abd. palpation d. EFM e. bed rest, quiet, dark room, no visitors f. padded side rails g. suction equipment at bedside h. toxemia box in room-resuscitation meds i. continue to monitor during the intra to postpartum pharmacology a. magnesium sulfate -helps prevent or treat convulsions -interferes with acetylcholine at synapses - neuromuscular and CNS irritability - cardiac conduction -increases blood flow in uterus to protect the fetus -increases prostracylins to prevent uterine vasoconstriction -secondary infusion loading dose-4-6 gms over 20-30 min maintenance-1-3 gms/hr -mag level in 4-6 hrs (therapeutic level 4-8 mg/dl) -frequently ck RR, UO, DTRs -have calcium gluconate at bedside (antidote) -toxicity-nausea, flushing, reflexes, slurred speech, and muscle weakness -may be given IM for transport yet absorption rate isnt controlled, IM is more painful -diuresis within 24 hours is an + prognostic sign

3.

128

22 -if eclampsia develops-2-6 gms MgSO4 IV push over 3-5 minutes amobarbital sodium-sedative -250 mg slow push over 3-5 min diazepam-occasionally used -may cause phlebitis, venous thrombosis -if given too rapidly-apnea, cardiac death antihypertensives -IV hydralazine (Apresoline) -labetalol HCl, methyldopa, or nifedipine

b. c. d.

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1 Pregnancy at Risk, Part 2 Lecture 9 VIII. IX. Maternal-fetal blood incompatibilities (See High Risk Neonates) Diabetes mellitus A. Classifications 1. Type 1: pancreatic cell destruction-insulin deficient prone to ketoacidosis (acidosis R/T excessive ketones) 2. Type 2: insulin resistant, relative insulin deficiency most prevalent form of DM, etiology unknown a. develops gradually, may miss S & S (polydipsia, polyuria, polyphagia) b. increase risk if obese or fat around abdomen c. age, sedentary lifestyle, HTN, previous GDM d. runs in families Pregestational: Type 1 or 2 that exists before preg. Gestational: any degree of glucose intolerance with onset or recognition during pregnancy a. may or may not be insulin dependent b. should be reclassified 6 weeks PP

3. 4.

B.

Pathophysiology 1. Group of metabolic diseases characterized by hyperglycemia R/T defects in insulin secretion, action, or both 2. 3. Beta cellsinsulinmoves glucose into adipose and muscle cells to be used for energy or ineffective insulinhyperglycemia hypersosmolarity intracellular fluid into the vascular system blood volume excess UO with glycouria cells burns proteins/fats for energy=ketoacidosis weight loss from breakdown of fat and muscle tissues complications: retinopathy, nephropathy, neuropathy, and premature atherosclerosis

4. 5. 6.

130

7.

metabolic factors: a. 1st trimester- estrogen/progesterone= insulin production= peripheral glucose utilization b. tissue glycogen stores= hepatic glucose production (this can affect insulin needs) c. 2nd & 3rd trimesters- levels of hPL, estrogen, progesterone, prolactin, cortisol, and insulinase = insulin resistance (they are insulin antagonists) (antagonists-counteract the action of another) (synergists-enhances the action of another) d. maternal insulin requirements may double or quadruple by 36 weeks of pregnancy (leaves abundant supply of glucose for fetus)

C.

Risk factors 1. best predictor of pregnancy outcome=degree of maternal control of glucose levels 2. 3. glycemic control in early pregnancy=SAB glycemic control late in pregnancy = a. macrosomic fetus = risk birth trauma b. risk for C/S c. for PIH or preeclampsia d. risk for polyhydramniosoverdistention of uterus which can lead to PTL or PROM e. infections f. ketoacidosis (DKA)fatty acids move from fat to circulationoxidizedketone bodies into circulation blood glucose and ketones=osmotic diuresis= fluids/electrolytes, volume depletion, cellular dehydration= maternal and fetal death fetal risks a. stillborn-etiology unk, ?chronic hypoxia b. congenital anomalies (6-10% chance) -cardiac most common c. macrosomia/birth traumas d. IUGR R/T vascular disease e. RDS

4.

131

3 f. hypocalcemia, hypoglycemia, hypomagnesemia, hyperbilirubinemia, and polycythemia

D.

Nursing Process 1. Lab work a. euglycemia=65-130 mg/dl b. assessment of glycosylated hemoglobin A1c -helps assess level of hemoglobin saturated with glucose caused by hyperglycemia -good control 7% ->10 % = risk for fetal anomalies (20-25%) c. urine screen for UTI, proteinuria, creatinine clearance d. thyroid function screening 2. 3. Educate to test glucose at home-dietary changes Dietary management based on blood sugar tests -1st trimester-2200 kcal/dy -2nd and 3rd trimester-2500 kcal/dy -40-45% CHO, 12-20% protein, 35-40% fats -need bedtime snack to maintain BS level thru night Exercise after meals to prevent drop in BS Insulin therapy a. 1st trimester, insulin dosage may decrease b. oral agents may be viable solution -Glyburide (sulfonylurea) insulin secretion -doesnt cross the placenta c. 2nd and 3rd trimesters insulin resistance = insulin dosage d. Some insulin can cross the placenta e. various regimens followed f. insulin pump may be used during pregnancy g. see California Diabetes and Pregnancy Program -CDAPP -Sweet Success Fetal surveillance to monitor well-being a. NSTs, BPPs, U/S, kick counts b. MSAFP c. Fetal echocardiogram (18-22 weeks)

4. 5.

6.

132

7.

Urine testing at home a. test first morning urine b. recheck if meal missed, ill, or BS > 200mg/dl c. spilling small amounts of ketones ok d. spilling large amounts of ketones-CALL MD Intrapartum a. follow hospitals P & P b. watch for dehydration, hypo/hyperglycemia c. mainline usually D5LR with insulin on secondary infusion d. sched C/S in morning-hold AM insulin, NPO Postpartum a. insulin needs drop dramatically with removal of placenta b. several days before CHO homeostasis c. complications -preeclampsia -eclampsia -hemorrhage -infection d. breastfeeding encouraged -helps use up CHO in milk production -risk for hypoglycemia -risk for mastitis -may reduce infants risk for DM -may need to recalculate insulin dose e. discuss contraceptive methods -barrier method safest -OCs have risk of thromboembolic/vascular complications -use of IUD risks infection -tubal ligation if completed family

8.

9.

E.

Gestational Diabetes 1. 4% of all pregnancies/90% of diabetic pregnancies 2. less common in Caucasians

133

5 3. risk factors a. obese b. over age 30 c. family history d. h/o macrosomic infant e. unexplained stillbirth f. miscarriage g. having an infant with congenital anomalies screening a. 1 hour glucola-50 gram oral glucose load -considered + if >140 mg/dl b. 3-hour glucose tolerance test -fasting glucose -drink a 100 gm loading dose -ck serum and urine every hour -+GDM if 2 or more of the results are elevated fasting = 95 1 hour = 180 2 hour = 155 3 hour = 140

4.

X.

Preexisting cardiac disease A. Overview 1. CV changes that occur normally with pregnancy can affect women with cardiac disease a. intravascular volume b. systemic vascular resistance c. change in CO d. change in intravascular volume postpartum 2. cardiac disease complicates 1% of all pregnancies a. leading cause of non-OB maternal mortality b. 4th ranking cause of maternal death some of the more common cardiac diseases a. mitral stenosis b. mitral valve prolapse -use Inderal if symptomatic, ie: chest pain -use abx if having regurgitation c. congenital heart defects, i.e. septal defect d. periparum cardiomyopathy -dysfunction of the L ventricle -seen in last month of preg or 1st 5 months PP

3.

134

6 -mortality rate of 25-50 % -tx-treat the symptoms B. Classifications 1. Class I: Asymptomatic at normal levels of activity mortality = 1% a. corrected Tetralogy of Fallot b. pulmonic/tricuspid disease c. mitral stenosis (class I, II) d. septal defects 2. Class II: Symptomatic with increased activity mortality = 5-15% a. mitral stenosis with atrial fibrillation b. artificial heart valves c. mitral stenosis (class III, IV) d. uncorrected Tetralogy of Fallot e. aortic coarctation (uncomplicated) f. aortic stenosis Class III: Symptomatic with ordinary activity mortality = 25-50% a. aortic coarctation (complicated) b. myocardial infarction c. Marfans syndrome d. true cardiomyopathy e. pulmonary HTN Class IV: Symptomatic at rest

3.

4. C.

Nursing Process 1. medical care is multidisciplinary 2. educated R/T S & S of cardiac decompensation a. subjective -increasing fatigue -difficulty breathing -frequent cough -palpitations -swelling of face, feet, legs, fingers b. objective -irregular, weak, rapid pulse, over 100 -progressive, generalized edema -crackles at base of lungs

135

7 -orthopnea -tachypnea, over 25 -moist, frequent cough -increasing fatigue -cyanosis of lips and nail beds 3. 4. 5. 6. 7. identify areas that may lead to stress identity coping mechanisms support groups consultation with dietician watch for S & S of thromboembolism a. redness b. swelling c. tenderness e. pain avoid constipation and straining for BM report any S & S of infection keep all PN appts. may be put on prophylactic abx labs/studies a. CBC, chem panel b. ECG c. chest x-rays d. EFM medications a. heparin for anticoagulation-doesnt cross placenta b. coumadin-contradindicated-teratogenic c. abx- risk of bacterial endocarditis d. diuretics to treat CHF e. digitalis for arrhythmias and heart failure intrapartum a. side lying or semi-fowlers b. O2 via mask

8. 9. 10. 11. 12.

13.

14.

136

8 c. d. e. f. g. h. i. 15. diuretics to fluid retention prophylactic abx encourage pain meds to decrease stress-Epid. monitor FHR and maternal may use vacuum to shorten 2nd stage no ritodrine/terbutaline for tocolysis -may cause myocardial ischemia no methergine

postpartum a. 1st 24-48 hours most important for hemodynamic stability b. bed rest, asst. with ADLs as needed c. prevent constipation d. breastfeeding may be contraindicated in higher classifications of disease

XI.

Anemias A. Iron deficiency anemia 1. most common a. < 11 g/dl in 1st b. < 10.5 g/dl in 2nd c. < 11 g/dl in 3rd 2. 3. iron for fetus comes from maternal serum oral iron supplements-30-60mg/dy a. clinical-325 mg ferrous sulfate tablets b. metabolized better with Vit. C risk to fetus a. LBW b. preterm c. perinatal mortality-maternal Hbg < 6g/dl

4.

B.

Folic acid deficiency anemiamegaloblastic anemia 1. increases risk for neural tube defect, cleft lip/palate 2. 3. recommended daily intake 400 microgram/day enriched foods have additional folic acid

C.

Sickle cell anemia-recessive autosomal disease

137

9 1. 2. abnormal hemoglobin in the blood recessive, hereditary, familial hemolytic a. African-Americans (10% have trait) b. Mediterranean ancestry crisis: fever, pain in abdomen, extremities a. attacks R/T vascular occlusion, tissue hypoxia, edema, RBC destruction, and organ failure b. associated with jaundice, normochromic anemia, reticulocytosis, + sickle cell test, and demonstrated abnormal hemoglobin maternal/fetal risks a. pyelonephritis b. bone infection c. heart disease d. PIH e. fetal loss due to impaired oxygen supply tx: a. b. c. d. folic acid-1mg/day abx as needed O2 and IVs SCDs postpartum

3.

4.

5.

XII.

Maternal infections Pages 352-357 KNOW: Type of organism, S/S, tx, and implications for pregnancy and fetussuch as: T-toxoplasmosis-retinochoroiditis, convulsions, microcephaly O-others-Hepatitis, HIV, syphilis-infection, SAB, R-rubella-DM, hearing loss, glaucoma, encephalitis C-cytomegalovirus-90% of survivors have neurological problems H-herpes simplex-hyper/hypothermia, jaundice, seizures Psychosocial problems during pregnancy A. Preexisting psychiatric illness-effect on pregnancy 1. women with bipolar disorder, schizophrenia, or chronic depression may be on psychotropic meds that can cross the placenta or be found in breast milk

XIII.

138

10 2. 3. need to weigh the benefits of therapy to risks to mom and fetus fetal risks to medications a. congenital anomalies b. tremors c. hypertonicity d. weakness e. poor sucking

B. C.

Abuse-pp. 108, 352 Substance abuse-pg. 302 1. barriers to tx a. little understanding how drug effects fetus or pregnancy b. delay seeking PN care c. stigma, shame, guilt d. conceal abuse 2. legal considerations a. risk to unborn may = criminal charges to mom b. may be arrested, jailed, housed in psychiatric hospital for rest of the pregnancy c. baby may be give to child protective services risks a. b. c. d. e. f. g. 3. SAB, preterm birth, IUGR, neonatal addiction, neonatal neurobehavioral handicaps, AIDS, fetal and maternal death alcohol-FAS cocaine-a. placenta, PTL, SGA, microencephaly heroin-PTL, PROM, IUGR, convulsions speed-PTL, IUGR, head circumference, altered sleep patterns smoking-SIDS, LBW, pediatric allergies, respiratory dysfunction caffeine-IUGR, LBW

3.

case management a. find out about pt.s environment, past drug use, current drug use, and support systems b. drug testing-blood and urine -alcohol can go undetected in urine

139

11 c. d. e. f. g. can test neonates hair or meconium to analyze past drug usage screen for h/o physical abuse or psychosocial problems determine need for womens health services, social services, and education for family support groups, i.e. AA alcohol withdrawal tx -benzodiazepines (psychotropic-sedative) -nutritional follow-up -psychotherapy methadone (synthetic opioid) controversial -impaired blood flow to placenta -detrimental fetal effects -stronger withdrawal symptoms for neonate compared to heroin

h.

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1 Complications of Labor and Delivery Lecture 10 I. Dysfunctional Labor A. Alterations in contraction patterns and quality 1. Hypertonic Uterine Dysfunction a. usually in latent phase, before 4 cm b. cause unknown, maybe R/T anxiety/fear c. assessment -pain out of proportion to intensity of U/C -U/Cs in frequency but uncoordinated d. risk to mom -loss of control -exhaustion e. risk to fetus -asphyxia -passage of meconium f. tx -analgesia -rest for mom g. after 4-6 hours rest, usually awaken in normal labor pattern 2. Hypotonic Uterine Dysfunction a. causes -pelvic contracture -fetal malpresentation -overdistention of uterus -unknown b. assessment - in U/C frequency and intensity -during the active phase of stage 1 -uterus easily indentable between U/Cs c. risk to mom -infection -exhaustion d. risk to fetus -infection -death e. tx -r/o CPD -labor augmentation -amniotomy -change position, ambulation, shower

141

Inadequate expulsive effort (secondary powers) a. causes -regional anesthesia -analgesia -exhaustion -lack of urge to push b. risk to mom -surgery (C/S) c. risk to fetus -asphyxia d. tx -change position -coaching -lower epidural strength or D/C -vacuum-asst. -C/S ***See Table 18-1 for a list of complications B. Fetal malpositions and malpresentations 1. anomalies a. affect relationship of fetal anatomy to the maternal pelvic capacity 2. CPD-cephalopelvic disproportion a. R/T macrosomic infants b. maternal causes -pelvis too small -pelvis abnormally shaped -pelvic deformity malpositions a. usually persistent OP (LOP or ROP) b. prolonged second stage c. usually c/o severe back pain d. may be able to change fetal position -knee chest position -squats -lunges -pelvic rocking -rolling side to side

3.

3.

142

3 4. malpresentation a. breech most common -frank-thighs flexed, knees extended -complete-thighs and knees flexed -incomplete one foot below the buttock or one knee below the buttock b. breech presentations associated with: -multifetal gestations -preterm birth -fetal and maternal anomalies -hydramnios c. risk of prolapsed cord d. might attempt vaginal delivery in multiparas e. face/brow presentations -uncommon -associated with fetal anomalies or pelvic contractures -may need forcep delivery f. if external version fails to rotate a breech or shoulder presentation = C/S

C.

Pelvic alterations 1. pelvic dystocia a. contractures (fibrosis of connective tissue in skin, fascia, muscle, or a joint capsule) of the pelvis b. deformities from MVA, traumas c. immature pelvis in teens 2. soft tissue dystocia a. placenta previa b. leiomyomas (fibroids) c. full bladder or rectum d. cervical edema e. Bandls ring (pathologic retraction ring) at the junction of the lower and upper uterine segments

D.

Psychological alterations 1. stress can slow or stop dilatation -pain and lack of support stress level -confinement in bed may make pt feel trapped 2. stress can increase pain perception

143

4 3. stress-related hormones act on smooth muscle a. beta-endorphins, epinephrine, cortisol, etc b. decrease uterine contractility

E.

Alterations in the length of labor 1. prolonged labors more frequent with moms over 40 2. abnormal labor patterns can occur because of: a. CPD b. ineffective U/Cs c. pelvic contractures d. malpresentation of fetus e. analgesia/anesthesia f. anxiety/stress precipitous labor/delivery a. labor less than 3 hours from start of U/Cs b. maternal complications -uterine rupture -lacerations -amniotic fluid embolism -PP hemorrhage c. risk to fetus -hypoxia -intracranial hemorrhage -bruising of head/face nullips >20 hrs <1.2 cm/hr >2 hrs <1 cm/hr >1 hr multips >14 hrs <1.5 cm/hr >2 hrs <2 cm/hr >1/2 hr

3.

pattern prolonged latent phase protracted active phase dilation secondary arrest: no change protracted descent arrest of descent failure of descent precipitous labor

No change in second stage >5 cm/hr 10 cm/hr

144

5 F. Related nursing interventions 1. support mother and family 2. 3. II. monitor mother/fetus pitocin augmentation/vacuum/C/S

Complications of the labor process A. Premature rupture of membranes (PROM) 1. ROM 1 hour before onset of labor 2. 3. PPROM-occurs before 37 weeks gestation cause unknown-possibly R/T infection a. chorioamnionitis b. life threatening to fetus and mom -mom-sepsis, death -fetus-pneumonia, sepsis, meningitis discuss ROM protocol a. kick counts/EFM c. ck AFI b. d. ck GBS status r/o prolapsed cord

4.

B.

Preterm labor-cervical change and U/Cs between 20-37 wks Preterm birth-completion of pregnancy before wk37-pg 347 1. risk factors a. demographic -African-American -<17 yrs old, >34 yrs old -low SES -unmarried -low level of education b. medical risks predating pregnancy -h/o PTL-triples the risk -multiple abortions -uterine anomalies -parity-0 or >4 -low prepregnancy weight -diabetes -HTN c. medical risks with pregnancy -multiple gestation -infection -incompetent cervix -UTIs -short interval between pregnancies -bleeding -anemia -placenta previa/abruptio -fetal anomalies -PROM

145

6 d. behavioral/environmental risks -DES (diethylstilbestrol) exposure -smoking -poor nutrition -substance abuse -late on no PN care other risks -anxiety/stress -uterine irritability -long working hours -inability to rest

e.

2.

predicting PTL a. fetal fibronectin-biochemical marker -glycoproteins-found in plasma -appear in cervical canal early/late in preg. -appearance between 24-34 weeks gest. is an indicator for PTL -negative predictive value=95% -positive predictive value=25-40% -easier to predict who will not have PTL -expense=$180-215 b. salivary estriol-biochemical marker -form of estrogen produced by fetus and present in plasma by 9 weeks -levels have been shown to before PTL -negative predictive value=98% -positive predictive value=7-25% -expense=$90 each test c. endocervical length -lengths less than 30 mm in singleton may predict risk for PTL causes of PTL a. unknown and thought to be multifactorial b. infection major etiological factor c. 25% are iatrogenic-intentionally delivery of fetus -R/T health of fetus/mom d. 25% R/T PROM followed by labor e. 50% idiopathic (conditions without recognizable cause) preterm births assessment a. contractions <10 minutes apart in frequency b. persistent cramping c. clear, pink, or brownish discharge d. pressure in vagina or low back

3.

4.

146

7 e. f. g. 5. diarrhea cervical effacement >80% 1 cm dilated

pt. education a. bed rest-no studies have proven its efficacy -wt. loss -loss of muscle tone -calcium loss -fatigue -depression -constipation b. notify MD of changes in S & S c. home uterine activity monitoring d. discuss lifestyle adaptations-need to -sexual activity -heavy lifting -long drives -standing more than 50% of the time -climbing stairs -not stopping when tired pharmacology a. tocolytics -magnesium sulfate CNS depressant can cause respiratory depression flushing, N & V, DTRs and BP -terbutaline/ritodrine beta-adrenergic receptor stimulant helps with hypertonic contractions tachycardia, palpitations fetal tachycardia -nifedipine calcium channel blocker headache, hypotension -indomethacin prostaglandin inhibitor risk of closure of ductus arteriosus risk of NEC or IVH

6.

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8 b. antenatal glucocorticoids -betamethasone-12 mg IM X 2 doses 24 hrs apart -dexamethasone-6 mg IM 2 doses 12 hrs apart stimulate lung maturity promote release of enzyme to induce surfactant production can cause maternal infection, pulmonary edema can worsen HTN or GDM

III.

Intrapartum emergencies A. Placental abnormalities 1. adherent retained placenta a. placenta accreta -cotyledons invaded uterine muscle b. placenta increta -chorionic villi invade the myometrium c. placenta percreta -invasion of myometrium to the serosa of the peritoneum covering of uterus -can lead to rupture of uterus 2. 3. abruptio placenta vasa previa -velamentous insertion-cord attached to membranes -no Whartons jelly -vessels exposes to laceration -high incidence of fetal mortality -Dx with U/S, palpation of vessels succenturiate -accessory lobes of fetal villi developed -vessels supported only by membranes risk of retained POC -fetal blood loss if vessel nicked battledore -insertion at or near placental margin rather than center -increased risk of fetal hemorrhage

4.

5.

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9 B. Prolapsed umbilical cord 1. umbilical cord lies below the presenting part 2. 3. 4. may be occult and occur even with intact BOW frank prolapse occurs with SROM-1 out of 400 births contributing factors a. long cord->100 cm b. malpresentation c. transverse lie d. unengaged presenting part risk to fetus a. hypoxia b. CNS damage c. Death care management a. hold presenting part off cord b. knee-chest or Trendelenburg position c. delivery -possible forcep/vacuum if 10 cm -usually stat C/S

5.

6.

C.

Uterine rupture 1. causes of rupture a. previous uterine scar -classical C/S -myomectomy b. uterine trauma c. congenital uterine anomalies d. multiparas e. intense spontaneous U/Cs f. hyperstimulation of uterine muscle g. overdistented uterus h. malpresentation i. external/internal version j. forceps 2. classifications a. complete -extends through the entire uterine wall into the peritoneal cavity/broad ligament

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10 b. incomplete -rupture extends to peritoneum but not into the peritoneal cavity/broad ligament

3.

S & S-may be silent or dramatic a. nonreassuring FHR b. vomiting c. fainting d. uterine tenderness e. sudden, sharp shooting pain f. hypovolemic shock g. hypotonic U/Cs h. lack of progress i. shoulder pain j. palpable fetal parts prevention a. no VBACs with classical uterine scar b. assess womans risk factors c. prevent hyperstimulation d. use of tocolytic drugs case management a. prepare pt for surgery-C/S, possible hysterectomy b. IV/oxygen c. type and cross for possible blood transfusion d. therapeutic communication/support e. fetal mortality>80% f. maternal mortality-50-75%

4.

5.

D.

Uterine inversion 1. classifications a. complete-protrudes b. incomplete-smooth mass palpated thru cervix 2. risk factors a. fundal implantation of placenta b. leiomyomas c. vigorous fundal pressure d. abnormally adherent placental tissue S&S a. shock & pain b. hemorrhage (loss of 800-1800 ml)

3.

150

11 4. interventions a. manual replacement b. oxytocin c. need for surgery is rare

E.

Amniotic fluid embolism 1. amniotic fluid with particles enters maternal circulation and obstructs pulmonary vessels 2. 3. 4. caused by opening in amniotic sac or maternal uterine vein with intrauterine pressure forcing fluid into vein maternal mortality=85%/fetal mortality=50% risk factors a. multiparity b. tumultuous labor c. abruptio placenta d. oxytocin induction e. fetal macrosomia f. fetal death in utero g. meconium passage case management a. assess for manifestations of RDS -restlessness -dyspnea -cyanosis -pulmonary edema -respiratory arrest b. assess for shock -hypotension -tachycardia -cardiac arrest -hemorrhage -uterine atony c. oxygenate-10 L d. intubate/bag with 100% oxygen e. CPR-30 degree angle of uterus f. IVs g. blood transfusion/tx coagulation defects h. foley catheter i. prepare for possible C/S j. emotional support/counseling if death occurs

5.

151

12

F.

Trauma 1. leading nonobstetric reason for maternal mortality 2. 3. 4. all female victims of childbearing age to be considered pregnant until proven otherwise 70% R/T MVAs (lack of seatbelt)-head injuries and shock physiological differences with pregnant women experiencing trauma a. physical observation less reliable b. CO can tolerate 1000ml blood loss c. no indicators until blood loss > 1500-2000 ml d. clinical signs dont appear until 30% of loss of circulating volume e. maternal pulse over 100 bpm=abnormal types of trauma a. blunt abdominal trauma -MVA, battering, falls, exsanguination -fetal skull fx or ICH -ck for abrupted placenta -pelvic fx can cause injury to fetus -uterine rupture rare b. penetrating abdominal trauma -bullet, stab wound -direct fetal injury from bullet, requires surgery -fetal injury from stab wound -better chances if injury occurs in upper maternal abdomen c. thoracic trauma-25% of trauma deaths -maternal life threatened by pulmonary contusion -can cause pneumo/hemothorax fetal death R/T maternal death or abrupted placenta a. C/S needed in most cases b. if maternal death occurs, C/S within 20 minutes other causes of trauma: burns, assaults complicates 8% of all pregnancies

5.

6.

7. 8.

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13

9.

tx: supportive care a. ABCs b. oxygen 10-12 liters c. large bore IVs-14-16 gauge f. LR or NS 3:1 ratio- 3 ml for every 1 am EBL over 30-60 minutes g. may give O negative if type unknown h. lateral positioning i. assess Glasgow coma scale j. focus on abdomen k. insert NG tube l. check for abrupted placenta m. fetal assessment testing-U/S n. peritoneal lavage-ck for blood, if +, laparotomy -if -, LR infused thru cath/fluid ck for cell count o. Rh negative women get Rhogam

G.

Shoulder dystocia 1. increase risk of maternal/fetal morbidity/mortality 2. 3. 4. 5. 6. fetal head is born but anterior shoulder cant pass under pubic arch fetopelvic disproportion or maternal pelvic abnormalities may be the cause may use McRoberts maneuver-legs flexed, knees on abdomen may use Gaskin maneuver-all-fours-hands and knees may use Mazzanti or Rubin techniques to deliver shoulder a. RN assists with the suprapubic pressure b. assess newborn for fx of clavicle/humerus c. assess mom for hemorrhage

IV.

Obstetrical Instrumentation and Procedures A. Amniotomy-AROM (artificial rupture of membranes) 1. most frequently used method of labor induction 2. induces labor when cervix is favorable or augments a slowing labor progress

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14

3. 4. 5. 6. 7. B.

labor usually begins 12 hours post rupture-if prolonged, can lead to infection-Ck temp q 2 hours can be used in combination with oxytocin explain to pt that procedure is painless but might feel increase in vaginal pain R/T movement of fetus presenting fetal part must be engaged in pelvis and applied to cervix to prevent cord prolapse assess color, odor, consistency and quantity of fluid

Induction and augmentation of labor 1. chemical agents a. PG gel-prostaglandin gel Cervidil/Prepidil/Prostin E2-dinoprostone -helps to ripen (soften and thin) cervix -may initiate labor without further medications -may be used to terminate pregnancy -adverse reactions headaches, N & V, diarrhea, fever hypotension, hyperstimulation of uterus fetal passage of meconium b. Cytotec (misoprostol)-synthetic prostaglandin E1 -not FDA approved for cervical ripening c. oxytocin -hormone produced by posterior pituitary gland -stimulates uterine contractions -used to induce or augment labor -indications for use suspected fetal jeopardy dystocia postdates maternal medical problems fetal demise -contraindications for use CPD, cord prolapse, transverse lie nonreassuring FHR placenta previa or vasa previa classical uterine incision active genital herpes invasive CA of the cx

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15 d. e. f. 2. infusion done on IV pump watch for hyperstimulation assess fetal well being and maternal pain level

mechanical methods a. dilators b. amniotomy

C.

Version 1. external a. attempt to rotate fetus from a malpresentation b. usually done at or after 37 weeks c. U/S scanning before to ck fetus and placenta d. may use a tocolytic agent like terbutaline e. obtain informed consent-usually done in L & D due to risk of complications f. MD or CNM give gentle, constant pressure to abdomen to rotate presenting fetal part g. Rh moms may receive Rhogam due to the risk of fetomaternal bleeding 2. internal a. MD inserts hand into the uterus and changes position or presentation b. may be used in multifetal pregnancies to rotate second fetus c. maternal/fetal injury possible d. RN role to monitor FHR and support mother

D.

Episiotomy 1. incision in the perineum to enlarge the vaginal outlet 2. types a. median-midline -most commonly used -effective, easily repaired -can possibly extend into rectum b. mediolateral -prevents 4th degree laceration -repair most difficult -more pain to mom

155

16 3. pros prevents tearing decreases stage 2 enlarges vagina cons lacerations can occur pain/discomfort lateral position can control head

4. E.

less rate of episiotomies with CNM vs. MD

Forceps 1. uses paired curved blades to asst. delivery of head 2. maternal indications for use a. second stage arrest b. cardiac moms c. poor pushing effort/fatigue/anesthesia fetal indications for use a. distress b. abnormal presentation-asynclitic c. delivery of head during breech delivery conditions a. fully dilated b. empty bladder c. engaged presenting fetal part d. vertex e. ROM f. No CPD care management a. assess FHR before and after delivery b. Pedi MD at delivery c. assess mother for lacerations, urinary retention d. assess baby for facial bruising, abrasions, palsy

3.

4.

5.

F.

Vacuum 1. attachment of vacuum cup and use of negative pressure 2. 3. indications/conditions the same as use of forceps follow hospitals P & P R/T method, suction pressure, duration, and charting

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17 4. G. newborns-ck for caput, cephalohematoma, scalp laceration

Surgical Birth 1. birth of the fetus thru a transabdominal incision in the uterus 2. 3. 4. 5. 6. term cesarean from Latin caedo-to cut C/S rate-20-30%-higher in women over the age of 35 rate of VBACs had lead to C/Ss but might purpose to preserve health or life of mom or baby in C/S rate R/T a. increased EFM b. epidural use d. of repeat C/S e. AMA moms f. private insurance/private hospitals g. moms with high SES indications for C/S a. fetal distress/intolerance of labor b. CPD/malpresentation/malposition c. placental abnormalities d. umbilical cord prolapse e. dysfunctional labor pattern/first stage arrest f. multiple gestation g. active genital herpes h. uncontrolled HTN i. PIH/preeclampsia type of incisions a. skin-vertical or horizontal (Pfannenstiel, bikini) b. uterus-vertical (classical), low vertical, and horizontal (low transverse) -classical-faster to perform, is performed in other countries, contraindication for VBAC -transverse-easier, less blood loss, decrease risk for infections, less likely to rupture, may attempt VBAC with next pregnancy

7.

8.

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18 9. risks/complications a. aspiration b. pulmonary embolism c. wound infection d. wound dehiscence e. thrombophlebitis f. hemorrhage g. UTI h. injury to bladder or bowel or fetus i. anesthesia complications j. decreased satisfaction with the birth process k. loss of ability to accomplish vaginal deliveries l. increase financial expense m. longer hospital stay n. bonding and breastfeeding may be delayed types of anesthesia a. regional blocks -epidural-most common, feel pressure, no pain -spinal-no pain or pressure b. general -higher risk of complications pre/intra/postoperative care-in the textbook

10.

11.

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1 Complications of the Puerperium Lecture 11 1. Postpartum Hemorrhage A. Definition/Risk factors 1. 500 ml or more blood loss after a vaginal delivery 2. 3. 4. 5. 1000ml or more blood loss after a C/S delivery 10% change in Hct from admission to PP or need for transfusion early PP hemorrhage-in the first 24 hours a. uterine atony -marked hypotonia -90% of PPH cases R/T atony -associated with overdistended uterus mag. Sulfate trauma anesthesia infections prolonged oxytocin usage rapid/prolonged labor b. retained placenta c. placenta accreta d. uterine rupture e. uterine inversion f. lower genital tract lacerations -cervix, vagina, perineum 1st-4th degree laceration of perineum -associated with precipitous delivery operative birth congenital anomalies contracted pelvis infection varicosities (distended, swollen veins)

159

g.

h. i. 6.

hematomas-collection of blood in connective tissue -vulvar-most common, visible, painful -vaginal-assoc. with forceps, episiotomy -subperitoneal-life threatening-assoc. with uterine artery branches/vessels in the broad ligament -cervical-usually shallow, min. bleeding infections coagulopathies

late PP hemorrhage-after 24 hrs to 6 weeks PP a. subinvolution of the uterus -delayed return of the enlarged uterus to normal size -caused by infection, retained placenta -S & S: prolonged lochia, excessive bleeding palpable boggy uterus, fundal height greater than expected b. retained POC c. endometritis dark blood-probably venous-varices/superficial lac. bright red blood-arterial-deep laceration of cx

7. 8. B. C.

Complication-Hypovolemic shock Care management 1. if hypotonic uterus a. massage b. express clots-1 gm=1ml (weigh pads) c. assess for tachycardia, BP, tachypnea, pale cool skin, in LOC, lethargy d. large bore IVs-LR 1000 ml with 10-40 units pitocin -watch for water intoxication, N & V e. empty bladder or place Foley cath f. O2 10-12L/min via mask if oxygen saturation low g. Methergine 0.2 mg IM-produces sustained U/C -elevates BP, N & V, headache -may exacerbate cardiac disease h. if unsuccessful-prostaglandin F2a (Hemabate) given IM or intramyometrially

160

3 -headache, N & V, diarrhea, fever -may aggravate asthmatics herbal remedies -witch hazel -motherwort-promotes U/C, vasocontrictive -blue cohosh-oxytocic -nettle- available Vit. K, Hgb -Shepards purse-promotes U/C -red raspberry leaves-promotes U/C follow-up with labs -CBC -coag panel -type and cross match

i.

j.

2.

bleeding with contracted uterus a. assess for clots in lower uterine segment b. inspection of vagina, cervix, perineum c. suture bleeding lacerations d. for hematoma -cold packs -ligation of bleeding vessel uterine inversion a. reposition uterus b. tx shock c. oxytocin d. broad spectrum abx e. NG tube if concerned R/T paralytic ileus subinvolution a. oxytocin/ergonovine b. D & C if placenta fragments retained

3.

4.

D.

Teaching 1. normal lochia progression 2. 3. 4. 5. review factors associated with hemorrhage check for bladder distention inspect perineum/vaginal pads assess fundus

161

4 6. II. if S & S change, call MD immediately

Thromboembolic disorders A. Classifications 1. superficial venous thrombosis a. most common type PP b. involves superficial saphaneous vein 2. deep vein thrombosis a. most common type during pregnancy b. involves veins from foot to iliofemoral pulmonary embolism a. blood clot dislodged-carried to pulmonary artery b. occludes vessel-obstruct blood flow to lungs

3.

B.

Incidence/etiology 1. superficial venous thrombosis-1 out of 500-750 women 2. 3. 4. declined R/T early ambulation causes: venous stasis, hypercoagulation, & injury to blood vessel risk factors: C/S, obesity, AMA over 35 yrs, h/o DVT, DM, smoker, varicose veins

C.

Clinical manifestations 1. superficial-pain/tenderness/warmth/redness 2. 3. deep-unilateral leg pain/calf tenderness/swelling pulmonary-dyspnea/tachypnea/apprehension/cough tachycardia/hemoptysis/pleuritic chest pain

D.

Case management 1. diagnosing a. Homans sign-can be false positive b. Doppler U/S (VUS) c. venography-less common-exposes mom/fetus to radiation d. pulmonary arteriogram 2. analgesic-antiinflammatory agent (i. e. Motrin)

162

3. 4. 5. 6. III.

rest, elevation, warm packs, elastic stockings (TEDS) DVT-tx with anticoagulants-IV heparinpo Warfarin PE-IV heparin therapy, supportive care if Coumadin ordered-need OC therapy -teratogenic to fetus

Infections A. Risk Factors -C/S -prolonged labor -poor health status -OB trauma -pre-existing vag. infection -manual removal of placenta B.

-PPROM -multiple vaginal exams -FSE/IUPC -chorioamnionitis -vacuum/forceps delivery -lapse in aseptic technique

Classifications 1. puerperal sepsis-any infection of genital canal within 6 weeks of miscarriage, abortion, or birth 2. endometritis-infection of the lining of the uterus a. most common PP infection b. usually starts at placental site c. higher incidence with C/S d. most frequent culprits: GBS, chlamydia parametritis (pelvic cellulitis) a. involves connective tissue of broad ligament b. if spreads to peritoneum=peritonitis c. may be result of pelvic vein thrombophlebitis wound infection a. often develops at home b. C/S site, episiotomy, laceration site c. broad-spectrum abx may be used UTIs a. occur in 2-4% of PP women b. risk factors: Foley, epidural, freq. exams, C/S c. most frequent culprit: E. coli

3.

4.

5.

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6 6. mastitis a. affects 5-10%, most first-time mothers b. develops unilaterally c. usually Staph aureus, E. coli, Streptococcus d. if organism is Candidaoral thrush in babies

C.

Manifestations 1. fever, chills, pulse, fatigue, lethargy, pain, tenderness 2. 3. 4. 5. profuse foul-smelling lochia, leukocytosis, sed rate wound separation, dehiscence dysuria, frequency, urgency redness, warmth

D.

Case management 1. abx appropriate for organism-improve hydration 2. 3. encourage proper perineal hygiene rest, analgesics, supportive care a. warm blankets b. sitz bath c. Tucks pads d. cool compresses to peri continue breastfeeding or pumping breasts reinforce good handwashing techniques consider I & D for wound if needed assist with ADLs or baby care

4. 5. 6. 7. IV.

Psychiatric disorders A. PP Blues 1. 50-80% of women experience the baby blues 2. 3. emotionally labile, cry often and for no reason peaks day 5, usually ends day 10

164

7 4. 5. 6. 7. 8. 9. B. mild depression, fatigue, poor concentration, H/A etiology unknown feeling overwhelmed with parental responsibility let-down feeling, lack connection of mom to fetus needs to learn coping strategies, seek support grps 5-30% of this group will experience PP depression

PP depression-PP Major Mood Disorder 1. intense, pervasive sadness, severe/labile mood swings 2. 3. 4. 5. 6. 7. 8. 9. 10. symptoms rarely disappear without help feel intense fear, anger, anxiety, and despondency feelings of guilt/inadequacy fuel worry of being incompetent parent odd food cravings, binge eating, sleeping heavily distinguishing feature: irritability prominent feature: rejection of the infant R/T jealousy may have thoughts about harming the baby/self with tx, gradually improves in 6 months Tx a. b. c. d. psychotherapy antidepressants anxiolytic agents electroconvulsive therapy

165

8 C. PP depression with psychotic features (PP psychosis) 1. depression, delusions, and thoughts of harming infant or self 2. 3. 4. 5. 6. 7. occurs in 1-2 of 1000 births/up to 50% chance to reoccur with subsequent births behavior evident within 1-3 months PP initial complaints: agitation, fatigue, insomnia, restlessness, emotionally labile-inability to move or work then suspiciousness, confusion, incoherence, irrational statements, and obsessive concerns R/T infants health delusions in 50% of cases, hallucinations in 25% severe delusions/hallucinations will command mom to kill infant or have her believe the baby is possessed by the devil nursing staff should be on alert for mothers who are agitated, overactive, confused, or suspicious course of syndrome similar to that seen in people with mood disorders psychiatric emergency: antidepressants and lithium mother may not be able to breastfeed on certain medications will probably need psychiatric hospitalization use screening tools: PP depression-pp 851-853 follow-up with advanced practice psychiatric RN a. home visits b. meet with mental health therapist c. support groups

8. 9. 10. 11. 12. 13. 14.

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9 V. Loss and Grief A. Situational life crises 1. infertility 2. 3. 4. 5. 6. 7. 8. 9. B. premature labor/birth C/section loss of control during birth process birth of a boy when expecting a girl/visa versa birth of a handicapped child maternal death-7-8 out of 100,000 women fetal death-6.8 out of 1000 births neonatal death-27,000 yearly

Phases of grief-(denial, anger, bargaining, depression, acceptance) 1. acute distress a. loss of identity as parent b. loss of a dream/hope c. state of shock/numbness d. confusion, disbelief, denial e. may have outburst of emotion or lack affect f. need to accept the loss g. normal functioning impeded/hard to make decisions h. may need help with funeral arrangements 2. intense grief a. loneliness, emptiness, guilt, yearning, anger b. have to accommodate the changes the loss has created-i.e. the nursery, clothes c. have to return to work-possibly meet insensitive coworkers/family d. difficulty handling leakage of breast milk-a reminder of loss e. guilt feelings may intensify if mother thinks she is being punished for a prior bad act f. responses: anger, bitterness, resentment

167

10 g. h. 3. focused anger on health care team for not saving the infants life physical symptoms: H/A, fatigue, dizziness, backaches

reorganization a. search for a meaning to the tragedy b. improved function at home and work c. start to enjoy simple pleasures without guilt d. reestablishing relationships e. bittersweet grief-grief response occurring with reminders of the loss f. grief can also be triggered by subsequent births

C.

Communication and caring 1. actualize the loss 2. 3. 4. 5. 6. provide time to grieve interpret normal feelings/allow for individual differences provide for the cultural/spiritual needs of parents assist with their physical comfort offer options a. see and hold the baby b. bath and dress the baby c. privacy d. visitation for other family/friends e. religious rituals f. special memorials/pictures

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1
Disorders of the Female/Male Reproductive Systems Lecture 12 I. Breast Masses A. Screening for breast masses 1. Breast self exams a. best if done 5-7 days after menses has stopped b. if periods are not regular, chose the same day each month c. while on back, palpate each breast in a circular or vertical motion to cover whole breast d. use finger pads to ck for indentations, change in contour/texture, lumps e. compress nipple to ck for discharge f. may also do while standing/in the shower g. note size and shape usually equal but not always symmetrical h. vary with womans age, nutritional status, and heredity i. contour should be smooth without puckering or dimpling j. assess nipples for shape, direction, rashes, ulcerations, and discharge k. 90% of brst lumps found by women -20-25% will be malignant 2. Exam by clinician a. usually done with yearly pelvic exam b. should not be on period at time of exam c. may request mammogram for women with dense breast tissue or palpable changes -mammograms-ACS guidelines annually age 40 and over if healthy and with no risk factors-sooner if risk factors present

B.

Benign Breast Disorders 1. Fibroadenoma a. occurs in women from puberty to menopause b. risk factors -nulliparity -low parity -later menopause -estrogen therapy -family h/o of brst CA c. masses are solid and made of connective tissue d. cause unknown e. usually solitary lump < 1cm to 15 cms in diameter f. lump may be tender during menses g. diagnosed by mammogram, U/S, MRI h. doesnt respond to changes in diet/hormones i. may need surgical excision if lump suspicious or symptoms are severe

169

2.

Fibrocystic breast condition a. most common breast problem-mostly found in upper, inner quadrant of breast b. characterized by lumpiness, with/without tenderness, and may be associated with changes in menstruation c. 70% nonproliferative (benign growing cells) d. others are proliferative lesions with atypical hyperplasia ( risk of brst CA) e. risk of brst CA with relative having brst CA f. etiology-unknown-possibly R/T imbalance of hormones g. usually in both breasts but may be singular h. S & S develop one week before menses -dull, heavy pain -sense of fullness -increasing tenderness i. cysts are usually soft, well differentiated, movable j. deeper cysts may not be differentiated from carcinomas k. U/S to determine if fluid filled-if so-aspirate l. if solid, mammogram followed by fine needle aspiration (FNA) or core biopsy m. management -dietary changes- caffeine - Na intake -Vit. B, C, and E supplements -use NSAIDS -some relief with smoking/alcohol intake -supportive bra -heat packs to breasts Ductus ectasia a. inflammation of ducts behind nipple b. etiology-unknown c. occurs most often in perimenopausal women d. characterized by thick, sticky nipple discharge either white, brown, green, or purple in color e. other S & S: burning pain, itching, palpable mass behind nipple f. workup: mammo, aspiration, culture of fluid g. Tx: symptomatic -no stimulation -good breast hygiene -I & D if abscess develops -abx -may need affected duct excised Intraductal papillomas a. found in women 30-50 years of age b. rare, benign lesion in the terminal nipple ducts -may be too small to palpate (2-3 cm) c. may note nipple discharge-serosanguinous d. do fluid Pap smear of nipple discharge e. Tx: excision

3.

4.

170

3
C. Breast cancer-Cancer.org (American Cancer Society) 1. Pathophysiology a. most common infiltrating ductal carcinoma -abnormal cells grow in the epithelial cells which line the mammary ducts -needs 5-9 years to be palpable b. noninvasive if stays in duct (ductal carcinoma in situ or DCIS) c. invasive if penetrates the tissue around the duct d. invasion of lymphatic channels/lymph ducts carry abnormal cells to lymph and to metastatic sites e. staging of disease must include lymph node examination, especially axillary nodes f. metastatic sites include bone, lungs, brain, liver 2. Etiology/risk factors/incidence a. exact cause unclear b. risk with of womans age c. other risk factors-family history -previous h/o brst CA -family history -h/o ovarian, endometrial, colon, or thyroid CA -early menarche (before age 12) -later menopause (after age 55) -nulliparity -first preg. age 3 -HRT -obesity -h/o benign breast disease with hyperplasia -Caucasians -African-Americans have a higher mortality rate due to late diagnosis -sedentary lifestyle -high SES d. incidence -in US, 1 out of 8 women will develop brst CA -risk factors help identify less than 30% of women -5% of brst CA attributed to heredity - risk for women with abnormal BRCA1/BRCA2 genes -testing expensive -often not covered by insurance -debate R/T prophylactic mastectomies or Tamofixen use - risk of brst CA with use of HRT -occurs in men < 1 % Clinical manifestations a. physical -most lumps in upper outer quadrant -may feel lump or thickening of brst -hard and fixed, soft and spongy -well-defined or irregular borders -may cause dimpling due to fixed to skin (orange peel) -may have nipple discharge-bloody or clear

3.

171

4
b. c. d. e. f. g. h. i. psychosocial -denial -grief and loss behaviors mammogram/U/S/MRI nipple discharge exam-culture/specimen to lab ductogram-fine plastic tube placed into duct, contrast media injected, assess duct FNA biopsy-aspiration or core-may use guide wire Triple test-physical exam, mammogram, FNA -if any benign-98% of lesion being benign staging-TNM-T=size, N=nodes, M=metastases -Stage 0-ductal carcinoma (in situ)-earliest form -Stage 1-2 cm tumor/hasnt spread -Stage 2-tumor >2 cm-in axillary nodes on same side -Stage 3-tumor >5 cm-spread to lymph nodeslocalized spread, no other organs -Stage 4-metastasis to distant-bones, lungs, liver lymph nodes not local

4.

Nursing diagnoses a. pain R/T surgical procedure b. risk for infection c. body-image disturbance R/T loss of body part Management a. surgery -lumpectomy (tylectomy, partial mastectomy) -removal of tumor -removal of small surrounding area -sampling of axillary lymph node -doesnt effect pectoral muscle -may follow-up with 6-7 weeks of radiation -modified radical mastectomy -removal of entire breast -sample of lymph nodes -spares pectoral muscle -risks: infections, hematoma lymphadema, limitation of arm/shoulder mobility -sentinel lymph node biopsy (SLNB) -radioactive tracer/dye injected -carried by lymph to sentinel node which is first node to receive lymph from tumor -most likely to contain metastasis if CA has spread -if sentinel node is cancerous, more nodes are excised

5.

172

5
-reconstructive surgery -goal is achievement of symmetry with preservation of body image -3 types of autologous flap reconst. -latissimus dorsi -TRAM-transverse rectus abdominis myocutaneous -inferior gluteus free -monitor skin flap for cap. refill, hematoma, infection, necrosis -may also receive breast expanders implants adjuvant therapy-radiation -after lumpectomy in non/microinvasive cases -any invasive ductal carcinoma <1 cm diameter -interstitial or balloon brachytherapy -intraoperative radiation adjuvant therapy-drug therapies -chemotherapy started soon after dx -most useful in premenopausal women with brst CA with + nodes -can increase time without CA -may be given alone or with HRT -tamoxifen attaches to hormone receptor on CA cell-cell unable to grow -side effects-leukopenia, neutropenia, anemia, thromobocytopenia, GI problems, hair loss

b.

c.

6.

Discharge planning -resources ACS Reach for Recovery program NCCN-National Comprehensive Cancer Network ACS home page

II.

Sexually Transmitted Diseases/Infections A. Infections associated with ulcers 1. Syphilis a. caused by treponema pallidum-spirochete b. transmission thru abrasion of tissue, kissing, biting, oral-genital sex c. can cross the placenta d. 120,000 new cases each year e. higher rates in young African-Americans f. attributed to use of sex for drugs/money g. primary-chancre appears day 5-90 post infection-nontender, shallow, indurated h. secondary-occurs 6 weeks-8 months -wide spread maculopapular rash on palms/soles -fever, headache, malaise -may have condylomata lata i. tertiary-neurologic, CV, MS, or multiorgan system complications j. screening:

173

6
-microscopic exam of lesions -serology-VDRL/RPR-may have false + -MHA-TP-microhemagglutination assays for antibody to T. pallidum used to confirm + tests -seroconversion takes 6-8 weeks post exposure management: -PCN G IM -treats primary, secondary, and early latent -if syphilis older than 1 year, weekly shots for 3 wks -alternatives: doxycycline, tetracycline -not used in pregnancy - erythromycin-unlikely to cure fetal infection

j.

2.

Genital herpes simplex a. results in painful, reoccurring ulcers b. HSV-1-usually nonsexually transmitted -oral labial ulcers -gingivostomatitis c. HSV-2-transmitted during oral/genital sex d. not a reported disease e. 20% Americans infected with virus-over 50 million people f. estimated 1 out of 4 women will get HSV-2 g. initial infection: -fever, chills, malaise -severe dysuria -painful lesions-may last 2-3 weeks h. lesions may progress from maculepapule vesiclepustuleulcer that crustsscar i. can cause cervical problems, purulent vaginal vaginal discharge and urinary retention j. reoccurring episodes not as severe k. HSV-2 can have adverse effects on mom/fetus -viremia -congenital infection -60% infant mortality if infant contracts HSV l. association between cervical CA and HSV-2 m. screening: -physical exam with complete H & P -viral culture of ulcer n. management: -chronic/reoccurring -proper hygiene -systemic antiviral medications -acyclovir, valacyclovir, famiciclovir -sitz bath with baking soda -oral analgesics -diet rich in Vit. C, B, zinc, and calcium -kelp powder, sunflower seed oil -relaxation techniques -support groups -condoms to prevent transmission to new partner -C/section delivery if primary outbreak -counseling to deal with shame, guilt, anger Lymphogranuloma venereum-CDC.gov-look for Facts Sheets

3.

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4. 5. B. Chancroid Granuloma inguinale

Infections of Epithelial surfaces Human papilloma virus-HPV 1. a. 100+ HPV types, 40 known mucosal serotypes b. 90% of cases cleared by immune system in 2 years c. if not cleared, can lead to genital warts, warts in the throat, cervical cancer d. ages at risk for HPV 14-19yrs old26.8% 20-24yrs old44.8% 25-29yrs old27.4% e. may look like a cauliflower-mass f. rarely transmitted to neonate at birth g. screening: -S & S-dyspareunia, itching, discharge, bumps -may need to change gloves between vaginal and rectal exams to prevent spread h. Diagnosis -cervical exam to include Pap smear & HPV test -pap only 30-60% sensitive -HPV screen is 90% sensitive -cervical screening guidelines-start at age 21 (whether or not sexually active) -intervals-every 2-3 yrs 21-29 if pap neg -every 3 yrs 30-65 if pap/HPV neg -age 30-HPV neg-1% risk (99% cx CA from HPV-low progression-8.1 to 12.6 yrs) -age 65 w/ 3 consequential neg paps in last 10 yrs -stop needing paps -colposcopy to view growth with biopsy i. need to differentiate between HPV &: -molluscum contagiosum-white papules -condylomata lata-secondary syphilis j. Prevention-vaccine Gardisil-start at age 9-26 -killed vaccine -give prior to sexual debut or early after -not given after >5 partners -series of 3 injections/6 mo -$$$, unaffordable to uninsured -lifetime immunity but still needs paps since not all strains covered k. Tx-no treatment can eradicates HPV-only symptoms -imiquimod, podophyllin, podofilox-topical -cryotherapy

175

2.

Gonorrhea a. caused by Neisseria gonorrhoeae-bacteria b. 600,000 contract gonorrhea each year c. rising incidence of drug-resistance d. transmission: oral, genital, anal e. higher incidence in people under 20 years old f. higher incidence in African-Americans g. women most often asymptomatic h. may present with pain/burning with urination, vaginal discharge, low back pain h. men may c/o pain with urination and yellowish discharge from penis i. may take up to 3-10 days before symptoms present j. screening: cultures taken from endocervix, rectum, and possibly pharynx k. people are frequently coinfected-should be tested for other STIs l. management: usually single dose antibiotic: ceftriaxone m. 45% women will also have chlamydia so should have concomitant tx Chlamydia a. caused by Chlamydia trachomatis b. most common/fast spreading STI in women c. untreated leads to PID and acute salpingitis d. may caused ulcers on the cervix increasing risk to acquire HIV e. higher incidence in women under age 20

3.

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f. g. h. i. j. k. l. m. n. sexually active individuals 25 yrs old-screen for chlamydia yearly all pregnant women should be screened at first PN visit repeat cultures if woman was previously + or has multiple partners may have spotting, postcoital bleeding, cervical discharge, or dysuria dx thru culture management-doxycycline or azithromycin if pregnant-erythromycin/amoxicillin since usually asymptomatic, must encourage completion of all the medication women tx with erythromycin need to be retested in 3 weeks due to poor validity of tx

4.

PID-Pelvic Inflammatory Disease a. involves fallopian tubes (salpingitis), uterus (endometritis), and possibly ovaries and peritoneal surfaces b. caused by multiple organisms and occasionally caused by more than one c. most commonly caused by C. trachomatis d. also caused by gonorrhea and other aerobic and anaerobic bacteria e. microorganisms spread from vagina to upper genital tract-usually occurring at the end of or just after menses f. during menses, spread supported by open cx, decrease cervical mucus, and blood used as a medium for growth g. each year, 1 million women will experience symptomatic PID h. risk factors: teens, multiple partners, new partners, history of PID, use of IUD i. leads to: risk for ectopic pregnancy, infertility, chronic pelvic pain, dyspareunia, pyosalpinx, abscesses, adhesions j. S & S: dull, cramping, or severe pelvic pain, bleeding, adnexal tenderness, pain with cervical movement (Chandelier sign), bilateral pelvic tenderness k. screening: good history taking to r/o other causes, temp 38.3 0 C, abnormal cervical/vaginal discharge, sed rate, lab documentation of chlamydia or gonorrhea l. need to teach prevention of causes to help prevent disease m. need to screen asymptomatic women with history of risky behavior n. tx: usually broad-spectrum abx, use analgesics,

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10
semi-fowlers position while resting encourage rest, proper nutrition, and hydration will need follow-up lab work to confirm cure teaching to include use of barrier methods, no sexual relations until completion of meds, follow-up pelvic exams, and other contraceptive methods other than IUDs

o. p. q.

III.

Gynecologic Disorders A. Postmenopausal bleeding-bleeding 12 months post menses cessation 1. Related factors a. atrophic vaginitis-tissues more sensitive, bleed easily b. polyps-masses in/on the cervix c. endometrial problems -endometrial hyperplasia may be a precursor to endometrial CA-need a D & C to evaluate d. ovarian function estrogen/progesterone 2. Management a. for vaginitis-use of creams to protect tissues b. for polyps-removal c. HRT Discussion regarding HRT a. most studies show risk factors and adverse reactions R/T dose and length of tx b. controversy R/T method of administration, doses, and efficacy c. must individualized to pts S & S , lifestyle, and medical history -need to deal with philosophy/beliefs regarding exohormones d. if ERT alone, 5-10X risk of endometrial CA e. problem with adding progesterone, bleeding f. new studies proving that HRT may lead to risk for brst CA g. short term HRT (1-5 years)-no protections against osteoporosis or CVD -risk factors for osteoporosis family history short, thin European or Asian descent early menopause smoker, alcohol use caffeine use, low calcium intake sedentary lifestyle use of steroids, synthyroid, diuretics -risk factors for CVD LDL, HDL, total serum cholesterol risk of atherosclerosis

3.

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11
MI emboli thromboses long term-may use estrogen alone or in combination with progesterone or testosterone -may be continuous or cyclic

h.

B.

Endometriosis 1. Assessment a. benign disease characterized by implantation of endometrial tissue outside the uterus b. implanted on the ovaries, cul-de-sac, uterine ligaments, rectovaginal septum, sigmoid colon, pelvic peritoneum, cervix, and inguinal area c. endometrial lesions can be found in the vagina, surgical scars, vulva, perineum, bladder, and other sites such as thoracic cavity, gallbladder and heart d. tissue responds to hormonal stimulation e. tissue bleeds during or after menses causing inflammatory response by adjacent organs/tissues f. can lead to scars and adhesions g. incidence -10% in women of reproductive age -25-35% infertile women -28% of women with chronic pelvic pain h. each year account for almost 50,000 hysterectomies i. may remain asymptomatic and disappear after menopause j. may worsen with repeated cycles k. found across all SES levels l. most widely accepted cause-retrograde menstruation -estimated to occur in 96% of women who menstruate m. possible reasons why some women develop the condition -individual immune system fails to destroy tissue -differences in genetic make-up -environmental challenges n. S&S -pain (dysmenorrhea)-possibly prior to menses -lower abdomen pain -dyspareunia -painful defecation -hypermenorrhea -sacral back pain -infertility

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2. Management a. NSAIDs b. suppression of endogenous estrogen production medically induced menopause -GnRH agonists (gonadotropin-releasing hormone) i.e. Lupron, Synarel pituitary gonadotropin secretion FSH/LH stimulation of ovaries ovarian functionhot flashes, vaginal dryness limited to 6 months R/T bone loss potential teratogen -androgen derivatives Danocrine (danozol) suppress FSH/LH secretion produces anovulation regression of endometrial tissues may produce masculinizing traits weight gain edema deepening of voice oily skin hirsutism in brst size other side effects H/A hot flashes vaginal dryness libido insomnia fatigue dizziness HDLs LDLs contraindicated-h/o liver disease use with caution if h/o heart or renal disease fetus-pseudohermaphroditism c. may use OCs with low E to P ratio to shrink endometrial tissues SE: N & V, bleeding, edema d. mifepristone (RU-486) being used with success e. surgery-nd to consider age, desire for children, location of disease -TAH-BSO -laser surgery to remove adhesions/tissue f. 40% reoccurrence-except in TAH-BSO cases

C.

Dysfunctional uterine bleeding-abnormal uterine bleeding Wide variety of menstrual irregularities 1. a. menorrhagia b. irregular cycles 2. Possible causes a. anovulation-polycystic ovary syndrome b. pregnancy-related-SAB c. genital infections-chlamydial cervicitis d. neoplasms-CA of cx

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13
e. f. g. 3. trauma-foreign body systemic diseases-DM iatrogenic-herbal preparations-ginseng

Severe bleeding with Hgb 8g/100ml=hospitalization a. given IV cong. estrogen (Premarin) b. possible D & C c. endometrial biopsy to r/o endometrial CA Incidence a. teens-20% b. women under 50-50% Management a. oral cong. estrogen X 21 days with progesterone (medroxyprogesterone-Provera) added for the last 7-10 days b. low dose OCP c. ablation of endometrium d. hysterectomy

4.

5.

D.

Inflammations and Infections 1. Vaginitis/Vulvitis a. inflammation of vagina and/or vulva b. S&S -irritation, malodorous abnormal discharge -itching, burning, urinary frequency -spotting c. causes -infections -lack of hormone estrogen -irritants/allergies chemicals medicines latex condoms spermicides diaphragm/cervical cap scented/colored toilet paper bubble baths douches laundry detergents hot tubs horseback riding wearing tight garments rubbing on a bicycle seat d. infections -candidiasis-yeast causes-abx, pregnancy, DM, problems immune system thick white odorless discharge in the mouth-called thrush tx-antifungal agents -bacterial vaginosis-BV caused by a variety of bacteria including gardnerella associated with PTL and birth

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14
etiology unknown heavy gray frothy malodorous D/C tx-oral metronidazole-Flagyl antiprotozoal/antibacterial contraindicated in women who breast feed may affect the CNS and hematopoietic systems with alcohol-can cause abdominal distress, N & V, H/A -trichomoniasis-anaerobic protozoan may be asymptomatic or have frothy musty-smelling discharge itching on or around the vagina spotting, urinary urgency tx-Flagyl-treat both partners since a STI-should screen for other STIs atrophic vaginitis-irritation without discharge -lack of estrogen due to childbirth, menopause, bilateral oophorectomy, radiation tx -estrogen creams restore lubrication and decrease soreness/irritation

e.

2.

Toxic Shock Syndrome a. assessment -primarily a disease of the reproductive age -caused by S. aureusproduces toxin TSST-1 -risk factors-retained tampons, barrier devices left in place, surgery, recent delivery -S & S-fever >102 F, 38.9 C, hypotension, widespread macular rash, dizziness, N & V, diarrhea myalgia, inflamed mucous membranes -lab tests- BUN, Cr, SGOT, SGPT, platelets b. management -mainly supportive -antibiotics-limited value -need to teach prevention, reoccurrence

E.

Problems R/T Pelvic Support Structures 1. Uterine Prolapse a. round ligaments hold uterus in anteversion uterosacral ligaments pull cx up and back b. 2 months PP, ligaments should return to normal length-1/3 of women, uterus remains retroverted c. causes: congenital or acquired pelvic relaxation -pregnancy -perimenopausal period -pelvic surgery -pelvic radiation

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15
d. e. 2. tx: -pessaries -estrogen creams -abdominal/vaginal hysterectomy education: use of Kegel exercises to strengthen pelvic floor muscles

Cystocele a. downward displacement of bladder-bulge in anterior vaginal wall b. causes: genetics, obesity, childbirth, advanced age c. S & S: urinary incontinence, vaginal fullness bulge in vaginal wall d. complete emptying of bladder difficult R/T the cystocele sags below the bladder neck e. tx: vaginal pessary or surgical repair colporrhapy (anterior repair)-shortens pelvic muscles to better support bladder Rectocele a. herniation of anterior rectal wall b. may lead to constipation, hemorrhoids, fecal impaction, feeling of vaginal/rectal fullness c. found by rectal exam or barium enema d. need to promote bowel elimination e. surgery-posterior colporrhaphy or A & P repair f. follow surgery with low residue diet

3.

F.

Common Benign Neoplasms 1. Types/Management a. ovarian masses -70-80% benign -S & S-asymptomatic -mass may be palpated on pelvic exam -may have a feeling of fullness, cramping -can lead to dyspareunia, irregular bleeding -may resolve on own -use of OCs -diagnostic laparoscopy with possible laparotomy b. uterine masses -fibroids-leiomyomas -minimal CA risk -S & S-frequently asymptomatic -low abdominal pain, fullness, pressure -menorrhagia, dysmenorrhea -metrorrhagia (intermenstrual bleeding) -may shrink with menopause -myomectomy, D & C, hysterectomy

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16
2. Total abdominal hysterectomy a. removal of uterus and cervix thru abdominal incision b. may include removal of fallopian tubes/ovaries BSO-bilateral salpingo-oophorectomy castration in females c. 600,000+ are done yearly d. questionable reasons for surgery e. may want to consider alternatives LAVH-laparoscopic assisted vaginal hyster. f. pre-op: lab work, ECG, chest x-ray, informed consent-must understand means sterility g. IV, shave, abdominal prep, Foley cath h. post-op care similar to post-op C/section i. need to deal with psychosocial issues

G.

Reproductive cancers 1. Endometrial a. most frequently occurring reproductive cancer b. 5th most common after skin, lung, breast, and colorectal c. asymptomatic in early development d. endometrial cancers are nearly all adenocarcinomas (80%) -cancer of glandular cells e. S &S-postmenopausal bleeding f. risk factors: obesity, advanced age, unopposed ERT, nulliparity, late menopause >age 52 Caucasians g. found by endometrial biopsy h. tests: CBC, liver function, renal function, BE, CT, liver and bone scan, CA-125 j. tx: radiation-intracavity (brachytherapy) -external beam chemo surgery-TAH/BSO 2. Cervicala. 3rd most common CA of reproductive tract b. risk factors -age (50-55) -early childbearing -non-Caucasians -smoking -multiple sexual partners -HPVGardasil vaccine c. testing -Pap smear -colposcopy -punch biopsy -ECC d. staging: Stage 0-carcinoma in situ-superficial Stage 1-invaded the cervix without spreading Stage 2-CA has spread but remains in pelvis -5 year survival rate 65-80%

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17
Stage 3-CA spread to lower wall of vagina -5 year survival rate as low as 20-40% Stage 4-CA spread to distant organs tx: Stage 0-cryosurgery, laser surgery, LEEP/LEETZ, cone biopsy, hysterectomy (loop electrosurgical excision procedure) Stage 1-simple hysterectomy if cancer is more than 3mm-may want radical hysterectomy with removal of lymph nodes in the pelvis Stage 2-hysterectomy with high-dose radiation and chemo Stage 3 & 4-treatment and predictive prognosis varies on severity of spread and response

e.

3.

Ovariana. most often occurs in 5th decade (age 45-65) b. most occur after menopause c. risk factors -fertility drugs -early menstruation -nulliparity -high fat diet -smoking -alcohol st -1 child after age 30 -h/o breast, colon, or endometrial CA -family h/o breast or ovarian CA d. risk -use of OCs -h/o BTL -BSO e. 5 year survival rate-90% (Stage 1), 10% (Stage IV) -discovery of CA not until advanced stage f. S&S -irregular menses -PM tension -menorrhagia -breast tenderness -early menopause -abdominal discomfort -dyspepsia -pelvic pressure - abdominal girth -urinary frequency g. in 75% of cases, CA had metastasized before dx -60% beyond the pelvis h. dx: transvaginal U/S, laparoscopy, laparotomy i. tx: -TAH/BSO -tamoxifen -chemo -radiation j. CA 125-associated with various epithelial CA may be used to assess response to tx in women with known ovarian CA Vulvar a. 90% squamous cell carcinomas b. accounts for 4% of Gyn malignancies c. more than 50% of cases occur in postmenopausal women (age 65-70) d. usually localized, slow-growing, and marked

4.

185

18
by late metastasis to regional lymph nodes risk factors: HTN, obesity, DM S & S: bleeding, malodorous D/C, pain, pruritus tx: excision, laser, radiation, vulvectomy

e. f. g. IV.

Male Reproductive DisordersA. Testicular Cancer 1. Leading cause of cancer deaths in men 15-35 yrs old a. highly treatable b. usually curable-over 90% in all stages combined c. rarely bilateral d. CA most commonly dx-solid tumor-age 15-40 e. most often in Caucasians, rare in African-Amer. 2. Pathophysiology a. germinal-sperm-producing cells-95%of cases -2 types seminomas- (40%) -occur in men late 30s to early 50s -localized-grow slow -metastasized later -response well to radiation -5 year survival rate-95% with surgery and radiation nonseminomas-not sensitive to radiation -occur in men late teens to early 40s -need surgery or chemo -embryonal carcinomas common in men 19-26 yrs old may spread via bloodstream -teratomas rarely occur often mixed with other tumors -choriocarcinomas lethal, fast spreading initial dx often in metastatic stage -25%-teratocarcinomas b. stromal-hormone producing -interstitial cell tumors(arise from Leydig cells) androgenic hormone secretions rare, usually benign -androblastomas rare, usually benign may secrete estrogen-feminization gynecomastia

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3. Causes a. mainly unknown b. may be R/T cryptorchidism -if develops CA, 75% will be in the undescended testis (assoc. with seminomas) c. may be R/T trauma, infection Testing a. tumor marker study -benign tumors never elevate marker proteins -AFP and HCG-for nonseminoma -in seminomas- hCG/LDH but not AFP if AFP, think mixed tumor-diff. Tx -if tx effective, markers should fall b. CT scan, U/S c. Chest x-ray to r/o metastasis d. lymphangiography to ck retroperitoneal lymph nodes Physical exam a. palpate for lump b. may see painless enlargement c. heaviness, dragging sensation d. dull ache in abdomen, inguinal Nursing diagnosis a. risk for sexual dysfunction R/T disease/surgery b. dysfunctional/anticipatory grieving c. disturbance of body image R/T dx and tx d. acute/chronic pain e. anxiety R/T dx of cancer Management a. sperm banking-before radiation and chemo b. chemo c. radiation-seminomas -used after orchiectomy -external beam therapy nonseminomas-radical lymph node dissection saves sympathetic ganglia d. stem cell transplantation-used with chemo to help prevent infection/anemia e. unilateral orchiectomy f. radical retroperitoneal lymph node dissection -helps to stage the disease and reduce tumor Post-op teaching a. watch for fever, chills, increasing tenderness, pain around the incision, drainage, or dehiscence of the incision b. no stair climbing or heavy lifting (>20 lbs) c. resume normal activities 1 week after discharge

4.

5.

6.

7.

8.

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d. B. needs follow-up studies/TSE

Other Reproductive Disorders 1. Hydrocele a. cystic mass with straw-colored fluid forming around the testis b. disorder of lymphatic drainage of scrotum c. no tx necessary unless compromises testis circulation d. aspirated or surgically removed e. may need surgical drain and hospitalization f. directed to wear scrotal support 2. Spermatocele a. sperm-containing cystic mass on the epididymus alongside the testicle b. usually small/asymptomatic-no intervention c. may be excised thru small incision in scrotum Varicocele a. cluster of dilated veins posterior/above testis b. uni or bilateral c. usually asymptomatic-no tx d. if painful-surgically removed -inguinal incision -may need to elevate scrotum with towel when in bed to help with drainage e. can cause infertility by scrotal temperature Scrotal trauma a. torsion of testes-twisting of spermatic cord -considered a surgical emergency -S & S-pain, N & V b. ice, elevate, avoid heavy lifting, scrotal support Cryptorchidism a. undescended testis b. mainly a pediatric problem -3% full term males -20% male premies c. 80% will spontaneously descend d. orchidopexy-surgical placement of testis into the scrotum Cancer of the Penis a. less than 1% of male malignancies b. carcinoma is a painless, wartlike growth/ulcer c. small areas may be excised or cured with radiation d. penectomy-partial (glans only) or total -with total-need a perineal urethrotomy for urinary drainage

3.

4.

5.

6.

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7. Phimosis a. prepuce constricted-cant retract over glans b. tx-circumcision Priapism a. uncontrolled, prolonged erection b. penis remains large, hard, and becomes painful c. causes -neurological -vascular -pharmacological d. urologic emergency e. need to improve venous drainage to corpora cavernosa f. tx: Demerol, warm enemas, catheter, aspiration of corpora cavernosa Epididymitis a. infection of the epididymis-tx with abx b. may come from infection of the prostate c. men under 35 yrs, chlamydia trachomatis d. c/o pain along inguinal canal and vas deferens e. may have pain and swelling of the scrotum f. if untreated, pyuria and bacteriuria may develop g. abscess may form necessitating an orchiectomy Orchitis a. acute testicular inflammation b. results from infection or trauma c. caused by bacteria from urethra or other sources d. may be uni or bilateral e. risk for sterility R/T testicular atrophy f. tx: bedrest, scrotal elevation, ice, analgesics, and antibiotics g. mumps orchitis-20% of males who have mumps after puberty-given gamma globulins -childhood vaccination is a good preventative measure Prostatitis a. may be bacterial or abacterial (more common) b. abacterial-after a viral illness or assoc. with STI -also called prostatodynia c. bacterial-assoc. with urethritis -common bad guys-E. coli, Proteus, Enterobacter and group D streptococci -S & S-fever, chills, dysuria, urethral discharge, and boggy, tender prostate d. can lead to inflammation of the bladder and epididymus e. sexual dysfunction may occur R/T pain f. tx: antimicrobials-Geocillin, Cipro g. encourage sitz baths and completion of meds

8.

9.

10.

11.

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22
h. i. j. use analgesics prn if UTI develops, may be put on Septra instructions on activities to drain prostate -sexual activities -masturbation -prostatic massage

01/13

190

1 Infertility and Genetics Lecture 13 I. The Couple Experiencing Infertility A. Incidence 1. Definition: Inability to conceive and carry a pregnancy to viability after at least one year of regular sexual intercourse without contraceptive use a. Primary-never pregnant b. Secondary-had been pregnant in the past 2. 3. B. Problem for 10-15% of reproductive-aged couples Women over age 35-21% chance of infertility

Risk Factors 1. Females a. abnormal external genitals b. abnormal internal reproductive structures c. anovulation -pituitary/hypothalamus hormone disorders -adrenal gland disorders d. amenorrhea after stopping OCP e. early menopause f. increased prolactin levels g. tubal motility reduced h. inflammation within the tube i. tubal adhesions j. endometrial/myometrial tumors k. Ashermans syndrome-uterine adhesions/scars 2. Males a. undescended testes b. hypospadias c. varicocele d. low testosterone levels e. testicular damage-trauma, mumps f. endocrine disorders g. genetic disorders h. STIs i. exposure to hazardous substances j. change in sperm -smoking, heroin, marijuana, amyl nitrate, butyl nitrate, methaqualone 1

191

k.

l. m. n. C.

decrease in sperm -hypopituitarism -chronic disease -gonadotropic inadequacy obstruction of the vas deferens or epididymis decreased libido impotency

Components of Fertility 1. Sperm viable in female reproductive tract for up to 48+ hours -fertility potential-24 hrs 2. 3. 4. Ova viable for about 24 hours -optimum time for fertilization may be only 1-2 hours Blastocyst must implant within 7-10 days into the hormonally prepared endometrium Women account for 50% of infertility cases a. male problems-35% b. unexplained factors-15% Assessment of female infertility a. complete history -duration of infertility -past obstetrical events -sexual history -review medical/surgical history -assess exposure to hazardous substances b. physical exam -assess endocrine systems for abnormalities -visualize secondary sex characteristics -tests to evaluate uterus and fallopian tubes -bimanual exam of organ mobility -lab tests c. testing -HSG-hysterosalpingogram -postcoital test Sims-Huhner test-ck cervical mucus abstain from intercourse for2-3 days performed several hours after ejaculation examine cervical mucus/sperm under 2

5.

192

3 microscope -sperm immobilization antigen-antibody reaction -assessment of cervical mucus spinnbarkeit-the formation of thread by mucus from the cervix when spread on a glass slide and drawn out by a cover glass -U/S dx of follicular collapse -serum assay of plasma progesterone -hormone analysis estrogen, progesterone FSH, LH thyroid -basal body temperature (BBT) biphasic- temp 12-14 days before menses ck temp before rising 0.5-1.00 rise=surge of LH, progesterone ova released 24-36 hrs before temp intercourse-3-4 days prior to 2-3 after -endometrial biopsy -laparoscopy -U/S 6. Assessment of male infertility a. H&P b. semen analysis -sperm density-20-200 million cells/ml -may vary day to day-collect over a month -effects of cervical mucus on sperms motility and survival -ck sperms ability to penetrate an ova

D.

Infertility management 1. Psychosocial a. may need counseling to deal with issues of loss or inadequacy b. dx of infertility may lead to problems with couples personal relationship c. discuss alternatives, i.e. adoption 2. Nonmedical therapies a. water soluble lubricants b. change to boxer shorts c. use of condoms if woman has immunologic 3

193

4 reaction to sperm-will reduce antisperm antibody production 3. Medical therapies a. ovulatory stimulants -Clomid (clomiphene) stimulates the ovarian follicle -multifetal rates-less than 10% -Parlodel (bromocriptine) inhibits release of prolactin (elevated levels of prolactin have an amenorrhea effect on the body) -Bravelle, Menopur (human menopausal gonadotropin) extremely potent requires daily monitoring daily IM for 7-14 days-first half of cycle incidence of multifetal > 25% -HCG-may be given to induce ovulations after ovaries stimulated with HMG -GnRH (gonadotropin-releasing hormone) used with hypothalamic-pituitary dysfunction or failure to respond to clomiphene b. hormone replacement therapy -use conj. estrogen and medroxyprogesterone c. male tx -thyroid/adrenal gland correction -abx for STI -clomiphene-unsure effectiveness -HCG-stimulates androgens- spermatogenesis Surgical treatments a. excise ovarian tumors b. removal of adhesions c. hysterosalpingography-may unblock tubes d. if uterine cavity too small to carry pregnancy, no medical tx available-each successive pregnancy enlarges uterus e. may be able to reconstruct uterus R/T bicornuate f. myomectomy g. chemo/thermocautery to eliminate chronic inflammation and infection

4.

194

5 5. Reproductive alternatives a. assisted reproductive alternative (higher risk for ectopic) -IVF-ET-in vitro fertilization-embryo transfer -GIFT-gamete intrafallopian transfer *after ovulation, ova and sperm moved into tube -ZIFT-zygote intrafallopian transfer -ovum transfer (oocyte donation) -embryo adoption -intracytoplasmic sperm injection -assisted hatching -TDI-therapeutic donor insemination b. preimplantation genetic diagnosis -eliminate defect embryos before implantation c. surrogate mothers -use surrogates ova and husbands sperm -use mothers ova and husbands sperm d. adoption

E.

Nursing diagnoses 1. Body image disturbance 2. 3. 4. Decisional conflict Altered patterns of sexuality Risk for social isolation

II.

The Family Experiencing a Genetic Disorder A. Chromosomal abnormalities 1. Human Genome Project-1990-international effort to map and sequence the genetic makeup of humans a. ELSI-Ethical, Legal, and Social Implications Program-sentinel to prevent discrimination or use of material for eugenic purposes (selective breeding) b. initial sequencing complete 06/00 c. goal-to facilitate study of hereditary diseases and provide potential for altering genes to treat and/or prevent occurrence

195

6 2. Chromosomes a. karyotype-pictorial analysis of chromosomesusually from peripheral blood but may come from any body tissue b. autosomal chromosomes-22 pairs control traits of the body c. sex chromosomes-pair 23 determines sex controls some other traits XX-female XY-male d. dominant gene-their trait is expressed over another (AA or Aa) e. recessive gene-only expressed when another another recessive is present (aa) f. terms-allele-gene that determines a specific trait each trait has a pair of alleles genotype-genetic makeup of an individual phenotypephenotype-expression of genes function either measurable or observed homozygoushomozygous-has identical alleles on each chromosome in the same locus hetrozygoushetrozygous-2 different alleles at a given locus Abnormalities in chromosomal numbers (aneuploidy) a. usually caused by nondisjunction b. occurs during meiosis when pair fails to separate c. trisomy-additional autosomal chromosome -21-Down Syndrome -18-Edwards Syndrome -13-Patau Syndrome (18 & 13-poor prognosis: cardiac & respiratory problems) d. lack of an autosomal chromosome (45)=death of embryo e. mosaicism-some cells have normal #, others missing/having an additional chromosome f. sex chromosome abnormalities -45X-Turners juvenile external genitalia undeveloped ovaries short in stature webbing of the neck 6

3.

196

7 impaired intelligence most affected embryos SAB -47XXY-Klinefelters poorly developed secondary sexual characteristics small testes-infertile tall, effeminate subnormal intelligence usually present 4. Abnormality of chromosome structure a. translocation-genetic material moved from one chromosome to another-may create an imbalance of materials no problem if all information present b. additions/deletions gamete produced has too many/too few gene-effect may be mildsevere

B.

Patterns of Inheritance 1. Multifactorial a. combination of genetic and other factors such as environment i.e.: cleft lip/palate, neural tube defects b. malformation may be mild to severe depending on # of genes affected c. tend to occur in families d. some malformations more common in one sex e. polygenic, multifactorial diseases: coronary artery disease, obesity, HTN, psychiatric disorders 2. Unifactorial-Single-gene disorders a. one gene controls a particular trait, disorder, or defect b. # of unifactorial abnormalities exceed the # of chromosomal abnormalities -50-100,000 genes in 23 chromosomes c. autosomal dominant inheritance -abnormal gene with trait is expressed even with a normal member of the pair-no carriers -mutation of the gene-spontaneous, permanent change -affected individual comes from a family with generations of the disorder-50% chance of have mutant allele if parent was affected 7

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8 -ex: Marfans-disorder of connective tissue achondroplasia-dwarfism polydactyly-extra digits Huntington disease autosomal recessive inheritance -both genes in the pair carry the abnormality -heterozygous-carriers of the recessive trait -ex: Tay-Sachs sickle cell anemia cystic fibrosis -phenylketonuria X-linked dominant inheritance -occur in males and heterozygous females -ex: Fragile X syndrome-mental retardation X-linked recessive inheritance -no male to male transmission -50% chance that carrier mother will pass abnormal gene to each son who will be affected (therefore, 50% of males will be unaffected) -50% chance that carrier mother will pass abnormal gene to each daughter who will become carriers -for daughters to be affected, father must be affected and mother be a carrier or affected as well -ex: hemophilia-defect in clotting factor VIIIc Duchenne muscular dystrophy

d.

e. f.

C.

Testing 1. Prenatal testing-see booklet a. MSAFP b. CVS/amniocentesis c. blood tests for: -Tay-Sachs -Sickle Cell Anemia -Thalassemia -Cystic Fibrosis d. U/S-fetoscopy 2. Newborn testing-see booklet a. PKU-mental retardation b. congenital hypothyroidism-retardation c. galactosemia-dehydration/sepsis d. maple syrup urine disease-neurologic e. homocystinuria-neurologic f. congenital adrenal hyperplasia-electrolytes 8

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9 g. D. biotinidase deficiency-neurologic

Clinical management 1. Genetic counseling a. understand facts about the disease-cause and treatment b. understand how heredity contributes c. understand rate of recurrence d. aware of options e. course of action f. use of coping mechanisms/support systems 2. Nursing roles a. identify risk factors b. identify physical/developmental abnormalities c. assess need for referral d. prepare for genetic counseling e. correct misconceptions f. demonstrate support and sensitivity g. explain typical outcomes

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