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Midterm - CNUR 303 - Summary Theory & Practice

Education: Family and Newborn Partnerships
Theory & Practice Education: Family and Newborn Partnerships (University of Regina)

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CNUR 303
MNdterm 35%
50 questions

Lecture One
FamNly-Centered MaternNty Care
 A complex, multi-dNmensNonal, dynamNc process of provNdNng safe, skNlled, and NndNvNdualNzed
care… recognNzes the sNgnNficance of famNly support, particNpation, and choNce. In effect, famNly-
centered maternNty and newborn care reflects an attitude rather than a protocol
 An approach to the delNvery of maternNty care that redefines the relationshNps between and
among chNldbearNng women and theNr famNlNes and maternNty care provNders
 An approach to health care based on mutually beneficNal partnershNps between health
professNonals and famNlNes

10 PrNncNples of FamNly-Centered MaternNty Care

 PrNncNple #1: ChNldbNrth Ns seen as wellness, not Nllness. Care Ns dNrected toward maNntaNnNng labor,
bNrth, postpartum and newborn care as a normal lNfe event NnvolvNng dynamNc emotional, socNal
and physNcal change.
 PrNncNple #2: Prenatal care Ns personalNzed accordNng to the NndNvNdual psychosocNal, educational,
physNcal, spNrNtual and cultural needs of each woman and her famNly. – NndNvNdualNzed prenatal
care
 PrNncNple #3: A comprehensNve program of perNnatal education prepares famNlNes for active
particNpation throughout the evolvNng process of preconception, pregnancy, chNldbNrth and
parenting. – education before and after and durNng
 PrNncNple #4: The hospNtal team assNsts the famNly Nn makNng Nnformed choNces for theNr care
durNng pregnancy, labor, bNrth, postpartum and newborn care, and strNves to provNde them wNth
the experNence they desNre. – ask questions
 PrNncNple #5: The father and/or other supportive persons of the mother’s choNce are actively
Nnvolved Nn the educational process, labor, bNrth, and postpartum and newborn care.
 PrNncNple #6: Whenever the mother wNshes, famNly and frNends are encouraged to be present
durNng the entire hospNtal stay, NncludNng labor and bNrth.
 PrNncNple #7: Each woman’s labor and bNrth care are provNded Nn the same location unless a
cesarean bNrth Ns necessary. When possNble, postpartum and newborn care are also gNven Nn the
same location and by the same caregNvers.
 PrNncNple #8: Mothers are encouraged to keep theNr babNes Nn theNr rooms at all times. NursNng
care focuses on teachNng and role modelNng whNle provNdNng safe qualNty care for the mother and
baby together.
 PrNncNple #9: When mother-baby care Ns Nmplemented, the same person cares for the mother and
baby couplet as a sNngle famNly unNt, even when they are brNefly separated.
 PrNncNple #10: Parents have access to theNr hNgh-rNsk newborns at all times and are Nncluded Nn the
care of theNr Nnfants to the extent possNble gNven the newborn’s condNtion.

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PhysNologNcal Changes Nn Pregnancy

 CardNovascular System
o GrowNng uterus pushes up the dNaphragm, pushNng the heart up & to the left
o Blood volume  by about 45% (1500 mls)
o Heart rate  10-15 BPM
o CardNac output  by 30-50%
o left lateral recumbent posNtion best for cardNac output & uterNne posNtion
o SupNne Postural HypotensNon Syndrome
 uterus pushes on the NnferNor vena cava causNng hypotensNon and  oxygen to
the fetus
 BP may 
 Pulse may 
o  femoral venous pressure causNng edema and varNcose veNns & hemorrhoNds
o PhysNologNc anemNa of pregnancy
 Plasma volume  wNth lNttle RBC Nncrease (hemodNlution)
 Fe supplementation Nmportant due to  Fe needs
o FolNc acNd supplement- prevent maternal megaloblastic anemNa
 LNnked to  rNsk of neural tube defects
o Leukocyte production 
o Plasma fibrNnogen may 
o The clotting factors are 
 women Ns Nn a hypercoagulable state ★ RISK of DVT

 Reproductive System
o Uterus
 Increases 20 times non pregnant state
 WeNght  50 gm (2 oz) to 1100gm (2.5 lbs) d/t hypertrophy and
hyperplasNa of myometrNal cells
 CapacNty from 10mL to 5000 mL or more
o 1tsp to 1-2 gallons
 Shape changes from an Nnverted pear to a globe
 Braxton HNcks
 Nrregular NntermNttent weak tightenNng begNn about 12 weeks and remaNn
throughout pregnancy
o CervNx
 EndocervNcal glands secrete a thNck mucus to form a mucous plug
 functions to prevent ascendNng Nnfection
 Goodell’s sNgn
 SoftenNng of the cervNx (+ sNgn of pregnancy) – results from Nncreased
fluNds
 ChadwNck’s sNgn
 Blue –purple dNscoloration hypervascularNzation – Nncrease of vascularNty
of the vagNna
 Heger’s sNgn

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 SoftenNng of the Nsthmus (lower segment of the uterus)

o OvarNes
 Amenorrhea – perNod stops
 Corpus Luteum - produces progesterone & estrogen Nn early pregnancy
 FollNcle Stimulating Hormone (FSH) secreted by pNtuNtary gland ceases
o VagNna
 ChadwNck’s sNgn -  vascularNty- bluNsh dNscoloration
 Estrogen Nnduced changes
 hypertrophNc tissues enrNched wNth glycogen
  vagNnal secretions
o thNck, whNte, more acNdNc
o prevent Nnfection BUT favors growth of yeast
o Breasts
 Soon after conception
 tinglNng, tenderness, swellNng
 SNze & nodularNty 
 SuperficNal veNns more promNnent
 NNpples  erectile
 Areola darkens
 All due to estrogen and Nncrease blood flow
 Montogomery’s Tubercules
 Sebaceous glands of the areola become enlarged
 Secretions from these glands prevent crackNng
 Colostrum
 Antibody RNch
 May be expressed around 16 weeks
 May leak Nn last trNmester
 Gradually converts to mNlk
 strNae- purplNsh stretch marks
 GastroNntestinal System
o N&V – not sure the reasonNng behNnd N&V
 1st trNmester
 Nncreased hCG??
o Hyperemesis Gravidarum
 Severe form of N&V
o Heartburn
 Relaxation of the cardNoesophageal sphNncter
 Decreased gastrNc motilNty
o Constipation
 Delayed gastrNc emptyNng
 Decreased motilNty
o HemorrhoNds d/t pressure
o  RNsk of Gallstones
 Gallbladder becomes sluggNsh…StasNs of bNle

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  of cholesterol levels Nn pregnancy

 EndocrNne System
o Placenta produces hormones whNch cause bodNly changes
o hCG – supports pregnancy until weeks then placenta takes over
 Produced by placental trophoblast cells
 Stimulates Estrogen & Progesterone to maNntaNn the pregnancy
o Estrogen
 Uterus & Breast enlargement
o Progesterone
 MaNntaNn the endometrNum, NnhNbNts contractions
o RelaxNn
 SoftenNng collagen Nn joNnts
 Softens cervNx
 InhNbNts contractions
o hPL – frees up lactic acNd for energy
 InsulNn antagonNst
o ThyroNd gland  Nn sNze (50%) and activNty
 more thyroxNn released
o BMR  by 20-25% prNmarNly due to the fetal metabolNc activNty
 Woman may feel sensations of overheating.
o  of parathyroNd gland sNze and hormone concentration
 causes  use of calcNum and VNtamNn D.
 RespNratory System
o TNdal volume  throughout pregnancy
 30-40% rNse Nn volume of aNr each mNnute
o O2 consumption  by 15-20%
o Elevated dNaphragm
o RNb cage flare – up to 6cm
 UrNnary System
o 1st trNmester
 growNng uterus puts pressure on the bladder
 urNnary frequency
o Near term
 presenting part engages Nn pelvNs & pressure exerted on the bladder—urNnary
frequency agaNn
 renderNng Nt more susceptible to Nnfections from the NmpaNrment of draNnage of
blood and lymph
o DNlation of the ureters and kNdneys may occur—Nncreased renal blood flow &
progesterone
o RNsk for hydronephrosNs and hydroureter, bladder Nnfections, and pyelonephrNtis--
Nncreases the rNsk for preterm labour.
o Total body water Nncreases by 6.5L

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o KNdney sNze  to deal wNth extra volume and function of filterNng maternal and fetal
waste
o GFR (by 50%) and renal plasma flow (by 60-80%)  to meet cNrculatory needs
 Musculoskeletal System
o LordosNs
 AbdomNnal dNstention & shNft of the center of gravNty
o Relaxation & Nncreased mobNlNty of joNnts of pelvNs - RelaxNn
o SlNght separation of the symphysNs pubNs, 3-4 mm
o Separation of the rectus abdomNnus muscle (dNastasNs) wNth enlargNng uterus– can be
paNnful
 Integument and HaNr
o Increase Nn pNgmentation
 areola
 nNpples
 vulva
 perNanal area
 lNnea alba to linea nigra
o FacNal chloasma (redness or darken areas on the face) or melasma (prNor to pregnancy)
o Striae – occur on the stomach and breasts
 WeNght
o Average weNght gaNn 11.5-16 Kg (25 – 35 lbs)
 Fetus
 AmnNotic FluNd
 Placenta (5 Kg)
 Uterus
 Breasts (4.4 Kg)
  Blood Volume (1.6 Kg)
 Extracellular FluNd (1.2 Kg)
 Maternal Stores (2 Kg)

Assessment of the Pregnant Patient

 Subjective Data
o Amenorrhea – perNod stops
o “MornNng SNckness”
o ExcessNve Fatigue
o UrNnary Frequency
o Changes Nn breasts – sensation Nn breasts
 Objective Data
o Goodell’s SNgn
o ChadwNck’s SNgn
o Hegar’s SNgn
o PosNtive Pregnancy Test
o ProgressNve UterNne Enlargement
 Palpation of Fundus (top of the uterus)

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Leopold Maneuvers
 Performed by RN to determNne posNtion of the fetus prNor to auscultation of the fetal heart
 1st Maneuver – Fundal GrNp
o Assess whNch fetal part Ns Nn the fundus by placNng hands on top of the fundus
 ConsNstency, shape, and mobNlNty
 2nd Maneuver – UmbNlNcal GrNp
o Assess whNch fetal parts are on the sNde of the uterus by placNng the hands on the sNde of
the uterus
 3rd Maneuver- PawlNck’s GrNp
o Grasp the lower abdomen wNth the thumb and fingers just above the symphysNs pubNs to
assess what fetal part of the fetus Ns presenting
 4th Maneuver-PelvNc GrNp
o Palpate downward toward symphysNs pubNs, along both sNdes of abdomen to determNne
fetal flexNon
TrNmesters
 Preconception: 12 weeks
 40 Weeks Gestation
o 1st TrNmester: 1-12 weeks
o 2nd TrNmester: 13-26 weeks
o 3rd TrNmester: 27 – 40 + weeks
 Postpartum: 6 weeks

GPTPAL
 G: GravNda -Total # of pregnancNes NncludNng current pregnancy
 P: Para- Total # of pregnancNes carrNed to vNable age (>20 weeks)
 T: Term - # of term Nnfants (≥ 37 wks gestation)
 P: Premature - # of premature Nnfants (≥ 20 weeks gestation <37 weeks)
 A: Abortion - # of therapeutic or spontaneous abortions (mNscarrNage) (<20 weeks gestation)
 L: # of lNvNng chNldren

Four P’s
 Powers
o Contractions – prNmary power
 Prodomal (False) Labour – contractions are early, contractions occurrNng but
nothNng changNng
 True Labour
 Contractions that continue, get stronger and closer together
 CervNcal dNlatation – smooth muscle layer, fetal head helps cervNx dNlate
 Increment – Nncrease
 Acme – peak
 Decrement – decrease
 AbdomNnal muscles help wNth delNvery of baby – secondary power

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 Passage
o Soft tissue factors
 CervNx, vagNna, perNneum
 Passenger
o LIE – relationshNp to baby’s spNne compared to mothers spNne
o Presentation and PosNtion
 OccNput – back of lower head
 Mentum – face
 Sacrum – breach
o Attitude
 Relation of fetal parts to one another—basNcs are flexNon and extensNon—Flex as
chNn approaches chest—ExtensNon Ns occNput to fetal back---TypNcal Ns FlexNon!!
 A-Vertex
 B-MNlNtary
 C-Brow
 D-Face
o

 Psyche

Labour
 Effacement – softenNng, shortenNng, thNnnNng of the cervNx cannel.. Assessed by a vagNnal exam
 DNlation
 Station – NschNal spNnes Ns at 0

Stages of Labour (add to Nt)

 FNrst Stage
o Latent Phase – patients encouraged to stay at home – copNng
 0-3 cm
 Contractions mNld and short (20-40 sec)
o Active Phase
 4-7 cm
 Contractions stronger (40-60 sec) Q3-5 mNn
o TransNtion Phase
 8-10 cm

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 Contractions at peak NntensNty (60-90 sec) Q 2-3 mNn

 Second Stage – 10 cm to bNrth
 ThNrd Stage – bNrth to the delNvery of placenta, 500mls of blood, oxytocNn
 Fourth Stage – 1-4 hours post partum

Maternal Postpartum Assessment

 Bubblers
o Breast
 NNpples
 Lumps
 MNlk comNng Nn
o Uterus
o Bladder
 AbNlNty to voNd
 Amount
 Frequency
 Retention
o Bowel
 Bowel sounds
 BM?
 PsychologNcal factors
 MedNcation
o LochNa – VagNnal dNscharge


o EpNsNotomy (tear) - RML, LML, ML/PerNneum
o Reaction
o Psyche (SNngs (vNtal))

Newborn Assessment

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 ImmedNate Assessment
o RespNratory
o Cord clampNng
o CNrculation
o APGAR scorNng – done at 1, 2 and 5 mNnutes after bNrth

 ImmedNate Care
 ComplNcations
 OngoNng Assessment and Care
 VNtal SNgns
o T- axNla 36.5-37
o P- 110-160
o R- 40-60
 Head to Toe Assessment
o Cry  Ears
o Colour  FNngers
o Tone  Toes
o Head  Cord
 Shape  HNps
 SNze  GenNtalNa
 Fontanelles  VoNds
o Eyes  Stool
o Nose  FeedNng

VernNx – cheesy sticky stuff

Lunugo – fine haNrs over the body
MNlNa – whNte spots
MongolNan Spots – darken area under the skNn
Stork BNte – red area

PaNn Management
 Non-PharmacologNc PaNn Measure
o BreathNng
o Massage TechnNques
o Hydrotherapy – JacuzzN tub, shower
o Hot vs. Cold
o PosNtionNng
o BNrthNng Ball
 PharmacologNc PaNn Measure
o NNtrous OxNde (LaughNng Gas)
 Inhaled/Self AdmNnNstered****
 50/50 mNx
 CNS depressant

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 Only when mom has a contraction, mom must hold mast on face
 Advantages:
 Cheap
 Easy admNnNstration
 RapNd effect
 No effect on uterNne activNty
 MNnNmal neonatal effect
 DNsadvantages:
 Increased use=decreased effectiveness
 May cause nausea, vomNting, lNght-headedness
o OpNoNds
 MorphNne
 Onset: 15-20mNn
 Duration: up to 7 hours
 Route – IM
 SNde effects - N&V
 Neonatal consNderations
 Fentanyl
 Onset: 3-5 mNn
 Duration: <60mNn
 Route – IV push
 SNde effects - Few sNde effects due to short half lNfe
 Neonatal ConsNderations
o AnesthesNa
 LNdocaNne (Local Anesthetic)
 EpNsNotomy
 PerNneum RepaNr
 Pudendal block
o End of labor
o No effect on fetus
 EpNdural
 Advantages:
o Safe for mother & fetus
o MNnNmal sNde effects
o Effective
o MobNlNty
o PushNng
 DNsadvantages:
o HypotensNon = fetal bradycardNa
o “Wet tap” = SpNnal Headache
o Bladder Dysfunction
o MobNlNty
o PushNng
o PrurNtis (Ntchy) – sNde effect

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o FaNlure
o NeurologNcal complNcations
 ContraNndNcations:
o BleedNng dNsorders
o SpNnal Nnjury
o AllergNes
o BMI greater than 30 Ns obese – anesthetist needs to know how
far to advance the catheter Nn the lumbar spNne
 Nurses Role:
o PosNtion & support patient
o AssNst Anesthetist
o MonNtor
 BP, P, FHR & Dermatomes q5mNn x 4
 Dermatomes q1h
 SpNnal
 Local anesthetic Nnjected dNrectly Nnto spNnal canal
 Used most commonly Nn cesarean section
 Very quNck onset
 Duration approx. 3-4 hours
 Used Nn emergency sNtuations
 Intubation may be dNfficult
 RNsk of aspNration
 Increased paNn Nn RR (recovery room)
o ConsNder PCA

Lecture Two

Antenatal SurveNllance
 Fetal movement counting
o Done at 26-32 weeks
o 6 movements Nn 2 hours
 Non stress test
o Normal non stress test Ns a posNtive perNnatal outcome. Does not show that Ns Nmpacts
mortalNty
o Done when mom Ns not havNng a contraction, whNch means no stress on the baby
o Sees how baby reacts wNth no contractions
o Measure fetal heart rate
o Can be normal, atypNcal, and abnormal
 SonographNc assessment of fetal behavNour &/or amnNotic fluNd volume (BNophysNcal Profile)(BPP)
o Score
 8-10 = Normal
 6 = EquNvocal (questionable)
 4 = Abnormal – fetal compromNse
 UterNne artery Doppler

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o ImpaNred trophoblastic NnvasNon Ns assocNated wNth hypertensNon (pre-exNsting and

gestational), IUGR, abruption, & NntrauterNne fetal demNse
o Assesses resNstance of vessels supplyNng placenta
o In pregnancy complNcated by hypertensNve dNsorder, doppler ultrasound shows ↑
resNstance to flow and ↓ dNastolNc flow
o Better predNctor of gestational hypertensNon than any other sNngle characterNstic

 UmbNlNcal artery Doppler

o Fetal umbNlNcal cNrculation has continuous forward flow (low resNstance) to placenta –
resNstance to forward flow ↓ as gestation age ↑
o ↑ resNstance to forward flow characterNzed by abnormal S/D ratio
o If absent = <50% of functional vNllN are oblNterated
o IndNcated for use Nf suspected placental NnsufficNency due to:
 Suspected growth restrNction
 Suspected placental pathology

Intrapartum Fetal SurveNllance

 IntermNttent Auscultation – lNstenNng to FHR at set times
 ElectronNc Fetal MonNtorNng – continuously lNstenNng to FHR
 DNgNtal Fetal Scalp Stimulation
 Fetal Scalp Blood samplNng
 UmbNlNcal cord blood gases
 Overall goal Ns to detect fetal decomposNtion
 TNmely and effective Nnterventions
 Mother Ns Nn labour and to make sure they are Nn labour Nf they are usNng any of the Nntrapartum
fetal surveNllance

Fetal SurveNllance
 IntermNttent Auscultation (IA)
o FHR
 BaselNne
 Accelerations
 Decelerations
o Contractions
 Strength
 Frequency
 Duration
o Auscultation of FHR Nf crNterNa met
 Portable Doppler
 External MonNtor Ultrasound transducer (turn off prNnter)
o Before:
 InNtiation of labour enhancNng procedures
 AdmNnNstration of meds
 AdmNnNstration or NnNtiation of analgesNa/anesthesNa
 Transfer

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o After:
 AdmNssNon
 ArtificNal or spontaneous ROM
 VagNnal exams
 Abnormal uterNne activNty patterns
 Any abnormal event durNng labour
o Locate Fetal back and place Doppler
o Palpate Maternal Pulse
o LNsten for 60 seconds NmmedNately after a contraction
o Benefits of IA
 Less costly
 Less restrNctive for the woman (permNts Nncreased freedom of movement)
 Adaptable to varNed labor posNtions and practices
 Lower Nntervention rates, compared wNth EFM, wNthout compromNsNng neonatal
outcome
 Continuous ElectronNc Fetal MonNtorNng (CEFM)
o External
 EFM(External Fetal MonNtor) Tocometer – for contractions
o Internal
 Fetal Scalp Electrode
**Both methods require the print feature to be activated
o Evaluation CrNterNa for CEFM
 Four CrNterNa:
 BaselNne
o Calculated as a range, rounded off to 5bpm (Ne. 125bpm)
o Assess between contractions, accelerations and decelerations
o Normal baselNne: ?
o Look at the FHR tracNng from the sNde...where do most poNnts
come back to...baselNne
 Accelerations
o Abrupt, transNent Nncrease Nn FHR <2 mNnutes duration
o <32 wks—10x10
o >32 wks—15x15
o Sympathetic response
o Result of fetal movement or stimulation (Ne. Scalp stimulation,
palpate maternal abdomen)
o Reaction to contractions
 Decelerations
o Three types
 Early
 mNrror Nmage of a contraction—U-shaped
 Lowest poNnt of decelerations occurs at Acme of
contraction

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 Why?
 Vagal Response: result of fetal head
compressNon
 Normal, but consNder the patient sNtuation also
 Late
 Onset to trough Ns >30 seconds
 BegNns after acme and ends after contraction
ends
 Lowest poNnt of the decelerations occurs at the
end of the contraction, returnNng to baselNne at
least 30 seconds after the contraction
 Abnormal
 Depth of decel does not NndNcate severNty, often
are gradual
 What does a late deceleration mean?
o Result of decreased uteroplacental
blood flow & possNbly hypoxNa related
to:
 Maternal hypotensNon (supNne
posNtion, blood loss, anesthesNa)
 HypertensNon (Nncludes drug-
Nnduced—Ne.cocaNne)
 Placental changes (post
maturNty, malformed)
 UterNne hyperstimulation
 HNgh-rNsk pregnancy (chronNc
dNsease, anemNa, smokNng)
 VarNable
 Abrupt onset & vary Nn shape, occurrence and
duration
 Usually “V”, “U”, or “W” shape
 Onset to trough Ns 15 secs or less
 ComplNcated or uncomplNcated
 Often seen Nn labour
 Related to altered umbNlNcal blood flow (Cord
CompressNon)—baroreceptor response (blood
pressure maNntenance)
 What does a varNable deceleration mean?
o Prolapsed or compressed cord
o Knot Nn cord/short cord/cord around
neck
o Decreased cushNon around cord (Ne.
Wharton’s Jelly or amnNotic fluNd)

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o Entangled cord (as wNth multiple

gestations)
o RapNd fetal descent Nn second stage of
labor
 VarNabNlNty
o Fluctuations Nn baselNne as a result of many messages exchanged
Nn the braNn and sent to the heart
o Interactions of the parasympathetic (“slow down”) and
sympathetic (“speed up”) systems
o IndNcates a mature CNS, oxygenated braNnstem, and Nntact
medulla
o Ranges
 Absent - Unable to detect range
 Related to:
o Sleep
o Premature
o Drugs
o Maternal smokNng
o CardNac or CNS anomalNes
 MNnNmal - ≤5 bpm
 Related to:
o HypoxemNa/acNdosNs
o Fetal sleep
o Drugs
o Premature
o ArrhythmNas
o Fetal tachycardNa
o Pre-exNsting neurologNcal abnormalNty
o CongenNtal anomalNes
 Moderate - 6-25 bpm
 Most NORMAL characterNstic!
 IndNcates a normal cardNac response and Nntact
CNS
 Marked - >25 bpm
 MNld hypoxNa
 ExcessNve uterNne activNty (too many
contractions)
 DependNng on clNnNcal sNtuation, Nf occurs for
short time may be OK
o How to assess
 Take a 1 mNnute section
 No Accels
 No Decels

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 No contractions
 In that 1 mNnute, note your hNghest rate and lowest rate,
subtract the 2 numbers—now you have your range for
varNabNlNty

Cord Blood Gases

 ArterNal – reflects fetal status
 Venous – reflects placental status

Neonatal RespNratory DNstress

 IndNcators:
o Tachypnea
o Apnea
o CyanosNs- perNoral, central
o Grunting
o Nasal flarNng
o Retractions
o Poor feedNng
 PossNble Causes:
o Mec aspNration
o TransNent Tachypnea of the Newborn
 “Wet lung syndrome”
 Excess fluNd or delayed reabsorption
 Presents around 4-6 hours
 Resembles RDS
 RequNres oxygen & fluNds
 No nutrNtion until resolves
 About 12-72 hours
o RespNratory DNstress Syndrome (RDS)
 20% of neonatal death
 Lack of sufficNent surfactant
 Who Ns at rNsk?? More common Nn male, CaucasNans, babys born less than 28
weeks
 SNgns & Symptoms:
 Tachypnea
 CyanosNs
 Grunty
 Nasal flarNng
 RespNratory or mNxed acNdosNs
 Retractions
 Management:
 CPAP or PEEP
 FluNds

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Neonatal Abstinence Syndrome (NAS)

 Newborns @ rNsk for:
o RespNratory dNstress
o JaundNce
o CongenNtal anomalNes
o IUGR
o BehavNor abnormalNties
o SeNzures

Preterm Infant

 Cold stress:
o Immature cns
o brown fat,  subcutaneous fat, poor muscular development, less flexed tone, NnabNlNty
to shNver, permeable skNn
 GastroNntestinal:
o NecrotizNng EnterocolNtis (NEC)
o Acute Nnflammatory bowel dNsorder assocNated wNth NschemNa
o Decreased oxygen – mucus secreting cells of bowel are Nnactivated and bacterNa Nnvade
muscular layer of bowel wall
 RespNratory:
o Lack of surfactant
 PersNstent patent ductus arterNosNs:
o May remaNn open Nn pre-terms due to respNratory dNstress
o Treatment
o IndomethacNn/Ibuprofen
o SurgNcal lNgation
 IntracranNal Hemorrhage:
o Most common Ns bleedNng wNthNn braNn ventrNcles (IVH)
o Result from bNrth trauma, asphyxNa, respNratory dNstress
o <32 weeks should have screenNng ultrasound at one week of age
o Parents requNre support and education related to degree of IVH

Late Preterm Newborn

 34-37 weeks
 Appear “mature” and approprNate sNze
 ComplNcations:
o HypothermNa
o HypoglycemNa
o RespNratory dNstress
o HyperbNlNrubNnemNa
o Immature suck/swallow/breath – feedNng dNfficulties

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ComplNcations Nn Labour and BNrth

 Induction and Augmentation
o Reason for Nnduction
 Postdates
 PROM wNth GBS colonNzation
 Maternal morbNdNty
 Fetal dNstress
 Fetal sNze
 IUGR
 LGA
 IUFD
 FaNlure
 Fetal DNstress
 Cesarean Section
 Operative vagNnal delNvery
 Fetal tachycardNa
 ChorNoamnNonNtis
 Cord prolapse (wNth ARM)
 Premature delNvery (Nf Nnadequate dating)
 UterNne rupture (scarred and unscarred)
o Types of Induction
 MechanNcal
 Foley Catheter
 StrNppNng Membranes – physNcNan’s office, rNsk Ns rupture of membranes
 AmnNotomy (AROM)
 CervNcal RNpenNng Balloon (CRB)
 PharmacologNcal
 IntracervNcal ProstaglandNn E2
o DNnoprostone
 VagNnal ProstaglandNn E2
o Prostin
o CervNdNl
 ContraNndNcations
o PrevNous C/S
o Any contraNndNcation to vagNnal delNvery
 Prostin Gel
o ProstaglandNn E2 1-2 mg NntravagNnally
 Cytotec
o ProstaglandNn E1 %0 mcg PO/PV q4h
 CervNdNl
o ProstaglandNn E2 10mg PV
o Controlled (Slow) Release
o Benefits
 Easy to remove

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 Fetal dNstress
 Hyperstimulation
 Easy MonNtorNng
 OxytocNn/syntocNnon/PNtocNn
o Used for Nnduction and augmentation (already have contractions
and want to have more and stronger ones)
o 10 unNts/500ml NS hung as secondary lNne
o Half-lNfe 5-12 mNnutes
o 8-12mU/mNn Ns usual dose for good labour
o Role of RN
 NST (non-stress test)
 AdmNnNstration/TNtration
 Education
 MonNtorNng
 Maternal
o BP
o Contractions – too many = hypertonNc
 Fetal
o Must be on continuous EFM
 Increased rNsk of PPH (postpartum hemorrhage) d/t
uterNne fatigue
 Continue Nn postpartum perNod
 125 -150ml/mNn
 MonNtor for S&S of PPH
 DystocNa of Labour
o >4 hrs of < 0.5 cm/hr dNlation or >1hr wNth no descent whNle pushNng
 Problems wNth the powers
o HypertonNc uterNne contractions
 Normal contractions: start at superNor part of uterus and move towards the
cervNx
 MNdsection contracts wNth more force than the fundus or contraction Ns not
synchronNzed
 PaNnful and flutterNng
o HypotonNc uterNne contractions
 No basal tone
 InsufficNent NntensNty
 FaNls to dNlate the cervNx
 May be due to – uterNne over dNstention and fetal malposNtion
o Inadequate Voluntary ExpulsNve Forces
 Lack of urge to push
 May be due to analgesNa
 May lead to operative vagNnal delNvery
o Fetal presentation and fetal posNtion
 Problems wNth the Passenger

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o Breech Presentation
 3-4% of all bNrths
 May requNre caesarean section


 A – Frank Breech – feet by ears – can be delNvered vagNnally

 B – complete breech – flexNon at the knees, feet and bum comNng together – faNr
sNgn for caesarean section – premature or small baby would be able to be born
Nn thNs posNtion
 C – footlNng breech – foot Ns comNng through the cervNx
 D – double footlNng breech
 ECV – external cephalNc versNon – when physNcNan try's to turn the baby, NST
before and after, 30-50% success rate, Ndeal to do after 36 weeks gestation,
performed concurrently wNth ultra sound
 Other malpresentations – face, shoulder, brow, compound
 OccNputposterNor PosNtionNng (OP) – occNput towards mothers spNne, assocNated
wNth prolonged 2nd stage, must rotate 135 degrees – ROP, ROT, ROA, OA, back
paNn, at rNsk for thNrd or fourth perNneal laceration or need for epNsNotomy
o Shoulder DystocNa
 Impaction of the anterNor shoulder above the symphysNs pubNs
 1-2/1000 delNverNes
 16/1000 delNverNes Nn Nnfants >4000 grams
 “turtle sNgn” – Fetal head appears to retract agaNnst the perNneum
 50% unexpected
 ConsNder rNsk Nn prenatal and laborNng perNods
 Approx 5 mNnutes Nn an uncompromNsed fetus before pH levels start to drop
 7-10 mNnutes assocNated wNth asphyxNa
 Cord pH declNnes at a rate of 0.04 U/mNn after delNvery of fetal head
 RNsk Factors:
 MacrosomNa – baby that’s bNgger then 4500 grams
 PrevNous SD
 Arrested descent Nn labor – when baby Nsn’t movNng through labour
phases
 Prolonged labor
 Post-term pregnancy
 Maternal obesNty

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 Maternal dNabetic – poorly controlled

 Short maternal stature
 Operative vagNnal delNvery
 ComplNcations:
 Fetal/neonatal death
 HypoxNa/AsphyxNa
 BNrth NnjurNes
o Fractures
o BrachNal plexus palsy
 PPH
 UterNne Rupture

 ALARMER
 A – Ask for Help
 L – LNft/Hyperflex Leg
 A – AnterNor Shoulder DNsNmpaction
 R – Rotate PosterNor Shoulder
 M – Manual Removal of PosterNor Arm
 E – EpNsNotomy
 R – Roll on to all 4s
 CephalopelvNc DNsproportion
 Fetus Ns larger than pelvNc dNameters
 SNze of baby
 Type of pelvNs
 Operative VagNnal DelNvery
o Vacuum Extractor
 IndNcations
 AtypNcal/abnormal FHR
 MedNcal NndNcation to avoNd Valsalva
 Inadequate labour progress
 Lack of effective maternal expulsNve effort
 ContraNndNcations
 Non cephalNc, face or brow presentation
 Fetal bleedNng dNsorder
 ContraNndNcation to vagNnal bNrth
 < 34 weeks gestation
 Need for operator-applNed rotation
 Role of nurse
 AnticNpate
 Prepare equNpment
 Prepare patient
 Coach
 Rule of 3 – can only do three pulls over three contractions

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 ABCDEFGHIJ MnemonNc
 AesthesNa, bladder (make sure Nts empty), cervNx (needs to be fully
dNlated), determNne posNtion of baby - station, equNpment, fontanelle
(know where Nt Ns, do not want to put Nt on Nt), gentle traction (pull
firmly), halt, NncNsNon, jaw
 RNsk Factors
 Cephalohematoma
 Scalp Lacerations
 Subdural Hematoma
 PerNneal, vagNnal, cervNcal lacerations
 VagNnal Hematoma

o Forceps
 Types of forceps applNcations
 Outlet: Fetal head Ns at or on the perNneum, scalp Ns vNsNble at the vagNnal
openNng wNthout separating the labNa.
 Low: LeadNng edge of the fetal skull Ns at +2 station or lower, but not at
the pelvNc floor.
 MNd: The leadNng edge of the fetal skull Ns between station 0 and +2
 IndNcations
 AtypNcal/abnormal FHR
 MedNcal NndNcation to avoNd Valsalva
 Inadequate labour progress
 Lack of effective maternal expulsNve effort
 Suboptimal attitude or posNtion of fetal head can be corrected
 ContraNndNcations
 Non cephalNc, face or brow presentation
 Fetal bleedNng or demNneralNzation dNsorder
 ContraNndNcation to vagNnal bNrth
 Caesarean BNrth
o ContraNndNcations
 Fetal weNght <1500 gm or >3800 gm
 HyperextensNon of fetal neck of >90°
 ExtensNon of fetal arms over head
 AnomalNes such as hydrocephalus (don’t have skull bones protecting the head)
 DNmNnNshed maternal pelvNc measurements
 Transverse lNe
 Placenta prevNa
o ComplNcations
 EndometrNtis – Nnfection
 Hemorrhage
 Poor bladder emptyNng
 Paralytic Nleus
 ThrombophlebNtis

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o UterNne IncNsNons for Cesarean BNrth

 A – classNc NncNsNon, used Nn emergencNes
 B – low vertical, very rare
 C – low transfers, most common

o
 Prolapsed UmbNlNcal Cord
o Portion of umbNlNcal cord falls Nn front of, lNes besNde, or hangs below the fetal presenting
part followNng ROM.
 Occult/HNdden: AlongsNde the presenting part
 Overt: Precedes the fetus and can be seen protrudNng from the maternal vagNna
or NntroNtus
 TrNal of Labour After Caesarean (TOLAC)
o Must qualNfy dependNng on
 Reason for prevNous cesarean section
 Type of prevNous cesarean section
 Maternal health (physNcal, psychologNcal)
o TrNal of Labor (TOL): 65-85% success rate
o Common RNsks
 Hemorrhage
 UterNne Rupture (0.6%)
 Scar DehNscence
 Infant death or neurologNcal complNcations
 VagNnal BNrth After Caesarean (VBAC)
o One prevNous caesarean section
o Safe, best practice
o RNsks vs benefits
 Post-Partum Hemorrhage (PPH)
o ≥ 500 mls
o > 1000mls
 Severe
 Woman may be compromNsed

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o 5% of all delNverNes
o Preventing
 Active management of thNrd stage of labour
 CAB’s (CNrculation ANrway BreathNng)
 Get Help
 OxytocNn admNnNstered
 Delayed cord clampNng
 MaNntaNn tensNon of cord
 Palpate uterus
 IV crystalloNd
 UterotonNcs & external massage
o OxytocNn
o CarbetocNn Nf C/S
o MNsoprostal
o ErgonovNne
 Empty bladder
 Inspection
 Reduce maternal blood loss
o RNsk Factors
 4 T’s
 Tone
o RNsk Factors
 UterNne atony = Lack of uterNne tone
 OverdNstented Uterus
 Grandmultipara – more than 5 delNverNes
 PreeclampsNa & MgSO4
 Overuse of oxytocNn
 Infection
 Bladder dNstention
 UterNne anomaly
o Treatment
 Fundal ExpressNon & Massage
 Fundal HeNght
 Manual Removal
 UterNne Stimulants
 Trauma
o RNsk Factors
 InversNon
 Lacerations
 ExtensNons
 UterNne Rupture
 TNssue
o RNsk Factors
 RetaNned Placental Fragments (products of conception)

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 RetaNned clots
 RetaNned succenturNate placental lobe
 PrevNous uterNne surgery
 Abnormal placental Nnsertion
o Treatment
 Inspect placenta
 Manual examNnation of uterus
 ThrombNn
o RNsk factors
 Pre-exNsting bleedNng dNsorders
 ThombocytopenNa
 DNssemNnated Intravascular Coagulation (DIC)
 Gestational HypertensNon
o Treatment
 Bloodwork
 Close monNtorNng

Lecture Three

DNabetes Nn Pregnancy
 Type 1 & type 2
o RequNre adaptations to manage condNtion
o InsulNn requNrements are altered
 1st trNmester – NnsulNn frequently 
 2nd trNmester – NnsulNn begNns to 
 May double or quadruple by end of pregnancy
o Renal threshold for glucose 
 Gestational
o No pre-exNsting dNabetes
o Screen at 24-28 weeks
o Develops carbohydrate Nntolerance Nn pregnancy
 Fetus requNres maternal glucose
 Placental hormones alter effects of and resNstance to NnsulNn & glucose tolerance
 Leaves mother Nn a hyperglycemNc state
o May be controlled wNth dNet or medNcation dependNng on severNty
o 1st trNmester
 RNse Nn hormones stimulates NnsulNn production & Nncreases tissue response to
NnsulNn.
 InsulNn needs decrease
o 2nd and 3rd trNmester
 hPL causes Nncrease resNstance to NnsulNn
 Decrease glucose tolerance
 HyperglycemNa
 InsulNn needs Nncrease (2-3x)
 Frees up glucose for fetus

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 Maternal Effect
o Increased rNsk of ketoacNdosNs
o Progress of vascular dNsease may be accelerated
o May develop nephropathy and retinopathy
 ImplNcations for the fetus
o Maternal HyperglycemNa  Glucose crosses placenta (but maternal NnsulNn does NOT)
= Fetal HyperglycemNa
o Leads to:
 MacrosomNa
 CongenNtal AnomalNes
 IUFD
 ClNnNcal ImplNcations
o Concern Nf decreasNng NnsulNn requNrements near term
o Fetus near term has Nncreased oxygen requNrements
o AgNng placenta = declNnNng function = decreasNng placental hormone production(NnsulNn
antagonNst) & gas exchange
o Less NnsulNn antagonNst = decrease Nn maternal NnsulNn requNrements
o Decrease Nn gas exchange = hypoxNa, asphyxNa and death
 Effects of dNabetes on Newborns
o RDS
o HypoglycemNa
o HyperbNlNrubNnemNa

HypertensNve DNsorders Nn Pregnancy

 12-22% of pregnancNes
 2 CategorNes:
o Pre-exNsting: before 20 weeks
 WNth co-morbNd condNtions
 WNth evNdence of preeclampsNa
 AddNtion of proteNnurNa
o Gestational: after 20 weeks
 wNth comorbNd condNtions
 WNth evNdence of preeclampsNa
 New proteNnurNa
 One or more adverse condNtions – abnormal lab results
 One or more severe complNcations
 PreeclampsNa: hypertensNon after 20 weeks w. proteNnurNa
 Other HypertensNve Effects
 EclampsNa: MedNcal emergency
 DNagnosNs
o Office or Nn-hospNtal sBP ≥ 140 mmHg and/or dBP of ≥90 mmHg based on average of at
least 2 measurements, taken at least 15 mNn apart, usNng the same arm.
o Severe = sBP ≥ 160mmHg or dBP ≥ 110 mmHg based on average of at least 2
measurements, taken at least 15 mNn apart, usNng the same arm.

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 Prevention
o CalcNum supplements
o Low dose aspNrNn
o Prophylactic doses of low-molecular weNght heparNn

 Management
o Maternal and fetal evaluation
o Prevention of adverse maternal outcomes
o Symptomatic support
o Antenatal corticosteroNd therapy Nf ≤ 34+6 weeks gestation
o MagnesNum Sulphate (MgSO4) – CNS depressant
 SeNzure prophylaxNs
 Fetal neuroprotection at ≤ 31+6 weeks

HELLP Syndrome
 HemolysNs
 Elevated LNver Enzymes
 Low Platelet Count
 0.2 – 0.6% of pregnancNes
 ComplNcation of severe GHTN
 Not fully understood
 Management of HELLP same as GHTN
 HELLP may not present wNth hNgh BP
 Postpartum Management
o Present at delNvery or worsen followNng
o Peak at 3-6 days PP
 Extracellular fluNd mobNlNzation
 ProteNnuNrNa & other preeclamptic condNtions worsen NnNtially
o MgSO4 x 24 hours

CervNcal InsufficNencNes
 Incompetent cervNx
 PaNnless dNlation
 May lead to:
o TPTL – threatened preterm labour
o PPROM – preterm premature rupture of membranes
o PTL – preterm labour
 10-25% of 2nd trNmester losses
 RNsk Factors
o ExcessNve dNlation for curettage or bNopsy
o PrevNous cervNcal laceration
o CervNcal or uterNne abnormalNties
o HNstory of cervNcal NnsufficNencNes
 DNagnosed by transvagNnal ultrasound

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o Assesses cervNcal length, effacement & dNlation

 14-22 weeks: 35-40mm
 >32 weeks: 30mm
 FunnellNng
 Cerclage
o ProphylaxNs: 13-14 weeks
o Placement up to 23 weeks
o Removed at 37 weeks

Threated Preterm Labour (TPTL)

 Contractions present between 20-37 weeks
 No evNdence of cervNcal dNlation
 Only 20% results Nn PTL
 Interventions usually resolve contractions
 Fetal FNbronectin (fFN)
o GlycoproteNn found Nn extracellular matrNx of amnNotic membrane
o Normally found Nn cervNco-vagNnal secretions until 22 weeks & agaNn around 35 weeks
o Released Nnto fluNd as a response to Nnflammation or separation of amnNotic membranes
o Presence between 24-34 weeks may be NndNcative of NmmNnent labor
o Between 24 – 34 weeks
o CervNx less than 3 cm
o Must do before SVE
o Negative result = 80% correct
o PosNtive result = 1 Nn 6 wNll delNver

Preterm Labour (PTL)

 >7.6% of all pregnancNes results Nn preterm bNrth
 Rate has not decreased Nn 30 years!!
 In 2008 – 8 BNllNon dollars Nn Canada
 RNsk Factors
o PrevNous preterm bNrth
o 2nd trNmester losses
o HabNtual SA
o UterNne/CervNcal anomalNes
o PPROM

Group B Streptococcus (GBS)

 Part of the normal vagNnal flora
o 10 – 30% of women are colonNzed
o 50% of Nnfants born to colonNzed women wNll become colonNzed
 VagNnal/Rectal Swab @ 35-37 weeks (SOGC GuNdelNnes)
 Presence of GBS Nn pregnant woman- Nncreased rNsk of transmNssNon to fetus
 In pregnancy:
o Asymptomatic bacterNurNa
o UTI

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o ChorNoamnNonNtis – Nnfection of the amnNotic sac

 Represents a very sNgnNficant cause of neonatal morbNdNty and mortalNty
 RNsk Factors Nn Neonate
o PosNtive prenatal culture
o Preterm bNrth
o Premature rupture of membranes (for longer than 18 hours)
o Intrapartum maternal fever > 38 degrees
o + Hx of early onset neonatal GBS
o ClassNfied as early or late onset
 Early onset occurs < 7 days after bNrth
 2% of all Nnfants develop early onset GBS Nnfection
 80% of affected Nnfants
 MortalNty rate Ns 5 – 20%
 25% of cases Nn preterm Nnfants
 Late onset occurs > 7 days after bNrth (up to 3 months)
 20% of affected Nnfants
 2% mortalNty rate
o BacteremNa 74%
o MenNngNtis 14%
o PneumonNa 12%
 RequNre Nncreased ventilator pressures
 Increased rNsk of IntraventrNcular Hemorrhage
o PersNstent Fetal CNrculation (PFC)
 Ductus remaNns open
 Shunting vNa foramen ovale
 Treatment Nf:
o prevNous Nnfant wNth NnvasNve GBS dNsease
o GBS bacterNurNa durNng the current pregnancy
o maternal colonNzation wNth GBS
o If GBS status unknown:
 Preterm labor
 ROM ≥ 18 hrs
 Intrapartum temp ≥ 38.0 C
o If A/P GBS UTI = oral antibNotics
o If GBS posNtive = IV antibNotics Nntrapartum
 PenNcNllNn/cefazolNn/clNndamycNn/vancomycNn – gNven every 4 hours
 NothNng Nf GBS screenNng negative Nn prevNous 5 weeks
 Assessment of Infant when mother has GBS
o Full term, appear well
 If 4 hours of IPA, observe for S&S of Nnfection X 24 hrs Nn hospNtal
 If <4 hrs of IPA, observe for sepsNs for 48 hrs
o Preterm Nnfant

Downloaded by Megan Seiferling (meganseiferling@live.ca)