COMPREHENSIVE EXAM

Core Concepts of Maternal and Newborn Nursing

• Childbirth methods have changed with support persons like Certified Nurse Midwives (CNM) and Doulas, varying birth settings, and shorter hospital stays.
• Family-centered care prioritizes normal, healthy events and allows for collaborative decision-making.
• It's crucial to be sensitive to family beliefs and cultural variations, ensuring alignment between cultural practices and clinical care plans.
• Early and adequate prenatal care is essential for preventative care and managing risks.
• Home birth poses higher risks due to delayed access to care.
• Postpartum care spans 6 weeks and includes outpatient clinics, phone consultations, home visits, support groups, and scheduled follow-up appointments.
• Postpartum depression (PPD) is a significant concern, impacting both the mother and family.
• Therapeutic communication and patient support are paramount during this period.

Preterm Birth

• Preterm birth is influenced by factors such as smoking, hypertension, unhealthy weight, diabetes, a history of preterm births, and multiple pregnancies.

Mortality and Morbidity

• Maternal mortality has doubled since 2019, with 700-900 women dying annually due to pregnancy-related complications.
• Fetal mortality covers deaths after 20 weeks of gestation.
• Neonatal mortality refers to deaths within the first 28 days of life.
• Infant mortality encompasses deaths within the first year of life.
• Maternal and newborn morbidity includes chronic diseases (cardiovascular, diabetes) and lifestyle habits.
• Environmental factors, including exposure to chemicals and air pollution, also contribute to morbidity.

Factors Affecting Maternal and Newborn Health

• Family dynamics play a crucial role, including changes in parental roles and family structures.
• Non-traditional family structures are common, emphasizing the importance of avoiding assumptions.
• Socioeconomic status, media influence, domestic/environmental violence, nutrition, lifestyle choices, environmental exposure, stress, coping mechanisms, and access to healthcare all impact health.

Intimate Partner Violence

• Universal screening for intimate partner violence is essential for all patients.
• Establish trust and rapport with patients, ensuring privacy and safety.
• Ask direct questions to assess safety ("Do you feel safe at home?", "Has anyone hit, punched, or kicked you?").
• Document and report evidence or incidents appropriately.
• Provide education and resources to victims, offering emotional support and safety plans.
• The cycle of violence includes tension building, physically abusive episodes, reconciliation, and repetition.
• The SAVE model (Screen, Ask, Validate, Evaluate) guides screening and interventions.

Sexual Violence

• Healthcare professionals should be prepared to address sexual abuse and rape, offering compassionate and non-judgmental support.
• Specially trained Sexual Assault Nurse Examiners (SANE) play a critical role in forensic evidence collection and care for survivors.
• Care includes evidence collection, screening for sexually transmitted infections (STIs) and pregnancy, and addressing potential post-traumatic stress disorder (PTSD) with counseling.

Complementary and Alternative Medicine Use

• Focuses on holistic treatment of the individual, not just the disease or event.
• Some common modalities include aromatherapy, herbal medicine, reflexology, acupuncture, massage therapy, and therapeutic touch.

Infertility

• Primary infertility refers to never becoming pregnant, while secondary infertility involves past pregnancies but inability to carry to term.
• Infertility is a significant stressor on family dynamics and may carry cultural considerations.
• Infertility is defined as 12 months of unprotected intercourse without pregnancy.

Nursing Assessment for Infertility

• Male assessment includes semen analysis and physical examination.
• Female assessment involves examining eggs and uterus, as well as analyzing the menstrual cycle timing.

Postpartum Physical Adaptations

• The uterus should descend one finger width below the umbilicus daily after birth.
• Lochia, the vaginal discharge, progresses through three stages: Rubra (dark red clots, first 3-4 days), Serosa (pinkish watery discharge, around 2 weeks), and Alba (creamy/yellowish, 12 days to 6 weeks).
• Afterpains, typical for a few days postpartum, can mimic labor pain.

Cardiovascular Adaptations

• Postpartum blood volume is higher due to pregnancy.
• Coagulation factors increase, potentially leading to bleeding or hemorrhage.
• Heart rate and blood pressure typically drop after delivery, stabilizing quickly.

Urinary System Adaptations

• Full bladder emptying is crucial to prevent uterine relaxation and potential hemorrhage.
• A distended bladder shifts the fundus to the right.

Mood Disorders

• Baby blues are common, peaking around day 4 and resolving by day 10.
• Postpartum depression (PPD), with a risk factor of previous depression, requires intervention if baby blues persist or worsen beyond two weeks.
• Postpartum psychosis represents a more severe mood disorder.

Phases of Maternal Adaptation

• Taking-In phase: Focus on self-care and meeting basic needs.
• Taking-Hold phase: Shift to caring for the baby and assuming the mother role.
• Letting-Go phase: Accepting the new family unit and adjusting to life changes.

Postpartum Nursing Assessment

• Vital signs are closely monitored for signs of infection or hemorrhage.
• Physical assessment using the BUBBLE-EE method is crucial (Breasts, Uterus, Bowels, Bladder, Lochia, Episiotomy, Extremities, Emotional Status).
• Psychosocial assessment includes evaluating mood and bonding with the infant.
• Frequency of assessment varies by time post-delivery (every 15 minutes in the first hour, 30 minutes in the second hour, 4 hours for the first 24 hours, and 8 hours after 24 hours).

BUBBLE-EE Physical Assessment

• Breasts: Size, contour, symmetry, engorgement, nipple condition.
• Uterus: Fundus height and position.
• Bladder: Diuresis, bladder distention (a full bladder displaces the fundus to the right).
• Bowels: Constipation, fecal elimination.
• Lochia: Amount, color, odor, stage (Rubra, Serosa, Alba).
• Episiotomy/Perineum/Incision/Epidural Site: REDDA scale (Redness, Edema, Ecchymosis, Discharge, Approximation).
• Extremities: Assess for signs of venous thromboembolism (VTE).
• Emotional Status: Interaction with the baby, bonding and attachment.

Lochia Assessment

• The typical progression of lochia is Rubra => Serosa => Alba.
• Any foul odor suggests infection.

Perineal Assessment

• REDDA scale assesses healing.

Postpartum Nursing Interventions

• Assisting Elimination: Manage constipation with ambulation, fluids, fiber, and stool softeners (docusate).
• Promoting Activity, Rest, and Exercise: Encourage early ambulation, recognize need for rest/sleep, promote balanced diet, and emphasize safety measures.
• Self-Care Measures: Teach proper perineal pad changes, avoid tampons, shower daily, and use a sitz bath and peribottle.
• Ensure Safety: Monitor for orthostatic hypotension, help with bathroom assistance.
• Contraception: Provide education and counseling.
• Nutrition: Increase calorie intake to 500 calories per day if breastfeeding.
• Infant Feeding Method: Support the mother's choice.
• Breast Care: Manage engorgement with warm compresses, gentle massage, ibuprofen for pain, and avoidance of soap on nipples.
• Promoting Family Adjustment: Encourage consistent contact with the baby and address family dynamics as they adapt to baby care.

Assistance with Breastfeeding

• Assess breasts for engorgement and nipple condition.
• Lactation consultants provide education.
• Babies feed every 2-3 hours, and mothers need to eat frequently.
• Ensure proper positioning (ear, shoulder, hip aligned) and latch.

Assistance with Bottle Feeding

• Use FDA-approved formulas and infant water.
• Teach proper formula preparation and bottle sterilization.
• Avoid microwaving the bottle.

Preparing for Discharge

• Educate the mother on newborn sleep-wake cycles, developmental milestones, crying cues, signs of illness, important phone numbers, follow-up appointments, immunizations, and expected postpartum changes.
• Confirm that the mother meets discharge criteria.

Immunizations

• Maternal TDAP vaccination is recommended around 27 weeks of gestation.
• A rubella titer is drawn during early pregnancy.
• Live vaccines are not safe during pregnancy.
• Rh status is critical, and RhoGAM is administered to Rh-negative mothers to prevent sensitization.
• All Rh-negative mothers receive a RhoGAM injection at 28 weeks gestation and again after delivery.

Follow-Up Care

• Encourage support groups and consistent follow-up appointments.

Cesarean Birth

• Nursing Management
  • Informed consent; diagnostic testing; therapeutic communication.
• Pre-Op Care
  • Planned or unplanned; anticipatory communication; indwelling catheter; pre-op medications.
• Post-Op Care
  • Pain management; infection prevention; hemorrhage monitoring; clot prevention; pneumonia prevention; abdominal dressing care; bowel sound monitoring; nausea and vomiting care; gradual return to solid food; incision protection when coughing.

Circulatory Adaptations (Newborn)

• Transition from fetal to newborn circulation.
• Change from placental to pulmonary gas exchange.
• Closure of fetal structures:
  • Foramen ovale: Hole between atria.
  • Ductus arteriosus: Bypass of lungs.
  • Ductus venosus: Bypasses liver.
  • Umbilical arteries and vein: Oxygenated blood from placenta.

Respiratory Adaptations

• Initiation of respirations.
• Surfactant production.
• Respiratory rate is 30-60 breaths per minute (count when baby is resting).
• Irregular breathing, shallow breaths, and short periods of apnea (<15 seconds) are normal.
• Signs of respiratory distress: Grunting, nasal flaring, seesaw breathing, stridor, gasping.

Body Temperature Regulation

• Premature babies are more susceptible to heat loss.
• Factors predisposing to heat loss: Thin skin, lack of shivering, large surface area, lack of subcutaneous fat, inability to communicate needs.
• Thermoregulation:
  • Heat production: Non-shivering thermogenesis (burning fat stores, leading to weight loss).
  • Heat loss: Conduction, convection, radiation, evaporation.
• Maintain a neutral thermal environment to minimize weight loss.
• Skin-to-skin contact with mother is essential.
• Cold stress: Weight loss, lethargy, poor feeding, poor elimination, hypoglycemia.

Hepatic System

• Iron storage.
• Carbohydrate metabolism and blood sugar stabilization.
• Bilirubin conjugation: Liver converts bilirubin into excretable form.
• Elevated bilirubin levels: Increased RBCs and impaired conjugation.
• Jaundice: Common in newborns, monitor closely.
• Nursing interventions: Encourage feeding and stooling.
• Kernicterus: Toxic bilirubin levels.

GI Adaptations

• Bowel sounds appear quickly after birth.
• Bacterial colonization of the gut.
• Small, frequent feedings (every 2-3 hours).
• Regurgitation is common due to sphincter immaturity.
• Frequent burping.
• Meconium: First stool; dark, sticky.
• Transitional stool: Normal progression.
• Weight loss: Normal within 5-10% of birth weight.

Immune System Adaptations

• Non-specific and specific immune responses develop.
• Dependence on IgA, IgG, and IgM immunoglobulins.
• Passively acquired immunity from mother (IgG and IgA).

Neurologic/Behavioral Adaptations

• Sensory capabilities: Hearing, taste, smell, touch, vision.
• Congenital reflexes.
• Periods of reactivity:
  • First period: High alertness, looking around (30 minutes to 1 hour).
  • Inactivity and sleep: Sleep for several hours.
  • Second period of reactivity: Increased alertness, feeding, and elimination (2-3 hours).

Second Period of Reactivity

• Newborn is alert, active, and may cry
• Demonstrates a need for food

Behavioral Responses

• Orientation to stimuli
• Habituation
• Motor maturity
• Self-quieting ability
• Social behaviors

Physical Assessment of the Newborn

• Signs Indicating a Problem:
  • Nasal flaring
  • Chest retractions
  • Grunting on exhalation
  • Labored breathing
  • Generalized cyanosis
  • Flaccid body posture
  • Abnormal breath sounds
  • Abnormal respiratory rate
  • Abnormal heart rate
  • Abnormal newborn size

APGAR Score

• Assesses newborn's overall health
• Scored on a scale of 0-10
• Scores:
  • 10 = Perfect
  • 7-10 = Good, no concerns
  • 4-6 = Concerning, requires further evaluation and intervention
  • <4 = Emergency, requires immediate intervention
• Components:
  • Appearance
  • Pulse
  • Grimace
  • Activity
  • Respirations

Newborn Vital Signs and Anthropometric Measurements

• Temperature: 97.7-99.5°F (axillary preferred)
• Heart Rate: 110-160 BPM (may increase to 180 while crying)
• Respiratory Rate: 30-60 breaths/min at rest (may increase while crying)
• Blood Pressure: 50-75 mmHg systolic / 30-45 mmHg diastolic (not routinely done, depends on hospital policy)
• Length: Measure from head to heel
• Weight:
• Head Circumference:
  • Should be larger than chest circumference
  • May change due to cone head molding
• Chest Circumference:
  • Right at nipple line
  • Should be smaller than head circumference

Gestational Age Assessment

• Ballard Score:
  • Assesses physical and neuromuscular maturity
• Classification:
  • Preterm/Premature: <37 weeks gestation
  • Term: 38-42 weeks gestation
  • Postterm/Postdates: >43 weeks gestation
• Birth Weight Classification:
  • Small for Gestational Age (SGA)
  • Appropriate for Gestational Age (AGA)
  • Large for Gestational Age (LGA)

Skin Assessment

• Color
• Texture
• Turgor
• Common Skin Variations:
  • Erythema Toxicum: Benign rash, resolves on its own
  • Jaundice: Caused by bilirubin build-up
  • Milia: White bumps, do not pop to prevent infection

Head Assessment

• Size: Variations in size and appearance are normal
• Fontanelles: Soft spots on the skull, should be palpable
• Face: Symmetry
• Neck: Should be able to support the head
• Caput Succedaneum: Swelling of the head due to difficult labor, crosses suture line, resolves within days
• Cephalhematoma: Blood buildup under the scalp, does not cross suture line, may take weeks to resolve

Chest and Respirations Assessment

• Respiratory distress: Observe for signs
• Heart: Assess for abnormalities
• Abdomen: Assess for abnormalities
• Umbilical Cord:
  • Should dry and shrivel
  • Assess surrounding skin for infection
  • Should not bleed
  • Falls off on its own within weeks; do not pull off
• Genitalia:
  • Scrotum: Should have rugae in older infants
  • Testes: Should be descended into scrotum
• Extremities:
  • Movement
  • Fingers and toes: 5 on each extremity
  • Creases: Should be symmetrical and well-defined
  • Clubfoot: Foot may curve inward, but should return to normal position

Neurological Status

• Alertness: Assess level of alertness
• Posture: Flexed posture is desired
• Muscle Tone: Assess for resistance
• Reflexes: Most disappear within the first year of life

Nursing Interventions

• Immediate Newborn Period:
  • Maintain airway patency
  • Ensure proper identification
  • Administer prescribed medications
  • Maintain thermoregulation

Early Newborn Period

• Bathing and Hygiene: Don't bath everyday, can lower baby's temperature
• Elimination and Diaper Care:
  • Monitor frequency of diapers
  • Females: Wipe front to back
  • Males: Direct tip of penis downward
• Cord Care: Keep clean and dry, watch for signs of infection
• Circumcision and Care of Penis:
  • Common methods: Gomco clamp, Mogen clamp, Plastibell
• Safety:
  • Sleep on back
  • Tight swaddle
  • Nothing in crib
  • Do not co-sleep
• Promoting Sleep:
  • Periods of Purple Crying (Peak of crying, Unexpected, Resists soothing, Pain-like face, Long lasting, Evening, Never shake the baby)
  • Soothing techniques: Swaddle, side or football hold, swaying, sucking, shushing
• Enhancing Bonding: Encourage skin-to-skin contact
• Screening Tests:
  • Metabolic screening (PKU)
  • Oxygen saturation: Should be above 95% on both hands and feet, with less than a 3% difference

Promoting Nutrition

• Small, frequent feedings
• No solid foods
• Nutritional Needs: Rapid growth and development, iron, vitamin D
• Support feeding method choice (breastfeeding or formula feeding)
• Educate and support parents: Prenatal and childbirth classes are beneficial
• Feeding Assessment Before Feeding:
  • Suck and swallow reflex?
  • Use bulb syringe if needed
  • Bowel sounds?
  • Anus patency?
• On-demand feeding schedule: Every 2-4 hours
• Hunger Cues: Large mouth opening, crying
• Assessing Adequacy of Feeding: Monitor diaper output

Breastfeeding

• Benefits: Numerous health benefits for both mother and baby
• Milk Composition:
  • Colostrum: First milk produced, rich in antibodies
  • Transitional Milk: Transitional milk
  • Mature Milk: Subsequent milk
• Breastfeeding Assistance:
  • Immediate post-birth support
  • Positioning, comfort, and assessment (LATCH score)
  • Positions: Football, cross cradle, across the lap, side-lying
  • Milk Storage and Expression: Current CDC recommendations
• Engorgement: Breast swelling, can be uncomfortable
• Mastitis: Breast infection, can continue breastfeeding

Preparation for Discharge

• Support and praise parents
• Allow parents to provide input
• Build self-esteem
• Ensure follow-up care: Pediatrician appointments

Perinatal History

• Pertinent maternal and fetal data
• Gather comprehensive information about the mother's overall health and history

Presumptive Signs of Pregnancy

• Reported by the patient
• Experienced:
  • Fatigue
  • Nausea
  • Breast tenderness (3-4 weeks)
  • Urinary frequency (6-12 weeks)

Probable Signs of Pregnancy

• Objective signs, detectable by the provider
• Goodell's Sign: Softening of the cervix (5 weeks)
• Chadwick's Sign: Bluish-purple discoloration of the cervix (6-8 weeks)
• Hegar's Sign: Softening of the lower portion of the uterus (6-12 weeks)
• Positive pregnancy test (4-12 weeks)
• Braxton Hicks contractions

Positive Signs of Pregnancy

• Ultrasound (4-6 weeks)
• Fetal movement felt by the provider (20 weeks)
• Auscultation of fetal heart tones (10-12 weeks)

Physiological Adaptations During Pregnancy

• Uterus:
  • Increased blood flow and capacity
  • Growth beyond pelvis after 12 weeks
  • Lower uterine segment: Thins and stretches
  • Supine hypotensive syndrome: Pressure on vena cava and aorta, causing dizziness and fainting
  • Fundal Height: Measurement of uterine size
  • Braxton Hicks Contractions: Practice contractions, become more regular as pregnancy progresses
• Cervix:
  • Goodell's Sign: Softening
  • Chadwick's Sign: Bluish-purple discoloration
• Vagina:
  • Mucosa thickens
  • Connective tissue loosens
  • Increased secretions
  • Increased vascularity
• Breasts:
  • Fullness
  • Tenderness
  • Nipple changes: Enlarge and darken
  • Colostrum: Yellowish discharge
• Gastrointestinal System:
  • GERD
  • Bleeding gums
  • Increased dental plaque, debris, and gingivitis
  • Delayed gastric emptying
  • Constipation
  • Heartburn
• Cardiovascular System:
  • Increased blood volume (1500 ml increase)
  • Elevated heart rate and blood pressure
  • Hypercoagulable state: Increased fibrin and fibrinogen levels
• Respiratory System:
  • Increased oxygen requirements
  • Faster and deeper breathing
• Renal/Urinary System:
  • Dramatic changes due to increased blood volume
  • May require dosage adjustments for medications
• Musculoskeletal System:
  • Postural changes: Lordosis (inward spinal curvature)
  • Gait changes: Waddle gait
  • Joint stretching
• Integumentary System:
  • Hyperpigmentation: Darkened nipples
  • Striae gravidarum (stretch marks)
  • Linea nigra (dark line down abdomen)
  • Varicosities
• Endocrine System:
  • Pancreas: Increased glucose demands
  • Insulin does not cross the placenta
  • Glucose intolerance: Can lead to gestational diabetes

Changing Nutritional Needs During Pregnancy

• Consider pre-pregnancy weight
• Food Concerns:
  • Mercury in fish
  • Listeriosis
• Maternal Weight Gain: Steady weight gain is important
  • Underweight: 28-40 lbs
  • Normal Weight: 25-35 lbs
  • Overweight: 15-25 lbs
  • Obese: 11-20 lbs
• Special Considerations:
  • Cultural variations
  • Vegetarianism
  • Pica (craving non-food substances)
• Dietary Recommendations:
  • Avoid processed foods
  • Limit caffeine
  • Avoid diuretics
  • Do not skip meals: Eat 3 meals a day with 1-2 snacks daily

Psychosocial Adaptations During Pregnancy

• Maternal Emotional Responses:
  • Ambivalence
  • Acceptance
• Partner: May experience emotional changes as well, supporting their adjustment is important
• Siblings: May experience feelings of jealousy and anxiety, help them adjust to the incoming baby

Preconception and Interconception Care

• Key areas of focus:
  • Immunization status
  • Underlying medical conditions
  • Reproductive health history
  • Sexuality and sexual practices
  • Support systems
  • Medications/drug use
  • Psychosocial status
  • Lifestyle practices
  • Nutritional history
• First Prenatal Visit: Anticipatory guidance
  • Comprehensive health history
  • Age
  • Menstrual history
  • Obstetric history
  • Medical/Surgical history
  • Psych/genetic screening
  • Nutritional habits
  • STD exposure
  • Reproductive history
• Nagele Rule: Estimate delivery date (EDD) calculation based on the first day of the last menstrual period
• Reproductive History: Gravida (pregnancy) / Para (delivery)
  • GTPAL:
    • G: Number of pregnancies
    • T: Number of full term deliveries
    • P: Number of preterm deliveries
    • A: Number of abortions (losses under 20 weeks)
    • L: Number of living children
• Physical Examination: Pelvic exam
• Laboratory Tests:
  • CBC
  • Blood type
  • Rubella titer
  • Hep B
  • HIV testing
  • Pap smear
  • UTI screening
  • RPR
  • Cultures

Follow Up Visits

• Every 4 weeks until 28 weeks
• Every 2 weeks from 29-36 weeks
• Every week from 37 weeks to birth

Assessments During Prenatal Care

• Weight
• Blood pressure
• Urinalysis
• Fetal growth monitored through fundal height measurements
• Fetal movement
• Apical heart rate
• Testing for gestational diabetes:
  • Between 24-28 weeks
  • Oral 50g glucose load followed by 1-hour plasma glucose

  • 140mg/dl indicates further testing is needed

• Testing for Group B Strep: Between 37-40 weeks

Protein in Urine or Excessive Weight Gain

• May indicate preeclampsia
  • Affects kidneys and can cause fluid retention

Determining Fetal Well Being

• Fundal Height Measurement:
  • McDonald's Method: Measure fundal height in centimeters, usually correlates with gestational age until 36 weeks
  • Fundal height typically decreases after week 36, as the baby drops into the pelvis
• Fetal Movement Determination:
  • Count to 10 method: Count fetal movements to assess well-being

Danger Signs During Pregnancy

• First Trimester (conception to 12 weeks):
  • Spotting or bleeding
  • Painful urination (infection)
  • Severe persistent vomiting (Hyperemesis gravidarum)
  • Fever over 100º (infection)
  • Lower abdominal pain with dizziness or shoulder pain (Ruptured ectopic pregnancy)
• Second Trimester (13-28 weeks):
  • Regular uterine contractions
  • Pain in calf (DVT)
  • Sudden gush or leakage of fluid from the vagina (prelabor rupture of membranes)
  • Absence of fetal movement for >12 hours
• Third Trimester (29-40 weeks):
  • Sudden weight gain
  • Periorbital/facial edema
  • Severe upper abdominal pain
  • Headache with visual changes (gestational hypertension, preeclampsia)
  • Decrease in fetal movement

Assessment of Fetal Well Being

• Ultrasonography:
  • Non-invasive
  • Transabdominal or transvaginal
• Doppler Flow Studies:
  • Non-invasive
  • Examine blood flow in fetal vessels
• Marker Screening Tests:
  • Alpha-fetoprotein (AFP): Screen for neural tube defects
  • Triple marker screen
  • Quad screen
  • Cell-free DNA testing: Detects fetal chromosomal abnormalities
• Amniocentesis:
  • Obtain amniotic fluid for analysis
  • Assess fetal abnormalities and lung maturity
  • Potential complications, informed consent is mandatory
• Chorionic Villus Sampling (CVS):
  • Obtain a sample of chorionic villi from the placenta
  • Transabdominal or transcervical
  • Significant risks, informed consent is mandatory
• Nonstress Test (NST):
  • Assess fetal heart rate patterns, looking for accelerations
  • Reactive = normal
  • Non-reactive = further evaluation needed
• Biophysical Profile (BPP):
  • Five components, scored 0-2 each
  • Evaluates fetal well-being
  • Ultrasound and NST components

Childbirth Preparation

• Perinatal Education:
  • Childbirth education classes:
    • Lamaze
    • Bradley
    • Dick-Read
• Options:
  • Birth setting
  • Care provider
  • Finding choices
• Final preparation for labor and birth:

Vulnerable Populations

• Pregnant adolescents
• Women of advanced maternal age

Factors Influencing the Onset of Labor

• Uterine Stretching: As the baby grows, the uterus stretches, triggering labor
• Cervical Effacement: Thinning and shortening of the cervix
• Cervical Dilation: Opening of the cervix
• Progesterone Withdrawal: A decrease in progesterone levels allows for increased uterine contractions
• Increased Oxytocin Sensitivity: The body becomes more sensitive to oxytocin, which stimulates labor
• Increased Release of Prostaglandins: Prostaglandins promote uterine contractions

Premonitory Signs of Labor

• "Lightning Bolt": Baby drops into the pelvis, causing a sensation of the belly dropping
• Braxton Hicks Contractions: Practice contractions, become more regular as labor approaches
• Cervical Changes:
  • Softening of the cervix
  • Effacement
• Bloody show: Expulsion of the mucus plug, may include some blood
• Rupture of Membranes (ROM): Water breaking, usually clear fluid, report any odor or color changes (green fluid may indicate meconium passage)
• Sudden burst of energy: "Nesting" instinct, a surge of energy to prepare for the baby's arrival

True vs. False Labor

• True Labor:
  • Contractions are regular
  • Contractions grow stronger with time
  • Contractions start in the back and radiate to the front
  • Contractions continue regardless of position
• False Labor:
  • Contractions are irregular
  • Contractions are often weak
  • Contractions are typically felt in the front of the abdomen
  • Contractions may stop or slow down with walking or position changes
• Stay or Go: Stay home if contractions are 5 minutes apart, last 45-60 seconds, and are strong enough to make conversation difficult. If contractions diminish in intensity, stay home
• If concerned, contact your healthcare provider

Factors Affecting Labor Process (5Ps)

• Passageway: The birth canal (pelvis and soft tissues)
  • Mother's pelvic size: Diameters of the true pelvis (inlet) and false pelvis (flares at hip)
  • Pelvic Shape:
    • Gynecoid: Most common and favorable
    • Android: Not favorable for vaginal birth
    • Anthropoid: May still allow for vaginal birth
    • Platypelloid: Not favorable for vaginal birth
  • Cervix: Dilation and effacement
  • Pelvic floor muscles: Provide resistance during birth
• Passenger: The fetus
  • Fetal Head: Reference point for the presenting part
    • Occipital bone: Landmark used to determine fetal position
    • Fontanelles: Soft spots on the skull
  • Fetal Attitude: Relationship of body parts, flexion of neck, arms, and legs
  • Fetal Lie: Relationship of the fetal axis to the maternal axis
    • Longitudinal: Parallel to the mother's axis (optimal)
    • Transverse: Perpendicular to the mother's axis
    • Oblique: Diagonal
  • Fetal Presentation: Presenting part entering the birth canal first
    • Cephalic: Head first (optimal)
    • Breech: Buttocks or feet first
    • Shoulder
  • Fetal Position:
    • R or L: Side of pelvis where presenting part is located
    • Presenting part: Occiput (vertex), Mentum (face), or Sacrum (breech)
    • Part-Pelvis relationship: Anterior, Posterior, or Transverse
  • Fetal Station: Level of the presenting part in relation to the ischial spines (narrowest diameter the fetus must pass through)
  • Engagement:
    • Floating: Not yet engaged, level of spine is 0
    • Dipping: Fetal head dips into the inlet
    • Engaged: Presenting part is at the level of ischial spines
• Powers: Forces of Labor
  • Primary Powers: Uterine contractions
    • Contractions/Waves:
      • Frequency: Time between the onset of one contraction and the onset of the next
      • Duration: Length of time from the beginning to the end of a contraction
      • Intensity: Strength of the contraction at its peak (mild, moderate, strong)
  • Secondary Powers: Abdominal muscles used for pushing
• Position: Maternal positioning can help labor progress
  • Standing and walking
  • Squatting
  • Kneeling
  • Side recline
  • Peanut ball
• Psychological Response:
  • Positive attitude
  • Willingness to birth
  • Sociocultural factors
  • Socioeconomic factors
  • Coping with the physical demands of labor
  • Maintaining physiological and emotional balance

Other P's to Consider

• Philosophy of care
• Partner's support
• Patience
• Patient preparation
• Pain management

Systematic Response to Labor (Maternal)

• Cardiovascular: Increased blood volume, cardiac output, and blood pressure
• Respiratory: Hyperventilation leading to respiratory alkalosis; pushing can lead to respiratory acidosis but acid-base levels should normalize within 24 hours
• GI: Slowed gastric emptying, leading to nausea and vomiting
• Lab Values: Elevated white blood cell count (WBC)
• Pain Receptors: Activated during labor

Systematic Response to Labor (Fetal)

• Heart Rate Changes: Accelerations and decelerations in response to stress
• Fetal Movement: Changes in fetal movement can indicate distress
• Fetal Scalp Stimulation: Used during labor to assess fetal heart rate response

Stages of Labor

• First Stage: Longest stage
  • Latent Phase (0-6 cm dilation)
  • Active Phase (6-10 cm dilation)
• Second Stage: Complete dilation to the birth of the newborn
  • Pelvic Phase: Period of fetal descent
  • Perineal Phase: Period of active pushing
• Third Stage: Placenta separation and delivery
  • Placental Separation: Placenta detaches from the uterine wall
  • Placental Expulsion: Placenta is delivered
• Fourth Stage: 1-4 hours after birth of the newborn, focuses on maternal recovery

Cardinal Movements of Labor

• Engagement: Presenting part enters the pelvis
• Descent: Movement of the presenting part through the pelvis
• Flexion: Fetal head flexes to minimize the diameter of the presenting part
• Internal Rotation: Fetal head rotates to align with pelvic outlet
• Extension: Fetal head extends as it passes through the pelvis
• External Rotation: Fetal head rotates to align with the shoulders
• Expulsion: Delivery of the baby

Maternal Assessment During Labor and Birth

• Vaginal Exam:
  • Cervical dilation and effacement
  • Fetal descent
  • Rupture of membranes (ROM)
• Uterine Contractions:
  • Intensity: Palpate at the fundus to assess strength
  • Frequency: Time between contractions
• Leopold Maneuvers: Used to assess fetal position
  • 1st Maneuver: Palpate the fundus
  • 2nd Maneuver: Palpate the sides
  • 3rd Maneuver: Palpate the base of the fundus
  • 4th Maneuver: Palpate the presenting part

Fetal Assessment During Labor and Birth

• Palpation: Used to determine the baby's position within the mother's uterus.
• Amniotic Fluid Analysis: Assesses the color of the fluid to differentiate between urine and amniotic fluid.
• External Fetal Monitoring: Consists of two devices attached to the mother's abdomen:
  • Top Device: Monitors contractions.
  • Bottom Device (Transducer): Monitors the fetal heart rate, placed over the fetus's back.
• Internal Fetal Monitoring:
  • Fetal Scalp Electrode: An internal fetal heart monitor.
  • Intrauterine Pressure Catheter (IUPC): Provides a specific pressure reading for the timing and intensity of contractions.
• Analysis of Fetal Heart Rate: Indicates how well the baby is tolerating labor.
  • Variability: Refers to the fluctuations in the fetal heart rate:
    • Absent: No detectable range.
    • Minimal: Range is less than 5 bpm.
    • Moderate: Range from 6-25 bpm (ideal).
    • Marked: Range is over 25 bpm.
  • Periodic Changes:
    • Accelerations: Increases in the fetal heart rate in response to fetal movements or tactile stimulation.
    • Decelerations: Decreases in fetal heart rate:
      • Early: Occur during contraction peaks, caused by head compression (considered good).
      • Late: Occur after contraction peaks, indicating potential uteroplacental insufficiency (not okay).
      • Variable: Sharp, unpredictable drops, suggesting cord compression (very concerning).
  • Fetal Tachycardia: Can indicate maternal infection.
  • Fetal Bradycardia: May indicate nervous system issues, oxygen deprivation, or other complications.

Fetal Heart Monitor Tracing

• Strip Components: Two graphs:
  • Upper Graph: Displays fetal heart rate data.
  • Lower Graph: Displays contraction data.
• Graph Interpretation:
  • Each small square represents 10 bpm (heart rate) or 10 seconds (time/contraction intensity).
  • One dark line to the next dark line represents one minute of time.
  • Stimulation should trigger a fetal heart rate increase of 15 bpm for at least 15 seconds.
  • Early Decelerations: Indicate the baby is navigating the birth canal (good).
  • Variable Decelerations: Resemble a V, U, or W shape, indicating potential cord compression (not good).
  • Late Decelerations: The fetal heart rate drop occurs after the contraction peak, indicating uteroplacental insufficiency (baby is compromised).

Interventions for Fetal Heart Rate Abnormalities

• Cord Compression:
  • Change the mother's position to her side.
• Late Decelerations:
  • Change the mother's position to the left lateral side.
  • Increase fluids.
  • Administer oxygen.
  • If two or three nursing interventions fail, consider internal monitoring and potential interventions such as vacuum delivery, forceps delivery, or a Cesarean section.

Non-pharmacologic Measures

• Continuous labor support
• Hydrotherapy
• Ambulatory and position changes
• Acupuncture and acupressure
• Attention focusing and imagery
• Therapeutic touch and massage (effleurage)
• Breathing techniques

Pharmacologic Interventions

• Adequate comfort and analgesia for both mother and baby:
  • Neuraxial analgesia/anesthesia
  • Systemic analgesia
  • Inhaled analgesia (Nitrous Oxide)
  • Regional analgesia/anesthesia (local anesthetics, epidural, combined spinal epidural, pudendal block)
  • General anesthesia (emergency only)
• Epidural Considerations: Can cause vasodilation and lower blood pressure requiring a fluid bolus and increased fluids to maintain blood pressure.

Maternal Nursing Assessments

• Admission and First Stage:
  • Prenatal Record Review: Maternal history, intrapartum high-risk screen.
  • Physical Assessment:
    • Vital signs
    • Fundus and contractions (palpation)
    • External fetal monitoring
    • Intrauterine pressure catheter (IUPC)
    • Cervical dilation and effacement
    • Amniotic fluid
    • Presenting part and descent
  • Cultural Assessment.
  • Laboratory Tests.
  • Psychosocial Concerns.

Stage 2 of Labor

• Nursing Management

• Breathing Techniques:

• Pushing Techniques:

• Contractions:

• Maternal Vital Signs:

• Fetal Heart Rate (FHR):

• Amniotic Fluid:

• Coping:

• Episiotomy: Surgical incision of the perineum to aid in delivery:

  • Midline or mediolateral:
  • Indications: Large for gestational age (LGA) baby, vacuum/forceps delivery, maternal exhaustion.
  • Assessment and Interventions: REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation)
  • Comfort Measures: Ice packs, tucks, sitz baths.

• Lacerations: Tears in the vaginal area:

  • First Degree: Vaginal mucosa and perineum.
  • Second Degree: Perineal muscles and fascia.
  • Third Degree: External anal sphincter.
  • Fourth Degree: Internal and external anal sphincters, anal mucosa.

• Prevention of Lacerations:

  • Perineal massage.
  • Different pushing positions.
  • Warm soaks.
  • Counterpressure.
  • Gradual pushing during crowning.

Assisted Delivery

• Forceps:
  • Outlet Forceps: Applied when the fetal skull reaches the perineum, the fetal scalp is visible, and the sagittal suture is not more than 45 degrees from the midline.
  • Low Forceps: Applied when the presenting part of the fetal skull is at station +2 or greater.
• Vacuum Assisted Delivery:
  • Indications: Prolonged second stage of labor, non-reassuring fetal heart rate tracing, inability to push effectively, maternal exhaustion, maternal heart disease.

Nursing Management of Third Stage

• Maternal Care:
  • Vital signs every 15 minutes.
  • Observe for placental separation.
  • Perineal trauma/repairs.
  • Comfort measures.
• Newborn Care:
  • Maintain respirations.
  • Provide/maintain warmth.
  • APGAR score at 1 and 5 minutes (activity, pulse, grimace, appearance, respiration).
  • Physical assessment.
  • Identification measures.
  • Facilitation of attachment.

Nursing Management of Fourth Stage

• Assessment:
  • Vital signs every 15 minutes for the first hour (blood pressure, pulse, respirations).
  • Temperature PRN.
  • Fundus and flow every 15 minutes for the first hour.
  • Perineum.
• Perineal Care:
• Encourage Bonding and Breastfeeding:
• CSM: Circulation, Sensation, Movement.
• Education:

Cesarean Birth

• Delivery: Through an incision on the abdomen and uterus.
• Indications: Maternal and fetal indications.
• Preoperative/Postoperative Care:
• Risks: Infection, hemorrhage, aspiration, ileus, urinary trauma.
• Anesthesia (Spinal): Once surgery is complete, monitor CSM.

Diabetes Mellitus in Pregnancy

• Pre-Gestational Diabetes: Alterations in carbohydrate metabolism before conception.
  • Management: Insulin, diet, exercise.
• Gestational Diabetes (GDM): Glucose intolerance that develops during pregnancy, usually diagnosed between the second and third trimesters (24-28 weeks).
  • Neonatal Complications: Excessive weight gain.

Hypertension in Pregnancy

• Gestational Hypertension: Two separate blood pressure readings of 140/90 or higher at least 4 hours apart after 20 weeks gestation.
  • Lifestyle Changes: LL recumbent position, limited sodium intake.
  • Antihypertensives:

Preeclampsia/Eclampsia

• Pathophysiology: Imbalance between thromboxane and prostacyclin.
  • Result: Reduced blood flow to the brain, liver, kidneys, and lungs.
  • Signs and Symptoms: Severe headache, seizures, hypertension, vision changes, proteinuria, decreased urine output, sodium retention, edema.

Nursing Management of Preeclampsia

• Mild: Few symptoms, blood pressure greater than 140/90, proteinuria of 1g or less in 24 hours.
• Severe: Blood pressure 160/110 or higher on at least two occasions 6 hours apart, bed rest on the left side, proteinuria of 5g or more in 24 hours, vision changes, oliguria, severe headache, thrombocytopenia.

Monitoring and Treatment of Preeclampsia

• Assessment: Blood pressure, weight, urine protein, and fetal movement.
• Medications:
  • Anticonvulsants (magnesium sulfate)
  • Corticosteroids
  • Antihypertensives (labetalol, hydralazine)
• Labor Induction: Indicated in severe cases.
  • Cesarean section may be necessary.
• HELLP Syndrome: Severe preeclampsia with liver involvement.
  • H: Hemolysis
  • E: Elevated Liver enzymes
  • L: Low Platelet count

Iron Deficiency Anemia in Pregnancy

• Cause: Reduced red blood cell count.
• Signs and Symptoms: Fatigue, shortness of breath, weakness, pallor.
• Treatment: Iron supplements, diet modifications.

Ectopic Pregnancy

• Pathophysiology: Fertilized egg implants outside the uterus, usually in the fallopian tube.
  • Result: Embryo grows, eventually exceeding the space within the tube, causing a rupture and bleeding into the abdominal cavity.
• Signs and Symptoms: Sharp, one-sided pain, syncope, referred right shoulder pain, adnexal pain.
• Assessment: Last menstrual period (LMP), pelvic exam for masses and tenderness.

Cervical Insufficiency

• Cause: Presumed weakness of the cervical tissue contributing to preterm delivery.
• Signs and Symptoms: Painless dilation of the cervix without contractions.
  • Cervical effacement occurs from the internal os out, funneling.

Placenta Previa

• Pathophysiology: Placenta implants in the lower uterine segment or over the internal cervical os.
• Signs and Symptoms: Painless, bright red vaginal bleeding.
• Assessment: Assess blood loss, pain, uterine contractions, vitals, labs, fetal heart rate.
• Fetal Implications: Depends on the extent of the placenta previa.
• Management:
  • Cesarean Section: If possible.
  • Have blood products readily available.
  • Hysterectomy: If a massive hemorrhage occurs.

Abruptio Placentae

• Pathophysiology: Premature separation of a normally implanted placenta from the uterine wall.
• Classification: Based on the extent and location of separation.
• Severe Abruptio:
  • Blood invades myometrial tissues between muscle fibers.
  • Uterine irritability.
  • Uterus turns entirely blue (due to blood filled muscle fibers).
• Maternal Implications:
  • Release of thromboplastin into the maternal blood supply.
  • Disseminated Intravascular Coagulation (DIC).
  • Hypofibrinogenemia.
  • Hemorrhagic shock.
• ** Fetal Implications**: Fetal death, especially with complete separation.
• Immediate Priorities:
  • Maintain maternal cardiovascular (CV) status.
  • Plan for fetal birth (over 90% require a Cesarean).
  • Blood administration.

Hyperemesis Gravidarum

• Cause: Excessive vomiting.
• Severe Hyperemesis: Severe dehydration leading to hypovolemia, hypotension, tachycardia, increased hematocrit, elevated BUN (blood urea nitrogen), decreased urine output, weight loss of 5% or more of pre-pregnancy weight.
• Fetal Implications: Fetal death may occur.
• Management: Control vomiting, correct dehydration, restore electrolytes, maintain nutrition.
  • Medications: Diclegis, promethazine, metoclopramide, ondansetron.
  • Total Parenteral Nutrition (TPN): May be necessary.

Rh Incompatibility

• Cause: Incompatible Rh blood types between mother and fetus.
  • If the mother is Rh-negative and the fetus is Rh-positive, the mother may develop antibodies against the fetal blood cells.
• Indirect Coombs Test: Used to assess for the presence of Rh antibodies in the mother's blood.

Polyhydramnios

• Definition: More than 2000 ml of amniotic fluid (normal is about 500 ml).
• Causes: Associated with fetal malformations.
• Maternal Implications: Shortness of breath, edema (compression of the vena cava).
• Fetal Implications: Preterm birth, prolapsed cord, malpresentations.

Oligohydramnios

• Definition: Less than normal amount of amniotic fluid.
• Fetal Implications: Skin and skeletal abnormalities, pulmonary hypoplasia (underdeveloped lungs), cord compression.
• Management:

Multiple Gestations

• Signs and Symptoms: Fundal height greater than expected.
• Maternal Complications: Shortness of breath, dyspnea on exertion (DOE), backaches, pedal edema.
• Fetal Complications: Decreased growth and weight, increased fetal abnormalities, increased risk of prematurity.
• Management: More frequent prenatal visits, Cesarean delivery is usually required.
  • First baby: Label as "A"
  • Second baby: Label as "B"

Prelabor Rupture of Membranes (PROM)

• Definition: Spontaneous rupture of amniotic sac before the onset of labor.
• Preterm PROM (PPROM): Before 37 weeks gestation.
  • Before 30 weeks: Increased risk of serious complications.
• Maternal Concerns: Infection.
• Management:
  • Exam: Detect amniotic fluid in the vagina.
  • Nitrazine Paper: To assess for the presence of amniotic fluid.
  • Ferning Test: To identify fern-like patterns of dried amniotic fluid.
  • Ultrasound: To determine gestational age, amniotic fluid volume, fetal well-being.
• Antibiotics for PPROM and GBS prophylaxis.
• Corticosteroids: For pregnancies at earlier gestational ages.

Shoulder Dystocia

• Definition: Emergency situation in which the anterior shoulder fails to deliver after the head is born.
• Cause: Often related to macrosomia (large baby).
• Management: The McRoberts maneuver is often used to attempt to deliver the shoulder.

Cephalopelvic Disproportion (CPD)

• Cause: Fetal head is too large to fit through the maternal pelvic diameters, or the baby is in an abnormal position.
• Signs and Symptoms: Prolonged labor, excessive molding of the fetal head, traumatic forceps delivery.

Post Term Pregnancy

• Definition: Pregnancy beyond 42 weeks gestation.
• Maternal Risks: Increased due to the size of the fetus.
• Fetal Risks: Increased risk of post-maturity syndrome due to the large size of the fetus.

Pre-Term Labor

• Definition: Occurs between 20-36 weeks gestation.
• Signs and Symptoms: Uterine contractions (4 in 20 minutes or 8 in one hour), documented cervical change.
• Goal of Management: Prevent preterm labor from progressing to the point where it no longer responds to treatment.
• Corticosteroids: Help the baby develop surfactant and mature their lungs.

Uterine Relaxants

• Indomethacin (NSAID)
• Nifedipine (Calcium Channel Blocker)
• Magnesium Sulfate (can create toxicity, utilize calcium gluconate)
• Terbutaline (Adrenergic agonist)

Prolapsed Umbilical Cord

• Pathophysiology: The umbilical cord is compressed, reducing or cutting off blood flow to the baby.
  • If pressure isn't relieved, the fetus will die.
• Signs and Symptoms: Fetal bradycardia? (slow heart rate), a visible cord protruding from the vagina.
• Management:
  • Immediately position the mother in a flat/knee-chest position.
  • Monitor fetal heart rate closely.
  • Prepare for immediate delivery.

Amniotic Fluid Embolism Syndrome

• A small tear in the uterus (amnion or chorion) can occur high in the uterus.
• Amniotic fluid can leak into the maternal system.
• The fluid is driven into the maternal circulation and lungs.
• Symptoms include sudden onset of respiratory distress, circulatory collapse, and acute hemorrhage.
• Other symptoms are dyspnea, cyanosis, hemorrhagic shock, and coma.
• Treatment involves immediate delivery of the baby and life-saving measures like CPR.

Perinatal Loss

• Perinatal loss is the death of a fetus from the time of conception till 28 days past birth.
• Intrauterine fetal demise (IUFD) occurs after week 20 and typically needs to be delivered (stillbirth).
• Support and counseling services are crucial for families experiencing perinatal loss.

Postpartum Hemorrhage

• This is a potentially life-threatening condition after vaginal or Cesarean birth.
• It is a leading cause of maternal death.
• Defined as cumulative blood loss of >1000 ml, with signs of hypovolemia.
• The most common cause is uterine atony.

Clinical Manifestations of Shock

• Mild Shock (20% blood loss): Diaphoresis, maternal anxiety, cold extremities, and increased capillary refill.
• Moderate Shock (20-40% blood loss): Tachycardia, postural hypotension, and oliguria.
• Severe Shock (>40% blood loss): Hemodynamic instability, hypotension, and irritability/agitation/confusion.

Causes of Postpartum Hemorrhage

• Tone: Lack of uterine tone (boggy uterus) is a major concern.
• Tissue: Retained placenta.
• Trauma: Lacerations.
• Thrombin: Clotting factor deficiencies or blood product issues.
• Traction: Excessive pulling on the umbilical cord.

Nursing Management of Postpartum Hemorrhage

• Fundal Assessment: Assess fundal height, uterine tone, and bladder distension.
• Pad Counts: Count and weigh pads to monitor blood loss.
• Uterine Massage: Massage the uterus if it is boggy.
• Bladder Management: Empty the bladder or catheterize the patient.
• IV Access: Maintain IV access.
• Orthostatic Hypotension: Monitor for orthostatic hypotension (fall risk).
• Uterotonics: Administer uterotonics like oxytocin, misoprostol, carboprost, and methylergonovine.

Postpartum Infections

• Endometritis: Uterine infection within 2-4 days, more common in Cesarean births.
• Surgical Site Infections: Infection at the surgical site.
• Urinary Tract Infections: Due to invasive manipulations of the urethra and frequent vaginal exams.
• Mastitis: Inflammation of the mammary glands. Risk factors include stasis of milk, infrequent feedings, nipple breakdown, oversupply, and rapid weaning. Symptoms resemble flu-like illness.
• Thromboembolic Disease: Changes in the maternal coagulation system contribute to hypercoagulability and compression of the common iliac vein by the gravid uterus. This leads to venous stasis. Risk factors include Cesarean birth, immobility, obesity, varicose veins, and family history. Signs and symptoms include edema, tenderness, pain, palpable cord, changes in limb color. Treatment involves heparin or LMWH.

Postpartum Affective Disorders

• Postpartum Blues: Transient mood swings and emotional lability.
• Postpartum Depression: Persistent sadness, anxiety, and feelings of inadequacy.
• Postpartum Psychosis: Most dangerous form with severe mood swings, hallucinations, and delusions.
• Edinburgh Postnatal Depression Scale: A screening tool for postpartum depression.

Birth Weight Variations

• Small for Gestational Age (SGA): Less than 2500 grams (at term).
• Large for Gestational Age (LGA): Greater than 4000 grams (at term) or >90th percentile on the growth chart.

SGA Newborn

• May be preterm, term, or post-term.
• Difficult vaginal birth and increased risk for birth trauma.
• Prone to hypoglycemia (low blood sugar). Signs include jittery behavior, tachypnea, drowsiness, low tone, and musty urine.
• Requires frequent blood sugar checks.

Nursing Management of SGA Newborn

• Assess for traumatic birth injuries.
• Monitor for hypoglycemia.
• Assess for developmental delays due to low motor skills and difficulty feeding.

Pre-Term Newborn

• Born before 37 weeks gestation.
• High mortality and morbidity due to immature body systems.
• Typically weighs 2500 grams or less.

Pre-Term Newborn: Respiratory System

• One of the last body systems to mature.
• High risk for complications.
• Surfactant deficiency can lead to apnea, cyanosis, grunting, nasal flaring, and retractions.

Pre-Term Newborn: Cardiovascular System

• Transitioning to extrauterine life requires a well-functioning respiratory system.
• Increased risk for patent ductus arteriosis (PDA).

Pre-Term Newborn: Gastrointestinal System

• Lack of neuromuscular coordination can lead to difficulty sucking, swallowing, and breathing simultaneously.
• Insufficient calorie and fluid intake.
• Ischemia and damage to the intestinal wall.
• May require IV or enteral feeding.

Pre-Term Newborn: Immune System

• Maternal antibody transfer is highest around 34 weeks.

Pre-Term Newborn: Central Nervous System

• Difficulty regulating body temperature.

Nursing Assessment of the Pre-Term Newborn

• Lack of flexion.
• Limited rugae on the scrotum.
• Lack of creases on the feet.
• Covered in vernix caseosa.
• Fused eyelids.
• Poor muscle tone.

Nursing Management of the Pre-Term Newborn

• Promote oxygenation.
• Maintain thermal regulation (prevent cold stress and hyperthermia).
• Prevent infection.
• Promote nutrition and fluid balance (oral, enteral, or parenteral).
• Monitor growth and development.
• Promote parental coping mechanisms.

Post-Term Newborn

• Born beyond 42 weeks gestation.
• Risks include asphyxia (lack of oxygen), hypoglycemia, hypothermia, and polycythemia.

Nursing Management of the Post-Term Newborn

• Monitor for signs of respiratory distress.
• Check glucose levels frequently.
• Maintain temperature.
• Provide frequent feedings.

Acquired Disorders

• Perinatal Asphyxia (lack of oxygen) due to maternal complications, placental insufficiency, or cord issues.

Transient Tachypnea of Newborn (TTN)

• Self-limiting condition often caused by delayed clearing of lung fluid post Cesarean delivery.
• Symptoms include tachypnea (fast breathing) and respiratory distress.

Respiratory Distress Syndrome (RDS)

• Inadequate production of pulmonary surfactant.
• The lungs collapse easily.
• Symptoms include cyanosis, nasal flaring, and grunting.

Meconium Aspiration Syndrome

• Meconium (first stool) in the lungs, leading to airway obstruction.
• Risk of pneumothorax, bacterial pneumonia, and inactivation of surfactant.
• Symptoms include respiratory distress, hypotonia, low heart rate, and low APGAR scores.

Nursing Management of Acquired Disorders

• Maintain temperature.
• Provide high oxygen supplementation.
• Ventilate with high pressure.
• Administer prophylactic antibiotics.

Retinopathy of Prematurity (ROP)

• Potentially blinding eye disorder primarily affecting preterm infants, particularly those with very low birth weights.
• ROP can develop when infants receive supplemental oxygen.
• Hyperoxemia can lead to vessel restriction and rupture in the eye, causing bleeding and potential blindness.

Necrotizing Enterocolitis (NEC)

• Bacterial invasion of the intestinal wall in preterm infants, causing inflammation and cell death.
• Symptoms include cardiorespiratory changes, feeding intolerance, abdominal distension and tenderness, bloody stools, respiratory distress, and signs of sepsis.

Infant of a Diabetic Mother (IDM)

• Large for gestational age (LGA), ruddy (high red blood cell count), macrosomic (large size), and excessive adipose tissue.
• Pathophysiology: The fetus is exposed to high levels of glucose, leading to increased insulin production and glycogen storage.
• Risk of hypoglycemia: Signs include slow mental development, vomiting, poor feedings, irritability, and musty urine.

Nursing Management of IDM

• Screen all newborns of diabetic mothers.
• Dietary restrictions may be needed.
• Regular monitoring of phenylalanine levels.

Infant of a Substance Abusing Mother

• Alcohol consumption during pregnancy can lead to fetal alcohol syndrome.
• Infants may experience withdrawal symptoms (especially from opioids).

Neonatal Abstinence Syndrome (NAS)

• Drug withdrawal symptoms in newborns.
• Opioids are the most common cause.
• May progress to seizures.
• Management focuses on providing comfort, meeting nutritional needs, preventing complications, and promoting parent-newborn interactions.

Core Concepts of Maternal and Newborn Nursing

• Childbirth methods have evolved, including support from certified nurse midwives (CNM) and doulas, diverse birth settings, and shorter hospital stays.
• Family-centered care prioritizes normal, healthy birth experiences, collaborative decision-making, and sensitivity to family beliefs and culture.
• Early and adequate prenatal care is crucial for preventative care and reduces the risk of complications.
• Home births are considered high-risk due to potential delays in accessing medical care.
• Postpartum care includes outpatient clinics, phone consultations, home visits, support groups, and follow-up appointments for both the mother and baby.
• Postpartum depression (PPD) is a significant risk, often impacting both the mother and the family.

Factors Contributing to Preterm Birth

• Smoking
• Hypertension
• Unhealthy weight
• Diabetes
• Prior preterm birth
• Multiple pregnancies

Maternal and Newborn Mortality and Morbidity

• Maternal Mortality rates have doubled since 2019.
• Mortality rates include maternal death, fetal death (over 20 weeks), neonatal death (first 28 days), and infant death (first 12 months).
• Morbidity is affected by chronic diseases, lifestyle habits, and environmental factors.

Factors Affecting Maternal and Newborn Health

• Family dynamics, including changes in parental roles and family structures.
• Socioeconomic status
• Media influence
• Violence in the family or environment
• Nutrition
• Lifestyle choices
• Environmental exposure
• Stress and coping mechanisms
• Access to healthcare

Intimate Partner Violence

• Universal screening methods for all patients are essential.
• Establish trust and rapport with patients.
• Ask direct questions about safety.
• Assess immediate safety risks.
• Document and report evidence.
• Educate the patient about available resources.
• Provide emotional support.
• Develop a safety plan.
• The cycle of violence includes tension building, physical abuse, reconciliation, and repetition.
• The SAVE model (Screen, Ask, Validate, Evaluate) is a helpful framework for screening.

Sexual Violence

• Trained sexual assault nurse examiners (SANE) provide specialized care for survivors.
• Collect evidence, screen for sexually transmitted infections (STIs) and pregnancy.
• Address post-traumatic stress disorder (PTSD) and offer counseling.
• Provide safe, non-judgmental, and supportive care.

Complementary and Alternative Medicine Use

• Focuses on treating the whole person.
• Includes aromatherapy, herbal medicine, reflexology, acupuncture, massage therapy, and therapeutic touch.

Infertility

• Primary infertility: never been able to get pregnant.
• Secondary infertility: had a previous pregnancy but cannot carry to term.
• Significant stressor on family dynamics.
• Cultural considerations can add to stress.
• Infertility is considered after 12 months of trying without success.

Postpartum Physical Adaptations

• Uterine involution: The uterus descends one finger width below the umbilicus per day.
• Lochia: discharge from the uterus, progressing from rubra (dark red) to serosa (pink) to alba (creamy).
• Afterpains: expected cramping, similar to labor, for the first few days after delivery.

Cardiovascular System Postpartum

• Increased blood volume to support pregnancy.
• Heavy blood loss after delivery.
• Increased coagulation factors to prevent bleeding.
• Heart rate and blood pressure may decrease briefly, but should stabilize quickly.

Urinary System Postpartum

• Full bladder emptying is essential to allow the uterus to contract.
• A distended bladder can cause the uterus to relax, increasing the risk of hemorrhage.
• Signs of bladder distention include a fundus that deviates to the right.

Mood Disorders Postpartum

• Baby blues: common, peaking around day 4 and resolving by day 10.
• Postpartum depression (PPD): more severe and persistent than baby blues, with a higher risk factor for those with a history of depression.
• Postpartum psychosis: a serious mental disorder characterized by delusions and hallucinations.

Phases of Maternal Adaptation

• Taking-In phase: focus on personal needs and recovery.
• Taking-Hold phase: actively engaging in caregiving and learning to manage new responsibilities.
• Letting-Go phase: adjusting to life as a parent and accepting new roles.

Postpartum Nursing Assessment

• Vital signs: monitor for infection or hemorrhage.
• Physical assessment: BUBBLE-EE (Breast, Uterus, Bowel, Bladder, Lochia, Episiotomy, Extremities, Emotional status).
• Psychosocial assessment: assess for baby blues, PPD, and bonding/attachment.

BUBBLE-EE Assessment

• Breasts: size, shape, symmetry, engorgement, nipple condition
• Uterus: fundus position and height.
• Bowels: constipation.
• Bladder: diuresis and distention.
• Lochia: amount, color, odor.
• Episiotomy/perineum: REEDA scale (Redness, Edema, Ecchymosis, Discharge, Approximation).
• Extremities: assess for deep vein thrombosis (DVT).
• Emotional status: assess interactions, bonding, attachment.

Lochia Assessment

• Typical stages are rubra => serosa => alba.
• Any foul odors indicate infection.

Postpartum Nursing Interventions

• Alleviate discomfort: use non-pharmacologic or pharmacologic interventions, such as cold compress, hot water bottle, peri bottle, sitz bath, witch hazel pads, local anesthesia spray, steroids, nipple creams, analgesics.
• Assisting elimination: address constipation with ambulation, fluids, fiber, and stool softeners.
• Promoting activity, rest, and exercise: encourage early ambulation, assess need for rest, promote balanced diet, and provide assistance.
• Self-care measures: change perineal pads, avoid tampons, shower daily, use a peri bottle or sitz bath.
• Ensure safety: assess for orthostatic hypotension and assist the mother to the bathroom, encourage CSM assessment, educate on safe sleep practices for the infant, address infant abduction concerns.
• Contraception: educate on available options.
• Nutrition: encourage a balanced and nutritious diet, especially if breastfeeding (add 500 calories daily).
• Infant feeding method: support the mother's decision regarding breastfeeding or bottle feeding.
• Breast care: alleviate engorgement through appropriate methods (massage, warm compress, ibuprofen if breastfeeding, cold compress if bottle feeding, tight bra, avoiding stimulation).

Promoting Family Adjustment

• Facilitate consistent contact between the baby and family.
• Recognize and support family dynamics as they learn to adjust to parenthood.

Assistance with Breastfeeding

• Assess breasts for engorgement.
• Assess nipples for erectness and suitability for latch.
• Work with lactation consultants for education and support.
• Maintain appropriate breastfeeding hygiene practices (avoid soap, gentle massage).
• Educate on positioning and latching techniques.

Assistance with Bottle Feeding

• Use FDA-approved formulas.
• Offer small, frequent feedings.
• Utilize infant water or purified water for formula.
• Educate on proper formula preparation.
• Sterilize bottles and nipples properly.
• Avoid microwaving bottles.

Preparing for Discharge

• Educate the mother on:
  • Newborn sleep-wake cycles
  • Developmental milestones
  • Interpreting crying cues
  • Signs of illness
  • Important phone numbers
  • Follow-up and immunizations.
  • Expected postpartum changes.
  • Discharge criteria.
• Ensure the mother meets discharge criteria.

Immunizations

• Administer TDAP vaccine to mothers around week 27 of pregnancy.
• Obtain rubella titer during the first prenatal visit.
• Ensure Rh immunoglobulin (RhoGAM) administration:
  • If the mother is Rh negative and the baby is Rh positive, RhoGAM is given at 28 weeks gestation and within 72 hours postpartum to prevent sensitization and future complications.
• If any mother is Rh negative, she will receive RhoGAM at 28 weeks gestation and again after delivery.

Ensuring Follow-Up Care

• Encourage support groups.
• Maintain consistency with follow-up appointments.

Cesarean Birth

• Informed consent: obtain from patient.
• Diagnostic testing: ensure appropriate testing is done.
• Therapeutic communication: provide clear and supportive communication.
• Pre-op care: involve both planned and unplanned procedures, ensure patient is adequately prepared (including indwelling catheter and pre-op medications).
• Post-op care: manage pain, prevent infection, monitor for hemorrhage, prevent clots, prevent pneumonia (incentive spirometer), manage abdominal dressing, monitor bowel sounds, manage nausea and vomiting, and ensure recovery (gradually increase food intake).
• Encourage deep breathing and coughing exercises.
• Important to note: Hold the incision when coughing to avoid dehiscence.

Circulatory Adaptations in Newborns

• Transition from fetal to newborn circulation at birth.
• Switch from placental gas exchange to pulmonary gas exchange.
• Fetal structures (foramen ovale, ductus arteriosus, ductus venosus, umbilical arteries and vein) close off.

Respiratory Adaptations in Newborns

• Initiation of respirations.
• Production of surfactant.
• Normal respiratory rate: 30-60 breaths per minute (count during restful periods).
• Irregular breathing, shallow breaths, and short periods of apnea (less than 15 seconds) are normal.
• Grunting sounds, nasal flaring, seesaw breathing, stridor, or gasping indicate respiratory distress.

Body Temperature Regulation

• Premature infants have a harder time regulating temperature.
• Characteristics that predispose infants to heat loss: Thin skin, lack of shivering, large surface area, limited subcutaneous fat, inability to communicate needs.
• Heat production: non-shivering thermogenesis (break down fat stores) can lead to weight loss.
• Heat loss: conduction, convection, radiation, evaporation.
• Maintain a Neutral Thermal Environment to prevent cold stress (hypothermia), which can lead to weight loss, lethargy, poor feeding, decreased elimination, and hypoglycemia.
• SKIN-TO-SKIN CONTACT IS ESSENTIAL!!!

Hepatic System Adaptations

• Iron storage.
• Carbohydrate metabolism: blood sugar stabilization.
• Bilirubin conjugation: the liver converts bilirubin into an excretable form (must be made water soluble).
• Increased red blood cells (RBCs) and impaired conjugation can lead to jaundice.
• Observe for jaundice: assess for color changes in the baby (skin, sclera).
• Ensure the baby is eating and pooping to excrete bilirubin.
• Monitor bilirubin levels with a bilirubin meter.
• Kernicterus: a toxic level of bilirubin can be harmful to the brain.

GI Adaptations

• Bowel sounds appear quickly after birth.
• Bacterial colonization of the gut begins after birth.
• Vitamin K injection is given at birth to stimulate clotting factors.
• Small, frequent feedings with a 2-3 hour window (from the beginning of the feeding, not the ending).
• Regurgitation is common due to underdeveloped sphincter - burp frequently, don't overfeed, don't lay flat on back.

Immune System Adaptations

• Non-specific versus specific immune response.
• Dependent on IgA, IgG, and IgM.
• Developing immunity.
• Passively acquired IgG and IgA from the mother.

Neurologic/Behavioral Adaptations

• Sensory capabilities: hearing, taste, smell, touch, vision.
• Congenital reflexes.
• Periods of reactivity: First period of reactivity (30 min to 1 hour), period of inactivity (sleep phase), second period of reactivity (starts around 2 hours).

Second Period of Reactivity

• Characterized by a period of alertness, crying and a need for food.

Physical Assessment of the Newborn

• Signs indicating a problem:

  • Nasal flaring.
  • Chest retractions.
  • Grunting on exhalation.
  • Labored breathing.
  • Generalized cyanosis.
  • Flaccid body posture.
  • Abnormal breath sounds.
  • Abnormal respiratory rate (RR).
  • Abnormal heart rate (HR).
  • Abnormal newborn size.

• APGAR Score

  • Evaluates the newborn's physical condition at 1 and 5 minutes after birth.
  • 10 is the highest score indicating a healthy baby.
  • Score of 7-10 is good, requiring no interventions.
  • Score of 4-6 is concerning, requiring further evaluation and interventions.
  • Score less than 4 is an emergency, requiring immediate intervention.
  • Appearance: Color of the newborn (Pink: 2 points, Blue extremities: 1 point, Full blue: 0 points)
  • Pulse: Heart rate (Over 100 bpm: 2 points, Under 100 bpm: 1 point, No pulse: 0 points)
  • Grimace: Reflex irritability and response to stimuli (Crying: 2 points, Grimace: 1 point, No response: 0 points)
  • Activity: Muscle tone (Active movement: 2 points, Some flexion: 1 point, No movement: 0 points).
  • Respirations: Breathing (Strong cry: 2 points, Slow or irregular breathing: 1 point, No breathing: 0 points)

• Measurements:

  • Temperature: 97.7-99.5F (Axillary temp preferred).
  • Heart Rate: 110-160 BPM (normal to increase to 180 while crying).
  • Respiratory Rate: 30-60 breaths/per min at rest (normal to increase while crying).
  • Blood Pressure: 50-75 mm Hg Systolic / 30-45 mm Hg diastolic (Not usually done, depends on hospital policy, can be done if persistent murmur).
  • Length: Mark head and feet on blanket, hold just above knee and head.
  • Weight:
  • Head Circumference: Should be bigger than chest, circumference may change due to cone head molding.
  • Chest Circumference: Right at nipple line, should be smaller than head.

Gestational Age Assessment

• Ballard Score - assesses physical and neuromuscular maturity characteristics.
• Classification According to Gestational Age
  • Preterm/Premature: prior to 37 week gestation.
  • Term: 38-42 weeks gestation.
  • Postterm/postdates: After week 43 gestation.
• Considering for gestational age and birth weight
  • Small for Gestational age, SGA
  • Appropriate for gestational age, AGA
  • Large for gestational age, LGA

Skin Assessment

• Color:
  • Erythema Toxicum - Most infants will get this rash, no need to worry, educate parents.
  • Jaundice - caused by an increase in bilirubin, tested with a TCB.
• Texture:
• Turgor:
• Common skin variations:
  • Milia - Little white heads, DON’T POP, HIGH CHANCE TO CAUSE INFECTION IN BABY.

Head

• Size: Variation and appearance.
• Fontanelles:
• Face: symmetry.
• Neck: support head?, able to move?
• Caput succedaneum: Swelling in baby’s head due to difficult labor, swelling crosses suture line, collection of serous fluid, self limiting after a few days.
• Cephilla: Blood buildup in skull doesn’t cross suture line, develop with vacuum assisted labor, takes weeks to resolve, watch baby closer for jaundice, blood collection needs to be broken down.

Chest and Respirations

• Respiratory: look for distress.
• Heart:
• Abdomen:
• Umbilical Cord: dries and shrivels, skin around it, look for signs of infection, no bleeding, takes weeks to fall off on own, DO NOT PULL OFF.
• Genitalia: Scrotum, older has more rugae, testes desend into scrotum.
• Extremities: Moving?, Hands and feet 5 fingers and toes? Look for creases should all be even and symmetrical, often feet curve inwards, clubbed feet wouldn’t return.

Neurological status

• Alertness
• Posture: want to see flexed.
• Muscle tone: Is there resistance, should be some.
• Reflexes: Most disappear within first year of life, standord reflexes tests feeding does baby suck on finger.

Nursing Interventions

• Immediate newborn Period: maintain airway patency, ensure proper identification, administer prescribed medications “Eyes (erythromycin) and Thighs (IM vit K)), Maintaining thermoregulation.

During the Early Newborn Period

• Bathing and hygiene (Don’t bath everyday, can also make baby temp go down).
• Elimination and diaper area care (How many diapers baby is having, females front to back, don’t reuse, males point tip of peantis down).
• Cord care (watch for signs of infection, males may want to do circumcision).
• Circumcision and care of penis (Comco clamp, mogen clamp, plastibell).
• Safety (Sleep on backs, tight swaddle, nothing in crib No Co-sleeping).
• Promoting sleep: Periods of purple crying (Peak of crying, Unexpected, Resists soothing, Pain-like face, Long lasting, Evening, Never shake the baby)(Swaddle, Side place on Side, football hold, Sway, Suck, Shush).
• Enhancing Bonding
• Screening Tests (Metabolic Screening, PKU) (O2 on hand AND foot at same time, looking for above 95%, can’t have more than a 3% difference in extremities).

Promoting Nutrition

• Small frequent feeding
• No solid foods
• Nutritional needs: rapid growth and development, iron, vit D
• Support choice of feeding method
• Educate and support: prenatal and childbirth classes
• Before feeding: Suck and swallow reflex?, Bulb syringe, Bowel Sounds?, Anus patency?
• On-demand feeding schedule: Every 2-4 hours.
• Hunger cues: Big T-Rex mouth, crying.
• Did the baby get enough? How do we know?(Output in diaper)

Breast Feeding

• Benefits:
• Compositions: Colostrum => transitional => Mature
• Breastfeeding Assistance: Immediately after birth, positioning, comfort, assessment: LATCH Score.
• Positions: Football, cross cradle, across the lap, side-lying.
• Storage and expression: Current CDC Recommendations.
• Engorgement
• Mastitis (Can continue to breastfeed).

Prep for Discharge

• Support and praise
• Allow parents to provide input
• Build self-esteem
• Ensure follow-up care: Pedi appointments.

Perinatal History

• Pertinent maternal and fetal data, look at mom overall + history

Presumptive Signs of Pregnancy

• Experienced by the patient:
  • Fatigue
  • Nausea
  • Breast tenderness (3-4 weeks)
  • Urinary frequency (6-12 weeks)

Probable Signs of Pregnancy

• Detectable by the provider:
  • Goodell sign (softening of the cervix) 5 weeks
  • Chadwick Sign- bluish-purple discoloration of the cervix (6-8 weeks)
  • Hegar Sign- softening of the lower portion of the uterus (6-12 weeks)
  • Positive pregnancy test (4-12 weeks)
  • Braxton hicks contractions

Positive Signs of Pregnancy

• Confirmation of pregnancy:
  • Ultrasound (4-6 weeks)
  • Fetal movement felt by provider (20 weeks)
  • Auscultation of fetal heart tones (10-12 weeks)

Physiological Adaptations During Pregnancy

Uterus

• Increase in blood flow, capacity

• After around 12 weeks, uterus starts growing past the pelvis

• Lower Uterine Segment

  • Supine Hypotensive syndrome

• Fundal Height

• Braxton Hicks contractions (practice contractions)

• Upper portion of the uterus has changes in circulation/blood flows

• Lower portion of uterus gradually gets thinner

• As baby grows uterus puts pressure on the diaphragm, bladder and stomach

• Mother lays on back, increases pressure on the vena cava and aorta- can cause dizziness, faint, ect.

• At week 20, uterus should be at level of the umbilicus (20 centimeters)

Cervix

• Goodells Sign - softening of cervix
• Chadwicks Sign - bluish-purple color

Vagina

• Vaginal mucosa thickens, connective tissue loosens, vaginal vault lengthens
• Increased/thickening of secretions (whitish vaginal discharge)
• Vascularity increases

Breasts

• Fullness
• Tenderness
• Nipple changes- enlarge and get darker in color
• Colostrum- yellowish discharge (liquid gold)

Gastrointestinal System

• GERD
• Bleeding gums
• Increased Dental plaque,
• Debris and Gingivitis
• Delayed Gastric Emptying
• Constipation
• Heartburn

Cardiovascular System

• Blood Volume (around 1500 ml increase) (expect to see a level of anemia because of the increase of plasma)
• Heart rate and blood pressure increase
• Blood components (hypercoagulable State) - fibrin and fibrinogen levels increase, and see an increase in venous stasis

Respiratory System

• Increased oxygen requirements
• Breathes faster and deeper

Renal/urinary

• Dramatic changes related to increased blood volume
• Consider dosage changes necessary

Musculoskeletal System

• Changes in posture and gait
• Stretching joints
• Lordosis (bulging of spine inward)
• Waddle Gait (change of elasticity of joints)

Integumentary System

• Hyperpigmentation (nipples expand and darken)
• Striae Gravidarum (stretch marks)
• Linea Nigra (dark line of pigmentation down the midline of the abdomen)
• Varicosities

Endocrine System

• Pancreas
• Growing fetus: growing glucose demands
• Insulin does not cross the placenta; fetus supplies its own
• Glucose Intolerance (resistance developed by other hormones later on during pregnancy), prolactin, progesterone and estrogen are thought to oppose insulin (Gestational Diabetes)

Changing nutritional needs of pregnancy

• Consider pre-pregnancy weight
• Food concerns:
  • Mercury;
  • Listeriosis

Maternal Weight Gain

• Should be steady weight gain, week by week
  • Underweight- 28-40lbs
  • Normal weight- 25-35lbs
  • Overweight- 15-25lbs
  • Obese- 11-20 lbs

Special Nutritional Considerations

• Cultural variations
• Vegetarians
• Pica

Avoid

• Processed foods
• Limit caffeine
• Avoid diuretics
• DO NOT SKIP MEALS eat 3 meals a day with 1-2 snacks daily

Psychosocial Adaptations

• Maternal Emotional Responses:
  • Ambivalence
  • Acceptance
• Partner
• Siblings

PRECONCEPTION AND INTERCONCEPTION CARE

• Key areas for focus:
  • Immunization status
  • Underlying medical status
  • Reproductive health data
  • Sexuality and sexual practices
  • Support systems
  • Medications/drug use
  • Psychosocial status
  • Lifestyle practices
  • Nutritional history

First Prenatal Visit

• Anticipatory guidance:

• Comprehensive Health history:

  • Age
  • Menstrual history
  • Prior obstetric history
  • Past medical/surgical hx
  • Psych/genetic screening
  • Nutritional habits
  • STD exposure
  • Reproductive history (Menstrual History)

• Nagele Rule - Subtract 3 months from the first day of your last normal menstrual period, add 7 days, and adjust the year by adding 1 if necessary. This will give you your EDD (Estimated Delivery Date).

• Reproductive history: Obstetric History: Gravida (pregnancy)/para(delivery)

• Physical Examination - pelvic exam

• Laboratory tests - CBC, blood type, rubella titer, hep B, HIV testing, pap smears, UTI screening: RPR, cultures

Understanding GPAL

• G (preganancies)
• P(any delivery over 20 weeks)
• T (Full term deliveries)
• P (preterm deliveries)
• A (abortion- loss of baby under 20 weeks)
• L (living children)

Follow Up Visits

• Every 4 weeks up to 28 weeks

• Every 2 weeks from 29-36 weeks

• Every week from 37 weeks to birth

• March of dimes: Prenatal care Checkups

• Assessments:

  • Weight
  • BP
  • Urinalysis
  • Fetal Growth
  • Fetal movement
  • Apical HR

• Testing for gestational diabetes:

  • Between 24-28 weeks
  • Oral 50g glucose load => 1 hr plasma glucose

  • 140mg/dl means further testing

  • Testing for Group B Strep:
    • Between 37-40 weeks

• Protein in urine or excessive weight gain towards the end of pregnancy can indicate preeclampsia (affects the kidneys and can cause fluid retention).

Determining Fetal Well being

• Fundal Height Measurement

  • McDonald Method (20 weeks old= 20 centimeters, week 21= 21 centimeters, ect.)
  • Until week 36, typically the largest height of the fundus, babys will drop afterward into the pelvic cavern

• Fetal Movement Determination

  • Count to 10 method - every time you feel baby movement, keep tracking movements.

DANGER SIGNS DURING PREGNANCY

• First Trimester (conception to 12 weeks)
  • Spotting or bleeding (miscarriage)
  • Painful urination (infection)
  • Severe persistent vomiting (hyperemesis gravidarum)
  • Fever over 100º (infection)
  • Lower abdominal pain with dizziness/Shoulder pain (Ruptured Ectopic Pregnancy)
• Second Trimester (13 to 28 weeks)
  • Regular uterine contractions (preterm labor)
  • Pain in calf (DVT)
  • Sudden Gush/leakage of fluid from the vagina (prelabor ROM- rupture of membranes)
  • Absence of fetal movement for >12hrs (fetal distress/demise)
• Third Trimester (29 to 40 weeks)
  • Sudden weight gain
  • Periorbital or facial edema
  • Severe upper abdominal pain
  • Headache with visual changes (gestational HTN, preeclampsia)
  • Decrease in fetal movement (fetal destress/demise)

Assessment of Fetal Well being

• Ultrasonography

  • Non invasive
  • Non radiating
  • Transabdominal
  • transvaginal

• Doppler Flow Studies

  • Non-invasive
  • Examine blood flow in vessels
  • Monitor fetal growth, placental function, central venous pressure, cardiac function

• Marker Screening Tests

  • Alpha-fetoprotein Analysis
  • Triple Marker Screen
  • Quad Screen
  • Cell Free DNA

• Amniocentesis

  • Obtain amniotic fluid
  • Fetal abnormalities
  • Fetal lung maturity
  • Ultrasound
  • Complications

• Chorionic Villus Sampling

  • Obtain small sample of chorionic villi from developing placenta
  • Transabdominal
  • Transcervical
  • Significant risks => informed consent

• Nonstress tests

  • FHR accelerations
  • Reactive or non reactive (Want to see reactive)

• Biophysical profile BPP

  • Five components
  • Ultrasound
  • NST
  • 10 points possible

Childbirth Preparation

• Perinatal education
  • Childbirth education
  • Lamaze
  • Bradley
  • Dick-read
  • Review options
  • Birth setting
  • Care provider
  • Finding choices
• Final preparation for labor and birth

Vulnerable populations

• Pregnant adolescents
• Woman of advanced maternal age

Factors influencing the onset of labor

• Uterine stretching
  • Elongates
  • Cervical effacement
  • Cervical Dilation
• Progesterone withdrawal
• Increased oxytocin sensitivity
• Increased release of prostaglandins
• Contractions happen fundus down

Premonitary Signs of Labor

• Lightning - belly drop, baby in pelvis
• Braxton-hicks Contractions - body getting ready for labor, not true labor contractions
• Cervical Changes - Softening of cervix (Streching and thinning), ephasion of uterine walls
• Bloody show - mucus plug (protective barrier for baby) stays in place for pregnancy, will dislodge and may pull capillaries and bleed some, sign that the cerxiv is changing, don’t immediately go to the hospital
• Rupture of membranes - water breaking, color should be clear, any odor, baby had maconium if fluid was green, if water broke make sure umbilical cord didn’t wash out THIS IS TRUE EMERGENCY, WILL PINCH OFF IMBILUCAL CORD
• Sudden burst of energy - Nesting, preparing everything for baby, hyperfocused

True VS.False Labor

• Contraction timing - During labor will be regular, during false labor will be irregular
• Contraction strength - Will become stronger with time, false frequently weak
• Contraction discomfort - Starts in back and radiates around towards front of abdomen, false usually felt in front of abdomen
• Any change in activity - Contractions continue no matter what postural change is made, contractions may stop or slow down with walking/positioning
• Stay or go - Stay home if contractions are 5 minutes apart, last 45-60 seconds, and are strong enough so that conversation isn’t possible, False drink fluids and walk to see if any change in intensity, if contraction diminish in intensity stay home

Factors Affecting Labor Process

• 5P’s

Passage Way

• Birth canal: pelvis and soft tissue
  • Mother’s pelvic size: diameters - True pelvis (inlet baby has to pass through); false pelvis (Bony flares at hip)
• Birth passage:
  • Pelvic Shape - Gynecoid (Most common and most favorable), android (Not favorable for vaginal birth), anthropoid (More narrow, may still work for birthing), platypelloid (Not favorable for vaginal birth)
• Cervix: Dilation & Effacement
• Pelic floor muscles - gives enough resistance, so baby trunks certain ways to get out

Passenger

• Fetal Head - reference point - make sure head is down, biggest part of baby coming out first, Nurses feel for occipital bone, and both frontanels

• Fetal attitude - relationship of body parts, flexion of neck, arms, legs

• Fetal Lie - Axis of mom-baby - Longitudinal (Parallel), transverse (side ways), Oblique (Diagonal)

• Fetal presentation - Presenting part entering first - Cephalic (optimal), breech (Many but EX feet first), shoulder, NC: vaginal exam, leopold’s maneuver

  • Vertex presentation (smallest diameter coming through),
  • Military presentation (A bit larger than vertex),
  • Brow presentation (Even larger),
  • Face presentation (Very large diameter),
  • Shoulder presentation (Not safe for baby, to the OR),
  • Hip or bottom presentation
    • Frank Breech, (legs stay flexed, won't do delivery vagianlly),
    • Complete breech (legs stay open),
    • Footling breech (feet first, to the OR)

• Fetal Position - R or L: side of pelvis, Presenting part: Occiput, Mentum, Sacrum, Part-Pelvis: Anterior, Posterior, Transversal

• Fetal Station

  • Level of presenting part in relation to the maternal ischial spines
  • Usually narrowest diameter through which the fetus must pass

• Engagement

  • Floating, level of spine is 0
  • Dipping, fetal head dips into inlet, ballotable
  • Engaged, presenting part is at level of ischial spines

Powers

• Forces of Labor
  • Primary : contractions => dialtion/effacement, thin and dilate the cervix
    • Contractions/Waves: frequency: onset-onset, duration: length beginning-end, Intensity: at peak, mild moderate, strong by palpation
  • Secondary: Abdominals => Pushing

Position

• Standing and walking promotes cervical changes
• Squating opens pelvis to help progress labor
• Kneeling brings baby forward and takes pressure of back
• Side recline opening pelvis
• Peanut ball open pelvis up in different ways

Psychological Response

• Positive attitude
• Willingness to birth
• Sociocultural
• Socioeconomic - Did they have the money to receive prenatal care
• Coping with the physical demands of labor
• Maintain physiological/emotional balance

Other P’s to Consider

• Philosophy
• Partners
• Patience
• Patient preparations
• Pain management

Systematic Response to Labor

• Maternal
  • Cardiovascular: Blood volume increase, increase cardiac output, increased BP
  • Respiratory: Hyperventilation => respiratory alkalosis, pushing respiratory acidosis, acid base levels WNL within 24 hours
  • GI: emptying is slowed => N/V
  • Lab values: Increased WBC
  • Pain receptors
• Fetal
  • Heart rate changes: Accelerations and decelerations, fetal movement, fetal scalp stimulation

Stages of Labor

• First stage is longest:
  • Latent phase (0-6cm)
  • Active phase (6-10cm)
• Second Stage: complete dilation to birth of newborn,
  • Pelvic phase - period of fetal decent,
  • Perineal phase - period of active pushing
• Third stage: Placenta separation and delivery,
  • Placental separation - detaching from uterine wall,
  • Placental expulsion: coming outside the vaginal opening,
  • Does it come out Fetal or maternal first, if retained then subinvolution can happen
• Fourth stage: 1-4 hours after birth of newborn, hypotonic bladder R/T trauma

Cardinal Movements of Labor

• Engagement
• Descent
• Flexion
• Internal rotation
• Extension
• External rotation
• Expulsion

Maternal Assessment During Labor and Birth

• Vaginal Examination must use sterile gloves

  • Cervical Dilation and Effacement - Baby should be head down,
  • Fetal descent
  • ROM

• Uterine Contractions

  • Intensity- palpate at the fundus during the contraction
  • Frequency

• Leopold Maneuvers

  • **1.**Feel the top of fundus to determine if baby is upside down
  • **2.**Feel the sides to determine which way the baby is facing
  • **3.**Feel the base of the fundus to determine is face or butt is pointing towards cervix
  • 4.

Fetal Assessment During Labor and Birth

• Palpate mother's head to determine fetal position
• Amniotic fluid analysis: note color to distinguish between fluid and urine
• External fetal monitoring: two devices belted to the mother:
  • Top device: determines contractions
  • Bottom device (transducer): monitors fetal heart rate. Place it over fetal back
• Internal fetal monitoring:
  • Fetal scalp electrode: internal fetal heart rate monitor
  • Intrauterine pressure catheter: Provides specific contraction timing and intensity
• Fetal heart rate analysis: indicates the baby's tolerance of labor
• Variability in heart rate:
  • Absent: undetectable range
  • Minimal: Less than 5 bpm
  • Moderate: 6-25 bpm (ideal range)
  • Marked: More than 25 bpm
• Periodic changes:
  • Accelerations: Baby's heart rate increases with movement or tactile stimulation.
  • Decelerations: Early, late, and variable
    • Early: Occurs at the peak of a contraction. Usually caused by fetal head compression. Considered normal.
    • Late: Dropping below baseline after the contraction peak. Indicates uteroplacental issues with insufficient oxygenation during contractions.
    • Variable: Sharp, unpredictable drops. Can mean cord compression.
• Baby tachycardia: May indicate maternal infection.
• Baby bradycardia: May indicate nervous system issues, lack of oxygen, and is a bad sign.

Fetal Heart Monitor Tracing

• Two components on a strip:
  • Upper graph: FHR data
  • Lower graph: Contraction data
• Each small square represents 10 bpm increases (upper graph) and 10-second duration (both graphs).
• Dark line to dark line represents one minute.
• When stimulated, the heart rate must increase by 15 beats and remain elevated for at least 15 seconds.
• Early decelerations are good, indicating the baby is working through the birth canal.
• Variable decelerations resemble a "V," "U," or "W" and are not good. They are often caused by cord compression.
• Late decelerations indicate uteroplacental insufficiency (baby is compromised) and the HR dips after contractions.

Nursing Management of Late and Variable Decelerations

• Cord compression: Change maternal position to her side.
• Late decelerations: Change to left lateral position, increase fluids, administer oxygen, and discontinue oxytocin if two or three interventions fail.
• Consider internal monitoring and possible vacuum delivery, forceps, or C-section if these interventions are ineffective.

Non-pharmacologic Labor Support

• Continuous labor support
• Hydrotherapy
• Ambulatory and position changes
• Acupuncture and acupressure
• Attention focusing and imagery
• Therapeutic touch and massage: effleurage
• Breathing techniques

Pharmacologic Interventions

• Adequate comfort and analgesia for both mother and baby
• Neuraxial analgesia/anesthesia
• Systemic analgesia
• Inhaled analgesia - Nitrous Oxide
• Regional analgesia/anesthesia - local anesthetics, epidural, combined spinal epidural, pudendal block
• General anesthesia - EMERGENCY ONLY
• Epidurals cause vasodilation and lower blood pressure. A fluid bolus is needed to increase blood pressure.

Maternal Nursing Assessments: Admission & First Stage

• Prenatal record: maternal history, intrapartum high risk screen
• Physical Assessment: VS, Fundus and contractions, external fetal monitoring, intrauterine pressure catheter, cervical dilation and effacement, amniotic fluid, presenting part and descent
• Cultural assessment
• Laboratory tests, psychosocial concerns

Stage 2

• Breathing techniques
• Pushing techniques
• Contractions
• Maternal VS
• FHR (Fetal HR)
• Amniotic fluid
• Coping

Nursing Management of Second Stage

• Episiotomy: Surgical incision of the perineum to assist with delivery. Types include midline and mediolateral. Indications: LGA, vacuum/forcep delivery, maternal exhaustion. Assessment and interventions: REEDA, comfort measures: ice, tucks, sitz bath
• Laceration:
  • First degree: Vaginal mucosa and perineum
  • Second degree: Includes fascia and perineal muscles
  • Third degree: Includes external anal sphincter
  • Fourth degree: Includes internal and external anal sphincters, and anal mucosa
• Prevention: Perineal massage, different pushing positions, warm soaks, counter pressure, and gradual pushing at crowning.

Assisted Delivery

• Forceps: Three categories
  • Outlet forceps: applied when fetal skull reaches the perineum, fetal scalp is visible, and the sagittal suture is not more than 45 degrees from midline.
  • Low forceps: Applied when the presenting part of the fetal skull is at station +2 or greater.
• Vacuum Assisted: Indications: prolonged second stage, non-reassuring FHR tracing, inability to push effectively, maternal exhaustion, maternal heart disease

Nursing Management of Third Stage

• Maternal care: VS every 15 minutes. Observe for placental separation, perineal trauma/repairs, and provide comfort measures.
• Newborn care: Maintain respirations, provide/maintain warmth, APGAR score at 1 and 5 minutes (activity, pulse, grimace, appearance, respiration), physical assessment, identification measures, and facilitate attachment

Nursing Management of Fourth Stage

• Assess vital signs every 15 minutes for the first hour.
• Assess temperature PRN.
• Palpate fundus and flow every 15 minutes for 1 hour.
• Assess perineum.
• Provide perineal care.
• Encourage bonding and breastfeeding.
• CSM
• Education

Care of the Family During Cesarean Birth

• Delivery through an incision on the abdomen and uterus.
• Maternal-fetal indications
• Pre/post-operative prep.
• Risks: infection, hemorrhage, aspiration, ileus, urinary trauma.
• Anesthesia (Spinal): Once surgery is complete, look for CSM.

Diabetes Mellitus

• Pre-gestational Diabetes: Alterations in carbohydrate metabolism before conception. Managed with insulin, diet, and exercise.
• Gestational Diabetes: Glucose intolerance that begins during pregnancy. Usually diagnosed in the second or third trimester (around 24-28 weeks).
• Neonatal complications include excessive weight gain.

Hypertension in Pregnancy

• Gestational hypertension: Diagnosed when there are at least 2 separate occasions of blood pressure readings over 140 systolic or 90 diastolic after 20 weeks.
• Lifestyle changes include LL recumbent position, limiting sodium intake, and antihypertensives.

Preeclampsia/Eclampsia

• Thromboxane and prostacyclin imbalance.
• Reduced blood flow to the brain, liver, kidneys, and lungs.
• Urine output decreases, sodium is retained, and edema occurs.
• Symptoms: severe headache, seizures, hypertension, vision changes, proteinuria.

Nursing Management of Preeclampsia

• Mild: Few symptoms, >140/90, proteinuria 1g or less in 24 hours.
• Severe: >160/110 on two occasions at least 6 hours apart, bedrest on the left side, proteinuria 5g in less than 24 hours, vision changes, oliguria, severe headache, thrombocytopenia.

Monitoring and Treatment

• BP, weight, urine protein, and fetal movement should be assessed.
• Anticonvulsants (magnesium sulfate), corticosteroids, and antihypertensives (labetalol and hydralazine).
• Labor induction if severe. Cesarean if severe and not responding to treatment.
• HELLP syndrome: preeclampsia with liver involvement.
  • H: Hemolysis
  • E: Elevated
  • L: Liver functions tests
  • L: Low
  • P: Platelet count

Iron Deficiency Anemia

• Reduction in RBC.
• Hgb < 11 g/dL.

Ectopic Pregnancy

• Fertilized ovum implants outside the uterus.
• Most commonly in the fallopian tube.
• Symptoms: vaginal bleeding, lower abdominal pain, positive pregnancy test.
• Treatment: Surgical removal of the ectopic pregnancy.

Cervical Insufficiency

• Presumed weakness in cervical tissue, potentially leading to early delivery of a healthy pregnancy.
• Painless dilation of the cervix without contractions.
• Cervical effacement occurs internally, with the internal os funneling.

Placenta Previa

• The placenta implants in the lower uterine segment or over the internal cervical os.
• With contractions and dilation, placental villi are torn from the uterine wall, exposing uterine sinuses at the placental site.
• Bleeding begins.
• Classification:
  • Complete: Placenta covers the entire cervix opening.
  • Marginal: Placenta's edge reaches the margin of the cervical os.
• Symptoms: Painless bright red vaginal bleeding.
• Assessment: Blood loss, pain, uterine contractions, VS, labs, FHR.
• Fetal Implications: Depend on the extent of placenta previa.
• Management:
  • Often requires a C-section.
  • Have blood ready in case of massive hemorrhage, which may necessitate a hysterectomy.

Abruptio Placentae

• Premature separation of a normally implanted placenta from the uterine wall.
• Can be a catastrophic event due to the severity of resulting hemorrhage.
• Classified based on the extent of the separation and location.
• Severe:
  • Blood invades myometrial tissues.
  • Uterine irritability.
  • Uterus turns entirely blue due to blood filling muscle fibers.

Maternal Implications

• Large amounts of thromboplastin are released into the maternal blood supply.
• Development of DIC (Disseminated intravascular coagulation).
• Resultant hypofibrinogenemia.
• Hemorrhagic shock.

Fetal Implications

• Fetal death, especially with complete separation.

Immediate Priorities

• Maintain the mother's CV status.
• Plan for the delivery of the fetus (over 90% require C-section).
• Administer blood products.

Hyperemesis Gravidarum

• Excessive vomiting.
• Severe dehydration leads to hypovolemia, hypotension, and tachycardia.
• Increased Hct, BUN, and decreased urine output.
• Weight loss of 5% of pre-pregnancy weight.
• Fetal death can occur.
• Management: Control vomiting, correct dehydration, restore electrolytes, and maintain nutrition.
• Medications: Diclegis, promethazine, metoclopramide, ondansetron.
• Can require TPN.

Rh Compatibility

• A negative indirect Coombs test means there is no maternal sensitization to Rh factor.

Polyhydramnios

• More than 2000 ml amniotic fluid (normal: 500 ml).
• Associated with fetal malformations.
• Maternal implications: SOB, edema (compression on vena cava).
• Fetal implications: Preterm birth, prolapsed cord, malpresentations.

Oligohydramnios

• Less than the normal amount of amniotic fluid.
• Fetal implications: Skin/skeletal abnormalities, pulmonary hypoplasia, cord compression.

Multiple Gestations

• Fundal height greater than expected for singleton gestation.
• Maternal implications: SOB, DOE, backaches, pedal edema.
• Fetal implications: Decreased growth/weight, increased fetal abnormalities, increased risk of prematurity.
• Increased frequency of prenatal visits.
• Usually requires C-section.
• First baby is labeled A, second baby B.

Prelabor Rupture of Membranes (PROM)

• Spontaneous rupture of membranes before the onset of labor.
• Premature rupture of membranes (PPROM): Before 37 weeks of gestation.
  • Before 30 weeks: Increased risk of serious complications.
  • Earlier GA: Greater likelihood of complications.
• Maternal risk: Infection.
• Management: Exam for amniotic fluid in the vagina.
  • Nitrazine paper.
  • Ferning test.
  • Ultrasound: GA, amniotic fluid, fetal well-being.
• Antibiotics for PPROM, GBS prophylaxis.
• Corticosteroids with earlier GA to promote fetal lung development.

Shoulder Dystocia

• Medical emergency.
• Occurs when the anterior shoulder fails to deliver spontaneously or with gentle traction after the birth of the head.
• McRoberts maneuver is used to help deliver the shoulder.
• Macrosomia increases the risk.

Cephalopelvic Disproportion (CPD)

• Fetal size is larger than the pelvic diameters.
• Abnormal fetal positions.
• Labor is prolonged, excessive molding occurs, and necessitates traumatic forceps use.

Post-Term Pregnancy

• Beyond week 42 of gestation.
• Increased maternal risk due to fetal size.
• Fetal risk: Post-maturity syndrome.

Preterm Labor

• Occurs between 20-36 weeks gestation.
• Occurs with uterine contractions (4 in 20 minutes or 8 in one hour) and documented cervical change.
• Increased morbidity/mortality for the fetus and neonate.
• Educate patients on preterm labor symptoms.
• Goal: Prevent preterm labor from advancing to a point where it no longer responds to treatment.
• Corticosteroids are given to promote fetal lung development and surfactant production.

Uterine Relaxants

• I: Indomethacin (NSAID)
• N: Nifedipine (Calcium Channel Blocker)
• M: Magnesium sulfate (can create toxicity, use calcium gluconate)
• T: Terbutaline (Adrenergic agonist)

Prolapsed Umbilical Cord

• The cord is pinched off, reducing or eliminating fetal oxygenation.
• Little time to safely deliver the baby.
• Fetal death can occur if pressure is not relieved.
• Have the mother lay flat to combat gravity.
• Monitor FHR closely (bradycardia is a concern).

Anaphylactoid Syndrome of Pregnancy

• Caused by a small tear in the uterus allowing amniotic fluid to leak into the maternal circulation
• Results in sudden onset of respiratory distress, circulatory collapse, and acute hemorrhage
• Symptoms include dyspnea, cyanosis, hemorrhagic shock, and coma
• Treatment involves immediate delivery to save the fetus and life-saving measures, including CPR

Postpartum Hemorrhage

• Potentially life-threatening complication following SVD or C-section
• Leading cause of maternal death
• Defined as cumulative blood loss greater than 1000 mL with signs of hypovolemia
• Most common cause is uterine atony
• Clinical manifestations of shock include diaphoresis, maternal anxiety, cold extremities, increased cap refill, tachycardia, postural hypotension, oliguria, hemodynamic instability, hypotension, irritability, agitation, and confusion
• Lack of uterine tone is a major concern due to potential for blood loss

Causes of Postpartum Hemorrhage

• Uterine tone: Should be firm, not boggy
• Tissue: Retained placenta
• Trauma: Lacerations
• Thrombin: Clotting factors or blood products
• Traction: Excessive pulling on the cord

Nursing Management of Postpartum Hemorrhage

• Assess fundal height, uterine tone, and bladder distension
• Monitor pad counts and weigh the pads
• Massage uterus if boggy
• Empty bladder or catheterize
• Maintain IV access
• Monitor for orthostatic hypotension (fall risk)
• Administer uterotonics (oxytocin, misoprostol, carboprost, methylergonovine)

Postpartum Infections

• Endometritis: Uterine infection occurring within 2-4 days, more common in cesarean births
• Surgical site infections: Occur at the incision site
• Urinary tract infections: Result from invasive manipulation of the urethra and frequent vaginal exams
• Mastitis: Inflammation of the mammary glands, risk factors include stasis of milk, infrequent and inconsistent feeding, nipple breakdown, oversupply, and rapid weaning
• Thromboembolic disease: Changes in maternal coagulation system contribute to hypercoagulability and compression of the common iliac vein by the gravid uterus, leading to venous stasis
• Risk factors include cesarean birth, immobility, obesity, varicose veins, and family history
• Signs and symptoms include edema, tenderness, pain, palpable cord, changes in limb colors
• Treatment includes heparin or LMWH

Postpartum Affective Disorders

• Postpartum blues: Transient and mild mood changes
• Postpartum depression: More severe and persistent depression
• Postpartum psychosis: Most dangerous form, characterized by severe mood swings, delusions, and hallucinations

Birth Weight Variations

• Small for gestational age (SGA): Less than 2500 grams
• May be preterm, term, or post-term
• Difficult vaginal birth and increased birth trauma are common
• Assess risk factors prenatally
• High risk for hypoglycemia
• Nursing management includes frequent blood sugar checks, monitoring for signs of hypoglycemia, addressing traumatic birth injuries, and assisting with feeding difficulties

Shoulder Presenting/Shoulder Dystocia

• Type of birth trauma where the baby’s shoulder cannot be delivered vaginally
• Can cause nerve damage and asymmetric infant movement

Pre-term Newborn

• Born before 37 weeks gestation
• Higher mortality and morbidity due to immature body systems
• Respiratory system: High risk for complications, less surfactant
• Cardiovascular system: Difficulty transitioning from fetal to newborn circulation
• GI system: Lack of neuromuscular coordination for feeding, increased risk for ischemia and damage to the intestinal wall
• Immune system: Immature and more susceptible to infection
• CNS: Difficulty with temperature regulation
• Nursing management includes promoting oxygenation, maintaining thermal regulation, preventing infection, promoting nutrition and fluid balance, growth and development, and parental coping

Post-term Newborn

• Born beyond 42 weeks gestation
• Susceptible to birth challenges such as asphyxia, hypoglycemia, respiratory distress, and cold stress
• Nursing Management: Monitor for signs of respiratory distress, check glucose levels, maintain temperature, and provide frequent feedings

Perinatal Asphyxia

• Results from circulatory, respiratory, and biochemical changes
• Monitor for risk factors including non-reassuring fetal heart rate, impairment of maternal oxygenation, and placental blood flow issues
• Rapid newborn assessment at birth includes color, work of breathing, heart rate, and temperature
• Resuscitation management focuses on effective ventilation

Transient Tachypnea of Newborn

• Self-limiting respiratory distress
• Caused by failure to clear the airway of fluid and debris
• Cesarean births are at increased risk due to lack of "thoracic squeeze"

Respiratory Distress Syndrome

• Inadequate production of pulmonary surfactant
• Lungs are easily collapsed requiring more energy to breathe
• Assessment includes respiratory distress signs, differentiating from TTN or GBS

Meconium Aspiration Syndrome

• Presence of meconium in the lungs
• Can lead to mechanical obstruction, pneumothorax, bacterial pneumonia, and inactivation of natural surfactant

Retinopathy of Prematurity

• Potentially blinding retinal disorder
• Primarily associated with pre-maturity and very low birth rate
• Also linked to newborns receiving supplemental oxygen

Necrotizing Enterocolitis (NEC)

• Bacterial invasion of the intestinal wall, leading to inflammation and cell death
• Common in preterm infants

Infant of Diabetic Mother

• Often LGA, macrosomic, ruddy, and have excessive adipose tissue
• Pathophysiology: Fetus is exposed to high glucose levels, leading to increased insulin production and glycogen storage

Infant of Substance Abusing Mother

• Alcohol consumption during pregnancy can cause significant issues, especially within weeks 3-8

Neonatal Abstinence Syndrome

• Drug withdrawal symptoms (opioids most common)
• Can progress to seizures and require comfort, nutritional needs, prevention of complications, and promotion of parent-newborn interactions

Explore the essential principles of maternal and newborn nursing, focusing on childbirth methods, family-centered care, and the importance of prenatal and postpartum support. Understand the risks associated with home births and the significance of addressing postpartum depression. This quiz aims to enhance your knowledge and awareness of culturally sensitive care in maternal health.