Physiology of Pregnancy

Physiology of Pregnancy

• Presumptive signs include subjective findings like flu-like symptoms, breast tenderness, nausea/vomiting, and a missed period.
• Probable signs are objective findings such as a positive pregnancy test, Chadwick's sign (bluish cervix), Gidelle's sign, softening of the cervix, and Hegar's sign (softening of the lower uterine segment).
• Positive signs of pregnancy include ultrasound visualization, fetal heart rate detection, and viewing the fetus.
• Nagele's rule estimates the due date by subtracting 3 months from the last menstrual period (LMP) and adding 7 days.
• Fundal height at 16 weeks is about halfway between the umbilicus and the pubic bone.
• At 20 weeks, the fundal height is at the umbilicus.
• At 40 weeks, the fundal height reaches the xyphoid process.
• GTPALEx is a system used to document pregnancy history, including G (gravida), T (term), P (preterm), A (abortion), L (living), and Ex.
• Example GTPAL: G4 T1 P0 A2 L2 Patient eight weeks gestation with history of one spontaneous abortion at 10 weeks, and has three-year-old twins, and one ectopic pregnancy.

Gestational Diabetes (GDM)

• GDM involves glucose intolerance during pregnancy.
• Risk factors include macrosomia, genetics/family history, obesity/sedentary lifestyle, PCOS, and pre-existing hypertension.
• Symptoms of hypoglycemia include jitteriness/tremors, lethargy, and diaphoresis.
• GDM symptoms include signs and symptoms of DKA and fruity breath and loss of consciousness
• Treatment includes diet, lifestyle changes, and monitoring blood sugar levels before and after meals and fasting.
• GDM is diagnosed via a 1-hour glucose tolerance test; levels above 135 mg/dL require a 3-hour fasting test.
• In a 3-hour fasting test, the blood draw levels are: 1 hour - <180, 2 hour - <155, 3 hour - <140.
• Diagnosed GDM patients are at higher risk for developing diabetes later in life (within 10 years).
• If dietary and lifestyle changes are insufficient, insulin may be needed instead of metformin.

Infertility

• Infertility is defined as the inability to conceive after one year of unprotected intercourse for those under 35 and six months for those over 35.
• Causes in women include PCOS, ovulatory disorders, tubal factors, STDs, age, eating disorders, cancer, hormonal/endocrine imbalances, and structural issues in the uterus or reproductive tract.
• Causes in men include exposure to toxic chemicals/radiation, age, marijuana use (decreased sperm count), eating disorders, cancer, obesity and structural issues in the testicles
• Diagnosis involves semen analysis for men.
• Diagnosis for women involves tests like hormone tests, HSG, and hysteroscopy to identify structural abnormalities.
• Common treatments for women who are not ovulating include Clomid, Letrozole, aromatase inhibitors and nursing interventions and emotional support.

Infections - Prenatal Testing

• Some infections can affect pregnancy such as STIs.
• The TORCH panel includes Toxic Other (HIV, GBS at 36 weeks), Rubella, CMV, and Herpes, all of which can cause fetal death and severe physical abnormalities/birth defects.
• If a mother is positive for GBS and goes untreated, it can be passed to the baby and require NICU admission for the baby with RSV symptoms and respiratory distress.
• A positive GBS result in the mother does not always affect the pregnant woman, it primarily affects the baby.

Labor & Delivery

• The 5 P's of labor are: Powers, Passage, Passenger, Psyche, and Position.
• Powers refers to contractions.
• Passage is both the structure of the pelvis and also soft tissue and the most conducive passageway for delivery is a gynecoid pelvis.
• Passenger refers to the fetus.
• Psyche refers to the mother's emotional state, including uncontrolled pain which impact's a mother's will to complete labor.
• Position refers to fetal position in relation to the birth canal (breech, transverse, vertex).
• Stage 2 of labor concludes when the cervix is dilated to 10 cm and when baby is descending/delivering.
• Active labor includes 100% effacement (cervix is thinned out) and contractions increasing in intensity, frequency, more than 60 seconds long, two minutes apart.
• The urge to push or have a bowel movement indicates pelvic pressure.
• Nursing interventions include monitoring the fetal heart rate before, during, and after contractions.
• Fetal strips are used to assess if the baby is in distress, assess uterine tone, and assess the other 5 P's.
• During a palpated contraction, uterus should be tensing up.

Post Delivery Contractions

• Following palpated contraction, uterus should relax. If not baby will go into asphyxia and mother will go into tachysystole.
• Positioning of patient and pushing with contraction for uterus helps the body push during delivery.
• If a patient pushes during non-contraction, they will tear or have lacerations.
• Fetal station is assessed to measure descent. Fetal station -3 means the baby is high and not engaged in the pelvis.
• Fetal station 0 states the head is right at the ischial spine. Fetal station +3 means the baby is crowning.
• Stage 3 of labor lasts between 5-15 minutes.
• Placenta detaches spontaneously from uterine wall postpartum.
• Signs and symptoms of placenta delivery include a gush of blood, lengthening of the umbilical cord, and rise of the abdomen.
• The abdomen no longer has an oval shape but a round ball shape.
• Nursing interventions include monitoring bleeding, Pitocin drip and PPH.
• Important to assess the placenta to see if anything is missing. If pieces of placenta are missing, they are retained placenta PPH.
• There should be two arteries and one vein in the umbilical cord.
• Interventions include providing peri care and promoting bonding with the baby.

Cardinal Movements of Labor

• Cardinal Movements: Every Day Fine Infants Enter Eager and Excited or Engagement, Descent, Flexion, Internal Rotation, Extension, External Rotation, Expulsion
• Engagement (E) occurs when the baby's head is engaged into the pelvis, usually at station 0.
• Descent (D) is how the baby moves down the birth canal, aided by contractions and bearing down efforts.
• Flexion (F) is when the baby flexes its head, chin to chest, due to resistance of the cervix.
• This reduces diameter of the head for passage through the canal.
• Internal Rotation (I) is when the baby rotates, aiding the baby's exit.
• Extension (E) is when the baby's head is out, face looking down at mom's anus.
• External Rotation (E) is when the baby rotates to facilitate delivery of the anterior shoulder.
• Expulsion (E) is when the baby exits.

Fetal Monitoring

• Strip Interpretation: VEAL CHOP (Variable, Early, Acceleration, Late - Cord compression, Head compression, Okay, Placental insufficiency).
• Interventions for non-reassuring strips include: Move, Identify Labor Stage, Nothing or Emergency action.
• Nursing interventions include repositioning the patient, administering oxygen, turning off oxytocin, and administering fluids.

Induction of contractions

• Induction begins with the deliberate stimulation of uterine contractions before spontaneous labor starts.
• Methods to begin induction include cervical ripening such as with Carvedilol.
• Misoprostol acts through effacement leading to uterine contractions.
• Indications include a low Bishop's Score (referring to how favorable the cervix and fetal station are), the patient is in labor but not progressing, infection, post-term pregnancy, abruptio.
• Cannot use if the patient has previa or they will bleed. Other situations that can indicate induction include: gestational hypertension, preeclampsia, PROM to decrease risk of infection and fetal distress.
• How to induce: Pitocin and/or Artificial ROM.
• Assess for engagement of head to prevent prolapsed cord.
• Risk - tachysystole (more than 5 contractions in 10 minutes, lasting longer than 2 minutes, contractions reoccurring 1 minute apart, not feeling sufficient relaxation of uterus).

Preterm Labor

• Preterm Labor: Risk factors include drug abuse, a history of preterm labor, trauma, smoking, multiple gestations, obesity, GDM, HTN, preeclampsia, infections, and existing comorbidities.
• Prediction involves cervical length measurement.
• Short cervical length, 15 mm, Cervical length can predispose to preterm labor.
• Can be treated with cerclage to bind the cervix closed around 14 or 15 weeks.
• Women with 30 mm cervical length or less, 3 cm, will probably get cerclage.
• Another risk factor of the patient acquiring preterm labor is cervical insufficiency.
• You can put patients on progesterone if they have a history of spontaneous preterm labor of abortion due to cervix.
• Signs and symptoms include lower back pain, contractions, cramping, pelvic pressure, diarrhea (with or without), bleeding, increased vaginal discharge, and fluid leaking (amniotic).
• Diagnosis is done via assessment that is done through nitrosamine paper and looking through microscope.

Preterm Labor: Stopping Medications

• Visualization of pelvis/Amnisure assists with diagnosis.
• Can use Tocolytics Terbutaline, and Nifedipine.
• Magnesium sulfate and Steroids (Betamethasone) for fetal lung maturity are common medications.
• Steroids are given to help mature the baby's lungs.

Cesarean Section Indications

• Cesarean section is indicated in cases of distressed baby, fetal issues, abnormal fetal positioning, abnormal is FHR and presence of meconium.
• Other indications include preeclampsia, comorbidities, tachysystole, preexisting pregnancy factors, abruption, previa, long labor, stalled labor, large fetal head, Cephalo Pelvic Disproportion (CPD), maternal obesity, increasing maternal age, and previous uterine surgery.

Distocia

• Fetal Dystocia includes CPD and can lead to complications like asphyxia, fetal injuries (bruising), and maternal lacerations.
• Assessment findings include FHR heard above umbilicus, SVE showing butt or feet, fetus not engaged in pelvis/fetal descent has stalled.
• Determine position of baby with Leopold's maneuver and assess location of the FHR.

High Blood Pressure

• Assessment includes alerting provider of findings.
• Diagnoses differ between chronic, gestational HTN, and preeclampsia.
• Chronic HTN is 140/90 consistenly and existed before the 20th week of gestation.
• Gestational HTN is diagnosed during pregnancy, occurs after 20 weeks and BP is 140/90 with no signs of preeclampsia.
• Preeclampsia is 140/90 x2, 4 hours apart and combined with proteinuria and/or other symptoms such as headaches that do not go away with medication, epigastric pain, visual disturbances, and renal insufficiency.
• It can also be determined by thrombocytopenia, HELLP syndrome which stands for Elevated liver enzymes.
• Risk factors include obesity, age, multiple gestations, first time pregnancy, smoking, lifestyle habits, family history, previous history of preeclampsia and other comorbidities Lupus, Diabetes, or Chronic HTN.
• Medications to treat HTN include Labetalol, Nifedipine and Magnesium.
• Magnesium is used to reduce Magnesium, reduce the risk of seizure activity but does but does not reduce BP.
• Signs include Magnesium toxicity, Absence of deep tendon reflexes, Decreased RR Oliguria, Due to strict Is and Os, Less than 30 ml/hr, give antidote, Calcium gluconate, HELLP H - Hemolysis, EL - Elevated Liver enzymes, LP - Low Platelets

Prolapsed Cord

• Prolapsed Cord occurs when the umbilical cord falls out and can also be hidden inside.
• Risk Factors is when the presenting part is not engaged in pelvis.
• The nursing intervention is to ensure that the head is engaged before ROM.
• Nursing interventions include Elevation of presenting part and Trendelenburg (knee to chest) position.
• Can give 02 an Bolus and perform an emergency c-section

Abruptio and Previa

• There is no pain with vaginal bleeding present with previa.
• There is Painless vaginal bleeding and a low lying placenta.
• Attachment in lower uterine segment.
• No vaginal exams unless absolutely necessary.
• Important to have pelvic rest and Monitor baby.
• Check the RH status and If negative, RhoGAM if bleeding.
• Causes related to structural, multiple gestations, age, and uterine surgery in the past.

Chorioamnionitis

• Abruptio presents with extreme pain and the placenta is getting ripped off uterine wall.
• Causes include trauma and preclampsia.
• Chorioamnionitis is the Infection of amniotic fluid or soft tissues.
• No temperature needed for diagnosis.
• Signs and symptoms include Fever, Fetal Tachycardia, Purulent fluid from cervical oss, Elevated WBC in the absence of steroid use ROM - meconium stain does not indicate chorio if the color, odor, amount is normal.
• A uterine tenderness when palpated indicates chorio
• Assess for S/S Warm/clamy.
• Tenderness, localized pain
• Redness
• May have fever
• May have flu-like symptoms
• Treatment is antibiotics and Encourage breastfeeding

Breasts

• Do not want clogged milk ducts any further
• Patient should be feeding every 2-3 hours and staying Hydrated, lots of rest.
• May be caused by improper latching, letting bacteria in
• If a patient has Cracked nipples you can refer to Lactation consultant appointment and rubbing Breastmilk on cracked nipples, Proper latching
• Asses for involution of patients U - Uterus and Fundus.
• Fundus should be at umbilicus immediately/6-12 hr postpartum
• Void before assessing fundus and If bladder is full, displace uterus and Rusk for PPH.
• Goes down 1 cm every day and Cannot feel at 14 days
• Assess. B - Bladder and B - Bowel L- Lochia
• Should encourage patient to change patient every time she goes to bathroom but every 2 hours at minimum
• Want to encourage to prevent infection and provide patient with Peri Bottledo Peri care and want to promote hygeine
• Lochia rubra - first discharge after delivery,
• Lochia serosa - a lot lighter, usually up to 10 days
• Lochia alba - turns into light brown, tan, cream color up until 6 weeks
• Risk Factors is If the patient is Hypotensive, PROM over 24 hours/Longer time of rupture. Also patients with history of STI, Sepsis, wound and bacterial infection and also Meningitis and Pneumonia

TOLAC, VBAC

• Need facility must be equip with emergency c-section equipment
• TOLAC/VBAC/Operative Vaginal Births is indicated for Good candidates that have a Horizontal scar from previous c-section
• And a Previous VBAC and C-section related to abnormal presentation of fetus
• As well Transverse baby and the Normal progression of labor but need c-section dur to baby asphyxiation. Also Spontaneous labo
• Contraindications include Pelvic abnormalities and Previous uterine surgeries as well as Placental previa

Postpartum Assessment

• Head must be engaged and head not premature
• Assessment begins with BUBBLE-LE
• B- Breast and Mastitis or
• Difference between engorgement and mastitis is mastitis is usually unilateral, engorgement is bilateral.
• Mastitis is related to infection
• Teach patients to Pat dry on Pat dry and Change pad every 2-3 hours and Wipe from front to back as well as assessing E - Episiotomy or incisions
• Aswell assess, L- Lower extremities and E- Emotion
• PPD/Blues/Postpartum Blues are common which have Symptoms that go away without intervention and Occurs within 2 weeks after delivery and She can still take care of herself and her baby as well as being self-limiting.
• Postpartum is different becuase of Depressions which can occur within the year after delivery so typically requires some sort of psychological intervention such as Medication and Therapy
• The patient may be unable to take care of herself or baby and exhibit No self-care and Wishes to stay in bed or No care of baby.
• Rick factors Hx of depression or anxiety and Socioeconomic issues and no support plus Low financialor Poor relationship with partner
• or Complications of pregnancy or traumatic pregnancy which may lead to Physical or sexual abuse and Postpartum psychosis which is Rapid, right after delivery May occur Within 2-3 days when patients exhibit Delusions or disorganization Can also cause Harm to themselves and baby or Paranoia as well as the lack of Mood swings and also do not enjoy their baby

Newborn Assessment Basics

• New born Assessment- Head to toe
• Newborn will have Fontanels and murmurs so listen to the Heart (read in textbook different defects*)
• Normal sounds include Murmur and RR assessment crackles - normal
• Assess for Abnormal: Abnormal cardiac and Very loud murmur, Central cyanosis
• Cyanosis when baby is feeding or sleeping
• Check newborns
• Low HR when baby is sleeping, less than <60s and Baby is crying and HR is >200
• GI
• After delivery bowel sounds may not be heard
• Skin
• Post term baby
• Peeled
• Dry
• Cracked
• Wrinkly
• Preterm baby
• Thin (almost transparent) Sensitive
• V/S for baby and Temp (axillary)

Definition of hyperbillirubemia

• Defined as Jaundice because it isRemoved from body through stoolmaternal factors such *Americans, Asians etc) . Can determine that this is happening if there is
• ABO incompatibility between mother and child (e.g., the mother has blood type O and the neonate has blood type A or B) this is also can be caused by Rh incompatibility
• breastfeeding also can be a trigger

Causes of Incompatibility

• Can be caused by; diabetes
• use of oxytocin
• cord issues
• hypoxia
• acidosis
• lethargy
• bruising
• prematurity, viral/infection
• previous of these factors or a sibling with similar complications
• Treatment - Phototherapy
• severe Transfusion
• during treatment must Have nursing interventions - like putting a protective cover over eyes and and monitor temp, give hydration
• may see loose bowels , mom must encourage to breast feed

Hypoglycemia

• Signs include low sugar, lethargy, tremors ect.
• Risk factors - diabetes, cold stress and trauma -Prematurity -RDS
• Over 9 Lbs -Intervention for Low blood pressure check -Nursing intervtions may need IV fluids or to maintain natural temps

Parenting Classes

• Must make sure patents understand these steps to take when dealing with Infant, circumcision care, aftercare needs to be thought as well
• After
• Assess for infection
• Redness or Purulent discharge
• Plastic ring falls off , yellow crusting is not an issue and vaseline on area is fine as well

Normalcy for Cord care include;

• Open up to expose to air Fold dipper to expose and dry out

Patients may go though

• Dysmenorrhea - painful periods: Related to primary or secondary
• Signs - nausea can be sharp or interment or steady, or even cause issues with intercourse
• Caused by
• UTI, STI'S
• Endometriosis or adhesions

STD/ STI

Signs include Abnormal discharge/ irregular cycle with pained Intercourse, Syphilis goes as primary, secondary, tertiary that goes on unless treated and is bad. Symptoms include

• Whichever organ system the disease is affecting, symptoms will present specific to this system.
• Ex. Brain - memory loss, dementia
• Trichomoniasis0. - Asymptomatic -
• If they do have symptoms, hallmark sign is perfuse, yellow-green frothy vaginal discharge with foul odor

Cancers

• HPV is the primary start to Cervical Cancer -PAP test:
• 29 years old, tested every 3 years
• over 30, co-tested with cytology and HPV every 5 years -If something comes back abnormal, guidelines may change
• Even -over 65 years old, may not need Pap test unless has had a positive test within the last 10 years Women who have has hysterectomies can still get cervical cancer
• • still need to follow procedure

Also need to have -

• recommendations for screening of PCOS A - testrone levels may be increased or can present a increase to acne and obese or
• Insulin resistance
• At risk for metabolic disease

Cancer Treatments

• Treatment -
• Lifestyle changes
• Diabetic and Hormone treatments
• increase risk for cancer

Risk For Breast Cancer

Risk Factors include: -Genetics (testing for BRCA) -Do mammograms yearly

• • Treatment = Radiation
• Side effects
• Side effects = Skin irritation, N/V, Anorexia = weight loss and Bruising
• Loss of bone mass due to lack of estrogen in women which is linked to menopause.
• Start to treat usually at 35: -9-19 years - 1,300mg -19-50 - 1,000mg -51+ - 1,200mg -50+ - 600 - 1,000 IU of vitamin D per day