Maternity.pptx

MATERNITY ANTEPARTUM Menstrual cycle Pituitary gland releases FSH and LH, which stimulates follicles in ovaries to mature Each follicle contains one ovum ”egg”, Maturing follicles secrete estrogen When estrogen ovulation begins, and the brain is told to ↓ FSH and ↓ LH production Ovulation : The most...

MATERNITY ANTEPARTUM Menstrual cycle Pituitary gland releases FSH and LH, which stimulates follicles in ovaries to mature Each follicle contains one ovum ”egg”, Maturing follicles secrete estrogen When estrogen ovulation begins, and the brain is told to ↓ FSH and ↓ LH production Ovulation : The most mature ovum bursts out of its follicle and travels via fallopian tubes for fertilization In the ovary, the now-empty follicle, the corpus luteum, secretes progesterone Stimulates uterine lining (endometrium) to plump with blood and nutrients to prepare for implantation of a fertilized ovum If an ovum gets fertilized, it implants itself into the plump wall of the uterus. Fertilization occurs when with the sperm and ovum unite Fertilized ovum is called a zygote, Zygote implants approximately 6-8 days after ovulation Blastocyst causes the body to produce human chorionic gonadotropin (hCG). hCG tells the corpus luteum to continue secreting progesterone Maintains the pregnancy until the placenta takes over production, 2-3 months later. If the ovum does not get fertilized, the progesterone and estrogen levels drop This tells the uterine lining to shed, because it’s not needed to support a pregnancy. Blood, tissue, and the ovum are shed and leave the body via the vagina. This can take up to 7 days, This is a period or menses. Menstrual Cramps The uterus contracts during menses, contractions cause temporary oxygen deprivation, which then causes the pain (or dysmenorrhea) associated with menses. Therapeutic Management This is a normal process, no treatment is required, NSAIDs can be used to manage pain, Eat complex carbohydrates and avoid high sugar items, Exercise Nursing Concepts Reproduction, Comfort Patient Education Use contraception if pregnancy is not desired, Diet and medication education to aid in dysmenorrhea, Ensure proper hygiene during menses to avoid UTI Birth Control Ovulation tracking Basal Body Temperature, Ovulation Predictor Kits, Calendar Method Infertility Meds, Surgical procedures: To fix whatever the problem is i.e.: blockage in the tubes carrying the sperm In vitro fertilization, Intrauterine insemination, Surrogacy, Embryo hosts, Adoption Tubal ligation and Vasectomy are for client finished having children and want to permanently prevent future pregnancy Nursing Concepts Reproduction, Patient education Patient Education Birth control pills should be taken at the same time every day Antibiotics and other meds may decrease the effectiveness of contraceptives – use other form of protection It is important to take a prenatal vitamin when trying to conceive – should include folic acid Intra Uterine Device – Potential Problems P-Period (menstrual: late, spotting, bleeding) A-Abdominal pain, dyspareunia (painful intercourse) I-Infection (abnormal vaginal discharge) N-Not feeling well, fever or chills S-String missing An intrauterine device is inserted into the uterus and is used to prevent pregnancy. There are two different types: hormonal and copper IUD. Oral Contraceptives Because oral contraceptives can cause clots, we should monitor for the following serious complications in patients taking oral contraceptives: abdominal pain, chest pain, headache, eye problems, swelling or aching in the legs or thighs. Contraindicated for smokers, Contraceptive patch Tubal Ligation Procedure to sterilize female patients Also known as “Tubal ligation” or “having tubes tied” Fallopian tube is ligated or Vasectomy clamped Procedure to sterilize male patients Prevents egg from traveling from Vas deferens is cauterized to the ovary through the fallopian prevent sperm & semen from tubes exiting the urethra Surgery requiring prolonged Takes approximately 3 months recovery before sterility is completed Will require follow-ups with provider for sperm count Minor surgery (outpatient Estimating Gestation Gestation is around 40 weeks long Assessment Nägele’s Rule ( for 28-day cycle) Find out when the last menstrual period happened (LMP), Subtract 3 months, Add 7 days, add a year -OR- Add 7 days to the first day of the last period, then count ahead 9 months Ultrasound: Obtain measurement of embryo length to estimate gestational age (off 7-10 days) Position woman comfortably on U/S table, Transvaginal or external U/S performed Comfort can be offered in explaining transvaginal ultrasound to ease the patient’s mind since this is intrusive. Nursing Concepts Educate on what due date is calculated and give necessary pregnancy education Types of Pelvis Gynecoid Normal female pelvis, Most favorable for successful labor and birth Gravida A pregnant woman; called "gravida I" (or "primigravida") during the first pregnancy, "gravida II" during the second, and so on. Parity The number of pregnancies that have reached viability regardless of whether the fetus was born alive or stillborn. Pregnancy outcomes are often described with the use of the GTPAL acronym: G stands for gravidity, or the number of pregnancies, including the current one. T represents term births, the number of children born at term (37 weeks’ gestation). P is preterm births, the number of children born before 37 weeks’ gestation. A represents abortions and miscarriages L stands for the number of current living children. Signs and Symptoms of Pregnancy Presumptive: Period absent (amenorrhea), Really tired (fatigue), Enlarged breast, Sore breast, Urination increased, quickening (16-20 weeks) Probable Uterine enlargement: fundal height Hegar sign : Compressibility and softening of the lower uterine segment, occurring around week 6 of gestation; a probable sign of pregnancy. Goodell sign: Softening of the cervix, occurring at the beginning of the second month of gestation; a probable sign of pregnancy. Chadwick sign Violet coloration of the mucous membranes of the cervix, vagina, and vulva, resulting from increased vascularity, occurring around 4 weeks of pregnancy; a probable sign of pregnancy. Ballottement Rebounding of the fetus against the examiner's finger on palpation. When the cervix is tapped, the fetus floats upward in the amniotic fluid. A rebound is felt by the examiner when the fetus falls back. Positive result on pregnancy test for human chorionic gonadotropin (hCG) Measuring fundal height The fundal height is measured to help gauge the fetus' gestational age. During the second and third trimesters (weeks 18-30), fundal height in centimeters approximately equals the fetus' age in weeks, plus or minus 2 cm. At 16 weeks, the fundus can be found halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process. Uterus Enlarges from a weight of 60 g to 1000 g Positive Fetal heart rate, detectable with an electronic device (Doppler transducer) at 10 to 12 weeks and with a nonelectronic device (fetoscope) at 20 weeks of gestation Active fetal movements palpable by examiner (Leopold maneuver) Outline of fetus on ultrasound Fetal circulation Assessment Hormones Estrogen, Progesterone, HCG, Aldosterone Cardiovascular More blood volume, Murmurs can be normal, Edema/fluid retention Increased pulse 10-15 BPM , Blood pressure decreased in second Trimester Increased preload and cardiac output, increased need for iron Gastrointestinal Progesterone slows GI, flatulence Constipation, Nausea/vomiting, Bloated feeling, hemorrhoids, ptyalism Renal Frequent urination : Uterine weight, fetal size, Increased risk of UTI Respiratory Increased oxygen consumption, Increased ventilation Musculoskeletal Gait changes: Relaxin hormone, Changes to pelvic girdle Hematologic Increased coagulopathies→ increased risk for DVT Assessment Reproductive Vagina Hypertrophy and thickening of the muscle occurs. Vaginal secretions increase; usually these are thick, white, and acidic. Breasts Size increases, Nipples become more pronounced Areolas become darker. Superficial veins become prominent. Hypertrophy of the Montgomery follicles occurs. Colostrum may leak from the breast. Ovaries: Ovulation stops Integumentary A dark streak, or linea nigra, may appear down the midline of the abdomen. Chloasma (the "mask of pregnancy"), a blotchy brownish hyperpigmentation, may appear over the forehead, cheeks, and nose. Stretch marks (striae) may appear on the abdomen, breasts, thighs, and upper arms. Vascular spider nevi may appear on the neck, chest, face, arms, and legs. The rate of hair growth may slow. Therapeutic Management Treat any discomfort that changes are causing Band to lift growing uterus and relieve back discomfort , Medications for GI discomfort, Diet to manage constipation Patient Education Normal changes to expect, Taylor sitting exercises, Sleep on the left side to prevent supine hypotension Ways to improve symptoms Eat crackers before rising from bed, Don’t let stomach get empty → increases nausea Importance of maintaining correct posture→ prevent musculoskeletal discomfort and back pain When to be concerned Frequent vomiting causing weight loss, Signs of blood clots, DVTs, UTI symptoms Routine diagnostics Blood type and Rh Factor Rubella titer to determine immunity Cannot give rubella vaccine during pregnancy due to it potentially crossing placenta because it is a live vaccine Complete blood count: H/H, Platelets STI testing Pap smear with cultures, May test for: HIV, HPV, herpes, gonorrhea, syphilis, chlamydia, trichomoniasis Hep B screening Glucose challenge Done around 28 weeks OGTT Patient drinks 50 g oral glucose, Check 1 hour BG, If they fail, they do a 3-hour glucose test 3-hour glucola Fasting sugar, Drink 100g glucose, Check at 1 hr., 2 hr., 3hr, If fail then gestational diabetic and need referral UA with culture Urine dip for glucose (diabetes) and protein (preeclampsia) at every prenatal visit Fetal Monitoring This noninvasive mode of monitoring is conducted with the use of a tocotransducer and Doppler ultrasonic transducer. After the Leopold maneuvers are used to determine the side on which the fetal back is located, the ultrasound transducer is placed over this area, then fastened with a belt. The tocotransducer is placed over the fundus of the uterus where contractions feel the strongest and fastened with a belt. Client is allowed to assume a comfortable position to help prevent vena cava compression. In invasive intervention, the membranes are ruptured and an electrode is attached to the presenting part of the fetus. Fetal Monitoring Routine diagnostics Ultrasound Abdominal (may also be transvaginal if early in gestation) A full bladder pushes up the uterus, making structures easier to visualize Checking anatomy of baby and maternal structures (cervix, placenta) Helps confirm the estimated gestational age and that structures are forming appropriately and at the appropriate rate, Can also assess the blood flow of placenta and baby Used as guidance in some testing such as amniocentesis, Chorionic villus sampling Nonstress test (NST) Noninvasive, not painful, completed outpatient 2 transducers: one for baby, one for contractions Assess fetal well-being, changes in their heart rate with movement (accelerates, decelerates), also how the placenta is functioning and its oxygenation We want a reactive NST (when the fetus moves, the heart rate increases appropriately, approx. 15 beats above baseline at least twice in 20 min) Baseline maternal BP and HR before Patient to press button when they feel fetal movement, examiner can note if it correlates with tracing We DO NOT want a nonreactive NST. Further testing will be required if this is noted. Routine diagnostics Not routine (only done if previous diagnostics or physical exam warrants them) Contraction stress (only performed if NST is non-reactive) Induce contractions either with Pitocin or nipple stimulation to see if the baby shows signs of stress. If there is stress, we see a decrease in FHR because of the contraction Percutaneous umbilical blood sampling Sample is obtained from fetal blood from the umbilical cord, Blood is tested usually detects for fetal anemia Alpha-fetoprotein screening Blood sample from mom between 16-18 weeks Protein is released by liver to maternal blood supply If Down’s Syndrome or spina bifida suspected Not 100% effective. Can miss anomalies or be detected without anomaly Chorionic villus sample (Invasive!) Checking genetic issues by sampling chorionic villus (fetal placental tissue), Done early in gestation (11-14 weeks) Mother must call if she has contractions, cramping, fever, chills, leaking fluid Routine diagnostics Group Beta Strep Vaginal swab at 34-36 weeks, Looks for beta strep bacteria that could cause infant to be sick/septic Kick counts Mother counts number of kicks during 2-hour period while lying on side, Notify if less than 10 in 2 hrs Amniocentesis (Invasive) Checking amniotic fluid for genetic and metabolic issues, fetal lung issues After this mother must be instructed to call MD with any sign of decreased fetal movement, uterine contractions, cramping, fever, chills, fluid leaking from site Nitrazine test Checking for amniotic fluid in vaginal secretions Water broke vs. urine Turns swab blue if it’s amniotic fluid, measures the pH Not 100% accurate Nutrition during pregnancy An increase of about 300 calories per day is needed during pregnancy. An increase of about 500 calories per day is needed during lactation. A diet high in folic acid and folic acid supplementation are important. The pregnant woman should drink at least eight to ten 8-oz (235ml) glasses of fluid each day, of which four to six glasses should be water. If a pregnant patient’s rubella titer is less than 1:8, she should be immunized after delivery. Labor and delivery Leopold Maneuvers Used to determine position, presentation, and engagement First maneuver is used to determine which part of the fetus is in the fundus Second maneuver reveals which side of the uterus the back is located on and on which side the fetal arms and legs are located Third maneuver confirms fetal position Fourth maneuver is used only in the late stage of pregnancy, in cephalic presentations, to determine how far the fetus has descended into the pelvic inlet Stages of Labor First stage of labor begins with the onset of labor and ends with full cervical dilation at 10 cm. Includes latent, active, and transition stages Effacement and dilation of the cervix occurs second stage of labor begins with full cervical dilation and ends with the neonate’s birth. third stage of labor begins after the neonate’s birth and ends with expulsion of the placenta. fourth stage of labor (postpartum stabilization) lasts up to 4 hours after the placenta is delivered. This time is needed to stabilize the mother’s physical and emotional state after the stress of childbirth. Process of Labor Attitude: relationship of fetal head position to maternal spine Flexion: normal attitude, head flexed down with chin to chest Extension: abnormal attitude, less commonly seen, head extended back Lie: relationship of fetal spine to maternal spine Longitudinal / vertical: normal lie, both spines parallel Transverse: both spines form cross, c-section required Fetal Presentation: This aspect is named for the portion of the fetus that enters the pelvis, or presents, first. Cephalic : In the most common presentation, the fetal head appears first. Vertex: most common, head fully flexed down Brow: head tipped back slightly, “eyebrows first” Face: head tipped back fully, full face first Breech In a frank breech, the fetus' legs are extended across the abdomen toward the shoulders. In a full (complete) breech, the head, knees, and hips are flexed but the buttocks are presenting. In a footling breech, one or both feet are presenting. Delivery by cesarean section may be required in the case of a breech presentation, although it is often possible to deliver vaginally. Shoulder Fetus is in a transverse lie, or the arm, back, abdomen, or side may present. If the fetus does not spontaneously rotate or it is not possible to turn the fetus manually, a cesarean section is almost always necessary. Position: This term is used to describe the position of the baby in relation to mom’s pelvis Must know landmark Occiput (most common, back of the head)- “O” Scapula- “Sc” Sacrum- “S” Mentum-”M” Look at where the landmark is in relation to mom’s pelvis Right vs. left Anterior vs. posterior Left occiput anterior is most common and where most babies naturally face.. It allows the widest part of the baby’s head to correspond with the widest part of mom’s pelvis ie:ROA Occiput is facing right side of pelvis and is towards the front of the pelvis Ie: LOA Occiput is facing the left side of pelvis and is anterior (towards the Fetal Station Measurement of the progress of descent, in centimeters, above or below the midplane from the presenting part to the ischial spine Station 0: at ischial spine Minus station: above ischial spine Plus station: below ischial spine Powers The forces acting to expel the fetus (Contraction) Effacement: shortening and thinning of the cervix during the first stage of labor Dilation: enlargement of the cervical os and cervical canal during first stage True labor vs. false labor True labor is progressive, regular, and becomes stronger If mom changes activity (going from resting to walking) and the contractions stop, it is FALSE labor True labor produces dilation, effacement, engagement and descent False labor does not do any of the above Other events that occur just before labor occurs Lightening Vaginal discharge increases Brown/blood-tinged cervical mucus passes Cervix gets ready by ripening, potentially dilating/effacing Burst of energy can occur 24-48 hrs before (“nesting”) Estrogen and progesterone levels fluctuate, causing a fluid shift and subsequent weight loss of 2.2-6.6 kg approximately 24-48 hrs prior to labor Rupture of Membranes Process Of Labor Engagement: where the presenting part descends through the pelvic inlet May be called lightening or dropping, Occurs approximately 2 weeks before delivery Descent and flexion: process of presenting part (typically the head) going through mom’s pelvis, occur simultaneously as a fluid movement Baby flexes head down Descent is measured by station, continuous process until delivery 0 station = presenting part at ischial spine Minus station is up Plus station is closer to delivery Internal rotation: baby rotates within the birth canal Baby’s face in line with mom’s rectum Extension: baby’s head extends Begins after crowning, Complete when chin is out of perineum Restitution and external rotation: occur simultaneously as a fluid movement Baby re-aligning its head with body Expulsion: baby’s entire body is out Fetal Heart rate monitoring Variability Variable decelerations: Cord compression Abrupt decreases from cord compression Early decelerations: Head compression Deceleration that occurs at the start of the contraction and returns to baseline at the end of the contraction, happens with head compression and is ok Accelerations: oxygenated FHR increases, Oxygenated and good Late decelerations: Placental insufficiency Deceleration that occurs after the start of the contraction, caused by fall in O2 to the fetus FHR patterns to watch out for Bradycardia (< 110 for 10+ min) Tachycardia (> 160 for 10+ min) Late decelerations ( issues with placenta) Prolonged decelerations Hypertonic uterine activity (uterus not resting in between contractions, which decreases uterine circulation and therefore O2 supply to fetus) Absent or decreasing variability Variable decelerations lasting longer than 1 minute with a FHR less than 70 Obstetric interventions Bishop Score This assessment, used to determine maternal readiness for labor because it aids evaluation of cervical status and fetal position, is indicated before the induction of labor. Five factors are each assigned a score of 0 to 3, after which the total score is calculated. A score of 6 or more indicates a readiness for labor induction. Induction Inducing labor (also called labor induction) is when your health care provider gives you medicine or uses other methods, like breaking your water (amniotic sac), to make your labor start. Artificial rapture of the membrane Artificial rupture of membranes (AROM) is performed by the primary health care provider or nurse-midwife to stimulate labor if the fetus is at zero or + station. The procedure increases the risk of cord prolapse and infection. Monitor FHR before and after AROM. External cephalic version External cephalic version (ECV) is an attempt to turn the fetus so that he or she is head down. ECV can improve chance of having a vaginal birth. If the fetus is breech and is greater than 36 If the mother is negative for Rh factor, check that RhoGAM was given at 28 weeks' gestation. Prepare client for non-stress test to evaluate fetal well-being. tocolytic therapy may be administered to relax the uterus and ease manipulation of fetus. Ultrasound is used during the procedure to evaluate fetal position and placental placement and guide direction to the fetus. Episiotomy An incision is made in the perineum to enlarge the vaginal outlet and facilitate delivery. After Episiotomy Check episiotomy site, Institute measures to relieve pain. Provide ice pack for 24 hours after procedure. Instruct the client in the use of sitz baths (immersion of the perineal or episiotomy area in a warm water solution). Apply analgesic spray or ointment as prescribed. Provide perineal care, using clean technique; apply a peripad without touching the inside surface of the pad. Instruct the client in proper care of incision. Instruct the client to dry perineal area from front to back and to blot area instead of wiping it. Instruct the client to shower rather than bathe in a tub to decrease the risk of infection at the episiotomy site. Report any bleeding or discharge to the primary health care provider. Forceps Delivery The forceps are two spoon-like articulated blades that are used to assist in the delivery of the fetal head. Reassure the mother and explain need for forceps. Monitor mother and fetus during delivery. Check neonate and mother after delivery for injury. Assist in repair of any lacerations. Nursing Intervention ID cause :  Prolapsed cord  Check mom’s vitals for hyper/hypotension, fever Stop oxytocin, if infusing (this can worsen the non reassuring pattern) Change mother’s position (preferably to left side-lying if not already there) Give oxygen at 8-10 L via face mask Prepare to initiate appropriate monitoring (i.e. internal monitoring) Notify provider of potential cause, interventions, mother and baby’s response and prepare for further potential intervention Remember safety and perfusion are priority Prolapsed umbilical cord Visualize the cord protruding from vagina Feel pulsation or something squishy on a cervical exam Decel in fetal heart rate Mom may feel something soft and squishy between her legs Management Never try to push presenting part or cord back in Elevate presenting part with your hand to relieve pressure Have mother get into knee-chest position Helps open pelvis Place in exaggerated Trendelenburg position This shifts baby toward the fundus by gravity, decreasing the pressure on the cord Give supplemental O2 Extra goes to fetus Monitor FHR for signs of hypoxia (increased variability, bradycardia) Prepare for emergent immediate delivery (c-section) Baby can never deliver after the umbilical cord or placenta = life line Vacuum Extraction The vacuum is a cap-like device applied to the fetal head to facilitate extraction by suction. Traction is applied during uterine contractions until descent of the fetal head is achieved. Assess FHR every 5 minutes if external fetal monitoring is not used. Assess newborn at birth and throughout postpartum period for S/S of cerebral trauma. Monitor neonate for developing cephalohematoma. Caput succedaneum (edema of the soft tissue over bone) is normal and will resolve in 24 hours. ANESTHESIA Local Anesthesia Used to block pain during episiotomy Administered just before birth of baby No effect on fetus Pudendal Block Administered just before birth of baby Injection site at pudendal nerve by way of a transvaginal route Blocks perineal area for episiotomy Effect lasts about 30 minutes No effect on contractions or fetus ANESTHESIA Injection site in epidural space at L3-L4 Administered after labor is established or just before a scheduled cesarean birth Relieves pain of contractions and numbs vagina and perineum May cause hypotension Does not cause headache because the dura mater is not penetrated Assess maternal blood pressure Mother maintained in side-lying position or with a rolled blanket beneath the right hip to displace the uterus from the vena cava Administration of intravenous fluids as prescribed Increased fluids as prescribed if hypotension occurs Monitor for adverse effects of opioid epidurals (e.g., nausea and vomiting, pruritus, respiratory depression) ANESTHESIA Subarachnoid (Spinal) Block Injection site in spinal subarachnoid space at L3-L5 Administered just before birth Relieves uterine and perineal pain and numbs vagina, perineum, and lower extremities May cause maternal hypotension May cause bladder distension and postpartum headache Requires mother to lie flat for 8 to 12 hours after spinal injection Administration of IV fluids as prescribed General Anesthesia May be used for some surgical interventions Mother not awake Presents the risk of respiratory depression and vomiting Placenta previa Placenta previa (placenta is near or covers the cervical opening) Painless, bright red vaginal bleeding Placenta location assessed on ultrasound Management Vaginal exams are contraindicated How it is managed depends on age of fetus, degree of placenta previa and if the fetus or mother are in distress If it’s marginal, vaginal delivery can be attempted C-section may be indicated otherwise Placenta Abrubtio Placental abruption (placenta detaches prematurely from the uterus) Can cause massive bleeding Blood Builds up behind placenta Dark red bleeding, Severe abdominal pain Uterine rigidity and/or pain: Boardlike abdomen Fetal distress: Bradycardia Shock symptoms, if extensive blood loss has occurred Management Monitor mother and baby Fetal heart tones and pattern: Decelerations? Vaginal bleeding, Change in PRECIPITOUS LABOR Rapidly progressing labor Strong close together contraction Feeling pressure to push early in labor “This baby is coming now!” Hemorrhage, Tears Management Prepare to potentially deliver baby if MD or midwife will not arrive in time Have supplies for delivery readily available Many ED’s and OB triage units have Precipitous Delivery Kits prepared Stay with mother, provide emotional support as pain is typically more intense and due to rapid progression and inability to administer pain meds so quickly Dystocia Difficult labor that may be prolonged or extraordinarily painful Excessive pain, Fetal distress Uncoordinated/disorganized contractions, Labor not progressing Management Assess for fetal distress Notify MD as appropriate Administer medications as ordered Pain meds, IVF, Tocolytics Promote rest If hypotonic contractions are occurring, oxytocin (Pitocin) may be indicated. Begin appropriate monitoring of mother and baby and titrate appropriately. COMPLICATIONS