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Antepartum Antepartum nutrition and weight gain ○ Foods to avoid: Fish advisory: mercury Do not eat: shark, swordfish, king mackerel and tilefish Limit white tuna to 6oz/ week n Certain soft cheeses and ready to eat meats (unless heat...

Antepartum Antepartum nutrition and weight gain ○ Foods to avoid: Fish advisory: mercury Do not eat: shark, swordfish, king mackerel and tilefish Limit white tuna to 6oz/ week n Certain soft cheeses and ready to eat meats (unless heated until steaming) Can cause miscarriage very easily Brie, feta, blue- listeria monocytogenes Unpasteurized milk, juice ○ Substances to avoid Abstain from alcohol/ no safe amount ETOH is a teratogen Tobacco (low birth weight and preterm births) Limit caffeine to 300 mg/day one cup of coffee 500-700 mg caffeine has been associated with miscarriage ○ Nutritional Requirements: Increase protein by 10g a day Folic acid is essential for neurological development Increase iron from 15-30 mg/day Iron supplements facilitate and increase in maternal RBC mass Iron is best absorbed with Vitamin C Calcium is important for bone/tooth formation 2 to 3 liters of fluid/day preferably eater, milk and fruit juice ○ Nutritional help for common problems Morning sickness Crackers before rising Protein snack at bedtime Avoid fatty/spicy meals Take prenatal vitamins at night Ginger tea/cookies help Constipation Fiber at 30 gms/hydrate  Heartburn Avoid spicy foods/ acidic foods Eat small frequent meals Sit up 1 hr after meals ○ Weight gain: Approximately 2-4 pounds during the entire 1st trimester Then 1 pound per week for the last 2 trimesters Danger signs of pregnancy ○ Pain on urination ○ Vaginal bleeding ○ Urinary urgency ○ Cramping ○ Blurry vision ○ Headaches Fetal Assessment- non stress test/Biophysical profile ○ Non stress test Most widely used technique for evaluation of fetal well being during the third trimester Primary means of detecting uteroplacental insufficiency Monitors response of the FHR to fetal movement Uses doppler transducer to monitor FH Trocotransducer to monitor uterine contractions ○ NST Indications Assess for intact CNS Decreased fetal movement IUGR Postmaturity Gestational Diabetes ○ NST Considered reactive if the FHR is normal baseline with moderate variability Accelerates to 15 beats/ min for at least 15 seconds Occurs 2 or more times in a 20 min period ○ Biophysical Profile (Especially high risk pts.)  Assesses fetal well being by measuring 5 parameters with a score of 2 for a normal finding and 0 for an abnormal finding Breathing movements Fetal movement (gross movements) Fetal tone (limb recoil) Reactive fetal heart Amniotic fluid volume (measures in pockets) Interpretation of findings 8-10 is normal 6 is equivocal (uncertain) 30) Family history of diabetes (primary relative) Previous delivery of baby >9 lbs PCOS Member of high risk ethnic group Maternal age older than 35 yrs ○ Lab Glucose screening 1 hr “glucose challenge test” at 24-28 weeks if no risk factors. Early screening (ideally at first prenatal visit) if risk factors are present Fasting not necessary 1hr later, serum glucose should be 35 (AMA) Uterine scarring from previous c/s or myomectomy Cocaine use Infertility treatments (IVF) Prior placenta previa Diagnosis Painless bright red vaginal bleeding during second or third trimester Uterus soft, non tender with normal tone Fundal height greater than usual for GA Fetal malposition (breech, oblique, or transverse) First episode of bleeding rarely caused hypovolemic shock Previa management Pelvic rest, possible bedrest Asses VS, vaginal bleeding, ctx Assess fetal heart rate and movement CBC/ blood type/ coagulation profile Ultrasound for placement of placenta Administer IV fluids and blood products as needed Avoid vaginal exams ○ Key points: Painless bleeding, bright red blood Soft abdomen V/S changes, hypotension Predisposing factors: surgical procedures of uterus, multiparity, older age Diagnosed via ultrasound Cautions: NO VAGINAL EXAMS or pitocin Intervention: C section, CANNOT deliver vaginal ○ Abruption Placenta Premature separation of the placenta from the uterus  Can be partial or complete detachment Occurs after 20 weeks Significant cause of maternal and fetal morbidity and mortality 1 in 90-200 pregnancies Sudden onset of intense localized uterine pain with dark red vaginal bleeding Contractions with hypertonicity- firm, rigid abdomen Fetal distress Signs of hypovolemic shock Diagnosed by ultrasound Emergency c/s if fetal distress Risk factors Maternal hypertension, preeclampsia, GHTN Blunt external trauma to abdomen Cocaine causing vasoconstriction Previous incidence of abruption Smoking Chorioamnionitis infection Uterine rupture Overdistension of uterus by polyhydramnios or multifetal pregnancy Mandagement Assess frequent VS, pain, bleeding, fundal height Assess FHR and movement CBC/blood work (HCT and HBG decreased) Coagulation factors decreased Cross and type for possible transfusion Administer IV/ blood products as ordered Administer 02 8-10L/ min via face mask Assess Urinary output Monitor for signs of DIC ○ Key Points: Sudden, painful dark red bleeding, board like abdomen V/S changes, hypotension Predisposing factors: trauma, HT, substance abuse (Cocaine)  External or internal hemorrhage Uterine irritability Management: maintain bedrest, monitor FHR, assess blood loss, prepare patient for C section Rh/ABO incompatibility ○ This happens when Rh- woman conceives a child who is rh+ ○ ABO incompatibility O blood type woman with naturally occuring anti-A and anti-B antibodies May result in hyperbilirubinemia of the infant Less serious than Rh incompatibility No medication to prevent it ○ RhoGam Prevention for Rh incompatibility Rh immune globulin Provides passive immunity “Tricks” the woman’s immune system - so she will not develop antibodies against Rh (+) blood ONLY administered to women who is Rh (-) who are indirect Coombs’ negative. Administered at 28 weeks or within 72 hours of any pregnancy interruption ○ Key points: Rh antibodies created in response to an rh+ fetus Rhogam stops the production of maternal antibodies and reduces complications. Given at 28 weeks to RH- woman and within 72 hrs after birth Could be given for trauma, spontaneous abortion, and amniocentesis Intrapartum VEAL CHOP, nursing actions ○ V: Variable = C: Cord compression = move/ reposition mom  ○ E: Early decelerations = H: Head compression = ok, chart and monitor, no other interventions needed. ○ A: Acceleration = O: Okay = chart ○ L: Late decelerations = P: Placental insufficiency = hypotension, 02 stat low, laying on back ; give 02 (8-10 L face mask), open IV line (increase fluid), left side lying, stop pitocin/ stop pushing to decrease uterine contractions Labor anesthesia/analgesia ○ Pharmacological Alleviates pain sensation or raises threshold for pain perception Includes systemic, regional and local analgesia and anesthesia Systemic analgesia Most important complication in respiratory depression Includes opioids, antibiotics and benzodiazepines Opioid analgesics (IV, PCA) Morphine, meperidine (demerol), butorphanol (stadol), nalbuphine (Nabaine), fentanyl (sublimaze) act on the CNS to decrease perception of pain without loss of consciousness Stadol & nalbuphine cause less neonatal respiratory depression Adverse effects Crosses placental barrier-may cause respiratory depression, newborn CNS depression Sedation, hypotension, decreased FHR variability, nausea/vomiting, pruritis *have naloxone (narcan) available* Epidural block (into lumbar epidural space) For vaginal and c/s Local anesthetic + opioid May cause nausea and vomiting, fever, pruritus, respiratory depression, longer 2nd stage of labor Spinal Block (into subarachnoid space) For planned or emergency c/s’s Local anesthetic +/- opioid -rapid onset pain relief  May cause hypotension, spinal h/a Priority nursing actions ○ Educate between true and false labor contractions True Contractions begin irregularly but increase in frequency and intensity Cervix veins to efface and dilate Bloody show Presenting part engages False Braxton hicks contraction irregular, decrease with intensity with walking or position changes Cervix shoes no significant change upon exam No bloody show Presenting part not engaged ○ Effacement-thinning and shortening of the cervix described in percentage ○ Dilation- opening of the cervix - 1 to 10 cm is full dilation ○ Back labor is from occipital posterior position ○ Breach is either butt or feet Easier way to have a prolapse bc there is more space ○ Fetal station Above ischial spine (-) Ischial spine 0 Below ischial spine (+) ○ 1st stage of labor Labor onset to complete dilation (focus is on cervical changes) Latent phase: cervix 0-6 (can last up to 20 hrs for 1st time moms) Active phase: cervix 6-10 cm ○ 2nd Complete dilation (10cm) to birth of infant (patient is focused on the work of pushing) ○ 3rd Birth of baby to expulsion of the placenta  ○ 4th Expulsion of placenta to 4 hrs postpartum - maternal stabilization of vital signs ○ Rupture of membranes Check FHR!!!! Should be clear, cloudy could mean infection, green meconium staining Odor: musty= normal; foul = possible infection ○ Looking at perineal lacerations ○ Emotional support ○ If bladder is full, fundus up and to the right High risk intrapartum Prolapsed cord ○ Fetus is not fully engaged allowing room for the cord to prolapse ○ Cord can slip down after the membranes rupture and becomes compressed between the fetus and the pelvis = decreased oxygen to fetus ○ This is an obstetric emergency! Call for help ○ The key intervention is to relieve pressure on the cord without compression of the blood vessels and to expedite delivery ○ Trendelenburg and knee-chest position ○ Prepare for rapid delivery ○ Do not attempt to replace cord in uterus ○ Factors that increase risk for prolapse Ruptured membranes Fetal presenting part at high station fetus that poorly fits pelvic inlet because of small size or abnormal presentation Excessive volume of amniotic fluid (polyhydramnios) ○ Key points: Can happen if baby is high and not engaged, small baby, breech presentation, transverse lie Intervention: put in trendelenburg, push presenting part upwards relieving pressure off cord, prepare for rapid delivery  Shoulder dystocia (passageway) ○ Obstetrical emergency resulting from difficulty or inability to deliver anterior shoulder ○ Can lead to fetal hypoxia or death ○ Baby's chest is trapped within vaginal vault, chest unable to expand with breaths ○ Risk of cord compression between fetal body parts and maternal pelvis ○ Fractured clavicle or humerus/ brachial plexy palsy ○ Risk factors Macrosomia Maternal obesity Maternal diabetes ○ Ways to check if there is nerve damage on a newborn Moro reflex ○ Key points: Shoulders are stuck, macrosomic babies at risk Do neonatal assessment of arms and clavicle Postpartum Fundal assessment/ priority nursing actions ○ Descent of the uterine fundus Involution (return to original shape) can be evaluated by measuring the descent of the fundus. Descends about 1 cm (fingerbreadth) per day 14 days after childbirth, the fundus should no longer be palpable Should feel like a grapefruit Intermittent uterine contractions (after-birth pains), cause discomfort for many women (esp. Multiparas and breastfeeding women) ○ Keeps oxytocin flowing to prevent bleeding Contractions cause uterine blood vessels to constrict to prevent hemorrhage  ○ Key points: Fundus should be firm, round and midline Boggy = bleeding Involution = reduction of fundus to prepregnancy fundus Lochia rubra, serosa, alba. SHOULD NOT GO BACK After pains: uterine contractility. Pitocin and breastfeeding help with this. Give NSAIDS Pitocin use Postpartum assessment ○ Vital signs with pain assessment ○ Breasts Tone, nipples ○ Fundus Placement and tone ○ Lochia Color, amount, odor ○ Perineum Edema, ecchymosis, hemorrhoids ○ Bladder elimination Output, burning, pain ○ Lower extremities Calf tenderness, edema Postpartum complications/ bleeding/ hematoma ○ Lochia Vaginal bloody discharge Lochia rubra: 1-3 days (dark red) Lochia serosa: 4-10 days (pink, brown; more watery) Lochia alba day 11 up to 6 weeks (light tan) ○ Assessment amount , type and odor Foul odor suggests endometrial infection Once lochia has changed to serosa it should not change back to rubra again ○ Bradycardia is normal, tachycardia should be investigated ○ Looking for clots, hemorrhaging  ○ Teaching proper hygiene Postpartum Infection ○ Monitor for S&S of infection Fever Foul smelling urine Fundus soreness Possible infection of perineal laceration or episiotomy Mastitis Instruct proper methods of hygiene- hand hygiene, perineal cleansing, and care of the breasts. Newborn Thermogenesis/ hypoglycemia ○ Thermogenesis Newborns increase temp by Increase metabolic rate Increase muscular rate Brown fat metabolism (non-shivering thermogenesis) Brown fat converts chemical energy into heat Brown fat found between scapulae, at axilla, nape of neck, in mediastinum, and around kidneys ○ Effects of Cold Stress: Increased oxygen and glucose consumption Decreased surfactant production Newborn assessment findings ○ Cardiovascular ○ Respiratory First breath = increase ○ Apgar scores At 1 and 5 min Can do a third at 10 min if baby had any interventions that needed to get done ○ Priority care at birth airway/ suctioning  Cardiovascular status Respiratory Rate 30-60 HR Length and weight in grams ○ Placement of ears ○ 2 arteries one vein what is in umbilical cors ○ Extremities Newborn reflexes ○ Moro= startle reflex, hands go out then come back in ○ stepping = feet on a level surface and look like they're walking ○ Palmar grasp= finger in babies palm & will go around your hands ○ Plantar grasp = same with feet ○ Sucking and rooting = touching babies side of cheek ○ Babinski = up along the outside of the foot (bottom side) Macrosomic infant Hyperbilirubinemia ○ Neonatal hyperbilirubinemia occurs 50% of term and 80% of preterm newborns ○ The incidence is increased in Asian, Native American, and Eskimo infants ○ Although neonatal jaundice is considered bening, bilirubin may accumulate to hazardous levels and lead to bilirubin encephalopathy which can lead to brain damage. Newborn nutrition/ breastfeeding ○ Glucose monitoring Discharge instructions/Danger signs to report to pediatrician ○ Family education in newborn care Umbilical cord care Circumcision care Feeding Bathing, diapering Elimination expectations Thermoregulation Newborn safety (carseat, safe sleep) ○ Monitor bonding and attachment  Cephalohematoma/caput ○ Caput: fluid, crosses the suture line, will reabsorb ○ Cehphlahemotoma: blood, under periosteum line, does not cross suture line Baby at risk for jaundice Breastfeeding is the healthiest thing for baby Stool turns yellow after a certain period Feed on demand or by cue ( open close mouth, make o’s with face, sucking on hand, don't want to get to the point where they're screaming ) Frequency 8-12 times and a good latch Family Planning Permanent methods ○ Sterilization Tubal ligation (permanent) Failure rate