Parent and Newborn Nursing PDF

EXAM 1 Healthy Pregnancy Lecture Human Pregnancy -Conception: the union of sperm from the male and the egg from the female -Attach to uterine lining -Length of term pregnancy= 40 weeks Human Development -Preembryonic Stage (fertilization- 14 days) -implantation in uterine lining from fallo...

EXAM 1 Healthy Pregnancy Lecture Human Pregnancy -Conception: the union of sperm from the male and the egg from the female -Attach to uterine lining -Length of term pregnancy= 40 weeks Human Development -Preembryonic Stage (fertilization- 14 days) -implantation in uterine lining from fallopian tubes -cellular multiplication/differentiation -yolk sac developed by day 8/9 -yolk sac contains the nutrients that these cells live off -Embryonic Development (day 15-8 weeks) ​ -structural changes ​ ​ -day 23: cardiac structure begins to beat ​ ​ -day 49: heart has four chambers ​ ​ -weeks 4-5: arm/leg buds are developed and brain is differentiated -Fetal Development (9 weeks-birth) ​ -9 weeks: all organs and structures present ​ -12 weeks: genitals are differentiated, produces urine, reflex and brain development ​ -14 weeks: greater muscle and skeletal development ​ -20 weeks: nails and lanugo (thin peach fuzz, particularly prominent on face, cheek, forehead, and shoulder area), exciting time for parents to see anatomy scan, and find out gender! Also feel fetal movements ​ -25 weeks: covered in vernix (coating that covers the baby’s skin as protectant), opens and closes eyes, immature lungs that would allow for (some) gas exchange, maturing neuro system -Third trimester: lungs becoming more mature, systems continue to develop, and fat is stored Teratogens -Harmful agents that affect the embryo -Most vulnerable time to teratogens is between 2-8 weeks gestation (embryonic period) ​ -illicit drug use highest in ages 15-17 ​ ​ -least ages 25 and older ​ -alcohol use ​ ​ -highest during first trimester because women don’t often know they are pregnant yet -Other non-teratogenic things that can impact the embryo ​ -quality of the sperm and egg ​ -environment ​ -genetic code Fertilization-12 weeks -Trimesters: pregnancy is divided into 3 trimesters (13 wk increments) ​ -first 12-13 wks is first trimester ​ ​ -rapid change happens here, by week 12 the baby resembles us! Pregnancy Development -Amniotic Fluid: fluid baby is surrounded with ​ -Origin: comes from the baby’s urine ​ -Purpose: protects the umbilical cord and the vessels surrounding it, acts as a decompressive agent, allows it to be more free-floating, also keeps fetus warm while development (thermoregulation), allows for fetal movement, fetus will begin practice breathing movements later in pregnancy (allows for lungs to be capable of breathing once the baby is born) -Umbilical Cord: blood flow to and from the placenta ​ -Structure: runs from fetal abdomen to placenta, AVA: artery, vein, artery (2 arteries and 1 vein), covered by wharton's jelly which is a gelatinous material (clear or white); they carry fetal blood to and from the placenta, there is NO maternal blood in the umbilical cord ​ -Anatomy Purpose: protects vessels from being compressed -Placenta: organ that grows on the uterine wall ​ -Purpose: fetal blood comes up to it through the umbilical cord, maternal side comes up to the maternal side, blood never mixes, but through osmosis, the fetal blood gets rid of waste and collects oxygen and nutrients through the mothers blood, produces hormones ​ -Function: allows fetus to get oxygen and nutrients, and to get rid of waste ​ -Anatomy: 2 sides of placenta: baby side (shiny schultz) or “dirty dunkin” side (spongy), mother and baby’s blood normally does not mix Formation of Twins -1 in 43 pregnancies are twins -Twin pregnancies can happen in 2 ways ​ -monozygotic twins: made from the same genetic material (1 sperm and 1 egg) ​ ​ -genetically identical ​ -dizygotic twins: two different sperm and 2 different eggs ​ ​ -not identical in chromosomal makeup Maternal Changes R/T Pregnancy -Uterus ​ -increases in size ​ ​ -goes from size of a pear or a fist, to just underneath the breast ​ ​ -usually palpated right at the belly button ​ -increases in thickness ​ ​ -due to progesterone and estrogen ​ -Braxton hicks contractions ​ ​ -not real contractions, do not result in any uterine changes -Breasts ​ -size ​ ​ -get larger ​ -tenderness ​ ​ -early sign of pregnancy ​ -pigmentation ​ ​ -can become darker ​ -production of Colostrum (initial breast milk the mother produces) -Cervix ​ -increased vascularization leads to ​ ​ -Goodell’s Sign: softening of the cervix ​ ​ -Chadwick’s Sign: bluish coloring -Vagina ​ -increased acidic secretions ​ -loosening of the connective tissue -Cardiovascular ​ -cardiac output increases and peaks by 30 weeks ​ -pulse increases ​ -BP decreases slightly and returns to near normal by term ​ -blood volume increases by 40-45% ​ -plasma volume increases by 50% ​ -labs ​ ​ -increases due to demand from pregnancy and keeping baby alive, as well as in preparation for delivery -Vena Caval Syndrome ​ -the pregnancy places pressure on the vena cava when supine ​ ​ -leads to decreased blood flow to the heart ​ ​ -leads to hypotension GI System ​ -N/V ​ -Pyrosis (heartburn) ​ -Ptyalism (excessive salivation) ​ -Changes in gum tissue (gingivitis) ​ -bloating and constipation ​ -risk for gallstone formation -Urinary Tract ​ -pressure from the pregnancy causes urinary frequency during the first and third trimesters -Integumentary ​ -Linea Nigra: line due to hormones in the pregnancy that extends over the abdomen, sometimes just above the pubic area to the umbilicus and above, gradually fades after pregnancy ​ -Chloasma: darkened area under the eyes, around the forehead, on the face d/t hormones of pregnancy ​ -Striae: stretch marks due to reduced connective tissue strength r/t elevated adrenal steroid levels ​ -Vascular spider nevi: spider veins, can occur on the feet, legs, face, etc due to reduced blood flow to subcutaneous tissue related to estrogen -MSK ​ -joints relax in preparation for delivery and d/t hormones ​ -center of gravity changes (abdomen can be pendulous with fetus growing) ​ -postural changes (waddle of pregnancy) ​ -diastasis recti: abdominal muscles separate, can be a problem if patient is seeking a second pregnancy, must exercise and rehab these muscles prior to getting pregnant again -Weight Gain and Caloric Requirements ​ -Normal weight women: 25-35 lbs ​ -Underweight women: 28-40 lbs ​ -Overweight women: 15-25 lbs ​ -during the second and third trimesters, caloric intake should increase by 300 kcal/day -Endocrine ​ -BMR: increases by 20-25% -Hormones in Pregnancy ​ -hCG: pregnancy hormone, human chorionic gonadotropin hormone, released by trophoblasts early on in pregnancy ​ -hPL: human placental lactogen, antagonist of insulin (allows for more free floating glucose so fetus can better develop) ​ -Estrogen: critical role in stimulating uterine development, helps prepare the breasts for nursing and lactation ​ -Progesterone: greatest role in maintaining pregnancy, small role in development lobes of breast for lactation ​ -Relaxin: helps diminish strength of contractions, aids in softening of the cervix in preparation for birth ​ -Prolactin: role in lactation ​ -Oxytocin: role in contractions, given to many women in labor (pitocin), also has role in milk let down during nursing ​ -Thyroid function can change Maternal Discomfort During Pregnancy -First Trimester (first 13 wks) ​ -N/V: can be a presumptive sign of pregnancy, usually related to hCG ​ -Ptyalism ​ -Fatigue ​ -Urinary Frequency: uterus is placing pressure on the bladder ​ -Breast Tenderness: also a presumptive sign r/t hormonal changes ​ -Vaginal discharge ​ -Nasal stuffiness: d/t hormones -Second and Third Trimester ​ -Pyrosis (heartburn) ​ -LE Edema ​ -Varicose veins ​ -Leg cramps ​ -Flatulence/Constipation ​ -Backache: changes in the back as abdomen protrudes ​ -Round ligament Pain: uterus and muscles supporting the uterus ​ -SOB: as fetus takes up room in abdominal cavity, can impact woman’s ability to breathe placing pressure on lungs and diaphragm ​ ​ -Urinary frequency ​ -Difficulty sleeping: baby can be more active at night Calculation of Estimated Due Date -Naegele’s Rule ​ -first day of LMP ​ -subtract 3 months ​ -add 7 days Estimated Date of Delivery Wheel -align date of LMP -shows estimated due date Signs of Pregnancy -Presumptive (subjective) changes (possibility) ​ -tired, nauseous, tender breasts, late period, etc. -Probable (objective) changes ​ -positive home pregnancy changes -Positive (diagnostic) changes (definite) ​ -seeing fetus on ultrasound ​ -or time of delivery Pregnancy History Terminology -Obstetric History ​ -Antepartum: during pregnancy itself (not L&D) ​ -Intrapartum: L&D portion of pregnancy ​ -Postpartum: after L&D -Gestational Terminology ​ -Gestation: pregnancy ​ -Abortion: loss of a pregnancy prior to 20 weeks gestation regardless of reason, can be considered a miscarriage, therapeutic or elective as well ​ -Term: 40 weeks gestation, but not every patient delivers exactly on their due date (37-42 weeks gestation is more accurate) -Pregnancy Terminology ​ -Gravida: number of times pregnant ​ -Nulligravida: never been pregnant before (null=zero) ​ -Primigravida: first pregnancy ​ -Multigravida: she has had pregnancies prior to this one -Labor and Delivery Terminology ​ -Preterm or premature labor: before 37 weeks ​ -Postterm labor: after 42 weeks ​ -Stillbirth: delivery of a fetus that is over 20 weeks gestation, but born with no heartbeat -Birth Terminology ​ -Para: number of births a woman has had after 20 weeks gestation ​ -Primipara: first birth ​ -Nullipara: never given birth ​ -Multipara: multiple births Pregnancy History -Gravida= number of pregnancies (any gestational age) ​ -can include stillbirths, living children, neonatal death, etc. -Para- number of deliveries (must be at least 20 wks gestation to be counted in para) TPAL Approach -Provides further explanation to pregnancy history -T= term pregnancies (37 weeks or greater) -P= preterm (20 weeks to 36 weeks 6 days) -A= abortions (less than 20 weeks, elective or non) -L= living Initial OB Visit -Height & weight ​ -can see wt gain -VS -Head to toe exam -Labs -Detailed history Initial OB History -OB History ​ -prior pregnancies, modes of deliveries, complications related to the baby or delivery, forceps or vacuum use, anesthesia issues, etc -GYN History ​ -any abnormal PAPs or pelvic exams, any reproductive tract issues -Medical History ​ -chronic diseases, diseases as a child, chronic HTN, psychiatric conditions, diabetic -Family History ​ -genetic issues -Social History ​ -support system, risky behaviors, will the baby be at risk of teratogens? Prenatal Labs -Initial prenatal labs ​ -Pap (if needed) ​ ​ -looks for cellular abnormalities ​ -STDs ​ ​ -gonorrhea and chlamydia ​ -H/H ​ -Blood Type and Rh factor ​ -Hepatitis B ​ -Rubella ​ ​ -immune or not? Can cause severe birth defects ​ -HIV/AIDS ​ ​ -controversial, patient has the option, but highly recommended for those exposed or working in the healthcare field -Nuchal Translucency ​ -11-13 weeks ​ -US and serum tested ​ -potential genetic issues (down syndrome; nape of neck and thickness of the neck) -Quad Screen ​ -16 weeks ​ -potential for NTD (neural tube defects), multiples, or genetic issues -four components -AFP: alpha fetoprotein; possibility of NTD (spina bifida, or anencephaly) -hCG: human chorionic gonadotropin -Inhibin A: help look for possible genetic problems -Estriol: help look for possible genetic problems -1 Hour Glucose Tolerance Test ​ -24-48 weeks ​ -50 gm glucose (sugary soda type substance) ​ -if above 130-140 mg/dl, 3 hour GTT indicated ​ -looking at risk for gestational diabetes -GBS (group beta strep) ​ -can be part of normal flora ​ -36 weeks ​ -baginal/rectal swab ​ -if +, must treat in L&D with PCN/Ampicillin ​ -can cause meningitis or septicemia in the neonate Prenatal Visits -Weight -Document gestational age -Fetal HR (normal is 110-160) -Urine dipstick -Fundal height ​ -by 20 weeks, reaches umbilicus and at term, at the ribcage -Discomforts -Answer questions, concerns -Vaginal exam (near term) ​ -dilation and effacement -Plans for delivery/feeding options ​ -tub? Breast feeding? -Patient Education ​ -when should a patient be concerned? ​ ​ -early pregnancy cramping ​ ​ -late pregnancy contractions that increase in intensity and frequency ​ ​ -decreased fetal movement ​ ​ -leakage of fluid from the vagina ​ ​ -vaginal bleeding ​ ​ -intense abdominal or back pain ​ ​ -HA, CP, Visual changes (HTN related to pregnancy) ​ ​ -fever ​ ​ -any questions or concerns, call Assessing Fetal Development -Fetal Heartbeat ​ -8 wks: transvaginal US looking for cardiac movement ​ -later on, can use an external monitor, doppler or abdominal US to find the fetal heartbeat -Ultrasound ​ -looks at development, chambers of the heart, GI contents internal, 2 ventricles in the brain ​ -measurements ​ -20 wks: anatomy US happens ​ -early on, can give estimated due date or gestational age ​ -earlier it is done, the more accurate it is in telling us how far along the pregnancy is -Quickening ​ -fetal movement felt by the mother ​ -should be reported around 20 weeks ​ -if decrease in fetal movement, she needs to be seen right away Psychological Adjustment to Parenthood -Changes in Roles ​ -first pregnancy, how it changes her role as a wife if married, or a daughter, role in the workplace happens, etc -Changes in Relationships ​ -changes in friendships, can cause a strain on relationships, can be testing or can make a relationship grow -Anxiety ​ -how this will change relationships, pregnancy or delivery process, etc. -Financial Implications of Parenthood ​ -plans for work? Who is taking care of the baby? May feel stressed about financial means/making ends meet -Special Considerations -Grandparents: what will their role be? Can be actively engaged, or they don’t -Siblings: only child at home? How will this affect this sibling -Teen Mothers: still going through other adjustments, how do they define what they want, biggest source of support is their mother -Maternal Reactions to Pregnancy -Intendedness ​ ​ -planned vs unplanned  -Ambivalence ​ ​ -maybe this caught them by surprise -Acceptance -Introversion -Mood swings -Changes in body image -Rubin’s Task of the Parent ​ -safe pregnancy and delivery ​ -acceptance of the child ​ -binding-in: acceptance of self as a mother to the infant ​ -giving of self: puts her own needs aside to meet the needs of the baby Assisting patients through the Journey -What does this mean to the client? -Childbirth education classes -Assessing family and relationship dynamics Culture and Alternative Therapies -Different cultures have different rituals -Nurse’s role: respect and advocate -Feel free to ask questions to meet patient needs Labor and Delivery Critical Factors in Labor -birth passage (passageway) -fetus (passenger) -relationship between the passage and fetus (proportion) -physiologic forces of labor (powers) -psychological factors (psyche) The Passenger -Fetal presentation -Fetal attitude ​ -flexion or extension ​ -baby should be well flexed -Fetal head size The Passenger- Fetal Presentation -Cephalic (head first) -Breech -Shoulder Types of Cephalic Presentation -Which is most ideal? -Cephalic/vertex, well flexed (chin to chest) is the most ideal for vaginal delivery A.​ Cephalic/Vertex- crown is presenting part, ideal B.​ Ciniciput (between a cephalic and brow presentation) C.​ Brow (forehead beginning to face up, not ideal) D.​ Extended (baby can bruise) Types of Fetal Presentation -What is the most common presentation? ​ -right occiput anterior (ROA), presenting part is to the right of the mothers pelvis and anterior (occiput is facing forward), baby facing down during delivery Ideal: cephalic/vertex, occiput first, allows for smallest diameter, flexed chin to chest -Brow Presentation ​ -feel forehead as presenting part, wider way of delivery -Facial Presentation ​ -posterior presentation, can make for a long labor and can be painful Types of Breech Presentation -3% of pregnancies are breech, usually C-Section A.​ Frank Breech: buttox first B.​ Footling Breech: one or both feet are presenting part Shoulder Presentation/Transverse and the Concept of Life -not breached -baby lies across mothers abdomen rather than up and down -shoulder presentation The Passenger- Fetal Attitude -Which is ideal? ​ -want to see body flexed, not extended The Passenger- Fetal Head -Fetal Head 3 major parts: ​ -FACE: bones well fused ​ -BASE OF SKULL: 2 temporal bones, well fused ​ -VAULT: not fused- held together by sutures ​ ​ -sutures are the membranous spaces between cranial bones ​ ​ ​ -may be helpful in delivery, sutures can adjust head to fit birthing canal ​ ​ -fontanels intersections of cranial sutures- molding (anterior- diamond shape and posterior- triangle shaped) ​ ​ ​ -anterior open longer than posterior Passageway -Birth Passage 1.​ Size of maternal pelvis (pelvic inlet and outlet) 2.​ Shape of maternal pelvis (Gynecoid is ideal shape) 3.​ Ability of the cervix to dilate and efface Cervical Effacement and Dilation -Effacement: gradual thinning, shortening and drawing up of the cervix measured in percentages from 0-100% -Dilation: the gradual opening of the cervix measured in centimeters from 0-10 cm ​ -measured with 2 finger exam ​ -becomes thinner and dilates at the same time (think life saver) Dilation -Cervix opening to allow for delivery -Cause by fetal axis pressure ​ -as uterus contracts, pushes fetus down, causing cervix to be drawn up -Closed: 0 cm -What does “complete” mean? ​ -10 cm dilated Effacement -Thinning of the cervix, expressed as a percentage -0% effaced: thick cervix -100% effaced: paper thin cervix (toward the end of labor, ready to push) Dilatation and Effacement A.​ Thick, 0% effaced B C D. Very thin, 100% effaced -Effacement and dilation usually happen simultaneously Relationship of Presenting Part to Pelvis -Engagement- largest diameter of the presenting part passes through the pelvic inlet (BPD) -Station- relationship of the presenting part to the ischial spines Dilation, Effacement, and Station -Station: how high up or how low the baby is ​ -5 to +5 ​ -negative station= higher up, positives mean closer to delivery, baby is further down -Zero station: presenting part at ischial spines -Assessing cervical dilation, effacement, and where is the baby’s head in relation to the spine (station) The Forces of Labor -Contractions ​ -Intensity- strength ​ -Frequency- from the start of one contraction to the start of the next ​ -Duration- from the start of the contraction to relaxation -Pushing ​ -push when complete Premonitory Signs of Labor -Lightening- engagement ​ -baby “drops”, mom can feel the baby is lower, may have increased urinary frequency -Increase in frequency and duration of contractions -Vaginal bleeding- bloody show, mucus plug (from cervix, as it softens, the barrier or mucus plug releases) -Cervix- ripens/softens -Back pain (relaxin hormone) -Spontaneous Rupture of Membranes (happens in 12% of women, water breaks), 80% of women experience spontaneous labor within 24 hours within water breaking -Sudden burst of energy ​ -urge to do a lot of things, nesting Rupture of Membranes (ROM) -Confirmation of Spontaneous ROM ​ -Ferning: get fluid, look at it under microscope, amniotic fluid will fern ​ -Nitrazine/Amnio Indicator: when exposed to amniotic fluid, turn dark blue/black in color True Labor vs False Labor -True labor ​ -regular contractions ​ -increase in frequency, duration and strength ​ -progressive dilation and effacement* ​ -discomfort starts in back and radiates around body -False labor ​ -irregular contractions ​ -do not increase in frequency, duration, and strength ​ -do not lead to dilation and effacement ​ -”hardening” sensation Common Labor and Delivery Medications -Pitocin ​ -chemically manufactured version of body’s natural Oxytocin ​ -used to augment (add to labor) or induce (start) labor ​ -used to promote increased uterine tone following delivery Maternal Responses to Labor -Cardiovascular- increase in cardiac output. Increased BP during contractions -Fluid and electrolyte balance- diaphoresis, hyperventilation, increase temp due to muscle activity -Respiratory system- increased demand for O2, mild metabolic acidosis compensated by respiratory alkalosis Maternal Responses to Labor (cont) -Renal system- increase renin and angiotensin to control uterine blood flow. Bladder is pushed forward and upward -GI system- gastric motility is reduced, gastric emptying time is prolonged, increased acidity of gastric contents -Immune system= increased WBC (25-30,000) due to stress, decreased blood glucose Birth Plan -What the patient would like to see in their ideal birthing situation -type of setting, provider, during labor what would she like, monitors, meds, touch, music, positions for birthing, filming/photography, breast feeding, separation after birth, placenta (keep?), etc. Stages of Labor and Birth -First stage -From 0cm-10cm dilated -Phases within the first stage of labor ​ -early/latent phase ​ ​ -starts with onset of contractions, able to cope with pain, excited ​ -active phase ​ ​ -contractions intensify, anxiety increases, 4-7 cm and fetal descent, typical pattern: nullipara=1.2 cm/hr, multipara=1.5 cm/hour ​ -transition phase ​ ​ -increasing force and intensity of contractions, significant anxiety, dilation slows and decent increases, 8-10cm, nullipara: lasts less than 3 hours, multipara: lasts less than an hour ​ -Second stage ​ -10cm- delivery ​ -pushing with urge to push ​ -how long does this last? ​ ​ -nullipara= 2 hours ​ ​ -multipara= 15 minutes​ -Third stage -Placental separation- begins d/t increase in uterine tone and decreased surface area -Delivery of the placenta= do not pull on cord!!* -Retained placenta= placenta is not delivered within 30 min following delivery of baby -Fourth stage -Post partum recovery period ​ -1-4 hours following delivery ​ -prime time for bonding and breastfeeding (within an hour after delivery) ​ -drop in BP, increase in pulse (d/t blood loss) ​ -fundus should be firm and measured between the umbilicus and symphysis pubis ​ -may be shaking ​ -hypotonic bladder Coaching the laboring client through pushing -Provide reassurance -Encourage her!​ -Birthing bar -Pulling -Open glottis pushing (rather than holding breath) is suggested EBP -Crowning- birth is imminent Mechanisms of Labor: Cardinal Movements -Cardinal Movements 1.​ Descent: head enters the inlet d/t a.​ Pressure from amniotic fluid b.​ Pressure from the uterus c.​ Contraction of abdominal muscles d.​ Extension of fetus 2.​ Flexion: chin flexes downward onto chest d/t resistance from soft tissues in the pelvis 3.​ Internal Rotation: occiput rotates from left ot right in order to fit the diameter of the pelvic cavity 4.​ Extension: fetal head extends as it passes under the symphysis pubis d/t resistance of the pelvic floor and opening vulva 5.​ Restitution: head emerges and turns to one side and aligns with the position of the back (neck became twisted through the process of the shoulders entering the pelvis) 6.​ External Rotation: head turns farther to one side because the shoulders are rotating to the anterior/posterior position in the pelvis 7.​ Expulsion: The anterior shoulder moves under the symphysis pubis. Flexion of the shoulder and head occur ​ -anterior shoulder born, followed by posterior shoulder and body Delivery -Head distends with each contraction -Extension under the symphysis pubis leads to delivery of the head -Provider asks client to push to deliver head/shoulders -Followed by birth of the body Lacerations and Episiotomies -Perineal Laceration: vaginal tissue tears to allow greater opening for delivery ​ -pro: tissue tears where it is weakest ​ -con: may be difficult to repair, may extend to 4th degree, labia, or urethra -Prevention: massage/mineral oil -Episiotomy- lengthening the vaginal opening to allow for delivery by cutting the tissue ​ -pro: controlled, repair is cleaner ​ -con: may be unnecessary Pain Management -Pain during first stage of labor ​ -lower belly/uterus region ​ -usually a lot of pain in this period -Pain during second stage and delivery ​ -lower abdomen, b/l upper leg region, perineal area Where pain comes from -dilation of cervix, abundance of nerve cells -hypoxia of uterine muscle cells -stretching of lower uterine segment -anxiety and stress Pain Management (cont) -Relaxation techniques: comfort measures, massage, distraction, effleurage, pattern paced breathing, change of position, tub -Narcotics: Stadol (Butorphanol Tartrate), Nubain (Nalbuphine Hydrochloride), Demerol (Meperidine), Morphine (have narcan nearby) -Epidural: local anesthetic and narcotic into epidural space -Spinal: local anesthetic into the spinal fluid in the spinal canal (often used for cesarean section births) Nursing Support -Massage -Breathing -Meditation -Focal point -Sips and chips of fluid ​ -usually will not be eating incase there is a need to go to surgery -Hygiene Pros and Cons to Epidurals -Advantages ​ -fully awake ​ -can be adjusted, don’t have the severe pain ​ -ideally, allows for urge to push -Disadvantages ​ -skilled procedure ​ -takes 30 min ​ -no control of movement below the waist, need catheterized every 2 hours ​ -costly -Possible SE ​ -HYPOTENSION* ​ ​ -will do a fluid bolus beforehand often times ​ ​ -take BP q 15 min ​ -seizures (rare) ​ -meningitis (rare) ​ -arrest (rare) ​ -spinal HA (can do a blood patch) Pain Management -Epidural ​ -local anesthetic placed into epidural space (done by CRNA) -Positioning ​ -sit on edge of the bed, assume position of a mad cat, curve back ​ -cleanse with iodine, numb with local, then inject anesthesia Supporting a Patient with an Epidural -Platelet count must be at least 100,000/mm3 -Fluid bolus prior to epidural -Monitoring BP frequently- would an epidural increase or decrease BP? DECREASE ​ -every 2, then every 5, then every 15 for duration of epidural -How does this affect the fetus? ​ -fetal HR may bottom out, fetus would be getting less O2 during this time -Positioning of patient following epidural ​ -left side -Frequent repositioning to avoid pressure ​ -move side to side to help balance out the epidural and avoid pressure points -Monitor for effectiveness -Empty bladder- straight cath q 2 hours Contraindications for Epidurals -Platelets less than 100,000/mm3 -Coagulation disorders/hemorrhage -Severe spinal abnormalities -Infection (do not want to spread infection) -Uncooperative patient Cesarean Birth -Surgical delivery via incision through the abdomen and uterus -Method of delivery for more than ⅓ of births -Common indications (there must be an indication!) -Prior C/S -Breech presentation -Failure to progress -Fetal distress -Placental complications Cesarean Birth: Incisions -Low transverse abdominal incision is most common is non-emergent situations (bikini line incision, most common in non-emergent situations) -May allow for the possibility of VBAC (if pt wants to get pregnant again), less risk for uterine rupture -More emergent cases: vertical incision Cesarean Birth: Nursing Care -In preparation for a C/S ​ -shave prep ​ -foley catheter ​ -SCDs ​ -prepare for spinal (spinal anesthesia) ​ -may need general anesthesia if emergent -Prepare and support the patient ​ -what is going to happen ​ -why this is being done ​ -sensations she may experience -Support the Father/Coach ​ -often allow someone to come in with her in non-emergent situations ​ -takes about an hour Cesarean Birth: Nursing Care -Following delivery ​ -encourage client to breastfeed in recovery room ​ -continue to provide emotional support -Orders ​ -Pitocin ​ -DVT prevention: Encourage ambulation/SCDs ​ -Advance diet ​ -Pain Management Fetal Monitoring -Electronic Fetal Monitoring: assess fetal well being -External Fetal Monitor ​ -Toco and EFM ​ ​ -When would this be used? If things are going well, non-invasive ​ ​ -benefits? ​ ​ -drawbacks? ​ ​ ​ -toco only tells the duration of contractions (may be inaccurate depending on size of woman- smaller woman may show larger hills in contractions, larger woman may show smaller hills in contraction regardless of how strong the contraction is that they are feeling) -Internal Fetal Monitor (scalp electrode) ​ -IUPC (intrauterine pressure catheter, tells is in mm of intensity of contractions) ​ -When would this be used? ​ ​ -use when not getting a good read with external monitoring ​ -benefits? ​ ​ -specific, accurate, see during contractions and in between contractions ​ -drawbacks? ​ ​ -risk of infection, risk of uterine perforation, baby may have small mark on scalp ​ -risks? ​ ​ -water must be ruptured to have access to baby’s head Contractions (external monitor) -Frequency: measure from beginning of one ctx to beginning of next ctx OR peak to peak -Duration: measure from beginning to end -How can we measure intensity? ​ -patient report (subjective) ​ -palpation: palpate the fundus during contraction -Mild: nose/easily indented -Moderate: chin/difficult to indent -Strong: forehead/hard Contractions (internal monitor) -Calculating MVUs ​ -baseline pressure is subtracted from each reading ​ -done with internal uterine monitor Normal Fetal HR -Baseline: 110-160 bpm -Slows with increased gestational age -Tachycardia= greater than 160 bpm -Bradycardia= less than 110 bpm Variability -Fetal well being (should be positive or present variability) -Jaggedness of the FHR pattern -Interaction between the sympathetic and parasympathetic nervous systems -sympathetic wants HR to go up -parasympathetic wants HR to go down Absent Variability -Lacks “jaggedness” -Potentially nonreassuring ​ -consider: if mom was exposed to meds like morphine or magnesium, maybe baby is in sleep/wake cycle -Nursing Interventions ​ -give mom sugary drink, acoustical stimulator, let physician know Fetal Monitoring -Accelerations- FHR elevation of greater than 15 bpm lasting at least 15 seconds -Indicates fetal well being -Lack of variability and accelerations (“flat”) -Is this reassuring or nonreassuring? nonreassuring -Nursing Interventions? ​ -acoustic stimulator, sugary drink for mom, notify physician Decelerations -Drop in fetal HR -What does this mean? ​ -depends on where it starts -Where does the drop from baseline start in relation to the start of a contraction? -Nursing Interventions? -Early Decelerations ​ -”mirror” contraction ​ -due to head compression, vasovagal response ​ -happen early in contraction ​ -can be single or repetitive in nature ​ -nursing interventions? ​ ​ -best intervention is to reassess the mother and do a vaginal assessment -Late Decelerations (most concerning kind) ​ -start with the peak of a contraction (late in contraction), baby HR starts to drop ​ -due to uteroplacental insufficiency (enough reserve until it gets to peak of contraction, no reserve left, baby compensates by dropping heartbeat, nonreassuring) ​ -can be repetitive consistent, or variable in nature ​ -sign of stress and hypoxia- concerning! ​ ​ -most concerned with the brain ​ -nursing interventions: ​ ​ -5 turns ​ ​ -turn patient to left side (may help with bf to placenta) ​ ​ -turn fluids on (boost fluids and ability to give blood to placenta) ​ ​ -turn pitocin off (contractions are causing late decelerations) ​ ​ -turn O2 on (boost O2 to baby) ​ ​ -turn call light on (for additional assistance) -Variable Decelerations ​ -variable in timing ​ -abrupt onset and abrupt return to baseline ​ -spiky looking ​ -variable is around midpoint ​ -due to cord compression (bf compromised) ​ -nursing interventions ​ ​ -continue to monitor, maybe fluids, maybe oxygen, change positions, can let doc know ​ ​ -23% of babies are born with cord around neck -Prolonged Deceleration ​ -lasts longest ​ -can happen with contraction or independent of it ​ -concerning, want to let physician know ​ -turn on O2, 5 turns, turn down pitocin Indirect Methods of Fetal Assessment -Scalp Stimulation -Cord blood analysis at birth -Blood gases -pH -helpful if APGAR score is below 7 -can tell us if baby has gone through acidemia The Healthy Postpartum Period Physical and Psychological Adaptations Physical ​ -Reproductive System ​ ​ -Uterine Involution: process of uterus returning to pre-pregnant state (6 wks) ​ ​ ​ -prior to having a baby, the uterus is the size of a pear or fist and sits very low in the pelvis ​ ​ ​ -at 3 wks, uterine muscle is healing well ​ -Placental Site: site where placenta was (normal state in 6 wks) ​ ​ -when placenta lets go, there is a wound left behind that needs to heal ​ -Return of menstruation (variable) ​ ​ -6-10 weeks if NOT breastfeeding ​ ​ -if nursing, period can be delayed ​ ​ -can the patient get pregnant if she has not had a period? If she has ovulated but has not had a period, she CAN get pregnant! ​ -Breasts ​ ​ -Lactation ​ ​ -Colostrum (initial milk): produced as woman is pregnant before baby is born ​ ​ -Milk may come in 3-5 days postpartum ​ ​ -2 days hospitalization for vaginal delivery, and 3-4 days for a C-section ​ ​ -Women can still develop breast milk if not breastfeeding ​ -GI System ​ ​ -May have decreased BS ​ ​ -Monitor for distention ​ ​ -Decreased peristalsis- d/t progesterone ​ ​ -Patient may have anxiety about BM ​ -Urinary Tract ​ ​ -Urinary output normally increases d/t Puerperal Diuresis by 2000-3000 mL ​ ​ -May have frequent urination d/t fluids during labor and use of Pitocin ​ ​ -May have difficulty voiding d/t edema ​ ​ -Monitor for trauma/s/sx UTI (d/t straight cathing) ​ ​ ​ -may be difficult to see blood in urine ​  -Cardiovascular Changes ​ ​ -Cardiac output generally stabilized within 1 hour ​ ​ -Initial hypervolemia ​ ​ ​ -from excess blood flow no longer going to placenta ​ ​ ​ -also acts as a protective mechanism ​ ​ ​ -PP diuresis corrects this (gets rid of extra volume) ​ -Lab Values ​ ​ -H&H initially difficult to interpret ​ ​ ​ -average Estimated Blood Loss (EBL): 200-500 mL ​ ​ ​ ​ -C-Section: about 1,000 mL ​ ​ -WBCs may initially be elevated d/t stress associated with labor ​ ​ -Platelets initially decrease because of the placenta giving way ​ -Vital Signs ​ ​ -Temp: up to 38 C for the first 24 hours d/t exertion and dehydration ​ ​ ​ -afebrile after 24 hours ​ ​ ​ -fever may indicate infection ​ ​ -BP: slightly elevated ​ ​ ​ -low BP may indicate hypovolemic shock or hemorrhage ​ ​ -Pulse: decreased pulse ​ ​ ​ -if tachycardic, concerned with blood loss ​ -Neuro ​ ​ -HA, can be caused by ​ ​ ​ -Fluid shifts ​ ​ ​ -HTN ​ ​ ​ -Spinal HA ​ ​ ​ ​ -epidural area can release some spinal fluid, causing less cushion around the brain causing a HA -Weight loss ​ ​ -initial weight loss of 10-12 pounds (infant, placenta and fluid) ​ ​ -PP diuresis= 5 lbs ​ ​ -weight loss- will lose weight gained during pregnancy (around 35-45 lbs) by 6-8 weeks PP ​ ​ -exercise regimen may be reestablished once the patient has seen the doctor for postpartum visit (between 4-8 weeks PP) ​ -After Pains ​ ​ -Uterine contractions/cramping ​ ​ -Multips have less uterine tone (more common to have after pains) ​ ​ -Exacerbated by use of Pitocin (used for augmentation and induction of labor, also used in PP to make sure uterus is firm and putting pressure on placental site to help with bleeding) ​ ​ -Cramping may be felt while breastfeeding (breastfeeding releases oxytocin, which is responsible for milk let down. But it does cause cramping as well) Psychological Adjustment to Parenthood -Rubin (1984) ​ -Taking in period ​ ​ -Passive ​ ​ -Allows others to make decisions for her ​ ​ -Can end around 2nd day PP ​ ​ -May be self-critical during this period ​ -Taking hold ​ ​ -Assumes more active role ​ ​ -Provide her with reassurance Nursing Assessment and Interventions Postpartum Nursing Assessment -B: breasts -U: uterus -B: bowel -B: bladder -L: lochia (vaginal drainage after having a baby) -E: Episiotomy-laceration/ or C/S incision -H: DVT assessment (formerly Homan’s) -E: Emotional status Breast Assessment -Consistency of the breast ​ -soft ​ -filling ​ -firm ​ -engorged (not a good thing, want to use ice packs) -Intactness of Nipples (if breastfeeding) ​ -intact, cracked, blistered, bruised ​ -what do these mean? ​ ​ -should be intact ​ ​ -if cracked, blistered or bruised, baby is not latching properly ​ ​ -breast feeding should not be painful Breast Care -Supportive bra -Nurse on demand -Use of lanolin or hydrogel dressings ​ -avoid perfume based lotions -If not breastfeeding ​ -avoid breast/nipple stimulation (face back to shower rather than chest) ​ -ice packs Assessing the Uterus -Have the client void prior to assessment, Place HOB flat -Location ​ -assess the fundus (top of uterus) in relation to the umbilicus -Consistency ​ -firm (should be firm) ​ -boggy (spongy, not firm or poor tone) ​ *-Intervention for a boggy uterus (massage the uterus, monitor bleeding, VS, level of consciousness, call for help) ​ ​ -expect tachycardic and hypotensive state if bleeding ​ ​ -ensure LOC is A&Ox3 -Support the Uterus -Palpate the fundus -Assess location in relation to umbilicus ​ -do this by finger widths above or below ​ ​ -if one finger above the umbilicus, +1 ​ ​ -if below, -1 ​ ​ -involution: as it goes down and returns to pre-pregnancy state -Assess consistency (ideally, nice firm fundus) Assessing Bowel and Bladder -Bowel ​ -when was last BM? ​ -passing gas? ​ -assess BS/Distention ​ -fear of having a BM d/t pain, suggest a stool softener if ordered -Bladder ​ -PP diuresis (will be urinating frequently) ​ -may be difficult to urinate d/t perineal edema ​ -does the client have frequency, urgency, burning upon urination? ​ -why is the PP client at risk for a UTI?- we straight cath patients q 2 with epidurals Assessing Lochia -Where does the lochia come from after delivery? ​ -placental site/uterine debris (not just vaginal trauma!) -What is lochia composed of? ​ -epithelial cells, erythrocytes, bacteria, occasionally fetal meconium and lanugo -Do c/s deliveries have lochia? -yes, d/t placental site -Color -Rubra (red): 2-3 days -Serosa (pink): 3-10 days -Alba (clear/white-yellow): 1-2 weeks -Amount -scant -light -moderate -heavy -how much is too much? -if saturating a pad in an hour (more than a pad an hour), or having clots bigger than the size of a plum or an egg, there is room for concern ​ -if uterus is firm but still bleeding, may have cervical laceration -should ask when the patient last changed her pad ​ Assessing the Perineum -have patient turn to side and assess perineum for intactness -assess episiotomy, or laceration/tearing (area between vagina and rectal area) -R: redness -E: edema -E: ecchymosis -D: drainage -A: approximation -Note edema, ecchymosis, hemorrhoids, purulent drainage, separation of sutures, hematoma Perineal Care -Change pad withe very void and prn -Use of peri bottle while bleeding continues -avoid use of tampons -ice packs for comfort and decrease swelling -sitz bath (warm water that swirls around) increases blood flow to aid in healing, soothing, cleansing Assessing the Cesarean Section Incision -most of the time, this will be a low transverse abdominal incision -R: redness -E: edema -E: ecchymosis -D: drainage -A: approximation *still do a lochia assessment! Assessing the Emotional Status -Educate patient about possibility of postpartum blues -transient period of depression (short term) -may start around 2 days PP, and lasts about 10-14 days PP -Mood swings, weepiness, anger -May be d/t hormones -Importance of support systems (lack of support system patients are at higher risk) ​ -ensure patient can identify a support system before going home Psychological Adaptation: Family Attachment -Bonding ​ -cares for baby ​ -consoles baby ​ -talks to baby ​ -assumes en face position (holding the baby closely with eye to eye contact while baby is awake) ​ -asks pertinent questions ​ -family-engrossment (father is absorbed in the baby) Development of Family Attachment -EBP: skin to skin contact -baby’s skin directly on parent’s skin -both mothers and fathers can do this! Common Medication Orders -Pitocin: helps with keeping uterus firm ​ -cesarean client: runs until next morning ​ -vaginal client: run 1 bag then discontinue it -Stool softeners -Pain Meds ​ -IBU ​ -Tylenol (concerned about the liver) ​ -Percocet (toxic to liver) ​ -Vicodin ​ ​ -Rubella Vaccine (should not get pregnant for 1 month following admin of rubella vaccine- can cause birth defects) ​ ​ -Rhogam (if mother is RH-, if blood type is A-, B-, AB-, or O-) Home Care of the PP Family -Teaching Self Care ​ -hygiene to prevent infection ​ -ice packs to axilla if no desire to breastfeed ​ -sitz baths to promote circulation and healing ​ -ice packs to perineum for comfort ​ -nothing per vagina (tampons or douches) ​ -rationale for abstaining from sexual intercourse (no sexual intercourse as long as bleeding lasts and until PP visit, usually between 4-8 weeks PP) ​ ​ -glucose and semen is a set up for infection, especially in the region where the placenta was ​ -birth control options Teaching: When should a client contact a provider? -Sore, red breasts (mastitis: they should call) -Saturating more than 1 pad/hour (worried about hemorrhage) -Purulent and/or foul smelling vaginal drainage -Urgency, dysuria, hematuria, and/or difficulty voiding -HA, CP, SOB, visual changes (hypertension, contact provider) -Incision red, edematous, draining, or opening, not well approximated -Fever -Depression longer than 10-14 day period, self-harm or thoughts of harming the baby, call provider Week 2 The Normal Newborn Physical Adaptations of the Newborn -Normal Newborn is a neonate for the first 28 days after birth ​ -Mother does everything to baby functioning on its own -Respiratory -CV -Thermoregulation -Hepatic -GI -Urinary -Immunologic -Neuro and Sensory-Perceptual functioning Respiratory: Initiation of Breathing -Intrauterine Considerations -Surfactant (lecithin and sphingomyelin): necessary for opening of alveoli in the lungs to allow gas exchange -as gestation progresses, there is greater surfactant -if someone delivers early, they may do an amniocentesis (sample of amniotic fluid) and analyze the lecithin and sphingomyelin ratio ​ -Ideal Ratio: 2:1, or greater than 2:1 (LS ratio) -Fetal breathing movements ​ -while baby is intrauterine, they do practice breathing movements to allow lungs to be able to breathe when born, and strengthen chest muscles -First breath: inspiratory gasp from CNS response to mechanical, reabsorptive, chemical, thermal and sensory changes -Mechanical Events -Lung fluid decrease prior to onset of labor -Chest compression during labor with vaginal delivery (chest is compressed in birthing canal and pushes fluid out of the lungs by compressing the area, then chest recoil so air enters lungs) -Higher intrathoracic pressure leads to absorption of lung fluid -Chemical Stimuli: stimulate chemoreceptors that stimulate the respiratory center -Transitory asphyxia (HR decelerations, baby may be with less oxygen during this time, transitory asphyxia can stimulate breathing/oxygen intake) -Elevation of PCO2 -Decrease in pH (acidosis)  -Clamping the umbilical cord, decreases prostaglandins (encourages baby to breathe) -Severe asphyxia and acidosis is BAD (causes respiratory depression) -Thermal Stimuli -cold stimulates sensory receptors -Sensory Stimuli -tactile, auditory, visual, and painful stimuli stimulate respirations -rubbing baby down, people are talking/excited, injections, etc. -Significant Changes 1.​ Pulmonary ventilation established through lung expansion (expand with air) 2.​ Increase in pulmonary circulation (much of blood bypasses the lungs bc placenta was doing the job of oxygenation, but now increase in pulmonary circulation so they can begin to do oxygenation and do their job) -Normal Respiratory Rate: 30-60/min ​ -initially, an increased respiratory rate after delivery is not uncommon -Irregular breathing pattern (not unusual to see), count for full minute to measure newborn respirations (count rise and fall, feel for chest expansion, or listen, although listening can be difficult since it is such a tiny cavity) ​ -if baby is crying, it is easier sometimes to count -Obligatory nose breathers ​ -they breathe more through their nose than their mouth (d/t soft palate) Some Potential Signs of Respiratory Distress -Increased RR​ -Grunting: making a singing noise when exhales -Retracting: working so hard to breathe -Flaring: see nostrils flare to let more air in -Color change: pale or cyanotic CV Adaptations -FETAL CIRCULATION -Ductus Venosus: allows blood from the umbilical vein to bypass the liver and enter the right atrium -Foramen Ovale (opening b/t right and left atrium): allows blood flow from right atrium to left atrium (bypasses the lungs) -Ductus Arteriosus: allows blood flow from pulmonary artery to aorta -Expect closure of these upon delivery so the lungs become perfused  CV: Circulation Transition from fetal circulation ​ -Ductus venosus (allows blood to bypass liver): initiation of respiration leads to increased Po2 levels, increased systemic vascular resistance, and decreased venous return ​ -when cord is cut, causes closure of ductus venosus (lack of umbilical venous return) ​ -Foramen Ovale: decreased right atrial pressure, and decrease pulmonary resistance, increased pulmonary blood flow, leads to increased pressure in the left atrium, leads to closure of foramen ovale ​ -Ductus Arteriosus: increased systemic vascular resistance greater than pulmonary pressure, left ot right shunt, leads to closure of ductus arteriosus -Main takeaway: When blood starts going to lungs and blood supply to umbilical cord is cut, fetal ducts start to close -Nursing Considerations -Normal HR: up to 180 following delivery -after delivery, 110-160 in the full term newborn -80-100 during deep sleep -Presence of Murmur (turbulent bf through narrow opening, could be d/t failure to close or other problems) -Color Changes/Poor feedings ​ -blood is going throughout body that is not completely oxygenated d/t oxygenated blood mixing with deoxygenated blood ​ -tucker out quickly from feedings because of this mixing of blood Hematopoietic Adaptations -What is a normal fetal pulse ox? ​ -50%, gradually increases to around 92% within first few minutes of life -Erythropoiesis: increase in nucleated RBCs and reticulocytes (comes from erythropoietin from kidneys in response to hypoxia and anemia)- body compensates because of initial low pulse ox -Hgb -levels rise initially d/t additional Hgb blood from placenta and transient dehydration (low oral fluid intake) -then physiologic anemia of the newborn takes place, cells die off faster than they can reproduce, peak takes place at around 3 months of age (see a lot of iron supplements being given), if formula- iron with it, if bf- iron supplements -Leukocytosis RH Incompatibility Photo -Rh-: A-, B-, AB-, O- -Rh+: A+, B+, AB+, O+ -A woman who is Rh negative becomes pregnant with a fetus who is Rh + -First pregnancy (not affected): mother Rh-, baby Rh+ -Blood mixes at delivery, she is exposed to fetal Rh+ blood -Mother produces antibodies to Rh+ in response to the mixture, but no harm is done/ no effect to the pregnancy, just antibodies are made -Subsequent pregnancy (affected), when exposed again terrible reaction because she has antibodies to attack Rh + blood -Rhogam: admin IM, works to prevent antibody formation against subsequent pregnancies, stops antibody formation, so if she gets pregnant again it will not affect subsequent pregnancy -Given during pregnancy -Given postpartum -Given after abortions -Any trauma or mixing of fetal and maternal blood -Is Rh incompatibility an issue for Rh+ mothers? ​ -does NOT affect mothers who are Rh+ (impossible for an Rh + to get pregnant with an Rh - baby) Thermoregulation: Methods of Heat Loss A.​ Convection: air current comes in, baby loses heat to air current B.​ Radiation: baby loses its heat because there is a colder surface around it C.​ Evaporation*: moist upon delivery, and dry air makes it cold (drying and stimulation, purpose of keeping baby warm/prevent heat loss and evaporation and stimulating baby to cry) D.​ Conduction: where baby loses its heat to a surface like a cold scale Thermoregulation -Normal Temperature: 36.4-37.2 C (each agency has its own normals) ​ -if abnormal, retake temperature -Brown Fat and Flexed Position ​ -full term babies have a better ability to flex and have more brown fat than a less mature baby has ​ -brown fatty layer: helps keep them warm while adapting and thermoregulating themselves ​ -flexed position: helps keep them warm -Normal Range: 36.4-37.2 C -Route: generally axillary*, sometimes rectal is obtained but rare ​ -ensure skin is covering the probe 360 degrees (or all around it) -Neutral Thermal Environment: allows for optimal oxygen use, metabolism, and internal temperature because of thermal balance -Thermogenesis: increased BMR, muscular activity, nonshivering thermogenesis (chemical thermogenesis- flexed position and brown fatty layer) -Interventions for hypothermia (may lead to cold stress) ​ -verify the reading (generally double check if abnormal) ​ -double wrap and place hat (warm blankets, swaddle, and place a hat on) ​ -Kangaroo care (great for bonding and hypothermia, take shirt off, leave diaper on, do skin to skin with mother or father) ​ -Warmer or isolette (provides a neutral thermal environment) Hepatic Adaptations -Role of liver ​ -iron storage (babies need to make more RBCs) ​ -carbohydrate metabolism (glycogen stores, usually babies glucose is typically lower than the mothers) ​ -conjugation of bilirubin (bilirubin is a product of breakdown of RBCs, baby has many that are being broken down after the delivery process. Conjugation is the excretion of excess bilirubin, if not excreted it floats through the body and can cause severe damage to other organs like the brain, however the liver in the newborn is immature). Jaundice -Normal biologic response of a newborn, still tx if severe, but within the normal scope of newborn -Increased bilirubin causes yellowing of the skin and eyes ​ -in darker toned skins, look in scleras and mouth -Nursing assessment ​ -skin assessment (skin, sclera, mouth) -Physiologic jaundice generally occurs after the first 24 hours of life ​ -transcutaneous bilimeter reading at 24 hours of life ​ -if number concerning, follow up with serum reading ​ ​ -too high: depends on age of baby ​ ​ ​ -24 hours: reading of 8 is high risk zone ​ ​ ​ -48 hours: reading of 8 is not as concerning anymore ​ -caused by: increased bilirubin delivered to the liver, defective uptake of bilirubin from plasma, conjugation of bilirubin, inadequate hepatic circulation, increased reabsorption in the intestines, etc. ​ -if in high risk zone reading, do serum check Physiologic Jaundice: Interventions -If suspected, notify pediatrician -Well hydrated (baby will excrete bilirubin out) -Phototherapy: overhead lights (blue light) that is transferred through the skin and allows bilirubin to be excreted ​ -max skin (no clothes on baby, roll diaper down) ​ -exposure cover eyes (protect eyes) ​ -monitor diapers (is baby excreting bilirubin) ​ -continue to check labs ​ -be supportive of parents, may need prolonged hospitalization ​ -in severe cases, may need IV fluids to flush out ​ ​ -Kernicterus: long term, irreversible permanent brain damage from bilirubin Breastfeeding and Breast Milk Jaundice -Breast Feeding Jaundice: associated with poor feeding and inadequate fluid intake -Interventions: frequent feedings and lactation support -Breast Milk Jaundice: begins after day 7 -R/T: ​ -breast milk causing reabsorption of bilirubin from the intestine ​ -free fatty acids in BM compete for binding sites on albumin and inhibit conjugation ​ -Kernicterus is not associated as much with breast milk jaundice GI Adaptations -Swallowing and peristalsis initiated in utero -Elimination ​ -first bowel movements (meconium) should happen within first 8-24 hours, for sure within first 48 hours -Implications for Vitamin K ​ -Fetus has a sterile gut, so they are born with limited vitamin K ​ -Give vitamin K shortly after birth -What is the function of Vitamin K? ​ -used for clotting GI Adaptations: Elimination -When should the first BM take place? ​ -8-24 hours after delivery, but can still be normal within 48 hours -What is the normal frequency? ​ -can range from 1 every 2-3 days or up to 10/day ​ -usually see more bowel movements than less -Types of stool ​ -meconium: in GI tract while in utero, first BM, contains amniotic fluid and intestinal secretions and mucosal cells, has tarry thick dark green appearance ​ -transitional: after a day or 2, turns to transitional, looks greenish and “seedy”, lasts usually 1-2 days ​ -breastfed: move to this after transitional ​ -formula: after transitional, more formed than breastfed stool Urinary Adaptations -Most void within 24 hours (nearly 100% void within first 48) -Lower GFR than an adult (newborns cannot dispose of water as rapidly if necessary) -Ability to fully concentrate urine by 3 months Circumcision -Definition: removal of foreskin of the penis -Rationale: usually cultural reasons, more commonly done but not assumed to be done -Elective procedure ​ -done either with a plastibell (piece of plastic inserted under foreskin that prevents bf to area, then it falls off) or sheldon/gomco where foreskin is cut off -Pain relief: numbed with lidocaine and order tylenol afterwards (however, controversial d/t immature livers) Nursing Care of the Circumcised Newborn -Pain Assessment (NIPS) ​ -Neonatal infant pain scale, assesses cry, flexion/extension of limbs -Pain Meds (local, emla (topical cream to numb area, has to be on 1 hr prior to procedure), tylenol, sweeteas (sucrose solution to help pain relief) -Monitor for active bleeding -Normal appearance: beefy red and raw (without swelling, active bleeding or purulent drainage) -Apply petroleum jelly liberally -Monitor ability to void -Teaching opportunities (care and healing of the circumcision) ​ -yellowish/white exudate is normal, do not pick it off/remove, part of healing process ​ -can look red/beefy and raw, but should not be actively bleeding ​ -do not apply anything dry to area, use vaseline so diaper does not stick ​ -concern with infection or bleeding, call provider Immunologic Adaptations -Active acquired immunity: the pregnant woman forms antibodies (exposed either through illness or vaccine) -Passive acquired immunity: IgG antibodies are transferred to the fetus -Only IgG crosses the placenta -IgM does not cross the placenta (may indicate intrauterine infection) -IgA is found in colostrum (first breast milk) Newborn Neurologic Function -First Period of Reactivity ​ -HR and RR are elevated ​ -Alert from birth- 30 mins ​ -Initiate breastfeeding -Period of Inactivity ​ -HR and RR decrease ​ -May sleep up to 4 hours ​ -Reassure mother that this is normal -Second Period of Reactivity ​ -HR and RR may increase ​ -Awake and alert for 4-6 hours -Sleep States ​ -Deep Sleep: baby's eyes are closed with no eye movements, breathing regular ​ ​ -100-120 beats per minute ​ -Light Sleep (REM): rapid eye movement, respirations can be irregular, irregular sucking motions with minimal activity -Alert States ​ -Drowsy, can have fluttering eyelids ​ -Quiet Alert: alert and may fixate on attractive object ​ -Active Alert: eyes open, motor activity is intense ​ -Crying: intense state of alertness -Sensory Capacities ​ -Visual: see human faces and bright objects at about 8-15 inches ​ -Auditory: hearing tests prior to baby being discharged ​ -Olfactory: babies often identify people through sense of smell and identify mother this way ​ -Taste: respond differently to various tastes Reflexes -Grasping Reflex: finger in palm of baby’s hand, they close their fingers around yours -Rooting Reflex: lightly stroke baby’s cheek, they move toward it and begin to suck (disappears around 4 months of age) -Stepping Reflex: hold baby upright over flat surface and baby will move legs in a walking motion (disappears within 4-8 weeks of age) -Babinski Reflex: gently stroke sole of foot, baby responds by fanning and extending toes (adults flex toes instead of extend) -Tonic Reflex: turn head to one side while infant lays on back, arms extended on side of head, opposite arm and leg are flexed Nursing Care and Assessment of the Newborn: Immediately Following Delivery -Dry and Stimulate ​ -do this to initiate respirations (cry and breathe) and thermoregulation to prevent evaporation -Assess for adjustment to extrauterine life -What is the priority? Think ABC’s ​ -Airway ​ -Breathing ​ -Circulation -Intervene with any abnormalities we see APGAR -Timing of newborn assessment: At 1 minute and 5 minutes of life -Purpose -Newborn assessment that gives idea of what kind of resuscitation may be needed and well being of baby -HR ​ -absent: 0 ​ -less than 100: 1 ​ -greater than 100: 2 -Respiratory effort ​ -absent (full minute, baby does not show respiratory effort with stimulation): 0 ​ -slow/irregular: 1 ​ -crying: 2 -Muscle tone ​ -flaccid: 0 ​ -some flexion of extremities: 1 ​ -active motion/well flexed: 2 -Reflex irritability ​ -none: 0 ​ -grimace: 1 ​ -vigorous cry: 2 -Color ​ -pale/blue: 0 ​ -body pink/blue extremities (acrocyanosis): 1 ​ -completely pink: 2 -Common APGAR: 9 at highest (acrocyanosis can be normal) -7-10 is good, just suction -4-7: need for stimulation -less than 4: resuscitation is needed Newborn Maturity Rating and Classification -Tells us by exam how mature baby is if mom isn’t sure what exact day she got pregnant -Consider posture of baby ​ -circle each diagram that looks like the baby (4 would be more mature for ex, or a 0 for lack of tone or immature finding) ​ -put fingers to wrist, (4 is fingers would touch wrist, immature would be -1, won’t touch wrist) ​ -arm recoil (move down to sides, mature baby will flex them up again, immature will leave it down) ​ -popliteal angle (angle from upper to lower leg, mature baby bring knee to chest and extend heel up, it will not go very far whereas an immature baby will go 180 degrees) ​ -scarf sign, move baby's elbow over nipple line to see where it is, immature baby allows you to move it all the way across, mature baby cannot move elbow even to chest ​ -head to ear, take baby’s heel and move it to ear, immature finding would be easier to do, mature finding would be harder to do Physical Maturity ​ -skin: immature: sticky transparent skin, mature baby is leathery, cracked or wrinkled skin ​ -lanugo: peach fuzz, immature will have none, mature babies will be mostly bald ​ -plantar surface: bottom of foot to see creases ​ -breast: areola and bud under skin ​ -eyes and ears: immature babies: fused shut, mature: look at ear cartilage ​ -genitals: immature males will have smooth flat scrotum, mature will have testes that are deeper rugae, female immature clitoris is prominent, mature is labia more prominent -Total should always be about the same regardless of small differences in number assessments between exams Assessments of the Newborn: Measurements -Measuring length ​ -heel to crown ​ -length combined with weight is where we find percentiles for size -Head and chest circumference ​ -head typically 2 cm larger than chest circumference -What does the average baby weight at birth? ​ -about 7 lbs 8 oz in the US -Avg for Gestational Age (AGA): combo of weight, length and head circumference -Small for Gestational Age (SGA)= smaller than the 10th % (out of 100, lower 10) -Large for Gestational Age (LGA)= larger than the 90th % (out of 100, top 10) -Must take into consideration gestational age, not just size! Assessment of the Newborn: Erythromycin Eye Ointment -Rationale: gonorrhea and chlamydia (legal requirement to give this) -Administer along lower conjunctival surface Assessment of the Newborn: Vitamin K Injection -Rationale ​ -Vitamin K is produced in the gut and since their GI system is sterile, baby lacks vitamin K when newborn -Newborn injection sites (Vastus Lateralis) Appearance: Skin Assessment -Color ​ -acrocyanosis: hands and feet bluish (oxygen going to main organs and brain)- common ​ -pink, pale, jaundice, etc. -Erythema Toxicum ​ -newborn rash: very common in newborns -Milia ​ -little acne/white heads, do not pick at this or apply meds, it will go away -Stork Bites ​ -common around nape of neck or around forehead, will fade with time -Port Wine Stain ​ -typically does not fade with time -Mongolian Spots ​ -seen with darker skin tones, look similar to bruising (r/o) Appearance: Head Assessment -Fontanelles “Soft Spots” -Anterior Fontanel: diamond shaped, larger -Posterior Fontanel: triangle shaped, smaller -When do they close? ​ -anterior: closes at 18 months of age ​ -posterior: closes between 8-12 weeks following delivery -What does the nurse assess? ​ -assess to see if fontanel is soft and level (normal) ​ -bulging: IICP ​ -sunken: dehydration -How does the nurse assess?​ ​ -feeling the spots -Molding: asymmetrical appearance of the head ​ -what causes this? Molding is caused from sutures overriding each other during birthing process (asymmetrical appearance, resolves itself) -Caput: Soft edematous area on the scalp, can be caused by long labor or vacuum -Cephalhematoma: collection of blood between the surface of the cranial bone and the periosteal membrane ​ -other concerns r/t cephalhematoma? Concerned if hematoma absorbs itself that there is an increased number of RBCs, baby may be at risk for jaundice Head Assessment -Cephalohematoma vs. Caput -Caput: superficial -Cephalohematoma: collection of blood ​ -which crosses suture lines? Caput (swelling) may cross suture line ​ ​ -cephalohematoma does not cross suture lines Appearance: Assessment -Symmetry of eyes, nose and ears -Eyes ​ -blue or grey in color (do not know until closer to a year of age) ​ -Strabismus: cross eyes, common d/t poor eye muscle control ​ -Doll’s eyes: turn baby's head to right and left, eyes remain in opposite direction ​ -Tears: no, not until a couple months of age -Mouth ​ -intactness of palate ​ -Epstein’s pearls: hard white marks in mouth, generally go away within a couple weeks -Neck ​ -short with skin folds ​ -inability to support head, normal finding ​ -assess for webbing: sign of abnormality -Chest ​ -symmetrical w equal rise and fall with respiration ​ -prominent xiphoid may be noted (normal) ​ -engorged breasts or white nipple discharge from withdrawal of mothers hormones, do not express this discharge it is normal and will disappear -Abdomen ​ -cylindrical ​ -may protrude slightly ​ -assess for softness and make sure there is no distension ​ -assess BS also -Umbilical Cord ​ -how many vessels ​ -gelatinous (wharton’s jelly) and will dry, when will it fall off? 1 wk-10 days ​ -s/sx of infection: red, purulent/foul smelling drainage ​ -no tub bath until cord falls off, sponge bath until then -Genitals ​ -Female: development, possible pseudomenses (small amount of pink or bleeding in diaper, will go away), smegma: cheesy coating may be within labia ​ -Male: development, position of urinary opening and testes as well as urinary opening (should be central) -Extremities ​ -ability to move all extremities ​ -Ortolani’s maneuver: get knees together, move the legs back, assessing for hip click and making sure hips are intact ​ -Club foot: feet turned inward, can be positional -Back ​ -straight spine ​ -assess base of spine (ensure closure) and assess for presence of hair in area (abnormality) -Neurologic status ​ -state of arousal ​ -jitteriness (sign of low blood sugar) ​ -reflexes (blinking to light, startle reflex, etc) -Cry ​ -strong, lusty, and medium pitched ​ -concerned if high pitched cry for neuro issues Home Care of the Newborn: Teaching -Common Questions ​ -choking or gagging baby? Blue bulb syringe ​ -what position should the baby sleep in? Placed on back to sleep to prevent SIDS, no blankets or stuffed animals should be in bed with baby ​ -what is shaken baby syndrome? If baby is shaken out of frustration, can cause permanent and irreversible brain damage ​ -When can the baby take a tub bath? ​ -how and when do I burp my baby? ​ -what is cluster feeding? ​ -should i let my baby sleep all night? -should have carseat (law) -notify active bleeding or signs of infection with circumcision, liberally apply vaseline -call provider if baby has a temp, jaundice, vomiting, diarrhea, or no BM -explain how to use axillary thermometer -burping baby in between breasts, with bottle feeding burp every ounce, or if it slows down, burp in upright position -reassure that babies cry sometimes, maybe it needs fed, diaper change, maybe its in pain, pacifier is good if bf is well established -talking or rocking baby gently is good too -it is okay to place baby in a crib or safe space and walk away for a minute if frustrated, (sometimes babies just cry even if all needs are met, and we aren’t always sure why!) -feed baby on demand, regardless of last feeding (sometimes babies cluster feed or feed frequently), do not want them to go longer than 4 hours without eating -talk about positioning of baby -keep an eye on wet and soiled diapers, assess pre and post weights, etc -let down reflex of milk, should expect colostrum and milk to come in 3-5 days postpartum -milk mature by 2 wks postpartum -supplements are not always necessary -eat a well balanced diet: about 200 calories over pregnancy requirements/day -sore nipples: sign of poor latch, engorgement: ice packs to axilla -bottle feeding: 45 degrees and storage according to recommendations, do not prop bottle, assess for intactness of nipple and clean via dishwasher or boil, do not water down formula -formulas are mostly all the same -mother signs this document of home care teaching once complete Newborn Nutrition -Doubles birth weight by 6 months, triples by a year Newborn Nutritional Requirements -normal for baby to lose up to 7% of its birth weight -normal weight gain is about 1 oz per day -newborn caloric needs ​ -100 cal/kg/day ​ -if eating every 3 hours, it would be 8 feedings per day which is average ​ -breast milk and formula are generally 20 cal/oz Breastfeeding -Benefits to breastfeeding -Benefits to Newborn ​ -nutritional advantages: breastmilk is made specifically for the baby (perfect fat and caloric content) ​ -immunologic advantages (antibodies that you cannot put into formula) ​ -enhanced bonding (increases maternal self esteem and mother baby interactions) ​ -decreased risk of disease (decreased risk of diabetes, obesity, hodgkin's disease, lymphoma, leukemia, hypercholesterolemia, and asthma) ​ ​ -breast produces exactly what the baby needs (prevents over feeding, which prevents hypercholesterolemia and obesity) -Benefits to Mother ​ -decrease risk of PP bleeding (breast milk letdown is enhanced by oxytocin which decreases risk of uterine bleeding) ​ -stimulates uterine involution ​ -decreased risk of breast and ovarian cancers ​ -decreased risk of osteoporosis ​ -saves money (formula feeding a baby is around 1300 dollars a year) Lactogenesis -Estrogen and Progesterone ​ -stimulate breast development during pregnancy -Prolactin (produced after delivery) ​ -released from anterior pituitary in response to breast stimulation ​ -milk production -Oxytocin (see this during L&D and post delivery) ​ -released from the posterior pituitary in response to breast stimulation ​ -ejection of milk (let down reflex) Breast Milk Composition -Fat: triglycerides (50% of caloric content) -Carbohydrates: lactose (40% of caloric content) -Protein (majority is from whey protein) -Vitamins, Minerals, and Trace elements -Average caloric content= 20 calories/oz (varies from woman to woman and where the sample is taken from that let down) Breast Milk Stages -Colostrum “Liquid Gold” -colostrum is produced as early as the first trimester -Produced during pregnancy -High in IgA -High in protein, vitamins, and minerals -Low in fats and carbohydrates (compared to mature milk) ​ -baby uses brown fat stores for energy as milk comes in Breast Milk: Stages -Transitional Milk ​ -contains more fat, vitamins, and calories ​ -still yellow in color, but much more in amount ​ -by day 5 PP, 16 oz/day -Mature Milk ​ -white or bluish in color ​ -present by 2 weeks PP ​ -by 6 mos PP, 800ml/day -Foremilk ​ -flows at the start of feeding session (as baby begins to suck) ​ -high in lactose and protein, low in fat -Hind Milk ​ -flows later in let down ​ -high in fat Diet of the Breastfeeding Mother -Increase caloric intake by 500 cals over non pregnant requirement (this means she should increase caloric intake about 200 over her pregnant requirement) -Generally no need to avoid certain foods -Restrict alcohol and caffeine while breast feeding Feeding Frequency -Milk supply established and maintained with frequent feedings -Initial feeding should take place within 1st hour of birth ​ -as long as no complications, it is best to do skin to skin immediately after baby is cleaned off after birth -Feed on demand ​ -feed baby when it acts hungry; maximum period of time they let babies go in hospital is every 3-4 hours ​ -do not place baby on a schedule -Encourage rooming in -Signs of hunger ​ -rooting: move mouth toward nipple ​ -hands to mouth: tries to suck on fingers or fist ​ -crying is a late sign Infant Arousal Techniques -Remove blanket -Change diaper -Sit baby up -Talk to baby Holding the Breast -The C Hold Establishing Latch (recommended hold, making a letter c with thumb and pointer finger, helps support while bringing babies nose to nipple) -The Scissor Hold (not recommended, can prevent or obstruct milk flow) -Proper Positioning of baby ​ -tongue of baby must be down, has a great amount of the areola in the mouth ​ -cradle: cradle the baby in the arm closest to the breast (right arm, support breast with opposite hand, tummy to tummy) ​ -cross cradle: baby on right breast, support with left arm, support breast with right hand, reach across lap to support baby’s back or shoulders, good supportive position) ​ -football hold: helpful with C-section women or women with larger breasts, support baby underneath arm, hold baby back and shoulders in palm of hand/forearm like a football, support breast with opposite hand and guide it into baby's mouth) ​ -side lying: nursing baby in bed, lie on side with pillow on back, tummy to tummy, prop up on elbow, support breast with opposite hand, support baby with arm on same side as baby, use opposite hand (opposite side of baby) to support the breast Assessment of Breastfeeding -Sometimes quantified by time nursed, but also other assessment tools are used like LATCH LATCH -Latch ​ -0: too sleepy or reluctant, no latch achieved ​ -1: repeated attempts, hold nipple in mouth, stimulate to suck ​ -2: grasps breast, tongue down, lips flanged, rhythmic sucking -Audible Swallowing ​ -0: none ​ -1: a few with stimulation ​ -2: spontaneous and intermittent 24 hours old -Type of Nipple ​ -0: inverted ​ -1: Flat ​ -2: Everted (after stimulation) -Comfort (breast/nipple) ​ -0: engorged, cracked, bleeding, large blisters or bruises, severe discomfort ​ -1: filling, reddened/small blisters or bruises, mild/moderate discomfort ​ -2: soft, nontender -Hold (positioning) ​ -0: full assist (staff holds infant at breast) ​ -1: minimal assist (elevate head of bed, place pillows for support), teach one side; mother does other, staff holds then mother takes over ​ -2: no assist from staff, mother able to position/hold infant Is My Baby Getting Enough? -Infant behavior ​ -falling asleep at breast or pulling away: baby might be full -Softening of breast ​ -after first week or so, softening of breast after nursing is a sign that the milk is being transferred -Output ​ -voiding and stools of baby, transfer of milk -Pre and post weights ​ -weigh baby before and after feeding (same clothes and diaper) ​ -amount gained is amount of milk the baby has transferred Problems Associated with Breastfeeding -Engorged Breasts ​ -full, hot, tender, warm ​ -breasts feel heavy ​ -encourage frequent feedings -Sore, cracked, blisters, or bruised nipples ​ -incorrect latch ​ -assess and support position (tummy to tummy, baby's head well aligned, good latch of breast tissue not just nipple) ​ -lanolin cream (for nipple soreness) ​ -hydrogel dressings (for nipple soreness) ​ ​ -cracks or sores, water based dressing that is soothing/cooling to area Breast Care -May clean with soap and water -Good fitting bra -If not breastfeeding: ​ -ice packs ​ -avoid breast stimulation -Nursing Assessment? ​ -consistency, filling/firm, engorged, intactness of nipple Supplementary Feedings -Not recommended (unless there are valid medical indications) -Generally not necessary -Can lead to incorrect suck -May interfere with milk production -May lead to nipple preference (“nipple confusion”) -Pacifier use? ​ -shouldn’t be used until breastfeeding is well established Tandem breastfeeding -if mother has multiples, she can feed them at same time Expression -Breast Pump ​ -milk drips into bottle or bag ​ -encourage baby to mothers breast if possible, but if necessary, breast pumping is good too -Hand Expression When Breastfeeding is not a Possibility -HIV or Aids -Active TB​ -Varicella -Active herpes on the breast -Use of drugs or alcohol -Specific Meds -Infant with Galactosemia Bottle and Formula Feeding -Type of Formulas (artificial baby milk) ​ -milk based: cow’s milk ​ -soy based: if they have a milk intolerance ​ -specialty formulas: used for babies with potential health problems Formula Preparation and Storage -Ready to feed: does not need to be reconstituted -Powdered formula: comes in a can, -Water is added -Must be used within 24-48 hours -Least expensive -Formula Concentrate ​ -formula concentrate, water is added ​ -less expensive than ready to feed How Much Should the Baby Eat? -Baby boy Jones eats every 3 hours, he weighs 3.6 kg. How many oz should he be eating per feeding ​ -100kcal/kg/day ​ -formula= 20 kcal/ounce 100 kcal x3.6kg= 360 kcal/da7 360 kcal/8 feedings= 45 kcal/feeding 45 kcal/20 kcal= 2.2 ounces Bottle Feeding Preparation -Clean bottle in dishwasher or briefly boil -Inspect bottle nipples (if not intact, they should be thrown away) -Shake the formula (so nutrients are well mixed) -Prepare formula according to directions!!!* -Warm bottles with warm water bath (do not microwave, this can breakdown contents of breast milk) -Use warmed formula within 1 hour Bottle Feeding Technique -Tilt the bottle at 45 degree angle to avoid air entering nipple -Observe bubbles rising (means baby is getting what is in the bottle) -Hold the infant up during the feeding -Never prop a bottle (choking hazard) -Allow a baby to stop eating when they are finished (no longer hungry, do not force feed) Week 3 High Risk Pregnancy Pregestational Problems: Diabetes -DM is an endocrine disorder involving inadequate insulin -Review ​ -carbohydrates are broken down into glucose ​ -the pancreas produces insulin ​ -insulin allows glucose to be stored as glycogen ​ -glucagon stimulates breakdown of glycogen into glucose to be used by cells ​ -with insufficient insulin, glucose remains in the bloodstream -Carbohydrate Metabolism in Normal Pregnancy ​ -Early: hormones stimulate insulin production and increase tissue response to insulin (bs will be low) ​ -Second Half: hyperglycemia and resistance to insulin. May have ketones in urine d/t fat metabolism (bs will be higher), protective mechanism to allow fetus to get the glucose in the bloodstream Gestational DM -DM that is diagnosed during the pregnancy -What causes this? -R/T pregnancy (compensation to a metabolic abnormality or changes in hormones related to pregnancy) -Pre existing -Will the woman be a diabetic for the rest of her life? ​ -15-50% will progress to type II DM later on in life Diagnosing Gestational Diabetes -All pregnant women are screened at 28 weeks gestation as part of well OB care -1 hour GTT results (50gm Oral Glucose) -Norm= 135-140 mg/dl (if result exceeds this, a 3 hour GTT is ordered) -3 hour GTT results (100 gm Oral glucose) ​ -1 hour blood glucose level at or greater than 180 mg/dl ​ -2 hour glucose level at or greater than 155 mg/dl ​ -3 hour glucose level at or greater than 140 mg/dl -Dx made: ​ -2 values meet or exceed value to be positive Maternal Implications of Diabetes -Ketoacidosis: hyperglycemia due to low amounts of insulin (increased in ketones in the body released when fatty acids are metabolized) -Vascular disease: high blood sugars settling in the vasculature -Nephropathy -Retinopathy: blood sugar settles in retina -Hydramnios: increased amniotic fluid levels (fetus urinating a lot) -HTN -Dystocia (difficult labor) (at greater risk because of cephalopelvic disproportion) ​ -since babies are not diabetic, they store glucose and become larger, making labor difficult Fetal Implications of Diabetes -Higher risk for fetal death related to acidosis -Congenital Anomalies (d/t increased glucose levels early on in pregnancy) -Large for gestational age (LGA)/Macrosomia: d/t greater levels of blood sugar levels and storing it as excess fat and weight -Intrauterine Growth Restriction (IUGR): vascular disease can cause this, baby does not get nutrients it needs (small for gestational age) -Respiratory Distress Syndrome (RDS): high glucose can interfere with surfactant levels -Hyperbilirubinemia -Hypocalcemia Critical Thinking Moment -A newborn born to a mother with dm is at risk for being large for gestational age. What does this mean for labor? ​ -may lead to difficult labor (cephalopelvic disproportion) -Do you expect this neonate’s sugar level to be high or low for several hours after delivery? ​ -low, because the baby is not diabetic (produces high levels of insulin d/t high blood sugar levels it is getting from the mom), when supply is cut off, sugar bottoms out Management of DM During Pregnancy -Insulin Requirements ​ -Early in pregnancy: insulin needs typically decrease ​ -Later in pregnancy: insulin needs greatly increased (double-quadruple) ​ -PP: insulin needs decrease Who is at Risk for Gestational Diabetes? -Women who have signs of dm: hyperglycemia, glucosuria, and or obesity -Family history of diabetes or gestational diabetes -Prior delivery or large for gestational age baby -Previous fetal demise Teaching Moments Mother with GDM -Encourage ADA diet (low carb diet, sustain proteins, calorie counting) -Encourage regular exercise -Glucose monitoring -Meds (insulin or oral agents) ​ -long acting, short acting or mixture of both ​ -sliding scale (amount of insulin depends on what their bs was) -Monitoring fetal activity (fetal kick counts) presence of fetal movement is an indicator of fetal well being (closer eye on these pts since they are at greater risk for fetal demise) Assessment of the Diabetic -Height and Weight ​ -baseline allows provider to determine if the in excess or inadequate weight gain -Pregnancy dates and Fundoscopic exam ​ -early eval allows provider to establish most accurate gestational age -Neuropathy and Infection Assessing the Fetus of Diabetic Mother -Presence of Fetal Movement -Non Stress Test (NST) -Bio Physical Profile (BPP) -ultrasonographer looks for signs of fetal well being coupled with the non stress test​ -Ultra sound ​ -can see other risk factors like congenital anomalies, large or small for gestational age GDM Considerations -Mother ​ -is this a chronic condition or condition of pregnancy? Can be either ​ -What are the risk factors for GDM? Family hx, weights of prior children (large?) ​ -What is a mother diagnosed with GDM at risk for later in her adult life? Type II DM ​ -GDM aids in vascular disease -Newborn ​ -baby is NOT diabetic ​ -are we concerned with the newborn having high or low bs? (the baby is not diabetic, low blood sugar) ​ -do you expect the newborn of a diabetic mother to be AGA (average for gestational age), LGA (large) or SGA (small)? Large Anemia; Generally Two Types -Insufficient Hgb production ​ -r/t nutrition deficiency -Types ​ -iron deficiency ​ -folate deficiency (can be connected to an increased incidence of Neural tube defects within the newborn) -Hgb destruction ​ -r/t inherited disorders (ex: sickle cell) Types ​ -Sickle Cell Iron Deficiency Anemia -Possible Maternal Complications ​ -infections ​ -fatigue (less ability to carry oxygen) ​ -preeclampsia ​ -tolerate blood loss poorly -Prevention ​ -prenatals ​ -60-120 mg of iron/day ​ -iron rich diet -Possible Fetal Complications ​ -low birth weight ​ -preterm delivery (prior to 38 weeks gestation) ​ -fetal demise ​ -neonatal death Folate Deficiency: Megaloblastic Anemia -Possible Maternal Complications ​ -N/V ​ -Anorexia -Prevention ​ -0.4 mg of folate/day ​ -1 mg folate and iron supplement -Possible Fetal Complications ​ -Neural Tube Defects Sickle Cell Anemia -AA at risk -Possible Maternal Issues ​ -Autosomal Recessive Disorder at risk -Sx ​ -abdominal and joint pain -Complications ​ -infections, CHF, renal failure -Treatment ​ -folic acid prompt treatment of infections, hospitalization during crisis (transfusions and pain management) -Possible Fetal Complications ​ -fetal death​ ​ -prematurity ​ -IUGR (small for gestational age) Heart Disease -Pre-existing Disease -Congenital Heart Disease (born with the problem: tetralogy of fallot, septal defect) ​ -If repaired successfully, treated with antibiotics to prevent infection ​ -Cyanosis is associated with greater maternal/fetal risk -Mitral Valve Prolapse ​ -Mitral valve leaflets prolapse into the left atrium ​ ​ -mitral regurgitation may result ​ -Generally asx (may have palpitations, want to decrease caffeine) ​ -Often tx with Inderal -Peripartum (during pregnancy) Cardiomyopathy ​ -No previous hx of heart disease ​ -Left ventricle dysfunction ​ -Happens in women with no prior heart issues prior to pregnancy ​ -Occurs during second half of pregnancy to early PP period -Sx ​ -CP, Dyspnea, Orthopnea (positional breathing), Weakness, Edema Heart Disease: Management of Labor -If patient has no or slight limitation d/t heart disease, may labor naturally with observation -May limit pushing (labor down- let contractions do the work, when baby is low they use forceps or vacuum extraction to limit pushing) -Limit pain and anxiety High Risk Pregnancy: Gestational Onset Spontaneous Abortion (loss of pregnancy prior to 20 wks gestation) -Threatened Abortion (miscarriage) ​ -unexplained bleeding, cramping, cervix closed, worried there is a threat of the loss of pregnancy ​ -20-25% of pregnancies do have bleeding during first trimester, and half result in a miscarriage -Imminent Abortion ​ -imminently going to have a miscarriage ​ -increased bleeding and cramping, cervix may dilate, membranes will rupture -Incomplete Abortion ​ -parts of the products of conception are retained (usually placenta) -Complete Abortion ​ -all products of conception are expelled -Missed Abortion ​ -fetus dies in utero, but not expelled at all ​ -note decrease size in uterus -Nursing Considerations ​ -bleeding (ensure stability physiologically) ​ -pt may be fearful ​ -pt may have acute pain (cramping) ​ -grief related to expected loss Ectopic Pregnancy -Pregnancy that implants outside the uterus -Most common place this would happen is in fallopian tube ​ -2 losses: 1 of this pregnancy, the other is the loss of that tube/fertility (often have to remove portion of tube where pregnancy is) ​ ​ -taking half of fertility away by doing this -This would not be a viable pregnancy Hydatidiform Molar Pregnancy -Gestational Trophoblastic disease ​ -trophoblasts (outermost layer of embryonic cells that give rise to the chorion (part of placenta) replicate and proliferate abnormally) ​ -grape like clusters of placental tissue occurs ​ ​ -can be difficult- loss of potential pregnancy ​ ​ -rare but possible risk of choriosarcoma Hyperemesis -N/V are so severe that they affect hydration and nutritional status ​ -lose at least 5% of body weight ​ -unsure of cause, but some thought that it is caused by Hcg -Treatment goal ​ -Control n/v ​ -correct fluid and electrolyte imbalance ​ -adequate nutrition ​ -medications: B6, Phenergan, Reglan, Zofran ​ -BRAT diet: bananas, rice, applesauce and toast (may start this once n/v stops) ​ -IV fluids ​ -TPN if cannot adequately control n/v (severe cases) Preeclampsia/Eclampsia -Preeclampsia (preeclamptic) ​ -Increase in BP after 20 weeks gestation ​ -+ proteinuria ​ -”gestational HTN”- cause is not well understood, only cure is delivery of the baby ​ -goal is to prevent seizures -Eclampsia (eclamptic) ​ -Presence of a seizure in the preeclamptic woman Preeclampsia -Maternal Vasospasms result in decreased perfusion -Decreased uteroplacental perfusion: IUGR ​ -d/t lack of nutrients and oxygen exchange -Decreased hepatic perfusion: liver enzymes, RUQ pain ​ -expect to see elevated liver enzymes, RUQ pain d/t obstructed flow to liver -Decreased renal perfusion, decreased urine output, protein in urine, BUN/Cr, edema ​ -BUN/Cr: elevated -Pulmonary Edema -Cerebral Edema -Platelets ​ -vascular damage can lead to platelet aggregation and low platelet count Preeclampsia Nursing Assessment -BP -FHR -Vaginal Bleeding ​ -looking for potential for placental separation -HA -Visual changes -RUQ pain ​ -d/t changes within blood flow to this area -Deep tendon reflexes ​ -hyperreflexic: state close to seizure -Clonus ​ -push feet back, upon letting go, patient usually relaxes feet ​ -if positive, feet will shutter down (count number of beats if present) -Edema -Pulmonary edema ​ -chest pain, SOB, dyspnea, shallow respirations -Decreased urinary output -Urine protein -BUN, Cr, protein enzymes, platelets -LOC (may be irritable) Eclampsia -Seizure -Assessment ​ -body involvement ​ -duration of seizure ​ -fetal status (monitor: watch baby’s HR and pattern, if not on monitor, use doppler or US) ​ -prevent injury (pad side rails, position pt to side) ​ -maintain respiratory ability HELLP Syndrome -Associated with SEVERE preeclampsia H: Hemolysis (breakdown of blood cells, vascular damage) E: Elevated L: Liver Enzymes L: Low P: Platelets (less than 100,000) -Sx ​ -n/v ​ -malaise ​ -flu like sx ​ -epigastric pain Management of Severe Preeclampsia -Goal: prevent seizures, prevention of liver and kidney disease, maintain pregnancy -Decreased stimulation -Magnesium Sulfate: CNS depressant, prevents seizure activity ​ -Antidote: Calcium gluconate (always have at bedside) -Corticosteroids: fetal lung development (betamethasone IM x2) and HELLP -Antihypertensives: decrease BP and prevent stroke -Cure for preeclampsia ​ -delivery of infant and placenta ​ -want baby to be mature, but look at labs, BP, fetal development to make decision regarding early delivery Magnesium Sulfate -CNS depressant given to tx preeclampsia -Loading dose: 6 gram bolus over 20-30 min -Maintenance dose: 2-3 gm/hour -Antidote: Calcium Gluconate -SE (may indicate mag toxic) ​ -flushing/warmth ​ -HA ​ -Blurred vision ​ -Lethargy ​ -Pulmonary edema (not breathing as deeply, fluids running) -Nursing Assessment ​ -HA (looking to see if magnesium is too high causing this) ​ -Visual changes (blurred vision d/t high magnesium) ​ -DTRs (hyporeflexia: magnesium suppressing too much) ​ -CP/SOB: respiratory compromise, pulmonary edema ​ -Arousal: decreased arousal may indicate magnesium is too high -*Another important use ​ -Fetal neuroprotection ​ ​ -stabilizes cerebral circulation allowing for better cerebral blood flow, decreases risk of cerebral palsy and stroke RH Alloimmunization: Review -Rh - mother exposed to Rh + blood from baby ​ -mom makes antibodies ​ -affects subsequent pregnancy (antibodies attack baby’s positive blood cells) -Concern only to women who are Rh - -Erythroblastosis Fetalis: Severe hemolytic disease of the fetus and newborn -Hydrops Fetalis: Edema r/t anemia -Congestive Heart Failure -Hyperbilirubinemia/jaundice ​ -can be born yellow! -Kernicterus: irreversible and permanent brain damage -Direct Coombs Test: testing the newborn for sensitization to antibodies the mother has produced against its positive blood type -Indirect Coombs Test: testing the mother for sensitization -Negative means no sensitization (antibodies have not become active) -Positive is bad, means there is sensitization -Kleihauer- Betke Test: estimates the extent of bleeding for administration of the appropriate amount of Rh immune globulin (Rhogam) ABO Incompatibility -Mother is type O and fetus is Type A or B -Anti A and Anti B antibodies are naturally occurring (not like Rh sensitization, these antibodies are naturally occurring, may affect first pregnancy) -Newborn may have mild anemia -Assess for jaundice -Typically not life threatening like Rh sensitivity Age as a Factor -Teen Pregnancy and Advanced Maternal Age Teen Pregnancy -Overview of Adolescence: physical-psychological development -Physical: puberty- includes menarche (12-13 yrs of age), weight changes, growth spurt -Psychosocial ​ -identity ​ -autonomy and independence ​ -developing intimacy relationships ​ -comfort with own sexuality ​ -sense of achievement (start making decisions independently, might feel like they are growing up) Factors Contributing to Adolescent Pregnancy -Lack of foresight (feel like it won’t happen to them, cannot look into the future or beyond the present) -Peer pressure -Sex is popular in music and TV -Family dysfunction causes higher rates of teen sexual activity -R/O incestuous relationships Graph -Rate of pregnancy per 1,000 women ​ -over time, 18-19 yr old has higher pregnancy rates than 15-17 year old population ​ -currently declining ​ -1970s: 110/1,000 women 18-19 yrs of age who were pregnant ​ -2000s: 80/1,000 Teen Pregnancy: Why Do Teens Have Sex? GIRLS -61% of girls say their partner is pressuring them (#1) -60% think they are ready -45% say they want to be loved -40% curiosity with boys and girls along with being popular -25% forced BOYS -think they are ready to have sex (#1) -do not want to be teased about being a virgin -movies and tv makes teen sex seem normal -someone forcing them Teen Pregnancy: Maternal and Newborn Risks -Maternal Physiologic Risks -Many fail to follow through with Prenatal Care -Smoking -Higher incidence of STIs -Greater risk for developing preeclampsia -Most common support person is their mom -Newborn Physiologic Risks ​ -Preterm births ​ -Low birth weight ​ -Cephalopelvic disproportion (baby’s head and body and maternal pelvis are not a good fit) -Maternal/Newborn Psychological Risks ​ -may interrupt her own development ​ -sociological risks ​ -risks to newborn: teen parent is not developmentally or socially prepared to be a parent Teen Pregnancy: The Father -Adolescent males tend to be sexually active at a younger age -66% of those that impregnate a teen girl are older than 20 years of age -Rela