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Maternity/L&D
| Pre-embryonic period- | First two weeks after conception |
| Embryonic period | Day 15-week 8 |
| Fetal period | Week 9-birth |
| Week 5 | Heart beats |
| Week 12 | Spontaneous movement, heartbeat can be detected by Doppler at 10-12 weeks, sex is visually recognizable |
| Week 24 | Fetus can hear |
| Week 28 | Lungs are developed sufficiently to provide gas exchange |
| Umbilical cord | Two arteries, one vein |
| FHR | (About twice maternal HR) 160-170 bpm 1st trimester, slows with growth to 120-160 bpm by term |
| Ductus arteriosus | Connects pulmonary artery to aorta, bypassing the lungs |
| Ductus venosus | Connects umbilical vein and inferior vena cava, bypassing the liver |
| Foramen ovale | Opening between right and left atria of the heart, bypassing the lungs |
| Gestation | Fertilization-delivery; about 280 days |
| Nagele's rule | Add 7 days to the first day of the last menstrual period, subtract 3 months, add 1 year |
| GTPAL | G: Gravidity (# of pregnancies), T: Term births; longer than 37 wks, P: Preterm births; before 37 weeks, A: Abortions/miscarriages, L: Living children |
| Presumptive signs of pregnancy | Amenorrhea, N/V, increased size in breasts, pronounced nipples, urinary frequency, quickening (perception of fetal movement), fatigue, discoloration of vaginal mucosa |
| Probable signs | Uterine enlargement, Hegar's sign, Goodell's sign, Chadwick's sign, Ballottment, Braxton Hicks contractions, positive pregnancy test |
| Hegar's sign | Compressibility and softening of the lower uterine segment, about week 6 |
| Goodell's sign | Softening of the cervix, beginning of 2nd month |
| Chadwick's sign | Violet coloration of the mucous membranes of the cervix, vagina, and vulva, about week 4 |
| Ballottment | Rebounding of the fetus against the examiner's fingers on palpation |
| Positive signs of pregnancy | Fetal heart rate detected by Doppler transducer (10-12 weeks) and by fetoscope (20 wks), active fetal movements palpable by examiner, outline of fetus via ultrasound |
| Maternal age for high risk pregnancy | Younger than 20 and older than 35 |
| Role of nurse in adolescent pregnancy | 1.) Encourage early and continued prenatal care, 2.) Refer adolescent for appropriate assistance |
| Folic Acid | Helps prevent neural tube defects and oro-facial clefts in the fetus |
| Fundal height during pregnancy | During 2nd and 3rd trimesters (weeks 18-30), fundal height is about equal in cm to fetal age in weeks. 16 weeks: halfway between the symphysis pubis and the umbilicus. 20-22 weeks: at the umbilicus. 36 weeks: at the xyphoid process |
| Maternal changes in vitals | HR may increase 10-15 bpm, BP decreases slightly, RR remains same or slightly increases |
| Linea nigra | Dark streak down the midline of the abdomen |
| Chloasma | Blotchy, brownish hyperpigmentation over the forehead, cheeks, and nose |
| Psychological maternal changes | Ambivalence, acceptance, emotional lability, body image changes |
| N/V, heartburn in pregnancy | Occurs in 1st trimester, subsides by 3rd mo. Interventions: crackers in AM, avoid brushing teeth right away, eat small frequent meals, low fat, drink liquids inbetween, avoid fried/spicy foods, accupressure, herbal medicine |
| Nasal stuffiness in pregnancy | Avoid nasal sprays and antihistamines, use humidifier |
| Antepartum Diagnostic Testing | Visits every 4 wks for the first 28-32 wks, every 2 wks from 32-36 wks, and every week from 36-40 wks |
| Blood type and Rh Factor | If client is Rh negative and has a negative Rh antibody screen, she should receive Rh immune globulin at 28 weeks |
| Rubella | If client has a negative titer, she should receive the appropriate immunization postpartum. Must use effective birth control for 1-3 mo after immunization and avoid anyone who is immunocompromised |
| H&H | H&H decrease because plasma volume increases |
| Urinalysis | Glycosuria is common, but if it persists it may indicate diabetes. Ketonuria may result from N/V. 2+ to 4+ protein in the urine may indicate infection or preeclampsia |
| Biophysical profile | Noninvasive, assesses fetal breathing movements, fetal movements, fetal tone, amniotic fluid index, and fetal HR via a nonstress test |
| Percutaneous umbilical blood sampling | FHR monitoring necessary for 1 hr postprocedure and followup ultrasound for bleeding or hematoma after 1 hr |
| Alpha-fetoprotein screening | Assesses the quantity of fetal serum proteins; elevation associated with neural tube and abdominal wall defects; can detect spina bifida and down syndrome. Drawn at 16-18 wks. |
| Chorionic villus sampling | Aspirate small sample of chorionic villus tissue at 10-13 wks to detect genetic abnormalities |
| Amniocentesis | Aspirate amniotic fluid; best between 15-20 wks; determines genetic disorders, metabolic defects, and fetal lung maturity. Position the pt supine |
| Kick counts | Pt lies down on side and counts fetal kicks for a period of time. If there are <10 kicks in a 12 hr period, notify physician |
| Fern test | Determines amniotic fluid leakage |
| Nitrazine test | Determines amniotic fluid leakage. Vaginal secretions have pH 4.5-5.5, amniotic fluid has pH 7.0-7.5. Amniotic fluid will turn swab blue |
| Expected maternal weight gain | 25-30 lbs |
| Calorie intake | Increase of about 300 calories/day, 500 calories/day during lactation |
| Abortion | Termination before 20 wks. Maintain bed rest, count perineal pads, save tissues and clots, give IV fluids, prepare for dilation and cuterrage if incomplete, give Rh IG if woman is Rh-negative |
| Interventions for cardiac disease in mother | Monitor maternal and fetal vitals, limit physical activity, avoid excessive weight gain, monitor for pulm. edema, lie on side, avoid anemia, limit sodium |
| Chorioamnionitis | May result in postpartum endometritis. S/S: uterine tenderness, increased temp, maternal & fetal tachycardia, foul smelling amniotic fluid, leukocytosis |
| Newborn of diabetic mother | May be at risk for hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, hypocalcemia, congenital anomalies, and may be large in size |
| Gestational diabetes mellitus | Screen between 24-28 wks, 3 hr oral glucose tolerance test. Can be treated with diet alone, some may need insulin. Most women return to normal after delivery. Oral hypoglycemics are never prescribed during pregnancy |
| DIC | Remove cause, monitor vitals, s/s of shock, give O2, volume replacements, blood, and heparin. Monitor urine output and maintain at 30 mL/hr |
| Ectopic pregnancy | Implantation outside the uterine cavity. Assessment: abd pain, vaginal spotting dark red/brown, rupture: increase pain, referred shoulder pain, s/s of shock. Interventions: Methotrexate, laparotomy and removal, antibiotics, Rh IG |
| Endometritis | Position in Fowlers, private room, monitor I&O, antibiotics, oxytocic meds to improve uterine tone |
| Hep B | Suction fluids from neonate immediately after birth, give Hep B IG and Hep B vaccine soon after birth, 2nd dose about 1 month later, and 3rd dose 6 months after birth. Breastfeeding okay |
| Hematoma | Apply ice, analgesics, monitor I&O, encourage fluid and voiding, cath if unable, blood replacements, monitor for s/s of infection, antibiotics, incision and evacuation if necessary |
| HIV/AIDS | Zidovudine (Retrovir) to prevent maternal/fetal transmission. Avoid amniocentesis, episiotomy, and administration of oxytocin. Suction fluids immediately, restrict breastfeeding |
| S/S of hydatidiform mole | HTN (Elevated BP, edema, proteinuria), bleeding, fundal height high, high HCG level, snowstorm pattern on ultrasound, no FHR. Evacuation by vacuum aspiration with oxytocin afterwards. HCG monitored q1-2 wks, q 1-2 mo, avoid pregnancy for 1 yr |
| Gestational HTN | BP elevation detected first time after mid-pregnancy without proteinuria |
| Transient HTN | Gestational HTN with no signs of preeclampsia present at time of birth and HTN resolves by 12 weeks after birth |
| Preeclampsia | Occurs after 20 wks of gestation; gestational HTN with proteinuria |
| Eclampsia | Seizures in preeclamptic woman |
| Mild Preeclampsia | BP:140-160/90-110, proteinuria >.3 but <2 |
| Severe Preeclampsia | BP: >160/110, proteinuria >5, Cr >1.2, platelets <100,000, increased liver enzymes, oliguria (<500 mL/day), HA, right upper quadrant/epigastric pain, N/V, visual disturbances, pulm edema, fetal growth restrictions, low amniotic fluid volume |
| Interventions for mild preeclampsia | Bed rest, lateral positioning, monitor neuro status, monitor deep tendon reflexes (clonus, hyperreflexia), give adequate fluids, I&O, limit sodium, meds, monitor for HELLP syndrome |
| HELLP Syndrome | Hemolysis, Elevated Liver enzyme levels, Low Platelet count |
| Interventions for severe preeclampsia | Bed rest, magnesium sulfate to prevent seizures, monitor for signs of magnesium toxicity (flushing, sweating, hypotension, depressed deep tendon reflexes, and CNS depression including resp depression), antidote: calcium gluconate. Prepare for induction |
| Eclampsia | Generalized seizures, respiration ceases during seizures |
| Eclampsia Interventions | 1.) Remain with client and call for help, 2.) ensure open airway, turn on side, O2 at 8-10 L/min, 3.) monitor FHR, 4.) meds, 5.) After seizure insert oral airway, 6.) prepare for delivery, 7.) Document |
| Incompetent cervix | Premature dilation of the cervix. Tx: cervical cerclage. S/S: bleeding, fetal membranes visible. Interventions: bed rest, hydration, tocolysis, avoid heavy lifting/prolonged standing, avoid sex. Cerclage removed at 37 wks |
| Toxoplasmosis | Rash and flu-like symptoms. Transmitted through raw meat and cat litter. Can cross the placenta and cause spontaneous abortion in the first trimester |
| Rubella | Teratogenic in 1st trimester, can cross placenta, causes congenital defects, if mother isn't immune, immunize postpartum and wait 1-3 months before becoming pregnant again |
| Cytomegalovirus | Transmitted through close personal contact, can cross placenta or be transmitted in birth canal. Causes low birth weight, intrauterine growth restriction, enlarged liver and spleen, jaundice, blindness, hearing loss, and seizures |
| Herpes simplex virus | Can be transmitted to the fetus during childbirth, can cause death or severe neurological impairment. Delivery is usually by C-section or can be done vaginally if no lesions are present |
| Group B steptococcus (GBS) | Can cause meningitis, fascitis, and intra-abdominal abscess, transmission occurs during delivery, Dx via vaginal cultures at 35-37 wks. Tx with antibiotics |
| Pyelonephritis | Can cause anemia, low birth weight, HTN, premature labor, and premature rupture of the membranes. Assessment: flank pain, painful urination, increased frequency, chills, N/V, ^temp, HR, and FHR, uterine contractions, high WBC. Tx: abx and antipyretics |
| The four P's (factors) of childbirth | 1.) Powers: uterine contractions (effacement, dilation, pushing efforts), 2.) Passageway, 3.) Passenger (fetus, membranes, placenta), 4.) Psyche: emotions, anxiety, fear |
| Attitude | The relationship of the fetal body parts to one another. Normal is flexion with the fetal back rounded, head forward on chest, and arms and legs folded. |
| Lie | Relationship of spine of the fetus to spine of the mother. If transverse/horizontal, C-section will be necessary |
| Presentation | Portion of the fetus that enters the pelvic inlet first. Cephalic: head first, most common. Breech: buttocks, c-section or vaginal possible. Shoulder: if fetus doesn't rotate, C-section is necessary |
| Position | Relationship of assigned area of the presenting part or landmark to the maternal pelvis |
| Station | Measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine. "0": at ischial spine, minus: above, plus: below |
| Engagement | When the widest diameter of the presenting part has passed the inlet ("0" station) |
| Lightening/dropping | Also known as engagement; fetus descends into the pelvis about 2 weeks before delivery |
| Assessment of impending labor | Lightening, Braxton Hicks increase, vaginal mucosa is congested, discharge increases, brown/blood-tinged cervical mucus is passed, cervix ripens (soft, partly effaced, may begin to dilate), extra energy ("nesting"), weight loss 1-3lbs, rupture of membrane |
| True labor | Contractions manifest as back pain or menstrual cramps. Increase in duration and intensity |
| False labor | Also known as prodromal labor, felt in abdomen and groin, more annoying than painful. Contractions are irregular and do not produce dilation, effacement, and descent. |
| Leopold's Maneuvers | Methods of palpation to determine presentation and position of the fetus and aid in location of fetal heart sounds |
| Fetal monitoring | Displays the FHR (in relation to maternal), monitors uterine activity, assesses frequency, duration, and intensity or contractions. Normal FHR:120-160, baseline determined between contractions |
| External fetal monitoring | Noninvasive; Doppler, Leopold maneuvers, and tocotransducer placed over fundus. Preferred position is side-lying |
| Internal fetal monitoring | Invasive; requires rupture of membranes and attachment of electrodes to presenting part of the fetus, must be dilated 2-3 cm |
| Periodic patterns in FHR | Bradycardia: FHR <120 for 10 mins or longer. Tachycardia: FHR >160 for 10 mins or longer. If either occur, change the position of the mother, admin O2, assess vitals, and notify physician |
| Variability | Fluctuations in baseline FHR. Absent or undetected variability is considered nonreassuring. |
| Decreased variability | Results from fetal hypoxemia, acidosis, certain meds. Temporary decrease can occur when the fetus is in a sleep state |
| Accelerations | Brief, temporary increases in FHR of at least 15 beats more than baseline, lasting at least 15 seconds; usually a reassuring sign, reflecting a responsive, nonacidodic fetus; usually occur with fetal movement; may or may not occur with contraction |
| Early decelerations | Decrease in FHR, rate at the lowest point usually remains >100 bpm; occur during contractions as the head is compressed. Tracing shows a uniform shape mirroring the contraction. Not associated with fetal compromise, no intervention needed |
| Late decelerations | Nonreassuring, reflect impaired placental exchange or uteroplacental insufficiency. Look similar to early, but occur after the contraction begins and return after contraction ends. Interventions: improve placental blood flow and oxxygenation |
| Variable decelerations | Caused by restriction of flow through umbilical cord; don't have uniform appearance; shape, duration, and degree of decline vary, falling and rising abruptly; can by unrelated to contractions. Significant when FHR repeatedly drops to <70 for >60 seconds |
| Hypertonic uterine activity | Frequency, duration, intensity of contractions, uterine resting tone; should relax 60 sec between contractions; intensity: 50-75mmHg during labor, 110 with pushing, resting: 5-15. Hypertonicity reduces uterine blood flow and fetal O2 supply |
| Nonreassuring FHR Patterns | Bradycardia, tachycardia, late decelerations, prolonged decelerations, hypertonic uterine activity, decreased or absent variability, variable decelerations falling to <70bpm for >60 seconds |
| Interventions for nonreassuring FHR patterns | 1.) Identify cause, 2.) d/c oxytocin, 3.) change position, 4.) admin O2 and give IV fluids, 5.) continuous fetal monitoring with internal device, 6.) prepare for C-section, 7.) document |
| Stage 1: Latent | Longest stage; Friedman curve used to determine dilation; cervical dilation 1-4 cm, mild contractions q15-30 mins, 15-30 sec duration; comfort measures, fluids, ice chips, encourage voiding q1-2hr |
| Stage 1: Active | Dilation 4-7 cm, moderate contractions q3-5 mins, 30-60 sec duration; encourage breathing, quiet environment, comfort measures, fluids, ice chips, voiding q1-2hrs |
| Stage 1: Transition | Dilation 8-10 cm, strong contractions q2-3 mins, 45-90 sec duration; encourage rest, breathing patterns, privacy, offer fluids, ice chips, void q1-2hrs |
| Stage 1 interventions | Monitor maternal vitals, FHR, uterine contractions, dilation, effacement, and fetal station presentation and position |
| Stage 2 | Dilation complete, progress measured by descent of fetal head, contractions occur q2-3 min, lasting 60-75 sec, increase in bloody show, urge to bear down |
| Stage 2 interventions | Assessments every 5 mins, monitor vitals, FHR before, during, and after contractions, and uterine contractions; encourage mother, provide ice, position, monitor for signs of approaching birth(bulging, visualization of head) |
| Stage 3 | Contractions occur until placenta is expelled, usually 5-30 mins |
| Schultze mechanism | Center portion of placenta separates first; shiny fetal surfaces emerges from vagina |
| Duncan mechanism | Margin of the placenta separates; dull, red, rough maternal surface emerges from vagina first |
| Stage 3 interventions | Monitor vitals, assess uterine status (should be firm and about 2 finger-breadths below umbilicus), verify that placenta is intact, provide warmth |
| Stage 4 | Period 1-4 hrs after delivery, BP returns to prelabor level, pulse slightly lower than in labor, fundus remains contracted, in the midline, 1-2 fingers below umbilicus. Monitor lochia (moderate and red) |
| Stage 4 interventions | Maternal assessments q15mins for 1 hr, q30mins for 1 hr, and hourly for 2 hrs, provide blankets, apply ice to perineum, massage the uterus if needed, support breast-feeding |
| Local anesthesia | Used during episiotomy just before birth of infant, no effect on the fetus |
| Pedundal block | Administered just before birth, blocks perineal area for episiotomy, lasts about 30 mins, no effect on contractions or fetus |
| Lumbar epidural block | Injection in epidural space at L3-L4; administered after labor is established or just before scheduled C-section. May cause hypotension, bladder distention, and prolonged 2nd stage. No HA.Maintain side-lying position or put towel under R hip, give fluids |
| Intrathecal opioid analgesics | Rapid onset of action, may be used in combination with a lumbar epidural block |
| Subarachnoid (spinal) block | Inject into subarachnoid space at L3-L5; administered just before birth; can cause maternal hypotension, can cause postpartum HA; lie flat 8-12hrs after injection, give IV fluids |
| General anesthesia | Mother is not awake, presents danger of respiratory depression, vomiting, and aspiration |
| Bishop score | Determines maternal readiness for labor and evaluates cervical status and fetal position. Dilation, effacement, cervix consistency, position of cervix, and station are each given 0-3 score, score of 6 or more indicates readiness for labor |
| Induction | Initiation of contractions using oxytocin; obtain baseline of contractions and FHR; increase as prescribed until desired pattern is obtained (q2-3min lasting 60 sec) |
| Oxytocin d/c | D/C if contraction frequency is less than 2 mins, duration is longer than 90 seconds, or if fetal distress is noted |
| Amniotomy | Artificial rupture of membrane; performed if fetus is at 0 or plus station; increases risk of prolapsed cord and infection; monitor FHR; meconium stain > fetal distress; bloody stain > placenta abruptio, unpleasant odor > infection; expect variable decels |
| Polyhydramnios | Associated with maternal diabetes and certain congenital disorders |
| Oligohydramnios | Associated with intrauterine growth restriction and congenital disorders |
| External version | Manipulation of fetus from abnormal position to normal presentation after 34 wks; monitor vitals, if mother is Rh-negative, gigive Rh IG after 28 wks; prep for nonstress test; give IV fluids and tocolytic therapy to relax uterus |
| Episiotomy | Incision made to enlarge the vaginal outlet; provide ice packs during first 24 hrs, use sitz baths, apply analgesic spray/ointment, peri-care, blot dry area front to back, shower rather than bathe, apply peri pad, report bleeding/discharge |
| Forceps delivery | Used to assist in delivery of the head |
| Vacuum extraction | Suction used to assist in delivery of the head; do not keep in place more than 25 mins; monitor FHR every 5 mins; assess infant for signs of cerebral trauma; monitor for cephalhematoma; caput succedaneum is normal and resolves in 24 hrs |
| Cesarean delivery | Delivery through a transabdominal, low-segment incision of the uterus; Pre: insert IV and foley, monitor mother and fetus continuously; post: monitor vitals, provide pain relief, encourage turning, coughing, ambulation |
| Supine hypotension (Vena cava syndrome) | Venous return to the heart is impaired by the weight of the uterus on the vena cava, resulting in reduced cardiac return, cardiac output, and BP. Position on side, wedge pillow, avoid supine, and monitor vitals and FHR |
| Premature rupture of the membranes | Spontaneous rupture of the amniotic membrane before the onset of labor; if before term, deliver is delayed; risk of infection; assess amount, color, consistency, and odor of fluid, monitor vitals and FHR, and admin antibiotics |
| Prolapsed umbilical cord | Cord is displaced between the presenting part and the amnion or protruding through the cervix, causing compression and compromising fetal circulation (FHR irregular, slow, variable decelerations) |
| Prolapsed umbilical cord interventions | 1.) Elevate the fetal presenting part off cord by applying finger pressure, 2.) place pt in extremem Trendelenburg, modified Sims, or knee-chest, 3.) admin O2 8-10 L, 4.) Monitor FHR, 5.) IV fluids, 6.) prepare for immediate birth, 7.) document |
| Placenta previa | Improperly implanted placenta in lower uterine segment near or over the cervical os (can be total, partial, or marginal). Sudden, painless, bright red bleeding, last 1/2 of pregnancy, uterus soft, nontended, fundal height may be high. |
| Placenta previa interventions | Interventions: ultrasound, monitor vitals, FHR, and fetal activity, no vaginal exams, maintain bedrest in a side-lying position, monitor bleeding, IV fluids, blood products, tocolytic meds. May need C-section |
| Abruptio placentae | Premature separation of the placenta from the uterine wall after the 20th week and before the fetus is delivered. Dark red bleeding, uterine pain or tenderness, uterine rigidity, severe abd pain, signs of fetal distress, signs of shock |
| Abruptio placentae interventions | Monitor vitals and FHR, assess bleeding, pain, and increase in fundal height, bedrest, O2, IV fluids, blood, place in Trendelenburg or lateral position with HOB flat, prepare for delivery, monitor for s/s of DIC |
| Placenta accreta | An abnormally adherent placenta |
| Placenta increta | The placenta penetrates the uterine muscle itself |
| Placenta percreta | Placenta goes all the way through the uterus |
| Preterm labor | Occurs after the 20th week, but before the 37th. Uterine contractions, abd cramping, low back pain, pelvic pressure, change in character and amount of discharge, rupture of membranes. |
| Preterm labor interventions | Interventions: Stop the labor, restrict activity, hydrate, bedrest, lateral positioning, monitor fetal status, tocolytics |
| Precipitous labor and delivery | Labor lasting less than 3 hrs. Have delivery tray ready, stay with client at all times, do not try to prevent delivery, apply pressure to head upward to prevent damage, support body, deliver between contractions, clear infant's mouth |
| Dystocia | Prolonged or painful labor; s/s: abnormal contraction pattern, fetal distress, tachy, lack of progress; can result in dehydration, infection, fetal injury, or death |
| Dystocia interventions | Assess FHR, fetal distress, uterine contractions, temp, admin antibiotics, IV fluids, I&O, breathing techniques, give/monitor oxytocin, color of amniotic fluid |
| Amniotic fluid embolism | Escape of amniotic fluid into maternal circulation, depositing in the pulm arterioles, usually fatal to mother. S/S: abrupt onset of resp distress, chest pain, cyanosis, seizures, heart failure, pulm edema, fetal bradycardia and distress |
| Amniotic fluid embolism intervention | Admin O2 8-10 L, intubate, mech vent, position on side, give IV fluids, blood, monitor fetal status, emergency delivery |
| Fetal distress | FHR <120 or >160, meconium stained amniotic fluid, fetal hyperactivity, progressive decrease in baseline variability, severe variable decelerations, late decelerations |
| Fetal distress interventions | Lateral positioning, O2 8-10 L, d/c oxytocin, monitor maternal and fetal status, prep for emergency C-section |
| Intrauterine fetal demise | Loss of fetal movement, absence of FHR, DIC screen, low H&H, low platelets, prolonged bleeding and clotting time |
| Rupture of the uterus | Complete or incomplete separation of the uterine tissure; abd pain, chest pain, contractions stop or fail to progress, rigid abd, absent FHR, s/s shock, fetus palpated outside uterus. Monitor for/treat s/s shock, prep for C-section/possible hysterectomy |
| Uterine Inversion | Uterus completely or partly turns inside out. Depression in fundal area, interior of uterus is seen through cervix, severe pain, hemorrhage, s/s shock. May need laparotomy with replacement |
| Involution | Rapid decrease in size of uterus after delivery; quickened by breastfeeding; endometrium regenerates, fundal height decreases by 1 cm/day. Flaccid fundus should be massaged until firm |
| Lochia rubra | Bright red discharge, day 1-3 |
| Lochia serosa | Brownish pink, day 4-10 |
| Lochia alba | White, day 11-14 |
| Ovarian function | Menstrual flow resumes in 1-2 months in non-breastfeeding mother, 3-6 months in breastfeeding mothers |
| Breasts | Colostrum for 48-72 hrs, increased prolactin levels stimulate breast milk production; become distended with milk on the 3rd day; engorgement occurs on day 4 if not breastfeeding |
| Postpartum vitals | Temp may be elevated during 1st 24 hrs, bradycardia common in 1st week (50-70), BP unchanged |
| Postpartum interventions | Monitor vitals, pain, fundus, color amount, and odor of lochia, breasts, perineal swelling, episiotomy, bowels, I&O, extremeties for thrombophlebitis; encourage voiding, ambulation; give Rh IG to Rh neg moms; assess bonding with infant, emotions; teaching |
| Breast discomfort | Wear supportive bra at all times, use ice packs between feedings, use warm soaks/showers before feeding, admin analgesics |
| Breastfeeding | Assess LATCH (Latch, Audible swallowing, Type of nipple, Comfort of mother, Help given to mother); wash breasts once daily, do not use soap; if nipples crack, expose nipples to air for 10-20 mins after feeding, rotate infant position; breasts may leak |
| Hemorrhage | Bleeding of 500 mL or more after delivery; massage fundus, stay with pt, notify Dr, monitor vitals and fundus q5-15mins, assess blood loss by pad count, LOC, H&H, maintain asepsis, give oxytocin, IV fluids, blood |
| Mastitis | Inflammation of the breast; primarily occurs in breastfeeding mothers 2-3 wks after delivery; localized heat/swelling, pain, high temp, flu-like sx. Apply heat or cold, maintain lactation, pump q4h, supportive bra, analgesics, antibiotics |
| Subinvolution | Incomplete involution; uterine pain on palpation, large, more than normal bleeding. Interventions: vitals, assess uterus and fundus, monitor for pain and bleed, elevate legs, frequent voiding, H&H, give Methergine (provides sustained contraction) |
| Apgar scoring | Heart rate, RR, muscle tone, reflex irritability, skin color; each rated 0-2 (higher=better)at 1 min and 5 mins after birth. 8-10: no intervention, 4-7: stimulate, give O2, 0-3: newborn requires resuscitation |
| Initial care after birth | Suction mouth then nose, dry, rub, wrap, place at breast, ID bracelets |
| Newborn vitals | HR: 100-160 bpm, RR: 30-60, temp: 96.8-99, BP: 73/55 |
| Fontanels | Anterior: soft, flat, diamond shaped, close 12-18 months. Posterior: triangular, close between birth and 2-3 months. |
| Caput succedaneum | Edema of soft tissue over bone (crosses suture line); subsides in a few days |
| Cephalhematoma | Swelling caused by bleeding into an area between bone and periosteum (doesn't cross suture line); usually absorbed within 6 wks, no tx |
| Acrocyanosis | Normal in first few hours after birth and may be noted intermittently for 7-10 days |
| Harlequin sign | Deep pink or red over one side of body while the other is pale or normal. May indicate shunting of blood with a cardiac problem or sepsis |
| Newborn GI | Abd depression indicates hernia, abd distention associated with obstruction, mass, or sepsis, B.S. occur in 1st 1-2 hrs, meconium should pass with 24 hrs, void within 24 hrs |
| Newborn hepatic system | Normal jaundice appears in 1st 24 hrs and after 48 hrs in premies; peaks around day 5. Jaundice before this time indicates pathological jaundice, notify dr. Admin IM vitamin K |
| Newborn immune system | IGG from placenta, IGA from colostrum, give opthalmic erythromycin or silver nitrate in 1st hr of life |
| Cord care | Clamp can be removed after 24 hrs if dry and occluded, clean with soap and water, keep dry, prevent diaper from covering, assess for odor, swelling, and discharge. Should fall off within 2 wks |
| Circumcision care | Apply petroleum jelly gauze (except if PlastiBell is used), remove after first voiding post-circ, observe for swelling, infection, or bleeding, clean after voiding by squeezing warm water over penis |
| Newborn metabolic system/GI | Small stomach (90 mL), rapid peristalsis (2.5-3 hrs). Breastfeed q2-3hrs, bottlefeed q3-4hrs; burp afterwards; position on R side after feeding. Seedy, yellow stool is normal; screen for phenylketonuria. Milk sufficient for 1st 4-6 months. |
| Reflexes | Sucking/rooting, swallowing, tonic neck/fencing, palmar/plantar grasp, Moro, startle, pull-to-sit, stepping, crawling |
| Respiratory distress syndrome | Tachypnea, flaring nares, expiratory grunting, retractions, seesaw respirations, decreased breath sounds, pallor, cyanosis, hypothermia, poor muscle tone. Get ABGs, suction, resp therapy, admin surfactant |
| Meconium aspiration syndrome | Resp distress at birth, tachypnea, cyanosis, retractions, crackles, rhonchi, stained yellow-green color. Suction immediately after head is delivered before the 1st breath |
| Intraventricular hemorrhage | Bleeding within the ventricles of the brain; dimished/absent moro reflex, lethargy, apnea, poor feeding, high-pitched shrill cry, seizures |
| Necrotizing enterocolitis | Acute inflammatory disease of the GI tract, 4-10 days after birth; increased abd girth, decreased B.S., vomiting, bile-stained emesis, abd tenderness, occult blood; hold oral feedings, decompress stomach with OG tube, IV fluids, antibiotics, surgery |
| Hyperbilirubinemia | Elevated serum bilirubin level (>12); jaundice, enlarged liver, poor muscle tone, lethargy, poor sucking reflex; hydrate, frequent feedings, phototherapy (cover eyes and genitals), report if in 1st 24 hrs |
| TORCH infections | Toxoplasmosis, Other infections (gonorrhea, syphilis, varicella, hep B, HIV, HPV), Rubella, Cytomegalovirus, Herpes |
| Drug-addicted newborn | Irritability, tremors, hyperactivity, resp distress, vomiting, high-pitched cry, sneezing, fever, diarrhea, sweating, poor feeding, extreme sucking of fists, seizures; hold firmly and close to body, seizure precautions, I&O, IV fluids, swaddle |
| Fetal alcohol syndrome | Short palpebral fissures, short upturned nose, flat midface, thin upper lip, low nasal bridge, resp distress, heart disorders, irritability, tremors, poor feeding, seizures; position on side, monitor for hypoglycemia, suction, I&O, weights |
| Newborns of HIV-positive mothers | May test positive for 18 mo because of mother's antibodies; give antiviral meds, reduce exposure to maternal blood at birth; may be asymptomatic for 1 yr. Clean skin carefully, don't circumcise. Don't use live vaccines. Don't breastfeed |
| Newborn of a diabetic mother | Monitor for hypoglycemia, hyperbilirubinemia, resp distress, hypocalcemia, weight; admin glucose IV if necessary |
| Hypoglycemia in newborn | <40 in 1st 72 hrs, <45 after 1st 3 days (Normal is 40-60 1st day, 50-90 afterwards). S/S: ^RR, twitching, unstable temp, lethargy, apnea, seizures, cyanosis. Admin glucose, feed early, monitor blood glucose levels |
| Rh IG | Give at 28 weeks gestation and again within 72 hrs of delivery if mother is Rh-negative |
| Tocolytics | Cause uterine relaxation and attempt to halt uterine contractions and prevent preterm birth. Indocin, magnesium sulfate, nifedipine, terbutaline |
| Magnesium sulfate | CNS depressant, smooth muscle relaxation, used to stop preterm labor and in preeclamptic pts, level: 4-7.5 Antidote=calcium gluconate if: resp depression, depressed reflexes, flushing, hypotension, muscle weakness, decreased urine output, pulm edema |
| Betamethasone and dexamethason | Corticosteroids that increase the production of surfactant; use for pt in preterm labor 28-32 wks whose labor can be inhibited for 48 hrs |
| Prostaglandins | Used to induce labor by ripening the cervix, causing it to begin to dilate and efface, stimulating contractions. Monitor vitals and FHR,tx d/c when biship score is >8 or an effective contraction pattern is established |
| Oxytocin (Pitocin) | Stimulate smooth muscle of the uterus, increasing the force, frequency, and duration of contractions; helps control postpartum bleeding; monitor vitals q15min, contractions, FHR q15mins, monitor for hypertonic contractions or nonreassuring FHR (stop!) |
| Rubella vaccine | Given SQ before d/c if nonimmune, don't give if pt has an egg allergy. Avoid pregnancy for 1-3 months |
| Hepatitis B vaccine | Give IM to newborn in vastus lateralis, give hep B IG within 12 hrs if mother is positive |
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kahadzima1
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