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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
Created by: kahadzima1