Maternal Health/ OB Final Exam Study Guide

OB FINAL STUDY GUIDE

OB DRUGSRUBELLA VACCINE:

• Given sub-Q before discharge in patients that are not immune.• Give when titer is lower than 1:8• SIDE EFFECTS: transient rash ***• NURSING INTERVENTION• Teach patient to avoid getting pregnant for 1-3months after

immunization.RhoGAM

• Given to pregnant women who are Rh- but carry an Rh+ fetus • Intramuscular injection * don’t give intravenously.• Prevents antibody reaction • Should be given at 28weeks gestation then 72hours after the

delivery of the fetus. • *watch for temp increase after giving this shot

OB DRUGS BETHAMETHASONE

• Corticosteroid that increases the production of surfactant.

• Intramuscular injection given 24hours before delivery of the infant.

• USED IN PRETERM LABOR * when the labor cannot be inhibited and the woman is likely to deliver in 48hours.

• Prevents RDS in the preterm neonate.• ADVERSE EFFECTS: pulmonary edema *** (watch

for crackles, wheezing and chest pain).

OB DRUGS MAGNESIUM SULFATE • CNS depressant and anticonvulsants • Tocolytic Used to STOP PRETERM LABOR by relaxing

the smooth muscle and prevent seizures during eclampsia.

• ADVERSE REACTIONS:• Decreased DEEP TENDON REFLEX ***• Decreased resps• Muscle weakness• Decreased urine output• Flushing • Pulmonary edema• * contraindicated in women with cardiac iddues because it

can cause heart block

OB DRUGS

• NURSING INTERVENTIONS:• Test patellar reflex before giving the med. • Use infusion pump • Assess deep tendon reflexes every hour *

decrease = sign for toxicity.• Watch magnesium levels *4-7.5 is therapeutic

range.• CALCIUM GLUCONATE = antidote for toxicity • Call doc if resps are less than 12 sign for resp

depression.• Monitor input and output.

OB DRUGS: MEDS THAT PREVENT HEMORRHAGE:METHERGINE:

• stimulates uterus contractions and increases the force, intensity and duration of contractions.

• Also produces vasoconstriction of the coronary artery.• INDICATION: post partum hemorrhage• ADVERSE EFFECTS: bradycardia, dysrrythmia,

*severe hypertension.• NURSING INTERVENTIONS:

• Monitor blood pressure closely• Vital signs • Watch for chest pain, SOB, itchiness, pale cold hands

and feet.

OB DRUGS: PITOCIN

PITOCIN• Stimulate the uterus and causes contractions

of the myocardium.• Oxytocin promotes milk let down.• ADVERSE EFFECT:

• Water intoxication *** big one• NURSING INTERVENTIONS:• Monitor vital signs closely.

CONTRACEPTION• CONTRACEPTION= deliberate prevention of conception

using a method or device that avoids the fertilization of the ovum.

• TWO TYPES OF CONTRACEPTION:• NATURAL FAMILY PLANNING METHODS • Rhythm method• BBT• Cervical mucus• Symptothermal• Ovulation awareness• Coitus interruptus.• PHARMACOLOGICAL METHODS• Condom • Diaphragm

CONTRACEPTION:PHARMACOLOGICAL METHODS

• Hormonal contraception contains estrogen and progestin or in some cases progestin alone.

• The Estrogen-progestin combination suppress ovulation and change the cervical mucus making it difficult for sperm to enter.

• The Hormones containing Progestin alone are less effective • Taken for 21days then stopped for 7 days during which the

patient will get her period.• Useful in controlling irregular periods.• Factors that increase the adverse risks of contraceptives are

Obesity, smoking and hypertension.• Contraceptives are contraindicated in people with

hypertension, thromboembolitic diseases, estrogen dependent cancers and pregnancy.


• Contraceptives increase the toxicity of tricyclic antidepressants, may alter glucose levels, and antibiotics decrease the absorption and effectiveness of oral contraceptives.

• Side Effects: break through bleeding (spotting), excessive cervical mucus production, breast tenderness, hypertension, nausea and vomiting.

• ADVANTAGE:– 99.9% effective – You can be spontaneous – May reduce the risk of ovarian cancer, ecptopic

pregnancy, ovarian cysts and non cancerous breast tumors.


• DISADVANTAGES:– Don’t protect against STD’s – Must be taken daily– Expensive– Illnesses that cause one to vomit may reduce the effectiveness of the

pills.• PATIENT TEACHING:• Reinforce the need to take the medication every day at the

same time if they are pills.• Keep yearly pap smear exams• Instruct the patients to do a breast self exam• When the patient now wants to conceive she may not be able

to do so for 8months after stopping the oral contraceptives because the pituitary gland requires a recovery period to begin to stimulate the cyclic gonadotropins FSH & LH (these regulate ovulation).

CONTRACEPTION• PATIENT TEACHING …• Increase vitamin B6 foods in diet (wheat, corn, liver, meat) and folic acid

(liver, greens, leafy vegetables). Because the hormonal contraceptives have dietary deficiencies in Vitamin B6 and folic acid.

• Use another form of contraception for the first 7 days of using the contraceptive because the contraceptives don’t take effect for 7 days.

• If you miss one pill , take one as soon as you remember • Use another form of contraception if you miss two pills in a row.• If you miss 3 pills in a row, then discard the pack and start a new pack • ADVERSE REACTIONS:• Fluid retention• Weight gain• Breast tenderness• Break through bleeding• Fatigue • Headache • Nausea and vomiting

CONTRACEPTION• TRANSDERMAL PATCH:• Weekly birth control patch that contains estrogen and

progestin and is worn on the skin,• The hormones are absorbed into the skin and

transferred into the blood stream.• The patch remains attached to the sin.• ADVANTAGES:• 99.9% effective • DISADVANTAGES:• Does not protect against STD’s• Some patients may react to the adhesive on the patch.

CONTRACEPTION• PARENTAL AGENTS : DEPO PROVERA• These are I.M injections administered every 12weeks • They stop ovulation from occurring by supressing the release of

gonodotropin hormones• They also change the cervical mucus to prevent the sperm from

entering the uterus.• ADVANTAGES:• Long lasting • Breast feeding patients can use them • DISADVANTAGES:• Invasive • Expensive• Don’t protect against STDs • Their effects can be reversed• * report shortness of breath, chest pain, swelling of the extremities

or heavy vaginal bleeding.

CONTRACEPTION: MORNING AFTER PILL

• MORNING AFTER PILL: EMERGENCY CONTRACEPTION• Taken 72hours after unprotected sex.• Antiemetic taken 1hour prior to taking the morning

after pill to overcome the feeling of nausea that can occur with high doses of estrogen and progesterone.

• If a period does not come in 21days then the woman should be evaluated for pregnancy.

• DISADVANTAGE:• Doesn’t provide long term contraception • Must be taken within that 72hour window but this

does not guarantee 100% protection.

CONTRACEPTION: BARRIER METHODS• MALE CONDOMS:• Synthetic sheath placed over the penis before intercourse.• Prevents pregnancy by colleting sperm in the tip of the

condom, preventing it from entering the vagina.• ADVANTAGES:• Prevents STD’s and pregnancy• DISADVANTAGE:• Must be put on before any genital contact because pre

ejaculation may contain spermatozoa.• There may be an allergic reaction to the latex.• May beak during intercourse• Cant be reused• Sexual pleasure may be affected.

CONTRACEPTION: BARRIER METHODS• DIAPHRAGM AND SPERMICIDE:• Dome shaped cup that fits over the cervix with spermicide cream or gel in the cup

and around the rim.• Its fitted by the primary care giver and must be refitted every 2years.• The diaphragm must remain in place 6 hours after intercourse and more

spermicide must be applied after each sexual activity.• Empty the bladder prior to inserting the diaphragm.• ADVANTAGES:• Gives the woman control over the contraception.• DISADVANTAGE:• Inconvinient• You cannot be spontaneous• Requires reapplication of spermicide with each sex act.• TEACHING:• Not recommended for patients that have had Toxic Shock Syndrome (caused by a

bacteria S/S high fever, watery diarrhea, drop in blood pressure, nausea and vomiting, muscle aches) *prevented by proper hand washing and removing the diaphragm 6 hours after sex, frequent UTI.

CONTRACEPTION• IMPLANTABLE PROGESTIN LEVONORGESTREL

(NORPLANT):• 6 rods implanted subdermally on the inner arm.• They contain levonorgestrel• PATIENT TEACHING: avoid trauma to the area of

implantation• ADVANTAGE:• Effective for 5 years• Reversible when the woman now wants to concieve.• DISADVANTAGE:• Can cause irregular menstrual bleeding• Does not protect against STD’s• Use condoms to protect against STD’s.

CONTRACEPTION: INTRAUTERINE METHOD• INTRAUTERINE DEVICE (IUD) • T shaped device inserted in the vagina to the cervix

and placed in the uterus.• Releases chemicals that damage sperm when they are

moving up to the uterine tubes, preventing fertilization.

• Patient must monitor that the small string that hangs from the device into the vagina is still there to make sure the IUD has mot migrated or slipped out during menstrual cycle.

• ADVANTAGE:• Provides protection for 1-10 years • DISADVANTAGES:

CONTRACEPTION:SURGICAL METHODS• TUBAL LIGATION: • Female’s fallopian tubes are tied • NPO after midnight prior to surgery• Permanent• Sex is not affected.• Disadvantage:• Infection • Hemorrhage • Trauma• There is a risk of an ectopic pregnancy • The procedure is irreversible.

CONTRACEPTION:SURGICAL METHODS• VASECTOMY:• Ligation and severance of the vas deferens• The male is not sterile until the proximal portion

of the vas deferens is cleared of all sperm (this will take approximately 20 ejaculations).

• Use another form of birth control until the vas deferens is cleared of all sperm.

• permanent,, but irreversible when the man finally decides he would like to conceive.

• Complications are: bleeding, infection and anesthesia reaction.

ANTEPARTUM PERIOD

NORMAL PHYSIOLOGICAL CHANGES DURING PREGNANCY

• SYMPTOMS OF PREGNANCY:• Divided into 3 groups • PRESUMPTIVE SIGN = – subject, what the woman says about why she thinks she’s

pregnant e.g missing her period, breast tenderness.– No periods for an unknown reason – urinary frequency– breast enlargement or tenderness– fatigue– Quickening = feeling like there's a baby moving in you.

• Multigravida (woman who has had previous pregancies can feel quickening at 16weeks

• Primigravida ( woman who is pregnant for the first time) feels quickening at 18weeks.


• PROBABLE SIGNS = test findings that suggests the woman is pregnant but not 100% guarantee.

• Hegars sign: softening of the uterus • Chadwicks sign: when the vaginal mucosa are a bluish-

purplish tint • Goodells sign = softening of the cervix• Braxton hicks = contractions that the woman feels through

out the pregnancy. These are painless and irregular• Positive pregnancy test• POSITIVE SIGN = confirm pregnancy.• FHR• Fetal movement when you palpate the abdomen • Visualization of the fetus by ultrasound.


NAGELE’S RULE • Determines the estimated date of delivery • 1ST DAY OF LAST MENSES – 3MONTHS + 7

DAYS.

• Gravida = number of pregnancies• Para = number of pregnancies that reach

viability 20-24weeks or fetal weight of more than 2lbs regardless of weather the baby is born alive or dead.


• REPRODUCTIVE • Enlargement of the uterus• Change in the cervix (thinnning and bluish-purplish tint).

• CARDIOVASCULAR • Increase in cardiac output • Increased blood volume to meet metabolic needs• Increased HR • Blood pressure remains the same within the first trimester, decreases

by 5-10mmhg in second trimester then should return to normal within 20weeks.

• Supine Hypotensive Syndrome = aka supine vena cava syndrome. Woman gets hypotension when laying down in supine position because weight and pressure is applied on the vena cava decreasing blood flow to the heart maternal hypotension and fetal S/S = dizziness, light headedness, pale clammy skin.

• * tell the patient to potion herself of the lateral position.


• RESPIRATORY:• Increased oxygen demand

• GI• Displacement of the stomach and intestines due to increases in the

abdominal cavity• Nausea and vomiting

• RENAL • Increased filtration rate urinary frequency

• ENDOCRINE • Increased production of progesterone, estrogen and Human Chorionic

Gonadotropin (hCG this is whats dictated in pregnancy test)• SKIN

• CHLOASMA = increased facial pigmentation (mask of pregnancy)• LINEA NIGRA = long dark line that goes across the umbilicus to the

pubic area• STRIAE GRAVIDARUM = stretch marks

NUTRITION DURING PREGNANCY• Recommended weight gain:

– 11-14kg (25-35lb) – Gain about 4lb in the first trimester then 1-2lb/week for the next 2

trimesters.– Excessive weight gain macrosomia & labor complications.

• Poor weight gain low birth weight of the newborn.• Increase protein intake • Increase the intake FOLIC ACID INTAKE * important for neurological

development and preventing neural tube defects. Foods high in folic acid – leafy vegetables, beans, seeds, orange

juice.• Iron to increase the martenal RBC• Calcium- for the developing fetus.• AVOID TOO MUCH CAFFEINE – increases the risk of spontaneous

abortion.

CULTURAL ISSUES DURING PREGNANCY CULTURAL COMPETENT NURSING = care that respects and is

compatible with each clients culture, and shows respect to their values and beliefs of others.

• NATIVE AMERICANS • Indians • Private and don’t like to share private information. * be patient

with these patients.• No person has a right to speak for another so they may not give you

any patient information.• Eye contact is seen as rude.• Strong handshake may be seen as offensive and prefer light greet.• Father of the baby may be absent during the delivery• Female family and friends attend to the patient during the labor

and delivery.• They may want to have the placenta.

CULTURAL ISSUES DURING PREGNANCY • AFRICAN AMERICANS • Don’t disclose more information than whats asked.• Communicate loudly, lots of hand movements and animated body

language.• Fathers are active during the labor.• Express pain openly.

• LATINOS• Admiring the child without touching it is considered giving the

CHILD THE EVIL EYE.• Direct eye contact is respectful• The man is usually in charge of all the decision making • The fathers prefer not to play an active role in the birthing process.• The woman prefer to keep their bodies covered during labor• Some mexican women may wear a cord around their waist because

they believe it prevents morning sickness and ensures a safe birth.

CULTURAL ISSUES DURING PREGNANCY • ASIAN AMERICANS • Prolonged eye contact is disrespectful.• More comfortable with arms length distance • The head of the baby is considered sacred (gate way to

the soul) so it can only be touched by the relatives only. * touching the baby’s head when you are a non-family member is considered bad omen.

• May not want a male physician because the womans waist and between the knees area is private.

• Modesty is important.• Father usually does not participate in the delivery of

the infant.

CULTURAL ISSUES DURING PREGNANCY

• FOODS PREFERRED DURING PREGNANCY:• Asian Families – warm foods during the

pregnancy and after delivery.• Muslim – halal meats• Jewish – Kosher foods

ANTERPARTUM PERIOD

COMPLICATIONS OF PREGANCY

COMPLICATIONS DURING PREGNANCYABORTION: • ABORTION = pregnancy ending before 20weeks

gestation• S/S: spontaneous vaginal bleeding, clots may be

seen through the vagina, lower uterine contractions, can lead to hemorrhage and shock.

• NURSING INTERVENTIONS: bed rest• vital signs• count the # of pads to evaluate blood loss, IV fluids • Avoid vaginal exams • Avoid sex with threatened abortions.

COMPLICATIONS DURING PREGNANCY: ABORTIONS TYPES OF ABORTIONS:• SPONTANEOUS

• Just occurs naturally before 20weeks gestation • INDUCED

• Elective choice to terminate pregnancy.• THREATENED

• Patient may have slight or no cramping at all • Moderate spotting • No tissue passes• The cervical opening is closed

• INEVITABLE• Spotting and cramping• Cervix begins to dilate and efface

COMPLICATIONS DURING PREGNANCY: ABORTION

TYPES OF ABORTIONS • INCOMPLETE

• Severe cramping • Continuous and severe bleeding • Partial fetal tissue or placenta• Dilated with tissue in cervical canal or passage of the tissue.

• COMPLETE• Loss of all uterine contents (conception products).

• MISSED• Patient may have a brownish discharge • The products of conception are retained in utero after fetal

death• HABITUAL

• Spontaneous abortions in 3 or more pregnancies

PLACENTA PREVIA• PLACENTA PREVIA = improper implantation of the uterus. Its

implanted on the lower segment or near the internal cervical os.• TYPES OF PLACENTA PREVIA :

– Total = the placenta covers the cervical os – Partial = covers the cervical os partially.– Marginal =

• SIGNS AND SYMPTOMS ?– Painless, bright red vaginal bleeding – Uterus is soft, relaxed and nontender.– Fundal height may be more expected than the gestational age.

• NURSING INTERVENTIONS:– Fetal heart rate and maternal vital signs should be assessed first.– There may be a need for a c-section if bleeding is heavy.– No vaginal exam or anything that will stimulate the uterus.– Position the patient in side lying position.

ABRUPTIO PLACENTAE• ABRUPTIO PLACENTAE: this is premature separation of the

placenta from the uterus wall after the 12th week of gestation and before the fetus is delivered.

• SIGNS AND SYMPTOMS:– Dark red vaginal bleeding – Uterine pain and tenderness– Uterine rigidness– Severe abdominal pain – Signs of fetal distress.– There may be signs of shock

• NURSING INTERVENTIONS:– Vital signs and FHR– Bed rest, oxygen, IV fluids and blood products – Trendelenburg position to decrease the pressure of the fetus on the

placenta.

GESTATIONAL DIABETES, PRE-ECLAMPSIA AND ECLAMPSIA

• Hypertension that occurs during pregnancy.• PREECLAMPSIA:

– Non convulsive form– Occurs after 20weeks gestation.

• ECLAMPSIA:– Convulsive form – Occurs at 24weeks gestation or the first postpartum week.

• SIGNS AND SYMPTOMS – Blood pressure higher than 140/90mmHg.– Weight gain of more than 5lbs (2.3 kg)/week.– Protein uria *this is the also the diagnostic finding.

• TREATMENT:– MAGNESIUM SULFATE (neuromuscular sedative that reduces

the amount of actelycholine preventing seizures).

MAGNESIUM SULFATE MAGNESIUM SULFATE • CNS depressant and anticonvulsants • Tocolytic Used to STOP PRETERM LABOR by relaxing

the smooth muscle and prevent seizures during eclampsia.

• ADVERSE REACTIONS:• Decreased DEEP TENDON REFLEX ***• Decreased resps• Muscle weakness• Decreased urine output• Flushing • Pulmonary edema• * contraindicated in women with cardiac iddues because it

can cause heart block

MAGNESIUM SULFATE• NURSING INTERVENTIONS:

• Test patellar reflex before giving the med. • Use infusion pump • Assess deep tendon reflexes every hour * decrease = sign

for toxicity.• Assess for ANKLE CLONUS but dorsing flexing the patients

ankle 3times if the foot stops moving when you move your hand then there is no ankle clonus, if the foot doesn’t stop moving this is a (+) sign for ankle clonus.

• Watch magnesium levels *4-7.5 is therapeutic range.• CALCIUM GLUCONATE = antidote for toxicity. Keep tab at

bedside.• Call doc if resps are less than 12 sign for resp

depression.• Monitor input and output.

HELLP SYNDROME• HELLP SYNDROME = HEMOLYSIS ELEVATED LIVER ENZYMES & LOW

PLATELETS • A category of gestational hypertension that involves the changes in

blood components and liver function• CONTRIBUTING RISK FACTOR: preeclampsia.• Hemolysis due to damage of erythrocytes.• Elevated liver enzymes caused by the obstrcution in the liver due to

the fibrin deposits.• SIGNS AND SYMPTOMS:• *pain in the upper right quadrant due to distended liver, epigastric

area and lower chest pain • INTERVENTIONS:• Don’t palpate the abdomen because this increases intra abdominal

pressure which could lead to a rupture and liver hematoma

ECTOPIC PREGNANCY

• Implantation of a fertilized egg outside the uterus • Usually the abnormal implantation is in the fallopian

tubes tubal rupture.• TESTING WILL SHOW:– High hCG levels – The ultrasound will show an empty uterus

• SIGNS AND SYMPTOMS– Unilateral stabbing pain– Missing two periods.– Dark red or brown vaginal spotting if the ruptures have

ruptured.– Referred shoulder pain *common symptoms.– Hemorrhage and shock (hypotension, tachycardia, pallor)

ECTOPIC PREGNANCY

• THERAPEUTIC MEASURES:– METHOTREXATE = to inhibit cell division and

enlarge the embryo– Avoid alcohol and folic acid to prevent a toxic

response to the meds– Laproscopic salpingostomy = removal of the tube

if the tube ruptured – Linear Salpingostomy = a section is cut to remove

the contents if the tube is not ruptured

MOLAR PREGNANCY• Aka GESTATIONAL TROPHOBLASTIC DISEASE• Proliferation and degeneration of trophoblastic villi in the

placenta which become swollen and fluid filled then look like grape like clusters.

• THERE ARE TWO TYPES OF MOLAR GROWTHS:• COMPLETE MOLE

– No fetus, placenta and amniotic membranes or fluid.– Theres no placenta to receive the maternal blood

hemorrhage into the uterus vaginal bleeding.– COMPLICATION = CHORIOCARCINOMA

• PARTIAL MOLE • Contains abnormal embryoninc or fetal parts an amniotic

sac and fetal blood.• COMPLICATIONS = CHORIOCARCINOMA

MOLAR PREGNANCY• DIAGNOSTIC

– High hCG levels – Ultra sound shows growths and vesicles but theres no fetus in utero.– Urine analysis shows proteinuria.

• SIGNS AND SYMPTOMS:– Rapid uterus growths – Dark brown vaginal bleeding – Hyperemesis gravidarum due to high hCG levels

• INTERVENTIONS – Bring any clots to the physician for testing – RhoGAM if the woman is Rh –– Not get pregnant for up to a year (so use contraception).– Testing of hCG levels for every 1-2weeks until the levels are normal ,

then every 2-4weeks for 6months & 2months for 1 year. * INCREASE IN HCG LEVELS IS A SIGN FOR MALIGNANT TRANSFORMATION.

– Chemotherapy is done choriocarcinoma.

HYPEREMESIS GRAVIDARUM• Excessive nausea and vomiting in the first trimester • Most common in young pregnant ,20yrs; first pregnancy, multifetal

gestation, GTD, Vitamin B6• HYPEREMESIS CAUSES: weight loss, electrolyte imbalance,

dehydration, ketosis.• RISKS IT HAS TO THE FETUS: intrauterine growth restriction or pre-

term birth.• DIAGNOSTICS: *most important lab results shows Ketones and

Acetones (protein & fat breakdown ; hematocrit concentration is elevated because of the inability to retain fluid leads to hematocrit concentration.

• NURSING INTERVENTIONS:• NPO for 24-48hours• IV fluids of lacated ringers for dehydration• Vitamin B6

HYPEREMESIS GRAVIDARUM• Excessive vomiting that lasts for more than 12weeks and causes 5%

weight loss.• RISK TO THE FETUS: Intrauterine Growth Restriction (IUGR) and

preterm births.• RISK FACTORS: younger than 20yrs, first pregnancy, multiple

gestation, gestational trophoblastic disease, Vitamin B deficiency.• S/S: excessive vomiting, electroltye imbalance, dehydration, poor

skin turgor.• Diagnostics: Urine analysis for Ketones and acetones (protein and

fat break down) is the most important lab; increased hematocrit concentration.

• NURSING INTERVENTIONS: NPO for 24-48hours, IV fluids of lacteted ringersm Vitamin B6 or vitamin supplements, if severe TPN.

GESTATIONAL DIABETES• Diabetes that starts during pregnancy . Normal glucose levels are

60mg/dl-120mg• Should be screened for gestational diabetes between 24-28weeks

pregnancy. • DIAGNOSTIC: 3 hour oral glucose tolerance test (GTT) *confirms

gestational diabetes. (NPO after midnight then 100g oral glucose given, then serum glucose test done in 1, 2, 3hrs after the dose).

• PREDISPOSING/RISK FACTORS: older than 35years, obesity, family history of diabetes.

• RISK TO THE FETUS: spontaneous abortions (big one) ; UTI because of the increased glucose in the urine; Ketoacidosis (increased resistance to insulin caused by untreated hyperglycemia).

• S/S: excessive thirst, hunger, weight loss, frequent urination, excessive weight gain during pregnancy, blurred vision.

• NURSING INTERVENTIONS: – Watch for hypoglycemia (clammy pale skin, shaking, tingling of mouth and

extremities, weak, shallow resps, nervousness).– Watch for hyperglycemia : excessive thirst and urination,flushed dry skin,

acetone (fruity breath.

TORCH• TORCH= group of infections that are teratogenes and can cross the placenta to the

fetus.• TOXOPLASMOSIS = infection caused by the protozoa Toxoplasma gondii.

– s/s: rash and flu like symptoms– Transmission: eating raw meats or handling cat liter.– RISK: causes spontaneous abortions.

• OTHER INFECTIONS = GBS most dangerous, transmitted during delivery usually occurs within 48Hours can cause meningitis, permanent neurological defects, sepsis and pneumonia.

• RUBELLA = – Teratogenic during the first semester– Causes congenital defects of the eyes, heart, ears and brains– If not immune (has a titer of 1:8 or less) then the mother must be vaccinated

and wait 3months before getting pregnant.

TORCH• CYTOMEGALOVIRUS=

– Transmitted through droplets, semen vaginal secretions, breast milk, urine *body secretions.

– There's no treatment– PREVENT EXPOSURE BY FREQUENT HANDWASHING BEFORE EATING,

AVOIDING CROWDS OF YOUNG CHILDREN.• HERPES SIMPLEX VIRUS =

– If the woman has herpes then vaginal exams are contraindicated – Can cause death or permanent neurological defects.– C-section indicated if the woman has lesions to avoid transmission to the fetus

during delivery.

INTRAPARTUM PERIOD

INTRAPARTUM PERIOD

LABOR AND DELIVERY BIRTHING ASSISTANT PROCEDURES

NORMAL LABOR AND DELIVERY • PROCESS OF LABOR: 4 P’S

• PASSENGER • PASSAGEWAY• POWERS• PSYCHE

NORMAL LABOR AND DELIVERY • PASSENGER: the fetus • Consider the fetal head, presentation, lie, attitude. All

these affect the fetus ability to pass through the birth canal.

• PRESENTATION= part of the fetus that enters the pelvic inlet first. – Occiput (back of the head)– Mentum (chin)– Scapula (shoulder)– Sacrum (breech)

• LIE = relationship of the moms spine to the fetus spine. – Longitudinal (cephalic or breech presentation.– Transverse = lying across/horizontally. C-section needed.

NORMAL LABOR AND DELIVERY • FETAL POSITIONING: relationship between the

presenting part of the fetus to the direction its facing in the maternal pelvis.– Maternal pelvis divided into four quadrants (anterior,

posterior, left, right) – Example: ROP (first letter is the side of the maternal

pelvis , 2nd letter is the presenting part, 3rd the direction the presenting part is facing, anterior, posterior or transverse part of the maternal pelvis.

– The occiput is facing the Left and its Anterior so its LOA.

NORMAL LABOR AND DELIVERY • PASSAGEWAY: the birth canal • POWERS:

– Contractions- force to push out the fetus *involuntary.– Effacement- thinning and shortening of the cervix– Dilation- enlargement of the cervix

• PSYCHE• Emotional state • Maternal stress, tension and anxiety can produce physiological

changes that impair progress of labor. • STATION • Measures the progress of descent in cm• Station 0 = at the ischial spine • (-) station = above the ischial spine• (+) station = below the ischial spine • ENGAGEMENT = when the presenting part has passed the pelvic

inlet.

MECHANISM OF LABOR• LIGHTENING = when the fetus descends into

the pelvis.• Braxton hicks contractions • Brownish or blood tinged cervical mucus.• Cervix ripens = softening, thinning of the

cervix leading to dilation.• NESTING = this is when the woman has a

sudden burst of energy. Usually occurs 24-48hours before the onset of labor.

• Spontaneous rupture of membranes.

FALSE LABOR VS. TRUE LABOR• FALSE LABOR – No dilation effacement or descent occurs – Irregular contractions that don’t progress in intensity,– Discomfort relieved by position change and walking.

• TRUE LABOR – Contractions may present as back pain.– Regular contractions– Contractions last longer, more intense and close together

e.g 4mins apart.– Leads to cervical dilation, effacement and engagement.– Bloody show– Mucus plug expelled– Rupture of the membranes * assess the color of the

amniotic fluid *meconium stained amniotic fluid is a sign of fetal distress.

TRUE SIGNS OF LABOR

• RUPTURE OF THE FETAL MEMBRANES:-• The membrane sac that contains and supports the fetus and amniotic fluid

ruptures.• May occur spontaneously at the start of labor or main remain intact till the

health care provider ruptures it.• May occur as a sudden gush or slow leakage.• May cause the fetal head to descend into the pelvis shortening the labor

process.• Labor usually starts 24hours after the rupture in most patients • The fluid should be clear and odorless, any variations from this report them

to the physician.• THE NITRAZINE TEST is used to test the amniotic fluid to make sure that the

membrane ruptured.• The nitrazine test uses litmus paper to detect the Ph of the secretions (+)

= when the paper turns into blue (this is fluid from the amniotic sac.• A MEMBRANE THAT RUPTURES 24HOURS BEFORE LABOR BEGINS IS CALLED

PREMATURE RUPTURED MEMBANES.

FETAL ASSESSMENT DURING LABOR• LEOPOLDS MANEUVER: helps determine the

fetal presentation.• If the head is the in fundus = hard and round,

movable object will be felt• The buttocks feel soft and irregular shape,

difficult to move.• Palpate the sides of the abdomen to feel for

the back. The back will feel smooth and hard, irregular bumps are the hands, elbows, knees.

FETAL ASSESSMENT DURING LABOR: MONITORING

• Monitors FHR (120-160 beats/min).• FHR monitored in relation to maternal contractions.• EXTERNAL FETAL MONITORING:• Tocotransducer or doppler ultrasound used.• Tocotransducer is placed over the fundus where the

contractions are the strongest.• Non invasive.• INTERNAL FETAL MONITORING:• Electrodes placed on the presenting part of the fetus.• REQUIREMENTS: ruptured membranes, woman must

be dilated for 2-3cm.• invasive

FETAL HEART RATE PATTERNS• VARIABILITY = fluctuation in baseline FHR• ACCELERATION;– Brief increase in FHR by 15beats more than the baseline

lasting longer than 15seconds.– Usually occur with fetal movement– Usually a positive (+) shows fetal responsiveness. – Can happen with uterus contractions, vaginal exams, cord

compressions or when the fetus is in breech presentation. • EARLY DECELERATIONS:– Normal don’t need intervention – Caused by head compression on the pelvis or cervix.– Decrease in FHR below the baseline (lower than 100

beats/min).– Occurs during contractions and returns to the baseline

FHR by the end of contractions.

FETAL HEART RATE PATTERNS• LATE DECELERATIONS– Not normal– Start AFTER the contraction begins and returns to

baseline when the contraction ends. (early decelerations start when the contraction starts).

– Sign of UTEROPLACENTAL INSUFFICIENCY, or impaired placental exchange.

• NURSING INTERVENTION:– Change the patient position to side lying– 8-10L/min oxygen

FETAL HEART RATE PATTERNS• VARIABLE DECELERATIONS:• Caused by restricted airflow to the umbilical cord.• SIGN OF COMPRESSED CORD, prolapsed cord,

nuchal cord (cord that’s around the fetus neck).• Do not occur at times of the contractions.• FHR decreases to less than 70beats/min and lasts

for 6seconds before returning to the baseline HR. • NURSING INTERVENTIONS• Change position • 8-10l/min oxygen mask• Vaginal exam• Amnioinfusion if ordered.

HYPERTONIC UTERINE CONTRACTIONS• In hypertonic contractions = the resting tone

of contractions is high reduces blood flow to the uterus and decreases fetal oxygen supply.

• The uterus should relax between contractions.• Resting time should be 60seconds or longer • The resting tone of the uterus is 5-15mmhg.

4 STAGES OF LABOR• STAGE 1 • LATENT PHASE• Cervical dilation 1-4cm • Contractions shorter in duration and 15-30mins apart.• INTERVENTION: position change and voiding q1-2hours.• ACTIVE• Cervical dilation 4-7cm • Uterus contractions lasting 30-60secondsoccuring every 3-

5mins • TRANSITIONAL PHASE• Cervical dilation 8-10cm • Contractions every 2-3cm, duration lasting 45-90seconds• Woman may feel like she is losing control, and becomes

restless.

STAGES OF LABOR: STAGE 2 • STAGE 2 OF LABOR • Starts from complete cervical dilation to the delivery • Occurs in 7 cardinal movements = this is POSITION CHANGES as the

fetus moves along the birth canal.• Cardinal movements are necessary because of the size of the fetus

head in relation to the irregular shaped pelvis.• The movements change to allow the smallest diameter of the fetus to

pas through the diameter of the patients pelvis.• THE 7 MOVEMENTS THAT OCCUR ARE :-• Engagement • Descent• Flexion• Internal rotation• Extension• External rotation• expulsion

STAGES OF LABOR: STAGE 2

• ENGAGEMENT = the presenting part of the fetus is inline with the mothers ischial spines.

• DESCENT = the downward movement of the fetus.- This is when the fetal head moves into the pelvic inlet. - Full descent is when the the fetal head passes beyond the

cervix and comes in contact with the posterior vaginal floor.• FLEXION = movement of the fetal head forward so that the chin

is pressed against the chin.- The pressure from the abdominal muscles and the contractions

causes the fetus head so that the chin is pressed forward against the chest.

STAGES OF LABOR: STAGE 2 • INTERNAL ROTAION = rotation of head making it easier for it to

pass through the ischial spines.• EXTENSION= - As the head passes the pelvis, the occiput emerges from the

vagina and the back of the neck is stopped by the symphis pubis,

- Further descent is halted temporarily because the shoulders are too wide to pass through the pelvis or under the pubic arch in this position

- Upward resistance from the pelvic floor causes the head to extend against the pubic arch & as this happens the brow, mouth and chin appear

STAGES OF LABOR : STAGE 3

• This is the time from the delivery of the baby to the delivery of the placenta.

• Last about 5-30mins • After the baby is delivered the uterus contractions stop for a

while.• Can be divided into 2 phases:-- Placenta separation - Placenta expulsion - SIGNS THAT THE PLACENTA IS READY TO BE DELIVERED ARE:-- Lengthening of the umbilical cord- Sudden gush of vaginal blood- Change in the shape of the uterus.


• PLACENTA SEPARATION :-• Occurs after the uterus starts contractions again • After the baby is delivered the uterus contractions allow the placenta

to fold and separate because there is no baby to exert pressure on the placenta preventing it from separating prematurely.

• As the placenta pulls away from the uterus wall bleeding begins and pushes the placenta further away.

• The placenta falls to the upper part of the vagina or lower uterine segment.

• Most placentas start separating in the middle/ center then folds onto itself this leads to delivery with the FETAL SURFACE EXPOSED = SCHULTZE PLACENTA.

• If the placenta separates from the edges first its delivered with the maternal surface exposed = DUNCAN PLACENTA.

STAGES OF LABOR : STAGE 3• THE SCHULTZE PLACENTA IS shiny and glistening • THE DUNCAN PLACENTA IS red and appears raw with irregular

ridges.• The outer lining of the uterus (endometrium / decidua ) is

expelled at the same time as the placenta.• The remaining layer of the uterus is shed in two layers: - The superficial layer is shed a lochia - The basal layer remains to regenerate a new endothelium.

- SIGNS THAT THE PLACENTA IS READY TO BE DELIVERED ARE:-- Lengthening of the umbilical cord- Sudden gush of vaginal blood- Change in the shape of the uterus.


- PLACENTA EXPULSION :- - The mother bears down and gentle pressure is applied on the

fundus of the contracting uterus ( CREDE’S MANUEVER).- If the plecenta doesn’t deliver spontaneously then it needs to

be removed manually.- * pressure should never be applied on a NON CONTRACTING

UTERUS to avoid the possibility of hemorrhage.

STAGES OF LABOR: STAGE 4

• Time immediately after the delivery of the placenta • This is usually the first hour after delivery – recovery period• The main activity is getting the neonate stabilized and getting

used to the environment outside the uterus.• Fundus is two fingers below the umbilicus.• Lochia may be red.• The focus is on promoting maternal – neonate bonding.

MATERNAL PSYCHOLOGICAL RESPONSES TO LABOR

• RESPONSE DURING FIRST STAGE:-- Feeling of anticipation, excitement or apprehension.- During active phase the mother becomes concerned about the

progress of the labor and may want pain medications.

• RESPONSE DURING STAGE 2 OF LABOR:- Feeling of exhaustion as the patient is now actively pushing

• RESPONSE DURING STAGE 3 OF LABOR:- Focus is on the condition of the neonate

• RESPONSE DURING STAGE 4 OF LABOR:- Focus is on the neonate - The patient starts adjusting to their new role as a mother- The primary activity is promoting maternal- neonate bonding

ANESTHESIA• LOCAL ANESTHESIA• Done just before the birth of the baby• Blocks the pain during an episiotomy• Does not affect the fetus.• PUDENDAL BLOCK• Injected through the pudendal nerve through

transvaginal block.• Indicated for the perineal area for an episiotomy.• Lasts for 30mins• No effect on the contractions and fetus.

OB PROCEDURES:

• FETAL BLOOD SAMPLING - Method of monitoring the fetal blood ph when indefinite FHr occur - Indicated when fetal hypoxia is suspected - Sample is usually taken from the scalp ( Or the presenting part if the fetus is

in breech position).- The membranes must be ruptured, the cervix dilated to 2cm and -2cm

station.- The fetal scalp blood has a ph of 7.25 or higher *this is normal. Any value

less than 7.20 = severe acidosis or fetal distress.• AMNIOINFUSION = replacement of the amniotic fluid volume through an

interuterine infusion of an isotonic solution, using a pressure catheter.- Indicated when repetitive variable decelerations are not being resolved by

interventions such as changing the position and oxygen- Helps relieve the umbilical cord compression.- Usually about 500ml is administered of warm solution to avoid chilling.- Assess the temp every 1hour to assess to infection- * tell the DOC if the fluid suddenly stops because this is a sign that the fetal

head is engaged and fluid is collecting in the uterus hydramnions or uterus rupture.

OB PROCEDURES: EPISIOTOMY

• EPISIOTOMY = surgical incision of the perineum used to enlarge the vaginal outlet.

- Prevents tearing and relieved the pressure of the fetal head during birth.

- 2 types: midline & Mediolateral

- MIDLINE = the middle of the perineum is cut, allos for easier healing, decreased blood loss and decreased postpartum discomfort

- MEDIOLATERAL = the cut starts of in the middle then its angled one side away from the rectum. The advantage to this method is it reduces the risk of rectal mucosal tears, but it may be more uncomfortable, and make the patient hesitant to use the bathroom for bowel movement.

OB PROCEDURES: AMNIOTOMY

• This is the artificial rupturing of the amniotic sac to induce labor - Allows for access to the fetal monitoring and blood sampling.- Can only be done if : the membranes are intact, the fetus is in

vertex position, the fetal head is at +2 station or lower, bishop score is 8 and the cervical dilation is 3cm.

- The patient is placed in dorsal recumbent position then the membranes are torn using an Amniohook inserted in the vagina.

- If done correctly then the fluid will gush out.- ADVANTAGE: you can access the fetus and induces labor - DISADVANTAGE: increased risk of umbilical cord prolapse,

increases the risk for infection, abruptio placenta may occur placenta unable to fit in the implantation site decrease in surface area for fetal oxygenation affecting the fetus oxygen consumption (possibly hypoxia).

BIRTH RELATED PROCEDURES- VERSION

• VERSION = aka turning the patient • Used to turn change the fetal position/presentation by abdominal

or intrauterine manipulation.

• TYPES OF VERSION:• EXTERNAL CEPHALIC VERSION (ECV)

- Done by manipulating the abdomen.- Pressure is applied to the fetal head and the buttocks so that the fetus

completes a backward flip or a forward roll. (the baby is flipped from breech to vertex position by applying pressure on the belly).

- The fetus is changed from breech , transverse or oblique to the CEPHALIC POSITION.

- If this is successful this reduces the chance of non-vertex and cesarean births.

- Best results are seen in baby’s that are in transverse position.


• PODALIC VERSION:- Used with only a second twin during a vaginal delivery.- The obstetrician places a hand in the uterus, grabs the feet of the fetus

and turns the fetus from transverse (or any non-vertex positions) to BREECH.

- The baby is born in breech position- Better than ECV because it causes fewer decelaration.- Some obstetricians may choose to do a C-section that use this method.

• ECV = EXTERNAL CEPHALIC VERSION- Done after 36-37 weeks gestations because before this time most fetuses

still in breech at this time will not spontaneously switch to vertex presentation.

- The stress of this procedure may increase the risk of intrapartum birth.


• BREECH FETUSES - Have a smaller head circumference from cephalic baby’s.- Lower birth weights - Fetuses that were previously breech tend to have higher

rates of none reassuring fetal status and dystocia.• MOTHERS OF BREECH BABY’S:- Tend to have small pelvis.• SUCCESS OF ECV IS INFLUENCED BY:- High parity - Adequate amniotic fluid- Lack of fetal enlargement - Transverse lie


• FAILURE OF ECV IS LINKED TO:- Nulliparity - Advanced dilation- Fetal weight less than 2500g- Anterior placenta- Low station- Maternal obesity - Anterior and posterior positioning of the fetal spine.• CRITERIA FOR EXTERNAL VERSION: - Single fetus ( if its multiples then they might get twisted during the ECV).- Enough amniotic fluid - The fetus must not be engaged (you cant do it if the fetus is engaged).- None Stress Test must be done immediately before.- The fetus must be 36-37 weeks. If less than 37weeks then the baby may

be born preterm.


• CONTRAINDICATIONS FOR ECV:-- fetal anomalies- Suspected intrauterine growth restriction = the fetus has been stressed

and amniotic fluid may be low at this time (you need an adequate amount of amniotic fluid for you to have an ECV done).

- Presence of an abnormal FHR =because this means that the fetus is already stressed.

- Rupture of the membranes – because it causes a low supply of amniotic fluid.

- Cesarean birth that’s indicated anyway – cesarean may be indicated for a mother with placenta previa. If ECV is done instead of a cesarean then it will cause bleeding.

- Maternal problems – e.g gestational diabetes, cardica probs, pre-eclampsia.

- Amniotic fluid abnormalities - OLIGOHYDRAMNIOS (amniotic fluid less than 5cm) makes the baby difficult to manuever and increases the chances of umbilical cord compression; HYDRAMNIOS (amniotic fluid greater than 25cm ) this stretches the uterus decreasing he chances that the fetus will remain in cephalic position if ECV is done.


- Previous lower uterine C- section because it increases the risk of uterine rupture or tear

- Nuchal cord because it will tighten around the fetus and choke it.

- Signs of uteroplacental insufficiency- 3rd trimester bleeding- Uterine malformation.

• ECV PROCEDURE:-- Woman must fast for 8 hours prior - Ultra sound to confirm that theres only one fetus, amount of

amniotic fluid, position of the uterus, position of the umbilical cord and that the baby is still in breech position.

- Maternal and Fetal vital signs taken external FHR monitor is used.

- CBC, NST, blood typing and antibody screening.


ECV PROCEDURE CONTINUED…..- Doc explains the procedure and gets consent.- Terbutaline or Magnesium sulfate if terbutaline is

contraindicated to RELAX THE UTERUS.- Woman placed in supine or trenderlinberg position.- Womans belly is covered with ultrasound gel to decrease friction

during the manipulation.- The fetal breech and head are moved in opposite directions

(rotating the baby)- If the woman is RH – then Rh immune globulin must always be

given after the version because there is a risk of Fetal- maternal hemorrhage.

- The version is stopped if the woman is in great pain or if the fetal vital signs are not reassuring. The doctor will resume in a week if the version was not successful the first time.


• ECV NURSING CARE

- Start by making sure the woman understands the procedure and that she can tell the doctor to stop if she becomes in too much pain.

- If the EVC fails there is a chance that cesarean birth will need to be done. (this prepares the woman).

- Explain the the version while the version is being done and answer any questions.

- Monitor blood pressure and pulse every 2mins throughout the time the terbutaline (beta mimetic) is being used and for 30mins after.

- Monitor the FHR for 1-2hours after the ECV.- Assess the response of both the fetus and the mother to the med give

(terbutaline)- Teach the mother how to monitor the uterine contractions, fetal

movement (a kick) and ways to recognize signs of reversion (excessive movement which most women describe as “the baby is turning round”).

- RhoGAM shoud be given to all Rh- women.

BIRTH RELATED PROCEDURES- CARE DURING RIPENING

• RIPENING = softening and effacing of the womans cervix.

• If induced labor has been indicated then PROSTAGLANDIN E2 gel (PGE2) is used for cervical ripening.

• The two common gels used are: PREPIDIL & CERVIDIL

• PREPIDIL contains 0.5mg of dinoprostone ( a form of prostaglandin E 2) is placed intracervically

• Cervidil is placed in the posterior vagina and is left in place to slow release at a rate of 0.3mghr over 10hours.


• DINOPROSTONE (CERVIDIL VAGINA INSERT)- Naturally occurring prostaglandin E2- Used for ripening and can stimulate smooth muscle uterus

contractions.- One vaginal insert is used, the oxytocin is used 30mins later.- The insert is placed transversely in the posterior fornix of the

vagina.- Patient is kept in supine for 2hours.- The insert is removed by pulling on the retrieval string when the

contractions start or after 12hours.- CONTRAINDICATIONS: nonreassuring fetal status, sensitivity to

prostaglandins, unexplained vaginal bleeidng, a client already on oxytocin, client who has had 6 or more previous pregancies, client who will give birth vaginally.

- CAUTION: in breech, ruptured membranes.


• SIDE EFFECTS OF CERVIDIL :-- Hyperstimulation- Fever - Nausea- Vomiting- Diarrhea- Abdominal pain.- Non reassuring FHR.- Increased chance of postpartum hemorrhage.- Uterine rupture (especially in women that have had a previous incision).- * should not be used on women with compromised Cardiac, hepatic,

renal, glaucoma, asthma.• NURSING CONSIDERATIONS - Assess the fetal status prior to administering - Report uterine stimulation , non reassuring fetal status to the DOC or the

CNM.


• PROSTAGLANDIN AGENT INSERTION:• PREPIDIL: a prefilled syringe attached to a catheter is

inserted into through the vagina into the endocervix where the gel is injected.

- The catheter has a small shield on top so gel cannot spill out into the internal OS.

- DINOPROSTONE : available in a gel form that can be applied on a diaphragm and inserted into the cervix or as a suppository that is inserted into the posterior fornix of the vagina.

- CERVIDIL: the vaginal insert is placed in the posterior vagina. * call the nurse if it is discharged. If hyperstimulation occurs then the cervidil can be removed. If active labor occurs Cervidil should also be removed.


• CYTOTEC (MISOPROSTOL): synthetic PGE1 used to soften and ripen the cervix and to induce labor.

- Available in a tablet form that can be taken orally or inserted into the vagina.

- Women usually deliver in 24hours.- Contraindicated in the 1990’s because it increased the chances of Uterine

Rupture.- Drug manufacture instructions say it should not be use to induce labor.- Some research has shown that its more effecttive than oxytocin and

prostaglandins & its associated with low cesasrean births.- Used in the 3rd trimester - One fourth of the full dose should be used at first (25mcg).- Keep the following doses consistant do not allow 3-6hours pass without

giving the next dose.- Pitocin should not be administered less than 4hours after the last dose of

CYTOTEC has been given.


- CONTRAINDICATIONS FOR CYTOTEC:- Uterine contractions 3times in 10mins- Asthma- Previous C-section or uterine scarring - Placenta previa- Non reassuring fetal status.• TRANSCERVOCAL CATHETER- balloon catheter is used for cervical ripening and

mechanical dilation.- Foley catheter balloon with 25-80ml of water is inserted

into the undilated cervix and then inflated.- The balloon applies pressure on the inetrnal os of the

cervix and ripens the cervix.


• NURSING INTERVENTIONS:- Delivery nurses with special training give ripening agents.- Maternal and fetal vital signs taken for baseline.- External Fetal Heart rate monitor is used for 30mins.- The woman must remain lying down with a rolled

blanket or hip wedge under her right hip to tip the uterus slightly to the left for the first 30-60mins to maintain the cervical ripening agent in place.

- Monitor for hyperstimulation and FHr variations.- If TACHYSYSTOLE = hyperstimulation of the uterus occurs

(5 contractions in 10mins) POSITION THE WOMNA IN THE LEFT SIDE AND ADMINISTER OXYGEN IF THERE IS FETAL DISTRESS.


- NURSING INTERVENTIONS FOR CERVICAL RIPENING CONTINUED…

- 0.25mg subcutaneous injection of Terbutaline should be considered if the hyperstimulation continues.

- The cervical ripening gel may be removed if the patient experiences nausea, vomiting or tachysystole develops * don’t give antiemetics though.

- Women using the transcervical technique for cervical ripening and dilation does not need continous fetal monitoring.

- Mark the caheter tubing at the point that’s outside the insertion point as a way to determine if the catheter at any point gets displaced.

- A woman who receives the catheter method should remain in the recumbent position * don’t perform any vaginal exams.

- Avoid ambulation and use a bedpan.

BIRTH PROCEDURES- AUGMENTATION & INDUCED LABOR

• INDUCED LABOR = deliberately initiating uterus contractions to stimulate labor.

• LABOR AUGMENTATION= stimulation of uterus contractions when spontaneous contractions have failed to result in cervical dilation or descent of the fetus.

• INDICATIONS OF INDUCED LABOR OR AUGMENTATION:- Diabetes - Renal disease- Preeclampsia- Hypertension- PROM- Post term gestation- Intrauterine growth restriction (IUGR)- Isoimmunization- History of precipitous labor- Abruptio placentae- olighydramnios.


• CONTRAINDICATIONS TO LABOR INDUCTION OR AUGMENTATION:-

- Abnormal fetal heart rate - Breech presentation - Unknown fetal presentation - Multiple gestations - Polyhyamnios- Presenting fetal part is above the pelvic inlet- Severe hypertension- Maternal heart disease.• BISHOP SCORING SYSTEM IS USED TO EVALUATE OF THE

WOMAN IS READY TO BE INDUCED.• Assessment is key before the induction is done, amniotic fluid

tests and phosphatidylglycerol to assess the fetal lung maturity must also be done.


• WAYS OF INDUCING LABOR:• STRIPPING MEMBRANES: aka sweeping.- Non pharm method of inducing labor - as an Augmentation method it can be done in the birthing room to

attempt to strengthen the contractions without the need for oxytocin. BUT if the contractions are still not strong enough then Oxytocin might need to be given.

- This is stripping of the amniotic membranes.- The physician uses his finger, inserts it into the the vagina as far as

possible into the cervix and rotates his finger 360 degrees twice this separates the amniotic membranes.

- Sweeping is believed to release PGE2 from the cervix.- Women who have this procedure done tend to have shorter pregnancy.- Uterine contractions, bleeding and abdominal cramping can occur from

this procedure.- If successful then labor occurs within 24-48hours


• OXYTOCIN INFUSION - Given through IV to create uterine contractions & INDUCE

LABOR.- THE GOAL IS TO HAVE contractions lasting in about 40-

60seconds in 10mins with good uterus relaxation and return to the baseline tone when between contractions.

- Oxytocin is also given during augmentation when the labor is not progressing as it should, the fetus is not descending so Oxytocin will be given in this case to create the desired uterus contraction pattern with strong contractions cervical dilation fetal descent.

• Before administering oxytocin for induced labor or augmentation the nurse should assess for:

- Assess the mothers pelvis * contraindicated in cephalopelvic disproportion

- Fetal positioning and fetal station


• HOW OXYTOCIN IS ADMINISTERED: - Should be given using a device that allows precise

control of the IV flow rate.- A primary line of IV fluid is started first this avoids the

risk of large dose of oxytocin being given. * let the line run.

- Oxytocin is then piggybacked into the primary tubing *use the port closest to the catheter insertion (this allows only a small amount of oxytocin to back flow into the tubing creating greater dosage accuracy.

- Oxytocin should not be given Intramuscularly and without an IV PUMP.

- To reduce pulmonary edema

BIRTH PROCEDURES- VACUUM ASSISTED BIRTH

• Cup like suction device placed on the fetal heal to help with delivery.

• INDICATED WHEN: the woman is having a difficult labor, labor not progressing, fetal distress during second stage of labor.

• CONDITIONS FOR VACUUM EXTRACTION: vertex presentation, ruptured membranes.

• Don’t apply for longer than 25mins.• Watch for lacerations and cephalohematoma.• Capput succedeneum is normal will resolve in

24hours.

OB PROCEDURES: FORCEP USE

• FORCEPS = spoon like blades used to assist with the delivery of the fetal head.

• RISK FOR USE: face nerve palsy and laceration of the cervix and vagina.

• INDICATED WHEN: fetal distress and when the fetus is in breech presentation and the head needs to be delivered.

INTRAPARTUM PERIOD:

COMPLICATIONS OF LABOR AND BIRTH

PRETERM LABOR• PRETERM LABOR = uterus contractions and cervical

changes occurring between 20-37weeks gestation.• RISK FACTORS THAT INCREASE CHANCES: infection,

hydramnios (excess amniotic fluid), below the age of 17yrs or above, diabetes, incompetent cervix (cervix that’s unable to remain closed to carry the pregnancy to term).

• SIGNS AND SYMPTOMS: low back pain, pain on the pelvis and cramping, increased vaginal discharge blood may be present, regular contractions lasting longer than an hour, PROM.

• NURSING INTERVENTIONS:• Priority is to stop the contractions. Done by: *restrict

activity, keep patient hydrated, give tocolytic meds, glucocorticoids for fetal lung maturity. Treating the infection if the patient has one.

PRETERM LABOR:tocolytics• Contraindicated when the woman is 34weeks

or more, fetal ditress, vaginal bleeding,dilation greater than 6cm.

• WATCH FOR PULMONARY EDEMA (chest pain, SOB, resp distress, wheezing and crackles, blood tinged sputum.

PRETERM BIRTH• PRETERM BIRTH: birth occurring at 20weeks

gestation but before 37weeks • COMPLICATION TO THE FETUS: RDS (watch

for nasal flaring, retraction of the chest wall during inspiration, grunting).

• GIVE THE WOMAN BETHAMETHOSONE FOR 24HOURS PRIOR TO DELIVERY TO PROMOTE LUNG DEVELOPMENT AND PREVENT RDS.

PREMATURE RUPTURE OF MEMBRANES• PROM= sudden rupture of membranes 1 hour or more

prior to the onset of true labor.• PPROM = PRETERM PREMATURE RUPTURE OF

MEMBRANES = the rupture of membranes after 27weeks but before 37weeks.

• Biggest risk when PROM occurs = INFECTION• NURSING INTERVENTIONS:– Nitrazine test to test that its amniotic fluid (ph 6.5-7.5 is

positive).– Check for PROLAPSED UMBILICAL CORD.– Tell patient to wipe from front to back to avoid infection,

no sex, no inserting anything vaginally.– Take temp at home every 4hours , report increase.– Avoid bath tubs.

PROLAPSED UMBILICAL CORD• The umbilcal cord appears/falls or before the presenting part of the

fetus.• Can cause cord compression & compromise circulation.• SIGNS AND SYMPTOMS:

– VARIABLE DECELERATIONS ***** BIGGIE– Woman reports that she feels something coming through her vagina.– The umbilical cord is protruding.

• FACTORS INCREASING THE RISK:– Fetus is in abnormal presentation– SGA– Cephalopelvic disproportion because if theres a loose fit between the

presenting part and the pelvis this leaves room for the fetus to pass through.

– The presenting part is not engaged when the membranes rupture

PROLAPSED UMBILICAL CORD

• NURSING INTERVENTIONS:– Change position to side lying with towel rolled

under the hip, knee-chest.– Using sterile gloved hands insert two fingers into

the vagina and apply finger pressure to relieve the pressure of the cord

– Monitor FHR– Oxygen 8-10L– Amnioinfusion of normal saline to relieve

compression if its been caused by oligohydramnios (too little amniotic fluid).

PRECIPITATE LABOR• PRECIPITATE LABOR: labor lasting 3hours or less from the time of

contractions to the time of birth.• CONTRIBUTING RISK FACTORS:• HYPERTONIC UTERUS CONTRACTIONS • HYPERTONIC CONTRACTIONS

– Non-cordinated – Non productive – Painful uterus contractions – Don’t allow for relaxation of the uterus between contractions decrease in

fetal oxygenation supply.• NURSING INTERVENTIONS.

– Don’t leave the mother unattended– Side lying position for fetal circulation and oxygenation– Don’t stop the delivery.– Control rapid delivery by applying pressure on the perineal area and fetal

head. *this helps prevent rapid expulsion preventing CEREBRAL DAMAGE & PERINEAL LACERATIONS FOR THE MOTHER.

PRECIPITATE LABOR

• COMPLICATIONS OF PRECIPITATE LABOR:• TO THE FETUS: – INTERCRANIAL HEMORRHAGE *** resulting from

the trauma during the rapid delivery.– Hypoxia due to the uteroplacental insufficiency

caused by the hypertonic uterine contractions.

• TO THE MOTHER:– Cervical, vaginal and perineal lacerations.

MECONIUM STAINED AMNIOTIC FLUID• Can be caused by fetal cord compression fetal

hypoxia vagus nerve which is responsible for HR and GI peristalsis is stimulated peristalsis of the fetus GI relaxation of the anal sphincter meconium released (the first stool of the fetus)

• SIGN OF FETAL DISTRESS if accompanied by variable or late decelerations, acidosis which is confirmed by scalp blood sampling.

• NURSING INTERVENTIONS:– Suction the nasopharynx at the time of birth to

prevent meconium aspiration syndrome.

POST TERM PREGNANCY• POST TERM PREGNANCY = pregnancy going beyond 42weeks gestation.• RISK TO THE MOTHER:

– Birth canal trauma because the fetal bones have matured and the skull has hardened.

– Post partum hemorrhage and infection.• RISK TO THE FETUS:

– Dystocia and prolonged labor fetal distress meconium in amniotic fluid– Macrosmonia (large for gestational age)– Polycythemia

• CONTRIBUTING FACTORS:– Decrease in estrogen decrease in oxytocin production decreased

contractions.• SIGNS AND SYMPTOMS:

– Weight loss of 3lbs/week and decrease in the size of the uterus which is caused by the decrease in amniotic fluid.

• NURSING INTERVENTIONS – AMNIOINFUSION

DYSTOCIA• Difficult labor • Related to the 4 powers of labor (power, passenger, passage,

psyche, position).• Related to abnormal uterus contractions (hypertonic or hypotonic

contractions).• CONTRIBUTING RISK FACTORS:• *LGA• Older than 40yrs, fetal head is larger than the pelvis, uterine

abnormalities, maternal fatigue and fear.• SIGNS AND SYMPTOMS:• Fetal distress • Lack of progress in labor*** (hypotonic contractions can be

indented during contractions, hypertonic contractions cant).• SHOULDER DYSTOCIA IS :• When the fetus anterior shoulders cannot pass under the

symphysis pubis after the delivery of the fetal head.

RUPTURE OF THE UTERUS• Complete or incomplete separation of the uterus caused by a tear

in wall of the uterus from the stress of labor.• Complete- rupture goes into the peritoneum• Incomplete – • SIGNS AND SYMPTOMS• The fetus may be palpated outside the uterus *in complete rupture• Absent FHR• Contractions can stop or fail to progress.• Rigid abdomen.• INTERVENTIONS:• Monitor for shock• IV fluids and oxygen • Prepare for C-section and hysterotomy.

PLACENTA PREVIA• PLACENTA PREVIA = improper implantation of the uterus. Its

implanted on the lower segment or near the internal cervical os.• TYPES OF PLACENTA PREVIA :

– Total = the placenta covers the cervical os – Partial = covers the cervical os partially.– Marginal =

• SIGNS AND SYMPTOMS ?– Painless, bright red vaginal bleeding – Uterus is soft, relaxed and nontender.– Fundal height may be HIGHER more expected than the gestational

age.• NURSING INTERVENTIONS:

– Fetal heart rate and maternal vital signs should be assessed first.– There may be a need for a c-section if bleeding is heavy.– No vaginal exam or anything that will stimulate the uterus.– Position the patient in side lying position.

ABRUPTIO PLACENTAE• ABRUPTIO PLACENTAE: this is premature separation of the

placenta from the uterus wall after the 12th week of gestation and before the fetus is delivered.

• SIGNS AND SYMPTOMS:– Dark red vaginal bleeding * DARK RED– Uterine pain and tenderness *PAINFUL– Uterine rigidness– Severe abdominal pain – Signs of fetal distress.– There may be signs of shock

• NURSING INTERVENTIONS:– Vital signs and FHR– Bed rest, oxygen, IV fluids and blood products – Trendelenburg position to decrease the pressure of the fetus on the

placenta.

PLACENTA ABNORMALITIES

• PLACENTA ACCRETA = abnormal attachment of the placenta

• PLACENTA INCRETA = placenta penetrates the uterus muscle itself

• PLACENTA PARCRETA = the placenta goes all the way through the uterus.

• SIGNS AND SYMPTOMS:• Hemorrhage immediately after birth because the

placenta will not separate as one would normally.• INTERVENTIONS:• Monitor for shock and hemorrhage

UTERUS INVERSION

• UTERUS INVERSION= the uterus is completely turned inside out.

• Occurs during delivery of the placenta • SIGNS AND SYMPTOMS:– Depression in the fundal area– The uterus may be seen protruding through the cervix

or through the vagina– Woman is in severe pain.

• NURSING INTERVENTIONS:– Watch for signs and hemorrhage and shock *

interventions to meet these.

AMNIOTIC FLUID EMBOLISM• This is when amniotic fluid escapes into maternal circulation.• The debri which is found on the amniotic fluid enters the mothers

pulmonary arteries and deposits there.• SIGNS AND SYMPTOMS:

– RD and chest pain– Cyanosis– Seizures– Pulmonary edema– Bradycardia.

• NURSING INTERVENTIONS:– Oxygen 8-10L/min– Position on side– IV fluids and blood products – Prepare for emergency delivery and monitor the fetal status.

POSTPARTUM PERIOD

NEONATE POSTPARTUM PERIOD

NEW BORN POSTPARTUM PERIOD

NEWBORN ASSESSMENT NEWBORN DRUG NEEDS CIRCUMSICION NEWBORN NUTRIONAL REQUIREMENTS POSTPARTUM NEWBORN COMPLICATIONS

APGAR SCORING • Done 1-5mins after birth • Assesses the extrauterine adjustment of the neonate.• Scoring based from 0-2 • 0 = poor / absent • 2 = excellent • 5 categories assessed• Heart rate ( 1= less than 100 bpm; 2= more than 100bpm).• Respirations (1= slow or weak cry ; 2= good vigorous cry)• Muscle tone• Reflex irritability (0= absent ;1 = minimal ; responds promptly)• Skin color (0 = pallor and cyanosis ;1= normal coloring with blue

extremities; 2= body and extremity coloring is normal) • When total is added up:• 0-3 = severe distress• 4-6 = moderate distress• 7-10 = no distress

GESTATIONAL ASSESSMENT

• Done within 2-12hours after birth • Measurements of the newborn and New Ballard

Scale is used to estimate gestational aging & its used as a baseline to assess growth and development.

• PHYSICAL MEASUREMENTS :• WEIGHT = 2500g – 4000g• LENGTH =45cm- 55cm. Measurement from top of the

head to the heal of the foot.• HEAD CIRCUMFERENCE= 32cm- 36.8cm (18-22inch)• CHEST CIRCUMFERENCE = 30 – 33cm (12.6 – 14.5inch)

GESTATIONAL ASSESSMENT• New ballard scale assesses the neuromuscular and physical

maturity to find the infants gestational age.• NEUROMASCULAR MATURITY:

• Posture – fully extended and fully flexed• Square window formation of the wrist• Arm recoil (the babys arms are extended then just let go and allows it

to spontaneously return to flexion.• Popliteal angel – degrees to which the knees can extend.• Scarf sign – crossing the neonates arms over the chest.• Heel to ear – how far the heels reach the ears.

• PHYSICAL MATURITY• Skin texture• Lanugo• Plantar surface creasess• Breast tissue • Genitalia (testes and labia)

INFANT VITAL SIGNS

• RESPIRTIONS • 30 – 60/ min may have short periods of apnea lasting

15seconds• Apnea periods occur mostly during REM• Apnea lasting longer than 15seconds may be a sign for

resp distress.• Crackles and wheezing can be a sign for fluid in the

lungs or infection• Grunting and nasal flaring = Respiratory distress.

• HEART RATE • 120- 160/min• Listen to apical pulse for full min

INFANT VITAL SIGNS

• BLOOD PRESSURE • Systolic = 60-80mmhg• Diastolic = 40-50mmhg

• TEMPERATURE• 36.5 – 37. 2 degrees celcius (97.7 – 98.9 F)• High risk for hypothermia and hyperthermia

because of the infants inability to thermoregulate. • If the baby becomes CHILLED (COLD STRESS)

increased oxygen demands acidosis • Fetal hypoxia depressed respirations

BODY ASSESSMENT OF THE NEW BORN• POSTURE: must be flexed and resistant to extension.• SKIN: pink or acrocyanotic, no jaundice on the first day but it may

appear a day later.• Texture: dry, soft and smooth. * full term babys may be peeling

*DESQUAMATION.• SKIN DEVIATIONS:• Milia= small white spots * don’t pop• MONGOLIAN SPOTS: bluish purple spots, usually on the neonates

back, shoulder and buttocks.• TELANGIECTATIC NEVI = * stork bite. flat and pink or red marks

found on the babys upper eyelids or the middle of the forehead. They fade by the time the baby is 2.

• NEVUS FLAMMEUS: port wine stain. Red or purplish mark, does not blanch or disappear.

• ERYTHEMA TOXICUM = erythema nenatorum. Rash that appears suddenly.

BODY ASSESSMENT OF THE NEW BORN

• THE HEAD:• Should be larger than the chest circumference.• If the head is greater or equal to 4cm larger than

the chest this could be a sign for HYDROCEPHALUS.

• LESS THAN OR EQUAL TO THE CHEST CIRCUMFERENCE = MICROCEPHALY (abnormally small head).

• BULGING FONTANELS = Increased intercranial pressure, infection or hemorrhage

• DEPRESSED FONTANELS = dehydration.

CAPUT SUCCEDANEUM & CEPHALOHEMATOMA• CAPUT SUCCEDANEUM • Localized swelling of the soft tissue on the scalp. (the

swelling is over the bone)• The swelling cross over the suture line• Caused by pressure on the head during labor • Usually resolves within 3-4days .• CEPHALOHEMATOMA:• Swelling caused by bleeding into an area between the

bone. *collection of blood between the periosteum and the skull bone.

• Absorbed within 6 weeks with no treatment.• Caused by trauma during birth for instance pressure of the

fetal head against the maternal pelvis in a prolonged difficult labor or the use of forcep delivery.

• Appears within 1-2days after birth.

NEW BORN ASSESSMENT• EYES:• Permanent eye color is established in 3-12months.• Immature lacrimal glands so there is tearless crying.• EARS: • The upper tip of the pina should be In line with the outer canthus of

the eye.• Low set ears could be a sign for downs syndrome.• Lack of cartilage = sign for immaturity.• NOSE:• Babys are nose breathers • They get the skill to breath with their mouths at 3weeks.• MOUTH • EPSTEIN PEARLS = white spots found in the palate and gums.

Caused by accumulation of epithelial cells * normal.• Tongue: if its large and protruding this is a sign for downs

syndrome.

NEW BORN ASSESSMENT

• REFLEXES:• MORO = you act like you are going to let go of the

baby or strike the surface that they are sleeping on. * the baby will extend the body and form a C with the hands (act like they are griping onto something).

• Palmar grasp = you touch the palm of the baby and they will try to grasp the object.

• Plantar grasp = the baby’s toes curl downward when the sole of the foot is touched.

• Stepping = you pick up the baby as if you are making them stand and they respond by dancing or stepping.

• Startle = loud noise * the baby will abduct his arms and flex his elbows.

NEW BORN ASSESSMENT

• Most important adjustments to extrauterine life are Respiratory and Circulatory. They must occur rapidly.

• Respirations established by the cutting of the umbilical cord *most important extrauterine adjustment because the infant now has to breath by themselves. Air enters the lungs with that first breath.

• ASSESSMENT OF THE NEONATE ARE:• Initial assessment immediately after birth (APGAR

SCORE)• GESTATIONAL AGING ASSESSMENT WITHIN 2HOURS • COMPLETE IN DEPT PHYSICAL EXAM WITHIN 24HOURS

NURSING CARE OF THE NEWBORN

• CARE OF THE NEWBORN IS DIVIDED INTO THREE PHASES:• PHASE 1: STABILIZATION• Stabilize or resuscitate to relieve airway obstructions if there's any• Thermoregulation to maintain body temperature.• PHASE 2: ASSESSMENT COMPLETION • Apgar score, physical exam, measurements and monitoring the

infants labs).• PHASE 3: NURSING INTERVENTIONS AND FAMILY TEACHING• Umbilical cord care • Prophylatic measures• New born screening • Infant feeding and bathing • Helping parent – infant attachment.


• Highest priority is the abduction safety * use identification bracelets for bothe the mother and the infant.

• Anyone coming in contact with the infant should be wearing an indentification bracelet.

• Children with respiratory distress are at risk for HYPOTHERMIA• Infants of mothers with diabetes are at highest risk for

HYPOGLYCEMIA• Infants delivered by c-section are at highest risk of FLUID IN THE

LUNGS.• NURSING ASSESSMENTS:• Vital signs q30mins x2; q1hr x2 then every 8hours.• Weight, length and chest circumference• Chest the umbilical cord• Watch periods of reactivity


• PERIODS OD REACTIVITY :• 1st period: the infant is exploring the world

making sucking noises, rapid resps and heart Rate which stabilize in 15-30mins.

• Period of relative inactivity: the infant is resting and sleeping.

• 2nd period of reactivity : the infant awakens and becomes alert again. Baby may be choking on their saliva and mucus this may last from 10mins to

NURSING CARE OF THE NEWBORN: THERMOREGULATION

• NEWBORN KEEPS WARM BY METABOLIZING BROWN FAT. • When the baby is chilled oxygen demand increases more

brown fat is used.• HYPOTHERMIA SIGNS: cyanosis,increased resps , temp of 36.5

degrees celsius.• CONDUCTION: loss of body heat from direct contact with a cooler

surface. * place the baby on the mothers stomach skin to skin then cover with a blanket.

• CONVECTION: flow of heat from the body to a cooler air. (so with a fan the heat moves away from you towards the cooler air which is being blown by the fan). *place the baby stuff out of the direct line of a fan.

• RADIATION: loss of heat from the body surface to a cool and solid surface that is close but not in direct contact like with conduction. *keep the examining tables away from stuff like windows.

NURSING CARE OF THE NEWBORN:

• ELIMINATION:• The newborn should void at least once in the 24hours after birth ,

then 6-10 days the day after or 4 days after.• Meconium should be passed in the first 24hours• Poo for breast fed infants is yellow and seedy• Formular fed babies have lighter and looser stool.

• BATHING THE BABY:• Done when the baby’s temperature stabilizes at 36.5 degrees.• Done after 1-2 hours after birth.• Should be done under the radiant heat warmer to prevent heat

loss.• After the initial bath, just clean the areas like the face, perineal and

skin folds daily , but do a complete bath 2-3 times a week.

NEWBORN MEDS

NURSING CARE OF THE NEWBORN: DRUGS

• GLUCOSE for hypoglycemia • NEW BORN GENETIC SCREENING:

• Capillary heel stick test done within 24hours after birth.• For accurate results the infant must have had breast milk or

formula within that 24hours.• If the newborn is discharged before the baby is 24hours old

then the test should be done again in 1-2weeks.• The genetic testing is assessing PKU (PHENYLKETONURIA) which

is a defect in protein metabolism.• The accumulation of the amino acid phenylalanine can result in

MENTAL RETARDATION.• Treatment in the first 2months of life can prevent mental

retardation.• Other genetic tests are: cystic fibrosis, maple syrup urine

disease, sickle cell disease.


• NEWBORN HEARING SCREENING:• To detect deafness early• PROPHYLACTIC EYE CARE:• Antibiotic ointment is placed in the eyes to prevent OPTHALAMIA

NEONATORUM.• Baby’s eyes can get infected when the baby is passing down the birth

canal.• OPTHALAMIA NEONATORUM = is caused by N. gonorrhoeae or

Chlamydia trachomatis which can cause blindness.• ERYTHROMYCIN (E-MYCIN) 0.5% ointment is used.• Applied in the lower conjuctiva sac (start inner canthus and move

outwards).• Close the eye for 5 seconds to allow the ointment to spread. Wipe the

excess ointment after 1min.• Adverse reaction = chemical conjuctivitis which is seen as redness,

swelling, drainage and temporarily blurred vision for 24-48hours. • Teaching = the chemical conjuctiva is a normal reaction and will pass in

24-48hours. This is normal.


• HEPATITIS B VACCINE • Given at birth , 1 month then at 6months if the

woman is Hep B –• If the mother is Hep B positive then they should

get Hep B immuno globulin and the Hep B vaccine in addition within 12hours of birth.

• The Hep B vaccine is then given at 1month, 2months and 12months

• Do not give the vitamin k and Hep B vaccine on the same thigh.

NEW BORN CARE DRUGS: VITAMIN K

• VITAMI K (AQUAMEPHYTON) injection• Used to prevent hemorrhagic disorders • Infants don’t priduce Vitamin K is not produced in

the GI tract of the newborn until Day 8.• Vitamin K is produced in the colon by the bacteria

that forms once formula or breast milk is introduced into the the GI system of the newborn.

• Shot is given IM into the VASTUS LATERALIS because this is where the muscle is most developed within 2hours after birth.

NEWBORN CARE: UMBILICAL CORD• Should have 1 vein 2 arteries. LESS = ABNORMALITY• Odorless and have not intestinal structures• Small thin cord = poor fetal growth.• Should be clamped for 24hours until the the cord is dry and occluded.• Clean with alcohol.• Signs of umbilical cord infection = moistness, oozing, discharge and

reddened base. • Bleeding umbilical cord = due to a cord that was pulled or loosened cord

clamp.• Foul smelling drainage = infection *treat immediately to prevent

septicimia.• Umbilical cord hernia is caused by patent omphalomesentric duct *

common in african infants.• Serous or serosanguineous drainage that continues after the cord falls off

is a sign for GRANULOMA (you will see a small red button deep in the umbilicus). TREATMENT = SILVER NITRATE STICK.

• MOISTNESS OR DRAINING URINE AT THE BASE OF THE UMBILICAL CORD IS A SIGN FOR PATENT URACHUS (abnormal connection between the umbilical cord and the bladder)

NEWBORN CARE: CIRCUMSICION• CIRCUMCISIONS = removal of the foreskin

• Jewish = do this 8days after birth • NOT DONE IMMEDIATELY AFTER BIRTH BECAUSE:• Low levels of Vitamin K so theres increased risk for bleeding• Danger of cold stress.

• CONTRAINDICATIONS:• Congenital abnormalities (hypospadias, Epispadias).• Hypospadias = abormal positioning of the urethra on the ventral

under surface of the penis.• EPISPADIAS = urethral canal terminates at the dorsum of the

penis• History of bleeding in the family• Ambiguous genitalia (both male and female parts)• Illness or infection

NEWBORN CARE: CIRCUMSICION• TYPES OF PROCEDURES:• YELLEN, MOGEN, GOMCO CLAMP PROCEDURES:• Clamp is applied to the penis, foreskin is loosened and a

cone is inserted under th foreskin to provide a cutting surface.

• The wound is covered with a petroleum gauze to prevent infection and bleeding.

• PLASTIBELL METHOD:• Plastibell is placed between the foreskin and the glans of

the penis.• The physician ties a suture tightly around the foreskin at

the coronal edge of the glans.• The suture becomes ischemic and atrophies• 5-8 days later the foreskin drops off with the plastibell

attached leaving the clean well healed incision.

NEWBORN CARE: CIRCUMSICION

• POSSIBLE COMPLICATIONS OF CIRCUMCISIONS:• BLEEDING: • Apply gentle pressure with gelfoam powder or sponge to

stop bleeding.• Tell the physician if the bleeding continues, continue to

apply pressure until the physician arrives.• COLD STRESS/HYPOGLYCEMIA• Watch for excessive heat loss from increased respirations

and lower body temp.• Use a radiant warmer during this procedure during the

procedure and swaddle the baby after.• OTHER COMPLICATIONS:• Monitor for infections, urethra fistula, delayed healing,

scarring.

POSTPARTUM: NEWBORN NUTRIONAL NEEDS

NEWBORN CARE: CIRCUMSICION

NURSING INTERVENTIONS AND TEACHINGS:• Tell the parents anesthesia will be given• Do not bottle feed 4hours prior the procedure to prevent the vomiting

and aspiration.• Breast feeding infants may nurse until the procedure.• Signed consent should be in the chart prior to the procedure.• Keep the area clean (change diaper q4hrs and clean the penis with

warm water with ach diper change, with clamp procedures apply petrolium jelly with each diaper change for at least 24hours after the circumcision)

• Fan fold the diaper to prevent pressure on the circumcised area.• Don’t wrap the penis in tight gauze• No tub bath until its completely healed• Tell the physician if there is any rednessm swelling, strong odor,

tenderness, decreased urination, excessive crying of the infant• There may be a yellowish mucus over the penis by day 2 * do not

wash it off• No baby wipes because they have alcohol.

NEWBORN CARE: NUTRITIONAL NEEDS • Normal Weight Loss and Weight Gain:• 5-10% weight loss immediately after birth gained after 10-

14days.• 110- 200g/week weight gain for the first 3months.• Breast feeding the best nutritional source of food for the first

6months.• COLOSTRUM =contains immunoglobulins providing passive

immunity. Secreted 1-3days.• FEEDING FREQUENCY:• Q2-3hours for breast feeding • Q 3-4hours for bottle feeding• Feed Q4hours at night• Healthy newborn fluid intake 100-10mml/kg/24hours• They receive enough water from breast milk so no need to

supplement with water.

NEWBORN CARE: NUTRITIONAL NEEDS

• CALORIE INTAKE :• 110/kg/day for the first 3months• 100/kg/day when they are now 3-6months• Baby’s cannot digest fat from cows as easily this is why cow

milk is not given.• They may be a need for vitamin D supplementation (especially

in dark skinned women who have limited exposure to the sun, vegetarian mothers who exclude meat from their diert, fish and dairy products.

• Iron = after 6 months the babys need to be given iron fortified cereal; babys that are bottle fed should receive iron fortified formula until they are 12months.

• Fluoride low in breast milk too so should be supplemented.• SOLIDS should be given at 6months

NEWBORN CARE: NUTRITIONAL NEEDS • BENEFITS OF BREASTFEEDING:• Reduce infection by providingantibodies, leukocytes• Large amounts of lactose provides rapid brain growth• Has electrolytes and minerals• Sucking associated with breastfeeding reduces dental

problems.• Colostrum provides IgA antibodies.• NEWBORN FACTORS THAT COULD CAUSE FAILURE TO

THRIVE:• Inadequate breastfeeding• Illness• Infection• Malabsorption

NEWBORN CARE: NUTRITIONAL NEEDS • MATERNAL FACTORS THAT CAN CAUSE FAILURE TO THRIVE:• Pain when feeding • Inappropriate timing of feeding• Inadeqaute breast tissue• Maternal hemorrhage• Illness• Infections • Breasts are not emptying well• THINGS TO ASSESS FOR :• Growth and weight gain • Weigh daily while I nursery • Weigh when 2weeks for breast fed infants • Weigh at 6 weeks for formula fed infants.• Adeqaute wieght gain is within the 10th to 90th percentile • Monitor length and head circumference• Calculate the newborns 24hour intake

NEWBORN CARE: NUTRITIONAL NEEDS • NURSING INTERVENTIONS:• Feed when the infant is showing signs of hunger rather than waiting

for the infant to start crying.• Signs of hunger (hand to mouth, or hand to hand movements,

sucking motions, rooting, mouthing.• SUCCESSFUL BREASTFEEDING:• Get comfortable, wash hands before holding the breast and have

fluids to maintain hydration and allow let down• Stimulation of the nipple releases oxytocin let down.• Uterine cramps are normal during breastfeeding (they care cuased

during oxytocin).• Show proper latch position (support the breast with one hand and

compress the breast, stimulate the infant by rubbing our nipple on the baby's mouth, the mouth should cover the areola as well as the nipple.

• Squeeze some colostrum and spread it over the nipple to lubricate the nipple

NEWBORN CARE: NUTRITIONAL NEEDS • Teach the mother to breastfeed for at least 15mins each breast • Insert the finger in the mouth to break the suctioning from the nipple this prevents

nipple trauma.• Burp between births.• Start the next feeding with the breast that she stopped the infant with in the last

feeding.• To make sure that the infant is receiving enough feeding the infant will gain weight,

void 6-8 times a day• Loose pale, yellow stools are normal with breast feeding • Place the baby in supine position after feeding • STORAGE OF BREAST MILK:• If the mother is using a breast pump store the milk in the fridge for up to 48hr after

being pumped.• Throw away after 48hours • Label the containers so you know the dates and time the milk was expressed.• Can be stored in the freezer for up to 1 year.• If kept in the freezer thaw the milk in the fridge for 24hours ( this preserves the

immunoglobulins.• Do not thaw by microwave.

NEWBORN CARE: NUTRITIONAL NEEDS • SUCCESSFUL BOTTLE FEEDING:• Prepared formular can be kept in the fridge for 48hours• Cradle the baby in a semi-upright position when holding the baby *

don’t feed the baby while in supine position this will cause aspiration.

• The nipple of the bottle must be kept filled to prevent the newborn from swallowing air if partially filled.

• Throw away any unused formula as it can cause bacterial contamination

• FAILURE TO THRIVE • This is slow weight gain• The baby falls in the 5th percentile• Evaluate the latch during breast feeding • Massage the breast during feeding to encourage let down• If the baby is formula feeding evaluate how much they feeding • Vomiting a lot if they are bottle feeding may be a sign that they are

allergic to cow milk and they may need to be moved to soy milk.

POSTPARTUM: NEW BORN COMPLICATIONS

CARE OF THE NEWBORN: COLD STRESS

• Complication of poor thermoregulation• Can lead to hypoxia, acidosis and hypoglycemia.• SYMPTOMS OF COLD STRESS: cyanotic trunk,

depressed respirations.• PREVENTION: avoid any heat loss (cover the babys

head with the hat to prevent heat loss, place the baby under the heating bed. * keep the baby warm.

• INTERVENTION FOR COLD STRESS: • Slowly warm the baby over 2-4hours • If the baby has hypoxia give oxygen• Correct the acidosis and hypoglycemia

NEWBORN COMPLICATIONS: RDS

• RDS = RESPIRATORY DISTRESS SYNDROME• Caused by not enough surfactant (phospholipid that helps

in the expansion of the lungs) in the lungs • Characteristics = poor gas exchange and ventilation failure.• Poor gas exchange ATELECTASIS (collapsing of the

portion of the lungs) increased breathing effort respiratory acidosis and hypoxemia.

• COMPLICATIONS OF RDS:• Pneumothorax• Pneumomediastinum• Retinopathy • Bronchopulmonary dysplasia• Infection• Intraventricular hemorrhage

NEWBORN COMPLICATIONS: RDS

• FACTORS INCREASING THE RISK OF RDS:• PRETERM * biggest one (but birth weight alone is not an

indicator).• Perinatal asphyxia (e.g meconium statining, cord prolapse,

nuchal cord).• Maternal diabetes• PROM• Mother who uses barbituates, and narcotics close to birth.• C- section birth • Hydrops fetalis = massive edema of the fetus caused by

hyperbilirubinemia.• DIAGNOSTICS :

• ABG’s will show hypercapnia (too much CO2 in the blood) and respiratory or mixed acidosis.

NEWBORN COMPLICATIONS: RDS• SIGNS AND SYMPTOMS OF RDS:• Tachypnea• Intercoastal and substernal retractions• Labored breathing• Rales when auscultation• Nasal flaring• Cyanosis• LATE SIGNS= infant is unresponsive, flaccid, apneic, decreased breath

sounds.• NURSING INTERVENTIONS • Suction mouth, trachea and nose• Thermoregulation • Give meds (NARCAN AND exogenous surfactant).• Give mouth and skin care• Give SODIUM BICARBONATE FOR METABOLIC ACIDOSIS• Oxygen • Decrease stimulation

NEWBORN COMPLICATIONS: LGA/MACROSMNIA

• LGA = weighing more than 4000g (8lbs 12oz).• Macrosmic infants are at high risk for birth injuries:

Clavicle fracture, hypoglycemia and polcythemia• Most common cause for Lga is uncontrolled

hyperglycemia during pregnancy. This can lead to congenital defects (most common congenital heart defects, CNS abnormalities).

• CONTRIBUTING FACTORS TO LGA INFANT:• Post term infant *• Maternal diabetes* • Genetics• Obesity • Multiparous mother

NEWBORN COMPLICATIONS: LGA/MACROSMNIA• SIGNS AND SYMPTOMS OF LGA

• More than 4000g• Plump and full faced(cushingoid appearance from increased

fat).• Signs of hypoxia• Birth traumas (fractures, intercranial hemorrhage, CNS injury).• Hypotonic muscles• Tremors caused by HYPOCALCEMIA• Signs of HYPOGLYCEMIA.• Signs of RD from immature lungs or meconium aspiration.

• NURSING INTERVENTIONS:• Heel stick for glucose testing• Early feeding or IV therapy to maintain normal glucose levels• Thermoregulation• Identify any injuries and treat.

NEWBORN COMPLICATIONS: LGA/MACROSMNIA

• DIAGNOSTICS & THERAPEUTIC INTERVENTIONS:• C- section• Chest x- ray to rule out meconium aspiration

syndrome.• Blood glucose level monitoring for hypoglycemia (less

than 40mg/dl)• ABG may show hypoxia• CBC may show POLYCYTHEMIA (hematocrit greater

than 65%) due to the utero hypoxia.• HYPERBILIRUBINEUMIA caused by polycythemia as

excess RBC break down after birth.• Hypocalcemia due to the long birth.

NEWBORN COMPLICATIONS: SGA• SMALL FOR GESTATIONAL AGE INFANT = SGA infant below the 10th

percentile.• COMPLICATIONS OF SGA:• Perinatal asphyxia• Meconium aspiration• Hypoglycemia• Polycythemia• Instability of body temp• CONTRIBUTING FACTORS TO SGA:• Genetic • Maternal infections, disease, malnutrition• Gestational hypertension or diabetes• Smoking alcohol, drug use• Multiple gestations• Placental factors (small placenta, placenta previa, decreased placental

perfusion).• Fetal infections (rubella and toxoplasmosis).

NEWBORN COMPLICATIONS: SGA

• SIGNS AND SYMPTOMS OF SGA:• Weight below the 10th percentile• Normal skull but reduced body dimensions• Reduced subcutaneous fat• Loose dry skin• Drawn abdomen *not well rounded.• Scalp hair sparse• Wide skull sutures from inadequate bone growth.• Wide eyed and alert which may be cause by prolonged

fetal hypoxia• Signs of meconium aspiration, hypoglycemia hypothermia• Thin, dry and yellow umbilical cord rather than grey,

glistening and moist.• Signs of respiratory distress and hypoxia.

NEWBORN COMPLICATIONS: SGA

• NURSING INTERVENTIONS:• Maintain open airway• Maintain thermoregulation• Parenteral nutrition • Hydration• Prevent skin break down • Protect from infection• Conserve the newborns energy level• Partial exchange transfusion to reduce the

viscosity of the blood if prescribed.

NEWBORN COMPLICATIONS: HYPOGLYCEMIA• HYPOGLYCEMIA = glucose levels less than 40mg/dl• Watch for hypoglycemia especially in infants with LGA.• It differs in preterm and term newborn.• Hypoglycemia that occurs in the first 3 days in a term born

newborn = glucose level <40mg/dl.• Hypoglycemia in pre-term newborn = blood glucose

<25mg/dl.• If left untreated can lead to mental retardation.• CONTRIBUTING FACTORS :

• Maternal diabetes• Pre term infant • LGA• Stress at birth Like cold stress and asphyxia• Maternal epidural.

NEWBORN COMPLICATIONS: HYPOGLYCEMIA• SIGNS AND SYMPTOMS:

• Poor feeding • Jitteriness and tremors• Hypothermia• Diaphoresis• Weak shril cry• Lethargic• Flaccid muscle tone• Seizures and comas• NURSING INTERVENTIONS:• Heel stick for glucose monitoring• Frequent oral or guavage feeding to treat the hypoglycemia.

• COMPLICATIONS• Seizures, brain damage and death if left untreated.

NEWBORN COMPLICATIONS: HYPERBILIRUBINEMIA• HYPERBILIRUBINEMIA = increased bilirubin levels jaundice.• Jaundice usually happens in cephalocaudal manner ( starts at the

head the sclera and mucous membranes then progresses down to the thorax, abdomen, extremities).

• JAUNDICE CAN BE PHYSIOLOGICAL OR PATHOLOGICAL.• PHYSIOLOGICAL JAUNDINCE :

• caused by increased bilirubin production due to the shortened lifespan and breakdown of fetal breakdown of fetal RBC and liver immaturity.

• Normal• The baby shows no other symptoms of jaundice fater 24hours.

• PHATHOLOGICAL JAUNDICE:• Appears after 24hours of birth and persists 7 days after.• Caused by blood group incompatibility or an infection OR RBC

disorder.• Will occur if the mothers blood group is incompatible with the fetus

blood type.

NEWBORN COMPLICATIONS: HYPERBILIRUBINEMIA• KERNICTERUS:

• Caused by untreated hyperbilirubinemia• The bilirubin levels will be higher or equal to 25mg/dl.• Neurological syndrome caused by bilirubin depositing in the

brain cells.• May lead to cerebral palsy, epilepsy, mental retardations• The infant may develop learning disorders or perceptual motor

disorders.• RISK FACTORS:

• Increased RBC production and breakdown• Rh or ABO incompatibility.• Decreased liver function• Maternal enzymes in breast milk• Hypoglycemia and hypothermia • Anoxia• Ineffective breast feeding

NEWBORN COMPLICATIONS: HYPERBILIRUBINEMIA• DIAGNOSTIC PROCEDURES:

• Elevated serum bilirubin level (monitor the infants bilirubin levels q4hrs until the levels return to normal).

• DIRECT COOMBS TEST shows antibody- coated (sensitized) Rh positive RBCs in the newborns.

• Electrolyte levels for dehydration from phototherapy.• SIGNS AND SYMPTOMS OF JAUNDICE:

• Yellowish tint to the skin, sclera and mucous membranes• Verify that the infant has jaundice (press the infants skin cheek,

abdomen with one finger then release and watch the skin color for a yellowish tint when the skin is blanched).

• Note when the jaundice started (this will help tell whether someone has physiological or pathological jaundice).

• SIGNS AND SMPTOMS OF KERNICTERUS • Yellowish ski• Lethargy, hypotonic, poor suck, backward arching of the back and

neck if left untreates, high pitched cry, fever.

NEWBORN COMPLICATIONS: HYPERBILIRUBINEMIA• TREATMENT:

• Phototherapy• Cover the babys eyes with an eye mask• Keep the new born undressed with the exception of males.

*surgical mask should be placed over the male (like a bikini over the genitals to prevent testicular damage from the heat and light waves).

• Remove any metal • Do not apply any lotions and ointments because this will cause

burns.• Remove the newborn from phototherapy every 4hours and

remove the eye mask for signs of inflammation and injury.• REPOSITION the baby every 2hours to prevent pressure sores

and expose all body surfaces.• Turn off phototherapy lights before drawing blood for testing.

NEWBORN COMPLICATIONS: HYPERBILIRUBINEMIA

• SIDE EFFECTS OF PHOTOTHERAPY:• Bronze discoloration• Maculopapular skin rash • Pressure areas • Dehydration • Poor skin turgor.• Elevated temperature.• NURSING INTERVENTIONS DURING PHOTOTHERAPY:• Monitor elimination daily watching for dehydration• Temperature monitoring because the temp will

become elevated.

NEWBORN COMPLICATIONS: HYPERBILIRUBINEMIA

• NURSING INTERVENTSIONS FOR HYPERBILIRUBINEMIA:• Feeding early and frequently q3-4hrs to promote

bilirubin excretion in the stools.• Adequate fluid intake to prevent dehydration• Reassure the parents that some level of jaundice

does occur.• Teach the parents that the stool will be containing

bile so the stool will look loose and green.• Explain the test and treatment procedures to the

parents.

NEWBORN COMPLICATIONS: SEPSIS

• INFECTION:• Babys are more susceptible because of the

immaturity of their immune system.• NEONATAL SEPSIS:• Micro- organisms or toxins in the blood or tissues of

the infant during the first month after birth • Presence of more than one micro-organism shows

infection.• PREVENTION OF INFECTION AND NEONATAL

SEPSIS:• Use asceptic technique during delivery• Care of the umbilical cord• Prophylatic eye treatment (erythromycin)


• RISK FACTORS CONTRIBUTING TO INFECTION OR SEPSIS:• PROM• TORCH (toxoplasmosis, rubella, cytomegalovirus,

herpes)• Premature birth • Low birth weight • Substance abuse• Maternal UTI• Meconium • HIV


• SIGNS AND SYMPTOMS OF INFECTION/ SEPSIS:• Temp instability • Drainage in the eyes and umbilical cords• Poor feeding • Vomitting and diarrhea• Poor weight gain • Abdominal distention • Large amounts of residual if the infant was feeing by

gavage• Apnea, grunting, nasal flaring and sternal retractions• Low oxygen saturations • Color changes : jaundice, pallor, petechae• Tachycardia or bradycardia• Poor muscle tone and lethargic


• NURSING INTERVENTIONS:• Specimens (blood, urine and stool to identify the

causative organisms).• Maintain temperature• Give meds• Iv therapy for electrolyte replacement• Hand washing, don’t store left over formula,

breast hygeine.

NEW BORN DISCHARGE TEACHINGS

NEWBORN CARE TEACHING DISCHARGE

• TEACH: • causes of crying, quieting techniques, sleeping patterns,

feeding, bathing and clothing the infant.• Following infant check ups and immunization schedules• Signs of illness and When to call the physician.• Infant safety and proper car seat use.

• CRYING:• Baby cries when they are hungry, wet, cold, hot, tired,

bored, over stimulated.• Do not feed the baby every time the baby cries.

• QUIETING TECHNIQUES:• Warm the crib sheets with hot water bottle.• Swaddle the infant• Comfort the baby by rocking and listening

NEWBORN CARE TEACHING DISCHARGE• SLEEPING

• Don’t sleep with the baby – risk of suffocation • Place baby in supine position – reduces SIDS.• Babys sleep 16-24hours in 2-3hours at a time• Bathe before bedtime • Last feeding at 11p.m• Ro reduce day/night confusion bring the baby into the living

room (centre of the action during the day).• ORAL AND NASAL SUCTIONING:

• Bulb syringe to suction nose and mouth• Start with the mouth first • Squeeze bulb first before inserting it into the nose or mouth.• When suctioning the mouth, place the bulb at the sides of the

mouth not the middle


• HOLDING THE NEWBORN • support the head ***

• BATHING THE NEWBORN:• Teach by demonstration then have the parents

demonstrate it back.• Start from eyes, face, head, chest, arms, legs ,groin last.• The soap used must not have HEXACHLOROPHENE.• Clean the face and perineal area daily but complete bath

2-3times a week.• Should be done before feeding to prevent vomiting and

spitting.• Sponge bath until the umbilical cord falls off.• Do not use any lotions, oils or powders because they

create an area for bacterial growth.

NEWBORN CARE TEACHING DISCHARGE• FEEDING AND ELIMINATION:

• Feeding = on demand or every 2-3hours• Breast feed 20-30mins per breast • Bottle fed infants should be fed every 3-4hours• 6-8 wet diapers/day • 3-4 stool diapers/day• Burp between breasts. Prevents gas and chances of the infant

vomiting.• Keep the infant upright for a few mins after feedings because

thee are chances they may want to spit up.• CORD CARE:

• Report any foul odor, drainage or redness• Avoid water on the cord until it falls off

• CIRCUMCISION CARE:• Petroleum jelly on the penis for the first 24hours so it doesn’t

stick to the diaper.


• SAFETY:• No small objects – choking hazard• Never leave the infant unattended with pets or other

small children or on the bed alone.• Don’t place on stomach• Eliminate potential fire hazards by keeping the baby

crib and stuff away from radiators, heat vents. *they can catch fire.

• INFANT WELLNESS CHECK UPS:• Check ups at 2-6weeks of age then every two months

until 6months of age.• Its important to get immunizations on time to protect

against diptheria, tetanus, pertussis, Hep B, flu, polio, measles, mumps, rubella and varicella.

NEWBORN CARE TEACHING DISCHARGE• ILLNESSES OR SIGNS TO REPORT:-

• Fever above 38 degrees celcius• Poor feeding or little interest in food• Frequent vomiting• Diarrhea or decreased bowel movements• Decreased urination• Labored breathing• Cyanosis• Jaundice• Lethargy• Difficulty walking• Inconsolable crying• Bleeding or purulent bleeding around the umbilical cord or

circumcision• Drainage around the eyes.

MATERNAL POSTPARTUM PERIOD

PHYSIOLOGICAL CHANGES POST PARTUM MATERNAL COMPLICATIONS

POSTPARTUM PHYSIOLOGICAL CHANGES

DIC • DIC = DISSEMINATED INTRAVASCULAR COAGULATION is a clotting

disorder in which the clotting and anticlotting mechanism is activated at the same time.

• Increased clotting consumes and destroys the amounts of clotting factor (platelets, fribinogen, prothrombin and factors V & VII).

• The decrease in clotting factor external and Internal bleeding formation of small clots in the microcirculation triggering vascular occlusion of the small vessels ischemia.

• FIRST SIGN OF COAGGULATION PROBLEMS ?• When the ways usually used to stimulate uterus contractions and

contractions fails to stop vaginal bleeding.• COMPLICATIONS OF DIC ?• Hemorrhage ; renal failure; organ ischemia tissue death

major organ failure.

DIC • RISK FACTORS OF DIC ?• Abruptio placenta• Amniotic fluid embolism• Missed abortion• Fetal death in utero• Septicimia• Gestational hypertension• SIGNS AND SYMPTOMS OF DIC ?• Unusual spontaneous bleeding from the clients gums or nose• Oozing or trickling of blood from the incision, lacerations and

episiotomy • Hematuria, hematemesis or vaginal bleeding • Presence of blood in stools.• Increase in Pt and PTT, clotting time fibrinogen degeneration

products.

DIC • NURSING INTERVENTIONS ?• The focus should be on assessing for the

correction of the underlying cause (removal of the dead fetus, treatment of infection, preclampsia or removal of placenta abruption).

• Monitor vital signs and signs for shock • Oxygen, volume replacement, blood component

therapy and possibly heparin.• Monitor for signs of complications associated

with the fluid and blood replacement.• Monitor urine output and maintain at 30ml/hr

(because renal failure is a complication of DIC).

CHP 34: POSTPARTUM PHYSICAL ADAPTATION

• POST PARTUM STAGE:• 4th stage of labor.• Starts after the delivery of the placenta to when the body returns to its

nonpregnant state.• Usually takes about 6weeks• The initial dangers are = hemorrhage, shock and infection.• The body starts to satbilize the internal organs returning to the non-

pregnant state.• Parent-infant bonding starts at this stage.• POSTPARTUM ASSESSMENT IMMEDIATELY AFTER DELIVERY SHOULD

LOOK AT :• Vital signs • Uterus : firmness, location in relation to the umbilicus, uterus position in

relation to the midline of the abdomen and the amount of vaginal bleeding.

• Cervix, vaginal and perineal healing • Bladder functions

POSTPARTUM PHYSICAL ADAPTATION: FUNDUS

• WHAT IS INVOLUTION OF THE UTERUS ?• Involution = decrease in the size of the uterus returning to its non

pregnant state.• Immediately after breastfeeding the fundus is found midline at

approximately the level of the umbilicus. 12hours postpartum its 1cm above the umbilicus

• Breast feeding stimulates the release of Oxytocin from the pituitary gland which strengthens uterus contractions rapid involution. 8 encourage early breast feeding

• the uterus decreases in weight from 2.2lbs to 2oz in 6weeks.• The fundal height decreases about 1cm (1 finger breadth) per day.• By day 10 the uterus is now within the true pelvis & cannot be palpated

abdominally.• Tender fundus = infection • Boggy (non firm uterus )= uterine atony massage till firm.• NURSING INTERVENTION ?• Document the consistency (firm or boggy), location & height of the fundus• Give Pitocin or methergene to promote uterine contractions.

POSTPARTUM PHYSICAL ADAPTATION: LOCHIA

• WHAT IS LOCHIA ?• Blood flow from the uterus during the postpartum stage • Lochia is made up of ?• Blood from the vessels of the placenta attachment site to the

uterus, debris from the exfoliation of the decidua (thickening lining of uterine endometrium during pregnancy).

• WHAT ARE THE 3 STAGES OF LOCHIA ?• LOCHIA RUBRA =bright red bloody consistency may have small

clots. Lasts 1-3days after delivery.• LOCHIA SEROSA= pinkish/brown color contains old blood,

leukocytes, tissue debris. Lasts day 4-10 after delivery • LOCHIA ALBA= yellowish/white creamish color. Contains

decidua, mucus, serum, bacteria, leukocytes. Lasts from day 11- week 6 postpartum


• ASSESSMENT OF LOCHIA ?• Color, amount and consistency• Usually trickles down but may gush down on

ambulation or massaging the uterus.• SIGNS OF ABNORMAL LOCHIA ?• Excessive spurting of bright red blood from the

vagina. Could be a sign of a tear.• Numerous large clots• Persistent lochia rubra beyond 3 days *this is a sign

that they are retained placenta fragments.• Continued flow of lochia for more than the

expected days with a fever or abdominal tenderness.


• NORMAL AND ABNORMAL AMOUNTS OF LOCHIA ?• Scant = less than 2.5cm/1in on the pad in 1hour• Light = less than 10cm/4inch • Moderate = less than 15cm/6inches• Heavy = saturated pad in an hour• Excessive = pad saturated in less than 15mins • CHANGES IN THE CERVIX, VAGINA & PERINEUM ?• CERVIX = soft after delivery but 2-3days postpartum

becomes firm again with the os gradually closing.• VAGINA= no rugae and thin mucosa due to the low

estrogen immediately after. But It gradually returns to its normal size with the reappear, thickening of the vaginal mucosa but the muscle tone is never fully regained.

•


• ASSESSMENT, NURSING INTERVENTIONS & COMFORT MEASURES FOR CERVICAL, VAGINAL & PERINEAL HEALING:

• Assess the episiotomy for drainage quality and quantity. Bright red blood early postpartum period is normal.

• Watch for edema, hematoma and erythema.• NURSING INTERVENTIONS • Stool softeners• Proper cleaning (from front to back each time you void)• COMFORT MEASURES:• Ice packs to the perineum for the first 24-48hours to

reduce edema.• Sitz bath at least twice a day.• Witch hazel (tucks) to the rectal area for hemorrhoids.

POSTPARTUM PHYSICAL ADAPTATION: BREASTS

• Secret colostrum for 48-72hours after delivery.• Decrease in estrogen and progesterone after delivery stimulates

increase in prolactin stimulating the production of breast milk.

• Breasts become distended with milk on the third day.• Engorged nipples usually occur in the 4th day in non-breast

feeding mothers.• Teach proper latch on techniques to prevent nipple soreness.• Breastfeeding releasing oxytocin promoting uterine

contractions.• HOW SHOULD NON BREAST FEEDING MOTHERS CARE FOR

THEIR BREASTS ?• Avoid nipple stimulation• Wear a tight fitting bra • Ice pack compress• Usually resolves 24-36hours after it begins.

POSTPARTUM: CARDIOVASCULAR

• blood loss during childbirth = 500ml vaginal birth, 1000ml c-section. Diaphoresis and diuresis occurs within the first 2-3days postpartum.

• Increase in WBC for the first 10-14days without and infection.• Coaggulation factors increased for 2-3weeks postpartum.

Venous stasis of the lower extremities during the last part or pregnancy and the client immobility during recovery risk for thrombus formation.

• VITAL SIGNS:• Temp= rises due to dehydration. Higher than 100.4 degrees is an

infection.• Pulse = bradycardia may decrease to 50 beats/min• Blood pressure = normal * if hypotension it may be

hypovolemia• RESPS= remain unchanged. * if they increase suspect pulmonary

embolism

POSTPARTUM: URINARY & GI CHANGES

• URINARY TRACT:• Urinary retention is the major issue due to the lack of

elasticity and tone and loss of sensation in the bladder from trauma, meds, anesthesia,

• Diuresis usually starts within the first 12hours after delivery.

• GI TRACT • Hunger • *constipation • Hemorrhoids are common (tuck is the herb for

hemorrhoids).• Eat high fiber diet • Encourage ambulation • Give stool softner.

POSTPARTUM: BONDING & INTERGRETING THE INFANT INTO THE FAMILY

• FACTORS AFFECTING INFANT BONDING ?• Mothers emotional and physical condition: unwanted

pregnancy, teen pregnancy, depression, difficult pregnancy and delivery infants physical conditions.

• Separation of the mother and infant after birth due to complications this delays the bonding process.

• Culture, age and socioeconomic status.

• BEHAVIOUS THAT FACILITATE AND INDICATE MOTHER-INFANT BONDING ?

• EN FACE = holding the infant face to face maintaining eye contact.

• Considers the infant a family member• Maintains close proximity with the infant.• Smiles and coos at the infant • Communicates with pride to the infant.


• SIGNS SHOWING LACK OF MOTHER-INFANT BONDING ?• Apathy when infant cries• Disgust when the infant voids, stools or spits up.• Expressing disappointment in the infant• Doesn’t want to be close to the infant• Does not talk about the infants unique features.• Ignores the infant totally• Views the infants behavior as deliberately unco-operative.• NURSING INTERVENTIONS TO ENCOURAGE BONDING ?• Allow skin to skin contact as soon as the infant is born• Encourage the mother when she is doing stuff like changing

diapers.• Encourage the mother to do stuff with the infant that will help

with bonding, for instance, bathing, feeding and talking to the baby.


• PATERNAL ADAPTATION = father becoming engrossed with the infant and transitioning to fatherhood & developing infant-parent bond.

• ENGROSSMENT = father being absorbed and preoccupied with the infant.• SIGNS OF ENGROSSMENT ?• Talking to the infant • Finding features in the infant that look like his (validating that its his)• Touching, holding and maintaining good eye contact with the infant.• STAGES OF TRANSITIONING INTO FATHERHOOD• Occurs in 3 stages • Stage 1: expectation =the father has ideas of what he thinks it will be like

when the infant comes home

• Stage 2: reality = the expectations may be different from reality. May have some sadness, jealousy of the infant, ambivalence, feeling of surprise at the reward of parenting.

• Stage 3: transition to mastery = father is more determined to be an active father.


• 3 STAGES OF FATHER INFANT BONDING PROCESSING ?• MAKING A COMMITMENT = having a sense of duty and

responsibility.• BECOMING CONNECTED= feeling of excitement, joy at the first

meeting with the infant. Will start to see the infant as predictable.

• MAKING ROOM FOR THE INFANT = starts to change his schedule to accommodate the infant.

• NURSING INTERVENTION TO HEP WITH FATHER-INFANT BONDING ?

• Educate the father on infant care • Assist the father in activities that will help the father become

more involved rather than just a helper.• Encourage the couple to discuss their expectations and division

of labor

POST PARTUM MATERNAL COMPLICATIONS

POST PARTUM HEMORRHAGE• Leading cause of mortality in the U.S• WHAT IS POSTPARTUM HEMORRHAGE ?

– Bleeding of more than 500ml after a vaginal delivery – Bleeding of more than 1000ml after a c-section birth.– EARLY HEMORRHAGE = occurs in less than 24hours after

delivery – LATE HEMORRHAGE = occurs after 24hours from delivery – 10% change in hematocrit values from the baseline values

(values taken during the admission from the postpartum values).

• WHAT COMPLICATION CAN HEMORRHAGE LEAD TO ?– Hypovolemic shock.– Anemia (so watch for hemoglobin & hematocrit levels plus

educate the patient on folic acid and iron dietary source).

POST PARTUM HEMORRHAGE• WHAT ARE THE SIGNS OF HYPOVOLEMIC SHOCK ?– Hypotension– Tachycardia– Weak thready pulse– Rapid shallow breaths– Oliguria

• WHAT ARE THE CAUSES OF POSTAPARTUM HEMORRHAGE ?– uterine atony (poor muscle tone) * MOST COMMON

CAUSE.– Vaginal laceration– Cervix, perineum or labia hematoma – Placenta fragments that remained.

POST PARTUM HEMORRHAGE• WHAT ARE THE CONTRIBUTING RISK FACTORS

FOR HEMORRHAGE ?– Dystocia – Pre-longed labor – Operative delivery – (c-section, forcep delivery, intra-

uterine manipulation).– Overdistention of uterus – polyhydramnios, multiple

gestations or large neonates.– Abruptio placentae – Previous history of postpartum hemorrhage – Infection – Placenta previa

POST PARTUM HEMORRHAGE• WHAT ARE THE SIGNS AND SYMPTOMS OF

POSTPARTUM HEMORRAHGE ?– Uterine atony – Blood clots larger than a quarter– Pad saturation in less than 15mins– Rising pulse rate & decreasing pulse rate (often the

first warning of decrease in blood volume).– The skin is cool and clamy with poor skin turgor – Oliguria – Constant oozing or flowing of bright red blood from

the vagina– When the lochia changes back from lochia serosa or

alba to lochia Rubra.

POST PARTUM HEMORRHAGE• WHAT ARE THE NURSING INTERVENTIONS

WHEN YOU SUSPECT POSTPARTUM HEMORRAHGE?– Assess the patient for the location of the bleeding – Assess the fundus for height, firmness and

position. * you are massaging the fundus for uterine atony.

– Check the lochia (it will be lochia rubia).– Check for signs of lacerations, the episiotomy sign

or a hematoma– Vital signs (tachycardia, hypotension).

POST PARTUM HEMORRHAGE• NURSING INTERVENTIONS FOR HEMORRHAGE ?

• Massage the fundus for uterine atony • Notify the physician• Monitor the vital signs and the fundus every 5mins-

15mins.• Remain with the patient.• Stop the site of the blood loss if possible.• IV fluids (volume expanders albumin, NS, PRBC)• Oxygen 2-3L per nasal cannula to increase the RBC

saturation of oxygen.• Catheter to get an accurate measurement of output.• Elevate legs to increase venous return.

INFECTION• Postpartum infection Aka puerperal infection• WHAT IS IT ?• Infection of the genital birth canal tht occurs after childbirth, abortion or

miscarriage.• WHAT ARE THE SIGNS OF INFECTION ?• Fever of 100 degrees (38 degrees Celsius) for 2 days or more during the

first 10days • Fever in the first 24hours is normal• WHAT IS THE MAJOR COMPLICATION OF POSTPARTUM INFECTION ?• Septicemia• WHAT ARE THE TYPES OF INFECTION ?• ENDOMETRITIS = infection of the endometrial lining, decidua, and

myometrium of the uterus. * most common infection, usually starts in the 2nd to 5th postpartum day

• PARAMETRITIS = infection spread by the lymphatic system through the uterine wall or pelvis

• PERITONITIS = infection of the peritoneum.

INFECTION• WHAT IS THE CAUSE OF INFECTION/PATHOPHYSIOLOGY ?• Introduction of the vaginal micro-organisms into the the

sterile uterine area through:• Premature rupture membranes • Operation incisions• Hematoma• Damaged tissue• Not using sterile technique • Retained placenta fragments because this allows for tissue

necrosis providing an area for bacterial growth.• Postpartum hemorrhage • Prolonged labor (one lasting more than 24hours. because it

opens up the cervix into the uterus with exposure to the external environment through the vagina.

INFECTION• WHAT ARE THE FINDING ASSESSMENTS WHEN ONE HAS A

POSTPARTUM INFECTION ?• Fever of 100 degrees for 2 consecutive days during the first

10-28days postpartum• Fever in the first 24hours is normal because of dehydration.• The fever usually comes with chills, backache, malaise,

restlessness & anxiety.• Foul smelling lochia• Lethargy• Abdominal pain• Anorexia• Pelvic discomfort.• Elevated WBC

INFECTION• NURSING INTERVENTIONS FOR POSTAPRTUM

INFECTION ?• Monitor vital signs every 2-4hours• Closely monitor intake and output• Place the mother in a position that promotes drainage • If the patient has chills keep her warm• If theres a chance of spreading the infection to the infant then

keep them separate but give constant updates on the infants well being

• Increase intake to 3000-4000ml unless contraindicated.• Encourage frequent voiding • Closely monitor intake and output.• Frequently check the perineum assessing the fundus to palpate

it for tenderness (subinvolution may be a sign for endometritis).• Note the color odor of the vaginal drainage and document your

observations.

MASTITIS • WHAT IS MASTITIS ?– Inflammation of the breast due to infection.– Usually seen as a tender localized hard mass with redness

in that area.– Usually on one breast.– Usually occurs in breast feeding women 2-3weeks after

delivery but may occur anytime during lactation.– Usually occurs in primiparas• WHAT IS THE CAUSE ?– Staphylococcus aureus from the neonates throat or nose– The bacteria usually enters through a crack or fissure in

the nipples.– The bacteria enters travels through the milk ducts.

MASTITIS • WHAT ARE THE RISK FACTORS THAT CAN CONTRIBUTE TO MASTITIS

?– Fissure or crack in the nipple – Blocked milk ducts (from wearing restrictive bras, or waiting too long

to breast feed)– Incomplete let down– Milk stasis from blocked milk ducts – Poor breast feeding technique with improper lacthing of the infant

onto the breast leading to sore cracked nipples.– Decrease in breast feeding when the mother is supplimenting with

bottle feeding.– Poor hand hyegeine

• HOW CAN MASTITIS BE PREVENTED?– Good breast and hand hygiene – Washing your hands before holding your breasts.

MASTITIS • WHAT ARE THE SIGNS AND SYMPTOMS OF MASTITIS ?

– Localized heat and swelling – Pain, tender axillary lymph nodes (axillary adenopathy)]– Elevated temp– Complaints of flu like symptoms (malaise and headache).

• WHAT ARE THE NURSING INTERVENTIONS FOR MASTITIS ?• Teach good hand washing and breast hygiene techniques.• Wash hands before touching your breast.• Apply heat or cold compress to the site• Encourage the use of a breast pump every 4hours • Give analgesic and antibiotics as prescribed.

UTERINE ATONY• WHAT IS UTERINE ATONY ?• Aka hypotonic uterus• Hypotonic uterus that is not firm • Boggy uterus • IF LEFT UNTREATED WHAT IS THE COMPLICATION?• Postpartum hemorrhage (because the myometrium of the uterus are

unable to contract and stay contracted so the blood vessels of the uteroplacenta implantation site are left open post partum hemorrhage.

• Uterine inversion• RISK FACTORS FOR UTERINE ATONY ?• Retained placenta fragments • Prolonged labor • Macrosomic fetus (fetus large for gestational age)• Trauma during the labor and birth during C-section, forcept assisted births

and vaccum assisted births.• Use of oxytocin or magnesium sulfate or anesthesia

UTERINE ATONY• WHAT ARE THE SIGNS FOR UTERINE ATONY ?

• Larger than usual uterus • Prolonged lochia • Irregular or excessive bleeding • The uterus feels boggy and may be laterally displaced

• WHAT ARE THE THERAPEUTIC PROCEDURES FOR UTERINE ATONY ?• All done by the physician• BIMANUAL COMPRESSION = fist inserted into the vagina then using

the knuckles pressure is applied on the anterior side of the uterus while the other hand is on the abdomen and massaging the posterior uterus.

• MANUAL EXPLORATION = physician manually removes the retained placenta fragments from the uterine cavity.

• HYSTERECTOMY

UTERINE ATONY

• NURSING INTERVENTIONS FOR UTERINE ATONY ?• Make sure the bladder is empty (because this can distend and

displace the uterus).• Massage the boggy fundus until its firm• Remove clots that have accumulated in the uterus. * do not do

this unless the uterus is firm because if the uterus is still boggy then this can cause uterine inversion and cause hemorrhage.

• Give OXYTOCIS :• PITOCIN : but watch for water intoxication (lightheadedness,

nausea, vomiting, headache, malaise. Can become SERIOUS: cerebral edema, seizures, coma, death).

• Q: METHERGINE : watch for Hypertension, N/V, headache • ERGOTRATE: watch for Hypertension, N/V, headache• PROSTAGLANDIN F (prostin 15M) : watch for fever, chills,

headache, N/V and diarrhea.

SUBINVOLUTION OF THE UTERUS• WHAT IS SUBINVOLUTION ?• Failure of the uterus to return to its normal size/pre-pregnant state.• The uterus remains enlarged with lochia.• May lead to postpartum hemorrhage.• WHAT MAY BE THE CAUSE/ RISK FACTORS?• Pelvic infection = endometritis • Incomplete removal of placental fragments • Retained fragments or infection interferes with the ability of the

uterus to contract effectively so the uterus remains enlarged and soft.

• WHAT IS THE TREATMENT ?• Methergine • Patient teaching about methergine: will cause menstrual cramps.

SUBINVOLUTION OF THE UTERUS

• WHAT ARE THE SIGNS AND SYMPTOMS OF THE SUBINVOLUTION?

• Uterus pain when you palpate• Uterus that is larger than expected• More than normal vaginal bleeding• WHAT ARE THE NURSING INTERVENTIONS ?• Assess the vital signs • Monitor vaginal bleeding• Assess the uterus and fundus for firmness• Elavate the legs to encourage venous return• Encourage frequent voiding• Monitor the hemoglobin and hematocrit values (if low=

blood loss).

Chp 38 : HEMATOMA• WHAT IS IT ?• Collection of 250ml-500ml of clotted blood in the soft tissue of the

perineum• Usually seen in the vulva and vagina • Vulvar hematomas are the most common.• Usually look like a buldging blue mass.• Usually results from the breakage of blood vessels in the soft tissue

of the vagina and the perineum.• An lead to postpartum hemorrhage of infection of the laceration.

• SIGNS AND SYMPTOMS ?• Severe vulva pain *most significant sign• Purplish discoloration • Feeling of fullness/pressure in the vagina.

HEMATOMA

• RISK FACTORS FOR LACERATIONS ?• Assisted Vaginal birth (forcep or vaccum assisted

births)• Precipitate birth• Cephalopelvic disproportion• Macrosmic infant• Prolonged pressure of the fetal head on the vaginal

mucosa• Damage is pronounced in NULLIPAROUS WOMEN

because their tissue is firm, more resistant and less distensible.

• Light skin women especially those with RED HAIR because they have less distensible tissue

HEMATOMA

• WHAT ARE THE SIGNS AND SYMPTOMS FOR A HEMATOMA OR LACERATION?• Most significant sign is SEVERE VULVAR PAIN.• firm contracted uterus despite vaginal bleeding • Constant oozing ot trickling of bright red blood from

the vagina (hematoma blood = bright red; lochia blood = dark red).

• Blood oozing from the laceration or episiotomy.• Inability to void due to the pressure on the urethra

from the hematoma.• Feeling you need to defecate because of hematoma

pressure on the rectum• Decreased hemoglobin or hematocrit levels.

THROMBOPHLEBITIS AKA DVT

• WHAT IS DVT ?• THROMBOSIS = Formation of a blood clot in the vessel

walls due to inflammation • Partial obstruction of the blood vessel can occur.• THROMBOPHLEBITIS = inflammation of a vessel wall caused

by the attachment of a blood clot to the wall with partial blockage of the blood vessel.

• Superficial venous thrombosis = involves the surface veins and saphenous veins.

• Deep Vein Thrombosis = involves the deep venous system. Can extend from the foot to the iliofemoral region.

• WHAT COMPLICATION CAN THROMBOPHLEBITIS LEAD TO ?• Pulmonary embolism

THROMBOPHLEBITIS AKA DVT• WHAT ARE THE SIGNS AND SYMPTOMS OF THROMBOPHLEBITIS ?• TENDERNESS, HEAT & PAIN ON PALPATION.• POSITIVE HOMANS SIGN (pain in the calf when you dorsiflex).• Localized redness and enlarged superficial hardened vein = sign for superficial vein

thrombosis.• One sided leg pain (pain on one leg) that travels up to the knees, tender calfs,

swelling, extermity coolness and pale color = deep vein thrombosis• Low grade fever and chills.

• WHAT ARE THE RISK FACTORS THAT LEAD TO POSTPARTUM THROMBOEMBOLIC DISEASE:

• Immobility postpartum• C-section• Prolonged sitting and standing • Smoking • Multiparity• History of thrombosis• Obesity • Women over 35yrs

THROMBOPHLEBITIS AKA DVT• SIGNS AND SYMPTOMS OF THROMBOPHLEBITIS BASED ON TYPES:• SUPERFICIAL THROMBOPHLEBITIS

• Palpable thrombus that feels bumpy and hard• Pain and tenderness of the lower extremities.• Warm and pinkish-red color over the thrombus area.• Redness along the vein

• FEMORAL THROMBOPHLEBITIS:• Malaise• Chills and fever • Positive homans sign (pain on the calf when dorsiflexing)• Shiny skin over the affected area• Pain, stiffness and swelling of the affected leg• Decreased peripheral pulses.

• PELVIC THROMBOPHLEBITIS • Severe chills• Dramatic body temp changes• Pulmonary embolism may be the first sign

THROMBOPHLEBITIS AKA DVT• NURSING INTERVENTIONS BASED ON THE TYPE OF THROMBOPHLEBITIS:• assess the lower extremity for edema, tenderness, varices and increased

skin temperature.• Maintain bed rest• Elevate the affected leg• Never massage the leg• SUPERFICIAL THROMBOPHLEBITIS:• Bed rest• Apply hot packs to the affected site• TED hose stockings • Analgesics.• FEMORAL THROMBOPHLEBITIS • Elevate leg• Apply moist heat continously• Prepare to give heparin

THROMBOPHLEBITIS AKA DVT• NURSING INTERVENTIONS FOR PELVIC THROMBOPHLEBITIS ?• Bed rest • Give meds as ordered • Avoid crossing the legs or sitting for long periods of time• Avoid pressure behind the knees (so no pillows under the knees)• TED hose • Anticoaggulants• TEACH THE PATIENTS SIGNS OF ADVERSE EFFECTS OF

ANTICOAGGULANTS:• Bleeding from gums and nose• Increased vaginal bleeding • Blood in urine • Bruising easily


• WHAT IS THE PATIENT TEACHING WHEN SOMEONE IS TAKING THE ANTICOAGGULANTS ?

• Heparin and Coumadin will be given• Avoid asprin • Use an electric razor when shaving • Avoid the use of alcohol because it inhibits the

action of anticoaggulation med coumadin.• Brush teeth gently• Avoid the massaging of the legs• Avoid sitting for long time and crossing legs


• WHAT ARE THE WAYS IN WHICH ONE CAN AVOID THROMBOPHLEBITIS ?

• Ambulate early • Avoid sitting, standing or any immobility for long

periods at a time• Elevate legs when sitting • Avoid crossing legs because it reduces circulation • Maintain fluid intake at 2500ml/day to prevent

dehydration which leads to sluggish/slowed circulation• Stop smoking• Use of TED hose.

PULMONARY EMBOLISM

• WHAT IS AN EMBOLI?• When a clot dislodges and moves into circulation.• WHAT IS PULMONARY EMBOLISM ?• Movement of a clot usually originating from the uterine or pelvic vein into

the lungs were it disrupts the circulation of the blood.• WHAT ARE THE SIGNS AND SYMPTOMS OF PULMONARY EMBOLISM ?• Dyspnea, tachycardia, tachypnea• Pleuritic chest pain• Cough and lung crackles• Hemoptysis • Pleuritic chest pain • Hypotension• Peripheral edema• Distended neck veins• High temp, hypotension • *feeling of impending doom /apprehension

PULMONARY EMBOLISM

• WHAT ARE THE NURSING INTERVENTIONS FOR PULMONARY EMBOLISM:

• Lace the patient in semi fowlers position • IV heparin• Oxygen

:UTI • WHAT IS A UTI ?• Infection of the bladder• Common infection postpartum due to the bladder trauma due to

delivery or break in septic technique during catheterization.

• WHAT IS THE COMPLICATION OF UTI ?• Pyelonephritis with permanent renal damage or renal failure.• WHAT ARE THE RISK FACTORS OF UTI IN POSTPARTUM PEROD ?• Postpartal hypotonic bladder • Urinary stasis or retention • Catheters • Epidural anesthesia• History of UTI

UTI • WHAT ARE THE SIGNS AND SYMPTOMS FOR UTI ?• Burning and pain on urination • Lower abdominal pain • Increased frequency on urination• Fever • Proteinuria, hematuria, bacteruria, WBC in urine• Pain at the costovertebral angle (pyelonephritis)• Elevated temp

• WHAT IS THE NURSING INTERVENTIONS FOR A UTI ?• Urine sample • Proper perineal hygiene = wipe from front to back• Increase fluid to 3000ml/day to dilute the bladder and flush out the

bladder.

POST PARTUM BLUES• POST PARTUM “blues” DEPRESSION :• Usually starts a few days after the birth and continues for 10days.• SIGNS AND SYMPTOMS OF POSTPARTUM DEPRESSION:• Tearfulness• Insomnia• Lack of appetite• Feeling of let down• Ambivalence toward the infant and family• Mother has an intense fear or anxiety, anger and inability to cope with the

slightest problems and become despondent.• Can progress to postpartum psychosis,• WHAT IS POSTPARTUM PSYCHOSIS?• Characterized by delusional thinking and possible hallucinations.• Monitor the patient for suicidal or delusional thoughts and monitor the

infant for failure to thrive secondary to the mother being unable to care for her newborn.

POST PARTUM BLUES• WHAT IS THE PRIORITY ?• Safety of the newborn • Get psychiatric supervision• Involve outreach programs concerned with self care and parent

child interactions, child injuries and failure to thrive.

• WHAT ARE THE CONTRIBUTING FACTORS TO POSTPARTUM BLUES ?• Hormonal changes with decline in estrogen and progesterone levels • Postpartum physical discomfort and pain• Fatigue from the work and labor and demand of the new role as a

mother• Decreased social support• Anxiety and being a new mother• History of depression • Low self esteem

POST PARTUM BLUES• WHAT IS THE NURSING INTERVENTION FOR

POSTPARTUM BLUE’S ?• Teach the patient to sleep when the infant is

sleeping• Encourage communication of feelings• Reschedule follow up visit in 6weeks postpartum

for women at risk of postpartum depression.• Reinforce that feeling down is normal but if the

condition persists then to notify the physician.

RUBINS STAGES• TAKING IN STAGE: first 3 days - The mother focuses on her own primary needs (sleep and food),- Nurses role is to listen and help the mother interpret the events of the

delivery- Excited and talks about the experience of labor and birth - Teach the mother about baby care• TAKING HOLD PHASE: DAY 3-10- The woman starts to assume the roles of mothering - Becomes more independent and focuses on caring for her newborn- May verbalizes feelings of incompetence in new role.- Best time for patient teaching.• LETTING GO PHASE:- Feeling of loss from separation of the fetus from her body.- Feeling of being caught in dependent-independent role (she wants to feel

safe and secure but at the same time wanting to make decisions).- Increased demand from home and newborn care may lead to depression.

OTHER ISSUES: FIBROIDS- FIBROIDS = aka leiomyomas- Common in african americans and women over

40yrs.- SIGNS AND SYMPTOMS:

- Lower abdominal pain - The woman may feel pressure or fullness- Dysmenorrhea or menorrhagia may occurs.- Diagnosis when masses are felt on the pelvic exam.

- GnRH used to reduce the size of the fibriods. * no meds to prevent them.

- Majority of the masses will shrink after menopause.

OTHER ISSUES: MENORRHAGIA- MENORRHAGIA = frequent heavy bleeding.- Commonly seen in pre-menopausal women

due benign causes (like cysts).- Also seen as heavy bleeding in menopausal

women.- can lead to iron deficiency anemia (heavy

period excess blood loss excess loss of iron found on RBC lost iron deficiency anemia

OTHER ISSUES: DOMESTIC VIOLENCE- DOMESTIC VIOLENCE = forceful behaviors and methods used to

gain and maintain power and control by one individual over another.

- This involves physical abuse, psychological abuse and sexual assault.

- TYPES OF PSYCHOLOGICAL ABUSE:- EMOTIONAL: putting her down - ISOLATION: controlling who she sees- OBFUSCATION : denying responsibility for his actions and blaming her

for his actions.- USING OTHERS: using children against the woman- MALE PRIVILEGE: treating the woman like a servant- ECONOMIC ABUSE : controlling the money or preventing her from

getting a job so shes dependent on you.- COERCISION THREATS: making or carrying out threats to harm her

family.- INTIMIDATION: making her afraid through looks and gestures.

OTHER ISSUES: DOMESTIC VIOLENCE- SEXUAL ABUSE IS WHEN = the husband/ spouse

forces the woman to have sex with him, includes the forced use of objects or forcing the woman to have sex with someone else against her will.

- CONTRIBUTING FACTORS TO DOMESTIC VIOLENCE:- Childhood experiences- Male dominance in the family - Marital conflict- Unemployment and low socioeconomic status - Traditional definitions of masculinity.

OTHER ISSUES: DOMESTIC VIOLENCE- CYCLE OF VIOLENCE:1. TENSION BUILD UP PHASE

• Batterer shows power and control• Starts blaming the woman for external factors, minor battering

incidents starts to occur• Woman senses growing danger.

2. ACUTE BATTERING INCIDENT• Phase of acute violence triggered by an external event.• The man blames the woman for the violence.• The woman may go somewhere else but return when she feels its

cooled down.3. TRANQUIL PHASE/ HONEYMOON PERIOD:

• The man is very kind and warm and tries to make it up to the woman.

• The woman may accept the gifts and the word of the batterer and take him back

OTHER ISSUES: DOMESTIC VIOLENCE- COMMON CHARACTERISTICS OF BATTERERS:

- Have feelings of insecurity, inferiority, powerlessness and helplessness.

- Tend to be emotionally immature - Express their overwhelming feeling of inadequacy

through violence.- Extreme jealousy and possessiveness are the

hallmark of abusers.

OTHER ISSUES: DOMESTIC VIOLENCE- SIGNS THAT THE WOMAN IS BEING DOMESTIC

VIOLENCE:- Woman shows hesitation about how she got hurt.- Inappropriate affect- Defensive injuries- Delayed seeking of care for the injuries- Explaining injuries as being an accident at home - Vague complaints - Lack of eye contact - Anxiety when the batterer is in the room

OTHER ISSUES: INFERTILITY- INFERTILITY= inability to get pregnant after one year of

trying without the use of contraception.- PRIMARY INFERTILITY = the woman has never been

able to get pregnant at all.- SECONDARY INFERTILITY = the woman was able to get

pregnant once but is not able to for a second time.- PATHOPHYSIOLOGY:- Hypothyroidism - Genital tract obstruction *tubal obstruction.- Cervical mucus is too thick- Male sexual dysfunction

OTHER ISSUES: INFERTILITY- DIAGNOSTIC EVAULATION FOR THE FEMALE:- BBT monitoring - Menstrual cycle mapping for 6months.- CERVICAL MUCOSAL TEST to assess the

elasticity.- FERN TEST = done before ovulation when

estrogen levels are the highest. The cervical mucus is thin with low stretch ability.

- SPINNBARKEIT TEST = cervical mucus is highly stretchable showing that ovulation is close.

OTHER ISSUES: INFERTILITY- OPTIONS FOR INFERTILE COUPLES:- ARTIFICIAL INSERMINATION: sperm from the partner

or donor is injected into the patients cervix or uterus on a day after ovulation.

- In Vitro FERTILIZATION: - Egg is removed from the woman, fertilized in the lab then

fertilized egg is reinserted into the woman's uterus.- GAMETE INTRAFALLOPIAN TUBE TRANSFER:

- Egg and sperm are fertilized in a tube then inserted into the woman's uterus.

- SURROGATE MOTHER- ADOPTION.

Maternal Health/ OB Final Exam Study Guide

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