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OB ATI Study Guide

Initial Prenatal Visit:

Estimated date of delivery based on LMP. Vaginal ultrasound may be done to establish DOD

Medical & nursing hx including past med health, family hx, social supports, social hx, & review of

systems (to determine risk factors) & past OB hx

Physical assessment: baseline weight, vitals, pelvic exam

Initial lab work:

o Blood type

o RH factor

o HIV status

o Hep B

o VDRL

o Rubella status

o Urinalysis

o Pap

o Indirect Coombs test will

determine if client is sensitized

to RH+ blood

Ongoing Prenatal Visits:

Monitor weight, BP, & urine for glucose, protein, & leukocytes

Present of edema

Fetal development:

o FHR heard by Doppler at 10-12 wks

o Heard with ultrasound stethoscope at 16-20 wks. Listen at the midline, right above the

symphysis pubis, holding stethoscope firmly on abd

o Measure fundal height after 12 wks. Between 18 & 30 weeks, fundal height measured in

cm should equal the week of gestation. Have pt empty bladder & measure from the

level of the symphysis pubis to the upper border of the fundus

o Begin assessing for fetal movement between 16 & 20 weeks gestation

Routine Lab Tests in Prenatal Care & Their Purpose

Blood type, Rh factor, presence of irregular antibodies

Determines risk for maternal-fetal blood incompatibility (erythroblastosis fetalis) or neonatal hyperbilirubinemia. For clients are are Rh(-) & not sensitized, the indirect Coombs test will be repeated b/t 24-28 weeks gestation

CBC w/ differential, Hgb, Hct Detects infection & anemia

Hgb electrophoresis Identifies hemoglobinopathies (sickle cell anemia & thalassemia)

Urinalysis: pH, gravity, color, sediment, protein, glucose, albumin, RBCs, WBCs, casts, acetone, & HCG

Identifies DM, gestational HTN, renal disease, & infection

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1 hr Glucose Tolerance (oral/IV admin of concentrated glucose w/ venous sample taken 1 hr later. Fasting not necessary)

Identifies hyperglycemia; done at initial visit for at-risk clients, & at 24-28 wks for all pregnant women (>140 requires follow up)

3 hr Glucose Tolerance (fasting overnight prior to oral or IV admin of concentrated glucose with a venous sample taken at 1, 2, & 3 hrs later)

Used in clients w/ elevated 1-hr glucose tst as a screening tool for DM. A dx of GD requires 2 elevated blood-glucose readings

Pap Test Screens for cervical cancer, HSV II, &/or HPV

Vaginal/Cervical Culture Detects streptococcus B-hemolytic, Group B (routinely done at 35-37 wks), BV, STDS (gonorrhea, chlamydia)

Rubella Titer Determines immunity to rubella. If non-immune, give shot!

PPD, chest screening after 20 weeks w/ + purified protein derivative

Identifies exposure to TB

Hep B Screen Identifies carriers of hep B

VDRL Syphilis screening mandated by law

HIV Detects HIV infection: recommended for all clients who are pregnant unless client refuses testing

TORCH (Toxoplasmosis, other infections, rubella, cytomegalovirus, & herpes) when indicated

Screening for group of infections capable of crossing the placenta & adversely affecting fetal development

Maternal serum alpha-fetoprotein (MSAFP) Between 15-22 wks

Rhogam Administration:

IM around 28 weeks for clients who are Rh (-)

For amniocentesis, car wreck, or any instance of possibility of fetal/maternal blood mixture

Health Promotion:

Avoid all OTC meds, supplements, & rx meds unless OB who is supervising care has knowledge

of this practice

Alcohol (birth defects) & tobacco (low birth weight) contraindicated during pregnancy

Substance abuse of any kind is to be avoid during pregnancy & lactation

Encourage flu vaccine during the fall months

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Treat current infections

Ascertain maternal exposure to hazardous materials

Avoid use of hot tubs/saunas

Consume at least 2-3 L of h20 daily from food & beverage sources

Exercise: moderate exercise (walking/swimming) consisting of 30 minutes; no new exercise

during pregnancy

Third Trimester Childbirth Prep:

Breathing & relaxation techniques

o Deep cleansing breaths at the usual respiratory rate during ctxns can promote

relaxation of the abd muscles, which lessens the discomfort of uterine ctxns.

discussion regarding pain management during labor & birth (natural child birth, epidural)

Fetal movement/kick counts to ascertain fetal well-being. Client should be instructed to count &

record fetal movements or kicks daily

o It is recommended that mothers count fetal activity 2-3 x/day for 60 mins each time

o Fetal movements

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Gingivitis, nasal stuffiness, & epistaxis can occur

Braxton Hicks ctxns

o Should subside with change of position & walking

Danger Signs of Pregnancy:

Gush of fluid from vagina (rupture of amniotic fluid) prior to 37 weeks of gestation

Vaginal bleeding (placental problems such as abruption or previa)

Abd pain (premature labor, abruption placenta, or ectopic pregnancy)

Changes in fetal activity ( fetal movement may indicate fetal distress)

Persistent vomiting (hyperemesis gravidarum)

Severe HA (PIH)

Elevated temp (infection)

Dysuria (UTI)

Blurred vision (PIH)

Edema of face & hands (PIH)

Epigastric pain (PIH)

Concurrent occurrence of flushed dry skin, fruity breath, rapid breathing, thirst & urination, &

HA (hyperglycemia)

Concurrent occurrence of clammy pale skin, weakness, tremors, irritability, & lightheadedness

(hypoglycemia)

Common birthing methods: prepare a pregnant woman for the l&d process & may anxiety:

Dick-Read method- childbirth w/out fear. Uses controlled breathing & conscious & progressive

relaxation of different muscle groups through the entire body. Instructs a woman to relax

completely between contractions & keep all muscles except the uterus relaxed during ctxns

Lamaze- promote a healthy, natural, & safe approach to pregnancy, childbirth, & early parenting

by advocating & working w/ HCP, parents, & prof. childbirth instructors

Leboyer- based on the idea of birth without violence. Environmental variables are stressed to

ease the transition of the fetus from the uterus to the external environment (dim lights, soft

voices, warm birthing room). Water births are based on this method.

Bradley- emphasizes partners involvement as the birthing coach. Emphasizes increasing self-

awareness & teaching the woman to deal w/ the stress of labor by tuning into her own body.

Mother is encouraged to trust her body & use natural breathing, relaxation, nutrition, exercise,

& education throughout pregnancy

Nutrition During Pregnancy:

protein intake

foods high in folic acid (leafy vegetables, dried peas & beans, seeds, orange juice. Breads,

cereals, & other grains are fortified with folic acid).

o 600 mcg during pregnancy

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o 500 mcg during lactation

Iron supplements facilitate an of the maternal RBC mass

o Best absorbed between meals & when given w/ good source of Vit. C

o Milk & caffeine interfere w/ absorption

o Sources of iron: beef liver, red meats, fish, poulty, dried peas & beans, & fortified

cereals & breads

o Stool softener may be added to constipation experienced w/ iron

Adolescents may have poor nutritional habits (a diet low in vitamins & protein, not taking

prescribed iron supplements(

Potential Diagnoses for Ultrasound during Pregnancy:

Confirm pregnancy, fetal viability, or

death

Confirm GA by biparietal diameter

(side-to-side) measurement

Identify multifetal pregnancy

Site of fetal implantation (uterine or

ectopic)

Assessment of fetal growth &

development

Assessing maternal structure

Ruling out fetal abnormalities

Locating site of placental attachment

Determining amniotic fluid volume

Fetal movement observation (FHR,

breathing, & activity)

Placental grading (evaluating placental

maturation)

Adjunct for other procedures

Client presentation:

o Vaginal bleeding eval

o Questionable fundal height

measurement in relationship to

gestational weeks

o fetal movements

o Preterm labor

o Questionable rupture of

membranes

Amniocentesis:

Aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into clients

uterus & amniotic sac under direct ultrasound guidance locating the placenta & determining

position of fetus. May be performed after 14 weeks

Indications:

o Maternal age >35 years

o Previous birth w/ chromosomal

anomaly

o Parent who is carrier of

chromosomal anomaly

o Family hx of neural tube defects

o Prenatal dx of genetic disorder

or congenital anomaly of fetus

o Alpha fetoprotein level for fetal

abnormalities

o Lung maturity assessment

o Fetal hemolytic disease dx

o Meconium in amniotic fluid

Interpretation of finding:

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o AFP (protein produced by fetus) can be measured from the amniotic fluid between 16-

18 weeks & may be used to assess for neural tube defects in fetus or chromosomal

disorders. May be evaluated to follow up a high level of AFP in maternal serum:

High level: associated w/ neural tube defects such as anencephaly (incomplete

development of fetal skull & brain), spina bifida (open spine), or omphalocele

(abd wall defect). May also be present with normal multifetal pregnancies

Low levels: chromosomal disorders (Down syndrome) or gestational

trophoblastic disease (hydratiform mole)

o Tests for fetal lung maturity may be performed if gestation < 27 weeks in event of

rupture of membranes, preterm labor, or for complication indicating C-section. Amniotic

fluid tested to determine if the fetal lungs are mature enough to adapt to extrauterine

life or if the fetus will likely have respiratory distress. Determination is made whether

the fetus should be removed immediately or if the fetus requires more time in utero w/

the admin of glucocorticoids to promote fetal lung maturity

Fetal lung tests

Lecithin/sphingomyelin (L/S) ratio- a 2:1 indicating fetal lung maturity

(2.5:1 or 3:1 for a client who has DM)

Presence of phosphatidylglycerol (PG)- absence of PG is associated w/

respiratory distress

Preprocedure for Amniocentesis

o Explain procedure & obtain informed consent

o Instruct client to empty bladder to reduce risk of inadvertent puncture

Intraprocedure:

o Assist client in supine position & place a wedge or rolled towel under right hip to

displace uterus off vena cava & place drape over client exposing only abd

o Prepare for ultrasound to locate placenta

o Obtain baseline vitals & FHR & document prior to procedure

o Cleanse abd w/ antiseptic solution prior to administration of a local anesthetic given by

the PCP

o Advise client that she will feel slight pressure as the needle is inserted for aspiration.

However, she should continue breathing because holding her breath will lower the

diaphragm against the uterus & shift intrauterine contents\

Postprocedure:

o Monitor vitals, FHR, & uterine ctxns throughout procedure & 30 mins following

o Have client rest for 30 mins

o Administer Rhogam if Rh (-)

o Advise client to report to PCP if she experiences fever, chills, leakage of fluid/bleeding

from insertion site, d fetal movement, vaginal bleeding, or uterine ctxns after the

procedure

o Drink plenty of fluids & rest for next 24 hours post procedure

Complications:

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o Amniotic fluid emboli

o Maternal or fetal hemorrhage

o Fetomaternal hemorrhage w/

Rh isoimmunization

o Maternal or fetal infection

o Inadvertent fetal damage or

anomalies involving limbs

o Fetal death

o Inadvertent maternal intestinal

or bladder damage

o Miscarriage or preterm labor

o Premature rupture of

membranes

o Leakage of amniotic fluid

Nursing Actions:

o Monitor vitals, temp, respiratory status, FHR, uterine ctxns, vaginaly discharge

o Provide med admin as prescribed, client education, & support

Alpha-Fetoprotein Screening

Abnormal finding should be referred for a quad marker screening, genetic counseling,

ultrasound, & an amniocentesis

Indications: all pregnant clients between 16 & 18 weeks

Interpretation of findings:

o High levels: neural tube defect or open abd defect

o Low levels: Down syndrome

Nursing actions:

o Discuss testing w/ client

o Draw blood sample

o Offer support & education as needed

Summary of Causes of Bleeding during Pregnancy

Time Complication S/S

First Trimester

Spontaneous abortion

Vaginal bleeding, uterine cramping, & partial or complete expulsion of products of conception

Ectopic pregnancy

Abrupt unilateral lower-quad pain w/ or w/out vag bleeding

Second Trimester

Gestational trophoblastic disease

Uterine size increasing abnormally fast, abnormally high levels of hCG, nausea & emesis, no fetus present on ultrasound, scant/profuse dark brown or red vag bleeding

Placenta previa

Painless vaginal bleeding

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Third Trimester

Abruptio placenta

Vaginal bleeding, sharp abd pain, & tender rigid uterus

Vasa previa

Fetal vessel cross over the cervix abrupt red vaginal bleeding following ROM

Other Causes of Bleeding:

Incompetent cervix

o Painless bleeding w/ cervical dilation leading to fetal expulsion

Preterm Labor

o Pink-stained vaginal discharge, uterine ctxns becoming regular, cervical dilation &

effacement

Spontaneous Abortion

When a pregnancy is terminated before 20 weeks of gestation or a fetal weight 35 y.o

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o Family hx of DM o Previous delivery of infant that

was large or stillborn

Subjective data

o Hypoglycemia (nervousness, HA, weakness, irritability, hunger, blurred vision, tingling of

mouth or extremities)

o Hyperglycemia (thirst, nausea, abd pain, frequent urination, flushed dry skin, fruity

breath)

Objective Data

o Hypoglycemia

o Shaking

o Clammy pale skin

o Shallow respirations

o Rapid pulse

o Hyperglycemia

o Vomiting

o Excess weight gain during

pregnancy

Lab tests

o Routine urinalysis w/ glycosuria

o Glucola screening test/1 hour GTT

Positive: 140 mg/dL or greater

Additional testing w/ 3 hr GTT is indicated

o 3-hr GTT

Avoidance of caffeine & abstinence from smoking for 12 hour prior to testing

100 g glucose load given

o Ketones tested to assess the severity of ketoacidosis

Dx procedures

o Biophysical profile to ascertain fetal well-being

o Amniocentesis w/ alpha-fetoprotein

o Nonstress test to assess fetal well-being

Nursing Care:

o Monitor clients blood glucose

o Monitor fetus

o Instruct client to perform daily kick counts

o Administer insulin as prescribed

Most oral hypoglycemic agents are contraindicated for GDM, but there is

limited use of glyburide at this time. The provider will need to make the

determination if these meds can be used

o Educate client about diet, exercise, & self-administration of insulin

o Desired client outcomes: effectively manage & control blood glucose level throughout

her pregnancy to ensure maternal/fetal well-being

Gestational Hypertension/ Pregnancy Induced Hypertension (PIH)

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Hypertensive disease in pregnancy is divided into clinical subsets of the disease based on end-

organ effects & progresses along a continuum from mild gestational hypertension, mild &

severe preeclampsia, eclampsia, & HELLP syndrome

Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the s/s of

pregnancy hypertensive disorders

Gestational hypertension (GH), which begins after the 20th week of pregnancy, describes

hypertensive disorders of pregnancy whereby the woman has:

o an elevated BP at 140/90 or greater

o or a systolic of 30

o or a diastolic of 15 from the prepregnancy baseline

o no proteinuria or edema

o clients bp returns to baseline by 12 weeks postpartum

Mild preeclampsia:

o GH w/ addition of proteinuria of 1 to 2+

o Weight gain of more than 2 kg (4.4 lbs) per week in the 2nd & 3rd trimesters

o Mild edema will appear in the upper extremities or face

Severe preeclampsia:

o BP >160/100

o Proteinuria 3 to 4+

o Oliguria

o Elevated serum creatinine >1.2

mg/dL

o Cerebral or visual disturbances

(HA & blurred vision)

o Hyperreflexia w/ possible ankle

clonus

o Pulmonary or cardiac

involvement

o Extensive peripheral edema

o Hepatic dysfunction

o Epigastric & RUQ pain

o Thrombocytopenia

Eclampsia is severe preeclampsia symptoms along w/ onset of seizure activity or coma.

o Usually preceded by HA, severe epigastric pain, hyperreflexia, & hemoconcentrations,

which are warning signs of possible convulsions

HELLP syndrome is a variant of GH in which hematologic conditions coexist w/ severe

preeclampsia involving hepatic dysfunction. Diagnosed by lab tests, not clinically:

o H- hemolysis resulting in anemia & jaundice

o EL- elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or

aspartate transaminase (AST), epigastric pain, n/v

o LP- low platelets (< 100,000), resulting in thrombocytopenia, abn bleeding & clotting

time, bleeding gums, petechiae, & possibly DIC

Gestational hypertensive disease & chronic hypertension may occur simultaneously

Gestational hypertensive diseases are associated w/ placental abruption, acute renal failure,

hepatic rupture, preterm birth, & fetal & maternal death

Risk Factors

o No single profile identifies risks for GH disorders, but some high risks include:

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Maternal age 40

First pregnancy

Morbid obesity

Multifetal gestation

Chronic renal disease

Chronic hypertension

Familiar hx of

preeclampsia

DM

Rh incompatibility

Molar pregnancy

Previous hx of GH

Assessment of Gestational Hypertensive Disorders

Subjective Data Severe continuous HA

Nausea

Blurred vision

Flashes of lights or dots before the eyes

Objective HTN

Proteinuria

Periorbital, facial, hand, & abd edema

Epigastric pain

RUQ pain

Dyspnea

Seizures

Jaundice

Scotoma

Diminished breath sounds

Pitting edema of lower extremities

Vomiting

Oliguria

Hyperreflexia

Rapid weight gain (2 kg [4.4 lb]) per week in 2nd & 3rd trimesters

Signs of progression of hypertensive disease w/ indications of worsening liver involvement, renal failure, worsening hypertension, cerebral involvement, & developing coagulopathies

Lab Findings Hgb

Creatinine

Thrombocytopenia

Plasma uric acid

liver enzymes (LDH, AST)

Hyperbilirubinemia

Lab Tests Liver enzymes

CBC

Clotting studies

Serum creatinine, BUN, uric acid, & Mg as renal function

Chemistry profile

Dx Procedures Dipstick urine for proteinuria

24 hr urine collection for protein & creatinine clearance

Nonstress test, ctxn stress test, biophysical profile, & serial ultrasounds to assess fetal status

Doppler blood flow analysis to assess fetal well-being

Nursing Care:

o Assess LOC

o Pulse ox

o Urine output & obtain clean-

catch urine sample to assess for

proteinuria

o Daily weights

o Vitals

o Lateral positioning

o Perform NST & daily kick counts

as prescribed

o Instruct client to monitor I&O

Meds:

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o Mag Sulfate

Anticonvulsant

Med of choice for prophylaxis or treatment.

Lowers BP & depresses CNS

Use infusion control device to maintain regular flow rate

Inform client she may initially feel flushed, hot, & sedated w/ MgSO4 bolus

Monitor BP, pulse, RR, DTRs, LOC, urinary output (indwelling cath for accuracy),

presence of HA, visual disturbances, epigastric pain, uterine ctxns, & FHR &

activity

Fluid restriction of 100 to 125 ml/hr, maintain urinary output of 30 ml/hr or

greater

Monitor for signs of mag toxicity:

Absence of patellar DTR

Urine output

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Dehydration stimulates pituitary gland to secrete an ADH & oxytocin. Preventing

dehydration will prevent release of oxytocin, which stimulates uterine ctxns

o Identifying & treating any infection

Client should report vag discharge, noting color, consistency, odor

Monitor vitals & temp

o Choroamnionitis should be suspected w/ occurrence of elevated maternal temp &

tachycardia

o Monitor FHR & ctxn pattern

Fetal tachycardia (prolonged in FHR >160/min) may indicate infection, which

is frequently associated w/ preterm labor

Medications

o Terbutaline (Brethine)

o Mag sulfate

Commonly used tocolytic that relaxes the smooth muscle of the uterus & thus

inhibits uterine activity by suppressing ctxns

Monitor closely. Therapy should be d/c immediately if the client exhibits s/s of

pulmonary edema (chest pain, SOB, resp distress, audible wheezing & crackles,

&/or productive cough containing blood-tinged sputum)

Monitor for side effects

Monitor for mag sulfate toxicity & d/c for any of the following adverse effects:

Loss of DTR

Urine output 34 weeks gestation

Acute fetal distress

Instruct client to notify nurse of blurred vision, HA, n/v, or difficulty breathing

Pain Management

Safety for the mother & fetus must be first consideration of the nurse when providing pain

management measures

Nurse is responsible for helping client maintain the proper position during admin of

pharmacological interventions

Nonpharmacological pain management: seek to reduce anxiety, fear, & tension, which are major

contributing factors of pain in labor

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o Gate-control theory of pain- based on concept that the sensory nerve pathways that

pain sensations use to travel to the brain will only allow a limited number of sensations

to travel at any giving time. By sending alternate signals through these pathways, the

pain signals can be blocked from ascending the neuro pathway & inhibit brains

perception & sensation of pain

o Gate-control theory assists in the understanding of how nonpharm pain techniques can

work to relieve pain

o Childbirth prep education, sensory & cutaneous strategies, & frequent position changes

Lamaze, Bradley, Dick-Read methods

Pattern breathing methods: nurse should assess for signs of hyperventilation

(caused by low blood levels of PCO2 from blowing off too much CO2) such as

light-headedness & tingling of the fingers

If hyperventilation occurs, have the client breathe into a paper bag or

cupped hands

o Sensory stimulation strategies:

Aroma therapy

Breathing techniques

Imagery

Music

Use of focal points

o Cutaneous Strategies:

Back rubs & massage

Effleurage:

Light, gentle circular stroking of clients abd w/ fingertips in rhythm w/

breathing during ctxns

Sacral counterpressure

Consistent pressure is applied by the support person using the heel of

the hand or fist against clients sacral area to counteract pain in the

lower back

Heat or cold therapy

Intradermal water block

Hypnosis

Acupressure

Transcutaneous

electrical nerve

stimulation (TENS) unit

Hydrotherapy (whirlpool or shower) s maternal endorphin levels

o Frequent maternal position changes:

Semi-sitting

Squatting

Kneeling

Kneeling & rocking back

& forth

Supine position only w/ the placement of a wedge under 1 of the clients hips to

tilt the uterus & avoid supine hypotension syndrome

Pharmacological Pain Management: avoid slowing the progress of labor.

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o Prior to administration, nurse should verify that labor is well established by performing

a vag exam & evaluating uterine ctxn pattern

Adverse effect of opioid analgesics: crosses the placental barrier; if given to the mother too

close to the time of delivery, opioid analgesics can cause respiratory depression in neonate

Epidural & spinal regional analgesia: fentanyl & sufentanil, which are short-acting opioids that

are administered as a motor block into the epidural or intrathecal space w/out anesthesia

o Produce regional analgesia providing rapid pain relief while still allowing client to sense

ctxns & maintain ability to bear down

o Adverse effects:

gastric emptying

resulting in n/v

Inhibition of bowel &

bladder elimination

sensations

Bradycardia or

tachycardia

Hypotension

Respiratory depression

Allergic rxn & pruritus

Elevated temperature

o Provide client w/ ongoing education r/t expectations for procedure

o Institute safety precautions such as side rails up. Patient may experience dizziness &

sedation, which s maternal risk for injury

o Assess the client for n/v & admin antiemetics as prescribed

o Monitor vitals per hospital protocol

o Monitor for allergic rxn

o Continue FHR pattern monitoring

Epidural Block: local anesthetic bupivacaine along w/ analgesic Morphine or fentanyl injected

into epidural space at 4th or 5th vertebrae. Eliminates all sensation from level of umbilicus to the

thighs, relieving discomfort of perineum.

o Admin when client is in active labor & dilated to at least 4 cm

o Continuous infusion or intermittent injections may be admin through an indwelling

epidural cath

o Patient controlled epidural analgeis is a new technique

o Adverse effects:

Maternal hypotension

Fetal bradycardia

Inability to feel the urge to void

Loss of the bearing down reflex

o Nursing Actions:

Admin bolus of IV fluids to help offset maternal hypotension as prescribed

Help position client into either sitting or side-lying modified Sims w/ back

curved to widen intervertebral space for insertion of the epidural cath

Remain in side-lying position after insertion to avoid supine hypotension

syndrome w/ compression of vena cava

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Coach pushing efforts & request evaluation of epidural pain mgmnt by

anesthesia if pushing efforts ineffective

Monitor maternal BP & pulse, observe for hypotension, resp depression, & o2

sats

Assess FHR continuously

Maintain IV line & have O2 & suction ready

Assess for orthostatic hypotension. If present, prepare to admin IV vasopressor

such as ephedrine, position laterally, IV fluids, initiate O2

Provide client safety: raise side rails. Dot not allow client to ambulate unassisted

until all motor control has returned

Assess bladder for distention at frequent intervals & catheterize if necessary

Monitor the return of sensation in legs after delivery but prior to standing.

Assist with standing & walking for the first time after delivery that included

epidural anesthesia

A nurse is caring for a client in active labor. The client reports lower back pain. The nurse

suspects that this pain is persistent occiput posterior presentation. Which of the following

nonpharmacological nursing interventions should best alleviate this pain?

B. Sacral counterpressure.

Late Deceleration of FHR

Slowing of FHR after ctxn has started w/ return of FHR to baseline well after ctxn has ended

Causes/Complications:

o Uteroplacental insufficiency causing inadequate fetal oxygenation

o Maternal hypotension, abruption placentae, uterine hyperstimulation w/ oxytocin

(Pitocin)

Nursing interventions:

o Side-lying position

o Start IV line or IV rate

o D/C oxytocin if being infused

o Admin O2 8-10 L/min per mask

o Notify PCP

o Prepare for assisted vag birth or

C-section

Assessments R/T possible rupture of membranes:

First assess FHR to assure there is no fetal distress from possible umbilical cord prolapse, which

can occur w/ gush of amniotic fluid

Nitrazine paper will turn blue in the presence of alkaline amniotic fluid (pH 6.5-7.5)

Sample of fluid obtained & viewed on a slide under microscope

o Amniotic fluid will exhibit frond-like ferning pattern

Fluid should be a clear straw color & free of odor

Bishop Score

Used to determine maternal readiness for labor by evaluating if cervix is favorable:

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o Cervical dilation

o Effacement

o Consistency (firm, medium, or

soft)

o Position (posterior,

midposition, or anterior)

o Presenting part station

5 factors are assigned a numerical value of 0-3, total score is calculated, & a score of 9 for

nulliparas & 5 or more for multiparas indicates readiness for labor induction

Indication:

o Any condition in which augmentation or induction of labor is indicated

Amniotomy

Artificial rupture of amniotic membranes by PCP using an Amnihook or other sharp instrument

Labor typically begins w/in 12 hrs after rupture

Client is at risk for cord prolapse or infection

Indications:

o Labor progression too slow & augmentation/induction is indicated

o Amnioinfusion is indicated for cord compression

Outcomes:

o Labor will progress w/out complications

Nursing Actions:

o Assure presenting part of fetus is engaged prior to an amniotomy to prevent cord

prolapse

o Monitor FHR prior to & following AROM to assess for cord prolapse AEB variable/late

decelerations

o Assess & document characteristics of amniotic fluid including color, odor, & consistency

Interventions:

o Document the time of rupture

o Obtain temp q 2 hr

Cesarean Birth

Incisions currently made horizontally into lower segment of uterus

Previously made as classical vertical incision into muscular body of the uterus

Indications:

o Malpresentation, particularly

breech

o Cephalopelvic disproportion

o Fetal distress

o Placental abn

Previa

Abruption placenta

o High-risk pregnancy

HIV +

Hypertensive disorders

such as preeclampsia &

eclampsia

Maternal DM

Active herpes outbreak

o Previous c-section

o Dystocia

o Multiple gestations

o Umbilical cord prolapse

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Client outcome: free of injury during birthing process

Preprocedure:

o Assess/record FHR, vitals, BP

o Obtain abd ultrasound to assess if c-section is indicated

o Supine position w/ wedge under 1 hip to laterally tilt her & keep her off of the vena cava

& descending aorta. This helps maintain optimal perfusion of oxygenated blood to the

fetus during procedure

o Insert indwelling cath

o Admin preop meds

o Prepare surgical site

o Insert IV line

o Obtain informed consent

o Determine client has had NPO since midnight before procedure. If she has, notify

anesthesiologist

o Assure preop dx tests are complete including Rh-factor test

Intraprocedure:

o Assist in positioning client on operating table

o Monitor FHR

o Monitor vitals, IV fluids, urine output

Postprocedure Assessments & Actions:

o Signs of infection & excessive

bleeding

o Uterine fundus for firmness or

tenderness

o Lochia amount & characteristics

Tender uterus & foul-

smelling lochia:

endometritis

o Productive cough or chills

(pneumonia)

o S/s of thrombophlebitis

(tenderness, pain, heat)

o I&O, vitals

o Provide pain relief &

antiemetics

o Turn, cough, & deep breath

o Splinting of incision w/ pillows

o Ambulation to prevent

thrombus formation

o Sx of UTI

Complications

o Maternal:

Aspiration

Amniotic fluid PE

Wound infection

Dehiscence

Severe abd pain

Thrombophlebitis

Hemorrhage

UTI

Injuries to

bladder/bowel

Anesthesia assoc

complications

o Fetal:

Premature birth of fetus if GA is inaccurate

Fetal injuries during surgery

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Meconium-Stained Amniotic Fluid

Typically associated w/ unfavorable fetal outcome

Fetus has had an episode of loss of sphincter control, allowing meconium to pass into fluid

Risk Factors:

o >38 weeks gestation

o Umbilical cord compression r/I fetal hypoxia that stimulates the vagal nerve in mature

fetuses

o Hypoxia stimulate vagal nerve, which induces peristalsis of fetal GI tract & relaxation of

the anal sphincter, which r/I release of meconium as well as fetal bradycardia

Objective Data:

o Presence of meconium via visual inspection

o Fluid may vary in color from black to greenish, yellow or brown, w/ thick fresh

consistency

o Criteria for evaluation of meconium-stained amniotic fluid:

Consistency that is thick & fresh: indicates fetal stress

Meconium is 1st passed in later labor w/ variable or late FHR decelerations

(ominous sign)

Meconium alone in the amniotic fluid isnt sign of fetal distress; it must be

accompanied by variable or late FHR decelerations w/ or w/out acidosis, which

is confirmed by scalp blood sampling to be considered ominous

o Dx Procedures

Intrapartal meconium requires further careful evaluation if birth is not imminent

Electronic fetal monitoring

Fetal scalp blood sampling

Nursing Care:

o Document meconium-stained amniotic fluid & its color

o Amnioinfusion of 0/9% NaCl or LR should be instilled into the amniotic cavitiy through a

transcervical cavity into the uterus to thin meconium-stained fluid

o Nurse should be prepared to suction the nasopharynx of neonate

o Suctioning reduces the incidence & severity of meconium aspiration syndrome in the

neonate

Postpartum Period

Greatest risks: hemorrhage, shock, & infection

Oxytocin coordinates & strengthens uterine contractions

o May be administered postpartum to improve quality of uterine ctxns

o Firm & contracted uterus prevents excessive bleeding & hemorrhage

o Uncomfortable uterine cramping: afterpains

Assessments immediately following delivery:

o Vitals

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o Uterine firmness & location relative to umbilicus

o Uterine position in relation to midline of the abd

o Amount of vaginal bleeding

Postpartum chill: occurs in first 2 hr puerperium. Uncontrollable shaking chills possibly r/t

nervous system response, vasomotor changes, shift in fluid, &/or work of labor.

o Normal occurrence unless accompanied by elevated temperature

o Provide client w/ warm blankets & fluids

Fundus:

o Immediately after delivery: firm, midline w/ umbilicus, at level of umbilicus

o At 12 hr postpartum: 1 cm above umbilicus

o Q 24 hr, descends approximately 1-2 cm

Should be halfway b/t symphysis pubis & umbilicus by 6th day

o By day 10, uterus should lie within true pelvis & not palpable

Comfort measures:

o Apply ice packs to perineum for 1st 24-48 hrs to reduce edema & provide anesthetic

o Encourage sitz baths at temp of 38-30 (100-104 F) or cooler at least BID

o Admin analgesia such as nonopioids, NSAIDS,& opioids as prescribed

o Opioid analgesia may be admin via PCA after c-section. Continuous epidural infusions

may also be used for pain control after c-sections

o Apply topical anesthetics to perineal area prn or witch hazel compresses to rectal area

for hemorrhoids

Immune System:

o Review the Rh status

All Rh(-) mothers w/ newborns who are Rh(+) must be given Rhogam

administered w/in 72 hrs of delivery to suppress antibody formation in mother

o Test client who receives both rubella vaccine & RhoGAM after 3 months to determine if

immunity to rubella has been developed

Bonding & Integration of Infant into Family System

Mothers emotional & physical condition (unwanted pregnancy, adolescent pregnancy, history

of depression, difficult pregnancy & delivery) & infants physical condition (prematurity,

congenital anomalies) after birth can affect familys bonding experience

Culture, age, & socioeconomic level can influence bonding

Bonding can be delayed secondary to maternal or neonatal factors

Psychosocial adaptation & maternal adjustment begin during pregnancy as the client goes

through commitment, attachment, & preparation for the birth of the newborn.

o 1st 2-6 weeks after birth: acquaintance, physical restoration, focus on competently

caring for newborn

o 4 months following birth: achieving maternal identity

o These stages may overlap & are variable based on maternal, infant, & environmental

factors

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Nursing interventions to assist w/ maternal-infant bonding:

o Provide quiet & private environment

o Place infant skin-to-skin w/ mother soon after birth in en face position

o Encourage bonding via cuddling, feeding, diapering, & inspection

o Provide frequent praise, support & reassurance to mother

o Encourage mother/parents to express feelings, fears, & anxieties about care for infant

Client Education & Discharge Teaching

Breast care:

o Wear well-fitting bra continuously for 1st 72 hours after birth

o Provide breast care for lactating women

Emphasize importance of hand hygiene prior to breast feeding

Breast engorgement:

Completely empty breasts at each feeding

Allow infant to nurse q 2 hr

Massage breast during feeding

Allow infant to feed 15-20 mins per breast or until breast softens

If 2nd breast doesnt soften after feeding, it may be emptied w/ pump

Apply cool compresses b/t feedings & warm compresses/warm shower

prior to feeding ( milk flow & promotes letdown reflex)

Cold cabbage leaves also swelling & relieve discomfort

Flat nipples

Suggest client roll nipples between fingers just before breastfeeding

Sore nipples:

Apply small amount of breast milk to nipple & allow to air dry after

feeding

Apply breast creams as prescribed & wear breast shields in bra to soften nipples

Promote adequate fluid intake b/c its important to replace fluid lost from

breastfeeding as well as produce an adequate amount of milk

o Non-lactating Women:

Suppression of lactation is necessary for women who are not breastfeeding

Avoid breast stimulation & running warm water over the breast for

prolonged periods until no longer lactating

For breast engorgement, which may occur on 3rd or 5th postpartum day:

Apply cold compresses 15 min on & 45 min off

Fresh cabbage leaves inside bra

Mild analgesics for pain & discomfort

Rest/Sleep

o Plan at least one daily rest period; rest when infant naps

Activity

o Dont perform housework that requires heavy lifting for at least 3 wks

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o Dont lift anything heavier than the infant

o Avoid sitting for prolonged periods of time w/ legs crossed

o Limit stair climbing for 1st few weeks

o C-section clients should wait until 6 wk follow-up visit before performing strenuous

exercise, heavy lifting, or excessive stair climbing

o Instruct client not to drive for 1st 2 weeks postpartum or while taking opioids

Postpartum Hemorrhage

Assessment:

o vaginal bleeding

o Uterine atony

o Blood clots larger than quarter

o Perineal pad saturation in 15

min or less

o Return of lochia rubra once

lochia has progressed to serosa

or alba

o Constant oozing, trickling, or

frank flow of bright red blood

from vag

o Tachycardia & hypotension

o Skin thats pale, cool, & clammy

w/ poor turgor & pale mucous

membranes

o Oliguria

Nursing Care:

o Monitor vitals

o Assess for source of bleeding

Fundus: height, firmness, & position

Lochia: color, quantity, & clots

Signs of bleeding from lacerations, episiotomy site, hematomas

o Assess bladder for distention

Insert indwelling cath to assess kidney function & obtain accurate measurement

of urinary output

o Maintain/initiate IV fluids w/ isotonic solutions (lactated Ringers or .9% NaCl), colloid

volume expanders (albumin), and blood products

o Provide O2 at 2-3 L per nasal cannula as prescribed to RBC sat

o Monitor O2 sat

o Elevate legs to 20-30 degree angle to venous return

Uterine Stimulant Meds:

o Oxytocin

Promotes uterine ctxns

Nurse should assess uterine tone & vag bleeding

Monitor for adverse rxns of H2O intoxication (lightheadedness, n/v, HA,

& malaise). These rxns can progress to cerebral edema w/ seizures,

coma, & death

o Methylergonovine (Methergine)

Controls postpartum hemorrhage

Nurse should assess uterine tone & vag bleeding.

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Dont admin to clients w/ hypertension

Monitor for adverse rxns: hypertension, n/v, HA

o Misoprostol (Cytotec)

Controls postpartum hemorrhage

Nurse should assess uterine tone & vag bleeding

o Carboprost tromethamine (Hemabate)

Controls postpartum hemorrhage

Assess uterine tone & vag bleeding

Monitor for adverse rxns: fever, chills, HA, n/v, diarrhea

Client education & Outcomes

o Provide d/c instructions:

Limit physical activity to conserve strength

iron & protein intake to rebuild RBC volume

o Outcomes:

Vaginal bleeding will be controlled w/ employed interventions

Vitals & lab results WNL

No complications or injury r/t postpartum hemorrhage

Dilation & curettage (D&C): performed by PCP to remove retained placental fragments if indicated

Infections

Mastitis: infection of breast involving interlobular connective tissue; usually unilateral

o May progress to abscess if untreated

o Most commonly occurs in first time breastfeeding mothers & well after establishment of

milk flow, which is usually 2-4 wks after delivery

o Staphylococcus aureus is usually the infecting organism

o Risk Factors:

Milk stasis from blocked duct

Nipple trauma, cracked/fissured nipples

Poor technique w/ improper latching of infant onto breast

breast feeding frequency due to supplementation w/ bottle

Poor hygiene, inadequate hand hygiene b/t handling perineal pads & breasts

o Client education:

Hand hygiene prior to breastfreeding

Maintain cleanliness of breasts w/ frequent changes of breast pads

Allow nipples to air dry

How to completely empty breasts

Use ice packs/warm packs

Continue breastfeeding frequently (at least q 2-4hr), especially on affected side.

Manually express milk or use a breast pump if too painful

Being breastfeeding on unaffected breast first to initiate the letdown reflex in

the affected breast that is distended or tender

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Rest, analgesics, fluid intake of at least 3,000 ml/day

Report redness & fever

Well-fitting bra

Antibiotics; complete entire prescription

The immediate postpartum period following birth is a time of risk for all women for

microorganisms entering the reproductive tract & migrating into blood & other parts of the

body, which could result in septicemia

o Risk Factors

Cervical dilation: provides uterus w/ exposure to external environment

Well-supplied exposed blood vessels

Wounds from lacerations, incisions, hematomas

Alkalinity of amniotic fluid, blood, & lochia during pregnancy & early postpartum

period, decreasing the acidity of the vagina

Risk Factors for Endometritis:

o C-section

o Retained placental fragments & manual extraction of placenta

o Prolonged labor

o Prolonged rupture of membranes

o Chorioamnionitis

o Internal fetal/uterine pressure monitoring

o Multiple vag exams after ROM

o Postpartum hemorrhage

Newborn Assessment

APGAR: done immediately following birth to rule out abn. Completed at 1 & 5 mins of life.

Allows nurse to rapidly assess extrauterine adaptation & intervene w/ appropriate nursing

actions

Score 0 1 2

Heart rate Absent < 100 100

Respiratory Rate Absent Slow, weak cry Good Cry

Muscle Tone Flaccid Some flexion Well-flexed

Reflex Irritability None Grimace Cry

Color Blue, pale Pink body, cyanotic hands & feet (acrocyanosis)

Completely pink

Quick initial assessment by nurse:

o External assessment:

0-3 Severe distress

4-6 Moderate distress

7-10 No distress

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Skin color

Peeling

Birthmarks

Foot creases

Breast tissue

Nasal patency

Meconium staining

o Chest:

PMI location

Ease of breathing

Auscultation for HR &

quality

Respirations for

crackles, wheezes

Equality of bilateral

breath sounds

o Abdomen:

Rounded abdomen

Umbilical cord for 1 vein & 2 arteries

o Neurologic:

Muscle tone

Reflex rxn (Moro)

Palpation of sutures

Fontanels: fullness or

bulge

o Other observations: inspection for gross structural malformations

Gestational age assessment:

o Performed w/in 2-12 hr of birth

o Neonatal morbidity & mortality are r/t GA & birth weight

o Involves measurements of newborn & New Ballard Scale

o Normal Ranges:

Weight: 2,500-4,000 g

Head: 32-36.8 cm (12.6-

14.5 in)

Length: 45-55 cm (18-

22 in)

Chest: 30-33 cm (12-13

in)

o New Ballard Scale: newborn maturity rating scale that assesses neuromuscular &

physical maturity. See images below.

6 ranges of development

Totals: maturity rating in weeks gestation (a score of 35= 38 wks gestation)

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Following physical assessment, classification by GA & birth weight is determined:

o Appropriate for gestational age (AGA)

Weight b/t 10th & 90th percentile

o Small for GA (SGA)

Weight < 10th percentile

o Large for GA (LGA)

Weight > 90th percentile

o Low birth weight (LBW)

Weight 2,500 at birth

o IUGR: growth rate doesnt meet expected norms

o Term:

Birth beginning of week 38 & prior to end of 42 wks

o Preterm/Premature:

Born prior to completion of 37 weeks

o Posterm:

Born after completion of 42 weeks

o Postmature:

Born after completion of 42 wks gestation w/ signs of placental insufficiency