MATERNITY ATI
Contraception
-Depo Provera: IM injection every 11-13 weeks
-Vaginal Ring: insert for 3 weeks, take out for 1 week
-Patch: change 1 x week
-Arm Implant: good for 3 years. Can be used while breastfeeding
-IUD: 1-10 yrs. Can be used while breastfeeding. Risk for PID, perforation, ectopic preg.
-Minipill: progesterone only. Fewer s/e. safe to take while breastfeeding
Infertility
-1 year w/o ability to conceive
-Semen analysis: first test done b/c least expenisive test to perform
Presumptive signs of pregnancy
-Woman things she is pregnant. Symptoms only.
- Quickening – fluttering movements of fetus at 16-20 weeks
- Uterine enlargement
Probably signs of pregnancy
-Signs & medical conditions
- Hegars Sign: softening and compressibility of lower uterus
- Chadwicks’s Sign: blue color cervix
- Goodells sign: softening of cervical tip
- Callottement: rebound of unengaged fetus
- Braxton Hicks
- Positive pregnancy test
- Fetal outline felf by examiner
Positive signs of pregnancy
-Signs only related to pregnancy.
- Fetal heart sounds
- Fetus in ultrasound
- Fetal movement felt by experienced examiner
hCG
-7-10 days after conception
-Peaks at 60-70 days
-Higher levels if mulitples, ectopic, molar pregnancy, down syndrome
-Do a pee-stick test on first-void morning sample
GTPAL
-Gravidity
-Term birth: 38 weeks or more
-Preterm: 37 weeks or less
-Abortion/miscarriages
-Living
Pregnant Vital Signs
-Blood pressure degreases 5-10 mmHG during 2nd trimester then returns to normal at 20 weeks
-Pulse increases 10-15 around 20 weeks and stays elevated
-Respirations increase by 1-2 breaths (due to elevated diaphragm)
Prenatal Check-ups
-Monthly for the first 7 months
-Every 2 weeks during 8th month
-Weekly during 9th month
Initial Check up
-EDD, medical hx, baseline physical assessment, lab tests (Blood type, Rh, CBC, H/H, Rubella, Hep, GBS, Glucose, TB, UTI, STD, HIV, TORCH)
Ongoing Check ups
-FHR at 10-12 weeks via ultrasound, 16-20 weeks w/ stethoscope
-Fundal height at 12 weeks
-Fetal movement at 16-20 weeks
-RhoGAM 28 weeks if mom is Rh Neg.
Discomforts of pregnancy
-1st Trimester: N/V, breast tenderness, Urinary frequency, Fatigue, Braxton hicks
-2nd Trimester: Heart burn, Constipation, hemorrhoids, backaches, Varicose veins, Braxton hicks
-3rd Trimester: urinary frequency, fatigue, heartburn, constipation, hemorrhoids, backaches, SOB, Leg cramps, varicose veins, Braxton hicks, supine hypotension
-Danger signs: ROM <37 weeks, vaginal bleeding, ab pain, decrease fetal movement, hyperemesis gravidarum, severe headaches (gestianiton HTN) dysuria (UTI), blurred vision (gest HTN) edema face and hands (Gest. HTN), epigastric pain, fruity breath & rapid breathing & increased urination (hyperglycemia), hypoglycemia
Nutrition
-2Nd trimester: increase calories by 340. 3rd trimester: increase calories by 452
-Breastfeeding: increase calories by 330 for first 6 month, then 400 for second 6 months
-High protein, High folic acid, calcium & iron supplements
-2-3 L fluid per day
-Limit caffeine to 300mg/day
-Nausea: eat dry crackers or toast. Do not eat fats, spices. Avoid drinking fluids with solid meals
-PKU: where high levels of phenylalanie cause danger to fetus. Avoid foods high in protein (fish, poultry, meat, eggs nuts, dairy)
Ultrasound
-Confirms pregnancy, gestational age, site of implanation, growth, abnormatlities, amniotic fluid volume, heartbeat, activity
-Make mother drink 1-2 quarts of fluid prior to fill bladder, lift utuers and displace bowel to get better image
BBP
-Biophysical profile: visual fetus and fetal response to stimuli
-Includes: reactive FHR, fetal breathing, body ovements, fetal tone, amniotic fluid
-Score 8-10 = normal, 4-6= abnormal <4= fetal asphyxia
NST
-Nonstress test: done during 3rdtrimester to assess for intact CNS. Mom pushes button when she feels fetal movement
-Reactive: FHR normal baseline w/ moderate variability accellearates 15 beats/min lasting 15 seconds. Must occur 2 + times during 20 mins.
-Nonreactive: after 40 mins the criteria of 15/15 hasn’t been met
-Do this test for: GDM, GHTN, hx of fetal demise, advanced maternal age, postmaturity, decrease fetal movement, IUGR
CST
-Contraction stress test: Nipple stimulation or Pitocin to create contractions
-Accurate data needs to have 3 contractions 40-60 sec duration during a 10 min time frame to get idea of how FHR responds
-Negative CST: Normal. Shows no LATE decels
-Positive CST: Abnormal: shows LATE decels. (That is bad).
Amniocentesis
-Aspirate amniotic fluid with needle into uterus and amniotic sac
-Diagnosis: chromosomal anomaly, neural tube defects, genetic disorders, lung maturity, meconium, hemolytic disease, Alpha -fetoprotein (high = for neural tube defects, low = downs syndrome, molar preg.)
-Fetal Lung test: Lecithin/sphingomyelin (L/S) ratio= a 2:1 ratio indicates maturity
-Phosphatidyglycerol (PG): if Absent = respiratory distress. We want PG!!!
Decels
-Early Decels: fetal head compression = not serious
-Late Decels: uteroplacental insufficiency = serious
-Variable Decels: cord compression = depends on amount and duration
Umbilical Blood Sample
-Most common method for fetal blood sampling and transfusion
Chronic Villi Sampling (CVS)
-1st trimester to check for abnormalities at 10-12 weeks
-Risk for miscarriage, SAB, ROM, fetal limb loss
Quad Marker Screening
-A blood test that includes hCG, AFP, Estriol, Inhibin - done at 16-18 weeks
-Low Estriol- down syndrome.
Alpha Fetal Proteins (AFP)
-16-18 weeks
-Protein produced by fetus
-High levels = nueral tube defect
-Low levels = down syndrome
Sponteanous Abortion
-1st trimester- bleeding, cramping, partial or complete expulsion of products of conception
-Terminated before 20 weeks gestation or less than 500 g
-Caused by: High maternal age, substance abuse, chromosomal abnormalities (most common), maternal illness, cervical dilation, trauma, antiphospholipid syndrome
-Don’t have bath, sex, for 2 weeks. Finish abx. Discharge will occur for 2 weeks. Wait 2 months to try again
Ectopic Pregnanancy
-Implanted outside uterine cavity usually in fallopian tubes which can cause a fatal hemmorahge if ruputured.
-Risks: STD, IUD, tubal surgery
-S/S: stabbing pain in lower ab. On one side. Delayed or irregular pregnancy, Dark red/brown spotting or RED if Ruptured. Shoulder pain!!, dizzy from bleeding into ab cavity
Gestational Trophoblastic Disease (GTD)
-Proliferation & degeneration of trophoblastic villi in placenta that looks like GRAPE CLUSTERS!
-No embryo develops instead a metastasizing malignancy (Choriocarcinoma) forms.
-COMPLETE MOLE: No genetic material or any placenta, fluids
-PARTIAL MOLE: Has genetic material plus some baby parts
-Risks: young and old mothers
-S/S: Excessive vomiting, High levels hCG, Rapid uterine growth that is way too big for age, prune-juice looking blood
Placenta Previa
-Placenta abnormally implants in lower utuerus resulting in bleeding in 3rd trimester
-Complete: cervical os is covered by placenta
-Incomplete: partially covered cervical os
-Low-lying: doesn’t reach cervical os
-Risks: Previous placenta previa, scarring, older mother, multiples, smoking
-S/S: PAINLESS. Bright red bleeding 2nd-3rd trimester
Abruptio Placenta
-Premature separation of placenta from utuerus AFTER 20 weeks.
-Causes baby and mother mortality. Leading cause of maternal death
-Risks: maternal HTN, trauma, previous incident of abruption, smoking, multiples,
-S/S: Sudden DARK RED bleeding, shock, fetal distress
TORCH
-Toxoplasmosos: Raw or undercooked meat & handling cat feces. Flu symtoms
-Rubella: joint & muscle pain
-Cytomeglovirus: droplet infection- can cause damage to baby during birth. Asymptomatic
-Herpes Simplex: Oral or genital lesions
Group B Strep (GBS)
-Bacterial infection passed to fetus during L&D
-Risks: <20y, black or Hispanic, prolonged ROM, low birth weight, preterm baby, fever
-Treat with PCN
Chlamydia
-Bacterial infection. Most common STD.
-S/S: ITCHING! Watery vaginal discharge
-Give erythro eye ointment to babies, treat with abx
Gonorrhea
-Urethral discharge, painful urination & frequency, Yellow/green vag discharge can lead to PID.
Candida Albicans
-Fungal infection
-S/S: thick, creamy white discharge, itching, grey-white patches on vag wall
-Patches in neonate mouth
Premature dilation of cervix
-Incompetent cervix: feel urge to push. Expulsion of products
-Risks: cervical trauma, defects
-Give Tocolytics to inhibit contraction, mom on bedrest, no sex
HyperemsisGravidarum
-Excessive n/v. past 12 weeks.
-Risk for IUGR or preterm birth if not treated
-Risks: <20 yo, migraines, obese, 1st pregnancy, multiples (high hCG), emotional stress, hyperthyroidism
-S/S: n/v, ketones in urine from protein breakdown, electrolyte imbalances, high hCG
GDM
-Can cause: SAB, infections, hydyramnios, ROM, preterm, hemorrhage, macrosomia
-Glucose test at 24-28 weeks, county daily kicks
GHTN
-20 weeks. BP >140/90 at least twice 4-6 hours apart in a 1 week period. No proteinuria
Mild Preeclampsia
-Same as GHTN but with proteinuria 1+
Severe Preeclampsia
-BP 160/100, proteinuria 3+, headache, blurred vision, hyperrfelxia, edema, hepatic issue, RUQ pain, thrombocytopenia
Eclampsia
-Seizure activity following severe preeclampsia
HEELP Syndrome
-H- hemolysis resulting in anemia & jaundice
-EL- elevated liver enxymes (ALT, AST), Epigastric pain, n/v
-LP- low platelet (<100,000), causing thrombocytopenia, bleeding, cant clot, DIC (intravascular coagupathy)
RISK FOR GHTN & elevated BP
-<20y or >40, Obesiety, muliltple babies, DM, molar pregnancy, hx of preivious HTN
-S/S: non-stop headache, blurred vision, flashes of light, n/v
-Treat: give HTN meds (NO ACE Inhibitors), give Mag
Preterm Labor
-20-37 weeks
-Risks: infections, previous preterm labors, hydramnios, young age, smoking, drugs, violence, hx or SAB, DM, HTN, remature dilation, placenta previa, abrputio placentae, preceding labor pregnant quickly after giving birth,
-Treatment: can give meds to slow, stop labor. Nifedipine, mag
Signs of preceding labor (Labor is coming)
-Backache, weight loss 1-3lb, leightning where fetal head descends down into pelvis 2 weeks prior, bloody show, energy burst, n/v, ROM (labor occurs 24 after this),
5 P’s
-Passenger: size of head, presentation (head/occiput, chin/mentum, shoulder/scapula, breech/sacrum or feet
Lie: transvers, longitudinal
Attitude: fetal flexion (chin to chest), fetal extension
-Passageway: birth canal
-Powers: uterine contractions, dilation, urge to push
-Position: how mom is positioned in labor
-Psychological: stress, anxiety can impair labor
Meachanism of Labor
-Engagement: head passes into pelvic – 0 station
-Descent: head through pelvis
-Flexion: head flexes chin to chest
-Internal rotation: rotates laterally to pass through pelvis
-Extension: Head is born
-External rotation: head roates to allow body to roate
-Expulsion: rest of baby born
Variability
-Absent
-Minimal: <5/min
-Moderate: 6-25/min
-Marked: >25/min
Category I
-FHR baseline 110-160 – normal
-Moderate variability
-Accel present or absent
-Early decels present or absent
-Variable or late decels are absent
Category II
-Baseline tachy or brady
-Variability minmal, absent, marked
-Decels b/t 2-10 mins
-No accels after stimulation
Category III
-Absent FHR
-Recrrent variable decls, late decles, brady
First Stage of Labor
-Latent (0-3cm), Active (4-7cm), Transition (8-10cm)
-Lepold maneuver to determine where baby is
-Vag exam for dilation and effacement & station
-Blood Pressure: Latent phase (30-60min), Active phase (30 min), Transiation Phase (15-30min)
-Temp: q4h or q1-2h for ROM
-Contraction Monitor: Latent phase (30-60min), Active Phase (15-30 min) Transition (10-15min)
-FHR Monitor: Latent (30-60min), Active (15-30), Transition (15-30)
-Encourage voiding q2h
Second stage of labor
-Dilation to birth – can take 30mins – 2 hrs for first time moms
-FHR q15 min.
-1st degree lac – does not involve muscle
-2nd degree lac- extends through skin & muscle to peri
-3rd degree lac- extends through skin muscle peri and anal sphincter
-4th degree- through skin, mucle, anal sphincter and anterior rectal wall. (WTF, seriously?)
Third Stage of Labor
-Delivery of baby to delivery of placenta
-Monitor vitals q15min
-Firm fundus
Fourth Stage of labor
-Placenta is out, recovery
-Vitals q15 for 1 hour
-Fundal and lochia check q15min for 1hour
-Massage fundus, encourage voiding
Amniotomy
-Rupture or membrane with amnihook
Amniofusion
-Supplement the amout of amniotic fluid and decrease cord compression or oligohyramnios
Induction of Labor
-39 weeks
-Bishop score greater than 8 for multip, 10 for nullip
-A prolonged ROM that has risk of infection
-DM, HTN, Fetal demise
Precipitous Labor
-3 hours or less. High risk for hemmroharge
-Panting will control urge to push
-Side lying position optimizes perfusion and fetal oxygenation
-Never stop delievery
Amniotic fluid embolism
-Ruprture in amniotic sac plus high pressure causes PE, resp distress and collapse
-S/S: respiratory distress, tachy, shock, cardiac arrest
Postpartum
-Vitals q15 mins for first hour, q30min for second hour, q1hour then q4-8hr
-BUBBLE : breast, uterus, bowel, bladder, lochia, episotomy/edema
-Fundus descend 1-2cm per day. Day 10, non palpabale uterus
-Lochia: Rubria (1-3 day), Serosa (4-10 days), Alba (11day – 6 weeks)
-Lochia amount: Scant, light, moderate (10 cm), heavy ( pad saturated in 2 hours) , excessive (one pad saturated in 15 mins)
-Blood loss: Vagdeliever = 500 mL C-sect.= 1,000 mL
-WBC increase to 20-25 for 10-14 days w/o infection present
-Bladder empty q2-3h. Bowel movement 2-3 days
Dependent- taking in phase
-24-48 hr
-Focus on personal needs
-Rely on others
-Excited, talkative, wants to share story
Dependent-independent – taking-hold phase
-2-3 days-weeks
-Baby care and improving care-giving competency
-Needs acceptance from others
-Learn and practice
Inderdependent – letting-go phase
-Focus on family as unit
-Resumption of role- wife
Discharge teaching
-Menses returns 4-10 weeks if not breastfeeding
-Contraception ASAP
-Fluids, rest, limit activity
-Infant feeding 8-12 x a day
ABGAR Score
Score / 0 / 1 / 2Heart 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, acrocyanosis / Completely pink
0-3 = severe distress 4-6= Moderate distress7-10= no distress
Initial Assessment
-External Assessment: skin color, peeling, birthmarks, meconium, nasal patency
-Chest: breathing, heart rate, any crackles, wheezes, point of maximum impulse
-Ab: round, umbilical cord with 1 vein, 2 arteries
-Neuro: muscle tone, reflex reaction, fontanels and sutures
-Abnormalities
Gestational Age
-Done 2-12 hours of birth
-Weight: 2500 – 4000g
-Length: 45-55 cm
-Head circumference: 32-36.8cm
-Chest circumference: 30-33cm
-Preterm: <37 weeks
-Term: 38 weeks
-Postterm: 42 weeks
-Postmature: 42+ weeks
Newborn Vitals
-Resp: 30-60/ min
-Heart rate: 100-160 bpm
-BP: 60/40 – 80/50
-Temp: 36.5-37.2 (97.7 – 98.9)
Head
-2-3 cm larger than chest circumference
-If 4 cm or larger than chest circumference it can be hydrocephalus.
-Head less than 32 – microcephaly
-Anterior fontanel: 5cm & dimanond shape. Posterior fontanel: smaller & triangle shaped
-Fontanels: soft, flat, may bulge when newborn cries/vomits/coughs. Abnromal bulge= hemorrhage, infection, pressure increase
-Sutures: palpable, separated, overlapping from molding
Eyes & ears
-Eyes should be equal 1/3 distance b/t outer canthus
-Ears should line up with outer canthus of eyes. Rule out down syndrome or kidney disorder
Chest & Ab
-Breast nodules 6 cm
-Bowel sounds present 1-2 hours after birth
GI & GU
-Anus should not be covered by membrane
-Meconium should be passed w/in 24 hours
-Rugae should be on scrtoum, testes in scrotum
-Vaginal blood-tinged discharge may occur in female newborns
-Hymenal take should be present
-Urine w/in 24 hours after birth.
Chapter 24-27… read on your own and take notes on the important stuff