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79 Cards in this Set

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What are some normal respiratory changes for a pregnant woman.
Changes in hormones increase o2 consumption by 15-20%, increase tidal volume increase 30-40%, and an increase in vital capacity (the max amount of air that can be moved in/out of the lungs w/forced respiration). change is related to elevated estrogen levels. Estrogen prompts hypertrophy of the lung tissue, progesterone decreases airway resistance by relaxing smooth muscle of bronchi and alveoli; all this creates increase in 02 consumption along with vital capacity. Lungs will go more outward to compensate for upward pressure on diaphragm from uterus; can’t go up and down as much, so goes outward to keep pulmonary fnctn stable.Increase mucus production (due to effects of progesterone (increased blood flow to mucus membranes of the sinus and nasal passages) and estrogen (hypertrophy & hyperplasia of mucosa); stuffiness; educate that these are normal changes; increase fluid intake to thin mucus. Edema (caused by estrogen) & vascular congestion (from progesterone) in upper respiratory tract (clogged due to excess mucus) Blurred vision due to fluid retention.
what are some gi system changes in the pregnant woman?
Starting with the mouth: Ptylaysm: excessive saliva production often w/bitter taste; encourage eating small, frequent meals; avoid starch (pasta, potatoes, bread); cause unknown; epulis gravidarum (growths on the gums that bleed easily and usually regress w/in 2 months after childbirth. ), gingivitis (inflammation of the gums. Down to esophagus and stomach: due to hight levels of hCG and relaxation of stomach, esophagus, and sphincters causes Pyrosis: heart burn; progesterone causes relaxation fo smooth muscle in esophagus, nausea and vomiting can occur. Inflammation of the gall bladder due to slow emptying time and bile back flow or bile stasis which can cause severe itching called pruritis gravidarum. Down to colon: constipation from iron, and slowing down of digestion, Constipation: uterus sits on top of intestines and cause constipation and Hemorrhoids: vein varicosities in lower rectum and anus
Puritis graviderum : itching with pregnancy; caused by bile that sits in liver;occurs in late preggo and can cause severe itching.
Encourage a lot of water!!!
What are some common issues for urinary system in pregnant women?
UTIs are common and pressure on the bladder causes urgency and frequency, glucose increase is normal, but should still be watched for diabetes.Urinary
Bladder compression in 1st trimester (cuz uterus is growing in pelvis & bladder is in pelvis) and 3rd trimester bladder compression due to fetal presentation descending into pelvis & urgency, frequency and nocturia return. (not usually in 2nd cuz uterus is growing up and becomes and abdominal organ, so no pressure on bladder)
Added pressure along w/progesterone induced relaxation of urethra and sphincter musculature leads to urinary frequency, urgency, and nocturia.
UTI: don’t get same s/s; may be back-up of urine, not voiding completely; why we want 1st morning urine to determine.
Infections occur more freq in preg due to relaxation of smooth muscle of bladder & urinary sphincter, changes that allow bacterial ascent into the bladder.
Relaxation of ureters, elongation and dilation, and reduced peristalsis that helps move urine from kidneys to bladder is reduced; cause obstruction of urine flow (stagnation=infection)
Increased GFR by 2nd trimester by 50%; alteration prompts body to excrete more glucose in virtually all pregnant women; normal finding to have increased glucose in urine; but have to r/o gestational diabetes cuz urine glucose doesn’t accurately reflect blood glucose levels.
What are the normal musculoskeletal changes of the pregnant woman?
Rectus abdominus muscles separate (called diastasis recti), lumbar lordosis in compensation of gravity, relaxin a hromone produced by the placenta and progesteron relax the ligaments including pubis symphysis, round ligament pain due to hypertrophy and stretching. Musculoskeletal uterus is growing and causes diastsis recti (separating of abdominal muscle/rectus abdominis); Lordosis (sway back); as weight of uterus shifts upward & outward, lordosis develops; compensates for changing center of gravity & allows centering to remain over womens legs. Back pain is normal from changes. Pregnancy waddle: relaxin hormone (produced by placenta) along w/action of progesterone relaxes all joints (ligaments) the makes more room from baby to grow; these changes result in waddle as the bones of pelvis shift and move; unsteady gait=greater risk for falls. Round ligament pain: sharp pain in lower abdominal quadrants or groin area (r/o appendicitis); caused by stretching & hypertrophy of round ligaments; right side most often affected due to dextrorotation of uterus. Leg cramps: caused by poor circulation to the extremities; also linked to imbalances w/calcium and phosphorus; to alleviate cramps: stand and lean forward to stretch calf muscle; daily walks to increase circulation to muscles will improve it.
Define the following terms: gravid, gravida, nulligravida, primigravida, gravidity, secundigravida, multigravida, and parity.
Gravid=pregnant; gravida=pregnant lady; nulligravida=never experienced pregnancy; primigravida=woman pregnant for the 1st time; secundigravida=woman pregnant for the 2nd time; multigravida a woman pregnant for the 3rd time, and parity=number of pregnancies carried to point of viability regardless of outcome. Example: para 1 indicateds that 1 preg reached the age of viability, para 2, etc...., does not reflect whether fetus lived or died.
What is the digital system used for recording number of pregnancies and there out comes? Also Woman is pregnant again and has 6 children at home she has had 2 miscarriages and 1 baby that was preterm, 1 set of twins. What is her GTPALM? Also...Her past period august 30. what is her EDC.
Called GTPAL, it is only used for people who have had multiple births.
G=Gravida, a current pregnancy, T= is number of term pregnancies (term meaning made it to 37 weeks, not necessarily alive), P=preterm delivery (at least 20 weeks, but before 37weeks), A=Aboritions both spontaneous (miscarriage),or induced, and L=number of living children. M=Multiple Births( only used if they have a multiple birth (twins...)

G=8 (how many pregnancies)
EDC= june 6
What is Naegel's rule?
It is a sytem of calculating the EDC "Estimated Date of Confinement". EDC now comes from date of last period. You add on 7 days to that date, then go back 3 months and that will be the due date for the baby.
What do the following pregnancy abbreviations stand for? EDD, EDB, LMP, and EDC?
Estimated date of delivery, estimated date of birth, last menstrual period, estimated date of confinment.
Explain the distinctive characteristics and the differences between presumptive signs of pregnancy, probable signs of pregnancy and positive signs of pregancy.
PRESUMPTIVE PREGNANCY: Subjective from patient: "I think I might be"- patient might think they are pregnant and have ammenorhea, nausea, vomiting, fatique, urinary frequency, they can be signs, but could be something else. PROBABLE PREGNANCY: Objective indicators that are observed by the examiner. But because other things could possible cause them, they are probable not positive. They include: Pskacek sign: a soft prominence on implantation side, Hegar sign: softening of lower uterine segment; Pap smears, and vaginal exams, Goodell sign: softening of tip of cervix; Chadwick sign:violet-blue color mucosa and cervix; Braxton Hicks: intermittent contractions; and positive pregancy test; blood in urine; and Ballotment: palpate one side and something moves on the other; passive movement of the unengaged fetus, passive movement. POSITIVE PREGNANCY: Fetal heartbeat w/ a doppler; Visualization of the fetus; and Fetal movements palpated by the examiner.
When does a fetus gain the most of its weight?
1st, 2nd or 3rd trimester. In the third trimester.
From where are the hormones estrogen and progesterone coming from during pregnancy?
adrenal cortex, placenta, corpus luteum, anterior hypophysis.

Answer is placenta.
In fetal bl vessels the o2 content is hightest in the
ductus venosus, umbilical artery, pulmonal artery or ductus arteriosis.

Answer is ductus venosus because it is opposite blood gas exchange to the fetus.
What are the first 2 psychological tasks of pregnancy?
1) Accepting pregnancy: denial due to being young or not coming to terms w/preg.; needs to create a safe place for baby & needs understanding from those around her. Woman needs to accept the pregnancy & incorporate it into her own reality & self-concept; process known as “binding in”.1st trimester: woman’s focus centers on her physical discomforts like fatigue, nausea and her own rather than on the developing child. 2nd trimester: by this time she feels fetalmovement (quickening), has most likely seen the baby (ultrasound) & heard heart beat, & begins to conceptualize the child as an individual w/in her.3rd trimester: as the due date nears, the mother wants the child just as much as she wants the pregnancy to be over with; @ this point, she is tired & needs lots of emotional and physical support from her family & friends.
Accepting the baby: ppl that don’t accept the pregnancy may end up getting abortion (have to ask yourself how you feel about the abortion to understand if you can work in that area); acceptance must come from expectant woman and others she values.Valuing unborn baby, re-ordering life (have to change how she does things so baby can fit into life), have to accept pregnancy and then the baby. Acceptance of the baby: acceptance must come from expectant mom and others she values. 1st trimester: during early pregnancy, announcements R made about pregnancy & positive responses from others about the pregnancy help foster her own acceptance of the child; she wants & needs others in the family to accept the child too 2nd trimester: immediately family needs to exhibit behaviors consistent w/relating to the child as a sibling, a son or daughter. 3rd trimester: the woman must develop an unconditional acceptance of the child or she & others may reject him for not meeting their expectations.
What are the last two psychological tasks of pregnancy?
Reordering relationships: reorder to allow for child to fit into her life, existing family structure, and learn to give of herself to the unborn child.
Woman becomes reflective /examines what things may need to be given up in her life or changed for the infant. If this is her 1st baby, she may grieve the loss of her carefree life/freedom she once had. As preg. progresses, she beings to identify w/the child and makes plans for their life together after the birth. During last few weeks of the pregnancy, she must work through doubts of her ability to be a good mother; positive support from family/friends is important to boost her confidence and assist her w/overcoming her self-doubt. Seeking safe passage: realizing that she has to make herself as safe as possible for the baby to come into the world; not smoking, drinking, huffing; they can get feelings of ambivalence when it comes close (they may want a c-section to “avoid” the pain); getting nursery ready; need a doula etc.
What are the routine lab tests that are part of the admission process at the hospital for labor and delivery?
Tests of rH factor & blood type, complete blood count, hemoglobin & Hematocrit, blood glucose; blood tests for syphilis, hep B and HIV; urine specimen tested for presence of glucose, protein, and ketones.
A woman goes through several physical changes during pregnancy: 1) reproductive 2) integumentary, 3) neurological and 4) cardiovascular. Explain the reproductive physical changes.
Reproductive: p.195 most obvious are physical change in theabdomen & breast changes. Uterus: @ 20 weeks uterus is @ belly button level; @ 38 weeks uterus is underneath breast level (times when breathing becomes really hard, esp with shorter women); @ 40 weeks uterus will drop a bit (couple cm); Cervix: blue tinge; high levels of estrogen cause stim. Of cervical tissue (increases cell # & becomes hyperactive); increased blood flow and engorgement results in blue tone. Vagina: thickening of mucus; blue tone from hyperemia (increased blood flow) as in cerix.
Breasts: become larger (from estrogen & progesterone that produce changes in mammary glands); superficial veins become more prominent; tingling & increased sensitivity; montgomery tubercles (sebaceous glands around nipple) enlarge & provide lubrication for the nipple tissue; 2nd trimester get leakage of colostrum (1st milk) (as early as 16 weeks); colostrum is converted to mature milk during 1st few days of life stretch marks (not genetic)
Explain the integumentary physical changes of a woman in pregnancy.
Integument: Ward, p 197; changes caused by estrogen, progesterone, and alpha-melanocyte stimulating hormones; outward changes in appearance may cause body image/ self-concept issues. Pigment changes occur due to estrogen levels; moles, freckles & scars darken; nipples, areola, perineum, & vulva also darken. Linea negra: linea alba (light line that darkens in pregnancy becomes the linea negra) line that extends from belly button down to mons pubis; when pregnant it gets dark (you will see it even on a fair skinned person). Chloasma/ melasma gravidarum or mask of pregnancy; (dark, blotchy brownish pigmentation change around hairline, brow, nose and cheeks; raccoon look) if darker skin tone it may show up more, but happens in fair skinned too.Chloasma fades after pregnancy but can recur after sun exposure; educate on sun protection due to increase in sunburn/photosensitivity in pregnancy. Nails get stronger, grow faster due to hormones. Lose less hair (this is reversed once baby is delivered=lose hair); reassure patient that virtually all hair will be replaced w/in 6-12 months; acne, sweating (caused by hyper-active sweat and sebaceous glands=skin changes). Stretch marks: striae gravidarum; reddish, wavy, streaks that fade to silver white after birth, but don’t totally disappear;abdomen, breasts, buttocks, thighs. Palmar erythema (palms get red), puritius (itiching due to increased blood flow and high hormone levels).
What are the neurological changes in a pregnant woman?
Neurologic: CNS is affected by hormonal changes in pregnancy; women may experience: Poor concentration and attention span, memory lapses during and just after pregnancy.Reduced sleep efficiency, fewer hours of sleep, freq awakenings & difficulty going to sleep; nurses should encourage naps to offset the fatigue due to these changes, and provide anticipatory guidance about what to expect. Carpal tunnel (due to increase fluid and puts pressure on nerves); usually develops in 3rd trimester; symptoms (pain, paresthesia, in the hand that radiates to elbow; intensified w/grasping objects; occurs in dominant hand or both hands); teach to elevate hands @ night to reduce edema, splint; usually subsides after preggo after edema is decreased. Syncope (transient loss of consciousness; passing out from pressure from uterus); attributed to orthostatic hypotension &/or inferior vena cava compression by the uterus ***BIG DEAL w/positioning a client! Left side lying position is preferred to avoid compression of the vena cava (leads to supine hypotension) from the gravid uterus.
May also occur as increased intra abdominal pressure from the uterus putting pressure on the vagas nerve; coughing, straining during bowel movements, & upward pressure from the fetus can trigger a vasovagal response producing faintness or loss of consciousness.
Warning signs: lightheadedness, sweating, nausea, yawning, and feelings of warmth all are signs that precede syncope.
What are the cardiovascular changes in a pregnant woman?
Cardiovascular: Heart:fetus grows- puts pressure on diaphragm & the mom’s heart is pushed upward & lateral to the left (would affect where you find PMI?)Cardiac hypertrophy: results from increased BV & CO more fluid, BV incrs by 40-45% (incrs starts in 1st trimester & peaks @ term; increase in BV is due to increase in plasma & erythrocyte volume; extra erythrocytes are need cuz of extra oxygen requirements of maternal & placental tissue that will ensure 02; elevated erythrocyte count remains throughout pregnancy) Murmurs (common during pregnancy) if they are symptomatic she will experience palpitations, chest pain, shortness of breath, or decrs activity tolerance; if this occurs, she should see doc immediately IRON: need extra for formation of extra hemoglobin (o2 carrying component of the erythrocyte) & o2 for baby; the incrs need for o2 requires pregnant woman incrs her Fe intake; Fetal Fe is greatest during last 4 wks of preg. when the fetal Fe stores are amassed. Supine hypotension: avoid laying flat on the back; impinges blood flow return from lwr extremities & causes decrs in BP (w/dizziness, diaphoresis, pallor); turn to left side, so not putting more pressure on vena cava; faintness related to bradycardia. BP: in 1st trimester BP usually stays the same as pre-preggo levels; then gradually decreases by 20 weeks; after 20 weeks, the vascular volume expands and BP incrs to reach pre-preggo levels by term
CO remains incrs throughout pregnancy; w/incrs vascular volume and CO, vasodilation (due to progesterone induced relacation of vascular smooth muscle), prevents and elevation in BP; women’s pr usually incrs by 10-15 beats/minute to effectively circulate the increased BV. O/hypotension another condition occuring in pregnancy; results from stagnation of blood in lower extrem. Woman stands too long/ gets up too quickly, gravity causes blood to flow to the lower extremities & away from her brain. All changes to cardio system return to normal by 2nd or 3rd week postpartum.
What are some endocrine changes in pregnancy?
Endocrine:Thyroid: changes size & activity during pregnancy; increased thyroid activity causes increased basal met. rate (the amount of 02 consumed by body over a unit of time); the incrs in BMR has effects of heat intolerance, increase HR, & increased CO; thyroid function returns to normal w/in few weeks of birth; Parathyroid glands (regulate Ca & PO4 metabolism; raises calcium); maternal concentrations of PTH increase as fetus requires more Ca for skeletal growth during 2nd & 3rd trimester. Ca+ intake VERY important; 1200-1500 mg/day recommended.Pituitary gland: ant. pit. gland incrs in size; prolactin (acts on breast milk; responsible for initial lactation); may play role in F&E shifts across fetal membrane. Oxytocin:posterior pituitary gland; stim. milk ejection/let down from breasts. Also stimulates uterine contractions; can be given to induce labor or augment a slow progression of labor due to ineffective uterine contractions. Adrenal glands (on top of kidneys) help incrs circ. fluid vol.; Happens cuz adrenal cortex secretes aldosterone (causes renal reabsorption of sodium=water retention, since water follows sodium);enhances circ. vol.;a protective response to body getting rid of Na+ due to effects of progesterone; it offsets that.
Cortisol (produced by adrenal cortex) has incrs production in pregnancy due to decreases renal secretion (prompted by high estrogen levels);cortisol regulates protein and carb metabolism & is believe to promote fetal lung maturation & stimulate labor at term.
Pancreas: increase in beta cells (means more insulin production); these changes R responsible for alterations in carb metabolism during pregnancy. Prostaglandins: lipid substances found in high amounts in female reproductive tract;R produced more; (helps w/BP); a decrs in these levels may contribute to hypertension & preeclampsia; @ term, the increased release of prostaglandins from the cervix as it softens and dilates may contribute to labor onset.
What do the following intitials stand for in L&D?
Fetal heart tones, fetal heart rate, fetal movement.
What are the important elements to Fetal Heart tones?
Fetal heart tones (FHT): range 120-160; if @ 180 (tachycardia) you have to figure out why baby is in stress (pressure, contraction, fever in mom will make HR go up)
HR goes down with contractions, or w/cord around neck
Use doplar or fetoscope for fetal heart tones (conduction is how it works, fetoscope) doplar works on sound waves (ultrasound
both used for Intermittent auscultation; doesn’t provide print out of fetal HR, but allows women freedom of movement in labor.
What are the important components to the FHR?
FHR is the average fetal heart rate observed between contractions over a 10 minute period.Variability: the fluctuations is baseline FHR observed on fetal monitor; absent or undetected variability is considered non-reassuring; presence of adequate variability is an important indicator of fetal well being.
Accelerations are considered sign of fetal well-being when they accompany fetal movement
Tachycardia in fetus: FHT greater than 160 beats/minute; conditions associated w/this include:Fetal hypoxia, Maternal fever: increase in mom’s temp accelerates the fetal metabolism increasing the HR; can occur in laboring women who become dehydrated or do to increased temp from being in a warm bath.Maternal medications,
infection: tachycardia may be initial sign of uterine infection Fetal anemia: FHR increases to compensate for decreased hemoglobinMaternal hyperthyroidism
Bradycardia of FHR: less than 110 beats/minute; may be associate with:
Late hypoxia Medications:
Maternal hypotension: results in decreased blood flow to fetus and can lower FHR; can result from supine hypotension & is common side effect of epidural Prolonged umbilical cord compression: decreased FHR due to vagal stimulation
What do the kick count test and the non-stress test do in relation to FHR/FHT?
Kick count: done by mom, give sheet to count hourly kicks or 2 hr time frame; need 10 in 2 hrs.
Advantage: need 10FM/hour; mom will be aware of baby; Mom relaxes take time out (once 10 kicks are counted, she can stop counting)
Non-stress test: done in hospital; hooked up to electronic fetal monitor (ultrasound part that is put on abdomen over fetal hear to get FHT; other piece is a toco that goes at top of uterus to detect any contractions); looking for fetal movement (to detect an increase in HR from fetal movement; 15 beats up, 15 beats over..see below. NON-STRESS TEST:If HR is 120, w/non stress test; look @ fetal monitor strip; should go up@ least 15 beats per minute for (3 in 5, 2 in 10 minutes; FHR see on monitor has to go up this many times; looking for accelerations);tells that baby is healthy, can raise their beats w/movement..if don’t meet criteria (they may end up doing biophysical profile to double check the well-being). Accelerations: incrs in FHR of 15bpm above fetal baseline that lasts @ least 15-30 sec
Will this baby do better outside the uterus or inside the uterus? This is final criteria/decision to decide if baby should come out. Clap over baby/over abdomen to get baby to move.

Non-stress test (NST) is most common method of antenatal screening; uses electronic fetal monitoring (EFM) for approx 20 minutes; based on premise that fetus moves @ various intervals and that the CNS and myocardium responds to movement
Response is demonstrated by acceleration of fetal heart rate (the FHR “reacts”)
Loss of FHR reactivity is associated most commonly w/fetal sleep cycle, but can be result of any cause of CNS depression (fetal hypoxia, acidosis, congenital abnormalities).
Reactivity is based on gestational age 32-34weeks (considered the appropriate age for reactivity to occur)
Acceptable criteria: FHR acceleration of 15 beats bpm that lasts for 15 seconds.
What are some nutritional guidelines for pregnant women?
Weight gain: Not eating for 2!. 25-35 lbs should be gained if u r average wt for ht; 40lbs if u r already too thin; Should not lose wt in preg. Diet: Need 1500-2700 calories/day (2700 calories would be for thinner person to start); 300kcal/ a day increase from pre-pregnancy needs. Cal. r most important in 2nd/3rd trimester when fetal growth is happening more than mom growth. Protein helps w/tissue growth & repair (devel of fetal tissues and organs); incrs intake by 2 serv, day to meet required (eggs, milk, cheese, yogurt r good proteins sources, calcium; meat, poultry, and fish too). Ca+ & vit.D for fetal bone growth & teeth develop- ment (vit D to absorb the calcium); ca+ 1000mg/day (see calcium sources below). Fe for hemoglobin (needs lots); as blood volume increases, # of circulating RBC increases; iron must be increased to maintain 02 carrying capacity of blood; 30mg/day starting @ 12 weeks gestation.Vit C for tissue growth & enhances the absorption of iron.Folic acid needed to prevent neural tube defects, help w/development of organs; essential in production of DNA & RNA, maintain normal brain function. Need 8-10 glasses H2O per day. (can get early contractions due to dehydration; gatorade doesn’t count!) Foods to avoid: High sodium drink (soda)NO alcohol, NOcaffeine, NO smoking (all can affect the baby)
Avoid swordfish (high mercury content) NO xtra sug or xtra na+,
Pica (eating non-nutritive; corn starch, dirt, red georgia clay, maybe gives iron/minerals) eating ice chips can indicate iron defficiency.
How is thyroid affected by pregnancy?
Increased activity, which increases metabolism (basal metabolic rate), affects how you tolerate heat, increases pulse rate and increases cardiac output.
What are the common discomforts of antepartum pregnancy?
Nausea/vomiting, Constipation, Hemorrhoids, Fatigue, Hypotension:
Round ligament pain,Varicosities: usually in legs, could get spider veins anywhere, Frequent urination: pressure of the baby on the bladder, Back aches: lordosis, Dyspepsia (heart burn): upset stomach, Dependent edema: all extra fluid; get cankles (large ankles)
Shortness of breath (SOB): will get air hungry (just can’t get enough air) as uterus grows, there is less room for diaphragm to go down; can hyperventilate (blow off too much C02)
Explain the differences between true and false labor.
Braxton-Hicks contractions: uterine contractions that happen to get you ready; usually felt in abdomen & often stops w/walking, position changes, etc.; they come and go, not consistent; when close to term it becomes hard to tell real labor from braxton hicks; usually felt in abdomen or groin area; do not lead to dilation or effacement of cervix so are termed “false labor”
True labor: contractions lead to progressive dilation & effacement of cervix; contractions occur w/regularity, increase in frequency, duration, and intensity; pain usually starts in woman’s back and radiates to abdomen; pain intensifies w/activity (walking).
Only difference is that true labor will change your cervix and braxton hicks won’t.
What is wharton's jelly?
A specialized connective tissue that surrounds the 2 arteries and 1 vein in the umbilical cord that helps keep it protected from compression.
Growth of the uterus displaces the maternal in which way?
Displacement moves the maternal heart upward and laterally to the left.
What is supine hypotension and vena caval syndrome?
Pressure from the enlarged uterus exerted on the vena cava decreases the amount of venous return from the lower extremities and causes a markedd decrease in blood pressure, that causes dizzyness, diaphoresis and pallor. Placing the woman on here left side can relieve symptoms.
What are common signals that the body is preparing for labor?
Lightening, Bloody Show, Rupture of Membranes, Nesting, and braxton hicks.
What is important to note about the rupture of membranes?
Can happen naturally or with a hook by doctor. If bag breaks we need to know color, smell, amount.
Color should be clear or can have slight yellowish color, may be white from vernix. Don’t want these colors: green (meconium would make this green; any shade of green means baby got stressed and had bowel movement in uterus; Not good), brown (old blood would make it brown; was mom in car accident, had placental bleed?), dark yellow (goes w/green= how much meconium), red (fresh blood; usually has to do with the placenta; don’t want to see this), black (could be chunks of meconium floating in fluid), white (white flecks can be normal; from vernix which is cheesey protection for baby’s skin to protect from water; it starts flaking off towards end of term), purple/blue (will take methalane blue in one of the bags/ multiples)Smell: should be odorless/not offensive even if it smells a little; odor would be from infection.Amount: big gush or slow trickle. Viscosity: goes with the color.
What are the 5 Ps of progressive labor and delivery?
Passage: maternal pelvis
Passenger: fetus & placenta
Powers of labor: physiological forces
Passageway + Passenger: engagement, attitude, position)
Psyche: previous experiences, emotional status.
Explain the passageway in relation labor and delivery?
Passage: concerns the pelvis; baby has to get out of the pelvis/it’s passageway; openings of pelvis determine what is going to happen; baby’s head molds so that the baby’s head can shift to allow for extra room to get out.
Relaxin makes the joints looser to allow the pelvis to open, but may not be enough
Different shapes/sizes of pelvis versus size of baby; antepartum (before baby is born) time is when they will discover if it will all fit.
False pelvis and true pelvis; true pelvis is the passageway
Explain the passenger in relation to presentation in L&D.
Passenger: the baby; how is baby presenting (butt down, shoulder down, feet down, etc); can deliver baby head down (preferred presentation is head down). Presentations: Frank breech: legs up, butt down.; Footling breech: one leg tucked into chest and one leg down into pelvis; or could be double footling breech (like standing up)
Biggest part of baby is head, second biggest are the shoulders; if delivery is attempted with a breech baby issues can arise (head may not be able to get out; smaller parts are coming out first, and head may end up getting stuck..why we end up with c-sections to avoid this from happening; Vertex presentation: head down Fetal lie (fig 12-4, p. 361): refers to relationship of the long axis of the woman to the long axis of the fetus; Longitudinal: head to tailbone axis of the fetus is the same as the woman’s; either head or fetal buttocks enter pelvis first.
Transverse: baby is sitting sideways in mom’s abdomen; horizontal lie.
Oblique lie: angle between longitudinal and transverse. Molding is the overlapping and overriding of the cranial bones due to the flexibilities from extra room in skull of open sutures and fontanels.
Explain the Powers of Labor in relation to L&D.
Powers of Labor: include uterine contractions and maternal pushing (how well can she push; effectiveness).
assess contractions; put hand on abdomen to feel contraction (contractions go from back to front @ bottom and then @ top front)
Feel for strength, length, how quick they come (peak to peak, start to start), ; duration, strength and time.
Power of contraction works on the cervix (it squeezes down); the cervix will then dilate & soften/thinning (effacement); cervix starts to get pulled up into the uterus (dilating @ same time) to allow passage of baby; powers of labor are making cervix dilate and efface & move fetus down toward birth canal during 1st stage of labor
Uterine contractions are considered primary force of labor.
Notice when contraction peaks and give mom hope that it is almost done.
Power of pushing comes in toward the end when the power of contraction (dilation/effacement have happened)
When mom pushes, we want her to work with gravity; push down into pelvis.
What is Passageway and Passenger mean?
Passageway+Passenger: baby engaging into true pelvis
What is the Psych part of labor and delivery?
Psyche: previous experiences, emotional status.Psyche: is mother ready for this; is she prepared for labor and delivery? Hard to prepare for when you have never experienced it before.
When does the fontanel close?
Anterior fontanel: closes @ approx 18 months to allow normal brain growth to occur.
Posterior fontanel: closes around 6-8 weeks after birth.
What phases are involved in the first stage of labor?
1st Stage: often referred to as stage of dilation; starts w/contractions & ends w/complete cervical dilation.
Phase 1: Contractions start happening (usually 5 minutes apart), debate when to go to hospital, water hasn’t broken, relaxed. (dilation up to 3cm); lasts approx 10-14 hrs; Phase 2: Contractions get stronger and get closer together and they last longer (about 60 seconds) (3-5 minutes apart); 3-7cm dilation; usually when people show up to hospital; where most of the work gets done; still have breaks between contractions, can carry on conversations, trying showers, balls, massage, etc to feel good.
Phase 3-Transition:between7-10cm; contractions are harder, last longer, occurring more often. (every 2-3 minutes and last 60-90 seconds); usually time when woman will throw up (good sign for transition period) ; body is making subtle change that indicates body is working; epidurals would be asked for now especially; 1st stage of labor ends w/complete dilation of cervix.
Describe the 2nd stage of labor.
2nd Stage: from 10cm to delivery of baby; usually approx 2hrs (if takes longer, are contractions inadequate?, is baby presented in different way?, is mom not pushing effectively?; would have to figure out why taking longer); if 2nd time mom, this may be only 1 push (encourage a little push since their body already knows what to do/so does mom); never leave her alone during this time. Crowning happens: see baby’s head on perineum (area between vagina and anus). Baby delivered.
Describe the 3rd stage of labor.
3rd Stage: from delivery of baby to delivery of the placenta (comes out from 5-35 minutes after the baby; usually delay time between; get some more contractions & push to birth placenta). Should come out intact; our job is to look at placenta to make sure it is all there; may come out in pieces (that is not good, some pieces may be left in mom and cause infection); Shiny shultze and dirty duncan (shiny shultze baby’s side of placenta; shiny side showing; dirty duncan is moms side that shows up; looks like hamburger)
If mom wasn’t on pitocin before, they can give a synthetic shot after the placenta to contract uterus down to stay down.
What are nursing interventions that the nurse can do in the first stage of labor?
1st Stage p. 375Non-pharmaco-logical: position changes (need them to move), present for them if they need you (you become the support person), hold their hand, massage, information/anticipatory guidance, interpret what the doctor says so they understand what is happening to them, hot & cold packs, fluid intake, toileting q2 hrs or qhr, encourage support people to take care of themselves (eat, drink, pay attn to how shocked the dad is, have them sit down). Doula work! Medications: meds that help her stay in control, don’t want to wipe them out; fentanyl nubane, epidurals (anesthesia that goes into epidural space; bathes nerve endings) so make sure she has plenty of fluids and have to help her in correct position while epidural is happening. Careful monitoring of VS since her BP can drop with epidurals.
What are nursing interventions for the 2nd stage of labor?
2nd Stage: help her focus; encourage low noise level and rest between contractions; don’t leave her alone
What are nursing interventions for the 3rd stage of labor?
3rd Stage: help with delivery of placenta (coach w/pushing to get placenta out); assist mother w/adjustment of Labor & birth, facilitate attachment.
What are nursing interventions for the 4th stage of labor?
4th Stage: assess her bleeding have to massage uterus; boggy (if uterus is boggy, you have to massage uterus until it feels like the back of hand) rub fundus (top of uterus until it tightens up) VERY important; uterus HAS to be firm, it means it contracts down and constricts blood vessels so she wont’ bleed/hemorrhage; assess lochia (bloody vaginal discharge)
Provide privacy and comfort, keep her covered
Monitor VS q15 minutes; rising pulse rate or decreased BP are signs of excessive blood loss.
Get her something to eat, drink, fluff pillows, encourage early bonding!
Help her w/breastfeeding positioning, latching on correctly, etc.
What is a pfannenstiel incision?
It is the most commonly performed incision method for caesarean. AKA transverse.
What is the percentage rate on caesarean?
Back in 1965 less than 5% were caesarean. In 2005 30%, This has increased to about 45%.
What are some of the indications for cesarean birth?
Indications : health of mom and baby in jeopardy, maternal risk factors (hypertension, positive HIV status & diabetes)
Fetal implications: malpresentations (breech, shoulder); placenta abnormalities, dysfunctional labor patterns, umbilical cord prolapse, multiple gestation. Indications – prolonged labor, CPD, fetal distress, maternal distress, genital herpes, any medical problem related to fetal passage through vagina, failure to progress etc.
What are the preoperative nursing interventions for a cesarean?
Pre-operative: blood work (type and cross match) obtained and entered into chart; NPO since midnight before admission; review prenatal history; make sure informed consent is signed.
Pre-op – help mother understand reason for C-section, prepare mother for surgery with IV, foley, shave and medications, support mother (hold her hand, talk with her, call family, reassure her etc.) Nurse maybe in the OR with mother and be able to follow her through the whole procedure.
What are the post operative nursing interventions for a cesarean.
Post-operative: assess her recovery from anesthesia, status of post-op uterus, make sure there is maintenance of patent airway if general anesthesia given ; assess VS q4h for 1st 2 hours, assess fundus, lochia, I&O, instruct her to perform leg exercises (DVT prevention); facilitate bonding & attachment.; BUBBLE-HE assessment;Post-op – care for mother in RR with assessments, assess dressing, turn cough and deep breathe, medications, information, help mother with breast feeding etc.
What are post partum nursing interventions?
Post-partum – same as vagina birth except need to help mother up for first time, assess incision at every check and show mother how to move in bed or get up without using abdominal muscles. Help breast feeding mothers with comfortable positions. Encourage mother to increase physical activity.
Name the general components of the Post-partum nursing assessments and interventions for mothers.
Bubble-He, REED, Lactation, Depression, and expected physical changes.
Explain the Homan's sign of the Bubble-He assessment.
Homans sign: looking for DVT; examiner dorsiflexes the foot, if there is pain in calf it means positive homans; pain is indicative of DVT, but negative sign doesn’t r/o DVT (need ultrasound, etc).
Explain the BREAST part of bubble-he assessment.
Breasts:Breasts: inspect nipples (inverted or everted?); will mom breastfeed? If so, inverted nipples need a breast/nipple shield. Notice if nipples are cracked. Breast tissue: palpate..are they soft, filling, firm? Are breasts engorged? Be aware of mastitis. Assess for good sucking, good latch, and bonding during breastfeeding. Temperature & color: warm, pink, cool, red streaked?
Explain the uterus assessment component of bubble-he
Uterus:Uterus/fundus (top of uterus): location (is it midline or deviated or right or left; deviation to right is more common w/bladder distention; deviation to left may be from mom “carrying to the left” or w/multiples)
Remember to have mom urinate first, since a full bladder will prevent the uterus from contracting & will push it upward & deviate it from midline; boggy uterus indicates a uterus that isn’t contracting, which is associated w/increased bleeding; worry about hemorrhage!
Risk for hemorrhage: an Atonic uterus (flabby, boggy, non-contracting)
Massaging uterus is #1 nursing intervention to prevent postpartum hemorrhage; breastfeeding also causes uterine contractions (educate the moms that this is GOOD)
When massaging fundus the upper hand cups the fundus, while lower hand stabilizes the uterus @ symphysis pubis to keep uterine inversion from occurring (uterus comes out, cuz not supported); fundus is measured @ or below the umbilicus (F@U or F@U-1, etc)
Explain the bladder assessment component of bubble-he.
Bladder: Bladder: when was last time patient emptied bladder..spontaneously or via catheter? (remember to have her void before fundus/uterine massage) Is the bladder palpable or not? Assess @ symphysis pubis: if bladder is firm, it is distended (if full, higher risk for bleeding). Note the color, odor and amount of urine. Educate moms that we want the bladder empty to not interfere w/uterine contractions/prevents bleeding.
Remember to dangle mom’s legs off bed for 1st time getting up to urinate; NEVER let her get up by herself the 1st time.
Explain the Bowel assessment component of Bubble-He.
Bowel:Bowel: Date/time of last BM? Listen to bowel sounds (especially if colon was manipulated as w/c-section); bowel movement may be difficult
Anesthesia, nausea & vomiting all make it harder to defecate.
Passing gas is an indication of intestines working; the more they walk, the more peristalsis will be stimulated.
Constipation help: early ambulation, abundant fluids, and high-fiber diet (stool softeners too).
What is the lochia assessment part of bubble-he?
Lochia:Lochia: the sloughing off of the superficial layer of the uterus after birth; the status of the lochia depends on the woman’s status of involution (process by which her uterus returns to pre-pregnant state)
Lochia rubra: occurs in first few days postpartum (1st 3-4 days approx); red color; fleshy odor; may be mixed w/tissues.
Lochia serosa: after 3-4 days, lochia becomrs pinkish-brown as bleeding stops and the uterus is healing.
Lochia alba: after 10-14 days the uterine discharge has reduced fluid content & is mostly composed of leukocytes.
Pattern of lochia flow should not reverse (or it could indicate more bleeding); lochia should NOT have large clots & no offensive odor.
Assess peripad for scant, light, moderate, or saturated lochia flow/hour. **important to assess when peripad was last changed to determine relevance of amount of lochia on the pad; the amount of time passed is important.
Amount should decrease; when woman stands up, may experience a gush (could be from pooling of lochia in the uterus; don’t be alarmed, but keep an eye on her).
What is the episiotomy part of Bubble-he?
Episitomy/tear/stitching:Episiotomy: an incision made to perineum to enlarge vaginal opening before birth; easier to heal that an tear. Tears can be 1 -4 degrees (from vagina to anus; 4th degree tear goes all the way to rectum, needs stitches and takes longer to heal.
Explain the EMOTIONS assessment of Bubble-He
Emotions: includes bonding, how is the mom associating w/baby (appropriate interaction?)
What is the REEDA assessment and its parts?
REEDA: perineum assessment
Redness/inflammation, Edema
Ecchymosis or bruising, Drainage from stitches for perineum specifically. Approximation of tissue.
What are some important elements to assess and understand about lactation?
Lactogenesis depends on release of prolactin & oxytocin; milk synthesis starts after the placenta is delivered. The delivery of placenta results in decrease in estrogen & progesterone,& increase in secretion of prolactin from ant pit gland; prolactin stimulates milk secretion. Stimulation from infant suckling or breast pumping triggers the release of oxytocin from the posterior pit; oxytocin prompts milk ejection/let down. May feel like a tingling to the mom. Lack of breastfeeding or failure to empty breasts by pumping causes an increase in hormones that act to inhibit the secretory cells of the breast, causing gradual decrease in milk volume and eventual death of those epithelial cells. Lactation: she will still lactate even if she isn’t going to breast feed; will still fillup; needs to bind herself if not breastfeeding, so breasts don’t get stimulted (if stimulated they will still produce). Cabbage leaves are used w/engorgement (washed, cooled in fridge, crushed and placed directly on breasts for 15-20 minutes 2-3 times only if they are using for engorgement, otherwise it can diminish the milk supply).Don’t pump if you don’t want to breast feed; supply and demand.
What are some important elements to consider in postpartum depression?
Depression: don’t usually show up in hospital (due to limited time w/ patients), but will show up in doctors’ office setting. Baby blues (just blue and life changes, anxious, don’t really know what to do ..)may last a day or awhile.1st few days and peaks on 5th day postpartum, then subsides; the “blues” do NOT affect the woman’s ability to care for her newborn. Postpartum depression: mom doesn’t take of herself or baby; SERIOUS. Usually shows up 2 weeks postpartum (sleep disturb- ances, guilt, fatigue, hopelessness/ worthlessness. Post partum psychosis: delusional,hallucinations, agitation, inability to sleep, bizarre irrational behavior.
What are some of the expected physical changes for a mother post-partum first week?
Physical changes in 1st week
Lose 500ml of fluid w/delivery; shift to blood stream, so you will diurese (pee a lot). Respirations improve
Skin changes will change back to normal; fade out. Get gas and constipation until bowels start to work
Muscle aches and fatigue from labor work. take 6 weeks to resume normal; can take up to 3 months to get it all back. (remind women)
What are some of the discharge topics that a nurse will need to discuss with a postpartum mother. What are the 9 danger signs she should watch for?
Objective 31 Postpartum discharge plan for 1st time mother including self care: SIDS prevention (225): breastfeeding recommended, avoiding cigarette smoke, and BACK to sleep. Other topics: infant bathing, breastfeeding, perineal hygiene, physical activity, rest and expected emotional changes.Sexual activity put off till 6 weeks postpartum (ovulation can resume 2 weeks after birth, so remind them to wait or use contraceptives if sooner)Box 15-5, p. 505 Danger signs: 1)Temp >100.4, chills, flu like symptoms 2)Incision that is red, tender to touch, painful, or if edges come apart. 3) Difficulty w/urination, frequency or painful urination. 4) Increased vaginal bleeding w/or w/out clots, or foul- smelling vaginal discharge. 5) Pain or persistent swelling of perineal laceration or episiotomy. 6) Swelling or masses in breasts, red streaks, shooting pain in breasts, or cracked bleeding nipples. 7) Swelling, warm, or tender, painful areas in the legs
8) Blurred vision or persistent headache that is not relieved by pain meds. 9) Overwhelming feelings of sadness or inability to care of self or baby.
What parts of the fetus have developed by the 4th week?
Spinal cord fused – neural tube defect occurs if not
Head, rudimentary heart, arms and legs budlike
Rudimentary eyes, ears and nose discernible
What parts of the fetus have developed by the 8th week?
End of 8th week: organogenesis complete
Heart with septum and valve, rhythmic beats
Arms and legs developed
External genitalia present, sex not distinguishable
What parts of the fetus have developed by the 12th week?
End of 12th week:
Faint, spontaneous movement present
Tooth buds present; bone ossification centers forming
Kidneys secreting urine
Heartbeat audible with Doppler
What parts of the fetus have developed by the 16th week?
End of 16th week: heart sounds audible with stethoscope
Liver and pancreas functioning
Active swallowing of amniotic fluid present
What parts of the fetus have developed by the 20th week?
End of 20th week:
Spontaneous fetal movement sensed by mother
Sleep and awake periods distinguishable
Hair forms, brown fat & vernix begins to form
What parts of the fetus have developed by the 24th week?
Passive antibody transfer from the mother begins
Active lung surfactant production begins
Eyelids are now open; pupils capable of reacting to light
24 weeks, 601 grams – low end age of viability if cared at tertiary centers
Hearing evident
What parts of the fetus have developed by the 28th week?
End of 28th week:
Lung alveoli begin to mature
Retinal blood vessels are thin and extremely susceptible to damage from oxygen
What parts of the fetus have developed by the 32nd week?
Subcutaneous fat deposition begins
Active Moro reflex evident
Iron stores begin
What part of the fetus develops by the 36th week?
Body stores of glycogen, iron, carbohydrate and calcium are deposited
Soles of feet with one or two crisscross creases
What part of the fetus develops by the 40th week?
Active kicking; Fingernails extend over fingertips
Fetal Hgb begins convert ing to adult Hgb
Creases cover 2/3 of sole of feet
What timeframe is defined as the neonatal or newborn period?
Birth: 0 to 28 days (Neonatal Period)
Transition to extrauterine environment