0133427269 Module33 Reproduction LectureOutline

Module Reproduction The Concept of Reproduction Reproduction requires understanding of structures functions that make childbearing possible Sexual intercourse Process by which sex cells unite Primary function Normal presentation of the female reproductive system Bony pelvis two unique functions Support and protect pelvic contents Form the relatively fixed axis of the birth passage Bony structure Four bones innominate bones sacrum coccyx Resembles bowl Lined by fibrocartilage held together tightly by ligaments See Figure PELVIC BONES WITH SUPPORTING LIGAMENTS p Innominate bones hip bones Three separate bones ilium ischium pubis fuse to form circular cavity acetabulum Ilium broad upper prominence of hip Ischium under ilium below acetabulum Pubis forms slightly bowed front portion Sacroiliac joints have a degree of mobility increases near end of pregnancy Relaxations of joints induced by hormones of pregnancy Sacrum wedge-shaped bone Obstetric guide in determining pelvic measurements Coccyx last bone on vertebral column Usually moves backward during labor to provide more room for fetus Pelvic floor Muscular floor designed to overcome force of gravity exerted on pelvic organs Deep fascia levator ani coccygeal muscles form part of pelvic floor known as pelvic diaphragm Levator ani makes up major portion of pelvic diaphragm muscles Iliococcygeus Pubococcygeus Puborectalis Pubovaginalis See Figure MUSCLES OF THE PELVIC FLOOR p Pelvic division False pelvis supports weight of enlarged pregnant uterus directs presenting fetal part into true pelvis True pelvis portion that lies below the linea terminalis Relationship between true pelvis and fetal head size and shape must be adequate for normal fetal passage Pelvic inlet upper border of true pelvis Diagonal conjugate Obstetric conjugate Conjugate vera Transverse diameter Pelvic cavity See Figure PELVIC PLANES p Pelvic outlet lower border of the true pelvis Transverse diameter extends from inner surface of one ischial tuberosity to the other Pelvic types CaldwellMoloy classification Four basic types Gynecoid Android Anthropoid Platypelloid See Figure COMPARISON OF CALDWELLMOLOY PELVIC TYPES p Female reproductive cycle Female reproductive cycle FRC composed of ovarian cycle uterine cycle Take place simultaneously Effects of female hormones Female undergoes cyclic pattern of ovulation and menstruation for period of years neurohormonal control Ovaries produce mature gametes and secrete hormones Estrogens Cause uterus to increase in size and weight Have effects on many hormones and other carrier proteins Progesterone Secreted by corpus luteum found in greatest amounts during secretory phase of menstrual cycle Hormone of pregnancy effects on uterus allow pregnancy to be maintained Prepares breasts for lactation Prostaglandins PGs Produced by cells of endometrium PGE relaxes smooth muscles vasodilator PGF vasoconstrictor increases contractility of muscles and arteries Production increases during follicular maturation seems critical to follicular rupture Neurohormonal basis of female reproductive cycle FRC controlled by complex interactions between nervous and endocrine systems and target tissues Hypothalamus secretes gonadotropin-releasing hormone GnRH to pituitary gland in response to signals from CNS anterior pituitary secretes follicle-stimulating hormone FSH and luteinizing hormone LH FSH and LH responsible for maturation of follicle Ovulation takes place following rapid growth of follicle Ruptured follicle undergoes rapid change complete luteinization occurs cells become corpus luteum Ovarian cycle phases follicular phase days luteal phase days See Figure VARIOUS STAGES OF DEVELOPMENT OF THE OVARIAN FOLLICLES p Mature graafian follicle appears about th day under control of FSH and LH As graafian follicle matures enlarges comes closer to surface of the ovary ovum discharged near the fimbria of fallopian tube Some women ovulation accompanied by midcycle pain mittelschmerz Ovum takes several minutes to travel through ruptured follicle to fallopian tube opening Luteal phase begins when ovum leaves follicle Under influence of LH corpus luteum develops from ruptured follicle If fertilization occurs fertilized egg begins to secrete human chorionic gonadotropin hCG to maintain corpus luteum If fertilization does not occur corpus luteum begins to degenerate Menstrual cycle Menstruation cyclic uterine bleeding in response to cyclic hormonal changes occurs when ovum not fertilized Menstrual parameters vary greatly generally every days Duration from to days Four phases Menstrual menstruation Proliferative phase endometrial glands enlarge becoming twisted and longer in response to increasing amounts of estrogen Secretory phase follows ovulation endometrium swells vascularity increases nourishing bed for implantation Ischemic phase if fertilization does not occur corpus luteum degenerates estrogen and progesterone levels fall Conception and fetal development Each human begins life as a single cell fertilized ovum or zygote Mitosis results in production of diploid body cells Cell undergoes several changes ending in cell division Meiosis process of cell division leading to development of eggs and sperm needed to produce new organism Special type of cell division diploid cells in testes and ovaries give rise to gametes with haploid number of chromosomes Two successive cell divisions Chromosomes replicate become closely intertwined physical exchange of genetic material new combinations Mutations may occur during second meiotic division if two of chromatids do not move apart rapidly enough when cell divides Gametogenesis Meiosis occurs during gametogenesis germ cells are produced Contain only half of genetic material of typical body cell chromosomes in female gamete ovum and male gamete sperm unite to form zygote fertilized ovum chromosomes Oogenesis Process that produces female gametes ovum egg First meiotic division produces two cells of unequal size with different amounts of cytoplasm same number of chromosomes At ovulation second meiotic division begins immediately proceeds as oocyte moves down fallopian tube When secondary oocyte completes second meiotic division after fertilization result is mature ovum with haploid number of chromosomes all of the cytoplasm Second polar body forms First polar body also divided Spermatogenesis During puberty germinal epithelium in seminiferous tubules of testes begins process of spermatogenesis produces male gamete sperm Fertilization Process by which sperm fuses with an ovum forms new diploid cell or zygote Preparation for fertilization Mature ovum and spermatozoon have brief time to unite Ovums cell membrane surrounded by two layers of tissue has no inherent power of movement Fertilization takes place in ampulla of fallopian tube Single ejaculation million spermatozoa only hundreds reach ampulla Sperm must undergo two processes before fertilization Capacitation removal of plasma membrane overlying the spermatozoons acrosomal area loss of seminal plasma proteins Acrosomal reaction follows capacitation acrosomes of sperm surrounding ovum release enzymes break down hyaluronic acid in ovums corona radiata At moment of penetration by fertilizing sperm reaction in zona pellucida prevents additional sperm from entering single ovum Moment of fertilization After sperm enters ovum chemical signals prompt secondary oocyte to complete second meiotic division forming nucleus of ovum ejecting second polar body Moment of fertilization when sex of zygote is determined Preembryonic development First days of development called preembryonic stage Cellular multiplication Begins as zygote moves through fallopian tube toward uterus three or more days Zygote enters period of rapid mitotic divisions cleavage Blastomeres form solid ball of cells morula enters uterus central cavity formed within mass Within cavity mass of cells called blastocyst surrounded by trophoblast Early pregnancy factor secreted by trophoblastic cells Implantation nidation Blastocyst nourished by uterine glands attaches to surface of endometrium most commonly upper part of posterior uterine wall Under influence of progesterone endometrium increases in thickness and vascularity in preparation for implantation and nutrition of ovum Cellular differentiation Primary germ layers days after conception homogeneous mass of blastocyst cells differentiates into primary germ layers Embryonic membranes Begin to form at time of implantation support and protect the embryo as it grows and develops inside uterus Chorion outermost membrane Amnion second to form contains amniotic fluid Amniotic fluid Functions Cushion to protect embryo Help control embryos temperature Permit symmetrical external growth and development of embryo Prevent adherence of embryofetus to the amnion Allow umbilical cord to be free of compression Act as an extension of fetal extracellular space Act as wedge during labor Provide fluid for analysis to determine fetal health and maturity Slightly alkaline contains albumin uric acid creatinine lecithin sphingomyelin bilirubin vernix leukocytes epithelial cells enzymes lanugo Volume at weeks mL Volume after weeks mL Yolk sac Small functions early in embryonic life Incorporated into umbilical cord Umbilical cord Body stalk contains blood vessels that extend into chorionic villi One vein smaller arteries Wharton jelly Appears twisted spiraled from fetal movement Nuchal cord umbilical cord encircles fetal neck Twins Normally occurs in pregnancies Fraternal or identical See Figure A DIZYGOTIC FRATERNAL TWINS Figure B MONOZYGOTIC IDENTICAL TWINS p Development and functions of the placenta Placenta means of metabolic nutrient exchange between embryonic and maternal circulations Placental development and circulation do not begin until third week of embryonic development Two parts Maternal decidua basalis and its circulation Fetal chorionic villi and their circulation Development of placenta begins with chorionic villi two layers that thin out to one Third layer of connective mesoderm anchoring villi eventually form septa of placenta divide mature placenta into segments cotyledons Exchange of substances is minimal during first months of development membrane is too thick Placental circulation After implantation of blastocyst cell differentiationfetal and trophoblastic trophoblast invades decidua basalis of endometrium opens uterine capillaries later opening the larger uterine vessels By end of th week placenta functioning as means of metabolic exchange between embryo and mother In fully developed placentas umbilical cord fetal blood flows through two umbilical arteries to capillaries of villi becomes oxygen-enriched flows back through the umbilical vein into fetus Maternal blood spurts from spiral uterine arteries into intervillous spaces Braxton Hicks contractions intermittent painless uterine contractions that may occur every minutes more frequently near end of pregnancy Believed to facilitate placental circulation Placental flow enhanced when woman lying on her side Placental functions Placental exchange functions occur in fetal vessels that are in contact with syncytial membrane Fetal respiration nutrition excretion Metabolic activities Continuously produces glycogen cholesterol fatty acids for fetal use and hormone production Transport function Simple diffusion Facilitated transport Active transport Pinocytosis Hydrostatic and osmotic pressures Blood flow alteration changes transfer rate of substances Endocrine functions Produces hormones hCG similar to LH prevents normal involution of corpus luteum at end of menstrual cycle if corpus luteum stops functioning spontaneous abortion th week placenta produces enough progesterone and estrogen to maintain pregnancy Immunological properties Placenta and embryo are transplants of living tissue within same species homografts Appear exempt from immunological reactions by host Development of the fetal circulatory system Circulatory system of fetus has several unique features Most of blood supply bypasses fetal lungs placenta assumes function of lungs See Figure FETAL CIRCULATION p Most of umbilical veins blood flows through ductus venosus fetal inferior vena cava right atrium foramen ovale into left atrium pours into left ventricle pumps blood into aorta Returning blood into right atrium through tricuspid valve into right ventricle pulmonary artery through ductus arteriosus into descending aorta returns through two umbilical arteries Fetus obtains oxygen via diffusion from maternal circulation Fetal circulation delivers highest available oxygen concentration to the head neck brain and heart Fetal heart Controlled by its own pacemaker Vagus nerve supplies sinoatrial node and atrioventricular node Also influenced by sympathetic nervous system baroreceptors chemoreceptors and central nervous system Embryonic and fetal development Pregnancy calculated to last average of lunar months weeks or days Postconception age about two weeks less weeks Embryonic stage Embryo stage starts on day until approximately eighth week crown-to-rump length of cm Most vulnerable to teratogens at this stage See Figure THE ACTUAL SIZE OF A HUMAN CONCEPTUS FROM FERTILIZATION TO THE EARLY FETAL STAGE p See Figure THE EMBRYO AT WEEKS p Fetal stage End of the eighth week Every organ system found in full-term newborn is present Remainder of gestation refining structures and perfecting function Full term Fetus is full term at weeks Amniotic fluid diminishes fetal body mass fills uterine cavity Head is generally pointed downward Physical and psychological changes of pregnancy Growth of developing fetus extraordinary physical and psychological changes in mother Pregnancy divided into trimesters Anatomy and physiology of pregnancy Reproductive system Uterus Increases in weight from g to g Increases in capacity from mL to mL Hypertrophy of preexisting myometrial cells Cervix Estrogen stimulates glandular tissue increases in cell number Increased cervical vascularity causes softening of cervix Goodell sign and bluish discoloration Chadwick sign Ovaries Stop producing ova during pregnancy Vagina Estrogen causes thickening of the vaginal mucosa loosening of connective tissue increase in vaginal secretions By end of pregnancy vagina and perineal body sufficiently relaxed to permit passage of infant Breasts Enlarge become more nodular as glands increase in size and number in preparation for lactation Colostrum may leak Respiratory system Volume of air breathed each minute increases As uterus enlarges presses upward elevates diaphragm Nasal stuffiness epistaxis may occur Cardiovascular system Blood flow increases to organ systems with increased workload Pulse may increase by as many as bpm Enlarging uterus puts pressure on pelvic and femoral vessels interferes with returning blood flow causes stasis of blood in lower extremities When pregnant woman lies supine enlarging uterus may press on vena cava reduces blood flow to right atrium lowers blood pressure causes dizziness pallor clamminess supine hypotensive syndrome vena caval syndrome or aortocaval compression See Figure VENA CAVAL SYNDROME p Have woman lie on left side Blood volume progressively increases until about weeks Total RBC volume increases about in women with iron supplementation Physiological anemia of pregnancy Iron necessary for hemoglobin formation Leukocyte production increases slightly Gastrointestinal system Nausea vomiting common during first trimester elevated hCG levels changed carbohydrate metabolism Elevated progesterone levels cause smooth muscle relaxation resulting in delayed gastric emptying decreased peristalsis Minor liver changes Emptying of gallbladder prolonged Urinary tract During first trimester enlarging uterus pelvic organ presses against bladder urinary frequency Ureters especially right elongate dilate Glomerular filtration rate GFR rises Skin and hair Skin pigmentation changes thought to be from hormone levels Areola nipples vulva perianal area Linea nigra Chloasma Sweat and sebaceous glands often hyperactive Striae Vascular spider nevi small bright red elevations of skin Rate of hair growth may decrease during pregnancy Musculoskeletal system No demonstrable changes in teeth Joints of pelvis relax somewhat hormonal influences Pressure of enlarging uterus on abdominal muscles may cause rectus abdominis muscles to separate diastasis recti Eyes Intraocular pressure decreases cornea thickens slightly disappears by weeks postpartum CNS Pregnant women often describe decreased attention concentration memory during and shortly after pregnancy Metabolism Increased demands of fetus support system Weight gain Adequate nutrition and weight gain important Normal weight gain kg lb kg lb first trimester kg lb per week during last two trimesters Water metabolism Increased water retention caused by hormone levels and lowered serum protein Extra water needed for fetus placenta amniotic fluid and mothers increased blood volume Nutrient metabolism Fetus make greatest protein fat demands during nd half of pregnancy Fats absorbed more completely during pregnancy Endocrine system Thyroid Often enlarges slightly during pregnancy Total serum thyroxine T increases in early pregnancy thyroid-stimulating hormone TSH decreases Parathyroid Increase in concentration of parathyroid hormone and size of parathyroid glands Pituitary Anterior pituitary produces FSH and LH Posterior pituitary secretes vasopressin and oxytocin Adrenals Circulating cortisol increases in response to increased estrogen levels Adrenals secrete increased levels of aldosterone by early part of second trimester Pancreas Pregnant woman has increased insulin needs islets of Langerhans are stressed to meet this increased demand Marginal pancreatic function signs of gestational diabetes Hormones in pregnancy Several hormones required to maintain pregnancy hCG Trophoblast secretes hCG early in pregnancy Human placental lactogen hPL Antagonist of insulin increases amount of circulating free fatty acids for maternal metabolic needs Estrogen Produced primarily by placenta as early as th week of pregnancy Progesterone Produced initially by corpus luteum then placenta Maintains endometrium inhibits spontaneous uterine contractility Relaxin Inhibits uterine activity Prostaglandins in pregnancy Exact function not known Signs of pregnancy Subjective presumptive changes Amenorrhea Urinary frequency Nausea and vomiting in pregnancy NVP Changes in breasts Quickening Objective probable changes Changes in pelvic organs Hegar sign McDonald sign Enlargement and softening of uterus Braxton Hicks contractions Uterine souffle Changes in pigmentation of skin Fetal outline by palpation Ballottement Pregnancy test hCG Clinical pregnancy tests Diagnostic positive changes Positive signs of pregnancy are completely objective Fetal heartbeat Fetal movement Visualization of fetus by ultrasound Psychological response of the expectant family to pregnancy Turning point in familys life accompanied by stress and anxiety Beginning families transition period from childlessness to parenthood Finances an important consideration in most pregnancies If pregnant person has no stable partner deals with role changes fears and adjustments of pregnancy alone Developmental tasks of the expectant couple For couple support or conflict Plan together for arrival During pregnancy expectant parents face significant changes psychosocial adjustments Pregnancy may be a crisis Maturational crisis family or individual in disequilibrium The mother Alters body image necessitates reordering social relationships roles in family Womans attitude toward pregnancy can be significant factor in outcome Unintended does not mean unwanted Conflicts about adapting to pregnancy no matter age of pregnant woman Differences may be due to maturity Pregnancy produces marked changes in womans body within a relatively short period of time Fantasies about unborn child common among pregnant women First trimester Feelings of disbelief and ambivalence common Mother may begin to exhibit early symptoms of pregnancy May also exhibit characteristic behavioral changes introspective passive emotionally labile Second trimester Quickening occurs helps woman to think of baby as separate person Generally excited about pregnancy Emotional lability persists Body image changes as pregnancy becomes more noticeable Third trimester Pride about pregnancy anxiety about labor and birth Physical discomforts increase Psychological tasks of the mother Ensuring safe passage through pregnancy labor birth Seeking acceptance of this child by others Seeking commitment and acceptance of herself as mother to the infant binding in Learning to give of oneself on behalf of ones child The father Makes transition from nonparent to parent Pride in virility same ambivalent feelings as mother Deals with reality of pregnancy Must establish fatherhood role First trimester After initial excitement may begin to feel left out Second trimester Role still vague involvement may increase as he watches feels fetal movement listens to fetal heartbeat during prenatal visit Anxiety lessened when both parents agree on paternal role the man is to assume As womans appearance begins to change partner may have several reactions Third trimester If couples relationship has grown through effective communication third trimester rewarding Concerns fears may recur Siblings Bringing baby home often marks beginning of sibling rivalry Preparation of young child begins several weeks before anticipated birth Concept of consistency important in dealing with young children Crib versus cosleeping If child ready toilet training most effective several months before or after birth Pregnant women may find it helpful to bring their children on prenatal visit School age pregnancy should be viewed as a family affair Older children adolescents may have misconceptions about pregnancy and birth After birth siblings need to feel they are taking part Amount of parental attention on new arrival versus older child Grandparents Often first relatives told about the pregnancy Peoples response to this role varies considerably Childbearing and childrearing practices have changed cohesiveness is promoted by effective communication Classes for grandparents may provide information about changes in birth parenting practices Cultural values and pregnancy Ceremonial rituals customs around important life events Identification of cultural values useful in predicting reactions to pregnancy Generalization about cultural characteristics values not every individual in culture may display these characteristics Cultural assessment important aspect of prenatal care Case Study Part Emma Halleck is a -year-old White female who presented at the antepartum clinic on June Alterations in reproduction that occur during pregnancy See CONCEPTS RELATED TO REPRODUCTION p Pregnancy affects all body systems and many concepts Adolescent pregnancy Health and social issue with no single cause or cure Adverse outcomes for mother Less likely to finish high school Less likely to go to college More likely to be single More likely to end up on welfare Adverse outcomes for child Often born prematurely and of low birth weight Increased risk for intellectual disability Increased risk for poverty welfare dependency poor school performance More likely to grow up without a father Suffer higher rates of abuse and neglect Pregnancy Over Age Advantages Parents tend to be well-educated and be financially secure Decision to have a baby is usually deliberate Medical risks Higher risk for maternal death Higher incidence of low-birth-weight and preterm births Higher rate of miscarriage Higher rate of pregnancy labor and delivery complications Higher risk of conceiving a child with Down syndrome Special concerns of the expectant couple over age Dealing with needs of child as they themselves age Social isolation Blended families More medical procedures Anemia during pregnancy Common anemias of pregnancy due to insufficient hemoglobin production related to nutritional deficiency in iron or folic acid during pregnancy or to hemoglobin destruction in inherited disorders Iron deficiency anemia Most common medical complication of pregnancy Supplementation recommended for pregnant women Folic acid deficiency anemia Folate deficiency is the most common cause of megaloblastic anemia during pregnancy prevented by daily supplement Diagnosis is difficult Sickle cell disease in every African American newborns has some form of sickle cell disease Women with sickle cell trait have good pregnancy prognosis with adequate nutrition and prenatal care Diabetes during pregnancy Gestational diabetes mellitus Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy Increases risk of perinatal morbidity and mortality Influence of preexisting and gestational diabetes during pregnancy Insulin requirements are changeable Renal threshold for glucose decreases Influence of preexisting and gestational diabetes on pregnancy outcome Maternal risks Hydramnios Preeclampsia-eclampsia Hyperglycemia Ketoacidosis Dystocia Retinopathy Fetal-neonatal risks Increased risk of death Congenital abnormalities Macrosomia Respiratory distress syndrome Hyperbilirubinemia Hypercalcemia Clinical therapy Screening Laboratory assessment of long-term glucose control Evaluation of fetal status Intrapartum management of preexisting and gestational diabetes mellitus Timing of birth Labor management Postpartum management of preexisting and gestational diabetes mellitus Glucose testing Reassessment weeks postpartum Cardiac disease during pregnancy Heart disease ranks fourth as cause of maternal mortality Congenital heart defects Most common defects tetralogy of Fallot atrial septal defect ventricular septal defect patent ductus arteriosus and coarctation of the aorta Marfan syndrome Autosomal dominant disorder of connective tissue which may have serious cardiovascular involvement Peripartum cardiomyopathy Dysfunction of the left ventricle that occurs in last month of pregnancy or months postpartum Mortality rate between and Mitral valve prolapse Usually asymptomatic Seems to be inherited Excellent prognosis Clinical therapy Early diagnosis and ongoing treatment Four classifications of functional capacity ranging from no limitations of physical activity and no cardiac insufficiency to inability for physical activity without discomfort and cardiac insufficiency symptoms even at rest Drug therapy Additional drugs may be needed to maintain health Labor and childbirth Recommendations vary by cardiac classification Antepartum period Required dietary and activity changes Avoid sources of infection Intrapartum period Monitor mother frequently Monitor fetus electronically Postpartum period Assess mother for signs of decompensation Evaluation mothers medications for effect on lactation and breast milk Follow-up for mother is imperative Assessment Nursing assessment Course of pregnancy depends on many factors See Box DEFINITION OF TERMS p Client profile Current pregnancy Past pregnancies Gynecological history Current medical history Past medical history Family medical history Religious spiritual and cultural history Occupational history Partners history Personal information about the woman social history Obtaining data Questionnaire Encourage expectant father or partner to attend prenatal visits Prenatal high-risk screening Many risk factors can be identified during initial assessment Physical examination Vital signs Clean urine specimen Nurse CNM other advance practice nurses complete physical assessment Nurse without advanced skills explain procedures vital signs position and assist Systematic approach See INITIAL PRENATAL ASSESSMENT pp Gestation calculator wheel estimated date of birth EDB quickly Ngele rule for calculating Uterine assessment Physical examination Uterine size compatible with menstrual history most important clinical method for dating pregnancy in first weeks of pregnancy Fundal height May be used as indicator of uterine size Less accurate late in pregnancy See Figure A CROSS-SECTIONAL VIEW OF FETAL POSITION WHEN THE MCDONALDS METHOD IS USED TO ASSESS THE FUNDAL HEIGHT p Assessment of fetal development Quickening Fetal heartbeat Ultrasound Assessment of pelvic adequacy clinical pelvimetry Assessment of pelvis to determine if size is adequate for vaginal birth Diagnostic tests Several tests used to detect hCG as well as to monitor safety of mother and child See Table SUMMARY OF SCREENING AND DIAGNOSTIC TESTS p Interventions and therapies Focused on teaching client appropriate self-care techniques especially protecting fetus relieving discomfort Independent Assessment to minimize complications and promote expected outcomes Prenatal education Programs provide important opportunities to share information about pregnancy childbirth enhance parents decision-making skills Content directed by overall goals of program Preconception Childbirth Vaginal birth after cesarean VBAC Siblings Familys culture may influence beliefs about practices surrounding many aspects of childbearing childrearing See FOCUS ON DIVERSITY AND CULTURE BELIEFS AND ATTITUDES ABOUT PREGNANCY p Medications Use of medications great concern Greatest potential for gross abnormalities in fetus occurs during first trimester of pregnancy U S Food and Drug Administration FDA following classification system for medications administered during pregnancy Category A no associated fetal risk few drugs Category B no risk no controlled studies in women penicillins Category C either no adequate animal human studies or animal studies show teratogenic risk but no studies in women any drugs Category D evidence of fetal risk exists but benefit of drug in certain situations thought to outweigh risks tetracycline vincristine lithium hydrochlorothiazide Category X demonstrated fetal risks outweigh any benefits System under revision Some medications known to have teratogenic effect in nd rd trimester Tetracycline Pregnant women should avoid all medication if possible Tobacco Smoking during pregnancy strong association with low-birth-weight infants Increased risk of preterm birth premature rupture of membranes fetal demise many others Increased risk of sudden infant death syndrome SIDS Relief of the common discomforts of pregnancy Nausea and vomiting Very common Exact cause of NVP unknown multifactorial Contact healthcare provider if she vomits more than once a day shows signs of dehydration Urinary frequency Occurs early in pregnancy and again in third trimester Maintain fluid intake at least mL per day Empty bladder frequently Backache More than experience backache during pregnancy Primarily due to exaggeration of lumbosacral curve that occurs as uterus enlarges and becomes heavier Pregnant woman advised to avoid bending over at waist bend from the knees Collaborative Interdisciplinary team to coordinate quality safe and evidence-based care Pharmacologic therapy Pregnant woman with chronic illness or disease discuss treatment during pregnancy with obstetrician and treating physician Of particular concern Respiratory or cardiac disease Diabetes mellitus HIV Case Study Part When Mrs Halleck returns to the clinic at weeks gestation she says I feel like I need to pee all the time Review The Concept of Reproduction Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Part After a month on bed rest Mrs Halleck is at the clinic for a weekly follow-up appointment Exemplar Antepartum Care Overview Moment woman finds out she is pregnant dramatic changes Expectant woman and family will have many questions especially if first pregnancy Promoting a healthy pregnancy Nurse can help promote maternal fetal well-being providing accurate information about health behaviors and issues that affect pregnancy childbirth Breast care Support of breasts important promote comfort retain breast shape prevent back strain Well-fitting bra Straps wide and do not stretch Cup holds all breast tissue comfortably Tucks other devices allow bra to expand accommodating enlarging chest circumference Supports nipple line approximately midway between elbow shoulder not pulled up in back by weight of breasts Cleanliness of breasts important especially as colostrum production begins Flat inverted nipples diagnosed during initial prenatal assessment Activity and rest Exercise during pregnancy maintain maternal fitness muscle tone Client can check with CNM or obstetrician strenuous sports Certain conditions contraindicate exercise Guidelines Even mild to moderate exercise is beneficial during pregnancy After first trimester avoid exercising in supine position Decreased oxygen available for aerobic exercise during pregnancy modify intensity of exercise based on symptoms As pregnancy progresses center of gravity changes avoid exercises in which loss of balance could pose risk Normal pregnancy requires additional kcal day To augment heat dissipation especially during first trimester comfortable loose clothing adequate hydration avoid prolonged overheating As result of cardiovascular changes heart rate not accurate indicator of intensity of exercise Suggest client wear supportive bra appropriate shoes Warning signs include pain decreased absent fetal movement difficulty walking dizziness Adequate rest important for physical and emotional health Sleeping more difficult during last trimester Exercises to prepare for childbirth Certain exercises help strengthen muscle tone in preparation for birth promote more rapid restoration of muscle tone after birth Pelvic tilt helps prevent reduce back strain as it strengthens abdominal muscles See Figure A B C D p Abdominal exercises Tightening abdominal muscles with each breath Partial sit-ups strengthen abdominal muscle tone Perineal exercises Kegel exercises strengthens pubococcygeus muscle increases elasticity See Figure KEGEL EXERCISES p Childbirth educators often tell woman to think of perineal muscles as an elevator Kegel exercises can be done at almost any time Inner thigh exercises assume cross-legged position when possible Sexual activity Couples usually have many questions concerns about sexual activity during pregnancy In past sexual activity avoided last weeks no medical reason to limit sexual activity See CLIENT TEACHING SEXUAL TEACHING DURING PREGNANCY p Expectant mother may experience changes in sexual desire and response Sexual desires of men also affected by many factors in pregnancy Expectant couple aware of changes normality of changes importance of communicating changes Dental care Proper dental hygiene important in pregnancy Nurse encourage pregnant woman to have dental checkup early in pregnancy Other self-care measures Immunizations Women of childbearing age aware of risks of receiving certain immunizations Attenuated live viruses should not be given in pregnancy Clothing Maternity clothes fuller lines as well as more fitted High-heeled shoes tend to aggravate back discomfort increase curvature of lower back Bathing Perspiration mucoid vaginal discharge increase during pregnancy Cultural norms Caution during tub baths vasodilation can cause woman to feel faint Employment Pregnant women with no complications can usually continue to work until they go into labor Fetotoxic hazards contact physician nurse about possible hazards Travel If medical pregnancy complications not present no restrictions on travel Travel by automobile fatiguing aggravating many discomforts of pregnancy As pregnancy progresses long-distance trips best by plane or train Complementary and alternative therapies Many pregnant elect to use CAM part of holistic approach to healthcare regimens Herbal products dietary supplements not regulated through U S FDA Should be avoided especially during first trimester Teratogenic substances Substances that adversely affect normal growth development of fetus teratogens Discuss all medications with obstetrician Relief of the common discomforts of pregnancy Common discomforts result from physiologic anatomical changes fairly specific to each trimester See Table - SELF-CARE MEASURES FOR COMMON DISCOMFORTS OF PREGNANCY p First trimester Fatigue presumptive sign of pregnancy Breast tenderness occurs early continues throughout pregnancy Increased vaginal discharge leukorrhea increased acidity encourages growth of Candida albicans Nasal stuffiness and epistaxis Edema of nasal mucosa stuffiness discharge obstruction Cool-air vaporizers normal saline nasal sprays Ptyalism rare discomfort bitter saliva produced Second and third trimesters Heartburn pyrosis regurgitation of acidic gastric contents into esophagus Liquid forms of low-sodium antacids often most effective in providing relief If severe not relieved by antacids antisecretory agent Ankle edema Most women experience ankle edema in last part of trimester increasing difficulty of venous return from lower extremities Varicose veins Result from weakening of walls of veins faulty functioning of valves Treatment by surgery injection not recommended during pregnancy Varicosities in vulva perineum may develop Flatulence Results from decreased GI motility leading to delayed emptying Hemorrhoids Varicosities of veins in lower rectum anus Some women not bothered until postpartum period Possible to relieve reinserting the hemorrhoid Report hardening tenderness Constipation Bowel sluggishness caused by increased progesterone steroid metabolism displacement of intestines oral iron supplements Leg cramps Painful spasms in gastrocnemius muscles often caused by extension of foot Client can achieve immediate relief of spasm by stretching Faintness May happen occasionally warm crowded areas Caused by changes in blood volume postural hypotension pooling of blood in dependent veins If pregnant woman begins to feel faint sit down lower head between knees Shortness of breath Occurs as uterus rises into abdomen pressure on diaphragm Considerable relief when lightening occurs last few weeks of pregnancy fetus and uterus move down in pelvis Difficulty sleeping Many physical factors Round ligament pain As uterus enlarges round ligaments stretch and hypertrophy Carpal tunnel syndrome Occurs in of pregnant women caused by compression of median nerve in carpal tunnel of wrist Alterations Complications can resume from many factors age parity blood type socioeconomic status psychological health preexisting chronic illness Prenatal substance abuse Motivating client to abstain Support through withdrawal and recovery Diabetes mellitus Client teaching Frequent monitoring Anemia Monitor for symptoms Promote nutrition HIV AIDS Transmission to fetus can be reduced Antiretroviral medications Most safe in pregnancy Cesarean birth abstaining from breastfeeding Heart disease Assess stress of pregnancy at all visits Vital signs activity level Factors increasing strain Asthma Promote oxygenation Teach client how to recognize signs of labor Premature birth higher in clients with asthma Prevent maternal exacerbations Inhaled albuterol for exacerbation Epilepsy Continue recommended medication Supplement with folic acid vitamin D Hyperthyroidism Focus on early identification and treatment Hypothyroidism Focus on early identification and treatment Teaching about importance of medication Weekly nonstress test NST recommended after weeks Multiple sclerosis MS Focus on promotion of rest and nutrition Rheumatoid arthritis Monitor for anemia Encourage rest range-of-motion exercises Client in remission May be advised to stop medications Systemic lupus erythematosus SLE Emotional support Often experience prenatal loss Monitoring fetal well-being Tuberculosis TB When isoniazid used in pregnancy Supplemental pyridoxine Extra rest limited contact with others if active TB inactive breastfeed care for infant TB active no direct contact with infant Until noninfectious Gestational onset Vaginal bleeding Monitor BP pulse frequently Observe for indicators of shock Count and weigh pads weeks or beyond assess fetal heart tones Prepare woman for IV therapy Prepare for examination Spontaneous abortion miscarriage Rarely reversed Focus on emotional support Preventing complications Discourage use of hot tubs Ectopic pregnancy Early identification emotional support Preventing complications Pain management Assess hCG levels Prepare client for surgery Provide reassurance re future pregnancy Gestational trophoblastic disease Teaching about screening Assess all for symptoms Follow quantitative hCG levels Hyperemesis gravidarum Assess hydration and nutritional status Administer IV fluids Total parenteral nutrition TPN may be administered Keep client away from food odors Hypertensive disorders Prevention Early identification Alloimmunization Administer RhoGAM at weeks If mother Rh and father Rh Immediately following spontaneous miscarriage Assess lab results for positive Coombs test If no RhoGAM ABO incompatibility Assess blood type Document for infant follow-up Herpes simplex virus Prepare mother for cesarean birth If active lesions present when labor starts Group B streptococcal infection Detection and early intervention Resolve before delivery Urinary tract infection UTI Signs to report for quick intervention Oral sulfonamides in last weeks of pregnancy Vulvovaginal candidiasis Teaching signs and symptoms Preventative measures Rapid recognition for quick treatment Syphilis Screening part of prenatal care Treat and eliminate before delivery Diagnostic testing to assess fetal well-being Tests to obtain accurate data about developing fetus Conditions that indicates pregnancy is at risk Maternal age less than or more than years Chronic maternal hypertension preeclampsia diabetes mellitus heart disease Presence of Rh alloimmunization Maternal history of unexplained stillbirth Suspected intrauterine growth restriction IUGR Pregnancy prolonged past weeks of gestation Multiple gestation Maternal history of preterm labor Previous cervical incompetence Maternal assessment of fetal activity Vigorous fetal activity provides reassurance of fetal well-being marked decrease in activity or cessation of movement may indicate possible fetal compromise or even death requires immediate follow up No standard of how many movements should occur within a specified time fewer than movements in a -hour period or significantly less than normal Fetuses make gross body movements of time Fetal tracking fetal movement record First movement felt around weeks Get stronger easier to detect Explain procedure for counting Daily record Counting at same time each day Approximately hour after meal Lie quietly in side-lying position When to contact provider Expectant mothers perception of fetal movements commitment to completing fetal movement count may vary See ALTERATIONS AND THERAPIES PREGNANCY p See CLIENT TEACHING MATERNAL ASSESSMENT OF FETAL ACTIVITY p Ultrasound Ultrasound testing intermittent ultrasonic waves transmitted by an alternating current to transducer applied to clients abdomen Advantages noninvasive painless nonradiating no known harmful effects to mother or fetus Four-dimensional ultrasound monitors live action Has limitations maternal body habits fetal positioning skill of sonographer Transabdominal ultrasound Transducer moved across clients abdomen full bladder Transmission gel spread over clients abdomen Takes minutes Transvaginal ultrasound Transducer probe inserted into vagina Procedure fully explained to client prepped in manner as for pelvic examination Benefits of ultrasound testing Early identification of pregnancy detection as early as fifth or sixth week after LMP Observation of fetal heartbeat fetal breathing movements as early as weeks of gestation Identification of more than one embryo or fetus Measurement of biparietal diameter BPD of fetal head fetal femur length to assess growth patterns Clinical estimations of birth weight Detection of fetal anomalies such anencephaly and hydrocephalus Examination of nuchal translucency in first trimester to assess for Down syndrome other fetal structure anomalies Examination of fetal cardiac structures Length of fetal nasal bone Identification of amniotic fluid index Location of placenta Placental grading Detection of fetal death Determination of fetal position and presentation Accompanying procedures amniocentesis chorionic villus sampling CVS Nonstress test NST evaluates fetal status used alone or part of biophysical profile Quick easy interpretation inexpensive Can be done in office clinic setting No known side effects Sometimes difficult to obtain suitable tracing Woman has to remain relatively still for at least minutes Procedure for NST Test can be done with client in reclining chair bed left tilted semi-Fowler or side-lying position Interpretation of NST results Reactive test Nonreactive test Unsatisfactory test Interpretation of decelerations CNM physician should be notified for further evaluation of fetal status Fetal acoustic and vibroacoustic stimulation tests Sound and vibration sound stimulate fetus as adjunct to NST Noninvasive Results rapidly available Time for NST shortened Biophysical profile Comprehensive assessment of five variables Fetal breathing Fetal movements Fetal tone Amniotic fluid volume Reactive fetal heart rate FHR with activity reactive NST First four variables assess by ultrasound See Table CRITERIA FOR BIOPHYSICAL PROFILE SCORING p Score of within normal limits Biophysical profile indicated when risk of placental insufficiency fetal compromise IUGR Maternal diabetes mellitus heart disease hypertension preeclampsia eclampsia sickle cell disease Suspected fetal postmaturity History of previous stillbirths Rh sensitization Abnormal estriol excretion Hyperthyroidism Renal disease Nonreactive NST Contraction stress test CST CST evaluating respiratory function of placenta Used where availability of other technology reduced Contraindicated in client with third-trimester bleeding premature rupture of the membranes incompetent cervix Critical component of CST presence of uterine contractions spontaneous or induced Electronic fetal monitor continuous data about FHR uterine contractions CST classification Negative desired result placenta functioning normally Positive not desired result pattern will most likely get worse with additional contractions Equivocal need more information Unsatisfactory quality of tracing poor Amniotic fluid analysis Amniocentesis obtaining amniotic fluid for genetic testing or fetal lung maturity Uses ultrasound guidance Quadruple screen serum test is only a screening amniocentesis accurate in diagnosing genetic abnormalities Newer penta screen covers quadruple screen and tests for ventral abdominal wall defects Fluid may be analyzed to determine maturity of lungs Lecithin sphingomyelin L S ratio Alveoli of lungs lined with surfactant in mature fetus Fetal lung maturity L S ratio two components of surfactant Phosphatidylglycerol PG Phospholipid in surfactant Appears when fetal lung maturity attained Chorionic villus sampling CVS CVS obtaining small sample of chorionic villi from developing placenta Performed between and weeks gestation Risks include failure to obtain tissue rupture of membranes leaking of amniotic fluid bleeding infection maternal tissue contamination of specimen Rh alloimmunization Cannot detect neural tube defects Maternal nutrition Nutritional status before during after pregnancy significantly influence mother and fetus health Several factors influence ability to achieve good prenatal nutrition General nutritional status before pregnancy Maternal age Maternal parity Fetal growth three overlapping stages nutritional problems that interfere with cell division permanent consequences Growth of fetal maternal tissues requires increased quantities of essential dietary components dietary reference intakes DRIs See Table DIETARY REFERENCE INTAKES DRIs FOR NONPREGNANT PREGNANT AND LACTATING FEMALES p See Table DAILY FOOD PLAN FOR PREGNANCY AND LACTATION p Factors influencing nutrition Environmental age lifestyle culture food beliefs availability economics symbolism Socioeconomic influences Families living at poverty level at risk for poor nutrition Cultural ethnic and religious influences Determine ones experiences with food influence food preferences and habits Certain foods have symbolic significance related to major life experience such as birth death Important for nurse to understand impact of cultural and spiritual beliefs Psychosocial influences Various factors influence food choices Knowledge about basic food components of balanced diet essential Expectant womans attitudes feelings about pregnancy influence nutritional status Eating disorders Women with eating disorders who become pregnant at risk for variety of complications Pregnancy difficult time for client with eating disorder even if a desired pregnancy Multidisciplinary approach education individualized meal plans Pica Craving for persistent eating of nonnutritive substances not ordinarily considered to be edible or nutritionally valuable clay soil soap Iron deficiency anemia most common concern in pica Assessment using nonjudgmental approach important part of nutritional history Vegetarianism Several types Lacto-ovovegetarians Lactovegetarians Vegans Pregnant vegetarian must eat proper combination of foods to obtain adequate nutrients Vegan diet careful planning to obtain complete proteins sufficient calories See Figure THE VEGETARIAN FOOD PYRAMID p Four servings of B -fortified foods daily Decreased mineral intake due to lack of animal products iron zinc calcium See Table VEGETARIAN FOOD GROUPS p Special dietary considerations Folic acid required for normal growth reproduction lactation and prevents macrocytic megaloblastic anemia of pregnancy Recommendations mcg folic acid daily Use of artificial sweeteners Generally recognized as safe GRAS aspartame within guidelines Splenda Truvia stevia safe Mercury in fish Omega- fatty acids in seafood essential for neural development in fetus Nearly all fish shellfish contain traces of mercury U S government guidelines Do not eat swordfish shark tilefish king mackerel Eat up to oz week of variety of shellfish and fish lower in mercury light tuna shrimp salmon catfish pollock Check local advisories about mercury content of fish caught by family and friends Lactase deficiency lactose intolerance Results from inadequate amount of enzyme lactase breaks down milk sugar lactose into smaller digestible substances Most adults of African Mexican Native American Ashkenazic Jewish Asian descent Even one glass of milk can produce symptoms Foodborne illnesses Risk to fetus and mother Salmonella raw eggs cake batter homemade eggnog sauces Listeriosis found in refrigerated ready-to-eat foods such as unpasteurized milk meat poultry seafood Maintain refrigerator temperature at F C or below and freezer at F - C Refrigerate or freeze prepared foods leftovers perishables within hours of preparation or eating Do not eat hot dogs deli meats luncheon meat unless reheated until steaming hot Avoid soft cheeses unless label clearly states they are made with pasteurized milk Do not eat refrigerated pts or meat spreads or foods that contain raw milk Avoid eating refrigerated smoked seafood unless it is in a cooked dish Hepatitis E Viral infection found most often in developing countries often more severe in pregnant women may lead to maternal death Prevent hepatitis E wash hands thoroughly after using bathroom changing diapers handling raw foods Nutritional care of the pregnant adolescent Nutritionally at risk variety of complex interrelated emotional social economic factors Estimates regarding nutrition needs of adolescents DRI for nonpregnant teenagers nutrient amounts recommended for all pregnant women More than years since menarche nutritional needs approaching those of pregnant adults In determining optimal weight gain for pregnant adolescent recommended weight gain for adult pregnancy that expected during postmenarchal year in which pregnancy occurs Specific nutrient concerns Caloric needs of pregnant adolescents vary widely satisfactory weight gain usually confirms adequate caloric intake Inadequate iron intake major concern with adolescent diet iron supplements indicated Calcium intake frequently a problem extra serving of dairy products Folic acid supplement recommended for all pregnant clients Inclusion of wide variety of foods helpful in obtaining adequate amounts of trace minerals fiber other vitamins Dietary patterns Healthy adolescents often have irregular eating patterns Assessment should consider eating pattern over time not single days intake Counseling issues Counseling about nutrition healthy eating practices important element of care that can be provided in community setting Pregnant teens understanding of nutrition influences her well-being that of child Maternal weight gain Important factors in fetal growth and infant birth weight Institute of Medicine IOM recommends weight gains in terms of optimum ranges Underweight woman kg lb Normal-weight woman kg lb Overweight woman kg lb Obese woman lb Pattern of weight gain important kg lb during first trimester kg lb per week during second and third trimesters Obesity major health problem increased risk for medical and pregnancy-related complications Maternal obesity implications for children See Figure IT IS IMPORTANT TO MONITOR A PREGNANT WOMANS WEIGHT OVER TIME p Long-term implications woman will retain weight following childbirth Nursing process Assessment Physical status Pregnancy Understanding of pregnancy changes that accompany it Couples attitudes expectations Health teaching needs Degree of support woman has available Womans knowledge of infant care Aspects of nutrition Ongoing assessment as pregnancy progresses Preparations Siblings Illnesses Medications Parenting ability assessment See SUBSEQUENT PRENATAL ASSESSMENT p Frequency of prenatal visits general guidelines Every weeks first weeks of gestation Every weeks until weeks of gestation Then every week until childbirth Assessing for previous pregnancies Previous miscarriage increased monitoring Gravida para in relation to pregnancies not number of fetuses Acronym for detailed system G number of pregnancies Gravida T number of Term infants born weeks gestation P number of Preterm infants born weeks weeks gestation A number of pregnancies ending in therapeutic or spontaneous Abortion L number of currently Living children Determining due date Estimated date of confinement EDC negative now EDB estimated date of birth LMP helpful Ngele rule First day of LMP months days EDB Gestation calculator even quicker Woman with menses every days fairly accurate If menses irregular not foolproof Diagnosis Deficient Knowledge related to self-care Deficient Fluid Volume secondary to vomiting hyperemesis gravidarum Decisional Conflict related to unexpected pregnancy Anxiety related to change in role deficient knowledge reaction of family members Imbalanced Nutrition may be Less Than Body requirements related to nausea and vomiting or More Than Body Requirements related to excessive caloric intake Readiness for Enhanced Parenting Readiness for Enhanced Family Processes Planning Woman will increase daily intake of calcium to DRI level Woman will articulate danger signs of pregnancy when to call doctors office or seek emergency care Woman will have opportunity to express concerns and ask questions Woman will articulate methods of self-care Woman with chronic condition will consult with obstetrician and treating physician during pregnancy Implementation Promote knowledge related to self-care Nurse sees woman once every weeks in first several months of pregnancy establish environment of comfort open communication Community services and education opportunities assist client in accessing services as needed Nurses share information written verbal Childbirth education classes Topics for teaching Self-care to promote positive outcomes Strategies to minimize discomforts of pregnancy Childbirth preparation classes Danger signs to report to provider Signs and symptoms of labor Evaluate readiness for enhanced family processes Nurse addresses needs of client her well-being intertwined with well-being of family unit Periodic prenatal examinations assess womans needs and status Care of the partner Assess support system is partner part of family structure Anticipatory guidance of partner necessary part of plan of care Culturally and personally acceptable to couple expectant parents class Assess intended degree of participation during labor and birth what to expect Care of siblings and other family members May include feelings of insecurity hostility Open communication between parents and children helps children master their feelings Cultural norms vary within cultures from generation to generation Monitor for altered family processes Risk of death declined advances in maternal health obstetric practice Birth rates for women between continued to rise Women over more likely to have chronic medical conditions Cesarean birth rate increased in women over age Risk of conceiving child with Down syndrome increases with age Additional concerns of expectant parents over age May feel socially isolated Response of couples with children vary greatly on whether pregnancy planned or unexpected Healthcare professionals may treat older expectant couple differently Increased risks social familial other healthcare concerns place many of these clients at risk for impaired family processes May require assistance in understanding how to integrate newborn into daily routines If couple has other children in teen preteen age children may be embarrassed by pregnancy fear being asked to contribute to newborns care Promote balanced nutrition Nurse gathers information Height and weight weight gain during pregnancy Pertinent laboratory values especially hemoglobin and hematocrit Clinical signs that have possible nutritional implications constipation anorexia heartburn Dietary history -hour recall Food frequency questionnaire Guidance about food purchasing and preparation Recommendations for calcium Plan with woman how to add more milk and dairy to diet Encourage use of other calcium sources such as leafy greens and legumes Plan for addition of powdered milk in cooking and baking Consider use of calcium supplements Identify anxiety concerns and promote strengths Nurse needs to discuss risks identify concerns promote strengths For couples who decide to have amniocentesis first few months of pregnancy difficult Provide information answer questions provide comfort and emotional support Evaluation Woman and her partner are knowledgeable about pregnancy and express confidence in ability to make appropriate healthcare choices Expectant couple and children if any are able to cope with pregnancy and implications for the future Woman receives effective health care throughout her pregnancy as well as during birth and postpartum period Woman and partner develop skills in child care and parenting Review Antepartum Care Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar Intrapartum Care Overview Mother and baby prepare for birth in final weeks of pregnancy Indications to call healthcare provider Rupture of membranes Regular frequent uterine contractions Any vaginal bleeding Decreased fetal movement Pregnant women and families increasingly seeking family-centered care Holistic Birthing rooms labor birth recovery and postpartum More relaxed than traditional hospital room Factors important to labor and birth Five factors important in labor and birth process Birth passage Fetus Relationship between passage and fetus Physiological forces of labor Psychosocial considerations See Box CRITICAL FACTORS IN LABOR p The birth passage True pelvis forms bony canal divided into sections inlet pelvic cavity outlet The fetus Fetal head least compressible largest part of fetus Three major parts face base of skull vault of cranium Cranial bones not fused overlap under pressure of labor unyielding pelvis molding Sutures of fetal skull are membranous spaces between cranial bones Intersections called fontanelles Frontal mitotic suture Sagittal suture Coronal suture Lambdoidal suture See Figure SUPERIOR VIEW OF THE FETAL SKULL p Anterior and posterior fontanelles useful in identifying position of fetal head in pelvis assessing status of newborn after birth Landmarks of fetal head Mentum Sinciput Bregma Vertex Posterior fontanelle Occiput See Figure LATERAL VIEW OF THE FETAL SKULL IDENTIFYING THE LANDMARKS THAT HAVE SIGNIFICANCE DURING BIRTH p Diameters of fetal skull vary considerably within normal limits Fetal attitude refers to relation of fetal parts to one another Fetal lie refers to relationship of cephalocaudal axis of fetus to cephalocaudal axis of woman Longitudinal Transverse Fetal presentation determined by fetal lie and body part of fetus that enters pelvic passage first Presenting part Malpresentation Fetal head presents itself of term births Vertex presentation smallest diameter of fetal head presents to maternal pelvis Military presentation top of head is presenting part Brow presentation fetal head partially extended largest anteroposterior diameter presented Face presentation fetal head hyperextended See Figure CEPHALIC PRESENTATION p Breech presentations of all births Sacrum is landmark to be noted Complete breech buttocks and feet present to maternal pelvis Frank breech buttocks of fetus present to maternal pelvis Footling breech feet foot of fetus present to maternal pelvis Transverse lie shoulder presenting part of all births Relationship between the passage and the fetus Engagement of presenting part when largest diameter of presenting part reaches or passes through pelvic inlet Determined by vaginal examinations and Leopold maneuvers Another variable of engagement relationship of fetal sagittal suture to the mothers symphysis pubis and sacrum Synclitism Asynclitism Station refers to relationship of presenting part to an imaginary line drawn between ischial spines of maternal pelvis See Figure MEASURING THE STATION OF THE FETAL HEAD WHILE IT IS DESCENDING p If presenting part higher than ischial spines negative number assigned Engagement fetal head reaches zero station is at pelvic inlet is at outlet During labor presenting part should move progressively from negative stations into positive stations Fetal position relationship between designated landmark on presenting fetal part and front sides back of maternal pelvis Landmark for vertex presentations occiput Landmark for face presentations mentum Landmark for breech presentations sacrum Landmark for shoulder presentations acromion process on the scapula To determine position nurse notes quadrant of maternal pelvis the appropriate landmark is directed toward R or L side of maternal pelvis O M S A landmark of presenting part A P T whether landmark is in front back or side of pelvis Used to help healthcare team communicate Assessment techniques include inspection palpation abdomen and vaginal examination See Figure CATEGORIES OF PRESENTATION p Physiological forces of labor Primary and secondary forces work together to achieve birth Contractions In labor uterine contractions rhythmic but intermittent Three phases to contraction Increment Acme Decrement Contractions described during labor frequency duration intensity Contractions increase in frequency intensity and duration as labor progresses involuntary muscle Bearing down Maternal abdominal muscles contract as woman pushes Psychosocial considerations Final critical factor parents readiness fears anxieties birth fantasies excitement level feelings of joy and anticipation level of social support Woman approaching first labor faces totally new experience woman who has given birth before knows it may be very different from previous experience Expectant women mentally prepare for labor action imaginary rehearsal Some women may fear pain of contractions others welcome opportunity to feel birth process Empowerment having control over ones body plays key role determining view of labor and birth as positive Laboring womans support system influences course of labor and birth How woman views birth experience in hindsight may affect mothering behaviors See Box FACTORS ASSOCIATED WITH A POSITIVE BIRTH EXPERIENCE p Physiology of Labor Possible causes of labor onset Process usually begins between weeks of gestation fetus mature and ready for birth Cause not clearly understood Myometrial activity True labor each contraction shortens muscles of upper uterine segment exert longitudinal traction on cervix causing effacement See Figure EFFACEMENT OF THE CERVIX IN THE PRIMIGRAVIDA p Contractions stimulated by hormone oxytocin Uterus elongates with each contraction decreasing horizontal diameter Muscular changes in the pelvic floor Levator ani muscle and fascia of pelvic floor draw rectum vagina upward and forward with each contraction along curve of pelvic floor Physiological anesthesia produced as result of decreased blood supply to area Premonitory signs of labor Lightening describes effects that occur when fetus begins to settle into pelvic inlet Increased downward pressure woman may notice Leg cramps pains caused by pressure on nerves Increased pelvic pressure Increased urinary frequency Increased venous stasis Increased vaginal secretions Braxton Hicks contractions may become uncomfortable more regular false labor Cervical changes Softening ripening collagen fibers loosen Bloody show pink tinged secretions when mucus plug is expelled Considered to be sign that labor will begin in hours Rupture of membranes of women at term before onset of labor Amniotic fluid may be expelled in large amounts If engagement has not occurred umbilical cord may wash out with fluid prolapsed cord Risk for infection with open pathway Notify physician CNM proceed to hospital birthing center Sudden burst of energy Some women report hours before labor Other signs Weight loss of lb fluid loss electrolyte shifts produced by changes in estrogen progesterone levels Diarrhea indigestion nausea vomiting just before onset of labor Differences between true and false labor Contractions of true labor produce progressive dilation and effacement of cervix regular increase in frequency duration intensity Contractions of false labor irregular no effacement and dilation may occur mainly in lower abdomen and groin Pregnant woman helpful to know characteristics of true labor premonitory signs See Table COMPARISON OF TRUE AND FALSE LABOR p Stages of labor and birth Theoretical separations First stage onset of true labor ends when cervix completely dilated at cm Second stage begins with complete dilation ends with birth of newborn Third stage begins at birth of newborn ends with delivery of placenta Some clinicians identify fourth stage hours after delivery of placenta uterus contracts to control bleeding at placental site See Table CHARACTERISTICS OF LABOR p First stage Latent phase starts with beginning of regular contractions Become established increase in frequency duration intensity Amniotic membranes bulge through cervix in shape of cone may rupture Amniotomy Active phase Anxiety and sense of need for energy and focus tend to increase Cervix dilates from to cm Fetal descent progressive Transition phase Last part of first stage of labor Woman may have acute awareness of need for energy and attention to be completely focused anxiety feel out of control Inner directed often tired Contractions every minutes seconds long strong intensity As dilation approaches cm increased rectal pressure desire to bear down increased amount of bloody show rupture of membranes Other characteristics of transition phase Hyperventilation Generalized discomfort Increased need for partners or nurses presence and support Restlessness Increased apprehension and irritability Inner focusing on her contractions Sense of bewilderment frustration anger at contractions Requests for medication Hiccupping belching nausea vomiting Beads of perspiration on upper lip or brow Increasing rectal pressure feeling urge to bear down Anxious to get it over with Second stage Begins with complete cervical dilation ends with birth of infant As fetal head descends woman usually has urge to push because of pressure of head on sacral and obturator nerves Perineum distends acute increasingly severe pain Crowning birth is imminent Woman may feel some relief that transition is over birth is near she can push Without childbirth preparation this stage can be frightening Spontaneous birth vertex presentation Fetal head distends vulva perineum becomes extremely thin anus stretches and protrudes See Figure THE BIRTH SEQUENCE p Positional changes of the fetus Fetal head and body must adjust to passage through birth canal cardinal movements Descent Flexion Internal rotation Extension Restitution External rotation Expulsion See Figure MECHANISMS OF LABOR p Third stage From birth of infant until completed delivery of placenta Placental separation After infant born uterus contracts firmly diminishing capacity and surface area of placental attachment Signs of placenta separation usually appear minutes after birth of infant Globular uterus Rise of fundus in the abdomen Sudden gush or trickle of blood Further protrusion of umbilical cord out of the vagina Placental delivery When signs of placental separation appear woman may bear down to aid in placental expulsion Considered to be retained if minutes have elapsed from completion of second stage of labor Placenta separates from inside to outer margins delivered with fetal shiny side presenting Schultze mechanism shiny Schultze Placenta separates from outer margins inward roll up present sideways with maternal surface delivered first Duncan mechanism dirty Duncan Fourth stage hours after birth physiological readjustment of mothers body begins Hemodynamic changes Uterus remains contracted in midline of abdomen Nausea vomiting usually cease may be thirsty hungry chilled Maternal systemic response to labor Cardiovascular system Stressed by contractions pain anxiety Increased cardiac output Maternal position affects cardiac output supine lateral position Blood pressure BP Increased cardiac output increased BP during contractions Respiratory system Oxygen demand consumption at onset of labor Hyperventilation may occur By end of first stage of labor mild metabolic acidosis compensated by respiratory alkalosis Changes in acidbase status quickly reverse in fourth stage Renal system During labor in maternal renin plasma renin activity angiotensinogen level Base of bladder pushed forward upward when engagement occurs Gastrointestinal system Gastric motility absorption of solid food reduced Immune system and other blood values WBC to cells mm during labor early postpartum difficult to identify presence of infection Maternal blood glucose decreases during labor glucose used as energy source during uterine contractions Pain Causes of pain during labor Pain associated with first stage of labor accompanies a normal physiological process Second stage of labor caused by hypoxia of contracting uterine muscle cells distention of vagina and perineum pressure on adjacent structures Third stage uterine contractions cervical dilation as placenta is expelled Factors affecting response to pain Many factors affect individuals perception response to pain Childbirth preparation classes may reduce need for analgesia during labor Cultural factors Influenced by fatigue sleep deprivation Previous experiences with pain anxiety level Attention and distraction influence perception of pain back rub can provide distraction refocus attention Fetal response to labor Heart rate Early FHR decelerations can occur as head pushes against cervix Acidbase status Blood flow decreased to fetus at peak of each contraction leads to slow decrease in pH Hemodynamic changes Adequate exchange of nutrients gases in fetal capillaries intervillous spaces depends on fetal blood pressure Reserves usually enough to ensure fetus comes through anoxic periods caused by contracting uterus unharmed Fetal sensation weeks gestation fetus able to experience sensations of light sound touch Alterations during intrapartum care Most births occur without need for operative obstetric intervention Women aware of possible need for procedure during labor and birth may feel disappointed angry guilty Cervical ripening Induction of labor may be necessary or beneficial Use of misoprostol Cytotec More effective than oxytocin or prostaglandin agents Less costly Associated with lower cesarean birthrates Use of prostaglandin agents Placed intracervically or intravaginally Reduced incidence of cesarean birth when used before labor induction Use of mechanical methods Balloon catheters Extra-amniotic saline infusion Nursing care during cervical ripening Maternal monitoring for vital signs uterine tachysystole Electronic fetal monitoring Labor induction Stimulation of uterine contractions before the spontaneous onset of labor with or without ruptured fetal membranes for purpose of accomplishing birth Indications Diabetes mellitus Renal disease Preeclampsia eclampsia Chronic pulmonary disease Premature of membranes Chorioamnionitis Postterm gestation greater than weeks Mild abruptio placentae without evidence of nonreassuring fetal status Intrauterine fetal demise Intrauterine fetal growth restriction Alloimmunization Oligohydramnios Nonreassuring fetal status Nonreassuring antepartum testing Relative indications Chronic hypertension SLE Gestational diabetes Hypercoagulation disorders Cholestasis of pregnancy Polyhydramnios Fetal anomalies requiring specialized neonatal care Logistical factors Previous stillbirth Postterm gestation greater than weeks Contraindications to spontaneous labor vaginal birth are contraindications to induction of labor Client refusal Placenta previa or vasa previa Transverse fetal lie Previous classical uterine incision Active genital herpes infection Umbilical cord prolapse Absolute cephalopelvic disproportion CPD Before induction attempted appropriate assessment must indicate woman and fetus ready for onset of labor Fetal maturity Cervical readiness Forceps-assisted birth Indications for use of forceps Presence of any condition that threatens the mother or fetus and that can be relieved by birth Risk factors Nulliparity Maternal age and over Maternal height less than cm ft in Pregnancy weight gain more than kg lb Postdate gestation weeks or more Epidural anesthesia Infant presentation other than occipitoanterior Presence of dystocia Presence of midline episiotomy Abnormal FHR tracing Neonatal and maternal risks Newborns Small area of ecchymosis and or edema along sides of face Caput succedaneum or cephalohematoma and transient facial paralysis Low Apgar score Retinal hemorrhage corneal abrasions ocular trauma Other trauma Elevated neonatal bilirubin levels Prolonged infant hospital stay Mothers Lacerations of the birth canal and periurethral lacerations Extensions of median episiotomy into the anus Postpartum perineal pain and sexual problems Increase in postpartum infections Prolonged hospital stay Urinary and rectal incontinence anal sphincter injury postpartum metritis Vacuum extraction Procedure to assist birth by applying suction to fetal head Neonatal complications include scalp lacerations bruising subgaleal hematomas cephalohematomas intracranial hemorrhages subconjunctival hemorrhages neonatal jaundice fractured clavicle Erb palsy damage to th and th cranial nerves retinal hemorrhage and fetal death Maternal complications include perineal trauma edema third- and fourth degree lacerations postpartum pain and infection and postpartum sexual difficulties Episiotomy Surgical incision of perineal body to enlarge the outlet Very common thought to decrease risks of lacerations may actually increase risks Other risks include blood loss infection pain perineal discomfort Increased risk for episiotomy Primigravid status Large macrosomic fetus Occiput-posterior position Use of forceps vacuum extractor Shoulder dystocia Use of lithotomy and other recumbent positions Encouraging or requiring sustained breath holding during second-stage pushing Arbitrary time limit placed by physician CNM on length of second stage Preventive measures Perineal massage during pregnancy for nulliparous women Natural pushing during labor avoiding lithotomy position pulling back on legs Side-lying position for pushing Warm or hot compresses on perineum firm counterpressure Encourage gradual expulsion of infant at time of birth by encouraging mother to push take a breath push take a breath Avoiding immediate pushing after epidural placement Episiotomy procedure Midline or mediolateral Usually performed with regional or local anesthesia may be done without anesthesia in emergency situations Repair of episiotomy any lacerations requires anesthesia Cesarean birth One of oldest known surgical procedures Rates differ dramatically in other parts of world worldwide women in urban areas times more likely to have cesarean compared to women in urban areas Increasing rate in U S linked to rise in repeat cesarean births risk of uterine rupture with a vaginal birth after cesarean Rise in number of nulliparous women requesting cesarean birth associated with increases in neonatal respiratory problems longer hospitalizations increased complications in subsequent pregnancies Many other factors Increased use of epidural anesthesia Maternal age over Failed labor inductions Decline in vaginal breech deliveries Reduced vaginal birth after cesarean birth rates Increased physician scheduling Policy statements encouraging cesarean birth Political pressure from malpractice insurance carriers Indications Commonly accepted indications include Complete placenta previa CPD Placental abruption Active genital herpes Umbilical cord prolapse Failure to progress in labor Nonreassuring fetal status Previous classical incision on uterus More than one previous cesarean birth Benign malignant tumors that obstruct birth canal Cervical cerclage Cardiac disorders Severe maternal respiratory disease CNS disorders that increase intracranial pressure Mechanical vaginal obstruction Severe mental illness that results in altered state of consciousness Other indications Breech presentation Major congenital anomalies Severe Rh alloimmunization Maternal mortality and morbidity Higher mortality rate than vaginal births associated with infection hypertensive disorders reaction to anesthesia blood clots bleeding problems Worldwide percentages vary Increased risks in subsequent pregnancies Skin incisions Transverse Pfannenstiel lowest narrowest part of abdomen Takes longer Vertical between navel and symphysis pubis Quick Uterine incisions Lower uterine segment transverse incision preferred Thinnest portion of uterus involves less blood loss Requires only moderate dissection of bladder from underlying myometrium Easier to repair although repair takes longer Site less likely to rupture during subsequent pregnancies Decreased chance for adherence of bowel or omentum to incision line Disadvantages Takes longer to make transverse incision Limited in size because of presence of major vessels on either side of uterus Greater tendency to extend laterally into the uterine vessels Incision may stretch become thin window Lower uterine segment vertical incision preferred for Multiple gestation Abnormal presentation Placenta previa Nonreassuring fetal status Preterm and macrosomic fetuses Disadvantages Incision may extend downward into cervix More extensive dissection of bladder needed to keep incision in lower uterine segment Vertical incision carries higher risk of rupture with subsequent labor Classic incision infrequent today Greater blood loss More difficult to repair Increased risk of uterine rupture with subsequent pregnancy labor birth Analgesia and anesthesia Advantages disadvantages risks side effects to each type Preparation for cesarean birth One in four births preparation for possibility integral part of all prenatal education Preferences of parent s Participating in choice of anesthetic Partner or significant other being present during procedures and or birth Partner or significant other being present in recovery or postpartum room Video recording and or taking pictures of the birth Delayed instillation of eyedrops to promote eye contact between parent and infant in first hours after birth Physical contact holding infant while in operating and or recovery room Breastfeeding in recovery area within first hour after birth Information couples need What preparatory procedures to expect Description or viewing of birthing room Types of anesthesia for birth analgesia available postpartum Sensations that may be experienced Roles of significant others Interaction with newborn Immediate recovery phase Postpartum phase Preparing woman and family for birth involves more than procedures communication therapeutic touch direct eye contact If not emergency nurse has time for teaching providing opportunity for woman to express concerns ask questions develop relationship NPO Epidural nurse assists with procedure IV with large-bore needle Preoperative medications Pediatrician notified Assist with positioning on operating table Fetal heart rate FHR monitoring Catheterization of bladder Provide reassurance describe procedures being performed Preparation for repeat cesarean birth Couple anticipating repeat cesarean birth general understanding of what will occur Provide all couples opportunity to discuss fears anxieties Preparation for emergency cesarean birth Nurses must use most effective communication skills in supporting couple Explain what is going to happen why what sensations woman may experience Supporting the partner Include and promote participation of partner in birth experience Stool beside womans head so partner can provide touch visual contact verbal reassurance Allow partner to be nearby to hear newborns first cry Encourage partner to carry or accompany infant to nursery Involve partner in postpartum care in recovery room If policies prohibit support person in operating room explain why is happening why when staff will return expected length of time for procedure Immediate postnatal recovery period Nurse assess Apgar score same initial assessment and identification procedures used for vaginal births Apgar scoring for each of following Heart rate Respiratory effort Muscle tone Reflex irritability Color Identification bands on infant mother support person before removing infant from operating room Assist parents with bonding en face position Assess mothers vital signs every minutes until stable every minutes for hour every minutes until discharged to postpartum unit Evaluate dressing and perineal pad every minutes for at least an hour Palpate fundus If general anesthesia positioned on side assisted to cough and deep breathe every hours for at least hours Vaginal birth after cesarean VBAC In cases of nonrecurring indications for cesarean American College of Obstetricians and Gynecologists ACOG guidelines considered for VBAC One previous cesarean birth low transverse uterine incision Clinically adequate pelvis requirement for VBAC A woman with two previous cesarean births who has also had a previous vaginal birth may attempt VBAC Must be possible to perform cesarean birth within minutes Adequate staff facilities readily available throughout active labor to perform cesarean birth if needed Classic or T uterine incision is contraindication to VBAC Most common risks Uterine scar separation uterine rupture Hysterectomy Surgical injuries Infant death Neurological complications Woman with successful VBAC lower incidences of infection less blood loss fewer blood transfusions shorter stays Close correlation between maternal weight and success for VBACs Nursing care of woman undergoing VBAC varies according to institutional protocols IV versus saline lock Fetal monitoring Supportive and comfort measures Intrapartum high-risk factors Number of alterations may occur during intrapartum period See ALTERATIONS AND THERAPIES Intrapartum p Nursing process Maternalnewborn nursing has kept pace with changing philosophy of childbirth Physiological and psychological events that occur during labor call for continual rapid adaptations by mother and fetus frequent accurate assessments crucial to progress of these adaptations Tools may provide more detailed information for assessment nurse monitors mother and baby Maternal assessment Client history screening for intrapartum risk factors Maternal and fetal vital signs immediately Prenatal records sent to labor and birthing unit before clients due date Admissions interview Name and age LMP EDB Attending physician CNM Personal data History of previous illnesses Problems in prenatal period Pregnancy data Method chosen for infant feeding Type of childbirth education or infant care classes Previous infant care experience Womans preferences regarding labor and birth Pediatrician family practice physician nurse practitioner Additional data Onset of labor status of amniotic membranes Review records for information regarding possibility of abuse or victimization by violence Intrapartum high-risk screening Integral part of assessing woman in labor Physical conditions socioeconomic and cultural variables mental illness posttraumatic stress disorder PTSD Smoking drug use consumption of alcohol during pregnancy Intrapartum physical and psychosociocultural assessment Physical examination admission ongoing care of client Psychosocial history psychotropic medications depressive symptoms Communication pattern between woman and support person Individualized nursing care when nurses know and honor values beliefs of laboring woman Ideas knowledge fantasies fears about childbearing See INTRAPARTUM ASSESSMENT FIRST STAGE OF LABOR p Assessing contractions Nurse must assess nature of the contractions and any accompanying pain Important to assess laboring womans perception of pain her description affect response to contractions documented Electronic monitoring of uterine contractions provides continuous data External electronic monitoring of contractions Portion of monitoring equipment called tocodynamometer toco positioned against fundus of uterus held in place with elastic belt External monitoring has several advantages continuous recording of frequency and duration of uterine contractions noninvasive Internal electronic monitoring of contractions Provides same data as well as accurate measurement of uterine contraction intensity Intrauterine pressure catheter inserted into uterine cavity Pressure within uterus in resting state during each contraction measured by small micropressure device located in tip of catheter Important for nurse to also evaluate womans labor status palpating intensity and resting tone of uterine fundus during contractions More accurate fetal tracing can cause vaginal bleeding fetal injury Cervical assessment Dilation and effacement evaluated directly by vaginal examination Fetal assessment Fetal position Inspection of womans abdomen Palpation of womans abdomen Vaginal examination to determine presenting part Ultrasound Auscultation of fetal heart rate Inspection Assess lie of fetus by noting whether uterus projects up and down longitudinal lie or left to right transverse lie Palpation Leopold maneuvers Systematic way to evaluate maternal abdomen Have woman empty bladder lie on back with knees bent feet on the bed Vaginal examination and ultrasound Vaginal examination palpate presenting part if cervix is dilated Ultrasound when fetal position cannot be determined Auscultation of fetal heart rate Handheld Doppler ultrasound used to auscultate FHR between during after contractions FHR heard most clearly at fetal back See Figure LOCATION OF FETAL HEART RATE IN RELATION TO THE MORE COMMONLY SEEN FETAL POSITIONS p After FHR located count for seconds multiply by Listen occasionally for full minute through just after contraction to detect abnormalities Intermittent auscultation found to be as effective as electronic method for fetal surveillance Electronic monitoring of fetal heart rate Produces continuous tracing of FHR allows many characteristics of FHR to be visually assessed Indications for electronic monitoring History of stillbirth at or more weeks of gestation Presence of a complication of pregnancy Induction of labor Preterm labor Decreased fetal movement Nonreassuring fetal status Meconium staining of amniotic fluid Trial of labor following a previous cesarean birth Maternal fever Placental problems Methods of electronic monitoring Usually accomplished by ultrasound Transducer placed on maternal abdomen See Figure ELECTRONIC FETAL MONITORING BY EXTERNALTECHNIQUE p Recent advances in technology have led to development of new ambulatory methods of external monitoring Internal monitoring requires internal spiral electrode women with internal monitoring cannot ambulate Membranes must be ruptured Cervix at least cm dilated See Figure TECHNIQUE FOR INTERNAL DIRECT FETAL MONITORING p FHR tracing on top of Figure internal monitoring Baseline fetal heart rate Average FHR rounded to increments of bpm observed during -min period of monitoring Normal FHR ranges from bpm Wandering baseline smooth meandering unsteady baseline in normal range without variability immediate interventions needed in order to enhance fetal oxygenation Fetal tachycardia sustained rate of bpm or above Causes of tachycardia Early fetal hypoxia Maternal fever Maternal dehydration Beta-sympathomimetic drugs Amnionitis Maternal hyperthyroidism Fetal anemia Tachydysrhythmias Ominous sign if accompanied by late decelerations severe variable decelerations decreased variability Fetal bradycardia rate of less than bpm during -minute period or longer Causes of fetal bradycardia include Late profound fetal hypoxia Maternal hypotension Prolonged umbilical cord compression Fetal arrhythmia Uterine hyperstimulation Abruptio placentae Uterine rupture Vagal stimulation in the second stage Congenital heart block Maternal hypothermia Arrhythmias and dysrhythmias Disturbances in FHR pattern not associated with abnormal electrical impulse formation or conduction in fetal cardiac tissue but related to structural abnormality or congenital heart disease Variability Baseline variability is measure of interplay between sympathetic parasympathetic nervous systems Amplitude of peak and trough in beats per minute defined as Absent Minimal Moderate Marked Reduced variability is best single predictor for determining fetal compromise Causes of decreased variability Hypoxia and acidosis Administration of drugs Fetal sleep cycle Fetus of less than weeks of gestation Fetal dysrhythmias Fetal anomalies affecting heart CNS or autonomic nervous system Previous neurological insult Tachycardia Causes of marked variability Early mild hypoxia Fetal stimulation or activity Fetal breathing movements Advancing gestational age Absent variability NOT associated with fetal sleep administration of drugs warning sign of nonreassuring fetal status Acceleration transient increases in FHR normally caused by fetal movement Decelerations periodic decreases in FHR from normal baseline Early deceleration associated with onset of uterine contraction Late deceleration associated with uteroplacental insufficiency resulting from decreased blood flow oxygen transfer to fetus through intervillous spaces Variable decelerations occur if umbilical cord becomes compressed reducing blood flow between placenta and fetus See Table GUIDELINES FOR MANAGEMENT OF VARIABLE LATE AND PROLONGED DECELERATION PATTERNS p Sinusoidal pattern appears similar to waveform absence of variability presence of smooth wavelike shape Deceleration also classified based on rate in which FHR leaves baseline Abrupt decelerations Variable decelerations Gradual decelerations Episodic decelerations Periodic decelerations Prolonged decelerations Evaluation of fetal heart rate tracings Systematic approach to evaluating FHR tracings accurate and rapid assessment Begins by looking at uterine contraction pattern Determine uterine resting tone Assess contractions Evaluate FHR tracing Determine baseline Determine FHR variability Determine if sinusoidal pattern is present Determine if there are periodic changes After evaluating nurse determines if tracing is reassuring Baseline bpm Variability is present Variability is at least two cycles per minute Nonreassuring Severe variable decelerations Late decelerations of any magnitude Absence of variability Prolonged deceleration Severe bradycardia Provide information to laboring woman about FHR pattern and interventions Responses to electronic monitoring by client can be varied and complex Cord blood analysis at birth When significant FHR patterns noted analyzed immediately following birth Cord clamped before infant takes first breath Third hemostat used to clamp in portion of umbilical cord small amount of blood aspirated with syringe from one of umbilical arteries Diagnosis First stage of labor Fear Anxiety related to discomfort of labor and unknown labor outcome Acute Pain related to uterine contractions cervical dilation fetal descent Readiness for Enhanced Childbearing Process related to the normal labor process and comfort measures Second and third stages of labor Acute Pain related to uterine contractions the birth process and or perineal trauma from birth Readiness for Enhanced Childbearing Process related to pushing methods to assist in the birth Fear Anxiety related to the outcome of the birth process Fourth stage of labor Acute Pain related to perineal trauma Readiness for Enhanced Childbearing Process related to the involution process and self-care needs Readiness for Enhanced Family Processes related to incorporation of the newborn into the family Planning Nurse can develop a general plan that encompasses total process or for each stage of labor and birth Implementation Client and partner support person tend to be concerned about arriving at birth center in time for birth See CLIENT TEACHING WHAT TO EXPECT DURING LABOR p Integrate cultural beliefs Knowledge of values customs practices important to provide high-quality care Modesty Important for most women regardless of culture Middle East uncomfortable when men present Orthodox Jewish women follow law of Tznuit requires modesty in order to preserve dignity Expression and meaning of pain Some women turn inward others vocal Asian cultures act in way that will not bring shame to family may not express pain outwardly Cultures have differing beliefs about meaning and value of labor pain See FOCUS ON DIVERSITY AND CULTURE CHILDBIRTH CUSTOMS p Provide nursing care on admission Manner in which maternity nurse greets laboring woman and partner influences course of womans stay in hospital Nurse escorts client support person to birthing room quick thorough orientation to facility Nurse helps woman undress get into hospital gown start to develop rapport begin assessment process Laboring women often face unfamiliar procedures that may seem routine for healthcare providers Laboring families have specific expectations of labor and birth experience of themselves of nurse of physician CNM Some families want nurse present at all times others desire privacy want to spend time alone If indicated assist client into bed Intrapartum assessment effective nursing decisions including Should ambulation bed rest combination be encouraged Is more frequent or continuous electronic fetal monitoring needed What preferences does the woman have for her labor and birth Is support person available What special needs do this woman and her partner have Nurse auscultates FHR clients vital signs contractions Informs client about vaginal examination procedure obtains consent conveys findings If signs of advanced labor vaginal examination must be done immediately upon admission Results of FHR assessment uterine contraction evaluation vaginal examination help determine whether admission proceeds leisurely or additional interventions are required Admission process includes collection of clean voided midstream urine specimen Nurse may dipstick test urine ketones protein glucose before sending to lab Lab tests hemoglobin hematocrit type and crossmatch platelet count Nurse notifies healthcare provider with report Parity Cervical dilation and effacement Station Presenting part Status of the membranes Contraction pattern FHR Vital signs that are not in normal range Significant prenatal history Womans birth preferences Womans reactions to labor Womans preferences for pain relief Enters admission note into computer or charting system Provide nursing care during first stage of labor Nurse evaluates physical parameters of woman and fetus Palpate uterus for frequency intensity duration every minutes FHR every minutes for low-risk women Latent phase Clear liquids ice chips at frequent intervals Volume of liquid less important than presence of particulate matter Active phase Contractions every minutes seconds moderate to strong intensity palpate every minutes Vaginal exams to assess dilation effacement station position limited because they introduce bacteria FHR auscultated evaluated every minutes for low-risk women maternal vital signs during FHR assessment Woman encouraged to void full bladder can interfere with fetal descent Amniotic membranes may rupture during this phase Note amount color odor consistency immediately auscultate FHR Drop in FHR may indicate undetected prolapsed cord Transition phase Contractions every minutes seconds strong dilation increases from to cm Palpate contractions at least every minutes FHR monitored every minutes for low-risk women maternal vital signs at same time Comfort measures important continual assessment to ensure appropriate intervention Some women have difficulty coping need help with breathing Encourage pant-blow breathing prevent involuntary pushing help prevent cervical edema Voice may change at end of transition beginning of second stage deeper more guttural quality Promotion of comfort Nurse identifies factors that may contribute to discomfort for laboring woman Many types of responses to pain Most frequent physiological manifestations of pain increased pulse respiratory rate dilated pupils increased blood pressure muscle tension Woman generally wants touching massage effleurage other forms of physical contact during first part of labor moves into transition may pull away General comfort Encourage to ambulate as long as no contraindications Upright positions can enhance comfort Side lying generally most advantageous If woman comfortable on back elevate head of bed to relieve pressure of uterus on vena cava Wearing socks may alleviate cold feet Diaphoresis amniotic fluid can dampen gown linen fresh linen absorbent underpads Empty bladder at intervals Encourage family members to maintain own comfort Handling anxiety Anxiety related to combination of factors may enhance or interfere with ability to deal with pain Give information establish rapport Stay with woman praise and encouragement for breathing relaxation and pushing efforts Client teaching Provide truthful information about nature of discomfort that will occur during labor Descriptions of sensations best accompanied by information on specific comfort measures Thorough orientation explanation of surroundings procedures equipment being used decreases anxiety reduces pain Labor and childbirth may be critical time for woman with history of childhood sexual abuse or rape evaluate on admission for history of sexual abuse rape Supportive relaxation techniques Tense muscles increase resistance to descent of fetus contribute to maternal fatigue Encourage laboring woman to rest relax between contractions Distraction activities focal points Touch hands effleurage massage Analgesics regional anesthetic blocks may be used to enhance comfort relaxation during labor Breathing techniques Patterned-paced breathing three levels Each starts with cleansing breath First slow deep breathing breaths per minute Second shallow modified-paced breathing four breaths every seconds Third pantblow similar to modified-paced except breathing punctuated every few breaths by forceful exhalation through pursed lips Abdominal breathing woman moves abdominal wall outward as she inhales inward as she exhales Hyperventilation result of imbalance of oxygen and CO too much CO exhaled too much oxygen remains in body Occurs with rapid breathing over prolonged period encourage woman to slow breathing rate take shallow breaths Role of the doula Role is to enhance laboring womans comfort decrease anxiety Advocate for woman family asset to labor nurse Provide nursing care during the second stage of labor Second stage reached when cervix completely dilated Contractions continue maternal pulse assessed BP assessed at least every minutes FHR every minutes in low-risk women Nurse remains with woman continually Woman pushes during second stage low-pitched grunting May be afraid to push support reassurance clear directions May feel intense rectal pressure urge to bear down Spontaneous pushing or forceful sustained pushing See EVIDENCE-BASED PRACTICE PASSIVE DESCENT VERSUS ACTIVE PUSHING IN WOMEN WITH EPIDURAL ANESTHESIA p Nullipara prepared for birth when perineal bulging noted Multipara may be prepared for birth when cervix dilated cm Nurse monitors womans BP and FHR between contractions Palpates contractions at least every minutes until birth Continually assesses level of pain ability to cope Promotion of comfort Comfort measures during first stage remain appropriate during second stage Encourage rest between contractions assist into comfortable position Assisting during birth Assists woman family healthcare provider in preparing for birth Birthing room or delivery room prepared with equipment materials needed typically in prepackaged kit If in surgical suite family dons scrubs Thorough hand washing of everyone If giving birth in other room moved shortly before birth between contractions Family can still be together during birth nurse provides clear simple directions to help support person participate throughout process Maternal birthing positions Upright considered normal until modern times squatting kneeling standing sitting Evidence-based practice research squatting position results in fewer instrumental deliveries fewer episiotomy extensions less perineal tearing compared to lithotomic positions Woman may be positioned for birth on bed leg supports squatting position on hands and knees Pad stirrups adjust to fit womans legs Cleansing the perineum After positioning for birth vulvar perineal area cleansed to increase comfort prevent infection Supporting the couple Womans partner and nurse continue to provide support during contractions As head emerges shallow breaths pant to prevent pushing Physician CNM assess for nuchal cord then suctions mouth nose with bulb syringe mouth first Provide nursing care during the third stage of labor Focuses on initial care of newborn enhancing attachment assisting with delivery of placenta providing care for mother Placental delivery Signs of placental separation Uterus rises upward in the abdomen As placenta moves downward umbilical cord lengthens Sudden trickle or spurt of blood appears Shape of uterus changes from disc to globe Nurse palpates for bogginess fullness uterine relaxation bleeding into uterine cavity Oxytocics frequently given at time of delivery of placenta uterus will contract bleeding minimized Oxytocin Pitocin Methylergonovine maleate Methergine Carboprost tromethamine Hemabate Cytotec After delivery of placenta physician CNM inspects placental membranes to make sure they are intact all cotyledons present Nurse notes in birth record time of delivery of placenta Provide nursing care during the fourth stage of labor Vagina cervix perineum inspected for lacerations healthcare provider makes repairs Nurse assesses uterus for firmness palpate fundus normal position midline below umbilicus Nurse massages fundus until firm exerts firm pressure on fundus in attempt to express retained clots Uterus very tender perform palpation and massage gently Wash perineum with gauze squares warmed solution dry peripad Ice pack may be placed against perineum to promote comfort decrease swelling Remove legs from stirrups Monitor woman closely hours Inspect perineum Vital signs See Table MATERNAL ADAPTATIONS FOLLOWING BIRTH p Assess mothers pain level Inspect bloody vaginal discharge for amount chart as minimal moderate heavy with or without clots Lochia rubra Peripad soaked within minutes blood pools under buttocks continuous observation If fundus rises displaces to right may indicate increased bleeding bladder distention Palpate bladder take measures to enable mother to void Couple may be tired hungry thirsty Transferred from birthing unit to postpartum or mother baby area after or more hours policy and criteria Stable vital signs Stable bleeding Undistended bladder Firm fundus Sensations fully recovered from any anesthetic agent received during birth For some women painful powerless experience risk for developing PTSD Supporting the adolescent during birth Nurse must assess what each teen brings to experience Has young woman received prenatal care What are her attitudes and feelings about pregnancy Who will attend birth and what is each individuals relationship to her What preparation has she had for the experience What are her expectations and fears regarding labor and birth How has her culture influenced her What are her usual coping mechanisms Does she plan to keep the newborn Any adolescent who has not had prenatal care requires close observation Support role of nurse depends on young womans support system during labor If support person accompanies adolescent that person needs nurses encouragement and support Adolescent who has taken childbirth education classes generally better prepared for labor than one who has not Adolescents need ongoing education throughout labor early postpartum period If relinquishing newborn still given option of seeing holding infant Individualized care for issues they face in postpartum period Evaluation Determine effectiveness of nursing care Mothers physical and psychological well-being has been maintained and supported Babys physical and psychological well-being has been protected and supported Woman family members have had input into birth process participated as much as desired Mother and her baby have had a safe birth Review Intrapartum Care Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Exemplar Postpartum Care Overview During puerperium woman readjusts physically and psychologically from pregnancy and birth birth to approximately weeks Physical adaptations Womans body changes as it begins to return to nonpregnant state Reproductive system Involution rapid reduction in size of uterus return of uterus to nonpregnant state Bleeding controlled by compression of retracted uterine muscle fibers Placenta site heals by process of exfoliation and growth of endometrial tissue gradually over weeks Dramatic decrease in levels of circulating estrogen and progesterone following placental separation uterine cells atrophy hyperplasia of pregnancy begins to reverse Fundus situated in midline midway between symphysis pubis umbilicus contracts to size of large grapefruit immediately following expulsion of placenta A fundus that is above umbilicus and is boggy associated with excessive uterine bleeding uterine atony When fundus higher than expected and not in midline usually to right distention of bladder suspected Bladder should be emptied immediately After birth top of fundus remains at level of umbilicus for about half a day descends approximately cm per day until into the pelvis on about th day If breastfeeding release of endogenous oxytocin in response to suckling hastens involution of uterus Uterus approaches prepregnant size location by weeks barring infection Afterpains common in multiparas uterus alternates contraction relaxation Often increased with breastfeeding Lochia Discharge from uterus as it rids itself of debris remaining after birth Lochia rubra dark red first days after birth may contain small clots Lochia serosa pinkish color day serous some red blood cells mucus Lochia alba day creamy or yellowish discharge leukocytes Lochia patterns vary trend should be toward lighter color and lighter flow Musty stale odor not offensive Total volume approximately mL Greater volume in morning pooling of secretions Evaluation of lochia determine hemorrhage assess uterine involution Continuous seepage of blood more consistent with cervical or vaginal lacerations diagnosed when evaluated in conjunction with uterine consistency Cervical changes Following birth flabby formless may appear bruised Admits fingertips for a few days only fingertip by end of st week First childbearing permanently changes shape of external os Vaginal changes Appears edematous may be bruised following birth quickly disappears Size of vagina decreases rugae return within weeks Hypoestrogenic state if breastfeeding may lead to dyspareunia reduce with addition of water-soluble personal lubricant Tone and contractility of vaginal orifice may be improved by perineal tightening exercises Kegel exercises Perineal changes Soft tissue may appear edematous with some bruising Episiotomy laceration edges should be together Heals weeks after birth Ovulation and menstruation Varies for each postpartum woman generally returns weeks after birth in nonbreastfeeding mother Return of ovulation days after birth longer in breastfeeding women Exclusive breastfeeding helps reduce risk of pregnancy for first months only temporary Abdomen Uterine ligaments stretched require length of puerperium to recover Diastasis recti abdominis may occur with pregnancy responds to exercise Striae stretching and rupture of elastic fibers of skin take on different colors based on mothers skin color Breasts and lactogenesis During pregnancy increased levels of estrogen stimulate breast duct proliferation development Levels of progesterone promote development of lobules and alveoli in preparation for pregnancy Once placenta expelled progesterone levels fall inhibition of lactation removed triggers milk production Initially lactation under endocrine control Milk that flows from breast at start of feeding pumping session foremilk high in protein low in fat Letdown reflex hindmilk rich in fat calories months of breastfeeding prolactin levels low milk production continues feedback inhibitor of lactation Number of factors can delay impair lactogenesis maternal factors other factors Stages of human milk Colostrum initial milk that begins to be secreted during midpregnancy immediately available to baby at birth thick creamy yellowish Between day and day maternal milk production noticeably more abundant transitional milk qualities intermediate to colostrum and mature milk Mature milk white or slightly blue tinged present by weeks postpartum Gastrointestinal system Following birth mother may be hungry often very thirsty Bowels tend to be sluggish following birth Woman with cesarean birth clear liquids shortly after surgery advance once bowel sounds are present Urinary system Increased bladder capacity swelling and bruising of tissue around urethra decreased sensitivity to fluid pressure decreased sensation of bladder filling Urinary output increases during early postpartum period postpartum diuresis If urine stasis exists chance for UTI increases Vital signs Should be afebrile except first hours after birth Immediately following childbirth transient rise in both systolic diastolic blood pressure Puerperal bradycardia of bpm common first days postpartum May experience intense tremors immediately after birth if not followed by fever chill is of no clinical concern Blood values Blood values should return to prepregnant state by end of postpartum period Nonpathological leukocytosis often occurs during labor immediate postpartum period Hemoglobin and hematocrit difficult to interpret during first days after birth changing blood volume Platelet levels typically fall as result of placental separation Cardiovascular changes Dramatic changes during birth then cardiac output stabilizes Diuresis first days Neurological and immunological changes Neurological problems disorders can predispose women to higher rates of morbidity and mortality Headaches Seizure more likely during labor first hours after birth Psychological adaptations Postpartum period readjustment adaptation for family especially mother Nurse plays key role in assessing facilitating maternalinfant bond Ongoing assessment critical Nutrition Initial weight loss approximately lb occurs as result of birth expulsion of placenta amniotic fluid Nutritional needs change following childbirth Postpartum nutritional status Determined primarily by assessing mothers weight hemoglobin and hematocrit clinical signs dietary history Amount of weight gained major determinant of weight loss after childbirth Mothers weight should be considered in terms of ideal prepregnancy weights and weight gain during pregnancy Hemoglobin erythrocyte levels within normal levels weeks after childbirth Nurse assesses clinical symptoms Nurse obtains specific information on dietary intake eating habits from woman Nurse informs dietitian cultural religious beliefs that require specific foods Risk for obesity during childbearing years promote effective weight management Nutritional care of formula-feeding mothers After birth mothers dietary requirements return to prepregnancy levels Nutrition teaching as necessary will eventually be reflected in diet of child Referral to dietitian if excessive weight gain wishes to lose weight Teaching about infants nutritional needs Nutritional care of breastfeeding mothers Nutritional needs of mother increase during breastfeeding Especially important for breastfeeding mother to consume sufficient calories inadequate caloric intake can reduce milk volume Protein intake of g day recommended Calcium requirements remain same as those during pregnancy Iron needs not substantially different from those of nonpregnant women Liquids important during lactation inadequate fluid intake may decrease milk volume Discussion of specific foods and breastfeeding may cause infant to be colicky develop skin rash Alterations See Table POSTPARTUM HIGH-RISK FACTORS p Preeclampsia Increased need for bed rest thrombophlebitis Diabetes Need for insulin regulation Decreased healing Cardiac disease Maternal exhaustion Cesarean birth Increased healing needs pain risk for infection Overdistention of uterus increases risk of Hemorrhage Thrombophlebitis anemia breastfeeding problems Stretching of abdominal muscles afterpains Abruptio placentae placenta previa Hemorrhage anemia Decreased uterine contractility after birth Precipitous labor Increased risk of lacerations Prolonged labor Exhaustion Increased risk of hemorrhage Nutritional and fluid depletion Bladder atony trauma Difficult birth Exhaustion Risk of lacerations hematomas hemorrhage Extended period of time in stirrups Increased risk of thrombophlebitis Retained placenta Increased risk of hemorrhage Increased risk of infections Nursing process Several physical and developmental tasks Restore physical condition Develop competence in caring for meeting needs of infant Establish relationship with new child Adapt to altered lifestyles family structure resulting from addition of new member Assessment Select time that will provide most accurate data Explain purpose Ensure woman is relaxed Document Prevent exposure to body fluids Physical assessment teaching at same time See POSTPARTUM ASSESSMENT FIRST HOURS AFTER BIRTH p Vital signs BP Baseline during pregnancy Pulse bpm RR breaths per minute Temperature C F Breasts Inspection Reddened may indicate mastitis Breasts Palpation Soft filling full engorged Palpable mass engorgement tenderness heat Nipples Supple pigmented intact erect w stimulation Fissures cracks soreness inverted Lungs Clear to bases bilaterally Abdomen Musculature Abdomen soft doughy texture Separation in musculature Fundus Firm midline following involution process Boggy May be tender when palpated Constant tenderness may indicate infection Cesarean section incision Dry and intact Moderate to large amount of blood drainage Lochia Scant to moderate amount Earthy odor no clots Large amount clots hemorrhage Foul-smelling lochia infection Normal progression Days rubra Days serosa Perineum Slight edema bruising Marked fullness bruising pain hematoma Episiotomy No redness edema ecchymosis discharge Edges well approximated Redness edema ecchymosis discharge Gaping stitches Hemorrhoids None or small nontender Full tender inflamed Costovertebral angle CVA tenderness None Present kidney infection Lower extremities No pain with palpation Positive findings thrombophlebitis Elimination Voiding sufficient quantities every to hours Inability to void urgency frequency dysuria Bowel elimination Normal bowel movement by second third day Inability to pass feces Cultural assessment Determine customs practices Foods liquids preferred Privacy with breastfeeding Psychological assessment Integral part of postpartum evaluation Clues indicating adjustment difficulties include Excessive continued fatigue Marked depression Excessive preoccupation with physical status discomfort Evidence of low self-esteem Lack of support systems Marital problems Inability to care for nurture newborn Current family crisis illness unemployment Attachment Is mother attracted to newborn Is mother inclined to nurture her infant Does mother act consistently Is womans mothering consistently carried out Is mother sensitive to newborns needs as they arise Does woman seem pleased with babys appearance and sex Are there any cultural factors that might modify the mothers response Is there a problem in attachment If so what is the problem What is its source Psychological Assessment Focus on mothers general attitude competence support systems caregiving skills Postpartum Psychological Adaptations Psychological assessment high-risk factors Excessive continued fatigue Marked depression Excessive preoccupation with physical status or discomfort Evidence of low self-esteem Lack of support systems Marital problems Inability to care for or nurture the newborn Current family crises Assessment of early attachment Observe and note progress toward attachment Is there a problem in attachment What is the problem What is the source Diagnosis Impaired Urinary Elimination Ineffective Breastfeeding Constipation Acute Pain Deficient Knowledge related to information about infant care Anxiety Readiness for Enhanced Family Coping Planning Goals may include Mother demonstrates bonding with infant as evidenced by en face position Mother meets infants needs as they arise Implementation Promote client teaching Individualized teaching to meet educational needs of new mother and family Assess learning needs Teaching during postpartum period continuous process identify learning opportunities with each interaction Nurses need to consider physical psychosocial needs when conducting postpartum teaching When performing teaching sessions partners schedule must also be considered Postpartum units use a variety of instructional methods handouts formal classes videotapes individual interaction Teaching content information on role changes psychological adjustments skills Following discharge services available in community to meet needs of postpartum family Home health care important form of community-based nursing Promote comfort and well-being Monitor uterine status vital signs cardiovascular status elimination patterns nutritional needs sleep and rest learning needs Important to ask woman if she believes any special measures will be particularly effective offer choices Many nursing interventions available Ice to episiotomy Sitz bath Topical anesthetics Rectal suppositories ointments witch hazel pads for hemorrhoid pain Encourage fluid intake Afterpains lie prone with small pillow under lower abdomen Enhance attachment Evidence indicates first few hours after birth important period for attachment of mother and infant If contact can occur during first hour after birth newborn will be in quiet state able to interact with parents First contact may be brief followed by more extended contact Darkening birthing room causes newborns to open eyes gaze around Encourage both parents to do whatever they are comfortable doing Discuss suppression of lactation For woman who chooses not to breastfeed suppress by mechanical inhibition Supportive well-fitting bra within hours of birth Ice packs over axillary area of each breast Advise woman to avoid stimulation of breasts until sensation of fullness has passed Relieve emotional stress Birth of child time of emotional stress emotionally labile New mother adjusts to loss of fantasized child accepts child she actually has Depression weepiness often a surprise to new mother reassurance that feelings are normal Promote rest Energy needed to make psychological adjustments to new infant assume new roles Physical fatigue can affect other adjustments functions of new mother as well Most mothers view postpartum period as a time for recuperation Cultural norms may vary Higher risk for specific groups Mothers of multiples Mothers with infants who are still hospitalized Mothers of infants with birth defects special needs Mothers who lack social familial support Mothers who return to work before the advised -week period Mothers who have been on extended bed rest during pregnancy Discuss sexual activity and contraception Typically postpartum couples resume sexual intercourse once episiotomy is healed lochia flow has stopped Vaginal vault may be dry estrogen deficit water-soluble lubrication Milk may spurt from nipples during orgasm Babys crying may spoil the mood Anticipatory guidance couple forewarned of potential temporary problems Information on contraception should be provided as part of discharge teaching Promote well-being after cesarean birth Most women ambulating day after surgery discharged by third day after birth Chance of pulmonary infection increased immobility uses of narcotics encourage cough and deep breathing Encourage leg exercises every hours Most complications due to prolonged bed rest Nurse monitors manages pain experience Administer analgesics as needed Promote comfort through proper position frequent changes of position massage back rubs oral care reduction of noxious stimuli Encourage visits by significant others Encourage use of breathing realization guided imagery distraction techniques taught in childbirth preparation class Epidural analgesia effective method of pain relief for most women in first hours following birth Continuous epidural infusion administered via electric pump through epidural catheter left in place Both continuous epidural infusion client-controlled analgesia help woman feel greater sense of control Continuous peripheral nerve block rarely used Use of general anesthesia declining Additional assessments in immediate postpartum period Abdominal distention leg exercises abdominal tightening ambulation avoiding carbonated beverages Nonsteroidal anti-inflammatory drugs NSAIDs Assist with decreasing inflammation Nurse assesses for other discomforts minimize discomfort promote satisfaction as mother assumes activities of new role Other measures aimed at needs that are unique to woman who has had an operative birth Assessing for return of bowel sounds in all four quadrants every hours Assessing IV site flow rate patency of intravenous tubing Monitor condition of surgical dressing or incision using REEDA scale Provide postpartum care of the adolescent Adolescent mother may have special postpartum needs Contraception counseling important part of teaching adolescent mother Nurse has many opportunities for teaching adolescent about her newborn in postpartum unit Adolescent mother appreciates positive feedback about her newborn and her developing maternal responses Group classes for adolescent mothers should include information about infant care skills Teenage mothers should visit adolescent clinics for assessment of self newborn for several years after birth Provide care for the woman who relinquishes her infant Women who choose to give their infants up for adoption typically single White never-married adolescents Increasingly mothers forced to relinquish infants because of lifestyle choices Infant safe haven acts provide means for mother to place baby for adoption anonymously Surrogacy relinquishment agreements Mother who chooses to let child be adopted usually experiences intense ambivalence After birth mother should have access to baby Postpartum nursing care also includes arranging ongoing care for relinquishing mother Evaluation Mother is reasonably comfortable has learned pain relief measures Mother is rested understands how to add more activity over next few days and weeks Mothers physiological and psychological well-being have been supported Mother verbalizes her understanding of self-care measures New parents demonstrate how to care for baby New parents have had opportunities to form attachment with their baby New parents have information access to community resources Review Postpartum Care Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Ready Go to Nursing Student Resources Reflect Case Study Exemplar Newborn Care Overview Newborn period birth through th day of life Adaptations to extrauterine life First few hours of life neonatal transition Respiratory and cardiac systems undergo the most dramatic changes within minutes after birth Respiratory adaptations Baby must immediately establish respiratory gas exchange in conjunction with marked circulatory changes Initiation of respiration Pulmonary ventilation must be established through lung expansion Marked increase in pulmonary circulation must occur See Figure INITIATION OF RESPIRATION IN THE NEWBORN p First breath initiates serial opening of alveoli begins transition from fluid-filled environment to air-breathing independent extrauterine life During latter half of gestation lungs continuously produce fluid To prepare for birth lung fluid production decreases fetal breathing movement decreases hours before onset of true labor As fetus experiences labor fetal gasp active exhalation that initiates removal of fluid from lungs After first inspiration newborn exhales with crying against partially closed glottis creating positive intrathoracic pressure distributes air throughout the alveoli Alveolar epithelium temporarily more permeable facilitates passive liquid absorption Protein molecules in pulmonary capillaries creates oncotic pressure draws interstitial fluid into capillaries Initial chest recoil assists in clearing airways of accumulated fluid permits further inspiration Newborns may have problems clearing fluid in lungs beginning respiration Lymphatic system may be underdeveloped Complications may occur before or during labor birth that interfere with adequate lung expansion cause failure to decrease pulmonary vascular resistance Chemical factors contribute to onset of breathing Significant decrease in environmental temperature results in chilling of moist newborn stimulates skin nerve endings rhythmic respirations At birth newborn experiences light sounds full effects of gravity for first time Factors opposing initiation of respiration Alveolar surface tension contracting force between moist surfaces of alveoli would cause small airways to collapse if not for surfactant Viscosity of lung fluid influenced by surfactant levels Lung compliance Resistive forces of fluid-filled lungs necessitate pressures of cmH O to open lung initially Functional residual capacity after first breath allows alveolar sacs to remain partially expanded on expiration decreasing need for continuous high pressures for following breaths Cardiopulmonary physiology Air enters lungs PO rises relaxation of pulmonary arteries triggers decrease in pulmonary vascular resistance Blood distributed throughout lungs if heart delivering sufficient blood to functional open alveoli shunting unstable transitional period Oxygen transport Transportation of oxygen to peripheral tissues depends on type of hemoglobin in the RBCs fetal hemoglobin HbF and adult hemoglobin HbA HbF greater affinity for oxygen oxygen saturation greater but amount of oxygen available to tissues is less Maintaining respiratory function Lungs ability to maintain oxygenation and ventilation influenced by lung compliance airway resistance Characteristics of newborn respiration Initial respirations diaphragmatic shallow irregular Newborns tend to be obligatory nose breathers Immediately after birth hours respiratory rates of breaths min normal Any increased use of intercostal muscles may indicate respiratory distress Cardiovascular adaptations Fetalnewborn transition During fetal life blood with higher oxygen content diverted to heart brain See Chart on FETAL AND NEONATAL CIRCULATION at nursing pearsonhighered com Expansion of lungs at first breath decreases pulmonary vascular resistance increases pulmonary blood flow Five major areas of change in cardiopulmonary adaptation Increased aortic pressure and decreased venous pressure Increased systemic pressure and decreased pulmonary artery pressure Closure of the foramen ovale Closure of the ductus arteriosus Closure of the ductus venosus See Figure TRANSITIONAL CIRCULATION p Evaluating cardiac function Assessment of newborns HR BP heart sounds cardiac workload BP tends to be highest immediately after birth lowest at about hours of age BP values during first hours of life vary with birth weight gestational age average mean BP mmHg in full-term resting newborn over kg Murmurs produced by turbulent blood flow of newborn murmurs are transient Before birth right ventricle does approximately two thirds of cardiac work larger thicker at birth Hematopoietic adaptations First days of life hematocrit may rise g dL above fetal levels Hemoglobin values fall Leukocytosis normal finding neutrophils decrease to Blood volume approximately mL kg for term infant Varies based on amount of placental transfusion received during delivery of placenta and other factors Delayed cord clamping Gestational age Prenatal and or perinatal hemorrhage Site of blood sample Temperature regulation Newborns homeothermic Several newborn characteristics affect establishment of thermal stability Newborn has thinner epidermis less subcutaneous fat than adult Blood vessels in newborn closer to skin than blood vessels of adult Flexed posture of newborn decreases surface area exposed to environment reducing heat loss Size and age may affect establishment of neutral thermal environment NTE Newborn at disadvantage in maintaining normal temperature large body surface in relation to mass limited insulating subcutaneous fat Hepatic adaptations In newborn liver frequently palpable cm below right costal margin Plays role in iron storage carbohydrate metabolism conjugation of bilirubin coagulation jaundice Iron storage As RBCs destroyed after birth iron stored in liver until needed for new RBC production Carbohydrate metabolism At term newborns cord blood glucose level is mg dL lower than maternal glucose level carbohydrate reserves very low Glycogen stores are twice those of adult Nurse may assess glucose level on admission Conjugation of bilirubin Conversion of lipid-soluble pigment into water-soluble pigment Total serum bilirubin conjugated direct unconjugated indirect bilirubin Fetal unconjugated bilirubin crosses placenta fetus does not need to conjugate bilirubin Bilirubin formed after RBCs destroyed transported in blood bound to albumin Even after bilirubin conjugated and bound can be changed back to unconjugated bilirubin via enterohepatic circulation Newborn liver has less glucuronyl transferase activity in first few weeks of life along with large bilirubin load decreases livers ability to conjugate bilirubin increases susceptibility to jaundice Coagulation Coagulation factors II VII IX X activated under influence of vitamin K vitamin K dependent Absence of normal flora in newborn gut low levels of vitamin K transient coagulation alteration Platelet counts at same range as for older children Physiological jaundice Caused by accelerated destruction of fetal RBCs impaired conjugation of bilirubin increased bilirubin reabsorption from intestinal tract Six factors interaction may give rise to physiological jaundice Increased amounts of bilirubin delivered to liver Defective hepatic uptake of bilirubin from plasma Defective conjugation of bilirubin Defective excretion of bilirubin Inadequate hepatic circulation Increased reabsorption of bilirubin from intestine of full-term preterm newborns exhibit physiological jaundice on about second third day after birth No consistent definition of neonatal hyperbilirubinemia rate varies with population characteristics age Nursery environment may hinder early detection of degree type of jaundice If suspected nurse can assess coloring by pressing skin generally on forehead or nose with finger as skin blanches nurse can observe icterus Several newborn care procedures will decrease probability of high bilirubin levels Maintain newborns skin temperature at or above C or above Monitor stool for amount and characteristics Encourage early feedings to promote intestinal elimination and bacterial colonization and provide caloric intake necessary for formation of hepatic binding proteins If jaundice becomes apparent nursing care directed toward keeping newborn well hydrated Physiological jaundice may be upsetting to parents emotional support thorough explanation of condition Breastfeeding and breast milk jaundice Breastfeeding jaundice occurs during first days of life in breastfed newborns Breast milk jaundice bilirubin level begins to rise after first week of life when physiological jaundice waning after mothers milk has come in Related to milk composition Newborns with breastfeeding jaundice appear well temporary cessation of breastfeeding may be advised if bilirubin reaches presumed toxic levels of approximately mg dL Gastrointestinal adaptations Full-term newborn has sufficient intestinal and pancreatic enzymes to digest most simple carbohydrates proteins fats Protein requires more digestion than carbohydrates well digested absorbed from newborn intestine Newborn digests absorbs fats less efficiently In utero fetal swallowing accompanied by gastric emptying peristalsis of fetal intestinal tract Air enters stomach immediately after birth stomach has capacity of mL Regurgitation of first few feedings during first day of life lessened by avoiding overfeeding burping well Continuous vomiting regurgitation should be observed closely Adequate digestion absorption essential for newborn growth and development Term newborns usually pass meconium stool within first hours of life almost always within hours Urinary tract adaptations Certain features of newborns kidneys influence ability to handle body fluids excrete urine Term newborns kidneys have full complement of functioning nephrons by weeks gestation Glomerular filtration rate of newborns kidneys low compared with adult rate Juxtamedullary portion of nephron has limited capacity to reabsorb HCO and H Full-term newborns less able than adults to concentration urine makes effect of excessive insensible water loss restricted fluid intake unpredictable Many newborns void immediately after birth by hours after birth newborn who has not voided by hours should be assessed Initial bladder volume is mL of urine Frequently appears cloudy has high specific gravity Pseudomenstruation related to withdrawal of maternal hormones Immunological adaptations Immune system not fully activated until sometime after birth limitations in newborns inflammatory response result in failure to recognize localize destroy invasive bacteria Only IgG crosses placenta transferred from pregnant woman to fetus passive acquired immunity IgG transferred primarily during third trimester preterm newborns may be more susceptible to infection Normal newborn can produce protective immune response to vaccines as early as a few hours after birth IgM antibodies produced in response to blood group antigens gram-negative enteric organisms some viruses in expectant mother Functions of IgA immunoglobulins not fully understood appears to provide protection mainly on secreting surfaces Neurological and sensoryperceptual function Newborns brain about one-fourth size of adults myelination of nerve fibers incomplete Postnatal period time of risk with regard to development of brain and nervous system Intrauterine experience Newborns respond interact with environment in predictable pattern of behavior somewhat shaped by intrauterine experience Affected by intrinsic factors external factors Factors such as exposure to intense auditory stimuli may manifest in behavior of newborn Characteristics of newborn neurological function Normal newborns usually in position of partially flexed extremities may exhibit purposeless uncoordinated bilateral movements of extremities Organization quality of newborns motor activity influenced by number of factors Intrauterine growth restriction Prenatal stress Environmental chemicals Obstetric medications Acute fetal distress Gestational and pregestational diabetes Intrauterine drug exposure Prematurity and low birth weight Eye movements observable alert newborn able to fixate on faces geometric objects patterns Cry of newborn should be lusty vigorous Newborns body growth progresses in cephalocaudal proximaldistal fashion Specific symmetrical deep tendon reflexes can be elicited knee jerk reflex normal ankle clonus may involve beats plantar flexion See Table COMMON REFLEXES OF THE NEWBORN p Performance of complex behavioral patterns reflect newborns neurological maturation and integration Periods of reactivity Sleep states Deep or quiet sleep Active rapid eye movement REM Sleep cycles recognized defined according to duration Alert states First minutes after birth many newborns display quiet alert state Tend to be shorter after first days after birth Drowsy or semidozing Wide awake Active awake Crying Behavioral capacities of the newborn Newborns have several behavioral capacities that assist in adapting to extrauterine life Self-quieting ability Habituation Sensory capacities of the newborn Visual capacity Orientation newborns ability to be alert to follow and fixate on appealing and attractive complex visual stimuli Auditory capacity Newborn responds to auditory stimulation with definite organized behavioral repertoire Olfactory capacity Newborns select mother and others by smell Taste and sucking Newborn responds differently to varying tastes When wake and hungry newborn displays rapid searching motions in response to rooting reflex Tactile capacity Newborn very sensitive to being touched cuddled held Alterations Neonatology field of medicine providing care for sick premature infants Various factors influence outcome of at-risk infants Birth weight Gestational age Type and length of newborn illness Environmental factors Maternal factors Maternalinfant separation At-risk newborn susceptible to illness death because of dysmaturity immaturity physical disorders complications during or after birth Low socioeconomic level of mother Limited access to health care no prenatal care Exposure to environmental dangers such as toxic chemicals illicit drugs Preexisting maternal conditions Maternal factors such as age and parity Medical conditions related to pregnancy and associated complications Pregnancy complications Birth of at-risk newborns can often be anticipated Course of labor and birth infants ability to withstand stress of labor cannot be predicted Newborn classification and neonatal mortality risk chart useful tool for identifying newborns at risk Preterm less than completed weeks Term completed weeks Postterm greater than weeks Large-for-gestational-age plot above th percentile curve Appropriate-for-age plot between th and th percentile growth curves Small-for-gestational-age plot below th percentile growth curve Neonatal mortality risk infants chance of death within newborn period Neonatal morbidity can be anticipated based on birth weight gestational age See Chart POTENTIAL BIRTH INJURIES at nursing pearsonhighered com See Chart CONGENITAL ANOMOLIES IDENTIFICATION AND CARE IN NEWBORN PERIOD at nursing pearsonhighered com See ALTERATIONS AND THERAPIES Newborn Care p Collaboration Newborn care is divided into initial care subsequent care and preparation for discharge Initial care of the newborn Immediately after birth provider places newborn on mothers abdomen or under radiant-heated unit Dried immediately wet blankets removed Newborns nose mouth suctioned with bulb syringe as needed Apgar scoring system Used to evaluate physical condition of newborn at birth See Table THE APGAR SCORING SYSTEM p Heart rate Respiratory effort Muscle tone Reflex irritability Skin color Score of indicates newborn in good condition Score less than at min repeat every min up to min resuscitative measures may need to be instituted Apgar score less than at min may correlate with neonatal mortality Clamping the cord Cord clamps placed after examining for presence of two arteries one vein Clamp placed to in from abdomen Clamp plastic Hollister cord clamp removed hours after cord has dried Timing of umbilical cord clamping focus of discussion research delayed clamping in premature infants may yield more benefits than immediate cord clamping Banking cord blood Parents obtain container from Cord Blood Registry After cord clamped cut physician CNM withdraws blood from umbilical vein Collected blood can be used to treat childhood cancers rare genetic disorders cerebral palsy Costly Newborn identification and security ID bands in set of four preprinted with identical numbers