Childbearing FINAL

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1

First Stage of Labor

˜Begins with regular uterine contractions

˜Ends with full cervical effacement and dilation

˜Obstetric triage

˜Prenatal data

  • The nurse reviews the prenatal record to identify the woman’s individual needs and risks

They are safer at home!

First look at prenatal record!! What are glaring problems

2

First stage of labor

phases

  • Three phases of the first stage of labor
  • Latent phase (up to 6 cm of dilation)
    • Latent/early- up to 6: if they don’t seem like they are managing, she could be in back labor/painful(r or l OcipPost). HOURS To DAYS . Irregular contractions
  • Active phase (4 to 7 cm of dilation).
    • Active phase: more regular contractions.
  • Transition phase (8 to 10 cm of dilation) Transition: hysterical or focused, asking for pain meds. Ordering people aound.
3

First stage of labor:

How do you recognize

Subjective or by palapation. Really subjective of how it feels though unless you have an internal.

Top of strip is fhr

Bottom is toco or contraction: frequency(start of one to the other), duration (how long) intensity-subjective or internal monitor

Expect contraction to start of further apart in latent phase: less frequency, duration shorter, intensity milder.

Active and transition- duration gets longer 90 seconds, minute of rest and another contraction, frequency decreases duration and intensity increases.

4

First stage: assessment, diagnoses

  • Assessment and nursing diagnosis
  • Determination of whether the woman is in labor
  • Contractions
  • Cervix: do cervical check, later stages can put more digits in
  • Fetus
  • \
  • How is the baby tolerating contractions? Contraciton patter, cervical dilation effacement Fetus: where is ti and how is it responding to the contractions
5

Assessmetn

  • Assessment and nursing diagnosis
    • Admission to the labor unit
    • Admission data
      • Prenatal data
      • Interview
        • Spontaneous rupture of membranes
        • Bloody or pink show
    • Psychosocial factors (P)
      • Women with history of sexual abuse
      • Other vaginal trauma (FGM)
      • Obstetrical History
      • Support
    • Stress in labor
6

first stage

cultural factors

˜

˜Cultural factors

  • Woman may have a preconceived idea of the “right” way to behave
  • Culture and father participation
  • Non–English-speaking woman in labor
7

first stage

assessment and physical data

˜Assessment and nursing diagnosis

  • Physical examination
  • General systems assessment
  • Vital signs: used as a baseline, lie down on side to prevent supine hypotension, temp for signs of infection
  • Leopold maneuvers (abdominal palpation)
    • answers what fetal part is in the uterine fundus
    • where is fetal back located
    • what is presenting fetal part
  • Assessment of FHR and pattern
    PMI-point of maximal intensity, where fhr is located and heard loudest is over bakc.
  • contractions:
    • regular? subjective, palpation and timing of contractins, wavelike, slow increments, gradually reaching peak and then diminishing.
8

What else is in a physical exam

what do you assess regarding uterine contraction

  • Assessment of uterine contractions
  • Frequency: how often the uterine contractions occur
    • from beginning of contraction to the beginning of the next
  • Intensity: the strength of a contraction at peak
  • Mild, moderate, or strong
  • Duration: the time that passess between onset and the end of a contraction
  • Resting tone: the tension in the uterine muscle between contractions;relaxation of the uterus.
  • Vaginal examination:
    • do on admission
    • when status changes in woman or fetus
    • significant change in uterine activity
    • on maternal requiest or perception to bear down
    • membranes rupture
    • if noted variable decels
  • Cervical effacement, dilation, fetal descent
  • on palpation:
    • mild: slightly tense fundus that is easy to indentt iwth fingers,
    • moderate: firm fundus that is diffuicult to indent with fingers : press on chin,
    • strong: rigid boardlike fundus that is impossible to indent with fingertips-forehead
9

labs done in first stage of labor

  • Laboratory and diagnostic tests
  • Analysis of urine specimen:
    • hydration, nutrition ,infection status, posssible preeclampsia( protein)
  • Blood tests:
  • Complete blood count (CBC)
  • Type and screen
  • Assessment of amniotic membranes and fluid
    • did they rupture already? (usually in transitional phase of first stage of labor)
    • or do they need an anmiotomy
    • how long have they been ruptured- longer rupture=vaginal microorgs can ascend into amniotic sack. = limit the number of vag assessments, assess maternal temp and vag discharge frequently.
  • Other tests
  • If GBS status unknown, rapid test can be performed
  • Signs of potential problems

2 labs we do do is CBC and BLOOD TYPE

CBC platelets also important: if thrombocytopenic- that comes into play if she asks for an epidural: if it is below 100,000 then the anesthesiologic wont do it, cause she cant clot .

Look at crit, hemoglobin and thrombo

Ask, when do you think labor started, do you feel like you have broken your water, any vag bleeding???

+pooling or ferning confirms that she broke here water

GBS: test all women for it at 35-37 weeks.

2dose penicillin= adequate

Inadequate- less than 2 dosese, watch baby for 48 hours. Sepsis gbs protocol

10

plan of care/interventions for first stage of labor

  • Standards of care
  • Physical nursing care during labor
  • General hygiene:
    • water emersion= decreased analgisea. minimizes discomfort of contractions. change linenes
  • Nutrient and fluid intake
  • Oral intake:
    • ice chips, npo or water during active labor,,,due to possibility of csection
    • needed to meet energy demands and fluid lossess of labor
    • need energy to bear down
  • Intravenous intake
    • mainqtain hydration
    • usually with glucose
  • Elimination
    • Voiding: at least every 2 hours
    • a full bladder may impede descent, or slow uterine contractions. may lead to uterine atony after birth. eespecially for person who recieves epidural !
  • Catheterization
    • if unable to void. clean first
  • Bowel elimination
    • most do not during labor
    • usually stool expelled due to bearing down efforts, increase risk of infection/embarraassment
  • Ambulation and positioning

change position every 30-60 min

  • emotional support-partner, nurse, doula
11

tools needed for labor

All sterile, bulb, clamp , cut, basin, steile gloves

When head stays in perineum then you can open birth packet.

12

Second stage of labor

˜Infant is born

  • Begins with full cervical dilation (10 cm)
  • Complete effacement 100%
  • The “pushing” stage
  • Ends with infant’s birth
  • Second stage: pushing stage, and delivery of babe. Shorter than 1st stage. Full dilation and effacement. Ends with baby born.
  • usually 50-60 minutes, or 20-30 in a multip
  • epidural increases length
13

two phases of second stage of labor

what is ferguson reflex

  • Latent: relatively calm with passive descent of baby through birth canal (laboring down)
    • delayed pushing results in less pushing time total
    • wait till urge intensifies
  • Active: pushing and urge to bear down
  • Ferguson reflex: the urge to “bear down”
  • station usualy +1, and position anterior.
  • bearing down rythmically.
14

preparing for labor

  • Preparing for birth
  • Maternal position: Supine, semirecumbent , or lithotomy positions are still widely used in Western societies despite evidence that an upright position shortens labor.
  • Bearing-down efforts
  • Valsalva maneuver:dont do!
  • Fetal heart rate and pattern
    • move to side, give o2 or fluids to fix fetal hr
  • Support of father or partner
  • Supplies, instruments, and equipment
  • vitals: every 5-30 mins, and fetal hr every 5-15 min
15

care managment- birth in delivery room

˜Birth in a delivery room or birthing room

  • Lithotomy position
  • Crowning
  • Nuchal cord

˜Use of fundal pressure: contraindicated

˜Immediate assessments and care of newborn

16

perineal trauma in birth:lacerations

what are the degress of lacerations

  • Perineal lacerations
  • First degree : laceration that extends through the skin and vaginal mucous membrane but not the underlying fascia and muscle
  • Second degree : laceration that extends through the fascia and muscles of the perineal body, but not the anal sphincter
  • Third degree : laceration that involves the external anal sphincter
  • Fourth degree : laceration that extends completely through the rectal mucosa, disrupting both the external and internal anal sphincters
17

types of perineal trauma in birth

  • Vaginal and urethral lacerations
  • Cervical injuries
  • Episiotomy
    • An incision in the perineum used to enlarge the vaginal outlet
    • Has steadily declined in recent years due to a lack of sound, rigorous research to support its benefits
18

Third stage of Labor: what happens

what is it

how many minutes

signs and symptoms

  • Birth of the baby until the placenta is expelled
  • The third stage is generally by far the shortest stage of labor
  • Usually expelled within 10 to 15 minutes after the birth; may be problematic if >30 minutes
  • Active management of the third stage (Pitocin, gentle traction of the cord to get placenta out!)
  • Signs:
    • Sudden gush of dark blood from the introitus
    • goal is preventing postpartum hemmorage! get placenta out!
    • Apparent lengthening of the umbilical cord
  • Vaginal fullness
  • Placental examination and disposal
    • Cultural preferences
19

what is friedmans curve

average time it takes for birthing in first time moms vs. multiparious mothers.

-standard is that first time takes much longer

-Women today are heavier and older than then.

-People question it.

20

what is fourth stage of labor

  • Care management
    • First 1 to 2 hours after birth
    • Assessment of maternal physical status
      • Physiologic changes to prepregnancy status
      • vitals every 15 min for 2 hr. temp eery 4 hr
    • Signs of potential problems
      • Excessive blood loss
      • Alterations in vital signs and consciousness
  • Care of the new mother and post anesthesia/analgesia care
      • postanestehia- same but make sure that they are feeling legs before they get up
      • 15 min assessment
  • Care of the family
    • Family-newborn relationships
    • Immediate postpartum Breastfeeding w/in 1st hour. If had an epidural, check BP and sensation in legs. General anesthesia they will stay longer
21

key poiints: what environment is best in the first stage of labor

whos resonsibility is it for keeping track of womens progress in the first stage of labor

  • The familiar environment of her home is most often the ideal place for a woman during the latent phase of the first stage of labor.

The nurse assumes much of the responsibility for assessing the progress of labor and for keeping the nurse-midwife or physician informed about that progress and deviations from expected findings

22

key points

how do you know babe is in stress

a womens expectation or perception of birth

  • The fetal heart rate and pattern reveal the fetal response to the stress of the labor process.
  • Regardless of the actual labor and birth experience, the woman’s or couple’s perception of the birth experience is most likely to be positive when events and performances are consistent with expectations, especially in terms of maintaining control and adequacy of pain relief.
23

key points

cultural differences

language barriers

comfort

  • The woman’s level of anxiety may increase when she does not understand what is being said to her about her labor because of the medical terminology used or because of a language barrier.
  • Coaching, emotional support, and comfort measures assist the woman to use her energy constructively in relaxing and working with the contractions.
24

key points

how to advance the progress of labor

culture

sex abuse/trauma

  • The progress of labor is enhanced when a woman changes her position frequently during the first stage of labor.
  • The cultural beliefs and practices of a woman and her significant others, including her partner, can have a profound influence on their approach to labor and birth.
  • Siblings present for labor and birth need preparation and support for the event.
  • Women with a history of sexual abuse or vaginal trauma often experience profound stress and anxiety during childbirth.
25

LABOR AND BIRTH COMPLICATIONS

...

26

Preterm labor and birth

what is ptl

what is preterm birth

what is late preterm birth

▫Preterm labor (PTL): cervical changes and uterine contractions occurring at 20 to 37 weeks of pregnancy

▫Preterm birth: birth that occurs before the completion of 37 weeks (<37 0/7 weeks of gestation)

▫Focus on late preterm birth (34 weeks to 36 weeks 6 days)

Late preterm births: 34-36 6 weeks.

preterm labor vs braxton hicks: 4 contractions in 1 hour=labor, braxton hicks= unregular and random

27

preterm labor:

what is spontaneous vs indicated

causes of

  • Spontaneous versus indicated preterm birth

▫Spontaneous: 75% of preterm births

▫Indicated: 25% of preterm births :

-htn, low fluids, little growth,

  • Causes of spontaneous preterm labor and birth

▫Multifactorial

▫Infection is the only definitive factor

▫Placental causes

28

how to predict spontaneous preterm labor

  • Predicting spontaneous preterm labor and birth

▫Risk factors:

-Infection hx, lifestyle, past ob hx, preterm labors…

- hx of one, non white, genital tract colonization, mutifetal gestation, second trimester bleeding, low prepregnancy weight.

▫Cervical length

–Not predictive of PTL or birth

–But cervical length >30 mm unlikely to give birth prematurely

short cervix= maybe go into preterm labor.

▫Fetal Fibronectin (fFN)Test

–fFN is a glycoprotein “glue” found in plasma and produced during fetal life.

-protein that acts like a glue- releases this when it starts to separate cervix- just signifies more likely that she will go into birth if the vaginal swab is +.

more of a "who will not go into labor" than who will

29

signs and symptos of preterm labor

Uterine:

contractions occuring more frequently than every 10 minutes persisty 1 or more hours

uterine contractions either painful or painless

discomfot:

lower ab cramping like gas, diarrhea

dull intermidden low back pain

painful mentrual like cramps

sujprapubocp pain or pressure

pelvic pressure or heavieness

urinary freuency

vaginal:

discharge chang in character or amount of discharge, thicker or thinner, bloody brown colorness, smelly

rupture of membranes

30

what do you do in a preterm birth

-Preterm birth= wait and watch

31

PTL care managment

early recognition: what do you tell women to do?

  • Assessment

▫Patient teaching

  • Interventions

▫Prevention

▫Early recognition and diagnosis

  • Lifestyle modifications
  • transfer her to hospital in order to prepare and care
  • gve antibiotics
  • glucocorticoids
  • mag sulfate

▫Activity restriction

▫Restriction of sexual activity: can cause labor due to prostaglandins!

▫Home care

32

ptl care managemtn

3 things you due as protective measures

  • Suppression of uterine activity

▫Tocolytic medications

  • Promotion of fetal lung maturity

▫Antenatal glucocorticoids: significantly reduce the incidence of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and death in neonates

  • Management of inevitable preterm birth

▫Fetal and early neonatal loss

33

Premature rupture of membranes

prom vs pprom

how long is it okay for membranes to be ruptured before we worry

what are the three things a rupture can cause that are important to know

  • PROM: Spontaneous rupture of amniotic sac and leakage of fluid prior to the onset of labor at any gestational age

- INFECTION risk. If the sack is gone= can be infecction. Longer the h20 is broken,= higher chance of infection.

- DON’T do exams if you don’t have to.

- Can go into spontaneous labor w.in 24 hours. Don’t want it to be >18 hours. Sometimes do an induction to get babes out.

- can cause Oligohyddraminos:not enough fluids, infection, prolapsed cord,

- DEFINITLY do a fetal assessment before they give them an okay before doing expectant managemet. Give them a time frame to see if they kik in to labor.

  • PPROM: membranes rupture before 37 0/7 weeks of gestation

▫Responsible for 10% of all preterm births

▫Often preceded by infection

–Chorioamnionitis

34

prom and pprom care management

  • Determined individually for each woman
  • Full-term birth is the best option.
  • PPROM <32 weeks is managed expectantly and conservatively.
  • Vigilance for signs of infections
  • Fetal assessment
  • Antenatal glucocorticoids
35

What is the goal in PPROM

-Want baby to get to 34 wk.

-Fetal tachycardia= 1st sign of infeciton. Or decreased variability (minimal or absent), late decels

36

what is chorioamniotis

risk factors

diagnosed how

neonatal risks

treatment

  • Bacterial infection of the amniotic cavity
  • Major cause of complications for mothers and newborns at any gestational age
  • Diagnosed by the clinical findings of maternal fever, maternal and fetal tachycardia, uterine tenderness, and foul odor of amniotic fluid
  • Neonatal risks
    • pneumonia, bacteremia, sepsis, death, resp disteresss syndrome, periventricular leukomalacia, cerebral palsoy
  • Treatment:
    • promt iv treatment, broad specturm antibiotics, peniccillin. postbirth antibiotic. use this especially in GBS to prevent chorio.
    • possible induction of labor, prophylactic antibio in pprom
  • risk factors: rubture of membranes, long labor, prolonged mebrane rupture, multiple vag exams. use of internal fhr and contraction monitors. young age, low socio status, nulliparity, preexisting genital infecitons.
37

Post term pregnancy and birth and labor

maternal risks because of this

what happens to placenta at this time

diagnostics?

risks for labor include

  • Postterm pregnancy (postdates) pregnancy ≥42 weeks of gestation
  • Maternal risks

▫Dysfunctional labor and birth canal trauma

▫Labor and birth interventions more likely

▫Woman may experience fatigue and psychologic reactions as estimated date of birth passes.

At 42 weeks and beyond the placenta does not function as well. Gets old and dies off.

Fetal testing and sonagram to locate fluid.

Larger baby than you want! Dysfunctional labor- dystocia, more at risk for intervening.

maternal fetal risk of hemmorage and infection higher

38

fetal risks in postterm pregnancy and labor

  • Fetal risks

▫Abnormal fetal growth (macrosomia) babe >4000 gram

▫Prolonged labor

▫Shoulder dystocia

▫Birth trauma

▫Compromising effects on fetus of “aging” placenta

less calcium and other nutrients, less fluid leading to cord compression and fetal hypoxemia

39

care managment in POSTERM labor

  • Care management

▫Perinatal morbidity and mortality increase greatly after 42 weeks of gestation.

▫More frequent fetal assessment, testing

twice weekly testing and BPP or NST, amniotic fluid volume. most likely induce at 41 wk

40

Dystocia

  • Long, difficult, or abnormal labor

▫Most common indication for c-birth

▫Five factors affect labor

–The powers

–The passage

–The passenger

–Maternal position

–Psychologic responses

–

41

dystocia sustpected when

risk factors in women

alteration in characteristics of uterine contractions, a lack of progress in rate of cervical dilation, or lack of progress in fetal descent and expulsion

womens risk factors

overweight, short, advanced maternal age, infertility, prior version, masculine, uterine bnormalities, malpresentations of fetus, cpd, uterine overstimulation, maternal fatigue, admin of analgesic too early

42

dystocia: abnormal uterine activity

  • Abnormal uterine activity

▫Hypertonic uterine dysfunction (prodromal labor)

usually occur in the latent phase of first stage of labor, ucoordinated.

exhaustion

Sleep!

–Therapeutic rest

▫Hypotonic uterine dysfunction

Initially makes normal progress into the active phase of first-stage labor but then the contractions become weak and inefficient or stop

Goal:

Calm uterus and start over.

Benedryl for sleep and rest

43

dystocia

what other things can cause it?

  • Secondary powers

▫Problems with bearing-down efforts, possibly due to epidural or analegesic

  • Abnormal labor patterns

▫Friedman’s classification of “normal” labor patterns

▫Updated, evidence-based awareness of “normal” labor

  • Precipitous labor

▫Labor that lasts less than 3 hours from the onset of contractions to the time of birth

-Push down, not upwards -Holding breath is bad

-Don’t get fatigued.

-Slow babies the fluids are squeezed out= less fluid

-Precipitous labor= fluids arent squeezed out= laborous breathing in baby, more hemmorage inn mom.

44

precipitous labor

birth occuring 3 hr or lesss

results from hypertonic uterine contractions, placental abrustipon, uterine tachysystoly or cocain

complications: uterine rupture, laceration of birth canal, amniotic fluid emborlism, pp hemmorage, shoulder dystosia, hypoxia, rapid birth causing intracranial trauma.

45

cause of dystocia

maternal and fetal

  • Alterations in pelvic structure: we dont know pelvic structure prior to them going into labor!
  • Fetal causes

▫Anomalies

▫Cephalopelvic disproportion (CPD), also called fetopelvic disproportion (FPD)

▫Malposition

▫Malpresentation

▫Multifetal pregnancy

-CPD- head and pelvis.

46

more cuase of dystociA

  • Position of the woman

▫Maternal position alters relationship between uterine contractions, fetus, and mother’s pelvis

  • Psychologic responses

▫Hormones and neurotransmitters released in response to stress can cause dystocia

▫Sources of stress and anxiety vary

mental blockage

47

obesity

  • Serious problem in affluent nations
  • BMI of 30 kg/m2 or greater
  • BMI of 40 kg/m2 or greater extremely obese
  • Complications

▫Venous thromboembolism

▫Cesarean birth

-Hard time monitoring cause of the extra tissue, hard to monitor babe.

-Use internal monitor

48

obstetric procedure- induction of labor

  • The chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about birth
  • Labor may be induced either electively or for indicated reasons.
49

elective induction of labor

risk for

elective induction should not be initiated until when...

  • Elective induction of labor

▫Labor is initiated without a medical indication.

▫Many are for the convenience of the woman or her primary health care provider.

▫Risks:

–Increased rates of cesarean birth

–Increased neonatal morbidity

–Increased cost

  • Elective induction of labor should not be initiated until the woman reaches 39 completed weeks of gestation.
50

induction of labor: bishop score

what 5 things does the bishop score look at

card image
  • Bishop’s score

▫A rating system used to evaluate inducibility or cervical ripeness

If less than 4 = not a great starting point- less of success of vaginal birth.

We like over 8 for vaginal delicery.

4 bishop score= not ready for pitocin, need a softening medication, miso or cervidel.

51

types of inductions of labor

how to

  • Cervical ripening methods

▫Chemical agents: misoprostill porstaglandins, cervidil

▫Mechanical and physical methods

▫Alternative methods

Cook catheter- one on uterine side and one vaginal and it compresses it.

  • Amniotomy
  • Oxytocin

▫Hormone normally produced by the posterior pituitary gland, which stimulates uterine contractions and aids in milk let-down

Synthetic oxytocin (Pitocin) may be used either to induce labor or to augment labor that is progressing slowly because of inadequate

52

What is augmentation of labor

  • Stimulation of uterine contractions after labor has started spontaneously and progress is unsatisfactory
  • Common augmentation methods include oxytocin infusion and amniotomy.
53

operative vag birth

  • Operative vaginal births are performed using either forceps or a vacuum extractor
  • Forceps-assisted birth
  • Has to be at pelvic floor before you assist with the vaccum or forceps-
  • done for a prolonged second stage of labor, and need to due due to maternal cardip or cerbrovas or exhaustion. also fetal malpresentation, arrest of ortation, extraction of head in breach.
54

other operative vag birth

  • Operative vaginal births are performed using either forceps or a vacuum extractor
  • Vacuum-assisted birth
  • not used prior to 34 weeks usually
  • head must be engaged
55

Cesarean births overview

things to consider

Birth of a fetus through a transabdominal incision of the uterus to preserve the well-being of the mother and her fetus
Cesarean birth rate in the United States has been over 32% since the early 2000s
VBAC = Vaginal birth after cesarean
TOLAC = Trial of labor after cesarean

-TOLAC- lets just try, if it doesn’t work- csectionàneed to be more cautious, liability, ob likes doing csections, more controlled.

things to consider

-Age, multi-fetal pregnacies, liability,

-Don’t induce before 39 weeks if not indicated, give them time to naturally birth.

-6cm is active labor.

56

csection surgical techniques and trials of labor

can you induce for vbac and tolac

-Rate of old scar opening up is 1% of all vbacs.

-Repeat csection increases to 2% if you have had multiple csections.

-Uterine scar is what matters.

-For vbacs we like low transverse incision.

-If it extends to the upper part of uterus, we don’t let vbac cause they are more at risk.

-Why did yu have csection/ breech, stall out labor, emergecy

-Must know HX so that we can predict.

-If breech, and planned c section, good vbac candidate

-If contracted pelvis that couldn’t fit baby, not really a candidate.

-Fof vbacs and tolacts- CANNOT INDUCE IF NOT IN LABOR because those meds can increase chancese of unterine rupture. Never induce a previous csection, but can augment- pitocin.

-Cant start the labor with meds though.

-Can mechanical ripening, foley, cook cath,

-Vbac- give less time too labor.

-2 hour push= p robably not, they wil have you csectin.

-Stalled with vbac- recommend repeat csection

-Success rate is 60-75%.

-3 times is max to cutting into uterus.

57

intraop csection care

blood loss vag bs. csection

300-500 ccs blood vaginal

1000 ccsection

58

types of obstetric emergencies

meconium stained fluid

shoulder dystocia

uterine rupture

prolapsed cord

59

ostetric emergencies

mec stained fluid

possible causes

  • Meconium-stained amniotic fluid

▫Indicates fetus has passed stool prior to birth

▫Possible causes

–Normal physiologic function of maturity

–Breech presentation

–Hypoxia-induced peristalsis

–Umbilical cord compression

stressed out babe= mec

60

obsetric emergecny

shoulder dystocia

when babies head is born, what wont you see

what should you do as anurse

  • Shoulder dystocia

▫Head is born, but anterior shoulder cannot pass under pubic arch

▫Newborn more likely to experience birth injuries related to asphyxia- less o2, brachial plexus damage, and fracture

▫Mother’s primary risk stems from excessive blood loss from uterine atony or rupture, lacerations, extension of episiotomy, or endometritis. Postpartum hemmorage and rectal injuries!

Brachial plexus- nerve damage near shoulder =erb palsy

Collar bone fracture- have to do this sometimes so baby can come out.

Don’t leave pt side, emergency –c all for help.

baby wont externally rotat, reatraction of fetal head against perineum called turtle sign happens

what to do: subrapubic pressure and maternal position changes, squqatting position, stay with women

61

obstetric emergency

prolapsed cord

definition

contributing factors

what do you do

  • Prolapsed umbilical cord

▫Occurs when cord lies below the presenting part of the fetus

▫Contributing factors include:

–Long cord (longer than 100 cm)

–Malpresentation (breech)

–Transverse lie

–Unengaged presenting part

-Prolaspsed cord : cord comes before babe.

-Sometimes when water breaks the fluid wooshes the water out

-Constant pressure- bradycardia – decels.

-Get fingers in and take pressure of of cord.

-Push head up so it is not sitting on cord.

62

what to do prolapsed cord pic

card image

trendelenburg or knee chest

63

obstetric emergency

rupture of uterus

most frequent causes

  • Rupture of the uterus

▫Rare, serious obstetric injury; occurs in 1 in 2000 births

▫Most frequent causes of uterine rupture during:

–Separation of scar of a previous classic cesarean birth

–Uterine trauma (e.g., accidents, surgery)

–Congenital uterine anomaly

bradycardia=loss of blood

64

rupture of uterus

during labor and birth common rupture reasons

  • Rupture of the uterus (Cont.)

▫During labor and birth

–Intense spontaneous uterine contractions

–Labor stimulation (e.g., oxytocin, prostaglandin)

–Overdistended uterus (e.g., multifetal gestation)

–Malpresentation, external or internal version

–Difficult forceps-assisted birth

–Occurs more in multigravidas than primigravidas

Uterine tachysystole

65

key points:

what is preterm labor defined as, how is it diagnoed, what is the cause

  • Preterm birth is any birth that occurs between 20 0/7 and 36 6/7 weeks of gestation.
  • Preterm labor is generally diagnosed clinically as regular contractions along with a change in cervical effacement or dilation or both.
  • The cause of preterm labor is unknown and is assumed to be multifactorial; therefore, it is not possible to predict with certainty which women will experience preterm labor and birth.
66

teaching to recognize preterm labor

using tocolytic therapy

  • Because the onset of preterm labor is often insidious and can be mistaken for normal discomforts of pregnancy, nurses should teach all pregnant women how to detect the early symptoms of preterm labor and to call their primary health care provider when symptoms occur.
  • The best reason to use tocolytic therapy is to achieve sufficient time to administer glucocorticoids in an effort to accelerate fetal lung maturity. Additionally, time is allowed for transport of the woman prior to birth to a center equipped to care for preterm infants.
67

key points

fetal death

signs of infection

  • If fetal or early neonatal death is expected, the parents and members of the health care team need to discuss the situation before the birth and decide on a management plan that is acceptable to everyone.
  • Vigilance for signs of infection is an essential component of the care management for women with preterm PROM.
  • Dysfunctional labor results from differences in the normal relationships among any of the five factors affecting labor and is characterized by differences in the pattern of progress in labor.
68

key points

obestiy

induction electivly

cevical ripening

  • Obese women are at risk for several pregnancy complications, including cesarean birth. Even routine procedures require more time and effort to accomplish when the client is obese.
  • Uterine contractility is increased by the effects of oxytocin and prostaglandin and is decreased by tocolytic agents.
  • Labor should not be induced electively until the woman has reached at least 39 weeks of gestation.
  • Cervical ripening using chemical or mechanical measures can increase the success of labor induction.
69

key points: assisted births

csections

vag after csection

  • Expectant parents benefit from learning about operative obstetrics (e.g., forceps-assisted, vacuum-assisted, or cesarean birth) during the prenatal period.
  • The basic purpose of cesarean birth is to preserve the well-being of the mother and her fetus.
  • Unless contraindicated, vaginal birth is possible after a previous cesarean birth.
70

key points:

labor management

obstetric emergencies

  • Labor management that emphasizes one-to-one support of the laboring woman by another woman (e.g., doula, nurse, nurse-midwife) can reduce the rate of cesarean birth and increase the VBAC rate.

Obstetric emergencies (e.g., meconium-stained amniotic fluid, shoulder dystocia, prolapsed cord, rupture of the uterus) occur rarely but require immediate intervention to preserve the health or life of the mother and fetus or newborn

71

POSTPARTUM

...

72

what is the postpartum period

Postpartum (PP) period is the interval between birth and return of the reproductive organs to their nonpregnant state

  • Uterus
  • Involution process
  • Contractions
  • Afterpains
  • Placental site
73

reproductive system and structures

  • Lochia: postbirth uterine discharge
  • Rubra
  • Serosa
  • Alba
  • Cervix
  • Vagina and perineum
  • Episiotomy and laceration assessments
  • Hemorrhoids
  • Pelvic muscular support
  • Pelvic relaxation
  • Kegel exercises
  • Lochia- 14 -16 days, 1st 2 or 3 days red, then pink then white. If lchia increases- someitmes it is activity level, maybe rest a little bit. Cervix goes back but the little oz in the middle is like a slit, stretched.
74

Endocrine system

  • Placental hormones
    • Estrogen and progesterone levels decrease
  • Pituitary hormones and ovarian function
    • Prolactin remains elevated in women who breastfeed
    • Ovulation in 27 days after birth for nonlactating women
    • Ovulation in 70 to 75 days for lactating women
75

urinary system

  • Urine components
  • Renal glycosuria disappears by 1 week postpartum
  • Fluid loss
  • Postpartal diuresis of extracellular fluid
  • Urethra and bladder

Immediately after birth, excessive bleeding can occur if bladder becomes distended

should void spontaneously 6-8 hr after birht

76

GI system

  • Appetite
    • if breastfeeding, need an extra 500 kcal a day
    • omega 3's with lactation
  • Bowel evacuation
    • Occurs 2 to 3 days after childbirth
    • Anal sphincter lacerations are associated with postpartum incontinence
    • can ambulate, senna, water, increase good bm
77

Breasts

  • Breastfeeding mothers
    • First 24 hours colostrum
    • Transitions to milk in 72 to 96 hours
    • Engorgement comfort measures for lactating mothers
  • Nonbreastfeeding mothers
    • Engorgement resolves in 24 to 36 hours after milk comes in
78

Cardiovascular

  • Blood volume
  • Cardiac output
  • Vital signs
  • Blood components
  • Hematocrit and hemoglobin: 12-15, 34-45
  • White blood cell count- higher, average 12000 can get up to 20-25000
  • Coagulation factors- eelvated in immediate postpartum
  • Varicosities
79

MUSCKUOLSKELETAL

  • Adaptations of system are reversed
  • Joints are stabilized 6 to 8 weeks after birth.
80

abdomen

  • Returns to prepregnancy state 6 weeks after birth
    • Striae may persist
    • Return of muscle tone
      • Previous tone
      • Proper exercises
      • Adipose tissue
  • Diastasis recti abdominis
81

integuementary

  • Melasma (mask of pregnancy) disappears
  • Vascular abnormalities regress
  • Hair loss often reported during the first 3 months postpartum
82

key points

estrogen

6 wks post birth=

lochia and fundal height

  • The rapid decrease in estrogen and progesterone levels after expulsion of the placenta is responsible for triggering many of the anatomic and physiologic changes in the puerperium.
  • Within 6 weeks after birth, the physiologic changes induced by pregnancy have reverted to their normal state.
  • Assessing lochia and fundal height is essential to monitor the progress of normal involution and to identify potential problems.
83

key points

uterine involution

vitals

ovulation and menses postpartum

  • The uterus involutes rapidly after birth and returns to the true pelvis within 2 weeks.
  • The return of ovulation and menses is determined in part by whether the woman breastfeeds her infant.
  • Few alterations in vital signs are seen after birth under normal circumstances.
84

key points

hypercoagubility

dirueses

pregancny induced hypervolemia

  • Hypercoagulability, vessel damage, and immobility predispose the woman to venous thromboembolism.
  • Marked diuresis, decreased bladder sensitivity, and overdistention of the bladder can lead to problems with urinary elimination.
  • Pregnancy-induced hypervolemia, combined with several postpartum physiologic changes, allows the woman to tolerate considerable blood loss at birth.
85

nursing care for postpartum women

  • Nurse provides family-centered care that focuses on assessment and support of a woman’s physiologic and emotional adaptation after birth
  • Care is wellness oriented
  • Typical hospital stay is 1 to 2 days after vaginal birth
86

plan ffor discharge

  • From their initial contact with postpartum women, nurses prepare the mother for her return home.
  • Length of stay (LOS) depends on many factors:
    • Physical condition of mother and infant
    • Mental and emotional status of the mother
    • Social support at home
    • Client education needs
    • Financial constraints
    • Criteria for early discharge
      • Mother recovered; able to care for self and baby
      • Those at low risk for complications may be discharged as early as 6 hours from a birth center and 24 to 36 hours from the hospital.
87

pstpartum care managemetn

  • Routine laboratory tests
  • Prevention of excess bleeding Postpartum: CBC (if hemmorgae potential), blood type, Excess bleeding- postpartum hemm, and infeciton are two big things we want to prevent.
  • Maintenance of uterine tone
  • Prevention of bladder distention
  • Prevention of infection
    • Promotion of comfort
    • Promotion of ambulation
    • Promotion of exercise
    • Promotion of nutrition
    • Promotion of normal bladder and bowel function
    • Promotion of breastfeeding
    • Lactation suppression
  • Walking and ambulation are important, especially in csection. Normal bowel and bladder. (cause utterus) Ambulalte and pee Promote breastfeeding.
88

pp care management

what vaccines

  • Health promotion for future pregnancies and children
    • Rubella vaccination
    • Varicella vaccination
    • Tetanus-diphtheria-acellular pertussis (Tdap) vaccine
    • Prevention of Rh isoimmunization
89

pp care managment: psych

  • Psychosocial needs
  • Effect of birth experience
  • Maternal self-image
  • Adaptation to parenthood and parent-infant interactions

Family structure and functioning

90

discharge teaching

  • Effect of cultural diversity
  • Rest, seclusion, dietary restraints, and ceremonies honoring the mother are common traditional practices
  • Self-management
  • Signs of complications
  • Sexual activity and contraception
  • Medications
  • Self management: pp depression, anxiety, depression- cant care for themselves or babe., ptsd. A lot of women need permission to recognize, feel and report it. Sexual activity and contraception- you can get pregnant! Ovulating risk! Don’t want you to have intercourse for 6 weeks, want healing. Meds: ibuprofen, senna, percoset,
91

follow up after discharge

  • Follow-up after discharge
  • Routine schedule of care
  • Home visits
  • Telephone follow-up
  • Help lines
  • Support groups
  • Referral to community resources
92

key points: teaching, counseling, postpartum problems

psych needs

  • Common nursing interventions in the postpartum period focus on preventing excessive bleeding, bladder distention, and infection; providing nonpharmacologic and pharmacologic relief of discomfort associated with the episiotomy, lacerations, or breastfeeding; and instituting measures to promote or suppress lactation.
  • Teaching and counseling measures are designed to promote the woman’s feelings of competence in self-management and infant care.
    • Meeting the psychosocial needs of new mothers involves taking into consideration the composition and functioning of the entire family.
    • Early discharge classes, telephone follow-up, home visits, help lines, and support groups are effective means of facilitating physiologic and psychologic adjustments in the postpartum period.
93

1.Postpartum fatigue (PPF) is more than just feeling tired; it is a complex phenomenon affected by a combination of physiologic, psychologic, and situational variables. Which of these is not a contributing factor to PPF?

a.Long labor or cesarean birth

b.Infant care demands

c.Social isolation due to lack of visitors

d.Anemia or infection

C- Correct: Well-intentioned visitors can interrupt periods of rest both in the hospital or at home. Nurses may be asked to limit visitors and phone calls in order for the woman to rest. PPF is recognized as a risk factor for postpartum depression

94

POSTPARUM COMPLICATION

...

95

PPH

postpartum hemorage

Definition and incidence

Traditionally defined as follows:

Loss of 500 ml of blood after vaginal birth

Loss of 1000 ml after cesarean birth

A 10% change in Hct between labor and postpartum

  • Leading cause of maternal morbidity and mortality
  • Often unrecognized until mother has profound symptoms
  • PPH is classified as early or late with respect to the birth.
    • Early, acute, or primary PPH occurs within 24 hours of the birth
    • Late or secondary PPH occurs more than 24 hours but less than 6 weeks after the birth.
    • Sometime you can discharge someone but they come back in with bleeding. Could be amissed cervical laceration.
96

casues of PPH

associated with what

  • Uterine atony
    • Marked hypotonia of uterus
    • Leading cause of PPH
    • Associated with
      • High parity
      • Hydramnios – too much fluid
      • Macrosomic fetus – big fetus
      • Multifetal gestation – twins, triplets
97

more causes of pph

  • Retained placenta- where palcenta does not spontaneously deliver in 30 mins.
    • Nonadherent retained placenta
    • Adherent retained placenta
  • Lacerations of genital tract
  • Hematomas
  • Inversion of the uterus (inside out)
    • Potentially life threatening
    • Occurs in 1 in 2500 births
  • Subinvolution of the uterus ( uterus does not go back to normal state. Could be distented bladder, retained placent, abnormal implanted placenta…. So forth)
    • Late postpartum bleeding
98

pph care managemete

biManual compression.

Baloon bachle- cutting off all blood vessels. Filing it with normal saline. Keep in for 12 to 24 hrs.

99

pph care managemetn

  • Early recognition and treatment of PPH are critical.
  • The initial intervention is firm massage of the uterine fundus.
  • Expression of any clots in the uterus
  • Elimination of bladder distention
  • Continuous intravenous (IV) infusion of 10 to 40 units of oxytocin added to 1000 ml IV fluid
  • Additional uterotonic medications
  • Pitocin- helps contract utuers Misoprostil- rectally Methergine im- don’t give to high blood pressure Hemabate- don’t give to asthmaàbronchocontrsiction and diarrhea
100

postpartum infections

  • Also called puerperal infection
  • Any clinical infection of the genital tract that occurs within 28 days after miscarriage, induced abortion, or birth
  • Defined as presence of a fever of 38° C (100.4° F) or more on 2 successive days of the first 10 postpartum days (not counting the first 24 hours after birth)
101

types of postpartum infections

sources

  • Source of infection: UTI, Vaginal lacerations/episiotomy, breasts-mastitis, clogged duct, endometritis uterine infection,
  • Endometritis
    • Infection of the lining of the uterus
    • Most common postpartum infection
  • Wound infections
    • Often develop after mothers are discharged home
    • Typically cesarean incision, repaired laceration, or episiotomy site
  • Urinary tract infections
102

key points

major cause of pp death

  • Postpartum hemorrhage is a major cause of obstetric morbidity and mortality throughout the world and is the leading reason for obstetric intensive care unit admissions.
  • Hemorrhagic (hypovolemic) shock is an emergency situation in which the perfusion of body organs can become severely compromised and death can ensue.
  • Postpartum infection is a major cause of maternal morbidity and mortality throughout the world.
    • Postpartum UTIs are common because of trauma experienced during labor.
    • Prevention is the most effective and least expensive treatment of postpartum infection.
103

A physician orders methylergonovine (Methergine) 0.2 mg IM for a postpartum client. Which intervention should the nurse take prior to administering this medication?

a.Obtain the client’s blood pressure (BP).

b.Determine the client’s blood glucose level.

c.Take the client’s pulse.

d.Have the client empty her bladder.

A

Correct: Prior to administering Methergine, the nurse must check the client’s BP. If the BP is greater than 140/90 mm Hg, the medication should not be given. In either case, the nurse must continue careful monitoring of vaginal bleeding and uterine tone.

104

NEWBORN AND FAMILY CARE

...

105

care managemetn birth - 2hr

  • Assessment
    • Immediate care after birth
    • Initial physical assessment
      • APGAR scoring
      • Activity (Muscle tone)
      • Pulse (Heart rate)
      • Grimace (Reflex irritability)
      • Appearance (Generalized skin color)
      • Respirations
106

Scoring APGAR

severely depressed, moderatly depressed, excellent condition

card image

Know these and know how to score it.

To see if baby is transitioning well.

Muslce tone-

Normal hr- 110-160.

Under 100 needs ventilation- positive pressure- mask

Under 60 is neonatal recucitation

Grimace is like muscle tone- flexing, sneezing coughing crying reacting to touch. (usually com out flexing)

Flaccid= no grimace or activity

Appearance: usualy pinkish blueish. Usually use o ne for color- acrocyanosis- extremities (get one point for that). DO NOT LIKE Central cyanosis.

Respirations: blue, retractions, nasal flaring, fluid in lungs, grunting

Is it using lungs, and becoming an air breather?? Transition to air breathing abe

Bulb suction – always suction mouth first- because they can aspirate, and then nose

107

Assessment birth through 1st two hours

  • Physical assessment
    • General appearance
    • Vital signs: Respirations and pulse
  • Neurologic assessment
    • Newborn reflexes
    • Moro- surpise Fencing Sucking Rooting Babisnki Plantar Palmar stepping
  • Baseline measurements of physical growth
    • Weight: 2500-4000 g- 5.5 to 8.8 lb
    • Head circumference: 32-37 cm (12-14 in)
    • Body length: 45-55 cm 17-21 in
    • chest 30-33 cm: 3 cm less than head usually
108

classification by gestation

preterm

late preterm

early term

full term

posterm

postmature

  • Classification by gestation
  • Preterm or premature—born before completion of 37 weeks of gestation, regardless of birth weight
  • Late preterm—34 0/7 through 36 6/7 weeks
  • Early term—37 0/7 through 38 6/7 weeks
  • Full term—39 0/7 through 40 6/7 weeks
  • Late term—41 0/7 through 41 6/7 weeks
  • Postterm—42 0/7 weeks and beyond
  • Postmature—born after completion of week 42 of gestation and showing the effects of progressive placental insufficiency
109

preterm infant

  • Majority of high risk infants are those born in less than 37 weeks
  • Organ systems are immature and lack adequate reserves of bodily nutrients.
110

care mangemetn high risk infant

  • Maintaining body temperature
  • Respiratory care
  • Nutritional care
  • Skin care
  • Environmental concerns
  • Developmental care
  • skin to skin still wanted and breastmilk from mom! even if in nicu
111

parental adaptation to hgigh risk infant

  • Parental tasks
    • Anticipatory grief
  • Parental responses
  • Parental support
  • Maladaptation
  • Parent education
112

anticipatory grief

  • Experienced when told of the impending death of infant
  • Prepares and protects parents who are facing a loss
  • Parents who have an infant with a debilitating disease, but one that may not threaten life of child, also may experience anticipatory grief.
  • provide accruate info, and give them hope too
113

neonatal intervnetions

bulb suction

  • Airway maintenance
    • Side-lying position
    • Bulb syringe: mouth-->nose, prevent aspiration
    • Use of nasopharyngeal catheter with mechanical suction apparatus
  • Maintaining an adequate oxygen supply
  • Maintaining body temperature
114

neonatal interventions

  • Immediate interventions
    • Eye prophylaxis
      • To prevent ophthalmia neonatorum or neonatal conjunctivitis
      • gonneria
  • Vitamin K administration
  • Promoting parent-infant interactions
  • vit k and eye can be done like 1 to 2 hours pp
  • parent infant interaaction 1st!
115

problems in infants postbirth

  • Common problems in newborns
    • Birth injuries
    • Retinal and subconjunctival hemorrhages- 5 days clear
    • Soft-tissue injuries: erythema, ecchymoses, petechiae- 2-3 day clear
    • Trauma secondary to dystocia:feel clavicle after!
    • Accidental lacerations: vacume assisted, forcepts, damaged, bruising, knick.
    • bruising= vit k!
116

birth trauma

  • Birth trauma (birth injury) is physical injury sustained by a neonate during labor and birth.
  • Incidence in the United States: 2.19 per 1000 live births
  • Some birth injuries are avoidable, but some are unavoidable despite skilled and competent obstetric care.

Care of the infant with a birth injury is individualized based on the type of injury

117

common newborn problems

  • Common problems in newborns (Cont.)
    • Physiologic problems
      • Jaundice
        • Assessment and screening
        • Therapy for hyperbilirubinemia
        • Phototherapy
        • Precautions
        • -Babies liver is undeveloped= cant really get rid of the jaundice, will be able to ppoop out soon enough, but som are undeveloped and will stay jaundiced, or need help. -Do 24 hours checks- tcb/serum bilirubin, cardiac tsting cchd, hearing test, stooling, voiding, genetic testing pku, is baby yellow? -Want babies to feed so they excrete it form stool and urine. -Yellow looking baby. -Sometimes you need light, unclothe baby, natural sunlight. To help convert from fat souble to water soluble -Phototherapy is like a tanning bed- naked with ht diaper, protect eyes. Feeding, hydration ,skin breakdown, in there for hours.
      • Hypoglycemia
        • Usually defined as blood glucose levels less than 45 mg/dl
        • -Hypoglycemia- not passive reception of glucose through placenta, they have to dig into their glucogen source. Don’t routinley check, unless there are signs. Large babies need more glucose so their sugars drop on glucose protocol.
        • -Infection- glucose protocol. Anything where baby is tstressed or out of normal you are going to check glucose.
        • most low right after birth 1-2 hr due to placental cut off
118

hyperbilirubinia

  • Bilirubin level in blood is increased.
  • Characterized by yellow discoloration of the skin, mucous membranes, sclera, and various organs
  • Referred to as jaundice or icterus
  • Caused by an accumulation of unconjugated bilirubin and hemolyzed red blood cells (RBCs) under the skin
119

hyper bili-

physiologic jaundice

  • Physiologic jaundice
  • Occurs in about 66% of healthy term newborns
  • Almost all preterm infants
  • Typically arises more than 24 hours after birth
  • Manifested by progressive increase in unconjugated bilirubin level in cord blood
  • usually appears at 5-6ml/kg.
  • interventions: feeding, colostrum helps baby to pass mec and pee to get rid of bili
  • preterm infants at a greater risk because they have a more underdeveloped system, also asian and natives higher risk.
120

pathologic jaundice

  • Pathologic jaundice
  • usually occurs within 24 hr of birth
  • Level of serum bilirubin that, if left untreated, can result in kernicterus
  • Acute bilirubin encephalopathy describes the acute central nervous system manifestations seen in the first weeks after birth.: lethargy, hypotonia, irritable, seizure, coma
  • Kernicterus is used to describe the chronic and permanent results of bilirubin toxicity. irreversible long term hypotonia, motor skill dealy hearing loss, cerebral paulsy
121

care managemnt

lab tests

  • Laboratory and diagnostic tests
  • Universal newborn screening
  • Mandated by U.S. law
  • Early detection of genetic diseases that result in severe health problems if not treated early
122

screening tests for babies after birth

  • Newborn hearing screening
  • Universal hearing screening- have a printout of how they are bouncing back sound waes. Screening for critical congenital heart disease (CCHD)
  • Congenital heart disease- o2 saturation, pulse, can screen out for large congenital heart defects.
123

interventions for new babies

  • Interventions
  • Protective environment: wash hands, hugs tags
  • Environmental factors
  • Infection control factors
  • Preventing infant abduction
  • Preventing newborn falls
124

neonatal infections interventions types

  • Bacterial infections
  • Group B streptococci (GBS)
  • A leading cause of neonatal morbidity and mortality in the United States
    • Universal screening at 36-37 weeks
    • Intrapartum prophylaxis:: penicillin 2 doses while in labor
    • Inadequate treatment: 48 hour observational stay protocol

n

125

immunizations and surgeries for newborn

  • Therapeutic and surgical procedures
    • Intramuscular injection
    • Immunizations:vit k and hep b
    • Circumcision
      • Policies and recommendations
      • Parental decision
      • Procedure
126

circumcision

-moms-petroilum over it, to help healing and keep it from sticking to diaper

-Clean with warm water- no soap and lotions, petrolium wrap cream so it doesn’t stick to diaper.

-Bleeding make sre thaey are not, espeically if no vit. K done

-Yellow formation on penis is normal, don’t wipe it off, it builds over to help heal

-Babt needs to pee normall!

-6-8 wet diapers/24 hrs

127

neonatal pain

  • Neonatal responses to pain
    • Behavioral responses
      • Most common sign is vocalization or cry
  • Physiologic/autonomic responses
    • Changes in heart rate
    • Blood pressure
    • Intracranial pressure
    • Vagal tone
    • Respiratory rate
    • Oxygen saturation
128

neonatal pain managemnt

pharamacleogic and nonpharm

  • Management of neonatal pain
  • Nonpharmacologic management
    • Containment (swaddling)
    • Nonnutritive sucking
    • Oral glucose
    • Skin-to-skin contact
    • Breastfeeding
    • Pharmacologic management
    • Local and topical anesthesia
    • Nonopioid analgesia
    • Acetaminophen
    • Opioid analgesia
    • Morphine
    • Fentanyl
129

parent infant interaction assessment

  • Promoting parent-infant interactions
    • Assess attachment behaviors
    • Support and education for parents
    • Cultural considerations
  • manage babe with gloves prior to bathing
130

discharge planning nad teaching

  • Temperature:Temperature we don’t like is over- 100.4 taken twice elevated mom and baby= bad.
  • Respirations
    • Use of bulb syringe
    • 30-60 respirations
  • Feeding patterns
  • Elimination: 6-8 wet diapers a day, stooling may be 1 per day
  • Positioning and holding
    • Safe sleep positions: sids is for real. Don’t put baby on abdomen,
    • co sleeping= can kill babe
    • Sudden infant death syndrome (SIDS
131

discharge planning and teaching

  • Rashes
    • Diaper
    • Other (rash on the cheeks, erythema toxicum)
  • Clothing
    • always cap and hat, one more layer than you would wear
    • skin to skin= best thermoreg
    • they dont have ability to have thermoregulation
  • Car seat safety
  • Nonnutritive sucking can calm down
  • Bathing
    • Don’t have to bathe baby every day. Face and genitals are dirty.
    • If you bathe them everyday wont get oils and bacteria they need. 2 times a week
  • Cord care
    • Cord falls off 10-14 days after
    • cord care- make sure nothing rubs on it, should dry off and fall of, exudate= warm water only. Anything smelly, pussy bleeding should be recorded. Sk
  • Skin care
    • will develop own oils and bacteri.
    • DON’T USE BABY POWdER, inhalation!
132

key points

assessment

airway

  • Assessment of the newborn requires data from the prenatal, intrapartal, and postnatal periods.
  • The immediate assessment of the newborn includes Apgar scoring and a general evaluation of physical status.
  • Knowledge of biologic and behavioral characteristics is essential for guiding assessment and interpreting data.
  • Gestational age assessment provides important information for predicting risks and guiding care management.
  • Nursing care immediately after birth includes maintaining an open airway, preventing heat loss, and promoting parent-infant interaction.
133

key points

pain

assess

cpr

  • Providing a protective environment is a key responsibility of the nurse and includes such measures as careful identification procedures, support of physiologic functions, and ways to prevent infection.
  • The newborn has social and physical needs.
  • Newborns require careful assessment for physiologic and behavioral manifestations of pain.
  • Nonpharmacologic and pharmacologic measures are used to reduce infant pain.
  • Before hospital discharge, nurses provide anticipatory guidance for parents regarding feeding and elimination patterns; positioning and holding; comfort measures; car seat safety; bathing, skin care, cord care, and nail care; and signs of illness.
  • All parents should have instruction in infant cardiopulmonary resuscitation (CPR).
134

Prior to discharging a male infant who has just been circumcised, the nurse must evaluate that the parents understand the instructions for care at home. The nurse is reassured when the parents report which of the following?

1.They will check for bleeding with every diaper change.

2.The baby is expected to void at least four times in 24 hours.

3.Soap and water should be used to clean the penis.

4.They will notify the provider if a yellow exudate develops and covers the head of the penis.

A Correct: Bleeding needs to be evaluated at every diaper change. If bleeding occurs, gentle pressure should be applied with a sterile gauze square. If the bleeding does not stop, the primary health care provider should be notified.

B Incorrect: The baby should void after the circumcision prior to discharge. He is expected to void six to eight times within 24 hours.

C Incorrect: The penis should be cleansed with plain water and petroleum applied. Soap should not be used until the circumcision is healed at 5 or 6 days after the procedure.

D Incorrect: This is normal and will remain for 2 to 3 days. The parents should not attempt to remove this exudate. Redness, swelling, or discharge indicates infection, and the physician should be notified.

135

Breastfeeding history

risk of artifical breast milk

nBreastfeeding was the method of infant feeding

nArtificial feeding attempted early in history

nDangers of artificial feeding

nInfection

nDiarrhea

nWet nurses popular

136

AAP breastfeeding recomendations

nExclusive breastfeeding for about the first 6 months

nThen begin “solids” and continue breastfeeding until 12 months or longer as mutually desired by mother and child.

137

benefits of breastfeeding to mom

nPromotes uterine involution, less bleeding PP

nReturn to pre-pregnancy weight more quickly

nConvenient, portable

nDecreases cost

nDecreases risk for breast cancer and rheumatoid arthritis

nProvides some protection against development of osteoporosis

138

contraindications to breastfeeding

nIllicit drugs use

nActive and untreated tuberculosis

nDiagnostic or therapeutic radioactive isotopes

nChemotherapeutic agents

nActive herpes simplex lesions on the breast

nGalactosemia in infant

nHIV positive (in USA & developed countries)

nCytomegalovirus (CMV) with preterm infants

nSome rare medications

139

lactation supply demand

nProgesterone

nProlactin - Primary hormone responsible for lactation (milk production) released from anterior pituitary

nOxytocin - Let-down reflex (milk ejection) released from posterior pituitary

140

after birth breastfeeding time

nEarly (first hour) and Frequent (minimum 8 times day) Feeding/Pumping/Hand Expression

n1st Choice: Baby

n2nd Choice: Hand Expression

n3rd Choice: Hospital Grade Breast Pump

nResearch shows that baby/milk expression within 1 hour of birth increases milk production at 1, 3, & 6 weeks

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why are breasts smart?

nBaby suckles at breast

nBreast is emptied

nBreast “realizes” it needs to make more milk

nHormones cause increased supply for next feeding

OR

nBottle is offered instead of breast or no feeding/pumping offered

nBreast is NOT emptied

nBreast “realizes” it doesn’t need to make milk

nHormones cause decreased supply for next feeding

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trends in breast feeding

nBreast milk Banks: Breast milk as “medicine”for preterm infants

nInformal Milk Sharing

nHand Expression http://newborns.stanford.edu/Breastfeeding/HandExpression.html

n

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baby friendly steps to breastfeeding

nBaby-Friendly Ten Steps to Successful Breastfeeding

1.Have a written breastfeeding policy that is routinely communicated to all health care staff.

2.Train all health care staff in skills necessary to implement this policy.

3.Inform all pregnant women about the benefits and management of breastfeeding.

4.Help mothers initiate breastfeeding within 1 hour of birth.

5.Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

6.Give newborn infants no food or drink other than breast milk, unless medically indicated.

7.Practice “rooming in”— allow mothers and infants to remain together 24 hours a day.

8. Encourage breastfeeding on demand.

9.Give no pacifiers or artificial nipples to breastfeeding infants.

10.Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

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skin to skin

nGI Microbiome- want goo dbacteria to be present in gut