1
Q
18 day grace period
A
no blood transfer if first 18 days, what mom ingests does not affect baby
2
Q
teratogens
A
Non genetic
Drugs and chemicals
Infections (eg. rubella)
Radiation
Maternal health conditions (eg. diabetes)
3
Q
conception
A
Union of a single ovum and sperm
4
Q
fertilization
A
Takes place in fallopian tube
Sperm successfully penetrates the membrane surrounding the ovum
5
Q
3 stages of pregnancy
A
Pre-embryonic: fertilization to 3 weeks
Embryonic: weeks 3 to 8
Fetal: weeks 8 to birth
6
Q
pre-embryonic stage
A
-fertilization - 3 weeks
- Blastocyst attaches to endometrium and proliferates
- germ layers form
7
Q
3 germ layers
A
-ectoderm
-mesoderm
-endoderm
8
Q
ectoderm
A
-epidermis, sweat glands, nails, hair, lens of the eye, epithelium, glands
9
Q
mesoderm
A
-bones, teeth, muscle, dermis, connective tissue, cardiovascular system, spleen, urogenital system
10
Q
endoderm
A
-lining of the resp and GI tract (liver, pancreas, bladder, vagina), epithelium, GUS
11
Q
Embryonic Stage
A
- Weeks 3 to 8: Zygote takes human shape = EMBRYO
- Organ systems develop
- Embryo vulnerable to injury by drugs, infections, malnutrition, tetragons
- Most critical time in development
- Placenta forms at implantation
- Functions as an endocrine gland which causes hCG
- hCG detected in maternal serum day 8 to 10
- Metabolic exchange system
- development of structures (chorion, amnion, amniotic fluid, yolk sac, umbilical cord, placenta)
12
Q
chorion
A
covering of the fetal side of the placenta
Contains major umbilical blood vessels
13
Q
amnion
A
fills with amniotic fluid
14
Q
amniotic fluid
A
- baby drinks, digest it, and pee it back out
- test the fluid to see if baby’s kidneys are working properly
- Increases every week
- 700-1000mL at term
- Provides temp control, cushion, oral fluid, repository for waste, freedom of movement, prevents chord from getting tangled, infection barrier
15
Q
Oligohydramnios
A
less than 300mL
Associated with fetal renal failure
16
Q
Polyhydramnios
A
more than 1000mL
Associated with GI malformations
17
Q
yolk sac
A
- Helps with nutrition and oxygenation
- At week 4 it turns into baby’s GI
- Works while placenta forms
18
Q
umbilical cord
A
- Rapidly increases in length
- metabolic exchange
- 2 arteries carry blood from the embryo
- 1 big vein brings blood to the embryo
- Wharton’s gelly - prevents cord from collapsing
19
Q
placenta
A
- Hormone production (hCG, progesterone, estrogen, relaxin)
- Metabolic exchange
- Week 12 - stops growing
- Week 23 - remodeling
- Function depends on moms bp
- If bp is too high placenta will shut down
- Always check bp
20
Q
fetal stage
A
- weeks 8-birth
- Changes are not dramatic and fetus is less at risk for malformations at this stage
- Fetal organs are started and viable to live outside the womb at 24 weeks (+/- 2 weeks) gestation with medical assistance
- Fetal circulation is well developed
- All systems are growing stronger and more complete
21
Q
dizygotic twins
A
Fertilization of 2 eggs
Fraternal
2/3
22
Q
monozygotic twins
A
Division of one egg
Identical
1/3
23
Q
complications of twin pregnancies
A
Often prematures
Spontaneous rupture of membranes preterm
Congenital malformations
Shunting of blood between placenta (one twin gets more blood/nutrients than other)
Congenital heart failure after birth
Higher chance of twins with fertility drugs
Generally a bit smaller than singleton pregnancy (more likely to flip)
24
Q
twin chorionicity
A
- Chorionicity scan looks at whether the twins share the same placenta or have separate placentas and whether or not they have 1 chorion or two
- twin to twin transfusion syndrome - if twins share the same placenta, one twin may get more blood and nutrients
- Dichorionic twins do not share circulation
25
pregnancy lasts
9 calendar months
10 lunar months
40 weeks
280 days
26
preterm labour
before 37 weeks
27
gravida
woman who is pregnant
28
gravidity
pregnancy
29
multigravida
woman who has had 2 or more pregnancies
30
multipara
woman who has completed 2 or more pregnancies to 20 weeks gestation or more
31
nulligravida
woman who has never been pregnant
32
nullipara
woman who has not completed a pregnancy with fetus or fetuses beyond 20 weeks of gestation
33
parity
number of pregnancies, in which the fetus reached at least 20 weeks
34
post term pregnancy
goes beyond 41 weeks
35
primigravida
woman who is pregnant for the first time
36
primipara
woman who has completed one pregnancy with fetus or fetuses who have reached 20 weeks of gestation
37
term
37-40 weeks
38
viability
capacity to live outside the uterus; about 22 to 25 weeks of gestation
39
pregnancy tests
- (hCG) is the earliest biochemical marker of pregnancy.
- Pregnancy tests are based on recognition of hCG or β subunit of hCG.
- Noticeable 8-10 days after conception
- 2 weeks after last period
- hCG should double every 48 hours
40
presumptive signs of pregnancy
Subjective changes felt by a woman
Amenorrhea, fatigue, breast changes
41
probable signs of pregnancy
Hegar's sign
Uterus enlargement
Braxton hicks
Ballotment
Positive pregnancy test
42
positive signs of pregnancy
Fetal movement/palpation
Fetal heart tone
Seeing the fetus (ultrasound)
43
Average weight gain during a singleton pregnancy of normal BMI
25-35 pounds
44
Average weight gain during a singleton pregnancy of overweight BMI
15-25 pounds
45
Average weight gain during multiple births
at least 40 pounds
46
fundal height
- Top of uterus
- Correlates with weeks of gestation
- Bellybutton = 20 weeks
- Should increase but then drops in the last 4 weeks as baby gets ready for birth
47
hegars sign
- softening of the lower part of the uterus
- happens at 6 weeks
48
reproductive system changes (cervix)
- Consistency changes (gets softer)
- Becomes vascular and edematous
- Dark violet rather than pale pink
- Goodell’s sign
49
goodells sign
Softening of the cervix due to increased vascularity
50
reproductive system changes (vagina and vulva)
- Chadwicks sign
- Production of operculum (thick mucous coating in vagina) → creates mucus plug (stops infection from getting in)
- Vaginal pH change from alkaline to acidic
51
Chadwicks sign
Deep violet colour of vagina
52
Montgomery's tubercles
hypertrophy of oil glands in the areola
53
changes in cardiovascular system
- blood pressure should remain unchanged
- blood volume increases
- cardiac output increases 30-50%
- pulse increases 10 beats
- increased clotting (DVT)
- supine hypotension syndrome
- edema
- varicose veins
- hemorrhoids
54
renal system changes
- Urinary frequency
- Kidneys increase in size
- Kidneys don't filter water as well → bladder infections
- Capacity to excrete water decreases → edema
55
chloasma
- mask of pregnancy
- Facial melasma (blotchy brownish hyperpigmentation over cheeks, nose and forehead
56
integumentary changes
- chloasma
- linea nigra
- striae gravidarum
- angiomas
- palmar erythema
57
musculoskeletal changes
- diastases rectum
- pelvic joints become pliable
- diastasis symphysis pubis
- lordosis
- sciatica
58
GI system changes
- Morning Sickness
- Hyperemesis Gravidarum
- Increased progesterone = decreased tone and motility of the smooth muscle = esophageal regurgitation and slow emptying of stomach
- Pyrosis (Heartburn)
- Gallstones
- Constipation (smooth muscle relaxation = slowed peristalsis in gut)
- Hemorrhoids
- Appetite
- Ptyalism (excessive salivation)
59
Hyperemesis Gravidarum
Excessive nausea and vomiting
High risk for electrolyte imbalance and dehydration
- Often require hospitalization for fluid and electrolyte replacement
Increased progesterone = decreased tone and motility of the smooth
60
neurological system changes
- Carpal Tunnel Syndrome
- Sensory changes in legs and hands (pressure on nerves)
- Tension headaches
- Light-headedness
61
endocrine system
- Placenta produces several hormones
- Thyroid gland increased up to 50%
62
adolescent pregnancy
- Less likely to access adequate prenatal care
- More likely to smoke
- Less likely to gain adequate weight
They may have:
- Low education level
- Poor familial support
- Limited finances or no housing
increased risk for
- Low birth weight babies
- Preterm labour
- Gestational hypertension
- Cephalopelvic disproportion
63
pregnancy after 35
Have higher incidences of:
- Obesity
- Depression
- Socioeconomic disadvantages
- Anxiety
- Pre-existing chronic condition
- Stress from life and work
- Caesarean Section
- Preterm birth
Risk for fetal death high with teens & women over 40
64
Näegele's rule
last menstrual period (LMP) - 3 months + 7 days
65
fetal assessment
- Fundal height = gestational weeks (GW) +/- 2
- Gestational age
- Health status - Fetal movement, heartbeat
66
the 5 P's
Passenger (fetus and placenta)
Passageway (birth canal - pelvic bones, soft tissue)
Powers (contractions)
Position of mother
Psychological response
67
passenger
Size of fetal head
Fetal presentation
Fetal lie
Fetal attitude
Fetal position
68
fetal head
- Fetal head either hinders or makes labour easy
- Bones of cranium not fused
- Adjust to shape of birth canal
- Cranial bones overlap under pressure of powers & demands of pelvis
- Molding occurs means overlapping (normal head shape returns within 3 days)
69
fetal presentation
- Refers to the the part of the fetus that enters the pelvis first and leads through the birth canal
- Normally occipital bone presents first
1) Cephalic presentation (head first)
normal/ideal, Vertex most common (occiput first)
2) Shoulder
3) Breech (butt, feet, or both first)
70
fetal lie
- The relation of the spine of the fetus to the spine of the mother
- Longitudinal (vertical) - spines are parallel
- Transverse (horizontal, oblique) - fetus’ spine is at a right angle to the mothers spine
Vaginal birth cannot occur
71
fetal attitude
- The relation of the fetal body parts to one another
- General flexion - the “normal” shape of the fetus in the womb, back of the fetus rounded, chin flexed in, thighs and knees are flexed in
- Deviation from the normal general flexion can cause issues with birth
72
fetal position
Fetal position refers to the relationship of the presenting part with the maternal pelvis
- eg. right occipitoposterior (ROP)
73
station
- How far down is the baby in the pelvic outlet
- Ischial spine = station 0 = baby is engaged and ready to come out
- Above ischial spine = - ; below ischial spine = +
- Birth is imminent when the presenting part is at +4 to +5 cm, below the spine
74
engagement
- The largest transverse diameter of the presenting part has passed through the maternal pelvic brim inlet into the true pelvis
- Usually the biparietal diameter
- Engagement is a good sign
- Nonengaged presenting part means floating & may be a malposition issue of cephalopelvic disproportion
75
passageway
Bony pelvis
Soft tissues of the cervix
Pelvic floor
Vagina
Introitus (external opening to the vagina)
76
passageway: cervical dilation
- Cervical dilation is the opening of the cervix during labour
- Accompanied by effacement and ripening
- Contractions cause dilation of the cervix
- Measure contractions in frequency, duration, intensity
77
powers
primary powers
- Effacement - shortening and thinning of the cervix
- Dilation - enlargement or widening of the cervical opening
- Ferguson reflex - urge to bear down and “push”
secondary powers
- Bearing-down efforts
78
induction of labour
Induction
- Amniotomy (artificial rupture of membranes) + oxytocin
- Must birth baby within 18 hours (risk of infection if left to long)
- Risk of infection and cord prolapse
- Amniotic fluid should be clear
- Weigh pads to estimate fluid loss
79
induction risks
- Failure to achieve labour or vaginal delivery
- Uterine hyper-stimulation with fetal compromise or rupture
- Increased risk of C-Section
- Umbilical Cord Prolapse
80
how to ripen cervix
- Foley catheter in cervix
- Lamineria hood (umbrella like thing opens in the cervix)
- Prostaglandin gel in cervix (don’t use this in risk of rupture or previous C section → bleeding risk)
81
do not use induction if
-the baby has abnormal fetal lie
-Vertical C section
82
tachysystole
more than 5 contractions in 10 minutes
83
tetanic contraction
Contractions lasting longer than 120 seconds at a time
84
tocolytic
medications that slow labour (morphine, nitroglycerin)
85
positioning
- Frequent changes in position
Relieve fatigue
Increase comfort
Improve circulation
- Labouring woman should be encouraged to find positions most comfortable to her
- Lithotomy position - supine hypotension syndrome
86
v-bac
- Vaginal birth after C section
- Higher risk of uterine rupture
- May need C section
- Dystocia - labour stops
87
signs preceding labour
Lightening (dropping)
Braxton-Hicks
Backache
Bloody Show
Spontaneous rupture of membranes
Diarrhea
Spurt of Energy
Weight loss
Restless or sleepless nights
Tension, fatigue, anxiety
88
first stage of labour
- Begins with onset of regular uterine contractions
- Ends with full cervical effacement and dilation
- Two phases:
Latent phase: up to 3 cm of dilation
Active phase: 4-10 cm of dilation, more rapid dilation of the cervix and increased rate of descent
89
things to consider during first stage
- Leopold's manoeuvres - Abdominal palpation
- Assessment of fetal heart rate (FHR) and pattern
- Fetal movement - 6-10 movements in 1 hour
Contractions
- Every 2 minutes
- Contractions last about 90 seconds
- Intensity - how hard the fundus gets during contraction
- Should have at least 30 second resting tone
- urine specimen
- blood tests
- assessment of amniotic membranes and fluid
Check for meconium (green or black)
Should be pale, watery
1000 mL come out at term
Want to birth baby within 18 hours of membrane rupture
90
second stage of labour
- full dilation-birth
- Latent - fetus continues to descend passively through the birth canal and rotate anteriorly. The urge to bear down is not strong
- Active - strong urges to bear down
91
things to consider during second stage
- When the head crowns, stop pushing to allow cervix to widen
- Intrauterine resuscitation - if fetus is in distress, give mom 8-10L of oxygen and position on left side
- Increase assessments and vitals
92
immediate assessment and care of newborn
- Cord clamping
- Care focused on assessing and stabilizing the newborn
- Apgar scores
1 minute & 5 minutes after birth
10 = perfect score
93
Apgar
appearance (skin colour)
pulse (heart rate)
grimace (reflex irritability)
activity (tone)
respirations
94
third stage of labour
Placental separation and expulsion
- Firmly contracting fundus
- Change in shape of uterus
- Sudden gush of dark blood from introitus
- Apparent lengthening of umbilical cord
- Vaginal fullness
- Active - comes out on own
- Passively - give oxytocin to help placenta come out
cord blood collection
maternal physical status (signs of concern - excessive blood loss, alterations in LOC and vitals)
uterus should fall back down, midline, firm
95
normal blood loss in birth
Normal is 500ml for vaginal, 1000ml for c section
96
fourth stage of labour
2 hours after labour
Assess newborn q15 minutes after birth
Assess uterus → should be firm
Care of the new mother, newborn, and family
Postanaesthesia recovery
Family–newborn relationships
97
7 cardinal movements
1) engagement
2) descent
3) flexion
4) internal rotation
5) extension
6) restitution and external rotation
7) birth by expulsion
98
maternal adaptations in labour
cardiovascular
- CO increases 10-15% in 1st stage and 30-50% in 2nd stage
- BP increases during contractions
- WBC increases
- 400 mL from uterus → back into body → edema
renal
-proteinuria
GI
-N&V
-motility slows
endocrine
-blood glucose decreases
99
objective sign that the second stage has begun
Inability to palpate the cervix during vaginal exam indicates complete effacement and full dilation
100
FHR assessment frequency for stages of labour
- FHR assessed hourly in latent stage of labour or when significant change occurs
- FHR assessed every 15-30 minutes in active stage
- FHR assessed every 5-15 minutes during active phase of second stage (pushing)
101
Abnormal FHR patterns are associated with
fetal hypoxemia
102
intermittent auscultation
- Indicated for healthy pregnancy
- Less restrictive
- Manually assessing FHR and contractions
- Can't assess variability, type of decelerations, pattern of contractions
103
Intrauterine Pressure Catheter (IUPC)
measures contraction intensity in mm Hg
104
internal EFM
- application of a spiral electrode to the fetal presenting part to assess the FHR
- more accurate than external
- the membranes must be ruptured, the cervix sufficiently dilated (at least 2 to 3 cm), and the presenting part low enough to allow placement of the spiral electrode
105
fetal monitoring: artifact
This pattern is likely from baby moving around, may need to reposition ultrasound
106
fetal monitoring: normal
- 110-160 bpm
- Normal contraction pattern
- Variability 6-25 bpm (moderate)
- Accelerations with scalp stimulation or spontaneous accelerations
- No decelerations, early decelerations, uncomplicated variable decelerations
107
fetal monitoring: atypical
- Tachysystole
- 100-110 bpm
- or FHR >160 beats/min for 30-80 min
- Variability ≤5 beat/min for 40 to 80 minutes
- Absence of acceleration with scalp stimulation
- Repetitive uncomplicated variables, non repetitive complicated variables, intermittent late decelerations
- Variable, occasional late decelerations
- Warrants further assessment
108
fetal monitoring: abnormal
- Tachysystole
- FHR <100 bpm
- FHR >160 bpm for >80 min
- Erratic baseline
- Variability: 5 or less for >80 min, 25 or more for >10 min
- Repetitive complicated variables, recurrent late deceleration
- Sinusoidal rhythms
- Decreased FHR during or within 30 seconds after a contraction
- Emergency → intrauterine resuscitation → try to deliver baby ASAP
109
baseline rate
average rate during 10 minute segment of contractions rounded to 5 beats/min, excluding periods of marked variability
110
absent variability
amplitude range is undetectable (0-2 bpm) `
111
minimal variability
- Amplitude range is detectable but less than or equal to 5 bpm
- Can result from fetal hypoxemia and metabolic acidosis; fetal sleep, tachycardia, medications, prematurity, congenital anomalies, anemia, cardiac arrhythmias, infection, pre existing neurological injury
- Intervention: Intrauterine resuscitation
112
moderate variability
Amplitude range is 6-25 bpm
Normal
Means normal fetal acid-base balance
113
marked variability
Amplitude range is greater than 25 bpm
intervention: intrauterine resuscitation
114
intrauterine resuscitation
- position on left side
- stop oxytocin
- increase IV fluids
- 8-10 L O2
- assess for meconium
115
fetal tachycardia: causes
- Maternal fever
- Maternal or fetal infection
- Maternal hyperthyroidism
- Fetal anemia
- Fetal early hypoxia
- Maternal medications (atropine)
- Maternal illicit drug use (cocaine)
116
fetal tachycardia: nursing interventions
- Confirm fetal heart rate by auscultation
- Check maternal pulse and temp
- Rule out other non-hypoxia, maximize oxygenation
Lateral positioning
Discontinue oxytocin
Increase main IV rate
O2 at 8-10 L/min via face mask
Check for meconium stained fluid
Rule out fetal dysrhythmias
Notify primary care provider
Explain the situation, reassure woman and partner
117
fetal bradycardia: causes
- Fetal cardiac problem (structural defects)
- Viral infections (cytomegalovirus)
- Maternal hypoglycemia
- Maternal hypothermia
- Cord prolapse
118
fetal bradycardia: nursing interventions
- Check maternal pulse
- Confirm FHR by auscultation
- Rule out other non hypoxic causes (post maturity, fetal malposition, drugs)
- Vaginal exam to assess labor progress and rule out cord occlusion or prolapse
- Check for meconium stained fluid
- If due to hypoxia, maximize fetal oxygenation
Lateral positioning
Discontinue oxytocin
Increase main IV rate
O2 at 8-10 L/min via face mask
- Notify primary care provider
- Explain the situation, - reassure woman and partner
- If not resolved prepare to deliver
119
moderate bradycardia
80-110
120
severe bradycardia
<80
121
periodic FHR changes
changes that occur with uterine contractions
122
episodic FHR changes
changes that are not associated with uterine contractions
123
accelerations
- visual apparent, abrupt increase in FHR from baseline
- 15 bpm above for 15 seconds or more
- If change lasts longer than 10 minutes, that = changes in baseline
- Normal
124
early decelerations
- gradual decrease with contraction
- Normal/no intervention
- Cause: compression of the fetus on the pelvis/soft tissue (compression of the head stimulates vagus nerve → HR decreases)
125
late decelerations
- gradual decrease after peak of contraction
- Concerning (not normal) - requires intervention
- Cause: Uteroplacental insufficiency (decreased perfusion from placenta)
- Do intrauterine resuscitation
- Typical: happens occasionally
- Atypical: if it happens in more than 50% of contractions
126
variable decelerations
- abrupt decrease at anytime of contraction
- Requires intervention
- Uncomplicated: abrupt decrease in FHR and abrupt return to baseline; less than 3
- Complicated: happens 3 or more times in a row (repetitive)
- Cause: cord compression (decreased blood flow to baby)
- Do intrauterine resuscitation
127
prolonged decelerations
- FHR below baseline of 15 beats/min and lasting more than 2 minutes, less than 10 minutes
- Do intrauterine resuscitation
128
VEAL CHOP
V - variable decelerations
E - early decelerations
A - accelerations
L - late decelerations
C - cord compression
H - head compression
O - okay
P - placental insufficiency
129
Fetal scalp blood sampling
- obtaining a capillary fetal blood sample in a fetus more than 34 weeks of gestation
- Tested for ph and lactate → acidosis
- Ph less than 7.2 → deliver
- Do this if there is abnormal EFM
130
amnioinfusion
infusion of room- or body-temperature isotonic fluid (usually normal saline or lactated Ringer’s solution) into the uterine cavity when the volume of amniotic fluid is low
131
non pharmacological pain management
- Relaxation
- Imagery and visualization
- Music
- Touch and massage
- Breathing techniques
- Effleurage - light massage, light stroking of the abdomen
- Counterpressure - steady pressure to the sacral area with a firm object (tennis ball) or the fist or heel of hand
- Water therapy (hydrotherapy) - Bath, shower, water immersion
- Transcutaneous electrical nerve stimulation (TENS)
Electrodes placed on both sides of the lumbar and sacral spine
Patient turns control knobs to provide continuous low voltage electrical impulses during contractions
Does not decrease pain, but helps release endorphins, and makes pain less disturbing
- Acupressure and acupuncture
- Application of heat and cold
- Hypnosis
- Biofeedback
- Aromatherapy
- Intradermal sterile water block
- Maternal position and movement
132
Opioid (narcotic) agonist analgesics
- Fentanyl & morphine
- No amnesia, but euphoria and well being
- Should not be administered until labour is well established
- Usually given after 5cm in primipara, 3cm in multipara (opioids can slow down labour if given to early)
- If given within 4 hours of baby being born it can affect baby (over sedated)
133
Opioid (narcotic) agonist–antagonist analgesics
Less risk of respiratory depression
134
Opioid (narcotic) antagonists
Naloxone
Reverses opioid effects (respiratory depression)
135
Local infiltration anaesthesia
Used during episiotomy
Inject lidocaine into local area
136
pudendal nerve block
- Administered late in second stage
- Useful for episiotomy, vacuum extractor, forceps
- Does not relieve pain from uterus, just lower vagina, vulva, perineum
137
spinal anesthesia
Subarachnoid space
Mixes with CSF
Not used for labour, only C section
Feeling lost from nipple down
Spinal headache
138
epidural anaesthesia
most effective pharmacological pain-relief method for labour that is available
Feeling lost from hips down
Often have catheter
don't feel the urge to bear down and push
139
Contraindications to subarachnoid and epidural blocks
- Maternal refusal or inability to cooperate
- Maternal cardiac conditions, significant hypotension
- Antepartum hemorrhage (bleeding while pregnant)
- Coagulopathy
- Infection at injection site
- Increased intracranial pressure
- Allergy to anaesthetic drug
140
gate control method
Using distraction techniques, such as massage or stroking, music, focal points, and imagery, reduces or completely blocks the capacity of nerve pathways to transmit pain
141
puerperium
- Postpartum period is interval between birth and return of reproductive organs to their nonpregnant state
- Traditionally lasts 6 weeks, although this varies among women
- Weight drops from 11- 13 lbs from uterine contents and blood
- Pulse rate decreases and stabilizes
- Hemoglobin rises by 6 weeks postpartum
- Hemorrhoids may become prominent
- Respirations stabilize and ease of respirations occurs
- Hormones levels normalize by 4-5 weeks post partum
142
length of hospital stay after birth
- 1-2 days is average length of hospital stay for vaginal birth
- 4-12 hours if they have midwife
- 2-4 days is the average length of stay for C section
- Delivery day is counted as day 0
143
involution
- return of uterus to nonpregnant state following birth
- Progresses rapidly; right after expulsion of th placenta
- Fundus descends 1 to 2 cm every 24 hours; takes 6 days for fundus to return
- 2 weeks after childbirth uterus lies in true pelvis and should not be palpable
- 1000g → 60-80g
144
sub involution
- failure of uterus to return to nonpregnant state
- Common causes are retained placental fragments and infection.
145
afterpains
- Periodic relaxation and vigorous contractions cause uncomfortable cramping
- Typically resolve in 3-7 days
- Common in multiparous women
- Worsens during breastfeeding (releases oxytocin)
- 2 hours postpartum bleeding should be equivalent to a heavy period
146
lochia
postbirth uterine discharge
147
lochia rubra
initially bright red, may contain small clots
148
lochia serosa
pink or brown after 3-4 days (old blood, tissue debris), last 2-4 weeks
149
lochia alba
whitish-yellow colour, contains primarily leukocytes and decidual cells, may continue for a few weeks
150
cervix after birth
- Soft immediately after birth
- Within 2 to 3 postpartum days, cervix is 2 to 3 cm, and by 1 week, it is about 1 cm.
- Ectocervix appears bruised and has small lacerations—optimal conditions to develop infections.
- Changes from hole shaped (pre pregnancy) to fish mouth shaped
151
vagina and perineum after birth
- Estrogen deprivation is responsible for thinness of vaginal mucosa and absence of rugae.
- The vagina gradually decreases in size and regains tone but never completely returns to prepregnancy state.
- Thickening of vaginal mucosa occurs with return of ovarian function.
- Dryness and coital discomfort (dyspareunia) may persist until return of ovarian function.
- Introitus is erythematous and edematous.
- Episiotomies heal within about 2 weeks.
- Hemorrhoids (anal varicosities) are common and decrease within 6 weeks of childbirth.
- Assessing lacerations 4-6 weeks after
152
abdomen after birth
- During the first 2 weeks, the abdominal wall remains relaxed.
- The woman has a still-pregnant appearance.
- Return to prepregnancy state takes 6 weeks.
- Depends on previous tone, proper exercise, and amount of adipose tissue
153
urinary system after birth
- Kidney function returns within 1 month
- Glycosuria disappears after 1 week
- Proteinuria and BUN increases due to autolysis of uterus
- Within 12 hours, profuse diaphoresis (nighttime)
- Profuse diaphoresis often occurs at night for the first 2 to 3 days.
- Urine output = 3000 mL per day during first 2-3 days
- Excessive bleeding can occur because of displacement of the uterus if the bladder is full.
- With adequate emptying of the bladder, bladder tone is usually restored by 5 to 7 days after childbirth
- High risk for UTI 1 month postpartum
154
bowel evacuation after birth
- Spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth.
- Increase fluid and fibre; stool softeners may be required; encourage walking
155
breastfeeding mothers
- Before lactation, a yellowish fluid, colostrum, can be expressed from nipples.
- Takes 72-96 hours after birth for colostrum to transition to milk (milk coming in)
- Tenderness may persist for 48 hours after start of lactation.
-Engorgement occurs 3-4 days after birth
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non breastfeeding mothers
- Engorgement resolves spontaneously, and discomfort decreases within 24 to 36 hours.
- Breast binder or tight bra, ice packs, fresh cabbage leaves, or mild analgesics may be used to relieve discomfort.
- If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.
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cardiovascular system after birth
- Increase in blood volume during pregnancy allows most patients to tolerate considerable blood loss during childbirth
- 12 weeks back to pre pregnancy numbers
- White counts are normally high after birth (as long as there are no other indications of infection)
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neurological system after birth
- Pregnancy-induced neurological discomforts abate after birth. (eg. carpal tunnel)
- Headache requires careful assessment.
- The most common form of headache occurs in breastfeeding patients and are those caused by muscular contraction or tension and migraines without aura.
- Postpartum headaches may be caused by postpartum-onset pre-eclampsia, stress, and leakage of cerebrospinal fluid into the extradural space during placement of the needle for administration of epidural or spinal anaesthesia.
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MSK after birth
- Reversal of pregnancy adaptations
- Joints are completely stabilized by 6 to 8 weeks after birth.
- A new mother may notice a permanent increase in shoe size.
160
integumentary system after birth
- Chloasma of pregnancy usually disappears in the postpartum period.
- It persists in about 30% of women.
- Hyperpigmentation of areolae and linea nigra may not regress completely after childbirth
- Vascular abnormalities, spider angiomas, palmar erythema regress with rapid decline in estrogens.
Extreme hair loss after pregnancy
161
immune system after birth
- mildly suppressed during pregnancy, gradually returns to the prepregnancy state.
- This rebound can trigger autoimmune conditions (e.g., multiple sclerosis).
RH vaccine
- 28 weeks gestation
- Within 72 hours after birth (miscarriage, abortion, stillbirth, live birth)
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psychological: 3 distinct phases of adjustment in the post partum period
- Taking in: 1-2 days post delivery, passive care giver
- Taking hold: 2-7 days, more independent with self care as well as baby
- Letting go: 7 days, adapts and adjusts well
163
postpartum blues
-Mild emotional sensitivity
- Normal
- Crying, feeling lonely
- Result from changes in hormones and anxiety about new baby
- Provide emotional support, reassurance, teaching
- 3 days postpartum and then gradually goes away
164
post partum depression
Baby blues lasting more than 2 weeks
165
Transfer From Recovery Area
- After the initial recovery period (1 to 2 hours), the woman may be moved to a postpartum room in the same or another nursing unit.
- Regardless of obstetrical status, no woman should be discharged from the recovery area until she has completely recovered from anaesthesia.
- vital signs stable, pain managed
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criteria for early discharge
- Woman and baby are in stable condition
- With no complications, approximately 24 to 36 hours after birth
- Mother is able to and confident in care for her newborn
- Adequate support systems in place
- The nurse and health care provider are legally responsible for ensuring that the woman is not discharged before she is stabilized within normal limits.
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Baby gets assessed by HCP at 1 week of age
Look for jaundice and weight
Baby can't lose more than 10% of birth weight
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2 most important things to prevent blood loss
Maintaining good uterine tone
Preventing bladder distention
169
indication of excessive blood loss
A perineal pad saturated in 15 minutes or less or pooling of blood under the buttocks
170
normal bladder function after birth
- After birth, spontaneous void occurs in about 6 to 8 hours.
- Measure first void
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caloric intake after birth
1800 to 2200 kcal/day; lactating women need to add 350 to 400 kcal/day.
172
BUBBLLEHE
B - breasts (milk production, nipples)
U - uterus (fundus - location and consistency)
B – bladder (function - amount, frequency)
B - bowel (passing gas or bowel movement, bowel sounds)
L - lochia (amount, colour)
L - legs (peripheral edema)
E – episiotomy/perineum (discomfort, condition of repair)
H – hemorrhoids/Homan’s Sign (DVT)
E - emotional (mood, fatigue)
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extrauterine adaptation
- happens after cord is cut
- lasts about 6 hours
Establishing and maintaining respirations
Adjusting to circulatory changes
Regulating temperature
Ingesting, retaining, and digesting nutrients
Eliminating waste
Regulating weight
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transition period
1. Initial Period of Reactivity
2. Period of Relative Inactivity
3. Second Period of Reactivity
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initial period of reactivity
-30 minutes after birth
-Newborn hr increases rapidly but gradually decreases within 30 minutes to baseline of 100-160 bpm
-Respiratory: irregular respirations, fine crackles, grunting, nasal flaring, retractions → these should resolve within the first hour
-Audible bowel sounds, meconium maybe
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period of relative inactivity
-Lasts from 60-100 minutes
-Respirations may be rapid and shallow, but not laboured
177
second period of reactivity
-Between 2-8 hours after birth
-Brief periods of tachycardia, tachypnea, increased muscle tone, skin colour changes, mucus production
-Meconium commonly passed during this stage
178
initiation of breathing
-decreased O2 and increased CO2 stimulate the respiratory center
-handling and drying newborn
-Transient tachypnea can last a few hours after birth
179
signs of respiratory distress
-Nasal flaring, intercostal or subcostal retractions, grunting with respirations
-Seesaw or paradoxical respirations
-Resp rate below 30 or above 60
-Acrocyanosis (blue discoloration of hands and feet) → normal in the first 7-10 days after birth
-Central cyanosis is abnormal → hypoxemia
-Hypoglycemia, hypotension
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newborn: cardiovascular system
- 110-160bpm
- Most murmurs during the newborn and infant periods are not significant and disappear by 6 months
- Avg systolic: 60-80
- Avg diastolic: 40-50
- A drop in systolic BP (about 15) is common in the first hour
- Premature babies have more blood volume
- Delayed cord clamping increases blood volume
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newborn: thermoregulation
- Lose heat about 4x faster than adult
- Inadequate insulation and fat stores
- Don't have metabolic capability to produce heat
- We need to maintain a neutral thermal environment
- Dry infant as soon as they’re born, hats, skin to skin contact
182
brown fat
when baby is hypothermic they will metabolize their very limited glycogen and fat stores to produce heat
183
cold stress
Cold baby → oxygen consumption increases → increased resp rate
184
hyperthermia
>37.5
Sepsis
Increased environmental temp, warmers, sunlight, excessive clothing or blankets
Can cause dehydration
185
conduction
loss of heat from body surface to a cooler surface in direct contact (eg. weighing scale)
186
convection
flow of heat from the body to cooler ambient air (hats help)
187
radiation
loss of heat from body surface to a cooler solid surface not in direct contact but in relative proximity (place cribs away from outside windows)
188
evaporation
vapourization of moisture from the skin (eg failing to completely dry the newborn)
189
newborn: glucose metabolism
-During fetal life, glucose is transferred across the placenta from the mother
-At birth, the energy demands are increased but the maternal glucose is cut off causing neonatal glycogenolysis
-RDS, cold stress, asphyxia, maternal diabetes and hypoglycemia will influence this transition process
190
newborn: renal system
-First pee within 24 hours of birth → indicates good kidney function
-40 mL of urine in bladder
-Void once a day initially
-then voids match the days alive until 7 days
-Brick dust spots and cloudy urine usually normal after birth
191
Newborn: GI
- Amylase and lipase not present at birth → limited ability to digest fats
- Meconium - Passed within 12-24 hours of life
Signs of gastrointestinal problems
- Failure to pass meconium could mean bowel obstruction
- Abdominal distention at birth
- Sunken abdomen + bowel sounds heard in chest + signs of respiratory distress = diaphragmatic hernia
- Projectile vomiting
192
Hypoglycemia signs
hypoglycaemia = <2.7
Jittery, lethargic, apnea, feeding problems, seizures
193
conjugated bilirubin
Soluble and excretable as a part of bile
194
unconjugated bilirubin
- insoluble and almost entirely bound to circulating albumin
- The unbound bilirubin can leave the vascular system and permeate other extravascular tissues (e.g., skin, sclera, and oral mucous membranes)
- It can also cross the blood–brain barrier and cause neurotoxicity (acute bilirubin encephalopathy or kernicterus).
- When levels of unconjugated bilirubin exceed the ability of the liver to conjugate it, plasma bilirubin increases and jaundice appears
195
causes of jaundice
Late feeding, GI obstruction, not passing meconium, medications, breakdown of lots of RBCs (vacuum birth causes hematoma)
196
physiological jaundice
-Transient (resolves without treatment) and occurs in most newborn during the first week of life (considered normal)
Increase number of RBC with shorter life span
Immature liver
Increased amounts bilirubin delivered to liver
Defective uptake of bilirubin from plasma
Defective conjugation of the bilirubin
Defect in bilirubin excretion
Inadequate hepatic circulation
Increased reabsorption of bilirubin from intestine
197
pathological jaundice
- Bad jaundice!
- Jaundice that appears on the first day of life (first 24 hrs) or jaundice that persists even with treatment
- Diagnose by doing blood tests
198
common causes of pathological jaundice
- Intrinsic blood disorders (hemolytic disease of newborn)
- Extravascular hemolysis (hemorrhage)
- Impaired hepatic function
- Biliary obstruction
199
breastmilk jaundice
- Small percentage of breastfed infants become jaundiced
- Caused by: Breastmilk containing high levels of fatty acids which inhibits bilirubin conjugation
- No treatment, usually resolves on own
200
kernicterus
- Caused by deposition of unconjugated (fat loving) bilirubin into the basal nuclei of the brain → causes brain damage
- Symptoms are hypotonia, absent reflexes, coma, followed by excitation
- About half of the infants survive but are affected with CP, hearing impairment and neurological deficits
- Common with intrinsic blood disorders or severe dehydration
201
jaundice treatment
- Frequent Feeding:
- Every 2 hours
- Encourage breastfeeding
- Use of supplemental systems if required
- Early feeding act as laxative and promote GI elimination & bacterial colonization
- Intensive Phototherapy
- Blood Transfusion
- IVIG
202
Desquamation
peeling skin does not occur until a few days after birth (common in post term)
203
nevi
-small, flat, and pink and are easily blanched
-common sites are the upper eyelids, nose, upper lip, and nape of the neck
-tend to be symmetrical
-They have no clinical significance and require no treatment
204
Erythema toxicum
transient rash, common
205
Caput succedaneum
- generalized, easily identifiable edematous area of the scalp, most commonly found on the occiput
- Crosses suture line
- Pressure on the head during birth → slow venous return → swelling
- Can cause trouble feeding → neurological deficit
206
Cephalhematoma
- collection of blood between a skull bone and its periosteum
- Unilateral, does not cross suture line
207
Subgaleal hemorrhage
- bleeding into the subgaleal compartment
- commonly associated with difficult operative vaginal birth, especially vacuum extraction
208
galeazzi sign
Asymmetry of gluteal and thigh folds with shortening of thigh
209
ortolani test
Limited hip abduction
210
allis sign
Shortening of the femur
211
newborn tremors
- Transient tremors during crying are normal
- Shouldn't have tremor at rest
212
signs of hypoglycemia
- tremors/shivering
- trouble feeding
- hypothermia
- irritability
- lethargy
- hypotonia
213
interpretation of APGAR
0-3 = severe distress
4-6 = moderate difficulty
7-10 = minimal or no difficulty adjusting
214
Birth Through the First 2 Hours
- Airway maintenance - Side lying, clear airway with suction or syringe
- Body temperature maintenance - Delay first bath at least 8 hours until the newborn can maintain body temperature
- Eye prophylaxis - Erythromycin ointment is always put in the eyes
- Vitamin K prophylaxis - Given intramuscularly (IM)
- Prevents hemorrhagic disease of the newborn (HDNB)
- Cord Care - Cord that is attached to them remains clean
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Large for gestational age (LGA)
above 90th percentile
216
Appropriate for gestational age (AGA)
between 10th-90th percentile
217
Small for gestational age (SGA)
below 10th percentile
218
Low birth weight (LBW)
<2500g
219
Very low birth weight (VLBW)
<1500g
220
Extremely low birth weight (ELBW)
<1000g
221
Very Pre-Term infant
<30 weeks
222
Term infant
38-41 weeks
223
post term infant
>42 weeks
224
Newborn Physical Assessment: Preterm Infant
-At risk for impaired vision/hearing, chronic lung disorders, cognitive impairment
Physical characteristics:
-Limp, weak muscles
- Weak cry
- Rapid, shallow respirations
- Pot belly abdomen, large genitalia
- Shiny skin
- Thin, permeable skin
- Retinopathy due to O2 therapy
- ++lanugo
225
Newborn Physical Assessment: Post-term Infant
- Fetus receives poor oxygenation and nutrient transfer which depletes glucose reserves
- Physical characteristics:
- Long, lean, angular body
- Little subcutaneous fat
- Hair is coarse and thick
- Wrinkled, dry skin
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grasp/palmer reflex
place finger in palm of hand, newborns fingers curl around examiners fingers
227
rooting/sucking reflex
Touch newborn’s lip, cheek, or corner of mouth with nipple or finger. Newborn turns head toward stimulus and opens mouth.
228
tonic neck reflex
when newborn is laying supine, turn head quickly to one side, arm and leg on that side extend, the opposite arm and leg flex (fencers position)
229
Stepping reflex
hold newborn upright with feet touching the floor/surface, newborns will stimulate walking
230
glabella reflex
tap over forehead, bridge of nose, or maxilla of the newborn whose eyes are open, newborn should blink for the first 4 or 5 taps
231
babinski reflex
stroke from heel of foot → lateral sole → across the ball of foot; infants toes should hyperextend with dorsiflexion of big toe (positive babinski sign)
232
newborn: normal skin findings
Pink with some acrocyanosis and mottling with bathing
Lanugo
Milia
Vernix
Erythema toxicum
Mongolian spots
Harlequin sign
Birthmarks
Port Wine Stains
Stork’s bite marks
Strawberry Marks
233
newborn: normal head findings
Skull consists of 6 bones
4 sutures separate the bones and are felt as ridges
2 fontanelles are soft areas at the junction of each of the sutures
Molding of the head following vaginal delivery
234
newborn: normal eye findings
Eye colour is dark
Sclera is bluish white
Eyelids swollen or reddened
Pseudostraismus (cross eyed)
Nystagmus
Pupil reaction – PERRLA
235
normal nose findings
Symmetrical
Nares patent
Random sneezing present
236
newborn: normal chest findings
At term, averages 30-37.2cm in size
Circular and symmetrical
Neonatal respirations are diaphragmatic and the thoracic cage remains immobile while the abdomen rises and falls
Breast tissue present, some milky secretion
RR 30-60/min, regular, distinct and rhythmic
HR 120-160/min, regular, distinct and rhythmic
Preterm infant may have chest pulsating with heart beat
Point of Maximal Intensity (PMI) at 4th intercostal space
237
normal abdominal findings
Liver palpation
Abdomen symmetrical, cylindrical, protrude slightly, moves with respirations
Umbilical stump bluish white with 3 vessels present
Back symmetrical
No distention or bulging
Auscultate four quadrants for bowel sounds
Present 1 hour after birth
Palpate clockwise for softness tenderness & masses
238
newborn: normal genital findings
Term female genitalia prominent
Pseudomenses
Term male testicles are usually in the scrotum and urethral opening at top of penis
Foreskin is not retractable until 6-8 mths
Anus is patent
239
Infants may be transferred to the NICU if
Malformations, congenital anomalies
Respiratory distress
Cardiac Anomalies
Hypoglycemia
Neonatal Abstinence Syndrome
240
Nonpharmacological management of pain in newborn
Non nutritive sucking/pacifier
Oral sucrose
Skin to skin contact
Breast milk/feeding
Swaddling
Touch, massage, rocking, holding
241
Pharmacological management of pain in newborn
Usually used for procedures
Local anesthesia - circumcision, chest tube insertion
Topical anesthesia - circumcision, lumbar puncture, venipuncture, heel sticks
Acetaminophen - mild to moderate pain from inflammatory conditions
Morphine and fentynal
242
Feeding patterns
- newborn should be put to the breast ideally within the first hour after birth
- Newborns should be allowed to feed when they awaken and demonstrate typical hunger cues, regard- less of the amount of time since the previous feeding (cue based feeding)
- Breastfed babies feed more often than formula-fed babies because breast milk is digested faster
243
elimination
- approximately one wet diaper for each day of life until the fifth to seventh day; then frequent, clear, pale yellow voiding
- Formula-fed newborns may have as few as one stool every other day after the first few weeks of life; stools are pasty to semiformed.
- Breastfed newborns should have at least five stools every 24 hours from 7 to 28 days of age. The stools are looser and resemble mustard mixed with cottage cheese.
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prevention of SIDS
the death of an infant under the age of 1 year of age which is sudden, unexpected, and with- out a clear cause
Sleep supine
Smoke free environment
Safe crib environment (no toys, loose bedding)
Room sharing for 6 months
Avoid overheating infant
Breastfeeding and pacifier
Don't co-sleep
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PURPLE Crying
P - peak of crying. Your baby may cry more each week—the most at 2 months, then less at 3 to 5 months
U - Unexpected. Crying can come and go and you don’t know why.
R - Resists soothing. Your baby may not stop crying, no matter what you try.
P - Pain-like face. Crying babies may look like they are in pain, even when they are not.
L - Long-lasting. Crying can last as much as 5 hours a day, or more.
E - Evening. Your baby may cry more in the later afternoon and evening.
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newborn: signs of illness
- Jaundice
- Fever (>38)
- Hypothermia (<36.5)
- Poor feeding
- Vomiting
- Diarrhea
- Decreased urination
Less than 6 wet diapers/day after 6 days of age
- Decreased bowel movement
Breastfeed → less than 3/day
Formula → less than 1 every other day
- Breathing difficulties
- Cyanosis
- Lethargy
- Inconsolable crying
- Bleeding or purulent drainage
- Drainage from eyes
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ways to relieve post dural puncture headache
Lay supine
Oral analgesics or caffeine
Epidural blood patch procedure
Monitor vital signs closely
Nurs 3031
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