1. Latent Phase (0-3 cm)- slow, infrequent, short contractions 
1. begins with contractions, ends with rapid dilitation
2. contractions 20-40 sec long
3. 6 hrs nullipara, 4.5 hrs multipara
2. Active Phase (4-7 cm)- frequent, longer, stronger contractions 
1. contractions 40-60 sec long, 3-5 minute frequency
2. three hours nullipara, 2 hrs multipara
3. show, water breaks
3. Transition Phase (8-10 cm)- frequent, intense contractions
1. peak intensity, 2-3 minute frequency, 60-90 sec duration
2. amniotopy to rupture non ruptured membranes, last of mucus plub out

Frequency- time from beginning of one contraction to beginning of next

Duration- length of one contraction beginning to end

Intensity- strength of contraction of musclee

What can external fetal monitors measure?

What can internal fetal monitors measure?

External = frequency and duration of contraction

Internal: frequency, duration, and intensity of contraction

Opening of the cervis

ranges from 0-10 cm

Relationship of presenting part of the baby to the mom's pelvis

Three letters (two outside letters are mother's pelvis, inside letters are baby)

Determines where the baby

s head is in relation to the ischial spines

0/engaged - in line with ischial spines

+1, 2, 3, etc = baby is past the ischial spine and heading out

-1, 2, 3, etc = baby is not yet past the ischial spine

cervial thickness change when internal oos gets drawn up into the body of the uterus

measure the thickness between the external oos and where the uterus opens up

not effaced - thick, 0

completely effaced - thin, 100

Done at 8-12 Weeks

as early as 5 weeks

• Done when mom's are older than 35 yrs and MSAFP is abnormal
• retrival and analysis of chorionic villi from growing placenta
• chorion cells located with ultrasound
• catheter or biopsy needle removes chorionic cells from placenta
• multiple fetuses = remove cells from each placenta
• results in next day
• analyzed to look for genetic disorderrs
• abnormal chromosomes or nondisjunction

• tell mom to report chills/fever
• 1% risk of excess bleeding/preg loss
• risk of child being born w/ missing limbs
• Rh isoimmunixation
• if mom is Rh-, Rhogam is given to guard against isoimmunization to fetus

• technique
• 20 mL pocket of amniotic fluid located by ultrasound
• withdraw amniotic fluid through abdomen wall
• kayotype skin cells in fluid
• analysis of AFP or acytylcholinesterace and amniotic fluid
• preperation
• void
• supine, expose ab, towel under right butt
• FHR and vitals monitored
• no deep breaths during procedure, could shift internal organs

• .5% risk of miscarriage
• monitor after procedure to make sure contractions don't start
• Rh- mom needs Rhogam after procedure (ensure mom's antibodies won't form against placental RBC's released during procedure) 

• acetylcholinesterace (breakdown of blood)- no acetylchoinesterace confirms high AFP level is not a false positive reading caused by blood in fluid (high acetylcholinesterace = neural tube defect)
• AFP (alpha feta protein)- high AFP = fetus has open body defect, low AFP- fetus has chromosome defects
• bilirubin- bilirubin present, analyze for blood incompatibility
• chromosome- fetal skin cells karyotyped for genetic disorders
• fibronectin- helps placenta attach to uterus, shouldn't be present past 20 weeks, returs again as labor approaches (could indicate preterm labor)
• inborn errors of metabolism
• lecithin/sphingomyelin ration- indicates protein of lung surfacant alveoli, formed at 22-24 weeks, shake test, ratio should be 2:1 to indicate lung maturity
• phosphatidyl glycerol and desat phosphatidylcholine- lung surfactant, found in am fluid = decreased risk for resp distress

Diagnose pregnancy at 4-6 weeks  (can see gestational sac)

8 weeks to see fetal outline (crown to rump length to estimate gestational age)

• preperation-
• full bladder wanted (1 glass of water every 15 min for the 90 minutes prior to ultrasound)
• supine, ab revealed, towel under right butt
• use room temperature gel, scan horizontally and vertically
• purpose
• diagnose pregnancy
• confirm presence, size, location of placenta and am flu
• estabilish sex and predict maturity (measure biparietal diameter of head)
• establish complications
• establish presentation and position of fetus

done with ultrasound

measures velocity of RBC's through uterine blood vessels

determines vasc resistance (diabetes, hypertension)

decreased velocity, decreased nutrients to fetus

done with ultraound

based on amt of Ca deposits in base of placenta

0= 12-24 weeks

1 = 30-32 weeks

2 =36 weeks

3 = 38 weeks (fetus is mature)

1. fetal reactivity
2. fetal breathing mvmts
3. fetal body mvmts
4. fetal tone
5. amniotic fluid volume

• 2 assessments= amniotic fluid index and nonstress test
• amniotic fluid should be between 5-25 cm and is determined by ultrasound
• fetal breathing (ultrasound) = one episode of 30 sec sustained fetal breathing mvmts in 30 min observation
• fetal mvmt (ultrasound) three seperate episodes of trunk/limb mvmt in 30 min
• fetal tone (ultrasound) extend/flex extremeties or spine once in 30 mins
• fetal heart reacitivty (non stress test) two fetal heart rate accel 15x15 occur w/fetal mvmt over 20 min (once in ten min) 

• measures respnse of FHR to fetal mvmt
• FHR and u.c. monitors
• fetus moves- FHR should accel 15x15
• no accel = fetus not getting enough oxygen
• done for 10-20 min
• reactive= two accel 15x15 occuring after mvmt
• nonreactive = no accel,no fetal mvmt, decrease in short term FHR varriability
• stimulate mvmt with carb snack or loud sound

• lightening (10-14 days befor labor begines, fetal desenct into lower uterus, not as dramatic with multiparas)
• increase in mom's energy (increase epinephrine, decrease progesterone)
• weight loss of 1-3 pounds (decrease in progesterone)
• ripening of cervix- softer and tips forward
• braxton hicks contractions
• always irregular
• inabdomen
• disappear with walking or sleep
• duration, f, and intensity do not change
• dowsn't achieve cervial dilatation 

• uterine contractions
• show- after cervix ripens, mucus plug is expelled with blood, looks pink
• rupture of membranes
• early rupture = short labor
• if labor doesn't begin within 24 hrs of rupture, could be a risk of prolapsed cord or intrauterine infection 

• molding of head, lasts 1-2 days
• fontanelles- at junction of main sutures
• anterior fontanelle (diamond shaped)
• posterior fontanelle (triangle shaped)
• diameter
• anteroposterior diameter- larger
• transverse diameter- must be smaller than the smallest diameter of the pelvis to pass easily 

• settling of fetal head into pelvis
• nonengagement- by begninning of labor, indicates complication
• floating- presenting part not yet engaged
• dipping-descending but not yet at ischial spines 

• degree of flexion and fetus assumes during labor
• good attitude- flexed spine, bowed forward chin to sturnum, arms flexed across chest, thighs flexed to abdomen
• moderate attitude- chin not touching chest, military position
• bad attitude- usually b/c of small amount of am flu
• brow of head to birth canal, complete extension, arched back, neck extended
• too wide, fetus can't move
• vertex = full flexion, sinciput = moderate flexion, brow = partial extension, face = complete extension

relationship between long/cephalocaudal axis of fetal body vs the long (cephalocaudal) axis of the mom's body

should be longitudinal- vertical (mom and baby are parallel) 

transvers is bad

1. cephalic presentation - head presents first (95%)
1. most frequent 
2. four types (all longitudinal)
1. vertex (best), brow, face, mentum (worst)
2. breech presentation- butt/feet first (3%)
1. good attitude, knees to ab
2. bad attitude, extended knees
3. three types
1. complete (good attitude, butt and feet), frank (butt only), footling (worst attitude, one or two feet first)
3. shoulder presentation (horizontal lie, 1%)
1. one shoulder, iliac crest, hand, elbow
2. caused by relaxed ab walls from multiparity, low placenta, placenta previa
3. need c-section

• four quadrants for outside letters
• right anterior, left anterior, right posterior, left posterior 
• four parts of fetus and landmark for middle letter
• vertex presentation (occiput) or O
• breech presentation (sacrum) or S
• face presentation (mentum) or M
• shoulder presentation (acromion) or A 

1. decent
2. flexion
3. internal rotation- widest part of shoulders in line with transverse diameter
4. extnesion- head extends up, front of head, face, chin are born
5. external rotation- head rotates to transerverse position, shoulders inline with outlet to emerge, anterior shoulder born
6. expulsion- rest of body born easily

1. incriment- increase in intensity
2. acme- contraction at strongest
3. decrement- decrease in intensity 
4. relaxation period

Danger!

Observable as indent in abdomen

obstructino must be relieved or lower uterus will rupture

full dilatation/effacement to full birth

anus may become everted, stoll expelled

• ends with delivery of placenta
• placental seperation- five minutes after birth
• placental expulsion- naturally or with pressure on fundus
• seperation presentations
• schultze presentation (80%)- shiny/baby side presents first, seperates at center then edges
• duncan presentation- mom/dirty side first, raw, red, irregular, seperates first at edges, then center
• normal blood loss = 300-500 mL vaginal, 800-1000 c-section

• increase blood to uterus, increased BP (increase by 15 mmHg with contraction)
• increased WBC's to 25-30000 vs normal 5-10000
• increased O2 consumption by 100% in second stage
• increase 1 degree F
• fluid loss
• decrease in urine/fluid = more concentrated urine and increase in specific gravity (1.02-1.03)
• softening of cartilage/back pain
• incavite GI, may have loose bowel with contraction

• pressure on head, increased intracranial pressure
• FHR decrease 5 bpm with contraction, returns to normal
• skin has petichae, edema, or ecchymosis on presenting part

• higher than 140/90 BP (systolic increase 15, dyastolic increase of 30) = HTN
• decrease of BP = hemorrhage
• pulse higher than 100 bpm = hemorrhage
• short/long contractions (longer than 70 sec)= uterine exhaution or no relaxation
• pathologic retraction ring
• abnormal lower ab contour
• buldge = full bladder (void q2hr during labor)
• increased apprehension = not enough O2 or hemorrhage

• HR higher than 160 or lower than 110
• meconium staining (green colored stool)- not always bad (common in breech) but can show that fetus has hypoxia (stimulates vagal reflex)
• hyperactivity (hypoxia)
• O2 saturation assessed though catheter near baby cheek
• lower than 40% is bad
• 40-70% is normal

• palpate superior fundus (head = firm, breech = soft)
• palpate sides of uterus (back = smooth and hard, opposite= angular knees and elbows)
• palpate lower abdomen between thumb and index finger
• presenting part pushed up easily (not engaged)
• firm = head, soft = breech
• palpate fingers on sides of abodmen 2 inches above inguinal ligaments, press down and in toward birth canal
• assesses fetal attitude in cephalic presentation

• surgical insicion of perineum to prevent tearing of perineum
• mediolateral or midline episiotomy 

1. taking in phase (2-3 days after birth)- review pregnancy and labor/birth, passive dependence
2. taking hold phase- independence and more interest in baby
3. letting go phase- redefines new role, gives up fantasy and old role of being childless

postpartal blues (50% women)- some feelings of sadness, tears, caused by decrease in progesterone and estrogen

postpartal depression (30% of women)- requires counseling

• reproductive organs return to normal state
• danger of hemorrhage until involution is complete
• two stages
• 1. area where placenta was implantedis sealed
• contraction, thrombi, endometrial tissue
• 2. uterus is reduced to pregestational size
• weight 1000 g after birth, 500 g after 1st week, 50 g at 6 wks (when involution is complete) = prepregnancy weight

• after birth, fundus is halfway between umbilicus and symphysis pubis
• one hour-twenty four house= fundus at umbilicus 
• decreases one fingerbredth/1cm per day after birth
• by ninth or tenth day, uterus contracts so it can no longer be felt
• breastfeeding mom may contract quickly because of oxytocin (stimulates contractions)
• fundus should be midline 
• on right = bladder full

Normal

Cramping like menstural periods

noticed more by multiparas/large babies/multiple births

noticed with breastfeeding because of oxytocin

• progression
• lochia rubra (1-3 days) = red (blood, decidua, mucus)
• lochia serosa (3-10 days) = pink (blood, mucus, leukocytes)
• lochia alba (10-14 days, can last 6 weeks) = white (mucus, leukocytes)
• mothers who breastfeed have less lochia, same with c-section
• lochia increases on exertion
• saturating a pad in less than an hour = BAD
• no clots (clots indicate placenta is retained and preventing closure of uterine blood sinuses)
• lochia shouldn't be absent during first 1-3 weeks (could indicate infection)

4 pt decrease in hematocrit

1 g decrease in hemoglobin

• human chorionic gonadotropin (hCG) and placental lactogen (hPL) are gone in 24 hrs
• by week one, progestin, estrone, and estradiol are at prepregnancy levels
• esterol elevated for additional week before it reaches prepregnancy levels
• follicle stimulating hormone (FSH) low for 12 days and then rises for new menstrual cycle

• diuresis of 2000-3000 mL accumulated during pregnancy
• daily output of 1500-3000 mL during the 2nd-5th day postpartum
• bladder may lose tone during vaginal birth, can decrease woman's ability to sense need to void
• prevent overdistention by assessing abdomen frequently
• full bladder felt just above symphysis pubis
• percussion- full bladder sounds resonannt, not dull
• hydronephrosis/increased size of uterus for 4 weeks after
• increased nitrogen, lactose

• blood volume reduces to normal level by 1st-2nd week postpartum
• vaginal EBL of 300-500, c-section EBL of 500-1000 mL
• excess fluid excreted, hematocrit rises to prepregnancy level by 6 wks
• high level of plasma fibrinogen during first prostpartal week to guard against hemorrhage
• increase in leukocytes to 30,000 (normal 5000-10000)
• varicosities recede

digestion/absorption begin after birth unless c-section

hemorrhoids (distended rectal veins) 

bowel sounds active

passage of stool may be slowed because of relaxin

bowel evacutaion may be painful

• stretch marks/striae gravidarum- redenned and more prominant, fade in 3-6 months, may remain dark in african americans
• chloasma (excess pigment in face/neck) and linea nigra (excess pigment in abdomen) fade in 6 weeks
• diastasis recti (overstretching and separation of abdominal musculature) will appear as indented or abluish in ab midline
• takes six weeks for muscles to return to normal strength

• 12 pounds lost at birth
• diuresis and diaphoresis in 2-5 postpartum days = five lb lost
• lochia flow = 2-3 lb loss
• total weight loss of 19 lb
• additional weight loss can used
• postpartal final weight at 6 wks

increase in temp during first 24 hrs (dehydration)

temp above 100.4 F after 24 hrs postpartum is febrile

filling of breast milk on 3-4th postpartum day can increase temp for a few hours

slightly slower than normal

increased stroke bolume from blood returning to heart

reduced pulse to 60-70 bpm

increased pulse = hemorrhage

shouldn't be higher than 140/90 (HTN)

• colostrum (white, bluish) in first few days
• third day- breasts become full/tender as milk forms
• milk forms in response to decreased estrogen and progesterone after placenta
• engorgement- tension/tenderness on 3rd/4th day postpartum
• release of oxytocin causes new milk to form

• production of estrogen and progesterone end with delivery of placenta
• increase of FSH
• not breastfeeding = return of menses in 6-10 weeks after birht
• breastfeeding = return of menses in 3-4 months (lactational amenorrhea) after birth
• sometimes not until lactation period is over 

• scant = 1" in 1 hr
• light = 4" in 1 hr
• moderat= 6" in 1 hr
• heavy = saturated in 1 hr 

• 2.5 kg-4.7 kg (5.5 lb-10 lb)
• baby loses 5-10% of weight (6-10 oz) in first few days after birth (newborn doesn't have salt and fluid retaining maternal hormones anymore)
• gains 2 lb per month for first 6 mos

• 46-57.5 cm (18-24 in)

• 33-37 cm (13.2-14.8 in)

99 F after birth

98.6 by 4 hrs after birth

• 120-160 bpm in utero
• 180 after birth
• 1 hr after birth = 120-140 bpm 
• sleep (90-110 bpm), crying (180 bpm) 

• after birh- as high as 80 bpm, settles to 30-60 breaths per minute
• apnea lasting less 15 is normal

• 80/46 mmHg newborn
• 100/50 mmHg by the tenth day

• too much blood rom heart to baby's lungs
• ducts to bypass lungs
• foramen ovale- goes from R atrium to L atrium directly
• closes when lungs increase amount of blood needed, soon after baby's first breath
• ductus arteriosis: from pulmonary artery to aorta
• decrease in pressure in pulmonary artery closes DA
• premature closing can be caused by motrin/ibuprofen 
• ducts to bypass liver
• ductus minosis- umbilical vein to inferior vena cava 
• vein in fetus CAN CARRY OXYGENATED BLOOD

1. drying/clamping of umbilical cord/stimulation of cold receptor
2. increased PCO2, decreased Po2, increased acidosis
3. first breath
4. decreased pulmonary arter pressure
1. increased PO2 (closure of ductus arteriosus)
2. pressure on L heart greater than R heart (closure of Foramen ovale)
3. closure of ductus venous and umbilical arteries and vein due to decreased flow

Hgb level for newborn

Hct level for newborn

RBC level for newborns

Bilirubin level for newborn

WBC count in newborns

Hbg- 17-18 g/ 100 mL 

Hct- 45-50%

RBC- 6 million cells/ cm3

bilirubin = 1-4 mg/100mL

WBC- 15-30000 (40,000 if birth was stressful)

• lower than normal vit K for most newborns
• prolonged coagulation or prothromvin time
• Vit K is necessary for formation of prothrombin (factor II), factor VII (proconvertin), factor IX (plasma thromboplastin component), and factor X (Stuart Prower factor)
• 24 hrs for vitamin K to be synthesized
• vit K given IM (.5cc or 1mg) 
• natural clotting ready by 8th day after birth

• stool should be passed within 24 hrs after birth
• meconium- sticky, tarlike, balck/green, odorless (from mucus, vernix, laugo, hormones, carbs)
• should pass meconium by 24-48 hrs after birth
• if not passed within 48 hrs, could be due to meconium ileus, imperforate anus, volvulus
• transitional stool- loose and green by the 2nd or third day after birth
• fourth day of life
• should pass three to four yello stools per day (formula fed babies produce less stool, two to three per day)
• grey stools- bild duct obstruction
• bloody stools- anal fissure or swallowed maternal blood during birth
• black stools- intestinal bleeding
• mucus- milk allergy or other digestion/absorption problem

• should void within 24 hrs after birth
• if doesn't void, could be because of urethral stenosis or absent kidneys/ureters
• projecting urine farther than normal = urethral obstruction
• light colored and odorless
• single voiding of newborn = 15 mL
• daily voiding of newborn = 30-60 mL for first 1-2 days
•  daily voiding at 1 week = 300 mL
• may be dusky or pink because of uric acid crystals (innocent finding)
• protein may be present until kidney glomeruli are mature

• difficulty forming antibodies against invading antigens until 2 mos of age
• born with passive antibodies (IgG) from mom that corssed the placenta
• Hep B vaccine given 12 hrs post birth and again at 1 mos and 6 mos
• HBIG given at birth when mom is Hep B +

• blink
• rooting
• sucking
• swallowing
• extrusion- newborn extrudes substance placed on anterior portion of tongue
• palmar and plantar grasp reflex
• step/walk in place reflex
• placing reflex- touch anterior surface of newborn's leg on hard surface, newborn will try and step up onto the surface
• tonic neck reflex- newborn on back, arm and leg on side head is turned towards extend, opposite arm and leg contract
• moro reflex- hold newborn supine, allow head to drop back 1 inch, causes extension of extrmeties 
• babinski
• magnet- pushes back with pressure to feet
• crossed extension reflex- one leg extended and the sole of foot is rubbed, infant raises other leg and pushes away hand irritating first leg
• trunk incurvation reflex- prone, with hand underneath, shouldn't sag
• deep tendon reflex- tap patellar tendon with tip of finger, lower leg should move

• lasts 15-30 min
• acrocynosis
• temp fall from intrauterine temp (100.6F)
• 180 bpm
• irregular resps (30-90 breath pm)
• nasal flaring and retraction
• alert
• vigorus reaction to stimulation
• mucus in mouth
• bowel sounds after 15 min

• 30-120 min after birth
• color stabilizes
• temperature stabilizes to 99 F
• HR slows to 120-140 bpm
• reps slow to 30-50 bpm, chest barrels
• sleeps soundly
• small amount of mucus present while sleeping
• bowel sounds heard

• 2-6 hr after birth
• quick color changes with mvmt and crying
• temp increase to 99.8 F
• wide swings in HR
• resps irregular with activity
• awakening, responsive
• mouth full of mucus/gagging
• passing first meconium stool

abnormal

cyanosis of the trunk

indicates decreased decreased oxygen 

resp obstruction or disease

normal 24 to 48 hours after birth

blue hands and feet 

jaundice

(how it is caused)

• yellow skin
• third day of life in 50% of newborns
• breakdown of fetal RBC's
• high RBC count build up in utero is destroyed, heme and globin released
• heme is broken into iron and protoporphyrin
• protoporphyrin is broken into indirect bilirubin
• indirect bilirubin can't be excreted by kidneys
• converted by liver enzyme into direct bilirubin, but some newborns have immature liver functions, so it can't be converted to direct bilirubin
• indirect bilirubin is more than 7mg/100mL, causes yellowed skin
• bruising can lead to jaundice (cephallhematomas = bruise under skull bone)
• intestinal obstruction causes buildup of stool and indirect bilirubin buildup in bloodstream

• caused by indirect bilirubin levels of 20 mg/ 100 mL or higher
• interferes with chemical synthesis of brain cells
• permanent cell damage and cognitive challenges

• excess blood loss when cord is cut
• inadequate blood flow from the cord to the infant at birth
• fetal-maternal transfusion
• low iron stores (poor maternal nutrition)
• blood incompatibility where large number of RBC's were hemolyzed in utero 
• internal bleeding 

• immature circulation
• newborn lays on side (red on side you're laying on, pale on the other side)
• fades after position is changed/baby cries

• vascular tumors of the skin
• 1. nevus flammeus- macular purple or dark red lesions (pot wine stain)
• face, thighs, bride of nose (only ones that fad), stork beak marks do not fade
• 2. strawberry hemangioma
• elevated area
• immature capilaries 
• enlarge until one year old, fade by age ten
• 3. cavernous hemangiomas
• dilated vascular spaces
• raised
• do not disappear

collection of pigment cells

slate grey patches across sacrum/buttocks/arms/legs

asian, southern european, african

disappear by school age

white cream chesse substance

lube in utero

takes on color of am fluid

wash away while wearing gloves

fine, downy hair

shoulders, back, upper arms

forehead and ears

 younger gest age = more hair

rubbed away by 2 wks old

dryness of newborn after 24 hours 

pals and soles of feet

may peel

can put lotion on

immature sebaceous glands

cheek and bridge of nose

disappear by 2-4 wks old

• rash (begins with papules, increases to erythema, disappears eventually)
• flea bite rash
• appears on first-fourth day, disappears by 2 wks

two fontanelles

fontanelle normal/abnormal

when do they close

• 1. anterior fontanelle- diamond shaped (between two parietal bones and two frontal bones)
• 2. posterior fontanelle- triangular, parietal bones and ocipital bones
• should be soft and flat
• indented = dehydrated
• bulge = increased intracranial pressure
• closes at 12-18 mos old (anterior) and 2 mos (posterior)

• overlapping sutures = pressure exerted on head during birth
• overriding should undo within 24-48 hrs after birth
• wide seperation suggests increased intracranial pressure because of abnormal brain formation/accumulation of CSF in cranium/blood from birth injury
• fused = prevent brain from expanding 

edema of scalp on presenting part of head

may look like large egg

disappear  in three days

blood between periosteum of skull bone and bone itself 

b/c of pressure of birth

appears 24 hours after birth

looks like egg, may be black or blue

disappears in weeks

causes jaundice

softening of cranial bones

caused by pressure during birth

common in firstborns

returns to normal in a few months

calcium can help

one vein

two arteries

1. heart rate (0=absent, 1=under 100, 2 = over 100)
2. respiratory effort (0=absent, 1 = slow, irregular, weak cry, 2 = good, strong cry)
3. muscle tone (0=flaccid, 1 = flexion of extremeties, 2= well flexed)
4. relfex irritability (cateter in nostril or slap to food) (0=no response, 1 = grimace, 2 = cough/sneeze)
5. color (0=blue/pale, 1 = body normal pigment, extremeties blue, 2 = normal skin skin color)

• state law
• disease of defective protein metabolism
• same test also screens for hypothyroidism and CF
• needs to have eaten formula or breast milk within first 24 hrs of birth for test or a false neg. might happen

• religious and tradision
• easy hyeigene
• fewer UTI's
• less risk of penile cancer and cervical cancer in their partners

• religious reasons
• no complications from surgery

congenital abnomalities (hypospadias, epispadias)

hisotry of bleeding

hemorrhage

infection

urethral fistula

calories for less than 2 mos old

calories for more than 2 mos old

linoleic acid- essential fatty acid necessary for growth and skin integrity

found in milk and formulas

lactose easily digested, improves Ca absorption and nitrogen retention

• formed in acinar and alveolar cells of mammary glands
• progesterone falls after placenta delivery
• proces prolactin (anterior pituitary)
• stimulates production of milk (production of milk increases prolactin production)
• colostrum for first 3-4 days
• thin, watery, yellow
• protein, sugar, fat, water, minerals, vitamine, maternal antibodies
• true breast milk produced by day 10
• constantly forming milk = fore milk 
• as infant sucks, oxytocin is released from posterior pituitary which causes the let down reflex
• hind milk (new milk) is formed

LMP - 3 mos + 7days + 1 yr

plus or minus 2 weeks

supposidly 280 days btween LMP and EDC, actually 266 days

4-6 hrs

12 hrs

18-24 hrs

can be fed directly after birth (best time is during first 90 minutes of life/quiet alert state)

1. chin drives into breast during feeding
2. tip of nose on breast
3. effective sucking in suck/swallow/suck/swallow rhythm
4. no nipple pain
5. baby has full cheeks, temple wiggling, flanged lips
6. audible swallowing

baby should nurse/breastfeed ___ times a day

babies will eat about every ___ hrs

other babies may ____

• prevent breast cancer
• oxytocin helps involution
• empowering
• reduced cost and time
• enhance bond
• IgA- binds viruses and bacteria and prevents it from being absorbed in GI tract
• lactoferrin and lysozyme prevent bacteria in baby
• leukocytes, interferon, bifidus factor prevent bacteria and viruses as well
• ideal electrolyte and minerals, lactose and linoleic acid
• easily digested, helps regulate Ca and phosphorous levels

1. Latch (0 = sleepy, no latch, 1= repeated attempts, hold nipple in mouth, 2 = grasp breast, tongue down, lips flanged, sucking)
2. Audible swallowing (0 = none, 1 = some with stimulation, 2 =spontaneous and intermittent at less than a day old, spontaneous and frequent in a day or older) 
3. Type of nipple (0= inverted,1 = flat, 2= everted after stimulation)
4. Comfort of breast/nipple (0=engorged, cracked, bleeding, blisters, 1 = filling, red, small blisters, some discomfort, 2 = soft and nontender)
5. Hold/position (0=full assist, 1 = minimal assist, pillows, some staff, 2 = independent)

1. total fluid in 24 hrs must meet fluid needs of 150-200 mL /kg/day
2. total calories in a day is 110/120 kcal/kg/day

muscle toning excersies during pregnancy

no foods with preservative

abdominal breathing in labor

internal focus

walk in labor

fear --> tension --> pain

prevent fear through education and breathing

gate control theory

prevent pain with mind

no inducing labor

no confinement in bed, move!

continuous support for mom

routine interventions

nonsupine position

mom and baby housed together

dark, warm birthing room

soft music

cut cord late

baby placed in warm bath after birth

constricted blood vessles, less blood to uterus

anoxia to muscles

streched cervix and perineum

distension of lower uterine segment

pressure on pelvic nerves

distension of pelvic floor

T10-L2 = uterus and cervix pain sensors

T6-T8 = blocked during c-secion

S2-S4 = perineum pain

analgesia = decreases awareness of pain

anesthesia= partial/complete loss of sensation

injected into spinal cord

effect felt in 15-30 min, last 4-7 hr

good for labor

• local anesthetic to block specific nerve paths
• block sodium and potasium, keeps nerve in polarized resting state
• pre eclampsia patients may have bleeding defects, regional anesthesia may be contradicted
• fetus has minimal effects from regional

• placed in ligamentum flauum in epidural space
• L4-5, L3-4, L2-3

• relief from labor and birth
• increased contractions and blood flow
• ok in preterm labor
• begin at 3-5 cm dialated

epidural anesthesia side effects

how long does it last?

• drowsy, metalic taste, slurred speech, blurred vision, unconsious, seizure, cardiac arrest
• hypotension (raise legs, lay on side, administer O2, 500-1000 mL IV fluids, epinepherine, fentanyl, bipivacaine)
• spinal headache if CSF leaks/air in CSF
• bladder sensation is decreased (void every two hours)
• legs numb (do not ambulate)

used in emergency

local anesthtic and narcotic agonist

numb from belly button down

weighted with glucose to prevent from rising too high in spinal cord

• hypotension (lie on L side, lactated ringers in IV fluid, vasopresser)
• postpartal dural puncture headache/spinal headache
• CSF leaks or air in CSF
• treat: lie flat, analgesia, cold cloth
• in bad cases, 10 mL of blood from a vein can be inserted into epidural space
• blood clots and seals leakage, stops headache

combined spinal epidural technique (CSB)

function and side effects

spinal anesthesia (immediate pain control, no ambulation after)

spinal and epidural

se: nause/vomitting, PDPH, hypotension, urinary retnesion, puritus

local anesthetics

where?

how long they last?

why?

local infiltration- inject anesthesia in perineum superficial nerves

along borders of vulva

last 1 hr used when fetal head is too low for pudendal block

pudendal nerve block

where?

how long they last?

why?

se?

• local anesthetic near R and L pudendal nerves at ischial spines through the vagina
• start in 2-10 min, last 1 hr
• deep relief for episiotomy repair
• check blood pressure for hypotension

general anesthesia

why?

typical drug used?

side effects for mom and baby?

• not preferred, causes hypoxia
• emergency c-section
• typically use thropental sodium (phentothal)- short acting barbituate, rapid relief, short half life
• cross placenta, infant may need recessitation
• side effects- uterine relaxation (atony/hemorrhage)

1. ephedrine (treat hypotension)
2. atropine sulfate (dries resp/oral secretions, prevent aspiration)
3. thiopental sodium/penothal (rapid general anesthtic)
4. succinylcholine/anectine (larengeal relaxation for intubation)
5. diazepan/valium (seizures)
6. isoproterenol/isuprel (bronchospasms/aspiration)

barbituates in labor

when?  

effect?

two examples

• used early in labor
• sleep/sedation
• 1. ambian (class c-->could cause problems, ok for some)-rapid onset, 2.5 hr half life
• 2. seconal (class d)- 15 min onset, 3-4 duration, 28 hr half life

tranqualizers

when?

why?

two examples

• given with narcotic to act as anti nausea and decrease dose of narcotic needed
• 1. vistaril (class c) 25-100 mg IM
• 2. phenergan (class c) 25-50 mg IM

narcotics

4 examples

1. demerol (class c)- 50-100 mg IM/IV (nausea/vomit/resp dep)
2. stadol (class c) 1-2 mg IM/IV (nause/vomit)
3. fentconyl citrate (class c) in mcg
4. morphine sulfate (class c) 2-10 mg IV in 4-5 min (pruritis, n and vomit, urinary retension in epidural)

1. 1st tri: accepting pregnancy
1. recover from shock
2. what it feels to be pregnant
3. positive and negaive feelings
2. 2nd tri: accepting baby (happens with quickening)
1. roll playing
2. narcissism/introverrted
3. figures out what it means to be a parent
3. 3rd tri: preparing for baby
1. clothing for baby, room for baby
2. impatient

• estrogen increase decreases sexual desire in 1st trimester
• fatigue, breast tenderness
• increase in sexual desire in 2nd tri
• increased blood flow to pelvis
• hard to have sex in third tri because of awkwar positioning due to growing belly

• detect human chorionic gonadotropin (hCG) in urine or blood serum
• hCG is podced in chorionic villi of placenta
• accurate 95-98% of the time
• pregnant woman have trace hCG 24-48 hrs after implantation
• measurable amount of HCG at 7-9 days post conception
• 60-80 days of gestation is peak hCG (100 mL/U)

• 97% accurate
• detect 35 mIU/mL of hCG or more
• false negative caused by psychotropic or contraceptives, proteinuria, postmenopausal, hyperthyroid
• double check at 1 week after first test

• breast change, nausea, vomiting, amenorrhea (2 weeks)
• frequent urination (3 wks)
• fatique, uterine enlarged over symphasis pubis (12 wks)
• quickening (18 wks)
• linea nigra, melasma (darkening of face), striae gravdorum (red streaks on abdomen) (24 wks)

• serum lab tests (1 wk)
• chadwicks (vagina changes from pink to violet), Goodell's (cervix softens), hegar (lower uterine is softer), gestational ultrasound (6 wks)
• ballottement-when lower uterine segment is tapped, fetus rises against abdomenal wall (16 wks)
• fetal outline and braxton hicks (20 wks)

• evidence of fetal outline on ultrasound, fetal heart rate is audible from 10-12 wks
• fetal movement felt by examiner (18 wks)

• length from 6.5 to 323 cm
• depth from 2.5 cm to 22 cm
• width from 4 to 24 cm
• weight from 50 to 1000 g
• thickness from 1 cm to 2 cm to .5 cm
• volume from 2 mL to 1000 mL and 7lb child 
• 20-22 wks at umbilicus
• 36 wks at xiphoid process

may not be felt by multipara

felt at 36 wks by primigravida

1. 1st: increased bp
2. 2nd: decreased bp
3. 3rd: increase to normal prepregnancy bp

1. 1st: increase clotting factor, active corpus leutum
2. 2nd: fading corpus leutum

1st tri: increased maternal glomerular filtration rate, increased aldosterone to retain sodium and fluid

2nd tri: glycosuria

1st tri: softens

3rd tri: ripens

uterine blood flow increases from ___ ml/min to ___ ml/min

____ of the body's blood is in the utereus by the end of pregnancy

15 mL/min to 500-750 mL/min

1/6 of the body's blood

• full, tender, tingle
• areola darkens and enlarges
• blue veins
• montgomery's tubercles: enlarged sebaceous glands on areola (secretions from them protect nipple from dryness)
• colostrum at 16 wks
• because of increased estrogen

pregnancy mask

increased melanocyte stimulating hormones

• temp: 99.6 (progesterone in 1st tri), decreases at 16 wks
• blood volume increases by 30-50%
• heart rate increases in pregnancy by 80-90 bpm
• resperation rate increases by 1-2 per minute (higher than 18-20 usually)

• congestion because of increased estrogen
• pressure on diaphragm
• increased progesterone decreases PCO2 to 32 mmHG
• fetal CO2 is higher than mom so CO2 can cross easily from baby to mom
• increased ventilation to decrease CO2
• increases by 40%
• respiratory alkalosis = exhales too much CO2, compansates by increased urination to excrete bicarb
• increased pH to increase binding of maternal hemoglobin

• 350-400 mg iron/day for fetal growth, 400 mg iron/day for increased RBC's in mom = total of 800 mg iron/day in mom
• anemia = hgb less than 11 g, hct less than 33% in first tri
• iron therapy needed for anemia
• inadequate folic acid increases risk for neural tube disorders

glom filtration rate increases by 50%

BUN decreases by 25%

creatine decreases by 25%

bladder capacity increases by 1000 mL

ureter diameter increase by 25%

10-12 voids per day in last 2 wks of pragnancy

enlargement to increase metabolic rate

increased TH productino to increase oxygen consumption

increased size to utilize calcium and vit b

increased PTH production

• decreased insulin because of fetal need for glucose
• increased insulin need after 1st tri because of estrogen and progesterone

• decreased FSH and LH
• prolactin increase for lactation
• melanocyte stimulating hormone increase to increase skin pigment
• human growth hormone for fetal growth

• estrogen and progesterone
• increased blood coag, increased Na and water retention
• sofen cervix and joints
• increased relaxin (increase glucose for fetus)
• human placental lactogen to decrease use of protein for energy

• G: number times being pregnant including present pregnancy
• T: number of full term infants born after 37 wks
• P: number of preterm infants born (before 37 weeks)
• A: number of spontaneous miscarriages or abortions
• L: number of living children

fetal heart sounds heard with doppler at ____ wks

fetal heart sounds heard with stethascope at ___ wks

doppler: 10-12 weeks

steth: 18-20 weeks

• pap
• vaginal culture for gonerrhea, HPV, chlamydia, tichomoniasis, GBS
• rectovaginal exam
• CBC
• genetic screen
• serologic test for syphillis (VDRL test)
• blood typing and Rh factor
• indirect coomb's test (28 wks, determines if Rh antibodies are in Rh- mom)
• HIV screen
• antibody titers for rubella and hep B
• glucose loading tolerance test (24-28 wks, shouldnt be over 140 mg after 1 hr)
• urinalysis
• TB screen

• vaginal bleeding
• persistant vomiting past 12 weeks and more than 1-2 times a day
• chills or fever
• escape of clear fluid from vagina
• ab pain (ectopic pregnancy, sep of placenta, preterm labor)
• chest pain (Pulm Emb)
• hypertension
• gain 2 lb/wk 2nd tri or 1 lb per wk 3rd tri, swelling in face and fingers, dots in vision, headache, decreased uring output
• increase or decrease in movment: responding according to O2 need

• tender breasts
• palmar erythema: red itchy palms, disappears eventually
• constipation: increase fibers and fluids
• n/v/heartburn
• fatique
• muscle cramps 
• hypotension
• leukorrhea- small white vaginal discharge
• hemarrhoids
• heart palpitations
• frequent urination
• ab discomfort
• varicosities

• backache
• headache
• dyspnea
• ankle edema
• braxton hicks

• A: adequate studies in pregnant women failed to show risk to fetus in 1st tri
• B: animal studies show no adverse effects on fetus
• C: animal studies have shown an adverse effect of fetus, no studies in humans or adequate animal studies. risk is unknon.
• D. no evidence of risk to human fetus but potential benefits in pregnant women, acceptable
• X: animals and humans show getal abnormalities or adverse reaction, risks outweigh benefits.

• cystic fibrosis
• HCG test
• progesterone levels
• first tri screen
• CVS

• ultrasound for dates
• MSAFP
• amniocentesis

• fetal movement/estimated fetal weight
• non stress test
• contraction stress test
• baseline variability
• biophysical profile
• doppler flow studies
• placenta grading
• amniocentesis
• l/s ratio
• phosphatidyglycerol

• electronic monitoring
• early/late/variable decels
• fetoscope

one value in bpm established by auscultating/rading graph

should be btwn 110-160 bpm

• indicative of fetal oxygen reserves
• absent = bad
• normal finding is moderate variability of +- 6 to 25 bpm above/below baseline 

• indicate neurological response to fetal movement
• less than 32 wks old = accels of 10 bpm over baseline for 10 sec
• more than 32 wks old = accels of 15 bpm over baseline for 15 sec

• four types of decels to indicate changes in fetal oxygenation
• in order from benign to most concerning:

1. early decels: decrease in FHR by less than 15 bpm below baseline for less than 30 sec, indicates fetal head compression, mirrors contractions
2. variable decls: decrease in FHR by more than 15 bpm or more below baseline for more than thirty sec, indicates umbilical cord compression
3. late decels: decreased HR more than thirty seconds, onset at peak of contraction, indicates uteroplacental insufficiancy (not enough blood to placenta)
4. prolonged decels: decreased heart rate for more than thirty seconds, resolution takes two minutes, fetal destress or uteroinsufficiency

• blood cells --> vessels --> single heart tube (10 days) --> beat (24 days) --> septum (wk 6-7) --> ECG (11-20 wks)

umbillical vein

oxygenated blood

ductus venous

fetal liver

inferior vena cava

r atrium

foramen ovale

l atrium

l ventricle

aorta

wk 3 = one tube

wk 4 = septum (trachea and esophagus) and lung bud

wk 7 = diaphragm (must close completely)

wk 24-28 = alveoli and capillaries for gas exchange

3 mos = spontaneous respiratory practice

surfactant at wk 24 (lecithin and sphingomylen 2:1 ration for surfacent)

• wk 4=separates from resp tract
• wk 10- intestines move to ab cavity
• meconium at wk 16
• wk 32 = suck and swallow
• wk 36 = enzymes to digest carbs/protein
• 3 mos POST BIRTH = amylase

0-2 wks = cartilage

12 wks = bone ossification

11-20 wks = movement and quickening

6 wks = gonads (testes and testosterone) and ovaries (no tesosterone)

8 wks = gender chromosomal analysis

wk 34-38 = testes descend into scrotal sac

• 4 wk = kidney
• 12 wk = urine formed
• 16 wk: urine excreted
• term = 500 mL /day

• IgG maternal antibodies cross placenta at wk 20-24
• baby has temporary immunity
• peaks at birth
• by 8 mos after birth infant builds own immunities
• fetus gets IgG IgA and IgM
• presense of IgA and IgM antibodies in fetus indicates that newborn/fetus has been exposed to the disease (IgA and IgM can't cross placenta)

move ten times per hour

lie in L recumbent position after meal and record mvmt after an hour, should be ten mvmts in sixty minutes

• FHR assessed in conjuction with contraction
• oxytocin rease of contraction achieved by nipple stimulation
• FHR monitors and external UC monitors
• need THREE contractions, 40 sec or longer, within TEN MINUTES
• negative or normal test = no FHR decels w/ contractions
• positive or abnormal test = 50% or more contractions cause decels late in contraction

• done at less than twenty weeks
• divide uterus in 1/2 vertically
• measure height of largest portion of am flu in both halves and add together
• done at greater than twenty weeks
• divide uterus in fourths
• add together largest portion of am flu in each fourth
• average = 12-15 cm at 28-40 wks
• oligohydraminos (less than normal, poor kidney) = less than 5-6 cm
• hyramnios (excess fluid, fetus can't swallow) = more than 20-24 cm

• AFP produced in fetal liver and is present in amniotic fluid and maternal serum
• high level of AFM in maternal serum = open spinal/ab defect
• less than normal AFP in maternal serum = downs