• Hyperemia (estrogen)
•  Upward displacememnt of diaphragm
•  ↑ respiration rage
•  20% ↑ in oxygen demand
•  ↓ functional residual capacity

§  IUFD: Intrauterine Fetal Demise

§  Lacking adequate reserves for stress of labor and continued intrauterine life

§  MAS: meconium aspiration syndrome

§  Hypoglycemia

§  Perinatal mortality increased 1-10 fold

§  Placenta: fewer gas-exchanging villi

• ultrasound 24-28 weeks
• NST & BPP
• DFMC (daily fetal movement count)
• constant monitoring in labor

Term

Preterm

Abortion (missed or induced)

Living

number of times woman has given birth to a fetus of 24 weeks or more (regardless if living)

Nagele's rule

How to calculate

NST

What does it stand for & why do we do it?

Nonstress Test

Assessment method by which the reaction of the fetal heart rate to fetal movement is evaluated - reflects intatness of nervous system

Put two belts/monitors (toco and fetal heart monitor) on mom and see what happens

baby moves - mother tells

movement - monitor

looking for 3 acceleration of 15+ bpm for 15+ seconds each

Need at least 15-20 minutes to perform

baby is not getting enough oxygen

possible baby is asleep

reassuring - positive things are as they should be

Not reassuring

If there are problems, how often are NSTs performed?

Why?

2x per week

They have predictive value for about 4 days

• past due date - post dates testing (41 weeks)
• Maternal report of decreased fetal movement
• suspect placenta not functioning adequately
• other high risk concern

Biophysical profile

Helps confirm healthy fetus and identify compromised fetus

• fetal breathing
• fetal movement
• fetal tone
• amniotic fluid volume
• NST (accelerations of fetal heart rate)

8-10 = reassuring

6 = equivocal

4 or less = consider deliering

Amniotic fluid volume

To determine if the amount of amniotic fluid is sufficient, too little or too much

Too little can demonstrate problems with fetal kidneys

Both are ultrasound

• 4 quadrant method
• Deepest vertical pocket

• divide belly into 4 quadrants at umbilicus
• meausure depth of fluid in all four pockets via ultrasound
• add up measurements (cm)
• ≤5 oligo
• ≥20 poly

• Uses ultrasound to determine the deepest verticle pocket of amniotic fluid
• <2cm = oligo
• >8cm = poly

daily fetal movement count (kick count)

We perform if mom doesn't feel like the baby is moving

mom lays on side and marks movement for one hour (a second hour if not felt 10-15 infirst hour) or until 10-15 kicks felt

Usually completed at 12 hour intervals

Laying on side provides optimum blood flow

human chorionic gonadotropin

• used to test for pregnancy
•  first urine in am – 2 weeks after missed period
• Blood: Quantitive β-hCG
•   Produced by: trophoblast
•   Maintains pregnancy

human placental lactogen

Produced by synctiotrophoblast

antagonizes insulin: increase glucose

produced by corpus luteum and then placenta

stimulates uterine development

produced: corpus luteum

maintains endometrium

decreases contractions

human chorionic thyrotropin

placental hormone

produced by corpus luteum

decreases contractions

remodels collagen and "relaxes" joints for widening of hips for labor

produced by decidua

maintains placental vasculature

produced: posterior pituitary

functions: lactation ductal and alveolar systems

At 5 weeks what fetal parts are sensitive to the effects of teratogens?

• CNS
• heart
• neural groove

• eyes
• heart
• arm and leg buds

• eyes
• heart
• arms and legs

• ears
• teeth

• palate
• urogenital system
• ears

• palate
• ears
• external genitalia

Organ structures are either there or not there by 8 weeks.

After 8 weeks histological development becomes more refined

the third week

(day 15)

What does the maternal side of the placenta look like?

What is it's nickname?

rough

Dirty Duncan

What does the fetal side of the placenta look like?

What is it's nickname?

shiny

Shiny Schultz

Where would you find the chorionic villi and fetal circulation?

fetal or maternal side of placenta?

move patient to where she will birth

 vitals q4h

CBC

urine dip

o   Placenta → Unbiblical vein → Abdominal wall of fetus

o   Liver (small amount enters liver) → Inferior vena cava via hepatic veins

o   Ductus venosus → Inferior vena cava (Bypassing liver)

o   Right atrium → Foramen ovale  → Left atrium → left ventricle →Aorta

o   From head& upper extremities via superior vena cava → Right atrium → Tricuspid valve →Right ventricle → Pulmonary artery (small amount into lungs for nourishment) → Ductus arteriosus → Descending aorta

o   Placenta

o   Increased aortic pressure and decreased venous pressure

o   Incrased systemic pressure and decreased pulmonary artery pressure

o   Closure of foramen ovale

o   Closure of ductus arteriosus

o   Closure of ductus venosus

§

•  Functionally closed 1-2 hours after birth
• Anatomical closure occurs within 30 months

•  Functional closure starts 10-15 hours after birth
• Fibrosis of the ductus occurs within 4 weeks after birth

• Fibrosis of ductus venosus occurs within 2 months
• Becomes ligamentum venosum

How is a Group B Strep test done?

·         Swab vagina and then rectum (can use same swab as we are not worried about transferring vaginal bacteria to rectum)

o   Might be positive in urine in other screens earlier – if positive once, no need to test further will treat at labor

·         If positive, no treatment until labor.

At onset of labor or ROM:

• Pen G 5 million units IV followed by:
•  2.5 million units IV every 4 hours until childbirth

Other antibiotics can work

What tests are completed at the new OB exam?

First time seen in clinic once pregnant

·         Blood type

o   ABO and Rh

o   Antibody screen (Coombs test)

·         CBC (complete blood count)

·         Hepatitis B surface antigen (HBsAg)

·         RPR (syphilis serology)

·         HIV test

·         Rubella titer

·         Cystic Fibrosis testing

·         Pap test (if needed)

·         CT/GC (Chlamydia/gonorrhea)

·         Urine culture

·         Consider (if needed)

o   TSH (thyroid stimulating hormone)

o   Hemoglobin electrophoresis (sickle cell anemia/thalassemias)

o   1-hour Glucose Challenge Test (50 gram glucola drink)- family history of diabetes or prior GDM

o   Varicella titer (if no maternal history of infection)

Maternal serum quad screen

completed 15-21 weeks

downs syndrome

spina bifida

o   1-hour Glucose Challenge Test (50 gram glucola drink)

o   CBC

• If Rh negative mother
•  Repeat Antibody screen (Coombs test)
•   Administer RhoGAM 300 mcg after blood draw

·         Continuous electronic fetal monitoring

·         Monitor/record fetal heart tones before/after each Pitocin dosage increase

·         Monitor strength and frequency of contractions

incision of the perineum to facilitate birth and to avoid laceration of the

§  Midline: median raphe of perineum. Extends from vagina orifice to fibers of retal sphincter

·         ***midline tear may extend through anal sphinter and rectum

§  Mediolateral: midline of the posterior fourchette and extends at a 45 degree angle downward to right or left

fourchette, perineal skin, vaginal mucous membrane

perineal skin, vaginal mucous membrane, underlying fascia and muscles of perineal body. May extend up on one or both sides of vagina

extends through perineal skin, vaginal mucous membranes, and perineal body and involves the anal sphincter; may extend up anterior wall of rectum

same as third but extends through rectal mucosa to lumen of rectum

o   Redness

o   Edema

o   Ecchymosis

o   Discharge

o   Approximation of lacerations/episiotomy

•  Sitz bath

•  Peri bottle after voiding or defecation

• Pad change following elimination and at regular intervals

o   Ice pack or glove immediately following birth

o   Sitz bath

o   Judicious use of analgesics or topical anesthetics

o   Tightening buttocks before sitting

after clamping before placental expulsion

§  Do not let blood sit in cord more than 30 minutes

§  Cut cord section

§  Draw blood from one of umbilical arteries

§  Send to lab

§  Abnormal FHR in labor

§  Depressed infant

§  Apgar <7 at 5 minutes

§  Meconium stained amniotic fluid

o   Cervidil: mesh insert

o   Prepidil: prostaglandin cervical gel

o   Misoprostel/Cytotec: pill placed on cervix

o   Cervical ripening balloon: can use foley catheter also

o   Amninotomy

o   Sexual intercourse

o   Nipple stimulation

o   Caster oil

o   Herbal

stripping the membranes

Pitocin

provider inserts gloved finger as far as possible into internal cervical os and rotates the finger 360 degrees two times

o   Separates amniotic membranes lying against lower uterine segment and internal os from distal part of the lower uterine segment

o   Thought to release prostaglandins from amniotic membrane or from cervix

o   Use for fewer than 3 contractions in a 10-minute period or < 25 mmHg uterine pressure for contraction

o   Must, Must, Must use IV pump

§  Mom is unable to effectively push

§  Baby needs to get out now

§  If baby has gotten close, will do assisted birth to avoid c-birth

§  Probably do an episiotomy

§  Fetal distress

§  Abnormal fetal  position

§  Maternal fatigue

§  Make sure bladder is empty – may have to cath

§  Fetal monitoring

§  Patient education

§  Maintain pressure on vacuum gun

§  Fetal monitoring

§  Patient education

§  Cervical dilation: primary

§  Hypoxia of uterine muscle cells

§  Stretching of lower uterine segment

§  Hypoxia of uterine muscle cells

§  Distention of vagina and perineum

§  Pressure (lower back, buttocks, thighs)

§  Uterine contractions

§  Cervical dilation (with passage of placenta)

§  Analgesic agents

§  Sedatives

§  Narcotics

§  Anesthetic Agents

§  TENS

§  Sterile water injections

§  Hydrotherapy

§  Aromatherapy

§  Music

§  Movement

§  Reflexology

§  hypnosis

Pain interventions during labor:

What nursing assessments should be done

·         Education and patient wants it

·         Vital signs are stable

·         Contraindications not present (drug allergies, respiratory compromise, current drug dependency)

Pain interventions during labor:

What fetal assessment should be completed by the nurse?

·         FHR is between 110-160 bpm

·         Reactive nonstress test (accelerations present with fetal movement)

·         Variability is present

·         Periodic late decelerations or nonperiodic decelerations are absent

Pain Interventions during labor:

What assessment of labor should the nurse do?

·         Contraction pattern

·         Cervical dilation

·         Cervical effacement

·         Fetal presenting part

·         Station of the fetal presenting part

·         Knowledge of other meds being administered (mag sulfate or tocolytics)

plpate down from top of abdomen and then you will not miss uterus

Shouldn't be hard of boggy

Risk factors that retard involution

• prolonged labor
• anesthesia
• instrumentation
• grandmultiparity
• overextension (multiples/polyhydramnios)
• infection
• retained placenta
• bladder distension

• one hand on pubic bone and one hand on fundus
• massage down from fundus

If feels deviated to the side, bladder is probably full

• Lochia Rubra
• Lochia Serosa
• Lochia Alba

• red
• small clots
• 2-3 days

• pink
• no clots
• lasts about a week

• white/yellow
• tends to less flow
• musty, stale odor

What should Lochia look like as time progresses (general)?

lighter and less

If darker and more or larger clots - call the provider

Anticipatory guidance needs

What should we educate mom on for herself?

(4 items)

• fatigue / sleep deprivation (it's okay if it takes an hour to take a shower)
• mood swings - post pardum blues - most get them - if they last longer than a few days may need follow up
• Breast Engorgement - about day 3 - lots of pressure - painful
• May need 2 week follow-up

Anticipatory Guidance

What should we educate parents on about baby?

(5 items)

• sleeping patterns (sleep frequently - growth changes patterns)
• hyperbilirubinemia (jaundice)
• cord problems - trend says no special care - educate how to diaper around cord
• feeding and elimination problems
• may need follow-up appointment 3-5 days after discharge

postpartum

When is bleeding a problem?

soak through two maxi pads in 15 minutes

• first one when you get up
• change it
• another within 15 minutes of change

• How can postpartum hemorrhage be prevented?

• oxytocic after delivery
• controlled traction on umbilical cord durint 3rd stge of delivery (provider)
• evaluate placenta for complete expulsion
• uterine massage after birth
• empty bladde
• monitor Lochia: increased amount / clots = problem
• ice to perineum

• presence of blood: blood changes pH
• diabetes is risk factor for infection

• REEDA
• cultures
• vitals
• increased lochia / atypical discharge

§  look at feet – pedal pulses

§  assess for edema

§  Homan’s sign: doesn’t rule out clot but can confirm it

§  swollen

§  hot/red

§  might be cool

§  ambulation

§  feet up on stool / pillows

§  compression stockings

·         shortness of breath

·         chest pain

·         increased respiration rate

·         increased heart rate

• unilateral
• red/tender wedge

§  Support bra

§  Rotate latch positions

§  Breast pump

§  Increase fluids

§  NSAID’s

§  Heat/ice

§  antibiotics

§  50-80% of postpartum women

§  Onset 3-5 days after delivery

§  Self-limiting, report being overwhelmed and anxious for no reason with happiness

§  Major mood disorder

§  4-28% of postpartum women

§  Onset 1-4 weeks to 1 year after delivery

§  Repot sadness, sleep and appetite changes, feeling worthless, lack of interest with typical activities, guilt and shame

§  Can feel hostile towards others, including newborn

§  Affects 1 out of 1,000 postpartum women

§  Rapid onset

§  Severe depression with agitation, hyperactivity, difficulty focusing, poor judgment, delusions and hallucinations with newborn depicted as evil

§  Might be related to bi-polar

§  Rh- mother with Rh+ baby

§  IM at 28 weeks to all Rh- moms

§  IM within 72 hours of birth to Rh- moms with Rh+ newborns

Can give after birth if negative titer for rubella

can give during pregnancy

• IUD - insert 1 hour after delivery or at 6 weeks postpartum
• progesterone only BC is okay at 6 weeks (ensure good milk supply before adding progesterone)
• barrier methods
• Lactating amenorrhea method