Maternal ATI Notes - ATI help PDF

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Maternal/Newborn ATI

CONTRACEPTION Barrier Methods  Condom  Diaphragm  Client must be re-fitted by the provider every 2 years, or if they have gained more than 15lbs (7KG), or if they have had a full-term pregnancy or second term abortion  When you use a diaphragm, you must use spermicide for each act of coitus  A diaphragm must remain in place for 6 hours after coitus and 6 hours before but no longer than 24 Hormonal Methods  Patches o Replace every week for 3 weeks, 4th week no patch  Oral contraceptives  Look for these following side effects:  Chest pain  SOB  Leg pain from possible clot  A headache or eye problems from a stroke or hypertension  Not recommended for patients who smoke  Contraindications for hormonal contraceptives:  History of blood clots  Stroke  Cardiac problems  Smoker  Breast or estrogen related cancers Depo Provera- an injectable progestin  It can cause decrease bone mineral density or loss of calcium  If they are on Depo Provera, make sure they have an adequate intake of calcium and vitamin D to protect their bones  5 days after delivery and get it ever 12 weeks IUD’s  Can increase the risk of inflammatory pelvic disease  Can cause uterine perforation  Ectopic pregnancy increases  If the patient has an IUD, they should be on the lookout for…  Change in string length  Foul smelling urine  Pain with intercourse  Fever/chills (infection) INFERTILITY Infertility  Defined as the inability to conceive for 12 months (1 year)  Start with sperm analysis- guys first!  Women tests- for tests that require dye, check for allergies to shellfish or seafood (iodine)  Assisted Reproductive Technologies (ART) 1

Maternal/Newborn ATI

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IUI (turkey baster) (multiple births) IVF (very expensive, hyper stimulate woman, remove eggs, and put in Petri dish and add sperm) Donor eggs/sperm Surrogate

SIGNS OF PREGNANCY  Presumptive Signs  Things that can be explained by a reason other than pregnancy (still may not be pregnant)  Amenorrhea (missed period)  Fatigue  Nausea & vomiting  Breast changes  Quickening (baby moving?)/fluttering in stomach- probs gas  Uterine enlargement (tumor?)  Probable Signs- Changes that make the examiner think a woman is pregnant  Positive pregnancy test  Abdominal enlargement  Haggar sign (softening of uterus)  Chadwick sign (blue cervix)  Goodall’s sign (softening of cervical tip)  Ballottement (rebound of unengaged fetus on cervix )  Braxton hicks (false contraction less than 60 sec)  Positive Signs- signs ONLY explained by pregnancy  Very distinct things  Hear fetal heart beat  Ultrasound of baby  Palpation of baby by expert  Ongoing Prenatal visits  Monthly visits from 16-28 weeks  Glucose tolerance test 24-28 weeks  Every 2 weeks from 29-36 weeks  Every week from 36 weeks-birth Naegele’s Rule  When your due date is  Based on last menstrual cycle  The Naegele's formula is simple arithmetic method for calculating the EDD (estimated date of delivery) based on the LMP (last menstrual period). To the date of the first day of the LMP (e.g. 22nd June 2008): add seven days (i.e 29th) subtract 3 months (i.e March) GTPAL  G- Gravidity: number of times a woman has been pregnant including any current pregnancy  P-Para: how many pregnancies past 20 weeks or greater (How many times something has to be pushed out of vagina)  T- Term: births that have gone to 38 weeks or more  P- Preterm: births below 38 weeks 2

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A- Abortions & Miscarriages L- Living Children Ex.: A Pt who has been pregnant 6 times has 4 children at term and one child at 27 weeks and one miscarriage at 15 weeks would read G6, T4, P1, A1, L5

WEIGHT GAIN & NUTRITION DURING PREGNANCY  Gain 25-35lbs for normal weight women  Gain 15-25 for overweight women  Gain 28-40 for underweight women  First trimester: (1-3M) 1-2 KG (2-4 lbs)  Second & third trimester: 1 lbs per week Extra Calories/Day  340 calories per day for the second trimester  450 calories for the 3rd trimester  The first trimester may not need any extra calories  Breastfeeding requires an extra 300-400 calories a day according to Galen (500)  Folic acid- helps to prevent neural tube defects, super important to eat dark leafy veggies, orange juice  Woman should drink between 2-3 liters of water a day and limit caffeine intake to 300mg per day (no alcohol) Rho(D) Immune Globulin (Rhogam)  Given 28 weeks’ gestation and 72 hours post-delivery, miscarriage, or abortion  Only given to Rh- moms  If mom and father are Rh-, don’t give to mom  Double check med  Mom needs to carry a card with her in case of medical emergency because some meds can interfere with rhogam  Med prevents mom from developing antigens within her blood that will attack the fetus is blood type is Rh+ DIAGNOSTIC TESTS DURING PREGNANCY  Ultrasound  You want a full bladder (helps sound waves)  Amniocentesis  Needle to test amniotic fluid  Screens for abnormalities  Empty bladder  Biophysical profile (BPP)  Score between 0-10  8-10 is normal (healthy baby)  Do on IUGR  Measures 5 different things 1. 2. 3. 4. 5.

Reactive HR Breathing Body movements Fetal tone Amniotic fluid volume

Non-Stressed Test 3

Maternal/Newborn ATI

 Noninvasive  Measures fetal well being w/in the last trimester of the pregnancy  Measures the response of the fetal heart rate to fetal movement  You can drink orange juice  No consent required (noninvasive)  Considered reactive (Normal) if the HR accelerates during movement  Considered non-reactive (Not Normal) if HR did not accelerate adequately if you get a nonreactive stress test result from the NST, more testing should be done  Biophysical profile (BPP)  Contraction stress test (CST) Contraction Stress Test  You bring on a contraction on purpose via the administration of Pitocin (oxytocin), or nipple stimulation  During that contraction, you will monitor the FHR to see if late decelerations are occurring  Late decelerations: BAD, positive CST result  No late decelerations: negative CST results- normal  Side effects or risks associated with running CST’s are that they can trigger preterm labor Amniocentesis  Empty bladder  Done around 14 weeks  They check for genetic abnormalities  Levels of AFP (alpha-fetoprotein)  If levels of AFP are high- neural tube defects  If levels of AFP are low- chromosomal disorders (downs syndrome)  They also check LS Ratios  Lecithin-sphingomyelin ratio  Tests for fetal lung maturity  Amniocentesis complications/risks  Amniotic fluid embolism  Hemorrhaging  Infection  Leaking of amniotic fluid  Rupture of membrane or miscarriage Chronic villus sampling (alternative to an amniocen tesis)  Can be done 10-12 weeks  VERY RISKY  Tests for genetic abnormalities  Taking a tiny piece of placenta  Advantage is that it can be done earlier than an amnio) ANTEPARTUM COMPLICATIONS Ectopic pregnancy  Ovum planted outside of uterus often in the fallopian tube  Symptom of unilateral stabbing pain and tenderness in the lower abdominal quadrants  Dangerous if fallopian tube bursts  Management includes laparoscopic surgery or methotrexate 4

Maternal/Newborn ATI

Molar pregnancy  Proliferation and degeneration of trophoblastic villi in the placenta- grape like cluster  Symptom of having bleeding that resembles prune juice, dark brown  HCG levels are drawn every 1-2 months for a year and are high Placenta previa  Placenta previa abnormally implants in the lower segment of the uterus (near cervix) opposed to near the top (fundus)  Painless vaginal bleeding that is bright red during the 2nd or 3rd trimester  Very dangerous, may hemorrhage, may have to give them blood  Complete placenta previa is when the cervix is completely covered by placental attachment  Incomplete or partial is when the cervix is only partly covered  No vaginal exam  High flow O2 Abruptio placenta  Premature rupture of the placenta from the uterus  Very high rate of fetal and maternal death  Symptoms: sudden onset of intense localized uterine pain with dark red vaginal bleeding or no bleeding at all  MEDICAL EMERGENCY!  C-section due trauma, HTN, cocaine use, smoker, premature rupture of membranes  Uterus will have no tone, monitor baby like crazy, load mom up with Oxygen Yeast infection  Are super common for pregnant women  Cottage cheese like drainage vulvar redness  White patches on the vaginal wall Incompetent cervix (cervical insufficiency)  When the cervix doesn’t stay closed (falls out)  Shortening of the cervix, premature dilatation  Lets uterus content out causing miscarriage  Recurrent premature dilatation of the cervix or cervical insufficiency  If a woman has an incompetent cervix she will get a cerclage (sutures) to help keeps the cervix closed and it is removed at 37 weeks of gestation or when spontaneous labor occurs Hyperemesis  Excessive nausea and vomiting that goes past 12 weeks  Weight loss  Electrolyte imbalance  Dehydration  Interventions include  Iv fluids  Administration of B6  Antiemetic medication (regulan, Zofran)  Intrauterine growth restriction (IUGR) due to mom not being able to hold nutrients Iron deficiency anemia 5

Maternal/Newborn ATI

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Take iron supplements with foods that are rich in vitamin c (orange juice) Increase fiber

Gestational diabetes  Higher risk at developing diabetes after pregnancy  Poses a risk to the fetus  Performs tests such as:  Biophysical profile (BPP)  Nonstress test  Most oral antidiabetic medication are contraindicated for pregnancy, so women will use insulin only  Keep taking insulin even if you feel nauseated  Diet is the best therapy When & How you test for gestational diabetes  Between 24-28 weeks  1-hour glucose tolerance test (non-fasting)  Given 50g of oral glucose  1 hour later they test blood sugar levels  If over 130 or 140 they proceed w/ the OGTT oral glucose tolerance test (requires fastening overnight), no smoking and test blood sugars at 1 hour, 2 hours, and 3 hours Gestational hypertension  Caused by vasospasm – poor tissue profusion 1. Gestational hypertension  After 20th week, and woman has a BP over 140/90 recorded at least twice 4-6 hours apart w/in one week  No protein in the urine yet 2. Mild preeclampsia  After 20th week, and woman has a BP over 140/90 recorded at least twice 4-6 hours apart w/in one week  Protein in urine is 1+  Edema may not be present 3. Severe preeclampsia  BP over 160/100  Protein in urine is 3+  Creatinine levels start to rise, greater than 1.2  Head ache  Blurred vision  Hyperreflexia  Peri peripheral edema  Epigastric pain 4. Eclampsia  Everything severe preeclampsia has plus seizures 5. HELP syndrome  Hemolysis- anemia (blood is breaking down) 6

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Elevated liver enzymes (ALT & AST levels increase) Low platelets (under 100,000) Everything eclampsia has Leads to DIC (clotting and bleeding cycle)

Antihypertensive medications  Methyldopa  Nifedipine  Hydralazine  labetalol Anticonvulsant medications  Magnesium sulfate- helps prevent seizures o FEEL LIKE CRAP!!! o Toxicity signs:  B: BP decreases  U: Urine output decreases  R: RR decreases  P: Patellar reflux absent o If they have these signs, stop the infusion, give calcium gluconate, prepare actions to prevent respiratory and cardiac arrest  Also a tocolytic (It’s Not My Time)  Monitor for magnesium toxicity o No reflexes o Low urine output o RR low o LOC is low o Dysrhythmias o Antidote is Calcium gluconate o Can cause pulmonary edema Preterm labor:  contractions and cervical changes that happen between 20-37 weeks  May put on bed rest and keep mom hydrated  They may check for FFN (fetal fibronectin)- this is a vaginal swab of secretions  Meds for preterm labor (ITS NOT MY TIME)- Never give them at the same time  Nifedipine  Calcium channel blocker that suppresses contractions (PO pill)  Magnesium  Relaxes smooth muscle (IV)  Can cause baby respiratory depression  Indomethacin  NSAID, inhibits prostaglandins, suppresses contractions  Be careful of fetal heart closure  Terbutaline  Slows contractions  Betamethasone 7

Maternal/Newborn ATI

 A steroid for developing fetal lungs If the membranes have already ruptured: PROM  Antibiotics- because infections cause PROM  Betamethasone- steroid for fetal lungs (2 injections – either 12 hours or 24 hours apart) CHANGES THAT OCCUR RIGHT BEFORE LABOR  Backache  Pain when walking  Weight loss  Lightening (when the fetal head descends into the true pelvis)  Contractions increase in strength and very regular  Bloody show  Energy burst (nesting)  GI changes (nausea & vomiting)  Rupture of membranes- Nitrazine paper test will be cobalt blue with presence of amniotic fluid Other tests  Group B streptococcus test (if they have not had one at 36-37 weeks)  Urinalysis STAGES OF LABOR 1.) Onset of labor- complete dilation of cervix 10cm 1.) Latent phase: 0-3 cm, mom is talkative and eager 2.) Active phase: over 3cm-7cm (4-7), restless and feelings of helplessness, trying to focus 3.) Transition phase: 8-10 cm o “I can’t go on” o Urge to push o Turns crazy o Feels like she needs to poop o Increased rectal pressure o Duodenal blocks can be given in this phase 2.) Fully dilated to the birth of the baby 3.) Birth of the baby to the delivery of the placenta 4.) Delivery of the placenta until mom’s vital signs return to normal- 4 hours WANT BABY DELIVERED OA!!!! CONTRACTION 5 MINUTES APART IS LABOR! PAIN MANAGEMENT Non-pharmalogical methods  Aromatherapy  Imagery  Music  Counterpressure on sacrum  Effleurage- light touch on abdomen 8

Maternal/Newborn ATI

Sedative or an opioid analgesic  Sedation  Hypotension  Decreased variability in FHR Epidural  Lack of sensation at the level of umbilicus to the thighs  Must be dilated 4cm or above  Given IV bolus before epidural to counteract the hypotension  IF MOM SAYS I FEEL LIKE I COULD BE SICK, CHECK BP THEY ARE HTN  Side effects:  Maternal hypotension  Fetal bradycardia  Avoid supine hypotension syndrome: do not compress the vena cava, prop mom up. Spinal blocks  Used for c-sections  Lack of sensation from the nipples to the feet  Side effects:  Maternal hypotension  Fetal brady cardia  Potential headache- leakage of spinal fluid  Higher incident of bladder and uterine atony (flaccid) FETAL HEART MONITORING (VEAL CHOP) TOCO: transducer applied to abdomen, displays uterine contractions only! EFM: transducer applied to abdomen, displays FHR IUPC: insert a solid, sterile, water-filled IUPC inside uterus  Normal FHR – 110-160  We want variability (moderate)  We do not want absent variability  We do not want late decelerations or variable decelerations  Accelerations and early decelerations (head compression) are ok!  Fetal brady cardia (not good)- below 110, due to epidural, or medications given to mom  Uteroplacental insufficiency (late decelerations)  Discontinue oxytocin (PIT)  Pt. on the side  Give more O2  Notify provider Fetal tachycardia (above 160)  Maternal infection – antipyretics and O2 given Late decelerations  Uteroplacental insufficiency- lack of fetal oxygenation  Small dip after the contraction, begins around the peak of a contraction  Interventions:  Side lying position 9

Maternal/Newborn ATI

 Increase IV fluids  Discontinue PIT!!!!!!  Administer O2  Notify Doctor Variable decelerations  Umbilical cord compression (no blood flow to baby)  15-point drop or more  U, V, or W shape  Interventions:  Side lying or knee chest position  Increase IV fluids  Discontinue oxytocin  Administer O2  FLIP MOM FLIP MOM FLIP MOM Umbilical cord compression or prolapsed umbilical cord  Presenting part of fetus, cord protruding through cervix & being crushed by fetus’s head  Interventions:  Get help/notify the provider  Turn mom on side  Using a sterile gloved hand, use 2 fingers to lift baby’s head off the cord “MY FINGERS ARE NUMB”  Reposition mom in the knee chest position or Trendelenburg Use a warm sterile gauze that is saline soaked to cover cord RhoGAM  Given at 28 weeks gestation  Administered 72 hours after giving birth for women who are Rh negative, and their baby is RH positive  To prevent issues with their next pregnancy FUNDAL HEIGHT AFTER BIRTH  Immediately after birth uterus should be firm and midline w/ umbilicus & approximately at the level of umbilicus  At the 12-hour mark, fundus may go up 1cm above the umbilicus  Every 24 hours after that it should go down 1 or 2cm  By the 6th postpartum day it should be halfway between umbilicus and the symphysis pubis  By day 10 you should not ab able to feel the fundus at all LOCHIA  Discharge after birth that contains blood, mucous, and tissue  Lochia rubra: bright red bleeding that occurs during day 1-3 after birth, fleshy odor, clots, should not be excessive (saturate pad is never normal) should NOT pass day 3  Lochia serosa: serosanguinous consistency & pinkish brown in color, occurs during days 4-10  Lochia alba: yellow creamy color and fleshy odor during days 11-6 weeks  Excessive bleeding- saturating a pad in 15 min (according to ATI) POSTPARTUM PAIN IN THE VAGINA 10

Maternal/Newborn ATI

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Ice pack for 24 hours SITZ bath -warm water promotes circulation Blood loss during vaginal birth is about 500ml & 1000ml for cesarean

MILK AND COLOSTRUM  Milk comes in 2-3 day after birth  Mom produces colostrum right away even before the baby is born, it is a thicker yellow fluid that is full of antibodies and nutrients (high in fat) URINE ATONY  Retaining urine  Bladder is distended, have mom void one way or another  Uterus can get displaced from midline  ALWAYS VOID PHASES OF MATERNAL ROLE ATTAINMENT (RUBIN’S STAGES) 1.) Dependent taking in phase:  First 24-48 hours after birth  Eager to talk about her experience  Relies on others for assistance in hospital 2.) Dependent/Independent taking hold phase:  Day 2-3 to the next couple of weeks  Focused on baby care, practicing skills, asking questions, learning 3.) Independent letting go phase:  Resuming roles pre-pregnancy  Letting other care for baby DISCHARGE TEACHING ABOUT BREAST ENGORGEMENT  Milk comes in 2-3 days after giving birth and breast engorgement is a very common problem  Cold compresses between feedings  Applying warm compresses/ shower prior to breast feeding  Cold fresh cabbage leaves for 20 min each POSTPARTUM DISORDERS  Deep Vein Thrombosis (DVT)  Unilateral area of swelling  Calf tenderness in one leg  Pulmonary embolism is what we want to avoid so we use bed rest  Encourage rest, bed rest and elevate extremity above the heart, warm compresses, NSAIDS and anticoags.  Pulmonary embolism S/S o Chest pain o Difficulty breathing o Anxiety Put in semi fowlers and high flow o2 11

Maternal/Newborn ATI

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Postpartum Hemorrhage  Lochia rubra longer than 3 days  More than 500 ml of blood loss after vaginal birth or more than 1000 with c section  Excessive bleeding  Uterine atony- boggy  Placenta fragments left inside  Monitor pads  Empty bladder  Massage fundus  Hypotension  Tachycardia

Medications for Hemorrhaging and Uterine Atony  Oxytocin (PIT) o Uterine stimulant- helps contract the uterus  Methylergonovine (Methergine) o Uterine stimulant o Do not give to a hypertensive pt.  Misoprostol (Cytotec) o Uterine stimulant Mastitis  Infection of the breast clogged up  Painful or tender localized hard mass  Red area usually on one breast  Flu like symptoms, chills, fever, & fatigue Education of Breast Hygiene to Prevent Mastitis  Wash hands prior to breast feeding  Keep breast clean  Allow nipple to air dry  Baby taking in entire nipple and areola  Have each breast emptied during each feeding  Alternate breast each feeding (20 min each) Postpartum Depression /Blues  Postpartum blues: o Very common o Feelings of sadness, crying, lack of appetite, sleep disturbances, feeling inadequate o...