Maternity Exam 3 PDF

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Maternity Exam 3 FINAL: Postpartum Thermoregulation (if the ba is laying on the scale how is the ba losing temperature?) Heat loss in the newborn occurs in fours ways: Loss of heat from warm body surface to cooler air currents room, oxygen mask and removal from an incubator Transfer of heat from hea...

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Maternity Exam # 3 FINAL: Postpartum Care/Comprehensive Thermoregulation (if the baby is laying on the scale how is the baby losing temperature?)

Heat loss in the newborn occurs in fours ways:

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Convection- Loss of heat from warm body surface to cooler air currents – air-conditioned room, oxygen by mask and removal from an incubator

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Radiation- Transfer of heat from heated body to cooler surfaces – walls

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Evaporation- Water is converted to vapor-amniotic fluid; bath

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Conduction- Heat loss to cooler surface; chilled hands; cold scales, cold stethoscopes

Heat Production:  When exposed to a cool environment the newborn requires additional heat.  The newborn has several physiologic mechanism that increase heat production, or thermogenesis.  Theses mechanisms include: basal metabolic rate, muscular activity and chemical thermogenesis (also called nonshivering thermogenesis [NST])  NST is an important mechanism of heat production unique to the newborn. It occurs when skin receptors perceive a drop in the environmental temperature and in response transmit sensations to stimulate the sympathetic nervous system.  NST uses stores of BAT to provide heat Drugs Pitocin: 

“Oxytocin” is used to induce labor at term and to augment uterine contractions in the first and second stage of labor.

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It may also be used immediately after birth to stimulate uterine contraction and thereby control uterine antony.

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The effects of Oxytocin on the cardiovascular system can pronounced. Blood pressure initially may decrease, but after prolonged administration may increase by 30% above baseline.

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Cardiac volume and stroke volume increase.

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Overdose can cause tachysystolic labor patterns, nonreassuring fetal status, and fetal bradycardia

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Contraindications: severe preeclampsia/eclampsia, predisposition to uterine rupture, cephalopelvic disproportion, malpresentations or malposition of the fetus, cord prolapse, more than one previous c-section, preterm infant, rigid unripe cervix; total placenta previa, presence of nonreassuring fetal status.

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Nursing Considerations: o

Apply fetal monitor and obtain 15 to 20 minute tracing and nonstress test to assess FHR before starting IV Oxytocin

o

Piggyback secondary IV with oxytocin. Pitocin can never be run without an infusion pump.

o

Ensure continuous fetal and contraction monitoring

o

Maternal vital signs, including BP, HR, and oxygen saturation every 15 min.

o

Assess FHR: decelerations, accelerations

o

Assess cervical dilation

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DISCONTINUE IV OXYTOCIN WHEN:

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Nonreassuring fetal status (bradycardia, late or variable decelerations)

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Uterine contractions are more frequent than every 2 mins

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Duration of contractions exceeds more than 60 seconds

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Insufficient relaxation of the uterus between contractions

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In addition to discontinuing IV oxytocin, turn patient to side, and if nonreassuring fetal status present administer oxygen, and maintain intake and output,

Meperidine (Demerol): 

Can cause decreased variability in the newborn

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Respiratory depression, convulsions, cardiovascular collapse, cardiac arrest

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Respiratory depression in newborn

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Bronchoconstriction.

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HAVE NALOXONE (NARCAN) AVAILABLE!  TO REVERSE RESP. DEPRESSION

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Contraindications: hypersensitivity to the drug, convulsive disorders, breastfeeding, undiagnosed acute abdomen

Magnesium Sulfate: 

Acts as a CNS depressant, which is why magnesium sulfate is used in the treatment of preeclampsia (seizures) anticonvulsant.

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It relaxes smooth muscles thereby may cause transient blood pressure readings.

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Also decreases the frequency and intensity of uterine contraction; as a result it is also used as a tocolytic n the treatment of preterm labor.

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Contraindications: myasthenia gravis, history of myocardial damage, heart block, extreme care in the administration of women with impaired renal function  toxic levels

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Side Effects: lethargy, weakness, warmth, flushing, nasal congestion, vasodilation, N/V, constipation, visual blurring, headache, slurred speech. SIGNS OF TOXICTY: depression or absence of refelexes, oliguria, confusion, resp. depression, circulatory collapse, resp. paralysis. Rapid administration of large dose may cause cardiac arrest.

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Nursing Considerations: o

Monitor BP every 10-15 minutes during administration

o

Monitor maternal serum magnesium levels

o

Monitor respirations closely

o

Assess knee jerk (patellar tendon reflex)

o

Determine urinary output

o

The antagonist of mag. Is calcium have calcium available at bedside

o

Monitor fetal heart tones continuously with IV administration

o

If mother received mag. Close to birth assess newborn for mag. Toxicity.

Steroid  Betamethasone (Celestone): 

Capable of inducing pulmonary maturation and decreasing the incidence of respiratory distress syndrome in preterm infants.

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The mechanism is unclear but related to the stimulation of enzyme activity, the enzyme required for biosynthesis of surfactant.

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Contraindications: inability to delay birth, adequate L/S ratio, presence of a condition that necessitates immediate birth (maternal bleeding), presence of maternal infection, diabetes mellitus, gestational age greater than 34 completed weeks

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Maternal side effects: increased risk for infection? Hyperglycemia, pulmonary edema

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Effects on Fetus/Newborn: lowered cortisol levels at birth but rebound occurs by 2 hours of age, hypoglycemia, neonatal sepsis

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Nursing Considerations: o

Administer deep into gluteal muscle IM

o

If membranes are ruptured, temperature monitoring is warranted every 2 hours or more frequently

o

Periodically evaluate BP, pulse, weight, and edema

o

Assess lab data electrolytes and blood glucose Breast

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Assess Breast: symmetry, consistency, lumps

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Engorgement: breasts, nipples, or both hard and distended with congestion and accumulation of milk

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Assess nipples: for intactness; note signs of redness, bruising, or cracking

Caring for the breasts in the nursing mother ◦

Engorgement: vascular congestion and milk stasis

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Infant not fully emptying mother’s breasts

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Encourage feeding every 2 or 3 hours

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Application of warm compresses

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Express small amount of breast milk: to soften breasts, to latch successfully

Nipple tenderness: progress to redness, bruising, or cracking ◦

Common cause: improper positioning and latch

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Pain or bruising: upper portion of nipple— infant pinching nipple with gums

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Lift infant’s head up: baby faces nipple directly

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Candida albicans causes nipple pain: bright red and shiny, sore nipples  check baby’s mouth for thrush

Remedies ◦

Application of small amount of expressed colostrum or breast milk, tea bags, warm water compresses, lanolin cream, and air drying nipples following feedings

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Warm water compresses

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Caring for the breasts in the non-nursing mother:

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Engorgement; assist with vasoconstriction: suggest wearing a well-fitting bra

Breast Feeding VS Non Breast Feeding Woman: 

The non breast-feeding woman is assessed for breast discomfort and relief measures are instituted it necessary.

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If mother is not planning to breastfeed encourage a tight bra (for support) and ice pack (to reduce pain)

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If mother is not feeding make sure breast/nipple is not stimulated which produces more milk.

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Lactation- nipple stimulation leads to pitocin release, which leads to the release of prolactin, which leads to milk production and let-down reflex

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Colostrum- first milk, rich in protein and immunoglobulins

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Breastfeeding also increases the frequency and severity of after pains

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Advise mothers inflicted with HIV or Tb NOT to Breastfeed GTPAL

(GTPAL): G (Gravida): the number of pregnancies T (Term): number of infants born at the completion of 37 weeks gestation or beyond) P (Preterm): number of infants born after 20 weeks but before the completion of 37 weeks. A (Abortion): number of pregnancies ending in either spontaneous or therapeutic abortion (birth that occurs before the end of 20 weeks. L (Living): number of currently living children. Example: Tracy Hopkins is pregnant for the fourth time. At home she has a child who was born at term. Her second pregnancy ended at 10 weeks gestation. She then gave birth to twins at 35 weeks. One twin died soon after birth. Answer: G:4 P1212

Estimated Date of Delivery (EDD) Estimated date of Birth (EDB): To calculate EDB it is essential to know the first day of the last menstrual period (LMP). An early ultrasound should be obtained if an accurate LMP is not available to help establish an accurate EDB. Nägele’s Rule: most common method of determining the EDB, which uses 280 days as the mean length of pregnancy. To use this method, begin with the first day of LMP, subtract 3 months and add 7 days. For Example:

Determiming Gestation: Last period Nov. 10 (count weeks from her last period) today is January 12 , what is her gestation?  9 weeks Postpartum blues 

Postpartum depression is a non-psychotic depressive episode that begins in the postpartum period

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Manifested by tearfulness, anorexia, difficulty sleeping and a feeling of letdown

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Can occur while still in hospital

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Usually resolves within 10-14 days

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If worsens; referral may be urgent

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Postpartum depression prevalence rates are estimated to be 10-15%.

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Etiologies: hormonal changes, genetic predisposition, and sleep loss

It is not a psychotic issue the difference between postpartum blues and postpartum depression is the length of time. After the 14 days if she is still sad and depressed and does not want to hold baby she needs to get help may be a sign of post partum depression Postpartum Psychosis: ◦

No interest in visitors, self, or baby

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Impaired reality

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Agitation

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Restless

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Suicidal

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Irrational

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Hallucinations

PKU 

MST  Metabolic Screening Test (PKU)

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Phenylketonuria (PKU) is an autosomal recessive inherited disorder of amino acid metabolism that affects the body’s use of protein.

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The defect results in accumulation of phenylalanine in the blood or phenylalanine metabolism in the urine.

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If untreated, this disease leads to irreversible brain damage and severe intellectual disability.

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Phenylalanine levels above 20 mg/dL are indicative of classic PKU.

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Accumulation of phenylalanine in the blood causes a musty or mousey body and urine odor, irritability, vomiting, hyperactivity, hypertonia, hyperreflexia deep tendon reflexes, seizures, and an eczema-like rash.

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Infants appear normal at birth except for lighter skin complexion than their nonaffected siblings.

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Microcephaly, prominent maxilla and widely spaced teeth, enamel hypoplasia, and growth retardation, are other common findings in untreated children.

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Testing the newborn: o

Screening for PKU is required by state law in all 50 states.

o

For best results the newborn should have begun formula or breast milk feeding before specimen collection.

o

Early hospital discharge places newborn at risk for false-negative screening tests if screened within 24 hours of birth.

o

Screening needs to occur no sooner than 48 hours after birth, or the test should be repeates at 1 to 2 weeks of age.

o

If the test shows elevated levels of plasma phenylalanine, a repeat quantitative test is performed. If the second test is positive, the family is referred to an outpatient treatment center.

o

Serum levels of phenylalanine should be measured periodically throughout life.

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PKU Treatment:

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Special formulas and diet low in phenylalanine to keep plasma phenylalanine levels between 2 and 6 mg/dL. The diet must also meet the child’s needs for optimal growth.

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Breast-feeding is possible if phenylalanine levels are monitored.

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High protein foods (meats and dairy products) and aspartame are avoided because they contain large amounts of phenylalanine.

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Low-phenylalanine diet should be maintained throughout life to avoid decline in IQ and neuropsychological abilities Prothrombin

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Disseminated Intravascular Coagulation (DIC) is a complex pathologic activation of coagulation mechanism that can occur as a complication in pregnancy.

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In DIC, small clots are formed within blood vessels that consume coagulation proteins and platelets.

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When this process occurs abnormal coagulation and abnormal bleeding results in various systems, including the skin, gastrointestinal, and respiratory systems.

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This cascade of events leads to microclots that disrupt normal blood flow to major organs and can lead to organ failure.

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Because of the risks of DIC, evaluating results of coagulation tests is imperative.

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In DIC, fibrinogen levels and platelet counts usually decrease and and prothrombin time and partial thromboplatin times are normal to prolonged.

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DIC can occur in the following conditions: Obstetric complications: abruptio placentae, preeclampsia or eclampsia, amniotic fluid embolism, retained intrauterine fetal demise, septic abortion

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A DIC profile test includes: Platelet count, Global clotting times (aPTT and PT  Prothrombin Time) One or two clotting factors and inhibitors (eg, antithrombin), Assay for D-dimer or FDPs

(Information from medline plus) If you are not taking blood thinning medicines such as warfarin, the normal range for your PT results is  

11 - 13.5 seconds, or INR of 0.8 - 1.1

If you are taking warfarin to prevent blood clots, your doctor will most likely choose to keep your INR between 2.0 and 3.0. Cardinal signs of delivery  know them in order that they occur

1. Descent: occurs because of four forces: (1) pressure of the amniotic fluid, (2) direct pressure of the uterine fundus on the breech, (3) contraction of the abdominal muscles, and (4) extension and straightening of the fetal body. The head enters the inlet in the occiput transverse or oblique position because the pelvic inlet is widest from side to side. 2. Flexion: occurs as the fetal head descend and meets resistance from the soft tissues of the pelvis, the muscles of the pelvic floor and the cervix. As a result of the resistance the fetal chin flexes downward onto the chest. 3. Internal rotation: the fetal head must rotate to fit the diameter of the pelvic cavity. 4. Extension: the resistance of the pelvic floor, assist with extension of the fetal head as it passes under the symphysis pubis. 5. Restitution: once the head is born and is free of pelvic resistance, the neck untwists, turning the head to one side (restitution) and aligns with the position of the back in the birth canal. 6. External rotation: as the shoulders rotate to the anteroposterior position in the pelvis the head turns farther to one side (external rotation) 7. Expulsion: as lateral flexion of the shoulder and head occurs the anterior shoulder is born before the posterior shoulder, the body follows quickly.

Darn Fetus Is Eager & Restless to Exit & be Expelled

Internal fetal monitoring

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Requires an internal spiral electrode.

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To place the spiral electrode on the fetal occiput, the amniotic membranes must be ruptured! The cervix must be dilated at least 2 cm, the presenting part must be known.

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This method of monitoring FHR provides more accurate

Baseline rate: Normal FHR (baseline) ranges from 110 to 160 beats/min.

Fetal Tachycardia Causes (161 bpm and above):  Early fetal hypoxia  Maternal fever  Maternal dehydration  Beta-sympathmimetics drugs (ritodrine, terbutaline, atropine)  Amnionitis (fetal tachy, may be the first sigh of developing intrauterine infection)  Maternal hyperthyroidism (TSH hormones may cross the placenta and stimulate FHR)  Fetal anemia Fetal Bradycardia Causes (less than 110 bpm during a 10 minute period or longer):  Late (profound) fetal hypoxia (depression of myocardial activity)  Maternal hypotension, which result in decreased blood flow to the fetus  Prolonged umbilical cord compression  Fetal arrhythmia  Uterine hyperstimulation  Abruption placentae  Vaginal stimulation in the second stage  Congenital heart block

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Maternal hypothermia Fetal position

Fetal Position refers to the relationship of a designated landmark on the presenting fetal part to the front, sides, or back of the maternal pelvis.  The landmark chosen for vertex presentation is the occiput  the landmark for face presentation is the mentum.  In breech presentation the sacrum is the designated landmark.  Should presentations the acromion process on the scapula is the landmark. 1. Right (R) or Left (L) side of the maternal pelvis 2. The landmark of the fetal presenting part: occiput (O), mentum (M), sacrum (S), or acromion process (A) 3. Anterior (A), posterior (P) or transverse (T), depending on whether the landmark is in the front, back or side of the pelvis.

Bonding Initial attachment behavior ◦

Mother explores infant with fingertips, then palms, and then enfolding newborn with whole hands and arms

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Holds infant in en face position, face-to-face position about 20cm , same plane

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Mother uses soft, high-pitched voice

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Advise mother to look at baby while breast feeding and not to be texting or looking elsewhere to create the “en face” position  face-to-face position for bonding

Engrossment 1.

Is the father’s absorption, preoccupation, an...