OB maternalnewborn ati notes PDF

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Maternal Notes for ATI. thorough and valid. from ati...

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ATI Maternal Newborn Female Sterilization Transcervical Sterilization - flexible agents inserted into fallopian tubes which causes scarring, and eventual occlusion of the fallopian tubes. Can be done WITHOUT anesthesia. 3month effectiveness, so use birth control while confirmation of occlusion. Do NOT use for postpartum patients. Tubule Ligation – Sever or burn fallopian tubes, done under general anesthesia. Can be done post-partum. Men Sterilization Vasectomy – sever the Vas Deferens. Least invasive procedure. Alternative form of birth control for 20 ejaculations. Follow up sperm testing for is important. Reversal may be possible. Infertility – when a couple has been unable to conceive for a long period of time, typically 12 months. Diagnostic tests can be done, test the guy first. Test the semen, if coast is clear, test the female. One test is hysterosalpingography, which is dye shooting through the fallopian tubes to check for clearance and patency. Make sure the patient is not allergic to shellfish or Iodine. Laparoscopy is another test that can be done where the provider assesses the internal organs under general anesthesia. The abdomen is blown up with CO2 gas. Retained gas might cause abdominal pain and shoulder pain (referred pain). Encourage patient to walk and consume fiber rich foods. Signs of Pregnancy - Presumptive Signs o Can be explained by other reasons o Amenorrhea (not getting period) o Nausea & Vomiting o Urinary Frequency o Breast Changes o Quickening (baby moving in stomach) o Uterus Enlargement - Probable Signs o Probably related to pregnancy o Hegar’s Sign – softening and compressibility of lower uterus o Chadwick’s Sign – deepened violet-bluish color of cervix and vaginal mucosa o Goodell’s Sign – softening of cervical tip o Braxton Hicks Contractions – false contractions that are painless, irregular, and usually relieved by walking o Positive pregnancy test - Positive Signs o No other explanation, definitely pregnant o Fetal heart sounds are heard o Fetal movement felt / o Visualization of fetus on ultrasound

ATI Maternal Newborn

Due Date For Delivery - Nagele’s Rule – take the first day of the client’s last menstrual cycle, - Subtract 3 months, add 7 days, and add 1 year. o April 1st, 2019 will deliver on January 8th, 2020. - Fundal Height o Measured in centimeters from the symphysis pubis to the top of the uterine fundus, between 18 and 30 weeks of gestation. o Fundal Height will equal gestation age. o If Fundal height is 20 CM, gestation will be 20 weeks. GTPAL - Gravidity o Total number of times pregnant - Term Births o Number of births at 38 weeks or more - Preterm Births o Number of births before 38 weeks - Abortions & Miscarriages o Number of abortions and miscarriages - Living Children o Number of living children - A woman is currently pregnant with twins, has triplets at home who were born at 32 weeks, another child born at 40 weeks, and one miscarriage. Score of G4, T1, P1, A1, L4 Expected Changes During Pregnancy - Cardiovascular Changes o Increase in cardiac output of approximately 30-50%. o Increase in blood volume of 30-45% o Increase in heart rate - Respiratory Changes o Oxygen need increase o Lung capacity decreases o Respiratory rate increases - Cervical Changes o Becomes softer o Blue/Purple color - Breast Changes o Become larger o Darker areolas - Skin Changes o Chloasma – brown patches on face o Linea Nigra – line that runs from navel to pubic bone

ATI Maternal Newborn o Striae Gravidarum – stretch marks often present Supine Vena Cava Syndrome - The mother gets HYPOTENSIVE when lying in a supine position due to the weight of the uterus on the vena cava. - Prevention is to lay on her left side, semi-Fowlers position, or place a wedge under one hip when supine. Assessment of the Baby During Pregnancy - Ultrasound o Noninvasive procedure o Uses high frequency sound waves to visualize fetus o Determines site of implantation of growth, development, and movement o Drink a FULL QUART OF WATER PRIOR TO PROCEDURE - Biophysical Profile o Uses real time ultrasound technology to assess for fetal well-being o Scoring: Fetus gets a 0 or 2 for the below areas. Score of 8-10 normal. Score under 8 indicates fetal asphyxia.  Reactive FHR: Reactive = 2, Non-reactive = 0  Fetal Breathing Movements: 1 or more episodes > 30 seconds = 2, Absent or less than 30 seconds = 0.  Gross Body Movements: 3 or more body/limb extensions with return to flexions = 2, less than 3 episodes = 0.  Fetal Tone: 1 or more episodes of extension with return to flexion = 2, lack of flexion or absent movement = 0.  Amniotic Fluid Volume: 1 pocket > 2cm in 2 perpendicular planes = 2, absent or < 2 cm = 0. - Nonstress Test o Noninvasive test that measures the FHR response to fetal movement. o Performed during third trimester. o Acoustic vibration device may be used to awake sleeping fetus. o May give the patient orange juice o Mother pushes button attached to monitor when she feels fetal movement o Indications: Decreased fetal movement, diabetes, gestational hypertension, post maturity. o Interpretations  Reactive: NORMAL Finding. FHR has a normal rate, moderate variability, and accelerates > = 2 times in 20-minute time period.  Non-reactive: ABNORMAL Finding: FHR does not accelerate sufficiently with fetal movement. - Contraction Stress Test o More invasive test used to measure FHR response to contractions. o Nipple stimulation or oxytocin used to induce contractions

ATI Maternal Newborn o BIOPHYSICAL PROFILE for a positive stress test o Indications: Nonreactive stress test, high risk pregnancies o Interpretations:  Negative: NORMAL Finding, no late decelerations of FHR with 3 contractions in 10-minute period.  Positive: ABNORMAL Finding, late decelerations present in 50% or more of contractions, indicative of uteroplacental insufficiency. o Complication: Contractions lead to preterm labor -

Amniocentesis o Amniotic fluid is aspirated under ultrasound guidance. Patient will feel pressure with needle comes into contact with uterus. o Used to locate a pocket of amniotic fluid o Performed after 14 weeks o Results:  Alpha-fetoprotein: HIGH levels associated with neural tube defects. LOW levels associated with chromosomal disorders  L/S Ratio: 2:1 Ratio indicates fetal lung maturity o Patient Care:  Have patient empty bladder prior to procedure.  After procedure, administer RhoGAM to Rh-negative moms  Encourage rest  Plenty of fluids for 24 hours o Complications  Amniotic fluid emboli, hemorrhage, infection, leakage of amniotic fluid, POM, miscarriage Conditions That Cause Bleedings During Pregnancy - Gestational Trophoblastic Disease (Molar Pregnancy) o Abnormal growth of trophoblastic villi in the placenta that prevents the embryo from growing appropriately o Appear as grape like clusters o May result in choriocarcinoma (type of cancer) o Signs & Symptoms  Dark brown bleeding that resembles prune juice  Nausea and vomiting  Abnormally high hCG levels o Diagnosis:  Ultrasound o Treatment:  Evacuation of mole via curettage  Chemotherapy for choriocarcinoma -

Placenta Previa

ATI Maternal Newborn o Placenta implants near the cervical os vs attaching to the fundus, resulting in bleeding during the third trimester of pregnancy. o 3 types  Complete (total): Placenta covers the cervical os completely  Incomplete (partial): Placenta covers part of the cervical os  Marginal (low-tying): Placenta attached to lower uterus, but does not cover the cervical os o Signs & Symptoms  Painless, bright red bleeding in the 2nd or 3rd trimester  Decreased HgB and Hct with blood loss o Diagnosis: Ultrasound o Nursing Care:  Do not perform vaginal exams or insert anything vaginally  Initiate continuous external fetal monitoring  Administer IV fluids and blood as prescribed  Insert a large bore IV cath  Obtain a blood sample for labs  Educate patient on need for bed rest  Administer corticosteroids to promote fetal maturation if delivery is anticipated

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Abruptio Placenta o Premature separation of the placenta from the uterus, usually in the 3rd trimester. Significant risk of maternal and fetal morbidity/mortality. o Khelihauer-Betke test o Risk Factors:  Maternal hypertension  Trauma  Cocaine use  Smoking o Signs & Symptoms:  Intense uterine pain with dark red bleeding  Decreased HgB and Hct  Signs of Hypovolemic Shock (hypotension, tachycardia, pallor)  Fetal distress o Nursing Care:  Administer IV fluids  Administer blood products  Administer oxygen as prescribed  Administer corticosteroids to promote fetal lung maturity

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Incompetent Cervix o Premature dilation of cervix, leading to expulsion of fetus o Signs & Symptoms  Pelvic Pressure  Bleeding or pink vaginal discharge  Gush of fluid (rupture of membranes o Therapeutic Procedure:  Cervical Cerclage  Cervix is sewn closed during pregnancy  Ideally done between 12-14 weeks gestation  Cerclage is removed at 37 weeks or when spontaneous labor begins o Patient Education  Activity restriction  Bed rest as ordered  Adequate hydration  No sexual intercourse  Spotting after 1 or 2 days of insertion

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Hyperemesis Gravidarum o Excessive nausea and vomiting that lasts pasts 12 weeks gestation, possibly related to hCG levels o Signs & Symptoms  Nausea & Vomiting  Dehydration  Electrolyte imbalances  Weight Loss  Ketones or acetones in urine  Elevated urine specific gravity o Nursing Care  Monitor Intake and Output  Monitor weight  Administer IV fluids  NPO for 24-48 hours o Medications  Pyridoxine (Vitamin B6)  Antiemetic Medications  Ondansetron  Metoclopramide

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Iron-Deficiency Anemia o Inadequate iron stores and/or insufficient consumption of iron-rich foods

ATI Maternal Newborn o Signs & Symptoms  Fatigue  Pallor  Shortness of breath  Low HgB and Hct  Pica (unusual food cravings o Nursing Care  Encourage increased intake of iron-rich foods  Meats, green leafy vegetables, fruit, beans o Medications:  Ferrous Sulfate  Take on empty stomach  Vitamin C increased absorption  Increase fluid and fiber to prevent constipation -

Gestational Diabetes o Impaired glucose tolerance during pregnancy. Normal Glucose = 70-110 o Risks  Miscarriage, infections, preterm rupture of membranes  Preterm labor, hydramnios, macrosomia, ketoacidosis  Hyperglycemia, hypoglycemia, increased risk of developing diabetes after pregnancy o Signs & Symptoms  Hypoglycemia  Headache, weakness, shakiness, blurred vision, diaphoresis  Hyperglycemia  Polyuria, polydipsia, polyphagia, N/V, fruity breath odor  GI upset, excess weight gain o Diagnosis:  1-hour glucose tolerance test: performed at 24-28 weeks gestation. No fasting required. If blood glucose is > 140, perform 3-hour OGTT  Drink glucose solution 1 hour before test  3-hour OGTT: overnight fasting, no caffeine, or alcohol for 12 hours prior to test. Fasting glucose is obtained. Glucose levels measured at 1, 2, and 3 hours after ingestion of 100 grams of glucose o Treatment:  Insulin is usually recommended, as most oral diabetes medications are contraindicated during pregnancy

Physiological Changes that Precede Labor - Backache - Weight loss (1 to 3 pounds) - Lightening (baby drops lower in pelvis)

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Contractions (Irregular Braxton Hicks contractions that becomes stronger and more regular) Blood show (brown or bloody discharge) Energy burst GI Upset Rupture of membranes (clear, watery fluids, Amniotic fluid will cause Nitrazine paper to turn BLUE, paper remains YELLOW with urine.

Stages of Labor - First Stage o Begins with onset of labor, ends with complete dialation  Latent Phase: Cervix 0-3cm, mild to moderate contractions, mom is talkative and eager  Apply pressure to the client’s sacral during contractions  Active Phase: Cervix 4-7cm, moderate to strong contractions, mom is anxious, restless, feeling helpless.  Hydrotherapy  Transition Phase: Cervix 8-10cm, strong to very strong contractions, mom feels need to push or have a bowel movement (rectal pressure), feels like she cannot continue  Bear down or pant during this - Second Stage o Full dilation to birth of baby o Encourage the client to frequently change positions - Third Stage o Delivery of baby to delivery of placenta - Fourth Stage o Delivery of placenta to stabilization of maternal vital signs 5 P’s of Childbirth -

Passenger o Baby and then placenta o Presentation  Head, chin, shoulder, breech o Lie  Transverse, parallel/longitudinal o Attitude  Fetal Flexion, fetal extension o Position  Right (R) or Left (L), if back of baby’s head is facing mom’s right side = R  Occiput (O), Sacrum (S), Mentum (M), Scapula (Sc)  Anterior (A), Posterior (P), Transverse (T)

ATI Maternal Newborn

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o Station  Station 0 is at level of ischial spines  If baby is farther DOWN than this, it’s a positive sign  If baby is farther UP than this, it’s a negative sign Passageway o Birth canal Power o Uterine contractions, resulting in effacement, dilation Position o Upright, sitting, kneeling, squatting promotes fetal descant Psychological Response o Stress, anxiety can impair labor

Pain Management During Labor -

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Nonpharmacological o Effleurage  Stroking of mom’s abdomen with fingertips during contractions o Sacral counterpressure  Heel of hand or fist is pushed against mom’s sacral area to relieve back labor pain. o Others  Breathing techniques (start with cleansing breath), imagery, hydrotherapy, music, heat/cold. Pharmacological o Sedatives (Barbiturates)  Can lead to lead to neonate respiratory depression. Use only in early or latent phase o Opioid Analgesics  Can lead to sedation, tachycardia, hypotension, decreased FHR variability, neonate respiratory depression  Naloxone is antidote  Use when cervix is dilated at least 4cm and fetus is engaged Epidural Block o Eliminates sensation from umbilicus to thighs. Administer when mom is at least 4cm dilated  Side Effects  Maternal Hypotension, fetal bradycardia  Monitor blood pressure every 5 or 10 minutes

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Spinal Block o Eliminates sensation from nipples to feet. Used in cesarean births  Side Effects  Maternal Hypotension, fetal bradycardia, headache from leakage of CSF, risk of maternal bladder and uterine atony. Nursing Care o Administer IV fluids (to offset maternal hypotension) o Position mom on side (to prevent supine hypotension syndrome) o Monitor maternal vital signs and FHR continually

Fetal Assessment and Fetal Heart Rate Patterns - Leopold Maneuvers o Palpitation of the uterus through the abdomen to determine the presenting part, fetal lie, fetal attitude, and point of maximal impulse (PMI) o Used to determine placement of external transducer for fetal monitoring - Expected findings for fetal heart rate o Between 110-160 beats/min o Moderate variability o Accelerations present or absent o Early decelerations present or absent o NO variable or late decelerations - Accelerations o Temporary increase in FHR above baseline o Reassuring o No interventions needed - Fetal bradycardia o FHR less than 110 beats/min for > 10 minutes o Due to uteroplacental insufficiency, umbilical cord prolapses, maternal hypotension, anesthetic meds o Discontinue oxytocin, place in side-lying position, administer oxygen, notify provider - Fetal tachycardia o FHR greater than 160 beats/min for > 10 minutes o Due to maternal infection, cocaine use, dehydration o Administer antipyretics, oxygen, IV fluid bolus - Early Decelerations o Slowing of FHR with start of contraction o Due to compression of baby’s head from contraction o No intervention necessary - Late Decelerations o Showing of FHR after contraction has started and prolonged return to baseline o Due to uteroplacental insufficiency

ATI Maternal Newborn

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o Place patient in side-lying position, administer IV fluids, discontinue oxytocin, administer O2, palpate uterus for tachysystole, notify provider Variable Decelerations o Transient, variable slowing of FHR o Due to umbilical cord compression o Place patient in knee-chest position (or reposition from side to side), discontinue oxytocin, administer oxygen.

Procedure to Assist with Labor and Delivery - Internal Fetal Monitoring o Electrode placed on fetal scalp to closely monitor FHR o IUPC monitors strength of mom’s contraction. o Average strength of contractions is 50-85 mmHg o Mom’s membrane must be ruptured, dilated 2cm, presenting part must be descended o Risks of infection for mother & baby - External Cephalic Version o Manipulate mom’s abdominal wall under ultrasound guidance to help move the baby from a transverse or breach position into a vertex position. Head ends up facing down. Performed after 37 weeks of gestations o Increased risk of umbilical cord compression and placental abruption o Nursing care: If mom RH negative, ensure RhoGAM was administered at 28 weeks, perform Kleihaur-Betke test to detect fetal blood in maternal circulation. o Administer IV fluids and tocolytics to relax uterus Ways to Induce Labor - Cervical Ripening o Promotion of cervical softening, dilation, and effacement. o Examples  Balloon catheter  Membrane stripping  Dilators

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Chemical agents  Misoprostol  Dinoprostone  Administer orally or vaginally

Oxytocin o Uterine stimulate, increases strength, frequency, and length of uterine contractions  Closely monitor contractions and FHR  Discontinue oxytocin for contractions that occur more frequently than every 2 minutes  Contractions lasting more than 90 seconds  Contraction intensity greater than 90 mmHg w/IUPC  Uterine resting tone great than 20 mmHg between contractions  Administer terbutaline to decrease uterine activity Amniotomy o Rupture of amniotic membranes by provider, using a sharp instrument o Indications  Induction or augmentation of labor, or preparation for amnioinfusion  Increased risk for cord prolapses (ensure presenting part of fetus is engaged prior to amniotomy) and increased risk of infection.  Assess for temperature, due to infection Amnioinfusion o Infusion of NaCl or LR into amniotic cavity o Indications  Oligohydramnios, fetal cord compression  Assist with amniotomy prior to infusion Vacuum o Traction applied to fetal head using cuplike suction device. Baby must be in a vertex position o Indications  Maternal exhaustion or ineffective pushing  Increased risk for maternal lacerations, infant subdural hematoma, cephalohematoma, caput succedaneum Forceps o Traction applied using curved spoon-like blades to assist in delivery  Indications  Abnormal fetal presentation and fetal distress  Increased risk for perineum lacerations, bladder injury, facial bruising or nerve palsy in infant

Complications During Labor and Delivery - Prolapsed umbilical cord o Umbilical cord protrudes through cervix ahead of the baby, causing cord compression and comprising fetal circulation o Nursing Care  Call for assistance FIRST

ATI Maternal Newborn With a sterile-gloved hand, insert two fingers into the finger and elevate the fetal presenting part off of the cord  Reposition mom in a knee-chest or Trendelenburg position  Apply warm, sterile, saline soaked towel over cord Meconium-stained amniotic fluid o Often present in breech presentation o Higher risk after 38 weeks’ gestation o May indicate fetal hypoxia o Nursing Care  Arrange for equipment and resources for possible neonatal resuscitation at birth  If respirations are depressed, muscle tone decreased, and heart rate < 100/min, suction below infant’s vocal cords with ET tube before spontaneous breaths occur Dystocia o Difficult or abnormal labor due to uterine abnormalities, cephalopelvic disproportion, fetal malpresentation o Signs & Symptoms  Insufficient progress in dilation, effacement, or fetal descent during l...