MATERNAL NEWBORN 275 OB QUIZ 1 STUDY GUIDE

CONTRACEPTION OB QUIZ 1 STUDY GUIDE 1. Oral contraceptives a. Use back up when taking i. Anticonvulsants ii. Antibiotics. b. Contraindicated i. Gallbladder disease PROBABLE SIGNS OF PREGNANCY 1. Hegar’s sign a. Softening and compressibility of lower uterus 2. Chadwick’s sign a. Deepened violet-bluish color of cervix and vaginal mucosa 3. Goodell’s sign a. Softening of cervical tip 4. Ballottement a. Rebound of unengaged fetus 5. Braxton Hicks contractions a. False contractions; painless, irregular, and usually relieved by walking, 6. Positive pregnancy test 7. Fetal outline felt by examiner. 8. Verifying Possible Pregnancy Using Serum and Urine Pregnancy Testing a. Presence of human chorionic gonadotropin (hCG) i. Production can start as early as the day of implantation and can be detected as early as 7 to 10 days after conception. GPTPAL 1. Gravidity b. Number of pregnancies. ● Nulligravida – a woman who has never been pregnant ● Primigravida – a woman in her first pregnancy ● Multigravida – a woman who has had two or more pregnancies 2. Parity a. Number of pregnancies in which the fetus or fetuses reach viability (approximately 20 weeks) regardless of whether the fetus is born alive ● Nullipara – no pregnancy beyond the stage of viability ● Primipara – has completed one pregnancy to stage of viability ● Multipara – has completed two or more pregnancies to stage of viability 3. Term births (38 weeks or more) 4. Preterm births (from viability up to 37 weeks) 5. Abortions/miscarriages (prior to viability) 6. Living children PREGNANCY 1. Leukorrhea a. White/slightly gray mucoid discharge with faint musty odor b. Occurs in response to cervical stimulation by estrogen and progesterone. c. Fluid is whitish because of exfoliated vaginal epithelial cells. d. Never pruritic or blood stained. e. Mucus fills the endocervical canal, resulting in formation of the mucus plug. 2. Blood pressure a. Decreases 5 to 10 mm Hg i. Both the diastolic and the systolic during the second trimester. b. Supine hypotensive syndrome or supine vena cava syndrome i. Position of the pregnant woman also may affect blood pressure ii. Signs and symptoms: 1. Dizziness 2. Lightheadedness Pale, clammy skin 3. Skin changes a. Chloasma i. Pigmentation increases on the face. b. Linea nigra i. Dark line of pigmentation from the umbilicus extending to the pubic area. c. Striae gravidarum i. Stretch marks most notably found on the abdomen and thighs. 4. Vaccinations a. Not ok: i. Live or attenuated live viruses 1. Mumps, Rubella, and chickenpox. b. Ok: i. Tetanus, Influenza (inactivated), Recombinant hepatitis B, and Diphtheria. 5. Fetal Heart Rate a. Can be heard by Doppler at 10 to 12 weeks of gestation b. Heard with a stethoscope or fetosope at 16 to 20 weeks of gestation. 6. Testing a. HgbA1C b. One and Three hours Glucose Tolerance Test (GTT) c. PAP d. HPV e. Vaginal culture f. PPD g. Syphilis h. HIV i. Toxoplasmosis j. Rubella k. Cytomegalovirus l. Herpes virus m. TORCH screening when indicated n. Maternal serum alpha-fetoprotein (MSAFP) 7. RhO(D) a. Administer RhO(D) immune globulin (RhoGAM) IM around 28 weeks of gestation for clients who are Rh-negative 8. Exercise a. Should consist of 30 min of moderate exercise (walking or swimming) daily if not medically or obstetrically contraindicated 9. Morning sickness a. May occur during the first trimester. b. Client Teaching: i. Eat crackers or dry toast 30 min to 1 hr before rising in the morning ii. Avoid an empty stomach and ingesting spicy, greasy, or gas-forming foods. iii. Drink fluids between meals. 10. Heartburn a. Second and third trimesters b. Due to stomach being displaced by enlarging uterus, slowing of gastrointestinal tract motility, and digestion brought about by increased progesterone levels. c. Client Teaching: i. Eat small frequent meals ii. Don’t allow the stomach to get too empty or too full iii. Sit up for 30 min after meals iv. Check with provider prior to using any over-the-counter antacids. 11. Constipation a. Second and third trimester b. Drink plenty of fluids c. Eat a diet high in fiber d. Exercise regularly. 12. Hemorrhoids a. Second and third trimesters. i. Treatment 1. Warm Sitz bath 2. Witch hazel pads 3. Application of topical ointments 13. Urinary frequency a. First and third trimesters. b. Client Teaching: i. Empty her bladder frequently ii. Decrease fluid intake before bedtime iii. Use perineal pads. iv. Perform Kegel exercises 14. Urinary tract infections (UTIs) a. Common during pregnancy because of renal changes and the vaginal flora becoming more alkaline. b. Client Teachings: i. Wipe front to back ii. Avoid bubble baths iii. Wear cotton underpants iv. Avoid tight-fitting pants v. Consuming plenty of water (8 glasses per day). vi. Urinate before and after intercourse vii. Urinate as soon as the urge occurs viii. Notify her provider if urine is foul-smelling, contains blood, or appears cloudy. 15. Backaches a. Common during second and third trimester b. Client Teaching: i. Exercise regularly ii. Perform pelvic tilt exercises (alternately arching and straightening the back) iii. Proper body mechanics by using the legs to lift rather than the back iv. Side-lying position 16. Leg cramps a. During third trimester b. Due to compression of lower-extremity nerves and blood vessels by the enlarging uterus c. Can result in poor peripheral circulation & imbalance in the calcium/phosphorus ratio. d. Client Teaching: i. Extend affected leg, keeping the knee straight, and dorsiflex the foot (toes toward head). ii. Apply heat over affected muscle or foot massage while leg is extended iii. Notify provider if frequent cramping occurs. 17. Varicose veins and lower-extremity edema a. Second and third trimesters b. Client Teaching: i. Rest with legs elevated ii. Avoid constricting clothing iii. Wear support hose iv. Avoid sitting or standing in one position for extended periods of time v. Don’t sit with legs crossed at the knees vi. Sleep in left-lateral position vii. Exercise moderately with frequent walking to stimulate venous return 18. Gingivitis, nasal stuffiness, and epistaxis (nosebleed) a. Occurs as a result of elevated estrogen levels causing increased vascularity and proliferation of connective tissue. b. Client Teachings: i. Gently brush teeth ii. Good dental hygiene iii. Use a humidifier iv. Use normal saline nose drops or spray. 19. Shortness of breath and dyspnea a. Occurs because of enlarged uterus, which limits inspiration. b. Client Teaching: i. Maintain good posture ii. Sleep with extra pillows iii. Contact provider if symptoms worsen. 20. Braxton Hicks contractions a. First trimester onward b. May increase in intensity and frequency during the third trimester c. Change of position and walking should cause contractions to subside d. If contractions increase in intensity and frequency (true contractions) with regularity, the client should notify her provider. 21. Emotional lability a. Unpredictable mood changes b. Increased irritability, tearfulness, and anger c. Alternating with feelings of joy and cheerfulness d. May result from hormonal changes. i. A feeling of ambivalence about the pregnancy, which is a normal response, may occur early in the pregnancy and resolve before the third trimester. ii. Consists of conflicting feelings (joy, pleasure, sorrow, hostility) about the pregnancy. e. Can occur simultaneously, whether the pregnancy was planned or not. 22. Nutrition a. Second trimester: increase of 340 calories/day b. Third trimester: increase of 452 calories/day c. Calcium: i. 1,000 mg/day for pregnant women over the age of 19 ii. 1,300 mg/day for those under 19 years of age. PREGNANCY TESTING 1. Fetal Heart Rate (FHR) a. Normal fetal heart rate baseline at term is 110 to 160/min excluding accelerations, decelerations, and periods of marked variability within a 10 min window. At least 2 min of baseline segments in a 10 min window should be present. A single number should be documented instead of a baseline range. 2. Biophysical Profile (BPP) a. Assesses fetal well-being b. Measures following five variables with a score of 2 for each normal finding, and 0 for each abnormal finding for each variable. i. Fetal Heart Rate 1. Reactive nonstress test = 2 2. Nonreactive = 0. ii. Fetal breathing movements 1. At least 1 episode of greater than 30 secs duration in 30 min = 2 2. Absent or less than 30 seconds duration = 0. iii. Gross body movements 1. At least 3 body/limb extensions with return to flexion in 30 min = 2 2. Less than 3 episodes = 0. iv. Fetal tone 1. At least 1 episode of extension with return to flexion = 2 2. Slow extension/flexion, lack of flexion, or absent movement = 0 v. Qualitative amniotic fluid volume 1. At least 1 pocket of fluid that measures at least 2 cm in 2 perpendicular planes = 2 2. Pockets absent or less than 2 cm = 0 BPP score Interpretation 8 to 10 is normal; low risk of chronic fetal asphyxia 4 to 6 abnormal; suspect chronic fetal asphyxia 4 abnormal; strongly suspect chronic fetal asphyxia c. Potential diagnoses i. Nonreactive stress test ii. Suspected oligohydramnios or polyhydramnios iii. Suspected fetal hypoxemia and/or hypoxia 1. Non-stress test (NST) a. Most widely used technique for antepartum evaluation of fetal well-being b. Performed during the third trimester. c. Noninvasive procedure d. Monitors response of the FHR to fetal movement. i. A Doppler transducer, used to monitor the FHR ii. A toco transducer is used to monitor uterine contractions iii. Attached externally to a client’s abdomen to obtain tracing strips. Result Interpretation Reactive NST FHR is a normal baseline rate with moderate variability, accelerates to 15 beats/m seconds and occurs two or more times during a 20-min period. Nonreactive NST It does not meet the above criteria after 40 min. If this is so, a further assessment, contraction stress test (CST) or biophysical profile (BPP), is indicated. e. Indications for the use of CST i. High-risk pregnancies (GDM, GHTN, post term pregnancy) ii. Nonreactive stress test iii. Decreased fetal movement iv. Intrauterine growth restriction (IUGR) v. Post maturity vi. Maternal chronic hypertension vii. History of previous fetal demise viii. Advanced maternal age (AMA) ix. Sickle-cell disease negative CST (normal finding) Is indicated if within a 10-min period, with three uterine contractions, there are no late decelerations of the FHR. positive CST (abnormal finding) indicated with persistent and consistent late decelerations on more than half of the contractions 2. Amniocentesis a. Alpha-fetoprotein (AFP) can be measured from the amniotic fluid between 16 and 18 weeks of gestation b. May be used to assess for neural tube defects in the fetus or chromosomal disorders. c. Process: i. Will feel slight pressure as needle is inserted. ii. Continue breathing because holding breath will lower the diaphragm against the uterus and shift the intrauterine contents. iii. Report 1. Fever 2. Chills 3. Leakage of fluid or bleeding from the insertion site 4. Decreased fetal movement 5. Vaginal bleeding 6. Uterine contractions d. Encourage the client to drink plenty of liquids and rest for the 24 hr post procedure. 3. Quad marker screening a. A blood test that ascertains information about the likelihood of fetal birth defects. b. Preferred at 16-18 weeks gestation c. Women at risk for giving birth to a neonate who has a genetic chromosomal abnormality i. Human chorionic gonadotropin (hCG) 1. Hormone produced by the placenta ii. Alpha-fetoprotein (AFP) 1. Protein produced by the fetus iii. Estriol 1. Protein produced by the fetus and placenta iv. Inhibin-A 1. Protein produced by the ovaries and placenta d. Interpretation of findings i. Low levels of AFP = risk for Down syndrome. ii. High levels of AFP = risk for neural tube defects. iii. Higher levels than the expected reference range of hCG & Inhibin-A = risk for Down syndrome. iv. Lower levels than the expected reference range of estriol = risk for Down syndrome 4. Glucose testing a. 1-hr glucose tolerance test i. 50 g oral glucose load ii. Followed by plasma glucose analysis 1 hr later iii. Performed at 24 to 28 weeks of gestation iv. Fasting not necessary v. Positive blood glucose screening is 130 to 140 mg/dL or greater vi. Additional testing with a 3-hr oral glucose tolerance test [OGTT] is indicated) b. OGTT 3 hour glucose tolerance test i. Overnight fasting ii. Avoidance of caffeine and smoking for 12 hr prior to testing iii. Fasting glucose is obtained, iv. 100 g glucose load is given v. Serum glucose levels are determined at 1, 2, and 3 hr following glucose ingestion vi. Presence of ketones in urine is tested to assess the severity of ketoacidosis ETOPIC PREGNANCY 1. Sharp, one-sided pain 2. Syncope 3. Referred right shoulder pain 4. Cullen’s Sign: a blue discoloration similar to ecchymosis around the umbilicus. 5. Lower abdominal pain a. Adnexal tenderness b. Abdominal rigidity and tenderness 7. Decreased hemoglobin and hematocrit MOLE (Gestational Trophoblastic Disease) 1. GTD is the proliferation and degeneration of trophoblastic villi in the placenta that becomes swollen, fluid-filled, and takes on the appearance of grape-like clusters. 2. The embryo fails to develop beyond a primitive state 3. These structures are associated with choriocarcinoma, which is a rapidly metastasizing malignancy. 4. Two types of molar growths are identified by chromosomal analysis a. Complete mole i. All genetic material is paternally derived. ii. The ovum has no genetic material or the material is inactive iii. There is no fetus, placenta, amniotic membranes, or fluid iv. Approximately 20% of complete moles progress toward choriocarcinoma b. Partial mole i. Genetic material is derived both maternally and paternally ii. A normal ovum is fertilized by two sperm or one sperm in which meiosis or chromosome reduction and division did not occur iii. A partial mole often contains abnormal embryonic or fetal parts, an amniotic sac, and fetal blood, but congenital anomalies are present iv. Approximately 6% of partial moles progress toward a choriocarcinoma. PLACENTA PREVIA 1. Painless, bright red vaginal bleeding during the second or third trimester 2. Uterus soft, relaxed and non-tender with normal tone 3. Fundal height greater than usually expected for gestational age 4. Fetus in a breech, oblique, or transverse position 5. Reassuring FHR 6. Vital signs within normal limits 7. Decreasing urinary output may be a better indicator of blood loss ABRUPTO PLACENTIA 1. Premature separation of the placenta from the uterus 2. Can be a partial or complete detachment 3. Separation occurs after 20 weeks of gestation, which is usually in the third trimester. 4. Significant maternal and fetal morbidity/mortality 5. Leading cause of maternal death 6. Moderate to severe abruption can cause disseminated intravascular coagulopathy (DIC). 7. Risk factors: a. Maternal hypertension (chronic or gestational) b. Cocaine use resulting in vasoconstriction c. Blunt external abdominal trauma (motor-vehicle crash, maternal battering) d. Previous incidents of abruptio placenta e. Cigarette smoking f. Premature rupture of membranes g. Multifetal pregnancy 8. Assessment a. Sudden onset of intense localized uterine pain with dark red vaginal bleeding b. Area of uterine tenderness c. May be localized or diffuse over uterus and board like d. Sudden, severe pain, uterine rigidity e. Uterus may also increase in size as a result of the hemorrhage f. Pain is an important symptom the distinguishes abruptio from Previa 9. OBSTETRIC EMERGENCY!!! DISSEMINATED INTRAVASCULAR COAGULATION 1. A complex disorder that may complicate abruptio Placentae. a. Blood clots that form behind the placenta & consumes clotting factors 2. Clot formation and anti-coagulation occurs simultaneously in DIC 3. A life threatening disorder 4. Results from alterations in the normal clotting mechanisms 5. Always a secondary diagnosis 6. Results from incomplete abortion 7. Expected findings a. Sudden onset b. May complain of chest pain or dyspnea c. Restlessness, cyanosis d. Circulatory shock e. May cause fetal and maternal death 8. Watch out for any signs of bleeding like epistaxis, bleeding gums ,petechiae excessive bleeding from puncture sites 9. Monitor maternal and fetal condition TORCH INFECTIONS 1. Associated with congenital anomalies. 2. Toxoplasmosis a. Caused by consumption of raw or undercooked meat or handling cat feces. T b. Symptoms are similar to influenza or lymphadenopathy. 3. Hepatitis A and B 4. Syphilis 5. Mumps Parvovirus B19 6. Varicella-zoster. 7. Rubella (German measles) a. Contracted through children who have rashes or neonates who are born to mothers who had rubella during pregnancy. 8. Cytomegalovirus (member of herpes virus family) a. Transmitted by droplet infection from person to person b. Virus found in semen, cervical and vaginal secretions, breast milk, placental tissue, urine, feces, and blood. c. Latent virus may be reactivated and cause disease to the fetus in utero or during passage through the birth canal. 9. Herpes simplex virus (HSV) a. Spread by direct contact with oral or genital lesions. b. Transmission to the fetus is greatest during vaginal birth if the woman has active lesions. RH IMMUNITY 1. Sensitivity 2. Causes a. If you are Rh-negative, your red blood cells do not have a marker called Rh factor on them. b. Rh-positive blood does have this marker. c. If your blood mixes with Rh-positive blood, your immune system will react to the Rh factor by making antibodies to destroy it. a. Sensitization can occur during pregnancy if you are Rh-negative and pregnant with a developing baby (fetus) who has Rh-positive blood. b. In most cases, your blood will not mix with your baby's blood until delivery. c. It takes a while to make antibodies that can affect the baby d. During your first pregnancy, the baby probably would not be affected. e. If you get pregnant again with an Rh-positive baby, the antibodies already in your blood could attack the baby's red blood cells. f. This can cause the baby to have anemia, jaundice, or more serious problems. This is called Rh disease. The problems will tend to get worse with each Rh-positive pregnancy you have. HELLP SYNDROME 1. Variant of Gestational Hypertension in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction. 2. Diagnosed by laboratory tests, not clinically. H – Hemolysis resulting in anemia and jaundice EL – elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), epigastric pain, and nausea and vomiting LP – low platelets (less than 100,000/mm3), resulting in thrombocytopenia, abnormal bleeding and clotting 3. Elevated liver enzymes (LDH, AST) 4. Increased creatinine 5. Increased plasma uric acid 6. Thrombocytopenia 7. Decreased Hgb 8. Hyperbilirubinemia MAGNEZIUM SULFATE 1. Use an infusion control device to maintain a regular flow rate. 2. Client may initially feel flushed, hot, and sedated with the magnesium sulfate bolus. 3. Monitor client’s blood pressure, pulse, respiratory rate, deep-tendon reflexes, level of consciousness, urinary output (indwelling urinary catheter for accuracy), presence of headache, visual disturbances, epigastric pain, uterine contractions, and FHR and activity. 4. Place the client on fluid restriction of 100 to 125 mL/hr, and maintain a urinary output of 30 mL/hr or greater. 5. D/C medications 6. Signs of magnesium sulfate toxicity. a. Absence of patellar deep tendon reflexes b. Urine output less than 30 mL/hr c. Respirations less than 12/min d. Pulmonary edema ● chest pain ● shortness of breath ● respiratory distress ● wheezing and crackles ● productive cough e. Decreased level of consciousness f. Cardiac dysrhythmias g. Administer calcium gluconate HERBS 1. St. John’s wort: ● Causes photophobia ● Patient should wear protective clothing, sun screen, and sun-glasses when outside. 2. Saw palmetto: ● Can result in falsely low prostate-specific antigen level ● Delay in diagnosing prostate cancer in some clients. 3. Chamomile: ● Has anti-inflammatory properties ● May provide relief from GI and upper respiratory tract inflammatory diseases. 4. Black cohosh ● Can potentiate the hypoglycemic effects of anti-diabetic medication. ● Has estrogenic properties ● Should not take during pregnancy ● Does not affect bleeding time 5. Garlic ● Decreases platelet aggregation ● Increases the risk for bleeding. 6. Ephedra ● Acts as a stimulant ● Increases heart rate ● Elevates blood pressure LABOR 1. Physiologic changes preceding labor (premonitory signs) a. Backache b. Weight loss (1 to 3 lb.) c. Lightening – fetal head descends into true pelvis about 14 days before labor; feeling that the fetus has “dropped;” d. Easier breathing e. More pressure on bladder, resulting in urinary frequency (more pronounced in clients who are primigravida) f. Contractions – begin with irregular uterine contractions (Braxton Hicks) that eventually progress in strength and regularity g. Bloody show – brownish or blood- mucus plug resulting from the onset of cervical dilation and effacement h. Energy burst i. Gastrointestinal changes j. Less common: i. Nausea ii. Vomiting iii. Indigestion k. Rupture of membranes: Spontaneous rupture of membranes can initiate labor or can occur anytime during labor. FIVE P’S There are five factors (the five “P’s”) that affect and define the labor and birth process: 1. Passenger i. Consists of the fetus and the placenta. ii. The size of the fetal head, fetal presentation, lie, attitude, and position affect the ability of the fetus to navigate the birth canal 2. Passageway i. The birth canal that is composed of the bony pelvis, cervix, pelvic floor, vagina, and introitus (vaginal opening). 3. Powers i. Uterine contractions cause effacement and dilation of the cervix and descent of the fetus. 4. Position i. Of the woman who is in labor 5. Psychological response i. Maternal stress, tension, and anxiety can produce physiological changes that impair the progress of labor. PUDENDAL BLOCK 1. Consists of a local anesthetic, such as lidocaine (Xylocaine) or bupivacaine (Marcaine), being administered transvaginally into the space in front of the pudendal nerve. 2. Has no maternal or fetal systemic effects 3. Provides local anesthesia to the perineum, vulva, and rectal areas during delivery, episiotomy, and episiotomy repair. 4. Administered during the second stage of labor 10 to 20 min before delivery providing analgesia prior to spontaneous expulsion of the fetus or forceps-assisted or vacuum-assisted birth. MECONIUM STAINED AMNIOTIC FLUID 1. Risk factors a. 38 weeks of gestation due to fetal maturity of normal physiological functions b. Umbilical cord compression results in fetal hypoxia that stimulates the vagal nerve in mature fetuses c. Hypoxia stimulates the vagal nerve, which induces peristalsis of the fetal gastrointestinal tract and relaxation of the anal sphincter. 2. Nursing care a. Document color and consistency of stained amniotic fluid. b. Notify neonatal resuscitation team to be present at birth. c. Gather equipment needed for neonatal resuscitation. d. Follow designated suction protocol. e. Assess neonate’s respiratory efforts, muscle tone, and heart rate. f. Suction mouth and nose using bulb syringe if respiratory efforts strong, muscle tone good, and heart rate greater than 100/min. g. Suction below the vocal cords using an endotracheal tube before spontaneous breaths occur if respirations are depressed, muscle tone decreased, and heart rate less than 100/min FETAL DISTRESS 1. Fetal distress is present when a. The FHR is below 110/min or above 160/min. b. The FHR shows decreased or no variability. c. There is fetal hyperactivity or no fetal activity. DYSTOCIA 1. Lack of progress in dilatation, effacement, or fetal descent during labor. ● A hypotonic uterus is easily indentable, even at peak of contractions. ● A hypertonic uterus cannot be indented, even between contractions. ● Client is ineffective in pushing with no voluntary urge to bear down. 2. Persistent occiput posterior presentation is when the fetal occiput is directed toward the posterior maternal pelvis rather than the anterior pelvis. 3. Persistent occiput posterior position prolongs labor and the client reports greater back pain as the fetus presses against the maternal sacrum. 4. Treatment: Oxytocin (Pitocin) ● Used to augment labor and strengthen uterine contractions. PRECIPITOUS LABOR 1. Hypertonic contractions can result in uteroplacental insufficiency leading to fetal hypoxia. 2. Oxytocin (Pitocin) stimulation: ● Administered to augment or induce labor by increasing intensity and duration of contractions ● Oxytocin stimulation can lead to hypertonic uterine contractions. 3. Multiparous client: May move through the stages of labor more rapidly. 4. Nursing care: a. Do not leave the client unattended. b. Provide reassurance and emotional support to help the client remain calm. c. Prepare for emergency delivery of the neonate. d. Encourage the client to pant with an open mouth between contractions to control the urge to push e. Encourage the client to maintain a side-lying position to optimize uteroplacental perfusion and fetal oxygenation. f. Prepare for rupturing of membranes upon crowning (fetal head visible at perineum) if not already ruptured. g. Do not attempt to stop delivery POSTPARTUM 1. Rh-negative mothers: a. RHO(D) immune globulin (RhoGAM) i. Administered within 72 hr to women who are Rh-negative and gave birth to infants who are Rh-positive to prevent sensitization in future pregnancies. 2. The Kleihauer-Betke test a. Determines the amount of fetal blood in maternal circulation if a large fetomaternal transfusion is suspected. b. If 15 mL or more of fetal blood is detected, the mother should receive an increased RhoGAM dose. 3. CBC: monitoring of Hgb, Hct, WBC and platelet counts. LOCHIA 1. Lochia rubra a. Bright red color, bloody consistency, fleshy odor, may contain small clots, transient flow increases during breastfeeding and upon rising. b. Lasts 1 to 3 days after delivery. 2. Lochia serosa a. Pinkish brown color and serosanguinous consistency. Lasts from approximately day 4 to day 10 after delivery. 3. Lochia alba a. Yellowish, white creamy color, fleshy odor. b. Lasts from approximately day 11 up to and beyond 6 weeks postpartum. URINARY SYSTEM & BLADDER FUNCTION 1. Urinary retention a. Secondary to loss of bladder elasticity and tone and/or loss of bladder sensation resulting from trauma, medications, or anesthesia. 2. Distended bladder a. Result of urinary retention b. Can cause uterine atony and displacement to one side, usually to the right. c. The ability of the uterus to contract is also lessened. 3. Postpartal diuresis with increased urinary output a. Begins within 12 hr of delivery b. Excessive urine diuresis (1,500 to 3,000 mL/day) is normal within the first 2 to 3 days after delivery. 4. Assess the client’s ability to void every 2 to 3 hr a. Perineal/urethral edema may cause pain and difficulty in voiding during the first 24 to 48 hr IMMUNE SYSTEM 1. Review rubella status a. Client who has a titer of less than 1:8 is administered a subcutaneous injection of rubella vaccine or a measles, mumps, and rubella vaccine during the postpartum period to protect a subsequent fetus from malformations. b. Client should not get pregnant for 1 month following the immunization. 2. Tetanus-diphtheria-acellular pertussis and varicella 3. Hepatitis B a. Newborns born to infected mothers should receive the hepatitis B vaccine and the hepatitis B immune globulin within 12 hr of birth. 4. Rhogam: Rh negative mother with Rh positive baby POSTPARTUM HEMMORRHAGE 1. Client loses more than 500 mL of blood after a vaginal birth or more than 1,000 mL of blood after a cesarean birth. 2. Two complications that can occur following postpartum hemorrhage a. Hypovolemic shock b. Anemia. 3. Vaginal hematoma cause severe pain with persistent pressure in the vaginal and rectal due to the blood that leaked into the tissue. NEWBORNS FONTANELS 1. Anterior fontanel a. Should be palpated and approximately 5 cm on average and diamond shaped. 2. Posterior fontanel a. Smaller and triangle shaped. b. Fontanels should be soft and flat. c. Fontanels may bulge when the newborn cries, coughs, or vomits, and are flat when the newborn is quiet. 3. Bulging fontanels a. May indicate increased intracranial pressure, infection, or hemorrhage. 4. Depressed fontanels a. May indicate dehydration. 5. Sutures a. Should be palpable, separated, and may be overlapping (molding) b. A normal occurrence resulting from head compression during labor. 6. Caput succedaneum a. Localized swelling of the soft tissues of the scalp b. Caused by pressure on the head during labor c. Expected finding that may be palpated as a soft edematous mass and may cross over the suture line. d. Usually resolves in 3 to 4 days e. Does not require treatment. CEPHALOHEMATOMA 1. Collection of blood between the periosteum and the skull bone that it covers. 2. Does not cross the suture line. 3. Results from trauma during birth such as pressure of the fetal head against the maternal pelvis in a prolonged difficult labor or forceps delivery. 4. Appears in the first 1 to 2 days after birth and resolves in 2 to 3 weeks. EPSTEIN’S PEARLS 1. Small white cysts found on the gums and at the junction of the soft and hard palates are expected findings. 2. They result from the accumulation of epithelial cells and disappear a few weeks after birth. HIPS & GLUTEAL FOLDS 1. No click should be heard when abducting the hips. 2. Gluteal folds should be symmetrical. MORO “STARTLE” REFLEX 1. Sudden jarring or change in equilibrium causes extension and adduction of extremities and fanning of fingers with the index finger and thumb forming a C shape, followed by flexion and adduction of extremities. 2. Disappears after 3-4 months. 3. In human evolutionary history, the Moro reflex may have helped the infant cling to his mother while she carried him around all day. 4. If the infant lost its balance, the reflex caused the infant to embrace its mother and regain its hold on the mother’s body ROOTING REFLEX 1. Present at birth 2. Assists in breastfeeding 3. Disappears around four months of age as it gradually comes under voluntary control. 4. A newborn infant will turn his head toward anything that strokes his cheek or mouth, searching for the object by moving his head in steadily decreasing arcs until the object is found. 5. After becoming used to responding in this way (if breastfed, approximately three weeks after birth), the infant will move directly to the object without searching. TONIC NECK REFLEX 1. When the infants head is quickly turned to one side, arm and leg will extend on that side and opposite arm and leg will flex, posture resembles a fencing position. 2. Disappears by 3 to 4 months of age to be replaced by symmetric position of both sides of the body 3. Tonic neck reflex is a precursor to the hand/eye coordination of the infant. 4. Prepares the infant for voluntary reaching DANCE OR STEPPING REFLEX 1. If infant is held so that the sole of foot touches a hard surface, there will be a reciprocal flexion and extension of the leg, simulating walking. 2. Disappears after 3 to 4 weeks, to be replaced by deliberate movement BABINSKI’S REFLEX 1. When the sole of the foot is stroked alongside of sole beginning at heel and then moving across ball of foot to big toe, toes fan out with dorsiflexion of the big toe. 2. Disappears by 1 year. GRASP REFLEX & PLANTAR 1. Palmar a. Place finger in the palm of the hand and infants fingers will curl around examiner’s finger. 2. Plantar a. Place fingers at the base of the toes, toes curl downward PULL TO SIT (TRACTION REFLEX) 1. Pull infant by the wrist from supine position with head in midline. 2. Head Lags until infant is in upright position, then head is held in the same place with chest and shoulder momentarily before falling forward 3. Infant will attempt to right head NEWBORN HYPERTHERMIA Heat loss occurs by four mechanisms: 1. Conduction a. Loss of body heat resulting from direct contact with a cooler surface. b. Preheat a radiant warmer c. warm a stethoscope and other instruments d. Pad a scale before weighing the newborn. e. The newborn should be placed directly on the mother’s abdomen and covered with a warm blanket. 2. Convection a. Flow of heat from the body surface to cooler environmental air. b. Place the bassinet out of the direct line of a fan or air conditioning vent c. Swaddle the newborn in a blanket d. Keep the head covered. e. Any procedure done with the newborn uncovered should be performed under a radiant heat source. 3. Evaporation a. Loss of heat as surface liquid is converted to vapor. b. Gently rub the newborn dry with a warm sterile blanket (adhering to standard precautions) immediately after delivery. c. If thermoregulation is unstable, postpone the initial bath until the newborn’s skin temperature is 36.5° C (97.7° F). d. When bathing, expose only one body part at a time, washing and drying thoroughly. 4. Radiation a. Loss of heat from the body surface to a cooler solid surface that is close to, but not in direct contact. b. Keep the newborn and examining tables away from windows and air conditioners. NEWBORN COMPLICATIONS 1. Cold stress (ineffective thermoregulation) a. Can lead to hypoxia, acidosis, and hypoglycemia. b. Newborns with respiratory distress are at a higher risk for hypothermia. 2. Hemorrhage a. Due to improper cord care or placement of clamp 3. Hypoglycemia a. Frequently occurs in the first few hours of life secondary to the use of energy to establish respirations and maintain body heat. b. Newborns of mothers who have diabetes mellitus, are small or large for gestational age, are less than 37 weeks of gestation, or are greater than 42 weeks of gestation, are at risk for hypoglycemia and should have blood glucose monitored within the first 2 hr of life. SURGICAL METHODS FOR CIRCUMCISION 1. The provider applies the Yellen, Mogen, or Gomco clamp to the penis, loosens the foreskin, and inserts the cone under the foreskin to provide a cutting surface for removal of the foreskin and to protect the penis. 2. The wound is covered with sterile petroleum gauze to prevent infection and control bleeding. 3. The provider slides the Plastibell device between the foreskin and the glans of the penis. 4. The provider ties a suture tightly around the foreskin at the coronal edge of the glans. This applies pressure as the excess foreskin is removed from the penis. 5. After 5 to 7 days, the Plastibell drops off, leaving a clean, healed excision. 6. No petroleum is used for circumcision with the Plastibell. CIRCUMCISION COMPLICATIONS 1. Hemorrhage: a. Monitor the newborn for bleeding. b. Provide gentle pressure on the penis using a small gauze square. c. Gelfoam powder or a sponge may be applied to stop bleeding. d. If bleeding persists, notify the provider that a blood vessel may need to be ligated 2. Cold stress/hypoglycemia: a. Monitor the newborn for excessive loss of heat resulting in increased respirations and lowered body temperature. b. Swaddle and feed the newborn as soon as the procedure is over. 3. Other complications: a. Report any frank bleeding, foul-smelling drainage, or lack of voiding to the provider. 4. Provide discharge instructions to the parents about manifestations of infection, comfort measures, medications, and when to notify the provider. FETAL ALCOHOL SYNDROME 1. Monitor the neonate for abstinence syndrome (withdrawal) and increased wakefulness using the neonatal abstinence scoring system that assesses for and scores the following: 2. CNS a. Increased wakefulness b. High-pitched, shrill cry c. Incessant crying d. Irritability e. Tremors f. Hyperactive with an increased Moro reflex g. Increased deep-tendon reflexes h. Increased muscle tone i. Abrasions and/or excoriations on the face and knees j. Convulsions 3. Metabolic, vasomotor, and respiratory findings a. Nasal congestion with flaring b. Frequent yawning c. Skin mottling d. Tachypnea greater than 60/min e. Sweating f. Temperature greater than 37.2° C (99° F). 4. Gastrointestinal a. Poor feeding b. Regurgitation (projectile vomiting) c. Diarrhea d. Excessive, uncoordinated, and constant sucking NEWBORN HYPOGLYCEMIA 1. Findings a. Poor feeding b. Jitteriness/tremors c. Hypothermia d. Hypotonia e. Diaphoresis f. Weak shrill cry g. Lethargy h. Flaccid muscle tone i. Seizures/coma j. Irregular respirations, or respiratory distress k. Cyanosis l. Apnea 2. Laboratory tests and diagnostic procedures a. Two consecutive plasma glucose levels less than 40 mg/dL in a newborn who is term, and less than 25 mg/dL in a newborn who is preterm RESPIRATORY DISTRESS SYNDROME (RDS)/ASPHYXIA/MECONIUM ASPIRATION 1. Respiratory distress syndrome (RDS) occurs as a result of surfactant deficiency in the lungs a. Characterized by poor gas exchange and ventilator failure. 2. Surfactant is a phospholipid that assists in alveoli expansion. a. Keeps alveoli from collapsing and allows gas exchange to occur. 3. Atelectasis (collapsing of a portion of lung) increases the work of breathing. a. As a result, respiratory acidosis and hypoxemia can develop. 4. Birth weight alone is not an indicator of fetal lung maturity. 5. Complications from RDS are related to oxygen therapy and mechanical ventilation. 6. Pneumothorax 7. Pneumomediastinum 8. Retinopathy of prematurity 9. Bronchopulmonary dysplasia 10. Infection 11. Intraventricular hemorrhage PRETERM NEWBORN COMPLICATIONS 1. Respiratory distress syndrome a. Decreased surfactant in the alveoli occurs, regardless of a newborn’s birth weight 2. Bronchopulmonary dysplasia a. Causes the lungs to become stiff and noncompliant, requiring a newborn to receive mechanical ventilation and oxygen b. Sometimes difficult to remove the newborn from ventilation and oxygen after initial placement 3. Aspiration a. Result of a newborn who is premature not having an intact gag reflex or the ability to effectively suck or swallow 4. Apnea of prematurity a. Result of immature neurological and chemical mechanisms 5. Intraventricular hemorrhage a. Bleeding in or around the ventricles of the brain 6. Necrotizing enterocolitis (NEC) a. An inflammatory disease of the gastrointestinal mucosa due to ischemia b. Results in necrosis and perforation of the bowel c. Short-gut syndrome may be the result secondary to removal of most or part of the small intestine due to necrosis 7. Infection 8. Hyperbilirubinemia 9. Anemia 10. Hypoglycemia 11. Delayed growth and development PREMIE GOALS 1. Meeting newborn’s growth and development needs 2. Anticipating and managing associated complications such as RDS and sepsis. 3. Main priority a. Supporting the cardiac and respiratory systems as needed. 4. Most newborns who are preterm are cared for in a neonatal intensive care unit (NICU) a. Meticulous care and observation in the NICU is necessary until the newborn can receive oral feedings, maintain body temperature, and weighs approximately 2 kg (4.4 lb.). JAUNDICE 1. Physiologic jaundice a. Considered benign (resulting from normal newborn physiology of increased bilirubin production due to the shortened lifespan and breakdown of fetal RBCs and liver immaturity). b. The newborn with physiological jaundice has no other manifestations and shows evidence of jaundice after 24 hr of age. 2. Pathologic jaundice a. Result of an underlying disease b. Appears before 24 hr of age or is persistent after day 7. c. In the term newborn, bilirubin levels increase more than 0.5 mg/dL/hr, peaks at greater than 13 mg/dL, or is associated with anemia and hepatosplenomegaly. d. Usually caused by a blood group incompatibility or an infection, but may be the result of RBC disorders. 3. Kernicterus (bilirubin encephalopathy) a. Can result from untreated hyperbilirubinemia with bilirubin levels at or higher than 25 mg/dL. b. A neurological syndrome caused by bilirubin depositing in brain cells. c. Survivors may develop cerebral palsy, epilepsy, or mental retardation. d. They may have minor effects such as learning disorders or perceptual-motor disabilities. 4. Expected Findings a. Very yellowish or orange skin b. Lethargy c. Hypotonic d. Poor suck reflex e. Increased sleepiness f. If untreated, the newborn will become hypertonic with backward arching of the neck and trunk. g. High-pitched cry h. Fever CONJENTIAL ABDNORMALITIES 1. Cleft lip/palate a. Failure of the lip or hard or soft palate to fuse 2. Tracheoesophageal atresia a. Failure of the esophagus to connect to the stomach b. Excessive mucous secretions and drooling c. Periodic cyanotic episodes and choking d. Abdominal distention after birth e. Immediate regurgitation after birth 3. Duodenal atresia a. Common in newborns who have Down syndrome b. First part of the small bowel has not developed properly and is not open c. Stomach contents are unable to pass d. Surgical intervention is required 4. Phenylketonuria (PKU) a. Inability to metabolize the amino acid phenylalanine b. Can result in mental retardation if untreated c. This will not be evident at birth, but will be identified with neonatal screening 5. Galactosemia a. Inability to metabolize galactose into glucose b. Can result in failure to thrive, cataracts, jaundice, cirrhosis of the liver, sepsis, and mental retardation if untreated c. Not be evident at birth, but will be identified with neonatal screening 6. Hypothyroidism a. Slow metabolism caused by maternal iodine deficiency or maternal antithyroid medications during pregnancy b. Can result in hypothermia, poor feeding, lethargy, jaundice, and cretinism if untreated 7. Neurologic anomalies (spina bifida) a. Neural tube defect in which the vertebral arch fails to close b. May be a protrusion of the meninges and/or spinal cord 8. Hydrocephalus a. Excessive spinal fluid accumulation in the ventricles of the brain causing the head to enlarge and the fontanels to bulge b. Sun-setting sign is common in which the whites of the eyes are visible above the iris 9. Patent ductus arteriosus a. Noncyanotic heart defect in which the ductus arteriosus connecting the pulmonary artery and the aorta fails to close after birth b. Manifestations include murmurs, abnormal heart rate or rhythm, breathlessness, and fatigue while feeding 10. Tetralogy of Fallot a. Cyanotic heart defect characterized by a ventricular septal defect b. Aorta positioned over the ventricular septal defect c. Stenosis of the pulmonary valve d. Hypertrophy of the right ventricle e. Distinguished by respiratory difficulties, cyanosis, tachycardia, tachypnea, and diaphoresis NURSING CARE 1. Dependent upon the type and extent of the anomaly. 2. Neurologic anomalies (spina bifida) a. Protect the membrane with a sterile covering and plastic to prevent drying. b. Observe for leakage of the cerebrospinal fluid. c. Handle the newborn gently by positioning him prone or to the side to prevent trauma. d. Prevent infection by keeping the area free from contamination by urine and feces. e. Measure the circumference of the newborn’s head to identify hydrocephalus. f. Assess the newborn for increased intracranial pressure. 3. Hydrocephalus a. Frequently reposition the newborn’s head to prevent sores. b. Measure the newborn’s head circumference daily. c. Assess the newborn for manifestations of increased intracranial pressure, such as vomiting and a shrill cry. 4. Patent ductus arteriosus a. Educate the parents about surgical treatment. 5. Tetralogy of Fallot a. Conserve the newborn’s energy to reduce the workload on the heart. b. Administer gavage feedings, or give oral feedings with a special nipple. c. Elevate the newborn’s head and shoulders to improve respirations and reduce the cardiac workload. d. Prevent infection. e. Place the newborn in a knee-chest position during respiratory distress. 6. Cleft lip/palate a. Determine the most effective nipple for feeding. b. Feed the newborn in the upright position to decrease aspiration risk. c. Feed the newborn slowly, and burp him frequently so that he does not swallow air. d. Cleanse his mouth with water after feedings. 7. Tracheoesophageal atresia a. Withhold the newborn’s feedings until esophageal patency is determined. b. Elevate the head of the newborn’s crib to prevent gastric juice reflux. c. Supervise the newborn’s first feeding to observe for this anomaly. 8. Duodenal atresia a. Withhold the newborn’s feedings until surgical repair is done and the newborn has begun to pass stools. b. Administer IV fluids as prescribed. c. Monitor the newborn for jaundice. 9. PKU a. Special synthetic formula in which phenylalanine is removed or reduced. b. The mother should restrict meat, dairy products, diet drinks, and protein during pregnancy. c. Aspartame must be avoided. 10. Galactosemia a. Give the newborn a soy-based formula because galactose is present in milk. b. Eliminate lactose and galactose in the newborn’s diet. c. Breastfeeding is also contraindicated.