Reproductive Health Planning All decisions an individual or couple make about having children

Natural Planning Method - No introduction of chemical or foreign body; not advisable for adolescents Abstinence- most effective way to protect against conception Fertility Awareness Methods -Rely on detecting when a woman is capable for impregnation Calendar Rhythm Method - abstain from coitus on days of menstrual cycle when women are most likely to conceive; 3 to 4 days before and after ovulation Subtract 18 days to shortest and 11 days to longest Ex. 25-29 days cycle, 25- 18 = 7 and 29 11=18, 7th to 18th day refrain from coitus

BBT decrease in temp (0.5 F) then suddenly rises (ovulation) refrain from coitus for 3 days Cause by progesterone After waking up before any activity

Cervical mucus/ Billing Method- on ovulation mucus becomes copious thin, watery and transparent slippery and stretches atleast 1 inch (spinnbarkeit property) Sympthothermal Method combines cervical mucus and BBT Ovulation Awareness use of kit detect LH from urine 12 to 24 hours before ovulation Lactation Amenorrhea Method breast feeding suppresses ovulation for about 6 mos. Coitus Interruptus spermatozoa is eliminated outside the vagina Oral Contraception - Pill or COCs synthetic estrogen combined with synthetic progesterone suppresses ovulation not effective on first 7 days -Biphasic preparation increased progesterone during last 11 days -Triphasic preparation varying progesterone and estrogen causes breakthrough bleeding - prescribed after papsmear or pelvic exam -21 -28 pills take first pill on Sunday after the beginning of menstrual flow end on Saturday then the woman would after 1 week, menstrual flow begins 4 days after finishing 1st cycle - Side effects -Nausea -Weight gain -Headache -Breast tenderness -Breakthrough bleeding - Report MI or thromboembolic complications: - Chest pain - Shortness of Breath - Severe Headache - Severe Leg Pain - eye problems

-Monilial vaginal infection (candida) -Mild hypertension -Depression - Not advisable for BF mothers instead take mini pill ( progesterone only) - Clomid Therapy to establish ovulation if COCs is discontinued Estrogen/Progesterone Patch - Transdermal patch slowly but continuously releases estrogen and progesterone - Applied once a week for 3 weeks - Less effective on women who weighs 90 kg - Four areas: upper outer . upper torso abdomen our buttock - Not applied on any area w/ make-up or lotion etc. - May cause irritation ; can be worn while swimming or bathing replace when loose Vaginal Rings - Silicone ring surrounds the cervix and release estrogen and progesterone - Inserted and left in place for 3 weeks then remove for 1 week - Indicated for women with renal disease Emergency post coital contraception - Morning after pills - Yuzpe regimen two fixed dose taken 72 hours after coitus two additional pills 12 hours later; causes nausea and vomiting - Preven emergency contraceptive kit; PT kit and 4 pills - Progestin plan B; 2 pills levonorgestel are taken 1 immediately and 1 after 12 hours Subcutaneous implants - Norplant ; six biodegradable small stick implants filled with levonorgestel embedded under skin inside the upper arm - Inserted using LA during the menses or no later than 7 day of the cycle - Not inserted imm. After abortion or 6 weeks after birth - Last for 5 years fertility returns after 3 mos. of removal - Side effects -weight gain -irregular menstrual (spotting, amenorrhea, prolonged period) -hair loss -depression -scarring Depo provera medroxyprogesterone IM - Given every 12 weeks or Lunelle given every 30 days - Can be used in BF; Side effects similar to implants - Include calcium in diet - Fertility returns 6 to 12 mos. after use IUD - Small plastic object inserted to the uterus through the vagina

Must be fitted ( pap smear, pelvic exam) After menstrual flow mabe done imm. After child birth Expect cramping and spotting for 2 to 3 weeks WOF: Infection, TSS and PID ( fever, lower abdominal tenderness pain upon coitus) Not advisable for adolescents and no prior pregnancies

Barrier Methods - Birth control that work by the placement of cheml or other barrier bet. Sperm and cervix Spermicides - Cause death of spermatozoa before entering cervix also change vaginal pH - Film of glycerin recommended for women near menopause - Cocoa butter and glycerin based suppositories inserted 15 mins before coitus - Sponges/ foam block sperm access ; must remain in place 6 hours after coitus Diaphragm - Circular rubber disk placed over the cervix before intercourse - Kept in place after 6 hours ; after coitus can remain as long as 24 hours - WOF TSS (fever, diarrhea, vomiting muscle ache and sunburn rash) and UTI - Fitted Cervical cap - Soft rubber shaped like thimble - Dislodged easily than diaphragm - Remain in place longer than diaphragm but should not exceed 48 hours - Fitted Male Condoms - Latex rubber synthetic sheath place over penis before coitus - Must be withdrawn before it can become flaccid from ejaculation Female condoms - Made of polyurethane and prelubricated with spermicide - Remove before ejaculation Surgical Methods Vasectomy - Cutting, cautery, or plugging the vas deferens - Can resume intercourse after 1 week after 2 negative sperm report - Complication: hematoma, urolithiasis and post vasectomy pain syndrome Tubal ligation - Fallopian tubes are occluded, cauterized, crushed or clamped - Through Laparoscopy, culdoscopy or colpotomy (incision through the vagina) - Expect abdominal bloating for 24 hours due to CO2 - Return intercourse 2 to 3 days - Risk for ectopic pregnancy

Elective Termination of Pregnancy Medically induced abortion - Mifepristone abortifacient progesterone antagonist taken as a sinlge dose 600 mg anytime w/in 49 days of gestation after 3 days misoprostol is administered - Methotrexate antimetabolite causes cell death for ectopic pregnancy and trophoblastic disease expect bleeding for 2 weeks Surgically Induced abortion Menstrual extraction/Suction evacuation simplest the lining of the uterus that would be shed with normal flow is suctioned and removed of a syringe by a vacuum pressure - Preparation : woman voids and perineum is washed with antiseptic, speculum is inserted and tenaculum stabilizes the cervix polyethylene catheter is inserted - Should remain supine 15 mins after - Do not douche use tampons or have coitus for 1 week D & C uterus is scraped clean with a curette removing zygote and TPBCells - If pregnancy is less than 13 weeks - Uses a paracervical anesthesia block for cramping and pressure - Should remain 1-4 hours after - Risk for perforation Dilatation and vacuum extraction evacuates uterine contents over a 15 mins period - 2nd trimester bet. 12-16 weeks chosen for young women - Misoprostol and laminaria tent (seaweed ) dilates cervix over 24 hour period - Lie flat 15 mins after remain in clinic for 4 hours - Expect spotting and bleeding 2-3 weeks cramping 24 to 48 hours - Do not douche use tampons or resume coitus after 2 weeks - Risk for incompetent cervix Prostaglandin or Saline Induction - Prostaglandin bet. 16-24 weeks; misoprostol and laminaria then administer prostaglandin; oxytocin w/ piggy back WOF: intoxication, decreased OU - Saline hypertonic soln causes fluid shift and sloughing of placenta; woman voids and inj. Is given after removing 100 -200 ml of amniotic fluid; 12 to 36 hours after inj. Contraction begins; WOF: hyperthermia stop imm. And administer 5 % dextrose Hysterotomy - 16 -18 weeks - Removal of the fetus similar to Cs because of oxytocin resistance Partial birth abortion - Last 3 mos of pregnancy - Combination of oxytocin and cervical ripening

All women w/ Rh negative blood should receive RH (D) (Rhogam or RHIG)w/in 72 hours

Contraindications:

Poor Memory Diabetes Cigarette Smoker Thrombophlebitis Liver Disease Vulvar Heart Disease Infection,cystocele, rectocele Retroflexed or irregular shaped uterus Undiagnosed Vaginal Bleeding Breast Cancer

OC OC OC OC OC , Depo provera IUD Diaphragm IUD, Cervical cap, diaphragm All forms Norplant, OC , Depo provera

Assessing Fetal Well Being Diagnostic Tests

Fetal movement Quickening(first fetal movement) 18 to 20 weeks peak 28 to 38 weeks Moves 2x every 10 mins an average of 10 to 12 an hour Sandovsky method ask mother to lie left recumbent after meal to record FM over the next hour Count to Ten method record time interval she feels 10 fetal movement

Fetal Heart Rate - 120-160 bpm ; 90-110 when sleeping - Early as 10-11th week Doppler; 20 weeks Fetoscope Rhythm Strip Testing assessment of FHR for a good baseline rate and long and short term variability; - Place woman semi-fowler monitors are attached abdominally FHR recorded for 20 mins Non Stress Testing measures the response of FHR to FM; - 10 to 15 mins - When movement occur heart rate must increase to 15 bpm and last for 15 sec - Non reactive if no acceleration, no movement or short term variability ( less than 6 bpm) - No FM may indicate fetus is sleeping give carbohydrates snack (orange juice) Vibroacoustic stimulation - A sound stimulator is applied in the abdomen to produce sharp sound if no acceleration has occurred 5 min in a non stress test Contraction Stress Testing - FHR in response to Uterine contraction - Achieved by nipple stimulation - Negative(normal) if no decelerations are present w/ contractions - Positive(abnormal) if 50 % or more contraction causes deceleration - Remain 30 mins after Ultrasonography - Response of sound waves solid objects - B mode most frequent gray scale picture - Real mode allow pictures to move Uses: - diagnose pregnancy as early as 6 weeks - To confirm size, location of placenta and AMF - To establish a fetus is growing and no anomalies - Establish sex - Establish pres and pos - To predict maturity by biparietal diameter Preparation - Must be at full bladder - Drink full glass of water every 15 mins beginning 90 mins before procedure and should not void before - Place towel under the right buttock to prevent SHS - A gel is applied Biparietal Diameter - Measure fetal maturity

- Head is 8.5 cm or greater 2500 g (40 weeks) Doppler Umbilical Velocimetry - Velocity at w/c RBC in the uterine and Fetal vessels are travelling predictor of poor placental outcome AFV - For less than 20 weeks two vertical halves by linea nigra in cm - For more than 20 weeks 4 quadrants linea nigra and umbilicus - Ave. is approx. 12 to 15 cm bet 28 and 40 weeks - Greater than 20 to 24 cm hydramnios - Less than 5 to 6cm oligohydramnios ECG - May be recorded as early as 11th week inaccurate until 2oth week MRI - Replace or complement UTZ - Diagnose ectopic or TPB diseases MSAFP - Produce by fetal liver present in AF and Maternal serum peak 13th 32 week - Done in 15th week - Increase if fetus has open or abdominal defect (neural, spinal bifida etc.) - Venipuncture Triple Screening - MSAFP unconjugated estriol and HCG CVS - Biopsy and chromosomal analysis of CV for DNA - 10 to 12 weeks - A needle is inserted abdominally or vaginally - May cause excessive bleeding or Limb reduction syndrome Amniocentesis - Aspiration of amniotic fluid 20 ml - 14 to 18th week (200ml at this point); 800 1200ml at term - Preparation: void and supine position remain 30 mins after procedure - Color: color of water may have slight yellow tinge; strong yellow suggest blood incompatibility; green meconium staining PUBS - Cordiocentesis or funicentesis - 17 th week - Aspiration of blood from umbilical vein for analysis - Kleihauer betke to ensure blood collected is fetal blood - Indicated for blood diagnosis Amnioscopy - Visualization of amniotic fluid through cervix w/ amnioscope - Detects meconium staining Karyotyping - Visual presentation of chromosome pattern - Sample of peripheral venous blood or scraping of cells in the membrane Fetoscopy Inspection through a fetoscope - To confirm intactness - To obtain biopsy

- To perform surgery - If fetus is active administer meperidine (Demerol) to sedate fetus - Usu. Antibiotics are prescribed 10 days after the procedure Biophysical Profile - Combine of parameters that predicts fetal well-being ; better than single parameters - Fetal breathing, Fetal movement, Fetal tone, AFV, Fetal heart reactivity - Highest score is 10; 8- 10 doing well - 6 suspicious - 4 jeopardy

Choromosomal Disorders
Syndrome Down Syndrome Trisomy 21 Chromosomal Characteristic Extrachromosome 21 Clinical Signs -Protruding tongue - Epicanthal folds inner canthus - Broad and flat nose -Hypotonia -White speck in iris (brushfield spots) -Back of the head is flat -Short neck -Extra fat at the base of the head -Rag doll appearance -Wide spaces on fingers and toes (1st and 2nd) -Peculiar crease (simian line) -Cognitively challenged -Palpebral fissure slant laterally upward - Altered immune system -Late closure of fontanels -Clinodactyl (curved finger) Same as Trisomy 21 -Severe cognitively challenged - SGA -Low set ears -Small jaw -Rocker bottom feet (rounded instead flat) - Heart defects -Misshapen toes and fingers -Overriding of fingers -Severe cognitively challenged - Cleft lip and palate -Heart defects(ventricular septal) -Abnormal genitalia (wide set nipples) - Microcephaly -Micropthalmos - Low set ears -Eye agenesis -Peculiar cat like cry - Downward slant palpebral fissure - Small head - Wide set ears -Cognitively challenged -Webbed neck - Streak gonads -Low set hair lines -Infertility -Edema

Translocation Down syndrome Trisomy 18 Edwards Syndrome

Translocation of chromosome 14/21 Extra chromosome 18 , 3 copies

Trisomy 13 Patau Syndrome

Extra chromosome 13

Cri du chat Syndrome

Deletion of short arm chromosome 5

Turner Syndrome

Only one chromosome present

Fragile X Syndrome

Distortion of x Chromosome long arm

Philadelphia Chromosome Klinefelter Syndrome

Deletion of one arm of chromosome 21 Extra chromosome X

-Coarctation -Hyperactivity & Autism -Speech and Arithmetic deficit - Large head long face -High fore head (bossing) -Prominent lower jaw -Protruding jaws -Large hands -Chronic granulocytic leukemia -Gynecomastia -Small testes -Infertility -Absence of 2nd characteristic

Cystic fibrosis chromosome 7 Prader willi- chromosome 15 DM- assoc. w/chromosome 6

Caring for women during vaginal birth

Theories of Labor Onset - Uterine Contraction - Pressure on the cervix release of oxytocin - Oxytocin stimulation - Change in estrogen and progesterone ratio - Placental age triggers contraction - Rising fetal cortisol level reduces progesterone releases prostaglandin - Fetal membrane production of prostaglandin Signs of Labor Prelim - Lightening 10-14 days before labor - Increase in activity level - Braxton hicks contractions - Ripening of the cervix True - Uterine contraction; uterotubal(pacemaker); originating in lower uterine than fundus(ineffective) phases: increment (start to peak), acme (peak), decrement (peak to decrease) - Show; precedes dilatation ;pink tinge; operculum (mucus plug) - ROM Major Components - Passage (pelvis) - Passenger( fetus) - Powers of labor ( uterine contractions) - Psyche Structure of fetal skull - Saggital suture meeting of two parietal bones - Coronal suture meeting of two frontal bones - Lambdoidal suture two parietal and 1 occipital bone - Anterior fontanel junction of sagittal and coronal suture; bregma - Posterior fontanel junction of sagittal and lambdoid suture; lambda - Vertex spaces bet. Fontanels Diameter - Suboccipitobregmatic from anterior fontanel to occiput narrowest 9.5 cm - Occipito frontal from bridge of nose to posterior fontanel 12 cm - Occipito mental from chin to posterior fontanel widest 13.5 Molding - Change of shape of the fetal skull produced by the force of uterine contractions pressing vertex against the not yet dilated cervix only last a day or two Attitude refers to degree of flexion Good/full complete flexion: chin touches the sternum arms flexed folded on the chest thighs flexef on the abdomen vertex is the presenting part

 Moderate/military flexion: chin not touching the sternum brow (partial extension) or sinciput is the presenting part Poor flexion : head is extended presenting part is the face (complete extension) Very poor flexion : completely hyperextended chin is the presenting part Station - Refers to the rel. of presenting part of the fetus to the level of ischial spines - Degree of engagement - 0 level of ischial spine - - stations above the ishial spine + stations below the ischial spine - -4 floating; 0 engaged; +4 outlet, crowning, vulva separation Fetal lie - Rel. bet. The long axis of the fetal body and the long axis of the mother(cephalocaudal) - Transverse(horizontal) perpendicular to the mother - Longitudinal (vertical) most common; parallel to the mother Fetal presentation - body part that will first contact the cervix Types: Cephalic head is the presenting part - Vertex; suboccipitobregmatic present to the cervix; fully flexed - Brow; brow or sinciput presenting part ; moderately flexed - Face; occipito mental face is the presenting part ; poorly flexed may result to CS - Mentum; occipito mental chin is the presenting part; very poor; CS Breech either the buttocks or feet - Complete booth the buttocks and feet are present to the cervix; Good flexion : fetus has thighs tightly flexed on the abdomen hips are flexed but knees are extended - Frank buttock alone present to the cervix ; moderate flexion :hips are flexed but knees are extended - Footling foot is the presenting part ; one foot (single footling) both feet (double footling); poor flexion: neither thighs or lower legs are flexed Shoulder - Tranverse one of the shoulders ( acromnion process) an iliac crest or elbow are the presenting part - Prob. Caused by relaxed abdominal wall due to grand multiparity, pelvic contraction, placenta previa - Usu. CS Fetal Position - Rel. of the presenting part to a quadrant of the pelvis - Quadrant: RA, LA, RP, LP - Landmarks : - Vertex occiput chosen point - Face chin chosen point - Breech Sacrum chosen point - Shoulder scapular or acromnion chosen point - First letter pointing L or R of the mothers pelvis

Second letter refers to land mark: O occiput, M mento , Sa sacro, A scapulo Third letter if the landmark points anteriorly or posteriorly or transverse ( front, back, side of pelvis) - ROA and LOA fetus born fastest - ROP or LOP more painful extended labor Cardinal Movements - E ngagement - D escent - F lexion - I nternal Rotation - E xtension - R otation External - E xpulsion Stages of Labor First stage Cervical Dilatation begins w/ true labor ends w/ complete cervical dilation Phases : Latent phase (early phase, prodomal) 6 hour in nulli, 4- 5 hours in multi - Cervix dilates from 0-3 cm - Uterine contractions : mild and short w/ a duration of 30-40 seconds frequency od every 5 -7 mins - Patient is excited - Thoughts centered to self ,labor and baby - Talkative , mute , calm or tense - Pain controlled fairly well - Patient is alert follow direction Active Phase (accelerated phase) 3 hours nulli, 2 hours multi - Cervix dilates 4-7 cm - Uterine contraction: mild to moderate 40 to 60 sec. 3-5 mins - More comprehensive more serious - Doubtful of pain control - Desires of companionship and encouragement - Has some difficulty ff. instruction Transition Phase (declaration phase) shortest and hardest - Contractions reach peak of intensity - Cervix dilates 8- 10 cm - Uterine contraction: moderate to strong duration of 60 to 90 sec frequency of 2-3 mins - Backache common - Fear loss of control - Irritable - Amnesia bet. Contractions - Hyperventilating - Perspiration forehead - Shrinking tremor of thighs - Feeling of need to defecate

 Second Stage of Labor Stage of Expulsion begins w/ full cervical dilatation ends with delivery of placenta - Takes about 1 hour - Crescendo descendo contractions Third Stage of Labor Placental Stage begins w/ expulsion of fetus ends with delivery of placenta (usu. Less than 20 mins) Signs that placenta is ready to deliver - Lengthening of the cord - Sudden gush of blood - Change in shape of uterus - Firm contraction of uterus - Appearance of the placenta at the vaginal opening Schultze placenta shiny and glistening Duncan placenta dirty raw red and irregular Fourth Stage of Labor Vigilant Stage from delivery of placenta to 1- 4 hours after postpartum

Complications of Labor and Delivery

Dystocia - An abnormal, long, or difficult labor or delivery COMPLICATIONS OF THE PSYCHE

Etiology and Pathophysiology: Hormones released in response to anxiety can cause DYSTOCIA

Intense anxiety stimulates Sympathetic nervous system which releases

catecholamines that lead to myometrial dysfunction.

Norepinephrine and epinephrine lead to uncoordinated or increased uterine

activity Nursing Care

Assess support available and be there for the patient Patient Teaching- breathing/relaxation Provide with non-pharmacological measures Keep informed Provide quiet calm environment
HYPERTONIC UTERINE CONTRACTIONS

Most often occur in first-time mothers, Primigravidas Contractions are ineffectual, erratic, uncoordinated, and involve only a portion of the uterus

Increase in frequency of contractions, but intensity is decreased, do not bring about dilation and effacement of the cervix. Signs and Symptoms: 1. PAINFUL contractions RT uterine muscle anoxia, causing constant cramping pain 2. Dilation and effacement of the cervix does not occur. 3. Prolonged latent phase. Stay at 2 - 3 cm. dont dilate as should 4. Fetal distress occurs early uterine resting tone is high, decreasing placental perfusion. 5. Anxious and discouraged Treatment of Hypertonic Uterine Contractions

Provide with COMFORT MEASURES Warm shower; Mouth Care; Imagery; Music; Back rub Avoid oxytocin Mild sedation morphine sulfate Bedrest Hydration Tocolytics to reduce high uterine tone

HYPOTONIC UTERINE CONTRACTIONS UTERINE INERTIA

Etiology and Pathophysiology:

Overstretching of the uterus

--large baby, multiple babies, polyhydramnios, multiple parity

 Bowel or bladder distention preventing descent Excessive use of analgesia

Signs and Symptoms of HYPOTONIC UTERINE INERTIA:

Weak contractions become mild Infrequent (every 10 15 minutes +) and brief, Can be easily indented with fingertip pressure at peak of contraction. Prolonged ACTIVE Phase Exhaustion of the mother Psychological trauma - frustrated
Therapeutic Interventions: 1. Ambulation getting up and walking will increase contractions 2. Nipple Stimulation causes release of endogenous Pitocin which can stimulate contractions 3. Enema--warmth of enema may stimulate contractions 4. AMNIOTOMY artificial rupture of the membranes Advantages of doing this before Pitocin Contractions are more similar to those of spontaneous labor Usually no risk of rupture of the uterus Does not require as close surveillance Disadvantages of an Amniotomy Delivery must occur Increase danger of prolapse of umbilical cord Compression and molding of the fetal head (caput) Nursing Care: # 1-Check the fetal heart tones Assess color, odor, amount Provide with perineal care Monitor contractions Check temperature every 2 hours 5. Pitocin for augmentation of labor Use only if CPD is not present Give 20 units / 1000 cc. fluid and hang as a secondary infusion, never as primary GOAL: Achieve contractions every 2 - 3 minutes of good intensity with relaxation between Nursing Care: Assess contractions--are they increasing but not tetanic Assess dilation and effacement Monitor vital signs and FHTs Prolonged Labor Definition: A labor lasting more than 18-24 hours Normally: Cervical dilation -- Primigravida 1.2 cm / hr. Multigravida 1.5 cm / hr Descent 1 cm. / hr in primigravida and 2 cm./ hr. in multigravida

PRECIPITIOUS LABOR OR DELIVERY Labor that last less than 3 hours Unexpected fast delivery

Etiology Lack of resistance of maternal tissue to passage of fetus Intense uterine contractions Small baby in a favorable position Complication: If the baby delivers too fast, does not allow the cervix to dilate and efface which leads to cervical lacerations Uterine rupture Fetal hypoxia and fetal intracranial hemorrhage Rapid Delivery Delivery Outside Normal Setting Everything is OUT OF CONTROL! mom is frightened, angry, feels cheated Nursing Care: Do NOT leave the mother alone Try to make the place clean, (dont break down table) Try to get the mother in control -- Have mom pant to decrease the urge to push Apply gentle pressure to the fetal head as it crowns to prevent rapid change in pressure in the fetal head which can cause subdural hemorrhage or dural tears. Deliver the baby BETWEEN contractions to control delivery Suction or hold babys head low and place on mom/s abdomen, tie off cord Allow to breast feed, Document! Pelvic Dystocia

Definition: Pelvic Inlet or Outlet is not of sufficient size or proper shape to allow the baby to get through Etiology Congenital defect Malnutrition -- Rickets Neoplasms Fracture / Trauma Signs and Symptoms:

Labor is arrested. cesarean delivery

Station does not decrease. Baby does not move down in the birth canal after long time in labor or with prolonged pushing.

Therapeutic Interventions:

Complications of the Passenger

Malpositions: Posterior position--usually mom complains of back pain Treatment:

Forceps -- low forceps or outlet forceps usually applied after crowning Vacuum extraction -- disk shaped cup placed over vertex of head and
vacuum applied.

Episiotomy - surgical incision to allow more room

Malpresentation -- brow, face, transverse, breech

may allow to deliver vaginally with caution or

Cesarean birth

Treatment: May allow to deliver with caution or C-birth

Version -- alteration of fetal position by abdominal or intrauterine

manipulation

Cephalopelvic Disproportion Large baby or small pelvis Usually diagnosed when there is an arrest in descent Station remains the same Treatment: Cesarean Delivery Multiple Fetus may be delivered by cesarean birth
CESAREAN DELIVERY OPERATIVE PROCEDURE IN WHICH THE FETUS IS DELIVERED THROUGH AN INCISION IN THE ABDOMEN REMEMBER -- IT IS A BIRTH ! Mom may feel less than normal, so may need support May have option of a VBAC the next time Premature Rupture of the Membranes / PROM

Definition:

Spontaneous rupture of the membranes

Etiology

Infections Fetal abnormalities

- Incompetent cervix - Sexual Intercourse

Major risk - ascending intrauterine infection Other risk -- Precipitation of labor Treatment and Nursing Care:

Wait and watch, bedrest, no intercourse Betamethasone / Celestone -- provides stressor to the lungs of the fetus to
stimulate production of surfactant

Assess time membranes ruptures and if labor started Check temperature frequently Describe character of amniotic fluid Check WBC Provide psychological support
Preterm Labor Definition: Labor that occurs after 20 weeks but before 37 weeks Etiology: urinary tract infections Premature rupture of membranes Goal -- STOP THE LABOR ! suppress uterine activity

Therapeutic Interventions: Drug Therapy / Tocolytics Uses: Stop or arrest labor Criteria for use, dont give if: Patient is in Active labor, cervix has dilated to 4 cm. or more Presence of Severe Pre-eclampsia Fetal complications / Fetal demise Hemorrhage is present Ruptured membranes Examples: Yutopar (ritodrine) or Brethine (terbutaline sulfate) SIDE EFFECTS or WARNING SIGNS: Palpitations Tachycardia - pulse ~120 Tremors, nervousness, restlessness Headache, severe dizziness Hyperglycemia

TOXIC EFFECTS - PULMONARY EDEMA - rales, crackles, dyspnea - Must perform chest assessment with nursing assessment every shift and chart lung sounds. Nursing Care:

Stop the medication Start oxygen Give ANTIDOTE: INDERAL

Patient Teaching: Teach how to take medication -- on time Teach patient to check pulse, call Dr. if > 120 140 (dehydration increases contractions) Teach to assess fetal movement daily, kick counts Drink 8-10 glasses of water per day Monitor uterine activity -- Home monitoring -- call dr. if has contractions Decrease activity Lie on side Keep bladder empty

Ruptured Uterus Spontaneous or traumatic rupture of the uterus Etiology: Rupture of a previous C-birth scar Prolonged labor Injudicious use of Pitocin -- overstimulation Excessive manual pressure applied to the fundus during delivery Signs and Symptoms: Sudden sharp abdominal pain, abdominal tenderness Cessation of contractions Absence of fetal heart tones Shock Therapeutic Interventions:

 Deliver the baby ! / Cesarean Delivery Prolapse of the Umbilical Cord Definition: Prolapse of the umbilical cord thorough the cervical canal along side of the presenting part Etiology: Occurs anytime the inlet is not occluded. Fetus is not well engaged GOAL: RELIEVE THE PRESSURE ON THE CORD SUPPORT MOTHER AND THE FAMILY NURSING CARE / Therapeutic Interventions: **Get the pressure off the Cord --place in trendelenberg or kneechest position OR elevate part with sterile gloved hand Palpate FHTs, NEVER ATTEMPT TO REPLACE CORD! Give O2 per mask at 10 Liters Cover exposed cord with sterile wet gauze Stay with the patient and offer support Amniotic Fluid Embolism

Escape of amniotic fluid into the maternal circulation

usually enters maternal circulation through open sinus at placental site

Usually fatal to the Mother

amniotic fluid contains debris, lanugo, vernix, meconium, etc.

Signs and Symptoms:

dyspnea chest pain cyanosis shock

Therapeutic Interventions:

Deliver the baby Provide cardiovascular and respiratory support to Mom