OB Exam

Unit 1
Terminology

Gravida any pregnancy, regardless of duration

Primigravida woman pregnant for the first time

Multigravida woman pregnant with second or any subsequential

pregnancy

Para birth after 20 weeks gestation, regardless of whether infant is

alive or dead

Multipara woman who has had two or more births at more than 20
weeks gestations

Preterm born after 20 weeks gestation but before completion of 37

weeks

Preterm labor labor occurring after 20 weeks but before completion

of 37 weeks

Postdate or postterm pregnancy that goes beyond 42 weeks

gestation

Term born between the beginning of the 38th week gestation and the
end of the 42nd week

Viability infant born that has the capacity to live outside of the
womb, 22 to 24 weeks or greater than 500 grams

Stillbirth - fetus born dead after 20 weeks gestation

Pregnancy tests

ELISA enzyme- linked immunosorbent assays (detects levels of hCG)

hCG quantitative (detects level of hCG in the bloodstream)

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Normal physiologic changes of pregnancy

Uterus

Described in 3 parts:

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o Fundus: upper portion
o Isthmus: lower segment
o Cervix: the lower narrow part or neck; the external part of the
cervix interfaces with the vagina

Before pregnancy, this elastic muscular organ is the size and shape of
a small pear weighing 40-50g

During pregnancy the uterine wall progressively thins as the uterus

expands to accommodate the developing fetus

By mid-pregnancy the uterine fundus reaches the level of the umbilicus

abdominally

Toward the end of the pregnancy, the enlarged uterus containing a fullterm fetus fills the abdominal cavity and has altered the placement of
the lungs and rib cage in addition to the abdominal organs

Dramatic increase in size and weight

o 20z non-pregnant size
o Hyperplasia and hypertrophy of myometrial cells and fibers due
to estrogen and progesterone, mechanical factors, stretching,
growing fetus
o Weight increases 50-1000 grams

Braxton hicks contractions

o Intermittent, painless and physiological uterine contractions,
begin in the second trimester but some women do not feel them
until the third trimester. These contractions are irregular with no
particular pattern
o Uterus contractibility increases in response to increased estrogen
levels leading to Braxton hicks contractions

Shape changes from and inverted pear to a soft globe

o Uterus rises out of the pelvis by the end of the first trimester
o Uterus at level of umbilicus by 22-24 weeks

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o Uterus at level of xyphoid process by term
McDonalds rule

Cervix

Mucus plug formed (creates a barrier against ascending infection) and

produced by endocervical glands
o Hypertrophy of cervical glands leads to formation of mucus plug,
which serves as a protective barrier between uterus/fetus and
vagina

Increased vascularity/slight hypertrophy (Goodells sign)

o Softening of the cervic and vagina with increased leukorrheal
discharge; palpated at 8 weeks

Bluish coloration (chadwicks sign)

o Bluish-purple coloration of the vaginal mucosa, cervix, and vulva
seen at 6-8 weeks

Leukorrhea

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o Increased vascularity and hypertrophy of vaginal and cervical
glands leads to increase in leukorrhea
Vagina and Vulva

An increase of vaginal discharge (leucorrhea), which is in response to

the estrogen-induced hypertrophy of the vaginal glands

Relaxation of the vaginal wall and perineal body, which allows

stretching of tissues to accommodate the birthing process

Increased vascularity and bluish color

Epithelium, elastic tissues hypertrophy

Acid pH 3.5-6.0
o Allows overgrowth of Candida albicians this places woman at risk
for candidiasis (yeast infection)
o Acid environment inhibits growth of bacteria

Breasts

Increase of estrogen and progesterone levels: initially produced by the

corpus luteum and then by the placenta.
o Tenderness, feeling of fullness and tingling sensation
o Increased in weight of breasts by 400g
o Montgomerys glands more prominent
o Nipple enlarge, more erect
o Straie: due to stretching of skin to accommodate enlarging breast
tissue prominent veins due to a twofold increase in blood flow

Increased blood supply to breasts

Increased of prolactin: produced by the anterior pituitary

o Increased growth of mammary glands
o Increase in lactiferous ducts and alveolar system

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o Production of colostrum, a yellow secretion rich in antibodies,
begins to be produced as early as 16 weeks

Size increases, nodularity, tenderness

Skin appears thinner

Superficial veins become more prominent

Increased pigmentation of areolar, nipple

Pre-colostrum secreted as early as 2nd trimester

Colostrum secreted 3rd trimester

Cardiovascular system heart

Supine hypotension can occur when the woman is in the supine

position as the enlarging uterus can compress the inferior vena cava

Some enlargement of the heart due to increased volume and cardiac

output, may hear systolic murmurs (S3)
o Decrease in blood pressure

Hemodynamic changes
o Heart rate increases 10-15 beats/min
o Blood volume increases 40-45%
o Cardiac output increases 30-50% by 32 weeks and declines to
about 20% by 40 weeks gestation
o Increased vasodilation

Hematologic changes
o Increased RBC production by 30%
Physiological anemia of pregnancy
o Increased volume of plasma and RBCs

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Hemodilution is caused by the increase in plasma volume
being relatively larger than the increase in RBCs which
results in decreased hemoglobin and hematocrit values
o Hct 37 47% WNL
o Anemia = Hgb < 11g/dl, Hct <35%
o WBCs increased during pregnancy
This increase is hormonally induced and similar to
elevations seen in physiologic stress such as exercise
Values up to 16,000 mm3 in the absence of infections

Clotting factors
o Increased fibrin by 40%
o Increased fibrinogen by 50%, factors VII,VIII, IX, X
o Hypercoagulable state increased risk of thrombosis
o Alterations in coagulation can lead to DIC

Increased venous pressure and decreased blood flow to extremities due

to compression of iliac veins and inferior vena cava
o Edema of lower extremities
o Varicosities in legs and vulva
o Hemorrhoids

Respiratory system

Hormones of pregnancy stimulate the respiratory center and act on

lung tissue to increase and enhance respiratory function
o Tidal volume increases 30-40%
o Slight increase in respiratory rate
o Increase in inspiratory capacity
o Decrease in expiratory volume
o Slight hyperventilation
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o Slight respiratory alkalosis
Decrease in PCO2 leads to an increase in pH and decrease
in bicarbonate

Estrogen, progesterone and prostaglandins cause vascular

engorgement and smooth muscle relaxation
o Dyspnea
o Nasal and sinus congestion
o Epistaxis

Diaphragm elevates and is displaced upward approximately 4 cm

Increase in chest circumference of 6 cm with an increase in the costal

angle of greater than 90 degrees

Hyperventilation as pregnancy progresses

Breathing changes from abdominal to thoracic

o Chest and thorax expand to accommodate thoracic breathing
and upward displacement of diaphragm

Gastrointestinal system

Increased levels of hCG and altered carbohydrate

o Nausea and vomiting during early pregnancy

Increased progesterone levels slow stomach emptying and relax of the

esophageal sphincter
o Reflux of gastric contents into lower esophagus resulting in
heartburn

Increased progesterone levels relax smooth muscle to slow the

digestive proves and movement of stool
o Bloating, flautence and constipation

Increased progesterone levels decrease muscle tone of gallbladder and

result in prolonged emptying time

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o Increased risk of gallstone formation and cholestasis

Changes in senses if taste and smell

o Increase or decrease in appetite
o Nausea
o PICA

Mouth and teeth

o Gums become swollen, soft, tendency to bleed (gingivitis
Due to increased levels of estrogen leading to increased
vascular congestion of mucosa
o Saliva more acidic (ptyalism)
o Client should have periodic dental check-ups

GI Tract
o Decreased peristalisis, decreased motility, constipation
o Hemorrhoids
o Heartburn slow gastric emptying (nausea & vomiting)

Gallbladder
o Increased emptying time
o Retained bile salts

Renal system

The kidneys undergo change during pregnancy as they adapt to

perform their basic function of regulating fluid and electrolyte balance,
eliminating metabolic waste products and regulate blood pressure

Alterations in cardiovascular system lead to increased renal blood flow

of 50-80% in first trimester and then decreases

Increased progesterone levels, which cause a relaxation of smooth

muscles

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o Increased urinary frequency

Dilation of renal pelvis and uterues. Uterus become elongates and

decreased motility

Pressure of enlarging uterus on renal structures. Displacement of

bladder in third trimester

Increased renal excretion of glucose and protein can normally occur in

small amounts related to tubal reabsorption threshold of protein and
glucose being exceeded due to increased volume
o Even though a small amount of proteinuria and glucosuria can be
normal, it is important to assess and monitor for pathology

Shift in fluid and electrolyte balance

o The need for increased fluid and electrolytes results in alteration
of regulating mechanism including the renin-angiotensinaldosterone system and antidiuretic hormone

Increased glomerular filtration rate

o Increase utinary output

Decreased bladder tone

o Increased risk of UTI

Increased risk of urinary stasis pyelonephritis

o 1st and 3rd trimester

Endocrine system

Significant alterations in pituitary, adrenal, thyroid, parathyroid and

pancreatic functioning occur in pregnancy. The hormonal production
activity and size of the thyroid gland increase during pregnancy in
support of maternal and fetal physiological needs and there is an
increase in pancreatic activity during pregnancy to meet both maternal
and fetal needs related to carbohydrate metabolism

The function of the high hCG level in early pregnancy is to maintain the
corpus luteum and its production of progesterone and to a lesser
extent, estrogen until the placenta develops and takes over its function
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After the development of a functioning placenta, the placenta produces

most of the hormones of pregnancy including estrogen, progesterone,
human placental lactogen and relaxin

Decreased FSH
o Amenorrhea

Increased progesterone
o Maintains pregnancy by relaxation of smooth muscles, leading to
decreased uterine activity, which results in decreased risk of
spontaneous abortions
o Decreases GI motility and slows digestive processes

Increased estrogen
o Facilitates uterine and breast development
o Facilitates increases in vascularity
o Facilitates hyperpigmentation
o Alters metabolic processes and fluid and electrolyte balance

Increases prolactin
o Facilitates lactation

Increased oxytocin
o Stimulates uterine contractions
o Stimulates the milk let-down or ejection reflex in response to
breastfeeding

Increased hCG
o Maintenance fo corpus luteum until placenta becomes fully
functional

Human placental lactogen/human chorionic somatomammotropin

o Facilitates breast development
o Alters carbohydrate, protein, and fat metabolism
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o Facilitates fetal growth by altering maternal metabolism; acts as
an insulin antagonist

Thyroid
o Increased BMR by 25%
Depletions of maternal glucose stores leads to increased
risk of maternal hypoglycemia
o Hyperplasia and increased vascularity of thyroid
o Enlargement of thyroid
o Heat intolerance and fatigue

Pancreas
o Increased insulin production

Immunological system
o Resistance to infection is decreased

Integumentary system

Estrogen and progesterone levels stimulate increased melanin

deposition, causing light brown to dark brown pigmentation
o Linea alba darkens (linea nigra)
o Melisma (chloasma mask of pregnancy)
o Nipples, areola, axilla, vulva, perineum darken
o Moles, freckles, scars may darken

Increased action of adrenocorticosteroids leads to cutaneous elastic

tissues becoming fragile
o Striae gravidarum stretching of skin due to grown of breast,
hips, abdomen, and buttocks plus the effects of estrogen, relaxin,
and andrenocorticoids may result in tearing of subcutaneous
connective tissue

Increased estrogen levels lead to color and vascular changes

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o Increased spider nevi

Abnormal gestational skin disorder

o Pupp Rash pruritic urticarial papules and plaques

Hot flashes and facial flushing: caused by increased blood supply to the
skin, increae in basal metabolic rate, progesterone-induced increased
body temperature and vasomotor instability

Oily skin and acne: affects of increase in androgens

Musculoskeletal system

Abdominal muscles stretch due to enlarging utereus

o Diastasis recti- separation of rectus muscles of abdominal wall
and caused by the abdominal distention. It is a benign condition
that can occur in the third trimester

Increased progesterone and relaxin levels lead to softening of joints

and increased joint mobility, resulting in widening and increased
mobility of the sacroiliac and symphysis pubis
o Lordosis abnormal anterior curvature of the lumbar spine. The
body compensates by a shift in center of gravity by developing
an increased curvature of the spine
o Waddle gait relaxation of joints is due to the secretion of a
hormone (relaxin) from the ovary

Joint discomfort hormonal influences of progesterone and relaxin

soften cartilage and connective tissue, leading to joint instability

Round ligament spasm estrogen and relaxin increase elasticity and

relaxation of ligaments and abdominal distention stretches round
ligaments causing spasm and pain

Maternity nursing: trends & issues ethics and standards of practice

issues

Hospital births LDR/LDRP

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o In the united states, approx. 99% of all births take place in
hospital setting
o Hospital maternity services can vary greatly, from traditional
labor and delivery rooms with separate newborn and postpartum
units to in hospital birth centers
o Labor, delivery and recovery rooms may be available in which the
expectant mother is admitted, labors, gives birth and spends the
first 2 hours of recovery
o In labor, delivery, recovery, postpartum units, the mother
remains in the room for the entire hospital stay
o Level 1 level 2 level 3

Home births
o Home births allow the expectant family to be in control of the
experience and the mother may be more relaxed than in the
hospital environment. It may be less expensive and there may be
a decreased risk of serious infection
o If home birth is the womans choice the following criteria will
promote a safe home birth experience
The woman must be comfortable with her decision
The woman should be in good health; home birth is not for
high-risk pregnancy
The woman should have access to a good transportation
system in case of transfer to the hospital

Free standing birth centers

o Are usually built in locations separate from the hospital but may
be located nearby in case transfer of the woman or newborn if
needed
o Only women at low risk complications are included in care
o Are usually staffed by midwives

Clinics/doctors offices

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Doulas
o Is an individual who provides support to women and their
partners during labor, birth, and postpartum. The doulas do not
provide clinical care

Lactation consultant

Sexual assault nurse examiners (SANE)

Maternal-infant terminology

Abortus
o An embryo or fetus that is removed or expelled from the uterus
at 20 weeks gestation or less, weights 500g or less, measures 25
cm or less

Stillbirth
o An infant who, at birth, demonstrates no signs of life, such as
breathing, heartbeat or voluntary muscle movements

Birthrate
o Number of live birth in 1 year per 1000 population

Fertility rate
o Number of births per 1000 women between the ages 15 and 44
(inclusive), calculated on a yearly basis

Infant mortality rate

o Number of deaths of infants under 1 year of age per 1000 births

Neonatal mortality rate

o Number of deaths of infants under 28 days of age per 1000 live
births

Perinatal mortality rate

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o Number of still births and the number of neonatal deaths per
1000 live birth

Maternal mortality rate

o Number of maternal deaths from births and complications of
pregnancy, childbirth, and puerperium (the first 42 days after
termination of pregnancy) per 100,000 live births

Mortality rates

Infant mortality rates in the united states

o Infant mortality rates in the US have significantly decreased from
47.0 per 1,000 live births in 1940 to 6.1 in 2011. The decrease is
related to
Improvement and advances in the knowledge and care of
high risk neonates

Infant mortality rates in Canada

Infant mortality rates internationally

Maternal mortality trends

o Hemorrhage
o Infections
o Eclampsia
o Obstructed labor
o Abortion complications

Trends and standards of nursing practice

NIC/NOC

Clinical benchmarking
o AWHONN
Advocates that nurses adhere the following principles

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Nurses have the professional responsibility to provide

nonjudgmental nursing care to all patients

Nurses have the professional responsibility to provide

high-quality, impartial nursing care to all patients in
emergency situation, regardless of nurses personal
beliefs

Nurses have a professional obligation to inform their

employers of any attitudes and beliefs that may
interfere with essential job function

o NANN
o ACOG
o AAP
o ANA
The code of ethics serve as:

A statement of the ethical obligations and duties of

every nurse

The professions non-negotiable ethical standard

An expression of nursings own understanding of its

commitment to society

o ACNM

Evidence-based practice
o Integrate best current evidence with clinical expertise and
patient/family preferences and values for delivery of optimal
health care

Cochrane pregnancy and childbirth database

Joanna Briggs Institute

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Ethical & legal issues in perinatal nursing

Reproductive technology.surgeries

Older-age pregnancies

Induced ovulation and in vitro fertilization

Multi-fetal pregnancy reduction

Cloning of humans

Fetal compromise

Timely cesarean (30 minutes from decision to incision)

Resuscitation

Oxytocin/cytotec (hyper-stimulation)

Forceps/vacuum (shoulder dystocia)

Vulnerable population

Groups at higher risk of developing physical, mental, or social health

problems or who are more likely to have worse outcomes from these
health problems than the population as a whole
o Adolescent girls
o Older woman
o Incarcerated woman
o Migrant workers
o Homeless women
o Refugees and immigrants
o Individuals with low literacy of developmental delays
o Rural versus urban community settings

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Newborn Chapter 15, 16, & 17
Transition to extrauterine life

Respiratory system
o Surfactant
The presence of surfactant, a phospholipid, within the
alveoli assists in the establishment of functional residual
capacity. This residual capacity assists in keeping the
alveolar sacs partially open at the end of exhalation, which
decreases the amount of pressure and energy required on
inspiration
o Thermal
o Mechanical

Cardiovascular system
o Closure of the foramen ovale
The opening between the right atrium and the left atrium,
closes when the left atrial pressure is higher than the right
atrial pressure. This closure occurs when:

Increased PaO2 decreased pulmonary pressure

increased pulmonary blood flow increased
pressure in left atrium closure of foramen ovale

Significant neonatal hypoxia can cause a reopening

of the foramen ovale

o Closure of the ductus arteriosus

Which connects the pulmonary artery with the descending
aorta, usually closes within 15 hours post birth.
This closure occurs when the pulmonary vascular
resistance becomes less than system vascular system
left to right shunt closure of ductus arteriosus
It will remain open if lung fail to expand PaO2
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o Closure of the ductus venosus
Connects the umbilical vein to the inferior vena cava,
closes by day 3 of life and becomes a ligament. Blood flow
through the umbilical vein
Two factors that negatively affect the
stops once the cord is
transition to extrauterine respirations
clamped
are:

Schematic illustration of the fetal

circulation

Decreased surfactant levels related to

immature lungs

Persistent hypoxemia and acidosis that

The initiation of respiration has
an effect on the pulmonary
circulation and gas exchange: first
breath increase alveolar oxygen
tension (PaO2) and decreased pH
dilation of pulmonary arteries
decrease pulmonary vascular
resistance increase blood flow
through pulmonary vessels
increase oxygen and carbon dioxide

The neonate responds to cold by:

An increase in metabolic rate

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An increase of muscle activity

Peripheral vascular constriction

Metabolism of brown fat

Neutral thermal environment (NTE)

o An environment that maintains body temperature with minimal
metabolic changes and/or oxygen consumption
A neutral thermal environment decreases possible
complicates related to the delayed response to
environmental temperature changes

Brown adipose tissue (BAT)

o Also referred to as brown fat or nonshivering thermogenesis, is a
highly dense and vascular adipose tissue. Neonates posses large
amounts of BAT, while children and adults have smaller amounts
BAT is located in the neck, thorax, axillary area,
intrascapular areas and around the adrenal glands and
kidneys
BAT promotes:

An increase in metabolism

Heat production

Heat transfer to the peripheral system

Heat is produced by intense lipid metabolic metabolism of

BAT
BAT reserves are rapidly depleted during periods of cold
stress
Preterm neonates have limited BAT
Thermoregulation system

Evaporation

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o Loss of heat that occurs when water on the neonates skin is
converted to vapors, such as during bathing or directly after birth

Conduction
o Transfer of heat to cooler surface by direct skin contact, such as
cold hands of caregivers or cold equipment

Convection
o Loss of heat from the neonates warm body surface to cooler air
currents, such as air conditioners or oxygen masks

Radiation
o Transfer of heat from the neonate to cooler objects that are not in
direct contact with the neonate such as cold walls of the isolette
or cold equipment near the neonate

Cold Stress

When an infant is stressed by cold

o Oxygen consumption increases
o Pulmonary and peripheral vasoconstriction
occur
o Decreasing oxygen uptake
o Anaerobic glycolysis increases

A decrease in
environmental
temperature
decrease in neonates
body temperature
increased respiratory
rate, heart rate
increased oxygen
consumption, a
depletion of glucose
and a decrease of

o A decrease in PO2 and pH leading to metabolic acidosis

Signs and symptoms

o A temperature below 97.7
o Cool skin
o Lethargy
o Pallor
o Grunting
o Tachypnea

Interventions for Cold Stress:

Place a stocking cap on the neonates
head.
Skin to skin contact
Swaddle in warm blankets
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Place neonate under preheated radiant
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o Hypotonia
o Jitterness
o Weak suck

Transition to extrauterine life continued

Hematopoietic system
o Blood volume
o Blood components

Hepatic system
o Functions of the liver include:
Carbohydrate metabolism

Converting excessive glucose to glycogen

Converting glycogen to glucose when glucose levels

are low

Amino acid metabolism

Lipid metabolism
Synthesis of plasma proteins
Blood coagulation

After birth neonate experiences a decrease in vitamin

L and is at risk for delayed clotting and for
hemorrhage

Vitamin K is synthesized in the intestinal flora, which

is absent in the newborn

Vitamin K is given as a prophylaxis to decrease the

risk of bleeding related to vitamin K deficiency.

o Conjugation of bilirubin

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Indirect bilirubin

A fat soluble substance, is produced from the

breakdown of RBC

Direct bilirubin

A water-soluble substance, by liver enzymes. Can be

excreted in the urine and stool.

Hyperbilirubinemia

Is a condition in which there is a high level of

unconjugated bilirubin in the neonates blood related
to the immature liver function, high RBC count that is
common in neonates and an increased hemolysis
caused by the shorter life span of fetal RBC

o Hypoglycemia
Hyperbilirubinemia

Physiological jaundice
o Results from the liver, commonly occurs after the first 24 hours of
birth and during the first week of life.

Pathological jaundice
o Results when various disorders exacerbate physiological
processes that lead to hyperbilirubinemia of the newborn

Breast feeding jaundice

o Causes
o Predisposition
o Characteristics
o Assessment
o Treatment

Bilirubin graph

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Nursing care

LOC assessments

Vital signs temperature

Eye shields

Genital shields

I&O

Hypoglycemia

Blood sugar at birth less than 40 mg/dL in a term infant

25 mg/dL in a preterm infant

o Causes
o Predisposition
o Signs and symptoms
Jitterness
Hypotonia

During intrauterine life, neonates of

diabetic mothers produce high levels
of insulin in response to the high
levels of circulating maternal
glucose. During the first few hours of
extrauterine life, the neonates insulin
level remains higher than normal

Irritability
Apnea
Lethargy
Temperature instability
o Treatment
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Transition to extrauterine life continued

GI system
o Gastric capacity for the first few days is approximately 5-10 ml
and increases to 60 mL by day 7
o Stomach emptying is 2-4 hours
o Stool patterns:
Meconium stool

Begins toform during the 4th gestational month and is

the first stool eliminated by the neonate. It is sticky,
thick, black and odorless. It is first passed within 2448 hours

Transitional stool

Begins around the 3rd day and can continue for 3 or 4

days. The stool transitions from black to greenish
black to greenish brown to greenish yellow. This
phase of stool characteristics occurs in both
breastfed and formula fed neonates

Breastfed stool

Is yellow and semiformed. Later it becomes a golden

yellow with a pasty consistency and has a sour odor

Formula-fed stool

Drier and more formed than breastfeed stools. It is a

paler yellow or brownish yellow and has an
unpleasant odor

Renal system
o Function of the kidneys are control of fluid and electrolyte
balance and excretion of metabolic waste

Immune system
o Active acquired immunity

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B cells detect antigens and produce antibodies against
them
Acquired immunity that develops from vaccination
Natural immunity that develops from exposure to antigen
after which the individual produces antibodies
o Passive acquired immunity
Is acquired either naturally or artificially
Psychosocial adaptation

First period of reactivity

o Occurs first 15-30 min post-birth
o The neonate is alert and active and vigorously responds to
external stimuli
o Respirations are irregular and rapid
o The neonate may exhibit momentary grunting, flaring and
retractions
o Brief periods of apnea may occur
o The heart rate is rapid and can be as high as 180 beats
o Brief period of cyanosis can occur
o The amount of oral mucus increases

Period of inactivity and sleep

o Begins approximately 30 minutes after birth and lasts 2 hours
o Sleep state
o Respiratory rate decreases along with a decrease in heart rate
and oral mucus production

Second period of reactivity

o Follows the period of relative inactivity and lasts 2 8 hours

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o Varies between active alert and quiet alert state
o Periods of rapid respiration in response to stimuli and activity
o Heart rate varies
o Increased bowl activity and may pass meconium stool

Sleep states

Apgar Score

Heart rate

Respiratory rate

Muscle tone

Reflexes

Color

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Physical assessment

Vital signs
o T: 97.7-99 R: 30-60 P: 120-160bpm BP: 50-75/30-45

Weight
o 5.8-8.13 pounds
o Weight loss of 5-10% of birth weight during the first week is
normal. This is due to water loss through urine, stools, and lungs
and an increase in metabolic rate. It is also related to limited fluid
intake. The neonate will regain birth weight within 10 days
o Abnormal: weight above the 90th percentile are common in
neonates of diabetic mothers. Weight below the 10th percentile is
due to prematurity, intrauterine growth restriction, malnutrition
during the pregnancy

Length
o 45-53 cm
o Abnormal: Molding may interfere with accurate assessment of
length. Neonates whose length is less than 45 cm should be
further assessed for causes of growth restriction or prematurity

Head circumference
o 33-35.5 cm
o abnormal: microcephaly: head circumference is below the 10th
percentile of normal for newborns gestational age. This is often
relates to congenital malformation, maternal drug or alcohol

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ingestion. Macrocephaly: head circumference is less than 90th
percentile this can be related to hydrocephalus

Chest circumference
o 20.5-33 cm
o 2-3 cm less than head circumference

Abdominal circumference

Skin
o Petechia
o Milia
o Erythema toxicum
o Mongolian spots
o Hemangiomas

Head frontanels
o Size
o Caput succedaneum
Appearance: a localizes soft tissue edema of the scalp.
Feels spongy and can cross suture lines
Significance: results from prolonged pressure of the head
against the maternal cervix during labor. Resolves within
the first few weeks of life
o Cephematoma
Appearance: hematoma formation between the periosteum
and skill with unilateral swelling. It appears within a few
hours of birth and can increase in size over the next few
days. It has w ell-defined outline. It does not cross suture
lines
Significance: related trauma to the head due to prolonged
labor, forceps delivery or use of vacuum extractor. Can

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contribute to jaundice due to the large amounts of blood
being hemolyzed. Resolves within 3 months
o Anterior fontanel
o Posterior fontanel
Milia
Appearance: white papules on
the face; more frequently seen
on the bridge of the nose and
chin
Significance: exposed sebaceous
glands that resolve without
treatment. Parents might
mistakes these for whiteheads
inform parents to leave them
alone and let them resolve on

Erythema Toxicum
Appearance: a rash with red
macules and papules that
appear in different areas of the
body, usually the trunk area
Significance: benign,
disappears without treatment

Mongolian spot

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Appearance: flat, bluish discolored
area on the lower back or butt. Seen
more often in African American,
Asian, Hispanic, and Native American
Infants.
Significance: might be mistaken for
bruising. Need to document size and
location, resolves on own by school

Hemangiomas

Molding
Appearance: elongation of the fetal head as
it adapts to the birth canal
Significance: resolves within 1 week

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Physical assessment Continued

Eyes
o Assess the position of the eyes. Open the eyelids and assess
color of sclera and pupil size. Assess for blink reflex, red light
reflex and pupil reaction to light.
o Eyes are equal and symmetrical in size and placement. The
neonate is able to follow objects within 12 inches of the visual
field. Edema may be present due to the pressure during labor
and birth and reaction to eye prophylaxis. The iris is blue-grey or
brown. The sclera is white or bluish-white. Subconjunctival
hemorrhages related to birth trauma. Positive red light reflex and
bling reflex. No tear production. Strabismus and nystagmus
related to immature muscular control
o Abnormal: Absent red light reflex indicates cataracts. Unequal
pupil reaction indicate neurological trauma. Blue sclera is a
possible indication of osteogenesis imperfecta

Ears
o Inspect the ears for position, shape, and drainage. Hearing test is
done before discharge.
o Top of the pinna is aligned with external canthus of the eye. Pinna
without deformities, well formed and flexible. The neonate
responds to noises with positive startle signs. hearing becomes
more acute as Eustachian tubes clear. Neonates respond more
readily to high-pitched vocal sounds
o Abnormal: Low-set ears are associated with genetic disorders
such as down syndrome. Absent startle reflex is associated with
possible hearing loss

Mouth palate
o Inspect lips, gums, tongue, palate and mucous membranes. Open
the mouth by placing gentle pressure on the lower lip. Text for
rooting, sucking, swallowing and gag reflexes

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o Lips, gums, tongue, palate and mucous membranes are intact,
pink and moist. Reflexes are positive. Epsteins pearls are
present.
o Abnormal: natal teeth, which can be benign or related to
congenital abnormality. Thrush, a fungal infection, can be
contracted during vaginal birth. It appears as white patches on
the mucous membranes of the mouth. Cleft lip or palate which is
a congenital abnormality in which the lip or palate does not
completely fuse

Neck
o Lift the chin to assess the neck area
o The neck is short with skin folds. Positive tonic neck reflex
o Abnormal: webbing is a possible indication of genetic disorders.
Absent tonic neck reflex is an indication of nerve injury

Chest
o Inspect shape, symmetry and chest excursion. Inspect the breast
for size and drainage. Auscultate breath sounds.
o The chest is barrel-shaped and symmetrical. Breast engorgement
is present in both male and female neonates related to the
influence of maternal hormones. This resolves within a few
weeks. Clear or milky fluid from nipples related to maternal
hormones. Lung sounds are clear and equal. Scattered crackles
may be detected during the first few hours after birth. This is due
to retained amniotic fluid which will be absorbed through the
lymphatics
o Abnormal: Funnel chest is a congenital abnormality. Pigeon
chest can obstruct respiration. Chest retractions are a sign of
respiratory distress. Persistent crackles, wheezes, stridor,
grunting, paradoxical breathing, decreased breath sounds or

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prolonged sounds of apnea are signs of respiratory distress.
Decreased or absent breath sounds are often related to
meconium aspiration or pneumothorax

Cardiac
o Auscultate heart sounds; listen for at least one full minute.
Palpate peripheral pulses
o Point of maximal impulse at 3rd or 4th intercostal space. S1 and S2
are present. Normal rhythm with variation related to respiratory
changes. Murmurs in 30% of neonates which disappear within 2
days of birth. Peripheral pulses are present and equal. The
femoral pulse may be difficult to palpate
o Abnormal: Dextrocardia: heart on the right side of the chest.
Displaced PMI occurs with cardiomegaly. Persistent murmurs
indicate persistent fetal circulation or congenital heart defects

Cleft lip and palate

Physical assessment continued

Abdomen

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o Inspect size and shape of the abdomen. Palpate the abdomen,
assessing for tone, hernias and diastasis recti. Auscultate for
bowel sounds. Inspect the umbilical cord
o The abdomen is soft, round, protuberant, and symmetrical. Bowel
sounds are present but may be hypoactive for the first few days.
Passage of meconium stool within 48 hours post-birth. The cord is
opaque or whitish blue with two arteries and one vein and
covered with Whartons jelly. The cord becomes dry and darker in
color within 24 hours post-birth and detaches from the body
within 2 weeks
o Abnormal: Asymmetrical abdomen indicates a possible
abdominal mass. Hernias or diastasis recti are more common in
African American neonates and usually resolve on their own
within the first year. One umbilical artery and vein is associated
with heart or kidney malformation. Failure to pass meconium
stool is often associated with imperforated anus or meconium
ileus
o Hernia

Genitalia
o Hypospadias
o Epispadias

Extremities

o Hip dysplasia

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o Simian Crease

Back

Anus stools
o Abnormal: imperforated anus requires immediate surgery. Anal
fissures and fistulas

Signs

Asymmetry of gluteal and thigh folds

Limited hip abduction

Shortening of the femur

Ortolanis maneuver

Club foot
New ballard assessment

Neuromuscular maturity

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o Posture
Assess the position the neonate assumes while lying
quietly on his back
The more mature, the greater degree of flexion in legs and
arms
o Square window
Assess the degree of the angle created when the examiner
flexes the neonates hand toward the forearm
o Arm recoil
With the neonate in a supine position, the examiner fully
flexes the forearm against the neonates chest for 5
seconds. The examiner extends the arms and releases
them
o Popliteal angle
Wuth the neonate in a supine position and pelvis flat, the
examiner flexes the neonates thigh to the abdomen. The
leg is then extended. The angle at the knee is examined
o Scarf sign
With the neonate in a supine position, the examiner takes
the neonates hand and moves the arm across the chest
toward the opposite shoulder. The examiner notes where
the elbow is in relation to the midline of chest
o Heal to ear
With the neonate in a supine position, the examiner takes
the neonates foot and moves it toward the ear

Physical maturity
o Skin
The examiner inspects the neonates chest and abdominal
skin areas for texture, transparency, thickness and for
peeling and or cracking

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A preterm neonates skin is smooth, thin and translucent
A full term neonates skin is thicker and more opaque with
some degree of peeling
o Lanugo
The examiner assess he amount of lanugo on the neonates
back
Begins to form around the 24th week of gestation. It is
abundant in preterm neonates and decreases in amount as
the neonate matures

o Plantar surface
The examiner inspects the bottom of the feet for location of
creases
The more creases over the greater proportion of the foot,
the more mature the neonate
o Breast
The examiner assess the degree of nipple formation. The
size of the breast bud is measured by gently grasping the
tissue with thumb and forefinger and measuring the
distance between thumb and forefinger
o Eye/ear
The more defined the ear is and the firmer it is the more
mature the neonate is
o Genitals
Male

The examiner palpates the scrotum for the presence

of testis and inspects the scrotum for appearance

Female

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The examiner moves the neonates hip one half

abduction and visually inspects the genitalia

Reflexes

Suck
o Present at birth
o Place a gloved finger or nipple of a bottle in the neonates mouth
o Sucking motion occurs
o Abnormal response: may not respond if recently fed. Prematurity
or neurological defects may cause weak or absent response

Grasp
o Present at birth
o The examiner places a finger in the palm of the neonates hand
o The neonate grasps fingers tightly. If the neonate grasps the
examiners fingers with both hands, the neonate can be pulled
into a sitting position
o Abnormal response: absent or weak response indicates possible
CNS defect

Root
o Brush the side of a cheek near the corner of the mouth
o The neonate turns his head toward the direction of the stimulus
and opens his mouth

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o Instruct mothers who are lactating to touch the corner of the
neonates mouth with a nipple and the infant will turn toward the
nipple for feeding
o Abnormal response: prematurity or neurological defects may
cause weak or absent response

Moro
o Jar the crib or hold the baby in a semisitting position and let the
head slightly drop back
o Symmetrical abduction and extension of arms and legs. Legs flex
up against trunk
o The neonate makes a C shape with thumb and index finger
o Abnormal response: a slow response might occur with preterm
infants or sleepy neonates
o An asymmetrical response may be related to temporary or
permanent birth injury to clavicle, humerus or brachial plexus

Tonic
o With the neonate in a supine position, turn the head to the side
so that the chin is over the shoulder
o The neonate assumes a fencing position with arms and legs
extended in the direction in which the head was turned
o Abnormal response: response after 6 months may indicate
cerebral palsy

Stepping
o Hold the neonate upright with feet touching a flat surface
o The neonate steps up and down in place
o Abnormal: diminished response may indicate hypotonia

Babinski
o Stroke the lateral surface of the sole in an upward motion

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o Hyperextension and fanning of toes
o Abnormal: absent or weak may indicate neurological defect

Implementation of care at delivery

ABCs

Vital signs

Maintain temperature

Medication: eye prophylaxis

o Erythromycin ointment

Medication: vitamin K
o Aquamephyton

Medication: hepatitis B vaccine

Cord care

ID bands

New ballard assessment scale

Accu check if necessary

Circumcision

Gomco/Morgen clamp
o Obtain consent

Benefits: decreased incidence of UTI and

STI

o Post-op
Assess bleeding

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Pain assessment scale
Vaseline dressing changes
Pain management
Teaching to caregiver regarding the healing process

Plastibell
o Obtain consent
o Post-op
Assess bleeding
Pain assessment scale
Pain management
Teaching to caregiver regarding the healing process

Chapter 16
Newborn nutrition and feeding

Breast feeding is strongly encouraged by American academy of

pediatrics

Benefits of breastfeeding to infants

Decreased risk for infant diarrhea

Decreased risk for respiratory infections

Decreased risk of being hospitalized for RSV

Decreased risk of otitis media

Decreased risk of necrotizing enterocolitis

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Decreased risk of childhood obesity

Breast milk enhances maturation of the GI tract

Breast fed infants receive antibodies

Lower incidence of allergies among breastfed infants

Breastfed infants are less likely to die from SIDS

Have enhanced cognitive development

Has an analgesic effect on infants undergoing painful procedures

May be protected against childhood lymphoma and insulin dependent

diabetes

Benefits of breastfeeding to mothers

Decreased risk of breast and ovarian and uterine cancer

Breastfeeding promotes involution

Mothers nursing return to their pre-pregnancy weight faster

Improves bonding and maternal role attainment

Contraindications to breastfeeding

Infants with galactosemia

Maternal cancer

Active TB untreated

HIV

Maternal herpes simplex lesion on breast

CMV cytomegalovirus

Maternal Substance Abuse

Some specific prescribed medications

o Example: lithium

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Benefits to Society

Convenient

Cost effective

Reduction in government expenses

Healthier infants reduce the rate of lost wages due to parents staying
home with ill children

Milk production

Colostrum
o Is a yellowish breast fluid that
is present for 2-3 days after
birth.
o It has a higher level of protein
and a lower level of fats,
carbohydrates and calories
than mature human milk

Composition of Human Milk

Protein in human milk is easier to digest
than protein in prepared formulas
Lactose is the main carbohydrate
Cholesterol, which is essential for brain
development is higher in human milk

o It is high in IgA and IgG

o Acts as a laxative and assists in the passage of meconium

Transitional milk
o Consists of colostrum and milk
o Lasts from day 3 to day 10
o Decreasing levels of protein and increasing levels of fats

Mature milk
o Composed of 20% solids and 80% of water
o It contains approximately 22-23 calories per ounce

Foremilk

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o Is the milk that is produced and stored between feedings and
released at the beginning of the feeding session. It has a higher
water content

Hindmilk
o Is the milk produced during the feeding session and released at
the end of the session. It has a higher fat content

Overview of milk production

Lactation is the production of breast milk

Milk is produced in the alveolar glands and is transported to the nipple

through the lactiferous ducts

Milk production is influenced by hormones and suckling

Prolactin, the primary hormone responsible for lactation is produced

during pregnancy, but high levels of estrogen and progesterone
suppress lactation
o Estrogen and progesterone levels decrease after childbirth and
prolactin levels increase, which results in the stimulation of milk
production

Suckling increases prolactin levels and volume of milk production

o Milk production can be viewed as a supply demand effect. The
more milk the infant takes in, the more milk is produced

Process of breastfeeding

Newborns indicate hunger by being in an awake/alert state, making

mouth and tongue movements, making hand to mouth movements and
rooting.

The woman needs to be in a comfortable position

o Pain and discomfort can prevent or delay the let-down reflex
o A sitting position in a chair is recommended because it facilitates
good body posture

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Other positions are lying on the side or back or sitting in
bed

The newborn is held in a cradle position, football position or crosscradle position.

Pillows are used to support the newborn and/or the woman

The front of the newborn is completely facing the breast to prevent the
newborns head from being turned.

The woman supports her breast by placing one hand around the breast
several inches behind the areola
o Supporting the breast takes the weight of the breast away from
the newborns chin and makes latching on easier
o The woman should avoid pushing down on the breast which can
tip the nipple upward and increase the risk for sore nipples

The newborn is brought to the breast and not the breast to the
newborn
o The woman brings the newborn to her breast when the newborns
mouth is open wide. This assists with latching on
To encourage the newborn to open wide, take the
advantage of the rooting reflex by touching the newborns
chin to the breast. This signals the newborn to open the
mouth. The newborn then reaches up and over the nipple
to achieve an asymmetrical latch and more areola visible at
the top of the mouth than on the bottom

Latch

Latch
o Refers to the newborns ability to grasp the breast and to
effectively suckle. The newborns mouth is around the areola with
the nipple in the back of the newborns mouth. The lips create a
firm seal around the areola
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o Signs that the newborns hunger has been satisfied are:
Spontaneously releases suction from breast
Does not respond with a rooting reflex when stimulated
Is released and calm
o The newborn should feed completely from one side and then be
offered the second breast. Many newborns and infant nurses only
from one breast each feeding. This promotes complete emptying
of each breast every 6-8 hours and facilitates adequate milk
supply in each breast

Audible swallowing

Type of nipple

Comfort

Holding
0

Latch

Too sleepy or
Repeated
reluctant. No latch attempts. Hold
achieved
nipple to mouth
Stimulate to suck

Grasps breast
Tongue down
Lips flanged
Rhythmatic
sucking

Audible
swallowing

None

A few with
stimulation

Spontaneous and
intermittenet <24
hours old
Spontaneous and
frequent > 24
hours old

Type of nipple

Inverted

Flat

Everted

Comfort

Engorged
Cracked, bleeding,
large blisters or
bruising

Filling
Reddened/small
blisters or bruises
Mild/moderate
pain

Soft
Tender

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Hold

Full assist

Minimial assist
Teach one side;
mother does the
other side

No assist from
staff
Mother able to
position/hold
infant

Total score 10
Positions for breastfeeding

Football hold
o The newborns head is cradled in the womans arm and her side.
The newborns head is directly facing the nipple

Side lying
o The woman lies in bed or on the sofa proper support of her head
and neck. The newborn lies next to the woman on his side so that
his head is directly facing the nipple. A pillow or rolled blanket
can be used to support the newborn in this position

Cradle
o The newborns head is cradled in the crook of the womans arm.
The woman supports the newborns back with her arm and his
buttock with her hand. The abdomen of the newborn is
facing/touching the womans abdomen

Across the lap

o The newborns head is supported by the womans hand, and the
newborns back is against the womans forearm. The abdomen of
the newborn is facing/touching the womans abdomen. This is an
ideal position to use when the woman is first learning to
breastfeed and it facilitates good head control

Problems related to nursing

Engorgement

Sore nipples

Monilial infections
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Plugged Duct

Mastitis

Breast abscess

Discharge teaching for lactation suppression

Tight fitting bra

Ice packs

Cabbage leaves

Analgesics

Antipyretics

Parent education on formula feeding

Types of commercial formula

o Cows milk based formulas
o Soy- based formulas
o Casein or whey hydrolysate formula
o Amino acid Formulas

Formula preparation
o Formulas are available in powder, concentrated and ready to use
formulas
o Instruct parents to follow the directions provided by the
manufacturer when mixing powder or diluting concentrated
forms of formulas. Prolonged overdilution of formulas can cause
water intoxication. If formula is underdiluted it can cause
dehydration

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o Inform parents that once bottles of formula have been prepared,
they need to be kept refrigerated and used within 48 hours to
decrease risk of bacterial contamination
o Instruct parents to clean bottles, nipples and can openers in a
dishwasher or with hot soapy water
o Instruct parents to discard unused formula that remains in the
bottle at the end of feeding to decrease risk of bacterial
contamination

Fluoride

Nipples/bottles
o Bottles: there are a variety of bottles. Parents need to select ones
that are free of BPA and can be easily cleaned
o Nipples: two types
Silicone: retain fewer odors and last longer
Rubber: are cheaper but tend to break down faster and
retain odors

Sterilization

Feeding techniques
o Newborns/infants should be held during feedings with the head
slightly higher than the trunk of the body
o Newborns are usually fed in a cradle holding position

Vitamin supplements

Human milk vs. formula

Breast
o Feeding every 3 hours
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o 8-12 feeding sin 24 hours
o Stools loose yellow and seedy
o Voiding 5-6 times per day

Bottle
o Feeding every 4 hours
o 6-8 feedings in 24 hours
o Stools darker stools and more formed
o Voiding 5-6 times per day

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Chapter 17
Assessment of preterm infants

Respiratory function
o Maintain a patent airway
o Administer oxygen to maintain oxygen saturation within ordered
parameters
Short-term oxygen administration may be given using a
mask
Long term oxygen administration may be given using nasal
cannula, oxygen hood, NCPAP or ventilator
Oxygen is humidified and warmed to prevent drying of
mucous membranes and dropping of body temperature. A
decrease in body temperature increases the body
metabolism and increases calorie consumption
o Suction airway as needed for removal of secretion as neonates
have a smaller airway diameter, which increases the risk of
obstruction

Cardiovascular function
o Monitor blood pressure, oxygen saturation and blood gases
o Obtain and monitor H & H
o Administer blood transfusion as per order

Maintaining body temperature

o Drying the infant gently immediately after birth to prevent heat
loss from evaporation
o Keeping the head covered to prevent heat loss due to radiation
and convection

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o Using plastic barriers made of polyethylene to cover preterm
neonates after birth to prevent heat loss and transepidermal
water loss
o Using a chemical warming mattress during resuscitation and
transport to the NICU
o Controlling environmental temperature with the use of servo
control. A temperature control probe should be places on the
neonates abdomen to assist in maintaining the neonates
temperature within the normal range

Central nervous system function

o Depending on the extent and location of the injury, CNS injuries
may result in normal outcomes or serious long-term problems
such as seizures, neurological deficits, developmental disability,
motor deficits, visual impairments or death

Maintaining adequate nutrition

o Obtain and monitor blood glucose levels as per order
o Administer parenteral nutrition if the neonate is unable to receive
enternal feedings
o Administer trophic feedings as per order. They are often given
while neonates are receiving parenteral feedings to ease the
transition to full enteral feedings and enhance GI function
o Administer enteral feedings orally or by gastric tube depending
on the infants gestational age and clinical condition. Most
neonates who are older than 34 weeks gestation usually receive
oral feedings soon after birth
Human milk is preferred for enteral feeding
Human milk requires fortification because it does not
provide the calories, protein, fat, carbohydrates, potassium,
calcium, sodium and phosphorus that the premature infant
needs

Maintaining renal function

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o Measure and weigh diapers

Maintaining hematologic status

Protection from infection

Skin care
o The skin of the preterm neonate is predisposed to injury related
to it being thin and fragile. It is important to carefully assess for
skin breakdown and signs of infection
o Use a neutral pH cleanser and sterile water when bathing and
only bathe the soiled areas
o Assess for signs of jaundice

Complications of pre-maturity
Respiratory distress syndrome

Life threatening disorder that results from underdeveloped and small

alveoli and insufficient levels of pulmonary surfactant.

These two combined factors can cause an alteration in alveoli surface

tension that eventually results in atelectasis
o Assessment findings

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Increased oxygen requirements are

increased to maintain a PaCO2 and
Pao2 within normal limits

Varies on the degree of

prematuritiy

Begins shortly after delivery

Tachypnea

Skin color is gray

Breath sounds on auscultation are

decreased

Intercostal retractions

Neonate is lethargic and hypotonic

Expiratory grunting

Nasal flaring is present

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o Medical management
Respiratory support as indicated. The mode of ventilation and settings are
based on the neonates condition and arterial blood gas results. Methods of
respiratory support include:

Oxygen therapy by mask, hood or cannula for neonates requiring short-term

oxygen support

CPAP used for neonates who are at risk for RDS or with RDS. It can be
administered by mask, nasal prongs, endotracheal tube, or nasopharyngeal
route

Mechanical ventilation when CPAP is not effective

High-frequency oscillatory ventilation used when mechanical ventilation has

proven unsuccessful

o Delivers small volumes of gas at a high right

o Less traumatic on fragile lung tissue

Extracorporeal membrane oxygenation therapy is a cardiopulmonary bypass

machine with a membrane oxygenator that is used when the neonate does
not respond to conventional ventilator therapy. Blood shunts from the right
atrium ad is returned to the aorta allowing time for the lungs to heal and
mature
o Nursing actions

Maintain patent airway

Assess for correct placement of endotracheal tube

Listen for equal breath sounds bilaterally, asses for equal chest rise, use
commercial end tidal CO2 detector

Administer oxygen as ordered to maintain oxygen saturation within ordered

parameters
Suction airway as needed for removal of secretions as neonates have a
smaller airway diameter, which increases the risk of obstruction
Patent ductus arteriosus

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Occurs when the ductus remains open after birth

Assessment findings

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o Increased work of breathing
o Bounding pulses
o Increased demand for oxygen
o The presence is confirmed by
echocardiogram
o Chest x-ray

o Heart murmur heard at the upper

sternal border
o Active precordium
o Widened pulse pressure with
decreased diastolic blood pressure
o Tachycardia and tachypnea
o Recurrent apnea

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Medical management

o Diagnostic tests
Echocardiogram
o Medications
Indomethacin, a prostaglandin inhibitor, is administered to facilitate the
closure and reduces the risk for surgical intervention
Diuretics
o Cardiology consultant to determine the method of treatment and need for
surgical intervention
o Surgical ligation of PDA is indicted for neonates who do not respond to
treatment

Nursing actions

o Administer oxygen and mechanical ventilation

o Restrict fluids
o Administer medications per order
o Monitor intake and output for signs of fluid overload
o Prepare the neonate and family for surgery
Periventricular-intraventricular hemorrhage

Are common forms of intracranial hemorrhage in the neonate. They

occur among premature neonate, neonates who experience RDS and
those who experience complications associated with ventilations such
as pneumothorax, hyoercarbia and acidosis. The majority of
hemorrhages occur within the first week of life

Four grade of intraventricular hemorrhage

o Grade 1
Hemorrhage in germinal matric
o Grade 2

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Intraventricular hemorrhage without ventricular dilation
o Grade 3
Intraventricular hemorrhage with ventricular dilation; clots
fill 50% of the ventricle
o Grade 4
Extension of blood into cerebral tissue or parenchymal
involvement

Assessment findings

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o Metabolic acidosis
o Shock
o Decreased hematocrit
o Full and/or tense
anterior frontannel

o Sudden change in
condition
o Bradycardia
o Oxygen desaturation
o Hypotonia

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Medical management

o Assessment signs for hemodynamic, neurological and behavior changes

o Diagnostic tests
Cranial ultrasounds for all high-risk neonates within the first week of life
Lumbar puncture to assist in evaluation of PVH. Cerebrospinal fluid is
analyzed for red blood cells, xanthochromia, decreased glucose and
increased protein

Nursing actions
o Assess for changes in vital signs, behavior and neurological
status which may indicated increase intracranial bleeding
o Reduce stress to neonate by maintaining a quiet and dark
environment
o Administer fluid volume replacement slowly to minimize
fluctuation in blood pressure

Necrotizing enterocolitis

Gastrointestinal disease that affects neonates. This disease results in

inflammation and necrosis of the bowel, usually the proximal colon or
terminal ileum. Preterm neonates are predisposed to NEC because:
o Altered blood flow regulation, particularly to the intestines
o Impaired gastrointestinal host defense when faced with
stress/injury to the intestinal tissue
o Alterations in the inflammatory response

Assessment findings

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o Abdominal distention,
bloody stools,
abdominal tenderness,
vomiting, increased
gastric residuals,
discoloration of
abdomen, visible bowel
loops

o Symptoms begin 3 and

10 days after birth

o Abnormally high or low

white blood cell count,
thrombocytopenia

o Unstable temperature

o Apnea, bradycardia and

tachycardia
o Respiratory failure
o Hypoxemia

o Hypotension, shock

o Medical acidosis

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Medical management
o Diagnostic tests
Abdominal x-ray
o Lab tests
Blood cultures
o Medication
Antibiotics
Analgesia
Antihypertensives

Nursing actions
o Assess the abdominal distension, visible bowel loops, emesis and
bloody stools
Early recognition and prompt treatment increase the
chances for medical management
o Withhold feedings as per orders and obtain IV access
o Perform gastric decompression as per orders by placing an
orogastric tube and connecting it to low suction
o Monitor intake and output

Complications of oxygen therapy

o Retinopathy of prematurity
Occurs in premature neonates who are less than 28 weeks gestation. Before
this age, the retina is not completely vascularized and is susceptible to stress
and injury
If injury or exposure to a stressor occurs, the normal vascularization of the
retina may be interrupted
Vasproliferation, an abnormal growth of vasculature occurs when tissue
grows within the retina or extends into the vitreous body

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o Bronchopulmonary dysplasia
Is a chronic lung problem that affects neonates who have been treated with
mechanical ventilation and oxygen problems such as RDS.
BPD leads to decreased lung compliance and pulmonary function secondary
to fibrosis, atelectasis, increased pulmonary resistance and overdistention of
the lungs.
Pulmonary edema results from the increased pulmonary vascular resistance.
The prognosis for infants with BPD is dependent on the severity of the
disease and the infants overall health status.
Long term outcomes may include prolonged hospitalization, long-term
oxygen therapy that may be required after discharge, cerebral palsy,
retinopathy of prematurity, and hearing loss
Complications of post-maturity

Meconium aspiration syndrome

o Respiratory failure in term and post-term neonates. The fetus
may pass meconium stool into the amniotic fluid. This occurs
when there is a relaxation of the fetal and sphincter, usually due
to fetal asphyxia in utero, but can also cause breech presentation
and in cephalic presentation without evidence of asphyxia.
o There is a risk that the fetus can aspirate the mecomiunstained
fluid at the time of delivery. The presence of meconium fluid in
the neonates lungs can cause a partial obstruction of the lower
airways that leads to a trapping of air and a hyperinflation of the
airway distal to the obstruction, causing uneven ventilation

Persistent pulmonary hypertension of the newborn

o Results when the normal vasodilation and relaxation of the
pulmonary vascular bed do not occur. This leads to elevated
pulmonary vascular resistance, right ventricular hypertension
and right to left shunting of blood through the foramen ovale and
ductus arteriosus

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o Predominately a problem among term or near term neonates who
experience hypoxia/asphyxia, RDS, meconium aspiration, sepsis
or congenital lung anomales such as diaphragmatic hernia.
o Even after the precipitating factor is treated, vasoconstriction
and increased vascular resistance may persist, causing
decreased pulmonary blood circulation, hypoxemia, lactic
acidosis and acidemia

SGA/LGA infants

SGA
o Small for gestational age and IUGR intrauterine growth
restriction. SGA infant is one whose weight is less than 10th
percentile for his or her gestational age. IUGR us dye to a
decrease in cell production related to chronic malnutrition
o Symmetric IUGR
A generalized proportional reduction in the size of all
structures and organs except for heart and brain, is the
result of a condition that occurs early in pregnancy and
affects general growth. When a complication occurs very
early in pregnancy, fewer cells develop, leading to smaller
organ size.
o Asymmetric IUGR
A disproportional reduction in the size of structures and
organs, results from maternal or placental conditions that
occur later in pregnancy and impede placental blood flow
o Assessment findings
Hypoglycemia
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Perinatal asphyxia
Heat loss

LGA
o Large for gestational age (weighing more than 4000g at birth)
Hypoglycemia
Birth trauma serious hazard

Shoulder dystocia

Cephalhematoma

Facial paralysis

Infants of diabetic mothers

Congenital anomalies

Macrosomia

Birth trauma and perinatal asphyxia

Respiratory distress syndrome

Hypoglycemia

Hypocalcemia and hypomagnesemia

Cardiomyopathy

Hyperbilirubinemia and polycythemia

Hemolytic disorders

Hemolytic disease occurs when blood groups of mother and newborn

are different
o Most common
Rh incompatibility
ABO incompatibility

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Hemolytic disorder occur when maternal antibodies are present

naturally or form in response to antigen from fetal blood crossing
placenta and entering maternal circulation
o Maternal antibodies of IgG class cross placenta, causing
hemolysis of fetal RBCs
Fetal anemia
Neonatal jaundice
Hyperbilrubinemia

Rh incompatibility

Only Rh-positive offspring of Rh-negative mother is at risk

If fetus is Rh positive and mother Rh negative, mother forms antibodies

against fetal blood cells

ABO

Occurs if fetal blood type is A, B, or AB and maternal type is O

Incompatability arises because naturally occurring anti-A and anti-B

antibodies are transferred across placenta to fetus

Exchange transfusions required occasionally

Discharge planning and developmental concerns for high risk

newborns

Parental adaptation to preterm infant

o Parental tasks
Positioning
Reducing inappropriate stimuli
Infant communication
Infant stimulation
Kangaroo care
o Parental support/responses
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o Parent education
Car seat testing
Apnea monitor
CPR
o Growth and development potential
Peripheral nervous system injuries and skeletal injuries

Brachial paralysis

Facial paralysis

Phrenic nerve injury

Fractured clavicle

Central nervous system anomalies

Anencephaly
o Incomplete formation of the cranium and brain. Most babies dies
within a few days of birth

Microcephaly
o

Hydrocephaly
o

Spina bifida
o A sac with meninges and cerebrospinal fluid bulge through defect
in undeveloped vertebrae
o A sac with meninges and nerve tissue bulge through a defect in
the spinal column
o Surgical repair can fix this

Discharge planning for neonate

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Temperature regulation

Respirations

Sleep habits/position

Feeding schedules positions

Elimination breast/bottle

Rashes newborn/diaper

Clothing/weather conditions

Car seat

Bathing

Well baby care immunizations

Newborn metabolic screening tests

Chapter 3: genetics, conception, fetal

development

Breast anatomy

External genitalia

Internal genitalia

Bony pelvis

Menstrual cycle

Ovaries-there are two oval shaped

ovaries; one on each side of the uterus.
The ovarian ligament and broad ligament
help keep the ovaries in place. Primary
follicles are present in the ovaries. Several
thousand follicles are present at birth.
Each follicle contains an oocyte. The
follicle cells secrete estrogen. Graafian

Fallopian tubes- there are two

fallopian tubes. The lateral end
partially surrounds the ovary. The
medial end opens into the uterus.
Fertilization occurs within the
fallopian tube.

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Uterus it is shaped like an upsidedown pear. It is approximately 3 inches

long; 2 inches wide, 1 inch deep. The
fundus is the upper portion of the
uterus. The body of the uterus is the
large central portion. The cervix of the
uterus is the narrow, lower end that
opens to the vagina. The inner lining of

Vagina a muscular tube

approximately 4 inches in
length that extends from the
cervix to the perineum.
Functions: receive sperm
during intercourse. Provide exit
for menstrual blood flow. Birth
canal during second stage of

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Clitoris- a small mass of
erectile tissue anterior to
the urethral orifice.
Responds to sexual
stimulation
Labia majora and minora
paired folds of skin that
cover the openings to the
urethra and vagina and
prevent drying of their
mucous membranes.
Bartholins glands they
are located in the floor of
the vestibule. The ducts of
the gland open onto the
mucus of the vagina orifice.
Their secretions keep the
mucosa moist and lubricate
the vagina during sexual
intercourse

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Endometrial cycle
Proliferative phase occurs following
menstration and ends with ovulation. During this
phase, the endometrium is preparing for
implantation by becoming thicker and more
vascular. These changes are in response to the
increasing levels of estrogen produced by the
graafian follicle.
secretory phase begins after ovulation and
ends with the onset of menstration. During this
phase the endometrium continues to thicken. The
primary hormone during this phase is
progesterone which is secreted from the corpus
luteum

Ovarian cycle
pertains to the maturation of
the ova and consists of 3
phases.
follicular phase begins the
first day of menstruation and
last 12-14 days. During this
phase, the graafian follicle is
maturing under the influence
of two pituitary hormones:
luteinizing hormone (LH) and
follicle-stimulating hormone
(FSH). The maturing graafian
follicle produces estrogen.
Ovulatory phase- begins
when estrogen levels peak and
ends with the release of the
oocyte (egg) from the mature
graafian follicle. The release of
the oocyte is referred to as
ovulation. There is a sure in LH
levels 12-36 hours before
ovulation. There is a decrease
in estrogen levels and an
increase in progesterone levels
before the LH surge.
Luteal phase- begins after
ovulation and lasts
approximately 14 days. During
this phase, the cells of the
empty follicle undergo changes
and form into the corpus
luteum. The corpus luteum
produces high levels of
progesterone along with low
levels of estrogen. If pregnancy
occurs, the corpus luteum
continues to release
progesterone and estrogen

Influences of female

hormones

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Estrogen

Progesterone

Prostaglandins

Chapter 18 Womens health menopause

Puberty

o Period of time when a person becomes sexually mature and capable of

reproduction
Onset of puberty in girls usually occurs between the ages of 8 13 years of
age
It is accompanied with accelerated growth of the body that usually begins
with the feet and ends with the face
It is triggered by the production of gonadotropin-releasing hormone from the
hypothalamus, which stimulates the anterior pituitary to release
gonadotropins. Gonadotropins stimulate the ovaries to secrete estrogen
Estrogen is responsible for the development of secondary sex characteristics
in females. These characteristics include:

Enlargement of breasts growth of the duct system of the mammary glands

and erection of nipples

Growth of body hair axillary and pubic hair

Widening of the hips

Menarche is the initial menstrual period, usually occurs 2 2.5 years after
the beginning of puberty
Puberty is completed when menstruation assumes a regular pattern

Menopause

o Is the stage of life that marks the permanent cessation of menstrual activity

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Usually occurs between ages 35 58
It is a natural biological process
Menopause is divided into three stages

Perimenopause: begins when the woman experiences menopausal signs and

symptoms and ends after the first year following the last menstrual period.
This stage can last several years as the woman experiences irregular
menstrual cycles. It is possible for a woman to become pregnant during this
stage

Menopause: occurs 12 months after a womans last menstrual period.

Average age in the united states is 51.

Postmenopause: refers to the time after menopause

o Signs and symptoms associated with menopause

Irregular periods

Menstrual cycle may become irregular

The time between cycles may become longer or shorter

Menstrual flow may become heavier or lighter

Cycles become anovulatory and the woman becomes infertile

Hot flashes

Hot flashes are the most common symptom of menopause

They are caused by a vasomotor response to changes in the hormonal levels.

This change triggers blood vessels near the surface of the skin to dilate
causing an increase blood supply, which causes an increase in heat to the
skin surface

Night sweats

Hot flashes that occur at night while the woman is sleeping

Sleep disturbances

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Woman may experience altered sleep patterns related to night sweats and
difficulty falling asleep and staying asleep

Vaginal dryness

Normal vaginal mucosa and secretions are dependent on estrogen. Estrogen

decreases, the vaginal tissue becomes thinner and drier

Mood changes and trouble focusing

Woman may also experience:

Decreased interest in sex

Fatigue

Hair loss

Incontinence

Irregular heartbeat/palpiatation
Health behaviors

Nutrition
o Nutritional deficiencies
A healthy diet is one that is rich in vegtables, fruits, whole
grains, fiber, fat-free or low fat dairy and fish and low in
foods that high in saturated fat and sodium.
The womens diet needs to include 3 cups of low fat or fat
free milk or low fat yogurt.
o Obesity
o Anorexia
o Bulimia
o Vegetarians

Physical fitness
o Exercise

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It is recommended that women of all ages engage daily in
30 minutes of moderate physical activity such as walking
briskly, swimming, bicycling or dancing
Physical activity/weight bearing exercise improves bone
health by slowing bone loss, improving muscle strength
and improving balance
Women should consult with their health care provider
before starting a new exercise program
o Kegel exercises
o Stress management

Sexual practices
o Assessment for potential risk
o STIs
Use condom correctly and for all sexual contact
Be in a monogamous relationship both the woman and
her partner have sex only with each other and no one else
Both the woman and her partner are screened for STIs
including HIV prior to engaging in sexual activities
o Contraceptive use

Substance abuse

Tobacco

Alcohol

Caffeine

Illicit drugs
o Cocaine
o Narcotics
o Marijuana

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o Hallucinogens

Prescription medications
o Stimulants
o Sleeping pills
o Narcotics
o Tranquilizers
o Psychotropic medications

Fetal alcohol syndrome

Physiological aspects of antepartum care

Medical conditions

o Diabetes
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o Urinary tract disorders
o Thyroid disease
o Hypertensive disorders of pregnancy
o Cardiac disease
o Seizure disorders

Violence against women

o Battered women
o Rape
o Female genital mutilation

Physical examination & screening

History

o Height and weight-calculate BMI

o Present health status/complaints
o Medical history
o Surgical history
o Family history
o Social history
o Review of systems
o Breast exam
o Pelvic exam
External inspection and palpation
Internal examination
Collection of specimens
Pap smear
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Vaginal examination
Bimanual palpation
Rectrovaginal palpation
Pelvic examination during pregnancy

Bimanual palpation
of uterus

Chapter 19: alterations in Womens health

Menstrual problems

Amenorrhea

o Absence of menstrual flow

o Primary
No menses by age 14 and no secondary sex characteristics or no menses by
age 16 with secondary sex characteristics
May be related to

Body build

Hereditary

Pituitary function

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o Secondary
No menses 6 months in a woman who has had normal menstrual cycles
May be related to

Lack of ovarian production

Pregnancy

Polycystic ovary syndrome

Nutritional disturbances

Endocrine disturbances

Uncontrolled diabetes

Hypogonadotropic amenorrhea

o Absence of menstrual flow due to hypothalamic suppression (stress, body fat

to lean ratio)

Dysmenorrhea

o Painful menstruation
Primary due to myometrium contractions induced by prostaglandins in the
second half of the menstrual cycle

Cramping usually begins 12-24 hours before onset of flow and lasts 12-24
hours. May experience chills, nausea, vomiting, headaches, irritability, and
diarrhea

Excessive endometrial production of prostaglandin; women with primary

dysmenorrhea produce 10x the amount of prostaglandin. Prostaglandin is a
myometrial stimulant and vasoconstriction

Secondary is associated with pelvic pathology (endometriosis, PID, fibroids,

IUD use)

Identify and treat underlying condition

o Management
Primary
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Heat

Effleurage

Guided imagery

Exercise

Diet modifications

Medications

o Prostaglandin inhibitors
o NSAIDS
o OCPs
Secondary

Surgical treatment
Premenstrual syndrome
PMS

A combination of emotional and physical symptoms that begin during

the luteal phase and diminish after menstruation begins

Etiology is unknown. PMS might be related to

o Hormonal changes related the menstrual cycle
o Estrogen-progesterone imbalance
o Chemical changes in the brain

Is the appearance of one or more of a large number (more than 100) of

physical and psychologic symptoms, beginning in the luteal phase of
the menstrual cycle, occurring to such a degree that lifestyle or work is
affected and followed by a symptom-free period

Management
o Diet

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Limit salt intake, caffeine, animal fat, refined sugars and
alcohol
o Exercise daily
o Sleep 8 hours each night
o Ibuprofen for physical symptoms such as cramps, backache and
breast tenderness
o Herbal remedies such as black cohosh, ginger and raspberry leaf
o Commonly prescribed medications are antidepressants, diuretics
and oral contraceptives
Endometriosis

Is characterized by the presence of and growth of endometrial tissue outside

of the uterus

The tissue responds to the changes in estrogen and progesterone levels of

the menstrual cycle

o Tissue is estrogen dependent, thus it is more common during the

reproductive years

Tissue and/or lesions are usually found in the peritoneal surfaces of

reproductive organs and adjacent structures of the pelvis, such as ovaries,
fallopian tubes, bladder, nowel and intestines

Common symptoms

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o Premenstrual spotting

o Dysmenorrhea

o Diarrhea

o Low back pain

o Bloody urine

o Pelvic pressure

o Fixed retroverted uterus

o Dyspareunia

o Enlarged and tender ovaries

o Infertility

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Other symptoms

o Pelvic heaviness, pain radiating to thighs, diarrhea, pain with defecation,

constipation, abnormal bleeding

Management

o NSAID
o OCPs
o Progestins
o GnRH agonists Lupron, Zoladex, Nafarelin
o Androgenic synthetic steroid danazol
o Total abdominal hysterectomy
Common sites for endometriosis

Abnormal uterine bleeding

AUB
o Uterine bleeding that is irregular in amount, duration or timing,
not related to regular menstrual periods

DUB
o Associated with excessive bleeding, flow that is too frequent, too
heavy, too prolonged or irregular

Oligomenorrhea
o Decreased menstruation, either in amount, time or both

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Metorrhagia
o Intermenstrual bleeding
Occurs with cancerous or benign tumors of the uterus
Associated with IUD and use of oral contraceptives
o Management

Endometrial biopsy to rule out endometrial cancer

Menorrhagia
o Excessive bleeding
Anovulatory cycle with continued estrogen production
Fibroids are most common anatomic cause
Inflammatory or infection
o Management

Treat underlying cause

Dilation and curettage

Endometrial biopsy to rule out endometrial cancer

Oral contraceptives

Pelvic inflammatory infections

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Acute infection of the upper genital track that can involve the uterus,
fallopian tubes, and ovaries and can spread to the peritoneum

Both aerobic and anaerobic bacteria are causative agents: chlamydia and
gonorrhea are the most common

Bacterial infections ascend from the vagina or cervix to uterus and fallopian
tubes and then to ovaries and spread to the peritoneum

Consequences of acute PID are infertility, ecotopic pregnancies and chronic

pelvic pain

Risk factors

o History of STI
o Multiple sex partners
o Under age 25 and sexually active
o Douching
o IUD

s/s

o Woman may be asymptomatic

o Severe pain
o Irregular menses
o Abnormal vagina bleeding

Medical management

o Antibiotic treatment
o Pain medication
Sexually transmitted infections

Chlamydia

o Chlamydia trachomatis
o Bodily fluids Sexually transmitted

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o Vaginal spotting, vulvar itching, white/watery vaginal discharge. Acute
salpingitis, PID, ectopic pregnancy, tubal factor infertility, cervical
ulcerations.
o Maternal Doxycycline orally for 7-10 days or azithromycin orally

Gonorrhea

o Neisseria gonorrheae
o Contact of sexual activity genital to genital, oral to genital, anal to genital
o Greenish-yellow purulent endocervical discharge, menstrual irregularities,
pain, profuse purulent anal discharge, rectal pain, blood in the stool, rectal
itching, fullness, pressure
o Maternal Ceftriaxone IM or orally

Syphilis

o Treponema pallidum
o Sexual intercourse, kissing, biting, or oral-genital contact, transplacental
transmission can occur during the pregnancy.
o Primary lesion (chancre) nontender, shallow, indurated, clean ulcer. Fever,
headache, and malaise, condyloma lata. Neuologic and cardiovascular,
musculoskeletal, or multiorgan system complications can occur.
o Penicillin IM injection

Human papillomavirus

o Condylomata acuminata and genital warts

o Sexually transmitted body fluids Genital warts in clusters, or singularly on
genital and anal region. Condylomata acuminata can be painless but may be
uncomfortable, large and inflamed and ulcerated.
o Maternal Untreated warts may resolve on their own; treatment may require
a topical application podofilox. Cryotherapy, electrocautery, and laser
therapy may be used.

Viral hepatitis B

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o HBsAg. Transmitted in blood, saliva, sweat, tears, vaginal secretions, and
semen.
o Skin eruptions, urticaria, arthralgias, arthritis, lassitude, anorexia, nausea,
vomiting, headache, fever and abdominal pain. Clay colored stools, dark
urine, jaundice.
o Maternal No specific treatment. Increase bed rest, eat high protein, low fat
diet, and increase fluid intake. Avoid drugs and alcohol

Herpes

o HSV-2. Transmitted sexually

o Genital discomfort, neurologic pain, fever, malaise, headache, and
photophobia, lesions.
o Maternal Clean lesions twice a day with saline. Medications can be given to
try to suppress outbreaks. Analgesics to relieve pain.

Human immunodeficiency Virus

o Retrovirus Transmission is through exhange of body fluids semen, blood,

vaginal secretions
o Fatigue, diarrhea, weight loss, anemia, and AIDS
o Maternal Prevent opportunistic infections, routine gynecologic care,
antiretroviral therapy

Vaginal infections

Bacterial vaginosis

o Most common vaginal infection, occurs when there is a disruption in the

normal vaginal flora; a decrease in lactobacilli and an increase in organisms
such as genital mycoplasms, peptostretococci and gardnerella

Candidiasis

o Yeast infection caused by candida albicans (gram positive fungus) that lives
on all surfaces of the human body. When the vaginal ecosystem is distributed
the fungus rapidly grows causing an infection. Factors that can affect the
vaginal ecosystem are
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Hormonal changes

High estrogen levels during pregnancy favor growth of fungus

Increased prevalence of candida vaginitis preceding and immediately

following menstrual period

Trichomoniasis

o Trichomonas vaginalis
o Manifestations
Most women are asymptomatic. Symptoms appear 5-28 days after exposure.
Symptoms include profuse frothy gray of yellow-green vaginal discharge with
foul odor, erythema, edema, pruritus of the external genitalia and pain
during sexual intercourse
Small, red ulcerations in the vagina or on cervix may be observed during
examination
Diagnosis: microscopic evaluation to confirm trichomoniasis or rapid
trichomoniasis test
o Treatment
Antibiotic Flagyl
Partner needs to be treated at the same time and condoms used to prevent
future infections

Group B strep

o Group B streptococcus-bacterial infection. Transmission- during labor and

delivery
o Preterm labor and delivery, maternal sepsis, urinary tract infection,
premature rupture of membrane
o Penicillin G- 5million units iv bolus followed by 2.5 units iv bolus q4hrs or
ampicillin 2 grams iv followed by 1 gram q4hrs. Test women late in
pregnancy and give antibiotics during labor
Torch infections
Certain maternal infections associated with various congenital malformations
and disorders. The most common infections are represented by the acronym

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TORCH

o T toxoplasmosis
o O other (Gonorrhea, syphilis, varicella, HBV, Hep B, HIV)
o R rubella
o C cytomegalovirus
o H herpes simplex virus
Neonatal herpes simplex virus

Neonatal cytomegalovirus

Neonatal syphilis lesions

Infertility

The inability to conceive after 1 year of unprotected intercourse

Pathophysiology contributing factors

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o Hormonal deficiencies, reproductive system disorders, congenital
anomalies, male impotence sexual knowledge deficit, debilitating
disease
Contraception
Natural family planning

Calendar method

o Based on the number of days in each cycle control from the first day of
menses
o The woman determines the fertile period after accurately recording the
lengths of menstrual cycles for 6 months
o The beginning of the fertile period is estimated by subtracting 18 days from
the shortest cycle
o The end of the fertile period is estimated by subtracting 11 days from the
length of the longest cycle
o The shortest cycle is 24 days and the longest cycle is 30 days
o Should abstain from sex for 6-19th day
Basal body temperature method
o Take your BBT every morning at the same time before you get out of bed,
always use the same site
o Record your temperature daily on a graph and connect the dots
o You may see a slight drop in temperature about the time of ovulation but
many wont experience a change
o Your temperature will rise 0.4-0.8 degrees Celsius around the time of
ovulation and stay elevated until just before the next menses
o Avoid intercourse until 3 days of higher temps occur after 6 days of lower
than baseline temps
Cervical mucus method
o (Billings method) (Creighton model ovulation method)
o Woman needs to recognize and interpret the cyclic changes in the amount
and consistency of cervical mucus that characterize her own unique pattern
of changes
o The mucus alters the pH environment, neutralizing the acidity, to be more
compatible for sperm survival
o To ensure an accurate assessment of changes the cervical mucus should be
free from semen, contraceptive gels or foams, and blood or discharge from
vaginal infections for at least one full cycle
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o Douches and vaginal deodorants, being in a sexual arousal state (thins
mucus) and taking antihistamines (dry up mucus) create difficulty in vaginal
assessments
o Intercourse is considered safe without restriction beginning 4 days after the
last day of wet, clear, slippery mucus (post ovulation)
o CERIVICAL MUCUS CHARACTERISTICS:
Post menopause: scant
Pre ovulation: cloudy, yellow/white, sticky
Ovulation: clear, wet, sticky, slippery
Post ovulation (fertile): thick, cloudy, sticky
Post ovulation (post fertile): scant
Right before ovulation the mucus becomes more abundant and thick
Symptothermal method
o Gain fertility awareness as she tracks the physiologic and psychological
symptoms that mark the phases of her cycle
o Combines cervical mucus and BBT methods in addition to heightened
awareness of secondary, cycle phase-related symptoms.
o Secondary symptoms: increased libido, mid-cycle spotting, mittelschmerz,
pelvis fullness or tenderness and vulvar fullness
o During the post ovulation stage the cervix drops, becomes firm and closes
o Calendar calculations and cervical mucus changes help to estimate the onset
of the fertile period and changes in cervical mucus or the BBT help to
estimate its end
Predictor test for ovulation
o
o
o

o
o

The urine predictor test for ovulation detects the

sudden surge of LH that occurs approximately 12-24 hours before ovulation
Unlike BBT: illness, emotional upset, or physical
activity do not affect the test
An electronic hormonal fertility-monitoring device,
the ClearBlue Early Fertility Monitor (CEFM) is a handheld device that uses
test strips to measure urinary metabolites of estrogen and LH
The monitor provides the user with low, high
and peak fertility readings
Incorporates the use of the monitor as an aid
to learning NFP and fertility awareness

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Barrier methods
o Spermicides, condoms, diaphragm, cervical cap, contraceptive
sponge

Spermicidal
Reducing the sperms mobility; the chemical attack the perm flagella and
body to the sperm cant reach the cervical os
The most commonly used one is a surfactant that destroys the sperm cell
membrane (frequent use of N-9 or lubricant during anal intercoursemore
than twice a day, may increase the transmission of HIV and cause lesions)
Women with high risk behaviors that increase their likelihood of catracting
HIV and other STI need to avoid lubricant with N-9, including lubricated
condoms,diaphragms, cervical caps to which N-9 is added
Effectiveness depends on consistent and accurate use
The spermicide should be inserted high into the vagina so that it makes
contact with the cervix
Some should be inserted 15 mins before but no longer than 1 hr before
sexual intercourse
Typical failure rate is (29%)
Condoms
(MALE) Made of latex rubber, polyurethane or natural membranes
Latex condoms will break down with oil-based lubricants and should be used
only with water-based of silicone-based lubricants
Thinner construction increases heat transmission and sensitivity
Typical failure rate (15%)
(FEMALE) made of polyurethane and has flexible rings at both ends
The closed end of the pouch is inserted into the vagina and is anchored
around the cervix, the open ring covers the labia
Only available in one size, single use only
Dont use both condoms at once (friction=tearing)
Typical failure rate (21%)
Diaphragm
Shallow, dome shaped latex or silicone device with a flexible rim that covers
the cervix
Three types: coil spring, arcing spring, and wide seal rim
Should be the largest size the woman can wear without her being aware of
its presence
Require prescription

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Typical failure rate (16%)

Effectiveness is less when used without spermicidal
Need annual gynecologic exam to assess the fit
Replace at least every 2 years
IF it is puckered, especially near the rim, means there are thin spots
The diaphragm needs to be left in place for at least 6 hrs after intercourse
You should not remove the diaphragm by trying to catch the rim from below
the dome
AVOID oil-based products
Contraindicated in women with uterine prolapsed or a large cystocele

Cervical Cap (Push cap up until it covers cervix. Press rim to

create a seal. To remove, push rim)
Made of rubber or latex free silicone and have soft domes and firm brims
The cap fits snuggly around the base of the cervix close to the junction of the
cervix and vaginal fornices
Remain in place no less than 6 hours and no more than 48 hours
Less spermicidal required than the diaphragm
Another form of birth control is recommended due to the risk of TSS for use
during menstrual bleeding and up to at least 6 weeks post partum
Contraindicated in women with abnormal pap smears
Contraceptive Sponge

Small, round, polyurethane sponge that contains N-9

spermicidal designed to fit over the cervix (one size fits all)

The side that is placed next to the cervix is concave for

better fit, the opposite side has a woven polyester loop to be used for
removal of the sponge

Moisten with water before insertion

Protection for up to 24 hours

Leave in place for at least 6 hours

Wearing longer than 24 hours poses risk of TSS

Failure for nulliparas (16%), multiparas (32%)

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Hormonal method
o Combined Estrogen-Progestin Contraceptives, Oral Progestins (Minipill),
Transdermal Patch, Vaginal Contraceptive Ring, Depo-Provera, Implantable
Progestins
o Emergency contraception oral progestins, COCs, IUD
Combined Estrogen-Progestin Contraceptives
The body secretes FSH and LH in response to fluctuating levels of ovarian
estrogen and progesterone
Regular ingestion of combined oral contraceptive pills (COCs) suppress the
action of the hypothalamus and anterior pituitary that inhibits the production
of FSH & LH (suppress ovulation)
Combined steroids induce other contraceptive effects---alter the
endometrium, making it less favorable site for implantation
COCs have a direct effect on the endometrium such that from 1-4 days after
the last COC taken the endometrium sloughs and bleeds as a result of
hormone withdrawal
Cervical mucus under the effect of progesterone does not provide as suitable
an environment for sperm penetration as does the thin, watery mucus at
ovulation
Monophastic pills provide fixed doses of estrogen and progesterone
Multiphastic pills alter the amount of progestin and sometimes the amount of
estrogen within each cycle
Offer protection against endometrial and ovarian cancer, reduce benign
breast disease and improve acne
Seasonale (levonorgestrel-ethinyl estradoil)---contains both estrogen and
progestin. You get your period on your thirteenth week of the pillLESS
PERIODS
DONT TAKE THESE MEDICATIONS WITH ORAL CONTRACEPTIVES:
Anticonvulsants
Systemic antifungals
Antituberculosis drugs
Anti-HIV protease inhibitors
Many women ovulate the next months after stopping oral contraceptive use
Women should begin folic acid supplements at least 3 months before
discontinuing the pill
Withdrawal bleeding tends to be short and scanty

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o A drop of blood or a brown smudge on a tampon or in the underwear counts
as a menstrual period
o Typical failure rate (8%)
Oral Progestins (Minipill)
o Same as COCs (take at same time every day)
o Progestin only pills (POPs) prevent ovulation, thickening and
decreasing the amount of mucus, thinning the endometrium and
alter cilia in the uterine tubes
Transdermal Patch
o Available by prescription only
o Delivers continuous levels of norelgestromin(progesterone) and
ethinyl estradiol
o Application is on the same day once a week for 3 weeks and 1
week without
o Site rotation is recommended, some skin irritation is common
o Can be worn during bathing, showering, swimming and exercise
o Increased risk of DVT/clots due to increased blood estrogen levels
than COCs
o Typical failure rate (8%)
Vaginal Contraceptive Ring
o Available by prescription only
o Worn in the vagina and delivers continuous levels of etonorgestrel
(progesterone) and ethinyl estradiol
o 3 weeks with ring and 1 week without
o If the woman or partner notices discomfort during sex, the ring should not be
removed from the vagina for longer than 3 hours for it to still be effective for
the rest of the 3 week period
o Typical failure rate (8%)
Implantable Progestins
o One or more non-biodegradable flexible tubes or rods that are inserted under
te skin of a womens arm
o Are effective for contraception for at least 3 years
o Insertion and removal are minor surgical procedures using a local anesthetic,
a small incision and no sutures
o Use your non-dominant upper arm
o Thickens cervical mucus and prevents some but not all ovulatory cycles
o It can be implanted immediately postpartum without affecting lactation
o The most common side effect is irregular bleeding
o Typical failure rate (0.05%)

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o
o
o
o
o
o

o
o
o
o
o
o
o
o
o

Depo-Provera (Injectable Progestins)

Depot medroxyprogesterone acetate (150mg) is given IM in the deltoid or
gluteus maximus muscle
21-23 gauge needle, 2.5-4cm long is used
SUBQ version also available given in the anterior thigh or abdominal wall
It is initiated during the first 5 days of the menstrual cycle and administered
every 12 weeks or 3 months (one shot every 4 months)
May be used by breastfeeding women
Side effects:
Decreased BMD, weight gain, lipid changes, increased risk of
DVT/thromboembolism, irregular spotting, decreased libido and breast
changes
Delay in return to fertility may be 6-12 months after discontinuing
Typical failure rate (3%)
Emergency Contraception-Oral Progestins-PLAN B PILL
Over the age of 18over the counter, under 18 needs prescription
Wait no longer than 120 hours after unprotected sex or birth control mishap
If taken before ovulationprevents ovulation by inhibiting follicular
development
If taken after ovulationeffect on ovarian hormone production or the
endometrium is little
If experiencing nausea with high doses of estrogen or progestin take an
antiemetic 1 hr before use
If you take the pill and dont have menstruation for 21 days, you should be
checked for pregnancy
IUD with copper is another emergency contraceptive optionshould be
inserted within 8 days of unprotected sex
Intrauterine Device-IUD
o Small, T-shaped device with bendable arms for insertion through
the cervix
o Inserted against the uterine fundus and the arms open near the
uterine tubes to maintain position of the device
o Two strings hang from the base of the stem through the cervix
and protrude into the vagina for the woman to feel to prevent
dislodgement
o When removed, can return to fertility immediately
o Side effects:
Increased risk of PID, unintentional expulsion of the device,
infection and possible uterine perforation
Nulliparity is related to an increased risk for expulsion
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o

Para-Guard T-380A (copper IUD)approved for 10 years of

use
Inflames the endometrium to prevent fertilization
Experience more bleeding and cramping within the 1st year
Typical failure rate (0.8%)
o
Mirena (hormone IUD)
Releases levonorgestrel from its vertical reservoir
Effective for 5 years or more
Impairs sperm mobility, irritates the lining of the uterus
and has some anovulatory effects
Uterine cramping and bleeding are usually improved with
this devicespotting is common for 1st few months
Typical failure rate (0.2%)
o
Early removal of the IUD decreases the risk of spontaneous
miscarriage or preterm labor
o
Flu like symptoms may indicate septic miscarriage
Cervical mucus characteristics

Mechanical barriers

Male condoms

Female condoms

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Cervical Cap

push cap up until it covers

the cervix

press rim to create a seal

Diaphragm

Hormonal methods

Birth control pills

Vaginal ring

Hormonal path

Depo-provera

Implanon

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IUD

Sterilization

Male- vasectomy

Sealing, tying, or cutting vas deferens to prevent sperm travel

Local anesthesia on an outpatient basis
Permanent because reversal is nearly impossible
2 methods: conventional and no-scalpel
Immobilizing the vas deferens through the scrotum, then each vas is ligated
or cauterizedsperm are unable to leave the epididymis
Use ice to prevent swelling
Use scrotal support to reduce discomfort
Sexual intercourse may be resumed at any time but sterility is not immediate
for sterility you may need to wait several months (12weeks)
Failure rate (0.15%)
Vasectomy REVERSAL
Microsurgery to reanastomose (restore tubal continuity)
The rate of success decreases as the time since the procedure increases
Female
o Tubal ligation fallopian tubes are cut, tied and sometimes
cauterized

o Bilateral Tubal Ligation (BTL)-fallopian tubes are cut, tied and sometimes
cauterized-failure rate is 0.5%.

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Usually performed immediately after childbirth (w/in 48hrs)
Can be performed on an outpatient basis
o Transabdominal (most common)mini-laparotomy/laproscopy OR
transcervical
Mini-Laproscopic is normally used after vaginal birth
most common and used on outpatient basis
small incision in the abdominal wall below the umbilicus
(two incisions are made with normal laproscopy)one under the umbilicus
for the scope and one above the symphysis publis to occlude or ligate the
tubes
Takes 20 mins
Very MINIMAL scarring
For laproscopic/laparotomyNPO @12pm and preoperative sedation is given
Use local, regional or general anesthetic
Transcervical uses hysteroscopic techniques
o Essure System-small metallic implants are placed in each fallopian tube
Small catheter is inserted holding the polyester fibers through the vagina
and cervix and places the implants into each tube
Stimulates own womans scar tissue formation to occlude the uterine tubes
and prevent conception
Convenient for obese women or those with abdominal adhesions, the
transcervical approach eliminates the need for abdominal surgery
Not immediately effectivemay take up to 3 months
Hysterosalpingogram will confirm success
Typical failure rate (<1%)
o Tubal RECONSTRUCTION
Restoration of tubal coniuity (reanastomosis) and function is technically
feasible EXCEPT after laparoscopic tubal electrocoagulation
COSTLY, DIFFICULT and UNCERTAIN

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essure system

First trimester abortion

o
o
o
o
o
o
o
o

Vacuum Aspiration with Laminaria

Most common procedure
Use local anesthesia in the physicians office, clinic or hospital
8-12 weeks after the menstrual periodideal time
Mild oral/IV sedation is administered
Bimanual examination is done before the procedure to assess uterine size
and position
Inserts speculum and anesthetizes the cervix with local anesthesia and
cannula connected to suction is inserted into the uterine cavity
Then remains in waiting area for 1-3 hours for detection of excessive
cramping or bleedingthen discharged
Most common complications
Endometritis and salpingitis
Retained products of conception are the primary reason for vaginal bleeding
May need uterine massage or administer Methergine
Prophylactic antibiotics
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o

POST OP
AVOID douches
Assess for signs of bleeding
Will resume menstrual period 4-6 weeks after procedure
Methotrexate given IM or orally followed by misoprostol (prostaglandin
suppository)

o
o
o

Up to 7 weeks after last menstrual period

cytotoxic drug blocks folic acid in fetal cells so that they cannot divide
followed by Misoprostol Cytotec (prostaglandin suppository) after 3-7 days
acts directly on the cervix to soften and dilate and on the uterine muscle to
stimulate contractions
o need follow up to confirm
Mifepristone (RU 486) US only available by prescription. Can be used up to
9 weeks following conception
o US only available by prescription
o Up to 8 weeks after last menstrual period
o Binds to progesterone receptors and blocking the action of progesterone,
which is needed to maintain pregnancy
o Takes 600mg of Mifepristone orally and then 48 hrs later returns to the office
and takes 400mcg of misoprostol orally
2 weeks after administration follow up needs to be done to examine or
ultrasound to confirm
o An alternative regimenup to 9weeks after last menstrual period
200mg mifepristone orally and then 800mcg of misoprostol vaginally in 6-72
hrs
Then follow up to confirm
o Side effects of meds:
N/V/D/headache/dizziness/fever/chills FROM misoprostol and subside within a
few hrs
o All women who are Rh- will receive Rh immunoglobulin
Second trimester abortion

Dilitation and Curettage

o D&C risk of perforation of the uterus

o Up to 20 weeks but most commonly between 13-16 weeks

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o The cervix requires more dilation because the products of contraception are
larger
o Often osmotic dilators (laminara) are inserted hours/day before procedure
o Similar to vaginal aspiration except a larger cannula is used and other
instruments may be needed to remove fetus and placenta
o Possible long term harmful effects to the cervix
o ****risk of perforation of the uterus****
o Assess women for grief, social support, depression, guilt, regret, and relief
o

Laminaria

Prostaglandins

Third trimester abortions

Prostaglandins

Laminaria

Oxytocin

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