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Complications of Pregnancy
Adolescent Pregnancy
Consequences
 Pregnancy < 21 y/o can’t make rational judgment until 24-25 (brain not fully developed till than)
o Erickson stage of development- Identity vs. role confusion (identify more with friends)
o Self gratification and immediate gratification
 Less likely to complete high school
 Dependence on welfare- no skills to enter labor force
 Single parenthood
 More likely to abuse/neglect the child bc they are “selfish”
Physical Consequences
 Poor nutritional intake- fighting for nutrients w/ baby bc their biggest growth spurt is at this time
 Preeclampsia, anemia, STI’s, & fetal death
 CPD- cephalopelvicdisproprtion (baby wont fit through vag)- #1 reason for c-section
 Drugs
 LBW  low birth weight d/t nutritional imbalance & preeclampsia
Nursing Objectives
 Provide support system sometimes scared of parents so nurse is only support
o Ask “how are you feeling today”  check up on their feelings
 Education offer options: adoption, abortion or keeping it
 Assessment of complications

Abortion
 Any interruption of pregnancy before viability (20W)
o Early  before 16W
o Late after 16 W
 Induced vs. natural abortion (miscarriage)
 Causes of natural abortion (miscarriage)
o Genetic disorders- incompatible with life
o Poor implantation
o Hormonal problems (ex: drop in progesterone)
o Partial molar pregnancy
 If miscarriage avoid insensitivity (comments such as “wasn’t meant to be” “good thing it was early”)
o Let them live through it & be there to hold their hand
o Allow parents to clean out babys room so they recognize they were a parent & could still be

Threatened Abortion
 Spotter bright red vag bleeding (spotting blood)
o Doesn’t always mean she’s going to lose baby but anytime there’s spotting there is a threat
 Bleeding with NO cramping or dilation
 Interventions:
o HCG & Progesterone levels to identify viability of pregnancy
o Limit activity can spot from over doing it- may need to slow down & de-stress
o Pelvic rest no sex, tampons or douche
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Imminent (Inevitable) Abortion

 Bright red vaginal bleeding WITH cramping & dilation
 Possible passage of tissue fragments
 Interventions:
o Save fragments
o Dilatation & Curettage- scrape out what’s left in uterus & send to lab
o Pad count of bright red bleeding
o Save whatever comes out to test

Incomplete abortion
 Fetus & embryo is lost placenta & uterine lining is all that’s left inside
 Moderate bright red vaginal bleeding WITH contractions & dilation
 Spontaneous expulsion of partial contents of conception (usually fetus only)
 Interventions:
o D & C explain “need to clean out uterus to prepare for next pregnancy”- easier to handle
o Save what comes out for testing

Complete Abortion
 Spontaneous expulsion of entire contents of conception- everything comes out no need for D & C
o Do US to identify that no contents of conception are left inside uterus
o Everything has passed so main job is emotional support

Clinical Interruption of Pregnancy

 Elective (induced abortion)/Therapeutic #1 rule is to leave personal morals aside
 Laminaria (seaweed) + Saline- induce labor & put in cervix to absorb fluid in uterus
o Causes her to go into labor & expel contents of conception done in 2nd trimester
 RU 486 “abortion pill”  Mifepristone/Misoprostol combination
o Mifepristone taken in drs office to block progesterone followed by misoprostol
o Misoprostol at home (within 72H to take 2nd pill) starts contractions to expel the pregnancy
 Dilation & evacuation of contents of conception
 Vacuum aspiration of contents of conception

Nursing Implications
 Watch for potential complications infection/hemorrhage
 Follow-up US & repeat pregnancy test within 2 weeks to make sure its over
 Rhogam- anytime there’s a mix of fetal blood & moms blood must do RH
o Given incase mom is RH- (prevents fetal blood from causing antigen/antibody rxn)
 Psychosocial support
 Education- sent home with instructions of what complications can include & side effects
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Ectopic PregnancyFertilized ovum is implanted in any tissue other than uterine wall
 98% in fallopian tube- gets stuck d/t cilia damage, scar tissue, or inflammation
o As it grows can rupture tube causing internal hemorrhage can die from shock
 2% outside of tubes ovaries, abdominal, cervix, or interstitial lining of uterus
Causes:
 Cilia damage & tube occlusion  usually hx of PID/infectious process, endometriosis, prior abd surgery
 Excessive estrogen & progesterone
 Advancing age > 35 y/o
 Smoking d/t vasoconstriction
 Vaginal douching sends pressure in opposite direction prevents it from coming down
Symptoms:
 Pain d/t tube inflammation (where tubes are- R or L) & referred shoulder pain on side tube’s blocked
 Cullen’s sign Discoloration around umbilicus (shows something is going on inside)
 Signs of shock bc she’s bleeding internally
 Vaginal bleeding & low serum Hct
 Elevated HCG bc pregnant just in the wrong place
Diagnosis US to identify & laparoscopy to take out some of the tube or entire tube
Surgical Treatment:
 Laparoscopy/Laparotomy- takes out some of the tube or entire tube
 Salpingectomy- “salping” = tube  removal of one or both tubes
Non-Surgical Treatmentdone if caught early in morula/blastocyst stage
 Methotrexate (chemo agent) works on rapidly dividing cells that’s why it works on embryo too
Future pregnanciesif mom had a problem once- big chance she’ll have a problem in other tube too
 30% difficulty conceiving again
 If tube is left in good shot at conceiving again- 60% future success
 Repeat tubal pregnancy – 15%

Gestational Trophoblastic Disease (Molar Pregnancy)

Hydatidiform mole abnormal placenta
 Abnml trophoblast proliferation trophoblastic villi overgrows embryo ends preg- birth to big placenta
 No fetus see snow storm pattern of huge placenta on US
 High risk in Asian population & if 1 incident of GTD (4-5X more at risk for another one)
Symptoms:
 Bleeding- clear fluid pockets that turns into brownish fluid as it disintegrates
 Enlarged uterus- uterus large for dates (fundal height at 12W @20 cm up & no fetal HR think moles)
 Preeclampsia symptoms- high BP, proteinuria, hyperemesis d/t high HCG levels
Treatment:
 US & Evacuation (need to evacuate to prevent choriocarcinoma)
 Check HCG for a year mole can turn into choriocarcinoma (rapidly metastasizing malignancy)
o Once its identified its already metastasizing
o Once evacuated only thing indicating it converted to choriocarcinoma is elevated HCG level
o Can’t get pregnant for the next year must ensure negative HCG level
o Some get prophylactic methotrexate (chemo agent)
o High risk for infection monitor for leukopenia
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Premature Laborcontractions that cause dilation & effacement before 37W (passed the point of viability)
 Associated with dehydration or infections (UTI or chorioamnionitis)
 Can stop labor if no ROM or bleeding, FHR is ok, Dilation < 3-4 cm & Effacement <50%
 Fetal fibronectin leak (FFN) in chorionic decidua- swab test if it leaks than inc risk for preterm labor
TocolyticsWhat we use to stop premature labor
 Bed rest & Hydration
 Beta adrenergic Terbutaline IV (most common now)- off label use usually for asthma short term
o S/E: hypokalemia & pulmonary congestion d/t inc cardiac output listen to lung sounds
o Used to use Ritrodrine (causes tachycardia)- started on IV than sent home with PO
o Antidote: beta-blockers “olol”
 CNS depressant Mg sulfate- must have cont pulse ox & cardiac monitor
o Check for toxicity neuro checks (DTR’s), lung sounds (risk for pulm edema) & strict I&O
 Prostaglandin antagonist Incidin (NSAID)- irritates GI lining & S/E: oligiohydramnios
o Crosses placenta closes ductus arteriosus causing neonatal pulmonary htn given short term
 Calcium channel blockers Nifetapine (Procardia)  given PO short term to prevent s/e
o S/E: hypotension causing dec uterine blood flow & inc risk for intrauterine growth retardation
Assessment of Premature Labor:
 Persistent dull low backache, tightening of abdomen, pelvic pressure & intestinal cramping
 Vagina spotting, menstrual-like cramps & increased vaginal discharge
Nursing Supportive Measures support & educate women- may be scared & on home bedrest for long time
 Fetal movement checks & nutritional status
 Corticosteroids- to mature babies lungs (betamethasone/dexamethasone to inc surfactant levels)
 Antibiotics- UTI’s and vaginal infections causing premature labor

Dysfunctional Labor
Hypertonic Labor- did all the labor but not dilating the cervix
 Ineffective labor characterized by erratic & poorly coordinated contractions
 Uterine resting tone higher than nml strip doesn’t go down to 0 so uterus is always a lil tense
 Muscles that are overused/not relaxing- it can break/rupture
Nursing Care Management:
 Acute pain pain control to slow down pain (extreme pain bc contractions Q2 min lasting 90 secs)
o Epidural & maybe a lil Terbutaline to slow labor down (labor control to let uterus rest)
o Look at fetal heartbeat during contractions variable decelerations “shoulders w/ v”
 Ineffective Coping & Anxiety provide support & give information
o Change positions
o May need c-section bc muscle may rupture
Hypotonic labor slow labor- not dilating fast enough in labor for a really long time
 Ineffective labor characterized by weak, infrequent & brief but coordinated uterine contractions
 Uterine resting tone is normal but contractions are worthless
Treatment: Amniotomy, Pitocin & c-section
 Amniotomy- break water to bring head right down to cervix to stimulate stronger contractions
 Pitocin- induction to try to get labor going
 C-section- if nothing happens after a while bc uterus gets tired done to prevent bandl’s ring
 Bandl’s ring- contraction ring in uterus that can strangle the baby and cause a still birth
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Shoulder Dystocia
 Baby’s too big to get through pelvis shoulders wider than head & get stuck on symphysis pubis
 Worry about cord getting trapped stops O2 flow & baby can die
o Delay in delivery leads to hypoxia severe brain damage from being stuck in that position
 Broken clavicle
 Brachial plexus damage
 Partial drooping
 Arms and shoulders will be asymmetrical
 Moro reflex will be asymmetrical
 Identify BFK early to do c-section to avoid this- don’t push kids back in

Multifetal Pregnancy
 Identical- 1 egg 1 sperm same placenta but different amniotic sacs
 Fraternal- 2 eggs 2 sperms separate placentas
o Inc risk as you get older bc body double ovulates to get rid of eggs
 2 kids, 2 placentas, 2 amniotic sacs Uterus is really stretched out:
o Inc risk of abruption or previa w/ more placenta tissue & implantation
o Inc risk of premature labor bc of a lot of fluid
o High risk for  preeclampsia & DM
o A lot of these moms go on bed rest

Labor Induction
 Starting labor when no labor has started
 Stimulation of uterine contractions before the spontaneous onset of labor with or without ruptured fetal
membranes for the purpose of accomplishing birth
 Uterus contracting that isn’t creating labor
 People may go up to 10 days past date
 Can induce with Cervidil/Cytotek  Q6H
Contraindication for Induction:
 Abnormal FHR
 Breech
 Unknown fetal presentation
 Multiple gestation
 Polyhydramnios & floating presentation bc head not engaged in pelvis & cord can come down first
 Severe hypertension- preeclampsia
 Maternal heart disease
Bishop Scoring
 Scoring to see if mom can be induced or not
 Looks at cervix position, consistency, effacement & dilation of cervix & correlate to babys station
 Anything 2-3 better chance of working
 Don’t want to induce baby if nothing is happening (0-1)
 Know what’s in chart: position, consistency, effacement, dilation & babys station
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Cesarean BirthBirth through an abdominal & uterine incision (major abd surgery)
Indications
 Fetal distress
 Failed induction
 Dystocia/poor positioning
 CPD- large baby
 Active herpes
 Placenta previa
 Post-term & nothing is happening
 Hydramnios- bc baby cant engage in pelvis & cord can come down first
Incisions
 Usually low segment transverse (pfannenstiel)- cuts through cartilage instead of muscle
o Can try TOLAC (trial of labor after c-section)- leading to VBAC (vaginal birth after c-section)
 Can’t do it if a person had a classic/vertical incision no vag deliver after bc disturbs integrity of uterus
 Always check inside incision if outside is vertical but inside is low segment can still try VBAC
Analgesia/anesthesia
 Epidural- possibly spinal may put narcotic before removing epidural (Fentanyl or Duramorph)
o S/E: itchiness- give Benadryl to sleep through it- wont take itch away bc not allergies
 May get morphine PCA
 Post-op: IV Tylenol
Nursing care
 Pain management
 Get them & get them moving

Prolapsed Cord Cord slips in front of presenting part & delivers before baby
 When baby comes down it can constrict the cord & prevent O2 flow can suffocate baby
 Causes: PROM, abnml position, previa, tumors, CPD, SGA, hydramnios, multiple gestation
 Interventions:
o Knee-chest position gets baby off cord- hand goes in to push fetus off- tip bed to trendeleburg
o O2
o Tocolytics- want to slow labor down (Terbutaline pump)
o Saline soaks gauze pads with saline put on the cord to keep moist until c-section
o Don’t ever touch cord only push baby off cord

Amniotic Fluid Embolism

 Amniotic fluid gets into bloodstream through defect in membranes, ROM, or partial placental separation
 Woman will grab her chest, collapse & eventually go into cardiac arrest bc of embolism
 Inc risk hx of abruptio, hydramnios & prolonged oxytocin (hrs in labor- over stimulates uterus)
 Interventions:
o O2
o CPR
o Intubate/ICU
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Post Partum Complications

Reasons for Maternal Mortality
 PE, infection, amniotic fluid embolism, HTN disorders of pregnancy (eclampsia/preeclampsia)
 Hemorrhage  #1 reason worldwide
Pulmonary Embolism
 Related to rising c-section rate  need thromboembolism prophylaxis
o Pneumatic compression devices, TEDs & LMWH (Lovenox)
Postpartum Hemorrhage#1 reason why women die
 Expect blood loss <500 mL for vaginal (nml ~300-500) & <1000 mL for cesarean
 Early anything in first 24H more than expected
 Late anything after first 24H (worry right up until the end of the 6 weeks)
 Main causes:
o Uterine atony boggy fundus- make sure its firm- most common cause of hemorrhage
o Lacerations if fundus is firm but moms still bleeding check for lacerations
o Retained placental fragments check placenta & make sure its completely empty
o Inversion of the Uterus
o Placenta Accreta
o Hematomas
Uterine Atony- myometrium doesnt contract & blood fills uterus bc no pressure on open vessels at placenta site
Predisposing factors  anything that over distends the uterus
 Over distention of the uterus– big fat uterus
 Hydramnios
 Multiple children inside (twins)
 Grand multiparty too many kids- uterus too loose to contract & can’t get blood vessels to lock down
 Excessive use of analgesia/anesthesia long term epidural administrations
 Too much Pitocin
 Trauma due to OB procedures  using forceps or vacuum for suction
 Prolonged labor for 24-36H due to uterine atony
 Prevention know pts at higher risk to anticipate complications & reduce the risk of excessive bleeding
S/S: A boggy uterus that doesn’t get firm after massage (#1 sign)
 Excessive/bright red bleeding filling pad 15-20 min later
 Unusual pelvic discomfort or backache- shouldn’t have it after delivery
 Abnormal clots- big huge clots regularly throughout day in regular flow not just in morning
Nursing Care:
 Assess & document vaginal bleeding
 Fundal massage/Bimanual compression
 Assess VS for shock
 Give meds: Pitocin- Rx usually says DC when stable- not a stable pt so hang another bag
o Methergine- given PO Q2H- watch BP- if high BP question order bc it’s a vasoconstrictor
o Hemabate- contraindicated in asthmatic- question if hx of asthma
Tx if we can’t stop bleed:
 D&C- scrape inside of uterus if its caused by anything that’s retained we can control it
 Hysterotomy/hysterectomy- take part where placenta was or take whole uterus out
 Replace blood/fluids- replace volume that she’s lost
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Lacerations/Tears in Vaginal Area or Perineum

Causes: usually d/t kids flying out precipitous delivery kids
 Spontaneous/Precipitous- big kid presenting awkwardly & we have to maneuver kid out of pelvis
 Size, presentation, & position of baby
 Contracted pelvis unable to expand & adapt to large baby
 Hx of Vulvar, cervical, perineal, urethral area & vaginal varices (any varices)
S/S: Bright red bleeding & uterus remains firm & hypovolemia
Treatment:
 Inspect the entire lower birth canal usually laceration is missed so take another look
 Doctor can suture any bleeders
 Vaginal pack to stop bleeding- nurse may remove & assess bleeding after removal
 Blood & fluid volume replacement

Retained Placental Fragmentsincomplete placenta separation & fragments left in- not everything came out
 If anything is left inside uterus cannot contract
 S/S: Boggy relaxed uterus & dark red bleeding trying to clot & coming from where placenta was
Treatment:
 D&C scrape whatever is left inside
 Administer oxytocin to make sure uterus clamps down
 Administer prophylactic abx- (triple abx) to prevent infection bc of exposure to outside

Hematoma
S/S: Deep severe unrelieved pain & feeling of pressure
 Pain in perineal area & pressure on rectum & bladder
 Showing signs of shock bc bleeding is internal
 Concealed bleeding- may see nml lochia & contracted uterus major S/S: rectal pain & tachycardia
TX: May have to be incised & drained

Inversion of the Uterus uterus inverts & comes out during delivery
Complete/Full inversion whole uterus comes out- large red rounded mass protrudes from vagina
 Traction on cord causes uterus to invert than uterus continues to be pulled & inverted
 If dr puts pressure on cord & tries to pull placenta out or fundal pressure done to push out baby
 Inc risk for grand multipara  looser cervix & uterus – uterus can come out easier
Incomplete/partial inversion uterus can’t be seen but is felt
Predisposing factors:
 Traction applied on cord before placenta separates don’t pull on cord unless placenta has separated
 Incorrect pressure on fundus, especially if uterus is flaccid don’t use fundus to push placenta out
TX & nursing care
 Replace the uterus manually push back into place & pack it
 Blood & fluid replacement to combat shock d/t hemorrhage
 Oxytocin to clamp uterus down once its back into place
 Initiate broad spectrum abx bc its been exposed to vagina which isn’t sterile
 NG tube to minimize paralytic ileus suction to slow the abdominal tract down
 Notify whole staff careful when massaging- prevent over assessing uterus to not push it back out again
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Placenta AccretaNo decidua basalis & placenta grows into uterine muscle– wants to be permanent
S/S:
 Placenta doesn’t want to separate during the 3rd stage of labor
 Can’t remove placenta in the usual manner & lacerations/perforation of uterus may occur
TX:
 If only a small portion is attached than manually remove
 If large portion is attached do hysterectomy to get placenta out

Postpartum Infectionsinfection of genital tract within 28 days after abortion or delivery- not unusual
 Risk for: mastitis, URI, UTI, thrombophlebitis, hematoma abscess, endometritis, perineal cellulitis
Causes: Streptococcus groups A & B, clostridium, & e.coli
Predisposing factors:
 Trauma/hemorrhage, prolonged labor or csection
 Hx of UTIs, anemia, hematomas & PROM more than 24 hr prior to delivery
 Excessive vaginal exams & bladder catheterization
S/S:
 Temp 100.4+ on 2 consecutive days of 1st 10 days post partum (not 1st 24H bc of dehydration)
 Foul smelling lochia/discharge  should just be musty/fleshy not stinky
 Any feeling of being sick malaise, anorexia, tachycardia, chills
 Pelvic pain
 Elevated WBC- look at differential not just count
TX: Triple abx treatment- admin broad-spectrum abx (usually ampicillin, gentamycin & clindamycin)
 Provide warm sitz baths- encourage warmth in area
 Semi/high fowlers to promote drainage by gravity
 Fluids & hydrate with IVs 3000-4000 cc/day
 PO Methergine to keep uterus contracted analgesics for pain
 NG suction if peritonitis develops
Complications of PP infection turns into peritonitis or pelvic cellulitisS/S of peritonitis:
 Fever 102-104, elevated WBC, chills, extreme lethargy, N/V, abd rigidity & rebound tenderness
Prevention:
 Prompt treatment of anemia & well-balanced diet
 No sex in late pregnancy if high risk
 Strict asepsis during labor & delivery
 Teaching of PP hygiene measures:
o Keep pads snug & change pads frequently
o Wipe front to back & use Peri bottle after each elimination

Localized Infection
 D/t episiotomy, perineal laceration, vaginal or vulva lacerations warm/dark place bacteria loves
o Wound infection of incision site look for REEDA & CATO
 S/s: red, edematous, firm, tender edges of skin, edges separate & purulent material draining from wound
 Tx: systemic abx, wound care- peri care, may have to take off stitches & pack so it can heal by intention
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Postpartum Cystitis
 Urinary infection not unusual to see
 Monitor I&O’s  make sure she’s emptying her bladder
Prevention:
 Monitor the patients urination diligently  I&O’s
 Don’t allow longer than 3-4 hrs before intervening
Treatment:
 Look for any discomfort, itching/burning down there
 Abx’s  usually ampicillin
 Urinary tract antispasmodics- to stop pt from going to the bathroom every minute
Causes:
 Stretching/trauma of base of bladder causing edema that obstructs urethra & causes acute retention
 Anesthesia- long term/not moving
 Secondary foley infections

Mastitis- infection of breast tissue 2 Types:

 Mammary Cellulitis- inflammation of connective tissue between the lobes in the breast
 Mammary Adenitis- infection in the ducts and lobes of breasts
 Caused by fluids, warm environment and kid not draining properly worry about abscess
S/S:
 Engorgement, pain chills, fever, tachycardia, hardness, redness, enlarged & tender lymph nodes
 Mom will feel very sick teach what it feels like so she can call immediately once symptoms occur
 Give information caused if kid is not draining properly- should BF to prevent getting backed up
Complication Breast Abscess- stop BF on affected side tx: incision & drainage

TX:  must treat to prevent abscess

- Rest
- Appropriate abx usually cephalosporin’s
- Hot/cold packs depending on if shes nursing/in pain
- DON’T STOP BREASTFEEDING!
- Milk contains the bacteria & the abx
- Stopping will cause severe engorgement
- BF stimulates circulation & moves milk bacteria
out of breast
-Take abx, fluids & breastfeed
Prevention:
- Meticulous hand washing
- Frequent feedings
- Massage distended area to help emptying
- Rotate baby position on the breast
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Postpartum Psychiatric Disorders

 Mental health problems can complicate the puerperium (6W after childbirth)
 Normal for mom to feel inadequate on some days if constant feeling than not normal
 Pregnancy wont cause disorders but psychological & physiological stressors can cause emotional crisis
 Psych disorders are a chemical imbalance usually self limiting (not long term) postpartum
 Pre-pregnancy psych problems cant take meds bc teratogenic effects

Mood Disorders
Baby blues majority of women will have some form of baby blues because of placental delivery & hormones
 Self-limiting usually up to 10 days
 Cause is r/t changes in progesterone, estrogen & prolactin levels
 S/S: tearful yet happy & overwhelmed
 Tx: prep them- it is nml may not always “like” baby/circumstance (ex: not having a full night sleep)
Postpartum depression major mood disorder
 Risk factors  risk factors + hormones being delivered = easily get depressed
o Primiparity
o Hx of postpartum depression if someone in family has had depression
o Lack of social & relational support if they’re all by themselves
o A lot of people are delaying having children so it’s a shock if always worked- weird not working
 Clinical therapies:
o Counseling & support groups  childcare assistance
o Meds: SSRI’s- takes ~1 month-6 weeks to kick in & reach a therapeutic level
 Doesn’t last forever  may not see postpartum, may occur down the road
Postpartum Psychosis Bipolar situation (highs & lows)
 Predisposing factors same as postpartum depression
 Will have hallucinations & be delusional (ex: see fire around baby
 S/s: grandiosity, insomnia, flight of ideas, psychomotor agitation/hyperactivity, infant rejection
 Hospitalize mom to get meds & wait for them to kick in so she isn’t a danger to herself or baby
Treatment:
 Drug therapy/Psychotherapy
 Explain importance of good nutrition & rest
 Reintroduce mother to baby at the mothers pace (once the drug/psycho therapy starts to work)

Newborn Complications
Identification of High Risk Infants
 Assess for congenital anomalies done with newborn assessment
 Determine gestation age assessment within 1st 24H mom can think she’s on time but can be past due

Priority Needs of Newborns

 Initiating & maintaining respirations  ABC’s
 Establishing extra uterine balance  good adaptation to extra uterine light
 Fluid & electrolyte balance & adequate nutritional intake  ensure feeding properly
 Temperature regulation
 Parent-infant bonding
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ENC Time-Bound Interventions

Within 30 Seconds Objective: stimulate breathing and providing warmth
 Put on double gloves dry thoroughly & remove wet cloth
 Quick check of NB’s breathing suction only if needed
After thorough drying Objective: provide warmth, bonding, prevent infection & hypoglycemia
 Skin-to-skin on chest/abdomen & cover w/ blanket
 Place identification on ankle Must do Apgar scoring within 1st minute
 Do not remove Vernix
Up to 3 minutesObjective: reduce anemia in term & preterm & IVH & transfusions in preterm
 Removes 1st set of gloves clamp & cut cord (1-3 min) DO NOT MILK CORD
 Give oxytocin 10 mg IM to mother
Within 90 minutesObjective: to facilitate initiation of BF through sustained contact
 Uninterrupted skin to skin contact
 Observe NB for feeding cues counsel on positioning & attachment
 Eye care, injections, etc. after 1st breastfeed

Disorders in Transition
Perinatal asphyxia from delivery
 Assessment early recognition: meconium-stained fluid & non-reassuring FHR tracing
o May have transient tachypnea (kid isn’t crying but respirations are too quick ~70)
o Look for grunting, flaring & retraction
 Intervention: resuscitation
Hypothermia
Birth Trauma
 Fractures/Skeletal injuries
 Nerve/head trauma Brachial palsy & facial nerve paralysis from shoulder dystocia
 Always check if baby is symmetrical big indicator is moro reflex

High-Risk Newborn
 Gestational Age Assessment must do assessment bc weight doesn’t indicate age
 Most common problems:
o Hypoglycemia, hypocalcemia (jittery baby), resp distress, hypothermia (unable to stabilize temp)
 SGA, AGA & LGA (BFK)
Small for Gestational Age (SGA) <2500G (5.5 lbs)
 Causes of IUGR:
o Placenta abnormality, dec blood flow, smoking & use of narcotics
o Vascularization issues of placenta, preeclampsia & any nutritional deficiencies (long term DM)
 Common Complications:
o Perinatal asphyxia, aspiration syndrome, heat loss, hypoglycemia, hypocalcemia, polycythemia
o Mental development
LGA Infants
 Causes: diabetic mother, babies with transposition of the great vessels, & multiparous mothers
 BFK’s can be early and still large & immature so will end up in NICU
 Should still have growth curve as long as they’re following curve its okay
 13

Hypoglycemia
 Less than 30 mg/100 mL of blood = harmful  threat to brain cells- after birth levels will fall
 Infants prone to hypoglycemia: diabetic mothers, macrosomic (LGA), prematurity & IUGR (SGA)
 S/S:
o Respiratory- tachypnea, apnea & respiratory distress
o Cardiovascular- tachycardia & Bradycardia
o Neurologic- jitteriness, lethargy, weak suck & temperature instability
Infants of Diabetic Mothers
 High risk for congenital anomalies- cardiovascular, skeletal, CNS, GI & GU
 Macrosomic but immature wanna deliver sooner rather than later bc very difficult to deliver vaginally
 Fat deposits & organomegaly  difficult delivery & birth trauma
 Develop preterm problems
 High insulin levels at birth drops sugar way down really fast NICU for 1st 24 hrs for observation
Hyperbilirubemia
 Physiological excessive RBC breakdown causes inc bilirubin load- liver is too immature to process
o Jaundice 2-3 days after  expected
 Pathological incompatibility b/w mother & infants blood type
o Jaundice in 1st day = pathological
o Caused by:
 Rh & ABO incompatibilities
 Bruising/hematomas (Cephalohematoma)
 Abnormalities of RBC’s (spherocytosis)
 Infections & illness in the infant (GBS)
 GI obstructions (cant drain)
 Nursing care:
o Assess for jaundice starts at head works it way down to toes
o Check infants blood type, CBC & coombs- checks for antibodies
 Coombs checks for antibodies  levels 0-4
 If baby has been sensitized against moms blood coombs + (will have jaundice issues)
o Assess intake & elimination  make sure what’s going in is coming out
o Check temp & ensure adequate feedings
o Phototherapy Overhead lights or biliblanket
 Cover eyes & scrotum
 Maintain pad contact & reposition frequently so it can get to skin all over
Hemolytic Disease of Newborn
 Rh or ABO incompatibility  can lead to pathologic jaundice (always test babys blood type)
 Tx: Exchange transfusions if bilirubin levels keep inc prevents kernicterus
 Rh immune globulin (Rhogam) given to prevent
o Give within 72 hrs after birth
o @ 28W pregnancy if mom is Rh-
o Anytime she bleeds she will get prophylactic
 If she spots will get Rhogam
 Threatened abortion
 Any procedures (amniocentesis, CVS)
 Tx for ectopic or mole
 14

Maternal Substance Abuse

 Effects on infant:
o Growth, development, body functions, long term effects  can be fatal if untreated
 Alcohol fetal alcohol syndrome
 Tobacco SGA & long-term issues with SIDs & asthma
 Marijuana tremors & IUGR
 Cocaine neurological & birth defects – also increases risk for abruption
 Phencyclidine (“PCP”– angel dust)  behavioral (ADHD) & frontal lobe (cant distinct right vs. wrong)
 Heroin IUGR, physical dependence & SIDS
 Methadone  prolonged dependence
Narcotic-Addicted Infants
 Withdrawal may not see on unit bc it depends on when she took drug last
o If right before birth wont see signs until 2 weeks later
o Get blood/urine test from mom to check if she has anything active in her body
 ANS hyperirritability, such vigorously but are poor suckers
 TX: sedative/hypnotic & antianxiety to calm them down as drug leaves system
 Prognosis: assess for neuro & growth problems  can get respiratory & cardiac issues too
 Nursing: dec stimuli in bassinet (NICU grandparents), nutrition, snuggle & protect skin
Neonatal Abstinence Syndrome
 Clinical manifestations:
o Tremors, hypertonic/reflexic, seizures (sometimes seizure activity depending on drugs effect)
o Irritable, restless, sleep disturbances, high-pitched cry
o Yawning, sneezing, sweating
o Tachypnea, nasal flaring, apnea (respiratory distress)
o Poor feeding, vomiting, watery stools, wt. loss
 NAS testing:
o NAS scoring system lists different symptoms & give score Q2H want score to dec Q2H
o Bowel movement testing
o Identify early with urinalysis check if there’s anything in system
o Sometimes put on NG feeding bc they cant suck well
Nursing Management:
 Supportive care
 Hydration/nutrition: small & frequent feeds
 Developmental needs: swaddle, reduce stimuli
 Meds- wean based off symptoms
o Phenobarbital, morphine, paregoric, methadone
Fetal Alcohol Syndrome
 Mom chronic alcoholic  1 night of binge drinking can cause FAS
 Mental retardation
 Characteristics:
o IUGR
o CNS manifestations
o Facial characteristics
o Failure to thrive
 15

Infertility
Definitions:
Infertility- inability to get pregnant for a year if <35 or 6 months if > 35 when actively trying
Secondary infertility- got pregnant before with no problem- second time u try there’s a problem
Sterility- just can’t get pregnant

Causes for male infertility

 Abnormal sperm production/fxn need at least 20 million sperm/mL of semen
o Caused by smoking, overweight, steroid use & heating up scrotum (tight jeans, hot tubs, etc)
 Impaired delivery of sperm- constricitures? Issues in prostate cause dec semen so cant deliver sperm
 General health & lifestyle smokers, drinker, bad diet, sexual problems, not attracted to partner
o Inflammation/infection
o Acute or chronic illness  paralysis, DM, htn, testicular cancer (can bank sperm before tx)
 Environmental exposure
o Radiation, hot tub, saunas
Causes of Female infertility
 Fallopian tube/cilia damage or blockage prevents egg from going where it will be fertilized
 Endometriosis can cause blockages & scar tissue formation
 Ovulation disorders  not producing an egg
 Elevated prolactin  body thinks its feeding a baby so it stops ovulating for a long time
 Polycystic ovary syndrome (PCOS) causes cystic ovaries & inc in androgens
 Early menopause (no period for a full year) before 40’s (nml is early 50’s)
 Benign uterine fibroids & pelvic adhesions can cause blockage or inhospitable uterine lining
 Other: meds, thyroid, cancer, & other medical conditions

Repeated Pregnancy Loss

 Abnormalities of:
o Fetal chromosomes
o Incompetent cervix or uterus
o Endocrine system
 Immunologic factors- allergic to their own baby or dads sperm
 Environmental agents
 Infections
Risk Factors
 Age older men or woman = harder to get pregnant
 Tobacco smoking & Alcohol
 Body mass  overweight or underweight
Screening & Diagnosis
Tests for men
 General physical exam & hx
 Semen analysis check if there’s enough semen/sperm (good tails or immature sperm?)
 Testosterone, estrogen, LH & FSH levels
 16

Tests for women

 Ovulation confirmation Spinnbarkheit take sample of cervical mucus with fingers
o Not ovulating = clumpy & thick // ovulating- thin & stretchy
o Can do Spinnbarkheit when u get Mittelschmerz- mid-cycle ovulation pain
 Hysterosalpingography dye looks at uterus & tubes- can cure infertility during if it’s a blockage
 Laparoscopy only way to diagnose endometriosis
 Basal body temp take temp before getting out of bed everyday- will get subtle curve (97.6  97.3)
 Urinary luteinizing hormone check if eggs are being produced
 Ovarian reserve testing
Complications
 Depression, guilt, anger, stress, disappointment, resentment & blame
 Fear of losing partner bc of infertility & diminished confidence & self-esteem
Non-Surgical Treatment
Restoring fertility in males
 Treatment of general sexual problems  sex therapist
 Address lack of sperm use boxers/briefs, wear ice packs, no saunas/hot tubs & stop riding bike
 Drugs: testosterone & tamoxifen (stimulates gonadotropin release to inc testosterone production)
Restoring fertility in women Fertility Drugs Ovulation induction:
 Clomiphene citrate  Serophene or Clomid PO- take 5 days during cycle (day 5-10 by 14 should ovulate)
o Inc dose each month until enough eggs are produced in conjunction with procedure or sex
 Human menopausal gonadotropin  Repronex or Pergonal (made from menopausal women pee)
o Can inject some hormones inject progesterone
 Follicle-stimulating hormone & Gonadotropin-releasing hormone
 Letrozole  Femara- dec estrogen to inc FSH/LH to produce eggs
 Metformin Glucophage- bc one of the s/s of PCOS is s/s similar to DM
 Bromocriptine Parlodel for hyperprolactinemia give to dec prolactin levels
Assisted Reproductive Technology
 IVF- collect eggs/sperm in petri dish to develop into embryos put embryo in uterus (1 or 2 at a time)
o Done for fallopian tube issues (blockage)- puts right into uterus (VERY expensive- ins only once)
 Intracytoplasmic sperm injection- inject sperm right into egg Sometimes used with IVF
 Gamete intrafallopian transfer (GIFT) egg & sperm into tubes- “more natural than ZIFT”
 Artificial insemination- put sperm into egg in moms body at right time for natural fertilization
 Zygote intrafallopian transfer (ZIFT) put zygote into tube to make trip down for implantation
 Assisted hatching If egg cant implant remove some zona pellucida so embryo leaves shell & implants
 Complications:
o Multiple pregnancy (twins, triplets) that’s why IVF should only be 1 embryo at a time
o Ovarian hyperstimulation syndrome produce 9-10 eggs at a time which is painful
o Bleeding & infection  increases risk of low birth weight & birth defects
Alternatives
 Adoption
 Surrogacy
o Traditional- surrogates egg with donor sperm
o Gestational- eggs & sperms of donor couple just use donor uterus to carry baby
 No children
 17

Introduction to Contraception
Women’s Reproductive Life Span
 Reproductive years are ages 15-44
 39 years spent in reproductive stages of life  ~20 years trying to avoid pregnancy
 Need contraception if at reproductive age at risk for sperm exposure that doesn’t want pregnancy
 Don’t need lesbians, celibate, women who want pregnancy or anyone who doesn’t want to use BC
 Never assume ASK “do you need contraception”  don’t say what kind of BC do you use?
Best Contraceptive Method
 Medically appropriate- no contraindications with any conditions that she has in her hx
 Effective in preventing pregnancy fully effective not only 50% effective (like pulling out)
 Used consistently & correctly if not wont work
 Satisfactory to woman at stage of life criteria changes depending on stage during reproductive life
LIFE STAGES:
Menarche to First Intercourse
 Fertility goals: postpone pregnancy & preserve future fertility
 Sexual behavior: no intercourse yet but possible experimenting (kissing, petting, etc)
 Contraceptive need: educate- prepare for next stage even if she don’t want to use it just give options
First Intercourse to First Birth
 Fertility goals: postpone pregnancy & preserve future fertility (want effective & reversible BC)
 Sexual behavior: multiple partners (?) & frequent spontaneous & unpredictable intercourse
 Contraceptive needs: efficacy, reversibility, not coitus-linked need additional for STI prevention
First Birth to Last Pregnancy
 Fertility goals: space pregnancies but still preserve future fertility
 Sexual behavior: may only have one partner (?) & moderate, predictable & low frequency of sex
 Contraceptive needs: efficacy, reversibility, okay to be coitus-linked, may need STI prevention
Last Birth to Menopause
 Fertility goals: no further pregnancies & no need to preserve fertility
 Sexual behavior: one partner (?) & predictable, low-moderate intercourse
 Contraceptive needs: efficacy, may be irreversible, OK if coitus- linked (?), STI prevention (?)
Contraceptive Considerations
 Effectiveness- teach them in % of how it works EX: pill is 97-99% & pulling out only 50%
 Frequency of intercourse EX: different for person 1X/week than polygamous person 5X/week
 Sexual behavior what kind of positions they use? What they consider as sex?
 Desire for future fertility want to have kids again? If not can consider tube ligation
 Cost of method some are expensive
 Side effects pill- HA, weight gain  some have pain/bleeding
 Contraindications smoker >35 not gonna offer hormonal method
 Non-contraceptive benefits some people us BC for acne
 Pt’s perceptions & misconceptions culture can influence & comfort touching privates (IUD)
 Patient’s health status & medical conditions determine whether or not they can use something

What a Women Want From a Contraceptive According to Sigmund Freud

 Is it safe? All contraceptives are generally safe & definitely safer than pregnancy & child birth
 Does it work? Will my partner accept it? Can I afford it? Some may ask does it cause abortion?
 18

Combination Contraceptives (Estrogen & Progestin)

 In different forms  Orthovera patch- transdermal, Nuvaring- Transvaginal & Lunelle- injection
 Ingredients: estrogen (ethinyl estradiol) 20-50 mcg & progestin (1/7 varying forms, doses, potency)
MOA:
 Suppress ovulation, thickens cervical mucus (blocks sperm), thins endometrium (stops implantation) &
slows tubal & endometrial motility (prevents implantation)
Advantages
 Highly effective when taken correctly
 Not related to coitus improve sexual satisfaction
 Rapid return to fertility after d/c ~ 2 weeks
 Safe for appropriate pts any age (non smokers) wont delay/quicken menopause onset
Health Benefits
 Fewer pregnancies = fewer maternal deaths
 Dec risk of ectopic pregnancy
 Dec in dysmenorrhea (painful menstruation) less school/work absences & less pain meds
 Dec in menorrhagia less days of bleeding & less blood loss dec risk of anemia
 Dec PMS s/s (appetite, breast tenderness, bloating, cramping, irritability, & inc appetite)
 Eliminates Mittelschmerz (mid-cycle bleeding/pain caused by ovulation)
 Dec anvulatory bleeding (when ovulation doesn’t occur)
 Fewer ovarian cyst problems bc it suppresses ovulation
 Dec risk for endometrial & ovarian cancer for up to 20 yrs after d/c of pill
 Dec risk of benign breast conditions & suppression of endometriosis
 Improves androgen-sensitivity/androgen-excess conditions (ex: PCOS)- does back when pill is d/c
 Improves hot flashes & hormonal fluctuation symptoms in perimenopausual women
 Improve acne
Disadvantages
 Must take consistently & correctly to be effective must remember to take them everyday
 Storage access, lack of privacy  store in a safe & easy access place- barrier bc people can easily see
 Can interfere with lactation reduces quantity of milk produced
 No protection against STI’s
 S/e: N/V, weight gain, dec libido, HA, breast tenderness & skin hyperpigmentation
Complications:
 Inc DVT risk d/t estrogen inc liver production of clotting factors (ex: factor 7,8 10 & fibrinogen)
 Estrogen dec antithrombin 3 & protein S & Inc platelet activity
 Progestin alone doesn’t impact clotting when combing with estrogen stops effect
 Existing clotting disorders inc risk for DVT, MI & stroke (many of these women are not diagnosed)
 HTN estrogen inc angiotensin 2 which inc BP & combo inc aldosterone causing fluid retention
 CANNOT GIVE TO WOMEN > 35 WHO SMOKE
 Atherosclerotic coronary vessel damage due to smoking, htn or hyperlipidemia are vulnerable to MI
Contraindications:
 Personal hx of thrombosis, stroke, MI or clotting disorder (factor V Leiden mutation, etc)
 Labile HTN (borderline) or active liver diseases
 Estrogen-sensitive malignancy (breast CA)
 Migraines with focal neurologic symptoms
 19

How to take combo Birth Control pills can start at anytime as long as woman isn’t pregnant
 28 day pack contains 21 active pills + 7 placebo pills ~$35 per cycle
 “First day” start:
o Advantage: certainly not pregnant & prevents ovulation during 1st cycle
o Disadvantage- get pregnant while waiting to start & start on day hard to remember (Thurs)
 Sunday start:
o If period starts on Sunday take 1st pill that day if starts any other day start following Sun.
 “Quick start”:
o Takes 1st pill right away in office- most effective way bc pt may forget instructions if she waits
 Continuing: one pill per day, every day
 Withdrawal bleeding during the placebo week bleeding is not real period but will feels like it is
How to use the PatchEach patch is worn for 7 days ~$40 per cycle
 To start: apply 1st patch to clean, dry skin anywhere except the breast
 Same day 2nd week remove 1st patch & apply new one to different site do this again 3rd week
 Same day 4th week remove patch & don’t apply for 1 week  bleeding will occur- repeat Q4 weeks
How to use the Ring:
 To start: squeeze ring between thumb & index finger & insert in vagina
 Leave in for 21 days (3 weeks) than remove by inserting a finger in vagina & pulling it out
 Discard & wait 1 week causes withdrawal bleeding repeat pattern (3 weeks in – 1 week out)
“Extended Use” Regimens: Seasonale86 active pills & 7 placebo pills  4 “periods” a year
 Monthly withdrawal bleeding is not necessary bc pregnancy isn’t desired
 Any monophasic pill, the patch or the ring can be used on an extended basis

Progestin-Only ContraceptivesPill-form, injectable, or intrauterine device

MOA:
 Inhibits ovulation inhibiting positive feedback of estradiol on FH & FSH
 Thickens & dec quantity of cervical mucus to prevent sperm penetration
 Endometrial atrophy to prevent implantation of blastocyst
Advantages:
 No estrogen no risk of clots- pts who don’t tolerate estrogen bc of N/V/HA/HTN can use
 Reversible
 Amenorrhea or scanty bleeding
 Improves dysmenorrhea, menorrhagia, PMS, endometriosis symptoms
 Dec risk of PID & endometrial/ovarian cancer
 Can BF- can interfere in beginning production of lactation but not once it starts (~6 week check up)
Disadvantages:
 Menstrual cycle disturbances- frequent or continuous bleeding
 Weight gain- 10-15 pounds
 Depression don’t cause it but makes it worse in women who already have it
 Lack of protection against STI’s
 20

Progestin-Only Pills (Micronor, Nor-QD, Ovrette) ~$45 per cycle:

 Cycle has 28 active pills no “placebo week”- can cause amenorrhea or unusual spotting
 Vulnerable efficacy MUST be taken on time Q24-hr (difference ~3 hrs inc risk of pregnancy)
 Can BF very good for mothers in first 6 months  good for pts with lactational amenorrhea
Depo-Provera (injectable): Depot medroxyprogesterone acetate 150 mg IM Q12 weeks
 Advantages: highly effective, private, not linked to coitus, remember only 4x a yr  not daily
 Disadvantages:
o Weight gain- stimulates appetite (usually 5-6 pound weight gain)
o Impossible to d/c immediatelydelayed return to fertility ~10 months
o Adverse effect on lipids (inc cholesterol & LDL & dec in HDL)
o Dec bone mineral density with long term use- encourage inc calcium intake & exercise
Progestin Implants (Norplant- off the market & Implanon- FDA approved coming soon)
 Advantages: very effective, eliminates user error, reversible & long-term (5yrs)
 Disadvantages: High initial cost, insertion/removal need specialized training& not easily d/c
Intrauterine Devices (IUDs):
 Advantages:
o Highly effective, no user error, convenient, long-lasting, discreet, cost-effective in long run
o Low incidence of s/e, not linked to coitus & reversible (rapid fertility after removal)
 Disadvantages:
o Menstrual issues, discomfort w/ insertion (cramping, bleeding & pain) & perforation of uterus,
expulsion of device- likely in 1st 3 months of use or during period, requires trained professional for
insertion & removal, high initial cost & no protection from STI’s
 Myths
o Inc risk of PID no risk of upper genital tract infection STI’s cause PID- not IUDs
o Cause abortions prevents fertilization bc its a true contraceptive not an abortifacients
o Inc risk of ectopic pregnancy reduces risk bc prevents all types of pregnancy
o Only for parous women more likely to expel & insertion in cervical os can be harder
Copper T 380A IUD (Paragard)
 Contents: T shaped polyethylene frame wrapped in copper wire & barium sulfate for X-ray visibility
o 2 white threads hang out to ensure its in place & to remove it easier
 Check strings after menstrual cycles to see if still there & fxning if not seen dr can bring it down
 MOA: Inc uterine/tubal fluids that impair sperm fxn & prevent fertilization
 Advantages: Lasts up to 10 yrs, nonhormonal & nml menstrual pattern continues
 Disadvantages: heavy menses w/ more severe cramping (1st few cycles after insertion)– give NSAID
Levonorgestrel Intrauterine System (LNG-IUS) (Mirena)
 Contents: T shaped polyethylene device, levonorgestrel, barium sulfate for xray, & dark threads
 Check strings after menstrual cycles to see if still there & fxning if not seen dr can bring it down
 MOA: thickens cervical mucus, inhibits sperm survival, suppresses endometrium & ovulation d/t systemic
absorption of progestin
 Advantages: lasts ~5 yrs, protects against endometrial ca bc of endometrial atrophy, reduces menstrual
bleeding by 90%, low incidence of s/e such as weight gain
 Disadvantages: Irregular bleeding, especially during first 6 months
 21

Barrier Methods
 Oldest form of contraceptives ex: male & female condoms, diaphragm, cervical caps & spermicides
Male condoms Latex (natural rubber), natural membrane (lamb intestine), polyurethane & spermicidal
 Physical barrier & prevents pregnancy by blocking semen passage
 Advantages: male participation, no Rx, inexpensive, Effective when used correctly, minimal s/e unless
latex allergy, STI protection including HIV (except for lambskin)
 Disadvantages: reduced spontaneity & pleasure for man, difficultly maintaining erection, lack of
cooperation, embarrassment when buying, not effective with typical use, latex allergy
 Minimizing User Error:
o Use with every act of intercourse from start to finish
o Unroll condom onto penis (don’t unroll first & do not test by filling with air or water first)
o Leave space at end for semen to collect & hold rim during withdrawal to prevent leakage
o Use right lubricants, have several condoms available & store correctly (not in fridge)
Female Condoms ~$3.50 each
 No Rx one time use- inserted up to 8hrs prior to sex; can stay in place for up to 8hrs
 Coated on inside includes lubricant – not with spermicide (not recommended bc can irritate tissue)
 2Rings closed end inside anchors it & open end outside to insert & protect of labia & base of penis
 Protects against STI’s
 Don’t use male & female condoms tg  can get stuck & cause condoms to displace
 Squeaks during intercourse
Diaphragms & Cervical Caps
 Physical barrier to prevent sperm from reaching cervix & chemical to kill sperm (spermicide)
 Advantages: no hormones & virtually no side effects
 Disadvantages: need professional fitting (refit if gain/lose 20lbs or after pregnancy), needs skill &
commitment & less effective than other methods
 Must be comfortable inserting fingers into vagina insert before sex & keep in for 6-8 hrs after
Spermicides (~$10-15 per package)- foam, gels, suppositories and squares of films
 MOA: Nonoxynol-9 is a surfactant that destroys the sperm cell membrane (used w/ another method)
 Advantages: no rx & easy to use, no need for advance planning
 Disadvantages: no STI protection, high failure rate, frequent use (>2x/day) causes tissue irritation that
could inc susceptibility to HIV
Fertility Awareness/Periodic Abstinence
 Identify days in cycle when likely to get pregnant & no sex or use barrier during “fertile window”
 Evaluation of cervical mucus & base of body temperature chart (rises at time of ovulation)
 Methods: (must stop having sex 2-3 days before & after expected ovulation date)
o Ovulation method (assessment of cervical mucus)
o Sympthothermal methods (basal body temperature & mucus)
o Calendar rhythm method counting calendar days
o Standard days method (CycleBeads- strand of colored beads- cycle tracking)
 Advantages: no hormones or s/e, enables understanding of cycles, promotes cooperation, can be used to
get pregnant or identify infertility & only method approved by catholic church
 Disadvantages: require training & cost, dec spontaneity (causes friction if partners don’t agree)
o Difficult when hormones in flux (recent childbirth & menarche, BF, approaching menopause, recent
d/c of hormonal method, irregular cycles, unable to interpret fertility signs)
 22

Sterilization Fallopian tubes cut or mechanically blocked to prevent sperm & ovum from uniting
 Done laproscopically or through a suprapubic “mini-laparotomy” incision or at c-section
 Not during emergency csection must have 30 days b/w 1st consent & 2nd consent (right before)
 Advantages: permanent, effective, safe, quick recovery, no long-term side effects (dec incidence of ovarian
cancer), cost effective, don’t need partner cooperation, not coitus linked
 Disadvantages: regret, difficult to reverse- may need assistive reproductive technology (IVF), more $ than
vasectomy
 Transcervical sterilization  new way “Essure” method- VERY effective- no incision or scar
o Micro inserts in tubes, expand on release & anchors- tissues grow into insert & occlude tubes
o 3 months to be effective so use other method until than
Vasectomy permanent male sterilization- vas deferens cut to prevent sperm passage into seminal fluid
 Takes 20 ejaculations to clear sperm left above use birth control until after 20 nuts
 Advantages: permanent, effective, safe & quick recovery, no long term s/e, less $ than tubal ligation, don’t
need partner cooperation, removes burden of BC for women
 Disadvantages: reversal is difficult, expensive, & often unsuccessful, may regret, not effective until all
sperm cleared from reproductive tract, no protection from STI’s

Emergency contraception- methods a woman can use after intercourse to prevent pregnancy
 Methods:
o Plan b- only dedicated product marketed specifically for emergency contraception
o Off label use of progestin only contraception pills & combination estrogen-progestin pills
o Insertion of copper-releasing IUD almost never done
 Use for: failed contraceptive (condom broke), error pulling out or periodic abstinence, rape, any
unintended “sperm exposure”
 Contraindications: pregnancy- pill wont work
Plan B 2 tablets 750 levonorgestrel per pill
 1st pill ASAP within 72 hr after unprotected sex Take 2nd tablet 12 hours later
 Sooner its taken the better less effective the more u wait (can take up to 120 hrs/5 days)
 MOA:
o Progestin same MOA as others- action depends if taken before or after ovulation
o Pregnancy starts about 7 days after ovulation if fertilization * implantation occurs
o Disrupts events leading to implantation  after implantation has no effect (not abortion pill)
 Alternatives to Plan B
o Progestin-only pill 2 doses – 12 hrs apart (ex: Micronor)
o Estrogen-Progestin pill 2 doses – 12 hrs apart
 Alesse 5 pink pills, Triphasil 4 yellow pills, Ovral 2 white pills
 If you give estrogen give an antiemetic also bc will be very nauseous
 Standards of care:
o Providing information
o Providing post-coital treatment
o Providing advance rx incase of emergency