Obstetric Nursing

I. Family Planning A. Contraception - the voluntary prevention of pregnancy 1. Attitudes toward contraception a. shaped by religion and culture b. influenced by family's attitudes c. affected by socioeconomic status 2. Contraception only works if the user a. accepts the method b. understands it c. is motivated to use it correctly 3. Nurse's role in family planning a. explain all available methods b. discuss effectiveness, benefits, and drawbacks of each method c. discuss how the user feels about contraception d. have user explain use of chosen method ("say back") Methods of Contraception e. clarify any misunderstandings

D. Hormonal contraceptives: hormone combinations that suppress ovulation 1. Single-hormone contraceptive pills - progesterone-only contraceptive pills
Nurses cervical mucous imprevious to sperm taken daily to make theRole in Family Planning

2. Combined-hormone therapy - combination of estrogen and progesterone

A. Ideally extends from pregnancy through insertion-ring forms on a 28 day cycle in pill, patch, or follow-up B. The nurse works with the woman, her partner, providerlast care - reinforcementis bleeding starts one to four days after the of active hormone pill of education taken or patch/ring removed C. Address use,contraindications: family history birth control methodshypertension, questions, and concerns about of stroke, migraines, 1. Build trust; acknowledge cultural and religious factors tobacco use diabetes, chronic renal disease, thrombophlebitis, 2. Assess client's (if over 35 years ofher own body smoking comfort level with age) 3. Ask about effects: nausea and vomiting, edema, weight gain, break side prior use and knowledge 4. Address lifestyle and desire for more children through bleeding, thrombophlebitis, pulmonary embolism, stroke) Include safe-sex practices also called emergency contraception; thought 3.5. Morning-after contraception:and abstinence 6. toIfprevent movement of thea class on a specific method of contraception indicated, refer client to egg towards the sperm as well as creating a such environment for planning hostile as natural family the sperm 7. Refer theMD, CNM, of hormones is taken as soon afterthat require a to first dose or Nurse Practitioner for methods intercourse as prescription or (up to 72 hours contraceptives, diaphragm, IUD) after possible special fit (oral after) and a second dose 12 hours 8. Refer the first MD for sterilization client to contraindications: pregnancy - also the combination pills are not recommended for women with a history of DVT, hypertension, Methods of Contraception diabetes, renal insufficiency or breast cancer side effects: severe nausea, vomiting, headache, breast A. Fertility awareness methods tenderness, mood swings 1. Calendar - - believed to of ovulation based of the fertilized egg E. Intrauterine devices estimate dateprevent implantationon length of cycle (rhythm method) effects - heavy menstrual bleeding, severe cramping, and side 2. Basal bleeding between periods - identifies ovulation by a rise in body temperature charting temperature complications - uterine perforation, infections 3. Cervical mucous method - identifies ovulation by increase in mucus F. Long-acting methods amount progestin (Depo (spinnbarkeit) 1. Injectableand stretchability Provera) - every 12 weeks B. Chemical agents: destroydoes not have sperm - creams, foams, jellies, or convenient, or immobilize the side effect or contraindications suppositoriesprofile that combination products have that contain a spermicide C. Mechanical barrier methods disadvantages/cautions: clients desiring to conceive should 1. Diaphragm - covers the external cervical OS years before the desired consider discontinuing Depo-Provera 2 conception as this productfitted by a physician; there up to be a risk disadvantages: must be may delay conception for may two of toxic shock syndrome of the product years after discontinuation(TSS) when left in too long; and may be perceived as a barrier to spontaneity G. Permanent sterilization most effective when used with a spermicidal agent 1. Male sterilization - vasectomy 2. Cervical cap - fits over the cervical OS under local anesthesia in the an outpatient procedure performed physician's office.same as diaphragm; only women with a certain disadvantages: Procedure takes 15-20 minutes shaped cervix may be fitted man to be instantly sterile - he will disadvantage: does not causefor this method 3. Condom - fits ejaculate 20 times and have a confirmed negative sperm need to tightly over the penis count before it can be counted on for birth control disadvantages: perceived decrease in penile sensation and spontaneity 2. Female sterilization - bilateral tubal ligation (BTL) a advantages: inexpensive, accessible, and reduces the spread of same-day-surgery procedure performed under general STDs anesthesia in the hospital. Procedure takes approximately 1 hour disadvantage: longer recovery than with a vasectomy and 4 times more costly. Immediate sterilization is accomplished

B. Sterilization 1. Surgical procedures intended to render the person infertile 2. Most states bar sterilizing minors (< 21 years of age) or mentally incompetent persons 3. Methods a. male: vasectomy b. female: tubal ligation 4. Informed consent must include: a. explanation of risks, benefits, and alternatives b. description that sterilization is permanent and irreversible c. mandatory 30 day waiting period from the time the consent is signed until surgery may occur d. Wording in person's native language or interpreter must be provided.

Uncomplicated Pregnancy
A. Preconception health 1. Teach about a. b. c. d. e. f. g. h. lifestyle for optimal health balanced diet including folic acid (at least 1 mg/day) fertility awareness stress management avoidance of harmful or teratogenic substances safe sex risk awareness parenting responsibilities

2. Conception

a. factors influencing conception 1. hormone cycles 2. cervical mucus 3. sperm motility, shape, and number 4. ovulation b. occurs when ovum is penetrated by sperm resulting in fertilization c. male gamete determines sex of child at fertilization d. fertilization typically occurs in outer third of the fallopian tube e. single or multiple fertilizations are possible 3. Implantation a. usually occurs seven - ten days after fertilization b. trophoblast secretes enzymes which enable it to burrow into endometrium c. trophoblast develops chorionic villi which secrete human chorionic gonadotropin (HCG) d. HCG inhibits further ovulation by stimulating secretion of estrogen and progesterone

e. HCG is detected by lab tests for pregnancy as early as six days after conception in blood and 26 days after conception in urine 4. Fetal development

a. embryo
i.

ii.
i. ii.

most critical developmental period developing areas most vulnerable to teratogens

b. fetus c. fetal-placental unit (illustration 1 and illustration 2) iii. iv.

oxygenation nutrition HCG levels screening for fetal problems daily count of fetal movements non stress test basic ultrasound screening

Fetal Development Stages and Circulation

By 8 weeks: Head and heart grow rapidly. Head is larger than trunk. Central hemispheres appear, face elongates and eyelid folds have developed but eyes are still far apart. Flat nose and recognizable mouth are evident. External ears look similar to final appearance. Arms, legs, fingers and toes are distinct. Heart and liver are prominent. Length: approximately 2.5 cm. Weight: approximately 2 gm. By 12 weeks: Intestinal villi form. Bladder and urethra separate from rectum. Kidneys begin to secrete urine which makes up the amniotic fluid. Bronchioles branch and pleural and pericardial cavities appear. Lungs assume definitive shape. Thyroid and pancreas begin to secrete hormones. Sex distinguishable. Bone ossification occurs. Able to suck and swallow. Length: approximately 7cm. Weight: approximately 28 gm. By 16 weeks: Joint cavities are present. Bile is secreted. Intestines assume normal position, meconium present. Kidneys in proper position. Testes begin to descend into inguinal canal. More human-like appearance. Length: approximately 10-17 cm. Weight: approximately 55-120 gm. By 20 weeks: Brain grossly formed. Spinal cord myelinization begins. Lanugo and vernix caseosa begin to form. Length: approximately 16-25 cm. Weight: approximately 225-300 gm. By 24 weeks: External genitalia discernible. Skin red and wrinkled. Lungs begin to produce surfactant. Meconium present in rectum. Eyes are structurally complete. Length: approximately 24-28 cm. Weight: approximately 680-1000 gm. By 28 weeks: Face matures. Eyelashes and eyebrows form. Viable as a neonate with intensive care. Length: approximately 35-38 cm. Weight: approximately 1000-1200 gm. By 32 weeks: Increase in subcutaneous fat. Hair evident. Still covered with vernix caseosa. Can turn head side to side. Skin begins to smooth out. Chances of survival outside utero increase. Length: approximately 3843 cm. Weight: approximately 1200-2400 gm. By 36 weeks: Lanugo begins to disappear. Subcutaneous fat continues to increase. Elongation of spinal cord almost complete. Good chance of survival. Length: approximately 43-48 cm. Weight: approximately 24002800 gm. By 40 weeks: Baby is full term. Both testes have descended in the male. Lanugo has disappeared. All organ systems have developed. Lecithin-sphingomyelin (L-S) ratio is 2:1. Length: approximately 48-52 cm. Weight: approximately 2800 gm or over. Fetal circulation Normally ceases to exist after birth Fetal lungs do not function until after birth Fetal blood is oxygenated via the placenta

B. Maternal Health in Pregnancy 1. Physical systems that must adapt a. b. c. d. e. f. g. h. i. reproductive respiratory cardiovascular endocrine metabolic gastrointestinal renal integumentary musculo-skeletal

Maternal Physical Changes A. B. C. D. E. F. G. H. I. J. K. L. Menses ceases Braxton-Hicks contractions Breast changes: areola and nipples darken, breast tissue grows larger and colostrums is produced Blood volume, stroke volume and cardiac output increases to meet demand of enlarging uterus and fetal oxygenation Enlargement of uterus causes urinary frequency As pregnancy progresses, body retains more water, resulting in dependent edema Melasma- brownish "mask of pregnancy" (formerly called chloasma) Linea nigra- darkened vertical line on mid abdomen Striae- gravidarum- "stretch marks" on abdomen, upper arms and legs Center of gravity shifts, so gait and posture change and low back pain may occur; posture described as lordosis Ovarian hormone relaxin causes connective tissue of joints to relax, so risk of falls increases. Potential for nausea and vomiting is greatest in first trimester from increased levels of HCG Digestive system is cramped, decreased peristalsis from increased progestin levels Pressure of uterus on the diaphragm may lead to dyspnea especially in third trimester

M.
N.

2. Psychologic adaptations a. b. c. d. maternal responses paternal responses adaptation to tasks of pregnancy factors in family dynamics that affect adaptation i. support systems: grandparents, siblings ii. cultural influence iii. religious influence iv. developmental needs v. previous experience with pregnancy vi. health beliefs vii. economic factors viii. stress management

Screenings for Fetal Problems in Uncomplicated Pregnancy First Trimester: A. Chorionic villis sampling 1. Involves obtaining a sample of chorionic villi from the placenta via a syringe/needle 2. Allows for early diagnosis of genetic, metabolic, and DNA 3. Performed between the 8th and 12th weeks of gestation 4. Allows a woman earlier/safer timing for pregnancy termination as results return quickly and allow for 1st trimester abortion Basic ultrasound screening 1. Performed vaginally or abdominally depending on gestation 2. Can be performed in the outpatient or inpatient setting in all three trimesters 3. A full bladder enhances visualization when abdominal ultrasound is performed 4. Confirms viability 5. Indicates fetal presentation 6. Confirms multiple gestation 7. Identifies placental location 8. Measurements can be taken to confirm/estimate gestational age 9. Identify morphologic anomalies

B.

Second Trimester: A. Quad marker screening (also called maternal serum expanded AFP screening) 1. Measure levels of maternal serum alpha fetoprotein (MSAFP), human chorionic gonadotropin (HcG), unconjugated estriol (UE), and inhibin A a. MSAFP = a protein produced by the baby's liver b. HcG = a hormone produced by the placenta c. UE = a protein produced in both the placenta and the baby's liver d. inhibin A = a hormone produced in the placenta 2. A screening test performed at 16 weeks gestation to assess risk for chromosomal anomalies and neural tube defects 3. Maternal blood sample is drawn and sent out for analysis 4. Does not indicate absolutely that abnormalities are detected, only that further investigation is recommended B. Amniocentesis 1. A procedure performed to obtain a sample of amniotic fluid for direct analysis of fetal chromosomes, development, viability and lung maturity 2. Performed under ultrasound guidance 3. Rh negative mother must receive Rhogam immediately aftr the procedure 4. Risks include: amnionitis spontaneous abortion, preterm labor/delivery, and premature rupture of membranes 5. Recommended for women 35 years of age or older and any pregnant woman with an abnormal quad marker screening Third trimester: C. Daily fetal movement counts (also called fetal kick counts) 1. Same time every day 2. Mother records how often she feels the fetus move 3. If fetus is quiet, mother is encouraged to drink some juice, like down on her left side and repeat the count of movements 4. If at least three movements are not noted within an hour's time, the mother is encouraged to call her physician immediately 5. An active fetus reflects adequate oxygenation by the uteroplacental unit D. Nonstress Test (NST) 1. The electronic fetal monitor is placed on the maternal abdomen for 20-30 minutes 2. Records fetal heart rate fluctuations continuously 3. Mother is given a button to press each time she feels the baby move 4. Each time the fetus moves, FHR should accelerate 15 beats/min above the baseline for 15 seconds 5. A reactive (good) outcome is one in which two or more such accelerations in FHR occur with associated fetal movement E. Biophysical Profile (BPP) 1. A comprehensive fetal assessment of five variables: a. fetal breathing movement b. fetal movement of the body or limbs c. fetal tone (extension or flexion of the limbs) d. amniotic fluid volume index (AFI) visualized as pockets of fluid around the fetus e. reactive non-stress test 2. First four components observed and measured under ultrasound; the non-stress test on an external fetal monitor 3. Allows for identification of a compromised fetus 4. A score of 0-2 points is awarded for each of the five components of the test 5. A score of 8-10 points with normal fluid volume is the desired result; less than that indicates need for intervention F. Percutaneous Umbilical Blood sampling 1. An ultrasound-guided procedure used to obtain a sample of fetal blood drawn from the fetal umbilical cord 2. A needle is introduced through the maternal abdomen, much like amniocentesis, but is then introduced into the fetal umbilical cord 3. Risks and treatment same as for amniocentesis 4. Fetal blood sample provides information about chromosomal anomalies, feta karyotyping, and blood disorders G. Contraction Stress Test (CST) - also called Oxytocin challenge test (OCT) 1. Evaluates the oxygen and carbon dioxide exchange within the fetoplacental unit 2. Allows for identification of the fetus at risk for intrauterine asphyxiation 3. Contraindications include: placenta abruption, placenta previa, undiagnosed third trimester bleeding, previous cesarean delivery, premature rupture of membranes (PROM), incompetent cervix, and/or multiple gestation 4. Procedure: a. performed in a labor and deliver unit under electronic fetal monitoring b. mother should have IV access and OR team available c. to initiate contractions, IV Pitocin is administered or the client is instructed in nipple stimulation procedure d. the desired result is a "negative" test which consists of three contractions of moderate intensity in a 10 minute period without evidence of late decelerations e. a positive result = repetitive, persistent late decelerations with >50% of the contractions; an equivocal result = nonpersistent late decelerations f. treatment of a positive CST is expeditious delivery, via cesarean section

C. First trimester Assessment Based on Adaptations 1. Initial history a. b. c. d. general health family health/partner's health history current health status reproductive summary (gravida, parity) i. past pregnancies ii. current pregnancy (subjective symptoms) e. social factors f. lifestyle g. diet history h. cultural and religious practices i. risk factors Conditions That Increase Risk in Pregnancy A. B. C. D. E. F. G. H. I. J. K. L. Age under 17 or over 35 Grand multiparity Hereditary conditions Chronic health problems Complications in past pregnancies Nutritional alterations Substance abuse Domestic violence Poverty Disability Infection Exposure to potential teratogens Autoimmune diseases such as Lupus or Multiple Sclerosis

M.

2. Initial physical exam j. k. l. m. n. o. baseline vital signs and weight/height head-to-toe assessment/general well being assessment breast examination abdominal examination pelvic exam signs of pregnancy i. Presumptive/possible: subjective findings and objective signs reported by woman (amenorrhea, fatigue, nausea and vomiting, breast changes, elevation of basal body temperature (BBT), skin changes). These may be caused by conditions other than pregnancy ii. probable: changes observed by examiner Chadwick's Sign: Increased vaginal vascularity Hegar's Sign: Increased vascularity and softening of uterine isthmus Goodell's Sign ballottement p. positive: signs attributed only to presence of fetus (fetal heart tones, visualization of fetus, palpating fetal movements)

3.

Laboratory tests a. urinalysis for glucose, protein, blood, and bacteria b. urine or blood HCG level c. complete blood count d. blood type and Rh factor e. rubella titer f. screening for syphillis g. cervical culture for Chlamydia and gonorrhea h. hepatitis B surface antigen/antibody (HBsAG/HBsAB) i. pap smear j. tuberculin skin test k. HIV antibody (with client permission) Rho(D) Immune Globulin or RHoGAM

A. Reasons 1. Rh negative mother and Rh positive father fetus may be Rh positive 2. If this occurs: Rh antigens from the Rh+ fetus may leak at the placental site 3. More Rh+ antigens may leak at delivery and invade mother's blood stream 4. To these Rh+ antigens, mother forms antibodies 5. This results in hemolysis of fetal RBCs the next time that the mother carries an Rh+ fetus B. Prophylaxis for Rh negative mother 1. Give Rh immune globulin during pregnancy (at 28-30 weeks) 2. After the birth of each Rh+ newborn, perform direct Coomb's test on newborn and indirect Coomb's test and antibody screen on the mother 3. Coomb's test detects antibodies a. mother - indirect Coombs b. neonatal cord blood - direct Coombs' test/antibody screen 4. If no antibodies are identified, the woman is considered to be a candidate for RhoGAM 5. Give RhoGAM within 72 hours of delivery 6. RhoGAM is an immune globulin (Ig) 7. RhoGAM blocks formation of antibodies 8. RhoGam suppresses the immune response of the nonsensitized Rh negative woman who has been exposed to Rh positive antigens 9. Give RhoGAM after each ectopic pregnancy, miscarriage, or abortion of 6 weeks gestation or greater 10. Administration of Rh immune globulin prevents Rh sensitization in mother and resulting hemolytic anemia called erythroblastosis or hydrops fetalis of the newborn if antibodies cross the placenta

4.

5.

Psychological assessment a. emotional response to pregnancy b. family relationships c. support systems d. developmental tasks/maternal tasks e. expressed feelings f. learning needs Gestational assessment a. ultrasound to confirm (dates vs. measurements/crownrump length) i. best determined in the first trimester scan (most accurate +/- one week) ii. confirms viability iii. divulges multiple gestation

6. Nursing care: first trimester a. build rapport b. discuss pregnancy confirmation c. calculate due date - Naegele's Rule: If last normal period's first day=N, then due date is N + seven days, minus three months, plus one year. Example: June 10, 2001 first day of last menstrual period 6 10 2001 -3 3 +7 17 +1 2002

Estimate date of birth (EDB): March 17, 2002

d. discuss maternal physical changes e. review development of embryo and fetus f. return scheduling: plan antepartum schedule of visits g. review and teach: identify learning needs h. perform risk assessment i. recommend prenatal vitamins with folic acid and iron j. offer anticipatory guidance i. ii. iii. iv. discomforts and remedies rest and exercise (including Kegel exercise) diet and fluid intake medications, tobacco, other substances Safety: avoid hot tubs, virus exposure, etc. refer (for example, to childbirth classes) warning signs

v.
vi. vii.

7. Role of expectant woman and partner e. f. g. h. i. keep appointment schedule (monthly visits) maintain healthy lifestyle follow diet and take vitamins cope safely with discomforts (such as dry toast for morning sickness) discuss sexual feelings and needs report warning signs

j.

Warning Signs in Pregnancy A. First trimester 1. Excessive vomiting 2. Lower abdominal cramping 3. Vaginal bleeding 4. Elevated temperature- greater than 101 F persistent temperature 5. Vaginal discharge 6. Dysuria 7. Exposure to infections including childhood diseases B. Second trimester 1. Absence of quickening 2. Change in fetal activity 3. Leaking vaginal fluid- water type consistency 4. Vaginal bleeding 5. Fever, chills 6. Vaginal discharge 7. Uterine contractions or low backache 8. Persistent vomiting 9. Dysuria 10. Edema of hands, face 11. Signs of preterm labor 12. Sudden weight gain, greater than 4 lbs. in one week C. Third trimester 1. Decreased or absent fetal movement 2. Vaginal bleeding 3. Abdominal pain especially sudden, severe, epigastric pain 4. Headaches 5. Visual disturbances and renumber the rest 6. Leaking of fluid from the vaginal orifice 7. Anasarca -generalized edema 8. Signs of preterm labor 9. Sudden weight gain of greater than four pounds in one week F. Second trimester Regular Monthly Assessments, Based on Adaptations 1. Current findings 2. Visualize or palpate fetal outline (Leopold's maneuvers) 3. Fetus

a. activity (date of quickening)

b. fetal heart rate (Doppler) i. first detected 12-14 weeks gestation c. physical exam i. compare weight, vital signs to baseline ii. fundal height uterus becomes an abdominal organ height of fundus in cm is approximately same as number of weeks gestation d. lab tests i. urinalysis for protein and glucose ii. quad screen at 16-18 weeks gestation- test for chromosomal and congenital malformations) human chorionic gonadotropin (HcG) alpha fetoprotein (AFP) estradiol (E2) inhibin A iii. gestational diabetes screening (24-28 weeks gestation)

nonfasting 1 hour (50gm) glucola screening performed; if greater than 140mg/dl then next step is ii fasting 3 hour glucose tolerance test if (2) out of the (4) values are higher than normal range = diagnostic for GDM. iv. viral screening for Hepatitis B, HIV etc. if high risk v. tuberculin test if high risk e. managing care, trimester two: role of nurse on team with physician or CNM i. the seven R's

The Seven R's In OB nursing, many interventions fall into these Seven R's categories. 1. 2. 3. 4. 5. 6. 7. Relationship (caring) Respond (to questions and concerns) Review and reinforce (including anticipatory guidance) Recommend (diet, vitamins, Kegel exercises, etc. Risk data Return scheduling Referral resources

discuss birth plan offer anticipatory guidance: adapting employment to motherhood safety discomforts and remedies travel, exercise, nutrition sexual relations childbirth education body image changes f. role of expectant woman and partner i. keep appointments (monthly) ii. verbalize concerns iii. modify lifestyle as needed; eat balanced diet iv. use safe remedies, such as small, low-fat meals for heartburn v. discuss emotional responses and birth plan vi. enroll in childbirth education vii. develop prenatal attachment, prepare other children for new siblings viii. report warning signs G. Third trimester Assessments based on adaptations 1. Current health status a. headaches b. visual changes c. epigastric distress d. contractions/cramps e. other concerns 2. Comfort and mobility 3. Physical examination

ii. iii.

The fetus is described in documentation according to its: -Position -Lie -Presentation -Attitude -and during the process, the Stations it passes.

a. comparison to baseline i. weight gain pattern ii. vital signs fundal height measurement fetal assessment i. fetal activity assessments/kick counts ii. fetal heart tones iii. Leopold's maneuvers position presentation lie pelvic examination i. performed at term ii. assess for cervical dilation and effacement observe for generalized edema (especially in the face and hands); indicative of preeclampsia assess maternal deep tendon reflexes (DTRs) and clonus if indicated Position

b. c.

d. e. f.

A. Fetal Position 1. Presenting part of baby 2. In relation to the front, back, or side of the mother's pelvis B. Position Denoted by 1. Presenting part: O for occiput M for mentum S for sacrum A for acromium process D for dorsal 2. Right or left (R or L) 3. Whether the presenting part faces the pelvis's: front (A for anterior) back (P for posterior) side (T for transverse) Examples of Position Left occiput anterior ( LOA ) Fetus's occiput is on the left side of the maternal pelvis toward the front. The fetus's face is toward the rear of the pelvis. Right Occiput Anterior (ROA) Fetus's occiput is on the right side of the maternal pelvis toward the front. The fetus's face is toward the rear of the pelvis. Left Occiput Posterior (LOP) Fetus's occiput is on the left side of the maternal pelvis toward the rear. The fetus's face is toward the front of the pelvis. Right Occiput Posterior (ROP) Fetus's occiput is on the right side of the maternal pelvis toward the rear. The fetus's face is toward the front of the pelvis.

Presentation (the part of the fetus entering the pelvis first)

A. Cephalic: Head alone is presenting part 1. Vertex 2. Brow 3. Military 4. Face Breech: head alone is not presenting part 1. Frank: buttocks present/fetal hips are flexed and knees extended 2. Complete: buttocks and feet present, fetal hips and knees are flexed, lower legs crossed 3. Kneeling: knees present 4. Footling: foot or feet present 5. Shoulder: shoulder presents. transverse lie 6. Compound: two presenting parts, such as head and hand

B.

4. Lab tests a. urinalysis for protein b. antibody screen at 28 weeks gestation if client is Rh negative c. cervical culture for group B streptococcus at 34-36 weeks gestation d. hemoglobin and hematocrit 5. Managing care, trimester three: role of nurse on team with physician or CNM a. the seven R's b. administer Rh immune globulin to Rh-negative woman (24 to 28 weeks) c. offer anticipatory guidance i. discomforts and remedies ii. body mechanics and safety iii. birth options iv. feeding choices and plans for newborn care v. childbirth classes vi. recognizing onset of labor vii. reportable/warning signs 6. Role of expectant woman and partner a. keep appointments-visits every two weeks or weekly b. prepare for role change; support each other; discuss sexual needs c. use safe remedies for discomforts (such as lateral posture for sleep) d. practice relaxation and breathing techniques; perform fetal movement count daily e. follow dietary and fluid advice f. maintain safety in daily activities g. meet psychological tasks h. arrange hospital or home birth, plan newborn feeding; learn newborn needs i. recognize signs of labor

j. report warning signs (see warning signs in pregnancy)

Signs of True vs False Labor

A.

B.

C.

Early labor 1. Lightening 2. Bloody show 3. Braxton-Hicks contractions 4. Burst of energy 5. Low backache 6. Weight loss 7. Diarrhea True labor 1. Cervical changes 2. Effacement 3. Cervical dilation 4. Contraction frequency increases 5. Intensity of contractions persists despite changes in position and activity 6. Membranes may be intact or ruptured False labor 1. No cervical change 2. Contractions diminish with activity, have irregular timing, and do not intensify

III.

Uncomplicated Labor and Birth A. Processes of labor 1. Factors affecting labor include the five P's: passageway, passenger, powers, position and psyche a. passageway (bony elvis and soft tissues of cervix, pelvic floor, vagina, and introitus) i. inlet ii. outlet

b.

iii. size iv. types passenger (fetus) i. fetal head diameters ii. position iii. presentation

iv. station Stations of Fetal Descent

"Stations" describe numerically the relationship of fetus's presenting part to the mother's ischial spines 1. 2. Ischial spines form narrowest slot through which the newborn's head must pass The head floats until it descends into the mother's pelvis (engagement) a. In primipara, usually about two weeks before birth b. In multipara, varies from several weeks prior to onset of labor to during the labor process At station zero, largest portion of the head (biparietal diameter) is level with ischial spines When the head is above the ischial spines the station is recorded as a negative number (-1, -2) When the head is below the ischial spines the station is recorded as a positive number (+1, +2) If the fetus stops descending, possible cephalopelvic disproportion may call for cesarean section

3. 4. 5. 6.

c.

d.

e.

powers i. primary powers uterine contractions o frequency o duration o intensity o rest phase responsible for effacement and dilation of cervix ii. secondary powers (bearing down efforts) aids in expelling fetus diaphragm and abdominal muscles position of laboring woman i. for comfort and safety ii. fetus receives more oxygen when mother maintains left lateral position iii. walking should be encouraged to allow gravity to assist fetal descent iv. constrained by condition of woman and fetus, environment, and health provider's confidence in assisting birth in a specific condition psyche (person)/psychology of birth (See section "5" on page 16 of this lesson)

2. Signs of labor versus true labor

3. Duration of stages and phases varies with parity, fetal presentation, position and station 4. Maternal systems adaptations a. reproductive i. effacement vaginal part of the cervix progressively shortens and thins as the cervix dilates

effacement is noted as a percentage from 0% (noneffaced) to 100% (fully effaced) ii. cervical dilation progressive dilation of the cervical os from less than 1 centimeter to 10 centimeters, also called, fully dilated b. cardiovascular i. as labor progresses, cardiac output increases between contractions ii. BP rises with contractions and with voluntary bearing down iii. BP can vary with mother's position, anxiety and pain iv. pulse rate rises slowly and progressively c. respiratory i. mother consumes more oxygen ii. pain, anxiety can cause hyperventilation iii. respiratory alkalosis, hypoxia or hypocapnia can occur d. renal i. uterus may squeeze ureters and impede urine flow ii. trace amounts of protein in urine are common e. gastrointestinal i. decreased peristalsis and absorption ii. stomach is slower to empty (gastric emptying time) iii. nausea and vomiting common f. musculo-skeletal i. diaphoresis, fatigue, proteinuria and possible increased temperature cause marked increase in muscle activity ii. backache, joint aches iii. leg cramps g. endocrine - progestin levels drop and as a result the labor process begins 5. Mother's behavioral changes are affected by a. stage and phase of labor b. psychological responses to pain c. preparation for labor d. presence of support person e. coping style f. culture g. previous childbirth experience h. feelings about this pregnancy 6. Fetal adaptations

a. mechanisms of labor (cardinal movements) Mechanisms of Labor (Cardinal movements)

Engagement, descent, flexion: the widest part of the head passes the ischial spines as the head is flexed onto the chest Internal rotation: the anteroposterior diameter of the head lines up with the anteroposterior diameter of the pelvis Extension: the head passes the symphysis pubis and extends from the perineum External rotation: the baby's rotates back to its position during engagement and then an additional 45 degrees to align the shoulders with the anteroposterior diameter of the pelvis. The anterior shoulder passes under the symphysis pubis followed by the posterior shoulder Expulsion: the rest of the body passes under the symphysis pubis and is expelled

i. engagement, descent, flexion ii. internal Rotation iii. extension iv. external Rotation v. expulsion b. fetal circulation i. changes when uterus contracts ii. maximum oxygenation during rest phase
B. Labor and birth (intrapartum) Brief Overview: Stages of Labor 1. first stage: onset until complete dilation a. latent phase: 1 to 3 cm dilation b. active phase: 4 to 7 cm dilation c. transition: 8 to 10 cm dilation 2. second stage: complete dilation through delivery of neonate 3. third stage: placental separation and delivery 4. fourth stage: maternal adaptation

1. First stage of labor: latent phase a. assessments i. history

critical admission data o due date o onset, frequency and duration of contractions o membranes intact or leaking o gravida and parity general health history reproductive history prenatal care antepartal health social history lifestyle allergies family history childbirth preparation risk factors including o problems identified on antepartal record o preterm labor o reduced or absent fetal activity o prolonged ruptured membranes o acute health problems o infection o bleeding with or without pain o substance abuse

ii.

iii.

iv.

physical examination baseline vital signs compared to antepartal chart weight intake and output contractions: mild and irregular Leopold's Maneuvers fetal activity and heart rate pelvic exam o confirm true labor (See true vs. False Labor) o identify fetal position, presentation, station o membranes: intact or ruptured head-to-toe assessment laboratory tests values compared to antepartal records complete blood count blood type and Rh urinalysis for protein psychological assessment How does the client respond to mild irregular contractions? What does the client expect and know about birth and labor process? learning needs developmental level support systems available during labor cultural influences on labor and care behavioral responses (such as, excited or talkative) what strategies does the client use to cope with labor pain?

b. managing care: stage one latent phase: role of nurse on team with physician or CNM c. in addition i. promote comfort through ambulation, position changes, shower, whirlpool ii. identify learning needs for labor and birth iii. review birth plan, analgesic and anesthetic options iv. explain intermittent/continuous fetal monitoring

d. role of woman and support person i. discuss questions and concerns ii. use appropriate relaxation methods for early labor iii. adapt the environment to cultural beliefs iv. empty bladder frequently v. report physical changes to caregivers vi. maintain adequate hydration

Fetal Monitoring
A. Can help to identify fetal-placental problems early in the labor process B. Fetal heart rate (FHR) may be measured externally or via internal electrode C. Timing 1. Intermittent 2. For 30 minute periods 3. Continuous 4. When membranes rupture, to rule out fetal distress or prolapsed cord D. Measures - Baseline heart rate usual range 120-160 bpm in the full term fetus. 1. Less than 120 bpm - bradycardia 2. More than 160 bpm - tachycardia 3. May signal hypoxia, maternal infection or other factors-notify physician/CNM E. Monitor strip assessment: 1. Variability: beat to beat rhythm fluctuations that indicate adequate acclamation to the internal environment. Variability is affected by medications or by hypoxia. If the fetal heart rhythm does not vary with contractions, position changes, etc. then the physician should be notified a. accelerations: heart rate increases during fetal movements and contractions b. decelerations: heart rate slows i. early decelerations: FHR decelerations that mirror the contraction and return quickly to baseline by the end of the contraction. These are very common and are caused by head compression. No intervention is needed as they are not a sign of distress ii. late decelerations: a pattern of FHR deceleration when the FHR slows after the peak of a contraction and returns to the baseline well after the contraction has ended. A cardinal sign of a stressed neonate and possible hypoxia. Indicates an inadequate feto-placental unit. Interventions include; immediately turn the woman onto her side; apply oxygen, discontinue oxytocin, if it is running; and call the physician/CNM iii. variable decelerations: an irregular pattern of fetal heart rate deceleration that occurs when a deep sudden drop in the fetal heart rate is noted that can often be eliminated by repositioning the client, at which time the FHR returns to its baseline pattern. Nursing intervention should include: turning the woman onto her side or a different position, applying O2, and informing the physician/CNM; caused by umbilical cord compression F. Methods of fetal monitoring 1. Doppler - utilized for intermittent monitoring a. FHR is located by Leopold's maneuvers and is monitored for 1-2 minutes for beat regularity and rate 2. External monitoring a. Tocodynamometer or "toco" i. attached via an elasticized strap to the woman's abdomen to assess uterine activity b. External fetal monitor or "EFM" i. attached via an elasticized strap to the woman's abdomen to ultrasonically monitor fetal heart rate patterns 3. Internal monitoring a. Intrauterine pressure catheter or "IUPC" i. inserted by the provider for a more accurate assessment of contraction strength and duration b. Spiral electrode or "SE" i. applied by the provider for a direct assessment of the fetal heart requires rupture of membranes client remains on bedrest during monitoring Note: Electronic fetal monitoring requires advanced training regarding interpretation of fetal monitor strips.

2. First stage of labor: active phase a. assessments i. physical examination compare present vital signs compared to baseline monitor contractions: increased frequency and duration, moderate to strong, more regular observe membranes: intact or ruptured measure fetal heart rate ii. psychological assessment: emotional response to increasing frequency, duration and intensity of contractions iii. behavioral changes (self focus; concentration) b. managing care, stage one active phase: role of nurse on team with physician or CNM i. intrapartum care: RAFAP eleven ii. encourage ambulation or position changes until membranes rupture iii. promote drugless comfort measures (such as effleurage, relaxation and paced breathing, massage, hydrotherapy, labor support) iv. offer analgesia safest time for fetus is 4 to 7 cm dilation safety measures for woman may include siderails v. discuss regional anesthesia such as epidural block

Epidural Anesthesia
A. During labor or just before birth, the anesthesiologist may inject regional anesthetic agents (or infuse them by catheter inserted into the epidural space). These anesthetics usually block from T - 10 to S - 5. The woman must sign a written consent to this pain relief. B. The anesthesiologist has primary responsibility for these anesthetics, the nurse must know: 1. The anesthetic agent used, and its effects and side effects. 2. The level of sensory and motor changes to expect 3. The woman's allergies to medications used for procedure. C. Nursing responsibilities 1. Before the epidural, take vital signs and fetal heart rate 2. Inform the woman that she must remain in bed, because she will not be able to walk safely 3. Encourage her to empty her bladder; or insert a Foley catheter 4. Help the woman to a sitting or lateral position 5. Explain that the epidural will reduce her pain perception and mobility 6. After the epidural, monitor the client's blood pressure and fetal heart rate every 5 minutes for 30 minutes. a. if the client remains stable, assess every 15-30 minutes. b. if hypotension, dizziness, headache or fetal bradycardia occur, turn the woman slightly to her side. The physician may elevate the head or foot of the bed, based on further assessments. IV rate may be increased and oxygen may be administered. 7. Observe for signs of maternal respiratory distress or other serious side effects of epidural anesthesia.

c. role of woman and support person i. continue effective breathing and relaxation techniques ii. alter position for comfort iii. Maintain bed rest (lateral position preferred) after membranes rupture. Lateral position promotes optimal uteroplacental and renal blood flow and increases oxygen saturation iv. communicate questions and concerns v. report physical changes

3. First stage of labor: transitional phase a. assessments i. physical examination perform pelvic exam 1. dilation 8 to 10 cm 2. membranes ruptured 3. fetal descent and station compare present vital signs to baseline monitor contractions: (usually occur every 2 to 3 minutes, duration and intensity increase) watch for these signs of progression to the second stage of labor 1. perineum will bulge with contractions 2. nausea and vomiting 3. trembling 4. feeling of need to defecate ii. psychological assessment emotional response to increased pressure and contraction intensity irritability and tension b. managing care, stage one transition phase: role of nurse on team with physician and CNM i. maintain safety (such as bedrails and lateral position) ii. follow standard precautions iii. watch for urge to bear down iv. treat hyperventilation v. promote rest between contractions c. role of woman and support person i. communicate physical changes ii. continue effective breathing techniques iii. maintain lateral position as much as possible 4. Second stage of labor: complete dilation through birth a. assessment i. physical examination fetal crowning increased bloody show

mother pushes involuntarily fetal heart rate response to contractions and pushing b. psychological assessment i. emotional response to perineal pressure ii. relief at labor's end c. managing care, stage two: role of nurse on team with physician or CNM i. help the woman to push with contractions ii. assist with the safe delivery of the newborn; clear newborn airway iii. dry newborn skin; maintain warmth iv. inform the couple of the newborn's gender and condition v. explain repair of episiotomy or lacerations vi. monitor uterine contraction after birth vii. follow Standard Precautions d. role of woman and support person i. breathe effectively ii. push with contractions iii. relax after contractions iv. follow directions to stop pushing v. hold and bond with newborn 5. Third stage of labor: placental separation and expulsion a. assessment i. physical assessment increased bleeding umbilical cord lengthens uterus contracts into a globe shape ii. psychological assessment emotional response to newborns birth: excitement and fatigue b. managing care, stage three: role of the nurse on team with physician or CNM i. inform couple of placental separation ii. observe for intact placenta iii. assess blood loss iv. monitor maternal vital signs v. administer oxytocic drugs per physician/CNM orders vi. document promptly and accurately c. role of woman and support person i. follows instructions of the physician/CNM for delivery of the placenta ii. bonds with newborn iii. attempts breastfeeding 6. Fourth stage of labor: maternal adaptation (one to two hours after birth) a. assessment i. physical examination monitor vital signs (every 15 minutes) compared to intrapartal data observe for 1. uterine contraction 2. vaginal bleeding: lochia 3. trembling or chills 4. bladder distention 5. fundal height observe episiotomy or repaired lacerations ii. psychological assessment emotional response to birth

 early interaction with newborn iii. family interaction b. managing care, stage four: role of nurse on team with physician or CNM i. massage fundus if boggy ii. monitor initial bleeding/clots iii. care of the perineum inspect for bruising or increased swelling assist client with peri care encourage ice to the perineum for the first 24 hrs encourage first void within 1 hr postpartum and then every 2-3 hrs iv. administer oxytocic medications IM or IV as ordered by physician/CNM v. offer food and fluids; help with ambulation vi. monitor recovery from regional anesthesia vii. administer pain medication as needed viii. facilitate breast feeding ix. administer rubella vaccination or Rh immune globulin (RhoGAM) if indicated c. role of woman and support person i. verbalizes questions and concerns ii. reports physical changes iii. asks for pain relief as necessary iv. holds the newborn

IV.

Normal Postpartum A. Maternal adaptations: birth to six weeks (puerperium) Before Discharge from Hospital

Systems adaptations a. reproductive i. uterine contraction ii. lochia (rubra) iii. perineal healing b. cardiovascular c. respiratory d. renal e. gastrointestinal f. integumentary g. musculo-skeletal h. endocrine i. hormonal influences on lactation ii. hormonal influences on uterine contraction 2. Psychologic adaptations Conditions That Increase Risk in a. emotional responses: taking in Pregnancy b. interaction with newborn c. family dynamics and bonding, attachment A. Age under 17 or over 35 role change: first 24 hours d. B. Grand multiparity Assessments based on adaptations 3. C. Hereditary conditions a. initial postpartum history D. Chronic health problems E. Complications in past i. labor and birth information pregnancies F. Nutritional alterations ii. present symptoms G. Substance abuse iii. health history H. Domestic violence iv. reproductive summary I. Poverty v. social factors J. Disability vi. cultural and religious practices K. Infection L. Exposure to potential teratogens M. Autoimmune diseases such as Lupus or Multiple Sclerosis

1.

vii. viii.

ix.

lifestyle diet history risk factors I. identified in pregnancy II. related to labor or birth III. adolescent parenting IV. substance abuse V. nutritional alterations VI. family relationships VII. poverty VIII. disability

b. physical examination i. monitor vital signs compared to intrapartal data ii. perform head-to-toe assessment iii. examine breasts iv. examine fundal height fundal height found at the umbilicus within 12 hrs after birth and descends 1-2 cm every 24 hrs there after v. observe lochia lochia rubra changes to lochia serosa after three to four days vi. observe perineum and repaired episiotomy or lacerations vii. observe legs for edema, Homan's sign viii. assess for common problems breast engorgement; sore nipples after pains bladder distention; altered bowel function; hemorrhoids swelling and discomfort from episiotomy c. lab data i. hemoglobin and hematocrit compared to earlier data ii. rubella titer iii. blood type and Rh factor d. psychological assessment i. initial emotional response to labor/birth ii. response to pain iii. early interactions with newborn iv. family support v. cultural and religious practices 4. Managing care, postpartum before discharge: role of nurse on team with physician or CNM e. f. g. h. i. j. k. l. m. maintain a caring demeanor inform woman of physical changes and assessments respond to questions and concerns promote physical comfort and rest offer analgesics for pain relief teach fundal massage encourage frequent emptying of bladder teach perineal hygiene and care encourage ambulation n. help with first breast feeding o. encourage fluids/food p. identify problems

q. document assessments and care 5. Role of woman and family r. expresses questions and concerns s. holds and interacts with the newborn t. maintains rooming-in u. reports physical or emotional changes

INITIAL LACTATION
Lactation mechanics

1. Begin with placental delivery, stimulates prolactin from anterior pituitary, which initiates milk production. 2. Newborn suckling stimulates the "let-down" response by initiating the release of oxytocin from the posterior pituitary. 3. Oxytocin causes the expulsion of milk through the duct system, and the contraction of the uterine muscle. 4. Nurse's knowledge and support play a vital role in reinforcing information and encouraging breast feeding. 5. Put the newborn to breast immediately after birth or during the recovery phase of the intrapartum. 6. Help the mother into a comfortable position to allow the newborn to fully grasp the areola. 7. Allow the baby to nurse vigorously, held so that the breast does not block its nose. Show mother how to break suction when the baby has finished nursing. Baby should nurse for 10-15 minutes on each side every 2-3 hours. 8. If woman has not breast fed before, stay until she feels comfortable. 9. Be aware of cultural practices that may influence the initial breastfeeding experience. 10. Briefly explain the lactation process to the breastfeeding mother. 11. Suggest warm compresses or a shower prior to nursing to assist the "let-down" reflex. 12. Suggest that the mother wear a supportive bra night and day. 13. Be available to answer questions, such as using alternating feeding positions or awakening a sleepy baby. 14. Offer encouragement to the woman . Follow up with printed materials, films, discussions with other mothers and referral to a lactation specialist or LaLeche League. 15. Colostrum - breast milk precursor. Present for first few days after birth then changes to mature milk. 16. Encourage 8 ounces of fluid be consumed by the mother with each feeding and 500 calories extra per day. 17. Anticipatory guidance regarding prevention of breastfeeding problems: a. changing positions each feeding (prevent wear-and-tear on nipples) b. start with the breast last nursed on (promote full emptying of each breast) c. avoid using soap and water on nipples (avoids drying and cracking of nipples) d. feed baby every 2-3 hours (at least) during the day and night (helps establish supply) e. encourage mother to avoid offering the baby supplements for the first month of life to help POSTPARTUM REPORTABLE SIGNS establish a milk supply

A. Maternal:
1. Temperature greater than 100.4 degrees Fahrenheit 2. Increased lochia, clots or foul odor B. Postpartum discharge teaching (24 to 48 hours) 3. Perineal pain orAssessments based on adaptations 1. swelling 4. Calf tenderness a. client self-assessment 5. Appetite loss b. reportable signs 6. Sleep disturbances 7. Continued mood swings or depression 8. Elimination problems (burning, frequency or urgency of urination, or persistent constipation) B. Newborn: 1. Temperature greater than 100.4 degrees Fahrenheit 2. Poor feeding effort 3. Vomiting or diarrhea 4. Inconsolable crying 5. Inability to arouse; exceedingly sleepy 6. Yellowing of the skin 7. No wet diaper in eight hours

c. taking-hold behaviors 2. Managing care, discharge - role of nurse on team with physician or CNM a. identify mother's learning needs b. offer anticipatory guidance: self care i. balanced diet for health and lactation ii. activity and rest iii. breast and nipple care iv. resources for questions and concerns v. family involvement at home vi. return of menses vii. sexual needs viii. birth control options (see contraception) ix. reportable conditions (mother and baby) c. offering anticipatory guidance: lactation i. early and frequent nursing ii. positions for comfort iii. pumping and storing milk d. caution woman to avoid pregnancy for 3 months e. Follow protocol of RhoGAM if indicated. f. teach mother to keep using multivitamins and iron 3. Role of woman and family a. Seek answers to questions and concerns b. report physical or emotional problems c. use resources as needed d. increase activities gradually e. integrate newborn into family C. Follow-up home visit (2-4 days after discharge) 1. Data collection a. self-assessment by client b. physical i. vital signs 1. temperature greater than 100.4 degrees Fahrenheit in the first 24 hours after delivery may indicate dehydration 2. temperature greater than 100.4 degrees Fahrenheit 6 hours apart after the first 24 hours after delivery for 2 consecutive days may indicate a postpartum infection ii. breasts filling - engorgement iii. nipples intact iv. uterine contraction and descent v. lochia serosa vi. perineal healing vii. lower extremities viii. comfort and fatigue ix. elimination c. psychological i. emotional responses; self image

ii. iii.

iv.
v. vi. vii.

taking hold adaptations parent-newborn interaction; family dynamics coping; "blues" family dynamics financial concerns health care follow-up concerns

2. Managing care, postpartum visit - role of nurse on team with physician or CNM a. continue caring demeanor b. respond to questions and concerns c. show interest in newborn and siblings d. evaluate safety in newborn care e. reinforce nurturing behaviors f. identify problems (mother and baby) g. remind woman of follow-up visit date h. offer anticipatory guidance regarding newborn/infant care issues 3. Role of woman and family a. verbalize questions and concerns b. report physical changes/problems c. demonstrate safe newborn care D. Follow-up clinic or office visit (3-6 weeks postpartum) 1. Assessments a. involution complete b. letting-go behaviors c. lactation established 2. Managing care, newborn follow-up: role of nurse on team with physician or CNM a. discuss health maintenance and promotion b. reinforce teaching of self care c. respond to questions and concerns d. refer to resources i. supplement teaching with handouts, films ii. discuss fertility awareness and birth control e. continued anticipatory guidance regarding newborn/infant care issues 3. Role of woman and family a. incorporate newborn into the family unit b. follow suggestions for a healthy lifestyle c. report reproductive health problems d. schedule regular health care visits V. Normal Newborn A. Newborn: adaptations in the first month Immediate Care after Delivery (from birth to two hours) 1. Systems adaptations a. fetal to newborn circulation

2.

b. cardiovascular c. respiratory d. temperature regulation e. gastro-intestinal f. renal g. immune h. hepatic i. coagulation j. neurologic Assessments a. respirations

APGAR SCORE

b.

apgar score

1. Five tests, at 1 minute and 5 minutes after birth, show baby's overall status

2. Apgar Scoring Totals and Interventions a. 8-10 is normal b. 5-7 means mild depression. The neonate may require some stimulation, such as gently but firmly slapping the soles of the feet or rubbing the spine or the back. Oxygen may be necessary. c. 3-4 means moderate depression. The baby may need oxygen, and/or the insertion of a feeding tube to decompress the stomach d. 0-2 means severe depression, requiring immediate life support

3.

c. appearance d. risks e. umbilical cord Management of care (physician or CNM and nurse) a. maintaining open airway b. drying the skin, maintaining warmth c. ensuring safety d. clamping the cord e. taking blood samples f. identifying mother and newborn g. instilling ophthalmic prophylactic ointment h. fostering parent contact i. documenting assessments and care

PROPHYLACTIC EYE TREATMENT OF NEWBORN

A. Choices of ointment or drops to prevent ophthalmic neonatorum

1. Ophthalmic Erythromycin 0.5% ointment or drops in single-dose tubes or ampules 2. Tetracycline 1% ointment or drops in single dose tubes or ampules 3. Silver Nitrate 1% in single-dose ampules Currently, most practitioners prefer Erythromycin or Tetracycline as they are less irritating to the eye. They kill many organisms, including Chlamydia. B. Timing

1. Some clinicians administer eye drops in the first hour, others in the first few hours after
delivery

2. First, promote bonding with the mother, then instill ophthalmic ointment, which may
temporarily obscure newborn's vision

B. Newborn (birth until discharge) 1. Assessments based on adaptations a. history i. antepartal data ii. labor and birth information iii. risk factors b. physical examination of newborn i. temperature (36.5 - 37.5 degrees Celsius [97.7 99.5 degrees Fahrenheit]) axillary ii. apical heart rate (110 - 160 bpm) iii. blood pressure (50 - 75mm Hg) iv. respirations (30 - 60 respirations per minute) v. weight vi. measurements of length, head, and chest circumference vii. head-to-toe assessment viii. reflexes

growth and gestational age assessment using Ballard assessment tool c. normal characteristics and common variations i. caput succedaneum ii. cephalohematoma iii. molding d. sensory responses e. behavioral responses f. elimination g. lab data i. complete blood count (if complications are evident) hemoglobin should be between 14.5 - 22 g/dl hematocrit should be between 44 - 72% ii. blood type and Rh factor iii. direct Coombs' antibody test if mother is Rh negative and baby is Rh positive - may develop hemolytic disease of the newborn if mother is O Rh positive - may develop ABO incompatibility iv. glucose level (40 - 60 mg/dl if newborn is symptomatic or LGA v. screenings as indicated (i.e. Sickle cell anemia or Tay Sachs disease screening) vi. bilirubin levels (0 - 1 mg/dl) bind risk 2. Managing care, normal newborn: role of nurse on team with physician a. analyze any vital signs outside normal range b. clear the baby's airway c. keep the baby warm d. position baby (on back or side) e. document findings of your assessments f. share assessments with parents g. report problems or concerns h. administer vitamin K i. observe behavioral and neurological changes j. note first void and stool within 24 hours k. assist with feedings i. if formula fed - feed newborn every 3-4 hours ii. if breast fed - feed newborn every 2-3 hours l. administer hepatitis vaccine (after 12 hours of age) m. newborn screen for Phenylketonuria (PKU) (after 48 hours of age) n. routine cord care with alcohol wipes every diaper change 3. Role of nurse: teaching parents

ix.

a. nurturing behaviors b. newborn care i. safety: use of car seat ii. feedings iii. hygiene iv. cord care v. circumcision care c. elimination patterns d. initial weight loss e. newborn stimulation f. positioning and holding 4. Role of mother and family a. expressing questions and concerns b. bonding/attaching to newborn c. recognize newborn as a separate person i. call baby by name ii. note unique things about baby d. describe cultural or religious beliefs e. demonstrate care giving skills f. introduce siblings to newborn C. Newborn: discharge teaching 1. Assessments a. share with parents b. follow-up lab tests i. PKU - phenylketonuria ii. bilirubin test 2. Reportable signs a. fever b. vomiting c. stool changes; diarrhea d. behavioral changes; irritability e. feeding problems f. jaundice 3. Resources a. newborn nursery staff b. pediatrician c. family members d. support groups, such as LaLeche League e. telephone numbers, such as abuse hot lines f. infant CPR courses D. Newborn: follow-up home visit 1. Assessment based on adaptations (compared to hospital records) a. parents' assessments b. nurse's physical assessment i. vital signs ii. weight iii. head-to-toe examination iv. reflexes v. behavior vi. sensory responses vii. elimination patterns viii. safe environment ix. contentment and sleep c. nurse's psychological and social assessment i. interaction between family and newborn ii. emotional responses of family to newborn and each other iii. responses to newborn cues 2. Management of care - role of nurse on team with physician a. establish caring relationship b. display interest in the newborn c. encourage questions

respond to concerns and questions share assessments with family demonstrate care giving skills as needed review newborn feeding reinforce parenting behaviors remind parents about well-baby schedule and immunizations j. review reportable signs for mother and infant 3. Role of family a. express questions and concerns b. incorporate newborn into family c. provide safe, nurturing care d. recognize reportable signs e. plan well baby follow-up care Points to Remember Before Birth

d. e. f. g. h. i.

Early and regular antepartal (before-birth) care is critical. First trimester health directly influences the development of organs in embryo and fetus. To identify risks, nurses need both subjective (client's) and objective (the nurse's own) assessment data. Prescribed medications, over-the-counter drugs, alcohol and tobacco may lead to problems for the fetus and woman. Pregnancy diet must include increased calcium, protein, iron and folic acid. If the client's situation warrants, suggest ways to adapt activity, employment, and travel. It is helpful if the woman can have the same support person throughout pregnancy and birthing classes.

Labor

Maintain safety and asepsis (sterilize instruments; wear gown, gloves, mask) through the labor and birth process to reduce risks to mother and fetus/newborn. Ideally, same caregivers stay through all stages of labor. Recognize urgent signs and act promptly. Constantly assess and analyze problems to prioritize actions. Reinforce the childbirth preparation techniques practiced by the couple during pregnancy. Effective teaching during labor must be flexible. Mother will have shorter attention span, increasing discomfort, and emotional responses to labor. Promote privacy of the woman and support person as much as possible. Respect the cultural and religious beliefs of the woman and partner. Involve the family in the birth process as noted in their birth plan or special requests. Provide for the woman's needs and comfort. Communicate caring and concern to the woman and her family through therapeutic techniques. Document assessments, changes in condition and care as promptly as possible.

Postpartum

Teach (by demonstration and praise) self assessment and care. Start soon after birth. The newborn is first of all a family member. Share your assessments and plans with parents; welcome their input. Respect culture and religious beliefs of the family. Praise the parent's skills. Media and pamphlets are useful teaching aids if the parent has a chance to discuss them.

Visits and Teachings

Mothers are discharged quickly, so you must teach accordingly. Home visits and follow-up telephone calls let the nurse and parents discuss adaptations, questions and concerns. Postpartum teaching should include women's health promotion. The adolescent mother benefits from developmentally appropriate teaching and referral to community resources, including parenting classes.