Respiratory depth and rate increase especially if the woman is anxious or in pain.

They may hyperventilate causing respiratory alkalosis from exhaling too much CO2.
.f

G] motility is reduced during labor which can result in nausea and vomiting. Most women are not hungry but thirsty and have dry mouths. Urinary-reduced sensation of a full bladder occurs in labor. A full bladder can inhibit fetal descent because it occupies space in the pelvis. Hematopoetic -500ml is the maximum normal blood loss during vaginal birth. This is acceptable and tolerable since the blood volume increases during pregnancy by 1-2 L. The levels of certain clotting factors are elevated during pregnancy and continue to be higher during labor and after delivery. This provides protection from hemorrhaging but increases the risk for DVT during pregnancy and after birth. Pvschologically-mild anxiety and fear decrease a womans ability to cope with pain in labor. Preparation for childbirth can enhance a womans ability to work with her body's efforts rather that resist the natural forces. A womans culture affects her views of birth and practices surrounding it. I can influence her reaction to labor and her expectations of interaction with her newborn. A woman who has a more realistic expectation about the birth is more likely to have a postitive experience. b) Discuss premonitory signs of labor Braxton Hicks, contractions throughout pregnancy, irregular and mild. Lightening: as the fetus descends toward he pelvic inlet the woman notices that she breaths more easily because the upward pressure on her diaphragm is reduced, but the pressure on the bladder increases. ^increased vaginal mucous secretions: occurs as fetal pressure causes congestion in the vaginal mucosa Cervical ripening and bloody show: cervix softens from hormone relaxin and increased water content, allowing the cervix to yield more easily to the forces of labor contractions. As the fetal head descend it puts pressure on the cervix starting the process of effacement and dilation. This causes expulsion of the mucous plug that seals the cervix during pregnancy. Energy spurt: energy spurt that causes women to "nest". Weight loss: a small weight loss of 2.2 to 6.6 kg may occur because of altered estrogen and progesterone ratio causing excretion of some of the extra fluid that accumulates during pregnancy. c) Distinguish between true and false labor True Labor: Contractions cause progressive change in the cervix. An increase in effacement and dilation occur. Contractions are consistent and increase in frequency, duration and intensity. Pain is felt in lower back gradually sweeping around the lower abdomen. False Labor: false contractions are inconsistent in frequency, duration, and intensity...do not change of may decrease with activity. Discomfort is felt in the abdomen and groin. Cervix does not change significantly d) Discuss the role of passage, passenger, powers and psyche in the labor process

The four P's of labor : Passage (pelvis, soft tissue) During birth, the true pelvis functions like a curved cylinder with different dimensions at different levels ^Passenger (fetus, membranes and placenta) Several fetal anatomic and positional variables influence the course of labor

Powers (uterine contractions, bearing down efforts) These are the primary forces that moves the fetus jr through the maternal pelvis

IT'

Psyche (psychological elements) Mild anxiety, and fear decrease the woman's ability to cope with pain in labor. Preparation for childbirth can enhance a woman's ability to work with her body's efforts rather than resist the natural forces. e) Identify factors that can indicate a greater than normal risk to the mother and fetus during labor.

Breech presentation: more likely to occur with abnormalities of the maternal uterus and pelvis and with placenta previa. The fetal head is the last part to be born which can cause the umbilical cord to compress and the fetus unable to breath. Fetal heart rate outside the normal range for a term fetus (110-160bpm for a term fetus) Meconium stained amniotic fluid Cloudy, yellowish or foul-smelling amniotic fluid (can indicate infection) Excessive frequency or duration of contractions (can reduce placental blood flow) Incomplete uterine relaxation and intervals <30sec between contractions (reduces placental blood flow) Maternal hypotension (may divert blood flow away from placenta to ensure adequate perfusion of the maternal heart and brain Maternal hypertension (associated with vasospasm in spiral arteries which supply the intervillous spaces of the placenta) Maternal fever (100.4 or >) f) Explain the stages and phases of labor

iDivided into 4 stages: First Stage: Effacement and dilation in three phases: 1) Latent- first 3cm of cervical dilation 8.6 to 5.3 hours duration. Can be unnoticed but eventually can be realized as the real thing. Contractions build in frequency, duration and intensity. 2) Active-pace of labor increases. Dilation is 4-7cm at 4.6 to 2.4 hours duration. The fetus descends into the pelvis and internal rotation begins. Contractions are 2-5 min apart and last 40-60 sec. Intensity ranges from moderate to severe. 3) Transition-cervix dilates from 8-1 Ocm and fetus descends further in to the pelvis. Contractions are strong and are 1.5 to 2 min apart, lasting 60-90 sec. May cause the woman to push and bear down during contractions. Second Stage: Expulsion with complete 10cm dilation and full (100%) effacement of the cervix ending with the birth of the baby. Duration last SOmin to 3 hours. Contractions are strong 2 to 3 min apart and lasting 40-60 sec. Duration last SOmin to 3 hours. Contractions are strong 2 to 3 min apart and lasting 40-60 sec. The woman exerts physical effort to push the baby out. This stage ends with the birth of the baby. Third Stage: Placental. Begins with the birth of the baby and ends with the expulsion of the placenta. Shortest stage lasting up to 30 min with an average length of 5-10 min. Placenta is expelled in two ways: Schultz which is shiny fetal side presenting first or Duncan, which is less common and the maternal side is presenting first. Fourth Stage: Physical recovery for the mother and infant. Lasts from the delivery of the placenta through the first 1-4 hours after birth.

Objective 2 The student will evaluate the intrapartum patient's needs

a)

Incorporate physiological, psychological and cultural factors

Physiological factors: Labor is work and therefore women often get hot and perspire. Offer cool damp washcloths. Offer ice chips, frozen juice bars. A full bladder can intensify pain during labor and delay fetal descent. Remind the woman to empty her bladder frequently. Positioning is helpful to reduce discomfort and assist the labor process. Encourage proper breathing techniques. Psychological factors: Provide encouragement to the woman and tell her when her labor is progressing. Praise her for correct breathing and reinforce her self control efforts. Soft indirect lighting is soothing as opposed to bright overhead lighting. Simply reassure that all is going well. Cultural factors: Arrange for a culturally acceptable interpreter who is fluent in the woman's language if needed. Cultural beliefs and practices give structure, meaning and richness to the birth experience. Incorporate the family' cultural practices into care as much as possible. Women who do not usually welcome touch may appreciate it during labor, but don't assume that, make sure you ask. b) Explain oxytocin in the post delivery period Reduces bleeding after expulsion of the placenta. Stimulates sustained contraction of the uterus and causes arterial vasoconstriction. c) Develop a nursing care plan for the intrapartum patient Refer to page 301 to 303 for care plan d) Calculate an Apgar score Apgar score is assessed at 1 and 5 minutes (10 minutes if response is poor) after birth for rapid evaluation of early cardiopulmonary adaption. If the Apgar score is 8 or higher, no intervention is needed. Arranged as most important (heart rate) to least important (color). Assigned a score of 0-2 in 5 areas and the scores are totaled. Heart rate 0=absent, 1=below 100/bpm 2=100/bpm or higher, 0=no spontaneous respirations 1= slow resp. or weak cry 2= spontaneous resp and strong, lusty cry 0=limp 1=minimal flexion of extremities; sluggish movement 2=flexed body posture; spontaneous and vigorous movement 0=no response to suction or gently slap on soles 1=minimal response (gimace) to suction or gentle slap on soles 2=Responds promptly to suction or a gentle slap to the sole with cry or movement 0=pallor or cyanosis 1=bluish hands and feet only 2=pink (light skin) or absence of cyanosis (dark skin), pink mucus membranes

Respiratory rate:

Muscle tone:

Reflex response:

Color: I

If score is: 0-3 4-7 8-10 Patient needs resuscitation Gently stimulate by rubbing the infant's back while administering oxygen. Determine whether mother received narcotics, which may have depressed infant's respirations Have Narcan available for administration Provide no action other than support the infant's spontaneous efforts and continued observation.

Objective 3 The Student will analyze extra uterine adaptation.

a) Describe changes from fetal to newborn circulation

During fetal life three shunts carry blood away from the lungs and liver. At birth, changes in blood oxygen level shifts pressure within the heart and pulmonary systemic circulation, and clamping of the umbilical cord allow the infants blood to circulate to the lungs for oxygenation and to the liver for filtration. Occur simultaneously within the first few minutes after birth. Ductus Venosus Blood flow occluded with end of umbilical circulation. Caused by occlusion of cord stops flow of blood from the placenta through umbilical vein to ductus venosus. The results are that blood travels through the liver to be filtered as in adult circulation. Occurs when cord is clamped and permanent at 1-2 weeks. It becomes ligamentum venosum. Foramen Ovale Closes when pressure in the LA becomes higher that pressure in the RA. Caused by cord occlusion elevates systemic resistance. Blood returns from PV to LA. Both increase L heart pressure. Decreased pulmonary resistance allows free flow of blood into lungs and decreased pressure in RA. This results in the blood entering RA can no longer pass through to LA; instead it goes to RV and through PA to the lungs. Occurs within minutes and becomes permanent at 3 mos. It becomes fossa ovale. Ductus Arteriousus Constriction preventing entrance of blood from PA. Caused by increased oxygen level in the blood. Results from blood in the PA is directed to lungs for oxygenation. Occurs within minutes after birth with complete closure in 15 to 24 hours. It is permanent at 3 to 4 weeks. It becomes ligament arteriosum. b) Describe respiratory changes at birth At 22 weeks gestation the lungs begin to produce surfactant which lines the inside of the alveoli and reduces surface tension within. This allows the alveoli to remain partially open when the infant begins to breathe at birth. Once the alveoli expand, surfactant acts to keep them partially open between respirations. With each cry, the pressure within the lungs increases, keeping alveoli open and causing remaining fetal lung fluid to move into the interstitial spaces where it is absorbed by the pulmonary circulatory and lymphatic systems. Pulmonary blood vessels Dilation of all vessels in the lungs caused by increase of oxygen level in the blood. Results from Decreased pulmonary resistance allowing blood to enter freely to be oxygenated. Begins with first breath. c) Describe mechanisms and effects of heat loss after birth Because the skin of an infant is thin and the blood vessels are close to the surface they can lose heat. Newborns have three times more surface area to body mass than adults do which gives them more area for heat loss. Some methods of heat loss are: Conduction -occurs when the infant comes in contact with cold objects or surfaces such as a scale. Evaporation-occurs during birth or anytime the infant is wet and from insensible water loss. Convection- occurs when drafts come from open doors, air conditioning, or even air currents created by people moving about. Radiation-occurs when the infant is near a cold surface. Thus the heat is lost from the infant's body to the sides of the crib or incubator and to the outside walls and windows.

Effects: Thermogenesis Newborns rarely shiver except at low temperatures, and shivering is not an effective method of heat production. Instead they cry and become restless. Exposure to cool temperatures also results in decreased flow of warm blood to the skin because of vasoconstriction. Acrocynosis can occur and in addition a drop in temperature increasing metabolic rate and markedly causing above-normal oxygen and glucose use. Cold Stress Can cause many body changes. Increases the need for oxygen due to the metabolism of brown fat. Can cause diminished production of surfactant impeding lung expansion, and respiratory difficulty. Mild respiratory distress can become severe hypoxia if oxygen must be used for heat production. Glucose demands are higher when the metabolic rate increases in efforts to produce heat. Metabolism of brown fat and glucose in the presence of insufficient oxygen causes production of acids and metabolic acidosis can occur. d) Describe body system changes after birth to include the immune, hematologic, renal, endocrine, gastrointestinal, hepatic and neurological systems Immune: WBC's respond slowly and inefficiently when the body is invaded by organisms. Leukocytes rise during the first 12 hours after birth and then decline slowly. The increase in VVBC does not necessarily indicate infection, actually may decrease in infections. An increased number of immature leukocytes are a sign of infection or sepsis in the neonate, along with a decrease in platelets. IGg is the only immunoglobulin that crosses the placenta providing the fetus with passive temporary immunity to bacteria, bacterial toxins ad viruses which the mother is immune to. IgM is the first immunoglobulin produced by the body when the newborn is challenged. IgA does not cross the placenta and must be produced by the infant, and is available in colostrums and breast milk. HematoloQic: Higher RBC's and higher Hgb and Hct than adults. RBC's have a shorter life span. Hemolysis fsoccurs and Hgb is broken down releasing bilirubin. Excess bilirubin can cause jaundice. Newborns are at risk for clotting deficiencies during the first few days of life because they lack vitamin K which is necessary to activate several of the clotting factors II, VII, IX, X. Renal: Full kidney function does not occur until after birth when the kidneys take over the elimination of waste. Blood flow to the kidneys increases after birth due to the decreased resistance in the renal vessels. The GFR does not reach adult levels until 1 to 2 years of age therefore infants have a decreased ability to remove waste products from the blood. The fist voiding occurs within 12 hours of birth and within 24 hours in 95% of all newborns. Insensible water loss is increased in the newborn because of the large surface area of the body and rapid respiratory rate. Newborns tend to lose bicarb at lower levels than adults, increasing their risk of acidosis. Endocrine: Glucose that has been supplied by the placenta is stored as glycogen in the fetal liver and skeletal muscle for use after birth. Until newborns begin regular feedings and their intake is adequate to meet energy requirements, the glucose present in the body is used. Glucose usually falls to the lowest level by 60 to 90 minutes after birth and rises within hours. Gastrointestinal: Capacity is about 6ml/kg at birth to 90ml within the first week. The cardiac sphincter between the esophagus and the stomach is relaxed causing the tendency to regurgitate feedings easily. Digestive tract is sterile at birth. Once the infant is exposed to the external environment and begins to take in fluids, bacteria enter the Gl tract. Normal intestinal flora is established within a few days of life. Pancreatic amylase is excreted by the infant. Usually passed within 12 hours of life and 99% neonates pass meconium within 48hrs. The second type of stool passed is called transitional stool. They are a combination of meconium and milk stool

Hepatic: Conjugating of biiirubin is a major function of the liver and some newborns liver's are not mature enough to prevent jaundice during the first week of life. Prothrombin and coagulation factors II, VII, IX, and X are produced by the liver and activated with Vitamin K which is deficient in newborns. The liver metabolizes drugs inefficiently in the newborn and certain drug amounts can be carried from breast milk to the infant. Neurological: Relfexes are tested...Babinski (lateral stroke on the foot from heel to across), Gallant (stroke the Back lateral to the vertebral column), Grasp (press finger against base of fingers and toes), Moro (drop head back 30 degrees), Rooting (stroke side of cheek), Startle (make loud noise), Stepping (hold infant so feet touch solid surface), Sucking (place nipple or finger in mouth rub & against the palate), Swallowing (place fluid at the back of the tongue), Tonic neck (turn infants head to one side while he or she is supine. Siezures indicate CNS abnormality. High pitched, shrill, hoarse, or catlike, may indicate neurologic disorders. e) Describe signs and symptoms of respiratory distress, jaundice, hypoglycemia, hypothermia, hyperthermia and birth injuries

Respiratory distress: Tachypenea within the first hour. Retractions Nasal flaring, grunting, gasping, moments of apnea>20sec, seesaw respirations, cyanosis Jaundice: Yellow skin and eyes Hypoglycemia: Jitteriness, poor muscle tone, diaphoresis, poor suck, tachypnea, resp. distress, tachycardia Dyspnea, cyanosis, apnea, low temp, high-pitched cry, irritability, lethargy, seizures, coma, may be asymptomatic Hypothermia: Crying and restlessness, Acrocyanosis, (95 to 96.8 F) Hypoglycemia, resp. distress, metabolic I Acidosis, jaundice Hyperthermia: Elevated temp, increased need for oxygen, increased glucose needs, and peripheral vasodilation occurs and may lead to fluid loss Birth Injuries: Absence of relflexes or asymmetric responses. Unilateral drooping of the mouth, one-sided cry No rooting reflex on the affected side, f) Describe periods of reactivity and behavioral states

Early hours after birth the infant goes through changes called the periods of reactivity. These two periods are separated by a period of sleep. After the first period of reactivity the infant becomes quiet and fall into a deep sleep that can last as long as 2-4 hours. Pulse and RR drop into normal range and temp may be low. When the infant awakes they enter the second period of reactivity which lasts for a short time or several hours. They are alert, and interested in feeding and may pass meconium. Pulse and RR increase and may have periods of apnea. 6 behavioral states: 1) Quiet Sleep Statedeep sleep with closed eyes and no eye movements. RR is slow and regular, no body movement. No response to stimuli or noise 2) Active Sleep Statelighter sleep. Moves extremeties, stretches, change facial expressions and sucking movements. RR rapid, irregular and REM occur. Startled by noise or disturbances. 3) Drowsy Statebetween sleep and waking. Eyes may remain closed or if open appear glazed and unfocused. Move extremities slowly and whimper...may gradually awaken. f} 4) Quiet Alert Statefocus on objects or people, respond to parents with intense gazing. Body movements are minimal and seem to concentrate on the environment.

5) Active Alert Stateoften fussy, restless and have faster and more irregular RR and seem more aware of feelings of discomfort from hunger or cold. 6) Crying State may quickly follow the alert state is no intervention occurs to comfort the infant.

g) Discuss initial assessment of the newborn The initial assessment is done to determine the neonates health status. It should include, cardiorespiratory status, thermoregulation, and the presence of abnormalities, measurements. When the infant is stable and oxygenating well, a more thorough assessment can be performs. Cardiorespiratory Status: RR, Breath sounds, Signs of resp. distress. Color Heart sounds Brachial and femoral pulses Blood pressure Capillary refill Temperature (axillary) Head and neck (fontanels, molding, caput succedaneum, cephalhematoma) Neck and clavicles Cord Extremities (hands, feet, hips) Vertebral column Weight, Length Head and chest circumference.

Thermo regulation: Presence of abnormalities:

Measurements:

Objective 4 The student will analyze ongoing newborn needs a) Discuss ongoing assessment of the newborn

Ongoing assessment of the newborn focuses on more specific areas and body systems. Neurological: Reflexes, sensory assessment Hepatic system: Blood glucose, bilirubin, Gl System: Mouth, suck, initial feeding, abdomen and stools, Gentourinary: Kidney palpation, urine, genitalia Integumentary system: Skin (color, lanugo, vernix,erythema toxicum, birth marks, delivery Marks) Breasts, hair, nails Neuromuscular. Posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear, b) Discuss dietary and fluid needs Daily calorie and fluid needs of the newborn are: Calories =110-120 Kcal/kg (50-55 kcal/lb) Fluid = 40 to 60 ml/kg (18-27 ml/lb) for the first two days of life 100 to 150 ml/kg (45-68 ml/lb) by the end of the first week. Breast milk is species specific and the nutrients are proportioned appropriately for the neonate and vary to meet the newborns changing needs. Can provide protection against infection and is easily digested. Breast milk and formula provide the infants fluid needs and additional water is unnecessary. c) Discuss neonatal pathogens and their effect on the newborn

Bacterial infection of the newborn affects 1 to 4 in every 1000 live births. And is the leading cause of death in the neonatal period. They can acquire infections before, during and after birth. Vertical infections are acquired before or during birth from the mother. Some of these organisms are: Cytomegalovirus infection Syphilis Toxoplamosis During labor and birth, organisms in the vagina such as group B streptococci, herpesvirus, and Hepatitis B virus may enter the uterus after rupture of membranes or can affect the infant as he passes through the birth canal. Infections that occurs after birth may result in sepsis neonatorum; systemic infection from bacteria in the blood stream. The blood brain barrier may be ineffective in keeping our organisms so a CMS infection can occur. The most common causative agents of neonatal sepsis are group B streptococci and E-coli. d) Discuss common medications/vaccines used in the neonatal period to include vitamin K, erythromycin, Hep B vaccine, Hep B immunoglobulin

Vitamin K vaccine: Promotes formation of factors II, VII, IX, X by the liver for clotting; provides Vitamin K which is not synthesized in the intestines for the first 5-8 day after birth. Ervthromvcin drops: Antibiotic used in the eyes as prophylaxis against the organisms Neisseria gonorrhoeae, & Chlamydia trachomatis. Required by law whether or not the mother is known to be Infected.

Hepatitis B vaccine: Used to immunize against Hepatitis B in exposed and unexposed infants. Usually given The day of discharge (or within 12 hours of birth) with the second dose is due at 1-2 Hep B Immune Globulin (HBIG): Prophylaxis for infants of hepatitis B surface antigen-positive mothers. Given within 12 hours of birth. Provides antibodies and passive immunity to Hep B. e) Discuss appropriate circumcision and unbilical cord care

Umbilical cord care: should be checked for bleeding or oozing during the early hours after birth. Cord clamp must be securely fastened with no skin caught in it. It will become brownish black within 2 to 3 days and fall off within 10 -14 days. It may be treated with bateriacidal substance such as triple-dye solution, antibiotic ointment, or alcohol and cleaned with at mild soap solution and allowed to dry naturally. Parents can clean the cord with alcohol 3 times a day and keep the diaper fold below the cord to keep it free of urine and dry. Circumcision care: a small piece of guaze may be placed over the area. The diaper is loosely replaced to prevent pressure. The nurse watches closely over the next few hours for complications after the procedure. If excessive bleeding occurs the physician is notified. Noting the first urination after circumcision is important to detect any obstruction. f) Discuss common laboratory studies performed on the newborn

Blood glucose: levels below 40-45 mg/dl have potential for hypoglycemia. PKU. Condition where the infant cannot metabolize amino acid phenylalanine which is common in protein foods and milk products. Accumulation of phenylalanine can result in severe mental retardation. Congenital hypothyroidism (CH): Most common preventable cause of mental retardation. Thyroid does not produce thyroxine hormone Galactosemia: Absence of the enzyme needed for the conversion of milk sugar galactose to glucose. Results in liver damage, brain damage, damage to the eyes and eventually causes death. Hemoglobinopathies: Include sickle cell anemia, thalassemia and other disease. These disease cause chronic anemia, sepsis and other serious conditions. Congenital adrenal hyperplasia: refers to a group of disorders with an enzyme defect that prevents adequate adrenal corticosteroida and aldosterone production, increasing the production of androgens. S/S ambiguous genitalia at birth, masculinized females infants. Salt wasting crisis. g) Discuss the Texas newborn screening program The program currently screens every infant born in Texas, testing for 27 disorders. Early detection and management of these disorders, which are caused by inherited genetic defects (with the exception of Hypothyroidism where only 15% of cases are inherited), prevents mental retardation and other catastrophic health problems in affected children. In most instances, the parents are unaware of being "silent carriers" for the genetic defect, and the diagnosis of a genetic disease in their newborn infant is unanticipated. h) Discuss methods to promote newborn safety in the hospital

{[identifying the Infant- Two bracelets are placed on the infant, one on the mother and one on the father. Information on the band is identical and includes the infants sex, date, and time of birth, delivering doctor, ; mother's name, mother's hospital number and a number imprinted on the plastic band. Other methods to identify the infant are footprints, fingerprints of the mother or photographs of the infant. Birthmarks or other distinguishing features are carefully documented in the nurses notes. Preventing Infant Abduction- teach parents how to recognize picture identification badges worn by the birth facility personel. Never give an infant to someone who does not have proper identification. People entering and leaving maternity units should be observed at all times. Remote exits are locked and often equipped with video cameras and alarms. Preventing infection- wash hands frequently and arms thoroughly throughout the day and before and after any infant is touched. A special disinfectant for cleansing the hands may be used in place of handwashing when the hands are not visibly soiled. Parents should discourage visitors with colds or other infections. Each infants supplies should be kept separate to avoid cross-contamination. If the mother has an infection it is up to the doctor to determine if it is safe for the newborn to remain with her. Nurses must be vigilant for signs of infection during assessment and infant care. i) Develop teaching plan for parents

Most new mothers feel unprepared, physically and emotionally to take over total care of their newborn and themselves. Topics to cover in teaching are: Newborn characteristics and behavior. Use of a bulb syringe Breastfeeding (frequency/length, positioning, latch on, supply and demand, supplementing, potential problems) Formula feeding (frequency/length, positioning, avoiding propping, formula preparation) ^Burping Cord care Care of the penis after circumcision or care of uncircumcised penis Holding and positioning Sleep patterns Elimination patterns Bathing and skin care Clothing Signs of problems Taking a temperature Infant safety Car seat use

Objective 5 The Student will discuss postpartum physiological needs. a) Describe physiological changes and needs Reproductive system: Involution of the uterusProcess involves: contraction of muscle fibers, catabolism, and regeneration of uterine epithelium. Begins immediately after birth of the placenta. Healing at the placental site takes 6-7 weeks. Descent of the uterine /undus--usua!ly has descended into the pelvic cavity by the 10th day and cannot be palpated abdominally. /\fferpa/ns--intermittent uterine contractions. Lochiaconsists mostly of blood with small particles of deciduas and mucos. Lasts usually for 3 weeks but can last as long as 6 weeks. CervixRapid healing takes place after birth and by the end of the first week, the cervix feels firm and the external os is the width of a pencil. The internal os is permanently changed an appears slit like. Vaginaafter birth the vaginal walls appear edematous and multiple lacerations may be present. Very few rugae (folds) are present and the hymen is permanently torn. Vaginal mucosa heals and rugae regained by 3 weeks. It takes 6 weeks for the vagina to complete involution and gain the same size and contour it had before pregnancy, but does not entirely gain its nulliparous size. Perineummay appear edematous and bruised. Episiotomy site takes 4-6 months to completely heal. Cardiovascular system: Cardiac outputdespite blood loss, a transient increase in maternal cardiac output occurs after childbirth. The rise in output which persists for 48 hours after childbirth is caused by an increase in stroke volume, therefore bradycardia may be noted in the early postpartum period, returning to normal within 6 to 12 weeks after childbirth. Plasma volumethe body rids itself of excess plasma volume that was necessary during pregnancy by two methods: Diuresis (increased excretion of urine) and Diaphoresis (profuse perspiration) Coagulationcontinuing elevations in clotting factors continue for several days or longer causing continued risk for thrombus formation. It takes 3-4 weeks for normal levels to return. Blood valuesleukocytosissss occurs while the WBC count increases to as high as 30,000/mm3. Values fall to normal within 4 to 7 days after birth. Hematocrit may return to normal within 4 to 8 wks. Gl sytem: Digestion- begins to be active again soon after childbirth. Constipation is a common problem during postpartum period because of bowel tone and restricted food intake and fluid during labor. Perineal trauma, episiotomy, and hemorrhoids cause discomfort that interfere with bowel elimination. Normal patterns of elimination return within 8 to 14 days. Urinary system: Kidneys return to normal function by 4 to 6 weeks after delivery. Urinary retention may be caused by complications from childbirth such as DTI and postpartum hemorrhage. Stress incontinence that occurs during pregnancy improves within 3 months after birth. Musculoskeletal system: Muscles and joints1 to 2 days after childbirth may experience muscle fatigue and aches because of the exertion during labor. Levels of hormone relaxin gradually subside and ligaments and cartilage of the pelvis return to their pre-pregnancy positions. Abdominal walllongitudnal muscles of the abdomen may separate during pregnancy. May return to normal position within 6 wks after birth.

Integumentary system: Skin changes that occur during pregnancy are caused by increase in hormones. Skin gradually reverts jj::: to pre-pregnancy state after hormones decline following childbirth. Striae gravidarum (stretch marks) gradually fade to silvery lines but do not disappear. Hair loss peaks at 3-4 mo and regrowth begins at 9 mo after birth. Neurologic sytem: Analgesics and anesthesia can produce temporary changes in neurological status (lack of feeling in the legs, and dizziness). Complaints of headache require careful assessment. Frontal headaches are not unusual in the first week postpartum, but severe headaches are not common and could be postpuncture headaches resulting from regional anesthesia. Endocrine system: Adrenal hormones return to prepregnancy levels. Resumption ofovulation and menstruationnon-nursing mothers resume menstruation within 7 to 9 weeks after childbirth. The first few cycles for both lactating and non lactating women are often anovulatory but ovulation may occur before the first menses. Breastfeeding delays the return of both ovulation and menstruation (within 12 wks or as late as 18 months). Lactationafter expulsion of the placenta, estrogen and progesterone decline rapidly and prolactin initiates milk production within 2 to 3 days after childbirth. Once milk is established, it continues because of frequent removal of milk from the breast...the more the infant nurses, the more milk is produced. Weight lossapprox. 4.5 to 5.5 kg are lost during childbirth. This include the weight of the fetus, placenta and amniotic fluid and blood lost. An additional 2.3 to 3.6 kg is lost from dieresis in the early days following birth. Most women approach their pre-pregnancy weight about 6 months after childbirth. _.. Prenatal and neonatal records are checked to determine if Rh(D) immune globulin (RhoGAM) should be fe administered, if the mother is Rh negative and the newborn is Rh positive and the mother is not already desensitized. If not immune, rubella vaccine is recommended after childbirth to prevent her from acquiring rubella during subsequent pregnancies. Both cold and warmth are used to relieve perineal pain after childbirth. Ice packs can be used to treat edema in the perineal area, while sitz baths can increase circulation to the area and promote healing within the first 24 hours. Analgesics such as Tylenol are given for pain and NSAID for inflammation and mild to moderate pain.. Bladder elimination should be encouraged as soon as they are able to ambulate. Approximately 2500ml of fluid should be encouraged a day. Meals and snacks should be available at all times. Assist with ambulation early after childbirth to avoid and prevent thombi b) Compare cesarean birth and vaginal birth in terms of nursing assessments and care Cesarean birth must be assessed like any other post operative patient. Pain relief is provided with a PCA. Respirations must be assessed frequently due to anesthesia and narcotics used for delivery. In addition to observing RR, the mother's breath sounds should be auscultated because of longer periods of immobility. Ausculate for bowel sounds until normal peristalsis returns. If surgical dressing is present, it should be observed for intactness and discharge. Incision is observed for signs of infections. Palpation of the fundus should be done gently with cesarean birth. IV site and rate should be assessed and signs of infiltrations such as edema and coolness at the site. The amount, color and clarithy of urine should be monitored.

c) Describe use of oxytocin, analgesics, Rh immune globulin, and rubella vaccine, methergine |5| Prenatal and neonatal records are checked to determine if Rh(D) immune globulin (RhoGAM) should be % administered, if the mother is Rh negative and the newborn is Rh positive and the mother is not already desensitized. If not immune, rubella vaccine is recommended after childbirth to prevent her from acquiring rubella during subsequent pregnancies Oxytocin can be used for reduction of bleeding after expulsion of the placenta. Methergine is used to prevent and treat hemorrhage caused by uterine atony. d) Develop nursing care to support the physiologic well being of the new mother during the postpartum period. Promote rest and sleep. Make every attempt to allow the mother adequate time for uninterrupted rest periods. Provide Nourishment- low-fat diet with adequate protein, complex carbs, fruits and veggies provide energy and nutrients needed. Promote regular bowel elimination-increase fiber and drinking at least 8 glasses of water a day. Promote good body mechanics- exercise has beneficial physical and psychological effects. Counsel about sexual activity- anticipatory guidance. Instructions about follow up appts-remind the mother to make an appt with her physician for a postpartum exam (usually between 2 to 6 weeks after childbirth)

Objective 6 The student will evaluate postpartum psychosocial needs. a) Indentify parent behaviors that indicate bonding and attachment Behaviors that indicate bonding and attachment refer to the rapid initial attraction felt by parents soon after childbirth. Bonding is unidirectional, from parent to child. This bonding takes place during interaction in the sensitive period extending through the first 30 to 60 minutes after birth. The newborn is quiet and alert and responds to the mothers voice and touch. Attachment is the process in which an enduring bond between parent and child is developed through pleasurable and satisfying interaction. Attachment is reciprocal. Alert infants have a repertoire of responses called reciprocal attachment behaviors. An infant's grasp around the mother finger means "I love you" to the parent. Other reciprocal attachment behaviors are: Make eye contact and engage in prolonged, intense, mutual gazing Move their eyes and attempt to "track" the parent's face Grasp and hold the parent's finger Move synchronously in response to rhythms and patterns of the parent's voice Root, latch onto the breast and suckle Be comforted by the parent's voice or touch.

b) Describe progressive phases of maternal adaptation (taking in, taking hold, letting go) Taking-ln: First phase of maternal adaption during which the mother passively accepts care, comfort, and : details about the newborn. Taking-Hold: Second phase of maternal adaption during which the mother assumes control of her own care and initiates care of the infant. Letting-Go: A phase of maternal adaption that involves relinquishment of previous roles and assumption of a new role as a parent. c) Explain process of family adaptation to the birth of a new infant The birth of an infant requires the reorganization of roles and relationships within the family Fatherfacilitated by engrossment. Characterized by intense interest in how the infant looks and responds, along with the desire to touch and hold. Attachment behaviors of the father increase when the infant is awake, makes eye contact, and responds to the father's voice. Some fathers have difficulty adapting to the changes in role the birth brings. Those with unsteady or part time jobs and those whose relationship with the mother is of shorter length or is less satisfactory are more likely to experience distress than those with steady jobs and longer relationships. One study shows that fathers maintain the same level of functioning in child care and household tasks as they had before the birth, but did not increase participation even though the need was greater. Siblingsadjustment depends on the age and developmental level. Toddlers usually are not completely aware of the impending birth. They may view the infant as competition or fear that they will be replaced in the parent's affection. Negative behaviors may indicated the degree of stress experienced by the youngster. , Preschool siblings may engage in more looking than touching. Older children may adapt more easily. All ^siblings need extra attention from the parents and reassurance that they are loved and important. Parents can encourage older siblings to participate in appropriate aspects of infant care.

GrandparentsGrandparents who live near the child frequently develop strong attachment that evolves into unconditional love and a special relationship that brings joy to the grandparents. Grandparents must try to 'devise ways to foster a relationship with grandchildren they seldom see. Many grandparents strive to be fully -involved in the care and upbringing of the grandchild while others desire less involvement. The degree of involvement my cause some conflict with parents, or it may be a comfortable arrangement for both families. d) Develop nursing care to support the psychosocial needs of the family Teach the family about the newborn. Some parents have unrealistic expectation of the newborn. Provide information about the infant's capabilities as well as the infants physical and emotional needs. Discuss the importance of responding promptly and gently to the cues such as crying and fussing that may indicate the infant needs attention Provide aniticipatory guidance about stress reduction and the demands of the first weeks at home. Help the father or co-parent become involved by including him in teaching and providing opportunities for him to participate in diapering, comforting and feeding the infant. Provide ways to reduce sibling rivalry. Suggest the parents plan time alone with other children and older siblings. Indentify resource for the mother to help with the division of labor. Community resources such as daycare centers, parenting classes,and breastfeeding support are available. Remind the mother that resources are available when she begins to feel isolated and exhausted. e) Identify maternal concerns of body image and postpartum blues. iSome mothers have unrealistic expectations of weight loss and the time it takes for their body to regain its nonpregnant shape. Should be emphasized that weight loss should be gradual and that about 6-12 months is usually required to lose most of the pregnancy weight. Mild depression a.k.a. postpartum blues is a frequently expressed concern. The mild transient condition affects more than 70% of the US women who give birth. The condition begins in the first week and usually lasts no longer than 2 weeks. Characterized by insomnia, irritability, fatigue, tearfulness, mood instability and anxiety. Usually cause by the emotional let down after birth. Hormonal fluctuations are often considered to be the source of the problem, but not the cause. Post partum blues is self-limiting and mothers benefit greatly when empathy and support are given by their family and health care team.

Objective 7
The student will explain pregnancy changes
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a) Differentiate presumptive, probable and positive signs of pregnancy Presumptive indications of Pregnancy Mainly subjective changes that are experienced and reported by the woman. They include: Amenorrhea Nausea and Vomiting Fatigue Urinary Frequency Breast and skin changes Cervical color changes Quickening Probable indications of Pregnancy Objective findings that can be documented by an examiner. They are primarily related to physical changes in the reproductive organs: Abdominal enlargement Cervical softening Changes in uterine consistency Ballottement Braxton Hicks contractions Palpation of fetal outline Postive result of pregnancy tests Positive indications of Pregnancy Only three signs are accepted as positive confirmation of pregnancy: Auscultation of fetal heart sounds, Fetal movement felt by an examiner, Visualization of the fetus with sonography b) Describe physiological changes which occur during pregnancy Physiological changes Changes in the reproductive system: Uterusthe most dramatic change occurs in the uterus and its growth potential. Before pregnancy the uterus is contained entirely in the pelvic cavity and weighs about 50-70g with 10 ml capacity. By 36 weeks of gestation the uterus weight 800-1200g and has a 5000ml capacity. As it enlarges, there is an increase in the number and size of blood vessels which expands the blood flow dramatically. It becomes contractile and by the 12th week of gestation, expands beyond the pelvic cavity and can be palpated above the symphysis pubis. Cervixchanges occur in color and consistency in response to increasing levels of estrogen. It becomes congested with blood resulting in characteristic bluish purple color that extends to the labia and vagina (a.k.a. Chadwicks sign) Vagina and Vulvaincreased vascularity and somewhat similar to those of the cervix. Softening of the connective tissue allow the vagina to stretch during childbirth, phi changes occur to help prevent growth of harmful bacteria found in the vagina . Edema, vascularity and connective tissue changes make the tissues of the vulva and perineum more pliable Ovariesonce conception occurs the main function of the ovaries is to produce progesterone for the first 6-7 weeks of pregnancy.

I? '

Breastschange in size and appearance. Estrogen stimulates growth of mammary ductal tissue and proteserone promotes the growth of lobes, lobules and alveoli. Nipples increase in size and become more erect and the areolae become larger and more pigmented. Changes in the cardiovascular system: Heartchanges are minor and reverse soon after childbirth. The muscles of the heart enlarge slightly because of the increased workload during pregnancy. The heart is pushed upward and to the left as the uterus elevates the diaphragm (3rd trimester). Heart sounds may be altered. The most common are the splitting of the first heart sound and a systolic murmur found in 90% of all pregnant women. Blood volumetotal blood volume (RBC's, WBC's, platelets, and plasma) increase about 40-50% during pregnancy Plasma volumebegins at 6-8 weeks of gestation and peaks at 4700 to 5200 ml at 32 wks. 50% above non pregnant values. Cardiac outputconsequence of the expanded blood volume. Rises rapidly during the first trimester and increased 30-50% by the third trimester. Primarily the result of a gain in the stroke volume but the heart rate also rises 10-20 bpm by 32 wks gestation. Peripheral vascular resistancefalls during pregnancy because 1) smooth muscle relaxation in vessel walls resulting from progesterone effects; 2) addition of the uteroplacental unit providing greater area for circulation; 3) fetal heat production which may produce vasodilation; 4) synthesis of prostaglandins that cause resistance to circulating vasoconstrictors such as angiotensin II and norepinephrine; 5) increased nitric oxide levels causing vasodilation. Blood pressureremains stable despite the increase in blood volume. BP is affected by maternal position Blood flowchanges during pregnancy: 1) Altered to include the uteroplacental unit. 2) About 50% more blood must circulate through the maternal kidneys to remove increased metabolic waste generated by the mother and fetus. 3) Skin requires increased circulation to dissipate heat generated by increased metabolism 4) Blood flow to the breasts is increased two to three times by the end of pregnancy 5) The weight of the expanding uterus on the inferior vena cava and iliac veins partially obstructs blood return from veins in the legs and blood pools in the deep and superficial veins in the legs. Blood componenetsincrease in erythrocytes (25-33%), leukocytes (12,000 to 25,000 cell/mm3), and clotting factors (Factor I: plasma fibrinogen; 50%) Factors II, VII, VIII, X and XII are also increased. Changes in the respiratory system: Oxygen consumptionincreases by 15-20% in pregnancy. Half is used by the fetus and placenta and the rest is consumed by the uterus, breast tissue, and increased maternal respiratory and cardiac demands. Hormonal factorsprogesterone is the major factor in the respiratory changes of pregnancy. Causes mild hyperventilation and along with prostaglandins, it helps decrease airway resistance by relaxing smooth muscle in the respiratory tract. Estrogen causes increased vascularity of the mucous membranes of the upper respiratory tract.

Physical changesby the third trimester, the enlarging uterus lifts up the diaphragm by about 4 cm preventing the lungs from expanding as fully as they normally do.

Changes in the gastrointestinal system: Appetiteoften increased during pregnancy unless the mother is nauseated. This helps to take in additional calories required. Mouthelevated levels of estrogen cause hyperemia of the tissues of the gums and mouth and may lead to gingivitis and bleeding gums. Esophaguslower esophagus sphincter tone decreases during pregnancy primarily because of the relaxant activity of progesterone on the smooth muscle. GERD can occur more easily Stomach and small intestineelevated levels of progesterone cause smooth muscle to relax and decrease tone and motility of the Gl tract. Large and small intestinethe small intestine may not empty durning pregnancy, which may allow additional time for nutrient to be absorbed. This slowed process benefits the growing fetus but may cause bloating and abdominal distention. Decreased motility may lead to constipation. Liver and gallbladderfunctional changes occur. The enlarging uterus pushes the liver upward and backward during the last trimester and liver function is also altered. Serum alkaline phosphatase rises two to four times the normal level and serum albumin level falls gradually. The gallbladder becomes hypotonic and emptying time is prolonged; bile becomes thicker and cholesterol crystal may be retained predisposing to the development of gallstones.

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Changes in urinary system: Bladderfrequency and urgency of urination. Uterus begins to exert pressure on the bladder as it enlarges and bladder capacity doubles by term. Kidneys and ureterskidneys change in size and shape because there is dilation of the renal pelves and calyces. The ureters also dilate above the pelvic brim. Functional changes of the kidneys due to increase in renal plasma flow or the total amount of plasma to flow through the kidneys. This change results from increase in plasma volume and cardiac output. GFR rises by as much as 50% by the end of the first trimester. Changes in the integumentary system: Skincirculation to the skin increases and encourages activity of the sweat and sebaceous glands. Hyperpigmentation increase in 90% of pregnant women as a result of increase progesterone and estrogen levels. Areas include brownish patches called chloasma, melasma. The linea alba, the line that marks the longitudinal division of the midline of the abdomen darkens to become linea nigra. Cutaneous vascular changes occur due to blood vessel dilation and proliferation during pregnancy. Angiomas (vascular spiders) occur on the face, neck upper chest and arms Connective tissuelinear tears occur on the abdomen, breast, and buttocks appearing as slightly depressed pink to purple streaks called striae gravidarum (stretch marks). Hair and nailsfewer follicles that are now in the resting phase so hair grows more rapidly and less hair falls out during pregnancy. Nail growth increases during pregnancy and nails thin and get soft as pregnancy progresses.

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Changes in the musculoskeletal system: Calcium storagefetal demands for calcium increase especially in the third trimester. Absorption of calcium from the intestine doubles during pregnancy. Calcium is stored to meet the later needs of the fetus. Postural changeschanges are progressive. Loosening and widening of the symphysis pubis and the sacroiliac joint creates pelvic instability and may cause pain at the symphysis and inner thighs. During the last trimester the mother must lean backward to maintain balance. Abdominal wallabdominal muscles are stretched beyond their capacity during the 3rd trimester causing the rectus abdominus muscles to separate. Changes in the endocrine system: Pituitary glandprolactin increases to prepare the breast to produce milk. Oxytocin stimulates the milk ejection reflex after birth and stimulates contractions of the uterus. This action is inhibited during pregnancy by progesterone which relaxes smooth muscle fiber of the uterus. Thyroid glandrise in total thyroxine (T-4) occurs along with corresponding gain in thyroxine binding globulin. The basal metabolic rate increase up to 25% primarily because of the metabolic activity of the fetus. Parathyroid glandparathyroid hormone is slightly decreased or at a low normal level during pregnancy. Pancreassignificant changes due to the alterations in maternal blood glucose levels and consequent fluctuation in insulin production. Blood glucose levels during pregnancy are 10-20% lower and hypoglycemia may develop between meals and at night as the fetus continuously draws glucose from the mother. Adrenal glandssignificant changes occur in two adrenal hormones: cortisol and aldosterone. Level of both total cortisol and free cortisol. Cortisol regulates carbohydrate and protein metabolism and stimulates gluconeogenesis whenever the supply of glucose is inadequate to meet the body's need for energy. Aldosterone increases to maintain the necessary level of sodium in the greatly expanded blood volume and to meet the needs of the fetus. Placental hormones hCG is produced by trophoblastic cells surrounding the developing embryo. It is produced to prevent deterioration of the corpus luteum so that it can continue producing progesterone until the placenta is suffieciently developed to assume the function. Estrogenstimulates uterine growth, increases blood supply to the uterine vessels, increases uterine contractions near term, aids in the development of the glands and ductal system of the breasts for lactation, causes hyperpigmentation, vascular changes in the skin and increased activity of the salivary glands Progesteronemaintain the endometrial lining of the uterus for implantation, prevents spontaneous abortion by relaxing smooth muscle of the uterus, helps prevent tissue rejection of the fetus, stimulates development of lobes, lobules in the breast for lactation, facilitates the deposit of maternal fat stores which provide energy reserve. hPLincreases availability of glucose for the fetus. Relaxininhibits uterine contractions, softens connective tissue in the cervix and relaxes cartilage and connective tissue of the pelvic joints.

Metabolismweight gain should average 25-35 Ibs during pregnancy. The fetus, amniotic fluid, and placenta make up less than half the recommended gain. The rest is composed of uterus, breasts, increase blood volume, interstitial fluid and maternal fat stores. Changes in sensory organs: Eyecornea thickens because of edema. Intraocular pressure decreases requiring less medication in women with glaucoma Earschanges in the mucous membranes of the Eustachian tubes causing women to have blocked ears and a mild hearing loss that is temporary. Immune systemaltered to allow for the fetus which is a foreign tissue for the mother, to grow undisturbed without being rejected by the woman's body. Resistance to infection is decreased due to WBC functioning. c) Describe psychological changes which occur during pregnancy Psychological changes First Trimester Uncertaintytries to confirm pregnancy with physician, nurse mid-wife or LNP. Reactions to pregnancy depends on the individual Ambivalencehalf of all pregnancies are unintended and unexpected. Conflicting feelings about being pregnant because it may not be the right time, even if the pregnancy is planned and wanted. Some women wish they had completed a specific goal before becoming pregnant. "Self as a primary focusearly pregnancy comes with nausea, vomiting fatigue and the concept of the fetus seems vague. Second Trimester Physical evidencefetus is now considered "real". Fetal movement can be felt at this time. "Fetus" as primary focusbecomes the womans major focus and producing a healthy infant, disinterested in information about diet and fetal development. Narcissism and introversionworry about being able to protect and provide for the fetus. Selecting the right foods to eat, the right clothes to wear may assume more importance now. Loss of interest in jobs and more on events taking place inside them. Daydreams about what life will be like with the baby. Body imagesome find the changes welcomed because it signifies the fetus is growing and gives a sense of pride, while others find it negative and affect the self image. Sexualityunpredictable and may increase or decline. Physical comfort and sense of well being are closely linked to her interest in sexual activity. Some fear of miscarriage and may avoid sexual activity especially if a miscarriage has occurred before Third Trimester Vulnerabilitymay feel the baby will be lost or harmed if not protected at all times. Nightmares about losing the baby or having a deformed baby cause them to become very cautious. They avoid crowds, or potential physical dangers.

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Increasing dependencedependence on the partner is significant and she may insist that he be easy to reach at all time and may call him several times a time just to be sure that is is available. They fear that something will happen to their partner. Preparation for birththe relationship between the fetus and the mother changes and she realizes that she and the fetus are interrelated, and the baby is a passive presence and not a part of herself. She longs to see the baby and get acquainted with him. They are often tired of being pregnant and want the pregnancy over. Some fear the process of childbirth (pain). Nesting takes place and negotiations with the partner or sharing care and household tasks (yeah, right!!) d) Describe each component of initial prenatal visit Primary objectives for the first prenatal visit are: Verify or rule out pregnancyblood test Evaluate the pregnant woman's physical health relevant to childbearinghealth history, menstrual history, contraceptive history, family history, psychosocial history, partners health history. Assess the growth and health of the fetusultrasound Establish baseline data for comparison to future observationsVS, urinalysis, blood sugar, weight Establish trust and rapport with the childbearing familyanswer questions, provide information, teach Evaluate the psychosocial needs of the woman and her family, childbirth classes, support groups for multipara pregnancy Assess the need for counseling and teaching Negotiate a plan of care to ensure both a healthy mother and a healthy baby. e) Describe each component of return prenatal visits Usual schedule for return visits are : Conception to 28wks every 4 weeks 29-36 wksevery 2-3 weeks 37 wks to birthweekly Assessment focuses on the following; Vital Signs: BP, Respirations, temperature, pulse Urinalysis: detect presence of ketones, protein, glucose, and bacteria Fundal height: evaluates fetal growth and confirms gestational age Leopold's maneuver: Palpation of the fetus through the abdominal wall Fetal heart rate: Doppler transducer or with a fetoscope Fetal activity: kick count, indicates a physically healthy fetus Ultrasound screen: 12 -20 wks, determines gestational age and some fetal anomalies and sex. Glucose screen: 24-28wks Isoimmunization: 28wks for Rh factor... RhoGAM is given. Pelvic exam: determines cervical changes, descent of the fetus and presenting part f) Determine rationales and normal values for prenatal laboratory studies

See Table 7-3 on page 134 of the text. g) Identify substances which have teratogenic effects Alcohol i Aminoglycosides Anticonvulsant agents Antihyperlipidemic agents (statins) Antineoplastic agents Antithyroid drugs

Cocaine Lithium Mercury Infections CMV Herpes simplex virus HIV Rubella

Diethylstibestrol (DES) Retinoic acid Tetracycline

Folic acid antagonist Tobacco Warfarin

Syphilis Toxoplasmosis Varicella

h) Explain the nurse's role in prenatal care

i)

Discuss teaching needs in pregnancy

Teach necessary lifestyle changes to ensure the health of the mother and fetus (prescription, over the counter drugs, tobacco, alcohol, illegal drugs, alternate and complementary therapies (herbal therapy) j) Calculate obstetrical history using 3 & 5 digit systems

The method for calculating gravid and para is to separate pregnancies and their outcome using the acronym GTPAL: G=gravid T=term P=preterm A=abortions L=living children Each letter will correspond with a number (# of pregnancies, #abortions, # of living children etc.) with a minimum of 3 and a maximum of 5 numbers Example: Kathleen Ebergave birth to twins at 32 weeks gestation and to a stillborn infant at 24 weeks gestation. Approximately 2 years later, she experienced a spontaneous abortion at 12 weeks gestation. If pregnant now, she is gravida 4, para 2 (twins count as one parous experience and the stillborn counts as one parous experience). Using the GTPAL acronym, to refer to pregnancies delivered, T=0 (no term babies) P=2 (two pregnancies ending in pretermtwin 32wks, stillborn 24wks) A=1 (one spontaneous abortion) L=2 (two live birthstwins) GTPAL would be 4-0-2-1-2 k) Calculate EDO using Naegele's rule Take the date of the last menstrual cycle, add 7days, subtract 3 months and add the following year. March 14, 2006 LNMP + 7 days March 21, 2006 Subtract 3 months December 21, 2005 Add the following year = December 21, 2006 EDO

Objective 8 The student will analyze pregnancy needs a) Determine physiological and psychosocial and cultural needs

Physiological needs: NauseaA/omiting Reassurance that this is usually temporary and will not harm the fetus. Taking a multivitamin at the time of conception may decrease symptoms. Several antihistamines can be prescribed safely for more severe nausea. IMonpharmacological remedies like ginger may also be used for nausea. Heartburnavoid drinks high in phosphorous such as soft drinks Maintain a well balance diet. Avoid laying down after meals. Eat several small meals a day instead of one large meal. Use antacids that are low in sodium. Eliminate smoking and curtail intake of caffeine. Backacheavoid high heel shoes and wear comfortable shoes. Do not bend at the waist when picking up item; squat instead. Get regular exercise and maintain correct posture. A maternity back binder for use in pregnancy is helpful. Round ligament painTry a heating pad if pain persists. Avoid stretching and twisting at the same time. When getting out of bed, turn to the side and then get up slowly Urinary frequencyPerform kegel's often to maintain bladder control; 30 times a day if possible. VaricositiesApply support hose or elastic stockings that reach above the varicosities before getting out of bed each morning. Take frequent rest periods with the legs elevated above the level of the hips. HemorrhoidsTake frequent tepid baths. Drink plenty of water. External hemorrhoids can be pushed aback into the rectum using a lubricated gloved index finger. Apply witch hazel or anesthetic ointments. ConstipationAdditional fiber is necessary in the diet. Restrict consumption of cheese. Drink at least 8 glasses of water each day (not tea, coffee, or carbonated drinks...these cause diuretic effect) Psvchosocial needs: First Trimester (period of maternal self-focus). Teaching should be aimed at the common early changes in pregnancy and their normality. Coping with morning sickness, sexuality and mood swings are important subjects to explore with the couple. It should be explained that these changes are normal and generally do not indicate problems. Second Trimester (the fetus is the primary focus) Ultrasound allows a visual confirmation of the fetus. Quickening, the feeling of fetal movement occurs during this time. This experience is important because it confirms the presence of the fetus with each movement. Teaching should be aimed at body image changes, diet and fetal development and changes in sexuality. Third Trimester (Preparation for the infant... nesting) Many couples complete childbirth classes at this time . Negotiation of changes in how she and her partner will share household task are among the plans. Teaching should be aimed supporting the womans fears of labor, and preparing for the delivery. Cultural: Culture often determines the health beliefs, values and expectations of the family when a woman becomes pregnant. A woman who does not normally follow certain beliefs of her culture may adhere to them jduring pregnancy. Cultural differences that cause conflict between health care providers and families during 'pregnancy are observed most often in the area of health care beliefs, communication, and time orientation.

When health professionals violate cultural norms, women are less likely to follow health instructions and education given.

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b) Discuss danger signs during pregnancy Vaginal bleeding Rupture of membranes Swelling of the fingers orpuffiness around the eyes Continuous pounding headache Visual disturbancesflashing light, spots before the eyes, blurred vision Perisistant or severe abdominal pain Chills or fever Painful urination Persistent vomiting Change in frequency or strength of fetal movements Signs of preterm laboruterine contractions, cramps, constant or irregular backache, pelvic pressure c) Develop nursing care for the antepartal woman

Discuss and practice self care measures taught to promote safety and health of the mother and fetus. Explain methods to help relieve common discomforts of pregnancy. Identify a plan early in pregnancy to modify habits that could adversely affect health, such as curtailing the use of alcohol and tobacco.

Objective 9 The student will evaluate pregnancy nutritional needs.

a) Identify special nutritional needs and b) Describe rationales for special nutritional needs Nutritional needs increase during pregnancy but the amount varies. Extra food needed to meet pregnancy requirements are: 1 carrot, 1 slice of whole wheat bread, Vz banana, and 1 glass of low-fat Energy (kcal): milk; second trimester. Add 1/2 banana in the third trimester. Rationale: Reals are obtained from carbs and proteins which provide 4 calories to each gram and fats which provide 9 calories to each gram. Extra calories are needed during pregnancy to provide maintenance of the fetus, placenta and added maternal tissue and increased basal metabolic rate. Protien: 1-2 oz. meat, fish, or poultry or 3 C. of milk, or 3 oz. cheese, or 1C cottage cheese or 1 block(4oz) of tofu or 1C. brown rice and 1 Y2 C. beans Rationale: necessary for metabolism, tissue synthesis, and tissue repair during pregnancy. If calories are too low and protein is used for energy, fetal growth is impaired. Iron: 1oz red meat and 1C lima beans and Y2 C spinach and 1C broccoli Rationale; needs for iron are increased during pregnancy. 200mg for normal daily losses, 300mg for transfer to fetus for production of RBC's and iron storage. If the transfer of iron to the fetus is inadequate due to decrease in maternal intake of iron, then the fetus will use the maternal stored iron. Thiamine: Vz C. bran flakes or% C. peanuts or 1 Y2 oz pecans or 1oz ham or 1 V2C rice or 1C macaroni Rationale: Needs to be increased because of intake of calories. They form coenzymes needed to release energy. Riboflavin: % C. milk or cottage cheese or 2oz oatmeal or 1 Y2 oz beef or 1C broccoli or 1C spinach Rationale: Needs to be increased because of greater intake of calories. Forms coenzymes necessary to release energy Niacin: 1T peanut butter or 4 slices of bread or 1oz meat; also made by body from tryptophan Rationale: Needs to be increased because of greater intake of calories. Forms coenzymes necessary to release energy. Vitamin C: 2tsp orange juice or Y2 C peaches or Y2 C apple or 1 1/2 T tomato juice

Rationale: Not stored in the body, therefore need to supplement. Necessary for the formation of fetal tissue. The need is increased in smoking, drug or alcohol abuse and aspirin use in mother. c) Describe nutritional status on the course and outcome of pregnancy

Age, knowledge about nutrition, exercise habits and cultural background influence the food choices women make and their nutritional status. Meeting nutritional requirements for pregnancy should focus on "energy needs, protein, calcium, iron, zinc, vitamin B12, vitamin A. Morning sickness is usually temporary and most women can consume enough food to maintain nutrition sufficiently. In addition to teaching dietary needs and changes, it is important to be alert to abnormal prepregnancy weight. Obese woman may have other health problems such as HTN that may affect the nurse's nutritional status. d) Describe fetal nutritional needs ???? not sure e) Analyze weight gain

Women should meet the RDA for pregnancy by eating the recommended number of servings of foods from each food group. She should gain 1.6kg during the first trimester and 0.4kg per/week during the second and third trimester. Total weight gain should be 11.5 to 16kg. Weight is assessed at the initial visit and subsequent visits. Other indication of nutritional status include any signs of deficiency (bleeding gums) Even though food intake may not be enough to allow for optimal health and storage of nutrients, most women obtain enough nutrients to avoid signs of deficiency. S/S include: pallor, low Hgb, fatigue, and increase susceptibility to infection. f) Describe common methods of nutritional assessment

Assessment begins with discussion of the woman's appetite; has it changed? Eating habits, food preferences, psychosocial influences (cultural or religious), diet history, physical assessment, laboratory tests. Reassessing nutritional status includes dietary status, any difficulty with the womans diet, check weight to see if it is in the expected range, evaluate Hgb and Hct level to check anemia. g) Discuss appropriate nutritional supplements

Ironnot supplied completely and easily by diet during pregnancy. Approximately 1000mg of iron is needed during pregnancy, of this SOOmg is used by the maternal RBC's, 200mg for daily losses, and SOOmg for transfer to the fetus for production of RBC's and iron storage. Folic acidnoi obtained in adequate amounts through normal food intake. Especially important before conception and in the first trimester after conception. 400mcg (0.4mg) of folic acid is required daily before pregnancy and 600mcg (0.6mg) during pregnancy. Deficiency in the first trimester can lead to spontaneous abortion and neural tube defects. h) Develop nursing care to meet the nutritional needs of the pregnant patient

Identify problems with nutrition. Explain nutrient needs. Provide reinforcement for eating appropriately. Evaluate weight gain, encourage supplement intake, and make referrals to dietician or public assistant programs.

Objective 10 The student will discuss methods of fetal surveillance during labor
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5 Two basic approaches to fetal monitoring are taken: Low technology and High technology Low Technology: uses intermittent auscultation (IA) of the fetal heart rate (FHR) and palpation of uterine activity. Most often used in home births and birthing centers. Uses either a nonelectronic fetoscope or Doppler ultrasound fetoscope. Fingertips palpate uterine activity High Technology: Uses electronic fetal monitoring (EFM) to monitor FHR. 85% of live births use EFM. Supplies more data about the fetus than IA and archives a permanent record on paper, computer media, or both. Continuous EFM shows how the fetus responds before, during, and after each contraction rather than occasional contractions. a) Identify the purposes of intrapartal fetal assessment The purpose of intrapartal fetal assessment is to monitor and identify signs associated with well-being and with compromise. At a minimum, intrapartum fetal assessment includes evaluation of the FHR and the mother's uterine contractions. b) Explain types of equipment used EFM equipment consists of the bedside monitor unit and sensors for FHR and uterine activity. Sensors for each function may be internal or external. Bedside Monitor Unitrecieves information about FHR and uterine activity from the sensors. It processes the info and provides output in the form of a numeric display and a printed strip. *" Paper StripFHR and uterine activity are printed on a paper strip having horizontal grid for the FHR and another for the uterine activity. FHR is recorded on the upper strip and the uterine activity on the lower grid as bell shaped curves. Data Entry Devices and Computer Softwareused to archive fetal monitoring information plus other info relating to the care of mother and fetus. May extend beyond the intrapartum stay and be used for documentation in the postpartum and newborn periods. Remote Surveillancedisplay units at the nursing station or other locations to allow surveillance when the nurse is not at the bedside. They have settings for alert such as upper and lower limits for the FHR, decelerations and end of paper. Devices for External Fetal MonitoringBoth FHR and uterine activity can be monitored by external sensors, or transducers secured on the mothers abdomen by elastic straps, a tube of wide stockinette, or an adhesive ring. Less accurate than internal ones but are non-invasive. c) Describe types of periodic patterns seen via electronic fetal monitoring Accelerations are abrupt, temporary increase in the FHR that peaks at least 15bpm above the baseline and lasts at least 15 seconds. Accelerations usually occur with fetal movement. Decelerations are classified into three types based on their shape and relationship to uterine contractions. !' *Early decelerationsnot associated with fetal compromise and require no intervention. They occur during contractions as the fetal head is pressed against the woman's pelvis or soft tissue such as the cervix.

Late decelerationsresults from a deficient exchange of oxygen and waste products in the placenta. This nonreassuring pattern suggests that the fetus has reduced reserve to tolerate the recurrent reductions in oxygen supply that occur with contractions. Variable decelerationsresult from conditions that reduce flow through the umbilical cord. They do not have uniform appearance of early or late decelerations. They fall and rise abruptly with the onset and relief of cord compression. Their shape, duration and degree of fall below baseline vary. d) Explain differences between reassuring and non-reassuring fetal heart rate patterns
Reassuring FHR patterns: Accelerations are usually a reassuring sign reflecting a responsive, non acidotic fetus. Nonreassuring FHR patterns suggest that the fetus has reduced reserve to tolerate the recurrent reductions in oxygen supply that occur with the contractions causing hypoxia or acidosis. Can be cause by maternal hypotension or chronic conditions that impair placental exchange such as hypertension, diabetes.

e) Analyze appropriate nursing actions when non-reassuring fetal heart rate patterns occur.
INTERVENTIONS:

Identify the cause of the nonreassuring patterns: Check the mothers vital signs can indentify hypertension or hypotension and fever. Some sedatives can alter variability in the well-oxygenated fetus. A vaginal exam may identify a prolapsed cord or compression causing bradycardia and decelerations or both. Internal monitoring is chosen for greater accuracy.(fetal scalp electrode) ' Increase placental perfusion: The woman is placed in a nonsupine position to eliminate aortacaval compression, which can reduce placental blood flow. Increase infusion of IV fluids such as LR solution to increase the maternal blood volume to better perfuse the placental if hypotension in the problem. Hypotonic uterine activity may compromise fetal reserves therefore, oxytocin is discontinued or slowed so uterine activity is not stimulated. Increase maternal blood oxygen saturation: Administer 100% oxygen through snug face mask to 8-10L/min Reduce cord compression: reposition the woman side to side or elevate her hips to shift the fetal presenting part toward her diaphragm. A hand and knee position may reduce compression on the cord. Amnioinfusion increases the fluid around the fetus and cushions the cord. LR solution or NS is infused into the uterus through an IUPC.

Objective 11 The student will evaluate intrapartal pain management a) Describe unique pain factors during labor

Involves two components: Physiological component including reception by sensory nerves and transmission to the CNS. Psychological component which involves recognizing the sensation, interpreting it as painful and reacting to the interpretation. Pain is subjective and personal. Childbirth pain is different from other pain in several aspects: 1) It is part of a normal process 2) Preparation time exists 3) It is self-limiting 4) Labor pain is not constant but intermittent 5) Labor ends with the birth of a baby. b) Describe factors that influence responses to pain Physiological reponses: Four sources of labor pain exists in most labor. Tissue eschemiablood supply to the uterus decreases during contractions leading to tissue hypoxia and anerobic metabolism causing ischemic uterine pain. Cervical dilationdilation and stretching of cervix and lower uterus are a major source of pain. Pressure and pulling on pelvic structuressuch as ligaments, fallopian tubes, ovaries, bladder and peritoneum. The pain is a visceral pain; referred to her back and legs.
3sycholoqical

responses: Poorly relieved pain can lessen the pleasure of this extrodinary life event for both partners. The womans support partner may feel inadequate during birth and feel helpless and frustrated when her pain is unrelieved.

Physical influences to pain: Intensity of laborshort intense labors are more severe in pain. Rapid labor may limit her options for pharmacologic pain relief as well Cervical readinessIf cervical changes are incomplete, the cerivix does not open as easily...more contractions are needed to achieve dilation and effacement resulting in longer labor and more fatigue. Fetal positionlabor is more likely to be longer and more painful when the fetus is in an unfavorable position. Characteristics of the pelvissize and shape influence the course and length of labor. Fatigue and hungerReduces ability to tolerate pain and to use coping skills she has learned. Extremely fatigued women have exaggerated responses to contractions and may be unable to respond to the sensations of labor such as the urge to push. Psychosocial factors: Cultureinfluences how she perceives, interprets, and responds to pain during childbirth. Anxiety and fearhigh anxiety and fear maginify sensitivity to pain and impair a woman's ability to tolerate it.

Previous experiences with painfear and withdrawal are a woman's natural reactions to pain during labor. Learning about the normal sensations of labor including pain, helps a woman suppress her natural reactions of : ,fear and withdrawal. Preparation for childbirthA woman should be prepared realistically including reasonable expectations about analgesia and anesthesia. Support systemAnxiety in others can be contagious, increasing the woman's anxiety. She may assume that is others are worried than something must be wrong. c) Analyze factors that affect the use of pharmacologic and non-pharmacologic pain management techniques during childbirth. Non-pharmacologic pain management: Methods usually used to compliment pharmacologic pain management although some may use them as their only pain management technique. They do not slow labor and have no side effects or risk of allergy. Non pharmacologic methods may be the only option for a woman who enter the hospital in advanced rapid labor....drugs may not have enough time to take effect. As a sole method of pain relief, women do not always achieve their desired level of pain control. Pharmocologic pain management: includes systemic drugs, regional pain management techniques and general anesthesia. Effects on the fetus may be direct (decreased FHR)or indirect (maternal hypotension and decreased blood flow to the placenta) Fetal hypoxia and acidosis may result. Regional analgesia can slow progress during the second stage of labor by impairing the woman's ability to push. Complications during pregnancy may limit the choices of analgesia or anesthesia. Interactions with other substances may limit choices of analgesia and anesthesia as well. I d) Discuss use of sedatives, analgesics, regional and general anesthetics, antiemetics and opiod antagonists

Opioid analgesics: during labor and postop pain. Cesarean birth. Administered IM, IV, or PCA postop. Epidural Opioids: mixed with local anesthesia for pain relief during labor. Postoperatively given as long lasting non sedative allowing mother and infant to interact. Intrathecal Opioid Analgesics: first stage labor without maternal sedation. Not adequate for late labor or birth. Local Infiltration Anesthesia: Numbs the perineum for episiotomy at vaginal birth. No relief of labor pain. Pudendal Block: numbs the lower vagina and perineum for vaginal birth. No relief of labor pain; done just before birth. Adequate anesthesia for forcepts assisted birth. Epidural Block: insertion of catheter provides pain relief for labor, and vaginal birth or planned cesarean birth. If used during labor of C-section, then it can be extended upward to T-4-T6 level. Subarachnoid Block: can be established faster than epidural block in C-section. Rarely used in complicated vaginal birth. Does not provide pain relief in labor. General Anesthesia: Used in C-section birth if epidural or spinal block is not possible or if the woman refuses regional anesthesia. May be required for emergency procedures such as replacement of inverted uterus.

Sedatives: barbiturates are not routinely given due to fetal depression, however, small amounts of short-acting ^barbiturates can be given to promote rest if a woman is fatigued from false labor or a prolonged latent phase.

e) Explain pharmacologic pain management methods in regard to body area affected, advantages, disadvantages, maternal effects, fetal effects, residual effects on the newborn, methods to overcome adverse effects Advantages: Provide pain relief without loss of consciousness. May be used for intrapartum analgesia, surgical anesthesia or both. Greatest relief of pain from labor and birth. Disadvantages: Any drug a woman takes is likely to affect the fetus. Drugs may have effects in pregnancy that they do not have in non pregnant persons. Pregnancy complications may limit the choice of pharmacologic pain management methods. Women who require other therapeutic drugs or preparations or practice substance abuse have fewer safe choices for pain relief. Maternal effects. Affects the cardiovascular system, respiratory system, Gl system, and nervous system. Drugs can affect the length and course of labor. Adverse affects from epidurals are maternal hypotension, bladder distention, prolonged second stage labor, catheter migration, cesearan births, maternal fevers. Adverse affects of epidural opioids are N/V, pruritis, delayed respiratory depression. Fetal effects: Cross the placenta to the fetus either directly or indirectly. Causes decrease in FHR. If the drug causes maternal hypotension then the blood flow to the placenta is decreased causing hypoxia and acidosis in the fetus. Residual effects on the newborn: General anesthesia can cause the baby to be slow to breathe at birth. Methods used to overcome adverse effects: Restricting fluids or maintaining NPO can reduce the risk for aspiration during anesthesia. Administering drugs to reduce the acidic secretions in the stomach can reduce nausea and vomiting. Neonatal respiratory depression can be prevented by reducing the time from induction of anesthesia to clamping of the umbilical cord. Keeping use of sedating drugs and anesthetics to a minimum until the cord is clamped. IV fluids are increased to reduce the effect of hypotension caused by eipidural and spinal blocks. Narcan can be given to the infant at birth to reverse the effects of general anesthesia. f) Develop nursing care to promote pain management Focus on reducing factors that hinder pain control and enhance those that benefit it. Non-pharmacologic Relaxationprovide environmental comfort and general comfort. Reduce anxiety and fear and implement specific relaxation technigues. Cutaneous Stimulationencourage self massage or massage by others. Apply counterpressure and touch. Many woman like warmth applied to the back, abdomen, and perineum during labor. Hydro therapytub bath, whirlpool is relaxing and provides thermal stimulation. Mental Stimulationpractice imagery technique. Focal point technique Breathing Techniquesfirst stage breathing (cleansing breath, slow-paced breathing, modified paced breathing, patterned-paced breathing, breathing to prevent pushing). Second stage breathing (prolonged breath holding while breathing) Pharmacologic |i | Vital signs and FHR are taken at the usual intervals for the woman's stage of labor. Treat N/V, hypotension, and ensure safety and avoidance of injury.

Objective 12 The student will analyze labor induction/augmentation a) Discuss indications for induction or augmentation

Performed when a continued pregnancy may jeopardize the health of the woman or fetus and labor and vaginal birth are considered safe. Induction is not done if the fetus must be delivered more quickly than the process permits, in which case a cesarean birth is performed. Augmentation of labor with Oxytocin is considered when labor has begun spontaneously but progress is slowed or stopped. Induction is indicated in the following conditions: Intrauterine environment is hostile to fetal well-being. Spontaneous rupture of the membranes at or near term without onset of labor Postterm pregnancy Chorioamnionitis (inflammation of the amniotic sac) Hypertension associated with pregnancy or chronic Htn Abruptio plancentae (separation of a normally implanted placenta) Maternal medical conditions that worsen with continuation of the pregnancy (ie. diabetes, renal disease heart disease, pulmonary disease) Fetal death b) Discuss contraindications for induction or augmentation Any contraindication to labor and vaginal birth is a contraindication to induction or augmentation of labor. l ^Induction is contraindicated in the following conditions: Placenta previa (abnormal implantation of the placenta in the lower uterus, presents first before the fetus). Results in hemorrhage during labor Vasa previa (fetal umbilical cord vessels branch over the amniotic sac rather than inserting into the Placenta) Results in fetal hemorrhage. Umbilical cord prolapsed (cord compression) Abnormal fetal presentation for which vaginal birth is often hazardous Fetal presenting part above the pelvic inlet Previous surgery in the upper uterus (previous cesarean incision or uterine fibroids) One or more low-transverse cesarean deliveries Breech presentation of the fetus Conditions in which the uterus is overdistended such as multi-fetal pregnancy Severe maternal conditions such as heart disease and severe HTN. Fetal presenting part above the pelvic inlet, Nonreassuring FHR patterns (added stress of stimulated contractions will reduce placental perfusion) c) Describe methods and medications used to induce or augment labor

Amniotomy is the method of surgical induction and augmentation because rupturing membranes stimulates uterine contractions and occasionally may be adequate in itself if the cervix is very favorable. A disposable plastic hook (AmniHook) is used to perforated the amniotic sac. Mechanical methods for cervical ripening involve placing hydrophilic inserts into the cervical canal where they labsorb water and swell, gradually dilating the cervix, (ie. Dilapen, Lamicel, Laminaria)

Medical methods for induction and augmentation use drugs such as prostaglandis, IVoxytocin (Pitocin) or both to stimulate contractions. Prostaglandisused to ripen the cervix via intravaginal gel, intracervical gel, time-released vaginal inserts IVOxytocin (Pitocin)Started slowly and increased gradually through a primary line. Uterine activity and FHR patterns are monitored when given. Oxytocin is reduced when the woman is in the active phase of labor and 5-6 cm of cervical dilation. d) Develop nursing care for the patient who is undergoing labor induction or augmentation Observe the woman and fetus for complications and take corrective actions if abnormalities are noted. Before induction and augmentation, the nurse determines whether the FHR and fetal heart patterns are reassuring. Observe the mothers response and uterine activity for hypertonus that may reduce fetal oxygenation and contribute to uterine rupture. Blood pressure and pulse are taken QSOmin. Temp is checked every 2-4 hours. Record intake and outtake to indentify fluid retention which may precede water intoxication. After birth the mother is observed for postpartum hemorrhage caused by uterine relaxation. Hypovolemic shock may occur with hemorrhage.

Objective 13 The student will discuss operative obstetrical procedures a) Describe operative obstetrical procedures Operative obstetrical procedures are referred to as operative vaginal births (forceps, or vacumm extraction) Cesarean births, and episiotomies. Cesarean birthregional anesthesia such as an epidural is commonly used. Premeds are used to control gastric and respiratory secretions. The fetus is monitored for 20 to 30 minutes after admission for a scheduled C-section. A wedge under one hip and a tilted operating table avoid aortocaval compression and promote placental blood flow. A single dose of prophylactic antibiotics are given. Two incisions are made, one in the abdominal wall the other in the uterine wall. The bladder is then separated from the uterine wall and held downward with a retractor; the uterus is incised. The physician lifts the fetal presenting part through the uterine incision. The infants face is wiped and nose is suctioned. Cord is clamped and cut. The physician then removes the placenta and oxytocin is given to contract the uterus firmly. Then the incisions are closed and wash with a topical antibiotic solution. Forceps birthcurved metal instruments shaped to grasp the fetal head. The are used to assist the descent and rotation of the fetal head from an occiput posterior or occiput transverse position to the occiput anterior position. Vacuum assisted birthuses suction to grasp the fetal head while traction is applied. It is not used to deliver the fetus in a nonvertex presentation such as breech or face; otherwise it's use is similar to that of forceps. Used to assist the descent and rotation of the fetal head to the occiput anterior position. Episiotomyincision made in the perineal area one when the fetal presenting part is crowned to a sdiameter of about 3-4 cm. Two types have different advantages and disadvantages: median (midline) and mediolateral (see figure pg 378 16-8) Amniotomybreaking of the amniotic sac. A disposable plastic hook is commonly used to perforate the amniotic sac. The hook is passed through the cervical opening, snagging the membranes. The opening is enlarged with the finger, allowing fluid to drain. Internal versionused to change fetal position. Used in malpresentation in twin gestation and is usually managed by cesarean birth but internal version is sometimes used for vaginal birth of the second twin. It is an unexpected, urgent procedure. The physician reaches into the uterus with one hand and with the other hand on the maternal abdomen, moves the fetus into a longitudinal lie to allow delivery. External Cephalic versionUsed to change fetal position from breech, shoulder or oblique presentation. Preformed at a location that allows for a possible c-section. The woman is given a tocolytic drug to relas the uterus while the version is performed. Epidural block or other analgesics may be given to reduce discomfort during the procedure. Labor induction is done immediately after successful ECV or the woman may await spontaneous labor or later induction. b) Describe indications for cesarean birth, forceps and vacumm assisted births, episiotomy, amniotomy, and internal and external version c) Describe precautions and contraindications for mother and fetus Cesarean birth Indications:performed when awaiting vaginal birth would compromise the mother, fetus or both. They include but are not limited to the following: Dystocia (difficult or prolonged labor) Cephalopelvic (fetopelvic) disproportion

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HTN Maternal disease such as diabetes, heart disease, or cervical cancer if labor is not advisable Active genital herpes Some previous uterine surgical procedures such as a classic cesarean incision Persistent nonreassuring FHR patterns Prolapsed umbilical cord (cord compression) Fetal malpresentation such as breech, or transverse lie Hemorrhagic conditions such as abruption placentae or placenta previa

Contraindicationsfew exist. Conditions include fetal death, a fetus that is too immature to survive and maternal coagulation defects. Risks/Precautionsmore potential risk than vaginal birth but the safest major surgical procedure. Mother: Infection Hemorrhage UTI Thrombophlebitis, thromboembolism Paralytic ileus Atelectasis Anesthesia complications Infant: Inadvertent preterm birth Transient tachypnea of the newborn caused by delayed absorption of lung fluid Persistent pulmonary HTN of the newborn Injury such as laceration, bruising, and other trauma

^Forceps and vacumm C *-, Indicationsconsideredassisted births should be shortened for the well-being of the woman, fetus or both if the second stage and if vaginal birth can be accomplished quickly without undue trauma. They may include the following: Maternal indications may include exhaustion, inability to push effectively. Cardiac and pulmonary disease. Fetal indications my include nonoreassuring FHR patterns, failure of the fetal presenting part to fully rotate and descend into the pelvis Paritial separation of the placenta or non reassuring FHR near the time of birth. Contraindicationsc-section is preferable if the maternal and fetal condition mandate a more rapid birth than can be accomplished with forceps or vacuum extraction and if the procedure would be too traumatic. Severe fetal compromise Acute maternal conditions such as congestive heart failure Pulmonary edema High fetal stations Disproportion between size of fetus and maternal pelvis Risks/Precautionsmain risk is trauma to fetal and maternal tissues. Mother Lacerations and hematoma of the vagina Infant Ecchymoses Facial and scalp lacerations and abrasions Facial nerve injury, Cephalhematoma Subgaleal hemorrhage and intracranial hemorrhage |f Vacuum extractor can cause scalp edema (chignon) at the application area ^*'The attempt at an instrumental birth usually is abandoned if the fetal head does not descend easily and a csection is preferred.

Episiotomy Indicationsconsidered to reduce pressure on the head when a small, preterm infant is born. Maternal benefits are unclear. Contraindicationsroutine prefomance of an episiotomy remains controversial Risks/PrecautionsInfection is the main risk of episiotomy; perineal pain impairs resumption of sexual intercourse and makes it uncomfortable for the woman.

Amniotomy Indicationsperformed in conjunction with induction and augmentation of labor and to allow for fetal monitoring and inducing uterine contractions. Contraindicationsnone noted however not used as the sole means to induce and augment labor. Risks/Precautionsthree risks associated with rupture of membranes which may lead to emergency procedures Prolapse of umbilical cord (cord compression) Infection (chorioamnionitis) Abruption placentae Internal and External version Indicationsused when the fetus is not in the proper position for birth (breech, transverse lie or oblique presentation);may allow for the avoidance of a c-section. Internal version is usually done for vaginal birth of athe second twin. Contraindicationsif the woman is likely to deliver vaginally, which is the goal of the procedure. Mother Uterine malformation that limit the room available to perform the version Previous cesarean birth with a vertical uterine incision Disproportion between fetal size and maternal pelvic size. Infant Placenta previa Multifetal gestation which reduces the room available in which to turn the fetus or fetuses Oligohydramnios, ruptured membranes and a cord around the fetal neck or body Uteroplacental insufficiency Engagement of the fetal head into the pelvis

d) Analyze nurses role in operative obstetrical procedures Assess the woman and the fetus and help reduce anxiety. Explain the indications and the risks to the woman before she signs an informed consent and verify their understanding of the purposes, risks and limitations of the procedure and related treatments. Observe appropriate site for edema and hematoma (episiotomy) and apply cold packs if needed. Provide emotional support with postoperative care. Observe fetal responses. In addition to temp, monitor vital signs, respiratory character and oxygenation Return of motion and sensation if a regional block was given. LOG particularly if general anesthesia and sedatives were given Abdominal dressing Uterine firmness and position ||_ochia (color, quantity, other characteristics) HV infusion (rate, fluid, condition of the IV site) Pain relief medication

The nurse is responsible for administering uterine stimulants to a pregnant woman. She must decide when to start, change and stop an oxytocin infusion using the facility's protocol and medical orders. This responsibility requires additional education and refinement of the nurses critical thinking skills. e) Develope nursing care for the patient who has an operative obstetrical procedure. Care plan on pg. 384-385 of text

Objective 14 The student will explain postpartum complications a) Indentify risk factors Two most common risk factors in the postpartum period are hemorrhage, and infection Hemorrhage: Grand multiparity (5 or more) Overdistention of the uterus or uterine atony (large baby, twins hydramnios) Precipitous labor (less than 3 hours) Prolonged labor Retained placenta Subinvolution of the uterua (delayed return of the uterus to prepregnancy size and consistency) Placenta previa or abruption placentae Induction and augmentation of labor Administering of tocolytics to stop uterine contractions Operative procedures (vacuum extraction, forceps, cesarean birth) Trauma to the birth canal (vaginal, cervical or perineal lacerations and hematomas Infection: Operative procedures (vacuum extraction, forceps, cesarean birth) Multiple cervical examinations Prolonged labor (more than 24 hrs) Prolonged rupture of membranes Manual extraction of placenta Diabetes Catheterization Anemia (Hgb <1 0.5 mg/dl) b) Describe multidisciplinary actions that can prevent postpartum complications To prevent hemorrhage: Frequent assessments; Q15min during the first hour after birth, QSOmin for the next 2 hours, and Q1 hr for the next 4 hours. Monitor for S/S of hemorrhage and infection, and perform actions to minimize postpartum hemorrhage and prevent hypovolemic shock. To prevent infection: Aseptic technique for all invasive procedures and meticulous handwashing. Prevent urinary stasis; adequate intake of fluids, encourage the woman to empty her bladder every 2-3 hours during the day, Teach breast feeding technique to empty the breast at each feeding to reduce the risk of nipple trauma Teach S/S of infection: fever, chills, dysuria, redness and tenderness of the wound c) Describe signs and symptoms of early and late postpartum hemorrhage, uterine subinvolution, hypovolemic shock, thromboembolic disorders, puerperal infection and affective disorders S/S of postpartum hemorrhage: Uncontracted uterus, large gush or slow steady trickle or ooze of blood from the vagina. Saturation of more than one peripad per hour. Severe unrelieved perineal or rectal pain. Tachycardia. of uterine subinvolution: Prolonged discharge of lochia, irregular or excessive uterine bleeding, and "sometimes profuse hemorrhage. Pelvic pain, pelvic heaviness, backache, fatigue and persisten malaise.

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S/S of hypovolemic shock: Tachycardia, gradual increase in the pulse rate. A decrease in blood pressure and narrowing of the pulse pressure. Respiratory rate increase. Vasoconstriction in the vessels cause the skin to become pale and cool to the touch. As hemorrhage worsens, the skin changes to pallor and becomes cold and clammy. S/S of thromboembolic disorders: DVT's: Swelling of the involved extremity as well as redness, tenderness, and warmth. An enlarged, hardened, cordlike vein may be palpated. Pain when walking. Sometimes there are no sign at all. Pulmonary embolism: Dyspnea, sudden, sharp chest pain, tachycardia, syncope, tachypnea, pulmonary rales, cough and hemoptysis. Pulse ox. shows low saturation. S/S of puerperal infection: Endometritis: Fever, chills, malaise, lethargy, anorexia, abdominal pain and cramping, uterine tenderness, and purulent, foul-smelling lochia. Additional signs include tachycardia and subinvolution. Wound Infection: Edema, warmth, redness, tenderness and pain. Edges of the wound may pull apart and seropurulent drainage may be present. Mastitis: Mother may think she has the flu because of fatigue and aching muscles. Symptoms progress to fever, chills, malaise, and headache. Localized are of pain, redness and inflammation. A hard tender area may be palpated. S/S of urinary tract infection: Dysuria, urgent and frequent urination and suprapubic pain, low grade fever. Upper UTI can cause, fever, chills, costovertebral angle tenderness, flank pain and N/V. S/S of septic pelvic thrombophlebitis: Pain in the groin, abdomen, or flank. May present with fever, tachycardia, Gl distress and decreased bowel sounds, a spiking fever that does not respond to antibiotics. d) Identify appropriate medications used to treat the various postpartum complication

Methergine: Used to treat and prevent postpartum or postabortion hemorrhage caused by uterine atony or t subinvolution. Hemabate, Prostin 15M: used for the treatment of postpartum hemorrhage cuased by uterine atony. Clindamycin, ampicillin, cephalosporins, metronidazole: Used to treat endometritis and UTI Heparin (IV) therapy: used to treat septic pelvic thrombophlebitis. Oxytocin, methylergonovine, and prostaglandis: used to treat postpartum hemorrhage. e) Discuss multi-disciplinary management of post partum complications Massage the fundus of the uterus until it is firm and express clots that may have accumulated in the uterus to manage uterine atony. Hemorrhage caused by trauma may require the woman to return to the surgical area to view the lacerations. She is place in a lithotomy position and carefully draped while repairs are made. Oxytocin is administered for postpartum hemorrhage. If bleeding continues, dilation and curettage may be necessary to remove placenta! fragments. To manage hypovolemic shock, treatment is focused on controlling bleeding. Second IV line is inserted to accommodate whole blood. Sufficient fluid volume in infused to produce urinary output of 30ml/hr. To manage subinvolution, Methergine is given for 24 to 48 hours to sustain uterine contractions. "'To manage thromoembolic disorders, analgesics, rest and elastic support (TED hose) are used. Elevation of the affected extremity improves venous return. As soon as able, the woman should ambulate frequently. If

unable to ambulate then ROM exercises should be done. SCO's can be used for mothers with varicose viens, a history of DVT or thrombosis or cesarean birth. f) Develop nursing care for the patient who has a postpartum complication Care plan on pg 752.

Objective 15 The student will analyze labor variations a) Describe types of dysfunctional labor patterns Normal labor is characterized by progress. Dysfunctional labor is one that does not result in normal progress of cervical effacement, dilation, and fetal descent mainly due to ineffective contractions: Two types of dysfunctional contractions. Hypotonic dysfunction: Contractions too weak to be effective; infrequent and brief. Usually occurs during the active phase of labor when progress normally quickens. Easily indented at peak. Minimal discomfort because the contractions are weak. Occurs after 4cm dilation. Hypertonic dysfunction: Contractions are uncoordinated and erratic in their frequency, duration and intensity. Painful but ineffective. Usually occurs in the latent phase of labor. Occur before 4cm dilation. Ineffective maternal pushing: Ineffective pushing may result from the following conditions: Use of incorrect pushing techniques and positions Fear of injury because of pain and tearing sensations felt by the mother. Decreased or absent urge to push Maternal exhaustion Analgesia or anesthesia that suppresses the woman's urge to push. Psychological unreadiness to "let go" of her baby. b) Describe maternal and fetal risks during prolonged labor to precipitous labor Possible maternal and fetal problems in prolonged labor include the following: Maternal infection, intrapartum or postpartum-lf membranes have ruptured for a prolonged time because organisms ascend from the vagina Neonatal infection, which may be severe or fatalIf membranes have ruptured for a prolonged time because organisms ascend from the vagina Maternal exhaustion Higher levels of anxiety and fear during a subsequent labor Precipitous labor is one in which birth occurs within 3 hours of its onset, (not the same as precipitate birth) Several conditions that are associated with precipitate labor can affect the mother or the fetus. These conditions may include: abruption placentae, fetal meconium, maternal cocaine use, postpartum hemorrhage, or low apgar scores for the infant. The fetus may suffer direct trauma such as intracranial hemorrhage or nerve damage during a precipitate labor. The fetus may become hypoxic because intense contractions with a short relaxation period reduce time available for gas exchange in the placenta c) Explain passage, passenger and the powers in the pathophysiology of dysfunctional labor Passage: The birth passage that consists of the maternal pelvis and soft tissue.The pelvic brim (linea terminalis) divides the bony pelvis into the false pelvis (top) and the true pelvis (bottom). The true pelvis is most important in childbirth and has three subdivisions: 1. The inlet or upper pelvic opening 2. The midpelvis or pelvic cavity 3. The outlet or lower pelvic opening problems with the passage associated with dysfunctional labor are: Dysfunctional labor may occur because of Variations in the maternal bony pelvis (passage) or soft-tissue that inhibits fetal descent. A small pelvis or abnormally shaped pelvis may retard labor and obstruct fetal passage. During labor a full bladder can cause

soft tissue obstruction but reducing the available space in the pelvis and intensifies maternal discomfort (cathing may be needed). Passenger: The passenger is the fetus, membranes and placenta. Problems with the passenger associated with dysfunctional labor are related to: Fetal size Fetal presentation or position Mutifetal pregnancy Fetal anomalies Powers in the pathophysiology of dysfunctional labor are responses to excessive or prolonged stress which interfere with labor in several ways: 1. Increased glucose consumption reduces energy supply available for contracting the uterus. 2. Secretions of catecholamines (EPH, NPH) by the adrenal glands stimulate beta receptors which inhibit uterine contractions. 3. Adrenal secretions divert blood supply from the uterus and placenta to skeletal muscle. 4. Labor contractions and maternal pushing efforts are less effective because these powers are working against resistance of tense abdominal and pelvic muscles. 5. Pain perception is increased and pain tolerance is decreased, which further increase maternal anxiety and stress. Problems associated with powers: The powers of labor may not be adequate to expel the fetus because of the ineffective contractions and ineffective maternal pushing efforts. Possible causes are: Maternal fatigue Maternal inactivity Fluid and electrolyte imbalance Hypoglycemia Excessive analgesics or anesthesia Maternal catecholamines secreted in response to pain or stress Disproportion between the maternal pelvis and the fetal presenting part Uterine overdistension such as multiple gestation or hydroamnios. d) Develop nursing care for the patient experiencing dysfunctional labor. Nursing care should center around maternal needs and safety of the fetus. Reduce the risk of infections and indentify infections. Conserve maternal energy and promote coping skills Goals and expected outcome relate to detecting the onset of infection: Maternal temp will remain below 38C (100.4 F) The FHR will remain near the baseline and below 160bpm The amniotic fluid will remain clear and without a foul or strong odor Contractions must continue for labor to progress. Two goals or expected outcomes should be: Rest between contractions with muscles relaxed Use coping skills such as breathing and relaxation techniques.

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Objective 16 The Student will analyze pre-term labor a) Define preterm labor Preterm laboronset of labor after 20 weeks and before the beginning of the 38th week of gestation. b) Identify risk factors Medical History: Low weight for height Obesity Uterine or cervical anomalies, uterine fibroids HX of cone biopsy DES exposure as a fetus Chronic illness (cardiac, renal, diabetes, clotting disorders, anemia, HTN) Peridontal disease Obstetric History: Previous pre-term labor Previous preterm birth Previous first trimester abortions (>2) Previous second trimester abortion History of previous pregnancy losses (>2) Incompetent cervix Cervical length 25mm or < at mid trimester of pregnancy Number of embryos implanted Present Pregnancy: Uterine distention (multi-fetal pregnancy, hydroamnios) Abdominal surgery during pregnancy Uterine irritability Uterine bleeding Dehydration Infection Anemia Incompetent cervix Preeclampsia/HELLP syndrome Preterm PROM (premature rupture of membranes) Fetal or placental abnormalities Lifestyle and demographics: Little or now prenatal care Improper nutrition < 18 yo or > 40 yo Low educational level Low socioeconomic status Smoking > 10 cigarettes daily Nonwhite Employment with long hours and/or standing for long periods of time Intimate partner violence Substance abuse

c) Explain methods used to predict preterm labor Methods used to predict preterm tabor: Cervical lengthmeasured by transvaginal ultrasound. PROM in previous birthsassessment and HX of predisposition to subsequent pregnancies Fetal fibronectin (fFN)a protein found in the fetal tissues is normally found in the cervical and vaginal secretions until 16-20 weeks gestation and again at or near term. If it appears too early, it suggests that labor may begin similar to the way cardiac enzymes rise in the person with at Ml. Infectionsoften increase the risk for preterm membrane rupture or birth even if the woman has no S/S initially. d) Explain multidisciplinary measures used to prevent/control preterm labor Initial measures to stop preterm labor: Indentify and treat infections, identify other causes of preterm labor that may be treatable, and reducing anxiety. Hydration with IV fluids may be chosen if maternal dehydration is a factor but not used to prevent preterm contractions. Some drugs are also used to stop preterm labor (magnesium sulfate) Limiting activity usually by relaxing in a side-lying or semi-sitting position increases placental blood flow and reduces fetal pressure on the cervix. e) Discuss tocolytics, beta-adrenergic agents and corticosteroids TocolvticsAdvantages used to reduce preterm labor is not clear. Most likely ordered if preterm labor occurs before the 34th week of gestation (respiratory and other complications in fetus are high during this time). The lowest possible dose to inhibit contractions is used. Beta-adrenergic(Brethine) stimulates beta-adrenergic receptors of the SNS. Action results primarily in bronchodilation and inhibition of uterine muscle activity. Increases pulse rate and widens pulse pressure. Causes tachycardia in mother and fetus. Magnesium sulfateused to treat PIH to prevent seizures it has the effect of quieting uterine activity and often used to inhibit preterm labor. Corticosteroids(Dex, Betamethasone) acceleration of fetal lung maturity to reduce the incidence and severity of respiratory distress syndrome. Studies suggest that antenatal steroids can also reduce the incidence of intraventricular hemorrhage and neonatal death in the preterm infant. Given between 24 to 24 weeks gestation because of the high incidence of RDS that affect infants of this age. f) Develop nursing care for the patient who is experiencing pre-term labor

Nursing care includes interventions related to drug therapies used to inhibit preterm labor (see above) or antibiotic drug therapy. If labor cannot be halted then care is given similar to that of the laboring woman with the additional care to prepare for a preterm infant needs at birth. Support for anticipatory grieving may be needed if the infant is very immature and expected to die. Interventions focus on providing information to decrease anxiety and fear related to the unknown. Promoting expression of concern about problems in pregnancy. Teaching what may occur during a preterm birth (visit the NICU).

Full Care plan for preterm labor Pg. 720-721 in the text

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Objective 17 The Student will explain obstetrical emergencies. a) Describe the following conditions: uterine rupture, uterine inversion, prolapsed umbilical cord, amniotic fluid embolous, and trauma Uterine rupturea tear in the wall of the uterus occurs because the uterus cannot withstand the pressure against it. May preceded labor's onset. Three variations exist: 1. Complete rupture: direct communication between the uterine and peritoneal cavities. 2. Incomplete rupture: rupture in the peritoneum covering the uterus or into the broad ligament but not the peritoneal cavity. 3. Dehiscence: a partial separation of an old uterine scar. Little or no bleeding may occur. No S/S may exist and the rupture may be found during a subsequent C-section birth or abdominal surgery. Uterine inversionsuterus is completely or partly turned out, usually during the third stage of labor. Uncommon but potentially fatal. Can be caused by: 1. 2. 3. 4. 5. 6. 7. Pulling on the umbilical cord before the placenta detaches from the uterine wall Fundal pressure on an incompletely contracted uterus after birth Fundal pressure during birth Increased intraabdominal pressure An abnormally adherent placenta Congenital weakness of the uterine wall Fundal placenta implantation

Prolapsed umbilical cord(aka cord compression) cord slips downward after the membranes rupture subjecting it to compression between the fetus and pelvis. May occur when membranes initially rupture or long after. This interruption in the blood flow through the cord interferes with fetal oxygenation and is potentially fatal. Amniotic fluid embolous(aka Anaphylactoid Syndrome) occurs when amniotic fluid is drawn into the maternal circulation and carried to the woman's lungs. Fetal particulate matter in the fluid obstructs pulmonary vessels....leading to hypoxemia. Abrupt respiratory distress, depressed cardiac function and circulatory collapse occur rapidly. Thrombo-rich amniotic fluid interferes with normal blood clotting and is often fatal (50% maternal death rate during the acute episode). Survivors may have neurological deficits. The mothers well being takes precedence in this case. If cardiac arrest occurs, survival is highly unlikely and the fetus may be delivered to improve survival odds for the baby. Traumausually occurs from accidents, assault or suicide. Battering is a significant cause of maternal-fetal trauma during pregnancy. As the uterus grows it protrudes and becomes a larger target for trauma. Trauma may not be fatal but infant neurological deficits may be found after birth. The most common cause of fetal death is death of the mother. b) Identify the multi-disciplinary management in obstetrical emergencies

When cord prolapsed occurs the priority is to relieve pressure on the cord to improve blood flow through it until delivery. Prompt actions reduce cord compression and increase oxygenation to the ^ gfetus: Position the womans hips higher than her head to shift the fetal presenting part toward her diaphragm a) Knee-chest position b) Trendelenburg position c) Hips elevated with pillows while side lying Avoid or minimize manual palpation or handling of the cord Ultrasound exam may be used to confirm presence of fetal heart activity before csection delivery. In uterine ruptures the management is to stabilize the mother and fetus and perfom cesarean delivery and blood is replaced as needed. Uterine inversion is managed by quick action to reduce maternal morbidity and mortality. Birth attendant tries to replace the uterus through the vagina into a normal position. If that is not possible, then a laparotomy with replacement is done. Hysterectomy may be needed. Therapuetic management for amniotic fluid embolous is medical and includes the following: CPR support Oxygen with mechanical ventilation Fluid volume expanders; blood transfusions as indicated Hemodynamic monitoring to guide therapeutic interventions Vasopressor therapy Blood component therapy such as fibrinogen packed RBC's platelets, fresh frozen plasma to correct coagulation defects. c) Develop nursing care for the patient who has an obstetrical emergency Nurse must remain calm while working quickly during this time and acknowledging the womans anxiety. Explanations must be simple.

Stay alert to S/S of uterine rupture. Notify the birth attendant if hypertonic contractions occur\e and maintain m

Nursing care of the trauma victim is focused first on maternal and then on fetal stabilization.

Objective 18 The student will analyze antepartal complications a) b) c) d) e) Describe common antepartal complications Describe pathophysiology of each complication Describe multi-disciplinary management of the each complication Discuss medications used to treat the various complication Explain maternal and fetal risk associated with the complication

Hemorrhagic conditions: Early pregnancy 1. Abortionspontaneous abortion is a termination of pregnancy without action taken by the mother or another person. Most common cause is congenital abnormalities that are often incompatible with life. Management: Exam of the reproductive system to determine whether anatomic defects are the cause. If anatomically normal then referral to genetic screening is given. 2. Ectopic Pregnancyimplantation of a fertilized ovum in an area outside the uterine cavity. Aka "a disaster of reproduction" for two reasons: it remains a significant cause of maternal death from hemorrhage, it reduces the woman's chance of subsequent pregnancies because of extensive damage to fallopian tubes Management: Depending on whether the tube is intact or ruptured. May not be managed if tube is ruptured. The goal is to preserve the tube and improve the chance of future fertility. Surgical management of a tubal pregnancy that is unruptured may involve a linear salpingostomy to salvage the tube. When the tube is ruptured the management is to control the bleeding and prevent hypovolemic shock. 3. Gestational Trophoblastic Disease(aka hydatidiform mole) occurs when trophoblasts develop abnormally, as a result the placenta but not the fetal part of the pregnancy develops. Grapelike clusters of tissue rapidly fill the uterus to the size of an advanced pregnancy. Can be with no fetus present of with partial in which fetal tissue of membranes are present. Management; Two phases: 1) evacuation of the trophoblastic tissue of the mole. 2) continuous follup of the woman to detect malignant changes of any remaining trophoblastic tissues. Treatment for any other problems such as HEG or preeclampsia. Late pregnancy 1. Placenta PreviaImplantation of the placenta in the lower uterus. Resulting in the placenta being closer to the internal cervical os thatn the presenting part (usually the head) of the fetus. Can be Marginal; 3cm from the os, Partial; within 3cm of os, Total; completely covers the os. Only 10% of placenta previa in the second trimester remain a previa at term. Management: evaluated to determine the amount of hemorrhage and electronic fetal monitoring is initiated to evaluate the fetus. Conservative management may take place in the home or hospital. 2. Abruptio Placentaeseparation of a normally implanted placenta before the fetus is born. Occurs in cases of bleeding and formation of a hematoma on the maternal side of the placenta. As the clot expands, further separation occurs. Hemorrhage may be apparent or concealed.

Management: Hospitalized is incurred and evaluation is done. If the condition is mild and the fetus is immature and shows no signs of distress, conservative management may be initiated. Best rest, and administration of tocolytic meds to decrease uterine activity are given. Immediate delivery of the fetus is necessary if signs of fetal compromise exists or if the mother exhibits signs of excessive bleeding (obvious or concealed) Pathophysiology of Hemorrhagic Conditions: Abortionfetus is not viable and able to live outside the uterus. Usually < 20wks gestation or weighing < 500g is not viable. Mostly caused by congenital abnormalities that are incompatible with life. Can be chromosomal (50-60%) Gestational Trophoblastic Diseasetrophoblasts develop abnormally, as a result the placenta but not the fetal part of the pregnancy develops. Grapelike clusters of tissue rapidly fill the uterus to the size of an advanced pregnancy. Can be with no fetus present of with partial in which fetal tissue of membranes are present. Placenta Previaimplantation of the placenta in the lower uterus. Resulting in the placenta being closer to the internal cervical os than the presenting part (usually the head) of the fetus. Abruptio Placentaeseparation of a normally implanted placenta before the fetus is born. Occurs in cases of bleeding and formation of a hematoma on the maternal side of the placenta. As the clot expands, further separation occurs. Medications used in treatment: After abortion, Oxytocin, Methergine or Prostiglandis is given to stimulate uterine contractions. ^ Risk to Mother and Fetus: following spontaneous abortion, maternal risk for DIC (consumptive f coagulopathy), a life threatening defect in coagulation that may occur with several complications of pregnancy. Ectopic pregnancy is the #1 cause of maternal death from hemorrhage and reduces the chance of subsequent pregnancies. Persistent gestational trophoblastic disease may undergo malignant change and may rnetastasize to distant sites such as the lung, vagina, liver and brain. Placenta previa can cause fetal compromise if maternal bleeding is excessive, then delivery is mandatory regardless of gestational age of the fetus. Maternal hypovolemia can occur with preterm labor. Abruptio placentae causes hemorrhage and hypovolemic shock in the mother. Fetal vessels are disrupted as placental separation occurs resulting in fetal and maternal bleeding. Major dangers for the fetus are asphyxia, excessive blood loss and prematurity. Hyperemesis gravidarum: (HEG) Persistent, uncontrolled vomiting that begins before the twentieth week of pregnancy. May continue throughout pregnancy although its severity usually lessens. Unlike morning sickness which usually lessens and is self-limited and causes no complications, HEG can have serious consequences. Management: R/O other cause of N/V. Lab studies include determining the Hgb/Hct which may be elevated as a result of dehydration which results in hemoconcentration. Electrolyte studies may reveal reduced sodium, potassium and chloride. Elevated creatinine levels indicate renal dysfunction. Drug therapy may be required. Pathophysiology of Hyperemesis Gravidarum: Cause is unknown but the condition is common among unmarried white women during first pregnancies and in multifetal pregnancies. Some theories include possible allergy to fetal proteins. Some hormones that are elevated during pregnancy (estrogen and hCG) are considered a possible cause along with thyroid dysfunction and most recently association with HelioBacter Pylori.

Medication used in treatment: Drug therapy may be required if the vomiting becomes severe. These medications are: Phenergan (Promethazine) Benadryl (Diphenhydramine) Pepcid or Zantac (famitodine, ranitidine) Nexium or Prilosec (someprazole, omeprazole) Reglan or Zofran (metoclopramide, ondansetron) Methylprednisolone Risk to Mother and Fetus: Maternal risks are loss of 5% or more of prepregnancy weight, dehydration, ketosis, acid-base imbalance, electrolyte imbalance. Metabolic alkalosis may develop due to large amounts of HCL acid are lost in the vomitus. Vit. K loss can cause coagulation problems and thiamine loss can cause encephalopathy.

Hypertensive Disorders: Preeclampsiasystolic BP of > = to 140mm Hg or diastolic BP of >=90mmHg occurring after 20 weeks of pregnancy accompanied by proteinuria and edema Eclampsiaprogression of preeclampsia to generalized seizures that cannot be attributed to other causes. Seizures may occur postpartum. Gestational hypertensionBP elevation after 20 weeks of pregnancy that is not accompanied by protienuria. Can progress to preeclampsia Management: Early identification allows intervention before the condition reaches the seizure stage in most cases. Magnesium sulfate is the drug of choice to control eclamptic seizures. Women are monitored carefully for ruptured membranes, signs of labor or abruption placentae. Activity restrictions apply and blood pressure is : monitored 2-4 times a day at home and weight should be taken each day. Monitor urine output for protein daily and a diet ample in protein and calories. Pathophysiology of Hypertensive disorders: Preeclampsia is a result of generalized vasospasm. During pregnancy, vascular volume and cardiac output increase significantly. Despite the increases, blood pressure does not rise in normal pregnancy. Peripheral vascular resistance decreases because of the effects of certain vasodilator, such as protacyclin and endothelium derived releasing factor. In preeclampsia however, peripheral vascular resistance increases because some women are sensitive to angiotensin II and a decrease in vasodilators. Medications used in treatment: Apresoline (hydralazine) is used if the systolic BP is >=160mmHg or diastolic BP is >=110mmHg. It relaxes arterial smooth muscle to reduce blood pressure. Other medications such as nifedipine, or labetalol may be used. Magnesium sulfate is used to prevent seizures. Phenytoin (Dilantin, Diphenylan) are sometimes used. Lasix may be given if pulmonary edema develops. Risk to Mother and Fetus: Vasopsasm decreases the diameter of the blood vessels, which results in endothelial cell damage. Vasoconstriction results in impeded blood flow thus causing elevated blood pressure. As a result, circulation to all parts of the body is decreased. The fetus is likely to experience intrauterine growth restriction and persistent hypoxemia and acidosis when maternal blood flow through the placenta is reduced.

HELLP Syndrome: Acronym for "hemolysis, elevated liver enzymes, and low platelets". Life-threatening occurance that complicates about 10% of pregnancies. Half have severe preeclampsia although Htn is not present. Management: women should be managed in a setting with intensive care facilities available. Treatment includes magnesium sulfate to control seizures and hypdralazine to control the blood pressure. Fluid

replacement is managed to avoid worsening the woman's reduced intravascular volume without giving her too much which could cause pulmonary edema or ascites. Labor induction is done if the gestation is at least 34 weeks. Pathophysiology of HELLP Syndrome: Hemolysis is thought to occur as a result of the fragmentation and distortion of erythrocytes during passage through small damaged blood vessels. Liver enzyme levels increase when hepatic blood flow is obstructed by fibrin deposits. Hyperbilirubinemia and jaundice amyoccur as a result of liver impairment. Low platelet levels are cause by vascular damage resulting from vasospasm; plateles aggregate at sites of damage, resulting in thrombocytompenia, which increases the risk for bleeding, usually in the liver. Medications used in treatment: magnesium sulfate to control seizures and hydralazine to control blood pressure. Risk to Mother and Fetus: Maternal risks are great. A sudden increase in intraabdominal pressure, including a seizure could lead to rupture of a subcapsular hematoma, resulting in internal bleeding and hypolovemic shock. Hepatic rupture can lead to fetal and maternal mortality Chronic Htn: whenever evidence suggests that htn preceded the pregnancy or when a woman is hypertensive before 20 weeks gestation. Management: a dietician should be consulted about approprieat dies and weight gain. Reduce salt intake. More frequent prenatal visits and monitoring of fetal kicking used to assess growth and development of fetus. Pathophysiology of Chronic Htn: Because the natural fall in blood pressure occurs during early prengnancy, the woman's blood pressure may appear normal when she enters prenatal care. Medications used in treatment: If diastolic pressure remains higher than lOOmmHg in early pregnancy, Aldomet (methyldopa) is the drug of choice. B-blockers and calcium channel blockers may also be used if Aldomet is not effective. Risk to Mother and Fetus: Maternal hazard is the development of preeclampsia which occurs in 20% of women with chronic Htn. Poor fetal growth patterns or signs that are nonreassuring such as falling amount of amniotic fluid compromise the fetus. Rh Factor: incompatibility between maternal and fetal blood. Possible only when two specific circumstances co-exist: 1. The expectant mother is Rh-negative 2. The fetus is Rh-postive The Rh factor affects the fetus and causes no harm to the expectant mother. Management: blood test done on initial prenatal visit to determine blood type and Rh factor. Coombs test is done in Rh neg women to determine whether they are sensitized (developed antibodies) as a result of previous exposure to Rh-pos. blood. RhoGAM is given at 28 weeks to prevent sensitization and then abain within 72hrs after delivery. Amniocentesis may be performed to determine the Rh factor of the fetus or to evaluat change in the optical density of amniotic fluid. Pathophysiology of Rh Factor. Rh incompatibility can occur if the Rh-neg woman conceives a child who is Rh-positive. As a result of exposure to the Rh-postitive antigen, maternal antibodies may develp that cause ,hemolysis of fetal Rh-positive red blood cells in subsequent pregnancies.

Medications used in treatment: RhoGAM (Rh (D) immunoglobulin) injection is given to the mother at 28 weeks gestation and within 72 hrs after birth.

Risk to Mother and Fetus: If antibodies to the Rh factor are present in the expectant mother's blood, they cross the placenta and destroys fetal erythrocytes. The fetus becomes deficient in RBC's which are needed to transport oxygen to fetal tissue. As fetal RBC's are destroyed, fetal bilirubin levels increase which can lead to neurologic disease. This hemolytic process results in rapid production of erythroblasts which cannot carry oxygen. This syndrome is known as erythroblastosis fetalis. The fetus can become so anemic that generalized fetal edema results and can end in fetal congestive heart failure.

ABO incompatibility: occurs when the mothers blood type is O and the fetus is blood type A, B or AB. These types contain a protein component (antigen) that is not present in type O blood. Management: No specific prenatal care is needed. During delivery the cord blood is taken to determine the blood type of the newborn and the antibody titer. Pathophysiology of ABO incompatibility: ABO incompatibility usually occurs when the mother has type O blood and naturally occurring anti-A and anti-B antibodies, which cause hemolysis if the fetus's blood is not type O. ABO incompatibility may result in hyperbilirubinemia of the infant, but usually presents no serious threat to the health of the child. Risk to Mother and Fetus: ABO incompatibility may result in hyperbilirubinemia of the infant, but it usually presents no serious threat to the health of the child.

f)

Develop nursing care to meet the needs of the antepartal patient who is experiencing: An adolescent pregnancy, diabetes mellitus, hyperemesis gravidarum, domestic violence, substance abuse, RH incompatibility, and infection

Care plan for Preeclampsia is on pg. 650-651 of the text. Care plan for Antepartum bleeding is on pag. 637-638 of the text.

Objective 17 The Student will explain obstetrical emergencies. a) Describe the following conditions: uterine rupture, uterine inversion, prolapsed umbilical cord, amniotic fluid embolous, and trauma Uterine rupturea tear in the wall of the uterus occurs because the uterus cannot withstand the pressure against it. May preceded labor's onset. Three variations exist: 1. Complete rupture: direct communication between the uterine and peritoneal cavities. 2. Incomplete rupture: rupture in the peritoneum covering the uterus or into the broad ligament but not the peritoneal cavity. 3. Dehiscence: a partial separation of an old uterine scar. Little or no bleeding may occur. No S/S may exist and the rupture may be found during a subsequent C-section birth or abdominal surgery. Uterine inversionsuterus is completely or partly turned out, usually during the third stage of labor. Uncommon but potentially fatal. Can be caused by: 1. 2. 3. 4. 5. 6. 7. Pulling on the umbilical cord before the placenta detaches from the uterine wall Fundal pressure on an incompletely contracted uterus after birth Fundal pressure during birth Increased intraabdominal pressure An abnormally adherent placenta Congenital weakness of the uterine wall Fundal placenta implantation

Prolapsed umbilical cord(aka cord compression) cord slips downward after the membranes rupture subjecting it to compression between the fetus and pelvis. May occur when membranes initially rupture or long after. This interruption in the blood flow through the cord interferes with fetal oxygenation and is potentially fatal. Amniotic fluid embolous(aka Anaphylactoid Syndrome) occurs when amniotic fluid is drawn into the maternal circulation and carried to the woman's lungs. Fetal particulate matter in the fluid obstructs pulmonary vessels....leading to hypoxemia. Abrupt respiratory distress, depressed cardiac function and circulatory collapse occur rapidly. Thrombo-rich amniotic fluid interferes with normal blood clotting and is often fatal (50% maternal death rate during the acute episode). Survivors may have neurological deficits. The mothers well being takes precedence in this case. If cardiac arrest occurs, survival is highly unlikely and the fetus may be delivered to improve survival odds for the baby. Traumausually occurs from accidents, assault or suicide. Battering is a significant cause of maternal-fetal trauma during pregnancy. As the uterus grows it protrudes and becomes a larger target for trauma. Trauma may not be fatal but infant neurological deficits may be found after birth. The most common cause of fetal death is death of the mother.

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b) Identify the multi-disciplinary management in obstetrical emergencies

Objective 19 The student will analyze pregnancy induced hypertension a) List characteristics Increased blood pressure; systolic increase of SOmmHg, diastolic increase of 15mmHg over the baseline pressure for the individual woman on two assessments at least 6-hr apart. Occurs mostly in the last trimester Proteinuria Edema b) Define classifications of hypertension during pregnancy Preeclampsiasystolic BP >= 140mmHg or diastolic BP >= QOmmHg that develops after 20wks gestation and is accompanine by proteinuria >0.3g ub a 24 hr urine collection (random urine dipstick is usually >=1+) EcclampsiaProgression of preeclampsia to generalized seizures that cannot be attributed to other causes. Gestational hypertensionSystolic BP >=140mmHg or diastolic BP >=90mmHg that develops after 20 wks gestation but without significant proteinuria (neg or trace on a random urine dipstick) Chronic HypertensionSystolic BP >=140mmHg or diastolic BP >=90mmHg that was known to exist before pregnancy or develops before 20 wks gestation. Also diagnosed if the hypertension does not resolve during the postpartum period. Preeclampsia superimposed on chronic hypertensionDevelopment of new-onset proteinuria >0.3g in a 24hr collection in a woman who has chronic hypertension. I a woman who had proteinuria before 20wks, - preeclampsia should be suspected if the woman has a sudden increase in proteinuria from her baseline levels, a sudden increase in BP when it had been previously well controlled, development of thrombocytopenia (platelets < 100,000/mm3) or abnormal elevations of liver enzymes (AST or ALT). c) Explain pathophysiology In normal pregnancy vascular volume and cardiac output increase significantly. Despite these increase, blood pressure does not rise in normal pregnancy. This is probably because pregnant women develop resistance to the effects of vasoconstrictors such as angiotensin II. Peripheral vascular resistance decreases because of the effects of certain vasodilators such as Prostacyclin and endothelium derived relaxing factors (EDRF). In preeclampsia, however, peripheral vascular resistance increases because some women are sensitive to angiotensin II. They also may have a decrease in vasodilators. Vasospasm decrease the diameter of blood vessels which results in endothelial cell damage and decreased EDRF. Vasocontriction also results in impeded blood flow and elevated BP. As a result, circulation to all body organs including kidneys, liver, brain and placenta is decreased. d) Determine genetic risk factors Family history of PIH, Mother or sister who had preeclampsia Expectant father previously fathered a pregnancy in another woman who had the disorder e) Discuss maternal and fetal risks Major cause of prenatal death and is often associated with intrauterine fetal growth restriction (IUGR), persistent hypoxemia and acidosis when maternal blood flow through the placenta is reduced.

Pulmonary edema, circulatory or renal failure and incracranial hemorrhage are additional risks associated with preeclampsia or eclampsia. Aspiration may cause maternal morbidity after an eclamptic seizure. f) Describe multi-disciplinary management

Preeclampsia can progress to eclampsia very quickly. The only cure is to deliver the baby. However, the decision is based on gestational age and the severity of the hypertensive disorder. If the fetus is <34 wks, steroids to accelerate fetal lung maturity will be given and an attempt made to delay birth for 48hrs. If maternal or fetal condition deteriorates, the infant will be delivered regardless of gestational age or administration of steroids. If preeclampsia is mild then activity restrictions and bed rest with 1 1/2 hours of lateral positioning a day. Blood pressure is monitored 2-4 X a day and weight should be taken daily at the same time each day. Urinalysis is tested for protein using a urine dipstick and the first voided midstream specimen daily. Fetal assessment is done via "kick counts". Diet should have ample protein and calories with restriction of sodium. If preeclampsia is severe, delivery is necessary even if gestational age is <34 weeks. A decrease in amniotic fluid is considered significant because is suggests reduced placental blood flow even if the BP is not high. Management during antepartum is to improve placental blood flow and fetal oxygenation and to prevent seizure and other maternal complications such as stroke. g) Explain pharmacological agents used in treatment Anti-hypertensive medication is given if the systolic BP is >= 160mmHg or diastolic BP is >=110mmHg. Hydralazine (Apresoline) is often used because of it's safety. Relaxes arterial smooth muscle to reduce blood pressure. Niphedipine B-blocker Calcium channel blockers Care is given with administering anti-hypertensive meds for the woman on magnesium sulfate to avoid hypotension. Anti-convulsants are given to prevent seizures. Magnesium Sulfate most commonly given Dilantin Diphenylan h) Develop nursing care for the patient who has PIH or preexisting hypertension Care plan for patient with PIH on pg 650-651 in the text.

Objective 20
The student will analyze pregnancy hemorrhagic conditions I a) Describe common hemorrhagic conditions during early pregnancy d) describe multi-disciplinary management for each condition Hemorrhaqic conditions: Early pregnancy 1. Abortionspontaneous abortion is a termination of pregnancy without action taken by the mother or another person. Most common cause is congenital abnormalities that are often incompatible with life. Management: Exam of the reproductive system to determine whether anatomic defects are the cause. If anatomically normal then referral to genetic screening is given. 2. Ectopic Pregnancyimplantation of a fertilized ovum in an area outside the uterine cavity. Aka "a disaster of reproduction" for two reasons: it remains a significant cause of maternal death from hemorrhage, it reduces the woman's chance of subsequent pregnancies because of extensive damage to fallopian tubes Management: Depending on whether the tube is intact or ruptured. May not be managed if tube is ruptured. The goal is to preserve the tube and improve the chance of future fertility. Surgical management of a tubal pregnancy that is unruptured may involve a linear salpingostomy to salvage the tube. When the tube is ruptured the management is to control the bleeding and prevent hypovolemic shock. 3. Gestational Trophoblastic Disease(aka hydatidiform mole) occurs when trophoblasts develop abnormally, as a result the placenta but not the fetal part of the pregnancy develops. Grapelike clusters of tissue rapidly fill the uterus to the size of an advanced pregnancy. Can be with no fetus present of with partial in which fetal tissue of membranes are present. Management: Two phases: 1) evacuation of the trophoblastic tissue of the mole. 2) continuous follup of the woman to detect malignant changes of any remaining trophoblastic tissues. Treatment for any other problems such as HEG or preeclampsia. b) Describe common hemorrhagic conditions during late pregnancy Late pregnancy 1. Placenta PreviaImplantation of the placenta in the lower uterus. Resulting in the placenta being closer to the internal cervical os thatn the presenting part (usually the head) of the fetus. Can be Marginal; 3cm from the os, Partial; within 3cm of os, Total; completely covers the os. Only 10% of placenta previa in the second trimester remain a previa at term. Management: evaluated to determine the amount of hemorrhage and electronic fetal monitoring is initiated to evaluate the fetus. Conservative management may take place in the home or hospital. 2. Abruptio Placentaeseparation of a normally implanted placenta before the fetus is born. Occurs in cases of bleeding and formation of a hematoma on the maternal side of the placenta. As the clot expands, further separation occurs. Hemorrhage may be apparent or concealed.

Management: Hospitalized is incurred arid evaluation is done. If the condition is mild and the fetus is immature and shows no signs of distress, conservative management may be initiated. Best rest, and administration of tocolytic meds to decrease uterine activity are given. Immediate delivery of the fetus is necessary if signs of fetal compromise exists or if the mother exhibits signs of excessive bleeding (obvious or concealed) c) Determine signs and symptoms for each condition Signs and symptoms are: AbortionVaginal bleeding followed by rhythmic uterine cramping, persistent backache, or feelings of pelvic pressure. Symptoms increase the chance that the threatened abortion will progress to inevitable abortion. Ectopic PregnancyMissed menstrual period, abdominal pain, vaginal spotting. If implantation occurs, early signs of pregnancy will be noted. Several weeks into the pregnancy, intermittent abdominal pain and small amounts of vaginal bleeding occur that initially are mistaken for threatened abortion. Gestational Trophoblastic Disease Elevated hCG Absence of fetal sac or fetal heart activity Uterus is larger than one would expect based on duration of pregnancy Vaginal bleeding varying from dk brown spotting to profuse hemorrhage Excessive N/V Early development of preeclampsia Placenta Previasudden onset of painless uterine bleeding in the last half of pregnancy. May be scanty or profuse and may cease spontaneously and then reappear later. \ PlacentaeBleeding vaginally or concealed behind the placenta Uterine irritability with frequent low intensity contractions Abdominal or low back pain described as dull or aching High uterine resting tone identified with use of an intrauterine pressure catheter Signs of concealed hemorrhage in Abrupto Placentae Increase fundal height Hard, boardlike abdomen High uterine baseline tone on electronic monitoring strip when intrauterine pressure catheter is used Persistent abdominal pain Systemic signs of early hemorrhage (tachycardia in mother and fetus), tachypnea, falling BP, falling urine output, restlessness Persistent late deceleration in fetal heart rate or decreasing baseline variability; absence of accelerations Slight or absent vaginal bleeding e) Develop nursing care for the woman who has a hemorrhagic condition Nursing care plans on pg 637-638 in the text.

Objective 21 The student will explain newborn complications a) Identify newborns who are at risk Preterm infantsborn before the beginning of the 38th week of gestation Postterm infantsborn after 42 weeks gestation LGA infants (large-for-gestational age)infant whose size is above the 90th percentile for gestational age SGA infants (small-for-gestational age)infant whose size is below the 10th percentile for gestational age Low birth weight infantsweighing less than 2500g (5lb, 8oz.) at birth Extremely low birth weight infantsweighing 1000g (2lb, 3oz.) or less at birth Drug exposed infantsmaternal drug abuse/use/exposure b) Identify the newborn problems associated with pre-term and post-term birth Problems associated with Preterm birth: Respiration: The presence of surfactant in adequate amounts is of primary importance. Surfactant reduces surface tension in the alveoli and prevents their collapse with expiration. Infants born before surfactant production is adequate develop respiratory distress syndrome. Also have premature cough reflex and narrow respiratory passages which increase respiratory difficulties. Thermoregulation: Skin is thin with blood vessels near the surface and little sub-Q white fat is present to serve as insulation. Heat loss is rapid. Fluid & Electrolyte balance: Because their skin has little protective sub-Q white fat and a greater water content it is more permeable than the skin of term infants. The large surface area in proportion to body weight and last of flexion further increase transepidermal water loss. Radiant warmers heighten insensible water losses enough to result in a 40-50% increase in fluid needs. Also fluid is lost through respiratory and Gl tracts....rapid resp. and use of oxygen can increase fluid loss from the lungs....runny loose stools will lead to rapid dehydration. Development of the kidneys is not complete and the ability of the kidneys to concentrate or dilute urine is poor causing a fragile balance between dehydration and overhydration. Fluid Needs ofpreterm infants: range from 80-120ml/kg on the first day to 90-140ml/kg/day on the second and third days of life and may reach to 100-175ml/kg/day by the end of the first week. Skin: Fragile, permeable and easily damaged skin. Alcohol, iodine, and other preparations used to disinfect the skin before invasive procedures can be damaging to fragile skin and may be absorbed. Infection: 3-10 times greater than that in full term newborns. Several risk factors for infection are: Maternal infection caused by labor to begin prematurely and expose the infant to the same infection May not have received adequate passive immunity of IgG from mother during the 3rd trimester Preterm immune response to infection is less mature than full term infants. Fragile skin easily damages causing opportunity infections. Prolonged stay in the hospital can expose them to nosocomial infections Pain: NICU infants undergo many painful procedures and treatments (intubation, heel sticks, chest tubes, venipuncture every day). Pain may be greater and last longer. Common Complications of preterm birth: RDS (respiratory distress syndrome): caused by insuffiecient surfactant production in the lungs Results in atelectasis, hypoxemia, hypercapnia

BPD (bronchopulmonary dysplasia): Chronic pulmonary condition in which damage to the infant's lungs requires prolonged dependence on supplemental oxygen. ROP (retinopathy of prematurity): Condition in which damage to blood vessels often associated with oxygen use may cause decreased vision or blindness. NEC (necrotizing enterocolitis): Serious inflammatory condition of the intestines. Problems associated with Postterm birth: Hypoglycemia: Due to rapid use of glycogen stores. Asphyxia: Due to loss of amniotic fluid causing cord compression and decreased oxygen and nutrients Thermoregulation: Poor temperature regulation due to fat store were used for nourishment in utero. Hyperbiliruinemia: Resulting from polycythemia secondary to hypoxia. c) Discuss newborn complications related to small for gestational age, large for gestational age, cold stress, respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, hyperbilirubinemia, infants of a diabetic mother, trauma, drug addiction, and neonatal sepsis. Complications from: SGA (stnall-for-gestational age): intrauterine growth retardation. Complications and severity depend on the cause and degree of growth restriction. Infants are more prone to meconium aspiration, polycythemia, and hypoglycemia, and inadequate thermoregulation. LGA (large-for-gestational age): due to the large size of the fetus, they are more likely to be injured during birth. Shoulder dislocations, fractures to the clavicle or skull, damage to the brachial plexus or facial and phrenic nerves can be damaged. Cephalhematomas and bruising occur more often in these infants. Congenital heart defects and higher mortality rate is more common. Cold stress: hypoglycemia and respiratory problems. This limits the glucose and oxygen available to increase metabolism as a method of heat production. Vasocontriction which occurs when body temp drops, may lead to metabolic acidosis, pulmonary vasoconstriction, and interfere with production of surfactant and more respiratory difficulties. Respiratory distress syndrome: Insufficient production of surfactant in the lungs results in atelectasis, hypoxemia and hypercapnia. Transient tachypnea: Rapid respiration caused by inadequate absorption of fetal lung fluid. Resolves within a few days. Mild immaturity of surfactant production may also be the cause. Meconium aspiration syndrome: Most often occurs in preterm infants who have decreased amniotic fluid and are prone to cord compression. It can lead to persistent pulmonary hypertension of the newborn. Hyperbilirubinemia: Pathologic jaundice; can lead to kernicterus which is a condition where bilirubin deposits cause yellowish staining of the brain especially the basal ganglia, cerebellum and hippocampus. Can result in acutre bilirubin encephalopathy, which may be reversible in early stages but can progress to bilirubin induced neurologic dysfunction and cause permanent damage to the brain.

Infants of diabetic mother: Depending on the type of diabetes and how well it is controlled in the mother. Cardiac, urinary tract, and Gl anomiaies, neural tube defects, and caudal regression syndrome are most frequent. Incidence of anomalies is less if glucose levels remain within normal limits, especially before conception an in the early weeks of gestation. Infants may be SGA because of decrease in placental blood flow causing intrauterine growth retardation. IDM may have a greater risk of asphyxia and RDS dues to increased levels of insulin interfering with surfactant production. Other risks are hypocalcemia, Low mag levels, and polychythemia. IDM are more likely to be born premature and admitted to the NICU. Trauma: Usually occurring in LGA due to abnormal size of fetus. Shoulder dislocations, fractures to the clavicle or skull, damage to the brachial plexus or facial and phrenic nerves can be damaged. Cephalhematomas and bruising occur more often in these infants. Drug addiction: abuse during the first 2 months of pregnancy may cause congenital anomalies. Later abuse interfere with development of functioning of organs already formed. Effects depend on the substance abused: Tobacco: carbon monoxide inactivates fetal and maternal Hgb. Reduce the amounts of oxygen delivered to the fetus. IUGR, and Low birth weight and premature infants. Alcohol: Results in FAS (fetal alcohol syndrome) which is the leading cause of preventable mental retardation. Low birth weight and developmental delay and hyperactivity may not be obvious until 1-2 years Marijuana: Infant may exhibit hyperirritability, tremors, sleep disruption, and unusual sensitivity to light. Long term effects are unclear.

C.

Cocaine: low birth weight, tremors, tachycardia, marked irritability, muscular rigidity, hypertension and exaggerated startle reflex. They are often poor feeders and have frequent diarrhea. Increased risk for SIDS. Methamphetamines: decreased weight and length at birth, Abnormal sleep patterns, agitation, diaphoresis, and vomiting associated with withdrawal. Opiods: Intermittent episodes of hypoxia in utero which increases the risk of prematurity and growth restriction, spontaneous abortion and stillbirth. May have meconium aspiration. They exhibit withdrawal syndrome which affects all body systems. Mostly visible signs are neurologic and Gl. Neonatal sepsis: Systemic infection from bacteria in the bloodstream. Preterm infants have fewer antibodies and are unable to localize infection as well as older children. Most common causes are Strep and E Coli. Candida albicans are the most common causes of nosocomial infection in low birth weight infants in the hospital. d) Discuss the impact on the family of having a newborn with complications Infants are often hurried to the NICU shortly after birth and parents cannot see them initially. Later when the parents see the infant attached to an array of machines, they have difficulty developing feeling of attachment to a tiny baby who looks so different from what they expected.

When the infant's appearance and behavior are different from the parents expectations, attachment may be f delayed. Interference in the attachment process increases vulnerability for parents inestablishing a nurturing ^*' relationship with the infant.

Extended hospitalization produces emotional trauma, and disrupts family life. Loss of the parental role is a major stressor for the parents. In addition, parents worry about the infant's condition and outcome. e) Develop nursing care for the newborn with various types of complications Nursing care plans for the preterm infant on pg 780-781 of the text. Nursing care plan for the infant with jaundice on pg 809-810 of the text Nursing care plan for the drug exposed infant pg 819-820 of the text

Objective 22 The student will analyze women's health promotion a) Indentify common health promotion teaching needs Prevention is better than a cure and early diagnosis allows early treatment Breast self-exams and clinical exams Vulvar self exam Regular pap test Recognizing CAD Managing PMS S/S of Menopause Osteoporosis Sexually transmitted diseases. b) Discuss health promotion practices to include breast exam, mammography, pap smears, vulvar examination, pelvic examination. Breast exam: CBE (clinical breast exam) should be routinely preformed every 3 years for women ages 20-39 and yearly for those 40 years and older. Self exams supplement rather than replace CBE, but most women detect breast cancer themselves so self exam is the only realistic means of early cancer detection. Mammography: Used either to screen for cancer or to assist in the diagnosis of a palpable mass in the breast. Can detect breast lumps well before they are large enough to be palpated. Pap smears: Changes occur in the cells of the cervix before cervical cancer develops. Cervical cytology or the _j pap test is the most useful procedure for detecting precancerous and cancerous cells that may be shed by the f cervix. Regular pap tests can increase survival for women who develop cervical cancer by identifying it when it ! is most treatable. Because HPV has been shown to contribute to cervical cancer, testing for this virus is often done during a pelvic exam. Vulvar exam: Vulvar self exam should be performed monthly by all women 18 and older and by those younger than 18 who are sexually active. It is a visual inspection and palpation of the female external genitalia to detect signs of precancerous conditions or infections. Pelvic Exam: complete gynecologic assessment. External organs are inspected for the degree of development or atrophy of the labia, distribution of hair, and character of the hymen. Internal inspection via a speculum is done to inspect the vagina and cervix. Bimanual exam provides information about the uterus, fallopian tubes and ovaries. c) Discuss the processes involved in the onset of menopause The entire process often called "change of life' is correctly termed climacteric. Premenopause refers to the early part of the climacteric, before menstruation ceases but after the woman experiences some of the climacteric symptoms such as irregular menses. Perimenopause includes premenopause, menopause and at least 1 yr after menopause. Post menopause refers to the phase after menopause when menstrual periods have ceased. The average age for natural menopause is 51.5 yrs. Climacteric takes place over 3-5 years. d) Develop nursing care for the woman who is experiencing Send them on a long vacation....ALONE!!! peri-menopause/menopause

Objective 23

aV.

The student will analyze common disorders affecting women a) b) c) d) e) Identify risk factors for each disorder Identify genetic risk factors for each disorder Describe pathophysiology of each disorder Describe multidisciplinary management of each disorder Discuss medication used in the treatment of various disorders

Rish Factors: Menstrual cycle disorders: 4 major disorders Amenorrheaabsence of menses. May be genetic (ovarian failure). May occur is girls with Turners syndrome, lower body weight for height, abnormalities of the uterus, vagina, or hymen and congenital enzyme abnormalities. Abnormal uterine bleedingprevious spontaneous abortion, anatomic lesions, either benign or malignant of the uterus, cervix or vagina, systemic disorders such as diabetes, uterine myomas (fibroids), and hypothyroidism, failure to ovulate. Cyclic pelvic painwomen who have pain midway between menstrual periods at the time of ovulation, edometriosis in women in their 30's and nuliparous and may have had fertility problems. PMSwomen who have had medical or psychiatric disorders are more at risk, but pms can affect 10% of all menstruating women. Genetic Risk Factors: Mothers with ovarian failure or congenital enzyme abnormalities. Systemic disorders (fibroid, diabetes, hyperthyroidism) can lead to genetic risk associated with the dysfunction. Pathophysiology: Menstrual cycle disorders are symptoms not a diagnosis. Dysfunctional uterine bleeding is bleeding that occurs with abnormal frequency and lasts an abnormal amount of time, occurs irregularly and is excessive in amount. Usually secondary to underlying systemic disorders. Cyclic pelvic pain is spasmodic and colicky in nature because of the increased prostaglandins secreted at this time. Can be symptoms associated with endometriosis. PMS causes physical and emotional changed during menstrual cycle and although the cause is unknown, several theories of PMS is that normal fluctuation in gonadal hormones during a cycle, mainly estrogen, progesterone and serotonin levels fall during the luteal phase. Management and Medications used: PMSrelaxation therapy, exercise, reduce salty foods, caffeine, chocolate, red meat, dairy products, and alcohol. Small and frequent meals may reduce mood swings. Supplemental calcium has some effect with magnesium. Carbs rich food and beverage may improve the mood and reduce food cravings. Women with emotional, cognitive and physical symptoms may be prescribed antidepressant meds, oral contraceptives to suppress ovulation or both. To help with PMS associated migraines, estrogen therapy may be given. Antianxiety, SSRI, TCA have all been shown to have benefits for PMS. For dysfunctional uterine bleeding, hormone treatment progesterone and estrogen oral contraceptives that suppress ovulation allow more stable endometrial lining to form. Surgical therapy may include dilation and curettage (D&C) to remove fibroid polyps and treated with progesterone to suppress excess uterine lining. For cyclic pelvic pain associated with endometriosis, treatment may be either medical or surgical. Continuous oral contraceptives suppress endometrial tissue proliferation. Progestins such as Depo-Provera or Micronor given to directly inhibit growth of excessive endometrial tissue. Surgical treatment is performed as Haparoscopy for lysis of adhesions and lasor vaporization of lesions of endometriosis. For women with severe

ts Risk Factors: ^-

pain who no longer want to have children, a hysterectomy and/or bilateral salpingo-oophorectomy to remove both fallopian tubes and ovaries, and excision of all lesions offer relief.

Benign disorders of the breast: Fibrocystic Breast Changes (Fibroadenoma, Ductal Ectasia, Intraductal Papilloma)Hyperplastic lesions with atypical cellular changes have an increase risk to become malingnant, but most women with fibrocystic breast changes do not have a greater risk for breast cancer. Genetic Risk Factors: In atypical hyperplasia in the lesion, these patients also have a history of breast cancer and their risk for developing cancer is greater. Pathophysiology: Changes are thought to be heightened responsiveness of breast parachyma and stroma to circulating estrogen and progesterone. Pain is produced by nerve irritation from connective tissue edema and fibrosis from nerve pinching. Management and Medications used: Avoiding caffeine, and other stimulants reduces methylxanthines that may increase discomfort during the last half of the menstrual cycle. Limiting salt intake in diet can decrease edema. In treating Intraductal Papilloma, the mass and ductal area is excised. In Fibroadenoma, the mass may be excised and a sample analyze to R/O malignancy. Risk Factors: Cardiovascular disease: , f (M = modifiable) (U= unmodifiable) Cigarette smoking (M) Hypertension (including isolated systolic hypertension) (U) Serum lipids: Elevated total cholesterol >=240 mg/dl (M) HDL <35 mg/dl Cholesterol ratio: ratio should be <5 and optimum of 3.5:1. Triglyceride level >150 mg/dl (M) Diabetes Mellitus (U) Overweight and obesity (M) Sedentary lifestyle (modifiable) (M) Poor nutrition (high in saturated fats and cholesterol and low in fiber and fruit) (M) Age >60 (U) Postmenopausal status (U) Family history of CAD (U)

Genetic Risk Factors: Diabetes Mellitus, CAD, family history of high cholesterol, hypertension, and obesity. Pathophysiology: Atherosclerosis is the major cause of CAD. Characterized by a focal deposit of cholesterol and lipids primarily within the arterial intimal wall. Plaque formation is the result of compex interactions between components of the blood and the elements forming the vascular wall. Inflammation and endothelial injury play a central role in the development of atherosclerosis Management and Medications used: Prevention is the key to reducing death and illness from all cardiovascular diseases in women. Lowering hypertension through medication and diet (DASH diet plan). The medications used to treat hypertension are f diuretics, Adrenergic inhibitors (SNS), direct vasodilators, angiotensin inhibitors, and calcium channel blockers. ^ Periodic monitoring of BP, smoking cessation, diet and glucose control, exercise and low dose aspirin therapy (81mg/day) is used to treat and manage CAD.

Risk Factors: Pelvic floor dysfunction: (Vaginal wall prolapsed, Uterine prolapsed) ' Traumatic vaginal deliveries, many vaginal deliveries, and large infants delivered at birth contribute to the risk - of Uterine prolapsed. Vaginal wall prolapsed is a risk for women with weakened upper anterior wall of the vagina and is unable to support the weight of urine in the bladder. Genetic Risk Factors: None found Management and Medications used: Treaments of disorders related to pelvic floor dysfunction depends on the womans age, physical condition, sexual activity and degree of prolapsed. Surgical procedure provide the most satisfactory therapy for women with significant discomfort. Most common is the anterior and posterior colporrhaphy. Involves suturing the pubocervical fascia to support the bladder and urethra when a cystocele exists. If a retrocele exists, then a posterior colporrhaphy is done which is suturing the fascia and perineal muscles that support the rectum and perineum. A vaginal hysterectomy is the most common surgery to correct vaginal wall prolapse. If surgery is contraindicated a pessary (device to support the pelvic structure) is inserted into the vagina. Pelvic exercise (Keegels) can be used to strengthen the pubococcygeal muscle. Some drugs used for overactive bladders and used to enhance bladder control are: Vaginal estrogen cream, tablet, vaginal ring to reduce atrophy of the urinary and vaginal areas, Anticholenergic drugs such as oxybutynin or tolterodine. Risk Factors: Disorders of the reproductive tract: (Cervical polyps, Uterine leiomyomas, Ovarian cysts) Estrogen dependent so they grow rapidly during childbearing years and shrink during menopause. Genetic Risk Factors: None found

Pathophysiology: Cervical polyps are caused by the proliferation of cervical mucosa. Uterine leiomyomas develop from smooth muscle cells that are completely dependent are estrogen and grow rapidly when estrogen is abundant. Ovarian cysts (follicular or luteal) develop when the corpus luteum becomes cystic and fails to regress. Mangement and Medication used: Treatment for uterine leiomyomas include progesterone only or combination progesterone-estrogen oral contraceptives to reduce excess menstrual flow. Short course of GnRH agonists (gonadotropin releasing hormone) may be effective in reducing the size of myomas and less the need for surgical removal. Cervical polyps are surgically removed outpatient. Ovarian cysts are removed laproscopically from the ovary and examined by a pathologist. Risk Factors: Infectious disorders of the reproductive tract: (Candidiasis, Sexually transmitted diseases) Sexually active women (teens, young adults) Multiple partners Pregnancy (candidiasis) Diabetes mellitus (candidiasis) Oral contraceptive use Prolonged systemic antibiotic therapy (candidasis) Use of diaphragms, cervical caps, and spermicidal foams and jellies for contraception Inadequate knowledge and education regarding transmission and prevention of STD. iGenetic Risk Factors: 'None found

Pathophysiology: Changes in Vaginal pH and flora that favor accelerated growth of C. Albicans (Candidasis), a yeastlike fungus | commonly found in the Gl tract and on the skin. Trichomoniasis is an anaerobic protozoon that thrives in an , - alkaline environment such as the vagina. Bacterial vaginosis (vaginitis) causes bacterial proliferation in the vagina by replacing normal lactobacilli with Gardnerella vaginalis. Chlamydial infection is caused by the gram negative bacterium C. trachomatis. Gonorrhea is an infection of the genitourinary tract by the gonococcus Neisseria Gonorrhoeas. Syphillis, caused by the spirochete Treponema pallidum is divided into primary, secondary and tertiary stages. First sign is a painless chancre that develops on the genitalia, anus, lips or oral cavity. Although the chancre disappears the spirochete lives and is carried by the blood to all parts of the body. After about 2 months infected people exhibit symptoms of secondary syphilis; enlargement of the spleen, liver, headache, anorexia and maculopapular skin rash. Skin eruptions may develop on the vulva during this time. If untreated the disease enters the latent stage that may last several years. Tertiary syphilis which follows mayinvolve the heart, blood vessels and CNS. General paralysis and psychosis results. Condylomata acuminata (aka: veneral or genital warts) are caused by the HPV and closely associated with cervical cancer. HPV can not be eradicated and may cause frequent reoccurrences. AIDS (HIV) is a ribonucleic acid (RNA) virus that replicates in a backward manner going from RNA to DNA. HIV infects human cells that have CD4 receptors on their surfaces (lymphocytes, monocytes/macrophages, astrocytes and oligodenrocytes). Caused by predominant destruction of CD4 Tcells (T-helper or CD4 lymphocytes) Leads to opportunistic diseases. Management and Medications used: CandidiasisMeds available W/O prescription include butoconazole, miconazole, clotrimazole, nystatin, terconazole, tioconazole by vaginal application. Patients with severe candidaisis can be given oral meds including Fluconazole. TrichomoniasisMeds given are Flagl, Protostat in oral dose for 7days. Women should be advised to avoid using alcohol during treatment with metronidazole until therapy is complete. Sexual partners should refrain from intercourse until a cure is established. Condoms should be used with new partners. Bacterial vaginosistreatment geared toward reestablishing the balance of flora in the vagina. Metronidazole is the durg of choice. Clindamycin is an alternative treatment. The woman should refrain from sexual activity until cured or her partner should use a condom. Chlamydial InfectionTreatment is usually directed to eradicate both Chlamydia and gonorrhea because the two often coexist. Meds given include Zithromax, doxycyline, clindamycin, ofloxacin, levofloxacin, and erythromycin. Treatment of all sexual partners is necessary to prevent recurrence. Use of condoms until cured. Gonorrheatwo considerations influence the treatment of gonorrhea: 1) the high number of organisms that have become resistant to previously used antibiotics and 2) the high frequency of Chlamydial infections in persons with gonorrhea. Suprax, Recephin and Cipro in combination with one of the antibiotics used for Chlamydia appear to be affective for gonorrhea treatment. All sexual partners should be treated simultaneously and intercourse avoided and the man should use a condom until a cure is confirmed. SyphlisBest treatment in all stages of syphilis is with penicillin. Ceftriaxone and doxycycline can also be used. Tetrcycline is an alternative if the woman is not pregnant. Women allergic to penicillin can be admitted to the hospital for desensitization to PCN followed by administration of the drug. Herpes genitalisNo cure exists but antiviral drugs reduce or suppress symptoms, shedding, and recurrent episodes. Zovirax, Famir, and Valtrex are all used. Women should be advised to abstain from sexual contact while the lesions are present to avoid transmission to their partner. } Condylomata acuminataTreatment does not eradicate the virus. The goal of treatment is to remove the warts which transmit the virus back and forth between sexual partners. Topical treatment options include podophyilin, trichloroacetic acit (TCA), bichloroacetic acid (BCA), and imiquimod cream. Extensive warts that

do not respond to topical treatment are removed by cryotherapy, eletrodessication, electrocautery, or laser. Interferon (antineoplastic drug) is sometimes used to treat condylomata acuminatat in woman >18yo who have not responded to conventional therapy. Sexual contact should be avoided until all lesions are healed and the use of condoms is recommended to reduce transmission. AIDSNo medications have been shown to cure AIDS. Treatment is centered around symptoms and combined drug therapy often benefits the HIV-infected woman and may have acceptable safety if she is pregnant. Drugs that my interrupt production of the virus are: Zidovudine (reverse transcriptase inhibitor). Protease inhibitors, such as indinavir and saquinavir, block the enzyme crucial to one step in the reproductive cycle of HIV. HIV is highly infectious through intimate contact with blood, blood products, infected bodily secretions and prenatal transmission from mother to infant f) Develop nursing care for the woman with: Osteoporosis, pelvic floor disorders, menstrual cycle disorders, benign and malignant breasts and reproductive tract disorders, PMS, cardiovascular disease, and infectious disorders of the reproductive tract.

Nursing care for women with: Osteoporosis:--teach about lifestyle factors that contribute to bone loss, such as cigarette smoking, excessive alcohol use or caffeine intake. Daily calcium supplements are recommended. Exercise with weight bearing and resistance is beneficial. Pelvic floor disorders: Have patient practice doing Keegel exercises holding for 10 sec with 24-45 repetitions a day. Lying down with legs elevated for a few minutes several times a day. Teach measures to prevent constipation. Menstrual cycle disorders: Benign & Malignanct breasts: Reproductive tract disorders: PMS: Cardiovascular disease: Infectious disorders of the reproductive tract:

Objective 24 The student will discuss induced abortion

a) Describe methods used for pregnancy termination

Medical termination of pregnancy is a voluntary method of ending a pregnancy by the use of drugs or surgical methods: Drugs: (Medical) Mifepristone (Mifeprex or RU-486)antiprogesterone drug, followed by misoprostol (Cytotec) a Prostaglandin drug commonly used to reduce gastric acid secretion. Methotrexate (Folex, Mexate)an antimetabolite also used to treat certain types of cancer. Misoprostol may be prescribed to enhance expulsion of the uterine contents. Misoprostol (Cytotec)a prostaglandin drug normally given to reduce acid secretion Medical methods (drugs) exist for abortion in the second trimester but these involve labor. Retention of the placenta often occurs, requiring a D&C to fully clean out the uterus. Prostaglandin E2 which stimulates uterine contractions may be given via vaginal suppository or intraamniotic infusion. Surgical: Through 12 weeks gestation, vacuum aspiration with curettage is the method of choice. The cervix is dilated after locally injecting anesthetic in the area, and a plastic cannula is inserted into the uterine cavity. The contents are aspirated with negative pressure and the uterine cavity may be scraped with a curet to ensure that the uterus is empty. Second trimester a dilation with removal of the fetus and placenta is generally performed. Similar to vacuum curettage, but requires greater cervical dilation and a larger spirator because the products of conception have grown in size and must be removed gradually. b) Explain physical and psychological needs of the patient prior to and after induced abortion Prior to and after abortion, provide physical and emotional support and information about the methods used. Rh-negative women should receive Rh (D) immune globulin (RhoGAM) Self care information, follow up visits and contraception. c) Explain post abortion teaching needs After termination provide information about self care and guidelines Normal activities may be resumed but strenuous work or exercise should be avoided for a few days Bleeding or cramping may occur for a week or two. If either becomes severe, seek medical advice Light spotting may occur for about one month Sanitary pads should be used instead of tampons for the first week after the abortion to avoid infection Intercourse should be curtailed until 1 week after abortion due to possible infection Birth control measures should be used if sex is resumed before menstruation begins. Temperature should be taken twice a day to detect possible infection; Above 100.F should be reported. Importance of keeping follow up appointment in 2 weeks or as recommended. d) Develop nursing care of the woman who seeks to terminate pregnancy physical and emotional Counseling and lending emotional C ' iProvide responsibilities althoughsupport and information.are also responsible to perform thesesupport are nursing designated counselors services.
i

Objective 25 The student will discuss contraception methods a) Describe various contraceptive methods b) Describe how each method prevents pregnancy c) Analyze advantages, disadvantages, side effects, effectiveness, contraindications and cost of each method Sterilization (vasectomy & tubal ligationused for couples who have completed their families. Both methods should be considered permanent to end fertility. In the female, the fallopian tubes are occluded and a section remove and tying the ends. In males the vas deferens which carries sperm from the testes to the penis is removed, severed or cauterized. Pregnancy rate is 0.15% for tubal ligation and .5% for vasectomy Advantages: Ends concern about contraception, low long term cost (usually covered by insurance), vasectomy can be perform in a physicians office with local anesthesia. Disadvantages: No protection against STD's, reversal is difficult, Side effects: potential complications as with any surgery, mild to moderate pain at site of incision Progestin injections & (Depo-Prevera)prevents ovulation for 12 weeks. Pregnancy rate is 0.8% Advantages: unrelated to coitus, avoids the need for daily use, may cause eventual amenorrhea Disadvantages: No protection against STD's, must remember to repeat every 12 weeks, may decrease bone density. Side effects: effects similar to other progestin contraceptive (birth control pills), headaches, nervousness, decreased libido, breast discomfort and depression Oral contraceptives (& transdermal patch) Estrogen and progestin in combination cause thickening of the cervical mucosa which prevents sperm from entering the upper genital tract. Also blocks the luteinizing hormone surge from pituitary, which inhibits maturation of the follicle and ovulation. Pregnancy rate is 8%. Advantages: unrelated to coitus, requires application only weekly(patch), regulates menstrual cycle. Diadvantages: No protection against STD's, requires a prescription, must apply on the right day, less effection for women over 90kg (198lbs), may cause skin irritation Side effects: Headache, weight gain or loss, fluid retention, amenorrhea, and melasma. Contraindicated for smokers, history of DVT, obesity, diabetes, hypertension. Impaired liver function. Vaginal contraceptive ringthe ring which measures 5cm in diameter and 0.3cm thick, releases small amounts of progestin and estrogen continuously to prevent ovulation. The woman removes the ring at the end of 3 weeks and bleeding occurs. A new ring is then inserted. Pregnancy rate is 8%. Advantages: unrelated to coitus, in place for 3 weeks at a time, no fitting required. Diadvantages: No protection against STD's, requires prescription, must remember when to remove and when to insert 'S/cte effects: expulsion, vaginitis, vaginal discomfort, others similar to those with oral contraceptives.

IUDinserted into the uterus to provide continuous pregnancy prevention. It causes a sterile inflammatory response resulting in a spermicidal intrauterine environment. Very few sperm reach the fallopian tubes. Pregnancy rate is 0.8%. Advantages: unrelated to coitus, in place at all times, low long-term cost Diadvantages: No protection against STDs, high initial cost, can be expelled without the woman knowing (must check for strings) Side effects: cramping, bleeding with insertion, increased bleeding during menstruation, complications can result in uterine perforations, infection, ectopic pregnancy and abortion Chemical spermacides(a.k.a. chemical barriers) Chemicals that kill spermicides and come in many forms. Creams and gels are the most widely used. Foams, suppositories and vaginal film may be used alone or with another contraceptive measure. They are effective for about 1 hour and should be reapplied if intercourse is repeated. Pregnancy rate is 29% if used alone. Advantages: quick and easy, no prescription required, inexpensive per single dose Diadvantages: no protection from STDs, coitus related, may interfere with sensation, contraindicated for allergies to components of spermicides. Films and suppostitories must melt before they become effective, effective for only 1 hour and must be reapplied for repeated intercourse, may be messy Side effects: frequent use can cause genital irritation which can increased susceptibility to infection and HIV Condoms(a.k.a mechanical barriers) placed over the penis or cervix to prevent passage of sperm into the uterus. They include: condom, sponge, diaphragm and cervical cap. Pregnancy rate is 15% for male condoms land 21% for female condoms. Advantages: quick and easy, no prescription needed, best protection against STDs (except the sponge), low cost per single dose, can be carried discreetly, vaginal condoms increase a womans control over contraceptive use and protection against STDs Diadvantages: must be checked for expiration date, can only be used once, can break or slip off, vaginal condom may seem unattractive. Sponge doesnot protect against STDs Side effects: contraindicated for allergies to latex, can be affected by vaginal medications and should not be used together. The sponge should not be left in the vagina for more than 30 hours, can result in toxic shock, Diaphragmlatex dome surrounded by a spring coil. Placement of spermicidal cream or gel into the dome and around the rim, then inserts over the cervix. Prevents passage of sperm into the uterus. Pregnancy rate is 16%. Sponge is 32% in parous women and 16% in nulliparous women. Advantages: can be inserted several hours before coitus Disadvantages: initially expensive, requires fitting by health care provider, requires education on how to use it, difficult to insert and remove for some women, added spermicide is needed for repeat coitus, needs to be checked annually for proper fit and following birth, abortion, or weight change of 10lb or more. Side effects: prolonged placement can result in toxic shock or bladder infections. ftCervical capinserts a cone cap over the cervix after placing spermicide on both sides. Keeps sperm from 'entering the uterus.

Advantages: smaller than a diaphragm and may fit a woman who cannot wear a diaphragm. No pressure on the bladder, less noticeable than a diaphragm, can remain in place 48 hrs. ^ Diadvantages: initially expensive, requires fitting by health care provider, requires education on proper use and insertion, added spermicide necessary for repeated coitus. Side effects: possibility of toxic shock. Natural family planninguses physiological cues to predict ovulation and avoid coitus when conditions are favorable for fertilization. Calendar method is based on timing of ovulation approximately 14 days before the onset of menses. Standard method uses a string of beads that is color coded to help keep track of the days of each cycle. Days 18-19 are considered fertile days. Basal body temperature method uses oral temperatures based on temperature drop just before ovulation, with ovulation, the temperature rises. The woman is no longer fertile after the temperature rises. Pregnancy rate is 25% Advantages: inexpensive, no drugs or hormones, helps women learn about their bodies, can be combined with barrier methods in increase effectiveness, acceptable in most religions, may be used to help achieve pregnancy Diadvantages: No protection from STDs, requires high motivation and education, abstinence necessary for large part of each cycle, high risk of pregnancy from error, many factors may change ovulation time Side effects: none d) Develop nursing care for the individual seeking contraception The role of the nurse in family planning is that of a counselor and educator. Use current and correct information \t contraceptive methods. Reinforce teaching and provide an opportunity to ask questions after initial use can help ensure the woman is using the method correctly. Nurses must be sensitive to the woman's concerns and feelings when discussing contraceptive use. In discussing family planning, the nurse must be careful not to introduce their own biases toward or against specific methods. Provide individualized family planning information to women in every situation in which it would be appropriate.