Transcript The Obstetrical Client

Care of the
Childbearing Family
NCLEX Preparation
Module 8
1
Maternal-Newborn Nursing in
Registered Nursing Practice





Registered Nurse, RN
Registered Nurse Certified, RNC
Clinical Nurse Specialist, CNS
Nurse Practitioner, NP
Certified Nurse Midwife, CNM
2
Legal Concepts in Maternal-Newborn
Nursing




Scope of Practice
Standards of Nursing Care
National Nursing Organizations
Healthcare Agency Policies and Procedures
3
Ethical Issues in Maternal-Newborn
Nursing


Ethics versus Laws
Common ethical issues





Maternal-Fetal Conflict
Abortion
Intrauterine Fetal Surgery
Reproductive Assistance
Embryonic Stem Cell Research
4
Legal Issues in Maternal-Newborn
Nursing

Informed consent

Confidentiality
5
Implications for Nursing Practice




Advances in science and technology
Provide information, not opinion
Remain neutral
Support patients even if you do not agree with their
decisions
6
Concepts in Contemporary Childbirth

Health care delivery settings






Acute care, birthing centers
Public health, school and college health
Adolescent pregnancy centers
Outpatient clinics, physician's offices
Home care visits
Complementary Alternative Medicine
Homeopathic and herbal remedies
 Evidence-based practice

7
Maternal-Newborn Terminology










Abortion
Abruptio Placentae
Amenorrhea
Amniotomy
APGAR
Braxton-Hicks contractions
Caput Succadeum
Cephalhematoma
Chadwick's sign
Colostrum
8
Maternal-Newborn Terminology












D.I.C.
Dilation
Effacement
Endometriosis
Endometritis
Gestational age
Gravida
Hyperemesis Gravidarium
Leukorrhea
Leopold's Maneuvers
Lightening
Linea Nigra
9
Maternal-Newborn Terminology










LMP and LNMP
Lochia
Mastitis
“Morning Sickness”
Parity
Placenta Previa
Pregnancy Induced Hypertension
Premature rupture of membranes
Primigravida
Pyelonephritis
10
Maternal-Newborn Terminology
Quickening
Station
Sexually
Transmitted Infection
Teratogenesis
Threatened abortion
Toxic Shock Syndrome
11
Maternal-Newborn Terminology
(continued)
T.O.R.C.H.
Infections
T= toxoplamosis
O= other; gonorrhea, chlamydia, syphilis,
varicella, hep B, Group B streptoccal, HIV;
R= rubella
C= cytomegalovirus
H= herpes
Urinary
Tract Infection
12
Female Reproductive Cycle



Ovarian Cycle
- Follicular and luteal phases
Endometrial Cycle
- Menstrural, proliferative, secretory and
ischemic phases
Menstruation
13
Female Reproductive Anatomy

External Genitals
-Mons Pubis
-Labia Majora
- Clitoris
- Uretral Meatus &
Skene’s Glands
- Vaginal Vetibule
- Perineal Body
Breasts

Internal Reproductive Organs
- Vagina
- Uterus
- Uterine Corpus
- Cervix
- Uterine Ligaments
- Fallopian Tubes
- Ovaries
- Bony Pelvis
- Bony Structure
- Pelvic Floor
14
Organs of the Female Reproductive System
Photo Source: National Assets Library, Health Education Assets Library, (HEAL), Royal
University of Ireland, Public Domain,
http://www.healcentral.org/healapp/showMetadata?metadataId=4912
15
Male Reproductive Anatomy

External Genitals
- Penis
- Scrotum

Internal Reproductive
Organs
- Testes
- Epididymis
- Vas Deferens
- Ejaculatory Ducts
- Urethra
- Accessory Glands
16
Photo Source: U.S. National Cancer Institute's Surveillance, Epidemiology and
End Results (SEER) Program,
http://training.seer.cancer.gov/module_anatomy/unit12_2_repdt_male.html
17
Male Reproductive System
Spermatogenesis
Testosterone
Testicular
Self Exam (TSE)
18
Women’s Gynecologic Health Issues
Gynecological Screening & Procedures





Breast Self-Examination- “7 P”- position, pads,
pressure, perimeter, pattern of search, practice with
feedback, plan of action
Mammography
Pelvic Exam
Pap Smear
Sexually transmitted infection screening
19
Nurse's Role in Infertility Evaluation
and Family Planning



Role of the nurse
Common Infertility Testing
Comprehensive history and physical examination



Sperm Count
Basal body temperature chart
Hormone evaluation
20
Nurse's Role in Infertility Evaluation
and Family Planning

Additional infertility procedures







Ultrasound
Hysterosalpingogram
Endometrial biopsy
Postcoital test
Ovulation induction
Therapeutic insemination
Assisted reproductive technology
21
Nurse's Role in Family Planning
Common Contraceptive Methods




Nurse's role as an educator regarding common
methods available to a woman and her partner
Sterilization-tubal ligation and vasectomy
Hormonal agents-implants, injections, oral, patches,
vaginal ring, emergency contraception
Intrauterine devise
22
Common Contraceptive Methods








Condom- male and female
Sponge
Spermicides
Diaphragm or Cervical Cap
Natural Family Planning (Sympto-Thermal)
Abstinence
Breastfeeding
Coitus Interruptus
23
Common Gynecologic and Urinary
Health Problems








Premenstrual Syndrome (PMS)
Menopause and Hormone Replacement Therapy
(HRT)
Endometriosis
Toxic Shock Syndrome (T.S.S.)
Pelvic Inflammatory Disease (P.I.D.)
Urinary Tract Infections (U.T.I.)
Vaginitis and Vaginosis
Breast and cervical cancer
24
Premenstrual Syndrome



A clustering of signs and symptoms that
occur only during the luteal phase in ovulatory
cycles
Severity can be mild to severe

Many treatments are available to manage the
symptoms

Education and prevention
25
Menopause and Hormone Replacement
Therapy
Perimenopause may begin in mid thirties
 Hot flashes, insomnia, vaginal dryness




Depression, mood swings, irritibility
Osteoporosis
Controversy regarding routine use of HRT
Use for shortest period of time at lowest
dose
26
Common Gynecologic and Urinary
Health Problems

Endometriosis
Condition where endometrial tissue is found outside
the uterine cavity
 Tissue responds to hormonal changes and bleeds
resulting in inflammation, scarring and adhesions in
pelvis and on peritoneum
 Many treatments are available to stop or slow the
growth of the abnormal tissue

27
Common Gynecologic and Urinary
Problems

Toxic Shock Syndrome (TSS)
 Caused
by Staphylococcus aureus
 May be related to tampon use and barrier contraceptives left
in place more than 48 hrs.
 S&S – Early signs



Fever > 38.9C or 102F
Rash on trunk
Hypotension, dizziness, vomiting, watery diarrhea
 Treatment
– Hospitalization, IVs, Antibiotics
28
Common Gynecologic and Urinary
Problems

Pelvic Inflammatory Disease (PID)
More common with multiple sexual partners
 Inflammatory disorders of upper female genital tract –
endometritis, salpingitis, tubo-ovarian abscess, pelvic abscess,
pelvic peritonitis
 Frequent organisms – chlamydia and gonorrhea
 Closely associated with infertility
 Treatment – IVs, pain medication, IV antibiotics, bedrest,
antipyretics

29
Common Gynecological and Urinary
Problems
Urinary
Tract Infections
Pyelonephritis






(Upper UTI)
Often preceded by cystitis or bladder infection (lower UTI)
More common in latter pregnancy or early post partum
Frequency, urgency and dysuria seen with UTI
May present with fever, chills, costovertebral angle (CVA) tenderness, flank
pain, nausea and vomiting
Treatment for cystitis is oral antibiotics
Treatment for pyelonephritis is IV therapy for antibiotics and hydration,
urinary analgesics, pain management and bed rest
30
Vaginitis and Vaginosis
A common reason to seek gynecologic care
 May be asymptomatic or part of a woman's
normal flora
 Common imbalance or normal flora in the vagina may
include candida vaginitis, bacterial vaginosis, and Group B
streptococcus
 Trichimonas, Human Papilloma Virus (HPV), Herpes
Simplex type I and II (HSV), Hepatitis B and Syphillis
 Gonorrhea and Chlamydia
 Early diagnosis and treatment

31
Breast and Cervical Cancer
Breast is leading cancer killer second only to lung cancer
in women
 Annual well-woman evaluation can aid in early diagnosis
of cancer
 PAP smear and preventive immunizations for cervical
cancer are helpful
 Mammogram annually can aid in early detection which
offers lower death rate and more treatment options which
are less invasive

32
Nurse's Role with Intimate Partner
Violence
Approximately 1.5 million women are physically assaulted by
an intimate partner annually in US.
 Does not stop because the women become pregnant.
• 3 categories include: psychological, physical, and sexual
abuse
• Universal screening important at every health care encounter
for symptoms of abuse

33
Nurse's Role with Intimate Partner
Violence
 Awareness
violence
of signs and knowledge about the phases of
 Careful
nursing assessment with standard questions while
the victim is alone
 Knowledge
of appropriate resources and health care
personnel who can assist and follow up, provide legal advise
and support
34
Signs of Intimate Partner Violence
 Signs of pain – grimacing, unsteady gait, complaints of
abdominal pain
 Bruises especially of the arms, lacerations, burns, evidence of
old fractures.
 Discrepancy between the explanation and the types of
injuries
 Flattened affect, anxiety, depression, panic attacks, suicide
attempts
 Late prenatal care, missed appointments
35
Intimate Partner Violence Cycles

Tension Building Phase

Battering Phase

Honeymoon Phase
36
Questions Regarding Intimate Partner
Violence
Assessment should be part of all health encounters
 Have you been threatened, hit, slapped, kicked, choked
or otherwise physically hurt by anyone within the last
year?
 Has this happened since you have been pregnant?
 Within the last year, has anyone forced you to have
sexual activities?
 Are you afraid of anyone?
 Be aware of resources for referral.
37
Conception, Fetal Development, Gestational
Risk and Fetal Well-being






Conception requires the maturation of gametes (sperm &
ova)
Ovulatory menstrual cycle includes preparation of uterine
lining for implantation
Patent female and male reproductive system allows passage
of sperm and ova
Fertilization of sperm & ova (zygote created)
Implantation of ovum into secretory endometrium
Hormonal support from the corpus luteum
38
Conception, Fetal Development, Gestational
Risk and Fetal Well-being
Stages of fetal development include:



Pre-embryonic stage - First 14 days of human development
starting at the time of fertilization
Embryonic stage - Beginning of the third week through
approximately 8 weeks
Fetal stage - From 9 weeks until birth (at approximately 40
weeks after the last normal menstrual period). All major organs
are formed by 8-12 weeks.
39
Conception, Fetal Development, Gestational
Risk and Fetal Well-being
Amniotic sac and fluid
 The
fetal membranes consist of the amniotic and chorionic
membranes that cover the fetal surface of the placenta which
contains, protects and supports the fetus and the amniotic
fluid.
 Amniotic fluid





Cushions and protects the fetus
Controls temperature
Permits symmetrical growth of the embryo
Prevents adhesion to the amniotic membranes
Allows for freedom of movement
40
Conception, Fetal Development, Gestational
Risk and Fetal Well-being
Umbilical Cord
 Contains blood vessels (one large vein and two smaller arteries)



Carries oxygen, waste products, and nutrients between the fetus
and placenta
Wharton’s Jelly - Helps prevent compression of the cord
No nerves in the cord
41
Conception, Fetal Development,
Gestational Risk and Fetal Well-being
Placenta provides for:
 Metabolic and nutrient exchange between the
embryo/fetus and the mother
 Fetal oxygen and carbon dioxide exchange
 Excretion of fetal waste products
 Hormones which support the pregnancy and are
responsible for the metabolism of sugar
42
Conception, Fetal Development, Gestational
Risk and Fetal Well-being
Fetal heart and circulatory system make intrauterine life
possible
 The ductus venosus empties directly into the fetal vena cava  the right
atrium and  the left atrium via the foramen ovale  left ventricle 
aorta.
 Blood returning from head and upper body via the superior vena cava
empties into right atrium  through tricuspid valve  right ventricle
 pulmonary artery ( small amount to the lungs for nourishment) 
ductus arteriosus  descending aorta  placenta
 Fetal heart is under the control of it's own pacemaker.
 Decreased oxygen to the fetus evokes changes in the heart rate and blood
pressure
43
Conception, Fetal Development, Gestational
Risk and Fetal Well-being
Factors affecting fetal well-being:
Quality of sperm or ovum
Intrauterine environment
First trimester exposure to hazardous agents
Maternal nutrition, hyperthermia, chronic diseases including
diabetes, thyroid, cardiac, and circulatory
Substance abuse
Known or unknown infections
44
Fetal Circulation
Photo Source: Little Hearts Matter, A registered charity in the UK, public
domain,
http://www.lhm.org.uk/patients/lhm/medical/general/circulation.asp
45
Barriers to Prenatal Care in U.S.








Sociodemographics
Insurance/finances
Inadequate care providers for low income
Child care
Delay in onset of prenatal care
Cultural factors
Transportation
Attitudes
46
Physical Changes During the Antepartum
Period and Maternal Nutrition
Signs of pregnancy
 Presumptive (generally subjective)
 Probable (objective)
 Positive (diagnostic)
47
Physical Changes During the Antepartum Period
and Maternal Nutrition
Expected Physical Changes - Cardiovascular
 Blood volume increase
 Physiological anemia
 Vital signs stable
 Increased clotting factors
 Edema
48
Physical Changes During the Antepartum Period
and Maternal Nutrition
Expected Physical Changes- Respiratory


Oxygen consumption increases with decrease airway
resistance
Deeper respirations and upward pressure on diaphragm
49
Physical Changes During the Antepartum
Period and Maternal Nutrition
Expected Physical Changes - Gastrointestinal and
Urinary Systems


Nausea, vomiting, constipation, slowed peristalsis
Bladder capacity increases and tone decreases; risk of
UTIs increases
50
Physical Changes During the Antepartum Period
and Maternal Nutrition
Expected physical changes - Integumentary System
Hyperpigmentation


Linea Nigra
Melasma
51
Physical Changes During the Antepartum Period
and Maternal Nutrition
Expected Physical Changes - Reproductive System
 Uterine enlargement
 12 weeks – At Symphysis
 16 weeks – Midway between symphysis and umbilicus
 20 weeks – At the umbilicus
 36 weeks - Near xyphoid process
Photo Source: Wellcome Library London, Creative Commons, http://medphoto.wellcome.ac.uk/
52
Determination of Estimated Day of
Delivery (EDD)

Nagele’s Rule
Subtract 3 months from that date then add 7 days
 1st day of LNMP (last normal menstrual period)

Example: LNMP: September 10, 2006
Expected Due Date (EDD): June 17, 2007
53
Maternal Nutrition
Nutritional Assessment Considerations
Nutritional deficits present at the time of conception and
during the early prenatal period
 Maternal age is important, especially in adolescent pregnancy
 Number of pregnancies and the interval between each
pregnancy

54
Maternal Nutrition
Maternal weight gain depends on BMI (Basal Metabolic
Index) and pre pregnant nutritional state
Weight Gain ranges:
Underweight woman: 28 -40 lbs (12.5 -18kg.)
 Normal-weight woman: 25-35 lbs (11.5-16kg.)
 Overweight woman: 15-25 lb (7 - 11.5kg.)
 Obese woman: at least 15 lbs. (7.0 kg.)
 Gain of 3.5 lb (1.6 kg) during 1st trimester
 Gain of about 1 lb (0.4 kg) weekly rest of pregnancy

55
Maternal Nutritional Requirements

The recommended daily allowance for calories - Increase 300
kcal/day during the second and third trimesters.

Recent changes:
• No extra daily calories in 1st trimester
• 340 in 2nd trimester
• 452 in 3rd trimester.
56
Maternal Nutritional Requirements





Carbohydrates- source of energy and fiber
Proteins-growth and repair of tissues
Fats-essential fatty acids and vitamins
Minerals-calcium, phosphorous, iodine, sodium,
zinc, magnesium and iron
Iron supplementation and
education regarding high iron foods
57
Maternal Nutritional Requirements



Fat soluble vitamins A (growth of epithelial cells in GI
track) ,D (absorption and use of Calcium and
Phosphorus),E (enzymatic and metabolic reactions) and
K (synthesis of prothrombin)
Water soluble vitamins C (development of connective
and vascular tissue), B complex (cell respiration, glucose
oxidation and energy metabolism) and folic acid 0.4 mg
daily for, prevention of neural tube defects
Fluids
58
Special Maternal Nutritional Issues
Vegetarianism
 Lactose Intolerance
 Eating Disorders
 Anorexia Nervosa
 Bulemia Nervosa
•Pica
•Common GI Discomforts
•Cultural, ethnic and religious influences
•Psychosocial factors

59
Special Nutritional Considerations
Nutrition
for the pregnant adolescent
Postpartum
nutritional support
Breastfeeding
Non-nursing
woman
woman
60
Psychosocial Aspects of Pregnancy

1st trimester

2nd trimester

3rd trimester
61
Common Issues of Concern During the
Childbearing Years

Three major tasks of childbearing families

Nurses need to assess the family unit
Pregnancy and birth effects on the childbearing
family

62
Fetal Diagnostic Tests









Ultrasonography
Fetoscope
Alpha-Fetoprotein
Screening
Amniocentesis
Nonstress test
Vibroacoustic Stimulation
Contraction Stress Test
Biophysical Profile
Maternal assessment of fetal movement “kick counts”
Photo Source: Wikimedia Commons, U.S. Food & Drug
Administration (Public Domain),
http://commons.wikimedia.org/wiki/Image:Fetal-endoscope.gif
63
Potential Complications During Pregnancy
 During initial antepartal care, risk factors may be
discovered or determined as labor progresses
 Risk factors include age, number of pregnancies, poor
or excessive nutrition, cardiovascular or hypertensive
disease
 Problems experienced during previous
pregnancies, diabetes, drug abuse, infections and other
factors may complicate pregnancy
64
Danger Signs in Pregnancy
Assess and report immediately:
 Vaginal bleeding in any amount - May indicate placenta
previa
 Premature rupture of membranes - Predisposes mom
and baby to infection
 Edema of face or hands, abdominal pain, epigastric pain
- Consider preeclampsia
 Severe, persistent headaches and visual disturbances Consider preeclampsia
65
Danger Signs in Pregnancy
Report any of the following immediately:
Fever and/or chills
 Painful urination
 Persistent nausea & vomiting
 Change in, or absence of fetal movement for
6-8 hrs.

66
Placenta Previa
Placenta implants near or over the cervical
opening (cervical os)




Painless vaginal bleeding which may occur in the 3rd
trimester
Soft non tender uterus
Vaginal exams are NEVER performed
Birth by cesarean indicated if the placenta does not migrate
up the uterine wall as gestation progresses
67
Nursing Management with
Placenta Previa





Assess the amount and character of bleeding
Monitor Fetal Heart Tones (FHT) and activity
monitoring (kick count)
Bedrest and no sexual activity
Report signs of preterm labor
Conservative management of pregnancy
68
Abruptio Placenta


Complete of partial premature separation of the
placenta from uterus
Precipitating Factors





Blunt trauma to abdomen
Drug abuse, especially cocaine
Hypertension
Premature rupture of membrane
Smoking
69
Abruptio Placenta (continued)





Medical emergency because of the risk of maternal
hemorrhage and fetal demise
May develop Disseminated Intravascular
Coagulation (DIC)
Bleeding may be obvious or concealed
Concealed bleeding may lead to uterine tenderness
and abdominal pain
Monitoring may reveal elevated uterine resting tone
and a rising FHT
70
Nursing Management of Abruptio
Placenta







Assess amount and character of bleeding
Assess abdominal/uterine tenderness, contractions and
resting
Monitor for shock
Assess FHT and activity
Measure fundal height since concealed bleeding may be
present
Provide emotional support
Prepare for possible C-Section
71
Ectopic Pregnancy




Any gestation outside the uterus
Most frequently in fallopian tube
As the conceptus grows it causes distention, then
possible rupture of site which usually occurs within
12 weeks gestation
Any condition that diminishes tubal patency may
predispose a woman to an ectopic pregnancy
72
Assessment of a patient with an Ectopic
Pregnancy






History of missed periods and symptoms of early
pregnancy
Abdominal pain, may be localized to one side
Rigid, tender abdomen; sometimes abnormal pelvic
mass
Bleeding if present may be severe and lead to shock
Low hemoglobin, hematocrit, rising white blood count
(WBC)
Human chorionic gonadotropin (hCG) usually lower
than in intrauterine pregnancy
73
Nursing Interventions with Ectopic
Pregnancy




Prepare patient for surgery.
Institute measures to control bleeding/treat shock if
hemorrhage severe and continue to monitor
postoperatively
May be given methotrexate instead of surgery
Allow patient to express feelings about loss of
pregnancy and concerns about future pregnancies.
74
Patient with Abortion





Spontaneous
Induced or elective
Monitor blood loss
Observe passage of tissue
Emotional support
75
Disseminated Intravascular Coagulation





Complication sometimes seen in high risk pregnancies
Pathologic clotting disorder
Clotting factors, platelets and fibrinogen are used up
inappropriately
Widespread internal and external bleeding seen with
inappropriate clotting in other locations
Treatment with whole blood, packed RBCs and
cryoprecipitate
76
Pregnancy Induced Hypertension


Also known as preeclamsia and if progression
occurs eclampsia
Major cause of maternal and fetal death.
 Preeclampsia
BP greater than 140/90
 Proteinuria dipstick 1-2+ or
greater than 3g/L in 24 hour specimen

77
Severe Preeclampsia








BP 160/110 or above
Hyperreflexia
Extensive edema including pulmonary edema
Headache and visual disturbances
Abdominal pain in the right upper quadant or
epigastric area
Nausea & vomiting
Decreased urine output
↑ proteinuria (3-4+)
78
Severe Preeclampsia

Maternal complication may include hemorrhage including
cerebral, cardiac or other organ failure and pulmonary edema

Severe maternal complications include DIC and/or HELLP
Hemolysis
Elevated Liver enzymes,
Low Platelets Syndrome

Fetal complication may include intrauterine growth restriction
and fetal distress from hypoxia
79
Eclampsia




Grand mal seizure hearlds eclampsia
Temporary coma may follow
May occur in pregnancy, L&D, or postpartum
Deliver as soon as possible when stable
80
Eclampsia Pharmacologic Treatments

Magnesium Sulfate (MgSO4) is used to control
seizures
 Toxic
effects
 Depressed
reflexes
 Depressed respirations
 Oversedation
 Circulatory collapse
 Calcium Gluconate serves as an antidote to MgSO4
81
Nursing Management with Preeclampsia











Frequent VS especially BP
Assess deep tendon reflexes
Assess Fetal Heart Rate (FHR) and observe for signs of
labor
Test urine for protein, I & O, Foley catheter
Bedrest/position on side
Have oral airway, O2, and suction available
Decrease environmental stimuli
Implement seizure precautions
Magnesium Sulfate with close observation
Calcium Gluconate prn
Seizure precautions
82
Diabetes in Pregnancy

Gestational
Occurs only during pregnancy
 Can usually be managed by diet and exercise alone


Pregestational
Diabetic prior to conception
 Requires insulin adjustment as pregnancy progresses

83
Gestational Diabetes

May cause





Polyhydramnios (excessive amniotic fluid)
Macrosomia (large fetus) or Intrauterine Growth Restriction
(IUGR)
Dystocia (difficult labor and delivery)
Fetal anomalies - more common in pregestational diabetes
Associated with increased incidence of preeclampsia,
premature birth, stillbirth, neonatal hypoglycemia,
respiratory distress syndrome, and jaundice.
Diabetes in Pregnancy
Risk Factors





Family history of diabetes in
first-degree relatives
Poor obstetric history
Previous macrosomic infant
Previous newborn with
congenital abnormalities
High parity
Nursing Considerations





Monitor fetal well-being
Monitoring to maintain glucose in
normal range
Frequent antepartum visits
Educate patient on glucose
monitoring, diet guidelines, and
about the effects of high blood
sugar on the mother and the fetus
Measure urine for protein and
ketones
85
Patient with Hyperemesis Gravidarum




Persistent, uncontrollable vomiting, unknown cause lasting
throughout pregnancy
Requires medical attention because of risk of dehydration,
fluid/electrolyte imbalance, ketosis and metabolic alkalosis
May require hospitalization for IV hydration, nutritional
supplements and prevention or correction of electrolyte
imbalance
Emotional support
86
Rh Incompatibility




Rh negative mother
Rh positive fetus
Maternal antibodies from exposure to Rh positive
blood cross placenta and destroy fetal RBCs
Rh Immune Globulin (RhoGam) given to mother at
28 weeks gestation and within 72 hours of birth of
Rh positive infant
87
Infections in Pregnancy

“TORCH” infections place mother and fetus in
jeopardy due to associated complications





T = toxoplamosis
O = other; gonorrhea, chlamydia, syphilis, varicella,
hep B, Group B streptoccal, HIV
R = rubella
C = cytomegalovirus
H = herpes
88
Infections in Pregnancy
(continued)

TORCH - Some related complications include:





Congenital heart defects
Physical fetal anomalies
Intrauterine growth restriction
Mental retardation
Brain dysfunctions including encephalitis and
hydrocephalus
89
Infections in Pregnancy
(continued)
Toxoplasmosis- a protozoan

Avoid raw or undercooked meat

Avoid contact with an infected cat or feces
Resultant problems:
Spontaneous
abortion
Hydrocephalus
Blindness
Deafness
Mental retardation
90
Infections in Pregnancy
(continued)
Gonorrhea- a bacterium that may

Cause endocervicitis
Cross the placenta

Cause spontaneous abortion

Result in preterm delivery

Premature Rupture of Membranes (PROM)

Blindness which can be prevented with Erythromycin eye ointment
given after birth

91
Infections in Pregnancy
(continued)
Syphilis- is a sexually transmitted spirochete that
can
 Cause congenital syphilis
 Cross the placenta
 Cause spontaneous abortion
 Cause preterm labor, stillbirth
 Result in fetal demise
 Cause disorders of CNS, teeth and cornea
92
Infections in Pregnancy
(continued)
Chlamydia- a virus-like bacteria that is the Most
common Sexually Transmitted Infection (STI)
in the U.S. It can cause:
 Weakness of fetal membranes
 PROM
 Preterm labor
 Chorieamnionitis
 Fetal conjunctivitis
 Pneumonitis
93
Infections in Pregnancy
(continued)
Varicella (chicken pox) - An acute maternal infection
during weeks 13-20 that is most damaging to newborn
which can cause:
 Limp hypoplasia
 Cutaneous scars
 Chorioamnionitis
 Cataracts
 Microcephaly
 Intrauterine Growth Restriction (IUGR)
94
Infections in Pregnancy
(continued)
Hepititis B virus
 Many modes of transmission including semen, vaginal
secretions, breast milk
 Readily crosses the placental barrier
 Prematurity, low birth weight, neonatal death
 Newborn fever, jaundice, liver enlargement
 Chronic maternal infection develops into newborn infection
90% of the time
 Infant receives immune globulin and vaccine at birth
95
Infections in Pregnancy
(continued)
Group B Streptococcus- gram positive bacterium
 Leading cause of life-threatening perinatal infection
 10-30% of women asymptomatic carriers
 Maternal infections-intraabdominal abscesses, meningitis,
fasciitis, sepsis
 Preterm labor, PROM
 Newborn sepsis, severe respiratory infection, apnea,
shock, CNS infection
96
Infections in Pregnancy
(continued)
Human Immunodeficiency Virus (HIV)
Retrovirus causes a breakdown in the immune system
 Perinatal infection transmitted at birth and through breast milk
 High levels of maternal circulating virus can lead to fetal transmission
 Fetal enlarged liver and spleen, adenopathy, failure to thrive (FTT),
persistent thrush, severe cradle cap,
 Chronic bacterial infections, sepsis, septic arthritis
 Mother and newborn treated with Zidovudine

97
Infections in Pregnancy
(continued)
Rubella virus is transmitted by nasopharyngeal
droplets and direct contact.
 Greatest risk first trimester but can cross the placenta
 Spontaneous Abortion (SAB)
 Microencephalopathy
 Congenital cataracts
 Congenital heart disease
 Deafness
 Intrauterine Growth Restriction (IUGR)
 Mental retardation
98
Infections in Pregnancy
(continued)
Cytomegalovirus is a member of the herpes group
and eventually infects most humans
 Highest rate of infection ages 15-35
 Primary maternal infection may lead to SAB
 Newborn jaundice, enlarged liver and spleen
 Chorioretinitis
 CNS abnormalities
 IUGR
 Hearing loss
99
Infections in Pregnancy
(continued)
Herpes virus is sexually transmitted and highly
contagious





Viral shedding with active lesions, before eruption and after healing;
virus migrates to sensory ganglion
Newborn transmission occurs during contact with lesions and after
Rupture of Membrane (ROM)
Primary maternal infection poses greatest risk to fetus
Preterm labor, SAB, IUGR
Neonate highly contagious – ISOLATE and observe for fever, poor
suck reflex, jaundice, seizures, lesions. Treat with Antiviral
therapy
100
Other Vaginal Infections-Newborn
Considerations

Trichomoniasis can lead to PROM and post partum

Human Papilloma Virus- Condyloma Acuminatancan lead
endometritis
to epithelial tumors of the larynx
 Candidiasis vaginal “imbalances” can lead to thrush, feeding
difficulties and be transmitted to the nipple
101
Substance Abuse





Addiction to or continued use of illegal or
prescribed substances or drugs
Substance abuse during 1st trimester places fetus at
greatest risk
Risk increases with strength, amount, frequency and
route of administration
Alcohol abuse is the number one cause of
preventable mental retardation in the U.S.
Can lead to Fetal Alcohol Syndrome (FAS)
102
Substance Abuse (continued)




Early prenatal care helpful to identify abuse early
This may help to prevent further complications
Women on heroin are placed on methadone to help
protect fetus
Infants may withdraw from substances depending
on what was used and when
103
Premonitory Signs of Labor
Lightening
 Braxton Hicks Contractions
 Cervical changes
 Increased vaginal secretions
 Bloody Show
 Sudden burst of energy
 Weight loss
 Rupture of Membranes (ROM)
 True versus False Labor

104
Labor Signs
True Labor
• Contractions
regular
• Back to abdomen
discomfort
• Cervical dilation &
effacement
• Increase in
frequency,
duration, and
intensity
False Labor
•
•
•
•
Irregular
contractions
Abdominal
discomfort
No dilation or
effacement
Inconsistent
frequency, duration,
and intensity
105
Stages of Labor

Processes and stages of labor and birth

Nursing assessments during labor

Nursing management during labor
106
Stages of Labor
First Stage begins with the onset of true labor to
complete cervical effacement and dilation
Divided into 3 phases:



Latent phase : 0-3 cm dilated
Active phase: 4-7 cm dilated
Transitional phase: 8-10 cm dilated
Stages of Labor
First Stage

Latent Phase or sometimes called early labor
Irregular, short contractions lasting 20 to 40 seconds
 Dilation of the cervix from 0 to 3 cm.
 Behavior: talkative, excited

108
Stages of Labor
First Stage

Active Phase
Cervical dilation measures 4 to 7 cm
 Contractions are 5 to 8 minutes apart and last 45 to
60 seconds.
 Behavior: more focused, concerned

109
Stages of Labor
First Stage

Transition Phase
Cervical dilation measures 8 to 10 cm
 Contractions are 1 to 3 minutes apart and 60 to 90
seconds.
 Behavior: feelings of losing control
 Feels urge to push.

110
Stages of Labor

Second Stage - complete cervical dilation to delivery
of the neonate
Crowning
Occurs when the fetal head is encircled by the external
opening of the vagina
 Birth is imminent

111
Stages of Labor
Second Stage
Positional changes of the fetus take place. These
are called Cardinal Movements. The head enters
the inlet of the pelvis in a transverse position
Descent - Occurs throughout labor as the fetus
moves down into the pelvic inlet.
112
Stages of Labor
Second Stage
Positional changes of the fetus continue with

Flexion – This occurs as the fetal head descends and meets
resistance causing the fetal chin to flex downward onto the
chest.

Internal Rotation – The fetal head moves to an oblique
position as it enters the midplane (the smallest diameter of
the pelvis). The head rotates to an anterioposterior position
to fit through the pelvic outlet.
113
Stages of Labor
Second Stage
Positional changes of the fetus continue with
Extension – The head extends to pass under the symphysis
pubis.
Restitution – As the head is born, the neck untwists, turning the
head to one side (restitution), and aligns with the position of
the back in the birth canal.
114
Stages of Labor
Second Stage
Positional changes of the fetus continue with
External Rotation – As the shoulders rotate to the
anteroposterior position, the head turns farther to one side
(external rotation).
Expulsion – the anterior shoulder moves under the symphysis
pubis and is born followed quickly by the rest of the body
115
Stages of Labor

Third Stage
Placenta Separation
 Signs: umbilical cord lengthening, gush of blood,
and change in uterine shape.
 Placenta delivery
 Avoid pressure on an uncontracted uterus to avoid
inversion of the uterus

116
Stages of Labor

Fourth Stage
Recovery - From delivery of the placenta,
approximately 1 to 4 hours after birth.
Focus - Stabilizing the mother and neonate and
promoting maternal-neonatal bonding.
117
Pain Management in Labor

Nonpharmacologic – Lamaze

Pharmacologic
Analgesics
 Anesthetics
 Epidural or Spinal
 Local

118
Fetal Monitoring




Fetal Heart Rate (FHR)
FHR Variability
FHR Accelerations
FHR Decelerations
Variable
 Early
 Late

119
Fetal Distress Assessment





Ominous FHR pattern
Fetal acidosis
Meconium-stained amniotic fluid
Decrease or cessation of fetal movement
Nurse's role in fetal distress
120
Causes of Fetal Distress









Utero-placental insufficiency
Congenital malformation
Maternal complications such as diabetes, heart disease or
preeclampsia
Maternal hypotension
Infections
Prolonged labor
Postmaturity
Oxytocin infusion
Vaginal bleeding
121
Key Nursing Interventions for Fetal
Distress





Monitor FHR, fetal activity and fetal heart variability
Identify and correct the cause if possible
Position patient on the side to enhance utero-placental
blood flow
Administer oxygen via face mask as ordered (usually 8 – 10
liters/minute)
Increase nonadditive IV fluids
122
Key Nursing Interventions for Fetal
Distress






Discontinue Oxytocin infusion if in use
Assist with AROM (artificial rupture of
membranes) and placement of internal fetal
electrode
Notify MD immediately if no improvement
Prepare for cesarean birth
Preoperative education and informed consent
Treatment depends on the underlying cause
123
Common Complications of Labor and
Delivery

Common Complications
Prolapsed Umbilical Cord
 Premature Rupture of Membranes (PROM)
 Preterm Labor

124
Prolapsed Cord

Key interventions
 Relieve
pressure on cord
Trendelberg or knee chest position
 Oxygen to increase maternal oxygen saturation
 Pressure on the presenting part

 Call
for help, but do not leave mother
 Expedite delivery
125
Premature Rupture of Membrane
(PROM)

Spontaneous break in the amniotic sac before onset of regular
contractions

Mother at risk for chorioamnionitis, especially if the time between
Rupture of Membranes (ROM) and birth is longer than 24 hours

Risk of fetal infection, sepsis and perinatal mortality increase with
prolonged ROM.

Vaginal examinations or other invasive procedure increase risk of
infection for mother and fetus.
126
PROM
Signs of Infection



Maternal fever
Fetal tachycardia
Foul-smelling vaginal discharge
127
PROM
Detecting Amniotic Fluid



Nitrazine
Ferning: Place a smear of fluid on a slide and
allow to dry. Check results. If fluid takes on a
fernlike pattern, it is amniotic fluid.
Speculum exam
128
PROM
Treatment



Depends on fetal age and risk of infection
In a near-term pregnancy, induction within 12-24
hours of membrane rupture
In a preterm pregnancy (28 -34 weeks), the woman
is hospitalized and observed for signs of infection.
If an infection is detected, labor is induced and an
antibiotic is administered
129
PROM
Nursing Interventions






Explain all diagnostic tests
Assist with examination and specimen collection
Administer IV Fluids
Observe for initiation of labor
Offer emotional support
Teach the patient with a history of PROM how to
recognize it and to report it immediately
130
Signs of Preterm Labor




Rhythmic uterine contraction producing cervical
changes before fetal maturity
Onset of labor 20 – 37 weeks gestation.
Increases risk of neonatal morbidity or mortality
from excessive maturational deficiencies.
There is no known prevention except for treatment
of conditions that might lead to preterm labor.
131
Treatment of Preterm Labor


Used if tests show premature fetal lung
development, cervical dilation is less than 4 cm, &
there are no that contraindications to continuation
of pregnancy.
Bed rest, drug therapy (if indicated) with a tocolytic
132
Preterm Labor Pharmacotherapies



Terbutaline (Brethine), a beta-adrenergic blocker, is
the most commonly used tocolytic
Side effects: maternal & fetal tachycardia, maternal
pulmonary edema, tremors, hyperglycemia or chest
pain, and hypoglycemia in the infant after birth
Ritodrine (Yutopar) is less commonly used.
133
Preterm Labor Pharmacotherapies

Magnesium Sulfate





Acts as a smooth muscle relaxant and leads to
decreased blood pressure
Many side effects including flushing, nausea,
vomiting and respiratory depression
Depression of CNS and DTRs
Should not be used in women with cardiac or renal
impairment
Excreted by the kidneys
134
Perterm Labor Pharmacotherapies

Corticosteroids
Help mature fetal lungs
 Betamethasone or dexamethasone
 Most effective if 24 hours has elapsed before
delivery

135
Nursing Interventions with Preterm
Labor
Nursing Intervention in Premature labor
Observe for signs of fetal or maternal distress
 Administer medications as ordered
 Monitor the status of contractions, and notify the
physician if they occur more than 4 times per hour.

136
Nursing Interventions with Preterm
Labor
Nursing Intervention in Premature labor
Encourage patient to lie on her side
 Bed rest encouraged but not proven effective
 Provide guidance about hospital stay, potential for
delivery of premature infant and possible need for
neonatal intensive care

137
Nursing Interventions with Preterm
Labor
Discharge teaching for home care:
Avoid sex in any form
 Take medications on time
 Teach to recognize the signs of preterm labor and
what to do

138
Induction and Augmentation of Labor



When continuing the pregnancy may be harmful to
the fetus induction with Oxytocin may be indicate
Hypotonic labor may need augmentation
Nursing responsibilities with Oxytocin
administration include:
Ensuring proper set up of intravenous lines
 Slowly increase Oxytocin dose (titrate)
 Observe for maternal or fetal problems

139
The Postpartum Period

Uterus
The fundus descends 1 cm/day and is not
palpable after 10 postpartum days. The
organs return to a pre-pregnant state.

Urinary tract
May become edematous and lose tone and
sensation. Anesthesia may cause urine
retention. Bladder retention may cause
the fundus to rise above the umbilicus.
140
The Postpartum Period
Immediate nursing interventions:
Assess fundal height and tone.
 Assess lochia amount and character - Heavy clots or
spurts of bleeding indicate uterine hemorrhage or
cervical tear.
 Assess perineum for swelling, discoloration, and
state of episiotomy (if performed).

141
The Postpartum Period






Renal system
Cardiovascular system
Fluid & electrolytes
Hematopoetic system
Gastrointestinal system
Musculoskeletal system
142
The Postpartum Period
Continued nursing interventions:






Monitor for infection and hemorrhage
Manage pain
Assess mother-infant bonding
Assess emotional status
Teach for discharge
Administer Rh immune globulin (RhoGam) or
rubella as indicated
143
Nursing Interventions after Cesarean
Birth

Pain relief via patient-controlled analgesia (PCA) or
morphine sulfate into the epidural

Early ambulation

Foley out first 12-24 hours

Incision care - “REEDA” (redness, ecchymoses, edema,
drainage, approximation)

Watch for and treat abdominal distention which is often gas
144
Postpartum Complications
Postpartum Hemorrhage (PPH)
Early PPH occurs during the first hour after birth
due to uterine atony, lacerations and hematoma.
 Treat with fundal massage and medications to cause
uterine contractions.
 Late PPH is 1-2 weeks due to retained placental
fragments, subinvolution.
 Treat with D&C, and medications including
antibiotics.

145
Postpartum Infections

Endometritis – malodorous lochia, fever (100.6), chills,
abdominal pain, uterine tenderness, tachycardia and
subinvolution



The infection may spread to cause peritonitis and septic
pelvic thrombophlebitis
Treat with IV antibiotics
Emotional support
146
Postpartum Infections
Mastitis - A breast infection occurring 1-2 weeks after
childbirth





Engorgement and blocked mild duct increases risk
Fever, localized breast pain, redness,warmth and
inflammation
Breastfeeding should continue
Antibiotics
Nurse's role is to support, educate and refer
147
Postpartum Adjustments
Nursing management of the new family
Families in crisis and the role of the nurse
Nursing management of families that have
suffered a loss, or other unfavorable outcome
 Relinquishing a newborn (adoption)



148
Postpartum Complications
Postpartum Depression (PPD)
Assess the presence and severity in all post partum
women
 Depression lasts at least 2 weeks
 Lack of interest, guilt instead of pleasure, but able to
care for infant
 Psychotherapy, antidepressants

149
Postpartum Complications
Postpartum psychosis





Rare, bipolar history common
Risk to self and/or newborn
Unable to properly care for newborn
Hospitalization necessary
Antidepressants, antipsychotics
150
Nursing Assessment of the Normal
Newborn
Initial Assessment immediately following birth
 Need for resuscitation
 APGAR scoring
 Heart rate
 Respiratory effort
 Muscle tone
 Reflex response
 Color
 Cry – strong and lusty
151
Nursing Assessment of the Normal
Newborn
Initial assessment (continued)
Newborn responses to birth
 Assessment and care of the newborn
 Check for congenital anomalies especially cardiovascular,
pulmonary and neurologic
 If stable, place with parents for initial bonding and early
breastfeeding

152
Nursing Assessment of the Normal
Newborn
Second physical assessment – within first 4 hours of life
 General appearance
 Measurements: weight, length, head & chest circumference
 Temperature (axillary not rectal)
 Respiration: Normal 30 – 60 (average 40s)
 Heart: Normal 120 – 160. Temporary murmur from open
ductus arteriosus common. Brachial and femoral pulses strong
and equal.
 Blood Pressure not routinely assessed
153
Nursing Assessment of the Normal
Newborn
Skin characteristics
Acrocyanosis
Mottling
Harlequin
Jaundice
Erythema
toxicum – “Newborn rash”
Milia
Skin
turgor
154
Nursing Assessment of the Normal
Newborn
Skin Characteristics (continued)
Vernix
caseosa
Ruddy color
Cracked and peeling skin
Lanugo
Forceps or vacuum marks
Birthmarks
Café-au-lait
155
Nursing Assessment of the Normal
Newborn
General appearance of the head




Cephalhematoma – bleeding between the periosteum and
the cranial bone
Caput succedaneum – localized edema from pressure
Molding – movement of the cranial bones during birth
Fontanels
156
Nursing Assessment of the Normal
Newborn
Face





Symmetry
Eyes
Nose
Mouth
Ears
157
Nursing Assessment of the Normal
Newborn





Neck
Chest
Cardiac
Peripheral vascular
Abdomen
158
Nursing Assessment of the Normal
Newborn

Umbilical cord
Examined for 2 arteries, 1 vein.
 Will dry up and detach in 10 to 14 days
 Cord Care: alcohol, soap & water

159
Nursing Assessment of the Normal
Newborn

Genitals

Female may have thick white mucousy vaginal discharge

Male evaluate for the position of the urinary meatus, scrotum,
testicles
160
Nursing Assessment of the Normal
Newborn




Anus – verify patency
Arms and hands- count fingers, evaluate palmar creases and
position of the arms
Legs and feet – count toes, legs of equal length and check for
hip dislocation (hip click)
Back – Spine straight, no spina bifida
161
Nursing Assessment of the Normal
Newborn

Neurologic Status
Alertness
 Resting posture
 Cry
 Muscle tone and activity

162
Nursing Assessment -Normal Newborn

Reflexes







Tonic neck
Grasp
Moro
Rooting
Sucking
Babinski
Plantar
163
Nursing Assessment of the Normal
Newborn



Estimation of gestational age through physical
assessment
Physical maturity characteristics – skin, lanugo,
plantar creases, breasts, ear/eye, genitals
characteristics
Neuromuscular characteristics: resting posture, arm
recoil, popliteal angle, scarf sign, heel to ear and
square window signs
164
Nursing Care of the Normal Newborn


Identification
Medications
Vitamin K
 Erythromycin



Thermoregulation
Feedings
165
Nursing Care of the Normal Newborn

Infant protection

Parent teaching
 Positioning
 Cord care
 Circumcision
 Car seat safety

Screening tests, immunizations and other procedures

Assessing and supporting bonding
166
Newborn Complications


Identifying complications
Hyperbilirubinemia (Jaundice)
Physiologic janudice
 Pathologic jaundice
 Jaundice associated with breastfeeding

167
Nursing Interventions with Newborn
Complications

Hyperbilirubinemia (Jaundice)
 Phototherapy
Changes bilirubin to water soluble easily excretable form
 Eye patch covering
 Frequent feedings to encourage frequent stools
 Bonding
 Parent Teaching

168
Newborn Complications

Preterm Birth






Respiratory problems
Thermoregulation
Fluid and electrolytes with parenteral feedings
Watch for and treat infection
Skin care
Pain management
169
Newborn Complications

Complications of preterm birth
 Respiratory distress syndrome
 Bronchpulmonary dysplasia
 Retinopathy of prematurity
 Necrotizing enterocolitis
 Periventricular-intraventricular hemorrhage
170
Newborn Complications






Postterm infants and postmaturity syndrome
Large-for-Gestational-Age Infants
Small-for-Gestational-Age Infants
Hypoglycemia
Sepsis
Congenital Anomalies
171
Case Study
 This case addresses complications seen in labor and in the
postpartum period.

Read the case study over carefully.
Answer the questions at the end of the case study using the
information provided.

You
may work individually or in a small group.
Come
to class prepared to discuss the case and share your
answers.
172
NCLEX-RN Questions
 There are 40 multiple choice questions on a wide range of
childbearing family topics.

Attempt to answer them in 45 minutes.
Do not look at the answers at the end of the study
guide.

Write down questions that gave you trouble so that they
can be discussed in class at the appropriate time.

173
Photo Acknowledgement:
Unless noted otherwise, all photos and clip art contained in this
module were obtained from the 2003 Microsoft Office Clip Art
Gallery.