ati-proctored-ob-maternal-newborn-study-guide

OB Maternal Newborn Study Guide Probable : Changes that make the examiner suspect a woman is pregnant (primarily related to physical changes of the uterus). Abdominal enlargement : Related to changes in uterine size, shape, and position Hegar’s Sign : Softening and compressibility of the lower uterus Chadwick’s Sign : Deepend violet bluish color of cervix and vaginal mucosa Goodell’s Sign : Softening of cervical tip Ballottement : Rebound of unengaged uterus Braxton Hicks Contractions : False contractions that are painless, irregular, and usually relieved by walking Positive Pregnancy Test : Woman’s hormonal level may not be normal Fetal Outline : Positive : Very distinct things.  Fetal Heart Sounds  Fetal Heartbeat can be heard  Can see the baby with ultrasound  Can feel movement in the uterus Naegele’s Rule: Last menstrual period minus (– ) 3 months + 7 days + 1-year ;Cathy’s Rule: + 9 months + 1 week Gravidity and Parity:  Gravida: a woman who is pregnant  Gravidity: number of pregnancies o Nulligravida: a woman who has never been pregnant o Primigravida: a woman who is pregnant for the first time o Multigravida: a woman in at least her second pregnancy.  Parity: the number of births (not the number of fetuses [ex: twins]) carried pat 20 weeks gestation, whether or not the fetus was born alive. o Nullipara: a woman who has not had a birth at more than 20 weeks of gestation. o Primipara: a woman who has had one birth that occurred after 20 weeks of gestation. o Multipara: a woman who has had two or more pregnancies to the stage of fetal viability. Know how to find out GTPAL numbers :  G = Gravidity (# of times a woman has been pregnant PLUS current pregnancy)  T = Term Births (How many babies were delivered at term 38 WEEKS OR MORE)  P = Preterm Births (Below 38 weeks)  A = Abortion (spontaneous or not) or miscarriages L= Living children Fundal height:  Measured to evaluate the gestational age of the fetus.  During the second and third trimesters (weeks 18-30), the fundal height in centimeters approximately equals the fetus’s age in weeks, plus or minus 2 cm.  At 16 weeks, the fundus can be found approximately halfway between the symphysis pubis and the umbilicus. Downloaded by devin dre (devinsco@gmail.com) lOMoARcPSD|24490294

OB Maternal Newborn Study Guide c) Chloasma (mask of pregnancy), a blotchy, brownish hyperpigmentation, may occur over the forehead, checks, and nose. d) Reddish-purple stretch marks (striae) may occur over the abdomen, breasts, thighs, and upper arms  Vascular spider nevi may occur on the neck, chest, face, arms, and legs.  The rate of hair growth may increase. Musculoskeletal System :  Changes in center of gravity begin in the second trimester and are caused by the hormones relaxin and progesterone  The lumbosacral curve increases  Aching, numbness, and weakness may result; walking becomes more difficult, and the woman develops a waddling gait and is at risk for falls.  Relaxation and increased mobility of pelvic joints occurs, which permit enlargement of pelvic dimensions.  Abdominal wall stretches with loss of tone throughout pregnancy, regained postpartum.  Umbilicus flattens or protrudes. * During pregnancy, postural changes occur as the increased weight of the uterus causes a forward pull of the bony pelvis. It is important for the nurse to encourage the client to implement measures that maintain safety and correct posture to prevent a backache . Discomforts of pregnancy:  Nausea and Vomiting . o Interventions : eating dry crackers before rising, avoiding brushing the teeth immediately after rising, eating small frequent low-fat meals during the day, drinking liquids between meals rather than at meals, avoiding fried and spicy foods, asking the primary health care provider about acupressure (some types may require a prescription), and asking if the PHCP about the use of herbal remedies.  Syncope . o Interventions : sitting with the feet elevated and changing positions slowly because of the risk for falls. o The nurse needs to inform the pregnant client to avoid lying in the supine position, particularly in the second and third trimesters. The supine position places the woman at risk for supine hypotension, which occurs as a result of pressure of the uterus on the inferior vena cava .  Urinary urgency and frequency . o Interventions : drinking no less than 2000 mL of fluid during the day, limiting fluid intake during the evening, voiding at regular intervals, sleeping on the side at night, wearing perineal pads if necessary, and performing Kegel exercises.  Breast tenderness . o Interventions : encouraging wearing a supportive bra, avoiding the use of soap on the nipples and areolar area to prevent drying of skin. Downloaded by devin dre (devinsco@gmail.com) lOMoARcPSD|24490294

OB Maternal Newborn Study Guide  Chlamydial infection . o Transmission may occur during vaginal birth and can result in neonatal conjunctivitis or pneumonitis. o Infection can cause premature rupture of the membranes, premature labor, and postpartum endometritis.  Trichomoniasis . o Associated with premature rupture of the membranes and postpartum endometritis.  Genital herpes simplex virus . o Characterized by painful lesions, fever, chills, malaise, and severe dysuria and may last 2 to 3 weeks. o Assessment includes questioning all women about signs/symptoms and inspecting the vulvar, perineal, and vaginal areas for vesicles or areas of ulceration or crusting; this is done during pregnancy and at the onset of labor. o Vaginal birth may be acceptable; cesarean birth is recommended if visible lesions are present. o Infants who are born through an infected vagina should be carefully observed, and samples should be taken for culture.  Human immunodeficiency virus (HIV). o HIV is transmitted via blood, blood products, and other body fluids such as urine, semen, and vaginal secretions; the virus is also transmitted through exposure to infected secretions during birth and via breast milk. o Repeated exposure to the virus during pregnancy through unsafe sex practices and/or intravenous drug use can increase the risk of transmission to the fetus. o Perinatal administration of zidovudine may be recommended to decrease risk of transmission of HIV from mother to fetus.  Substance abuse . o Substance abuse threatens normal fetal growth and the successful term completion of the pregnancy. o Substance abuse places the pregnancy at risk for fetal growth restriction, abruptio placentae, and fetal bradycardia. o Many substances cross the placenta and can be teratogenic; (drugs, tobacco, alcohol, medications, certain foods such as raw fish); no OTC medications should be taken unless prescribed. o Smoking (tobacco) can lead to low birth weight, a higher incidence of birth defects, and stillbirths. o Physical signs of drug abuse may include dilated or contracted pupils, fatigue, track (needle) marks, skin abscesses, inflamed nasal mucosa, and inappropriate behavior by the mother. o The consumption of alcohol during pregnancy may lead to fetal alcohol syndrome and can cause jitteriness, physical abnormalities, congenital anomalies and growth deficits. Video #3: Weight Gain & Nutrition During Pregnancy AND Diagnostic Tests During Pregnancy Weight Gain & Nutrition  Normal weight gain = 25- 35 pounds  Overweight person weight gain = 15- 25 pounds  Underweight person weight gain = 28-40 pounds Downloaded by devin dre (devinsco@gmail.com) lOMoARcPSD|24490294

@ShopWithKey on Etsy 10 o Reactive: FHR accelerates during movement (normal; positive) o Nonreactive : No accelerations during movement (not normal; negative)  If non-reactive, the DR will perform another test called: Contraction Stress Test (CST) or a BPP. Video #4: Diagnostic Tests Contraction Stress Test (CST)  Induce contraction with administration of Pitocin/oxytocin or nipple stimulation  During the contraction, monitor FHR for late decelerations  Negative CST Response (no late decelerations, which is what you want)  Positive CST (late decelerations happen, not a good thing)  Risk o Can send woman into PTL Amniocentesis .  Aspiration of amniotic fluid; best performed between 15 and 20 weeks of pregnancy because amniotic fluid volume is adequate and many viable fetal cells are present in the fluid by this time. Performed to determine genetic disorders, metabolic defects, and fetal lung maturity  You want an empty bladder because you will poke into amniotic sac to test for genetic abnormalities (levels of AFP aka alphafeto-protein) o Interventions : if less than 20 weeks gestation, the woman should have a full bladder to support the uterus. If more than 20 weeks gestation, the woman should have an empty bladder to minimize the chance of puncture. Prepare the client for ultrasonography, which is performed to locate the placenta and avoid puncture of it. Obtain baseline vital signs and fetal heart rate. Monitor every 15 minutes. Position the client supine during the procedure and on the left side after the procedure. o High AFP = NTD o Low AFP = Chromosomal disorders such as down syndrome  LS Ratio (Lecithin Sphingomyelin)  tests for fetal lung maturity o Ratio of 2:1 = fetal lung maturity o Ratio of 2.5:1 or 3:1 = fetal lung maturity for client with DM  Risks/Complications : o Amniotic Fluid Emboli (AFE) o Maternal Hemorrhaging o Infection o Premature rupture of the membranes o Rh isoimmunization o Miscarriage o Abruptio placentae Chorionic Villus Sampling (CVS)  Alternative to Amniocentesis :  Performed for the purpose of detecting genetic abnormalities; the PHCP aspirates a small ample of chorionic villus tissue at 10 to 13 weeks gestation.  Can be done between 10-12 weeks  Also tests for genetic abnormalities by testing the placenta instead of the amniotic fluid .  Advantage  Can be done earlier Downloaded by devin dre (devinsco@gmail.com) lOMoARcPSD|24490294

contractions with a duration of 40 seconds or more during a 10 minute period have been achieved. o Frequent maternal blood pressure readings are obtained and the mother is monitored closely while increasing doses of oxytocin are given. Video #5 Bleeding and Complications During Pregnancy  Ectopic Pregnancy  Ovum is planted outside of the uterus, often in the fallopian tube. Need to know the symptom of unilateral stabbing pain in the lower abdominal quadrant o If it burst the fallopian tube, it can be life threatening to the mom  Gestational Trophoblastic Disease (GTD)  the proliferation and degeneration of trophoblastic billi in the placenta that becomes swollen, fluid-filled, and takes on the appearance of grape-like clusters or prune juice.  Placenta Previa  Placenta previa occurs when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus. PAINLESS BRIGHT RED VAGINAL BLLEDING during the 2nd or 3rd trimester o Very dangerous  May hemorrhage and may need to give blood o Complete or Total : Cervix is completely covered by placental attachment o Incomplete or Partial : Partially covered by the placental attachment o Marginal or low-lying  Abruptio Placenta : the premature separation of the placenta from the uterus, which can be a partial or complete detachment. o Sudden onset of intense localized uterine pain with dark, red, vaginal bleeding. o Clinical Findings : Hypovolemic shock  Yeast Infections are quite common for pregnant woman o Signs/Symptoms :  Cottage cheese discharge  Vulvar redness  White patches on vaginal wall  Incompetent Cervix : Recurrent premature dilation of the dilation of the cervix or cervical insufficiency (basically the cervix cannot stay closed and will lead to a spontaneous abortion if not taken care of). If woman has incompetent cervix, she will get a cerclage to help keep cervix closed and from dilating and is removed at 37 weeks of gestation or when spontaneous labor occurs.  Hyperemesis Gravidarum  Nausea and vomiting that goes past 12 weeks. End up having weight loss & electrolyte imbalances & dehydration. o Nursing Interventions: IV Fluids, administration of B6, antiemetic medication (Reglan or Zofran). Video #6: Medical Conditions Iron Deficiency Anemia  Provider will prescribe FE supplements  Take FE Supplement that is rich in Vitamin C (i.e orange juice) Gestational Diabetes (GDM)  If a patient has GDM during pregnancy, it increases her risk of developing DM after her pregnancy Downloaded by devin dre (devinsco@gmail.com) lOMoARcPSD|24490294

4 Stages of labor :  1st  Onset of labor until complete dilation of cervix (10 cm) o Has 3 phases  Latent  0-3 cm dilation o Mother is talkative & eager  Active  >3-7cm o Mother is restless, anxious, and may feel helpless  Transition  >7cm-10cm o Mother is experiencing a lot of pain, has urge to push and may feel like she is having a bowel movement (increased rectal pressure)  2nd  Full dilation of cervix to birth of the baby  3rd  Birth of baby to delivery of placenta  4th  Delivery of placenta until mothers’ vitals are stable Video #8 Pain Management & FHR Monitoring Non-pharmacological methods  Aromatherapy  Imagery  Music  Effleurage : light, gentle circular stroking of the client’s abdomen with the fingertips in rhythm with breathing during contractions  Sacral Counter-pressure : Consistent pressure is applied by the support person using the heel of the hand or fist against the client’s sacral area to counteract pain in the lower back Pharmacological Methods (Sedative & Opioid analgesics) Sedative  puts baby at risk for respiratory depression Opioid Analgesic  puts mom at risk for sedation, hypotension, and increased variability in FHR Epidural Analgesia  Provides lack of sensation at level of the umbilicus to the thighs.  Needs to be dilated at least 4cm or above  Side effects include : maternal hypotension and fetal bradycardia.  Nursing Interventions  Give IV Bolus to counteract hypotension; want to avoid supine hypotension syndrome (avoid this by placing patient on her side and not on her back). Spinal Block : provides lack of sensation from the nipples to the feet. Given for C-Sections.  Side effects include : maternal hypotension and fetal bradycardia, potential headache from leakage of CSF, and increase incidence of bladder and uterine atony.  Nursing Interventions  Give IV Bolus to counteract hypotension; want to avoid supine hypotension syndrome (avoid this by placing patient on her side and not on her back). Downloaded by devin dre (devinsco@gmail.com) lOMoARcPSD|24490294

 After birth; 2-3 days milk will come in. Before milk comes in, colostrum is what is being excreted (thicker and yellow consistency. High fat content with antibiotics)  Average blood loss during vaginal birth = 500ml.  Average blood loss for a c-section =1000ml. Uterine Atony  If woman is retaining urine, her bladder will be distended which will displace her uterus.  Intervention : o Have woman empty her bladder Video #10: Baby Friendly Care 3 phases  Dependent: Taking in phase : o First 24-48 hrs after birth o Mom is eager to talk about birth experience o Relies on others for assistance  Dependent-Independent: Taking hold phase : o Day 2-3 and goes up to a few weeks o Mother is focused on baby care o Practicing skills and learning how to take care of baby  Independent: Letting Go : o Its not all about how to take care of the baby o Mother resumes her roles as a partner, individual, returns to work, etc Discharge Teaching  Breast Engorgement & Post-Partum Disorders  Milk comes in 2-3 days after giving birth o Breast Engorgement is common  Cold compress between feedings, warm shower prior to feeding to help with circulation  Cold fresh cabbage leaves on the breast  Mild analgesics o If she is not going to breast feed, do not promote milk flow  Cold compress, and tight bras are the interventions Post-Partum Disorders  Higher risk of getting DVT  Pulmonary Embolism may occur  Signs & Symptoms  Chest pain, difficulty breathing  PPH  Different types of lochia (COCA) o Lochia rubra lasting longer  Culprit = uterine atony or retaining placental fragments  Make sure bladder is empty  Monitor pads and saturation  If she’s losing a lot of blood, she will have tachycardia and hypotension Downloaded by devin dre (devinsco@gmail.com) lOMoARcPSD|24490294

 Make sure to massage the fundus o Medications used for PPH (Post-Partum Hemorrhage)  Oxytocin/Pitocin (help contract uterus)  Methylergonovine  Methergine  Misoprostol  Cytotec  Mastitis  infection of the breast o Signs & Symptoms :  Painful or tender localized hard mass  Reddened area on one breast  Flulike symptoms (chills/fatigue) o Interventions to Prevent Mastitis :  Wash hands prior to breast feeding  Keep breast nice and clean  Allow nipples to air dry  Make sure baby is taking in the entire nipple and areola into their mouth  Empty breast with each feeding Video #11: Post-Partum Depression Vs. Post-Partum Blues & Newborn Assessment Post-Partum Blues  Very common, can last up to 10 days (if extends over 10 days or symptoms get more severe, assess for PPD)  Signs & Symptoms : o Tearfulness o Insomnia o Lack of appetite o Feeling of letdown Post-Partum Depression  Occurs w/in 6 months of delivery and includes persistent feelings of sadness and intense mood swings (10% of new moms) Post-Partum Psychosis  Common with moms with history of bipolar disease  Signs & Symptoms: o Disorientation o Hallucination o Obsessive behaviors o Paranoia Newborn Assessment (APGAR ).  7-10 = No Distress  4-6 = Moderate Distress  Under 4 = Severe Distress  Score is based on 5 areas o HR (0/1/2) Downloaded by devin dre (devinsco@gmail.com) lOMoARcPSD|24490294

@ShopWithKey on Etsy 20 o RR (0/1/2) o Muscle Tone (0/1/2) o Reflex Irritability (0/1/2) o Color (0/1/2) Video #12: New Ballard Scale  Neuromuscular Maturity o Full Term = Well Flexed  Physical Maturity o Preterm  Skin: Thinner/Transparent skin, may be sticky  Lanugo  No plantar creases  No breast tissue/ not well developed  Boys  Flat/ Smooth scrotum  Female  prominent clitoris and flat labia o Full Term .  Skin: Thicker  No lanugo  Plantar creases  Will have breast tissue (5-10mm in width)  Boys  Pendulum/Rugae scrotum  Girls  Labia will be more developed and will encompass clitoris o Post-mature .  Skin: Wrinkled, crack, leathery appearance.  Normal Deviations in Newborns o Milia = small raised white spots on the nose or chin  will go away w/o treatment o Mongolian Spots = bluish purple spots on their back or bottom o Head = 2-3 cm larger than chest circumference; chest should be barreled shaped  Should have anterior and posterior fontanel; should be soft and flat  Anterior = diamond shape, 5 cm in size  Posterior= smaller in size, triangular shape  If fontanel is bulging, it is NOT NORMAL .  Sunken is NOT NORMAL .  Caput Succedaneum “conehead” & Cephalohematoma “bleeding under scalp” will resolve on their own. o Eyes = Blue or grey at birth; true eye color established in 3-5 months o Ears = low set  may indicate down syndrome o Epstein’s Pearls  small white cysts found at the gums and junctions of the soft and hard pallets  Grey white patches on the tongue and gums IS NOT NORMAL . May be infection!! Video #13: Reflexes Sucking & Rooting  Birth to 3-4 months but can last up to a year. Palmar Grasp  Birth to 6 months Downloaded by devin dre (devinsco@gmail.com) lOMoARcPSD|24490294

@ShopWithKey on Etsy 21 Plantar Grasp  Birth to 8 months Moro Reflex  Birth to 6 months Tonic Neck Reflex  Birth to 3-4 months Babinski Reflex  Birth to 1 year Stepping  Birth to 4 weeks Must keep baby warm. Baby can lose heat in 4 different mechanisms:  Conduction : Direct contact with a cooler surface  Convection : Lose heat from cooler, environmental air (i.e fan)  Evaporation : Lose surface liquid through vapor  Radiation : Loss of heat from the body surface to another surface that is close by (window or air conditioner) Side Notes : * Meconium should be passed within 24 hours after birth. * Prophylactic eye care  Erythromycin to prevent eye infection from chlamydia or gonorrhea. * Vitamin K  Needed to prevent hemorrhaging given until they can produce their own. * HEPB Vaccine is given at birth (immediately) * Be on lookout for hypoglycemia (S/sx  jitteriness, twitching, high pitched cry, irregular respirations, lethargy, cyanosis, eye rolling, seizures, blood glucose level will be under 40 mg/dl) Video #14: Newborn Nutrition  May lose 5-10% of body weight right after birth but should regain weight within 10-14 days after they are born  Breastfeeding is highly advised  reduces risk of infection, helps with brain growth, is inexpensive and convenient, reduces instances of SIDS o For the first 6 months of life, babies only need milk o First food that is introduced (6 months of age) FE fortified cereal (rice)  Do not introduce solids until 6 months of age o Breastfeeding is encouraged right after birth to begin breastfeeding  Can expect uterine cramps while breastfeeding (release of Pitocin; will help uterus contract and reduce incidences of uterine atony)  Breastfeed 15-20 mins per breast  Empty the breast  Best indicator that baby is eating well  Voiding 6-8 diapers per day  How to store breastmilk and formula ;  Breastmilk : o Stored at Room temp under clean conditions up to 8 hrs o Refrigerated in sterile bottles for 8 days o Frozen for up to 6 months o Deep freezer = 12 months o Thawing milk  Thaw in fridge for 24 hrs ( DO NOT MICROWAVE OR REFREEZE )  Use portions of breast milk must be discarded. DO NO REUSE Downloaded by devin dre (devinsco@gmail.com) lOMoARcPSD|24490294

 How to store Formula :  Can be stored in fridge up to 48 hrs  Discard any unused portion just like you would breast milk  Always put baby to sleep on their back to reduce chances of SIDS  Cord Care & Circumcision Care o Umbilical Cord :  Keep dry & above diaper (fold diaper in front so it doesn’t cover cord)  Sponge baths only until cord falls off (10-14 days after birth)  Monitor cord and make sure it is not moist, red, or house foul odor or purulent drainage. o Circumcision care :  Clamp procedure  Apply petroleum jelly with each diaper to prevent diaper from sticking to penis  Tub bath is not to be given until circumcision is completely healed  Yellow film of mucus will form over glands by day 2, DO NOT wash off .  May give baby acetaminophen  Care Safety o Rear facing car seat, middle seat until age 2! Video #15: Newborn Complications Hypoglycemia  Glucose level < 40; GET BABY FOOD . Preterm Newborn  At risk for complications : o Respiratory distress o Bronchopulmonary dysplasia o Necrotizing Enterocolitis (inflammatory disease of GI system) o Hypotonic Muscles  LGA (Large for Gestational Age ): o Macrosomic (large baby with organs that are not fully developed)  Born to mothers with diabetes  Suffer from hypoxia, hypoglycemia, or hypocalcemia (can cause tremors)  Post-Term : o Lose subcutaneous fat o Hair and nails may be long o May have meconium staining on nails or umbilical cord  Hyperbilirubinemia  Jaundice o Physiologic Jaundice = Benign (occurs 24 hrs of age and resolves w/in 7 days)  Due to immaturity of baby liver o Pathologic Jaundice = extends over 7 days. Related to blood group incompatibility related to some kind of infection. Downloaded by devin dre (devinsco@gmail.com) lOMoARcPSD|24490294

o Bilirubin Encephalopathy = very dangerous. Related to untreated hyperbilirubinemia. Levels >25 mg/dl. Associated with cerebral palsy, epilepsy, mental handicap o *Note time that jaundice set in to be able to differentiate types of jaundice o Phototherapy is prescribed if bilirubin is :  15mg/dl in newborn prior to 48 hrs of age  18 mg/dl in newborns prior to 72 hrs of age  >20 mg/dl at anytime then phototherapy is considered  Interventions :  Eyes mask over baby  Keep newborn undressed  Cover up genitalia on baby  Avoid applying lotion (absorbs heat and can cause burn)  Remove baby Q4 hrs, check eyes  Reposition Q2 hrs  Effects :  Bronze discoloration & rash is not serious  Monitor for dehydration (sunken fontanels, wet diapers)  Make sure you feed baby frequently or provide formula to help excrete bilirubin Downloaded by devin dre (devinsco@gmail.com) lOMoARcPSD|24490294