Maternity Introduction to Maternity & Pediatric Nsg; Leifer, 7 th ed., Ch. (1, 2, 3 review), 4, 6, 7, 8 1. Discuss stages of fetal development. 2. Discuss major functions of each reproductive structure. 3. Explain expected Δ’s in the major body systems during pregnancy. 4. Describe diagnostic tests & estimating due dates. 5. Describe the 4 components of the birth process. 6. Explain the normal processes of childbirth: premonitory signs, mechanisms of birth & stages & phases of labor.
The Present: Maternity https://www.youtube.com/watch?v=q0NRngqwqEg Family involvement during pregnancy & birth Necessary for bonding & support Hospitals 3 separate sections of the maternity unit Labor-delivery Postpartum Newborn nursery Some facilities have merged all 3 areas into 1
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
MaternityIntroduction to Maternity & Pediatric Nsg; Leifer, 7th
ed., Ch. (1, 2, 3 review), 4, 6, 7, 81. Discuss stages of fetal development.2. Discuss major functions of each reproductive
structure.3. Explain expected Δ’s in the major body systems
during pregnancy.4. Describe diagnostic tests & estimating due
dates.5. Describe the 4 components of the birth process.6. Explain the normal processes of childbirth:
premonitory signs, mechanisms of birth & stages & phases of labor.
The Present: Maternityhttps://www.youtube.com/watch?v=q0NRngqwqEg
• Family involvement during pregnancy & birth• Necessary for bonding & supportHospitals
• 3 separate sections of the maternity unit• Labor-delivery• Postpartum• Newborn nursery
to the vaginal opening in the perineum• Known as the birth canal• Passageway for menstrual blood flow,
penis intercourse, & the fetus
Ovaries• Form the expel ova• Primary source of estrogen &
progesterone
• Attached to each side of uterus• Passageways for ovum to travel to
uterus• Fertilization occurs in middle or outer part of tubes & then fertilized egg travels to uterus to implant itself• ~ 5 – 7 days for ovum to travel
•Occurs in the ampulla of the fallopian (uterine) tube when sperm & ova unite•When fertilized, the membrane of the ovum undergoes changes that prevent entry of other sperm•23 chromosomes per reproductive cell•Sperm carry X or Y chromosome, XY, male;
XX, femaleImplantation•The zygote implants in the uterus 6 to 8 days
after ovulation.•The blastocyst secretes chorionic gonadotropic, so the luteum remains viable & secretes estrogen & progesterone for the first 2 - 3 months of gestation.
• Blood volume ↑’s by 40%–50%• RBC volume ↑’s up to 30%• Plasma volume ↑’s by 50%• Hemoglobin Δ’s to 11–12 g/100mL• Hematocrit ↓’s• WBC count ↑’s up to 16,000 mm3
(Normal Hgb 11.7 - 15.5, & Hct 38 - 44)
Discomforts of Pregnancy -
Nausea & vomitingBegins 1st trimester & subsides by 3rd monthCaused by elevated hCG levels & Δ’s in carbohydrate metabolismInterventions
Eat dry crackers before rising; eat small, frequent, low-fat meals.Drink liquids between rather than at meals.Avoid brushing teeth after rising; avoid fried & spicy foods.Ask health care provider (HCP) about acupressure & use of herbal remedies.
Discomforts of Pregnancy (cont’d)• Syncope
• Occurs during 1st trimester• Supine hypotension occurs during 2nd & 3rd
trimesters• May be caused by hormones, anemia, fatigue,
• Sit upright for 30 mins after meals.• Drink milk between meals.• Consult HCP about antacids.
Discomforts of Pregnancy (cont’d)• Ankle edema
• Occurs during 2nd & 3rd trimesters• Result of vasodilation, venous stasis, & ↑’ed venous pressure below uterus
• Interventions• Elevate legs twice daily & when resting; wear supportive stockings.
• Sleep on side.• Avoid sitting or standing in one position for long periods.
Discomforts of Pregnancy (cont’d)• Varicose veins
• Occurs during 2nd & 3rd trimesters• Caused by weakening walls of veins or
valves & by venous congestion• Interventions
• Wear supportive stockings.• Elevate feet when sitting; elevate feet
& hips when lying down.• Avoid long periods of standing or
sitting.• Move about while standing.• Avoid leg crossing & constricting
clothing.• Exercise legs, avoid airline travel to
prevent thrombophlebitis.
Discomforts of Pregnancy (cont’d)• Headaches
• Occur during 2nd & 3rd trimesters• Result of Δ’s in blood volume & vascular tone
• Interventions• Δ positions slowly.• Apply cool cloth to forehead.• Eat small snacks.• Use acetaminophen if prescribed.
Discomforts of Pregnancy (cont’d)• Hemorrhoids
• Occur during 2nd & 3rd trimesters• Result of ↑’ed venous pressure & constipation
• Interventions• Soak in warm sitz bath; sit on soft pillow.
• Eat high-fiber foods & drink sufficient fluids.
• ↑ mild exercise; apply tx’s as prescribed
Discomforts of Pregnancy (cont’d)• Constipation
• Occur during 2nd & 3rd trimesters• Results from ↑ in progesterone, ↓’ed
intestinal motility, displacement of intestines, pressure of uterus, iron supplements
• Interventions• Eat high-fiber foods.• Drink at least 2000 mL daily.• Exercise regularly.• Consult with HCP about stool softeners,
laxatives, & enemas
Discomforts of Pregnancy (cont’d)• Backache
• Occur during 2nd & 3rd trimesters• Result of exaggerated lumbosacral curve• Risk for falls; use deliberate, slow
movements• Interventions
• Rest; sleep on a firm mattress.• Use correct body posture & mechanics.• Wear comfortable, supportive shoes.• Perform pelvic tilt exercises.
Discomforts of Pregnancy (cont’d)• Leg cramps
• Occur during 2nd & 3rd trimesters• Result of altered calcium–phosphorus balance,
pressure of uterus, fatigue• Interventions
• Engage in regular mild exercise.• Dorsiflex foot of affected leg.• ↑ calcium intake.
• Shortness of breath• Occur during 2nd & 3rd trimesters• Result of pressure on diaphragm form enlarged
uterus• Interventions: take small rest periods; avoid
overexertion; sleep on side or with head elevated
Psychological Maternal Δ’sAmbivalence
May occur in early pregnancyMother may experience a dependence–independence conflict related to role Δ’sPartner may experience ambivalence r/t new role, financial responsibilities, & sharing attention
AcceptanceFactors include readiness for experience & identification with motherhood role
Emotional liabilityManifested by frequent or extreme Δ’s in emotional state, which are common
Body image Δ’sPositive or negative Δ’s in woman's perception of her image occur gradually during pregnancy.Physical Δ’s & symptoms contribute to body image.
Relationship with fetusWoman may daydream & think about desired maternal qualitiesAccepts biological fact of pregnancyAccepts fetus is a distinct person to nurturePrepares realistically for birth and parenting
Psychological Maternal Δ’s cont’d
The father • ambivalent feelings • Fears • question his ability • feel rejected
• Hegar’s sign: softening & thinning of lower uterine segment at about 6 wk of gestation
• Goodell’s sign: softening of cervix, beginning at 2nd month of gestation
• Chadwick’s sign: violet coloration of mucous membranes of cervix, vagina, vulva at ~ 6th wk of gestation
• Ballottement: rebounding of fetus against examiner’s fingers on palpation
16-20 wks floating fetus
• Uterus enlargement• Positive pregnancy test d/t presence of
hCG which appears in the urine 8-10 days after conception
• Braxton-Hicks contractions – irregular contractions occur intermittently throughout pregnancy but don’t ↑ in intensity or duration or cause cervical dilation
• Darkening of nipples & areola• Linea nigra- dark line from symphysis to
xiphoid process, chloasma of the face, striae gravidarum- stretch marks
• Confirm or r/o a dx of pregnancy• Ascertain risk factors• Determine the estimated date of delivery (EDD)
• Provide education on maintaining a healthy pregnancy
• Hx taking‒Chief complaint‒Reproductive hx‒Medical-surgical hx‒Family & Social hx
Prenatal Visit (cont.)•Physical examination•Head-to-toe physical•Vaginal speculum examination •Bimanual examination of the uterus
Diagnostic Tests•Laboratory workCBC (Hemoglobin & hematocrit levels)•Tests for presence of infection•Group B streptococcus (GBS) after 35 wks & before the end of 37 wks.
• Based on the presence of the hormone hCG which is secreted by the chorionic villi of the placenta
• Appears in the urine or blood 9-10 days after conception (or 24-48 hrs) after implantation
• HPT (home pregnancy tests 97% accurate
Pregnancy Tests
Diagnostic Tests cont’dBlood type & Rh factor https://www.youtube.com/watch?v=7OWp8d8WKkg
• Mother is Rh-negative & has negative antibody screen
• Will need to repeat antibody screens
• Should be given Rho(D) immunoglobulin (RhoGAM) within 72 hrs of birth of first baby when detected
• With every pregnancy, should be given RhoGAM at 28th wk of gestation & within 72 hrs of birth of baby
• Pt with negative titer (<1:8) is at risk of contracting rubella, which can be transmitted to fetus & cause birth anomalies; thus, titer should be assessed before conception
• If negative titer, pt must be using effective birth control at time of immunization, must be counseled to not become pregnant for 3 mons following immunization
• Determines presence of amniotic fluid in vaginal secretions; shades of blue indicate that membranes probably ruptured
• Nonstress test• Performed to assess placental function &
oxygenation • Assesses fetal well-being
• Contraction stress test• Performed to assess placental oxygenation
& function • Assesses fetal ability to tolerate labor, fetal
well-being
Gravidity & Parity• Gravidity: # of pregnancies
• Gravida: woman who is pregnant• Nulligravida: woman who has never been
pregnant• Primigravida: woman pregnant for the first time• Multigravida: woman having had 2 or more
pregnancies• Parity: number of births carried past 20 weeks’
gestation, whether or not the fetus was born alive• Nullipara: woman who has not had a birth at
more than 20 weeks’ gestation• Primipara: woman who has had one birth that
occurred after 20 weeks’ gestation
Gravidity & Parity (cont’d)Parity (cont’d)
• Multipara: woman who has had 2 or more pregnancies that resulted in viable offspring
Use of GTPAL: pregnancy outcomes can be described with the GTPAL acronym
• G = gravidity, including present pregnancy• T = term births, after 37 weeks• P = preterm births, before 37 weeks• A = abortions or miscarriages• L = live births
• Teaching• Avoiding substance abuse• Diet, nutrition, & exercise• Infection control & medications• Dental hygiene • Hygiene & clothing• Breast care• Sexual activities• Employment & travel
Prenatal Visit
Methods of Determining the Due Date • Nagele’s rule
• Add 7 days to the date of the first day of the LMP, then subtract 3 months & add 1 yr.
• Pelvic examination• The practitioner feels the size of the uterus to
determine the term of the pregnancy• Obstetric sonogram
• High frequency sound waves reflect off fetal & maternal pelvic structures, allowing visualization
Trimesters
• Pregnancy divided into 3- 13-week parts
• Important to know what occurs during each trimester to both woman & fetus
• Helps provide anticipatory guidance• Identify deviations from the expected pattern of development
• Baseline TPR, BP, ht., wt• Head-to-toe physical
Vaginal speculum examination Bimanual examination of the uterus
Physical examination
Fundal Height– Measured to evaluate gestational age of
fetus– During the 2nd & 3rd trimesters, fundal ht
in cms ~ equals the fetus' age in wks plus or minus 2 cm
– At 16 wks, fundus can be found approximately halfway between the symphysis pubis & the umbilicus
– At 20 to 22 wks, fundus is ~ at the location of the umbilicus
– At 36 wks, fundus is at the xiphoid process
McDonald's rulethe length in cms of the abdominal contour from the upper margin of the pubic symphysis to the fundus of the uterus, divided by 3.5, gives the duration of pregnancy in lunar months; applicable only after the 6th month of pregnancy.
• ↑ kCal by 300 per day, & should include– Protein—60 g/day– Calcium—1200 mg/day– Iron—30 mg/day– Folic acid—400 mcg (0.4mg)/day
• Recommended wt gain–First trimester: 3–4 lbs total–Remainder of pregnancy: 1 lb/wk–Total wt gain: 25–35 lbs for a woman
with a normal BMI• Breast feeding– ↑ 500 kCal or total 2700
kCal
Nutritional Requirements of Pregnancy
Weight Gain• Women of normal weight: 25 to 35 lbs (11.5
to 16 kg)• Obese women: 11 to 20 lbs (5 to 9 kg)• Overweight women: 31 to 50 lbs (14 to 22.7
kg)• Multifetal pregnancy: twins—woman should
gain 4 to 6 lbs in first trimester, 1½ lbs per week in second & third trimesters, for a total of 37 to 54 lbs
• Edema of lower extremities, face, hands
• Discomforts of pregnancy • Eating & sleeping patterns• Psychosocial concerns• Fundal ht for uterine & fetal growth
Milestones of fetal growth: fundus over symphysis at 12-16 wks, at umbilicus at 18-22 wks, at xiphoid at 36wks
Class: serum immune globulinDrug: RhoGAM, Rho (D) Immune GlobulinAction: prevents production of anti-Rh antibodies in Rh- people & therefore prevents hemolytic disease in RH+ newbornRoute IM: Administered at 28 wks of gestation & within 72 hrs of delivery, also administered after amniocentesis, miscarriage, abortion, ectopic pregnancyContra: Rh+ patientsSide effects: painful injection site, feverNursing: educate pt. in purpose of drug
Drugs Used in Prenatal Period
PNVVitamins – A,D,E,C, folic acid, thiamine, riboflavin, niacinanmide, B6, B12Minerals – Ca, copper, iron, zincIndications – vitamin & mineral supplement throughout pregnancy & lactationDosage – 1 dailySide effects – rare, epigastric distress sometimes occurs when admin. On an empty stomach, admin. With meals, citrus juice enhances absorption
Drugs Used in Prenatal Period cont’d
The Process: The Four P’s of LaborProcess of labor; coordinated sequence of involuntary uterine contractions to move fetus through birth canal, to delivery, actual birth of newborn
• 4 major factors interact during normal childbirth; four Ps of labor depend on each other for safe delivery• Power: uterine contractions• Passageway: mother’s rigid bony
pelvis, soft tissues of cervix, pelvic floor, vagina, introitus
• Passenger: fetus, membranes, placenta
• Psyche: woman’s emotional system
• Attitude• Relationship of fetal body parts
to one another• Lie
• Relationship of spine of fetus to spine of mother
• Presentation• Portion of fetus that enters
pelvic inlet first
The Process: The Four P’s of Labor (cont’d)
The Process: The Four P’s of Labor (cont’d)
• Presenting part: specific fetal structure lying nearest cervix
• Position: relationship of assigned area of presenting part to maternal pelvis
• Station• Measurement of progress of
descent in centimeters above or below midplane, from presenting part to ischial spine
• If head is in fundus, hard, round movable object is felt; if buttocks is in fundus, then soft, irregular shape is noted, more difficult to move
• Back of fetus should be felt on one side of abd
• Irregular knobs & lumps, hands, feet, elbows, & knees felt on opposite side of abdomen
• Phases of involuntary uterine contraction– Increment: Building up of the
contraction - longest phase– Acme: Peak of the
contraction– Decrement: Letting up
phase– Relaxation period: Rest
period between contractions
Powers
Descriptors of contractions• Frequency: How often the contractions are occurring • Measured by counting the time interval from the beginning of one contraction to the beginning of the following contraction
• Duration • The interval from the beginning of a contraction to its end
• Intensity • The strength of the contraction
Uterine Contractions• Effect of contractions on the cervix
• Efface• Dilate
• Phase of contractions
• Increment• Peak• Decrement
• Frequency• Duration • Intensity
• Mild• Moderate• Firm
• Maternal pushing
Cervical Effacement & Dilation
True labor • Contractions ↑ in duration
&intensity • Cervical dilation, effacement are
progressiveFalse labor
• Normal contractions are exaggerated
• Labor does not produce dilation, effacement, or descent
• Contractions are irregular, without progression
• Walking has no effect on contractions; often relieves false labor
• Factors impacting the psyche of a laboring woman– Current pregnancy
experience– Previous birth experiences– Expectations for current birth
experience– Preparation for birth
Psyche
Breathing Techniques
Provide focus during contractions• Promote relaxation & oxygenation between contractions
• Slow deep breathes – in through the nose, out through the mouth
Childbirth Education• Δ’s of pregnancy• Fetal development• Prenatal care• Hazardous substances to avoid• Nutrition• Common discomforts• Work, benefits of exercise• Coping with labor & delivery
Types of Classes Available• Gestational DM• Early pregnancy• Exercise for pregnant women• Infant care• Breastfeeding • Sibling• Grandparent• Adolescent childbirth
Variations of Basic Childbirth Preparation Classes•Refresher•Cesarean birth •Vaginal birth after cesarean•Adolescent
• Braxton Hicks contractions• Increased vaginal discharge• Bloody show ~ 1 wk before
labor• Rupture of the membranes• Energy spurt• Weight loss
Signs of Impending Labor (Prelabor)
Anticipatory signs of labor
• Prelabor
• EffacementMeasured in % from 0 –
100% . 0 = no effacement, 100%= complete
Process of Labor
Induction of Labor•Elective induction
• Major cause of ↑ in # of induced labors
• Often result in • More interventions• Longer labors• Higher costs• Possible cesarean birth
Induction of Labor (cont.)• Indications for induced labor
• Postdate pregnancy• Premature rupture of membranes (PROM)• Spontaneous rupture of membranes (SROM) without the onset of spontaneous labor
• Chorioamnionitis• Pregnancy-induced HTN• Preeclampsia • Severe intrauterine fetal growth restriction • Maternal medical conditions
Induction of Labor (cont.)
• Contraindications• Maternal contraindications for spontaneous & induced labor
• Complete placenta previa• Hx of a classical uterine incision• Structural abnormalities of the pelvis• Invasive cervical CA • Medical conditions (active genital herpes)
• Fetal contraindications• Certain anomalies, (hydrocephalus)• Certain fetal malpresentations• Fetal compromise
Induction of Labor (cont.)• Labor readiness
• Prerequisite for induced labor = “ripe cervix”
• Bishop Score often used to determine readiness for labor
• 5 factors evaluated• Each factor scored 0 to 3• Score of 8 or greater associated with successful oxytocin-induced labor
• Score of 5 or less indicates cervix is not ripe – associated with unsuccessful induction of labor
Induction of Labor (cont.)• Labor readiness (cont.)
• Transvaginal ultrasound • Relatively new method • Cervix 27 cm or less is a predictor of successful induction of labor despite Bishop score
• Measurement of fetal fibronectin levels • Newer method• Presence in cervical secretions is associated with labor readiness
• More often used as a predictor of preterm labor risk
Induction of Labor (cont.)
• Labor readiness (cont.)• Fetus should be mature • Several ways to assess fetal maturity
• At least 38 weeks’ gestation considered mature
• Date fetal heart tones first heard• Other pregnancy milestones• Fetal lung maturity is the major point of consideration
• Measure L/S ratio by amniocentesis
Induction of Labor (cont.)
•Methods of cervical ripening• Mechanical methods
• Membrane stripping• Inserting a catheter into the cervix & inflating the balloon
•Artificial rupture of membranes (AROM)• Also called amniotomy
•Oxytocin induction• IV oxytocin (Pitocin) most common
Induction of Labor (cont.)
• Nursing care • The LPN role during induction depends upon the procedure
• Assist with pelvic exam in mechanical ripening of cervix or amniotomy (AROM)
• Document FHR before & after amniotomy
• Suprapubic or fundal pressure during the procedure if trained
• RN responsible for monitoring mother & baby during pharmacologic ripening of cervix
When to go to the hospital
• Instruct Mom when to call MD & when to go to the hospital
• Wait for contractions to be 5-10 mins apart
• Clear liquids once labor begins• Prenatal records, medical hx & prenatal course sent to hospital before mother’s admission & include any special requests mother or father have regarding procedures, meds, etc.
Admission to L&D suite• Baseline VS’s, breath sounds, wt., urine spec. for blood, protein & glucose, nitrazine test prn.
• Leopold’s maneuvers • Onset of labor, S&S of prelabor, Rh factor, blood type, gravada/para status, ? breast/bottle feeding
Nursing Interventions During the Latent Phase (Early Labor)
•Assessment• Assess FHR & contractions at least once every hour
• Assess maternal status• Assess status of fetal membranes• Assess the woman’s psychosocial state
Active phase
• Cervix dilates from 4- 8 cm• Contractions occur every 3- 5 minutes, last 40 -60 seconds & are moderately intense
• Mom begins to use breathing techniques to help reduce discomfort
Nursing Interventions During Active Labor
•Assessment•Assess woman’s psychosocial state
•Assess labor progress•Assess fetal status•Assess maternal status
• Period of cervical dilation from 8–10 cm
• Most difficult time for Mom• Intense contractions occur every 2-
3 mins. & last 60 -90 sec.• Mom may experience loss of control
of breathing techniques & experience N/V
• Other S&S: restlessness, anger, difficulty following directions, rectal pressure, “don’t touch me stage”
Transition Phase
• Offer fluids & ice chips; IV fluids• Record I&O’s• Provide oral care• Enc. Urination Q 2 hrs• Back Rubs• Freq. position Δ’s• Enc. Ambulation (membranes intact);
Pericare ruptured; Δ linens prn• Offer pain meds prn• Offer encouragement & praise• Inform Mom & support person of progress
Nursing Interventions Stage 1
Fetal MonitoringMeans of assessing fetal heart rate (FHR) as it relates to uterine contractions• Normal FHR 110 to 160 beats/min
• External fetal monitoring• Noninvasive; performed using
tocotransducer or Doppler ultrasonic transducer; transducer, fastened with belt, should be placed on side of mother where fetal back is located (find using Leopold’s maneuvers)
• Internal fetal monitoring• Invasive; requires rupturing of membranes;
attachment of electrode to presenting part of fetus; mother must be dilated 2 to 3 cm to perform this procedure
• Opioids are used for epidural analgesia. An adverse effect of epidural analgesia is a delayed respiratory depression. Naloxone (Narcan) is an opioid antagonist, which reverses the effects of opioids & is given for respiratory depression.
Pharmacological Interventions (cont.)• Complications Associated With Epidural & Spinal Anesthesia
• VS’s, • Position on left side• Monitor FHR• Monitor Contractions• I&O’s• Examine epidural/spinal catheter for placement
• Observe for side effects
Nursing Interventionsepidural/saddle blocks
Pharmacological Interventions (cont.)
•Life-Threatening Complications Occurring With General Anesthesia•Failed intubation•Aspiration•Malignant hyperthermia
Oxytocic Medication: Oxytocin (Pitocin)
• Stimulates smooth muscle of uterus; induces contractions of the myocardium; promotes milk letdown
• Uses• Induces or augments labor; controls postpartum
bleeding; promotes milk letdown & facilitates breast-feeding; induces or completes an abortion
• Adverse reactions• May include allergies, dysrhythmias, Δ’s in blood
pressure, uterine rupture, hyperstimulation of uterine contractions
• ContraindicationsShouldn’t be used in a woman who can’t
deliver vaginally or in a woman with hypertonic uterine contractions.
Oxytocic Medication: Oxytocin (Pitocin) (cont’d)
• Interventions• Monitor maternal & fetal status closely, including frequency, duration, force of contractions, FHR every 15 minutes
• Administer med with IV infusion device only
• Do not leave pt unattended during infusion
• If uterine hyperstimulation or nonreassuring FHR occurs, stop med immediately, turn pt to side, infuse IV NS, administer oxygen via face mask as prescribed; then notify healthcare provider
• Nursing care during an assisted delivery• Obtain needed equipment & supplies• Monitor maternal & fetal status before, during, & after the procedure
• Assist the birth attendant• Provide support for the woman• Document the type of procedure • Document maternal & fetal response to the procedure
Indications for Cesarean Birth•Hx of previous cesarean birth•Previous surgery on the uterus•Labor dystocia (failure to progress in labor) Fetal compromise, Abnormal labor•Non-reassuring fetal status •Fetal malpresentation• Placenta previa or abruptio placentae Maternal conditions (GH or DM)
•Active maternal herpes virus
Cesarean Birth (cont.)
• Maternal complications• Laceration of uterine artery, bladder, ureter, or