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MATERNITY ATIContraceptionDepo Provera: IM injection every 11-13 weeksVaginal Ring: insert for 3 weeks, take out for 1 weekPatch: change 1 x weekArm Implant: good for 3 years. Can be used while breastfeedingIUD: 1-10 yrs. Can be used while breastfeeding. Risk for PID, perforation, ectopic preg.Minipill: progesterone only. Fewer s/e. safe to take while breastfeedingInfertility1 year w/o ability to conceive Semen analysis: first test done b/c least expenisive test to performPresumptive signs of pregnancyWoman things she is pregnant. Symptoms only.Quickening – fluttering movements of fetus at 16-20 weeksUterine enlargementProbably signs of pregnancySigns & medical conditionsHegars Sign: softening and compressibility of lower uterusChadwicks’s Sign: blue color cervixGoodells sign: softening of cervical tipCallottement: rebound of unengaged fetusBraxton HicksPositive pregnancy testFetal outline felf by examiner Positive signs of pregnancySigns only related to pregnancy. Fetal heart soundsFetus in ultrasoundFetal movement felt by experienced examiner hCG7-10 days after conceptionPeaks at 60-70 daysHigher levels if mulitples, ectopic, molar pregnancy, down syndromeDo a pee-stick test on first-void morning sample GTPALGravidity Term birth: 38 weeks or morePreterm: 37 weeks or lessAbortion/miscarriagesLiving Pregnant Vital SignsBlood pressure degreases 5-10 mmHG during 2nd trimester then returns to normal at 20 weeksPulse increases 10-15 around 20 weeks and stays elevatedRespirations increase by 1-2 breaths (due to elevated diaphragm) Prenatal Check-upsMonthly for the first 7 monthsEvery 2 weeks during 8th monthWeekly during 9th monthInitial Check upEDD, medical hx, baseline physical assessment, lab tests (Blood type, Rh, CBC, H/H, Rubella, Hep, GBS, Glucose, TB, UTI, STD, HIV, TORCH)Ongoing Check upsFHR at 10-12 weeks via ultrasound, 16-20 weeks w/ stethoscope Fundal height at 12 weeks Fetal movement at 16-20 weeks RhoGAM 28 weeks if mom is Rh Neg. Discomforts of pregnancy1st Trimester: N/V, breast tenderness, Urinary frequency, Fatigue, Braxton hicks2nd Trimester: Heart burn, Constipation, hemorrhoids, backaches, Varicose veins, Braxton hicks3rd Trimester: urinary frequency, fatigue, heartburn, constipation, hemorrhoids, backaches, SOB, Leg cramps, varicose veins, Braxton hicks, supine hypotension Danger signs: ROM <37 weeks, vaginal bleeding, ab pain, decrease fetal movement, hyperemesis gravidarum, severe headaches (gestianiton HTN) dysuria (UTI), blurred vision (gest HTN) edema face and hands (Gest. HTN), epigastric pain, fruity breath & rapid breathing & increased urination (hyperglycemia), hypoglycemia Nutrition 2Nd trimester: increase calories by 340. 3rd trimester: increase calories by 452Breastfeeding: increase calories by 330 for first 6 month, then 400 for second 6 monthsHigh protein, High folic acid, calcium & iron supplements2-3 L fluid per dayLimit caffeine to 300mg/dayNausea: eat dry crackers or toast. Do not eat fats, spices. Avoid drinking fluids with solid mealsPKU: where high levels of phenylalanie cause danger to fetus. Avoid foods high in protein (fish, poultry, meat, eggs nuts, dairy) UltrasoundConfirms pregnancy, gestational age, site of implanation, growth, abnormatlities, amniotic fluid volume, heartbeat, activityMake mother drink 1-2 quarts of fluid prior to fill bladder, lift utuers and displace bowel to get better imageBBP Biophysical profile: visual fetus and fetal response to stimuliIncludes: reactive FHR, fetal breathing, body ovements, fetal tone, amniotic fluid Score 8-10 = normal, 4-6= abnormal <4= fetal asphyxiaNSTNonstress test: done during 3rd trimester to assess for intact CNS. Mom pushes button when she feels fetal movement Reactive: FHR normal baseline w/ moderate variability accellearates 15 beats/min lasting 15 seconds. Must occur 2 + times during 20 mins. Nonreactive: after 40 mins the criteria of 15/15 hasn’t been metDo this test for: GDM, GHTN, hx of fetal demise, advanced maternal age, postmaturity, decrease fetal movement, IUGRCSTContraction stress test: Nipple stimulation or Pitocin to create contractionsAccurate data needs to have 3 contractions 40-60 sec duration during a 10 min time frame to get idea of how FHR responds Negative CST: Normal. Shows no LATE decelsPositive CST: Abnormal: shows LATE decels. (That is bad). Amniocentesis Aspirate amniotic fluid with needle into uterus and amniotic sacDiagnosis: chromosomal anomaly, neural tube defects, genetic disorders, lung maturity, meconium, hemolytic disease, Alpha -fetoprotein (high = for neural tube defects, low = downs syndrome, molar preg.)Fetal Lung test: Lecithin/sphingomyelin (L/S) ratio= a 2:1 ratio indicates maturityPhosphatidyglycerol (PG): if Absent = respiratory distress. We want PG!!!DecelsEarly Decels: fetal head compression = not seriousLate Decels: uteroplacental insufficiency = seriousVariable Decels: cord compression = depends on amount and duration Umbilical Blood Sample Most common method for fetal blood sampling and transfusion Chronic Villi Sampling (CVS)1st trimester to check for abnormalities at 10-12 weeksRisk for miscarriage, SAB, ROM, fetal limb lossQuad Marker ScreeningA blood test that includes hCG, AFP, Estriol, Inhibin - done at 16-18 weeksLow Estriol- down syndrome. Alpha Fetal Proteins (AFP)16-18 weeksProtein produced by fetusHigh levels = nueral tube defectLow levels = down syndromeSponteanous Abortion1st trimester- bleeding, cramping, partial or complete expulsion of products of conceptionTerminated before 20 weeks gestation or less than 500 gCaused by: High maternal age, substance abuse, chromosomal abnormalities (most common), maternal illness, cervical dilation, trauma, antiphospholipid syndrome Don’t have bath, sex, for 2 weeks. Finish abx. Discharge will occur for 2 weeks. Wait 2 months to try againEctopic PregnanancyImplanted outside uterine cavity usually in fallopian tubes which can cause a fatal hemmorahge if ruputured. Risks: STD, IUD, tubal surgeryS/S: stabbing pain in lower ab. On one side. Delayed or irregular pregnancy, Dark red/brown spotting or RED if Ruptured. Shoulder pain!!, dizzy from bleeding into ab cavityGestational Trophoblastic Disease (GTD)Proliferation & degeneration of trophoblastic villi in placenta that looks like GRAPE CLUSTERS! No embryo develops instead a metastasizing malignancy (Choriocarcinoma) forms. COMPLETE MOLE: No genetic material or any placenta, fluidsPARTIAL MOLE: Has genetic material plus some baby partsRisks: young and old mothersS/S: Excessive vomiting, High levels hCG, Rapid uterine growth that is way too big for age, prune-juice looking bloodPlacenta PreviaPlacenta abnormally implants in lower utuerus resulting in bleeding in 3rd trimesterComplete: cervical os is covered by placentaIncomplete: partially covered cervical osLow-lying: doesn’t reach cervical osRisks: Previous placenta previa, scarring, older mother, multiples, smokingS/S: PAINLESS. Bright red bleeding 2nd-3rd trimester Abruptio PlacentaPremature separation of placenta from utuerus AFTER 20 weeks. Causes baby and mother mortality. Leading cause of maternal deathRisks: maternal HTN, trauma, previous incident of abruption, smoking, multiples, S/S: Sudden DARK RED bleeding, shock, fetal distressTORCH Toxoplasmosos: Raw or undercooked meat & handling cat feces. Flu symtomsRubella: joint & muscle painCytomeglovirus: droplet infection- can cause damage to baby during birth. Asymptomatic Herpes Simplex: Oral or genital lesionsGroup B Strep (GBS)Bacterial infection passed to fetus during L&DRisks: <20y, black or Hispanic, prolonged ROM, low birth weight, preterm baby, feverTreat with PCNChlamydiaBacterial infection. Most common STD. S/S: ITCHING! Watery vaginal dischargeGive erythro eye ointment to babies, treat with abxGonorrheaUrethral discharge, painful urination & frequency, Yellow/green vag discharge can lead to PID. Candida AlbicansFungal infectionS/S: thick, creamy white discharge, itching, grey-white patches on vag wallPatches in neonate mouthPremature dilation of cervixIncompetent cervix: feel urge to push. Expulsion of productsRisks: cervical trauma, defectsGive Tocolytics to inhibit contraction, mom on bedrest, no sexHyperemsis GravidarumExcessive n/v. past 12 weeks. Risk for IUGR or preterm birth if not treatedRisks: <20 yo, migraines, obese, 1st pregnancy, multiples (high hCG), emotional stress, hyperthyroidismS/S: n/v, ketones in urine from protein breakdown, electrolyte imbalances, high hCGGDMCan cause: SAB, infections, hydyramnios, ROM, preterm, hemorrhage, macrosomiaGlucose test at 24-28 weeks, county daily kicksGHTN20 weeks. BP >140/90 at least twice 4-6 hours apart in a 1 week period. No proteinuria Mild PreeclampsiaSame as GHTN but with proteinuria 1+Severe Preeclampsia BP 160/100, proteinuria 3+, headache, blurred vision, hyperrfelxia, edema, hepatic issue, RUQ pain, thrombocytopeniaEclampsiaSeizure activity following severe preeclampsia HEELP SyndromeH- hemolysis resulting in anemia & jaundiceEL- elevated liver enxymes (ALT, AST), Epigastric pain, n/vLP- low platelet (<100,000), causing thrombocytopenia, bleeding, cant clot, DIC (intravascular coagupathy)RISK FOR GHTN & elevated BP<20y or >40, Obesiety, muliltple babies, DM, molar pregnancy, hx of preivious HTNS/S: non-stop headache, blurred vision, flashes of light, n/vTreat: give HTN meds (NO ACE Inhibitors), give MagPreterm Labor20-37 weeksRisks: infections, previous preterm labors, hydramnios, young age, smoking, drugs, violence, hx or SAB, DM, HTN, remature dilation, placenta previa, abrputio placentae, preceding labor pregnant quickly after giving birth, Treatment: can give meds to slow, stop labor. Nifedipine, magSigns of preceding labor (Labor is coming)Backache, weight loss 1-3lb, leightning where fetal head descends down into pelvis 2 weeks prior, bloody show, energy burst, n/v, ROM (labor occurs 24 after this), 5 P’sPassenger: size of head, presentation (head/occiput, chin/mentum, shoulder/scapula, breech/sacrum or feetLie: transvers, longitudinalAttitude: fetal flexion (chin to chest), fetal extensionPassageway: birth canalPowers: uterine contractions, dilation, urge to pushPosition: how mom is positioned in laborPsychological: stress, anxiety can impair laborMeachanism of LaborEngagement: head passes into pelvic – 0 stationDescent: head through pelvisFlexion: head flexes chin to chestInternal rotation: rotates laterally to pass through pelvisExtension: Head is bornExternal rotation: head roates to allow body to roateExpulsion: rest of baby bornVariabilityAbsentMinimal: <5/minModerate: 6-25/minMarked: >25/minCategory IFHR baseline 110-160 – normalModerate variabilityAccel present or absentEarly decels present or absentVariable or late decels are absentCategory IIBaseline tachy or bradyVariability minmal, absent, markedDecels b/t 2-10 minsNo accels after stimulationCategory IIIAbsent FHRRecrrent variable decls, late decles, bradyFirst Stage of LaborLatent (0-3cm), Active (4-7cm), Transition (8-10cm)Lepold maneuver to determine where baby isVag exam for dilation and effacement & stationBlood Pressure: Latent phase (30-60min), Active phase (30 min), Transiation Phase (15-30min)Temp: q4h or q1-2h for ROMContraction Monitor: Latent phase (30-60min), Active Phase (15-30 min) Transition (10-15min)FHR Monitor: Latent (30-60min), Active (15-30), Transition (15-30)Encourage voiding q2hSecond stage of laborDilation to birth – can take 30mins – 2 hrs for first time momsFHR q15 min. 1st degree lac – does not involve muscle2nd degree lac- extends through skin & muscle to peri3rd degree lac- extends through skin muscle peri and anal sphincter 4th degree- through skin, mucle, anal sphincter and anterior rectal wall. (WTF, seriously?)Third Stage of LaborDelivery of baby to delivery of placenta Monitor vitals q15minFirm fundusFourth Stage of laborPlacenta is out, recoveryVitals q15 for 1 hourFundal and lochia check q15min for 1hour Massage fundus, encourage voidingAmniotomyRupture or membrane with amnihookAmniofusionSupplement the amout of amniotic fluid and decrease cord compression or oligohyramnios Induction of Labor39 weeksBishop score greater than 8 for multip, 10 for nullipA prolonged ROM that has risk of infectionDM, HTN, Fetal demisePrecipitous Labor3 hours or less. High risk for hemmroharge Panting will control urge to pushSide lying position optimizes perfusion and fetal oxygenationNever stop delievery Amniotic fluid embolismRuprture in amniotic sac plus high pressure causes PE, resp distress and collapseS/S: respiratory distress, tachy, shock, cardiac arrest PostpartumVitals q15 mins for first hour, q30min for second hour, q1hour then q4-8hrBUBBLE : breast, uterus, bowel, bladder, lochia, episotomy/edemaFundus descend 1-2cm per day. Day 10, non palpabale uterus Lochia: Rubria (1-3 day), Serosa (4-10 days), Alba (11day – 6 weeks)Lochia amount: Scant, light, moderate (10 cm), heavy ( pad saturated in 2 hours) , excessive (one pad saturated in 15 mins)Blood loss: Vag deliever = 500 mL C-sect.= 1,000 mLWBC increase to 20-25 for 10-14 days w/o infection present Bladder empty q2-3h. Bowel movement 2-3 daysDependent- taking in phase24-48 hrFocus on personal needsRely on othersExcited, talkative, wants to share storyDependent-independent – taking-hold phase2-3 days-weeksBaby care and improving care-giving competencyNeeds acceptance from othersLearn and practice Inderdependent – letting-go phaseFocus on family as unitResumption of role- wife Discharge teachingMenses returns 4-10 weeks if not breastfeedingContraception ASAPFluids, rest, limit activityInfant feeding 8-12 x a day ABGAR ScoreScore012Heart RateAbsent<100>100Respiratory RateAbsentSlow, weak cryGood CryMuscle ToneFlaccidSome flexionWell-flexedReflex IrritabilityNoneGrimaceCryColorBlue, PalePink body, acrocyanosisCompletely pink0-3 = severe distress 4-6= Moderate distress7-10= no distressInitial AssessmentExternal Assessment: skin color, peeling, birthmarks, meconium, nasal patencyChest: breathing, heart rate, any crackles, wheezes, point of maximum impulseAb: round, umbilical cord with 1 vein, 2 arteriesNeuro: muscle tone, reflex reaction, fontanels and suturesAbnormalities Gestational AgeDone 2-12 hours of birthWeight: 2500 – 4000gLength: 45-55 cmHead circumference: 32-36.8cmChest circumference: 30-33cmPreterm: <37 weeksTerm: 38 weeksPostterm: 42 weeksPostmature: 42+ weeksNewborn VitalsResp: 30-60/ minHeart rate: 100-160 bpmBP: 60/40 – 80/50Temp: 36.5-37.2 (97.7 – 98.9)Head2-3 cm larger than chest circumferenceIf 4 cm or larger than chest circumference it can be hydrocephalus. Head less than 32 – microcephalyAnterior fontanel: 5cm & dimanond shape. Posterior fontanel: smaller & triangle shapedFontanels: soft, flat, may bulge when newborn cries/vomits/coughs. Abnromal bulge= hemorrhage, infection, pressure increase Sutures: palpable, separated, overlapping from moldingEyes & earsEyes should be equal 1/3 distance b/t outer canthus Ears should line up with outer canthus of eyes. Rule out down syndrome or kidney disorderChest & AbBreast nodules 6 cmBowel sounds present 1-2 hours after birthGI & GUAnus should not be covered by membraneMeconium should be passed w/in 24 hoursRugae should be on scrtoum, testes in scrotumVaginal blood-tinged discharge may occur in female newbornsHymenal take should be presentUrine w/in 24 hours after birth. Chapter 24-27… read on your own and take notes on the important stuff ................
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