Mental Health - Maternity and Neonatology

Maternity and Neonatology Determining the estimated date of delivery • Use the Naegele rule—take first day of last menstrual period (LMP), add 7 days and subtract 3 months from it o For instance, if the last menstrual period of a pt was between June 10 and 15 o The estimated date of delivery = March 17 Weight gained during pregnancy If weight gained during pregnancy is within • 1st trimester (12 weeks) +/–1 to 2 lbs of the ideal weight for the o 1 lb per month = Total of 3 lbs • gestational week … Pt is WNL • 2nd and 3rd trimesters lbs … Assess her If weight gained is within o Add 1 lb every week • +/–3 • The 28 ideal lbs, weightplus or gainedminus 3during pregnancy • +/–4 lbs or more… There is trouble o Between 25 to 31 lbs o perform a BPP on the fetus o Alternative method A quick and dirty way to come up with the ideal weight gained during pregnancy is to • Take the number of weeks gestation minus 9 Question A woman is in her 28th week gestation. She gained 22 lbs, what is your impression? • Using the long method o First trimester (12 weeks) … She gained 3 lbs o 28 weeks minus 12 weeks = 16 weeks o Therefore, she would add an extra 16 lbs on her weight o 3 + 16 = 19 lbs … She has 3 lbs extra than her ideal weight o Therefore, assess the pt • Alternatively, subtract 9 from the number of weeks gestation o 28 – 9 = 19 lbs Question A pregnant woman at 31 weeks gestation gained 15 lbs. what is your impression? • Using the short method, this pt ideal weight should be o 31 – 9 = 22 lbs o However, 22 – 15 = 7 lbs less than the ideal o Therefore, the nurse needs to assess the biophysical profile (BPP) on the fetus Fundal Height • Fundal height cannot be palpated until week 12 o That when the fundus is midway between the umbilicus and the pubic symphysis • The fundus can be palpated at the umbilicus between 20 and 22 weeks What is the significance of being able to palpable fundal height? • The examiner should be able to determine in what trimester the pregnancy is o In case pt is unconscious, for instance o It has diagnostic significance as well … A much bigger than normal fundus may indicate molar pregnancy Positive Signs of Pregnancy The Boards test positive signs and everything else 1. Fetal skeleton on x-ray 2. Presence of fetus on ultrasound 3. Auscultation of fetal heart (Doppler) 4. Examiner palpates fetal movement (outline) • Not the mother but the examiner Ranges of Values In OB, there are 3 types of questions regarding range of values For instance, the fetal HR can be heard first between 8 to 12 weeks gestation Quickening (baby Qicks) may be first felt between 16 to 20 weeks gestation Therefore, if the question ask • When would you first? o Fetal Heart: 8 weeks o Quickening: 16 weeks o This is the earliest date • When would you most likely? o Fetal Heart: 10 weeks o Quickening: 18 weeks o This is the date midway in the range • When should you __________ by? o Fetal Heart: 12 weeks o Quickening: 20 weeks o This is the latest date Maybe Signs of Pregnancy 1. Positive urine/blood hCG tests • A positive pregnancy test may result from other conditions • For instance, cancer 2. Chadwick sign—cervical color change to cyanosis (Cs) • Bluish discoloration of the vulva, vagina and cervix Goodell sign—good and soft • Softening of the cervix Hegar sign—uterine softening • Softening of lower uterine segment Chadwich ! Goodells ! Hegar • All 3 signs are in alphabetical order and • Move up from the vulva, vagina, cervix to the uterus Patient Teaching for Prenatal Visit During pregnancy, pt is advised to go for prenatal visits as follows • Once a Month until week 28 • Every other week between 28 and 36 • Once a week after week 36 until delivery or week 42, whichever comes first o At week 42, delivery can be induced or by C-section Question If a woman comes in for her 12th week prenatal checkup, when is her next prenatal visit? • Her next visit is at 16 weeks Lab Values Hemoglobin (Hb) level will fall during pregnancy UWorld Hemoglobin (Hb) • Normally Hb in female = 12 – 16 • 1st & 3rd trimester • A pregnant woman can tolerate lower levels of Hb • First Trimester: Hb can fall to 11 and be perfectly normal o 11 g/dL • Second Trimester: Hb can fall to 10.5 and be perfectly normal • 2nd trimester o 10.5 g/dL • Third Trimester: Hb can fall to 10 and be perfectly normal • If Hb <9, anemia evaluation Question How do you treat morning sickness? • Morning sickness is usually seen during the 1st trimester • Treatment: Dry carbohydrates—not before breakfast but—before pt gets out of bed Question How do you deal with urinary incontinence? • Urinary incontinence is seen in the 1st and 3rd trimesters • Pt needs to void every 2 hours from the day she gets pregnant until 6 weeks postpartum Question Figure 7. Tripoding. A pregnant pt complains of difficulty breathing. What should you advise her to do? • Difficulty breathing is a problem during the 2nd and 3rd trimesters • Advise pt to assume to tripod position o Tripod position is a physical stance often assumed by people experiencing respiratory distress o The pt will be leaning forward with hands on knees or the surface of a desk or table Question A pregnant pt complains of back pain. What should you advise her to do? • Back Pain is seen during the 2nd and 3rd trimester • Advise pelvic tilt exercises to pt Labor and Birth What is the truest most valid sign that she is in labor? • The truest most valid sign of labor is the onset of regular/progressive contractions To Know • Dilation is opening cervix from 0 to 10 cm • Effacement is thinning of the cervix. It goes from thick to 100% efface (thin like paper) • Station is the relation between fetal presenting part and the mother’s ischial spines (know this)—the narrowest part of the pelvis o Positive numbers mean the baby has made it through this tight squeeze—good to go o Positive numbers = Positive news o If a baby stays at a –3, –2, –1, it can’t get through vaginally. It needs C-section for delivery • Engagement is station zero—this means the presenting part is at the ischial spines Lie is relationship between the spine of the mother and spine of the baby • You want a vertical lie—compatible with vaginal birth o If the mother’s spine and the baby’s spine is parallel—we got a baby • If lie is perpendicular—tranverse lie = Trouble … C-section o If we got them perpendicular, we’ve got trouble—T Most common presentation is ROA or LOA—that’s the guess—don’t bother memorizing • ROA (right occiput anterior) • LOA (left occiput anterior) Note • Pick ROA before LOA Before giving digitalis, always take an apical HR Delivery of the Fetus and the Placenta (heart rate) • There are 4 stages of labor Stage 1 Onset of Labor—It has 3 phases • Latent—cervical dilation from 0 to 4 cm o Phase 1 o Contractions are 5 to 30 minutes apart, lasting 15 to 30 seconds o Mild intensity • Active—cervical dilation from 5 to 7 cm o Phase 2 o Contractions are 3 to 5 minutes apart, lasting 30 to 60 seconds o Moderate intensity • Transition—cervical dilation from 8 to 10 cm o Phase 3 o Contractions are 2 to 3 minutes apart, lasting 60 to 90 seconds o Strong intensity Question A pregnant woman comes in to L&D (labor and delivery). She is 5 cm dilated, with contraction 5 minutes apart, lasting 45 seconds. What phase of labor is the pt in? • The pt is in ACTIVE phase One good studying strategy to use for memorizing the 3 phases of Stage 1 labor is to know everything about the Active (or Phase 2) of Stage 1 • Once you know the upper and lower limit values, you can deduce the values of Phase 1 and Phase 3 o Phase 2 — Contractions: 3 to 5 minutes and last 30 to 60 seconds Stages and Phases of Labor • Stage 1—Onset of Labor ! Cervical Dilation and Effacement o Phase 1—Latent o Phase 2 —Active o Phase 3—Transition • Stage 2—Delivery of Baby • Stage 3—Delivery of Placenta • Stage 4—Recovery: 2 hours until bleeding stops HESI Questions What is purpose of uterine contraction in first stage? • Dilation and effacement of the cervix What is the purpose in 2nd stage? • Delivery of baby What is the purpose 3rd stage? • Delivery of placenta What is the purpose of 4th stage? • Stop bleeding When does postpartum technically begin? • 2 hours after delivery of placenta Pay attention to whether the question is asking about stages or phases • There are 4 stages • There are 3 phases, which are part of Stage 1 Questions What is the #1 priority of second phase? • Pain management What is the #1 priority of second stage? • Clearing baby’s airway Questions What is the #1 priority of third phase? • Checking cervical dilation, Helping pregnant mother with breathing and pain management What is the #1 priority of third stage? • Assess the placenta for smoothness and intactness, and for 3-vessel (not 2) umbilical cord present Stages and Phases of Labor • Stage 1—Onset of Labor o Phase 1—Latent … Dilation from 0 to 4 cm Contractions are 5 to 30 minutes apart, lasting 15 to 30 seconds Mild intensity o Phase 2—Active … dilation from 5 to 7 cm Contractions are 3 to 5 minutes apart, lasting 30 to 60 seconds Moderate intensity o Phase 3—Transition … dilation from 8 to 10 cm Contractions are 2 to 3 minutes apart, lasting 60 to 90 seconds Strong intensity • Stage 2—Delivery of Baby • Stage 3—Delivery of Placenta • Stage 4—Recovery: 2 hours until bleeding stops Memorize for the following 3 quetions Uterine contraction should be no longer than 90 seconds and no closer than 2 minutes Questions What is a sign of uterine tetany? • No longer than 90 seconds and no closer than 2 minutes What parameters regarding uterine contraction would make you stop Pitocin? • No longer than 90 seconds and no closer than 2 minutes What is uterine hyperstimulation? • No longer than 90 seconds and no closer than 2 minutes Know that phrase • No longer than 90 seconds and no closer than 2 minutes Assessment of frequency of contraction • Frequency is from the beginning of one contraction and beginning of the next Assessment of duration of contraction • Duration of contraction is from the beginning to end of one contraction Intensity of labor • Assessment of intensity of labor is purely subjective • Teach her how to palpate with one hand over the fundus with the pads of the fingers Complications of labor • There are 18 complications • Know them all • But only 3 protocols—focus on the 3 protocols Painful Back pain—“OP” = Oh Pain. What do you do? • Position—Push • What position? o KNEE-CHEST position then o PUSH with fist into sacrum to use counter pressure “OP” … Anything (right or left) occiput posterior Prolapsed Cord • Push head in off cord and position knee-chest or Trendelenburg • Prep for C-section • Think PUSH/POSTION o Push head off the cord of fetus and position mother to knee-chest Figure 8. Knee -chest position. Interventions for all other complications • Tetany • Maternal hypertension • Vena cava syndrome • Toxemia • Uterine rupture • All treated the same—with “LION” o Left side (place mother on the left side) o IV o Oxygen o Notify HCP • Stop Pitocin (pit) if it was running—the first thing to do Implement before “LION” • In an OB crisis, if pitocin is running, stop it first. Then, implement “LION” When to administer systemic pain medication • Do not administer a systemic pain medication to a woman in labor if the baby is likely to be born when the med is at its peak … For example Questions • You have a primagravida at 5-cm dilated who wants her IV push pain med. What is the nursing intervention? o Hold the pain medication o This is because the pt is primagravida and will deliver in about 15 to 30 minutes when the medication peaks • You have a multigravida at 8-cm wants her IM pain med. What is the nursing intervention? o Do not administer the pain medication Labor and Delivery (Continued onto next lecture)