Lecture 10 Maternal Newborn

LECTURE 10 MATERNAL NEWBORN PREGNANCY: • you must be able to calculate a due date! - take the 1st day of the last menstrual period! - add 7 days, subtract 3 months! - ex. PT’s last menstrual period was from June 10-15! = due date is apx. March 17 • you need to know how much weight should/ shouldn’t be gained:! ** don’t worry about multiples or about women who ! are underweight/over-weight to begin w/! - Total weight gain = should be 28 lbs, +/- 3! -> 1st T = 1 lb/month (3 lbs; too much is bad)! -> 2nd & 3rd T = 1 lb/week! ** on the test, if they give you a particular week of ! gestation, you have to be able to predict what the ! weight should be! - ex. Woman in 28th week who has gained 22 lbs. ! What is your impression?! -> Week 12 (end of 1st T) = 3 lbs., after that, each ! week is 1 lb. ! -> she should have gained 19 lbs, she gained 3 ! more than supposed to! -> HINT: if you take the week & subtract 9, that is ! the weight that should be gained! * 12 - 9 = 3; 13 - 9 = 4, 20 - 9 = 11! - being over 1-2 lbs. is ok but if she’s 3 lbs. off she ! needs further assessment! -> 4 lbs. or more off = could be trouble! * ex. if PT is 6 lbs. underweight, she needs a biophysical ! profile to make sure the baby is still alive! - ideal weight gain = week - 9 • Fundal Height:! - fundus = the top part of the uterus! -> not palpable until week 12 (after 1st T)! - When is the fundus at the umbilicus?! = 20-22 weeks of gestation! - it is important to know fundal location to recognize ! date of viability and know what trimester the PT is in:! = 20-22 weeks (24 is the end of the 2nd)! ** ex. if a PT is brought into ER and w/ history about the ! pregnancy (or she can’t tell you), you need to know what ! trimester she’s in to know what’s going on with the baby! -> fastest way to know the trimester = palpate the ! fundus (if you don’t feel it at all, she’s in the ! 1st T & she is the priority, not the baby)! -> if you feel the fundus at/below the ! bellybutton she’s in 2nd T (she is still priority)! -> if the fundus is above the umbilicus she is in ! the 3rd T and baby is the priority! Signs & Symptoms of Pregnancy: • probable, presumptive, positive -> BUT on the test there is only POSITIVE & everything else (maybe’s) • 4 Positive Signs:! a) fetal skeleton on x-ray! b) fetal presence on ultrasound! c) auscultation of a fetal heart rate! -> starts beating at 5 weeks but you hear it ! between 8-12 weeks! d) when examiner palpates fetal movement/outline! -> not a positive sign when mom feels it (i.e. quickening)! ** none of them have false positives • most OB information has a range where/when it occurs (because every woman is different)! -> because of this it is critically important that you ! read OB questions carefully & properly • there can be 3 different questions for every fact in OB:! a) when would you first…! -> pick the earliest part of the range! b) when is it most likely…! -> pick the mid part of the range! c) when should you ___ by…! -> pick the end of the range ex. When should you first auscultate a fetal heart? = at 8 weeks! ex. When would you most likely auscultate fetal heart? = 10 weeks! ex. When should you auscultate a fetal heart by? = by 12 weeks *** PAY ATTENTION TO WHICH ONE THEY ASK! • quickening = when the baby kicks -> 16 to 20 weeks! - first feel = 16 weeks! - when is it most likely to feel = 18 weeks! - when should you feel it by = 20 weeks • The MAYBE Signs: (probable’s & presumptive’s)! a) all urine & blood pregnancy tests! -> a positive pregnancy test is NOT a positive sign ! of pregnancy (because it only means you have ! the hormones that go w/ pregnancy, but doesn’t ! mean you always have a fetus)! ** which is why you can have false positives! b) Chadwick’s sign = cervical color change to ! cyanosis (bluish; includes vagina & labia)! Goodell’s sign = cervical softening! Hegar’s sign = uterine softening! *** all occur in alphabetical order (boards tends to the ! order instead of the weeks they occur because ! weeks vary, order doesn’t) Patient Teaching in Pregnancy: • teaching PT’s the pattern of office visits! *** good prenatal care is a major factor in infant ! mortality so teach women how often to come in for ! good prenatal care! a) once a month until week 28! - for all of 1st & 2nd T! - for the early part of 3rd T! b) once every 2 weeks until week 36! c) once every week until delivery or week 42! - by then, schedule for induction/c-section • ex. If a woman comes in for her 12th week checkup, when does she come in next?! = week 16! ex. If she comes in for her 28th week checkup?! = week 30 (& then 32, 34, 36)! ex. If she comes in for her 36th week checkup?! = week 37, 38, 39, 40, 41, 42, take the baby • teach her that her hemoglobin will fall:! - we don’t worry about low HgB unless it gets really low! - normal HgB for females = 12 - 16! -> 1st T - can fall to 11 & be perfectly normal (not ! considered low)! -> 2nd T - can fall to 10.5 & be normal! -> 3rd T - can drop to 10 & still be called normal! ** acceptably low can be as low as 9! - tolerate lower HgB’s in pregnant women the further ! along they are than you would w/ non-pregnant PT’s • teaching about the discomforts of pregnancy:! a) morning sickness = 1st T problem! - treat by eating dry carbohydrates (ex. crackers) ! BEFORE you get out of bed! b) urinary incontinence = 1st & 3rd T problem! - why not the 2nd? the baby is an abdominal ! pregnancy at this point and off the bladder! - treat by voiding every 2 hrs (should do this from ! the start of pregnancy until 6 weeks after delivery)! c) difficulty breathing = 2nd & 3rd T problem! - teach tripod position (like COPD clients)! d) back pain = usually 2nd & 3rd T! - tends to get worse and worse the further along you ! get in the pregnancy! - treat w/ pelvic tilt exercises (tilt pelvis forward)! * ex. put foot on stool • pregnancy questions are a good place for using common sense because it is not a disease, it’s a healthy state! -> using good health patterns ! -> if you get a question you don’t know, ask yourself ! “what would be good for anybody?” & pick that answer LABOUR & BIRTH • what is the truest, most valid sign that a woman is in labour???! = onset of regular, progressive contractions! —> not bloody show or water breaking (you can have ! these and not be in labour) • Terminology:! - dilation = the opening of the cervix! -> goes from 0 - 10 cm! -> 0 = closed; 10 = fully dilated! - effacement = thinning of the cervix! -> goes from thick to 100% effaced! - station = relationship of the fetal presenting part to ! mom’s ischial spines! -> ischial spines = the smallest diameter through ! which the baby has to fit for a vaginal birth (the ! tight squeeze, the narrowest part of the pelvis)! ** if the baby cannot fit through there, the baby ! cannot be born vaginally! -> negative stations = the head/presenting part is ! above the “tight squeeze” ! * negative news! -> positive stations = the presenting part is below ! the ischial spines and has already made it through ! the “tight squeeze! * positive news! ** ex. if the baby’s head stays at -1 & -2 for 17 ! hours after fully dilated & 100% effaced, the ! head is too big and PT needs a C-section! ** ex. if the baby’s head stays at +3 for 17 hours, ! the baby can still be born vaginally but needs a ! vacuum extractor, forceps, or an episiotomy! - engagement = station 0 ! -> the presenting part is at the ischial spines! - lie = relationship of the spine of the mother & the ! spine of baby! -> longitudinal lie = parallel to mom’s spine (good!)! -> transverse lie = perpendicular, sideways (spines ! at a right angle); looks like a T; bad, trouble! -> oblique lie = baby is diagonal into mom’s hip ! instead of straight into the pelvis! - presentation = the part of the baby that enters the ! births canal first! -> ROA, LOA etc.! -> don’t spend a ton of time memorizing the ! presentations (this is a hard OB question; know ! the stuff that everyone needs to know!)! ** you cannot miss the easy ones!! -> the most common ones are ROA & LOA (right & ! left occiput anterior)! ** you have much better chances guessing by ! picking one of these (R before L) Stages of Labour & Delivery: • 1 = Labour (all of it)! - 3 Phases of Labour:! a) Latent b) Active c) Transition! Phases Dilation Contraction! FREQUENCY Contraction DURATION Contraction INTENSITY LATENT 0 - 4 cm every 5 - 30 mins. 15 - 30 seconds “mild” ACTIVE 5 - 7 cm every 3 - 5 mins. 30 - 60 seconds “moderate” TRANSITION 8 - 10 cm every 2 - 3 mins. 60 - 90 seconds “strong” Hint: memorize the middle column (active labour) because everything is sequential! ! NOTE: contractions should not be longer than 90 seconds or closer than every 2 mins. —> means trouble in labour!! - signs of uterine tetany, uterine hyper-! stimulation; parameters to stop Pitocin ex. A woman comes into L & D. She is 5 cm dilated, • contractions 5 mins. apart lasting for 45 seconds. What phase is she in? = active • 2 = Delivery of the Baby • 3 = Delivery of the Placenta • 4 = Recovery! - 2 hours • What is the purpose of uterine contractions in:! - 1st stage = dilate & efface the surface! - 2nd stage = push the baby out! - 3rd stage = push the placenta out! - 4th stage = stop bleeding by contracting the uterus • When does postpartum technically begin?! = 2 hrs after delivery of the placenta • DON’T MIX UP PHASE & STAGE! pay attention!! - ex. What is the #1 priority in the 2nd phase? ! = pain management! - ex. What is the #1 priority in the 2nd stage?! = clearing the baby’s airway! - ex. What are major nursing actions to take in the 3rd ! phase? = check dilation, help w/ pain & breathing! - ex. What are major nursing actions to take in the 3rd ! stage? = assessing blood loss, making sure there ! are 3 vessels in the cord, making sure the whole ! placenta comes out • Teaching PT’s how to time contractions:! - frequency = beginning of one contraction to ! beginning of the next (A to C)! - duration = beginning to end of 1 contraction (A to B)! - intensity = strength of contraction -> subjective! - teach her to palpate w/ one hand over the fundus ! with the pads of the fingers (fingertips) ! * use other hand to time it COMPLICATIONS OF LABOUR • there are 18 that can occur in L & D that you need to know BUT there are only 3 protocols you need to know for all of them • a) Painful Back Labour! - usually for OP positions (occiput posterior)! —> think “oh pain!”! - low priority! - do 2 things:! i. position = place her in knee chest position (face ! down on hands & knees, bum up in air)! -> to have baby come off the coccyx ! ii. push = take your fist and push it into her sacrum ! (applies counter pressure to relieve pain) • b) Prolapsed Cord! - OB MEDICAL EMERGENCY!!! high priority!! - when the cord is the presenting part (comes out first) ! & so when the head comes down it presses on the ! cord and cuts of the supply causing baby to “kill itself”! - do 2 things:! i. push = baby’s head off cord (DON’T touch the cord)! ii. position = knee chest position to take ! compression off of the cord! ** delivery is then usually emergency C-section (take ! mom to OR in knee-chest position while holding head) Interventions for ALL Other Complications in Labour & Birth: • ex. include uterine atony, uterine hypoTN, vena cava syndrom, uterine tetany…etc. • all treated the same, treated with LION:! L = 1st, turn them on their left side! I = increase IV ! O = oxygenate them! N = notify MD! ** RPN’s can do all except increase IV! - left side position is first but also probably best ! because it addresses uterine perfusion which ! protects/saves baby • PIT: in an OB crisis, if Pitocin is running, STOP IT!! = this would become the first thing then before turning ! them onto their left side Pain Meds in Labour: • do not administer a pain med to a woman in labour if the baby is likely to be born when the med peaks (review peaks lecture)! - ex. You have a primigravida at 5 cm who wants her ! IV push pain med. Will you give it or not?! -> is it likely that a primigravida at 5 cm will deliver ! in the next 15-30 mins? NO, so give her the med! - ex. A multigravida at 8 cm wants her IM pain med. ! Do you give it?! -> is it likely that she could deliver in the next 30-60 ! mins? YES, so no IM med for her