Maternity

Maternity Gestation: Time from fertilization until date of delivery; approximately 280 days (9 mos) Nagele’s rule: first day of last menstrual period - 3 months + 7 days + 1 year = estimated date of delivery Gravidity + Parity: Gravida = pregnant woman Gravidity = number of pregnancies (e.g. nulligravida is woman who’s never been pregnant, primigravida is pregnant for the first time, multigravida is in at least her 2nd pregnancy) Parity = number of births past 20 weeks gestation (whether born alive or not) (e.g. nullipara has not had a birth more than 20 weeks gestation, primipara has had 1 birth that occurred after 20 weeks gestation) GTPAL: gravidity, term births (longer than 37 weeks), preterm births, abortions/miscarriages, current living children Presumptive Signs Probable Signs Positive Signs • • • • • • • • • • • • • • • Pregnancy Signs Amenorrhea Breast enlargement/tenderness Fatigue Nausea and vomiting Quickening (first movement of fetus) Urinary frequency Ballottement (fetal movement in response to tapping lower uterus/cervix) Braxton Hicks contractions Chadwick’s sign (light pink-deep violet vaginal wall colour) Hegar’s sign (softening of cervix) Positive pregnancy test Abdominal + uterine enlargement Fetal heartbeat Fetal movement Ultrasound findings Fundal Height: Measured to evaluate gestational age of fetus *In 2nd and 3rd trimester: fundal height in cm = fetal age in wks +/- 2 cm Priority: 1. Monitor for supine hypotension when placing pt in supine position Physiological changes when pregnant: Cardiovascular: heart displaced upward, increased blood volume, increased resting HR, increased venous pressure, increased RBC GI: displacement of intestines, nausea and vomiting, hemorrhoids, constipation Endocrine: increased basal metabolic rate, increased prolactin, estrogen, and cortisol levels, decreased insulin production Respiratory: compression of lungs, displacement of diaphragm, abdominal breathing, increased RR Integumentary: hyperactive sweat glands, increased pigmentation, stretch marks Genitourinary: dilated uterus, increased renal function (increased urea and creatinine clearance), decreased bladder tone, sodium retention Nutrition: calories, protein, vitamins, minerals, and fiber intake should increase during pregnancy. *Folic acid is important to prevent fetal anomalies (e.g. neural tube defect) 42 Discomforts during pregnancy Prevention/Interventions: Eat dry crackers before arising, avoid brushing teeth right occurs in 1st month, subsides by 3rd month after arising, eat small frequent meals, drink in between meals, avoid fried/spicy food occurs in 1st trimester, supine Elevate feet when sitting, change positions slowly hypotension in 2nd and 3rd trimester 2L fluid restriction, void regularly, side lying sleep position, occurs in 1st + 3rd trimester due to uterus pushing on bladder Kegel exercises Nausea/Vomiting Syncope Urinary Urgency Breast tenderness Vaginal discharge Fatigue Heartburn 1st-3rd trimester 1st-3rd trimester 1st and 3rd trimesters 2nd and 3rd trimesters Ankle edema 2nd and 3rd trimesters Varicose veins 2nd and 3rd trimesters Hemorrhoids 2nd and 3rd trimesters Wear supportive bra, avoid soap on nipples Proper cleansing, cotton underwear, avoid douching Frequent rest periods, regular exercise Small frequent meals, sit up right 30 mins post-meal, drink milk between meals, avoid fatty/spicy food Elevate legs BID, side lying sleep position, supportive stockings, avoid sitting/standing in one position for long Wear supportive stocking, elevate legs when sitting, lay with feet elevated, avoid crossing legs Soak in warm sitz bath, sit on soft pillow, high fiber foods + fluid intake, increase exercise Pregnancy Health Care Visits: Visit MD every 4 weeks for first 28-32 weeks, every 2 weeks from 32-36 weeks, and every week from 36-40 wks Nonstress Test Noninvasive test measuring fetal heart accelerations in response to fetal movement Done between 32-34 weeks gestation Nonreactive result = further testing is needed to determine if the result indicates fetal hypoxia or if result is due to sleep pattern, or maternal prescription drugs Reactive result = normal. Indicates that blood flow and oxygen to fetus is adequate First Stage Second Stage Third Stage Fourth Stage Stress Test Test triggers contractions and predicts how baby will react during labour If fetal HR slows during contraction = positive result. Fetus may be experiencing stress during contractions (cannot tolerate contractions) Further testing may be needed If fetal HR doesn’t slow down during contraction = normal result. Indicates that the fetus is reacting properly to stress of contractions Stages of Labour Onset of true labour – complete dilation of cervix Lasts anywhere from 2-18 hours 3 phases: 1. Latent phase – cervix dilated 0-3 cm, irregular contraction, cervical effacement almost complete 2. Active phase – cervix dilated 4-7 cm, contractions 5-8 minutes apart, cervical effacement complete 3. Transitional phase – cervix dilated 8-10 cm, contractions 1-2 minutes apart + lasting 60-90 seconds Complete dilation of cervix – delivery Usually lasts ~40 minutes Delivery – expulsion of placenta Usually lasts 5-30 minutes Maternal-neonatal bonding period Usually lasts 1-4 hours 43 Presentation: Cephalic – head first (most common), can be vertex, military, brow, or face Breech – buttocks first (C section may be required), can be frank, full, or footling Shoulder – transverse lie or arm/back/abdo/side can be present (C section may be required if fetus doesn’t turn) Station: Progress of descent in cm above or below midplane 0 – at ischial spine Minus – above ischial spine Plus – below ischial spine True Labor Regular contractions that become stronger, last longer, and occur closer together Cervical dilation + effacement progress Fetus becomes engaged in pelvis and begins to descend False Labor Contractions are irregular, without progression No dilation, effacement, or descent Activity (e.g. walking) relieves false labor Preterm Labor: After 20th week but before 37th week gestation Leopold’s Maneuvers: Palpating to determine presentation + position Head = hard, round, movable Buttocks = irregular shape, more difficult to move Back = smooth, hard surface (should be felt on 1 side of abdomen) Fetal Heart Rate: FHR < 110 for 10 mins+ = bradycardia FHR >160 for 10 mins+ = tachycardia Priority: 1. Change mother’s position 2. Administer O2 3. Check mother’s VS Accelerations: brief increase in FHR lasting about 15 seconds; reassuring sign showing a responsive fetus; usually occurs with fetal movement (or with contractions) Early decelerations: decrease in FHR occurring during contractions (fetus’ head pressed against mother’s pelvis); not associated with any fetal compromise; no intervention needed Late decelerations: decrease in FHR well after the contraction; indicates uteroplacental insufficiency; fetal oxygenation is a priority Variable decelerations: due to restricted flow through umbilical cord; significant when FHR is <70 bpm for more than 60 seconds V C V = variable decelerations; C = cord compression E H E = early decelerations; H = head compression A O A = accelerations; O = okay, not a problem! L P L = late decelerations = placental insufficiency Priority with an un-reassuring FHR: turn woman on L side, give O2, stop Pitocin, increase IV fluids Premature Rupture of Membranes: S/S: fluid pooling, positive nitrazine test Priority: 1. Monitor for infection 2. Avoid vaginal exams 3. ABX if needed 44 Prolapsed Umbilical Cord: Causes compression of cord and compromised fetal circulation S/S: feeling of something coming through vagina, visible/palpable cord, slow FHR with variable decelerations, potential fetal hypoxia Priority: 1. Elevate fetal part lying on cord 2. Place pt into Trendelenburg 3. Admin O2 (8-10 L) 4. Monitor FHR 5. IV fluids 6. Prepare for birth APGA APGAR: R: 2 points Appearance Pulse Grimace Activity Respiration All pink >100 Cough Flexed Strong cry 1 point Pink and blue <100 Grimace Flaccid Weak cry 0 points Blue/pale Absent No response Limp Absent Score of 7-10 is excellent, 4-6 indicates moderate depression, and 0-3 is severely depressed (resuscitation needed) Placenta Previa Placenta implanted low in uterus or over cervical os S/S: sudden painless, bright red bleeding Abruptio Placentae Premature separation of placenta from wall S/S: painful dark red bleeding, uterine pain, uterine rigidity, abdo pain Priority: 1. Ultrasound to confirm 2. Avoid vaginal exam 3. Side Priority: 1. Trendelenburg 2. Monitor bleeding 3. O2, IV fluids, lying position 4. Monitor amount of blood 5. IV fluids and blood products 4. Prepare for delivery ASAP blood products 6. C-section may be needed Supine Hypotension: S/S: pallor, dizziness, tachycardia, hypotension, cool skin, fetal distress Priority: 1. Side lying position Lochia: (Postpartum) Scant – less than 2.5 cm in 1 hr Light – less than 10 cm in 1 hr Moderate – less than 15 cm in 1 hr Heavy – saturated pad in 1 hr Excessive – saturated pad in 15 mins Day 1-3: rubra, Day 4-10: serosa, Day 11-14: alba Postpartum Blue Anger, anxiety, cries easily, letdown feeling, fatigue, headache, insomnia, restless, sad Emotional Changes Postpartum Depression Anxiety, change in appetite, cries, difficulty making decisions, fatigue, guilty, irritable, lacks energy, less responsive to baby, loss of pleasure in normal activities, suicidal thoughts Postpartum Psychosis Break with reality, confusion, delirium, delusions, hallucinations, panic 45