Vernix caseosa: 

   Lanugo: 

  Brown fat: 

A hormone produced in the incipient placenta of a pregnant woman that stimulates the production of estrogen and progesterone;  Its presence in the blood or urine is an indication of pregnancy.

Also known as Human Chorionic Somatomammotropin, promotes normal nutrition and growth of the fetus and maternal breast development for lactation.

Any of several major female sex hormones produced primarily by the ovarian follicles of females; capable of inducing estrus developing and maintaining secondary sex characteristics, and preparing the uterus for the reception of a fertilized egg.

 A hormone, C21H30O2, that prepares the uterus for the fertilized ovum and maintains pregnancy.

  What are three functions of amniotic fluid?

Protects the growing fetus and promotes normal prenatal development.

Cushioning against an impact to the maternal abdomen

 Keeps the membranes from adhering to the developing fetal parts

  Explain the umbilical cord structures and functions.

1.             Umbilical vein:  Carries freshly oxygenated and nutrient-rich blood from the placenta back to the fetus.

2.             Umbilical arteries (two):  Carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta, where these substances are transferred to the mother’s circulation for elimination.

3.             Wharton’s jelly:  The entire cord is cushioned by this soft substance to prevent obstruction caused by pressure.

      Monozygotic is when the union of a single ovum and spermatozoon later divide the conceptus into two.  Dizygotic is when two ova are fertilized by different sperm.

        Chadwick’s sign: 

Blood from disruption of cervical capillaries, and dislodged mucus plug when cervix  begins to thin and dilate.

 To maintain pregnancy, inhibits release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) necessary for ovulation.

 Increased fibrinogen protects against hemorrhage, but increases risk of thrombus formation.

 Maternal tissue sensitivity to insulin begins to decline because of the effects of human placental lactogen, prolactin, progesterone, estrogen, and cortisol.  The mother uses fat stores to meet her energy needs.

 Caused by diminished gastric motility, displacement of stomach by enlarged uterus, & relaxation of the lower esophageal sphincter.  Bad diet & nervous tension may be factors.

 UNCERTAINTY, unsure if she is pregnant, wanting to confirm by body changes.  AMBIVALENCE, wondering if it’s the right decision or time for a baby.  THE SELF AS PRIMARY FOCUS, the woman’s primary focus is on herself; her own physical and psychological feelings.

PHYSICAL EVIDENCE OF PREGNANCY, physical changes occur (uterus can be palpated in the abdomen, weight increases, and breasts change), making the pregnancy “real”.  THE FETUS AS PRIMARY FOCUS, concern is shifted from woman to fetus; woman is now concerned about producing a healthy infant.  NARCISSISM AND INTROVERSION, very critical about foods that are eaten, right clothes to wear, and may be fearful of things outside their body that may seem a danger for the fetus.  BODY IMAGE, rapid and profound changes that may be welcome or bring a negative body image.  CHANGES IN SEXUALITY, are unpredictable; may increase, decline, or remain unchanged. 

 Low birth weight, preterm labor, and increased risk of fetal and newborn mortality and morbidity.

   What three major consequences are associated with excessive prenatal weight gain? 

       Normal prepregnancy weight:  25-35 lbs (11.5-16kg)

  Prepregnancy BMI < 19.8:  28-40 lbs (12.5-18kg)

Prepregnancy BMI 26-29:  15-25 lbs (7-11kgs)

Prepregnancy BMI > 29:  15 lbs (at least 7kg)

 Proteins and complex carbs are tolerated best; fatty foods increase nausea; drinking liquids between, instead of with meals helps decrease nausea; protein snacks at bedtime, and dry toast/crackers in the morning reduce nausea. 

 Down syndrome; gestational trophoblastic disease, normal fetus with overestimating gestational age/incorrect maternal weight (higher than true weight)

What conditions are suggested by alpha-fetoprotein levels that areHigh

 Anencephaly, spina bifida; esophageal obstruction; abd wall defects; hydronephrosis; threatened abortion; fetal demise; normal fetus with maternal insulin-dependant diabetes, multifetal gestation.

The AFP, hCG, and unconjugated estriol are the three to increase detection of trisomy 18 and 21.  A 4^th marker, placental hormone inhibin A, improves accuracy of triple-marker screening for detection of trisomy 21 in women over 35.

Which direction baby lies before entering pelvis.  LONGITUDINAL LIE: Either head or buttocks enter first.  TRANSVERSE LIE:  When baby perpendicular to pelvis.  OBLIQUE LIE:  Somewhere between the two.

Relation of fetal body parts to each other.  Normal is in flexion, with head flexed toward the chest, with arms/legs flexed over the thorax.

  The fetal part that enters the pelvis first.  Either cephalic, breech, or shoulder.

Describes the location of a fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvis: right and left anterior and right and left posterior. 

1ST STAGE OF LABOR DISCOMFORT

(contractions)

2nd stage of labor discomfort

delivery of baby

third stage of labor discomfort

placenta delivery

4th stage of labor discomfort

1-4 hrs after birth

 Most important is assessing fetal movement; if decreased, notify immediately and rush to labor unit.  Assess bleeding; normal is dark red/pink mixed with mucus.  Bright red, not mixed with mucus should be evaluated promptly.

  A sustained blood pressure of 140/90 or higher and/or temperature of 100.4 or higher can show hypertension or infection.

 fetal heart rate values

       Normal:  110-126 bpm

     Bradycardia:  Less than 110 bpm

   Tachycardia:  More than 160 bpm

Accelerations

Early decelerations

Late decelerations

Variable decelerations

   Observe fetal response (HR, late decelerations).  Observe mom for uterine response, BP & HR, temp, fluid retention (I&O), assess for uterine atony & hemorrhage postpartum.

Reduce or stop infusion and increase rate of non-additive IV fluids.  Keep woman on her side, give 100% O2 by facemask at 8-10L/min.  Doc may order terbutaline (Brethine) or mag sulfate.

- prepare breast for lactation (inhibits until after labor)

prepare breast for lactation (inhibits until after labor)

initiates milk production within 2-3 days after childbirth

necessary for milk ejection, or “letdown.”  Oxytocin auses milk to be expressed from th alveoli into the lactiferous ducts during suckling.

   The nondominant hand must support and anhor the lower uterine segment.  To expel clots, the nurse must support the lower uterine segment.  This support prevents inversion of the uterus when the nurse applies firm pressure downward toward the vagtina to express clots that have collected in the uterus.

Fundus 

Lochia 

Taking-in

Taking-hold

Letting-go

 first stool excreted, greenish black with thick, sticky, tarlike consistency.  Usually passed within first 12 hours after birth.  Concern of bowel obstruction if not passed within 48hrs.

combination of meconium and milk stools.  Greenish brown and looser consistency. 

-are characteristic of the type of feeding the infant receives. 

Breast milk are seedy and have consistency of mustard with sweet-sour smell.  As many as ten small stools a day, should have at least 4. 

Formula-fed infants excrete pale yellow to light brown stools, firmer in consistency.  May have several daily, or only one or two.  Stools have characteristic odor o feces.

120-160 (100 sleeping, 160 crying)  Listen to apical pulse.

- 30-60 (average 40/min)  place stethoscope of right side of chest

varies with activity, gestational age and size.  Average systolic 65-95.  Average diatolic 30-60. 

 axillary 36.5-37.3C (97.7-99.1 F)  along chest wall with tip in in center of axillary space with arm held firmly over probe.   

Rectal  36.5-37.7C (97.7-99.8F)   lube probe, insert no more than 1.25 cm (0.5 inches), securely hold to avoid injury until time to read temp.

  increased risk for preeclampsia, anemia, cephalopelvic disproportion, preterm labor, and birth, low birth wt babies, and depression.

 Preexisting disorders-increased risk for complications  (hypertension, diabetes, uterine fibroids most common)

 Obstetric complications-spont abortion, stillbirth, vaginal bleeding, preeclampsia, multiple gestation, preterm birth, gestational diabetes, placenta previa, prolonged labor and cesarean birth more common problems.

Tobacco effects

Alcohol effects

Cocaine effects

Marijuana effects

Heroin effects

Inevitable abortion

Incomplete abortion

Complete abortion

Missed abortion

If fetus is not expelled, fetal death is confirmed by ultrasound and may be evacuated by D&C.  Prostaglandin compounds may be necessary to induce contractions and empty the uterus during the second trimester.  Infection and DIC major complications.

Recurrent abortion

 fetal tachycardia, maternal tachycardia, decreased BP, increased resp rate, low oxygen saturation, cool pale skin and mucus membranes.

Placenta previa

Abruptio placentae

 Position woman in lateral position, with HOB flat to increase cardiac return.  Restrict maternal movements and activity to decrease the tissue demand for oxygen.  Emotional support to help reduce anxiety, which increases the metabolic demand for O2.

 Kidneys- Decreased renal profusion.  Increased creatinine, BUN, uric acid levels.  Glomerular damage secondary to reduced renal blood flow allows protein to leak across the glomerular membrane.

   Liver-decreased circulation to the liver impaired liver function and leads to hepatic edema and subcapsular hemorrhage, which can result in hemorrhagic necorosis.  Process is manifested by elevated liver enzymes.

Brain-vasoconstriction of cerebral vessels leads to pressure-induced rupture of thin-walled capillaried, resulting in small cerebral hemorrhages.  Headache and visual disturbances, blurred vision and “spots” as well as hyperreflexia.

 Lungs-Decreased colloid oncotic pressure can lead to pulmonary capillary leaks that result in pulmonary edema.  Dyspnea is the primary symptom.

  Placenta- Decreased placental circulation results in infarction that increase the risk for abruption placentae and HELLP syndrome.  Fetus may experience IUGR and persistent fetal hypoxemia.

 Particularly ominous because indicated distention of the hepatic capsule and often warn that a seizure is imminent. 

   Flushing, sweating, hypotension, depressed deep tendon reflexes, CNS depression, respiratory depression

       Calcium gluconate, slow IV administration of 1g (10mL of 10%) at 1 mL/min.

Rh incompatibility is a problem that affects the fetus: causes no harm to the expectant mother.  When Rh factor present in the mom’s blood, they cross the placental barrier and destroy fetal RBCs.

  Rh of the woman- negative and Rh of the fetus or newborn-   positive

Indirect Coombs’ test (woman)- a test to determine whether a mom is sensitized (have developed antibodies) as a result of previous exposure to Rh-positive blood.  Done at initial prenatal visit, repeated at 28weeks.  Negative test indentifies the fetus as not at risk for hemolytic disease of the newborn at this time (RhoGAM administered at 28 weeks).  Positive test indicated presence of antibodies against Rh-postitive erythrocytes and must be repeated frequently to determine if fetus is in jeopardy because fetal erythrocytes are being attacked by maternal anti-RH antibodies.

Direct Coombs’ test (newborn)-umbilical cord blood is taken at delivery to determine blood type, Rh factor, and antibody titer of the newborn.  Rh-neg mom who gave birth to Rh-pos baby given RhoGAM within 72 hours after delivery so she does not form natural, permanent antibodies.

maternal metabolic rates and energy needs change little.  Insulin needs generally decline during first trimester because the secretion of placental hormones that are antagonistic to insulin remains low during this time. 

 Insulin needs increase markedly, placental hormones rise sharply, create resistance to insulin in maternal cells to provide an abundant supply of glucose for the fetus.  Pancreas responds by increasing the production of insulin.

maintenance of tight maternal glucose control during birth is desirable to reduce neonatal hypoglycemia (titrate infusion of reg insulin combined with sep infusion of D5 to maintain tight control 80-110)

  Should decline rapidly, blood glucose should be checked at least 4 times a day.

What anticoagulant is recommended if one is needed during pregnancy? Why?

During pregnancy, clotting factors normally increase and thrombolytic activity decreases. These changes predispose the pregnant woman to thrombus formation. Warfarin (coumadin) is associated with fetal manifestations and should be avoided throughout pregnancy. SubQ heparin, which does not cross the placental barrier, is an effective alternative anticoagulant for most woman. Enoxaparin ( Lovenox) may be used instead of heparin because it requires less-frequent monitoring for bleeding complications.

 Every effort is made to minimize the effects of labor on the cardiovascular system.  For example, with every contraction, 300 to 500 ml if blood is shifted from the uterus and placenta into the central circulation.  The fluid shift causes sharp rise in cardiac workload.  Therefore careful management of IV fluid administration is essential to prevent fluid overload.  The fourth stage of labor is associated with special risks.  After delivery of the placenta, about 500ml of blood is added to the intravascular volume.  To minimize the risks of overloading the heart, abrupt positional changes should be avoided.

Maternal position changes promote fetal head rotation to an occiput anterior position  and fetal descent.

-Hands and knees. Rocking the pelvis back and forth while lying on hands and knees encourages rotation - 

Side-lying (on her left side if the fetus is in a right OP position, and on her right side for a left OP position. –

The lunge,  in which the mother places one foot on a chair with her foot and  knee pointed to that side. She lunges sideways repeatedly during a contraction for 5 seconds at a time. This action can also be performed in a kneeling position.

–squatting (for second stage of labor. – Sitting, kneeling or standing while leaning forward. Using a birthing ball- helps support the woman when in the hands and knees position.

The main side effects for beta-adrenergic drugs involve the caridorespiratory system. Maternal and fetal tachycardia are common. Other maternal side effects may include decreased BP, wide pulse pressure, dysrhythmias, myocardial ischemia, chest pain, and pulmonary edema.  Metabolic changes include hyperglycemia and hypokalemia. Headaches, tremors, and restlessness are other side effects, with headaches often becoming less severe as the woman becomes accustomed to the drug.

Propenolol (Inderal), an agent that blocks beta-adrenergic drugs is used to reverser serious adverse effects.

Calcium is essential for muscle contraction in smooth muscles such as the uterus, so blocking calcium reduces the muscular contraction.

The nurse whould observe the woman for side effect such as nausea, heartburn, vomiting, and rash, prolonged bleeding times from injections and bruising, for no apparent cause. Fever may be masked due to drugs anti-inflammatory effect. Checking the fundus at the beginning of therapy and daily thereafter helps identify reduced amniotic fluid. Decreased fetal movements and absent fetal heart rate accelerations with fetal movement may occur if the etal condition deteriorates.

When postpartum hemorrhage is caused by trauma to the birth canal, surgical repair is often necessary.  The mother is returned to the delivery area and the laceration is repaired.  Small hematomas usually reabsorb naturally.  Large hematomas may require incision, evacuation of the lcots, and location of the bleeding vessel so that it can be ligated.

Initial Treatment-

Subsequent Treatment- 

monitor aPTT and adjust to maintain therapeutic level of 1.52.5 X the control woman is placed on  bed rest with affected leg elevated to decrease interstitial swelling and to promote venous return from that leg. Ambulate when symptoms have disappeared. 

 depends on whether the woman is pregnant of in the postpartum period- pregnant woman cont. coag therapy for atleast 20 wks. Warfarin is contraindicated during pregnancy. The postpartum woman is placed on warfarin while she is still being treated with heparin. The heparin is D/C and warfarin is cont. for 6 wks- 6 mos.

.  full term babies that have failed to grow normally while in the uterus

1) They  have thin skin with blood vessels near the surface and little subcutaneous(white) fat for insulation.

2) Less brown fat is present for no shivering thermo genesis.

3) Preterm infants body surface area in porportion to their body mass is five times that of adults, their extended extremities increase exposure to the air for heat loss. 

4) the temperature control center of the brain of preterm infants is less mature and may be further impaired by asphyxia.

What factors typically increase a preterm infant’s risk for infection?

Exposure to maternal infection, lack of transfer of immunoglobulin (IgG) from the mother during the third trimester, and immature immune response to infection. They are often exposed to situations that my cause infection such as invasive procedures; IV insertions, drawing blood specimens, and prolonged stay in the hospital increases the likelihood of acquiring an infection from multiple exposures to organisms.

Preterm infants are born before they are able to accumulate stores of nutrients and their digestive system is immature. Fat stores are minimal or absent, and glucose reserves are used up soon after birth.  Low blood glucose levels develop very rapidly and must be prevented or treated quickly. These infants also need increased amts of Protein, iron, calcium, and phos. The gastrointestinal tract of preterm infants does absorb nutrients as well as that of full term infants., preterm infants have insufficient bile acids and pancreatic lipase to absorb fat adequately. They have some lactase deficiency but digest glucose and sucrose adequately, preterm infants require supplementation because they need more of many nutrients per kilogram than do full term infants.

Pacifiers are often used during gavage feedings because  they have been exposed to aversive stimulation around the mouth, such as intubation and suctioning. As a result, they may react negatively to any addtl oral stimulation, thus interfering with feedings. Providing a pacifier during gavage feedings gives positive oral stimulation and  helps associate the comfortable feeling of fullness with sucking.

Apneic episodes are a lack of breathing lasting more than 20 sec. often accompanied by a drop in heart rate and O2 sat. The nurse observes the effort required for breathing and the location and severity of retractions.  Retractions are particularly noticeable in a preterm infant, whose weak chest wall is drawn with each inspiration. The excessive compliance (elasticity) of the chest cage during retractions may interfere with full expansion of the lungs. Grunting may be an early sign of RDS, it closes the glottis and increases the pressure within the alveoli, keeping the alveoli partially open between breaths and increasing the amt of O2 absorbed.

Placental functioning decreases when pregnancy is prolonged.  If placental insufficiency is present, decrease amniotic fluid volume (oligohydramnios) may occur, increasing the risk of umbilical cord compression. The fetus may  not receive the appropriate amt of O2 and nutrients and may be small for gestational age. This condition is known as post maturity syndrome or dysmaturity syndrome. When labor begins, poor oxygen reserves may cause fetal compromise. The fetus may pass me conium as a result of hypoxia before or during labor, and me conium aspiration may occur at delivery. Postterm infants have a higher perinatal mortality rate than infants born at term.

Symmetric growth restriction may be caused by congenital anomalies, genetic disorders, or exposure to infections or drugs early in pregnancy. Asymmetric restriction is caused by complications that begin in the third trimester that interfere with uteroplacental function or nutritional deficiency.

LGA infant is more likely to go through longer labor, have injury during childbirth, or need a cesarean birth. Shoulder dystocia may occur because the shoulders are too lrg to fit through the pelvis. Fractures of the clavicle, damage to the brachial plexus or facial nerve, cephalhematoma, and bruising occur more often in these infants than in those of normal size. Congenital heart defects are more common, and the mortality rate is greater.

If asphyxia occurs after birth, rapid respirations are followed by cessation of respirations (primary apnea) and a rapid fall in heart rate. Stimulation alone or with oxygen may restart respirations.     If asphyxia continues w/o intervention, gasping respirations may resume weakly until the infant enters a period of secondary apnea. 

 In secondary apnea, the oxygen levels in the blood continue to decrease, the infant loses consciousness, and stimulation is ineffective.  Resuscitative measures must be initiated immediately to prevent permanent damage to the brain or death.

TTN, also called "wet lungs" or type II respiratory distress syndrome, usually can be diagnosed in the hours after birth. It's not possible to detect before the birth whether a child will have it.

TTN can occur in both preemies, because their lungs are not yet fully developed and full-term babies.

Newborns at higher risk for TTN include those who are:

• delivered by cesarean section (C-section)
• born to mothers with diabetes
• born to mothers with asthma
• small for gestational age (small at birth)

If an infant inhales meconium before, during, or after birth, it may be sucked deep into the lungs. Three main problems occur if this happens:

• the material may block the airways
• efficiency of gas exchange in the lungs is lowered
• the meconium-tainted fluid is irritating, inflaming airways (pneumonitis) and possibly leading to chemical pneumonia.

at birth the infant may look cachexic and show signs of yellowish meconium staining on skin, nail and the umbillical cord, these infants usually progress onto Infant Respiratory distress syndrome within 4 hours.

    Because preterm infants are more vulnerable to bilirubin toxicity, phototherapy is started at lower TSB levels than for full-term infants.

Insulin acts as a growth hormone. Protein synthesis is accelerated and fat and glycogen are deposited in fetal tissues, resulting in macrosomia. Infants of mothers with long-term diabetes and vascular changes may have intrauterine growth restriction instead of macrosomia because of decreased placental blood flow. Hypertension occurs more often in diabetic women and further compromises uteroplacental blood flow.

Polycythemia, a response to chronic hypoxia in utero may result in hyperbilirubinemia as the large number of RBC’s break down after birth.

The macrosomic IDM has hypertrophy of the liver, adrenals, and heart.  All organs except the brain are larger than normal. The length and head size are generally within the normal range for gestational age. These infants may have characteristic appearance. The face is round, the body is obese, and the skin is red (plethoric) The infant has poor muscle tone at rest but becomes irritable and may have tremors when disturbed. 

The most common sign of low glucose is jitteriness or tremors. Diaphoresis is uncommon in newborns but  may occur with hypoglycemia. Rapid respirations, low temperature, and poor muscle tone are common, HOWEVER, hypoglycemia is often present without observable signs

Infants with NAS may be irritable and have hyperactive muscle tone and high pitched cry.  Tremors may be present, but the blood glucose level is normal.  Infants appear to be hungry and suck vigorously on their fists but have poor coordination of suck and swallow. Frequent regurgitation, vomiting, and diarrhea, are common.  The infant’s excessive activity, coupled with poor feeding ability, results in failure to gain weight. Also, irritability, jitteriness, tremors, seizures, muscular rigidity, increased muscle tone, restlessness, excessive activity, exaggerated moro reflex, prolonged high pitched cry, difficult to console, poor sleeping patterns, yawning.

Phenylketonuria is a genetic disorder that causes central nervous system damage from toxic levels of the amnio acid phenylalanine in the blood.  Severe intellectual disability occurs in untreated infants and children. In the US all newborns are screened for this condition before or shortly after discharge.

BSA conversions

:

Square root of (Inches X Pounds) / 3131

(Childs BSA X adult dosage )/ 1.73

IV replacement protocol

:

• First 10 kg add 100 ml/kg

• Second 10 kg add 50 ml/kg

• Remainder add 20 ml/kg

Total and divide by 24 to get ml/ per hour

Case #1: Your patient is 5 feet even, and weighs 200 pounds

Step 1: convert pounds to kg 200 / 2.2 =

90.9 kg

Step 2: convert feet to inches 5 * 12 = 60 in

Step 3: convert inches to cm 60 * 2.54 = 152.4 cm

Step 4: convert cm to meters 152.4 / 100 = 1.524 meters

Step 5: square meters 1.524 * 1.524 =

2.323 meters squared

Step 6: apply formula 90.9 / 2.323 =

39 BMI

You have an order to administer a bolus of magnesium sulfate, 4 grams over 20 minutes, then 3

grams per hour. The pharmacy sends up a bag of 40 grams magnesium sulfate in 1000 ml lactated ringers.

Step 1: do you need to convert?

no

- the order and the supply are in the same units and you don’t

have to account for weight

Step 2: calculate the bolus dose 4 g in 20 min / 40 grams * 1000 mL = 100 mL in 20 min

Step 3: calculate the bolus vol 100 / 20 min * 60 min =

300 mL per hour

Step 4: calculate the hourly dose 3 g per hour / 40 grams * 1000 mL =

75 mL per hour

You have an order to start a pitocin induction on a patient at 2 milliunits per minute. The supply is 20

units of pitocin in 1000 mL lactated ringers.

Step 1: do you need to convert?

yes

- the order and the supply are in different units. I always convert

to whatever the order is - in this case, convert the supply to milliunits:

20 units * 1000 = 20,000 milliunits

Step 2: calculate the dose 2 milliunits per min / 20,000 milliunits * 1000 mL = 0.1 mL per min

Step 3: calculate the hourly dose 0.1 mL per min * 60 min =

6 mL per hour