Solution Manual for Olds Maternal-Newborn Nursing & Women Health Across the Lifespan, 11 Edition

Solution Manual for Olds Maternal-Newborn Nursing & Women Health Across the Lifespan, 11 Edition

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Instructor’s Resource Manual for Olds' Maternal-Newborn Nursing & Women's Health Across the Lifespan, 11e

Olds' Maternal-Newborn Nursing & Women's Health Across the Lifespan Eleventh Edition

Michele Davidson Marcia London Patricia Ladewig

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

Chapter 1 Contemporary Maternal-Newborn Nursing Contemporary Childbirth..................................................................................

2

The Self-Care Movement..................................................................................

3

The Healthcare Environment............................................................................

3

Culturally Competent Care................................................................................

4

Professional Options in Maternal-Newborn Nursing Practice.........................

5

Legal and Ethical Considerations......................................................................

6

Special Ethical Situations in Maternity Care.....................................................

9

Evidence-Based Practice in Maternal-Child Nursing........................................

12

Focus Your Study……………………………………………….............................................

15

Activities.............................................................................................................

15

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

Contemporary Childbirth

A. Scope of Practice of Maternal and Newborn Nurses Has Changed Dramatically 1. Broader responsibilities 2. Focus on goals of childbearing woman and her family, family-centered care a) Fathers, siblings, family members b) New definitions of family evolving 3. Characterized by increasing number of choices about childbirth a) Place b) Primary caregiver c) Birth-related experiences 4. Home follow-up nursing care a) Cost-effective b) Favorable long-term family outcomes 5. Internet access a) Families have wealth of information and advice 6. Complementary and alternative medicine (CAM) practices growing nationwide a) Impact care of childbearing families b) Nurses need to recognize families may not share this information with their healthcare provider 7. Choice of certified nurse-midwife (CNM) to manage pregnancy, birth a) CNM direct entry (1) As of 2010, graduate degree is required b) Certification agencies (1) American College of Nurse-Midwives (ACNM) (a) Certified nurse midwife (CNM) (2) North American Registry of Midwives (NARM) (a) Certified professional midwife (CPM) 8. Choice of home birth a) Healthcare professionals do not generally recommend

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

II.

The Self-Care Movement

A. Late 1960s 1. Consumers sought to understand technology, take interest in health, basic self-care skills 2. Requiring greater information and accountability from healthcare providers

B. Practicing Self-Care → Assuming Responsibility for One’s Own Health 1. Assertiveness 2. Active role in seeking information 3. Foster self-care by focusing on health promotion education a) Exercise, bike helmet b) Related to specific health concerns c) Promoting health decreases healthcare costs d) Health promotion education activities increased significantly 4. Maternal-newborn care essentially health focused 5. Health promotion education, self-care vital part of healthcare a) Nursing recognizing that people who are able should take an active role in their own health care

III.

The Healthcare Environment

B. Healthcare Issues: Cost, Access, Quality 1. Healthcare expenditures increasing 2. Almost all adults over age 65 are covered by Medicare 3. Vast majority of the uninsured are under age 65

C. Early Prenatal Care Reduces Adverse Pregnancy Outcomes 1. 77.1% of United States pregnant women began prenatal care in first trimester

D. Healthy People 2020 1. Goal: Increase proportion of women who receive early and adequate prenatal care a) Demographic changes b) Recognition of the need to improve access to care c) Public demand for more effective healthcare options d) New research findings e) Women’s preferences for healthcare

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E. Primary Healthcare Services the Base on Which Secondary and Tertiary Services Built 1. System currently focuses on high-tech care rather than prevention

IV.

Culturally Competent Care

A. U.S. Population Ever Increasing in Diversity 1. Culture develops from socially learned beliefs, lifestyles, values, patterns of behavior 2. By 2020, less than half of all children in the United States will be non-Hispanic White 3. Specific elements contribute to value system a) Religion and social beliefs b) Presence and influence of extended family c) Communication patterns d) Beliefs and understanding about concepts of health, illness e) Permissible physical contact with strangers f) Education 4. Specific differences in beliefs between families, providers a) Help-seeking behaviors b) Pregnancy and childbirth practices c) Causes of diseases or illnesses d) Death and dying e) Caretaking and care giving f) Childrearing practices 5. Influence of cultural beliefs, values → making group unique a) Misunderstandings when healthcare professional, family from different cultural groups b) Nurses must recognize, respect, respond to ethnic diversity c) Identify culturally relevant facts about patient 6. Developing cultural competence a) Values conflicts (1) Traditional rituals and practices versus current healthcare practices 7. Cultural values incorporated into care plan → family likely to accept and comply with needed care a) Avoid imposing personal cultural values

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V.

Professional Options in Maternal-Newborn Nursing Practice A. Settings for Maternal-Newborn Nurses 1. Maternity department of acute care facilities 2. Physicians’ offices 3. Clinics 4. College health services 5. School-based programs 6. Community health services

B. Titles Include 1. Professional nurse, registered nurse (RN) 2. Certified registered nurse (RNC) 3. Nurse practitioner (NP) a) Doctor of Nursing Practice (DNP) or master’s degree b) Specialization areas c) Ambulatory care services d) Acute care 4. Clinical nurse specialist (CNS) 5. Certified nurse-midwife (CNM) 6. Advanced practice nurse → additional education, practice, function in expanded role 7. Nurse researcher

C. Interprofessional Cooperation and Collaborative Practice 1. Comprehensive model of health care using multidisciplinary team a) Cost-effective b) High-quality care 2. Maternal-newborn setting a) CNMs, NPs, in practice with physicians b) Autonomous but functions within clearly defined scope of practice

D. Community-Based Nursing Care 1. Increasing emphasis on primary care a) Health promotion b) Illness prevention c) Individual responsibility for one’s own health 5 Copyright © 2020 Pearson Education, Inc.

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2. Third-party payer plans offer opportunities and challenges a) Model for coordinated, comprehensive care b) Challenge to integrate essential community providers (1) Essential element of health care for uninsured and underinsured c) Consumers requesting “seamless” system d) Shortened lengths of stays have resulted in need for coordination of services 3. Maternal-newborn nurse involved in changes a) Most health care provided to childbearing families takes place outside hospitals

E. Home Care 1. Important dimension of community-based nursing care 2. Nurses major providers of home care services a) Providing and supervising care 3. Postpartum and newborn home visits

F. Healthy People 2020 Goals 1. Maternal, infant, and child health 2. Adolescent health (new) 3. Family planning 4. Injury and violence prevention 5. Lesbian, gay, bisexual, and transgender health (new) 6. Sexually transmitted infections 7. Genomics

VI.

Legal and Ethical Considerations

A. Full Understanding of: 1. Practice standards 2. Institutional or agency policies 3. Local, state, and federal laws 4. Understanding of ethical implications

B. Scope of Practice 1. State nurse practice acts protect public by broadly defining legal scope of practice a) Most cover expanded practice roles

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2. Nurse must function within scope of practice or risk being accused of practicing medicine without a license 3. Correct interpretation and understanding state practice acts a) Enables nurse to provide safe care within limits of nursing practice

C. Standards of Nursing Care 1. Establish minimum criteria a) Competent, proficient delivery of nursing care

D. Sources of Care Standards 1. American Nurses Association (ANA) 2. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) 3. National Association of Neonatal Nurses (NANN) 4. Association of Operating Room Nurses (AORN) 5. Agency policies, procedures, protocols 6. The Joint Commission 7. Clinical practice guidelines a) Comprehensive interdisciplinary care plans b) Reduce variation in care management c) Limit costs of care d) Evaluate the effectiveness of care

E. Patients’ Rights 1. Include patient safety, informed consent, privacy, confidentiality

F. Patient Safety 1. The Joint Commission identified patient safety as important responsibility of healthcare providers a) Patient safety goals 2. Quality and Safety Education for Nurses (QSEN) project, 2005 a) Patient-centered care b) Teamwork and collaboration c) Evidence-based practice d) Quality improvement e) Safety f) Informatics

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G. Informed Consent 1. Allows patients to make intelligent decisions regarding own health care 2. Patient (legally designated decision) granted permission for treatment or procedure a) Based on full information b) Pertains to any nursing, medical, or surgical intervention 3. Several elements ensure informed consent a) Clearly and concisely presented b) Understandable to patient c) Include risks and benefits d) Probability of success e) Significant treatment alternatives f) Consequences of receiving no treatment or procedure g) Told of right to refuse specific treatment or procedure h) Told that refusing specified treatment or procedure does not result in withdrawal of all support or care 4. Individual ultimately responsible for treatment or procedure should provide information a) Nurse may witness signature b) May help by clarifying information physician provides c) Determine that patient understands information before making decision 5. Parents have authority and responsibility to give consent for minor children 6. Children younger than 18 or 21 can give legally informed consent when they are: a) Minor parents of the newborn, infant, or child patient b) Emancipated minors 7. Mature minors can give consent in some states 8. Problems in maternity nursing a) Minor might be able to give consent for infant but not for self 9. Refusal of treatment, medication, procedure a) Sign release form 10. Nurses responsible for educating patients about any nursing care

H. Right to Privacy 1. Right of person to keep person and property free from public scrutiny 2. Statutory or common law a) ANA, National League for Nursing (NLN), The Joint Commission b) HIPAA 3. Laws, standards, policies specify information can be shared a) Only by health professionals responsible for their care 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

b) Authorization for release c) Legal versus ethical considerations

I. Confidentiality 1. Crucial for development of trust in relationship 2. Privileged communications 3. Federal Patient Self-Determination Act a) Advance directives

J. Professionalism in Practice 1. Confidentiality and the pregnant adolescent a) Openly discuss limits of confidentiality

VII.

Special Ethical Situations in Maternity Care

A. Maternal–Fetal Conflict 1. Fetus viewed as patient separate from mother 2. Divergent interests rather than shared interests

B. Most Women Strongly Motivated → Protect Health, Well-Being of Fetus 1. Forced intervention on behalf of fetus a) Cesarean birth, coercion to enter substance-abuse treatment, mandating experimental in utero therapy or surgery 2. Intervention infringes on autonomy of mother 3. Criminalize behaviors that are considered harmful 4. American College of Obstetricians and Gynecologists (ACOG) Committee on Ethics a) Affirmed fundamental right of pregnant women (1) To make informed, uncoerced decisions about medical interventions (2) Direct stand against coercive and punitive approaches to maternal–fetal relationship, citing “overwhelming rationale” for avoiding such approaches (3) ACOG and American Academy of Pediatrics (AAP) recognize cases of maternal–fetal conflict that involve two patients, both of whom deserve respect and treatment

C. Abortion 1. 1973 Roe v. Wade, abortion legal in United States 2. Performed until period of viability a) After viability, abortion permissible only when the life or health of the mother is threatened b) Before viability, the mother’s rights are paramount; after viability, the rights of the fetus take precedence 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

3. Personal beliefs, cultural norms, life experiences, religious convictions 4. Decisions about abortion made by woman and physician a) Nurses have right to refuse to assist → may be dismissed for refusing (1) Ensure that someone with similar qualifications is able to provide appropriate care for patient

D. Fetal Research 1. Fetal tissue research 2. Therapeutic research with living fetuses a) Aimed at treating fetal condition 3. Intrauterine fetal surgery a) Open uterus during second trimester → treat fetal lesion → replace fetus in uterus b) Experimental c) Risks of the surgery, commitment to cesarean birth, alternatives to treatment d) Caregivers must respect pregnant woman’s autonomy, she retains right to refuse any surgical procedure

E. Reproductive Assistance 1. Infertile couples have wide range of options a) Intrauterine insemination (IUI) (1) Husband, partner, or donor (2) Child is biologic child of mother → donor must sign form waiving parental rights (3) Donor → health information b) Assisted reproductive technology (ART) (1) Any treatment in which both egg and sperm are handled (2) In vitro fertilization and embryo transfer (IVF–ET) (a) Legislative effort to address consumer concerns about ART (b) Increases multifetal pregnancies (i) Increases risk of miscarriage, preterm birth, neonatal morbidity, and mortality (c) American Society for Reproductive Medicine (ASRM) and Society for Assisted Reproductive Technology (SART) → guidelines to limit number of embryos transferred (i) Fetal reduction (ii) Ethical concerns (d) Prevention should be first approach to problem of multifetal pregnancy 2. Surrogate childbearing 3. Ethical questions a) Religious objections b) Financial and moral responsibility for child with congenital defect

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c) Candidate selections d) Threat of genetic engineering e) What should be done with surplus fertilized oocytes f) To whom do frozen embryos belong g) Who is liable if woman or offspring contracts HIV disease from donated sperm h) Should children be told the method of their conception

F. Embryonic Stem Cell Research 1. Human stem cells found in embryonic tissue 2. Stem cell tissue cultures → cells for blood, nerve, heart a) Used to treat problems 3. Positions vary dramatically a) Additional questions arise (1) Sources acceptable (2) Cloning (3) Use of embryos remaining after fertility treatments 4. How embryo should be viewed a) Person or property b) Includes issue of consent

G. Implications for Nursing Practice 1. Complex ethical issues facing maternal-newborn nurses a) Social, cultural, legal, professional ramifications

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2. Anticipate, clarify own positions and values

VIII.

Evidence-Based Practice in Maternal-Child Nursing

A. Evidence-Based Practice (EBP) → Interventions Supported by Current, Valid Research or Evidence 1. Useful approach to problem solving/decision making 2. Self-directed, patient-centered, lifelong learning

B. Clinical Nurses Must Meet Three Basic EBP Competencies 1. Recognize which clinical practices are supported by sound evidence, which practices have conflicting findings as to their effect on patient outcomes, which practices have no evidence to support their use 2. Use data in their clinical work to evaluate outcomes of care 3. Appraise and integrate scientific bases into practice

C. Need for More Responsible Clinical Practice 1. Need to know what data being tracked a) How care practices, outcomes improved as result of quality improvement initiatives 2. Impact of EBP → moves clinicians beyond practices of habit and opinion

D. Nursing Research 1. Vital to expanding science of nursing a) Fostering EBP b) Improving patient care c) Advancing profession of nursing 2. Gap between research and practice being narrow by publication of findings

E. Nursing Care Plans and Concept Maps 1. Nursing care plans a) Use nursing process as organizing framework 2. Concept maps

F. Statistical Data and Maternal-Infant Care 1. Health-related statistics provide objective basis a) Projecting patient needs b) Planning use of resources c) Determining effectiveness of treatment

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2. Descriptive statistics → describe, summarize a set of data 3. Inferential statistics → allow investigator to draw conclusions, inferences about what is happening a) Between two or more variables in a population b) Suggest or refute causal relationships between them 4. Descriptive statistics starting point for formation of research questions 5. Inferential statistics answer specific questions, generate theories

G. Birth Rate → Number of Live Births per 1000 People 1. 2016 → 12.2/1000 2. Fell for all 5-year age groups from 15 to 29 years of age 3. Increased for women 30 to 49 years of age 4. Remained unchanged for girls 10 to 14 years of age 5. Live births declined in 2016 by 1% to 3,945,875 6. Childbearing by unmarried women continued to decline in both actual number of births and birth rate 7. Caesarean birth rate in 2016 was 42.4% a) See Table 1–1: Births and Birth Rates by Race, 2016, p. 12 8. Research questions a) Association between birth rates and changing societal values? b) Differences in birth rates between various age groups reflect education or changed attitudes toward motherhood? c) Differences in birth rates among various countries reflect cultural differences? Represent availability of contraceptive information? Other factors at work? d) See Table 1–2: Live Birth Rates and Infant Mortality Rates for Selected Countries, p. 12

H. Infant Mortality 1. Number of deaths of infants younger than 1 year of age per 1000 live births in a given population a) Neonatal mortality → number of deaths of infants younger than 28 days of age per 1000 live births b) Postnatal mortality → number of deaths of infants between 28 days and 1 year of age c) Perinatal mortality → includes both neonatal deaths and fetal deaths per 1000 live births d) Fetal death → death in utero at 20 weeks’ or more gestation e) 2015: U.S. rate 5.90 f) Varied widely by race of mother

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2. United States ranks significantly higher among industrialized nations a) High percentage of preterm births in United States main cause b) Stress need in United States for better prenatal care, coordination of health services, provision of comprehensive maternal-child services c) Range is dramatic d) Information prompts questions (1) Infant mortality correlated with specific maternal age?

(2) Leading causes of infant mortality in each country?

(3) Difference in mortality rates among racial groups? If so, is it associated with availability of prenatal care? With educational level of mother or father?

I. Maternal Mortality Rate → Number of Deaths from Any Cause Related to or Aggravated by Pregnancy or Its Management during the Pregnancy Cycle per 100,000 Live Births 1. 2015 → 17.3 per 100,000 live births 2. In general, maternal mortality rates significantly lower than 25 years ago a) Increased use of hospitals, specialized healthcare personnel b) Establishment of care centers for high-risk mothers and infants c) Prevention and control of infection d) Availability of blood, blood products e) Lowered rates of anesthesia-related deaths 3. Research questions a) Correlation between maternal mortality and age? b) Correlation with availability of healthcare? Socioeconomic status?

J. Implications for Nursing Practice 1. Healthy People 2020 a) Determine populations at risk b) Assess relationship between specific factors c) Help establish databases for specific patient populations d) Determine the levels of care needed by particular patient populations e) Evaluate success of specific nursing interventions f) Determine priorities in caseloads g) Estimate staffing and equipment needs of hospital units and clinics 2. Information available from many sources a) Professional literature b) State and city health departments c) Vital statistics sections of agencies d) Special programs or agencies e) Demographic profiles of specific geographic areas

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IX.

Focus Your Study

X.

Activities 1. Individual Assign students to find research reports related to maternal-child nursing interventions and write a two- to three-page paper discussing how they influence evidence-based practice.

2. Small Group Divide the class into small groups of three to five students and have the groups share family values and practices related to maternal-child health and how they influence their values.

3. Large Group Invite maternal-child nurses with different clinical responsibilities to talk about their roles with your class.

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Chapter 2 Families, Cultures, and Complementary Therapies The Family........................................................................................................

2

Cultural Influences Affecting the Family..........................................................

3

Culture and Nursing Care…………………………………………………………………………….

5

Complementary Health Approaches and the Family…….................................

8

Focus Your Study…………………………………………………………………………………………

10

Activities............................................................................................................

10

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

The Family

A. Definitions of Family 1. U.S. Census Bureau: two or more individuals who are joined together by marriage, birth, or adoption and live together in the same household 2. Broad definition: families as individuals who have established bonds of emotional closeness, sharing, and support

B. Family Values 1. Guided by a common set of values or beliefs about the worth and importance of certain ideas and traditions 2. Bind family members together 3. Influenced by external factors

C. Types of Families 1. Nuclear family a) Children live in a household with both biological parents and no other relatives or persons b) Dual-career/dual-earner family now considered the norm 2. Child-free (childless) family 3. Extended family a) Couple shares household and childrearing responsibilities with parents, siblings, or other relatives 4. Extended kin network family a) Two nuclear families of primary or unmarried kin live in proximity to each other 5. Single-parent family 6. Single mother by choice family 7. Blended or reconstituted nuclear family a) Two parents with biological children from a previous marriage or relationship who marry or cohabitate 8. Binuclear family a) Postdivorce family in which the biological children are members of two nuclear households, with parenting by both the father and the mother b) Heterosexual couple who may or may not have children and who live together outside of marriage c) Gay and lesbian families

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9. Heterosexual cohabitating family

D. Family Development Frameworks 1. Family’s progression over time according to specific, typical stages in family life 2. Multiple models 3. See Table 2–1: Eight-Stage Family Life Cycle, p. 19

E. Family Assessment 1. Definition: collection of data about the family’s: a) Type and structure b) Current level of functioning c) Support system d) Sociocultural background e) Environment f) Needs 2. Nurse needs to establish trusting relationship 3. Basic information a) Name, age, sex, family relationship of all people residing in the household b) Family type, structure, roles, values c) Cultural associations, including norms and customs related to childbearing, childrearing, newborn/infant feeding d) Religious affiliations e) Support network f) Communication patterns g) Disabilities

II.

Cultural Influences Affecting the Family

A. Culture Characterized by Certain Key Elements 1. Shared values and beliefs 2. Is learned and dynamic 3. Is integrated into life and uses symbols 4. Race (a) Group of people who share biologic similarities such as skin color, bone structure, and genetic traits 5. Ethnicity a) A cultural group’s sense of identification associated with the group’s common social and cultural heritage b) Stereotyping: assuming all members of a group have the same characteristics 3 Copyright © 2020 Pearson Education, Inc.

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6. Acculturation a) Process of modifying one’s culture to fit within the new or dominant culture 7. Assimilation a) Related to acculturation; adopting and incorporating traits of the new culture within one’s practice b) Improved health status and health behaviors c) Health sometimes declines

B. Family Roles and Structure 1. Largely dependent on cultural influence 2. Family structure defines acceptable roles and behavior of family members 3. Culture defines gender roles, role of the elderly, and role of the extended family 4. Family goals determined by cultural values and practices, as are family member roles and childbearing and childrearing practices and beliefs

C. Health Beliefs, Approaches, and Practices 1. Incorporation of spirituality a) Health and illness determined by supernatural forces such as God, gods, magic, spirits, or fate b) Miscarriage or the illness of a pregnant woman may be perceived as a punishment for actions 2. Scientific or biomedical health paradigm d) Physiology explains all illness and life itself e) Biochemical reactions and genomic code explain all health states f) Approach often called “Western medicine” 3. Holistic health belief a) Illness results when the natural balance or harmony is disturbed b) Common in North American Indian and Asian cultures c) Hot and cold theory of disease d) See Table 2–2: Hot and Cold Conditions and Foods, p. 22

D. Healthcare Practitioners 1. Combination of spiritual, holistic, or biomedical healthcare providers 2. Folk healers vary according to the culture a) Hispanic Americans: curanderismo, sobador b) Latin America and the Caribbean: espiritistas describes a healer who communicates with spirits for the physical and emotional development of the patient c) Native Americans: shaman

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E. Impact of Religion and Spirituality 1. Diverse meanings of religion and spirituality 2. Religion → belief in or worshipping of a supernatural being or Supreme Being (such as God or Allah) 3. Spirituality → individual’s experience and own interpretation of his or her relationship with a Supreme Being 4. Religious beliefs, affiliations, practices → influence experiences, attitudes toward healthcare, childbearing, childrearing a) Belong to large institutionalized religious groups b) No formal affiliation c) Agnostic d) Atheist 5. Attempt to accommodate religious rituals, practices requested by family 6. Not unusual to encounter childbearing families with belief in conflict with own a) Nurse must respect family’s view and avoid being judgmental about their beliefs

F. Childbearing Practices 1. Families in the United States and Western countries commonly have only one or two children 2. In many cultures, it is common to have as many children as possible 3. In some cultures, a woman who gives birth attains a higher status, especially if child is male 4. Culture may influence attitudes and beliefs about contraception 5. Health values and beliefs important in understanding reactions and behavior 6. Individuals of many cultures take protective precautions based on their beliefs a) Taboo: behavior or thing that is to be avoided 7. In developing countries, mortality rates among infants and young children are extremely high a) Traditions focus on protecting baby from evil spirits

III.

Culture and Nursing Care

A. Without Cultural Awareness, Caregivers Tend to Project Their Own Cultural Responses 1. Ethnocentrism a) Conviction that the values and beliefs of one’s own cultural group are the best or only acceptable ones

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b) Inability to understand the beliefs and worldview of another culture 2. Culture shock a) Experience of attempting to understand or adapt to a culture fundamentally different from own culture 3. Cultural competence a) Ability to understand and effectively respond to the needs of individuals and families from different cultural backgrounds

B. Culturally Influenced Responses 1. Biologic differences a) Genetic and physical differences occur among cultural groups b) Can lead to disparity in needs and care c) Blood type, body build, skin color, drug metabolism, susceptibility to certain diseases d) Fundamental differences between genders, ages, and races 2. Communication patterns a) Members of cultural groups share information and preserve their beliefs, values, norms, and practices b) Essential families communicate with nurses and other healthcare providers c) Language can affect health literacy skills d) Translation services should be available in all healthcare settings e) Variations reflected in word meaning, voice inflection and quality, verbal styles f) Use of first names and surnames varies among cultural groups g) Address family members respectfully h) Nonverbal communication: body language such as posture, gestures, facial expressions, eye contact, and touch, use of silence (1) Eye contact has different meanings among different cultures (2) Silence considered sign of respect in some cultures (3) Appropriateness of touch varies with each culture (4) Sense of personal space differs by culture 3. Time orientation a) Cultures have specific values and meanings regarding time orientation b) Events of the past, events that occur in the present, events that will occur in the future c) Time refers to punctuality regarding schedules and appointments 4. Nutrition a) Nutritional habits and patterns vary among cultures; related to both religious practices and health beliefs b) Nutrition essential to culture’s practices for health promotion and care during illness

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C. Nursing Management for Providing Culturally Competent Care 1. Focus of nursing care is assessment of cultural influences on patient’s health a) Determining family’s cultural healthcare beliefs and practices b) See Table 2–3: Sample Cultural Assessment, p. 27 2. North American Nursing Diagnosis Association (NANDA) nursing diagnoses a) May be culturally biased b) Specific nursing diagnoses dependent on reason family seeks contact with healthcare professionals c) Apply culturally sensitive techniques when dispelling any cultural myths d) Collaborate with a multidisciplinary team

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IV.

Complementary Health Approaches and the Family A. Complementary Therapy 1. Procedure or product used as adjunct to conventional medical treatment 2. Acupuncture, acupressure, and massage therapy often used with conventional medical care 3. Many health insurance plans cover at least a portion of the cost

B. Integrative Health Approaches 1. Use of complementary and conventional medical techniques together in a coordinated manner 2. Used in the relief of pain, addressing side effects of drug therapies, cancer pain, health promotion

C. Alternative Therapy 1. Substance or procedure used in place of conventional medicine 2. Not usually available in conventional clinics and hospitals 3. Costs not typically covered under health insurance policies

D. Western Healthcare 1. Integration between conventional medicine and complementary therapies 2. National Center for Complementary and Integrative Health (NCCIH) 3. Complementary and alternative therapies must be assessed for safety, including positive and negative benefits, cost, efficacy, and clinical usefulness

E. Benefits and Risks 1. Many health benefits a) Health promotion, wellness, holistic healing vs. physical cure 2. Safety alert a) Complementary and alternative therapies must be assessed for safety.

(1) Positive and negative benefits, cost, efficacy, clinical usefulness b) Use of herbs and natural products (1) Issues regarding misleading claims and safety (2) Especially important for pregnant women

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F. Types of Complementary Health Approaches 1. Homeopathy: person treated with small doses of medicines that would cause illness when given to someone who is healthy 2. Naturopathy: utilizes healing forces of nature; referred to as natural medicine 3. Traditional Chinese medicine (TCM): seeks to ensure the balance of energy, called chi or qi a) Yin and yang, opposing internal and external forces that, together, represent the whole b) Acupuncture c) Acupressure (Chinese massage) d) Herbal therapy e) Qi gong f) T’ai chi g) Moxibustion 4. Mind-based therapies a) Biofeedback b) Hypnosis c) Visualization d) Guided imagery 5. Chiropractic a) Concepts of manipulation to address health problems thought to be result of abnormal nerve transmissions caused by misalignment of the spine 6. Massage therapy a) Manipulation of the soft tissues of the body to reduce stress and tension, increase circulation, diminish pain, and promote a sense of well-being b) Swedish massage, shiatsu massage, Rolfing, trigger point massage c) Techniques: pressing, kneading, gliding, circular motion, tapping, and vibrational strokes d) Most common recommended complementary therapy during the prenatal and intrapartum period 7. Herbal therapies a) Used since ancient times to treat illnesses and ailments b) Herbs categorized as dietary supplements and controlled by Dietary Supplement Health Education Act c) Do not require approval by Food and Drug Administration (FDA) d) Lists identifying common herbs women are advised to avoid or use with caution during pregnancy and lactation are available 8. Therapeutic touch a) Belief that people are a system of energy with a self-healing potential b) Healing promoted when the body’s energies are in balance c) Applied cautiously to pregnant women and newborns by trained providers

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9. Other types of complementary health approaches a) Ayurveda b) Meditation c) Craniosacral therapy d) Reflexology e) Hydrotherapy f) Hatha yoga g) Regular physical exercise h) Aromatherapy i) Color and light therapy j) Music and sound therapies k) Magnetic therapy l) Reiki

G. Nursing Care of the Family Using Complementary Therapies 1. Complementary and alternative medicine (CAM) used by 33.2% of adults and 11.6% of children in United States 2. Use of CAM in pregnancy: desire for normal birth and rewarding emotional birth experience 3. Nurses should use a nonjudgmental approach in assessing pregnant women and families for use of CAM 4. Nurses should use complementary modalities in the scope of their nursing practice and nursing practice act in their state 5. Nurses should document their use of CAM within the context of nursing practice 6. Nurses have a role in conducting and supporting research on CAM

V.

Focus Your Study

VI.

Activities 1. Individual Have students develop a family tree and identify the type of family to which they belong.

2. Small Group Divide the class into pairs. Have pairs of students interview each other and conduct a transcultural assessment.

3. Large Group Survey students about their families’ cultural and ethnic backgrounds. Discuss how the backgrounds may affect healthcare practices related to maternal–child nursing.

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Chapter 3 Health Promotion Community-Based Nursing Care……………………………………………………………………..

2

The Nurse’s Role in Addressing Issues of Women’s Wellness and Sexuality …..

2

Menstruation.......................................................................................................

3

Health Promotion Education................................................................................

7

Menopause...........................................................................................................

8

Focus Your Study..................................................................................................

14

Activities................................................................................................................

14

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I.

Community-Based Nursing Care

A. Women’s Health 1. Holistic view of women and health-related needs 2. Within context of everyday lives 3. Health teaching and information a) In schools b) During routine examinations c) At senior centers d) At meetings of volunteer organizations e) Through classes offered by local health department, community college f) In the home 4. Vast majority of women’s healthcare provided outside of acute care settings

II.

The Nurse’s Role in Addressing Issues of Women’s Wellness and Sexuality

A. Expectation for Nurse to Be Knowledgeable About Gynecologic Health and Wide Variety of Health Topics 1. Most women experience concern, anxiety about some aspect a) Menstruation, contraception, or sexual activity b) Adolescents and young adults c) Older women 2. Nurse must be secure in own sexuality a) Structures, functions of reproductive systems b) Accurate, up-to-date information

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B. Taking a Sexual History 1. Open sexual history discussion with brief explanation of purpose of questions 2. Use direct eye contact, if culturally acceptable 3. Little writing during this part of interview 4. Open-ended questions 5. Be alert to body language, nonverbal cues 6. Do not assume woman is heterosexual 7. Assess information a) Concerns → refer to nurse practitioner, certified nurse-midwife, physician, counselor as necessary b) Develop nursing diagnosis → plan and implement appropriate intervention

III.

Menstruation

A. Education of Girls About Puberty, Menstruation at Young Age 1. Some education from peers, media → incomplete, inaccurate, sensationalized 2. Cultural, religious, personal attitudes part of menstrual experience

B. Counseling the Premenstrual Girl About Menarche 1. Average age is about 12.43 years for girls in United States a) Range between 9 and 15 years of age b) Genetics most important factor in determining age at which menarche starts c) Series of physical changes prior to menarche 2. Cycle length a) Determined from first day of one menses to first day of next b) May be irregular c) Usually about 28 to 30 days, normal varies from 21 to 35 days 3. Amount of flow a) Approximately 25 to 60 mL per period b) Often heavier at first, lighter at end 4. Length of menses a) Usually lasts from 4 to 6 days, may last up to 7 days

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5. Nurse should stress variations in age at menarche, length of cycle, and duration of menses are normal, acknowledge negative aspects and stress positive role as symbol of maturity 6. Cultural factors may play important role in menstruation

C. Educational Topics 1. Pads and tampons a) Variety of disposable products available b) Deodorants and increased absorbency from chemicals → irritation to mucosal lining c) Eco-friendly menstrual products → reusable pads, cups, sponges d) Determine amount of bleeding → frequency and type of pad or tampon use and change e) Use tampons with minimum absorbency needed to control menstrual flow to avoid complications such as toxic shock syndrome (TSS) f) Change every 3 to 6 hours g) Hand hygiene before and after insertion and removal h) Avoid using tampons in the absence of a heavy menstrual flow i) May want to use tampons during day and pads at night j) Individual need and comfort 2. Vaginal sprays and douching a) Sprays can cause itching, burning, rashes, other problems; external use only b) Douching as hygiene practice unnecessary (1) Upsets normal vaginal flora (2) Essential to avoid douching during menstruation (3) Contraindicated during pregnancy 3. Cleansing the perineum a) Secretions that continually bathe vagina odor-free in vagina b) Combined with perspiration and air → develop odor c) Keep skin clean and free of bacteria with soap and water d) Cotton panties and clothes loose enough to allow air to circulate e) Wipe from front to back f) If odor persists, see healthcare provider

D. Associated Menstrual Conditions 1. Abnormal uterine bleeding (AUB) 2. Heavy menstrual bleeding (HMB) 3. Intermenstrual bleeding (IMB) 4. Polymenorrhea 5. Oligomenorrhea 6. Amenorrhea a) Absence of menses 4 Copyright © 2020 Pearson Education, Inc.

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b) Classified as primary or secondary c) Causes (1) Hypothalamic dysfunction (2) Pituitary dysfunction (3) Chronic anovulation or ovarian failure (4) Anatomic abnormalities d) Diagnosis (1) Thorough history and physical examination (2) Pregnancy test (3) Pelvic exam (4) Specific tests e) Treatment dictated by causative factors 7. Dysmenorrhea a) Painful menstruation b) At or day before onset of menstruation, disappears by end of menses c) Primary defined as cramps without underlying disease (1) Prostaglandins primary cause (2) Treatment: oral contraceptives, NSAIDs, self-care measures d) Secondary: associated with pathology of reproductive tract (1) Endometriosis, pelvic inflammatory disease (PID), cervical stenosis, uterine fibroids, ovarian cysts, benign or malignant tumors, presence of intrauterine device (IUD) (2) Testing: transvaginal ultrasound, hysterosalpingography, and hysteroscopy (3) Treatment: (a) Continuous OC therapy—does not allow ovulation or menstruation (b) Hysterectomy if anatomic disorders, childbearing not desired (c) Presacral neurectomy may control severe dysmenorrhea (4) Self-care measures (a) Some nutritionists suggest vitamins B6 and E, avoiding salt (b) Heat—soothing, promotes increased blood flow (c) Daily exercise, especially aerobic 8. Premenstrual syndrome (PMS) a) Symptom complex characterized by behavioral and physical changes b) Several days to 2 weeks before onset of menstrual flow c) Diagnosis when woman experiences one to three troublesome symptoms 9. Premenstrual dysphoric disorder (PMDD) a) More serious form of PMS b) Depressive disorder c) Relieved by menstruation, occurs in most cycles d) Symptoms (1) Psychologic (2) Neurologic (3) Respiratory 5 Copyright © 2020 Pearson Education, Inc.

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(4) Gastrointestinal (5) Urinary (6) Dermatologic (7) Mammary (8) Musculoskeletal e) Cause unknown f) Evidence suggests progesterone, estradiol levels involved g) May include abnormal sensitivity to hormonal changes h) Risk factors i) Diagnosis generally made after woman keeps menstrual calendar for 3 months j) Daily symptoms rated on scale of 0 to 4 k) Treatment: selective serotonin reuptake inhibitor (SSRI) may benefit woman with PMDD

E. Nursing Management for the Woman with PMS 1. Help woman identify specific symptoms, develop healthy behaviors 2. Restrict intake of foods containing methylxanthines (chocolate, cola, coffee) 3. Restrict intake of alcohol, nicotine, red meat, animal fats, sugar, salt 4. Increase intake of complex carbohydrates, protein, vegetable oils 5. Supplementation a) 50 to100 mg daily of vitamin B6 b) 1,200 mg per day of calcium → may reduce physical, psychologic symptoms c) 400 mg magnesium → may decrease fluid retention, bloating d) Vitamin E 400 IU daily → may reduce cramping, breast tenderness

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6. Herbal remedies 7. Aerobic exercises 8. Empathetic relationship 9. Journal to identify events associated with PMS 10. Stress reduction education, self-care groups, self-help literature

IV.

Health Promotion Education A. Value of health maintenance and disease prevention B. Lifestyle choices that promote health and well-being 1. Eating nutritious, balanced diet 2. Maintaining normal weight for height 3. Performing regular aerobic exercise and weight training several times per week 4. Getting adequate sleep 5. Avoiding smoking and/or stopping smoking 6. Consuming alcohol in moderation 7. Managing stress effectively 8. Developing enjoyable hobbies and leisure activities 9. Developing an inner life in some form (religion, spirituality, personal reflection, yoga) 10. Fostering bonds of support and affection with family and friends 11. Obtaining regular health screenings and assessments 12. Ensuring that immunizations are up to date 13. Health screening recommendations vary by age, as do recommendations for vaccines 14. See Table 3-2: Recommended Screening Tests for Low-Risk Women, p. 41–42

C. Body piercings and tattoos 1. Tattooing → application of minute amounts of pigments into skin with indelible inks 2. Body piercing sites → multiple 3. Health risks a) Infection such as hepatitis B, C, and HIV b) Allergic reactions c) Local swelling, burns, granuloma, keloid formation 7 Copyright © 2020 Pearson Education, Inc.

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d) Oral piercing associated with tooth and gum damage 4. Pregnant or breastfeeding → nipple piercing associated with mastitis, damaged milk ducts, difficulty with breastfeeding, galactorrhea

D. Education about risks 1. Information about infection, permanent scarring, keloid formation, care afterward 2. Avoid passing judgment, making generalizations

V.

Menopause A. Definition: absence of menstruation for 1 full year 1. Time of transition 2. End of reproductive abilities 3. Occurs between 45 and 58 years of age 4. Not all physiologic mechanisms initiating menopause precisely understood 5. Onset occurs when estrogen levels drop because of cessation of ovarian function 6. Onset influenced by: woman’s overall health, weight, nutrition, lifestyle, culture, genetic factors 7. Climacteric, or change of life: host of psychologic and physical alterations that occur around the time of menopause

B. Perimenopause 1. Time before menopause during which woman moves from normal ovulatory cycles to cessation of menses 2. Can last 5 to 8 years 3. Symptoms vary significantly a) 80% of women report some degree of vasomotor symptoms (hot flashes) b) Mood and cognitive changes common c) Changes in sexuality 4. Contraception remains a concern a) Fertility decreases, risk of spontaneous abortion increases b) Female sterilization most commonly used method among women older than 35 c) Hormonal contraceptives continue to be popular; noncontraceptive benefits d) Other contraceptive options

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5. Exercise, calcium, vitamin D may help

C. Psychologic Aspects of Menopause 1. Psychologic adaptation to menopause multifactorial a) Dealing with other life circumstances b) Personal factors c) Stressors 2. Help women to understand the basic physiology of menopause and provide education, supportive resources, and encouragement 3. Help women understand changes, deal with feelings 4. Alert for signs that distinguish hormonal mood swings and depression

D. Physical Aspects of Menopause 1. Changes in the reproductive system a) Shift from cyclic to noncyclic hormonal pattern b) Ovulation generally ceases 1 to 2 years before menopause c) Estrogen levels decline → physiologic changes (1) Uterine lining thins (2) Myometrium, fallopian tubes, ovaries atrophy (3) Vaginal mucosa loses elasticity, thins (4) Loss of cervical gland function (5) Change in vaginal ecology → atrophic vaginitis (6) Pubic hair thins, grays, may disappear (7) Labia shrink, lose pigmentation (8) Loss of pelvic tone and support; Kegel exercise, regular sexual activity (9) Breasts lose density d) Sexual functioning declines 2. Vasomotor changes a) Hot flash → typically described as feeling of heat rising from chest, spreading to neck, face b) Night sweats c) May occur 20 to 30 times a day 3. Changes in the musculoskeletal system and skin a) Osteoporosis → decrease in bone strength related to diminished bone density and bone quality b) See Table 3–3: Risk Factors for Osteoporosis, p. 45 (1) Personal history of fracture after age 50 (2) Current low bone mass (3) History of fracture in a first-degree relative (4) Being female

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(5) Being thin (weight less than 127 lb and/or having a small frame) (6) Advanced age (7) Family history of osteoporosis, especially a maternal hip fracture (8) Use of certain medications (e.g., corticosteroids, chemotherapy, barbiturates, anticonvulsants) (9) Abnormal absence of menses; early onset of menopause (10) Anorexia nervosa (11) Low lifetime intake of calcium (12) Vitamin D deficiency (13) Current cigarette smoking, excessive alcohol use (14) Inactive lifestyle (15) Being Caucasian or Asian c) Collagen and elastin weaken → skin appears looser, thinner, wrinkles (1) Nurses can remind women to wear sunscreen d) Evidence suggests estrogen regulates weight, fat metabolism (1) Change in fat distribution (2) Total body fat increases (3) Calculate waist to hip ratio → less than 0.80 4. Changes in the cardiovascular system a) Shift in lipid and lipoprotein levels b) Normal estrogen level → higher levels of high-density lipoprotein (HDL) cholesterol c) Lower levels of low-density lipoprotein (LDL) cholesterol d) Cardiovascular disease (CVD) number one killer of women in United States e) Coronary heart disease (CHD) major cause of heart attacks in women f) See Table 3–4: Risk Factors for Coronary Heart Disease in Women, p. 45 (1) Family history of heart disease (2) Advancing age—over 55 or postmenopausal (3) Overweight and obesity (4) Cigarette smoking and/or tobacco use (5) Sedentary lifestyle (6) Hypertension (7) Diabetes (8) Elevated cholesterol (9) Race (highest incidence in African American women) g) Metabolic syndrome predisposing factor for CHD, individual has three or more of the findings: (1) Waist > 35 inches (2) Triglycerides > 150 mg/dL (3) HDL < 50 mg/dL (4) BP > 130/85 mmHg (5) Fasting glucose levels > 100 mg/dL 5. Changes in cognitive function a) Memory, cognitive function change with advancing age 10 Copyright © 2020 Pearson Education, Inc.

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b) Declining estrogen might contribute to loss of function c) Change influenced by lifestyle, genetics, socioeconomic status d) Cause of Alzheimer disease (AD) unknown; risk factors include: (1) Specific genotypes (2) Family history (3) Obesity (4) Diabetes (5) Elevated cholesterol (6) Hypertension (7) Inflammation e) No therapies that slow the progression of the disease f) Cholinesterase inhibitors and N-methyl-D-aspartate antagonists only medications approved by FDA for treating cognitive dysfunction g) Lifestyle changes (1) Exercise at least 30 minutes 5 days per week.

(2) Quit smoking.

(3) Maintain a healthy blood pressure.

(4) Maintain a normal weight.

(5) Eat a healthy diet; research shows Mediterranean or DASH is best.

(6) Stay mentally active with writing, playing games, reading, or learning something new.

(7) Get enough sleep.

(8) Stay socially engaged.

(9) Prevent diabetes.

(10) Deal with depression, anxiety, and other mental health concerns.

E. Premature Menopause 1. Premature ovarian insufficiency (POI) 2. Occurs in about 0.1% of women by the age of 30 and 1% of women by the age of 40 3. 4 to 6 months of no menses in women under the age of 40 years who have elevated FSH and low estradiol levels 4. Retain intermittent ovarian function; although difficult, pregnancy may occur 5. Long-term health a consideration; strengthen muscle and maintain bone mass

F. Medical Therapy 1. Menopausal hormone therapy a) Menopausal hormone therapy (MHT) → administration of specific hormones to alleviate symptoms b) Estrogen therapy (ET): only given to women who have undergone a hysterectomy c) Estrogen-progestogen therapy (EPT): used for women with intact uterus

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d) ET never given alone to woman with uterus because it increases risk of endometrial cancer e) Prescribed orally; transdermally (patch); topically as a gel, lotion, mist, or cream; and through a vaginal ring (1) Daily or cyclic (2) Women with decreased libido experience improvement with testosterone added to HT f) MHT remains the most effective therapy for moderate to severe menopausal vasomotor symptoms g) Decision to use MHT is individual one based on quality of life, health priorities, and personal risk factors h) Local low-dose vaginal estrogen recommended to treat vaginal dryness or dyspareunia i) MHT effective for the prevention of fractures related to osteoporosis in women who are at risk before age 60 or within 10 years of menopause j) Risk of venous thromboembolism and stroke does increase with MHT, but absolute risk is rare in women younger than age 60 k) The risk of breast cancer is complex; MHT should not be used in breast cancer survivors l) Estrogen-alone MHT may decrease coronary heart disease in women younger than age 60 and within 10 years of menopause 2. Bioidentical hormones → structurally identical to those produced by ovaries a) Not proven safer b) Not approved by FDA c) Use is not recommended 3. Prevention and treatment of osteoporosis a) More than 54 million adults have osteoporosis and low bone mass b) Bone mineral density (BMD) testing useful in identifying those at risk c) BMD testing of all women ages 65 and older and all men ages 70 and older d) Diagnosis and treatment of osteoporosis based on comprehensive approach e) BMD testing indicated for premenopausal or postmenopausal women with risk factors, certain medical conditions, certain medications (1) Eating disorders (2) Thyroid disorders (3) Leukemia (4) Rheumatoid arthritis (5) Multiple sclerosis (6) On medications such as corticosteroids, anticonvulsants f) Measure height at each visit g) Prevention of osteoporosis primary goal (1) Adequate intake of calcium and vitamin D (2) Regular weight-bearing, muscle-strengthening exercises (3) Smoking cessation (4) Moderate intake of alcohol (5) Fall-prevention strategies 12 Copyright © 2020 Pearson Education, Inc.

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(6) 1,200 mg of calcium, increasing to 1,500 mg if patient is not on hormone therapy (7) Vitamin D supplement of 1,000 to 2,000 international units per day h) For women who are unable or unwilling to take estrogen, other medications are available (1) Bisphosphonates are calcium regulators (2) Selective estrogen receptor modulators (SERMs) preserve the beneficial effects of estrogen (3) Salmon calcitonin is a calcium regulator (4) Parathyroid hormone activates bone formation (5) Receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor decreases bone resorption and increases bone mass and strength 4. Prevention of coronary heart disease a) Cardiovascular disease (CVD) leading cause of death in women in United States b) Prevention begins with lifestyle choices, modifications c) Women need to be familiar with signs of myocardial infarction (1) Pain in neck, back, epigastric region (2) Loss of appetite (3) Shortness of breath (4) Nausea or vomiting (5) Weakness in shoulder, arms, chest (6) Women more likely than men to delay seeking treatment and more likely to die from attack 5. Complementary and alternative therapies a) Black cohosh → mixed results, liver safety issues b) Red clover → no effect on hot flashes e) Ginseng → may help moodiness, sleep disturbances c) DHEA: dietary supplement that may help with hot flashes, further research needed d) Phytoestrogens → plant products, inconsistent results e) Weight-bearing exercises → increase bone mass, potentiating effect of estrogen (1) Improves cholesterol profiles, overall health f) Pelvic floor exercises (Kegel) g) Vaginal lubricants, adequate foreplay → maintain satisfactory sexual experience h) Stress management and relaxation techniques

G. Nursing Management for the Woman Experiencing Menopause 1. Some women may need counseling 2. Help menopausal woman achieve high-level functioning a) Provide support for woman’s views and feelings (1) Discuss areas of deep concern, including history of abuse, current distress, life problems (2) Referrals as necessary (3) Explore question of woman’s comfort during sexual intercourse 13 Copyright © 2020 Pearson Education, Inc.

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(4) Explain ways to address dryness, shrinking of vagina 3. Adequate information about changes taking place in their bodies and their lives and support in adjusting to the changes that occur

VI.

Focus Your Study

VII.

Activities 1. Individual Assign students to identify three lifestyle choices they consider healthy in their lives. Have students research the effects of their choices on long-term women’s health.

2. Small Group Divide the class into small groups of three to five students. Assign each group a topic to research in complementary health approaches and women’s health. The rubric should include identifying the effects of supplements on women’s health. Instruct the groups to substantiate their reports with APA-formatted citations and to be prepared to share their reports with the entire class.

3. Large Group Using 35-, 50-, and 60-year-old women as examples, discuss and role-play taking a reproductive history.

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Chapter 4 Family Planning Overview of Family Planning............................................................................

2

Fertility Awareness–Based Methods...............................................................

3

Spermicide........................................................................................................

5

Barrier Methods of Contraception...................................................................

6

Long-Acting Reversible Contraception.............…………………………………………….

9

Hormonal Contraception..................................................................................

10

Postcoital Emergency Contraception...............................................................

14

Operative Sterilization......................................................................................

14

Male Contraception..........................................................................................

15

Clinical Interruption of Pregnancy....................................................................

16

Preconception Counseling……………………………………………………………………………

17

Focus Your Study...............................................................................................

18

Activities............................................................................................................

18

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

Overview of Family Planning

A. Demographics 1. In 2014 → more than 20 million women in United States of reproductive age were at risk for unintended pregnancies due to unmet contraceptive needs 2. 45% of all U.S. pregnancies unintended a) In 2011, 42% of 6.1 million pregnancies ended in abortion 3. Millions of women in United States in need of contraceptive services a) Affordable Care Act requires insurance companies to cover contraception as a preventive health measure b) Some organizations have a religious exemption from this requirement c) Millions of women remain in need of publicly funded contraceptive care (Medicaid) 4. Of reproductive-age women living in developing countries, 225 million have unmet modern contraceptive needs a) Maternal morbidity and mortality remain major health challenges b) 99% of preventable maternal deaths occur in the poorest countries with unmet contraceptive needs c) Of these preventable deaths, more than half are from sub-Saharan Africa d) Lack of contraceptive services in developing countries

B. Contraception 1. Women who are able to use contraception and plan the desired number of pregnancies benefit in several ways a) Healthier with lower incidence of sexually transmitted infections, including HIV b) Lower rates of induced, often unsafe, abortions c) Fewer unwanted pregnancies and births d) Better educated Children healthier and better educated

C. Choosing a Method of Contraception 1. Decision made individually or jointly 2. Leading methods in United States a) Combined oral contraceptive (COC) pill for women younger than 35 years b) Sterilization in women older than 35 years c) Use of male condom to prevent STIs 3. Decisions should be made voluntarily with full knowledge a) Outside factors influence choice b) Consistency of use outweighs absolute reliability

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4. See Table 4–1: Factors to Consider in Choosing a Method of Contraception, p. 53 a) Effectiveness of method b) Safety of method c) Woman’s age and future childbearing plans d) Contraindications in health history e) Religious, cultural, or moral factors f) Personal preferences, biases g) Lifestyle of patient h) Cost i) Partner’s support, willingness to cooperate j) Personal motivation to use method k) Woman’s weight in pounds or percent over ideal body weight

II.

Fertility Awareness–Based Methods

A. FAB Methods 1. Require a woman to monitor her fertile window and use a barrier method during that time 2. Most fertile 5 days before ovulation until 1 day post-ovulation 3. Natural family planning (NFP) → abstain completely during fertile days a) Free, safe, acceptable to many whose religious beliefs prohibit other methods 4. All FAB methods, including NFP, require extensive initial counseling a) Best for women with regular menstrual cycles b) Interfere with spontaneity c) Not ideal for those with irregular cycles, breastfeeding, perimenopause

B. Standard Days Method 1. Good for women with regular menstrual cycles between 26 and 32 days a) Intercourse avoided, or a barrier method used, during cycle days 8 through 19 b) CycleBeads® or its software program is useful when using this method

C. Calendar Rhythm Method 1. Assumption ovulation tends to occur 14 days (plus or minus 2 days) before start of next menstrual period a) Woman records her menstrual cycle for 6 months to identify shortest and longest cycles b) First day of menstruation is first day of cycle c) Fertile phase calculated from 18 days before end of shortest recorded cycle through 11 days from end of longest recorded cycle d) For effective use, she must abstain from intercourse during fertile phase or use barrier method during that time

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D. Billings Ovulation Method 1. Assessment of cervical changes that occur during menstrual cycle 2. During follicular phase of cycle → mucus is nonmalodorous, thick, white, sticky 3. At ovulation → mucus more clear, water, stretchable (spinnbarkeit) a) Friendly to sperm b) Characteristic fern pattern 4. Luteal phase → cervical mucus thick, white, and sticky a) Forms network that traps sperm b) Makes passage upward into female reproductive tract difficult 5. Woman abstains from intercourse for one entire menstrual cycle a) Assess cervical mucus daily b) Assumes that peak day of wetness and clear stretchable mucus is day of ovulation c) Abstain from first noticing mucus becoming clearer, more elastic, slippery until 4 days after peak wet mucus

E. Two-Day Method 1. Woman’s ability to distinguish difference between progesterone-mediated and estrogenmediated cervical mucus 2. If she notices cervical secretions of any type either yesterday or today, she is fertile today 3. If no secretions were noted today or yesterday, she is not fertile today

F. Symptothermal Method 1. Recording various indicators of fertility by the couple for a number of months a) Cycle length b) Frequency and timing of coitus c) Cervical mucus changes d) Secondary signs of ovulation e) Changes in basal body temperature (BBT)

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2. Training courses available

G. Basal Body Temperature Method 1. Incorporated into symptothermal method 2. Provides objective record of fertile days 3. Used to detect ovulation by an increase in the basal temperature during the menstrual cycle 4. Requires the woman to take her temperature every morning upon awakening 5. After 3 to 4 months of recording temperatures, if she has regular cycles, she should be able to predict when ovulation will occur 6. To avoid conception, the woman and her partner abstain from intercourse or use a barrier method on the day of the temperature rise and for 3 days following

H. Other Options 1. Lactational amenorrhea method (LAM) a) Breastfeeding woman for first 6 months after childbirth b) High levels of prolactin should prevent ovulation c) Most reliable when used with a barrier method 2. Abstinence a) Primary → woman who has never had sexual intercourse b) Secondary → woman chooses to abstain for a period of time 3. Coitus interruptus a) Requires that male withdraw from female’s vagina when he feels ejaculation is impending b) Demands great self-control on part of man c) Man may not be aware he has released pre-ejaculatory fluid 4. Douching a) Ineffective, not recommended b) May facilitate conception

III.

Spermicide

A. Nonoxynol-9 (N-9) Approved for Use in United States 1. Cream, gel, foam, vaginal film, suppository, cervical sponge 2. N-9 minimally effective alone → increases in conjunction with barrier method of contraception a) Diaphragm b) Cervical cap c) Male and female condoms 5 Copyright © 2020 Pearson Education, Inc.

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3. Does not offer protection against STIs

IV.

Barrier Methods of Contraception A. Prevent Transport of Sperm Up Reproductive Tract of Woman to Ovum 1. Male and female condom, diaphragm, cervical cap, cervical sponge 2. Made of latex, silicone, or polyurethane 3. Often used in conjunction with N-9 to increase contraceptive effectiveness 4. Proactively decide which type to use and then take action 5. Few side effects 6. Good choice for women who: a) Have contraindication to using specific method such as oral contraceptives, combined oral contraceptives (COCs), intrauterine contraception (IUCs) b) Are opposed to taking systemic medications c) Are in early postpartum period or lactating d) Need backup method of contraception e) Have intercourse rarely or sporadically f) Are perimenopausal but smokes 7. Before insertion, wash hands with soap and water 8. Avoid oil-based products, vaginal medications → negative effect on latex 9. Can be worn for up to 24 or 48 hours 10. Cleaned with soap and water after use 11. Not shared with other women 12. After intercourse, should remain in place for 6 to 8 hours 13. Female barrier methods more effective when used with male condom 14. Be alert for signs of toxic shock syndrome (TSS)

B. Male Condom 1. Viable means of contraception when used consistently and properly 2. Provide protection from STIs 3. Condom applied to erect penis → rolled from tip to end of shaft a) Before vulvar or vaginal contact b) Most have reservoir at end for ejaculate

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4. Water-soluble lubricants only 5. Remove penis from vagina while still erect, holding condom rim to prevent spillage 6. Effectiveness determined by use a) Small, lightweight, disposable, inexpensive b) No side effects c) Polyurethane, silicone, lambskin condoms for men allergic to latex d) Require no medical examination or supervision e) Visual evidence of effectiveness f) Decrease transmission of STIs 7. Slippage, risk of breakage, perineal or vaginal irritation, dulled sensation disadvantages

C. Female Condom 1. Thin polyurethane sheath with flexible ring at each end a) Closed end with inner ring fits over cervix like diaphragm b) Second ring remains outside vagina, covers portion of perineum c) Covers base of penis during intercourse 2. OTC, one-time use a) High cost, noisy, cumbersome feel

D. Diaphragm 1. Barrier method that consists of steel band that forms ring a) Covered with latex or silicone b) Ring lodges high in vagina covering cervix c) Used with spermicidal cream or gel 2. Three types available a) Wide-Seal Omniflex b) Arcing-Style c) Caya → only type that does not require a fitting 3. Woman must be fitted by healthcare provider and rechecked for size with weight gain/loss 4. Inserted before intercourse, approximately 1 teaspoonful of spermicidal gel placed around ring and in cup a) Inserted through vagina and covers cervix b) Last step in insertion is to push edge of diaphragm under pubic symphysis → may result in popping sensation c) Correct placement of diaphragm can be checked by touching cervix with fingertip through cup

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5. More than 6 hours elapse between insertion and intercourse → additional spermicidal gel inserted into vagina 6. Periodically diaphragm should be held up to light or filled with water a) Inspect for holes, tears b) Can last for years c) Wash and dry after each use → store in clean dry container 7. Some couples feel diaphragm interferes with spontaneity a) Potentially reduces incidence of cervical gonorrhea, chlamydia b) Protects against human papilloma virus (HPV) 8. Woman has to touch genitals to insert and check a) Very obese, short fingers → difficulty b) Not recommended for history of urinary tract infection (UTI)

E. The Cervical Cap 1. Used with a spermicide inside the cap 2. Placement requires it be inserted prior to coitus and left in for 6 to 8 hours afterward 3. Should not remain in the vagina longer than 48 hours due to risk of TSS 4. FemCap cervical cap: reusable, looks like a small sailor’s cap, made of soft silicone

F. Contraceptive Sponge 1. Available without a prescription 2. Pillow-shaped, soft, absorbent synthetic sponge containing spermicide 3. Designed to fit over cervix 4. Releases spermicide N-9 (gradually over 24-hour period) 5. Moisten before use to activate spermicide → insert into vagina 6. Worn up to 24 hours 7. Advantages a) Professional fitting not required b) May be used for multiple acts of coitus for up to 24 hours c) One size fits all 8. Problems a) Difficulty removing b) Irritation, allergic reactions c) Vaginal dryness due to absorption of vaginal secretions d) Higher failure rate than diaphragm for women who have borne children

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V.

Long-Acting Reversible Contraception A. Intrauterine Contraception 1. Designed to be inserted by qualified healthcare provider, left in place 2. Provides continuous contraceptive protection for 3 to 10 years 3. Copper IUC (ParaGard T 380A) a) Small, T-shaped device that has copper covering parts of its stem and arms b) Not an option for women allergic to copper c) Choice for women who have medical conditions that preclude use of other contraceptives, hormonal or barrier d) Effective contraception for 10 years 4. Mirena levonorgestrel intrauterine system (LNg-IUC) a) 5 years of protection b) Progestin-only 5. The Skyla LNg-IUC a) Total of 13.5 mg of levonorgestrel b) 3-year indication c) Progestin-only 6. Copper IUC local inflammatory or atrophic effects on endometrium 7. All IUC produces a spermicidal intrauterine environment 8. Advantages a) High rate of effectiveness b) Continuous contraceptive protection c) Non-coitus-related contraception d) Relative inexpensiveness over time e) Excellent contraceptive option for women with diabetes f) Used in women with history of breast cancer, cesarean birth, or uterine or cervical surgery 9. Adverse reactions a) Discomfort b) Increased bleeding during menses c) Increased risk of pelvic infections for approximately 3 weeks following insertion d) Perforation of uterus during insertion e) Unscheduled bleeding f) Dysmenorrhea g) Expulsion of device 10. Contraindications a) Current pregnancy 9 Copyright © 2020 Pearson Education, Inc.

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b) Caution woman to use condom in addition if multiple sex partners → STI 11. Insertion a) Into uterus with strings protruding through cervix into vagina b) Any time during cycle c) Instructed to check strings weekly for 1 month → after each menses 12. Contact healthcare provider a) If exposed to STI b) Late period, abnormal spotting or bleeding c) Dyspareunia d) Abdominal pain e) Abnormal discharge f) Signs of infection g) Missing strings, lengthening of strings

B. Nexplanon 1. Replaced Implanon 2. Radiopaque, single-capsule implant inserted subdermally in woman’s upper underarm 3. 68 mg of etonogestrel, a progestin; releases up to 45 mcg the first year, 40 mcg the second year, and 20 mcg the third year 4. Good contraceptive method for 3 years 5. Prevents ovulation 6. Effective continuous contraception removed from the act of coitus 7. Side effects: spotting, irregular bleeding or amenorrhea, increased incidence of ovarian cysts, weight gain, headaches, fluid retention, acne, hair loss, mood changes, depression

VI.

Hormonal Contraception

A. Combination Estrogen–Progestin Approaches 1. Inhibit release of an ovum, creating atrophic endometrium 2. Maintaining thick cervical mucus 3. Limit participants to those weighing less than or equal to 198 pounds 4. Combined oral contraceptives a) Commonly called birth control pills or “the pill” b) Highly successful, safe, readily reversible c) Taken daily for 21, 28, or 84 days d) Day 1 start → begins taking pill on first day of menstrual cycle; no backup contraception required 10 Copyright © 2020 Pearson Education, Inc.

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e) Sunday start → begins taking pill on Sunday after first day of menstrual cycle and ends packet on a Saturday; backup contraception necessary during first 7 days of use f) Quick start → begins taking pill in practitioner’s office; backup method necessary for 7 days g) 21- or 28-day COC pack—always begin new pack on the same day h) Pill taken at approximately same time each day i) Extended use COCs: four withdrawal bleeds per year or no withdrawal bleeding at all j) Estrogen → either ethinyl estradiol (EE) or mestranol (1) Originally high levels of estrogen → risks (2) Lowered estrogen component → decreased risk k) Progestins → 10 formulations (1) Inhibit ovulation l) Low-dose pills (1) Safe, safer if smokers did not take them (2) Weaker cycle control → breakthrough bleeding (3) Side effects → estrogen or progestin related m) See Table 4–2: Side Effects Associated with Combined Oral Contraceptives, p. 64 (1) Estrogen effects (a) Alterations in lipid metabolism (b) Breast tenderness, engorgement, increased breast size (c) Cerebrovascular accident (d) Changes in carbohydrate metabolism (e) Chloasma (f) Fluid retention; cyclic weight gain (g) Headache (h) Hepatic adenoma (i) Hypertension (j) Leukorrhea, cervical erosion, ectropion (k) Nausea (l) Nervousness, irritability (m) Thromboembolic complications (2) Progestin effects (a) Acne, oily skin (b) Breast tenderness; increased breast size (c) Decreased libido (d) Decreased high-density lipoprotein (HDL) cholesterol levels (e) Depression (f) Fatigue (g) Hirsutism (h) Increased appetite; weight gain (i) Increased low-density lipoprotein (LDL) cholesterol levels (j) Oligomenorrhea, amenorrhea (k) Pruritus (l) Sebaceous cysts 11 Copyright © 2020 Pearson Education, Inc.

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n) Absolute contraindications (1) Pregnancy (2) History of thrombophlebitis, thromboembolic disease (3) Acute or chronic liver disease of cholestatic type with abnormal liver function tests (4) Presence of estrogen-dependent carcinomas (5) Undiagnosed uterine bleeding (6) Heavy smoking (7) Gallbladder disease (8) Hypertension (9) Diabetes (10) Migraine with visual disturbances (11) Hypercoagulable disorders (12) Hyperlipidemia o) Relative contraindications (1) Migraine headaches without visual disturbances (2) Epilepsy (3) Depression (4) Oligomenorrhea (5) Amenorrhea p) Noncontraceptive benefits (1) Relief of menstrual symptoms and premenstrual syndrome (2) Cramps diminish (3) Flow decreases (4) Cycle more regular (5) Mittelschmerz is eliminated (6) Reduction in incidence of ovarian, endometrial, and colorectal cancer; menstrual migraines; iron deficiency anemia (7) Improvement in bone mineral density (8) Treatment of acne, hirsutism (9) Treatment of pelvic pain due to endometriosis (10) Treatment of bleeding due to leiomyomas (11) Assists with some physiologic changes experienced by women during perimenopause q) Patient contacts healthcare provider (1) Becomes depressed (2) Develops breast lump (3) Becomes jaundiced (4) Abdominal or leg pain, severe (5) Chest pain, severe, or shortness of breath (6) Headaches, severe, or dizziness (7) Eye vision loss or blurring (8) Speech problems

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5. Transdermal hormonal contraception a) Weekly contraceptive skin patch → Xulane b) Applied weekly for 3 weeks to one of four sites c) During week 4 → no patch → menses typically occurs d) Highly effective in women who weigh less than 198 lbs. e) Patch as safe and effective as COCs f) Risk of venous thromboembolism (VTE) 6. Vaginal contraceptive ring a) NuvaRing → flexible, soft vaginal ring inserted for 3 weeks and removed for 7 days b) Fits virtually all women

B. Progestin Contraceptives 1. Progestin-only pills a) Also called minipill b) Primarily by nursing mothers → does not interfere with breast milk production c) Women who have contraindication to estrogen component d) Major problems: amenorrhea or irregular bleeding patterns e) Slightly less effective than a COC 2. Long-acting progestin contraceptives a) Depo-Provera and Nexplanon b) Lactating women c) Women who cannot use estrogen or copper IUC d) Women who forget to take COCs daily e) Those not bothered by unscheduled bleeding f) Depo-Provera (1) Long acting, injectable, progestin only (2) Intramuscular (im) or subcutaneous (sc) (3) Effective birth control for 3 months (4) Subsequent injections scheduled every 10 to 13 weeks (5) SC can be self-administered (6) Suppresses ovulation (7) Safe, convenient, private, and relatively inexpensive (8) Blocks luteinizing hormone (LH) → suppress ovulation g) Side effects (1) Unscheduled bleeding (2) Headache (3) Weight gain (4) Breast tenderness (5) Hair loss (6) Depression (7) Return of fertility delayed average of 10 months (8) Associated with bone demineralization → is reversible 13 Copyright © 2020 Pearson Education, Inc.

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VII.

Postcoital Emergency Contraception 1. Once known as the morning after-pill 2. Indicated when woman is worried about pregnancy because of unprotected intercourse, sexual assault, or possible contraceptive failure 3. Taken 72 hours, but up to 5 days, can reduce risk of pregnancy after single act of unprotected intercourse by at least 74% 4. High doses of levonorgestrel and ethinyl estradiol (Yuzpe regimen) 5. High doses of levonorgestrel (Plan B®, Plan B One-Step®) 6. Ulipristal acetate, a progesterone agonist-antagonist 7. Placement of Copper IUC within 5 days → effective emergency contraceptive 8. Healthcare providers counsel women about availability of EC during routine screenings and appointments

VIII.

Operative Sterilization

A. Surgical Procedure to Permanently Prevent Pregnancy 1. Tubal ligation, vasectomy 2. Theoretically reversible; permanency of procedure should be stressed and understood

B. Vasectomy 1. Severing vas deferens in both sides of scrotum 2. 3 months and 15 to 20 ejaculations to clear remaining sperm 3. Sperm count checked 4. Side effects a) Pain b) Infection c) Hematoma d) Sperm granulomas e) Spontaneous reanastomosis 5. Microsurgery can sometimes reverse

C. Tubal Ligation 1. Female sterilization a) Laparotomy following C-section, other abdominal surgery b) Minilaparotomy in postpartum period c) Laparoscopy done postabortion, interval period 14 Copyright © 2020 Pearson Education, Inc.

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d) Done at any time the woman is not pregnant; postpartum period ideal time e) Tubes ligated, clipped, electrocoagulated, banded, or plugged 2. Complications a) Regret b) Coagulation burns on bowel c) Bowel perforation d) Pain e) Infection f) Hemorrhage g) Adverse anesthesia effects

IX.

Male Contraception A. Vasectomy, Condom 1. Only forms available in United States 2. Hormonal contraception under study a) Side effects of too much testosterone b) How to stop pituitary LH and FSH to block testicular cell function c) How to interfere with sperm production d) How to disrupt transport of mature sperm

B. Nursing Management for the Woman Choosing a Contraceptive Method 1. Provide information and guidance about contraceptive methods 2. Men encouraged to participate in contraceptive counseling 3. Complete history and assessment for medical contraindications to specific methods 4. Learn about woman’s lifestyle 5. Attitudes about birth control may be influenced by cultural factors a) Gender inequities b) Acquiescence to nurses decision for woman c) Attitudes toward bleeding d) Roman Catholic Church’s views e) Value of large family, lack of stigma for unplanned, or adolescent pregnancy 6. Once woman chooses a method, help her learn to use it effectively 7. See Teaching Highlights: Using a Method of Contraception, p. 68 a) Discuss factors to consider → supportive atmosphere b) Review reasons for selecting → provide accurate information c) Discuss advantages, disadvantages, risks → focus on open discussion d) Describe correct procedure → break down into small steps e) Provide information regarding unusual circumstances → written handout 15 Copyright © 2020 Pearson Education, Inc.

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f) Stress warning signs → arrange to talk with woman again soon g) Evaluation

X.

Clinical Interruption of Pregnancy A. Abortion → Legalized in United States 1973 1. Much controversy → moral, legal considerations 2. Physical and psychosocial factors 3. Decision made by woman or couple involved 4. 1 in 5 pregnancies ends in abortion worldwide

B. Medical Interruption of Pregnancy 1. Medical abortion available in United States 2. Provides effective alternative to surgical abortion 3. Combination of mifepristone, an antiprogesterone, and misoprostol, a prostaglandin analog that causes smooth muscle to contract, leads to complete abortion in 92% of women 4. Mifepristone combined with vaginal misoprostol used up to 70 days results in complete abortion 92% of the time 5. Endometritis risk with any abortion 6. Misoprostol inhibits local immunity

C. Surgical Interruption of Pregnancy 1. First trimester a) Easier, safer than in second trimester b) If less than 8 weeks’ gestation, manual vacuum aspiration can be performed c) After 8 weeks’ gestation, cervix dilated mechanically with metal dilators, osmotically with Laminaria japonica, or medicinally with misoprostol or mifepristone; anesthetized using a paracervical block 2. Major risks a) Perforation of the uterus b) Laceration of the cervix c) Systemic reaction to the anesthetic agent d) Hemorrhage e) Retained products of conception f) Infection 3. Second trimester a) Greater than 13 weeks’ gestation up to 24 weeks or as per state law

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b) Medical termination: misoprostol; woman will need to labor and pass the fetus in the hospital c) Surgical termination: using dilation of cervix and evacuation of products of conception (D&E) d) May combine vacuum aspiration with use of appropriate instrumentation

D. Nursing Management for the Woman Having an Abortion 1. Decision to terminate a) Unwanted/unintended pregnancy b) Sexual assault c) Lack of finances d) Woman’s health e) Health of fetus f) Assist in finding postprocedure support 2. Verify pregnancy a) By 5 weeks’ gestation if possible b) Provide information about methods and associated risks c) Available alternatives and implications d) Encourage to verbalize feelings e) Provide support before, during, and after procedure f) Monitoring vital signs, intake and output (I&O) g) Providing for comfort h) Patient self-care i) Importance of postabortion checkup j) Use of reliable contraception postprocedure

XI.

Preconception Counseling

A. Preconception Health Measures 1. Health assessment: known or suspected risks 2. Modifiable risk factors a) Smoking b) Alcohol c) Social drugs and street drugs d) Caffeine e) Medications f) Environmental hazards 3. Physical examination a) Both partners physical examination to identify health problems that might affect pregnancy b) Woman may have laboratory tests c) Women assessed for mental illness 17 Copyright © 2020 Pearson Education, Inc.

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4. Nutrition a) Nutritious diet that contains ample quantities of all essential nutrients b) Calcium, protein, iron, B complex vitamins, vitamin C, magnesium, and folic acid c) Consumption of balanced diet with appropriate distribution of food pyramid groups 5. Exercise a) Woman to establish regular exercise plan b) Aerobic conditioning and general toning c) Woman generally encouraged to continue during pregnancy d) Prepregnancy obesity puts woman at risk for a variety of complications

B. Contraception 1. Women who take birth control pills advised to stop the pill and have two or three normal menses before attempting to conceive 2. Women using intrauterine device advised to have it removed and wait 1 month attempting to conceive before

C. Conception 1. Personal and emotional experience 2. Even if a couple is prepared, they may feel some ambivalence, which is a normal response 3. Healthcare provider should remind overly zealous couple moderation is always appropriate

XII.

Focus Your Study

XIII.

Activities 1. Individual Using the standard drug card format, have students make drug cards for combined oral contraceptives (COCs), minipills, mifepristone, misoprostol, and laminaria.

2. Small Group Divide the class into small groups of three to five students. Assign the groups to research support and counseling services in your area for birth control and abortion information. Have the groups present their findings to the class.

3. Large Group Contact local agencies and invite a certified nurse-midwife (CNM) and/or a nurse practitioner (NP) to come to your class and discuss contraceptive counseling and services for teens and lowincome women.

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Chapter 5 Commonly Occurring Infections Care of the Woman with a Lower Genital Tract Infection (Vaginitis)...............

2

Care of the Woman with a Sexually Transmitted Infection..............................

4

Care of the Woman with an Upper Genital Tract Infection (Pelvic Inflammatory Disease).................................................................

12

Care of the Woman with a Urinary Tract Infection...........................................

14

Focus Your Study................................................................................................

17

Activities.............................................................................................................

17

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I.

Care of the Woman with a Lower Genital Tract Infection (Vaginitis)

A. Vaginitis → most common reason women seek gynecologic care 1. Symptoms a) Vaginal discharge b) Vulvar irritation and pruritus c) External dysuria d) Dyspareunia (painful sexual intercourse) e) Bleeding with intercourse f) Foul odor 2. Bacterial Vaginosis a) Most prevalent vaginal infection in United States b) Etiology related to change in normal vaginal flora c) Increase in vaginal pH from variety of causes d) Gardnerella vaginalis and Mycoplasma hominis most common e) Symptoms (1) Excessive thin, watery, white or gray vaginal discharge, foul odor (2) Vaginal pH usually >4.5 f) Increased risk of pelvic inflammatory disease (PID), HIV, abnormal cervical cytology, postoperative cuff infections after hysterectomy, postabortion PID g) Treatment (1) Nonpregnant (a) Metronidazole (Flagyl) 500 mg orally (PO) twice daily (BID) for 7 days (b) Metronidazole gel (0.75%): one full applicator intravaginally, once daily for 5 days (c) Clindamycin 2% cream, one full applicator at bedtime (HS) for 7 days (d) See Drug Guide: Metronidazole (Flagyl), p. 75 (2) Pregnant (a) Metronidazole was considered a potential teratogen for many years → studies have not shown this 3. Vulvovaginal Candidiasis (VVC) a) Candidiasis → very common b) Candida albicans → most common pathogen (1) Predisposing factors c) Symptoms and signs (1) Thick, white, nonmalodorous discharge with severe itching, dysuria, dyspareunia (2) Male partner → rash, excoriation of skin of penis, pruritus (3) Vaginal pH usually 4 to 4.5 or less (4) Labia swollen, excoriated (5) Speculum exam d) Treatment (1) Over-the-counter (OTC) or prescription intravaginal agents 2 Copyright © 2020 Pearson Education, Inc.

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(2) Intravaginal butoconazole, clotrimazole, miconazole, ticonazole cream, tablets, suppositories, nystatin, and terconazole and orally, fluconazole (3) 1-day regimen (4) 3-day, 5-day, and 7-day treatment regimens (5) Treatment of male partner e) Recurrent → four or more episodes in 1 year (1) Test for elevated blood glucose (2) Evaluate for immunosuppression f) Pregnant → topical azole preparations for 7 days g) Nursing Management for the Woman with Vulvovaginal Candidiasis (1) Nursing assessment and diagnosis (a) Suspect VVC → intense itching, thick, nonodorous white discharge (b) Those susceptible → HIV positive, immunosuppressed, pregnant, have diabetes mellitus (c) Nursing diagnoses (i) Skin Integrity, Risk for Impaired (ii) Knowledge, Readiness for Enhanced (d) Nursing plan and implementation (i) Factors contributing to VVC (ii) Ways to prevent recurrences (e) Evaluation (i) Expected outcomes (a) Symptoms relieved, infection cured (b) Woman able to identify self-care measures to prevent further episodes

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II.

Care of the Woman with a Sexually Transmitted Infection

A. Sexually transmitted infection (STI) or sexually transmitted disease (STD) → most common reason for outpatient, community-based treatment of women 1. More than one can occur at same time

B. See Table 5–1: Summary of Common Vaginal and Sexually Transmitted Infections, p. 77 C. Disease → organism → diagnosis → treatment (nonpregnant/pregnant) 1. VVC → Candida albicans → wet-mount hyphae → topically applied azole drugs 2. BV → Gardnerella vaginalis, mycoplasma hominis → wet-mount clue cells → Metronidazole or clindamycin/metronidazole 3. Trichomoniasis → Trichomonas vaginalis → wet-mount trichomonads → Metronidazole or tinidazole 4. Syphilis → Treponema pallidum → dark-field examination, Venereal Disease Research Laboratories (VDRL), Rapid Plasma Reagin (RPR), microhemagglutination assay-Treponema pallidum (MHA-TP) → Benzathine, Penicillin G 5. Herpes genitalis →herpes simplex virus → herpes culture or titer → acyclovir 6. Chlamydia → Chlamydia trachomatis → chlamydia culture → doxycycline or azithromycin/azithromycin or amoxicillin 7. Gonorrhea → Neisseria gonorrhoeae → gonorrhea culture → ceftriaxone, azithromycin, doxycycline 8. AIDS → HIV → enzyme-linked immunosorbent assay (ELISA) test and Western blot → varies 9. Condylomata acuminata → human papilloma virus → Virapap, biopsy, Pap smear, colposcopy → cryotherapy, trichloroacetic acid (TCA), bichloracetic acid (BCA), podophyllum, podofilox, excision 10. Pediculosis pubis → Phthirus pubis → microscopic identification of lice or nits → permethrin 1% liquid or malathion 0.5% lotion /permethrin 1% liquid 11. Scabies → Sarcoptes scabiei → confirmation of symptoms or scraping of furrows → permethrin 5% cream or crotamiton 10% cream or lotion/ permethrin 5% cream

D. Prevention of Sexually Transmitted Infections 1. Effective prevention and control based on a) Education and counseling on safer sexual behavior b) Identification of infected, asymptomatic individuals and symptomatic people not likely to seek diagnostic and treatment services 4 Copyright © 2020 Pearson Education, Inc.

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c) Effective diagnosis and treatment of people with an STI d) Evaluation, treatment, counseling, and education for sex partners of people with an STI e) Pre-exposure vaccination of individuals at risk for vaccine-preventable STIs f) Expedited partner therapy (EPT) 2. Lowest risk → abstain from sexual intercourse a) Monogamous relationship with partner who is free of infection b) Nurses educate and counsel → tailored to individual needs, specific risk factors

E. Trichomoniasis 1. Trichomonas vaginalis → protozoan 2. Most common curable STI 3. Coinfection with other STIs common → HIV transmitted more easily 4. Often asymptomatic, mild symptoms a) Yellow-green frothy discharge, vulvar itching b) Dysuria and dyspareunia c) Microscopic visualization, vaginal pH of 5 or higher, positive whiff test d) Pregnant → increased risk for premature rupture of membranes 5. Diagnosis a) Microscopic visualization of mobile trichomonads and increased leukocytes (Figure 5-3) b) Vaginal pH of 5.0 or higher c) Positive whiff test d) Two other tests with greater sensitivity than the wet-mount preparation are also available and are performed on vaginal secretions (CDC, 2015) (1) Nucleic acid amplification test (NAAT) (2) Aptima T. vaginalis assay 6. Treatment → metronidazole in single 2-g dose, tinidazole, single 2-g oral dose a) Metronidazole 500 mg twice daily for 7 days for both male and female sexual partners b) Avoid intercourse until both are cured

F. Chlamydial Infection 1. Chlamydia trachomatis a) Most common bacterial STI in United States b) Major cause of nongonococcal urethritis (NGU) in men c) Similar infection in women to gonorrhea d) Pelvic inflammatory disease (PID), infertility, and ectopic pregnancy (1) Newborn exposure 2. Symptoms a) Thin or mucopurulent discharge b) Cervical ectropion 5 Copyright © 2020 Pearson Education, Inc.

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c) Burning and frequency of urination d) Lower abdominal pain e) Up to 50% of women asymptomatic 3. Diagnosis a) Nucleic acid amplification testing (NAAT) most sensitive b) Polymerase chain reaction (PCR) assay and antigen detection c) May be made after treatment of male partner for NGU 4. Treatment a) Single-dose azithromycin 1 g orally, doxycycline 100 mg by mouth for 7 days b) Sexual partners should be treated c) Abstinence for 7 days following treatment 5. Annual screening a) All sexually active adolescent females, women age 20 to 25 even if asymptomatic b) Women older than age 25 at risk c) Screening for high-risk pregnant women (1) First prenatal visit and third trimester d) Endocervical, urethral, or urine specimens

G. Gonorrhea 1. Neisseria gonorrhoeae bacterium 2. Second most commonly reported STI in United States a) Highest rates in females aged 15 to 24 years b) Men symptomatic c) Women often asymptomatic 3. Pregnant woman infected after third month of gestation a) Mucous plug prevents infection from ascending b) Newborn exposure: at risk of developing ophthalmia neonatorum c) Cervical culture during initial prenatal exam 4. Symptoms a) Purulent, greenish-yellow vaginal discharge b) Dysuria and urinary frequency c) Vulvar inflammation, swelling d) Cervix may appear swollen and eroded e) Cervicitis, acute cystitis, or vaginitis f) Bilateral lower abdominal or pelvic pain 5. Treatment a) Nonpregnant → antibiotic therapy with ceftriaxone intramuscularly or with cefixime orally b) Combined with azithromycin or doxycycline orally

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c) Additional treatment may be required if cultures remain positive 7 to 14 days after completion of treatment d) Treat all sexual partners e) Recommend abstinence 7 days following treatment f) Retesting recommended 3 months following treatment 6. Education a) Need to verify cure b) Abstinence or condom until cure confirmed c) All sexual partners should be treated d) Signs that infection worsening

H. Herpes Genitalis 1. Herpes simplex virus (HSV) 2. Recurrent, lifelong infection a) Spread through vaginal, anal, oral sex b) Skin to skin c) At least 50 million people infected d) HSV-1 and HSV-2 3. Primary episode → single, multiple blisterlike vesicles a) Genital area, vaginal walls, cervix, urethra, anus b) Within a few hours of exposure → 20 days c) Vesicles rupture → painful, open ulcerated lesions d) Genital pruritus, tingling e) Flulike symptoms f) Lesions heal → 2 to 4 weeks g) Most severe episode 4. Dormant phase → reside in nerve ganglia of affected area a) May or may not recur b) Less severe than primary episode c) Triggers (1) Emotional stress (2) Menstruation (3) Ovulation (4) Pregnancy (5) Frequent or vigorous intercourse 5. Diagnosis a) Clinical appearance b) Culture of lesions c) PCR identification, glycoprotein G-based type-specific assay

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6. Treatment a) No known cure (1) Control symptoms, prevent complications of secondary infections b) Acyclovir, valacyclovir, or famciclovir (1) Start therapy in prodromal period (2) Daily suppressive therapy for those with frequent recurrences (3) Pregnant → oral acyclovir for first episode, severe recurrent (4) Third trimester use → reduce frequency of C-section c) Palliative treatment (1) Keep genital area clean, dry (2) Wear loose clothing (3) Sitz baths (4) Cotton underwear or none at all d) Primary or recurrent lesions will heal without treatment

I. Syphilis 1. Treponema pallidum 2. More common in men than women a) Acquired through vaginal, oral, or anal sex 3. Early → primary stage → chancre a) Slight fever, weight loss, malaise b) Chancre for about 4 weeks and then disappears 4. Secondary → 6 weeks to 6 months a) Skin eruptions (condylomata lata); wartlike and highly infectious b) Acute arthritis c) Enlargement of liver, spleen d) Nontender enlarged lymph nodes e) Iritis f) Chronic sore throat with hoarseness g) Latent phase with no lesions may be followed by a tertiary stage. h) Transplacental transmission (1) Intrauterine growth restriction, preterm birth, stillbirth (2) Serologic testing of every pregnant woman 5. Diagnosis a) Early primary → dark-field microscopic examination of chancre b) VDRL, Rapid Plasma Reagin (RPR), or fluorescent treponemal antibody absorption test (FTA-ABS) 6. Treatment a) Pregnant and nonpregnant → less than 1 year duration (1) million units of benzathine penicillin G intramuscularly once a week for 3 weeks

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(2) Tertiary syphilis treated with 2.4 million units of benzathine penicillin G intramuscularly at 1 week intervals for 3 doses (3) Doxycycline or tetracycline for allergy

J. Human Papilloma Virus/Condylomata Acuminata 1. Viral a) 100 HPV subtypes (1) Transmission through vaginal, oral, or anal sex (2) Incidence of HPV infection is 14.1 million mostly in women (3) Link with cervical and anorectal cancers 2. Symptoms a) Most HPV infections are unrecognized, asymptomatic, or subclinical b) Single or multiple soft, grayish pink, cauliflower-like lesions in genital area c) May cause itching, be friable, painful d) Incubation 3 weeks to 3 years e) All atypical pigmented and persistent warts should be biopsied, treated promptly 3. Treatment a) Patient-applied therapies (1) Podofilox solution or gel, imiquimod cream, or sinecatechin ointment. b) Provider administered (1) Cryotherapy (2) Topical podophyllin, TCA, BCA c) Surgical removal d) Intralesional interferon, laser surgery e) Topical cidofovir f) Imiquimod, podophyllin, podofilox, sinecatechin ointment not during pregnancy g) Frequent Pap smears to monitor cervical cellular changes h) Use of condoms can reduce transmission i) Vaccine (1) Gardasil (2) Cervarix (3) CDC recommends 3-dose HPV vaccine be routinely given to boys ages 11 to 12

K. Pediculosis Pubis (Pubic or Crab Lice) 1. Pthirus → grayish, parasitic “crab” louse 2. Symptoms a) Itching, usually in pubic area 3. Treatment a) 1% permethrin liquid or mousse (1) Applied to clean hair, saturating hair (2) Remove after 10 minutes with warm water 9 Copyright © 2020 Pearson Education, Inc.

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(3) Malathion applied to dry hair, massaged in, allowed to air dry b) Retreatment may be necessary c) Linens, towels, clothing → machine washed, dried in hot dryer for 20 minutes (1) Dry-cleaned (2) Sealed in airtight bag for 2 weeks d) Both partners treated and tested for other STIs

L. Scabies 1. Sarcoptes scabiei → parasitic itch mite 2. Symptoms a) Itching that worsens at night b) Erythematous, papular lesions, furrows may be present 3. Treatment a) Permethrin cream 5% applied to all body areas (1) Neck down and washed off after 8 hours (2) Retreat in 7 days if live mites still exist (3) Can be used during pregnancy b) Crotamiton cream or lotion (1) Thin layer to all body areas from neck down (2) Reapply 24 hours after first application c) Clothing, linens washed and dried in hot dryer or dry-cleaned (1) Sealed in plastic bag for minimum of 72 hours

M. Viral Hepatitis 1. See Table 5–2: Types of Viral Hepatitis, p. 82 a) Type A (1) Fecal–oral, contaminated food/water (2) 15–50-day incubation (3) Not chronic (4) Immunization available b) Type B (1) Blood/body fluids (2) 45–108-day incubation (3) Chronic (4) Immunization available c) Type C (1) Blood/blood products (2) 14–180-day incubation (3) Chronic infection (4) No immunization available d) Type D (1) Blood/body fluids 10 Copyright © 2020 Pearson Education, Inc.

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(2) 45–160-day incubation (3) Chronic infection (4) No immunization available e) Type E (1) Fecal–oral (2) 21–56-day incubation period (3) Not chronic (4) Immunization available in China only 2. Symptoms a) Hepatitis A (1) Jaundice, anorexia (2) Nausea, vomiting (3) Malaise, fever (4) Gray-colored bowel movements b) Hepatitis B, C, D (1) Similar symptoms to A (2) Also arthralgias, arthritis, skin eruptions, rash c) Hepatitis E (1) Primarily in East and South Asia (2) Symptoms like hepatitis A

N. AIDS 1. AIDS: serious, often fatal, disorder caused by HIV 2. Alters presentation of STIs, complicates treatment of STI 3. Fetal implications

O. Nursing Management for the Individual with a Sexually Transmitted Infection 1. Nursing Assessment and Diagnosis a) Thorough history to identify women at risk for STIs b) Complaints suggestive of infection (1) Sore or lesion (2) Increased or malodorous vaginal discharge (3) Burning with urination (4) Dyspareunia (5) Bleeding after intercourse (6) Pelvic pain (7) Woman asymptomatic but may report symptoms in her partner c) Nursing Diagnoses (1) Family Processes, Interrupted (2) Knowledge, Readiness for Enhanced d) Cultural Competence (1) STI rates in United States → racial minorities have highest rates 11 Copyright © 2020 Pearson Education, Inc.

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(a) African American > Native Americans/Alaska Native > Hispanic populations (i) Significantly greater rates of gonorrhea and chlamydia than Caucasians e) Nursing Plan and Implementation (1) Provide information about infection (2) Prevention of reinjection (3) Abstain from sexual activity, if necessary, during treatment (4) Condom use (5) Encourage woman to explore feelings (a) Matter of fact versus embarrassing, shameful (b) Straightforward acceptance by nurse f) Health promotion education (1) Risk increases with number of partners (a) Plan ahead → develop strategies to refuse sex (b) Limit number of sexual contacts, mutual monogamy (2) Condom use for every act of vaginal, anal intercourse (a) Plan strategies for negotiating condom use with partner (3) Reduce high-risk behaviors (4) Refrain from oral sex if active sores in mouth, vagina, anus, penis (5) Seek care as soon as symptoms noticed (a) Make sure partner gets treated (6) More frequent Pap tests as recommended by caregiver g) Evaluation (1) Infection identified, cured (2) Supportive therapy (3) Woman and partner can describe infection, transmission, implications, therapy (4) Woman copes with impact on self-concept

III.

Care of the Woman with an Upper Genital Tract Infection (Pelvic Inflammatory Disease)

A. Pelvic inflammatory disease (PID) 1. Occurs most often in women of childbearing age, especially sexually active women under age 25 2. More common in women who a) Have had multiple sex partners b) Partner who has had more than one sex partner c) History of PID d) Early onset of sexual activity e) Recent insertion of intrauterine device (IUD) f) Douche regularly

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3. Definition → clinical syndrome of inflammatory disorders of upper female genital tract a) Any combination or endometritis, salpingitis tubo-ovarian abscess, pelvic abscess, pelvic peritonitis b) Organisms most common → C. trachomatis and N. gonorrhoeae 4. Symptoms a) Bilateral sharp, cramping pain in lower quadrants b) Fever >100.4°F, chills c) Mucopurulent cervical or vaginal discharge d) Irregular bleeding e) Cervical motion tenderness during intercourse f) Malaise, nausea, vomiting g) Possible to be asymptomatic 5. Diagnosis a) Clinical examination to define symptoms b) Cultures for gonorrhea and chlamydia (1) Complete blood count (CBC) with differential, RPR, VDRL (2) C-reactive protein, sedimentation rate often elevated (3) Physical examination c) Ultrasound d) Laparoscopy 6. Treatment a) Outpatient or inpatient based on clinical judgment b) Ceftriaxone plus doxycycline with or without metronidazole c) IV fluids, pain medication d) IV antibiotics often cefoxitin, or cefotetan plus doxycycline, or clindamycin plus gentamicin e) Follow up within 48 to72 hours f) Treat sexual partner

B. Nursing Management for the Woman with Pelvic Inflammatory Disease 1. Nursing Assessment and Diagnosis a) Assessment of risk factors for PID (1) Woman’s history at risk for PID (2) Symptoms b) Nursing diagnoses (1) Pain, Acute (2) Knowledge, Deficient c) Nursing Plan and Implementation (1) Education (a) Woman with IUD and multiple sexual partners (b) Signs and symptoms of PID (c) Importance of completing antibiotics and follow-up 13 Copyright © 2020 Pearson Education, Inc.

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(d) Possible outcomes of PID → decreased fertility or infertility d) Evaluation (1) Expected outcomes include (a) Describes condition, therapy, possible long-term implications (b) Woman completes course of therapy

IV.

Care of the Woman with a Urinary Tract Infection A. Urinary Tract Infection (UTI) → significant bacteriuria in presence of symptoms 1. Approximately 50% women will experience UTI in lifetime 2. Bacteria enter urinary tract via urethra 3. Causes a) Shortness of female urethra b) Incompetence of urinary sphincter c) Frequent enuresis before adolescence d) Pregnancy e) Urinary catheterization f) Voluntarily suppressing desire to urinate g) Age h) General poor health, lowered resistance 4. Asymptomatic Bacteriuria a) Bacteria in urine without symptoms b) Escherichia coli most common c) In pregnancy (1) 2 to 7% of pregnancies, and as many as 20 to 30% of pregnant women with untreated ASB will develop pyelonephritis (2) Physiology (3) Treatment: amoxicillin-clavulanate, nitrofurantoin, cefixime, fosfomycin d) Woman who has had a UTI susceptible to recurrent infection

B. Lower Urinary Tract Infection (Cystitis and Urethritis) 1. UTIs ascend → important to diagnose early 2. Cystitis → inflammation of the bladder 3. Risk factors a) Sexual intercourse b) Use of diaphragm and spermicide c) Pregnancy d) History of recent UTI

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4. E. coli → vast majority of UTIs 5. Symptoms a) Dysuria at end of urination b) Urgency and frequency c) Suprapubic, low back pain d) Low-grade fever e) Hematuria occasionally 6. Diagnosis a) Urine culture b) Bacteriuria dipstick screening (1) High false-positive, -negative rates 7. Treatment a) Depends on causative pathogen (1) Oral (a) Nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMZ) (b) Fluoroquinolones (FQ) such as ciprofloxacin, levofloxacin, gatifloxacin, or norfloxacin reserved for treatment failures and for women with suspected upper UTI infection b) In pregnancy (1) Cystitis may occur in pregnant women (2) Common treatment regimens: oral cephalexin, nitrofurantoin, sulfisoxazole, fosfomycin, ampicillin

C. Upper Urinary Tract Infection (Pyelonephritis) 1. Inflammatory disease of kidneys a) More serious than cystitis (1) Significantly increased risk of preterm labor, preterm birth, development of adult respiratory distress syndrome, septicemia 2. Symptoms a) Sudden onset b) Chills, high temperature c) Costovertebral angle tenderness, flank pain d) Nausea, vomiting, general malaise 3. Physiology a) Edema of renal parenchyma, ureteritis → blockage, swelling of ureter b) Temporary suppression of urinary output → severe, colicky pain c) Vomiting, dehydration, ileus of large bowel d) Significant bacteremia in urine culture, pyuria, presence of white blood cell casts 4. Treatment a) May be hospitalized 15 Copyright © 2020 Pearson Education, Inc.

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b) IV antibiotics, IV hydration c) Urinary analgesics, pain management d) Medication to manage fever e) Blood culture in case of obstructive pyelonephritis f) Bed rest g) Possible catheterization 5. Medications a) Ceftriaxone IV → followed with oral ciprofloxacin, ofloxacin, levofloxacin, gatifloxacin (1) Oral to complete 10 to14 days of therapy 6. Follow-up urinary cultures

D. Nursing Management for the Woman with a Urinary Tract Infection 1. Nursing Assessment and Diagnosis a) Medical history including sexual history (1) Risk factors b) Symptoms (1) Fever, chills, nausea, vomiting, flank or back pain (a) Clean-catch urine sample 2. Nursing Diagnoses a) Pain, Acute b) Knowledge, Deficient c) Fear 3. Nursing Plan and Implementation a) Education (1) Hygiene (2) Signs and symptoms of UTI (3) Reinforce instructions regarding treatments b) Three or more infections yearly → long-term prophylaxis may be needed 4. Health Promotion a) Avoid bladder irritants b) Make regular urination a habit, avoid long waits c) Practice good genital hygiene d) Be aware that initial, vigorous, frequent sexual activity may contribute e) Complete medication regimens f) Do not use medication left over from previous infections g) Drinking cranberry juice or taking cranberry tablets is often recommended to decrease urinary tract infection, evidence does not support its value 5. Evaluation a) Expected outcomes (1) Woman implements self-care measures to help prevent recurrent UTIs 16 Copyright © 2020 Pearson Education, Inc.

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(2) Woman completes prescribed course of antibiotic therapy (3) Woman can identify signs of recurrent UTI, worsening urinary symptoms (4) Woman’s infection is cured

V.

Focus Your Study

VI.

Activities 1. Individual Assign students to complete drug cards for medications used in treating VVC, BV, chlamydia, gonorrhea, herpes genitalis, syphilis, HPV, PID, UTIs, and PID. 2. Small Group Divide the class into small groups of three to five students. Assign each group a commonly occurring infection to research. The rubric should include statistics regarding demographics, morbidity and mortality, and new research. Instruct students to use APA format for citing resources. Have each small group present its findings to the entire class.

3. Large Group Invite an adult nurse practitioner (ANP) to speak to the class regarding adolescents and older women and UTIs.

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Chapter 6 Women’s Health Problems

Care of the Woman with a Disorder of the Breast............................................

2

Care of the Woman During a Pelvic Examination..............................................

7

Care of the Woman with Vulvitis.......................................................................

9

Care of the Woman with an Abnormal Finding During Pelvic Examination.....

9

Care of the Woman with Endometriosis...........................................................

18

Care of the Woman with Polycystic Ovarian Syndrome...................................

19

Care of the Woman with Pelvic Relaxation.......................................................

21

Care of the Woman Requiring Gynecologic Surgery........................................

22

Focus Your Study...............................................................................................

29

Activities……………………………..............................................................................

29

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I.

Care of the Woman with a Disorder of the Breast

A. Screening Techniques for the Breasts 1. Breast examination a) Regular cyclic changes in response to hormonal stimulation (1) Mastodynia, mastalgia common b) Menopause → connective breast tissue atrophies (1) Hormone therapy (HT) may cause breast engorgement c) Breast self-awareness (BSA) (1) Need for woman to be aware of how her breasts normally look (2) BSA versus BSE (3) Women at high risk for breast cancer (4) One way for a woman to develop self-awareness (5) Effectiveness determined by woman’s ability to perform correctly d) See Teaching Highlights: Breast Self-Examination, p. 90 (1) Inspection (a) Should do standing or sitting in front of mirror (b) Done in three positions: both arms relaxed at sides, both arms over head, both hands on hips (c) Size and symmetry, shape, contours and direction (d) Thickening or edema (e) Surface of the skin (f) The nipples (2) Palpation (a) Lying down, one hand behind head and other hand to palpate (b) Check each breast lying down, then again sitting up (c) Squeeze nipples to check for discharge (3) Describe and demonstrate correct procedure for BSE (a) Timing (i) Monthly self exams (ii) Every 1–3 years by trained healthcare provider e) Clinical breast examination (CBE) essential element of routine gynecologic examination (1) ACS → CBE every 1–3 years from 20 to 39, yearly thereafter 2. Mammography a) Soft tissue x-ray image of the breast (1) Used to detect lesions before they can be felt b) American Cancer Society (ACS) → annual after age 45, at 40–45 discuss need with healthcare provider, after 55 discuss continued need with healthcare provider c) ACS recommends both mammogram and magnetic resonance imaging (MRI) beginning at age 30 in women at high risk for breast cancer due to gene mutations and/or a strong family history of breast cancer and in women who had radiation to chest between 10–30 years old 2 Copyright © 2020 Pearson Education, Inc.

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d) Sensitivity of mammography increases with age (1) Decreases with increased breast density (2) Assessment protocol (a) Mammogram or ultrasound (b) Fine-needle aspiration e) Breast sensitivity varies (1) May be scheduled 2 weeks after onset of menses (2) Compression, not pain (3) Refrain from lotion, powder, deodorant, etc., to torso

B. Benign Breast Conditions 1. Fibrocystic breast change → benign breast disease (BBD) a) Most common benign breast disorder b) Generally not a risk factor for cancer c) Fluctuations in size, rapid appearance/disappearance of breast masses d) Bilateral, cyclic pain, tenderness, swelling just before menses (late luteal phase) (1) Improves to 1–2 days into cycle (2) Physical exam reveals mild irregularity to dense, irregular, nodular “lumpiness” (3) May experience fluid-filled cysts large or small (a) Tend to be mobile, tender, without skin retraction e) Mammography, sonography, magnetic resonance imaging (MRI), palpation, fine-needle aspiration → confirm fibrocystic breast changes f) Medical management (1) Restrict sodium, mild diuretic week before onset of menses (2) Mild analgesic (3) Oral contraceptives (4) Severe (a) Danazol → undesirable side effects (b) Bromocriptine (c) Limit methylxanthine intake, tobacco 2. Fibroadenoma a) Common benign tumor most often seen in women in teens and early twenties b) Asymptomatic, mobile, well-defined, painless palpable mass with rubbery texture c) Ultrasound younger than age 35 (1) Observe and follow versus excision 3. Galactorrhea a) Nipple discharge not associated with lactation (1) Common (2) Generally not significant (3) Varies from white to brown b) Likelihood of malignancy increases → spontaneous discharge (1) From single duct in one breast 3 Copyright © 2020 Pearson Education, Inc.

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(2) Watery or bloody c) Mammogram for initial evaluation d) Ultrasound → nipple discharge accompanied by palpable mass, positive findings on mammogram 4. Intraductal papilloma a) Tumors growing in terminal portion of duct, sometimes throughout duct system within section of breast (1) Symptoms may include unilateral mass, spontaneous, bloody nipple discharge (2) Most present as solitary nodules b) Typically benign 5. Duct ectasia (comedomastitis) a) Inflammation of the ducts behind the nipple (1) Typically near onset of menopause (2) Not associated with malignancy b) Typically in women who have borne and nursed children (1) Thick, sticky nipple discharge (2) Burning pain, pruritus, inflammation (3) Nipple retraction c) Drug therapy for symptomatic relief 6. See Table 6–1: Summary of Benign Breast Disorders, p. 92

C. Malignant Breast Disease 1. Second leading cause of cancer deaths in women a) Risk is 1 in 8 b) 14% of all cancer deaths c) In United States, most common in non-Hispanic White women 2. Predisposing factors a) Age; incidence increases steadily with age b) Female gender c) History of previous breast cancer d) Have a known BRCA1 or BRCA2 gene mutation, from either parent with mutation e) Family history of first-degree relative with breast cancer (mother, sister, daughter with breast cancer) f) Long-term postmenopausal combined estrogen and progestin hormonal therapy g) Being overweight or obese after menopause h) Alcohol consumption i) No history of pregnancy, first pregnancy after age 30 j) Never breastfeeding a child k) Longer reproductive phase (early menarche [before age 12] and late menopause [after age 55]) l) History of high-dose radiation to chest between ages of 10 and 30 4 Copyright © 2020 Pearson Education, Inc.

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m) Physical inactivity n) Smoking 3. Diagnosis a) May originate in duct or epithelium b) 50% upper outer quadrant (1) Metastasize to axillary lymph nodes (2) Distant metastasis → lymph nodes, lungs, liver, brain, bone c) Discovery (1) By woman herself, clinician who palpates or observes an abnormality, or mammogram (2) Painless mass or lump d) Worrisome findings (1) Dimpling of breast tissue (2) Recent, acute nipple inversion (3) Change in breast size or shape (4) Increase of size in breast mass (5) Skin erosion or ulceration (6) Presence of axillary lump e) Routine mammography screening → 2 to 3 years before clinical appearance f) Fine-needle biopsy g) Ultrasonography h) MRI i) Biopsy essential for diagnosis 4. Clinical Therapy a) Treatment decision based on (1) Stage of cancer (2) Optimal treatment for that stage (3) Woman’s age (4) Personal preferences (5) Risks and benefits of each treatment protocol b) Surgery (1) Breast-conserving surgery (BCS) (lumpectomy or partial mastectomy) (2) Simple to total mastectomy (3) Modified radical mastectomy (4) Reconstruction (5) Lumpectomy (a) Stages I or II (b) Followed by radiation therapy (6) Sentinel node biopsy c) Adjunctive therapy (1) Chemotherapy (a) Typically combination of drugs (2) Radiation therapy 5 Copyright © 2020 Pearson Education, Inc.

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(a) Destroy remaining cells, reduce size of tumor (b) Neoadjuvant therapy (3) Hormone therapy (a) Estrogen receptive (b) Antiestrogen drug such as tamoxifen or toremifene (c) Raloxifene → selective estrogen receptor modulator (SERM) (d) Aromatase inhibitors stop body from making estrogen (e) Prevent return of breast cancer (f) Herceptin → immune system protein that stops HER2/neu (growth-promoting protein) (4) Allopathic and complementary therapies (a) Combined approach (b) Herbal remedies, therapeutic touch, acupuncture, aromatherapy, massage d) Multidisciplinary approach (1) Second opinion (2) Primary care provider (3) Radiotherapist (4) Surgeon (5) Oncologist (6) Nursing specialists

D. Psychologic Adjustment 1. Emotional feelings include fear a) Loss, treatment, death b) Encourage woman to discuss feelings, concerns c) Information 2. Adjustment phases a) Shock (1) “Everything is unreal”; “I can’t understand why this is happening to me” b) Reaction (1) In conjunction with initiation of treatment (2) Coping mechanisms become evident (a) Denial c) Recovery (1) Begins during convalescence following completion of medical treatment (2) Anxiety diminishes, looks to future if successful (3) Depression, social isolation if unsuccessful (4) Looks to family and friends (a) Partner reaction to breast cancer (5) Support groups d) Reorientation (1) Follows recovery (2) Acknowledges breast cancer, returns to living 6 Copyright © 2020 Pearson Education, Inc.

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E. Nursing Management for the Woman with Breast Cancer 1. Multidimensional 2. Nursing Assessment and Diagnosis a) Therapeutic communication (1) Ongoing assessment (2) Diagnoses that may apply (a) Knowledge, Readiness for Enhanced (b) Anxiety 3. Nursing Plan and Implementation a) Prediagnosis period (1) Emotional support, clarify misconception, encourage expression of anxiety, urge her to ask questions b) Diagnosed (1) Ensure woman understands condition, treatment options (2) Assist to locate appropriate resources (3) Encourage woman and partner to discuss treatment alternatives with healthcare provider (4) Advocacy c) Preoperative interventions 4. Health Promotion a) Reduce modifiable risks b) Avoiding obesity c) Exercising regularly d) Reducing dietary fat e) Limiting intake of processed meat and red meat f) Limiting alcohol intake 5. Evaluation a) Expected outcomes include (1) Woman able to discuss fears, concerns, questions during period of diagnosis (2) Diagnosis made quickly, accurately, treatment initiated

II.

Care of the Woman During a Pelvic Examination

A. Pelvic exam → health maintenance to disease diagnosis 1. First pelvic exam a) Typically as a teenager (1) Sensitive to teen’s attitudes and concerns 2. Create trusting atmosphere, incorporate practices that help to maintain sense of control a) Nonjudgmental and safe environment

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3. Educational pelvic exam a) Mirror to watch, pointing out anatomy, drape patient to allow for eye-to-eye contact with practitioner b) Encourage to ask questions, giving feedback 4. Nurse practitioner, certified nurse-midwife, physician perform a) See Clinical Skill 6–1: Assisting with a Pelvic Exam, p. 96 b) Preparation (1) Ensure room is warm (2) Explain procedure → decreases anxiety (3) Ask woman to empty bladder, remove clothing below waist → promotes comfort (4) Have padding on stirrups → decrease discomfort (5) Disposable drape, sitting at end of table → provide exposure to conduct exam (a) Position in lithotomy position, thighs flexed, abducted (b) Feet in stirrups (c) Buttocks extend slightly below edge of examining table (d) Drape woman with sheet → drape helps preserve sense of dignity, privacy c) Equipment and supplies (1) Vaginal specula of various sizes, warmed (2) Gloves (3) Water-soluble lubricant (4) Materials for Pap smear or ThinPrep® Pap test and cultures (5) Light source d) Procedure (1) Examiner dons gloves (2) Explain procedure, let woman know when examiner begins with inspection of external genitalia (3) Let her know when examiner ready to insert speculum (a) Speculum inserted → visualization of cervix, vaginal walls, specimen (4) Lubricate examiner’s fingers prior to bimanual exam (a) Bimanual exam after speculum withdrawn (b) Rectal exam (5) Ask woman to breathe slowly, regularly (6) After examiner finished, move to end of table (a) Face woman (b) Cover with drape (c) Encourage to move to head of table, apply gentle pressure to knees (d) Assist to remove feet from stirrups (i) Assisting important → awkward position; may have difficulty (ii) Provide tissues to wipe lubricant from perineum (iii) Provide privacy while she dresses (a) Be sure she is not dizzy e) Clinical Tip: With examiner’s consent, offer woman hand mirror to watch examination

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5. Three segments to pelvic exam a) Inspection of vulva b) Inspection of vagina and cervix via speculum exam c) Palpation of cervix, uterus, ovaries via bimanual exam

B. Vulvar Self-Examination 1. Important to promote self-awareness 2. Assume sitting position on bed, chair (pregnant or obese women may find easier to stand) 3. Hold mirror and expose tissues of perineum a) Inspect, palpate b) Palpable masses c) Open sores and lesions d) Areas of marked tenderness

III.

Care of the Woman with Vulvitis

A. Defined as inflammation of vulva, external female genitalia 1. Result of nonpathologic factors a) Douching; feminine deodorant spray; detergents, harsh soaps, bubble bath; colored or perfumed toilet paper; contraceptive creams/foams/suppositories; condoms; dye; synthetic clothing; tight clothing; repetitive motion exercise, frequent shaving; frequent intercourse; deodorant feminine hygiene products; estrogen deprivation 2. Result of inflammation, infection of vagina or cervix a) Vulvovaginitis

B. Difficult to differentiate, by symptoms alone, vulvitis from vaginitis C. Nursing Management for the Woman with Vulvitis 1. Assessment 2. Education about contributing factors 3. Behaviors to avoid 4. Strategies, therapies to improve symptoms

IV.

Care of the Woman with an Abnormal Finding During Pelvic Examination A. Vulvar Lesion 1. Bartholin gland cyst a) Infection resulting in inflammation common b) Unilateral pain, swelling 9 Copyright © 2020 Pearson Education, Inc.

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(1) Pain ranges from mild discomfort to moderate or severe pain c) Incision and drainage, culture and sensitivity, antibiotic therapy 2. Lichen sclerosus a) Chronic disorder of the vulva b) More common in perimenopausal and postmenopausal women c) Link between lichen sclerosus → autoimmune-related disorders d) Diagnosis by clinical exam confirmed with biopsy e) Appears as white papules, plaques, often with keyhole appearance around vulva, introitus, and anal area f) Treatment includes topical antihistamine for mild cases and high-dose topical steroid cream for difficult cases applied nightly for 6 to 12 weeks and then decreased to once or twice weekly thereafter 3. Vulvar vestibulitis a) Local irritation and inflammation of vulvar vestibule b) Severe pain with vaginal penetration c) Precipitating factors d) No definitive treatment → comfort measures e) Burrow soaks, sitz baths, lubricants, topical anesthetics, local interferon injections, oral antifungal medications, oral tricyclic antidepressants, biofeedback techniques, surgical intervention 4. Vulvar intraepithelial neoplasia a) Cancer of the vulva increasing in occurrence (1) Women in 40s (2) Changes related to increased incidence of human papilloma virus (HPV) infections (3) Presents with pruritus, lump, flat lesion, or asymptomatic (4) Risk factors vulvar inflammation, immunosuppression from steroid use, smoking, diabetes, HPV, HIV, history of lower genital tract cancer (5) Clinical appearance varies (6) Biopsy necessary (7) Treatment usually involves surgery

B. Cervicitis 1. Acute inflammation of cervix a) Usually from Neisseria gonorrhoeae or Chlamydia trachomatis b) Other causes include intravaginal feminine hygiene products, frequent tampon use, frequent intercourse, presence of foreign body, contraceptive sponge, diaphragm, or tampon c) Symptoms often include yellowish-white vaginal discharge, or purulent discharge d) Dyspareunia common e) Diagnosis and evaluation include pelvic exam, wet-mount smear, cultures, Pap smear f) Treatment based on identified problem

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C. Abnormal Pap Smear Results 1. Various abnormal findings common → may cause significant anxiety a) Reassurance regarding early detection b) Information about expected further evaluation, treatment, follow-up 2. Pap smear → screens for presence of cellular abnormalities a) Obtain cells from cervix and endocervical canal b) Performed by preparing Pap smear slide c) Liquid-based medium Pap smear increased accuracy (1) Allow for HPV screening, and some sexually transmitted infections (STIs) (2) Screening tool, biopsy for diagnosis 3. Pap smear preparations a) See Professionalism in Practice: Pap Smear Preparation, p. 98 b) Avoid anything in vagina 24 hours before the examination c) 2012 new guidelines for cervical cancer screening issued by U.S. Preventive Services Task Force, American Cancer Society, other groups. See Table 6–2: Screening for Cervical Cancer, p. 98 (1) Women under 21—no screening unless has HIV or is immunocompromised (2) Women 21 to 29—screening with cytology alone every 3 years (3) Women ages 30 to 65—preferred approach: screen with cytology every 3 years and HPV co-testing every 5 years; acceptable approach: test with cytology alone every 3 years (4) Women over 65 years of age who have had adequate prior screening and are not at high risk—do not screen (5) Women who have undergone hysterectomy and have no history of high-grade precancer or cervical cancer—do not screen 4. Bethesda System → standardized method of reporting Pap smear findings a) See Table 6–3: The Bethesda System for Classifying Pap Smears, p. 99 b) Specimen type c) Specimen adequacy d) General categorization (optional) e) Automated review f) Ancillary testing g) Interpretation/result (1) Negative for intraepithelial lesion or malignancy (2) Reports if there are organisms or other nonneoplastic findings h) Other nonneoplastic findings i) Other j) Epithelial cell abnormalities (1) Atypical squamous cells of undetermined significance (ASC-US) (2) Atypical squamous cells cannot exclude HSIL (ASC-H) (3) Low-grade squamous intraepithelial lesion (LSIL) 11 Copyright © 2020 Pearson Education, Inc.

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(4) High-grade squamous intraepithelial lesion (HSIL) k) Glandular cell (1) Atypical (2) Endocervical adenocarcinoma in situ (3) Adenocarcinoma (4) Other malignant neoplasms

D. Cervical Abnormalities 1. Most common in women who have never been screened (50%) or screened inappropriately (10%) 2. Almost always caused by HPV 16 or 18 3. Pap smear screening has decreased mortality dramatically a) Preventable disease b) High-risk factors (1) Coitus at early age (<16 years old) (2) History of multiple sexual partners (3) Sex partner with history of numerous sexual partners (4) Exposure to STIs (5) History of HPV infection (6) History of immunosuppressive therapy (chemotherapy), immunocompromised state (HIV) (7) Long-term oral contraceptive use (>5 years) (8) Smoking (9) Antenatal exposure to DES (10) History of dysplasia c) Virtually all cases of cervical cancer associated with HPV infection (1) Bethesda System → three categories for premalignant squamous cell lesions (a) Atypical squamous cells (ASC) (b) Low-grade squamous intraepithelial lesion (LSIL) (c) High-grade squamous intraepithelial lesion (HSIL) (2) Pap smear focus is detection of high-grade cervical disease (3) Category ASC-H includes those changes suggestive of high-grade lesion but lacking sufficient criteria for definitive evaluation and interpretation (a) Immediate colposcopy 4. Colposcopy a) Direct, detailed visualization and examination of cervix (1) Speculum in vagina (2) Cervix isolated (3) 3% acetic acid solution applied → abnormal epithelial cells take on characteristic white appearance (4) Lesions, abnormalities identified, documented (5) Biopsies obtained 12 Copyright © 2020 Pearson Education, Inc.

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(6) May remove entire lesion → diagnostic and therapeutic 5. Atypical glandular cells (AGUS) a) Cells glandular rather than squamous in origin (1) Atypical endocervical cells (2) Atypical endometrial cells (3) Atypical glandular cells not otherwise specified b) Colposcopy done immediately (1) Repeat Pap with HPV co-testing in 12 months; if either test is positive, refer for colposcopy; if both tests are negative, return to routine testing (2) Test for HPV 16 or 16/18 genotypes (high-risk types); if positive, refer for colposcopy c) Evaluation of Abnormal Cytology d) Endocervical curettage (ECC) → scraping from internal os to external os e) Woman may experience moderate to severe cramplike pains (1) Premedicate with 600 mg ibuprofen, 30 minutes before procedure (2) Small amount of bleeding normal for up to 2 weeks

E. Surgical Treatment for Abnormal Cytology 1. Premalignant, malignant → surgical procedures a) Simple biopsy to radical surgery b) Depends on diagnosis and extent of disease 2. Goals of management to exclude presence of invasive cancer, determine extent, distribution, provide treatment 3. Treatment depends on stage of disease a) Total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), bilateral lymphadenectomy b) May include radiation, chemotherapy 4. Loop electrosurgical excision procedure (LEEP) a) Can be used to treat cervical, vaginal, vulvar intraepithelial neoplasia b) Small electrically hot wire loop can excise entire lesion c) Outpatient, local anesthesia d) Complications minimal e) Slight bleeding normal → moderate to heavy abnormal 5. Cryosurgery a) Negative ECC and no endocervical gland involvement b) Double freezing c) Less widely used due to scarring and now with LEEP available 6. Laser therapy a) Carbon dioxide (CO2) laser used to treat cervical, vaginal, vulvar lesions b) Used when all boundaries visible on colposcopy, ECC negative c) Outpatient, or office, without anesthesia 13 Copyright © 2020 Pearson Education, Inc.

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d) Minimal cramping and discharge for 5–7 days e) No tampon use, intercourse, douching for 2 weeks f) Less common with effective use of LEEP 7. Conization a) Performed when entire lesion cannot be visualized or positive ECC sampling b) Cone-shaped section of cervical tissue excised c) Can be diagnostic and therapeutic d) General anesthesia e) Risks include infection, hemorrhage f) Long-term risks: spontaneous abortion, incompetent cervix, preterm labor with future pregnancies g) Prolonged, profuse menstrual period in 2 to 3 cycles h) Less frequent with availability of LEEP

F. Abnormal Uterine Bleeding 1. AUB common gynecologic problem a) Uterine bleeding in absence of pregnancy abnormal in volume, frequency, regularity, or duration b) Chronic or acute 2. Structural causes (PALM) a) Polyp b) Adenomyosis c) Leiomyoma d) Malignancy and hyperplasia 3. Nonstructural causes (COEIN) a) Coagulopathy b) Ovulatory dysfunction c) Endometrial d) Iatrogenic e) Not otherwise classified 4. Systemic diseases: coagulation disorders (von Willebrand disease, thrombocytopenia, acute leukemia, advanced liver disease) 5. Evaluation a) History and physical including pelvic exam, Pap smear b) Exclude organic causes c) Laboratory tests d) Possible additional tests (1) Transvaginal ultrasound (2) Saline infusion sonography (3) Hysteroscopy

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(4) MRI (5) Endometrial biopsy 6. Goals of treatment a) Control bleeding b) Prevent, treat anemia c) Prevent endometrial hyperplasia or cancer d) Restore quality of life 7. Pharmacologic treatment varies a) Combined oral contraceptives (COCs) b) Short-term, high-dose estrogen therapy c) Cyclic progesterone d) Tranexamic acid e) Levonorgestrel intrauterine system 8. Surgical interventions if conservative measures not effective a) Dilation and curettage (D&C) b) Endometrial ablation c) Uterine artery embolization d) Hysterectomy

G. Dysfunctional uterine bleeding (DUB) 1. AUB without demonstrable organic cause 2. Can occur at any age but most common at either end of reproductive age span 3. Surgical intervention limited to cases in which medical therapy contraindicated or has failed

H. Ovarian (Adnexal) Masses 1. Commonly ovarian abnormality a) Can refer to masses in fallopian tubes, broad ligament, bowel, lateral mass of uterus b) 70 to 80% ovarian masses are benign (1) 50% functional cysts 2. Ovarian cysts → physiologic variation in menstrual cycle a) No relationship between benign ovarian masses and ovarian cancer b) Risk factors for ovarian cancer (1) Increased age (2) History of breast cancer (3) Gene mutation (BRCA1 and BRCA2) (4) Family history of breast or ovarian cancer (a) Most fatal → difficult to diagnose, often widespread at detection c) Symptoms of ovarian cancer may include (1) Bloating (2) Increased abdominal size 15 Copyright © 2020 Pearson Education, Inc.

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(3) Difficulty eating (4) Abdominal or pelvic pain (5) Urinary symptoms d) Risk decreases significantly by bearing children, taking COCs for more than 5 years, tubal ligation e) May be asymptomatic → noted on routine pelvic f) Diagnosis (1) Palpable mass, with/without tenderness (2) Often observation for 1 to2 months → most cysts resolve (a) Oral contraceptives (OCs) for 1 to2 months (3) Still present after 60 days of observation → diagnostic laparoscopy, laparotomy may be considered (4) Surgery not always necessary (a) Mass >6 to7 cm circumference (b) Older than 40 years of age (c) Woman taking OCs (d) Infant, young girl, postmenopausal woman (5) Clear explanation on why initial therapy may be observation

I. Uterine Masses 1. Endometrial polyps → pedunculated overgrowths of endometrium a) Common b) Often accompanied with mid-cycle bleeding or spotting c) Bleeding or spotting after intercourse (1) Prolonged bleeding or spotting with menstrual cycles d) Treatment → dilation and curettage (D&C) using hysteroscopy for visualization 2. Fibroid tumors → leiomyomas a) Most common benign disease entity in women b) Most are asymptomatic, requiring no treatment c) Symptoms (1) Pelvic pain (2) Menstrual irregularities (3) Infertility (4) Most seek treatment for bleeding and pain (5) May be asymptomatic and require no treatment d) Diagnosis (1) Pelvic exam (a) Irregular shaped, enlarged uterus (b) Pelvic ultrasound (c) MRI e) Treatment (1) OCs to control heavy bleeding (2) Hormones → gonadotropin-releasing hormone (GnRH) analogs 16 Copyright © 2020 Pearson Education, Inc.

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(a) May be used preoperatively to reduce size of fibroid, decrease complications (b) MRI guided ultrasound of fibroid (3) Myomectomy (4) Uterine artery embolization (a) Radiologic procedure (5) Hysterectomy (6) Levonorgestrel intrauterine system (LNG-IUS) 3. Endometrial cancer a) Most common female genital tract cancer b) High rate of cure if detected early c) Risk factors include (1) Increased age (mean age 60) (2) Obesity with adult weight gain (3) Nulliparity (4) Polycystic ovary syndrome (5) Hereditary nonpolyposis colon cancer syndrome (Lynch syndrome) (6) Early menarche or late menopause (7) Use of tamoxifen 4. Nursing Management for Woman with an Abnormal Finding During a Pelvic Examination a) Nursing assessment generally toward evaluating understanding of findings, implications, psychosocial response (1) Accurate information on etiology, symptoms, treatment options (2) Realistic reassurance (3) Counseling and effective emotional support if malignancy likely (4) If surgery indicated → assist in obtaining second opinion, making decision

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V.

Care of Woman with Endometriosis A. Presence of endometrial tissue outside the uterine cavity B. Has been found almost everywhere in the body 1. Most common is pelvis 2. Tissue responds to hormonal changes of menstrual cycle → bleeds cyclically

C. Occurs any age after puberty D. Exact cause unknown E. Symptoms 1. Pelvic pain related to menstrual cycle, may be chronic 2. Dyspareunia 3. Infertility 4. Fixed, tender retroverted uterus, palpable nodules in cul-de-sac on pelvic exam

F. Diagnosis → confirmed by laparoscopy G. Treatment 1. Medical a) Observation b) Analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs) c) COCs d) Progestins e) Danazol f) GnRH analogs g) Nafarelin acetate and leuprolide acetate 2. Surgical a) Presacral neurectomy for severe dyspareunia or dysmenorrheal b) In advanced cases: hysterectomy with bilateral salpingo-oophorectomy 3. Complementary therapies a) Acupuncture b) Vag Packs c) Yoga d) Massage e) Traditional Chinese herbal medicine f) Spiritual therapies

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H. Nursing Management for the Woman with Endometriosis 1. Nursing Assessment and Diagnosis a) Accurate history b) Diagnoses that may apply (1) Pain, Acute (2) Coping: Family, Compromised

I. Nursing Plan and Implementation 1. Education 2. Support 3. Referrals

J. Evaluation 1. Woman able to discuss condition, implications for fertility, treatment options 2. After considering alternatives, woman chooses appropriate treatment options

VI.

Care of the Woman with Polycystic Ovarian Syndrome

A. Complex endocrine disorder of ovarian dysfunction B. Symptoms 1. Menstrual dysfunction 2. Hyperandrogenism 3. Obesity 4. Hyperinsulinemia 5. Infertility

C. Diagnosis of PCOS 1. Complaints of hirsutism, menstrual irregularities, acne, difficulty conceiving, and unexplained weight gain 2. Rule out a) Hyperthyroidism, hypothyroidism b) Congenital adrenal hyperplasia c) Cushing syndrome d) Hyperprolactinemia e) Androgen-producing tumors

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3. Process a) History b) Physical examination c) Ultrasound examination may reveal polycystic changes in one or both ovaries

D. Clinical Therapy 1. Goals a) Decrease effects of hyperandrogenism b) Restore reproductive functioning for women desiring pregnancy c) Protect the endometrium d) Reduce long-term risks, specifically type 2 diabetes and cardiovascular disease e) Menstrual irregularities treated with combined oral contraceptive (COC) or cyclic progesterone f) Antiandrogens used to decrease symptoms of androgen excess

E. Long-Term Implications 1. May increase risk for developing a) Overt type 2 diabetes b) Dyslipidemia c) Hypertension d) Cardiovascular disease e) Endometrial cancer f) Breast cancer g) Ovarian cancer h) Emotion responses

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F. Nursing Management for the Woman with Polycystic Ovarian Syndrome 1. Role in identification, evaluation, management, follow-up 2. Signs of PCOS negatively impact women’s feelings of femininity 3. Assist woman to recognize feelings, develop ways to develop more positive body image

VII.

Care of the Woman with Pelvic Relaxation

A. Muscles of pelvic floor 1. Form supportive layer that prevents abdominal and pelvic organs from prolapsing 2. Weakened or damaged → cystocele, rectocele, uterine prolapse 3. Contributing factors

B. Cystocele 1. Downward displacement of bladder 2. Symptoms a) Stress incontinence b) Complaints of feeling like something is “falling out” of her vagina c) Complaints of urinary retention, sexual dysfunction, or pelvic pressure 3. Mild → Kegel exercises a) Estrogen may improve in menopausal women 4. More severe a) Meds Detrol, DetrolLA, Oxytol, or Sanctura b) Vaginal pessaries c) Surgery

C. Rectocele 1. Posterior vaginal wall weakened → anterior wall of rectum protrudes forward into vagina a) Pocket → traps stool → constipation 2. Diagnosis a) History and physical 3. Treatment decisions a) Based on size, presence and severity of symptoms, individual situation b) Surgery often indicated

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D. Uterine Prolapse 1. Prolapse of uterine cervix associated with prolapse of upper vagina 2. Symptoms a) Dragging sensation, backache → relieved when lying down 3. Treatment a) Topical or systemic estrogen b) Vaginal pessaries c) Surgery → often hysterectomy and repair of prolapsed vaginal walls

VIII.

Care of the Woman Requiring Gynecologic Surgery 1. GYN surgeries common, particularly hysterectomies a) Informed decision (1) Indications (2) Risks (3) Success rates (4) Alternatives (5) Effects on childbearing and sexual performance (6) Effects on general functioning of body b) Second opinion c) Concerns (1) General anesthesia (2) Fear of death or disability (3) Concerns about limitation of normal functioning dependency during recovery (4) Financial coverage and potential financial loss (5) Concerns about welfare of family members d) Self-concept (1) Body image affected (2) Loss of reproductive organ 2. Hysterectomy a) Removal of uterus b) Most common non-pregnancy-related surgical procedure in United States for women c) Types (1) Total abdominal hysterectomy (TAH) (2) Bilateral salpingo-oophorectomy (BSO) (3) TAH-BSO (4) Total vaginal hysterectomy (TVH) (5) Laparoscopic-assisted vaginal hysterectomy (LAVH) d) Treatment for several conditions (1) TAH (a) Cancer of cervix, endometrium, ovary (b) Large fibroids 22 Copyright © 2020 Pearson Education, Inc.

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(c) Severe endometriosis (d) Chronic pelvic inflammatory disease (PID) (e) Adenomyosis (2) TVH (a) Pelvic relaxation (b) AUB (c) Small fibroids (d) Repair of vaginal walls at same time (e) Advantages (f) Disadvantages (3) BSO at same time remains controversial 3. Dilation and Curettage a) D&C: most frequent minor gynecologic procedure b) Indications (1) Diagnostic (a) Uterine malignancy, infertility evaluation, investigation of dysfunctional uterine bleeding (DUB) (2) Therapeutic (a) Elective abortion, treatment of heavy bleeding, incomplete abortion, dysmenorrhea, removal of polyps 4. Uterine Ablation a) To treat DUB b) Involve heat source (1) Cautery or balloon filled with hot water (2) Day-surgery setting (3) Often following hysteroscopy/D&C c) Success rate varies 5. Salpingectomy a) Unilateral or bilateral removal of fallopian tube b) For ectopic pregnancy → generally emergency 6. Oophorectomy a) Unilateral or bilateral removal ovary b) Indications (1) Severe PID (2) Malignancy (3) Ectopic pregnancy (4) Symptomatic ovarian cysts c) Will experience (1) Abrupt surgical menopause (2) Can be treated with estrogen replacement

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7. Vulvectomy a) Simple vulvectomy (1) Removal of labia majora, labia minora, clitoris (2) Leukoplakia and intractable pruritus b) Radical vulvectomy (1) Removal of entire vulva including skin, fat of femoral triangle, pelvic lymph nodes (2) Skin grafts may be necessary (3) Malignant disease c) Associated with marked psychosexual disturbances (1) Decreased sexual arousal levels (2) Low self-image 8. Nursing Management for Women Undergoing Gynecologic Surgery a) Nursing Assessment and Diagnosis (1) Identify woman’s physiologic, psychosocial, and sexual needs as surgery approaches (2) Understand her learning needs (a) Age, cultural background, education level, attitude of partner and family, preoperative status (b) Is cancer diagnosis involved? (c) Self-image b) Nursing diagnoses may include (1) Knowledge, Deficient (2) Fear c) Nursing Plan and Implementation (1) Preoperative teaching may be brief or extensive (2) Include information about procedure (a) Expected preparation (b) Type of anesthesia (c) Possible risks and complications (d) Postoperative care routines (e) Expected recovery time (3) Postoperative care (a) Monitoring of physiologic responses, emotional responses (b) Nursing interventions to facilitate physical and emotional well-being (c) Discuss psychosocial issues d) Evaluation (1) Woman can discuss reasons for surgery, alternatives, aspect of self-care after surgery (2) Woman has uneventful recovery without complications (3) Woman feels she is able to ask questions and obtain support (4) Woman participates in decision making about her care (5) Woman is aware of available resources if she has physical or emotional concerns in the postoperative period

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A. Infertility 1. Failure to achieve a successful pregnancy after 12 months or more of regular, unprotected intercourse 2. Profound emotional, psychologic and economic impact on couple 3. Sterility absolute factor preventing pregnancy 4. Subfertility couple who has difficulty conceiving because both partners have reduced fertility 5. Primary infertility: women with no prior pregnancies 6. Secondary infertility: couples who have been unable to conceive one or more successful pregnancies

B. Essential Components of Infertility 1. Correlated with possible causes found in Table 6–4: Possible Causes of Infertility, p. 108 2. Infertility due to male (30%) factor, female (60%), or unknown or both partners (10%) 3. Refer for infertility evaluation if unable to conceive after 1 year, after 6 months if female > 35 years old.

C. Initial Investigation: Physical and Psychosocial Issues 1. Easiest and least intrusive, done first: provide information about signs and timing of ovulation, most effective times for intercourse within cycle, fertility-awareness behaviors 2. Take comprehensive history and physical assessment 3. Assess ovarian function, cervical mucus and receptivity to sperm, sperm adequacy, tubal patency, condition of pelvic organs 4. Very emotional and personal issue as couple

D. Assessment of the Woman’s Fertility 1. Evaluation of ovulatory factors a) Testing for ovulation: basal body temperature (BBT), serum testing if irregular menses, progesterone levels during cycle, serum prolactin, TSH, FSH and assessment for PCOS b) OTC urinary ovulation prediction kits c) Endometrial biopsy (EMB) d) Transvaginal ultrasound 2. Evaluation of cervical factors a) During ovulation cervical mucus increases 10-fold and elasticity increases (stretches 8 to 10 cm) b) Ferning capacity increases as ovulation approaches 25 Copyright © 2020 Pearson Education, Inc.

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c) To be receptive sperm, mucus must be thin, clear, watery, profuse, alkaline, and acellular. (Figure 6–5A). Otherwise, it is inhospitable (Figure 6–5B).

(1) Intrauterine insemination (IUI) is most appropriate therapy for these issues d) Secretory immunologic reactions: antisperm antibodies causing agglutination or immobilization of sperm. IUI with washed sperm may be an option for this issue.

3. Evaluation of uterine structures and tubal patency a) Relatively uncommon b) Tubal patency and uterine structure evaluated with hysterosalpingography (HSG) or laparoscopy c) Invasive tests used include hysteroscopy and sonohysterography d) HSG (hysterography) (1) Instilation of radiopaque substance into uterine cavity for visualization (2) Injection pressure could have therapeutic effect to flush debris, break adhesions, or induce peristalsis (3) Perform early in follicular phase of cycle e) Hysteroscopy and laparoscopy (1) Hysteroscopy definitive method for diagnosis and treatment of intrauterine pathology (2) Laparoscopy enables direct visualizing of the pelvic organs to evaluate endometriosis and pelvic adhesions

E. Assessment of the Man’s Fertility 1. Some causes are reversible (ductal obstruction, varicocele) 2. Some not reversible (bilateral testicular atrophy secondary to viral orchitis, congenital bilateral absence of vas deferens) 3. Idiopathic male infertility factor is when etiology of abnormal semen analysis is not identifiable 4. Male factor usually defined by semen analysis (sperm quality, quantity, motility) a) Sample obtained after 3 days of abstinence by masturbation, before female partner’s invasive testing. Minimum of two separate analyses are recommended for confirmation (1) Low motility or number can compromise fertility (2) Morphology, motion patterns, and progression important prognostic indicators (3) Quality of sperm decreases with age

F. Methods of Infertility Management 1. Pharmacological Agents a) Clomiphene citrate is often first-line therapy: binds to estrogen receptors in the hypothalamus and pituitary gland, restores ovulation in 70% of women b) Gonadotropins such as human menopausal gonadotropins (nMGs) first line of anovulatory infertile women with low to normal FSH and LH levels; second line in women who fail to ovulate or conceive on clomiphene citrate 26 Copyright © 2020 Pearson Education, Inc.

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c) Letrosole for ovulation induction: blocks conversion of androgens to estrogens d) Bromocriptine for anovulation related to hyperproactinemia e) GnRH for inducing ovulation but is limited to women who have insufficient endogenous release of GnRH f) Insulin-sensitizing agents for anovulatory women with PCOS that causes insulin resistance and hyperinsulinemia

G. Intrauterine insemination 1. Done with partner’s or donor’s sperm 2. Indicated for seminal deficiencies, anatomical defects related to inadequate deposition of semen, ejaculatory dysfunction, cases of unexplained infertility, some female factory infertility (inhospitable mucus, persistent cervicitis, or cervical stenosis) 3. Donor insemination (DI) alternative option with donor sperm for genetic or multifactorial disorders, single women, lesbian couples a) DI complicated and expensive

H. In vitro fertilization 1. Selectively used in cases in which infertility has resulted from tubal factors, mucus abnormalities, male infertility, unexplained infertility, male and female immunologic infertility, cervical factors 2. Overall success rates 36.8% 3. Woman’s ovaries are stimulated by a combo of fertility medications, one or more oocytes are aspirated from ovaries 34–36 hours after ovulation occurs, fertilized in a lab, then placed into her uterus after normal embryo development begins. a) Occurs over 2 weeks

I. Other assisted reproductive techniques 1. Gamete intrafallopian transfer (GIFT): retrieval of oocytes by laparoscopy; immediate placement of oocytes in catheter with washed, motile sperm; and placement of gametes into the fimbriated end of the fallopian tube. a) Fertilization occurs in fallopian tube instead of in the lab b) May be acceptable option for some religions over ZIFT 2. Zygote intrafallopian transfer (ZIFT) and tubal embryo transfer (TET): eggs are retrieved and incubated with the man’s sperm a) Eggs transferred back into woman’s body at earlier stage of cell division than IVF 3. Preimplantation genetic diagnosis a) Single cell removal from embryo for genetic testing b) Detects single-gene or chromosomal anomaly c) Preimplantation genetic testing called blastomere analysis or preimplantation genetic diagnosis (PGD) 27 Copyright © 2020 Pearson Education, Inc.

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d) Preimplantation genetic screening (PGS) is used when parents presumed to have normal chromosomes and embryos are screened e) All types can produce false negatives or positives f) Raises ethical concerns

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J. Adoption 1. U.S. adoptions can be long, expensive, and difficult 2. Some couples choose to do international adoption 3. May need support if unable to be parents through books, websites, support groups

K. Pregnancy after infertility 1. Fear and anxiety common, don’t know where they “fit in” 2. Cautious about impact of treatments on the fetus, need reassurance 3. Nurses should acknowledge their past experiences, validate their fears, and provide support and education

L. Recurrent Pregnancy Loss 1. Distinct from infertility 2. Defined as three or more consecutive pregnancy losses, but definition not standardized 3. Etiologies include chromosomal abnormalities, uterine abnormalities, maternal medical complications, autoimmune disorders, and thrombotic causes

M. Nursing Management for the Infertile Couple 1. Treatment and care costly and taxing, may feel discriminated against due to inability to have children easily 2. Be aware of emotional needs of couple 3. Couples may experience feelings of loss of control, reduced competency and defectiveness, loss of status and ambiguity as a couple, sense of social sigma, stress on marriage 4. Assess and respond to emotional and educational needs using multidimensional needs of the couple 5. Refer as needed to mental health professionals

IX.

Focus Your Study

X.

Activities 1. Individual Assign students a diagnosis or surgical procedure. Have students develop a teaching plan for the 25–30-year-old patient. Have each student identify adjustments to be made for the 65–75year-old patient with the same diagnosis or procedure.

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2. Small Group Break the class into small groups of three to five students. Ask each group to pick one of the individual activities to research. Instruct the students to include pharmacologic therapy, complementary therapy, and the demographics of the patients, as well as the common psychosocial and cultural implications.

3. Large Group Invite a nurse from a gynecologic oncology practice or infertility practice to speak to students about postoperative care, and include case studies with examples of “typical” and “atypical” patients and their procedures.

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Chapter 7 Social Issues Social Issues Affecting Women Living in Poverty..............................................

2

Social Issues Affecting Women in the Workplace.............................................

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Social Issues Affecting Older Women................................................................

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Social Issues Affecting Women with Disabilities...............................................

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Social Issues Affecting Lesbian, Bisexual, and Transgender Women................

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Female Genital Mutilation (FGM)......................................................................

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Focus Your Study................................................................................................

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Activities.............................................................................................................

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I.

Social Issues Affecting Women Living in Poverty

A. The Feminization of Poverty 1. Single mothers in poverty a) Single-mother–headed households 🡪 36.5% b) Race → minority parents 2. Globally—not just in the United States a) Women work more hours than men but are paid less b) Expected to bear and raise many children and work c) Frequently abused; have few legal rights 3. Poverty linked to lack of literacy and education

B. Economic Effects of Divorce 1. Woman’s standard of living generally decreases significantly, man’s increases a) Lower earning capacity b) Custody of children c) Child support

C. Factors Contributing to Poverty for Working Women 1. Increasing participation in labor force 2. Increased earnings → significant wage discrepancy still exists a) 2012 statistics b) Factors (1) Pink collar occupations (2) Women paid less than men for work in virtually all occupations (3) Smaller pensions and social security benefits due to lower pay 3. Child care expenses a) Single mother → miss work when child sick

D. Public Assistance 1. Often fail to provide adequate assistance 2. Temporary Assistance for Needy Families (TANF) grant program a) Purpose (1) Provide assistance to needy families so children may be cared for in own homes or homes of relatives (2) End dependence of needy parents on government benefits by promoting job preparation, work, marriage (3) Prevent and reduce incidence of out-of-wedlock pregnancies (a) Goals for preventing and reducing 2 Copyright © 2020 Pearson Education, Inc.

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(4) Encourage the formation and maintenance of two-parent families 3. State has flexibility in designing programs to meet needs of recipients a) Recipients required to find employment after they receive assistance for 2 years b) Live at home (or in adult-supervised setting) and stay in school if unmarried teenage parents c) Pay child support if noncustodial parents

E. Homelessness 1. 2016 estimate—564,708 people homeless on any given night in United States a) Veterans: 6% b) Members of families → 206,286 c) Children: 36% of homeless population 2. Factors contributing to homelessness a) Families headed by single mother b) Lack of affordable housing or low-cost housing c) Job loss d) Unstable economics e) Eroding work opportunities f) Mortgage foreclosure g) Low-paying jobs h) Substance abuse i) Untreated or undertreated mental illnesses j) Poverty k) Recent prison release l) Changes and cuts in public assistance programs m) Poor educational attainment n) Minority race o) High number of children p) Lack of family or social support 3. Health risks of homeless women and children a) Malnutrition predisposes to variety of disorders b) Preventative healthcare services not received c) Inadequate prenatal care d) Increased incidence of low-birth-weight newborns e) Higher rate of infant mortality f) Higher incidence of substance abuse, including alcohol g) Higher rates of sexually transmitted infections h) Higher rates of hepatitis A, B, and C and HIV/AIDS 4. Homelessness in adolescence a) Can be related to disagreements with parents, divorce, prenatal substance abuse, neglect, and abuse.

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b) Increased risk for commercial sexual exploitation of children (CSEC) c) Adverse outcomes further increased in those in the LGBTQI population

F. Effects of Poverty on Women’s Healthcare 1. Medicaid provides healthcare to low-income in four categories a) Children b) Adults in families c) The elderly d) Blind and disabled 2. Traditionally financing maternity care → 48% of births in United States a) No automatic connections with TANF and Medicaid b) TANF recipients eligible for Women, Infants, and Children nutrition program (WIC) and other programs c) 2010 passage of the Affordable Health Care Act (1) Increase quality and affordability of health insurance (2) Lower the uninsured rate (3) Expand public and private insurance coverage (4) Reduce costs of healthcare 3. Lack of health insurance a major problem a) 2015: 10.5% of non-elderly Americans still did not have health insurance b) Led to decline in preventive services c) Implications for childbearing care 4. Assessing woman’s financial status is part of the initial family assessment a) Resources may be unavailable to buy infant supplies, etc. b) Ask in sensitive manner c) Be knowledgeable about community resources and referrals d) Working with community groups, organizations

II.

Social Issues Affecting Women in the Workplace

A. In 2016, 72.5% of women with children under the age of 18 were employed outside the home 1. Tremendous day-to-day stress → career and family a) Financial pressures

B. Wage Discrepancy 1. Historical trends a) Perception that men are sole breadwinners b) Women in past generations limited to certain occupations c) Women accepted lower salaries in exchange for provisions d) Perception that women who were competitive are viewed negatively 4 Copyright © 2020 Pearson Education, Inc.

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e) Increase in societal importance focusing on appearance rather than intellect f) Societal trends that did not support higher education opportunities for women

C. Maternal and Paternal Leave Issues 1. Full-time employment and motherhood challenging a) 1993 Family and Medical Leave Act (FMLA) signed into law (1) Up to 12 weeks unpaid leave from work following birth or adoption or foster child (2) Serious illness of self, spouse, child, parent (3) Continued health insurance benefits (4) Job security to return to person’s former position or one considered comparable (5) Applies to companies with 50 or more employees (6) Employees must work 25 hours per week to be eligible (7) Employees must be in their position for 1 year 2. U.S. parental leave benefits meager compared to other countries a) Paid parental leave is a rule rather than an exception

D. Discrimination Against Pregnant Women 1. Due to stereotypes about pregnancy 2. Pregnancy Discrimination Act of 1978 guarantees a) Pregnant woman cannot be denied job if able to perform major job functions b) Same procedure for using sick leave pay or disability benefits must be used for pregnant woman as for others c) Employee medical coverage must include pregnancy benefits d) Mother can use all maternity benefits without penalty 3. Planning pregnancy a) Acquire information about pregnancy benefits in work setting

E. Child Care 1. 1947 to 2016 → 12% to 60.8% of mothers with small children were employed a) Number of stay-at-home dads has doubled b) 69% of children raised in two-parent households c) 35% of children raised in single-mother households d) 4% of children raised in single-father households 2. Child care costs a large portion of family budget 3. Costs vary based on a) Geographic location b) Age of children c) Children with disabilities d) Type of facility e) Educational level of staff 5 Copyright © 2020 Pearson Education, Inc.

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4. Women with college educations and working outside the home a) More likely to enroll children in high-quality child care centers b) Creative approaches by some employers 5. million children live with their grandparents a) Grandparents with guardianship may qualify for benefits

F. Advocacy for Working Women 1. All women should find out prior to accepting employment a) Inquire about maternity, paternity leave, child care benefits, flexible hours, onsite day care b) Flexible break periods to breastfeed or pump breast milk

G. Environmental Hazards in the Workplace and at Home 1. Environmental toxins a) Air, food, water → can lead to adverse health effects b) Gases, chemicals at work and home, substances that contaminate food sources c) Lead-based paint (1) Adverse outcomes in children: learning disabilities, behavioral disturbances, cognitive changes, adverse kidney and nervous system functioning (2) Women during pregnancy: risk for spontaneous abortion, prematurity, low birth rate, intrauterine growth restriction, and brain, kidney, and nervous system dysfunction d) Air pollution (1) Minor problems to serious problems (2) Indoor air pollution → cigarettes, candles, wood-burning stoves, kerosene lamps, oil furnaces, cleaning products, paint, varnish, carpets (3) Pressed-wood products may release formaldehyde gas (4) Radon (5) Cat dander, molds and mildew, dust mites, cockroaches 2. Chemicals a) Only 1,500 of 80,000 chemicals in industry tested b) May harm unborn children (1) Increased risk working around paints, varnishes, sealants, dry cleaning chemicals, synthetic perfumes, hair and clothing dyes, organic solvents (2) Chemicals in home → polyvinyl chloride (PVC) releases harmful chemicals when heated (3) Beauty products → phthalates 3. Pesticides a) Vague symptoms b) Increased risk of cancer c) Nervous system abnormalities d) Birth defects 6 Copyright © 2020 Pearson Education, Inc.

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e) Endocrine abnormalities f) Hormonal imbalances g) Liver damage h) Kidney failure (1) Organochlorines degrade slowly (a) Passed from mothers to babies in womb and breast milk i) Pesticide residue in produce, fish, meats j) Mercury and PCBs found in certain types of fish k) Commercially raised meat animals contain antibiotics 4. Biological and chemical toxins a) Nurses exposed (1) Toxoplasmosis, rubella, cytomegalovirus, herpes simplex, hepatitis B (2) HIV via needle stick (3) Latex allergy b) Occupational Safety and Health Administration (OSHA) 5. Nurses need to educate women, childbearing families about risks they face

III.

Social Issues Affecting Older Women

A. Economic Vulnerability of Older Women 1. Older women more likely to be widowed, live alone, be disabled, or be poor a) Older women of color highest poverty rate 2. Factors a) Older women tend to have less educational preparation than older men b) Women must stretch financial resources further because of longer life expectancy c) Historically, women economically dependent on men d) Typically earn less, work in jobs without pension benefits, limited benefits e) Intermittent employment common → decreases social security and retirement benefits f) Generally have more family caregiving responsibilities than men g) Husband’s long, costly illness and decrease or loss of his pension following his death can negatively impact a woman’s financial resources h) Women are living longer, more likely to have out-of-pocket medical expenses after the age of 65 i) Women spend twice as much as men on long-term care expenses

B. Elder Abuse 1. See Table 7–2: Definitions of Elder Abuse, p. 130 2. Definition a) Any deliberate action, or lack of action, that causes harm to an elderly person b) Difficult to determine

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3. Five categories a) Physical abuse (1) Any physical pain or injury that is intentionally inflicted upon an elderly person by caregiver or person in position of trust (2) Includes sexual assault, physical attacks, unreasonable physical restraint, prolonged deprivation of food and water b) Financial abuse (1) Any theft or misuse of elderly person’s property or money by a caregiver or person in position of trust c) Neglect (1) Failure on part of caregiver to provide adequate reasonable care, which is the degree of care that a reasonable person would provide d) Psychologic abuse (1) Intentional infliction of mental suffering on an elder by a caregiver or person in position of trust (2) Includes, but not limited to, verbal assaults, threats, humiliation, intimidation, isolation e) Abandonment (1) Desertion of an elder by any person responsible for the care and custody of that elder, under circumstances in which a reasonable person would continue to provide care 4. Nursing responsibility a) If you suspect elder abuse → take steps to address the problem when it is identified

C. Implication of Aging for Women’s Health and Healthcare 1. Older women often face health problems a) Hypertension, coronary artery disease, arthritis, diabetes, osteoporosis, dementia, depression b) Heart disease, cancer, and chronic lower respiratory disease → leading causes of death for all women age 65 or older c) By age 65, half of all women have developed two or more chronic diseases 2. Older women face multiple barriers in obtaining adequate healthcare services a) Lack of transportation b) Lack of private health insurance coverage c) Excessive medical costs 3. Polypharmacy a) Elderly women: multiple healthcare providers b) Multiple medications with possible side effects or dangerous interactions c) Polypharmacy may be justified; may be inadvertent d) Nutritional supplements → can interact with prescription medication (1) Maintain a medication list (2) Fill prescriptions at same pharmacy 8 Copyright © 2020 Pearson Education, Inc.

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(3) Provide family member or care provider with updated medication list e) Diminished kidney and liver function → central nervous system (CNS) medications may cause forgetfulness, confusion, disorientation, inability to concentrate

IV.

Social Issues Affecting Women with Disabilities A. Definitions of Disability 1. Chronic physical or health problem or impairment that restricts an individual’s ability to perform one or more major activities 2. Work disability restricts individuals from employment 3. Severe disabilities prohibit individuals from performing basic activities of daily living without assistance

B. Types of Disabilities 1. Developmental disabilities create severe limitations in three or more of these areas a) Self-care b) Receptive and expressive language c) Learning d) Mobility e) Self-direction f) Ability to live alone g) Financial independence 2. Intellectual disability most common 3. Women with intellectual disabilities often faced mandatory sterilization in early to mid-20th century a) Human rights → sexual choices b) May pursue prenatal care services later than other women c) Failure to recognize signs and symptoms related to pregnancy d) Common to request termination services and sometimes after gestational age limit e) 25% of women with intellectual disabilities who give birth become involved with Child Protective Services (CPS) f) Additional social support, parenting education, peer support, modified teaching methods

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4. Learning disabilities can inhibit educational attainment and employment 5. Common neurologic disabilities 6. Psychiatric disabilities 7. Sensory disabilities

C. Economic Vulnerability of Women with Disabilities 1. Only 18% of women with disabilities employed a) Many part time 2. Barriers to employment a) Lack of education and training b) Transportation c) Disability access d) Need for special accommodations e) Rural areas; fewer employment options f) American with Disabilities Act (ADA) intended to reduce barriers 3. Typically earn less than women who are not disabled a) Greater number live in poverty

D. Violence Against People with Disabilities 1. Women with disabilities twice as likely to be victims of domestic violence than nondisabled women a) 50% of disabled women will experience abuse or violence

E. Effects of disability on women’s healthcare 1. Health services often suboptimal a) Barriers b) Receive less preventive care c) Assumption that the disabled are not sexually active → not screened for sexually transmitted infections (STIs)

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V.

Social Issues Affecting Lesbian, Bisexual, and Transgender Women A. Quality of Life 1. Employment and housing discrimination 2. Discrimination involving marriage, domestic life, and parenting issues 3. General social discrimination

B. Employment Discrimination 1. Most common complaint to American Civil Liberties Union (ACLU) is from LGBTQI individuals 2. Private sector and military a) Don’t Ask, Don’t Tell Repeal Act of 2010 (1) Allows military service members to be openly gay or lesbian and serve in the military

C. Marriage Discrimination 1. In 2015, same-sex marriage became legal in all 50 states

D. Spousal Benefits 1. Married LGBTQI families now have equality and receive the following benefits: a) Social security benefits b) Tax return benefits for joint filing c) Estate tax and estate planning benefits d) Estate and gift tax exemptions e) Estate tax portability f) Life estate trusts g) Veteran and military benefits h) Federal employee benefits i) Immigration benefits

E. Housing Discrimination 1. Fair Housing Act a) Protects various groups b) Generally does not apply to LGBTQI community

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2. Some states and municipalities have enacted antidiscrimination laws 3. Some states discriminate on basis of sexual orientation 4. May not be able to use combined income to determine eligibility for mortgage

F. Parenting Issues 1. Second-parent adoption 2. Many lesbian women wish to adopt a) Barriers b) Policies, legislation 3. Foreign adoptions not necessarily easier 4. Discriminatory tax laws because partners/parents not legally married

G. Social Barriers 1. Discrimination, danger a) Treated rudely, ostracized 2. Hate crimes 3. Acceptance of gay men and women on rise

H. Effects of Discrimination on Lesbian, Bisexual, Transgender, and Intersex Women’s Healthcare 1. Healthy People 2020 acknowledged sexual orientation as risk factor a) Lack of insurance (1) Less likely than heterosexual women to have health insurance b) Fear of discrimination on part of providers c) Provider ignorance of lesbian and bisexual women’s healthcare needs (1) Increased risk of suicide (2) Increased risk of homelessness (3) Increased risk of violence (4) Increased risk of obesity (5) Increased risk of depression rates (6) Increased tobacco use (7) Higher incidence of alcohol use (8) Increased risk of substance abuse disorders (9) Lack of screening for female-related cancers

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VI.

Female Genital Mutilation

A. FGM: practice of removing all or part of a girl’s or woman’s genitalia for cultural reasons B. Origin and demographics 1. Performed most commonly in sub-Saharan Africa and to a lesser extent in Asia and the Middle East 2. Reasons a) Perceived improved hygiene b) Social acceptance c) Marriageability d) Preservation of virginity/reduction of female sexual desire e) Male sexual desire f) Religious requirement 3. Varying degrees of mutilation a) Complete removal of external genitalia to complete removal of clitoris

C. Health problems 1. Bleeding 2. Infection 3. Urinary tract infections 4. Urinary strictures 5. Reproductive tract infections 6. Infertility 7. Painful intercourse 8. Difficulties relating to childbearing

VII.

Focus Your Study

VIII.

Activities 1. Individual Have students review Healthy People 2020. Have students identify issues that are identified that are specific to women, issues that have been resolved or improved, and issues that have not been improved. Have each student write a short paper (one to two pages, references cited using APA format) linking health issues to other social issues affecting women.

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2. Small Group Divide the class into small groups of three to five students. Have each group identify an issue of interest to group (or assign an issue to each group). Ask the groups to use the Internet and other available resources to identify community support resources for their assigned health or social issue. Instruct each group to compile a resource list with phone numbers and addresses and to confirm the resources by calling or visiting to determine the available services.

3. Large Group Invite a community nurse or social worker to you classroom to discuss the procedures necessary for unemployed mothers to access healthcare services, housing assistance, and so on.

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Chapter 8 Violence Against Women Endemic in Society............................................................................................

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Historic Factors Contributing to Violence Against Women.............................

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Domestic Violence............................................................................................

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Sexual Assault...................................................................................................

8

Sex Trafficking...................................................................................................

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Focus Your Study..............................................................................................

15

Activities............................................................................................................

15

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I.

Endemic in Society

A. Intimate partner violence (IPV) and sexual assault B. Statistics 1. IPV declined between 1994 and 2010 a) Rates of violence are higher among lesbian and bisexual woman b) Older woman can be victims of intimate partner violence c) Estimated health-related costs of violence against women: $8.3 billion annually in United States d) Controlling individuals are more likely to be physically assaultive

C. Role of healthcare providers, organizations 1. Healthy People 2020: IPV prevention for violent behavior national priority 2. Nursing role

II.

Historic Factors Contributing to Violence Against Women 1. Patriarchal societies 2. Legal status of women improved 3. Traditional view of rape 4. Violence against women and girls now being used as weapon of war

III.

Domestic Violence

A. Defined (intimate partner violence [IPV]) 1. Pattern of coercive behaviors and methods used to gain and maintain power and control by one individual over another in an adult intimate relationship

B. Common in the United States 1. 1 in 4 women will experience domestic violence 2. Forms of abuse a) Physical abuse (1) Pushing (2) Shoving (3) Slapping (4) Hitting with fist or object (5) Kicking (6) Choking (7) Threatening with a gun or knife 2 Copyright © 2020 Pearson Education, Inc.

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(8) Forcing alcohol or drug abuse b) Emotional abuse (1) Constant criticism (2) Name calling (3) Unreasonable demands (4) Damaging relationship with children and others c) Sexual abuse (1) Forced sex (2) Sexually demeaning treatment d) Isolation (1) Controlling who she sees and where she goes (2) Jealousy to restrict actions (3) Interfering with job (4) Forbidding her to see friends and family (5) Limiting outside involvement e) Economic abuse (1) Preventing her from getting a job or keeping a job (2) Controlling the money; having her ask for money (3) Destroying her property (4) Making all the financial decisions f) Coercion threats g) Intimidation h) Using others i) Male privilege j) Stalking (1) See Figure 8–2: The power and control wheel, p. 141 3. Abuse typically begins slowly, subtly 4. Consequences of abuse profound a) Physical consequences b) Adverse psychologic consequences (1) Post-traumatic stress disorder (2) Depression (3) Antisocial behavior (4) Anxiety (5) Suicidal behavior (6) Low self-esteem (7) Fear of intimacy c) Social consequences

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C. Contributing Factors 1. Childhood experiences 2. Male dominance in the family 3. Marital conflict 4. Unemployment/low socioeconomic status 5. Traditional definitions of masculinity/hypermasculinity 6. Internalized homophobia (within lesbian relationships)

D. Common Myths about Battering and Women with Abusive Partners 1. Battering occurs in a small percentage of the population a) As many as 1 in 4 are victims; widely underreported crime 2. Women who are abused provoke men to beat them; women push men beyond the breaking point and incite physical violence a) People are responsible for their individual behavior b) Batterers violent because of their own inadequacies 3. Alcohol and drug abuse cause battering a) Claims that substance abuse causes domestic violence are false b) Alcohol and drug reduce batterer’s inhibitions, increasing likelihood of violent acts 4. Battered women can easily leave situation a) Difficult → society, finances, support b) Battered women may fear for her safety, the safety of her children, and those that help her 5. Domestic violence is a low-income or minority issue a) All sectors of society 6. Battered women will be safer when they are pregnant a) Battering may escalate in intensity

E. Cycle of Violence 1. Tension-building phase a) Batterer demonstrates power and control b) Woman may blame self, believe she can prevent escalation 2. Acute battering incident a) Typically triggered by external event, or internal state of batterer b) Batterer blames woman for abuse 3. Tranquil phase or honeymoon period a) Characterized by extremely loving, kind, contrite behaviors by batterer 4 Copyright © 2020 Pearson Education, Inc.

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b) May be absence of tension and violence

F. Characteristics of Batterers 1. All racial, ethnic, religious groups 2. All professions, occupations, socioeconomic strata 3. Commonalities a) Feelings of insecurity, inferiority b) Powerlessness, helplessness → conflict with assumptions of male supremacy c) May feel undeserving of partners d) Jealousy and possessiveness hallmarks of abusers e) May select partner they feel to be vulnerable f) May lack respect toward women in general g) May have been abused

G. Nursing Management for the Woman Experiencing Domestic Violence 1. Women enter healthcare system in many different settings a) Physician’s office b) Emergency department c) Obstetric services d) Psychiatric-mental health 2. May have no visible injuries 3. Women may return to abusive situations a) Statistics show risk for homicide, additional violence → greatest during separation, attempts at separation 4. Nursing Assessment and Diagnosis a) Universal screening advocated b) Importance and need for comprehensive education and training c) Nurses may be hesitant to ask questions d) Basic screening questions useful in identifying women who are experiencing abuse e) Signs that may indicate woman in abusive relationship include (1) Neurologic (2) Gynecologic (3) Obstetric (4) Gastrointestinal (5) Musculoskeletal (6) Psychiatric (7) Constitutional (8) Trauma (9) Other signs f) Nurse alert for cues of abuse

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(1) Hesitation in providing details (2) Inappropriate affect for situation or about injury and how it occurred (3) Defensive injuries (4) Delayed reporting (5) Pattern of injury (6) Inappropriate explanation (7) Vague complaints without accompanying pathology (8) Lack of eye contact (9) Increased anxiety in presence of possible batterer g) Arrange for private place in which woman can feel safe (1) Encourage woman to talk about her injuries and home situation (2) Demonstrate willingness to talk about violence (3) Remain nonjudgmental 5. Assessment a) Determine sense of history and pattern of abuse b) Information about strengths, support system c) Cultural context d) Building relationship based on trust, understanding, advocacy e) Record extent of injuries f) Note woman’s exact words g) Describe incident 6. Diagnoses a) Powerlessness, Risk for b) Knowledge, Readiness for Enhanced 7. Nursing Plan and Implementation a) Reestablish feeling of control (1) Provide information that woman can understand b) Supportive counseling, reassurance (1) Acknowledge and support woman for discussing situation (2) Let woman work through story at her own pace (3) Let woman know that she is believed, feelings reasonable and normal (4) Anticipate ambivalence in relationship with batterer (5) Assist in identifying specific problems, support realistic ideas (6) Help clarify woman’s beliefs and myths (7) Stress that no one should be abused → abuse is not her fault 8. Health promotion education a) If woman returns to abusive situation → encourage her to develop an exit/safety plan for self and children (1) Pack a change of clothes for herself and her children (2) Ask a neighbor to call the police if violence begins (3) Have money and identification documents ready (4) Have a plan of where to go regardless of time of day or night 6 Copyright © 2020 Pearson Education, Inc.

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(5) Identify friends and family who know about the situation and are willing to help (6) Have a planned escape route and emergency numbers to call 9. Community-based nursing care a) Inform woman of services available (1) Hospital (2) Agencies (3) Community (4) Phone numbers b) Needs of abused women (1) Medical treatment for injuries (2) Temporary shelter (3) Legal assistance (4) Financial assistance (5) Job training, employment counseling (6) Counseling c) Network of community agencies (1) Emergency department services (2) Shelters (a) Contacted through community crisis line (3) Legal services and options (a) Vary according to state laws and services (b) Restraining/protective order (c) Legal advocacy services (4) Financial services (5) Employment training or placement (6) Counseling or advocacy 10. Evaluation a) Woman receives compassionate, respectful, individualized medical attention b) Woman recovers from physical effects of physical and sexual abuse c) Woman has information she needs to make a decision about future based on thoughtful consideration of alternatives d) Woman able to identify culturally appropriate community resources available to her, develops strategies for keeping herself safe e) All necessary documentation is recorded in medical records in case of prosecution

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IV.

Sexual Assault A. Refers to variety of types of unwanted sexual touching or penetration without consent 1. From unwanted sexual contact or touching of an intimate part of another person 2. To forced anal, oral, or genital penetration 3. Rape → forced sexual intercourse including both psychologic coercion as well as physical force a) Includes penetration by offender or foreign object 4. One of most underreported crimes in United States a) Reporting varies by type of rape or sexual assault b) 9 out of 10 victims female

B. Common Myths about Rape 1. Only certain types of women are raped 2. Men rape women because that is men’s nature, biologic role 3. Women who party hard, drink, and do drugs are setting themselves up for sexual assault 4. If woman just relaxes, it will all be over with soon, might even find it isn’t so bad after all 5. Rapist is easy to spot in crowd 6. Women lie about rape as an act of revenge or guilt 7. Fighting back incites rapist to violence

C. Characteristics of Perpetrators 1. All ethnic, racial, religious, socioeconomic, educational, professional backgrounds 2. Attitudes toward women 3. Impulsive, antisocial tendencies 4. Male, alcohol, drug use 5. Emotionally unsupportive family environment 6. Beliefs that support male entitlement and sexual violence

D. Types of Rape 1. Power rape → purpose is control or mastery a) Vast majority of rapes

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2. Anger rape → used to express feelings of rage a) Brutality and degradation characterize this type of rape 3. Sadistic rape → antisocial personality, delights in torture, mutilation a) Cause the most injuries, including homicide 4. Stranger rape → sudden, unexpected 5. Acquaintance rape → assailant is someone the victim has had previous nonviolent interaction a) Nonstranger rape b) Marital rape c) Date rape 6. Gang rape → reinforcing mechanism for membership in particular group of men a) Provides means for demonstrating power → prove status in group

E. Role of Substances in Sexual Assault 1. Used to sedate intended victim a) Alcohol most common b) Flunitrazepam (Rohypnol) c) Gamma hydroxybutyrate (GHB) d) Ketamine e) MDMA (Ecstasy) f) Clonazepam g) Scopolamine 2. See Table 8–1: Indicators of Possible Drug-Facilitated Sexual Assault, p. 150 a) Becoming intoxicated very rapidly b) Having just one or two drinks, then suddenly feeling very drunk c) Feeling drowsy, dizzy, agitated weak, confused, nauseous, increased heart rate or blood pressure, slurred speech, lack of motor coordination d) Waking up suspecting she may have been raped because of vaginal soreness, finding self in unfamiliar place, other indicators e) Being told she suddenly appeared drunk, drowsy, dizzy, confused with impaired motor skills, judgment, amnesia or partial amnesia

F. Date Rape and Violence on College Campuses 1. 23.1% of all undergraduate females experience sexual assault or rape 2. Increased awareness of rape and violence has occurred in the wake of high-profile cases 3. Title IX Legislation a) Best known for its requirement that all colleges and universities that receive federal funding provide equal opportunities for women in athletic programs, facilities, educational programs, etc.

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b) Also addresses the issue of sexual harassment and violence against women. c) Campuses now have Title IX officers who actively work to provide education to students, faculty, and staff about these issues.

G. Rape Trauma Syndrome 1. Four phases a) Acute (disorganization) phase (1) Begins during rape → few days, up to 3 weeks (2) Shock, disbelief, denial (3) May feel humiliated, guilty, unclean (4) May suppress emotions or reveal them (5) Alterations in sleep patterns b) Outward adjustment (denial) phase (1) After acute stage passed → may appear adjusted (2) Means of regaining control of life (3) May move, institute security measures c) Reorganization (1) As denial and suppression deteriorate → depression, anxiety, urge to talk about rape (2) Alters self-concept, resolve feelings (3) May develop phobias (4) Frequently report menstrual, GYN disorders, sexual dysfunction (5) Long-term physical, psychologic health consequences (a) Pregnancy (b) Chronic pain (c) Gastrointestinal disorders (d) Headaches (e) Sexually transmitted infections (f) Depression (g) Fear and anxiety (h) Sleep disorders (i) Difficulty trusting others (j) Eating disorders (k) Attempted or completed suicide (l) Postraumatic stress disorder (m) Unhealthy behaviors d) Integration and recovery (1) Resolution (2) Blame lies with assailant e) Silent reaction (1) Women who do not report (2) May seek help for injuries without disclosing rape

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H. Sexual Assault as a Cause of Posttraumatic Stress Disorder 1. Diagnosis a) Must have been exposed to traumatic event that triggered feelings of intense fear, horror, helplessness b) Reexperience event in recurrent, intrusive thoughts, images, perceptions, flashback c) Persistently avoid stimuli associated with the trauma, demonstrate generalized numbness of responsiveness d) Demonstrate persistent signs of increased arousal 2. Marked by varying degrees of intensity a) Prior mental health issues b) Woman’s own resiliency 3. Difficult to treat

I. Physical Care of the Sexual Assault Survivor 1. Primary purpose of care to meet needs of survivor a) Evaluate and treat injuries b) Conduct prompt examinations c) Provide support, crisis intervention, advocacy d) Provide prophylaxis against STIs e) Assess for pregnancy risk, discuss treatment options f) Provide follow-up care (1) Medical and emotional needs 2. Secondary purpose of care a) Collect and preserve legal evidence for use in prosecuting assailant b) Even though evidence collected → survivor does not have to prosecute c) Respect rights of survivor 3. Secondary victimization a) Victim blaming, insensitive and prying care b) Forensic nurse examiner (FNE) and sexual assault response team (SART) → multidisciplinary community programs c) Advocacy in the emergency department 4. Detailed history a) Essential first step in acquiring medical and forensic data b) Caring and sensitive → therapeutic tool 5. Collection of evidence a) May be traumatic for the woman b) Thorough explanation → informed consent form c) Chain of evidence (1) Physical evidence and specimens in hands of professional and then police officer

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(2) Vaginal and rectal examinations (3) Complete physical examination for trauma d) Clothing (1) Clothing marked, placed in individual paper bag, sealed, labeled e) Swabs of stains and secretions (1) Analyzed for semen or sperm (2) Cultures f) Hair and scrapings (1) Clippings or scrapings of woman’s fingernails (2) Hairs pulled from woman’s head, pubic area (3) Pubic hair combed to check for loose hairs g) Blood samples h) Urine samples (1) If drug-facilitated sexual assault suspected (2) Drug ingested within 96 hours of evidentiary exam i) Photographs (1) Of injured areas (2) Informed consent form 6. Prevention of sexually transmitted infections a) Common → trichomoniasis, bacterial vaginosis, gonorrhea, chlamydia b) Preventative therapy recommended (1) Centers for Disease Control (CDC) → single-dose intramuscularly (IM) ceftriaxone, single-oral dose metronidazole, single-oral dose azithromycin (2) Instruct to see caregiver in 2 weeks for assessment c) Hepatitis B risk → hepatitis B vaccination if never immunized 7. Prevention of pregnancy a) Questioned about menstrual cycle, contraception b) Receive information about treatment options

J. Nursing Management for the Woman Who Has Been Sexually Assaulted 1. Often access healthcare system through ED a) Nurses must examine own attitudes and beliefs about sexual assault and survivors b) Mindful of potential for increased complexity of treatment → cultural backgrounds 2. Nursing Assessment and Diagnosis a) Create safe, secure environment b) Full mental status examination c) Scrupulous documentation d) Diagnoses may include (1) Fear (2) Powerlessness

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3. Nursing Plan and Implementation a) See Table 8–3: Nursing Actions Appropriate to Phases of Recovery Following Rape, p. 154 (1) Acute phase (a) Create safe environment (b) Explain sequence of events in healthcare facility (c) Allow woman to grieve and express feelings (d) Provide care for significant others (2) Outward adjustment phase (a) Provide advocacy, support at level requested by the woman (b) Provide assistance to significant others (3) Reorganizational phase (a) Establish a trusting relationship (b) Assist woman in understanding her role in the assault (c) Clarify and enhance woman’s feelings (d) Assist the woman in planning for her future (4) Integration and recovery (a) Acknowledge victim’s success in overcoming trauma (b) Support advocacy efforts 4. Community-based nursing care a) Reorganization phase → urge to discuss, resolve feelings (1) Specially trained sexual assault advocate, counselor (2) Information and support to explore, identify feelings b) Health promotion education (1) Preventive strategies (2) What to do during and after an attack c) See Table 8–4: General Guidelines for Helping Victims of Sexual Assault, p. 155 (1) Believe the victim (2) Listen and be patient (3) Reinforce that sexual assault was not victim’s fault (4) For recent assaults, encourage reporting, and preservation of evidence (5) Encourage person to seek medical attention (6) Suggest seeking counseling, other support services (7) Help victim to organize thoughts, let survivor make own decisions (8) Take care of yourself (9) Acknowledge limits, realistically identify abilities to assist survivor 5. Sexual assault advocacy and information a) Sexual assault crisis centers → 24 hours/day, 7 days/week 6. Evaluation a) Woman receives prompt, compassionate, respectful individualized medical attention b) Woman recovers from physical effects of sexual assault c) Woman able to verbalize recognition that sexual assault is crime of violence expressed sexually 13 Copyright © 2020 Pearson Education, Inc.

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d) Woman able to identify culturally appropriate community resources available to her e) Woman able to make decision about whether to prosecute assailant f) If victim decides to prosecute, all necessary forensic evidence collected

K. Prosecution of the Assailant 1. Considered crime against state rather than victim a) Victim must initiate process 2. Second rape: victim must identify assailant, repeat details of assault 3. Cross-examination by defendant’s attorney can be degrading, intimidating 4. Rape shield laws 5. Nurse needs to be aware of judicial sequence a) Anticipate rising tension, frustration in the victim and support system

L. Responding to Violence Against Women: Vicarious Trauma 1. Gradual internal transformation a) Negatively affect commitment to one’s work b) Reduce sense of accomplishment c) Lead to questioning of personal belief system 2. Burnout 3. Similar to vicarious trauma, more severe

V.

Sex Trafficking 1. Refers to “the recruitment, harboring, transportation, provision, or obtaining of a person, through force, fraud, or coercion, for the purpose of commercial sex” (Nurse Practitioner’s in Women’s Health [NPWH], 2017, p.8).

2. Domestic minor sex trafficking (DMST) is a subset of the problem. a) Refers to the specific engagement of minors less than 18 years of age. b) Refers to sexual acts in which the child is the victim of sexual exploitation for remuneration to survive (1) i.e., money, shelter, food, or clothing 3. In 2000 the U.S. Trafficking Victims Protection Act (TVPA) was passed to address this issue. a) Updated the post-Civil War slavery statutes b) Narrow in scope and only provides assistance to undocumented immigrant women who are victims of severe forms of trafficking and to girls under age 18.

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d) Live in extreme poverty e) History of abuse in their family f) Adolescent runaways at greatest risk 5. Long-term health issues for victims of sex trafficking: a) Unintended pregnancies b) Poor dentitian due to malnutrition c) Sexually transmitted infections d) Depression e) PTSD 6. Nursing assessment for signs an individual may be in an exploitive situation: a) Similar to signs of domestic violence b) Submissive behavior and evidence of being controlled c) Vague answers to questions about history d) Discrepancies between clinical injury and the client’s explanation of how the injury occurred e) Delay in seeking treatment for an injury f) Signs of physical abuse g) Depression, substance abuse, or PTSD h) Recurrent STI’s i) Genital or rectal trauma j) History of repeat miscarriages or abortion

VI.

Focus Your Study

VII.

Activities 1. Individual For a major city in the state or for a specific state, have each student develop a resource list for the survivors of domestic violence and rape that can be submitted electronically for compiling.

2. Small Group Divide the class in small groups of three to five students. Assign each group an ethnic group or culture in their local area. Have each group research the views and customs regarding domestic violence and rape and prepare a short presentation for the class.

3. Large Group Invite a domestic abuse counselor or rape counselor (nurse if available) to discuss the care of victims with the entire class.

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Chapter 9 Reproductive Physiology, Conception, and Fetal Development Female Reproductive System...........................................................................

2

Female Reproductive Cycle..............................................................................

6

Male Reproductive System…………………………………………………………………………

8

Gametogenesis…………………………………………………………………………………………..

10

The Process of Fertilization………………………………………………………………………..

11

Preembryonic Stage…………………………………………………………………………………..

12

Twins………………………………………………………………………………………………………....

15

Development and Functions of the Placenta………………………………………………

15

Development of the Fetal Circulatory System…………………………………………….

18

Embryonic and Fetal Development…………………………………………………………….

19

Factors Influencing Embryonic and Fetal Development……………………………..

25

Focus Your Study.............................................................................................

25

Activities...........................................................................................................

25

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I.

Female Reproductive System

A. External Genitals 1. Vulva a) Mons pubis (1) Softly rounded mound of subcutaneous fatty tissue (2) Covered with pubic hair b) Labia majora (1) Longitudinal raised folds of pigmented skin on either side of vulvar cleft (2) Extensive venous network → varicosities may occur during pregnancy (3) Trauma (sexual or birth) → hematoma (4) Lymphatic supply c) Labia minora (1) Soft folds of skin within labia majora converge near anus (2) Many sebaceous glands, tactile nerve endings d) Clitoris (1) Between labia minora (2) Tissue erectile (3) Covered by fold of skin → prepuce or clitoral hood (4) Rich blood and nerve supply (5) Primary erogenous organ of women e) Urethral meatus and opening of paraurethral glands (1) 1 to 2.5 cm beneath clitoris (2) Difficult to visualize (3) Skene glands open into posterior wall of urethra to close opening f) Vaginal vestibule (1) Boat-shaped depression enclosed by labia majora → visible when separated (2) Hymen → thin, elastic collar of tissue surrounding vaginal opening (a) Essentially avascular (3) Vulvovaginal (Bartholin) glands under constrictor muscles of vagina (4) Secretions enhance viability and motility of sperm deposited in vaginal vestibule (5) Innervated by perineal nerve from sacral plexus g) Perineal body (1) Wedge-shaped mass of fibromuscular tissue (2) Found between lower part of the vagina and anus (3) Superficial area referred to as perineum (4) External sphinctor ani, levator ani, bulbocavernosus 2. See Figure 9–1: Female external genitals, longitudinal view, p. 158

B. Female Internal Reproductive Organs 1. Vagina a) Muscular, membranous tube → connects external genitals with uterus 2 Copyright © 2020 Pearson Education, Inc.

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(1) Birth canal b) Cervix of uterus projects into upper part of anterior wall c) Upper part of vagina → vaginal vault (1) Recess around cervix → vaginal fornix d) Space in fornix permits pooling of semen e) Walls of vagina covered with ridges → rugae (1) Stretch for childbirth and coitus f) Vaginal environment normally acidic during reproductive life (1) Lactic acid–producing bacilli and vaginal epithelial cells maintain environment g) Distinct vascular, lymphatic pattern in each third of vagina (1) Vaginal lymphatics → drain to external and internal iliac, hypogastric, and inguinal nodes (2) Posterior wall → nodes in rectovaginal system h) Pudendal nerve → lower third i) Functions (1) Serve as passage for sperm, fetus (2) Provide passage for menstrual blood flow (3) Protect against trauma and infection 2. Uterus a) Hollow muscular thick-walled organ b) Upside-down pear shape c) Center of pelvic cavity d) One fourth of women exposed to diethylstilbestrol (DES) in utero have structural variations of the cervix, uterus, and vagina e) Divided into two major parts (1) Corpus → uterine body (a) Myometrium (b) Fundus (c) Cornua (2) Lower segment → isthmus (a) Between cervical os and endometrial cavity f) Extensive blood and lymphatic supply (1) See Figure 9–4: Blood supply to the vagina, ovary, uterus, and fallopian tube, p. 160 g) Autonomic nervous system (1) Vasoconstriction, muscular contraction h) Pain of contractions → 11th and 12th thoracic nerve roots i) Motor fibers → 7th and 8th thoracic vertebrae j) Function (1) Safe environment for fetal development (2) Nidation k) Body of uterus, cervix → permanently changed by pregnancy l) Uterine corpus (1) Three layers 3 Copyright © 2020 Pearson Education, Inc.

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(a) Serosal layer → perimetrium (b) Muscular layer → myometrium (i) Smooth involuntary muscle (ii) Longitudinal muscle fibers (iii) Interlacing muscle fibers (iv) Circular fibers (v) See Figure 9–5: Myometrium uterine muscle layers placement and function, p. 160 (c) Mucosal layer → endometrium (i) Monthly renewal and degeneration (ii) Glands produce secretion → keeps cavity moist, facilitates sperm travel to fallopian tubes (iii) Blood supply unique → differing responses to hormone cycle 3. Cervix a) Distal end of uterus (1) Internal os to external os → approximately 2.5 cm (2) Protective portal for body of uterus b) Vaginal cervix → pink, ends at external os c) Supravaginal cervix → surrounded by ligaments that give uterus main support (1) Uterosacral, transverse, and pubocervical d) Cervical canal e) Elastic f) Three functions (1) Provide lubrication for vaginal canal (2) Act as bacteriostatic agent (3) Provide alkaline environment to shelter deposited sperm from acidic vaginal secretions (a) Cervical mucus clearer, thinner, more alkaline at ovulation g) See Figure 9–2: Female internal reproductive organs, p. 159 h) See Figure 9–3: Structures of the uterus, p. 159 4. Uterine ligaments a) Broad ligament → keeps uterus centrally placed, provides stability b) Round ligaments → keep uterus in place c) Ovarian ligaments → anchor lower pole of ovary to cornua of uterus d) Cardinal ligaments → chief uterine supports, suspending uterus from side walls of true pelvis → Mackenrodt ligaments, transverse cervical ligaments e) Infundibulopelvic ligament → suspends and supports ovaries f) Uterosacral ligaments → provide support for uterus, cervix at level of ischial spines g) See Figure 9–7: Uterine ligaments, p. 162 5. Fallopian tubes a) Oviducts, uterine tubes → arise from each side of uterus (1) 8 to 13.5 cm long 4 Copyright © 2020 Pearson Education, Inc.

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(2) Short section inside uterus b) Divided into three parts (1) Isthmus (2) Ampulla (3) Fimbria c) Wall of fallopian tube four layers (1) Peritoneal (serous) (2) Subserous (adventitial) (3) Muscular (4) Mucous d) Tubal transport system e) Rich blood, lymph supply f) Three functions (1) Provide transport for ovum from the ovary to the uterus (2) Provide a site for fertilization (3) Serve as warm, moist, nourishing environment for ovum, zygote 6. Ovaries a) Two almond-shaped glandular structures just below pelvic brim b) Each side of pelvic cavity c) 6 to 10 g, 1.5 to 3 cm wide, 2 to 5 cm long, 1 to 1.5 cm thick d) Enlarge after puberty → decrease in size after menopause e) No peritoneal covering (1) Assists mature ovum to erupt (2) Also allows easier spread of malignant cells from cancer of ovaries f) Primary source of estrogens (characteristics of femaleness) and progesterone (hormone of pregnancy) g) Interplay between ovarian hormones and FSH, LH responsible for cyclic changes → allow pregnancy to occur 7. See Figure 9–6: Fallopian tube and ovaries, p. 161

C. Bony pelvis 1. Two unique functions a) Support and protect pelvic contents b) Form relatively fixed axis of birth passage

D. Breasts 1. Mammary glands a) Accessories of reproductive system b) Specialized sebaceous glands c) Conical, symmetrically placed on sides of chest d) Cooper ligaments suspend fibrous tissue

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2. Nipple → center of each mature breast a) Erectile tissue b) Surrounded by heavily pigmented areola c) Small papillae → tubercles of Montgomery → secrete fatty substance that helps lubricate and protect the breasts 3. Composed of glandular, fibrous, and adipose tissue a) Alveoli arranged in series of 15 to 24 lobes b) Grapelike clusters around tiny ducts c) Cyclic hormonal control is complex 4. Biologic function a) Provide nourishment and protective antibodies to infants through lactation process b) Source of pleasurable sexual sensation c) See Figure 9–8: Anatomy of the breast, p. 163

II.

Female Reproductive Cycle

A. Ovarian cycle and menstrual cycle B. Effects of Female Hormones 1. Cyclic pattern of ovulation and menstruation from menarche through menopause a) Menstruation under neurohormonal control b) Ovaries → mature gametes, secrete hormones → estrogens, progesterone, testosterone (1) Sensitive to FSH and LH c) Uterus → sensitive to estrogen and progesterone 2. Estrogens a) Hormones that control development of female secondary sex characteristics b) Assist in maturation of ovarian follicles c) Cause endometrial mucosa to proliferate following menstruation d) Have effects on many hormones, other carrier proteins 3. Progesterone a) Secreted by corpus luteum b) Hormone of pregnancy → allows pregnancy to be maintained (1) Vaginal epithelium proliferates (2) Cervix secretes thick, viscous mucus (3) Breast glandular tissue increases in size and complexity (4) Breasts prepare for lactation (5) Temperature rise that accompanies ovulation, secretory phase of menstrual cycle 4. Prostaglandins a) Oxygenated fatty acids produced by cells of endometrium b) Prostaglandin E (PGE) relaxes smooth muscle, vasodilator c) Prostaglandin F (PGF) increases contractility of muscles, arteries vasoconstrictor 6 Copyright © 2020 Pearson Education, Inc.

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d) Prostaglandin production increases during follicular maturation 5. See Figure 9–9: Female reproductive cycle: interrelationships of hormones with the three phases of the uterine cycle, and the two phases of the ovarian cycle in an ideal 28-day cycle, p. 164

C. Neurohormonal Basis of the Female Reproductive Cycle 1. Hypothalamus secretes gonadotropin-releasing hormone (GnRH) → pituitary gland → anterior pituitary secretes FSH and LH 2. FSH responsible for maturation of ovarian follicle a) Final maturation requires action of LH → peak production precedes ovulation by as much as 12 hours to 24 hours b) LH increases production of progesterone by granulose cells of follicle (1) Estrogen production declines, progesterone secretion continues (2) Ovulation → following rapid growth of follicle (3) Ruptured follicle → rapid change → complete luteinization accomplished → cells become corpus luteum 3. Ovarian cycle a) Follicular phase → days 1 to 14 b) Luteal phase → days 15 to 28 c) Graafian follicle → day 14 → dual control of FSH and LH (1) Produces estrogen (2) Mature graafian follicles surrounded by granulose cells (3) Zona pellucida develops around oocyte (4) Two cells form → polar body, secondary oocyte d) Travels to surface of ovary e) Mid-cycle pain → mittelschmerz caused by local peritoneal reaction to expelling of follicular contents f) Body temperature increases 24 to 48 hours after ovulation g) Ovum travels through ruptured follicle to fallopian tube opening h) Luteal phase begins when ovum leaves follicle i) Under influence of LH → corpus luteum develops j) If fertilized → implants → begins to secrete human chorionic gonadotropin (hCG) k) If no fertilization → degenerates → connective tissue scar called corpus albicans → decrease in estrogen, progesterone

D. Uterine (Menstrual) Cycle 1. Menstruation → cyclic uterine bleeding in response to cyclic hormonal changes a) Menses → blood mixed with cervical vaginal secretions, bacteria, mucus, leukocytes, cellular debris b) Menstrual parameters vary greatly c) Arterial blood supply

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(1) See Figure 9–11: Blood supply to the endometrium (cross-sectional view of the uterus), p. 166 2. Three phases a) Menstrual phase (1) Menstruation occurs b) Proliferative phase (1) Endometrial glands enlarge (2) Blood vessels become prominent, dilated → endometrium increases thickness (3) Cervical mucus thin, clear, watery, alkaline (4) Cervical mucus increased elasticity (5) Ferning c) Secretory phase (1) Follows ovulation (2) Endometrium → estrogen causes slight cellular growth (3) Progesterone causes swelling and growth (4) Vascularity increases → nourishing bed for a fertilized ovum d) Ischemic phase (1) If fertilization does not occur (2) Estrogen and progesterone levels fall (3) Vascular changes (4) Escape of blood into stromal cells

III.

Male Reproductive System

A. External Genitals 1. See Figure 9–13: Male reproductive system, sagittal view, p. 168 a) Penis (1) Elongated, cylindrical structure → body → shaft, cone-shaped end → glans (2) Lies in front of scrotum b) Shaft → three longitudinal columns of erectile tissue (1) Corpora cavernosa (2) (2) Corpus spongiosum (a) Contains urethra (b) Ends at tip of glans → urethral meatus c) Prepuce → foreskin d) Hypospadias or epispadias e) Innervated by pudendal nerve (1) Sexual stimulation causes erection (2) Parasympathetic nerve stimulation → engorgement (3) Ejaculation → intense stimulation f) Urinary and reproductive systems 2. Scrotum a) Pouchlike structure → hangs in front of anus, behind penis 8 Copyright © 2020 Pearson Education, Inc.

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(1) Skin and dartos muscle (2) Sebaceous glands open directly onto scrotal surface → distinctive odor b) Two lateral compartments inside (1) Testis in each (2) Function → protect testes, sperm (a) Maintain temperature lower than body temperature

B. Male Internal Reproductive Organs 1. Gonads → testes 2. See Figure 9–14: The testes. A. External view. B. Sagittal view showing interior anatomy, p.

169 a) Pair of oval, compound glandular organs (1) Site of spermatozoa production, secretion of male sex hormones → in sexually mature male (2) 4 to 6 cm long, 2 to 3 cm wide, 3 to 4 cm deep b) Seminiferous tubules in each lobule in testes (1) Contain sperm cells in all stages of development (2) Interstitial cells produce testosterone (3) Sertoli cells → nourish, protect spermatocytes (4) Come together → rete testis → forms ducts → empty into duct of epididymis (5) Cells lining seminiferous tubules → spermatogenesis c) Process of spermatogenesis → result of complex neural and hormonal controls (1) Hypothalamus → releasing factors → anterior pituitary → release gonadotropins → cause testes to produce testosterone → maintains spermatogenesis, increase sperm production, stimulate production of seminal fluid d) Testosterone → most prevalent, potent of testicular hormones (1) Secondary male characteristics, behavioral patterns (2) Action is constant, not cyclic (3) Production not limited to certain number of years e) Functions (1) Serve as site of spermatogenesis (2) Produce testosterone 3. Epididymis a) Duct behind each testis → 5.6 m long b) Provides reservoir where spermatozoa can survive (1) As sperm transported along course of epididymis → become motile, fertile 4. Vas deferens and ejaculatory ducts a) 40 cm long → connects epididymis with prostate b) One from posterior border of each testis c) Unites with seminal vesicle → form ejaculatory duct → enter prostate gland d) Function → rapidly squeeze sperm from storage sites into urethra e) Vasectomy → scrotal portion of vas deferens incised or cauterized 9 Copyright © 2020 Pearson Education, Inc.

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(1) Sperm can be produced but can no longer reach outside of body 5. Urethra a) Male urethra → passageway for urine and semen 6. Accessory glands a) Seminal vesicles (1) Many lobules (2) Between bladder and rectum, above base of prostate (3) Secretes fluid → helps provide environment favorable to sperm motility, metabolism b) Prostate gland (1) Many lobules (2) Encircles upper part of urethra, below neck of bladder (3) Secretes fluid → protects sperm from acidic environment of vagina, male urethra c) Bulbourethral glands (Cowper glands) (1) On either side of membranous urethra (2) Secrete fluid that becomes part of semen (3) Lubricates penile urethra, neutralizes acid in male urethra, vagina d) Urethra glands (Littre glands) (1) Mucus-secreting glands throughout membranous lining of penile urethra 7. Semen a) Male ejaculate, seminal fluid → spermatozoa and secretions of accessory glands (1) Transports viable, motile sperm (2) Nutrients, pH about 7.5, concentration of sperm to fluid, osmolarity b) Spermatozoa (1) Made up of head and tail (2) Head → carries male’s haploid number of chromosomes (3) Tail (flagellum) → specialized for motility (4) Stored in male genital system up to 42 days (5) Average volume → 2 to 5 mL (6) Sperm lives 2 to 3 days once ejaculated into female genital tract

IV.

Gametogenesis A. Process by which germ cells (gametes) produced 1. Haploid genetic material

B. Oogenesis → process that produces female gamete 1. Ovaries begin to develop early in fetal life a) All ova present at birth

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2. First meiotic division → produces two cells of unequal size 3. Second meiotic division begins at ovulation → continues as oocyte moves down fallopian tube a) Division not equal 4. Second oocyte completes second meiotic division after fertilization → mature ovum with haploid number a) Second polar body forms b) Both divide → four haploid cells → three small polar bodies, one ovum 5. See Figure 9–15: Gametogenesis involves meiosis within the ovary and testis, p. 171

C. Spermatogenesis 1. Germinal epithelium in seminiferous tubules of testes a) Begins spermatogenesis during puberty b) Diploid spermatogonium replicate before first meiotic division (1) Primary spermatocyte c) First meiotic division → replicates → two haploid cells → secondary spermatocytes d) Second meiotic division → four spermatids → haploid e) Series of changes → nucleus compacted, lose most of cytoplasm

V.

The Process of Fertilization A. Process by which sperm fuses with ovum → form new diploid cell (zygote) 1. Zygote → single cell → complete set of genetic material

B. Preparation for fertilization 1. Brief time to unite 2. Ovum’s cell membrane surrounded by two layers of tissue a) Zona pellucida, corona radiata 3. Ovulation → estrogen levels increase peristalsis in fallopian tubes 4. Fertilization usually takes place in ampulla of fallopian tube 5. Single ejaculation → 200 to 500 million spermatozoa in vagina a) Only about 1000 reach ampulla b) Flagellar movement of tails propel spermatozoa c) 5 minutes to 2 to7 hours from cervix into fallopian tube 6. Prostaglandins in semen → help transport sperm 7. Sperm undergoes two processes a) Capacitation → removal of plasma membrane, glycoprotein coat b) Acrosomal reaction → follows capacitation 11 Copyright © 2020 Pearson Education, Inc.

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(1) Acrosome caps of sperm surrounding ovum → release enzymes → break down hyaluronic acid that holds corona radiata together (2) Thousands of caps for one sperm to penetrate c) At moment of penetration by fertilizing sperm → zona pellucida reacts (1) Prevents additional sperm from entering single ovum

C. The moment of fertilization 1. After sperm enters ovum → chemical signal prompts secondary oocyte → complete second meiotic division → forms nucleus of ovum → ejects second polar body 2. Sex of zygote determined a) XX → female → mature ovum → only one type of sex chromosome b) XY → male → spermatogenesis yields two X and two Y sperm

VI.

Preembryonic Stage

A. First 14 days of human development B. Cellular multiplication → begins as zygote moves through fallopian tube 1. Rapid mitotic divisions → cleavage a) Divides → 2 cells → 4 cells → 8 cells → etc. b) Blastomeres → eventually form solid ball of 12 to 32 cells → morula 2. Morula enters uterus → intracellular fluid increases, central cavity forms a) Inside cavity → mass of cells → blastocyst b) Outer layer of cells → trophoblast → develops into chorion c) Blastocyst → embryonic disc 3. Early pregnancy factor (EPF) → secreted by trophoblastic cells a) Appears in maternal serum → 24 to 48 hours after fertilization

C. Implantation (nidation) 1. While floating in uterine cavity → blastocyst nourished by uterine glands a) Trophoblast attaches to surface of endometrium b) Upper part of posterior uterine wall c) Between days 7 to10 → blastocyst implants d) Lining of uterus thickens below implanted blastocyst 2. Endometrium increases in thickness, vascularity → influence of progesterone a) After implantation → endometrium called decidua b) Covers blastocyst → decidua capsularis c) Directly under blastocyst → decidua basalis → maternal part of placenta develops from decidua basalis d) Lines rest of uterine cavity → decidua vera

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D. Cellular differentiation 1. Primary germ layers a) 10 to 14 days after conception → homogenous blastocyst cells differentiate b) Ectoderm, mesoderm, endoderm → formed at same time as embryonic membranes c) All tissues develop from these primary germ cell layers d) See Table 9–1: Derivation of Body Structures from Primary Cell Layers, p. 175 e) From ectoderm (1) Epidermis (2) Sweat glands (3) Sebaceous glands (4) Nails (5) Hair follicles (6) Lens of eye (7) Sensory epithelium of internal and external ear, nasal cavity, sinuses, mouth, anal canal (8) Central and peripheral nervous system (9) Oral glands and tooth enamel (10) Pituitary gland (11) Mammary glands f) From mesoderm (1) Dermis (2) Wall of digestive tract (3) Kidneys and ureter (suprarenal cortex) (4) Reproductive organs (gonads, genital ducts) (5) Connective tissue (cartilage, bone, joint cavities) (6) Skeleton (7) Muscles (all types) (8) Cardiovascular system (heart, arteries, veins, blood, bone marrow) (9) Pleura (10) Lymphatic tissue and cells (11) Spleen g) From endoderm (1) Respiratory tract epithelium (2) Epithelium (except nasal) (3) Lining of digestive tract (4) Primary tissue of liver and pancreas (5) Urethra and associated glands (6) Urinary bladder (except trigone) (7) Vagina (parts) 2. Embryonic membranes → begin to form at time of implantation a) Chorion → first, outermost membrane (1) Fingerlike projections → chorionic villi

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(2) Early genetic testing (3) Villi degenerate → except those just under embryo (4) By fourth month of pregnancy → surface smooth, except at place of attachment to uterine wall b) Amnion → second membrane, from ectoderm (1) Contains amniotic fluid (2) Space between membrane and embryo → amniotic cavity (3) Expands until comes in contact with chorion (4) Form fluid-filled amniotic sac (bag of waters) → protects 3. Amniotic fluid a) Functions (1) Acts as cushion against mechanical injury (2) Helps control embryo’s temperature (3) Permits symmetric external growth and development of embryo (4) Acts as extension of fetal extracellular space (5) Prevents adherence of embryo-fetus to amnion to allow freedom of movement (6) Allows umbilical cord to be relatively free of compression (7) Acts as wedge during labor (8) Provides fluid for analysis to determine fetal health and maturity b) Slightly alkaline → contains albumin, urea, uric acid, creatinine, lecithin, sphingomyelin, bilirubin, fat, fructose, leukocytes, proteins, epithelial cells, enzymes, lanugo (1) Amount of fluid at 10 weeks → about 30 mL → 210 mL at 16 weeks (2) Constantly changing (3) Fluid contributes to volume → excretes urine (4) After 23 to 25 weeks → thickening of fetal skin inhibits diffusion (5) Fetal kidneys source of fluid (6) Abnormalities of fetal urine production (a) Potter syndrome (b) Bartter syndrome (7) Fluid removed in last half of pregnancy → fetal swallowing c) Abnormal variations (1) Oligohydramnios → <500 mL (2) Hydramnios (polyhydramnios) → >2000 mL 4. Yolk sac a) In humans → small, functions only in early embryonic life b) Develops as a second cavity about day 8 or 9 c) Forms primitive red blood cells 5. Umbilical cord a) Formed from mesoderm and covered by amnion b) Contains blood vessels c) Body stalk fuses with embryonic portion of placenta → elongates → vessels decrease → one large vein, two small arteries 14 Copyright © 2020 Pearson Education, Inc.

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d) Wharton’s jelly surrounds blood vessels e) Prevents compression of the umbilical cord in utero f) Central insertion into placenta considered normal g) Appear twisted spiraled → likely caused by fetal movement (1) True knot rare

VII.

Twins

A. Twinning → 33 in 1000 births B. Fraternal → dizygotic → two placentas, two chorions, two amnions 1. Placentas sometimes fuse 2. Increases with maternal age up to about 35 years → decreases abruptly 3. Tends to occur in certain families 4. Reported more often among black than white → more often in white than Asian

C. Identical → monozygotic → single fertilized ovum 1. Same sex, same appearance 2. Usually have common placenta 3. Originate from division of fertilized ovum at different stages of early development a) Within 4 days of fertilization → 2 embryos, 2 amnions, 2 chorions → dichorionicdiamniotic b) Division about 4 to 8 days after fertilization → 2 embryos, 2 amnion sacs, common chorion → monochorionic-diamniotic placenta c) Division about 8 to 12 days after fertilization → 2 embryos, common sac and chorion → rare 4. Monozygotic twinning random event → 3 to 4 per 1000 live births a) Survival rate 10% lower than of dizygotic twins b) Congenital anomalies more prevalent

VIII.

Development and Functions of the Placenta

A. Placenta → means of metabolic and nutrient exchange between embryonic and maternal circulations 1. Begins about third week of embryonic development 2. Expansion until about 20 weeks → covers about half of inside of uterus a) After 20 weeks → thicker, not wider 3. Maternal portion → decidua basalis and circulation a) Surface red, fleshlike → Dirty Duncan 15 Copyright © 2020 Pearson Education, Inc.

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4. Fetal portion → covered by amnion → shiny, gray appearance → Shiny Schultze 5. See Figure 9–23: Maternal side of placenta (Dirty Duncan) and Figure 9–24: Fetal side of placenta (Shiny Schultze), p. 178 6. Begins to form at implantation → chorionic villi grow into spaces in tissue of decidua basalis 7. Two trophoblastic layers a) Syncytium → direct contact with maternal blood → functional layer of placenta b) Cytotrophoblast 8. Anchoring villi → third inner layer → eventually form septa of placenta a) 15 to 20 cotyledons → complex vascular system (1) Exchange of gases and nutrients b) Exchange of substances across placenta minimal first 3 to 5 months (1) Membrane initially too thick (2) Permeability increases as membrane thins until last month of pregnancy

B. Placental circulation 1. After implantation → cells differentiate into fetal cells, trophoblastic cells a) Trophoblast invades endometrium → opens uterine capillaries, then larger uterine vessels b) Completion of maternal-placental-fetal circulation → about 17 days after conception → embryonic heart begins functioning c) End of fourth week embryonic blood circulating d) 14 weeks → placenta is discrete organ e) Cotyledons of maternal surface → branches of single placental mainstream villus (1) Compartmentalization of uteroplacental circulation 2. Fully developed placenta’s umbilical cord → fetal blood flow through two umbilical arteries to capillaries of villi a) Oxygen-enriched blood flow back through umbilical vein to fetus b) See Figure 9–25: Vascular arrangement of the placenta, p. 179 3. Maternal blood moves from actuate artery → radial artery → uterine spiral arteries → spurts into intervillous spaces a) Circulation within intervillous spaces → depends on maternal blood pressure b) Fresh blood continually enters, exerts pressure → pushing blood toward exits in basal plate c) Blood drained through uterine, other pelvic veins (1) Uterine souffle

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4. Braxton Hicks contractions → believed to facilitate placental circulation → enhances movement of blood from center of cotyledon through intervillous space

C. Placental functions 1. Placental exchange functions a) Only in fetal vessels in intimate contact with syncytial membrane 2. Metabolic activities a) Provides glycogen, cholesterol, fatty acids continuously b) Provides numerous enzymes required for fetoplacental transfer c) Breaks down certain substances, such as epinephrine and histamine d) Stores glycogen and iron 3. Transport functions a) Simple diffusion b) Facilitated transport c) Active transport d) Pinocytosis 4. Reduction of placental surface → less is functional for exchange 5. Blood flow alteration changes transfer rate of substances 6. Maternal blood → picks up fetal waste products and carbon dioxide → drains back into maternal circulation

D. Endocrine functions 1. Produces hormones vital to survival of fetus 2. Human chorionic gonadotropin (hCG) → similar to luteinizing hormone (LH) → prevents normal involution of corpus luteum at end of menstrual cycle a) Causes corpus luteum to secrete increased amounts of estrogen and progesterone b) After 11th week → placenta produces enough progesterone, estrogen to maintain pregnancy c) In male fetus → hCG exerts cell stimulating effect on testes → produces testosterone d) hCG present in maternal blood serum → 8 to10 days after fertilization → as soon as implantation has occurred 3. Progesterone → hormone essential for pregnancy a) Increases secretion to provide for nutrition of morula and blastocyst b) Must be present in high levels for implantation c) Implantation occurs at time of peak production of progesterone by corpus luteum → 7 to 10 days after ovulation d) After 11 weeks → placenta takes over production of progesterone → more than 250 mg/day late in pregnancy

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4. Estrogens production → 50% by placenta by 7 weeks a) Cause enlargement of uterus, breasts, breast glandular disuse b) Increasing vascularity, vasodilation c) Placenta → estriol d) Ovaries → estradiol e) Placenta → needs dehydroepiandrosterone sulfate (DHEA-S) to synthesize estriol 5. Human placental lactogen (hPL) → similar to human pituitary growth hormone

E. Immunologic properties 1. Placenta, embryo → homografts a) Exempt from immunologic reaction by host b) Chorionic villi may not evoke rejection responses

IX.

Development of the Fetal Circulatory System A. Most of blood supply bypasses fetal lungs → no respiratory gas exchange 1. Placenta assumes function of fetal lungs

B. See Figure 9–26: Fetal circulation, p. 181 C. Blood from placenta → umbilical vein → enters abdominal wall → some blood through portal circulation, most through ductus venosus → inferior vena cava → right atrium → foramen ovale → left atrium → left ventricle → aorta 1. Some blood from head, upper extremities → superior vena cava → right atrium → tricuspid valve into right ventricle → pulmonary artery → small amount to lungs for nourishment only 2. Larger portion of blood → pulmonary artery through ductus arteriosus → descending aorta (bypassing lungs) → umbilical arteries to placenta 3. Fetus receives oxygen via diffusion → gradient difference of PO2 in maternal blood → 50 mmHg to 30 mmHg (fetus) a) Highest available oxygen concentration → head, neck, brain, heart (1) Cephalocaudal development of fetus

D. Fetal heart 1. Under control of own pacemaker → sinoatrial (SA) node, atrioventricular (AV) node 2. When fetus stressed → sympathetic nervous system causes release of norepinephrine → increases fetal heart rate a) Baroreceptors counteract increase in blood pressure b) Chemoreceptors in fetal PNS and CNS → respond to decreased oxygen tensions, increased carbon dioxide tensions → fetal tachycardia, increase blood pressure

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3. Increased activity of fetus → increase in beat-to-beat variability of fetal heart baseline

X.

Embryonic and Fetal Development A. Pregnancy → average 10 lunar months 1. 40 weeks, 280 days a) From beginning of last normal menstrual period to birth b) Estimated date of birth (EDB) (estimated date of delivery [EDD]) calculated by this method c) Most fetuses born within 10 to14 days of calculated date of birth

B. Organ development 1. Up to 8 weeks → embryonic period → ninth week until birth → fetal period 2. See Table 9–2: Timeline of Organ System Development in the Embryo and Fetus, pp. 182– 184 a) Age: 2–3 weeks (1) Length: 2 mm C–R (crown to rump) (2) Nervous system: Groove forms along middle back as cells thicken; neural tube forms from closure of neural groove (3) Cardiovascular system: Beginning of blood circulation; tubular heart begins to form during third week (4) Gastrointestinal system: Liver function begins (5) Genitourinary system: Kidneys formation begins (6) Respiratory system: Nasal pits forming (7) Endocrine system: Thyroid tissue appears (8) Eyes: Optic cup, lens pit formed; pigment in eyes (9) Ears: Auditory pit now enclosed structure b) Age: 4 weeks (1) Length: 4–6 mm C–R (2) Weight: 0.4 g (3) Nervous system: Anterior portion of neural tube closes, forms brain; closure of posterior end forms spinal cord (4) Musculoskeletal system: Noticeable limb buds (5) Cardiovascular system: Tubular heart beats at 28 days, primitive red blood cells circulate through fetus, chorionic villi (6) Gastrointestinal system: Mouth—oral cavity forms; primitive jaws present; esophagotracheal septum begins division of esophagus, trachea. Digestive tract— stomach forms; esophagus, intestine become tubular; ducts of pancreas, liver forming c) Age: 5 weeks (1) Length: 8 mm C–R (2) Weight: Only 0.5% of total body weight = fat (to 20 weeks) (3) Nervous system: Brain differentiated, and cranial nerves present 19 Copyright © 2020 Pearson Education, Inc.

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(4) Musculoskeletal system: Developing muscles innervated (5) Cardiovascular system: Atrial division occurred d) Age: 6 weeks (1) Length: 12 mm C–R (2) Musculoskeletal system: Bone rudiments present; primitive skeletal shape forming; muscle mass develops; skull, jaw ossification begins (3) Cardiovascular system: Chambers present in heart; groups of blood cells identifiable (4) Gastrointestinal system: Oral, nasal cavities, upper lip formed; liver begins to form red blood cells (5) Respiratory system: Trachea, bronchi, lung buds present (6) Ears: Formation of external, middle, inner ear continues (7) Sexual development: Embryonic sex glands appear e) Age: 7 weeks (1) Length: 18 mm C–R (2) Cardiovascular system: Fetal heartbeat detectable (3) Gastrointestinal system: Mouth—tongue separates; palate folds. Digestive tract— stomach attains final form (4) Genitourinary system: Separation of bladder, urethra from rectum (5) Respiratory system: Diaphragm separates abdominal, thoracic cavities (6) Eyes: Optic nerve formed; eyelids appear, thickening of lens (7) Sexual development: Begin differentiation of sex glands into ovaries, testes f) Age: 8 weeks (1) Length: 2.5–3 cm C–R (2) Weight: 2 g.

(3) Musculoskeletal system: Digits formed; further differentiation of cells in primitive skeleton; cartilaginous bones show first signs of ossification; development of muscles in trunk, limbs, and head; some movement of fetus now possible (4) Cardiovascular system: Development of heart essentially complete; fetal circulation follows two circuits—four extraembryonic and two intraembryonic. Heartbeat can be heard with Doppler at 8 to12 weeks (5) Gastrointestinal system: Mouth: completion of lip fusion. Digestive tract: rotation in midgut; anal membrane has perforated (6) Ears: External, middle, and inner ear assuming final forms (7) Sexual development: Male and female external genitals appear similar until end of ninth week g) Age: 10 weeks (1) Length: 5–6 cm C–R (2) Weight: 14 g (3) Nervous system: Neurons appear at caudal end of spinal cord; basic divisions of brain present (4) Musculoskeletal system: Fingers and toes begin nail growth (5) Gastrointestinal system: Mouth: separation of lips from jaw; fusion of palate folds.

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(7) Endocrine system: Islets of Langerhans differentiated (8) Eyes: Eyelids fused closed; development of lacrimal duct (9) Sexual development: Males: production of testosterone and physical characteristics between 8 and 12 weeks h) Age: 12 weeks (1) Length: 8 cm C–R; 11.5 cm C–H (crown to heel) (2) Weight: 45 g (3) Musculoskeletal system: Clear outlining of miniature bones (12 to 20 weeks); process of ossification is established throughout fetal body; appearance of involuntary muscles in viscera (4) Gastrointestinal system: Mouth: completion of palate. Digestive tract: appearance of muscles in gut; bile secretion begins; liver is major producer of red blood cells (5) Respiratory system: Lungs acquire definitive shape (6) Skin: Pink and delicate (7) Endocrine system: Hormonal secretion from thyroid; insulin present in pancreas (8) Immunologic system: Appearance of lymphoid tissue in fetal thymus gland i) Age: 16 weeks (1) Length: 13.5 cm C–R; 15 cm C–H (2) Weight: 200 g (3) Musculoskeletal system: Teeth beginning to form hard tissue that will become central incisors (4) Gastrointestinal system: Mouth: differentiation of hard and soft palate. Digestive tract: development of gastric and intestinal glands; intestines begin to collect meconium (5) Genitourinary system: Kidneys assume typical shape and organization (6) Skin: Appearance of scalp hair; lanugo present on body; transparent skin with visible blood vessels; sweat glands developing (7) Eyes, ears, and nose: Formed (8) Sexual development: Sex determination possible j) Age: 18 weeks (1) Musculoskeletal system: Teeth beginning to form hard tissue (enamel and dentine) that will become lateral incisors (2) Cardiovascular system: Fetal heart tones audible with fetoscope at 16 to 20 weeks k) Age: 20 weeks (1) Length: 19 cm C–R; 25 cm C–H (2) Weight: 435 g (6% of total body weight is fat) (3) Nervous system: Myelination of spinal cord begins (4) Musculoskeletal system: Teeth beginning to form hard tissue that will become canine and first molar. Lower limbs are of final relative proportions (5) Gastrointestinal system: Fetus actively sucks and swallows amniotic fluid; peristaltic movements begin (6) Skin: Lanugo covers entire body; brown fat begins to form; vernix caseosa begins to form

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(7) Immunologic system: Detectable levels of fetal antibodies (immunoglobin G [IgG] type) (8) Blood formation: Iron is stored and bone marrow is increasingly important l) Age: 24 weeks (1) Length: 23 cm C–R; 28 cm C–H (2) Weight: 780 g (3) Nervous system: Brain looks like mature brain (4) Musculoskeletal system: Teeth are beginning to form hard tissue that will become the second molars (5) Respiratory system: Respiratory movements may occur (24 to 40 weeks). Nostrils reopen. Alveoli appear in lungs and begin production of surfactant; gas exchange possible (6) Skin: Reddish and wrinkled, vernix caseosa present (7) Immunologic system: IgG levels reach maternal levels m) Age: 28 weeks (1) Length: 27 cm C–R; 35 C–H (2) Weight: 1200–1250 g (3) Nervous system: Begins regulation of some body functions (4) Skin: Adipose tissue accumulates rapidly; nails appear; eyebrows and eyelashes present (5) Eyes: Eyelids open (26 to 29 weeks) (6) Sexual development: Males: testes descend into inguinal canal and upper scrotum n) Age: 32 weeks (1) Length: 31 cm C–R; 38–43 cm C–H (2) Weight: 2000 g (3) Nervous system: More reflexes present o) Age: 36 weeks (1) Length: 35 cm C–R; 42–48 cm C–H (2) Weight: 2500–2750 g (3) Musculoskeletal system: Distal femoral ossification centers present (4) Skin: Pale; body rounded, lanugo disappearing, hair fuzzy or woolly; few sole creases; sebaceous glands active and helping to produce vernix caseosa (36 to 40 weeks) (5) Ears: Earlobes soft with little cartilage (6) Sexual development: Males: scrotum small and few rugae present; descent of testes into upper scrotum to stay (36 to 40 weeks). Females: labia majora and minora equally prominent p) Age: 38–40 weeks (1) Length: 40 cm C–R; 48–52 C–H (2) Weight: 3200+ g (16% of total body weight is fat) (3) Respiratory system: At 38 weeks, lecithin-sphingomyelin (L/S) ratio approaches 2:1 (indicates decreased risk of respiratory distress from inadequate surfactant production if born now)

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(4) Skin: Smooth and pink; vernix present in skin folds; moderate to profuse silky hair; lanugo on shoulders and upper back; nails extend over tips or digits; creases cover sole (5) Ears: Earlobes firmer due to increased cartilage (6) Sexual development: Males: rugous scrotum. Females: labia majora well developed and minora small or completely covered 3. Human development follows three stages

C. Embryonic stage 1. Day 15 → 8 weeks (C-R length of 3 cm) a) Tissues differentiate into essential organs → most vulnerable to teratogens b) 3 weeks → most advanced organ is heart c) 4 to 5 weeks → somites (vertebra develop from somites) tail bud (1) Tubular heart beating regular rhythm d) 5 weeks → optic cups, lens vesicles of eye, nasal pits develop (1) Partitioning of heart (2) Brain differentiated, 10 pairs cranial nerves recognizable e) 6 weeks → head structure more developed, trunk straighter f) 7 weeks → head rounded, nearly erect (1) GI, GU tracts changing g) 8 weeks → 3 cm C–R, resembles human being (1) External genitals appear h) See Figure 9–27: The human conceptus from fertilization to the early fetal stage; Figure 9–28: The embryo at 4 weeks; Figure 9–29: The embryo at 5 weeks; Figure 9–30: The embryo at 7 weeks; Figure 9–31: The embryo at 8 weeks, pp. 185–186

D. Fetal stage 1. 9 weeks → birth a) 9 weeks → fetus → every organ system, external structure present (1) Refining and perfecting b) 9 to 12 weeks → C–R 5cm, 14 g → 8 cm C–R, 45 g (1) Face well formed, spontaneous movement, fetal heart tones c) 13 to 16 weeks → rapid growth, lanugo develops, active movements, skeletal ossification identifiable d) 20 weeks → doubles C–R to 19 cm, 435 to 465 g (1) Lanugo covers body, brown fat, muscles well developed, nails and hair e) 24 weeks → C–R 28 cm, 780 g (1) Hair longer, eyes complete, grasp reflex, startle reflex (2) Vernix caseosa f) 25 to 28 weeks → skin red, brain developing rapidly, testes begin to descend (1) C–R 35 to 38 cm, 1200 to 1250 g (2) Viable → lungs sufficiently developed to provide gas exchange g) 29 to 32 weeks → pupillary light reflex at 30 weeks 23 Copyright © 2020 Pearson Education, Inc.

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(1) C–R 31 cm, 2000 g (2) CNS direct breathing, partially control body temperature h) 35 to 36 weeks → plump, less wrinkled, lanugo disappears, nails to edge of fingertips (1) 2500 to 2750 g, C–R 42 to 48 cm i) 38 to 40 weeks → full term at 38 weeks up to 40 weeks after conception (1) C–R 48 to 52 cm, 3000 to 3600 g (2) Males usually weigh more than females (3) Lanugo on upper arms and shoulders, hair coarse (4) Vernix caseosa in skin folds, creases 2. As fetus enlarges → amniotic fluid diminishes a) Assumes position of comfort → lie (1) Head generally down

E. What parents want to know 1. See Key Facts to Remember: Embryonic and Fetal Development: What Parents Want to Know, p. 188 2. 4 weeks: fetal heart begins to beat 3. 8 weeks: all body organs are formed 4. 8 to 12 weeks → fetal heart tones can be heard by Doppler device 5. 16 weeks → baby’s sex can be seen, fetus looks like a baby 6. 20 weeks → heartbeat can be heard with fetoscope a) Mother feels movement (quickening) b) Baby develops a regular schedule of sleeping, sucking, kicking c) Hands can grasp d) Baby assumes a favorite position in utero e) Vernix protects body, lanugo keeps oil on skin f) Head hair, eyebrows, eyelashes present 7. 24 weeks → weighs 780 g (1 lb 10 oz) a) Activity is increasing b) Fetal respiratory movements begin 8. 28 weeks → eyes begin to open and close a) Baby can breathe at this time b) Surfactant needed for breathing at birth is formed c) Baby is two-thirds final size 9. 32 weeks → has fingernails and toenails a) Subcutaneous fat being laid down b) Baby appears less red and wrinkled

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10. 38+ weeks → baby fills total uterus a) Baby gets antibodies from mother

XI.

Factors Influencing Embryonic and Fetal Development

A. Include 1. Quality of sperm or ovum 2. Genetic code established at fertilization 3. Adequacy of intrauterine environment 4. Time of injury critical in development of anomalies

B. Organs formed primarily during embryonic development 1. Vulnerable to hazardous agents during first months of pregnancy 2. Teratogen → any agent that can cause development of abnormal structures in an embryo 3. Developmental vulnerability a) Weeks since conception → potential teratogen-induced malformation (1) 3 → ectromelia, ectopia cordis (2) 4 → omphalocele, tracheoesophageal fistula, hemivertbra (3) 5 → nuclear cataract, micropthalmia, facial clefts, carpal or pedal ablation (4) 6 → gross septal or aortic abnormalities, cleft lip, agnathia (5) 7 → interventricular septal defects, pulmonary stenosis, cleft palate, micrognathia, epicanthus, brachycephalism, mixed sexual characteristics (6) 8 → persistent ostium primum, digital stunting 4. Adequacy of maternal environment important a) Maternal nutrition affects brain and neural tube development b) Maternal hyperthermia → spontaneous abortion, CNS defects, failure of neural tube closure c) First trimester use of prescription medications d) Cigarette smoking → intrauterine growth restriction (UGR)

XII.

Focus Your Study

XIII.

Activities 1. Individual Assign each student a potential teratogen-induced malformation to research. The rubric should include the following: the week of gestation at risk, the germ layer involved, and the teratogen suspected. Have students write a two-page paper summarizing their research and instruct the students to use APA format and citation style.

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2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan for the expectant parent. For each group, assign the gestational age by weeks of gestation.

Instruct the groups to included printed material in their plans and remind them to use APA style for their citations.

3. Large Group Show an appropriate video related to fetal development. Some possible choices include: • National Geographic, In the Womb, DVD, Dilly Barlow • From Conception to Birth, DVD, Mark Petersson • National Geographic, Inside the Living Body, DVD, Kate Burton • In the Womb, Collection, DVD • NOVA, The Miracle of Life, DVD, Michael Agaton

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Chapter 10 Reproductive Genetics Genetic Disorders………………….…………….…………………………………………………….

2

Modes of Inheritance…………….…………….…………………………………………………….

3

Prenatal Diagnostic Tests…………….…………….………………………………………………

5

Genetic Evaluation…………….…………….………………………………………………………..

8

Focus Your Study.............................................................................................

9

Activities..........................................................................................................

9

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I.

Genetic Disorders

A. Desired outcome of pregnancy → birth of healthy, perfect baby 1. Grief, fear, anger → baby born with defect, genetic disease 2. Many questions → nurse to anticipate questions, concerns, direct to appropriate resources, support family

B. Chromosomes and Chromosomal Analysis 1. All hereditary material → carried on strands of DNA 2. Chromosomes carry genes → smallest unit of inheritance 3. Somatic cells → 46 chromosomes → diploid 4. Sperm and egg → 23 chromosomes, haploid a) 22 pairs → autosomes (non-sex chromosomes) b) 1 pair → sex chromosome (1) See Figure 10–1: Normal female karyotype and Figure 10–2: Normal male karyotype, p. 192 (2) See Figure 10–5 A. Karyotype of a male who has trisomy 18. B. Infant girl with trisomy 18, pp. 192, 193 5. Karyotype → pictorial analysis of individual’s chromosomes a) Chromosomal abnormalities → autosomes, or sex chromosomes (1) Small alterations can cause problems 6. Abnormalities of chromosome number a) See Table 10–1: Chromosomal Syndromes, p. 194 b) Most commonly seen as trisomies, monosomies, mosaicism (1) Nondisjunction (a) In either sperm or egg → abnormal chromosome makeup in all cells (b) After fertilization → cells with two or more different chromosome makeup c) Trisomies → product of union of normal gamete with gamete that contains extra chromosome (1) 47 chromosomes → trisomic (2) Down syndrome most common (a) Distinctive clinical features (b) See Figure 10–4: A boy with Down syndrome, p. 193 (3) Trisomy 18, trisomy 13 (a) Prognosis poor → 70% die within first 3 months of life d) Monosomies → normal gamete unites with gamete missing a chromosome (1) Monosomy generally incompatible with life e) Mosaicism → after fertilization → two different cell lines, each having different chromosomal number f) Most common with Down syndrome 2 Copyright © 2020 Pearson Education, Inc.

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7. Abnormalities of chromosome structure a) Involve parts of chromosomes → translocations, deletions, duplications (1) Most Down syndrome children have trisomy 21 → some have abnormal rearrangement of chromosomal material → translocation b) Translocation → transfer of segment of one chromosome to another chromosome (1) Nonhomologous → reciprocal translocation relatively common (2) Balanced → no deletion or duplication of material (a) Individual may not have health concern → offspring may have unbalanced translocation (3) Unbalanced → chromosome material deleted or duplicated (a) Pregnancy loss, congenital anomalies, intellectual disability, other health concerns (4) Robertsonian translocations → individual has 45 chromosomes (a) See Figure 10–8: Diagram of various types of offspring …, p. 195 c) Duplication or deletions (1) Structural abnormality (2) Any portion of chromosome may be lost or added resulting in some adverse effect 8. Abnormalities of the sex chromosome a) Early embryonic stage → females: one of two normal X chromosomes becomes inactive (1) Forms dark-staining area known as the Barr body (2) Female has one, male has no Barr bodies → he has only one X chromosome b) Common abnormalities (1) Turner syndrome in females → 45, X with no Barr bodies present (2) Klinefelter syndrome in males → 47, XXY, with one Barr body present

C. Modes of Inheritance 1. Two major categories: Mendelian (single-gene) inheritance and non-Mendelian (multifactorial) inheritance a) Phenotype → responsible for observable expression of traits → single gene trait b) Genotype → pattern of genes on chromosomes c) One of genes for trait from mother, one from father d) Two identical → homozygous for trait e) Two different alleles → heterozygous 2. Autosomal dominant inheritance a) Disease trait is heterozygous, individual inherits disorder (1) May be familial (2) De novo mutation b) Family pedigree may show multiple generations c) Affected individuals have 50% chance of passing abnormal gene d) Males and females equally affected e) Autosomal dominant inherited disorders have varying degrees of presentation (1) May be difficult to diagnose 3 Copyright © 2020 Pearson Education, Inc.

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(a) Penetrance → individual with genetic trait fails to express features of disorder → reduced penetrance (b) Expressivity → severity of expression of phenotype (c) Pleiotropic → single abnormal gene produces diverse phenotypic effects f) See Figure 10–9: Autosomal dominant pedigree, p. 196 3. Autosomal recessive inheritance a) Individual must have two abnormal genes to be affected (1) Carrier → individual is heterozygous for abnormal gene, clinically normal (2) Two carriers mate → pass on abnormal gene (a) Affected individual can have clinically normal parents → both carriers (b) 25% chance abnormal gene passed to any offspring (c) Each pregnancy 25% chance resulting in affected child (d) Child or two carrier parents clinically normal → two-thirds chance child is carrier (e) Both males and females equally affected (f) Increased history of consanguineous matings b) Common disorders (1) Cystic fibrosis (2) Phenylketonuria (PKU) (3) Galactosemia (4) Sickle cell disease (5) Tay-Sachs disease (a) See Figure 10–10: Autosomal recessive pedigree, p. 196 4. X-linked recessive inheritance a) Sex-linked disorders → abnormal gene carried on X chromosome (1) Manifested in male who carries abnormal gene on his only X chromosome → hemizygous (2) Two thirds of the time → mother carrier (3) Most carrier females do not have symptoms b) Characteristics (1) No male–male transmission (2) 50% chance that carrier mother will pass abnormal gene to each of her sons → affected (3) 50% chance that carrier mother will pass normal gene to each of her sons → unaffected (4) 50% chance that carrier mother will pass abnormal gene to each of her daughters → become carriers (5) Father affected cannot pass disorder to sons → all daughters become carriers c) Common disorders (1) Hemophilia (2) Duchenne muscular dystrophy (3) Some forms of color blindness

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5. X-linked dominant inheritance a) Rare (1) Most common → vitamin D–resistant rickets b) Pattern similar to X-linked recessive inheritance except heterozygous females can also be affected (1) No male-to-male transmission c) Some so severe → lethal in utero or newborn period in hemizygous males (1) Rett syndrome (2) Severe form of otopalataldigital 6. Trinucleotide repeat disorders a) Anticipation → trinucleotide repeats during meiosis → gene passed from generation to generation with a larger and larger number of triplet repeats b) Associated with phenotypic expression condition c) Diseases (1) Huntington disease (2) Myotonic dystrophy (3) Fragile X syndrome 7. Multifactorial inheritance a) Many common malformations → do not follow clear pattern of Mendelian inheritance (1) Interaction of many genes (2) Cleft palate (3) Heart defect (4) Spina bifida (5) Dislocated hips (6) Clubfoot (7) Pyloric stenosis b) Characteristics (1) Malformations may range from mild to severe (2) Often a sex bias (a) Pyloric stenosis more common in males, cleft palate more common in females (b) Greater number of genes present if less commonly affected sex shows condition (3) Increased risk among closest relatives, multiple family members affected c) Careful family history (1) Other disorders within multifactorial inheritance group (a) Diabetes (b) Hypertension (c) Some heart diseases (d) Mental illness

D. Prenatal Diagnostic Tests 1. Parent–child, family-planning counseling → responsibility of nurses a) Counseling before prenatal screening, diagnostic testing 5 Copyright © 2020 Pearson Education, Inc.

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(1) Include conditions detectable (2) Diagnostic test available if screen positive (3) Risk to mother and pregnancy of test (4) Accuracy of test (5) Limitations of test b) Should be available to all women regardless of maternal age c) Women counseled on difference between screening and invasive diagnostic testing 2. Genetic ultrasound a) Visualize (1) Fetal head for abnormalities (2) Craniospinal defects (3) Gastrointestinal malformations (4) Renal malformations (5) Skeletal malformations b) Best done at 16 to 20 weeks c) Nuchal translucency measurement at 10 and 13 weeks → chromosomal abnormalities 3. Maternal serum screening a) Specific hormones, proteins → risk for Down syndrome, trisomy 18, open spina bifida b) Nuchal translucency measurement → often added in first trimester 4. Noninvasive prenatal testing (NIPT) through cell-free fetal DNA a) Measuring circulating cell-free DNA in maternal serum b) Not meant to replace diagnostic testing such as CVS or amniocentesis c) Recommended for women of advanced age and women with abnormal fetal ultrasound findings 5. Genetic amniocentesis a) Risks (1) Infection (2) Miscarriage (3) < 0.1 to 0.3% b) Indications (1) Maternal age 35 or older (2) Previous child born with a chromosomal abnormality (3) Parent carrying a chromosomal abnormality (balanced translocation) (4) Mother carrying an X-linked disease (5) Both parents carrying an autosomal recessive disease (6) Family history of neural tube defects (7) Fetus with major or minor abnormalities on ultrasound (8) Women with positive serum screening results, including NIPT c) See Figure 10–12: A. Genetic amniocentesis for prenatal diagnosis …, p. 199 6. Percutaneous umbilical cord sampling and chorionic villus sampling (CVS) a) Percutaneous umbilical cord sampling (PUBS) 6 Copyright © 2020 Pearson Education, Inc.

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(1) Blood obtained from umbilical cord during pregnancy (2) More rapid chromosome diagnosis (3) Transfusion for Rh alloimmunization or hydrops fetalis (4) Risk of pregnancy complication higher then CVS b) Chorionic villus sampling (CVS) (1) Obtains chorionic villi tissue either transabdominally or transcervically (2) Diagnostic capability similar to amniocenteses (3) Advantage → information available at 10 to 12 weeks’ gestation c) Risks (1) Infection (2) Pregnancy loss (3) Estimated 1% 7. Nursing Management for the Woman with Possible Risk Factors for Genetic Disorders a) See Key Facts to Remember: Couples Who May Benefit from Preconceptual or Prenatal Genetic Counseling, p. 201 (1) Women age 35 or older at time of birth (2) Couples with a balanced translocation (3) Family history of known or suspected single-gene disorder (4) Couples with a previous pregnancy or child with chromosomal abnormality (5) Couples in which either partner or a previous child is affected with or in which both partners are carriers for a diagnosable metabolic disorder (6) Family history of birth defects and/or intellectual disability (7) Ethnic groups at increased risk for specific disorders (8) Couples with a history of three or more first trimester spontaneous abortions (9) Women with an abnormal maternal serum screening test (10) Women with a teratogenic risk secondary to an exposure or maternal health condition b) Counseling precedes any procedure for prenatal diagnosis c) Couple may decide to interrupt pregnancy d) Can give parents opportunity to prepare for a child with special needs e) Every pregnancy 3% to 5% risk of infant with birth defect 8. Newborn screening a) Hearing loss, congenital heart disease, hemoglobinopathies, certain endocrine diseases, and other inherited genetic diseases b) State-level program 9. Postnatal diagnosis a) Genetic disorders often discussed in newborn period (1) Anomalies, does not progress → genetic evaluation b) Incorporate: (1) Complete and detailed histories → determine if problem prenatal, postnatal, familial in origin (2) Thorough physical and dysmorphology examination by trained clinical geneticist 7 Copyright © 2020 Pearson Education, Inc.

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(3) Laboratory analysis → includes chromosome analysis, enzyme assay for inborn errors of metabolism, DNA studies, antibody titers for infectious teratogens c) Human Genome Project → implications for identification, management of inherited diseases (1) Ethical considerations

E. Genetic Evaluation 1. Communication → a) Helps family, individual → understand, adapt to implications of genetic contributions to disease 2. Referral advised for a) Congenital abnormalities, including intellectual disability b) Familial disorders c) Known inherited diseases d) Metabolic disorders e) Chromosomal abnormalities 3. Process a) Form for family pedigree (1) See Figure 10–13: Screening pedigree, p. 201 b) Initial session (1) Counselor gathers additional information (a) Affected child’s growth and development (b) Family’s understanding of problem (c) Ethnic background (i) See Developing Cultural Competence: Genetic Screening Recommendations for Various Ethnic Groups, p. 203 (2) Child given physical examination (3) Other family members may be examined (4) Laboratory studies, if any, done at this time c) Follow-up counseling (1) After data examined and analyzed (2) Parents given all information available (3) Discuss course of action appropriate for the family (4) See Key Facts to Remember: Nursing Responsibilities in Genetic Evaluation and Counseling, p. 204 (a) Identify families at risk for genetic problems (b) Determine how the genetic problem is perceived and what information is desired before proceeding (c) Assist families in acquiring information about the specific problem (d) Act as liaison between family and genetic counselor (e) Assist the family in understanding dealing with information received (f) Provide information on support groups 8 Copyright © 2020 Pearson Education, Inc.

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(g) Aid families in coping with this crisis (h) Provide information about known genetic factors (i) Ensure continuity of nursing care to the family 4. Nursing Management for the Family Undergoing Genetic Evaluation a) Key role in preventing recurrence b) Inform parents genetic counseling is available c) Answer additional questions d) Attend counseling sessions e) Act as liaison between family and genetic counselor

II.

Focus Your Study

III.

Activities 1. Individual Have students prepare a screening pedigree for a patient. Instruct students to include two preceding generations.

2. Small Group Divide the class into small groups of three to five students. Have each group prepare a patient teaching plan for one of the following: a. Following basal body temperature (BBT) b. Hysterosalpingography c. Therapeutic insemination d. Transvaginal ultrasound e. Amniocentesis f. Maternal serum alpha-fetoprotein g. In vitro fertilization 3. Large Group Invite a nurse from a fertility clinic or a genetic counselor to talk to the students about specific nursing care of their patients.

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Chapter 11 Physical and Psychologic Changes of Pregnancy Anatomy and Physiology of Pregnancy.........................................................

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Signs of Pregnancy.........................................................................................

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Psychologic Response of the Expectant Family to Pregnancy......................

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Cultural Values and Pregnancy......................................................................

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Focus Your Study....................................................................................... …..

14

Activities.........................................................................................................

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I.

Anatomy and Physiology of Pregnancy

A. Reproductive System 1. Uterus a) Size → 7.5 × 5 × 2.5 cm → 28 ×24 × 21 cm b) Weight → 70 g → 1100 g c) Capacity → 10 mL → 5000 mL d) Hypertrophy of preexisting myometrial cells (1) Uterine walls get thicker → stimulated by increased estrogen, progesterone levels (2) Enlarges more around fundus and placental insertion site (3) Myometrial hypertrophy continues first few months → musculature begins to distend e) Braxton Hicks contractions → irregular contractions of uterus 2. Cervix a) Major component of cervical tissue → connective tissue b) Estrogen stimulates glandular tissue → increases in cell number, hyperactive c) Thick mucus plug seals endocervical canal → expelled when cervical dilation begins d) Goodell sign e) Chadwick sign 3. Ovaries a) Cease ovum production during pregnancy b) Human chorionic gonadotropin (hCG) maintains corpus luteum → persists until about 6 to 8 weeks of pregnancy (1) Secretes progesterone to maintain endometrium until placenta produces enough to maintain pregnancy 4. Vagina a) Estrogen-induced changes → hypertrophy, increased vascularization, hyperplasia (1) Increased secretions → thick, white, acidic → pH plays role in preventing infections, except yeast organisms b) Smooth muscle cells hypertrophy → accompanying loosening of supportive connective tissue c) Increased blood flow → may show same blue-purple color seen in cervix 5. Breasts a) Changes occur soon after first missed menstrual period b) Estrogen- and progesterone-induced changes (1) Increases in breast size, nodularity → result of glandular hyperplasia, hypertrophy (2) End of second month → superficial veins prominent, nipples more erectile, pigmentation of areola obvious (3) Hypertrophy of Montgomery follicles (4) Striae may develop

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c) Colostrum → antibody-rich yellow secretion (1) May be expressed manually by 12th week (2) Gradually converts to mature milk during first few days following childbirth

B. Respiratory System 1. Pulmonary function modified throughout pregnancy 2. Small degree of hyperventilation → tidal volume increases steadily throughout pregnancy 3. Oxygen consumption increases → meet increased needs of mother, fetus, placenta a) Progesterone-induced marked decrease of airway resistance 4. Chest circumference may increase → elevated diaphragm 5. Lung disease may be aggravated 6. Rhinitis of pregnancy a) Epistaxis b) Estrogen-induced edema and vascular congestion of nasal mucosa

C. Cardiovascular System 1. Uterus exerts pressure on diaphragm → pushes heart upward, to left, rotating forward a) May appear somewhat enlarged on x-ray 2. Blood volume progressively increases throughout pregnancy a) No increase in pulmonary capillary wedge pressure or central venous pressure → decrease in systemic vascular resistance, pulmonary vascular resistance b) Cardiac output begins to increase in early pregnancy → peaks at 25 to 30 weeks 3. Pulse frequently increases during pregnancy → 10 to 15 beats/min 4. Blood pressure decreases slightly → second trimester then rises to near prepregnant by term 5. Femoral venous pressure slowly rises → uterus exerts increasing pressure on return blood flow → edema 6. Enlarging uterus may put pressure on vena cava when supine → supine hypotensive syndrome a) Marked decrease in BP, with dizziness, pallor, clamminess → lie on left side to correct b) See Figure 11–1: Vena cava syndrome, p. 209 7. Total erythrocyte volume increases about 25% a) Supports additional oxygen transport b) Physiologic anemia of pregnancy c) Iron necessary for hemoglobin formation → recommended to add supplemental iron to diet

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8. Leukocyte production equal or slightly greater than increased blood volume a) Occasional physiologic leukocytosis of 15,000/mm3 b) During normal labor → may reach 25,000/mm3 9. Platelet count does not change much in pregnancy 10. Plasma fibrinogen known to increase by as much as 50% a) Clotting time does not differ significantly b) Blood factors VII, VIII, IX, X increased → pregnancy somewhat hypercoagulable c) Pregnant woman at increased risk of developing venous thrombosis

D. Gastrointestinal System 1. Nausea and vomiting during first trimester → sometimes associated with hCG, change in carbohydrate metabolism a) Gum tissues hyperemic, softened b) Increased secretion of saliva 2. Second half of pregnancy → numerous symptoms attributable to pressure of growing uterus, smooth muscle relaxation due to elevated progesterone levels a) Heartburn b) Bloating, constipation c) Hemorrhoids 3. Mild liver changes 4. Gallbladder emptying may be slow

E. Urinary Tract 1. First trimester → urinary frequency 2. Second trimester → uterus becomes abdominal organ → no pressure on bladder 3. Near term → pressure on bladder a) Susceptible to infection, trauma b) Capacity reduced 4. Dilation of kidneys, ureter → right side, due to lie of uterus 5. Glomerular filtration rate (GFR), renal plasma flow (RPF) increase early in pregnancy a) GFR elevated until birth b) Increased renal tubular reabsorption → compensates for increased glomerular activity

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6. Glycosuria not uncommon, not necessarily pathogenic

F. Skin and Hair 1. Changes in skin pigmentation common → increased estrogen, progesterone, α-melanocytestimulating hormone levels a) Increased pigmentation primarily in areas already hyperpigmented b) Linea nigra (1) See Figure 11–2: Linea nigra, p. 211 c) Chloasma 2. Striae → stretch marks 3. Vascular spider nevi → disappear after pregnancy ends 4. Rate of hair growth may decrease during pregnancy a) After birth → number of hair follicles in resting phase increases → increased shedding of hair for 1 to 4 months 5. Sweat and sebaceous glands → frequently hyperactive

G. Musculoskeletal System 1. Teeth → no demonstrable changes 2. Sacroiliac, sacrococcygeal, pubic joints of pelvis relax in later part of pregnancy → hormonal changes a) Waddling gait 3. Lumbodorsal spinal curve accentuated as pregnant woman’s center of gravity changes a) Late in pregnancy → aches in shoulder, neck, upper extremities 4. Diastasis recti

H. Eyes 1. Intraocular pressure decreases 2. Slight thickening of cornea 3. May affect fit of contacts

I. Central Nervous System 1. Many describe decreased attention, concentration, memory during and after pregnancy 2. Sleep problems common in pregnancy

J. Metabolism 1. Weight gain a) Growth of uterus, contents, breasts, increases in intravascular fluids 5 Copyright © 2020 Pearson Education, Inc.

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b) Maternal reserves 2. Recommended total weight gain a) 11.5 to 16 kg (25 to 35 lb) → normal prepregnancy weight b) to 11.5 kg (15 to 25 lb) → overweight prepregnancy c) 5 to 9 kg (11 to 20 1b) → obese prepregnancy d) 12.7 to 18.1 kg (28 to 40 1b) → underweight prepregnancy e) 0.5 to 2.0 kg first trimester f) 0.45 kg per week during last two trimesters 3. Water metabolism a) Increased water retention → basic chemical alteration of pregnancy b) Increased level of steroid sex hormones c) Lowered serum protein d) Extra water needed for products of conception, increased blood volume, interstitial fluids; enlarged organs 4. Nutrient metabolism a) Fetal demands greatest during second half of gestation (1) Doubles in weight in last 6 to 8 weeks b) Increased protein retention → hyperplasia, hypertrophy of maternal tissues c) Fats more completely absorbed during pregnancy (1) Marked increase in serum lipids, lipoproteins, cholesterol d) Fat deposits increase from 2% midpregnancy to 12% at term e) Woman’s body switches from glucose metabolism to lipid metabolism once glucose from food intake has been used up f) Demand for carbohydrate increases g) Intermittent glucosuria not uncommon h) Diabetes → plasma levels of insulin increase during pregnancy (1) Rapid destruction of insulin within placenta (2) Insulin production must be increased by mother during second trimester i) Demand for iron accelerated (1) Iron transfer at placenta toward fetus (a) Stored in fetal liver (b) Compensates for inadequate amounts of iron in breast milk j) Progressive absorption, retention of calcium

K. Endocrine System 1. Thyroid gland a) Often palpable change → increase in vascularity, hyperplasia of glandular tissue b) Serum thyroxine (T4) increases early in pregnancy, thyroid-stimulating hormone (TSH) decreases c) Basal metabolic rate (BMR) increases by as much as 20% to 25% during pregnancy

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2. Parathyroid gland a) Concentration of parathyroid hormone, size of glands increase b) Paralleling fetal calcium requirements 3. Pituitary gland a) Enlarges somewhat → returns to normal size after birth b) Pregnancy possible by hypothalamic stimulation of follicle-stimulating hormone (FSH) → stimulates follicle growth; luteinizing hormone (LH) → effects ovulation c) Thyroid-stimulating hormone and adrenotropin → alter maternal metabolism to support pregnancy d) Prolactin responsible for initial lactation e) Posterior pituitary contains mechanism for release of oxytocin, vasopressin 4. Adrenal glands a) Little structural change in adrenal glands b) Circulating cortisol levels regulate carbohydrate and protein metabolism c) Increased secretion of aldosterone by early part of second trimester 5. Pancreas a) Increased insulin needs b) Latent deficiency → symptoms of gestational diabetes 6. Hormones in pregnancy a) hCG → from trophoblast early in pregnancy b) Human placental lactogen → antagonist of insulin (1) Decreases maternal metabolism of glucose to favor fetal growth c) Estrogen → originally by corpus luteum, primarily produced by placenta d) Progesterone → originally by corpus luteum, then placenta → greatest role in maintaining pregnancy e) Relaxin → inhibits uterine activity, believed to be produced by placenta, uterine decidua throughout pregnancy 7. Prostaglandins (PGs) in pregnancy a) PGs → lipid substance that can arise from most body tissues b) May be responsible for maintaining reduced placental vascular resistance

II.

Signs of Pregnancy

A. Subjective (Presumptive) Changes 1. Amenorrhea 2. Nausea and vomiting of pregnancy (NVP) a) Changed carbohydrate metabolism b) Morning sickness c) Usually disappears spontaneously 6 to 12 weeks after it starts

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d) Women who experience NVP → have more favorable pregnancy outcome than those who do not 3. Excessive fatigue 4. Urinary frequency 5. Change in breasts 6. Quickening → about 18 to 20 weeks after last menstrual period (LMP)

B. Objective (Probable) Changes 1. Changes in pelvic organs a) Goodell sign b) Chadwick sign c) Hegar sign d) Ladin sign e) McDonald sign f) Braun von Fernwald sign g) Piskacek sign 2. Enlargement of abdomen 3. Braxton Hicks contractions 4. Uterine souffle 5. Changes in pigmentation of skin 6. Appearance of abdominal striae 7. Fetal outline may be identified by palpation after 24 weeks’ gestation a) Ballottement 8. Pregnancy tests → analysis of maternal blood or urine for detection of hCG a) Clinical pregnancy tests (1) β-Subunit radioimmunoassay (RIA) → very accurate (2) Enzyme-linked immunosorbent assay (ELISA) → sensitive, quick → 7 to 9 days after ovulation and conception (3) Fluoroimmunoassay (FIA) → 2 to 3 hours to perform, extremely sensitive b) Over-the-counter pregnancy tests (1) Home pregnancy tests (HPTs) → convenient, private (a) Multiple brands (b) Many variables that affect accuracy of home pregnancy tests (c) False-positive rate low → false negatives more common

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C. Diagnostic (Positive) Changes 1. Fetal heartbeat can be detected with electronic Doppler device as early as 10 to 12 weeks 2. Fetal movement → after about 20 weeks’ gestation 3. Visualization of the fetus by ultrasound → confirms pregnancy a) Gestational sac → 4 to 5 weeks’ gestation b) Fetal parts, fetal heart movement → as early as 8 weeks c) Transvaginal ultrasound → gestational sac as early as 10 days after implantation

III.

Psychologic Response of the Expectant Family to Pregnancy

A. Developmental challenge 1. Stress, anxiety → whether desired or not a) Transition period 2. Couple may be unaware → physical, emotional, cognitive states peculiar to pregnancy 3. Roles a) Mate → adds mother, parent role b) Career goals, mobility → altered c) Without stable partner (1) Role changes, maturation → alone or seek support (2) Face future as single parent 4. Financial considerations a) Breadwinners → impact b) Decisions to be made 5. Labor and birth a) Must face realities → childbirth classes can address lack of information, misinformation b) Threats for woman → pain, disfigurement, disruption of bodily function, death c) Partner → woman’s disfigurement, impairment of her health, her death d) Both → fear baby may be ill, disfigured 6. Developmental tasks a) Support or conflict for couple b) Plan for first child’s arrival → collect information on how to be parents (1) Social support c) Other family members also adjust to pregnancy d) Major psychosocial adjustments (1) See Table 11–3: Parental Reactions to Pregnancy, p. 218 (2) First trimester (a) Mother’s reactions (i) Informs father (ii) Feels ambivalent 9 Copyright © 2020 Pearson Education, Inc.

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(iii) Aware of physical changes, daydreams of possible miscarriage (iv) Develops special feeling for, renewed interest in own mother (b) Father’s reactions (i) Differ according to age, parity, desire for child, economic stability (ii) Acceptance of pregnant woman’s attitude or complete rejection, lack of communication (iii) Aware of sexual feelings, may develop more or less sexual arousal (iv) Accepts, rejects, or resents mother-in-law (v) May develop new hobby outside of family as sign of stress (3) Second trimester (a) Mother’s reactions (i) Remains regressive, introspective; projects problems with authority figures onto partner (ii) Continues to deal with feelings as mother, shops for nursery furniture as concrete action (iii) May experience anxiety or be lackadaisical and wait until ninth month to shop for baby (iv) Feels movement, aware of fetus (v) Dreams that partner will be killed, telephones him often for reassurance (vi) Experiences more distinct physical changes, sexual desires may increase or decrease (b) Father’s reactions (i) If he can cope → will give her extra attention; if cannot cope → develop new time-consuming interest outside home (ii) May develop creative feeling, closeness to nature (iii) May become involved in pregnancy, buy or make furniture (iv) Feels for movement of baby, listens to heartbeat or remains aloof, no physical contact (v) May have fears and fantasies about himself being pregnant (vi) May react negatively if partner too demanding, may become jealous of physician, and physician’s importance to partner and pregnancy (4) Third trimester (a) Mother’s reactions (i) More anxiety and tension, physical awkwardness (ii) Feels much discomfort, insomnia (iii) Prepares for birth (iv) Dreams about misplacing baby, not being able to give birth, fears birth of deformed baby (v) Feels ecstasy and excitement (b) Father’s reactions (i) Adapts to alternative methods of sexual contact (ii) Becomes concerned over financial responsibility (iii) May show new sense of tenderness, concern, treat partner like doll (iv) Dreams about child as if older, dreams of losing partner 10 Copyright © 2020 Pearson Education, Inc.

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(v) Renewed sexual attraction to partner (vi) Feels he is ultimately responsible for whatever happens e) Late pregnancy (1) Focus mostly on unborn child, safety of mother (2) Couples typically agree on primary concern → health of unborn child f) May be crisis → disturbance or conflict in which the individual cannot maintain state of equilibrium (1) Maturational crisis (2) Disequilibrium, disorganization (3) If not resolved → maladaptive behaviors, possible disintegration of family

B. Mother 1. Alters body image, reorders social relationships, changes roles of family members 2. Intendedness a) Unintended pregnancy not necessarily unwanted b) May be risk factor for depression 3. Ambivalence a) Surprise → conception actually occurred b) Individuals who do not view parenthood as being important c) Higher perceived cost of having children d) Lack of positive attitude toward the partner e) Lower socioeconomic variables f) May be more pronounced if pregnancy unwanted, unintended g) Financial and emotional support from partner → essential to positive attitude h) May have negative thoughts → feel guilty for negative thoughts 4. Acceptance a) Influenced by many factors → planned/unplanned b) First trimester → evidence of pregnancy amenorrhea, word of caregiver c) Second trimester → begins to accept reality of pregnancy → primigravida may wear maternity clothing (1) Quickening → about week 20 (2) Adjusts to idea of change → prepares for new role, new set of relationships (3) “Glow” d) Third trimester → pride with anxiety (1) Accepts help due to advanced pregnancy or rejects (2) Physical discomforts increase, needs rest (3) Worries (4) Vulnerable to rejection, loss, insult 5. Introversion a) Turning in on oneself → common b) More concerned with needs for rest, time alone 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Partner may feel she is being overly sensitive d) Fantasies about unborn child common 6. Mood swings a) Great joy to deep despair b) Tearful with little cause c) Unsettling to partner → may withdraw → feels confused and inadequate 7. Changes in body image a) Marked changes in body → short period of time b) Explanation and discussion may help 8. Psychologic tasks of mother a) Ensuring safe passage through pregnancy, labor, and birth b) Seeking of acceptance of this child by others c) Seeking of commitment, acceptance of self as mother to infant (binding-in) d) Learning to give of oneself on behalf of one’s child

C. Father 1. View of role changed from bystander → nurturing, caring involved parent, provider a) Many of same feelings, conflicts of expectant mothers b) Psychologic stress → transition of roles c) Must establish fatherhood role d) Role of father is crucial both prenatally and postnatally 2. First trimester a) After initial excitement, announcement → may feel left out of pregnancy b) Confused by mood changes, his responses to her changing body 3. Second trimester a) Role still vague, involvement increasing (1) Can hear fetal heartbeat b) Needs to confront, resolve own conflicts about fathering they received c) Anxiety may be lessened → both parents agree on role man to assume d) Woman’s appearance begins to alter → men react differently 4. Third trimester a) Communicated concerns to one another → special, rewarding time b) Involved in childbirth education classes c) Concrete preparations d) Concerns, fears may recur → fear of injuring baby during intercourse e) Couvade → unintentional development of physical symptoms that pregnant woman experiencing

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D. Partners of Lesbian Mothers 1. More obstacles to overcome including the basic decision as to which woman will become the biological parent.

2. Legal barriers as to legal parents

E. Siblings 1. Introduction of new baby → may be beginning of sibling rivalry a) Fear of change in security of relationships with parents 2. Preparation of young child → several weeks before a) Feel baby moving in uterus → “special place where babies grow” 3. Consistency with people, places, things a) Crib or cosleeping b) Toilet training → several months before or after baby’s arrival (1) May regress 4. Introduce older children to new baby → not playmate yet 5. Pregnancy a family affair → school-age children a) Teaching based on level of understanding, interest 6. Older children → discuss concerns, involve in preparation a) Dispel misconceptions 7. After birth → program at hospital

F. Grandparents 1. Usually first relatives told about a pregnancy 2. Response can vary considerably → interest or seeming disinterest 3. Signal change in grandparents’ own lives 4. Childbearing, childrearing practices very different → advice comes because they care 5. Too much advice → perceived as criticism 6. Classes for grandparents

IV.

Cultural Values and Pregnancy A. Ceremonial rituals and rites around important life events 1. Identification of cultural values useful in planning, providing culturally sensitive care 2. Generalizations difficult a) Not every individual in a culture may display characteristics 13 Copyright © 2020 Pearson Education, Inc.

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b) Related to social, economic factors 3. Cultural assessment important aspect of prenatal care a) Identify main beliefs, values, behaviors that relate to pregnancy, childbearing

V.

Focus Your Study

VI.

Activities 1. Individual Ask students to identify cultural values, beliefs, and behaviors in their personal cultural and/or ethnic group. Alternatively, ask students to pick a group to research. Instruct students to include in their rubrics: an outline of common values, beliefs, and behaviors and subgroup differences, if identified. Students should use APA format for their reference citations.

2. Small Group Divide the class into small groups of three to five students. Assign each group a body system that is altered in some way during pregnancy. The groups should prepare a visual presentation of some type with a short (two to four pages) written report with references in APA format.

3. Large Group Invite a childbirth educator to speak to the class specifically about grandparent, sibling, and partner preparation in light of the physical and psychological changes of pregnancy.

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Chapter 12 Antepartum Nursing Assessment Initial Patient History.....................................................................................

2

Initial Prenatal Assessment...........................................................................

7

Subsequent Patient History..........................................................................

24

Subsequent Prenatal Assessment.................................................................

25

Focus Your Study...........................................................................................

32

Activities........................................................................................................

32

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I.

Initial Patient History

A. Factors that influence pregnancy course B. Definition of Terms 1. Antepartum 2. Intrapartum 3. Postpartum 4. Gestation 5. Abortion 6. Term a) Early term b) Full term c) Late term d) Postterm 7. Preterm labor 8. Postterm labor 9. Gravida 10. Nulligravida 11. Primigravida 12. Multigravida 13. Para 14. Nullipara 15. Primipara 16. Multipara 17. Stillbirth 18. TPAL a) Gravida, para → refer to total number of pregnancies b) T → number of term births c) P → number of preterm births d) A → number of pregnancies ending in spontaneous or therapeutic abortions e) L → number of currently living children to whom the woman has given birth f) Examples g) Five-digit system → multiple births 2 Copyright © 2020 Pearson Education, Inc.

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C. Patient Profile 1. Current pregnancy a) First day of last menstrual period (LMP) b) Cramping or bleeding since LMP c) Opinion about conception, due date d) Attitude toward pregnancy e) Date of positive/negative pregnancy test f) Any pregnancy discomforts since LMP g) Spontaneous conception? Infertifility treatments?

2. Past pregnancies a) Number of pregnancies b) Number of abortions, spontaneous or therapeutic c) Number of living children d) History of previous pregnancies (1) Length of pregnancy (2) Length of labor and birth (3) Type of birth (4) Location of birth (5) Type of anesthesia/medication used (6) Perception of the experience (7) Complications e) Neonatal status of previous children (1) Apgar scores (2) Birth weights (3) General development (4) Complications (5) Feeding method f) Loss of child g) Blood type, Rh factor h) Prenatal education classes, resources, knowledge about pregnancy, childbirth and parenting 3. Gynecologic history a) Date of last Pap smear? Results? b) Previous infections c) Previous surgery d) Age of menarche e) Regularity, frequency, duration of menstrual flow f) History of dysmenorrheal g) History of infertility h) Sexual history i) Contraceptive history

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4. Current medical history a) Weight, height, body mass index (BMI) b) Blood type, Rh factor c) General health: nutrition, regular exercise program, monthly breast exams, eye exam, dental exam d) Any medication use, any medications taken since LMP e) Previous or present use of alcohol, tobacco, caffeine (1) Amount (2) Planning cessation f) Illicit drug use (1) Specific drugs (2) Planning cessation g) Drug or food allergies, latex allergy or sensitivities, what type of reaction h) Potential teratogenic insults to this pregnancy (1) Viral infections, medications, x-ray examinations, surgery, cats in the home i) Presence of chronic disease conditions (diabetes, hypertension, asthma, cardiovascular disease, renal problems, or thyroid disease) j) Infections or illnesses since LMP k) Record of immunizations l) Presence of any abnormal signs/symptoms 5. Past medical history a) Childhood diseases (varicella) b) Past treatment for any disease condition; hospitalizations; major accidents? c) Surgical procedures d) Presence of bleeding disorders or tendencies e) Blood transfusion history; will she accept blood transfusions?

6. Family medical history a) Presence of diabetes, cardiovascular disease, hypertension, hematologic disorders, tuberculosis, thyroid disease, cancer b) Occurrence of multiple births c) History of congenital diseases or deformities d) History of mental illness e) Occurrence of cesarean births and cause, if known f) Cause of death of deceased parents or siblings 7. Genetic history a) Thalassemia, neural tube defect, congenital heart defect, Down syndrome, Tay-Sachs disease, Canavann disease, sickle cell disease or trait, hemophilia or other blood disorder, cystic fibrosis, Huntington chorea, intellectual disability/autism, other genetic disorder b) Recurrent pregnancy loss or stillbirth

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8. Religious/cultural history a) Does woman wish to specify religious preference on her chart? Any beliefs or practices that might influence her healthcare or that of child? b) What practices are important to maintain her spiritual well-being? c) Are there practices in her culture or that of her partner that might influence her care or that of her child?

9. Occupational history a) Occupation b) Physical demands c) Exposure to lead, chemicals, or other harmful substances d) Opportunity for regular meals and break for nutritious snacks e) Provision for maternity or family leave 10. Birth father’s physical history a) Presence of genetic conditions or diseases in him, or in family history b) Age c) Significant health problems d) Blood type, Rh factor e) Immunizations up to date 11. Father’s/partner’s social history a) Occupation b) Educational level; methods by which he or she learns best c) Current tobacco use, drug use, and alcohol intake d) Thoughts/feelings regarding pregnancy 12. Personal information about the woman (social history) a) Age b) Relationship status c) Educational level; methods by which she learns best d) Race or ethnic group e) Housing, stability of living conditions f) Economic level g) Intimate partner violence (IPV): Any history of emotional or physical deprivation or abuse of herself or children (1) Abuse in current relationship (2) Has she been hit, slapped, kicked, or hurt within the past year or since she has been pregnant?

(3) Afraid of her partner or anyone else h) History of emotional/mental health disorder i) Support systems/postpartum support j) Personal preferences about the birth k) Plans for care of child following birth l) Feeding method for the baby

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D. Obtaining Data 1. American College of Obstetricians and Gynecologists (ACOG) questionnaire a) Filled out by woman b) Nurse review, obtain further information

E. Prenatal Risk-Factor Screening 1. Any findings shown to have negative effect on pregnancy outcomes a) Woman or unborn child 2. See Table 12–1: Prenatal High-Risk Factors, p. 231 a) Social-personal (1) Low income level or low educational level (2) Poor diet (3) Living at high altitude (4) Multiparity greater than 3 (5) Weight <45.5 kg (100 lb) (6) Weight >91 kg (200 lb) (7) Age <16 years (8) Age >35 years (9) Smoking one pack/day or more (10) Use of illicit drugs (11) Excessive alcohol consumption b) Preexisting medical disorders (1) Diabetes mellitus (2) Cardiac disease (3) Anemia: hemoglobin less than 11 g/dL, hematocrit (Hct) <32% (4) Hypertension (5) Thyroid disorder (6) Hypothyroidism (7) Hyperthyroidism (8) Renal disease (moderate to severe) (9) Diethylstilbestrol (DES) exposure 3. Obstetric considerations a) Previous pregnancy (1) Stillborn (2) Recurrent abortion (3) Cesarean birth (4) Rh or blood group sensitization b) Current pregnancy (1) Large for gestational age (LGA) (2) Gestational diabetes mellitus (3) Rubella (first trimester) (4) Rubella (second trimester) 6 Copyright © 2020 Pearson Education, Inc.

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(5) Toxoplasmosis (6) Cytomegalovirus (7) Herpesvirus type 2 (8) Syphilis (9) Urinary tract infection (10) Abruptio placentae; placenta previa (11) Preeclampsia/eclampsia (12) Multiple gestation (13) Elevated hematocrit (> 41%) (14) Spontaneous premature rupture of membranes

II.

Initial Prenatal Assessment

A. Focuses on woman holistically → physical, cultural, psychosocial factors 1. Establishment of nurse–patient relationship 2. Discuss factors that may influence woman’s expectations of childbearing experience 3. Be familiar with common practices of groups in the community

B. Prepare woman for physical examination 1. Vital signs 2. Head-to-toe examination with pelvic exam last a) Give anticipatory guidance and reassurance → may be first gynecologic examination b) Thorough, systematic antepartal examination 3. Clean urine specimen for screening prior to pelvic exam a) Disrobe → gown and sheet for modesty, comfort, warmth

C. See Assessment Guide: Initial Prenatal Assessment, p. 234 D. Vital signs 1. Physical assessment/normal findings a) Blood pressure (BP) less than or equal to 120/80 mmHg b) Pulse 60 to 100 beats/min c) Respiration 12 to 22 breaths/min d) Temperature 36.2°C to 37.6°C (97°F to 99.6°F) 2. Alterations and possible causes a) High BP → essential hypertension, renal disease, apprehension, preeclampsia b) Increased pulse rate → excitement, anxiety, dehydration, infection, cardiac disorders c) Marked tachypnea, abnormal patterns d) Elevated temperature

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3. Nursing responses to data a) BP of 120 to 139/80 to 89 mmHg considered prehypertensive b) BP greater than 140/90 mmHg requires immediate consideration (1) Establish woman’s BP (2) Refer to healthcare provider if necessary (3) Assess woman’s knowledge about high BP (4) Counsel on self-care and medical management c) Count pulse for 1 full minute (1) Note irregularities (2) Evaluate temperature, increase fluids d) Assess for respiratory disease e) Assess for infection process (1) Refer to healthcare provider

E. Height and weight → normal findings 1. Physical assessment/normal findings a) Depends on body build 2. Alterations and possible causes a) >91 kg (200 lb) b) <45 kg (100 lb) c) Rapid sudden weight gain → preeclampsia 3. Nursing responses to data a) Evaluate need for nutritional counseling (1) Obtain information on eating habits (2) Income limitations, need for food supplements (3) Food allergies, pica, other abnormal food habits (4) Note initial weight → establish baseline for weight gain throughout pregnancy (5) Determine BMI, recommended weight gain for pregnancy

F. Skin 1. Physical assessment/normal findings a) Color → consistent with racial background; pink nail beds b) Condition → absence of edema c) Lesions → absence of lesions (1) Spider nevi common d) Moles e) Pigmentation changes of pregnancy f) Café-au-lait spots 2. Alterations and possible causes a) Pallor b) Bronze, yellow c) Bluish, reddish, mottled 8 Copyright © 2020 Pearson Education, Inc.

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d) Dusky appearance, pallor of palms and nail beds in dark-skinned women e) Edema→ preeclampsia, normal pregnancy changes f) Rashes, dermatitis→ allergic response g) Ulceration→ varicose veins, decreased circulation h) Petechiae, multiple bruises, ecchymosis→ hemorrhagic disorders, abuse i) Change in size or color→ carcinoma j) Six or more→ Albright syndrome or neurofibromatosis 3. Nursing responses to data a) Tests to perform b) Refer to healthcare provider (1) For preeclampsia, if severe lesion, suspect bleeding disorder, allergic reaction c) Counsel on relief measures d) Assess for preeclampsia, circulatory status e) Counsel on normal manifestations of pregnancy and physiologic basis for changes

G. Nose 1. Physical assessment/normal findings a) Character of mucosa → redder than oral mucosa, edematous 2. Alterations and possible causes a) Olfactory loss 3. Nursing responses to data a) Counsel about possible relief measures

H. Mouth 1. Physical assessment/normal findings a) May note hypertrophy of tissues because of estrogen 2. Alterations and possible causes a) Edema, inflammation, pale in color 3. Nursing responses to data a) Assess hematocrit for anemia b) Counsel regarding dental hygiene habits c) Refer to healthcare provider or dentist d) Routine dental care appropriate during pregnancy

I. Neck 1. Physical assessment/normal findings a) Nodes → small, mobile, nontender b) Thyroid → small, smooth, lateral lobes palpable on either side of trachea (1) Slight hyperplasia by third month of pregnancy

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2. Alterations and possible causes a) Tender, hard, fixed, or prominent nodes b) Enlargement or nodule tenderness 3. Nursing responses to data a) Examine for local infection b) Refer to healthcare provider c) Tests d) Question about dietary habits

J. Chest and lungs 1. Physical assessment/normal findings a) Chest → symmetric, elliptic, smaller anteroposterior than transverse diameter b) Ribs → slope downward from nipple line c) Inspection and palpation → no retraction of bulging of intercostal spaces (ICS) during inspiration or expiration, symmetric expansion d) Percussion → bilateral symmetry in tone (1) Low-pitched resonance of moderate intensity e) Auscultation → upper lobes → bronchovesicular sounds above sternum and scapulas; equal expiratory, inspiratory phases f) Remainder of chest → vesicular breath sounds heard; inspiratory phase longer 2. Alterations and possible causes a) Increased anteroposterior (AP) diameter, funnel chest, pigeon chest b) More horizontal c) Angular bumps d) Rachitic rosary e) ICS retractions with inspirations, bulging, with expiration; unequal expansion→ respiratory disease f) Tachypnea or hyperpnea→ respiratory disease g) Flatness of percussion (1) May be affected by chest wall thickness h) High diaphragm (atelectasis or paralysis)→ pleural effusion i) Abnormal breath sounds (if heard on any area) (1) Rales, rhonchi, wheezes, pleural friction rub j) Absence of breath sounds (1) bronchophony, egophony, whispered pectoriloquy 3. Nursing responses to data a) Evaluate for emphysema, asthma, pulmonary disease b) Evaluate for fractures c) Consult nutritionist d) Refer to healthcare provider e) Evaluate for pleural effusions, consolidations, tumor

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K. Breasts 1. Physical assessment/normal findings a) Supple → symmetric, darker pigmentation of nipple, areola b) Axillary nodes nonpalpable, or pellet size c) Pregnancy changes (1) Size increase primarily in first 20 weeks (2) Become nodular (3) Tingling sensation, feeling of heaviness (4) Pigmentation darkens (5) Superficial veins dilate, more prominent (6) Striae seen in multiparas (7) Tubercles of Montgomery enlarge (8) Colostrum may be present after 12 weeks (9) Secondary areola → 20 weeks (10) Breasts less firm, old striae in multiparas 2. Alterations and possible causes a) Pigskin or orange-peel appearance b) Nipple retractions c) Swelling d) Hardness (carcinoma) e) Redness f) Heat g) Tenderness h) Cracked or fissured nipple i) Tender, enlarged, or hard axillary node 3. Nursing responses to data a) Encourage regular self-examination b) Instruct woman how to examine own breasts c) Refer to healthcare provider for evaluation of abnormal findings d) Discuss normalcy of changes, meaning with woman e) Teach/institute appropriate relief measures f) Encourage use of supportive well-fitting brassiere

L. Heart 1. Physical assessment/normal findings a) Normal rate, rhythm, heart sounds b) Pregnancy changes (1) Palpitations may occur due to sympathetic nervous system disturbance (2) Short systolic murmurs that increase in held expiration → normal due to increased volume

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2. Alterations and possible causes a) Enlargement b) Thrills, thrusts c) Gross irregularity or skipped beats d) Gallop rhythm or extra sounds 3. Nursing responses to data a) Complete initial assessment b) Explain normalcy c) Refer to healthcare provider if indicated

M. Abdomen 1. Physical assessment/normal findings a) Normal appearance, skin texture, hair distribution b) Liver nonpalpable c) Abdomen nontender d) Pregnancy changes (1) Purple striae, linea nigra (2) Diastasis of rectus muscles late in pregnancy (3) Size flat or rotund, progressive enlargement of uterus (4) Fetal heart rate with Doppler 110 to 160 beats/min (10 to 12 weeks) (a) Fetoscope at 17 to 20 weeks (5) Fetal movement palpable by trained examiner after 18th week (6) Ballottement 2. Alterations and possible causes a) Muscle guarding, tenderness, mass b) Size of uterus inconsistent with length of gestation (1) Intrauterine growth restriction (IUGR) or multiple pregnancy (2) Fetal demise (3) Incorrect estimated date of birth (EDB) (4) Abnormal amniotic fluid (5) Hydatidiform mole c) Failure to hear fetal heartbeat with Doppler → fetal demise, hydatidiform mole d) Failure to feel fetal movements after 20 weeks’ gestation → fetal demise, hydatidiform mole e) No ballottement → oligohydramnios 3. Nursing responses to data a) Assure woman of normalcy of diastasis b) Provide initial information about appropriate prenatal, postpartum exercises c) Evaluate anxiety level d) Refer to healthcare provider e) Reassess menstrual history regarding dating f) Evaluate increase in size using McDonald method 12 Copyright © 2020 Pearson Education, Inc.

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g) Ultrasound to establish diagnosis

N. Extremities 1. Physical assessment/normal findings a) Skin warm, pulses palpable, full range of motion b) May be some edema of hands, ankles in late pregnancy c) Varicose veins may become more pronounced d) Palmar erythema may be present 2. Alterations and possible causes a) Nonpalpable or diminished pulses b) Marked edema → preeclampsia 3. Nursing responses to data a) Evaluate for other symptoms of heart disease b) Initiate follow-up if woman mentions rings are tight c) Discuss prevention/self-treatment for varicose veins d) Refer to healthcare provider

O. Spine 1. Physical assessment/normal findings a) Concave cervical, convex thoracic, concave lumbar b) In pregnancy (1) Lumbar spinal curve may be accentuated c) Shoulders, iliac crests should be even 2. Alterations and possible causes a) Abnormal spinal curves → flatness, hypnosis, lordosis, scoliosis b) Backache c) Uneven shoulders and iliac crests 3. Nursing responses to data a) Refer to healthcare provider if indicated b) May have implications for spinal anesthesics c) Refer very young women to healthcare provider; back-stretching exercise with older women

P. Reflexes 1. Physical assessment/normal findings a) Normal, symmetric 2. Alterations and possible causes a) Hyperactivity, clonus → preeclampsia 3. Nursing responses to data a) Evaluate for other symptoms of preeclampsia 13 Copyright © 2020 Pearson Education, Inc.

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Q. Pelvic area: external female genitalia 1. Physical assessment/normal findings a) Normally formed, female hair distribution b) In multiparas, labia majora loose, pigmented c) Urinary, vaginal orifices visible, appropriately located 2. Alterations and possible causes a) Lesions, genital warts b) Hematomas, varicosities c) Inflammation of Bartholin’s glands d) Clitoral hypertrophy (masculinization) 3. Nursing responses to data a) Explain pelvic examination procedure b) Encourage woman to minimize discomfort by relaxing hips c) Provide privacy

R. Vagina 1. Physical assessment/normal findings a) Pink or dark pink b) Vaginal discharge odorless, nonirritating c) In multiparas, vaginal folds smooth, flattened d) May have episiotomy scar 2. Alterations and possible causes a) Abnormal discharge associated with vaginal infections 3. Nursing responses to data a) Obtain vaginal smear b) Provide understandable verbal, written instructions about treatment for woman and partner, if indicated

S. Cervix 1. Physical assessment/normal findings a) Pink color b) Os closed except in multiparas → os admits fingertip c) Pregnancy changes (1) 1 to 4 weeks’ gestation: enlargement in anteroposterior diameter (2) 4 to 6 weeks’ gestation: softening of cervix (Goodell sign); softening of isthmus of uterus (Hegar sign); cervix takes on bluish coloring (Chadwick sign) (3) 8 to 12 weeks’ gestation: Vagina and cervix appear bluish violet in color (Chadwick sign) 2. Alterations and possible causes a) Eversion, reddish erosion, nabothian or retention cysts, cervical polyp 14 Copyright © 2020 Pearson Education, Inc.

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b) Bleeding granular area (carcinoma of cervix) c) Lesions (herpes, human papilloma virus [HPV]) d) Presence of string or plastic tip from cervix (intrauterine device [IUD] in uterus e) Absence of Goodell sign → inflammatory conditions, carcinoma f) Fixed → pelvic inflammatory disease (PID) g) Nodular surface → fibroma 3. Nursing responses to data a) Provide woman with a hand mirror and identify genital structures for her b) Encourage her to view cervix if she wishes c) Refer to healthcare provider if indicated d) Advise woman of potential serious risks of leaving an IUD in place during pregnancy e) Refer to healthcare provider for removal

T. Uterus 1. Physical assessment/normal findings a) Pear shaped, mobile, smooth surface

U. Ovaries 1. Physical assessment/normal findings a) Small walnut shaped, nontender 2. Alterations and possible causes a) Pain on movement of cervix → PID b) Enlarged or nodular ovaries → cyst, tumor, tubal pregnancy, corpus luteum of pregnancy 3. Nursing responses to data a) Evaluate adnexal areas b) Refer to healthcare provider c) Ultrasound

V. Pelvic measurements: internal measurements 1. Physical assessment/normal findings a) Diagonal conjugate at least 11.5 cm b) Obstetric conjugate estimated by subtracting 1.5 cm from diagonal conjugate c) Inclination of sacrum d) Motility of coccyx; external intertuberosity diameter > 8 cm 2. Alterations and possible causes a) Measurement below normal b) Disproportion of pubic arch c) Abnormal curvature of sacrum d) Fixed or malposition of coccyx

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3. Nursing responses to data a) Vaginal birth may not be possible if deviations are present

W. Anus and rectum 1. Physical assessment/normal findings a) No lumps, rashes, excoriation, tenderness; cervix may be felt through rectal wall 2. Alterations and possible causes a) Hemorrhoids, rectal prolapse; warts; nodular lesion (carcinoma) 3. Nursing responses to data a) Counsel about appropriate prevention and relief measures b) Refer to healthcare provider for further evaluation

X. Laboratory evaluation 1. Physical assessment/normal findings a) Hemoglobin 12 to 16 g/dL b) ABO, Rh typing c) Complete blood count (CBC) (1) Hematocrit 38% to 47% (2) Red blood cells (RBC) 4.2 to 5.4 million/microliter (3) White blood cells (WBC) 5000 to 12,000/microliter (4) Differential (5) First trimester aneuploidy screening (6) Integrated screening (7) Syphilis tests negative → serologic test for syphilis (STS), venereal disease research laboratory (VDRL) test (8) Gonorrhea culture → negative (9) Urinalysis → normal color, specific gravity, pH 4.6 to 8 (a) Negative for protein, RBCs, WBCs, casts (b) Glucose negative (small degree of glucosuria may occur) (10) Rubella titer → 1:10 or above indicates immune (11) Hepatitis B screen negative (12) HIV screen → offered to all → negative (13) Illicit drug screen → offered to all → negative (14) Sickle-cell screen for African American patients → negative (15) Pap smear negative 2. Alterations and possible causes a) Hgb <11 g/dL → anemia b) Rh negative c) Marked anemia, blood dyscrasias d) Presence of infection e) Increased nuchal translucency, elevated β-HCG, reduced PAPP-A f) Positive STS → false positive, acute infection 16 Copyright © 2020 Pearson Education, Inc.

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g) Positive culture h) Cloudy, abnormal color of urine i) HAI titer less than 1:10 j) Positive hepatitis B or HIV k) Positive l) Positive m) Abnormal cells, with negative or positive high-risk HPV 3. Nursing responses to data a) Nutritional counseling, iron supplementation b) Rh negative → check for antibodies, partner blood type (1) Discuss need for Rh immune globulin at 28 weeks c) CBC, Schilling differential cell count d) Evaluate for other signs of infection e) If findings positive, genetic and diagnostic testing offered f) Positive results confirmed with fluorescent treponemal antibody-absorption (FTA-ABS) test (1) Antibiotics (2) Refer for treatment g) Refer for treatment h) Repeat urinalysis, refer to healthcare provider i) Assess blood glucose, test urine for ketones j) Immunization postpartum k) Positive Hep B/HIV refer to physician (1) Infants born to HepB positive → HepB immune globulin soon after birth followed by first dose of hepatitis B vaccine l) Refer to healthcare provider

Y. Cultural assessment 1. Physical assessment/normal findings a) Determine fluency in written/oral English b) How does she prefer to be addressed? c) Customs and practices regarding prenatal care (1) To be followed or avoided d) Activities to avoid e) Foods to eat or avoid f) Caregiver gender g) Partner/family involvement preferred h) Type of support and counseling available 2. Variations to consider a) May be fluent in language other than English b) Formal or informal c) Acts related to sleep, activity, clothing 17 Copyright © 2020 Pearson Education, Inc.

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(1) Sexual activity, work d) Lactose intolerance e) Female only? f) Partner or female family member g) Family members, tribal healers, religious leaders 3. Nursing responses to data a) Work with translator b) Address woman according to preference c) Honor practices unless contraindicated because of safety (1) Have information printed in language she understands d) Respect food preferences (1) Help to plan adequate prenatal diet (2) Refer to dietitian if necessary e) Arrange for female caregiver if preference f) Respect preferences about partner involvement g) Respect sources of support

Z. Psychologic status 1. Physical assessment/normal findings a) Excitement and/or apprehension, ambivalence 2. Alterations and possible causes a) Marked anxiety, fear b) Apathy, display of anger with pregnancy diagnosis 3. Nursing responses to data a) Establish lines of communication b) Establish trusting relationship c) Encourage woman to take active part in care d) Begin counseling

AA. Educational needs 1. Physical assessment/normal findings a) May have questions about pregnancy b) May need time to adjust to reality of pregnancy 2. Nursing responses to data a) Establish educational, supporting environment that can be expanded throughout pregnancy

BB. Support system 1. Physical assessment/normal findings a) Can identify at least two to three individuals with whom is emotionally intimate

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2. Alterations and possible causes a) Isolated b) Cannot name neighbor or friend whom she can call on in an emergency c) Does not perceive parents as part of her support system 3. Nursing responses to data a) Institutes support system through community groups b) Help woman to develop trusting relationship with healthcare professionals

CC. Family functioning 1. Physical assessment/normal findings a) Emotionally supportive b) Communications adequate c) Mutually satisfying d) Cohesiveness in times of trouble 2. Alterations and possible causes a) Long-term problems of specific problems related to the pregnancy b) Potential stressors within the family c) Pessimistic attitudes d) Unilateral decision making e) Unrealistic expectations of the pregnancy or child 3. Nursing responses to data a) Help identify the problems and stressors b) Encourage communication c) Discuss role changes and adaptations d) Refer to counseling as indicated

DD. Economic status 1. Physical assessment/normal findings a) Source of income is stable and sufficient to meet basic needs of daily living and medical needs 2. Alterations and possible causes a) Limited prenatal care b) Poor physical health c) Limited use of healthcare system d) Unstable economic status 3. Nursing responses to data a) Discuss available resources for health maintenance and the birth b) Institute appropriate referral for meeting expanding family’s needs

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EE. Stability of living conditions 1. Physical assessment/normal findings a) Adequate, stable housing for expanding family’s needs 2. Alterations and possible causes a) Crowded living conditions b) Questionable supportive environment for newborn 3. Nursing responses to data a) Refer to appropriate community agency b) Work with family on self-help ways to improve situation

FF. Determination of Due Date 1. Families eager to know due date a) EDB = estimated date of confinement (EDC) = estimated date birth (EDB) (1) Need LMP (2) If precise LMP not available → early ultrasound (US) 2. Nägele’s rule a) First day of LMP – 3 months + 7 days b) Gestational calculator or wheel (1) See Figure 12–1: The EDB wheel can be used to calculate the due date, p. 242 c) Fairly accurate if (1) Menses every 28 days (2) Accurate LMP (3) Not using hormonal contraception d) Not useful if (1) Irregular periods that include amenorrhea (2) Amenorrhea but ovulating and conceive while breastfeeding (3) Conceive before regular menstruation established following discontinuation of oral contraceptives or termination of a pregnancy

GG. Uterine Assessment 1. Physical examination a) At first prenatal visit 2. Fundal height a) Indicator of uterine size b) Not used for dating late in pregnancy c) McDonald method (1) Distance in centimeters from top of symphysis pubis over curve of the abdomen to top of uterine fundus (2) See Figure 12–2: A cross-sectional view of fetal position when McDonald method is used to assess fundal height, p. 243 20 Copyright © 2020 Pearson Education, Inc.

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d) In centimeters correlates well with weeks of gestation (1) 22 to 34 weeks e) Accuracy → same examiner each time f) Maternal position g) Inaccurate in following situations (1) Obese women (2) Women with uterine fibroids (3) Women who develop hydramnios h) Empty bladder before measuring i) Measurements may yield other information (1) Lag from month to month → may indicate IUGR (2) Sudden increase → twins, hydramnios, LGA fetus

HH. Assessment of Fetal Development 1. Quickening → fetal movements felt by mother a) May be experienced between 16 to 22 weeks b) May be described as feeling butterfly movements, gas, flicking sensations, bubbles 2. Fetal heartbeat a) Doppler device → primary tool (1) 10 to 12 weeks’ gestation (2) Normal range →110 to 160 beats/min b) Ultrasound if unable to auscultate between 10 and 12 weeks 3. Ultrasound a) First trimester → transabdominal ultrasound can detect gestational sac as early as 4 to 5 weeks after LMP (1) Fetal heart activity by 6 to 7 weeks (2) Fetal breathing movements by 10 to 11 weeks (3) Crown-to-rump measurements → can be used for gestational age from 4 days to 12 weeks b) Biparietal diameter (BPD) by approximately 12 to 13 weeks, most accurate 14–26 weeks (1) Predicts EDB within 7 to 10 days

II. Assessment of Pelvic Adequacy 1. Clinical pelvimetry → series of assessments and measurements to determine whether size and shape adequate for a vaginal birth 2. Pelvic cavity a) False pelvis b) True pelvis 3. Pelvic inlet a) Diagonal conjugate (1) Distance from lower border of symphysis pubis to sacral promontory 21 Copyright © 2020 Pearson Education, Inc.

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(2) Typically 12.5 cm b) Obstetric conjugate (1) Smallest and most important anteroposterior diameter (2) Extends from middle of sacral promontory to the upper inner point on symphysis (a) Estimated by subtracting 1.5 cm from length of diagonal conjugate (3) Should measure 10 cm or more c) Conjugata vera (true conjugate) d) See Figure 12–6: Manual measurement of inlet and outlet, p. 245 e) Midplane → anteroposterior diameter, posterior sagittal diameter, transferse diameter (1) Cannot be accurately measured by clinical examination f) Evaluation made based on prominence of ischial spines (1) Locate sacrospinous ligament → run fingers along it laterally (2) Toward anterior portion of pelvis g) Sacrosciatic notch should admit two fingers (1) Wide → sacrum curves posteriorly (2) Narrow → decreased diameter h) Capacity of cavity assessed by sweeping fingers down side walls bilaterally (1) Convergent (2) Divergent (3) Straight → normal finding 4. Pelvic outlet a) Anteroposterior diameter of pelvic outlet (1) Lower border of symphysis pubis to tip of sacrum (2) Measured digitally, should be 9.5 to 11.5 cm (3) See Figure 12–6: Manual measurement of inlet and outlet, p. 245 b) Transverse diameter (1) Measured by placing fist between ischial tuberosities (2) Should be 8 to 10 cm (3) See Figure 12–7: Use of a closed fist to measure the outlet, p. 246 c) Mobility of coccyx → determined by pressing down on it during initial vaginal exam d) Subpubic angle (1) Estimated by palpating bony structure externally (2) See Figure 12–8A: Evaluation of the outlet. Estimation of the subpubic angle, p.247 e) Length and shape of pubic rami f) Height and inclination of symphysis pubis measured (1) Contour of pubic arch estimated (2) Posterior inclination with lower border of pubis slanting inward decreases anteroposterior diameter g) See Figure 12–8C: Evaluation of the outlet. Estimation of the depth and inclination of the pubis, p. 247

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JJ. Screening Tests 1. Initial prenatal visit a) Pap smear b) Complete blood count c) HIV screening d) Rubella titer e) ABO and Rh typing f) Urine culture g) Hepatitis B h) Sexually transmitted infections (STIs) i) Hemoglobin electrophoresis (1) Women of African, Southeast Asian, Mediterranean descent (a) Evaluate for sickle cell disease and thalassemias j) Tuberculin test (PPD) for high risk (1) Cystic fibrosis (CF) k) Women who have not received varicella immunization, negative disease history (1) Evaluate varicella immunity (2) Immunize after pregnancy 2. Throughout pregnancy a) Gestational diabetes mellitus (GDM) (1) Between 24 and 28 weeks (2) 2 approaches (a) 1 step 75-g oral glucose tolerance test (OGTT) (b) 2 step: initial nonfasting test using 50-g 1-hr glucose followed by a 3-hr 100mg OGTT if initial results are positive b) Group B streptococcus (GBS) testing (1) Between 35 and 37 weeks (2) Women with positive GBS in urine do not get cultured, considered positive 3. Testing for fetal aneuploidy (trisomy) and neural tube defects a) All women, regardless of age, should be offered screening b) Nuchal translucency: ultrasound assessment of thickness of fetal nuchal fold c) Combined with serum screening for free β-hCG and pregnancy-associated plasma protein A (PAPP-A) d) Genetic counseling e) Chorion villus sampling; amniocentesis f) Quadruple screen (Quad screen): performed on mother’s serum between 15 and 20 weeks

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III.

Subsequent Patient History

A. Continue to gather data 1. Over course of pregnancy 2. Adjustment of support person and family 3. Preparations made for new baby 4. Discomfort 5. Physical changes 6. Exposure to contagious illnesses 7. Medical treatments and therapies 8. Over-the-counter or prescription medications, herbal supplements, alcohol, nicotine, illicit drugs use 9. Use of complementary or alternative therapies 10. Danger signs of pregnancy and preterm labor a) Discussed at initial prenatal visit b) Reviewed each subsequent visit c) Printed information (1) See Table 12–2: Danger Signs of Pregnancy, p. 249 (2) Danger sign → possible cause (3) Sudden gush of fluid from vagina → premature rupture of membranes (PROM) (4) Vaginal bleeding → abruptio placentae, placenta previa, lesions of cervix or vagina, bloody show, cervical or vaginal infection, irritation of cervix from intercourse (5) Abdominal pain → premature labor, abruptio placentae (6) Temperature above 38.3°C (101°F) → infection (7) Dizziness, blurring of vision, double vision, spots before eyes → hypertension, preeclampsia (8) Persistent nausea and vomiting → hyperemesis gravidarum (9) Severe headache → hypertension, preeclampsia (10) Edema of hands or face → preeclampsia (11) Seizures or convulsions → preeclampsia, eclampsia (12) Epigastric pain → preeclampsia, ischemia in major abdominal vessel (13) Dysuria→ urinary tract infection (14) Absent or decreased fetal movement → maternal medication, obesity, fetal death, fetal distress (15) Signs of Preterm Labor, p. 248 (a) Painful menstrual-like cramps (b) Dull low backache (c) Suprapubic pain or pressure 24 Copyright © 2020 Pearson Education, Inc.

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(d) Pelvic pressure or heaviness (e) Change in character or amount of vaginal discharge (bloody, thinner, thicker) (f) Diarrhea (g) Uterine contractions felt every 10 minutes for 1 hour (h) Leaking of water from vagina 11. Provide time to ask questions, voice concerns a) Encourage woman and partner to bring list of questions, concerns to visits b) Be sensitive to religious, spiritual, cultural and socioeconomic factors that may influence response to pregnancy 12. Begin assessing developing readiness to take on responsibilities of parenthood a) See Table 12–3: Guide to Prenatal Assessment of Parenting, p. 250 b) Areas assessed (1) Perception of complexities of mothering (a) Desires for baby itself (b) Expresses concern about impact of mothering role on other roles (c) Gives up routine habits because “not good for baby” (2) Attachment (a) Strong feelings regarding sex of baby (b) Interested in data regarding fetus (c) Fantasies about baby (3) Acceptance of child by significant others (a) Acknowledges acceptance by significant other of the new responsibility inherent in child (b) Concrete demonstration of acceptance of pregnancy/baby by significant others (4) Ensures physical well-being (5) Family/patient decisions reflect concern for health of mother and baby

IV.

Subsequent Prenatal Assessment A. Depression during and after pregnancy common 1. Challenges can be overwhelming 2. Infants of depressed women at increased risk a) Social-emotional development, cognitive development, behavioral development, and physical health negatively impacted

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B. Signs of psychologic problems 1. Increasing anxiety 2. Depression or feelings of sadness (common in pregnancy and should be screened regularly for it) 3. Inability to establish communication 4. Inappropriate responses or actions 5. Denial of pregnancy 6. Inability to cope with stress 7. Intense preoccupation with the sex of the baby 8. Failure to acknowledge quickening 9. Failure to plan and prepare for the baby 10. Indications of substance abuse

C. Refer as appropriate D. Frequency of subsequent visits 1. Every 4 weeks for the first 28 weeks’ of gestation 2. Every 2 weeks until 36 weeks’ gestation 3. After week 36 → every week until childbirth

E. Assessment Guide: Subsequent Prenatal Assessment, pp. 251–255 F. Vital signs 1. Physical assessment/normal findings a) Temperature 36.2°C to 37.6°C (97°F 99.6°F) b) Pulse 60 to 100 beats/min c) Respirations 12 to 20 breaths/min d) Blood pressure less than or equal to 120/80 mmHg 2. Alterations and possible causes a) Elevated temperature → infection b) Increased pulse rate → anxiety, cardiac disorders c) Marked tachypnea or abnormal patterns → respiratory disease d) BP greater than 120 to 139/80 to 89 mmHg considered prehypertensive e) Greater than 140/90 mmHg or increase of 30 mm systolic and 15 mm diastolic → preeclampsia

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3. Nursing responses to data a) Evaluate for signs of infection (1) Refer to healthcare provider b) Note irregularities (1) Assess for anxiety and stress c) Refer to healthcare provider d) Assess for edema, proteinuria, hyperreflexia (1) Refer to healthcare provider (2) Schedule appointments more frequently

G. Weight gain 1. Physical assessment/normal findings a) Total 11.5 to 16 kg (25 to 35 lb) b) First trimester → 1.6 to 2.3 kg (3.5 to 5 lb) c) Second trimester → 5.5 to 6.8 kg (12 to 15 lb) d) Third trimester → 5.5 to 6.8 kg (12 to 15 lb) 2. Alterations and possible causes a) Inadequate weight gain → poor nutrition, nausea, IUGR b) Excessive weight gain → excessive caloric intake, edema, preeclampsia 3. Nursing responses to data a) Discuss appropriate weight gain b) Provide nutritional counseling c) Assess for presence of edema or anemia d) Refer to dietitian as needed

H. Edema 1. Physical assessment/normal findings a) Small amount of dependent edema, especially last weeks of pregnancy 2. Alterations and possible causes a) Edema in hands, face, legs, feet → preeclampsia 3. Nursing responses to data a) Identify correlation between edema and activities, BP or proteinuria b) Refer to healthcare provider if indicated

I. Uterine size 1. Physical assessment/normal findings a) See Assessment Guide: Initial Prenatal Assessment 2. Alterations and possible causes a) Unusually rapid growth → multiple gestation, hydatidiform mole, hydramnios, miscalculation of EDB 27 Copyright © 2020 Pearson Education, Inc.

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3. Nursing responses to data a) Evaluate fetal status b) Determine height of fundus c) Use diagnostic ultrasound

J. Fetal heartbeat 1. Physical assessment/normal findings a) 110 to 160 beats/min, funic souffle 2. Alterations and possible causes a) Absence of fetal heartbeat after 20 weeks’ gestation → maternal obesity, fetal demise 3. Nursing responses to data a) Evaluate fetal status

K. Laboratory evaluation 1. Physical assessment/normal findings a) Hgb →12 to 16 g/dL, pseudoanemia of pregnancy b) Quad marker screen c) Indirect coombs test → Rh negative women → negative (at 28 weeks) d) 50-g 1-hour glucose screen at 24 to 28 weeks’ gestation e) Urinalysis (UA) (1) Protein negative (2) Glucose negative, glycosuria may be present due to physiologic alterations in glomerular filtration rate and renal threshold.

(3) GBS negative 2. Alterations and possible causes a) Less than 11 g/dL → anemia b) Elevated maternal serum alpha-fetoprotein (MSAFP) → neural tube defect, underestimated gestational age, multiple gestation (1) Lower than normal MSAFP → Down syndrome, trisomy 18 (2) Higher than normal hCG and inhibin-A → Down syndrome (3) Lower than normal UE → Down syndrome c) Rh antibodies present → maternal sensitization occurred d) Plasma glucose >140 → abnormal e) See Assessment Guide: Initial Prenatal Assessment for deviations (1) Proteinuria, albuminuria → contamination by vaginal discharge, urinary tract infection, preeclampsia (2) Persistent glycosuria → diabetes mellitus (3) Positive culture → maternal infection 3. Nursing responses to data a) Provide nutritional counseling (1) Hgb repeated at 7 months gestation 28 Copyright © 2020 Pearson Education, Inc.

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(2) Women of Mediterranean heritage → possibility of thalassemia b) Offered to all pregnant women (1) Abnormal → further testing → ultrasound or amniocentesis c) Rh negative and unsensitized → Rh immune globulin given (1) Rh antibodies present → Rh immune globulin not given → fetus monitored closely for isoimmune hemolytic disease d) Refer for diagnostic 100-g oral glucose tolerance test (1) Discuss implications of GDM if diagnosis made (2) Refer to healthcare provider e) Urinalysis and culture at initial visit, as indicated (1) Dipstick urine sample (2) Refer to healthcare provider if deviations are present f) Explain maternal and fetal/neonatal risks (1) Refer to healthcare provider for therapy

L. Cultural assessment 1. Physical assessment/normal findings a) Determine mother’s, family’s attitudes about sex of unborn child b) Ask about woman’s expectations of childbirth (1) Someone with her? Who? Role of partner? c) Ask about preparations for baby 2. Variations to consider a) Some women have no preference, some do (1) Some cultures value boys as firstborn b) Some women want partner present for labor, birth (1) Others prefer female relative or friend (2) Some women expect to be separated from partner once labor begins c) Some women have fully prepared nursery (1) Others may not have separate room 3. Nursing responses to data a) Provide opportunities to discuss preferences, expectations (1) Avoid judgmental attitude b) Provide information on birth options but accept woman’s decision c) Explore reasons for not preparing for baby d) Support preferences, provide information about sources of assistance if decision related to lack of resources

M. Expectant mother: psychologic status 1. Physical assessment/normal findings a) First trimester/period of adjustment b) Second trimester/period of radiant health c) Third trimester/period of watchful waiting 29 Copyright © 2020 Pearson Education, Inc.

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2. Alterations and possible causes a) Increased stress and anxiety b) Inability to establish communication c) Inability to accept pregnancy d) Inappropriate response or actions e) Denial of pregnancy f) Inability to cope 3. Nursing responses to data a) Encourage woman to take active part in care b) Establish lines of communication c) Provide anticipatory guidance regarding normalcy of feelings as necessary

N. Educational needs: self-care measures and knowledge 1. Physical assessment/normal findings a) Health promotion b) Breast care c) Hygiene d) Rest e) Exercise f) Nutrition g) Relief measures for common discomforts of pregnancy h) Danger signs in pregnancy i) Signs of preterm labor j) Sexual activity k) Preparation for parenting l) Preparation for childbirth m) Patient aware of (1) Prepared childbirth techniques (2) Normal processes, changes during childbirth (3) Problems that may occur due to drug, alcohol use, smoking n) Woman met other physician or nurse-midwife who may be attending in absence of primary caregiver o) Impending labor (1) Patient knows signs of impending labor (a) Uterine contractions that increase in frequency, duration, and intensity (b) Bloody show (c) Expulsion of mucous plug (d) Rupture of membranes 2. Alterations and possible causes a) Inadequate information b) Lack of information about effects of pregnancy and/or alternative positions during sexual intercourse 30 Copyright © 2020 Pearson Education, Inc.

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c) Lack of preparation d) Continued abuse of drugs, alcohol e) Denial of possible effect on self, baby f) Introduction of new individual at birth may increase stress, anxiety for woman and partner g) Lack of information 3. Nursing responses to data a) Provide information and counseling b) Refer to classes for childbirth preparation c) Encourage prenatal class attendance d) Review danger signs e) Introduce woman to all members of group practice f) Provide appropriate teaching, stressing importance of seeking appropriate medical assistance

O. Expectant partner: psychologic status 1. Physical assessment/normal findings a) First trimester (1) Excitement (2) Financial concerns b) Second trimester (1) More confident (2) Less concerned with financial matters (3) Concerns about wife’s changing size and shape, increasing introspection c) Third trimester (1) Feelings of rivalry with fetus (2) Energetic (3) More interest in self (4) Fantasize about child, usually older child (5) Fears mutilation, death of woman and child 2. Alterations and possible causes a) Increasing stress and anxiety b) Inability to establish communication c) Inability to accept pregnancy diagnosis d) Withdrawal of support e) Abandonment of the mother 3. Nursing responses to data a) Encourage expectant partner to come to prenatal visits b) Establish line of communication c) Establish trusting relationship d) Counsel e) Include expectant partner in pregnancy activities as he desires 31 Copyright © 2020 Pearson Education, Inc.

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f) Provide education, information and support

V.

Focus Your Study

VI.

Activities 1. Individual Have students interview an older family member or a neighbor focusing on his or her traditions, beliefs, and practices related to pregnancy and childbirth. Students should prepare a short (one- to two-page) narrative describing these cultural practices.

2. Small Group Divide the class into small groups of three to five students. Have each group practice collecting and completing a complete history on each other. Instruct groups to include cultural and psychosocial assessments to identify variations and potential risk factors.

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Chapter 13 The Expectant Family: Needs and Care Nursing Care During the Prenatal Period........................................................

2

Care of the Pregnant Woman’s Family...........................................................

3

Cultural Considerations in Pregnancy.............................................................

4

Childbearing Decisions……………………………………………………………………………….

5

Classes for Family Members During Pregnancy…………..................................

6

Relief of the Common Discomforts of Pregnancy..........................................

8

Health Promotion During Pregnancy..............................................................

12

Focus Your Study.............................................................................................

18

Activities..........................................................................................................

18

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

Nursing Care During the Prenatal Period

A. Nursing Diagnoses 1. Written care plan that anticipates certain diagnoses a) Constipation b) Sexuality Pattern, Ineffective c) Nausea 2. Nursing Plan and Implementation a) Prioritize (1) Results of findings during a prenatal visit (2) Interventions most used by nurses common → communication and teaching– learning strategies b) Community-based nursing care (1) Typically clinic or private office c) Health maintenance organization (HMO) or clinic d) Wealth of community services and resources to assist families e) Home care (1) Assessments vary according to scope of practice (2) Home care visit or phone contact (3) Health promotion (4) Informal and formal teaching (5) Used with complicated and uncomplicated pregnancies (6) See Table 13–-1: Topics for Patient Teaching During Pregnancy, p. 259 f) All three trimesters (1) Discomforts of pregnancy (2) Nutrition and weight gain (3) Sexual activity (4) Sibling preparation g) First trimester (1) Attitude toward pregnancy (2) Exercise and rest (3) Smoking; use of alcohol and other drugs (4) Traveling (5) Fetal growth and development (6) Danger signals associated with spontaneous abortion (7) Employment (8) Early pregnancy classes h) Second trimester (1) Concerns related to changes in body (2) Fetal growth and development (3) Fetal movement (4) Clothing 2 Copyright © 2020 Pearson Education, Inc.

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(5) Care of the skin and breasts (6) Beginning preparation for care of the infant (7) Decisions about infant feeding i) Third trimester (1) Exercise and rest (2) Traveling (3) Danger signals (4) Preparation for labor and birth (5) Completion of preparation in home for new baby (6) Decisions about the infant (7) Decision making for the early postpartum period (8) Education about psychologic and physical expectations in the early postpartum period

II.

Care of the Pregnant Woman’s Family

A. Care of the Father or Partner 1. Father generally present, but don’t assume presence 2. May not be part of family structure 3. Assess support system to determine which significant persons will play a role in childbearing experience 4. Provide anticipatory guidance a) Information about changes related to pregnancy b) Culturally acceptable → refer to expectant parent classes c) See Figure 13–1: The Empathy Belly..., p. 259 d) Assess intended degree of participation during labor and birth, knowledge of what to expect

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5. Support decision

B. Care of Siblings and Other Family Members 1. Consider effect of pregnancy on other children 2. Discussion about ambivalence 3. Encourage bringing children to antepartum visits 4. Grandparent participation

III.

Cultural Considerations in Pregnancy

A. Include cultural backgrounds in care → cultural humility 1. Intercultural exchange → adapt to specific needs of each perinatal patient 2. Goal → understand and assist people of diverse cultural groups

B. Should be patient specific → have conversation with each patient to develop a transcultural nursing diagnosis and care plan C. Pregnancy, childbirth → special, transitional event in virtually all cultures D. Beliefs 1. Prescriptive beliefs or requirements that describe expected behaviors 2. Restrictive beliefs → stated negatively, limit behaviors 3. Taboo beliefs → refer to specific supernatural consequences 4. See Table 13–2: Cultural Beliefs and Practices During Pregnancy, p. 261 a) Home remedies b) Nutrition c) Alternative healthcare providers d) Exercise e) Spirituality f) Birth rituals

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5. Be open to other beliefs if not harmful 6. See Nursing Care Plan: Language Barriers at First Prenatal Visit, p. 263

IV.

Childbearing Decisions A. Decisions parents face about childbirth experiences and preferences → birth plan B. See Figure 13–4, Birth plan for childbirth choices, p. 264 1. Identify options 2. Set priorities 3. Clarify requests as needed 4. Discuss need for change if unexpected complications occur 5. See Table 13–3: Benefits and Risk of Some Consumer and Medical Decisions During Pregnancy, Labor, and Birth, p. 265 a) Breastfeeding b) Ambulation during labor c) Electronic fetal monitoring d) Whirlpool (jet hydrotherapy) e) Analgesic f) Episiotomy

C. Healthcare Provider 1. Nurse explains options and what can be expected from each 2. General philosophy and characteristics of certified nurse-midwives, obstetricians, family practice physician, lay midwives 3. Help the woman/couple develop interview questions 4. Discuss qualities of care provider for the newborn

D. Prenatal Care Services 1. Individual prenatal care services 2. Centering or group prenatal care 3. Centering pregnancy a) Health assessment, education, and support b) Unified program c) Replaces one-on-one visits d) Patients meet in small groups at 12 to 16 weeks and meet monthly for first 4 months then biweekly until due date e) Increased investment in pregnancy and self-care after attending group sessions 5 Copyright © 2020 Pearson Education, Inc.

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E. Birth Setting 1. Tour facilities 2. Nurse describes options available 3. Concept of individuality 4. Encourage personalizing the birth setting

F. Labor Support Person 1. Coaches or support person during childbirth classes, labor, and birth 2. Some men welcome the role; others do not 3. Nurse provides encouragement and support to both woman and support person 4. Role of the nurse cannot be overestimated 5. Doula → companion who provides support, but does not perform any clinical tasks a) Provides labor support → emotional, physical, informational, does not perform clinical tasks b) Acts as advocate for woman and her family c) May be trained to provide support and care during postpartum period d) May or may not be paid a fee 6. Monitrice a) Specially trained nurse who provides assessment, nursing care, and support b) Not common in United States

G. Siblings at Birth 1. Prepared through books, audiovisual materials, models, discussion, and sibling classes 2. Imperative child has own support person or coach 3. Child should have option of relating to the birth in manner they choose as long as not disruptive

V.

Classes for Family Members During Pregnancy A. Taught by certified childbirth educators (CBEs or CCEs) 1. Many CBEs also registered nurses, but nursing education is not required 2. Coalition for Improving Maternity Services (CIMS) → mother-friendly care a) Normalcy of the birthing process b) Empowerment c) Autonomy d) Do no harm 6 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

e) Responsibility

B. Parental education 1. Labor and birth 2. Pain relief 3. Obstetric complications and procedures 4. Breastfeeding 5. Normal newborn care 6. Postpartum adjustment 7. Content of each class directed by overall goals of the program a) Gestational changes and fetal development b) Childbirth choices available today c) Preparation of the mother d) Preparation for cesarean or vaginal birth e) Preparation for couples who desire an unmedicated birth f) Preparation of grandparents or siblings g) Newborn care and safety h) Self-care during postpartum period i) Identify parents’ needs, goals, and learning styles j) By end of classes, parents should be able to make appropriate and informed decisions k) Nurses can help direct parents to programs 8. Education of the Family Having a Cesarean Birth a) 32% of births in the United States b) Need for cesarean birth not often known in advance c) Many birthing units provide preparation classes if known in advance d) Woman concerned about postoperative pain 9. Preparation for Parents Desiring Trial of Labor After Cesarean Birth a) TOLAC → previously termed vaginal birth after cesarean (VBAC) b) Nurse can supply information on criteria necessary to attempt TOLAC c) Parents may want to develop two birth plans to prepare 10. Breastfeeding Programs a) La Leche League, lactation consultants b) Healthy People 2020 objective is 81.9%, but rates are well below c) Classes & support groups can include information on: (1) Advantages and challenges (2) Techniques and positioning (3) Methods of breast pumping and milk storage (4) How to involve the father or partner (5) Successfully breastfeeding and returning to work 7 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

11. Sibling Preparation: Adjustment to the Newborn a) Formal sibling preparation classes (1) Children 3 to 12 years (2) Help children feel part of the birthing process (3) Reducing anxiety (4) Express feelings and concerns (5) Realistic expectations (6) Active participant in baby’s care (7) Parent and child attend class together 12. Classes for Grandparents a) Current roles b) Transitioning to new role c) Beliefs regarding childbirth d) Ways to support the new family

VI.

Relief of the Common Discomforts of Pregnancy

A. First Trimester 1. Nausea and vomiting of pregnancy (NVP) a) Very common (50–80%) b) Exact cause unknown → multifactorial c) Health promotion (1) Assess onset, frequency, duration, severity, nutritional intake (2) Decrease potential development of hyperemesis gravidarum (3) Avoid odors, causative factors (4) Dry crackers, toast before arising (5) Small frequent meals (6) Avoid greasy, highly seasoned foods (7) Carbonated beverages (8) Complementary and alternative medicine therapies → acupressure, ginger (9) Medications (10) Extreme nausea and vomiting → antiemetics 2. Urinary frequency a) Common early in pregnancy, third trimester b) Health promotion (1) Empty bladder frequently, reduce incidence of UTIs (2) Maintain adequate fluid intake (2000 mL per day) 3. Fatigue a) So common → presumptive sign b) Health promotion (1) Plan nap, rest period (2) Go to bed earlier 8 Copyright © 2020 Pearson Education, Inc.

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(3) Seek family support, assistance 4. Breast tenderness a) Occurs early, continues throughout pregnancy b) Increased estrogen and progesterone cause soreness and tingling of breasts and increased sensitivity of nipples c) Health promotion d) Wear well-fitting supportive bra 5. Increased vaginal discharge (leukorrhea) a) Common → hyperplasia of vaginal mucosa b) Health promotion (1) Promote cleanliness by daily bathing (2) Avoid douching, nylon underpants (3) Cotton underpants 6. Nasal stuffiness, nosebleed (epistaxis) a) Health promotion (1) Cool-air vaporizer 7. Ptyalism a) Rare discomfort where excessive, bitter saliva is made b) Health promotion (1) Astringent mouthwashes, chew gum, candy (2) Carry tissues or small towel to spit when necessary

B. Second and Third Trimesters 1. Heartburn (pyrosis) a) Displacement of stomach by enlarging uterus b) Health promotion (1) Eat small, frequent meals (2) Use low-sodium antacids (3) Avoid overeating, fatty and fried foods, lying down after eating, sodium bicarbonate (4) Sit upright after eating 2. Ankle edema a) Difficulty of venous return from lower extremities b) Health promotion (1) Practice frequent dorsiflexion of feet when prolonged sitting or standing necessary (2) Elevate legs (3) Avoid tight garters, constrictive bands around legs 3. Varicose veins a) Result of weakening of walls of veins, faulty functioning of the valves b) Weight of gravid uterus on pelvic veins aggravates condition c) Health promotion 9 Copyright © 2020 Pearson Education, Inc.

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(1) Regular exercise, such as swimming, cycling, walking (2) Elevate legs frequently (3) Wear supportive hose (4) Avoid crossing legs at the knees, standing for long periods, garters, hosiery with constrictive bands (5) Commercial product to provide support for vulvar varicosities (6) Pillows under hips to elevate pelvic area (Figure 13–9) 4. Flatulence a) Decreased gastrointestinal motility b) Health promotion (1) Avoid gas-forming foods (2) Regular bowel habits (3) Exercise 5. Hemorrhoids a) Varicosities of veins in lower end of rectum, anus (1) May appear in second stage of labor (2) Bleeding, itching, swelling, pain b) Health promotion (1) Avoid constipation (2) Apply ice packs, topical ointments, anesthetic agents, warm soaks, (3) Gently reinsert into rectum if necessary (4) Contact healthcare provider → hardened, noticeably tender to touch 6. Constipation a) Bowel sluggishness → hormonal, displacement of intestines, oral iron supplements b) Health promotion (1) Increase fluid intake, fiber in diet, exercise (2) Develop regular bowel habits (3) Use stool softeners as recommended by caregiver (4) Drink warm beverages or glass of prune juice 7. Backache a) Common, 70% of women experience it b) Increased curvature of lumbosacral vertebrae c) Health promotion (1) Use proper body mechanics (Figure 13–10) (2) Practice pelvic tilt exercise (3) Avoid uncomfortable working heights, high-heeled shoes, heavy lifting 8. Leg cramps a) Painful muscle spasms, often at night b) Extension of foot can trigger cramps c) Health promotion (1) Stretches (Figure 13–11) 10 Copyright © 2020 Pearson Education, Inc.

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d) Massage and warm packs (1) Stretching exercises before bedtime 9. Faintness a) Caused by a combination of changes in blood volume and postural hypotension b) Health promotion (1) Avoid prolonged standing in warm or stuffy environments c) Arise slowly from resting position (1) If continues, go assisted to area to lie down or get fresh air 10. Shortness of breath a) Occurs as uterus rises into abdomen and causes pressure on diaphragm b) Worse in final weeks of pregnancy, improves after lightening occurs c) Health promotion (1) Use proper posture when sitting and standing (2) Sleep propped up with pillows if problem occurs at night 11. Difficulty sleeping a) Common into postpartum period after 12 weeks b) Enlarged uterus, active fetus, other discomforts of pregnancy contributing factors c) Health promotion (1) Thorough assessment about habits, activities (2) Warm caffeine-free beverage before bed (3) Back rub from partner (4) Pillows (5) Relaxation techniques 12. Restless leg syndrome (RLS) a) More common in second half of pregnancy, effects 15 to 25% of women b) Also called Willis-Ekborn Disease (WED) c) Health promotion (1) Has been associated with iron deficiency anemia and inactivity (2) Moderate intensity, low impact exercise (3) In severe cases carbidopa/levodopa may be prescribed for use at bedtime 13. Round ligament pain a) Stretch, hypertrophy and lengthen as uterus rises in abdomen b) Causes intense “grabbing” sensation in lower abdomen and inguinal area c) Health promotion (1) Warn women of possible discomfort (2) Heating pad may bring some relief (3) Bring knees up on her abdomen 14. Carpal tunnel syndrome (CTS) a) Numbness and tingling of hand near thumb caused by compression of median nerve in carpal tunnel of wrist

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b) Health promotion c) Avoid aggravating activities and repetitive motions (1) Use splint as prescribed (2) Can resolve after pregnancy (3) Severe cases may require injecting steroids or surgery

VII.

Health Promotion During Pregnancy

A. Fetal Activity Monitoring 1. Encourage to monitor fetal well-being a) Vigorous fetal activity provides reassurance of fetal well-being b) Mothers should monitor regularly after 28 weeks’ gestation c) Marked decrease in activity or cessation of movement may indicate possible fetal compromise

B. Breast Care 1. Proper support of breasts important a) Retain shape, prevent back strain, promote comfort b) Well-fitting, supportive bra has following qualities (1) Straps wide, do not stretch (2) Cup holds all breast tissue comfortably (3) Bra has tucks, other devices → allow it to expand (4) Bra supports nipple line approximately midway between elbow and shoulder c) Cleanliness of breasts (1) Colostrum can crust → remove with warm water d) Inverted or flat nipples (1) Diagnoses with pressure on areola → nipple retracts (2) See Figure 13–12: Normal and inverted nipples A, B, and C, p. 277 (3) Breast shields may be effective e) Resources (1) La Leche League (2) American Academy of Pediatrics (3) National Organization of Mothers of Twins Club

C. Clothing 1. Traditionally fuller lines → allow increase in abdominal size a) Soft, elastic waistbands, stretchable panel over abdominal area 2. Now includes more fitted styles 3. Loose, nonconstricting 4. Large pendulous abdomen → well-fitting supportive girdle a) Tight bands should be avoided

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5. High heel shoes can aggravate back discomfort

D. Bathing 1. Daily bathing → increased perspiration, mucoid vaginal discharge a) Practices influenced by cultural norms 2. Caution with tub baths → balance becomes a problem as pregnancy advances a) Vasodilation due to warm water b) Contraindicated with vaginal bleeding, rupture of membranes 3. Avoid hyperthermia associated with hot tub, whirlpool 4. Limit time to 10 minute a) Avoid submerging head, arms, shoulders, and upper chest

E. Employment 1. With no complications → work until women go into labor a) Jobs that require prolonged standing, strenuous physical activity, and/or use of industrial machines → higher incidence of poor pregnancy outcomes 2. Major deterrents a) Fetotoxic hazards b) Excessive physical strain c) Overfatigue d) Medical- or pregnancy-related complications e) Occupations involving balance need adjusted for the pregnant mother 3. Contact company physician or nurse about possible work-environment hazards

F. Travel 1. If medical or pregnancy complication not present → no restrictions on travel 2. Travel by automobile can be especially fatiguing a) Frequent opportunities to get out of car and walk b) Limit to 6 hours per day c) Every 2 hours for 10 minutes d) Three-point seat belt 3. As pregnancy progresses → airplane or train recommended for long distances a) Medical or obstetric complications → avoid flying b) Check with airlines → may restrict travel after 36 weeks’ gestation

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4. Avoid dehydration, hemoconcentration 5. Carry copy of medical records 6. Consider availability of medical care

G. Activity and Rest 1. Exercise during pregnancy helps maintain maternal fitness and muscle tone a) Improved self-image b) Increases energy c) Improves sleep d) Relieves tension e) Helps control weight gain f) Promotes regular bowel function g) Associated with improved postpartum recovery 2. Prevention of maternal and fetal complications a) May assist in prevention of gestational diabetes 3. Should be examined by certified nurse-midwife or physician prior to beginning exercise program a) Seek opinion of healthcare provider before taking part in part in contact sports 4. Certain conditions do not contraindicate exercise 5. Rupture of membranes a) Preeclampsia-eclampsia b) Cervical insufficiency (cerclage) c) Persistent vaginal bleeding in second or third trimesters d) Multiple gestation at risk for preterm labor e) Preterm labor in the current pregnancy f) Placenta previa after 26 weeks’ gestation g) Chronic medical conditions might be negatively impacted by vigorous exercise such as significant heart disease, restrictive lung disease h) Warning signs (1) Chest pain (2) Vaginal bleeding (3) Regular uterine contractions (4) Decreased or absent fetal movement (5) Leakage of amniotic fluid (6) Calf pain or swelling (7) Dizziness (8) Headache (9) Dyspnea before exertion (10) Muscle weakness (11) Adequate rest important for physical and emotional health 14 Copyright © 2020 Pearson Education, Inc.

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(a) Find time to rest during day (b) Sleeping more difficult during last trimester

H. Exercises to Prepare for Childbirth 1. Pelvic tilt, or pelvic rocking a) Strengthens abdominal muscle tone b) See Figure 13–14: Pelvic tilt on hands and knees, p. 280 c) Body alignment when pelvic tilt correctly done → maintained throughout the day 2. Abdominal exercises a) Tightening abdominal muscles with each breath b) Partial sit-ups 3. Perineal exercises → Kegel exercises (Figure 13–15) a) Feel specific muscle group by stopping urination midstream (1) Discourage Kegel exercises while urinating b) Technique for teaching Kegel exercises → perineal muscles as an elevator (2) Should not contract muscles of buttocks or thighs c) Can be done at almost any time 4. Inner-thigh exercise a) Assume cross-legged sitting position whenever possible b) Stretches muscles of inner thighs (Figure 13–16)

I. Sexual Activity 1. Many changes of pregnancy → brings up questions and concerns about sexual activity 2. No medical reason to limit sexual activity 3. Intercourse contraindicated if threatened spontaneous abortion, placenta previa diagnosis, or risk of preterm labor 4. Changes in sexual desire and response a) Related to discomforts b) Increased vascular congestion of pelvis → greater sexual satisfaction c) Third trimester → decreased interest in coitus 5. Sexual activity does not have to include intercourse 6. Sexual desires of men affected by many factors a) Previous relationship with partner b) Acceptance of pregnancy c) Attitudes toward the partner’s change of appearance (1) Concern about hurting expectant mother or baby d) Couple should be aware of changes, normality of changes, communication e) See Teaching Highlights: Sexual Activity During Pregnancy, p. 282

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J. Dental Care 1. Important to maintain regular oral hygiene a) Have extensive dental work done before becoming pregnant if possible b) Inform dentist so not exposed to teratogenic substances c) Dental x-rays permitted as long as abdomen shielded by lead apron

K. Immunizations 1. Ideally prior to becoming pregnant 2. Attenuated live viruses → should NOT be given in pregnancy 3. See Table 13–4: Recommendations for Immunization Before, During, and After Pregnancy, p. 283

L. Complementary Health Therapies 1. Part of integral approach to their healthcare a) Herbal medicine (1) Categorized as dietary supplements (a) Not regulated as prescription or over-the-counter drugs (2) Advise pregnant women not to ingest any herbs during first trimester (a) National Center for Complementary and Alternative Medicine (b) Office of Dietary Supplements b) Acupuncture, acupressure, ginger root, vitamin B6 for nausea c) Chiropractic manipulation for backache

M. Teratogenic Substances 1. Teratogen → adversely affects normal growth and development of fetus 2. Medications a) Greatest risk is during first trimester b) FDA → classification system for medications administered during pregnancy (1) Category A → no associated risk → few drugs (2) Category B → animal studies show no risk, no studies in women or animal studies indicate a risk, but controlled human studies fail to demonstrate risk (3) Category C → no adequate studies or animal studies show teratogenic effects, but no controlled studies in women available (4) Category D → evidence of human fetal risk does exist, but benefits of drug in certain situations thought to outweigh risk (5) Category X → demonstrated fetal risks clearly outweigh any possible benefit (6) Lactation → consider medication risk for lactating mothers (7) Females and males of reproductive potential → medications have potential effect on fertility (8) If woman has taken drug in category D or X → inform of risks associated, alternatives 16 Copyright © 2020 Pearson Education, Inc.

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(a) Avoid all medication if possible (b) Woman has right to most comprehensive information available concerning medications (c) Remind woman to check with caregiver about medications being taken when pregnancy occurred 3. Tobacco a) Modifiable cause of poor pregnancy outcomes (1) Spontaneous abortion (2) Intrauterine growth restriction (IUGR) (3) Low birth weight infants (4) Preterm birth (5) Perinatal mortality (6) Placenta previa (7) Abruptio placentae (8) Premature rupture of membranes (PROM) (9) Increased risk of sudden infant death syndrome (SIDS) b) Public health education → decreased smoking during pregnancy (1) Five As (a) Ask about tobacco use (b) Advise to quits smoking (c) Assess willingness to quit (d) Assist in attempt to quit (e) Arrange for follow-up care (2) More than 20 cigarettes/day → provider may consider nicotine replacement therapy (3) Educational resources (4) American Lung Association (5) March of Dimes (6) American Cancer Society (a) Healthy Mothers, Healthy Babies 4. Alcohol a) One of primary teratogens in Western world b) Fetal alcohol syndrome (FAS) (1) Growth restriction (2) Behavioral disturbances (3) Craniofacial abnormalities (4) Brain, cardiac, spinal defects (5) Major preventable cause of intellectual disability in the United States c) Moderate consumption of alcohol during pregnancy unclear (1) Passes placental barrier within minutes after consumption → fetal blood alcohol levels becoming equivalent to maternal blood alcohol levels (2) Risk of neurologic damage decreases with cessation of heavy drinking (3) Assessment of alcohol intake chief part of each woman’s medical history

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5. Caffeine a) No evidence that moderate levels of caffeine are linked to birth defects, spontaneous abortions, or preterm birth 6. Evaluation a) Essential part of effective nursing care b) Recognize situations that require referral for further evaluation c) Ongoing and cyclic nature of nursing process → effective if (1) Common discomforts of pregnancy quickly identified, relieved or lessened effectively (2) Woman able to discuss physiologic, psychologic changes of pregnancy (3) Woman implements appropriate self-care measures, if indicated, during pregnancy (4) Woman avoids substances, situations that pose risk to her well-being or that of child (5) Woman seeks regular prenatal care

VIII.

Focus Your Study

IX.

Activities 1. Individual Have students compile a list of the medications in their households. Instruct students to research the medications in the Physician’s Drug Handbook, or to use another resource such as a pharmacotherapy textbook, for the FDA pregnancy classification of each medication. Have students present their findings to the class.

2. Small Group Divide the class into small groups of three to five students. Have each group prepare one teaching plan regarding the common discomforts of pregnancy. Have groups present their teaching plans to the class.

3. Large Group Have all the students practice the abdominal, perineal, and inner-thigh exercises described in this chapter. As a class, develop strategies for discussing the need to exercise with the pregnant woman who is resistant to exercising.

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Chapter 14 Maternal Nutrition Maternal Nutrition…………………………………………………………………………………….

2

Maternal Weight.............................................................................................

2

Nutritional Requirements...............................................................................

3

Vegetarianism.................................................................................................

7

Factors Influencing Nutrition..........................................................................

7

Nutritional Care of the Pregnant Adolescent.................................................

10

Postpartum Nutrition......................................................................................

11

Focus Your Study.............................................................................................

13

Activities..........................................................................................................

13

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I.

Maternal Nutrition

A. General Nutritional Status Before Pregnancy 1. Prepregnancy nutrition status important 2. Nutritional deficits at conception and during prenatal period influence pregnancy

B. Maternal Age 1. Expectant adolescent must meet the nutritional needs for her own growth in addition to the nutritional needs of pregnancy

C. Maternal Parity 1. Number of pregnancies and interval between them influence nutritional needs

D. Maternal Nutritional Status Affects the Fetus E. Fetal Growth Occurs in Three Phases 1. Increase cell number 2. Increase cell number and size 3. Increase in cell size alone

II.

Maternal Weight

A. Prepregnancy Weight 1. Important for mothers and babies a) Risks for underweight and obesity 2. Maternal weight gain a) Adequate weight gain indicates adequate caloric intake (1) Tends to be variable b) Optimal weight gain depends on woman’s pre-pregnant BMI, pre-pregnant nutritional state (1) Recommendations for total weight gain (a) BMI < 18.5 = 12.5–18 kg (28–40 lb) (b) BMI 18.5–24.9 = 11.5–16 kg (25–35 lb) (c) BMI 25–29.9 = 7–11.5 kg (15–25 lb) (d) BMI > 30 = 5–9.1 kg (11–20lb) c) Pattern of weight gain important (1) Normal weight → 0.5 to 2 kg in first trimester (a) Average 0.45 kg/week during last two trimesters (b) Slightly higher → underweight (c) Slightly lower → overweight 2 Copyright © 2020 Pearson Education, Inc.

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(d) Twin pregnancy → 1.5 kg/week during second half of twin pregnancy d) Average weight gain distribution (1) 5 kg (11 lb) → Fetus, placenta, amniotic fluid (2) 0.9 kg (2 lb) → Uterus (3) 1.8 kg (4 lb) → Increased blood volume (4) 1.4 kg (3 lb) → Breast tissue (5) 2.3–4.5 kg (5–10 lb) → Maternal stores 3. Obesity in pregnancy a) Association between maternal weight gain and outcome 4. Weight gain alone → not guarantee of adequate nutrition 5. Eating a well-balanced diet a) See Table 14–1: Dietary Reference Intakes for Nonpregnant, Pregnant, and Lactating Females, p. 288 6. U.S. Department of Agriculture online website: choosemyplate.gov a) See Figure 14–2: MyPlate, p. 290

III.

Nutritional Requirements

A. Calories 1. Dietary reference intakes for total energy a) Unchanged during first trimester b) Second, third trimester → additional 300 kcal/day

B. Carbohydrates 1. Primary source of energy, fiber 2. Promotes weight gain, growth → fetus, placenta, maternal tissues 3. Dairy, fruits, vegetables, whole-grain cereals, breads

C. Protein 1. Increased to provide amino acids for fetal development, blood volume expansion, maternal tissues 2. 71 g → increase of about 25 g 3. Quality and quantity a) Animal products → sources of high-quality proteins b) Dairy c) See Table 14–3: Amount of Protein in Common Foods, p. 292 d) Soy-based products as alternative for women with allergies to milk, who are lactose intolerant, or who are vegetarian

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D. Fat 1. Valuable sources of energy a) More completely absorbed in pregnancy b) Essential fatty acids important for development of central nervous system of fetus (1) Omega-3 (2) Eicosapentaenoic (EPA): heart and immune function (3) Docosahexaenoic acid (DHA): brain, eye, and CNS development

E. Minerals 1. Calcium and phosphorus a) Involved in mineralization of fetal bones and teeth, energy and cell production, acid– base buffering (1) Calcium absorbed and used more efficiently during pregnancy b) Adequate intake → pregnant, lactating over age 19 = 1000 mg/day (1) 1300 mg/day if under age 19 c) Food is preferred source d) 4 cups of milk or equivalent dairy (Table 14–4, p. 293) (1) Recommended dietary allowance (RDA) for phosphorus → 700 mg/day >19 years old (a) 1250 mg/day <19 years 2. Iodine a) Essential part of thyroxine b) Iodized salt → will be able to meet requirement of 220 mcg/day c) Seafood good source d) If sodium restricted, supplement may need prescribed 3. Sodium a) Metabolism, fluid balance b) Moderate sodium intake → fresh food lightly seasoned c) Avoid extra salt at table, salty foods, and sodium-based seasonings d) Zinc (1) Part of numerous enzymes, protein metabolism, DNA & RNA synthesis (2) RDA >19 years → 11 mg/day pregnant (3) 12 mg/day lactation (4) Best sources meat, shellfish, poultry; good sources whole grains, legumes 4. Magnesium a) Cellular metabolism, structural growth b) RDA pregnancy → 350 mg for women 19 to 30; 360 for women 31 to 50 c) Milk, whole grains, dark green vegetables, nuts, legumes 5. Iron a) Increase → growth of fetus, placenta, expansion of maternal blood volume (1) Iron deficiency anemia → decrease in oxygen-carrying capacity of the blood 4 Copyright © 2020 Pearson Education, Inc.

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(2) Increase incidence of preterm birth, low-birth-rate infants, maternal and infant mortality b) Fetal liver stores iron → first 4 months of life c) Increase intake → lean meats, dark green leafy vegetables, eggs, whole-grain enriched cereals, dried fruits, legumes, shellfish, molasses (1) Absorption generally higher for animal products (2) Combine with foods rich in vitamin C d) Recommended intake in pregnancy → 27 mg per day (1) Impossible diet alone, supplements recommended (2) Supplements may cause gastrointestinal upset

F. Vitamins 1. Grouped by solubility a) Fat soluble → A, D, E, K b) Water soluble → C, B complex c) Balanced diet generally provides necessary vitamins 2. Fat-soluble vitamins a) Stored in liver b) Excessive intake can lead to toxicity (1) Symptoms nausea, GI upset, dryness & cracking of skin, loss of hair c) Vitamin A (1) Growth of epithelial cells, metabolism of carbohydrates and fats (2) Maternal stores of vitamin A adequate → effects of pregnancy not remarkable (3) RDA 770 mcg/day for pregnant women >19 years old (4) Deficiencies uncommon in US (5) Green and yellow or deep orange vegetables and some fruits, liver, egg yolk, cream, butter, fortified margarine, milk d) Vitamin D (1) Role in absorption and utilization of calcium and phosphorus in skeletal development (2) Pregnant woman → 600 IU (15 mcg) per day (3) Fortified milk, margarine, butter, liver, egg yolks (4) Synthesis of sunlight on skin (5) Overdoses due to vitamin supplementation (a) Symptoms excessive thirst, loss of appetite, vomiting, weight loss, irritability, high blood calcium levels e) Vitamin E (1) Antioxidant (a) Vitamin E takes on oxygen—preventing other nutrients from undergoing chemical changes (2) Enzymatic and metabolic reactions (3) Newborn’s need for vitamin E → human milk (4) Recommended intake unchanged → 15 mg/day 5 Copyright © 2020 Pearson Education, Inc.

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(5) Vitamin E → vegetable fats and oils, whole grains, greens, eggs (6) Excessive intake associated with abnormal coagulation in newborns f) Vitamin K (1) Essential factor for the synthesis of prothrombin (2) Synthesis occurs in intestinal tract by E. coli (3) Needs do not increase during pregnancy → 90 mcg/day 3. Water-soluble vitamins a) Vitamin C (1) Increased needs in pregnancy from 75 to 85 mg/day (2) Aid in formation of connective tissue and vascular system (3) Symptoms of scurvy (4) Plasma levels of vitamin C progressively decline throughout pregnancy (5) Nutritious diet should meet needs (6) Citrus fruits, tomatoes, cantaloupe, strawberries, potatoes, broccoli, leafy green vegetables b) B vitamins (1) Include (a) Thiamine (B1) (b) Riboflavin (B2) (c) Niacin (d) Folic acid (folate) (e) Pantothenic acid (f) Vitamin B6 (pyridoxine) (g) Vitamin B12 (cobalamin) (2) Coenzyme factors in many reactions (3) Thiamine requirement increases → 1.1 to 1.4 mg/day (a) Pork, liver, milk, potatoes, enriched breads, cereals (4) Riboflavin requirement increases → 0.3 to 1.4 mg/day (a) Cheilosis (b) Milk, liver, eggs, enriched breads, cereals (5) Niacin requirement increases → 4 mg/day to 18 mg/day (a) Meat, fish, poultry, liver, whole grains, enriched breads, cereals, peanuts (6) Folic acid (a) Normal growth, reproduction, lactation (b) Inadequate intake associated with neural tube defects (c) 400 mcg/day (d) Green leafy vegetables, liver, peanuts, whole-grain breads, cereals (7) Pantothenic acid → no requirement set → 5 mg/day considered adequate (a) Meat, egg yolk, legumes, whole grain bread, cereals (8) Vitamin B6 → associated with amino acid metabolism (a) RDA during pregnancy → 1.9 mg/day (b) Wheat germ, yeast, fish, liver, pork, potatoes, lentils (9) Vitamin B12 → animal sources only 6 Copyright © 2020 Pearson Education, Inc.

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(a) Pernicious anemia (b) Supplement vegans (c) RDA 2.6 mcg/day

G. Fluid 1. Water essential for life 2. Pregnant woman → 8 to 12 8 oz glasses of fluid a) 4 to 6 glasses of water b) Juice and milk c) Caffeine (1) In beverages, foods, medications (2) Diuretic effect

IV.

Vegetarianism A. Well-planned vegetarian diets usually adequate, appropriate for all stages of life B. Several types 1. Lacto-ovo-vegetarians 2. Lacto-vegetarians 3. Vegans

C. In pregnancy 1. Appropriate meal planning ensures adequate growth of fetus a) Supplementation: zinc, iron, vitamin B12, calcium b) Protein needs to increase c) See Table 14–6: Vegetarian Food Groups, p. 296

V.

Factors Influencing Nutrition A. Common Discomforts of Pregnancy 1. GI discomfort

B. Complementary and Alternative Therapies 1. Caution with pregnant consumer 2. Consult with healthcare provider

C. Use of Artificial Sweeteners 1. Safe for use a) Acesulfame potassium b) Aspartame 7 Copyright © 2020 Pearson Education, Inc.

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c) Saccharin d) Sucralose e) Stevia f) Advantame

D. Energy Drinks 1. Boost performance and delay fatigue a) Monster Energy b) Red Bull c) 5-Hour Energy 2. Soft drinks with caffeine, ginseng, guarana, taurine, sugar a) Pregnant women advised to use cautiously b) Limit total caffeine intake < 200 mg/day

E. Mercury in Fish 1. Can pose threat to unborn baby or young child 2. Recommendations a) Do not eat swordfish, shark, tilefish, king mackerel b) Eat up to 12 oz/week of variety of shellfish, fish lower in mercury (1) Salmon (2) Herring (3) Trout (4) Sardines c) Pollack (1) Mussels d) Only 6 oz/week of albacore tuna

F. Foodborne Illnesses 1. Salmonella and listeria monocytogenes infection 2. Salmonella in raw eggs → pregnant women advised to avoid foods that may contain raw, undercooked eggs 3. Listeria monocytogenes → found in refrigerated, ready-to-eat foods a) Recommendations b) Maintain refrigerator temperature at 40°F (4°C ) or below and freezer at 0°F (–18°C) (1) Refrigerate or freeze prepared foods, leftovers, perishables within 2 hours of eating or preparation (2) Do not eat hot dogs, luncheon meats unless reheated until steaming hot (3) Avoid soft cheeses such as feta, brie, Camembert, blue-veined cheeses, queso fresco or queso blanco unless label clearly states made with pasteurized milk (4) Do not eat refrigerated pâtés, meat spreads, or foods containing raw milk

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(5) Avoid eating refrigerated smoked seafood (salmon, trout, cod, tuna, mackerel) unless in cooked dish (a) Canned or shelf-stable pâtés, meat spreads, smoked seafood considered safe to eat

G. Lactase Deficiency (Lactose Intolerance) 1. Lactose intolerance → inadequate amount of enzyme lactase 2. Common a) African Americans, Hispanic Americans, American Indians, Asian Americans 3. Abdominal distension, discomfort, nausea, vomiting, loose stools, cramps

H. Cultural, Ethnic, and Religious Influences 1. Different nationalities accustomed to eating foods available in country of origin 2. Certain foods have symbolic significance related to major life experience, developmental milestone 3. Nurse needs to understand cultural influences on woman’s eating habits

I. Psychosocial Factors 1. Sharing of food → friendliness, warmth, social acceptance 2. Socioeconomic level may be determinant of nutritional status 3. Knowledge about basic components of balanced diet essential 4. Attitudes and feelings about pregnancy → influence nutritional status

J. Eating Disorders 1. Anorexia nervosa 2. Bulimia nervosa 3. Woman with eating disorders who becomes pregnant at risk for complications a) Miscarriage b) Low birth weight c) Premature birth d) Perinatal mortality e) Birth defects f) Treatment a team approach (1) Medical, nutritional, psychiatric practitioners g) Woman closely monitored

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K. Pica 1. Persistent craving and eating of nonnutritive substances a) Soil, clay (geophagia) b) Powdered laundry starch, corn starch (amylophagia) c) Soap d) Baking powder e) Ice (pagophagia) f) Freezer frost g) Burned matches h) Paint i) Ashes j) Iron deficiency anemia most common concern (1) Assessment important part of nutritional history

VI.

Nutritional Care of the Pregnant Adolescent

A. Risk factors 1. Interrelated a) Emotional b) Social c) Economic 2. Follow adult recommendations for weight gain determined by BMI a) Take nutritional needs of adolescents and add nutrient amounts recommended for all pregnant women to determine the pregnant teen needs

B. Specific Nutrient Concerns 1. Caloric needs vary widely 2. Inadequate iron intake a major concern 3. Calcium intake frequently a problem 4. Folic acid 5. Common deficiencies in this age group a) Zinc b) Vitamins A, D, E, B6

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C. Dietary Patterns 1. Often have irregular eating patterns 2. Frequent snackers (Figure 14–5, p. 300) 3. Consider eating pattern over time, not just single day

D. Counseling Issues 1. Positive approach to nutritional counseling 2. Include individual who does most of meal prep 3. Stress health of the baby 4. Focus on foods rather than nutrients 5. Group with teens

VII.

Postpartum Nutrition

A. Postpartum Nutritional Status 1. Assess new mother’s weight, hematocrit, hemoglobin, clinical signs, dietary history 2. Weight loss at birth approximately 4.5 to 5.4 kg (10 to 12 lb) a) First few weeks → additional weight loss b) Breastfeeding weight loss tends to be greater 3. Rate of weight loss influenced by many factors a) Weight gain during pregnancy 4. Evaluate weight, ideal weight for height, weight before pregnancy, weight before birth 5. Assess clinical symptoms a) Cravings, aversions b) Constipation 6. Obtain information on diet and eating habits 7. Communication with dietitian a) Risk for obesity increases during childbearing years

B. Nutritional Care of Formula-Feeding Mothers 1. Daily requirements return to prepregnancy levels (Table 14–1) 2. Understanding of nutrition a) Opportunity to teach b) Referral to dietitian if excessive weight gain

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C. Nutritional Care of Breastfeeding Mothers 1. Nutrient needs increase during breastfeeding (Table 14–1) 2. Calories a) Inadequate intake can reduce milk volume b) Increase caloric intake by 200 kcal over pregnancy → 500 kcal over pre-pregnancy requirement, total 2500–2700 kcal/day c) MyPlate food guide d) Weight loss not more than 1 lb/week 3. Protein a) 65 g/day during first 6 months b) 62 g/day thereafter 4. Calcium a) 1000 mg/day 5. Iron a) Continue supplementation of mother for 2 to 3 months after parturition (1) Replenish maternal stores 6. Fluids a) 8 to 10 8-oz glasses daily

D. Counseling Issues 1. Increased nutrient needs, issues related to infant feeding 2. Some foods may cause distress → avoid onions, turnips, cabbage, chocolate, spices, seasonings

E. Nursing Management for the Pregnant Woman Desiring Optimum Nutrition 1. Nursing Assessment and Diagnosis a) Data collection including (1) Height, weight, weight gain during pregnancy (2) Pertinent laboratory values (3) Clinical signs that have possible nutritional implications (4) Diet history to determine woman’s views on nutrition b) Diet history (1) 24-hour recall (2) Food frequency questionnaire include foods, fluids, supplements (3) Discuss important aspects of nutrition in context of family’s needs, lifestyle c) Formulate nursing diagnoses from data analysis (1) Nutrition, Imbalanced: Less than Body Requirements, related to nausea and vomiting (2) Overweight, Risk for, related to excessive calorie intake 12 Copyright © 2020 Pearson Education, Inc.

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(3) Knowledge, Readiness for Enhanced, related to nutrition 2. Nursing Plan and Implementation a) Health promotion education (1) Present information in clear, logical way → avoid jargon and “talking down” to client (2) Dietary change usually necessary (3) Develop plan with pregnant woman b) Implementation: Nutrition, Imbalanced: Less than Body Requirements related to low intake of calcium (1) Patient goal: woman will increase intake of calcium to DRI level (2) Implementation (a) Plan with woman additional milk or dairy products (b) Encourage the use of other calcium sources (c) Plan for addition of powdered milk in cooking, baking (d) Consider use of calcium supplements (3) Guidance about food purchasing and preparation c) Community-based nursing care (1) Meeting nutritional needs → challenge for families on limited incomes (2) Services offered through clinics, local agencies, schools, volunteer organization (a) Supplemental Nutrition Assistance Program (SNAP)—formally the Food Stamp Program (b) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (i) Income guidelines, residency requirements, nutritionally at risk 3. Evaluation a) Food journal b) Writing weekly menus c) Returning for weekly weighing d) Periodic hematocrit assessment e) Referral to dietitian → work with nurse, patient

VIII.

Focus Your Study

IX.

Activities 1. Individual Ask students to prepare a teaching plan for a prenatal class of adolescents. The students should include food safety and sanitation information in a developmentally appropriate presentation.

2. Small Group Divide the class into small groups of three to five students. Have each group conduct a nutritional assessment using a food questionnaire and collect physical data to prepare an analysis of protein, carbohydrate, and fat (in grams) dietary adequacy.

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3. Large Group Watch the movie SuperSize Me. Facilitate a class discussion about fast food and adolescent pregnancy.

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Chapter 15 Pregnancy in Selected Populations Adolescent Pregnancy.........................................................................................

2

Care of the Expectant Parents Over Age 35..………………………………………………….

11

Care of the Pregnant Woman with Special Needs………….………………………………

12

Focus Your Study.................................................................................................

14

Activities………………………………………………………………………………………………………..

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I.

Adolescent Pregnancy

A. Health, social, and economic long-term consequences for teen parents and their children 1. In 2011, birth rate (number of births per 1,000 women) for adolescents 15–19 years of age fell to 20.3, a historic low a) Improvements in rate contributed to improvements in contraceptive technology and increased education & labor market opportunities for women b) U.S. teenage birth rate remains highest of any industrialized nation

B. Overview of the Adolescent Period 1. Physical changes a) When individuals are capable of reproduction b) Puberty lasts 1.5 to 6 years c) Menarche usually occurs in last half of puberty d) Contraception important for all sexually active adolescents 2. Psychosocial development a) Following major developmental tasks (1) Developing an identity (2) Gaining autonomy and independence (3) Developing intimacy in a relationship (4) Developing comfort with one’s own sexuality (5) Developing a sense of achievement b) Resolving tasks is a developmental process → occurs over time (1) Need to “try on” roles in process of experimentation, exploration (2) Teens work to separate themselves from their parents c) Early adolescence → < 14 years (1) Psychosocial development marked by rapid physical changes (2) Initiate struggle for independence (3) Conformity to peer group standards (4) Very egocentric; concrete thinker d) Middle adolescence → 15 to 17 years (1) Time for challenging authority (2) Experimentation with drugs, alcohol, sex (3) Move from concrete thinking to formal operational thought (4) Struggle for independence can lead to challenging family relationships e) Late adolescence → 18 to 19 years (1) More at ease with individuality, decision-making ability (2) Think abstractly, anticipate consequences (3) Formal operational thought f) See Evidence-Based Practice: Risk Factors for Adolescent Pregnancy, p. 307

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C. Factors Contributing to Adolescent Pregnancy 1. Socioeconomic and cultural factors a) Poverty → major risk factor for adolescent pregnancy (1) See pregnancy as option for adult status (2) Higher among African American and Hispanic teens than white teens b) Teens with warm, nurturing families who value future accomplishments, and are engaged academically are less likely to engage in risky sexual behavior c) Younger a teen is with first pregnancy → more likely to have another pregnancy in teens 2. High-risk behaviors a) Developmentally adolescents → not able to foresee consequences of actions b) Peer pressure to become sexually active during teen years c) Sexual innuendo permeates every aspect of popular media (1) Sexting → sending or posting sexually suggestive text, images d) High-risk sexual behaviors (1) Multiple partners (2) Lack of contraceptive use (3) Account for nearly half of new cases of sexually transmitted infections (STIs) e) Increased use of condoms but inconsistent contraceptive users overall f) Sex education programs (1) Do not increase rates of sexual initiation at an earlier age (2) Helps teens to withstand the pressure to have sex too soon 3. Psychosocial factors a) Pregnancy desire tends to be higher among teens who are older, who were younger when they became sexually active, who are in a short-term relationship, and who have greater perceived stress in their lives b) Family dysfunction, poor self-esteem (1) Use pregnancy → way out, punish parent(s) (2) Form of acting out (3) Milestone to enhanced maturity c) Incest, sexual abuse or rape as possible cause of pregnancy in very young adolescent

D. Risks to the Adolescent Mother 1. Physiologic risks a) Adolescents over age 15 → early, thorough prenatal care → no greater risk than pregnant women older than 20 (1) Many fail to seek early prenatal care (2) Risks include (a) Preterm births (b) Low-birth-weight (c) Cephalopelvic disproportion (d) Preeclampsia-eclampsia (e) Iron deficiency anemia 3 Copyright © 2020 Pearson Education, Inc.

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(i) Problem in all pregnant women → adolescent already b) Prenatal care critical factor c) High incidence of STIs in pregnant moms 15–19 years d) Cigarette and drug use, often before pregnancy is confirmed 2. Psychologic risks a) Interruption of progress in developmental tasks b) Add tasks of pregnancy to normal developmental tasks c) See Table 15–1: Initial Reaction to Awareness to Pregnancy, p. 309 d) Early adolescent (< 14) → fears rejection by family and peers, enters healthcare system with adult, pregnancy probably not result of intimate relationship, self-consciousness, low self-esteem as physical changes of pregnancy progress (1) Nursing implications (a) Nonjudgmental (b) Focus on needs and concerns of adolescent (c) Encourage daughter, parent to express concerns, feelings about pregnancy and options (d) Realistic and concrete e) Middle adolescent (15 to 17) → fears rejection by peers and parents, unsure in whom to confide, may seek confirmation of pregnancy on own, economic dependence on parents (1) Nursing implications (a) Nonjudgmental approach (b) Reassure of confidentiality (c) Help adolescent identify individuals in whom she can confide (d) Be aware of state laws regarding notification requirements for abortion (e) Be aware of state laws regarding requirements for marriage (f) Encourage realistic expectations about parental response f) Late adolescent (18 to 19) → most likely to confirm pregnancy on own and earlier; relationship with father of baby, future educational plans, personal value system significant determinants of decision about pregnancy (1) Nursing implications (a) Nonjudgmental (b) Reassure of confidentiality (c) Help identify individuals in whom she can confide (d) Refer to counseling as appropriate (e) Encourage realistic expectations about parental response g) See Table 15–2: The Early Adolescent’s Response to the Developmental Tasks of Pregnancy, p. 310 (1) First trimester (a) Pregnancy confirmation, early prenatal care, diet and health habits evaluated, ambivalence (b) Early adolescent may delay confirmation of pregnancy, physical changes may be perceived as signs of puberty

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(c) Nursing implications → explain physiologic changes of pregnancy, normal ambivalence, need for good nutrition (i) Simple explanations, audiovisuals (ii) Have adolescent listen to fetal heart with Doppler (2) Second trimester (a) Changes in physical appearance begin, fetal movement (b) May delay validation of pregnancy until now, family turmoil, emotional turmoil with physical changes and “loss of control” of body (c) Nursing implications → continue to discuss nutrition and adequate weight gain, ways of using common teen clothing, plans for baby, education, role of teen’s parents (3) Third trimester (a) Begins to view fetus as separate from self, buying clothes and supplies, prepares to give birth, increasing anxiety about labor, delivery, well-being of fetus (b) May focus on wanting it to be over, may have fears, fantasies, of labor and birth (c) Nursing implications → assess whether adolescent preparing for baby, childbirth education, discomforts of pregnancy 3. Sociologic risks a) Schooling interrupted or drop out, less likely to graduate high school and enroll/finish college. b) More likely to have big families and be single c) Higher risk for social and economic disadvantages than nonpregnant counterpart (1) Forced into adult role (2) May marry father of baby → may be teen (3) Frequently end in divorce → lack of maturity d) Dating violence often issue for teens (1) Especially younger girls dating older boys e) Costs $9.4 billion each year (1) Increased incidence of maternal complications, premature birth, low-birth-weight (LBW) babies

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E. Risks for the Child 1. Teen parent not developmentally or economically prepared to be parents 2. Adverse socioeconomic factors 3. High rates family instability and behavior problems 4. High rates of abuse and neglect 5. Likely to become adolescent parents themselves

F. Partners of Adolescent Mothers 1. Average age difference between teen mothers and their partners is 2–3 years 2. Adolescent males → sexually active earlier age than females, more partners 3. More likely to have problems with school, self-esteem, drugs, alcohol, work, aggression 4. May be involved in meaningful relationship 5. Unintended pregnancy seen as negative 6. Family and financial issues are barriers a) Included on birth certificates → legal paternity b) Special situations → rape, incest, exploitative sexual relations, casual sexual relations (1) Referral to other resources c) Support in decision to assume responsibility (1) Pregnant adolescent has opportunity to decide if father to participate in health care d) Caring relationship → may still not understand all changes partner experiencing (1) Mentoring e) Assess stressors, support systems, plans for involvement, future plans (1) Referrals as indicated

G. Reactions of Family and Social Network to Adolescent Pregnancy 1. Family reactions as varied as motivation and cause of pregnancy a) Anger, shame, sorrow → common reactions b) More likely to use contraception, or choose abortion unless culture or religious beliefs prevent it c) Adolescent pregnancy more prevalent, socially accepted → family and friends more supportive d) Mother of pregnancy adolescent usually among first to be told (1) Involved in decision making (2) Helps teen access health care, accompanies to first visit (3) Younger adolescent is → more she needs mother’s support

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H. Nursing Management for the Adolescent Mother-to-Be 1. Nurse may be first contact with healthcare system 2. May be first time to give health history—should include a) Family, personal health history b) Medical history c) Menstrual history d) Obstetric and gynecologic history e) Substance abuse history 3. Nursing Assessment and Diagnosis a) Establish database to plan interventions (1) Diagnosis can vary based on age, support systems, socioeconomic status, health, and maturity (2) Include those for normal pregnancies plus additional as needed (3) Potential diagnosis (a) Nutrition, Imbalanced: Less than Body Requirements (b) Self-esteem, Situational low, Risk for

I. Planning and Implementation 1. Early, thorough prenatal care critical for reducing risk for mother, newborn 2. Community-based nursing care a) Agencies evolved to provide care for high-risk patients (1) Help access healthcare system as well as social services (a) Food banks (b) Special Supplemental Food Program for Women, Infants, and Children (WIC) b) Education in groups according to ages (1) Visual teaching aids (2) Realistic models (3) At reading level (4) Extensive counseling → challenges c) Issue of confidentiality (1) Emancipated minors (2) State legislation differs d) Development of a trusting relationship with the pregnancy adolescent (Figure 15–2, p.

312) (1) May be anxious and vulnerable (2) May be first pelvic examination (3) Honesty, respect for individual (4) Caring attitude e) Promotion of self-esteem and problem-solving skills (1) Overview of prenatal course, thorough explanations and rationale for procedures (2) Consider decision making capacity and influences from age perspective 7 Copyright © 2020 Pearson Education, Inc.

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(3) Give her some measure of control f) Promotion of physical well-being (1) Baseline weight, blood pressure → may have adolescent take own weight (2) Use time to teach nutrition (3) Lab work → hemoglobin and hematocrit values (a) Preeclampsia-eclampsia → most prevalent medical complication of pregnant adolescents (b) High BP (usual for ages 14–20 is a diastolic 50–66 mmHg) (i) Proteinuria (ii) Edema (iii) Increased incidence of STIs → tests, education (iv) Substance abuse → discussion of effects of woman, fetus (4) Ongoing care → same as older pregnant woman (Figure 15–3, p. 313) g) Promotion of family adaptation (1) Assess family situation at first prenatal visit (a) Ascertain level of involvement desired by adolescent from each member (b) Daughter–mother relationship → may change during teen’s pregnancy (c) Help mother to assess daughter’s needs, assist her in meeting them (d) Daughter–father relationship → may change during teen’s pregnancy (2) Include father of infant if desired (a) Goals for prenatal classes (Figure 15–4, p. 314) (i) Provide anticipatory guidance (ii) Prepare participants for labor and birth (iii) Help participants identify problems, conflicts of teenage pregnancy and parenting (iv) Increasing self-esteem (v) Providing information about available community resources (vi) Helping participants develop more adaptive coping skills (b) Use variety of teaching strategies (c) Teens may not retain information due to being present oriented (d) See info box: Health Promotion: Education: What Schools Can Do, p. 315 3. Hospital-based nursing care a) Adolescent in labor has same care needs as any pregnant woman (1) Sustained presence very important (2) Education to guide choices (3) Assist support people, often the adolescent’s mother (4) Postpartum (a) Make aware of community resources available b) Discharge Teaching: Contraception (1) Most teens adamant about not becoming pregnant again → statistics differ (2) Contraception critical part of effort to decrease adolescent pregnancy (a) Condoms, most common (i) Dual approach → pregnancy and STI prevention 8 Copyright © 2020 Pearson Education, Inc.

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(ii) AAP & SAHM recommends LARC methods that limit reliance on individual adherence (b) Combined oral contraceptives (COC) (c) Intrauterine contraceptives (IUC) 4. Evaluation a) Expected outcomes include (1) Trusting relationship established (2) Adolescent is able to use her problem-solving abilities to make appropriate choices (3) Adolescent follows recommendations of healthcare team → receives effective health care throughout her pregnancy, birth, postpartum period (4) Adolescent, partner, families able to cope successfully with the effects of the pregnancy (5) Adolescent able to discuss pregnancy, prenatal care, childbirth (6) Adolescent develops skill in child care and parenting

J. Prevention of Adolescent Pregnancy 1. Individual level a) Balanced, realistic sexuality education → can delay onset of sexual activity, increase use of contraception, reduce number of sexual partners (1) Include information on abstinence and contraception 2. Strategies for prevention a) Provision of services that ensure accessible and high-quality reproductive health care b) Sex education programs that provide developmentally appropriate, evidence-based curricula c) Youth development strategies to enhance life skills d) Connection to supportive adults e) Educational and economic opportunities 3. National level → campaign to prevent teen and unplanned pregnancy a) Goals by 2026 (1) Working to reduce teenage pregnancy by 50% (2) Reduce unplanned pregnancy by 25% for 18–29-year-olds (3) Reduce socioeconomic and racial/ethnic disparities in teens and unplanned pregnancies by 50% b) Multifaceted problem → no easy answers 4. Major problem a) Intense conflict among different groups about how to approach adolescent pregnancy prevention (1) Abstinence-only versus abstinence-plus approaches b) Comprehensive programs (1) Information about unplanned pregnancies and STIs (2) Support both abstinence and use of contraceptives 9 Copyright © 2020 Pearson Education, Inc.

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5. Characteristics of effective programs a) Evidence-based, long term and intensive b) Involve adolescents in program planning (1) Include good role models from same cultural and racial backgrounds c) Focus on adolescent male 6. Recommendations for parents see Key Facts to Remember: Recommendations for Parents to Help Their Teens Avoid Pregnancy, p. 316 a) Parents should be clear about own sexual attitudes and values → communicate clearly with children b) Parents need to talk with their children about sex early and often, and be specific c) Parents should supervise and monitor their children and teens with well-established rules, expectations, curfews, standards of behavior d) Parents should know their children’s friends and their families e) Parents need to clearly discourage early dating as well as frequent and steady dating f) Parents should take a strong stand against allowing a daughter to date a much older boy; similarly they should not allow a son to develop an intense relationship with a much younger girl g) Parents need to help children set goals for their future and have options that are more attractive than early pregnancy and childrearing h) Parents should show their children that they value education and take school performance seriously i) Parents need to monitor what their children are reading, listening to, and watching j) It is especially important that parents build a strong, loving relationship with their children from an early age by showing affection clearly and regularly, spending time with them doing age-appropriate activities, building children’s self-esteem, and have meals together as a family often

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II.

Care of the Expectant Parents Over Age 35

A. Increasing rates, 2015 → birth rates increased ages 30–44 and decline for women < 30 years B. Factors contributing to this trend 1. Availability of effective birth control methods 2. Expanded roles, career options available for women 3. Increased number of women obtaining advanced education, pursuing careers, delaying parenthood until they established professionally 4. Increased incidence of later marriage, second marriage 5. High cost of living → delay childbearing until more secure financially 6. Increased availability of specialized fertilization procedures 7. Advantages to having first baby after age 35 a) Well educated b) Financially secure c) More aware of realities of having children

C. Medical Risks 1. Risk of maternal death higher for women over 35 → even higher for age 40 and older a) Chronic medical conditions 2. Incidence of multiple gestation, miscarriage, stillbirth, low-birth-weight infants, preterm births and perinatal morbidity and mortality higher 3. Down syndrome risk increases with age a) See Genetic Facts: Incidence of Down Syndrome Increases with Maternal Age, p. 317 b) Quadruple screening for Down and trisomy 18, typically between 15–22 6/7 weeks c) Follow-up testing for abnormal results 4. Amniocentesis routinely offered to all women over age 35

D. Special Concerns of the Expectant Parents Over Age 35 1. Having enough energy to care for new baby 2. Ability to deal with needs of older child as they themselves age 3. Financial concerns regarding college and retirement 4. May feel isolated socially a) Only couple in peer group expecting first baby b) Couples who already have children → response varies 11 Copyright © 2020 Pearson Education, Inc.

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(1) Attitudes of friends (2) Financial implications (3) Previous marriages-Blended families 5. Healthcare professionals may treat couple differently 6. May be concerned about limited time to bear children 7. Amniocentesis options

E. Nursing Management for the Pregnant Woman Over Age 35 1. Nursing Assessment and Diagnosis a) Decisional conflict b) Anxiety (moderate) 2. Planning and Implementation a) Respect and support older couple’s decision to have a child b) Identify and discuss concerns during pregnancy c) Childbirth education classes important d) Woman >35 and having first baby tend to be more educated e) Be sensitive to special needs (1) amniocentsis 3. Evaluation a) Outcomes: b) The woman and her partner are knowledgeable about the pregnancy and express confidence c) Able to cope with the pregnancy and its implications d) The woman receives effective healthcare (1) The woman and her partner develop skills in child care and parenting.

III.

Care of the Pregnant Woman with Special Needs

A. Approximately 163,700 women with chronic physical disability that cause need for assistance with ADLs become pregnant yearly 1. Can include: mobility difficulties that involve upper or lower extremities, arthritis, vision or hearing problems, disorders such as multiple sclerosis or cerebral palsy, heart or lung problems, and a variety of diseases.

2. Changes in societal attitudes → decreased stigmatization of disability 3. ADA increased support and acceptance 4. Decision to become pregnant influenced by biologic, personal, social factors a) The personal importance of pregnancy and motherhood b) The feasibility of pregnancy and raising a child in light of the woman’s health condition, finances, support, and available resources 12 Copyright © 2020 Pearson Education, Inc.

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c) The costs of pregnancy including the physical risks (including death), genetic issues, dangers for the fetus of maternal medications, and potential impact of the woman’s disability on the child’s future quality of life.

5. IDD a) High incidence of unplanned pregnancy b) Seek prenatal care late c) Lower reading and comprehension levels d) higher rates of preterm birth, preeclampsia, longer hospital stays, higher rate of cesarean births e) Babies more likely to be low birth weight f) Family-centered approach recommended, professional support and team effort essential

B. Nursing Management for the Woman with a Disability 1. Nursing Assessment and Diagnosis a) Condition specific b) Will vary based on extent of woman’s disability c) Careful assessment for mobility disorders (1) Hypotension (2) Bradycardia (3) Pulmonary complication (4) Pressure ulcers (5) Bladder infection (6) GERD (7) DVT (8) Stool impaction (9) Anemia (10) Autonomic dysreflexia (11) Increased fall risk → change in center of gravity (12) Assess for level of understanding of instructions & materials 2. Nursing diagnosis a) Dysreflexia, Autonomic, related to a spinal cord injury b) Skin Integrity, Risk for Impaired, related to decreased or absent mobility c) Knowledge, Deficient, related to a documented learning disability 3. Nursing Plan and Implementation a) Lower extremity disability may need assistance in transferring b) Use adaptive equipment c) Weight gain can limit wheel chair function d) During labor, monitor for respiratory distress, DVT, autonomic dysreflexia (1) Pushing may be difficult (2) may need additional support caring for newborn

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4. Evaluation a) Outcomes (1) The expectant woman is able to cope with the pregnancy and its implications for the future.

(2) The woman receives effective healthcare throughout her pregnancy and during birth and the postpartum period.

IV.

Focus Your Study

V.

Activities 1. Individual Have students interview a woman who has had a child, ideally one who represents one of the special populations. Have them investigate at what age the women became pregnant, what their experiences were, and if they had any special considerations related to their age, health or a disability.

2. Small Group Divide the class into small groups of three to five students. Have each group prepare a spreadsheet that lists the details. Have the groups analyze the results based on the age of their findings.

3. Large Group Show the movie Juno in class, discussing the developmental tasks that Juno met and did not meet.

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Chapter 16 Assessment of Fetal Well-Being Psychologic Reactions to Antenatal Testing..........................................................

2

Ultrasound..............................................................................................................

3

Assessment of Fetal Well-Being in the First Trimester.........................................

4

Assessment of Fetal Well-Being in the Second Trimester....................................

6

Assessment of Fetal Well-Being in the Third Trimester........................................

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Other Diagnostic Tests...........................................................................................

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Focus Your Study....................................................................................................

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Activities.................................................................................................................

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

Psychologic Reactions to Antenatal Testing

A. Severe maternal morbidity (SMM): physical and psychologic conditions that result from or are aggravated by pregnancy and have an adverse effect on a woman’s health B. Approximately 3% newborns are born with a birth defect, 10% prematurely C. Studies indicate testing leads to maternal anxiety 1. Ultrasound has become routine a) Counseling to minimize shock, confusion b) Invasive testing → fear, anxiety 2. All testing → present as optional

D. Nursing Management for the Woman Undergoing Antenatal Testing 1. Nursing Assessment and Diagnosis a) Assessment (1) History of present prenatal course, possible indications (2) Assess knowledge of woman and family’s understanding b) Diagnoses c) Knowledge, Readiness for Enhanced (1) Fear (2) Attachment, Risk for Impaired (3) Anxiety 2. Nursing Plan and Implementation a) Education b) Advocate c) Support (1) Remain nonjudgmental d) Community care integral through antepartum period 3. Evaluation 4. Woman and family understand antepartum testing procedures a) Determine if family understands indication for follow-up testing b) Woman and family have adequate resources for support c) Women from different cultures have necessary support

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II.

Ultrasound

A. Diagnostic procedure → high-frequency sound waves exceeding 20,000 cycles per second 1. Produce image that varies based on density of structure under transducer a) Very dense → bone → white b) Soft tissues → gray c) Fluid → black 2. Higher frequency of sound → shallower depth → better resolution of image 3. Transducer → turns sound waves into electrical signals 4. Motion (M) mode → moving display 5. Brightness mode (B) → produces two-dimensional image 6. Three dimensional → uses algorithms to project image

B. Extent of Ultrasound Exams 1. Limited → address specific question a) Determine fetal presentation b) Locate placenta c) Confirm fetal heart activity d) Estimate amniotic fluid volume e) Diagnose multiple gestation f) Evaluate interval growth g) Evaluate cervix h) Guide amniocentesis 2. Standard ultrasound examination a) Performed during second or third trimesters b) Evaluates presentation, number, amniotic fluid volume, placental position, cardiac activity, fetal biometry, anatomic survey c) Specialized ultrasound examination (1) Suspect anomaly (2) May include fetal Doppler, biophysical profile, fetal echocardiogram, amniotic fluid assessment, biometric studies

C. Methods of ultrasound Scanning 1. Transabdominally a) See Figure 16–1: Ultrasound scanning permits visualization of the fetus in utero, p. 325 2. Transvaginally a) See Figure 16–2: Transvaginal ultrasound, p. 326 b) See Table 16–1: Comparison of Transvaginal and Transabdominal Ultrasound, p. 327 3 Copyright © 2020 Pearson Education, Inc.

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D. Indications for Ultrasound 1. US should be performed by licensed medical practitioners to obtain the following data a) Estimation of gestational age b) Evaluation of cervical insufficiency c) Evaluation of fetal growth or fetal well-being d) Evaluation of vaginal bleeding e) Determination of fetal presentation f) Evaluation of abdominal or pelvic pain g) Suspected multiple gestation h) Significant discrepancy between uterine size and clinical date i) Evaluation of pelvic mass or uterine abnormality j) Examination of suspected hydatidiform mole k) Adjunct to special procedures including amniocentesis, cervical cerclage placement, or external cephalic version l) Evaluation for premature rupture of the membranes or premature labor m) Evaluation of suspected fetal death n) Evaluation of suspected ectopic pregnancy o) Evaluation of suspected amniotic fluid abnormalities p) Evaluation of suspected placental abruption q) Evaluation of abnormal biochemical markers r) Follow-up evaluation of fetal anomaly s) Follow-up evaluation of placental location for suspected placenta previa t) Evaluation of those with history of previous congenital anomaly u) Evaluation of fetal condition in late presentation for prenatal care v) To assess findings that may increase the risk of chromosomal abnormalities w) To screen for fetal anomalies

III.

Assessment of Fetal Well-Being in the First Trimester

A. Viability 1. Potential for pregnancy to result in live infant a) Urine human chorionic gonadotropin (hCG) → presence of hormone, does not confirm viability b) Bleeding common symptom associated with first-trimester ultrasound → miscarriage, ectopic or extrauterine pregnancy c) Previous fetal loss, unknown LMP, and dating & size discrepancy → need first-trimester ultrasound 2. Quantitative Beta hCG testing a) Beta human chorionic gonadotropin b) Product of trophoblast or placenta c) Accurate marker of presence of pregnancy and placental health d) Double every 2 days in first 10 days 4 Copyright © 2020 Pearson Education, Inc.

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e) Peaking at 60 to 90 days after conception f) See Table 16–2: Approximate Beta hCG Values in Pregnancy, p. 328 g) If beta hCG plateaus or drops → ectopic pregnancy suspected h) Serologic evaluation with history of spontaneous abortion, ectopic pregnancy, risk of ectopic pregnancy, vaginal bleeding, conception through assisted reproductive methods i) 48 hours between tests can be anxious for couple 3. Progesterone-level testing a) Secreted in early pregnancy by corpus luteum until about 8 weeks (1) Placenta manufactures own progesterone b) Low levels associated with spontaneous abortions, ectopic pregnancies c) Levels above 25 ng/mL → associated with normally developing intrauterine pregnancy d) Levels < 5 ng/mL indicate nonviable fetus e) Levels 5–25 are inconclusive, levels can be treated with supplementation for first trimester 4. Ultrasound a) Sonographic landmarks predictable (1) Gestational sac → yolk sac approximately 5½ weeks (2) Embryo visible → 6 to 6½ weeks → cardiac motion (3) Gestational sac and crown-rump length measured for gestational age estimate 5. Gestational age a) Accurate estimated date of birth (EDB) essential for evaluating well-being b) Traditional means (1) Last menstrual period (LMP) (2) Measure uterine size (3) Date of first recognized fetal heart tones (4) Date of quickening (5) Early transvaginal or abdominal sonogram if LMP uncertain (a) Accurate within ±3 to 5 days (b) Based on crown–rump length, most accurate at 6–12 weeks (c) After 12 weeks, femur length, abdominal circumference, biparietal diameter most accurate (d) See Figure 16–5: Measurement of crown–rump length, p. 329 (6) After 26 weeks (a) Femur length, abdominal circumference, biparietal diameter (b) See Figure 16–6: Measurement of the biparietal diameter, p. 329 (c) Accurate to ±7 to 14 days (7) See Table 16–3: Parameters for Estimating Gestational Age, p. 330 (8) After 26 weeks, fetal growth rates less uniform, making ultrasound inappropriate means of determining EDB 6. Genetic Screening Options a) First-trimester single screening tests → nuchal translucency testing, serum free beta hCG, total hCG, PAPP-A 5 Copyright © 2020 Pearson Education, Inc.

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(1) Combination of ultrasound and maternal serum test (2) Screens for risk of chromosomal disorder (3) If nuchal folds > 3 mm → incidence of Down syndrome increased (4) Performed in conjunction with PAPP-A and free beta hCG (5) 82 to 87% accurate for Down syndrome b) Cell-free fetal DNA (cff-DNA) (1) 98% detection rate for fetal trisomy 13, 18, 21 (2) Done any time after 10 weeks’ gestation

IV.

Assessment of Fetal Well-Being in the Second Trimester A. Integrated test: first-trimester combined test, nuchal translucency testing, PAPP-A, and second trimester maternal serum testing (quadruple screen) 1. Contingent testing → follow up to first-trimester results 2. Stepwise screening

B. Ultrasonographic Screening 1. Most advantageous time for basic obstetric ultrasound a) Uniformity of fetal growth b) Large volume of amniotic fluid relative to fetal size c) Fetal anatomy can be visualized in extreme detail 2. Standard second trimester sonogram provides the following information: a) Fetal life b) Fetal number c) Fetal presentation d) Fetal anatomy survey (1) Head (2) Spine (3) Thorax and heart (4) Abdomen (5) Extremities e) Gestational age and growth f) Amniotic fluid volume g) Placental localization h) Umbilical cord, number of vessels i) Survey of uterine anatomy j) Further evaluation of multiple gestations

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3. Fetal life → cardiac motion 4. Fetal number → identify number of fetuses in uterus 5. Fetal presentation → will change repeatedly before birth 6. Fetal anatomy survey a) Head (1) Symmetrical, cranium ossified and intact (2) Ventricular system (3) Nuchal thickness (4) Anencephaly b) Spine (1) Sagittally and coronally (a) Sac or outward splaying may suggest spinal cord defect c) Thorax and heart (1) Transverse plane of fetal thorax → information about size, shape, symmetry of the chest (2) Size, location, and axis, 4 chambers of heart d) Abdomen (1) Bladder, stomach, kidneys should be visualized (2) Abdominal wall, transverse image of umbilical cord with 3 vessels e) Extremities (1) Femur the only bone routinely measured on basic ultrasound (a) If length is abnormal, comprehensive follow-up needed (2) Upper extremities, presence of hands, feet documented 7. Gestation age and growth a) Hadlock method (1) Average of measures of biparietal diameter, head circumference, abdominal circumference, and femur length to estimate gestational age (2) See Figure 16–7: Measurement of the head circumference, p. 332; Figure 16–10: Measurement of the abdominal circumference, p. 333 8. Amniotic fluid volume a) Changes with gestational age (1) Subjective assessment b) Amniotic fluid index (AFI) (1) Divide maternal abdomen into quadrants (2) Deepest vertical pocket of fluid in each quadrant measured (3) Four measurements summed 9. Placenta location a) Appearance, location, relationship to cervical os b) Placenta previa (1) Location of placenta may change

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(2) Low-lying placenta on second trimester ultrasound → confirm with follow-up ultrasound in third trimester 10. Survey of uterine anatomy a) Examine maternal anatomy, identify defects, abnormalities b) Measure cervical length, dilatation of internal cervical os (1) Shortened cervix and a dilated internal os → be predictive of preterm birth

V.

Assessment of Fetal Well-Being in the Third Trimester A. Conditions Warranting Fetal Surveillance 1. Maternal conditions a) Hypertensive disorders b) Diabetes mellitus c) Chronic renal disease d) Cyanotic heart disease e) Systemic lupus erythematosus f) Hyperthyroidism (poorly controlled) g) Antiphospholipid syndrome h) Hemoglobinopathies 2. Prenatal conditions a) Preeclampsia b) Gestational diabetes c) Decreased fetal movement d) Oligohydramnios e) Hydramnios f) Intrauterine growth restriction g) Postterm pregnancy h) Isoimmunization (moderate to severe) i) Previous fetal demise j) Multiple gestation k) Known fetal anomaly l) Abnormal biochemical test results

B. Fetal Movement Assessment 1. Acceptable, noninvasive, cost-effective fetal surveillance a) Vigorous fetal movement reassuring → fetal well-being, oxygenation b) Monitored by mother daily, beginning at 28 weeks c) Cardiff Count-to-Ten method (Figure 16–11, p. 334) d) Education of woman at 28 weeks (1) The woman should feel fetal movement at least 10 times in 12 hours (2) Many women will feel 10 fetal movements in much less time, perhaps as little as 2 hours 8 Copyright © 2020 Pearson Education, Inc.

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e) Daily Fetal Movement Record (DFMR) (1) Woman lies on her side in a comfortable position (2) Counts the number of movements until she reaches a minimum of three movements within a 1-hour period f) Reduced fetal activity (1) Possible fetal or placental issue (2) Warrants further assessment (3) Indirect measure of fetal CNS integrity and function (4) Variation in fetal movement dependent on individual, gestational age (5) Fetal rest-sleep cycle (6) See Teaching Highlights: What to Tell the Pregnant Woman About Assessing Fetal Activity, p. 335

C. Nonstress Test 1. External electronic fetal monitor → tracing of fetal heart rate (FHR) a) Observe acceleration of FHR with fetal movement (1) Acceleration → intact central nervous system and autonomic nervous system (2) Nonreactive NST not diagnostic of fetal compromise b) Advantages (1) Quick and easy to perform (2) Inexpensive (3) Easy to interpret (4) Can be performed in an outpatient setting (5) No known side effects c) Disadvantages (1) Can be difficult to obtain a suitable tracing (2) Results are influenced by fetal sleep cycle (3) Extended monitoring may be required (4) Maternal obesity, excessive fetal movement, hydramnios, and other factors can make the test difficult to perform d) Fetal age → 30 to 32 weeks → accelerations with movement e) Accelerations (1) 15 beats/min above baseline for 15 to 120 seconds (2) Two accelerations within 20-minute period f) Assessment tool → especially in (1) Diabetes (2) Preeclampsia (3) Intrauterine growth restriction (4) Spontaneous rupture of membranes (5) Multiple gestation (6) Postdates 2. Procedure for performing an NST a) Inpatient or outpatient 9 Copyright © 2020 Pearson Education, Inc.

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b) Eat prior to, no smoking for 2 hours before exam c) Semi-Fowler’s position → small pillow under right hip d) FHR monitored by placement of electronic metal monitor (1) One or two belts (2) Second belt for tocodynamometer → detects uterine, fetal movement (3) Monitor for 20 to 40 minutes 3. Interpretation of the NST a) Negative (normal) (1) Two or more fetal heart accelerations within 20 min period, with or without discernible fetal movement (Figure 16–12, p. 336) b) Positive (1) Lacks sufficient FHR accelerations over 40 min period (Figure 16–13, p. 338) (2) Spontaneous decelerations → variable decelerations (a) If nonrepetitive and brief → does not indicate fetal compromise (b) Repetitive variable decelerations (3+ in 20 minutes) → associated with increased risk of cesarean for fetal intolerance (3) Deceleration lasting 1 minute or longer → ominous (4) Responsibility of nurse performing test to contact physician, midwife regarding reactivity 4. Clinical application a) Reactive after 20 minutes → concluded (1) Next test scheduled as indicated (2) One to two times weekly 5. Nursing Management for the Woman Undergoing a Nonstress Test a) Assess woman’s understanding of NST b) Review indications for NST c) Maternal blood pressure monitored during test d) Report findings to healthcare provider

D. Contraction Stress Test 1. Means of evaluating respiratory function of placenta 2. Identify fetus at risk of intrauterine asphyxia 3. In many areas, CST given way to biophysical profile 4. CST procedure a) Necessary component of CST → uterine contractions b) Spontaneous contractions or induced (1) Breast stimulation → produces oxytocin (2) Intravenous (IV) oxytocin c) Electronic fetal monitor → uterine activity and FHR recorded d) 15 minutes → baseline 10 Copyright © 2020 Pearson Education, Inc.

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e) If three spontaneous contractions of good quality and lasting 40 to 60 seconds occur in a 10-minute window, the results are evaluated, and the test is concluded f) If not, after baseline → intravenous oxytocin CST or breast self-stimulation test g) Conducted only in setting where tocolytic medications are available 5. Interpretation of CST results a) Negative → three contractions of good quality lasting 40 or more seconds in 10 minutes without evidence of late decelerations (Figure 16–14, p. 339) b) Positive → repetitive persistent late decelerations with more than 50% of the contractions (Figure 16–15, p. 339) (1) Not a desired result (2) Hypoxic stress of the uterine contraction causes a slowing of the FHR (3) Pattern will not improve and will most likely get worse with additional contractions c) Equivocal or suspicious (1) Has nonpersistent late decelerations (2) Decelerations associated with tachysystole (contraction frequency of every 2 minutes or duration lasting longer than 90 seconds) (3) More information is needed 6. Clinical application a) Negative CST with reactive NST desired result b) Placenta is functioning normally c) Fetal oxygenation is adequate (1) Fetus will probably be able to withstand stress of labor d) Positive CST with nonreactive NST → fetus would probably not withstand stress of labor

E. Amniotic Fluid Index 1. Based on rationale that decreased uteroplacental perfusion → diminished fetal renal blood flow, decreased urination, ultimately oligohydramnios 2. AFI of 5 or less requires further assessment (oligohydramnios)

F. Biophysical Profile 1. BPP assesses five criteria a) FHR acceleration b) Fetal breathing c) Fetal movements d) Fetal tone e) Amniotic fluid volume

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2. FHR assessed with NST 3. Other assessment → ultrasound 4. Combination identifies compromised or healthy fetus 5. Indications a) Situations in which NST or CST would be done b) Decreased fetal movement c) Management of other conditions 6. Most important components: NST, AFI a) See Table 16–4: Criteria for Normal and Abnormal Assessments of the BPP, p. 341 (1) Fetal breathing → 30 seconds within 30 minutes (2) Gross body movements → greater than or equal to discrete body, limb movements in 30 minutes (3) Fetal tone → extension/flexion of extremity, opening or closing of hand (4) Reactive FHA and NST → ≥2 accelerations ≥15 sec in 20 to 40 minutes (5) Amniotic fluid volume > 5 cm (6) Each normal variable assigned score of 2, abnormal 0 (7) FHR most sensitive to hypoxia (8) Total possible score 10 (9) See Table 16–5: Biophysical Profile Test Interpretation and Recommended Management, p. 341 (a) 10/10 → normal → no intervention, repeat weekly (diabetics, postterm → twice weekly) (b) 8/10 (normal fluid), 8/8 with no NST → no intervention, repeat weekly (diabetics, postterm → twice weekly) (c) 8/10 (abnormal fluid) → induce birth (d) 6/10 → induce birth (i) If repeat test 6 or less → induce (ii) If repeat test above 6, observe, repeat per protocol (e) 4/10 → repeat same day, if less than 6 induce birth (f) 2/10 → induce birth (g) 0/10 → induce birth

G. Modified Biophysical Profile 1. Labor intensive, expensive 2. NST plus AFI 3. Considered normal if amniotic fluid volume >5 cm, NST reactive

H. Doppler Flow Studies 1. Noninvasively study changes in maternal, fetal circulation a) Done in high risk pregnancies 12 Copyright © 2020 Pearson Education, Inc.

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b) Determine placental function and velocity of blood flow in vessels c) Analyze wave form of signal (1) Highest peak is systolic (2) Lowest point is diastolic (3) Most common evaluation of blood flow velocity → systolic/diastolic ration (S/D) (a) Normally decreases as pregnancy nears term (b) Decrease in fetal cardiac output, increase in resistance of placental vessels → reduced umbilical artery blood flow (i) Use when intrauterine growth restriction diagnosed (cerebroplacental ratio) (ii) Hypertension (iii) Preeclampsia

I. Evaluation of Placental Maturity 1. Grading process 2. 0 through III, III → mature, extensive calcifications 3. Factors that cause placenta to mature a) Smoking, postterm pregnancy, and certain maternal conditions, such as preeclampsia and gestational diabetes 4. See Figure 16–18: Placental grading, p. 343

J. Estimation of Fetal Weight 1. Intrauterine growth restriction (IUGR) a) Fetus that falls below 10th percentile in ultrasonic estimation of weight at given gestational age b) Etiology (1) Fetoplacental (2) Maternal c) Management includes careful surveillance of fetus 2. Macrosomia a) Excessive fetal growth b) Weight greater than 4000 to 4500 g (8 1b 13 oz to 9 1b 4 oz) c) Carefully manage labor and birth → prevent complications (1) Shoulder dystocia d) Diagnosis imprecise (1) Leopold maneuver (2) Measuring fundal height (3) Combined estimation e) Greatest risk → shoulder dystocia (1) Mother in McRoberts position, stool available for suprapubic pressure (2) Trial of labor (TOL) after previous cesarean birth → increased risk

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VI.

Other Diagnostic Tests

A. Birth defects 1. Structural abnormalities present at birth 2. 1 in 33 infants in United States, 1 in 5 infant deaths annually 3. Biochemical markers, ultrasound → prenatal diagnosis

B. Maternal Serum Alpha-Fetoprotein 1. Alpha-fetoprotein (AFP) Fetal protein excreted from fetal yolk sac during first 6 weeks 2. Quadruple Check a) MSAFP component of quadruple check b) Alpha-fetoprotein (AFP), hCG, diametric inhibin-A, estriol c) Screens for neural tube defect (NTD), trisomy 21 and 18 d) 15 to 22 weeks e) Universal screening for all women (1) 90% of NTD cases in women with no risk factors (2) Risk factors include previous fetus with an NTD, maternal age less than 20 or greater than 35 years, primiparity or grandmultiparity, low socioeconomic status with nutritional deficiencies, English or Irish ancestry, and inadequate folic acid intake f) MSAFP first marker in quadruple check (1) 2 to 2.5 multiples of the mean (MoM) of AFP → high (2) 90% detection rate (3) Majority of elevated MSAFP → fetus not affected (a) In 90 to 95% of the group with an elevated MSAFP, the elevation is caused by other variables, such as incorrect gestational age, more than one fetus, other fetal anomalies such as gastroschisis (a hole in the abdominal wall that allows the abdominal contents to protrude outside the body), or fetal death g) Quadruple screen (1) Trisomy 21 (Down syndrome) → most common live-birth chromosomal abnormality (2) Trisomy 18 → death of infant within first year of life h) Abnormal test → reported as a calculated Down syndrome risk (1) Patient education, counseling (2) MSAFP, quadruple check not diagnostic tests → screening (3) Ethical issues

C. Amniocentesis 1. Used for genetic diagnosis a) Sterile needle under ultrasound guidance inserted into uterine cavity through maternal abdomen b) Small amount of amniotic fluid removed c) Ideally done at 15–16 weeks’ gestation 14 Copyright © 2020 Pearson Education, Inc.

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d) Chromosomal and biochemical determinations early in pregnancy, at 30–39 weeks lung maturity studies 2. Indications a) Pregnant woman will be 35 or older on due date b) Couples who have had child with birth defect c) Pregnant women with other abnormal screening or genetic test results 3. Procedure a) Outpatient (1) Near birthing area b) Abdomen scanned by ultrasound → locate placenta, fetus, adequate pocket of fluid (1) Need to avoid fetus, placenta, umbilical cord, bladder, uterine arteries c) Skin cleansed with povidone-iodine d) 22-gauge spinal needle inserted into uterine cavity (1) First few drops discarded → syringe to aspirate e) 15 to 20 mL amniotic fluid f) Fluid put into appropriate test tubes g) Needle withdrawn using ultrasound h) Fluid contaminated with blood → centrifuge immediately i) Monitor FHR for 20–30 minutes afterward j) See Figure 16–20: During amniocentesis, amniotic fluid is aspirated into a syringe, p. 346 4. Risks/side effects a) Minor b) Transient vaginal spotting, cramping, amniotic fluid leakage, chorioamnionitis c) Needle injuries rare with ultrasound use d) Early amniocentesis (< 14 weeks) → higher rate of loss, complications 5. Nursing Management for the Woman Undergoing Amniocentesis a) Assists physician b) Supports woman

D. Chorionic Villus Sampling 1. CVS is procedure to detect genetic, metabolic, and DNA abnormalities a) Small sampling of chorionic villi from edge of developing placenta b) First-trimester diagnosis after 9 completed weeks c) Cannot detect neural tube defects 2. Risks and Benefits of CVS a) Risks (1) Spontaneous abortion (0.22%—double amniocentesis risk) (2) Fetal limb reduction defects especially when performed before 9 completed weeks (3) Failure to obtain tissue (4) Rupture of membranes (5) Leakage of amniotic fluid 15 Copyright © 2020 Pearson Education, Inc.

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(6) Vaginal spotting or bleeding (7) Chorioamnionitis (8) Intrauterine infection (9) Maternal tissue contamination (10) Oromandibular defects (11) Rh isoimmunization b) Benefits (1) Earlier diagnosis (a) Detect fetal karyotype, hemoglobinopathies (e.g., sickle cell disease and alpha and some beta thalassemias), phenylketonuria, alpha antitrypsin deficiency, Down syndrome, Duchenne muscular dystrophy, factor IX deficiency (2) Decreased waiting time for results 3. Procedure for CVS a) Ultrasound to determine placental location, uterine position b) After counseling regarding diagnosis, procedure c) Full bladder d) Transcervical CVS → lithotomy position (1) Vulva cleansed with povidone-iodine solution (2) Sterile speculum inserted into vagina (3) Vaginal vault and cervix cleanse to decrease contamination (4) Catheter/cannula slowly inserted under ultrasound guidance (5) Obturator withdrawn (6) 30-mL syringe aspirated e) Transabdominal sampling → supine position (1) Skin cleansed (2) Local anesthesia (3) 18- to 20-gauge needle inserted through abdominal wall, uterine myometrium (4) Tip of needle advanced into long axis of chorion frondosum under ultrasound guidance (5) Repeated rapid aspirations of syringe containing culture medium, heparin f) Normal CVS result indicating normal chromosomal configuration in first trimester (1) Does not ensure healthy infant

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E. Nursing Management for the Woman Undergoing CVS 1. Assess understanding of CVS, procedure, results 2. Support 3. Education

F. Fetal Fibronectin 1. fFN → glycoprotein produced by trophoblast, other fetal tissues 2. Absence of cervicovaginal fFN between 20 and 34 weeks → strong predictor of not experiencing premature labor or premature rupture of membranes 3. Negative predictive value is 99.5% but positive findings only 12.7% 4. No longer recommended by ACOG

G. Evaluation of Fetal Lung Maturity 1. Possibility of inducing birth of woman and fetus at risk if preterm a) Repeat cesarean birth, premature rupture of membranes, diabetes, hypertensive conditions, placental insufficiency b) Prematurity most common cause perinatal mortality, especially neonates weighing < 1000 g c) Need to determine lung maturation of fetus by amniotic fluid analysis (1) Typically at < 32 weeks’ gestation 2. Lecithin/sphingomyelin (L/S) ratio a) Alveoli of lungs lined with surfactant b) Fetal lung maturity can be assessed → determining ratio of two components of surfactant → L/S ratio (1) 30 to 32 weeks amounts of two substances becomes equal (2) Concentration of lecithin begins to exceed sphingomyelin → 35 weeks L/S ratio 2:1 (3) Ratio two times → respiratory distress syndrome (RDS) unlikely (4) Infants of diabetic mothers → lung maturation can be delayed (5) Infants of mothers with nonhypertensive renal disease, isoimmunization → delay lung maturation c) Chronic intrauterine fetal stress → acceleration of lung maturation in fetus (1) Premature rupture of membranes (> 24 hr) d) Cumbersome, labor intensive method of testing 3. Phosphatidylglycerol a) Phosphatidylglycerol (PG) second most abundant phospholipid in surfactant (1) Appears after 35 weeks’ gestation b) Presence of PG associated with low-risk RDS c) Absence of PG associated with development of RDS d) Combination of L/S ratio and PG 17 Copyright © 2020 Pearson Education, Inc.

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e) Useful in blood contaminated specimens 4. Lamellar body counts a) Lamellar body counts (LBCs)-Concentrated phospholipids produced by type II alveoli cells b) Representative of stored surfactant c) Amniotic fluid LBC < 15,000/mcl → indicate fetal lung maturity and increased risk of RDS d) Values > 30,000 mcL and < 50,000 mcL, L/S ratio testing may be performed to ensure accuracy in determining fetal lung maturity status e) Foam stability index (FSI) is a measure that assesses total surfactant activity (1) 47 are positive → fetal lung maturity

H. Nursing Management for the Woman Undergoing Testing for Fetal Lung Maturity 1. Premature rupture of membranes → specimen obtained for analysis 2. Assists in gathering supplies 3. Positioning for speculum exam in lithotomy

VII.

Focus Your Study

VIII.

Activities 1. Individual Have students prepare a teaching plan for the procedure of their choice. The teaching plans should include strategies for different types of learning needs.

2. Small Group Divide the class into small groups of three to five students. Have each groups observe nonstress testing at an antenatal testing center and write a short evaluation of the nursing process observed.

3. Large Group Role-play teaching scenarios for the patient undergoing the following procedures: • Ultrasound • Fetal activity • Nonstress test (NST)—nonreactive, reactive • Contraction stress test • Biophysical profile (BPP) • Amniocentesis • Chorionic villus sampling (CVS) • Percutaneous umbilical blood sampling (PUBS) • Nuchal testing

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Chapter 17 Pregnancy at Risk: Pregestational Problems Care of the Woman with Diabetes Mellitus..........................................................

2

Care of the Woman with Anemia..........................................................................

8

Care of the Pregnant Woman with Substance Abuse……………………………………….

12

Care of the Woman with a Psychologic Disorder………………………………………………

17

Care of the Woman with HIV.................................................................................

19

Care of the Woman with Heart Disease................................................................

22

Other Medical Conditions and Pregnancy…………..................................................

25

Focus Your Study....................................................................................................

27

Activities.................................................................................................................

27

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

Care of the Woman with Diabetes Mellitus

A. Normal Glucose Homeostasis 1. After meal → body metabolizes carbohydrates into glucose a) Insulin lowers blood glucose levels → enables glucose to move from blood into muscle, liver cells

B. Carbohydrate Metabolism in Normal Pregnancy 1. Early pregnancy → hormones stimulate maternal insulin production 2. Second half of pregnancy → prolonged hyperglycemia, hyperinsulinemia following meal a) Increased maternal peripheral resistance to insulin → sustained supply of glucose for fetus (1) Catabolic state during fasting → maternal fat metabolized → ketones may be present in urine 3. Balance between glucose production/use stressed by growing fetus (diabetogenic effect of pregnancy) → any diabetic potential may precipitate gestational diabetes mellitus

C. Pathophysiology of Diabetes Mellitus 1. Pancreas does not produce sufficient amounts of insulin for necessary carbohydrate metabolism and/or there is a diminished tissue response to insulin 2. Body cells energy depleted → fats and proteins used as source of energy 3. High level of glucose in blood eventually spills into urine 4. Four cardinal signs and symptoms a) Polyuria (frequent urination) b) Polydipsia (excessive thirst) c) Weight loss d) Polyphagia (excessive hunger)

D. Classification of Diabetes Mellitus 1. Type 1 diabetes 2. Type 2 diabetes 3. Gestational diabetes mellitus 4. Other specific types → genetic defects, drug-induced diabetes, endocrine disorders, and other causes 5. Gestational diabetes mellitus (GDM) → glucose intolerance of variable severity a) Onset or first recognition during pregnancy b) Even if only mild diabetes increases risk of perinatal morbidity and mortality 2 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

E. Influence of Pregnancy on Diabetes 1. Physiologic changes of pregnancy drastically alter insulin requirements 2. Accelerate progress of vascular disease 3. More difficult to control during pregnancy a) Insulin requirements changeable (1) Decrease early in first trimester (2) May double or quadruple by end of pregnancy (3) Increased energy needs during labor (4) After delivery of placenta → insulin requirements decrease abruptly b) Nausea and vomiting may cause dietary fluctuations (1) Increase risk of hypoglycemia c) Other factors (1) Renal threshold for glucose decreases (2) Increased risk of ketoacidosis (3) Vascular disease (4) Hypertension (5) Nephropathy (6) Retinopathy (7) Increased energy needs during labor→ may need more insulin to balance IV glucose (8) Delivery of placenta→ abrupt decrease in insulin requirements

F. Influence of Diabetes on Pregnancy Outcome 1. Higher risk of complications → perinatal mortality, congenital anomalies 2. Maternal risks a) Hydramnios b) Preeclampsia-eclampsia c) Hyperglycemia → leads to ketoacidosis d) Dystopia → fetopelvic disproportion with fetal macrosomia e) Monilial vaginitis, urinary tract infections f) Worsening retinopathy 3. Fetal-neonatal risks a) Congenital anomalies (1) Heart (2) Central nervous system (CNS) (3) Skeletal system (4) Large for gestational age (LGA) → result of high levels of fetal insulin production (a) Macrosomia, deposition of fat (5) After umbilical cord severed → risk for hypoglycemia (6) Interuterine growth restriction (IUGR) → infants of mothers with diabetes with vascular involvement (7) Respiratory distress syndrome (RDS) 3 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

G. Clinical Therapy 1. Detection and diagnosis of gestational diabetes a) More common than pregestational diabetes b) All pregnant women should have risk assessed at first prenatal visit (1) High risk (a) Non-Caucasian (b) Prior history of GDM or birth of LGA infant (c) Marked obesity (d) Diagnosis of polycystic ovarian syndrome (e) Hypertension (f) Presence of glycosuria (g) Strong family history of type 2 diabetes mellitus c) Two-step approach (1) Recommended by National Institutes of Health (NIH) Consensus Conference and ACOG (2) Step 1: Non-fasting, 50-g, 1-hour OGTT (3) Step 2: 100-g, 3-hour OGTT (4) Gestational diabetes diagnosed if two or more of the following values are met or exceeded: (a) Fasting: 95 mg/dL (b) 1 hour: 180 mg/dL (c) 2 hours: 155 mg/dL (d) 3 hours: 140 mg/dL d) One-step approach (1) Recommended by International Association of Diabetes and Pregnancy Study Groups (2) In the morning, following an overnight fast, 75-g oral glucose solution (3) Gestational diabetes diagnosed if any one of these values are equaled or exceeded in plasma glucose levels (a) Fasting: 92 mg/dL (b) 1 hour: 180 mg/dL (c) 2 hours: 153 mg/dL 2. Laboratory assessment of long-term glucose control a) Glycosylated hemoglobin (HbA1c ) → loosely reflects glucose control over previous 4 to 8 weeks b) Measures percentage of glycohemoglobin in the blood c) Women with known pregestational diabetes → abnormal HbA1c correlates directly with frequency of spontaneous abortion, fetal congenital anomalies d) Target level → less than 6%

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H. Antepartum Management of Diabetes Mellitus 1. Major goals a) Maintain physiologic equilibrium of insulin availability, glucose utilization b) Ensure optimally healthy mother, newborn 2. Team approach a) Education of woman and her partner → active involvement of managing her care b) Diagnosis may be shocking and upsetting c) Interventions (1) Counseling, preconception counseling if pregestational diabetic (2) Careful dating of pregnancy (3) Diet therapy and regular exercise 3. Dietary regulation a) Pregnant woman → additional 300 kcal/day (1) 30 kcal/kg of ideal body weight (IBW) → first trimester (2) 35 to 36 kcal/kg IBW→ second and third trimesters (3) 33 to 40% from complex carbohydrates (4) 20% from protein (5) 40% from fats (6) Divide calories/food among three meals, 2–3 snacks b) Dietitian works out meal plans (1) Lifestyle, culture, food preferences (2) Teaches food exchanges 4. Glucose monitoring a) Essential part of diabetes management → determining need for insulin, assessing glucose control b) Office visits for weekly assessment of fasting glucose levels & one or two postprandial levels.

5. Insulin administration a) Need for additional insulin depends on control of blood glucose levels with diet alone b) Pregestational diabetic, type 1 diabetic → requires insulin c) Semi-synthetic human insulin or insulin analog should be used d) Multiple injections or continuous subcutaneous infusion (1) Three-dose approach e) Certain oral hypoglycemic agents may be safe to use but do cross placenta 6. Evaluation of fetal status a) See Key Facts to Remember: Fetal Surveillance by Weeks of Gestation, p. 357 (1) 8–10: Ultrasound crown–rump measurement for estimated date of birth (EDB) (2) 16–18: Maternal serum alpha fetoprotein (3) 18–20: Targeted ultrasound examination (4) 20–22: Fetal echocardiogram 5 Copyright © 2020 Pearson Education, Inc.

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(5) 24: Begin ultrasounds for assessment of fetus and fetal growth (6) 28: Ultrasound for growth; begin daily fetal movement counting (7) 32: Ultrasound for growth (8) 32: Twice-weekly nonstress tests; fetal surveillance should be initiated earlier in pregnancies complicated by IUGR, hypertension, nephropathy, ketoacidosis, pyelonephritis, preeclampsia, and poor compliance (9) 36: Ultrasound for growth (10) 37–39: Consider birth if there is poor compliance or clinical concern for fetal wellbeing (11) 39: Childbirth

I. Intrapartum Management of Diabetes Mellitus 1. Medical therapy includes a) Timing of birth (1) Most allowed to go to term (2) Induction before 39 weeks if nonreassuring fetal status or worsening HTN (3) If fetal weight estimate >4500 g, counsel on risks and benefits of schedule cesarean birth b) Labor management (1) Maternal prenatal and laboring euglycemia → important in preventing neonatal hypoglycemia (2) Every 1–2 hours measure serum glucose (3) No long-acting insulin, only regular (4) Two IV lines → saline for IV insulin in one, 5% dextrose in other

J. Postpartum Management of Diabetes Mellitus 1. Maternal insulin requirements fall significantly postpartum a) Levels of hPL, progesterone, estrogen → fall after placental separation b) Mother with preexisting diabetes may require little or no insulin; managed on sliding scale c) Women with GDM seldom need insulin during postpartum period d) Antihyperglycemic agents contraindicated during breastfeeding e) Reassess at 12 weeks postpartum f) Breastfeeding encouraged → insulin requirements decrease should consider prenursing snack 2. Diabetic control and establishment of parent–child relationships priorities a) Newborn in special care nursery → effort to provide parental/newborn contact b) Family planning information (1) Barrier and LARCs versus combined oral contraceptives (COCs)

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K. Nursing Management for the Woman with Diabetes Mellitus or Gestational Diabetes Mellitus 1. Nursing Assessment and Diagnosis a) Assessment of disease process, woman’s understanding (1) Physical exam, lab work at first prenatal visit (2) Twice monthly during first two trimesters (3) Weekly during last trimester (4) Assessment of woman’s ability to cope and follow regimen of care b) Diagnoses that may apply (1) Overweight, Risk for (2) Injury, Risk for (3) Family Processes, Interrupted 2. Nursing Plan and Implementation a) Prepregnancy counseling (1) Culturally sensitive approach (2) Team approach b) Community-based nursing care (1) May be hospital initially → stabilize (2) Majority of ongoing teaching and supervision → outpatient c) Effective insulin use (Figure 17–2, p. 361) (1) Nurse ensures couple understands (a) Purpose of insulin (b) Types of insulin (c) Number of doses (d) Correct procedure for administration (e) Insulin pump as appropriate (2) Monitoring blood sugar → appropriate levels, importance (a) Glucose meter (b) Tips about finger puncture (i) Spring-loaded devices available → easier (ii) Hanging arm down for 30 seconds increases blood flow to fingers (iii) Warming hands increases blood flow (iv) Sides of fingers (c) Record each blood sugar d) Planned exercise program (1) After meals (2) Monitor blood glucose levels (3) Wear diabetic identification (4) Carry a simple sugar (5) Avoid injecting insulin into extremity to be used soon during exercise (6) Begin gradually (7) If not exercising regularly, encourage to start 7 Copyright © 2020 Pearson Education, Inc.

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e) Health promotion education (1) Glucose monitoring (a) Home glucose monitoring accurate and convenient (b) Four times/day (2) Symptoms of abnormal blood glucose levels (a) Hypoglycemia may develop fairly rapidly. Symptoms: sweating, periodic tingling, disorientation, shakiness, pallor, clammy skin, irritability, hunger, headache, blurred vision (b) Carry snack at all times (c) Fast sources of glucose at hand (d) Hyperglycemia, ketoacidosis → develop more slowly (i) More common during second half of pregnancy (ii) Symptoms: polyuria, polydipsia, dry mouth, fatigue, nausea, hot flushed skin, rapid deep breathing, abdominal cramps, acetone breath, headache, drowsiness, depressed reflexes, oliguria or anuria, stupor, coma (3) Smoking contraindicated (4) Travel: keep insulin at room temperature when traveling and kept with the traveler (5) Support groups (6) Cesarean birth risk increased f) Hospital-based nursing care (1) Evaluate blood glucose, adjust insulin dosages 3. Evaluation a) Woman able to discuss condition, possible impact b) Woman participates in developing healthcare regimen to meet needs → follows it throughout pregnancy c) Woman avoids developing hypoglycemia, hyperglycemia d) Woman gives birth to a health newborn e) Woman able to care for newborn

II.

Care of the Woman with Anemia

A. Hemoglobin less than 11 g/dL; indicates inadequate levels of hemoglobin 1. Race, altitude, smoking, nutrition, medications 2. Common anemias of pregnancy due to a) Insufficient hemoglobin production related to nutritional deficiency iron or folic acid (1) Hemoglobin destruction (sickle cell disease or thalassemia)

B. Iron Deficiency Anemia 1. Dietary iron needed to synthesize hemoglobin a) Most common medical complication of pregnancy b) Pregnant needs 1000 mg more iron intake during pregnancy c) Greatest need in second half of pregnancy 8 Copyright © 2020 Pearson Education, Inc.

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d) Many women begin pregnancy slightly anemic → can rapidly become more severe 2. Maternal risks a) Asymptomatic → still more susceptible to infection, tire easily, increased chance of preeclampsia, bleeding (1) Blood loss not well tolerated (2) Healing may be delayed (3) Severe → cardiac failure 3. Fetal-neonatal risks a) Increased risk → low birth weight, prematurity, stillbirth, neonatal death b) Increased risk for developing iron deficiency during infancy 4. Clinical therapy a) Prevention first goal (1) Pregnant women → at least 30 mg supplements of iron daily starting at first prenatal visit (2) Iron-rich diet b) Anemia diagnosed → dosage increased to 60 to 120 mg/day of iron (1) If the woman remains anemic after 1 month of therapy, further evaluation is indicated (2) Twin pregnancy → larger dose (3) Large dose may cause vomiting, diarrhea, constipation → parenteral iron 5. Nursing Management for the Pregnant Woman with Anemia a) Nursing Assessment and Diagnosis (1) Main presenting symptom → fatigue (a) Nutritional history → poor dietary intake (b) Lab studies → hemoglobin (Hb) <11 g/dL, low serum ferritin levels (c) Possibly microcytic and hypochromic red blood cells (late finding) (2) Diagnoses include (a) Nutrition, Imbalanced: Less than Body Requirements, Risk for (b) Constipation b) Nursing Plan and Implementation (1) Education (a) Importance of iron-rich diet, iron supplements (b) Take iron tablets with vitamin C (c) Iron absorption is reduced by 40 to 50% if the tablets are taken with meals (d) Stool will turn black (e) Out of reach of children → may be fatal if ingested by young children c) Evaluation (1) Woman able to identify risks associated with iron deficiency anemia during pregnancy (2) Woman takes her iron supplements as recommended (3) Woman’s Hb levels remain normal, return to normal

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C. Folic Acid Deficiency Anemia 1. Most common cause of megaloblastic anemia during pregnancy a) Folic acid needed for DNA and RNA synthesis, cell duplication b) Inadequate intake associated with neural tube defects (NTDs) 2. Clinical therapy a) Diagnosis may be difficult b) Serum folate levels normally fall during pregnancy c) Prevent with daily supplement of 0.4 mg folate d) Iron deficiency anemia almost always coexists → iron supplements 3. Nursing Management for the Pregnant Woman with Folic Acid Deficiency Anemia a) Education → food sources of folic acid, cooking for preserving folic acid (1) Fresh leafy green vegetables, orange juice, other citrus fruits and juices, red meats, fish, poultry, legumes (2) All women of childbearing age should consume 0.4 mg folic acid daily

D. Sickle Cell Disease 1. SCD → recessive autosomal disorder in which normal adult hemoglobin (hemoglobin A [HbA]) abnormally formed a) African descent b) Occasionally Southeast Asian, Mediterranean origin c) Abnormal cells breakdown → causing anemia d) Homozygous for sickle cell gene → disease e) Heterozygous → carriers sickle cell trait (SCT) f) Hemoglobin S (HbS) causes RBCs to be sickle shaped (1) Low oxygenation → HbS semisolid, distorts RBC shape (2) Sickling (3) Diagnosed → hemoglobin electrophoresis 2. Maternal risks a) Sickle cell trait (SCT) mothers (1) Good prognosis for pregnancy → adequate nutrition, prenatal care (2) Increased risk → nephritis, bacteriuria, hematuria, tend to become anemic b) SCD (1) More risk (2) Low oxygen pressure → precipitate vaso-occlusive crisis (a) caused by high temperature, dehydration, infection, or acidosis (3) More often in second half of pregnancy (4) Maternal mortality rare (5) Complications include anemia requiring blood transfusion, infections, and emergency cesarean births. Acute chest syndrome, congestive heart failure, or acute renal failure may also occur

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3. Fetal-neonatal risks a) Incidence of fetal death decreased greatly in recent years (1) Fetal death is believed to be due to sickling attacks in the placenta b) Prematurity, IUGR associated with SCD 4. Clinical therapy a) Additional folic acid (4 mg/day) b) Treat maternal infection promptly → can trigger sickling and crisis c) Vaso-occlusive crisis → perinatal team in medical center d) Rehydration, oxygen, antibiotics, analgesics e) Monitoring fetal heart rate (FHR) f) Crisis during labor → same therapies, left lateral position maintained (1) May promote labor → oxytocic agents 5. Nursing Management for the Pregnant Woman with Sickle Cell Disease a) Nursing Assessment and Diagnosis (1) History → frequent illnesses, recurrent abdominal, joint pains, anemic (a) Diagnosis SCD confirmed by hemoglobin electrophoresis (b) Assess for infection (c) Fetal status assess during crisis → electronic fetal monitoring (d) Frequent vital signs, continuous FHR monitoring during labor (e) Blood available for transfusion (f) Oxygen (2) Diagnoses include (a) Pain, Acute (b) Knowledge, Readiness for Enhanced b) Nursing Plan and Implementation (1) Education → prevent sickle cell crisis, improve anemia, prevent infection (2) Genetic counseling if both partners SCT or SCD c) Evaluation (1) Woman able to describe condition, identify impact (2) Woman take appropriate healthcare measures to avoid sickle cell crisis (3) Woman gives birth to healthy infant (4) Woman and caregivers quickly identify and successfully manage any complications that arise

E. Thalassemia 1. Group of autosomal recessive disorders 2. Characterized by defect in synthesis of alpha or beta chains in hemoglobin molecule 3. Most often in persons from Greece, Italy, southern China (Mediterranean anemia and Cooley anemia) a) β-thalassemia frequently encountered in United States (1) Heterozygous → half beta chains formed normally → β-thalassemia minor or trait 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Minor anemia only symptom (3) Homozygous → β-thalassemia major → no symptoms in newborns for several months (a) Severe anemia → dependent on transfusions (b) Iron chelation therapy must be instituted after chronic transfusions to prevent liver & heart damage 4. Maternal–fetal-neonatal risks a) β-thalassemia minor → mild anemia, small red cells b) No iron therapy unless also deficient in iron c) β-thalassemia major → pregnancy rare d) If it occurs → severe anemia, needs transfusion therapy, risk for congestive heart failure e) Perinatologist 5. Clinical therapy a) Folic acid supplements, no iron supplements b) Transfusion, chelation therapy discontinued during pregnancy → lack of data on effect on fetus

III.

Care of the Pregnant Woman with a Substance Abuse Disorder

A. Perinatal substance abuse → highly variable 1. Women 15 to 44 years of age: 5.4% illicit drug users 2. See Table 17–1: Possible Effects of Selected Drugs of Abuse/Addiction on Fetus and Newborn, p. 367 a) Depressants → alcohol b) Narcotics → heroin, methadone c) Barbiturates → phenobarbital d) Tranquilizers → diazepam e) Antianxiety drugs → lithium f) Stimulants → amphetamines, cocaine, nicotine g) Psychotropics → PCP, marijuana 3. Frequently missed diagnosis a) Present late for prenatal care b) Challenges for clinicians c) May not voluntarily disclose addiction d) See Table 17–2: Possible Signs of Substance Abuse, p. 367 (1) History (a) Vague, unusual medical complaints (b) Family history of alcoholism, other addiction (c) History of childhood physical, sexual, emotional abuse (d) History of cirrhosis, pancreatitis, hepatitis, gastritis, sexually transmitted infections, unusual infections such as cellulitis, endocarditis

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(e) History of high-risk sexual behavior (f) Psychiatric history of treatment and/or hospitalization (2) Physical signs (a) Dilated or constricted pupils (b) Inflamed nasal mucosa (c) Evidence of needle “track marks” or abscesses (d) Poor nutritional status (e) Slurred speech or staggering gait (f) Odor of alcohol on breath (3) Behavioral signs (a) Memory lapses, mood swings, hallucinations (b) Pattern of frequently missed appointments (c) Frequent accidents, falls (d) Signs of depression, agitation, euphoria (e) Suicidal gestures

B. Alcohol 1. Central nervous system depressant and potent teratogen 2. 9.4% of pregnant women ages 15–44 reported using alcohol in past month, 2.3% reported binge drinking 3. Chronic abuse → undermines maternal health 4. Effects on fetus → fetal alcohol spectrum disorders (FASDs) a) Characteristic physical and mental abnormalities b) Expectant woman should avoid alcohol completely c) Nursing staff should be aware of manifestations of alcohol abuse → prepare for patient’s needs (1) Sedation with benzodiazepines (2) Seizure precautions (3) Intravenous (IV) fluid therapy for hydration (4) Thiamine replacement (5) Preparation for addicted newborn d) Breastfeeding not contraindicated (1) Alcohol secreted in breast milk

C. Cocaine/Crack 1. Acts on the nerve terminals to prevent reuptake of dopamine and norepinephrine 2. Results in vasoconstriction, tachycardia, and hypertension 3. Ingested three ways: snorting, smoking, IV injection a) Crack → freebase cocaine made of baking soda, water, cocaine paste → microwaved to form rock → smoked

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b) Quicker, more intense high c) More often seen in low-income areas, cheaper and more readily available form d) Euphoria lasts only about 30 minutes e) Irritability, depression, pessimism, fatigue, and a strong desire for more cocaine usually follow this profound euphoria and excitement 4. Difficult to identify cocaine user prenatally a) Subtle signs (including mood swings and appetite changes, and withdrawal symptoms such as depression, irritability, nausea, lack of motivation, and psychomotor changes) b) Adverse maternal effects (1) Seizures, hallucinations (2) Pulmonary edema (3) Respiratory failure (4) Cardiac problems 5. Increased incidence a) First trimester abortion b) Abruptio placentae c) Intrauterine growth restriction (IUGR) d) Preterm birth e) Stillbirth 6. Exposure of fetus to cocaine a) Intrauterine growth restriction (IUGR) b) Microcephaly c) Altered brain development d) Shorter body length e) Congenital anomalies f) Neurobehavioral abnormalities g) Exposed infants found to have more feeding difficulties 7. Newborns exposed a) Neurobehavioral disturbances b) Marked irritability c) Exaggerated startle reflex d) Labile emotions e) Increased risk of sudden infant death syndrome 8. Feeding a) Cocaine crosses into breast milk b) Cocaine-using mothers were found to be less flexible, less engaged, and less responsive to their babies’ feeding cues

D. Marijuana 1. Link to childhood outcome unclear a) linked to lower birth weights 14 Copyright © 2020 Pearson Education, Inc.

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b) smoking of any type—be it tobacco or marijuana— poses a risk during pregnancy and is best avoided

E. MDMA (Ecstasy) 1. “Club drugs” a) MDMA, Molly b) Flunitrazepam (Rohypnol) c) Gamma hydroxybutyrate (GHB) d) Ketamine hydrochloride e) Sometimes include phencyclidine (PCP) and lysergic acid diethylamide (LSD) 2. Adverse responses unpredictable a) Taken by mouth, effects last for about 3–6 hours b) Euphoria, feelings of empathy (“hug drug”) c) Clouded thinking, agitation, disturbed behavior, sweating, dry mouth, increased heart rate, muscle spasms, jaw clenching, hyperthermia d) Multiple doses (“stacking”) → hyperthermia, hyponatremia, hypertension, arrhythmias, kidney failure 3. Effects on fetus → preliminary research a) Delay on motor development at 4 months to 2 years of age

F. Prescription Opioids and Heroin 1. Opioid use disorder (OUD) increased dramatically in recent years, 0.9% of pregnant women between the ages of 15 and 44 misused opioids in the past month a) Includes prescribed medications and illicit substances like heroin 2. Central nervous system (CNS) depressant narcotic; addictive drug 3. Oral, IV, sniffed, smoked 4. Risks in pregnancy a) Preeclampsia-eclampsia b) Abnormal placenta implantation c) Premature rupture of membranes (PROM) d) Abruptio placentae e) Preterm labor f) Meconium staining 5. Fetal effects a) Preterm birth b) IUGR c) Withdrawal d) Meconium aspiration e) Fetal distress

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6. Heroin a) Illicit opioid b) Addictive c) Pregnancy if user high risk because of associated poor nutrition, iron deficiency anemia, and preeclampsia-eclampsia d) Users higher risk of STIs, HIV e) Fetus of woman addicted to heroin (1) Risk for preterm birth, IUGR, and withdrawal symptoms (NAS) after birth (2) NAS (a) Restlessness; lack of habituation; shrill, high-pitched cry; irritability; fist sucking; vomiting; seizures (b) Signs of withdrawal usually appear within 72 hours and may last for several days (3) Can interfere with successful maternal-newborn attachment (4) Increase risk for parenting problems or abuse 7. Methadone as treatment for prescription and illicit drug use a) Blocks withdrawal symptoms and the craving b) Dosage should be individualized to achieve the most therapeutic level for the mother during pregnancy c) Crosses placenta, can lead to NAS d) Buprenorphine (1) May decrease severity of NAS (2) Newborns require less morphine and have a shorter hospital stay than babies born to mothers on methadone therapy

G. Clinical Therapy 1. Hospitalization for withdrawal, detoxification a) “Cold turkey” not recommended in pregnant women 2. Urine screening done regularly if woman suspected of abusing drugs 3. Informed consent before screening a) Review state laws

H. Nursing Management for the Pregnant Woman with Substance Abuse Disorders 1. Nursing Assessment and Diagnosis a) Screen all pregnant women for substance abuse (1) Screening tools (2) Clues in history, appearance (3) Direct questions (4) Focus on general health (5) Nutrition (6) Susceptibility to infections (7) Evaluation of body systems b) Diagnoses 16 Copyright © 2020 Pearson Education, Inc.

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(1) Nutrition, Imbalanced: Less Than Body Requirements (2) Infection, Risk for (3) Health Maintenance, Ineffective c) Nursing Plan and Implementation (1) Prevention ideal goal → education (2) Ongoing assessment, teaching (a) Provide care that is truly effective (b) Maintain a nonjudgmental, nonpunitive, positive attitude when caring (3) Review with woman what screen revealed → express concern for woman, unborn child (a) If possible, discuss strategies to help the woman quit (b) Suggest a referral for more in-depth assessment by a specialist (c) If feasible, make an appointment while the woman is in the office or clinic (d) Treatment options available for women who lack financial resources (e) Make a follow-up appointment to see the woman again after her drug or alcohol assessment (f) Establish a relationship of trust and support → woman’s cooperation may be gained (4) Preparation for labor and birth (5) Postpartum follow-up and referral (a) May include home visits (b) Coordinate community resources d) Evaluation (1) Woman able to describe impact of substance abuse on self and unborn child (2) Woman successfully gives birth to healthy infant (3) Woman agrees to cooperate with referral to social services for follow-up

IV.

Care of the Woman with a Psychologic Disorder A. Roughly 17.9% adults in United States 1. Characterized by alterations in thinking, mood, behavior

B. Maternal implications 1. Depression a) 1:7 women have perinatal depressive episode during pregnancy or 12 months postpartum (1) May be more likely to deliver preterm birth, small-for-gestational-age (SGA) infant, low-birth-weight (LBW) infant (2) Reduce woman’s ability to concentration or process information (3) Labor process may feel overwhelming b) Bipolar disorder → depressive, manic episodes (1) Depressive and manic episodes (2) Behaviors dangerous to herself or her fetus 17 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Hyperexcitable (4) May exhibit poor judgment c) Anxiety disorder (1) Panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD) (2) Wide range of symptoms d) Schizophrenia (1) Most disabling of psychologic disorders (2) Uncontrolled → difficulty managing emotions, interacting with healthcare team, thinking clearly (3) May be dramatically inappropriate, withdrawn (4) Difficult to treat schizophrenia in pregnant women because many of the medications are teratogenic, contraindicated (a) Risk for medication-related congenital malformations (5) Antipsychotics can cause cardiovascular defects

C. Clinical therapy 1. Support to a) Decrease anxiety b) Keep woman oriented to reality c) Promote optimal functioning while in labor d) Pharmacologic measures (1) Sedatives (2) Analgesics (3) Antianxiety medications (4) Determined on an individual basis following careful assessment 2. Nursing Management for the Pregnant Woman with a Psychologic Disorder a) Nursing Assessment and Diagnosis (1) Assess background (2) Knowledge of labor process (3) History of psychologic disorders (4) Alert for verbal, nonverbal responses to pain, anxiety (5) Recognize impact of fatigue, pain, or anxiety (6) Nursing diagnoses include (a) Anxiety (b) Fear (c) Coping, Ineffective b) Planning and implementation (1) Ensure environment free from excessive stimuli (2) Maintain consistency in care providers as possible (3) Encourage woman to identify, use coping mechanisms that work well for her (4) Identify, reduce source of distress if possible (5) Acknowledge fears, pain, other symptoms 18 Copyright © 2020 Pearson Education, Inc.

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(6) Repeatedly orient woman to person, place, time (7) Offer methods to promote relaxation, comfort (8) Provide clear, succinct information about labor, medical procedures, environment, simple breathing exercises, relaxation techniques (9) Employ calm, caring, confident, nonjudgmental approach (10) Provide frequent attention and therapeutic interaction (11) May continue to have symptoms → medication, support c) Evaluation (1) Woman experiences decrease in physiologic, psychologic stress and increase in physiologic and psychologic comfort (2) Woman remains oriented to person, place, time (3) Woman uses effective coping mechanisms to manage her stress, anxiety in labor (4) Woman verbalizes feelings about her labor (5) Woman’s and family’s fear is decreased

V.

Care of the Woman with HIV A. AIDS caused by human immunodeficiency virus (HIV) 1. Estimated 973,846 persons in United States living with HIV/AIDS in 2016 2. Estimated 2322 children < 13 years of age→ majority exposed perinatally 3. Pediatric cases declining → Centers for Disease Control (CDC) guidelines a) Universal counseling about risks of HIV transmission from mother to fetus b) Recommended opt-out HIV screening of all pregnant women during each pregnancy c) Repeat HIV testing in third trimester in areas with high HIV prevalence rates (1) HIV-negative individuals with high-risk behaviors (2) Individuals with unknown HIV status at the time of labor d) Immediate antiretroviral prophylaxis for HIV-positive pregnant women in labor and infants following birth

B. Pathophysiology of HIV/AIDS 1. Found in blood, semen, and vaginal fluid; breast milk implicated in disease transmission 2. Once infected with virus → develops detectable antibodies

C. Maternal Risks 1. Antiretroviral therapy (ART) increases life expectancy 2. Priorities a) Maintaining the health of the mother before, during, and after the pregnancy b) Preventing transmission to a potentially seronegative father c) Preventing mother-to-child transmission

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3. Women who have not had access to ART, noncompliant → AIDS-defining symptoms more common

D. Fetal-Neonatal Risks 1. HIV transmission can occur during pregnancy, breast milk 2. Majority of infections occur during labor and birth 3. HIV infected pregnant women → prophylactic ART, elective cesarean at 38 weeks before rupture of membranes, no breastfeeding → rate of transmission drops to 1% or less

E. Clinical Therapy 1. Treatment of the HIV-infected mother a) CDC screening guidelines → routine part of all prenatal care b) Initial testing c) Enzyme-linked immunosorbent assay (ELISA) (1) Confirmed with the Western blot test or immunofluorescence assay (IFA) d) Informed reproductive choice e) cART recommended to all infected pregnant women → reduce rate of perinatal transmission (1) Combination ART (a) Contains at least three drugs (b) Consistent with the principles of treatment for nonpregnant adults (2) ARV regimens include dual nucleoside reverse transcriptase inhibitor (NRTI) backbone that includes one or more NRTIs with high levels of transplacental passage (zidovudine, lamivudine, emtricitabine, tenofovir, or abacavir) f) Evaluate and treat for other STIs, common conditions occurring with HIV g) Assess regularly for serologic changes h) Monitor for early signs of complications (1) Weight loss (2) Fever i) Considered high-risk pregnancy (1) Increased risk for preterm birth, IUGR (2) Weekly NST after 32 weeks (3) Serial ultrasounds (4) Biophysical profiles (5) Invasive procedures avoided j) Scheduled cesarean birth indicated for women with HIV RNA levels >1000 copies/mL, and unknown levels k) Intrapartum care similar to that for all pregnant women (1) Strict universal precautions l) At risk for complications (1) Postpartum infection (2) Poor wound healing 20 Copyright © 2020 Pearson Education, Inc.

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(3) Infections of genitourinary tract m) Referred to physician knowledgeable about treating individuals with HIV infection

F. Nursing Management for the Pregnant Woman Who Is HIV Positive 1. Nursing Assessment and Diagnosis a) Woman who tests positive for HIV may be asymptomatic or present with symptoms (1) Fatigue, anemia, malaise, progressive weight loss, lymphadenopathy, night sweats, diarrhea, fever, neurologic dysfunction, cell-mediated immunodeficiency, and evidence of Kaposi sarcoma b) Tests positive or in relationship/activity that places her at high risk → assess knowledge level c) Nursing diagnoses include (1) Knowledge, Readiness for Enhanced (2) Infection, Risk for (3) Family Processes, Interrupted d) Nursing Plan and Implementation (1) Community-based nursing care (a) Help women understand that AIDS can be treatable disease (b) Education for women at risk (c) Discuss HIV testing during normal prenatal assessment (i) No testing without her knowledge, no written consent required (d) Nurse should assure woman of confidentiality (e) Nurse should provide environment that is private, comfortable, nonjudgmental (f) Nurse should provide woman with information about HIV/AIDS (g) Posttest counseling should be provided (h) If test results positive, offer supportive follow-up (i) Woman should not donate blood or share implements that could be contaminated with blood (j) Information can be overwhelming for woman who is HIV positive (i) Orally and in writing (k) Monitoring of asymptomatic HIV-positive pregnant woman (i) Explain HIV positive does not mean has AIDS (l) Education about nutrition, maintenance of wellness (2) Hospital-based nursing care (a) See Nursing Care Plan: The Woman with HIV Infection, p. 376 (b) Precautions with all patients → standard precautions e) Health promotion education (1) Psychologic implications of HIV/AIDS for childbearing family is staggering (a) May have decreased life expectancy (b) Provide complete, accurate information (2) Couple must deal with the impact of the illness on the partner (3) Comprehensive program: social services, psychologic support, appropriate health care

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f) Evaluation (1) Woman discusses implications of her positive HIV-antibody screen (2) Woman uses information about referral to social services for follow-up assistance, counseling (3) Woman begins to verbalize her feelings about her condition, implications

VI.

Care of the Woman with Heart Disease

A. Healthy woman with normal heart has adequate cardiac reserve for easy adjustment to pregnancy demands B. Cardiovascular diseases were the leading cause of pregnancy-related deaths in the United States from 2011 to 2013 (15.5%), followed by noncardiovascular diseases (14.5%), infection or sepsis (12.7%), hemorrhage (11.4%), and cardiomyopathy (11.0%) C. Congenital Heart Defects 1. More common finding in pregnant women a) Seen are tetralogy of Fallot, atrial septal defect, ventricular septal defect, patent ductus arteriosus, and coarctation of the aorta 2. Exact pathology depends on specific defect

D. Rheumatic Heart Disease 1. Declined rapidly in last four decades 2. Develops in untreated streptococcal infections a) When heart affected → mitral valve stenosis, aortic insufficiency 3. Increased blood volume of pregnancy → stresses heart of woman with mitral valve stenosis

E. Mitral Valve Prolapse 1. MVP → usually asymptomatic condition commonly found in women of childbearing age 2. Midsystolic click and a late systolic murmur are heard 3. Women with MVP usually tolerate pregnancy well 4. Some women experience symptoms a) Palpitations, chest pain, dyspnea, which are usually due to arrhythmias

F. Marfan Syndrome 1. Autosomal dominant disorder of connective tissue a) Serious cardiovascular involvement → dissection or rupture of aorta

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b) Women with aortic roots greater than 40 mm → delay pregnancy until after repair or root replacement c) Aortic root less than 40 mm → better outcomes in pregnancy 2. Careful cardiovascular assessment, counseling → prognosis for pregnancy 3. 50% chance disease will be passed to offspring

G. Peripartum Cardiomyopathy 1. Dysfunction of left ventricle occurs in last month of pregnancy, first 5 months postpartum a) Rare but serious b) Mortality rate is as high as 25 to 50% c) Symptoms related to CHF (1) Dyspnea, orthopnea, chest pain, palpitations, weakness, edema d) Cause unknown e) Presentation → with anemia, infection f) Treatment → digitalis, diuretics, vasodilators, anticoagulants, sodium restriction, strict bedrest often part of treatment

H. Clinical Therapy 1. Primary goal is early diagnosis, ongoing treatment 2. Heart disease severity determined by functional capacity a) WHO-I → Low risk of maternal mortality and morbidity; limited cardiology follow-up required; includes conditions such as uncomplicated or mild pulmonary stenosis and successfully repaired simple lesions such as patent ductus arteriosus (PDA) b) WHO- II → Small increase in risk; includes conditions such as unoperated atrial septal defect (ASD), ventricular septal defect (VSD), repaired tetralogy of Fallot (TOF), and most arrhythmias c) WHO-III → Significantly increased risk requiring expert cardiac and obstetric care; includes conditions such as cyanotic heart disease, mechanical valves, systemic right ventricle, and other complex congenital heart disease d) WHO-IV → Very high risk of maternal mortality; pregnancy contraindicated; if pregnancy occurs, termination may be discussed; includes conditions such as pulmonary hypertension, severe mitral stenosis, severe symptomatic aortic stenosis, severe coarctation of the aorta e) Class I and II → normal pregnancy, few complications f) Class III and IV → at risk for more severe complications (1) Preconception counseling g) See Table 17–4: Severity of Heart Disease by Functional Category, p. 379 h) Anemia can increase work of heart → diagnose early i) Minimize cardiac workload, promote tissue perfusion 3. Drug therapy a) Additional drug therapy 23 Copyright © 2020 Pearson Education, Inc.

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b) Antibiotic prophylaxis not indicated unless infection suspected c) Heparin for anticoagulant therapy (1) Does not cross placenta d) Thiazide diuretics, furosemide for CHF e) Digitalis glycosides, common antiarrhythmic drugs (1) Cross placenta → no reported teratogenic effect 4. Labor and childbirth a) Classes I and II → spontaneous natural labor with adequate pain relief b) Classes III and IV → hospitalized before onset of labor → cardiovascular stabilization c) Vaginal birth with low-dose regional analgesia → forceps, vacuum assistance → limit maternal pushing

I. Nursing Management for the Pregnant Woman with Heart Disease 1. Nursing Assessment and Diagnosis a) Note category of functional capacity assigned to woman at each visit b) Vital signs c) Identify, evaluate other factors that increase strain on heart d) Symptoms indicative of CHF (1) Cough (2) Dyspnea (3) Edema (4) Heart murmurs (5) Palpitations (6) Rales e) Diagnoses include (1) Cardiac Output, Decreased (2) Gas Exchange, Impaired (3) Fear 2. Nursing Plan and Implementation a) Antepartum period (1) Varies according to severity of the disease (2) Woman should thoroughly understand condition, management (3) Explains purposes of dietary, activity changes (4) 8 to 10 hours of sleep and frequent daily rest periods are essential (5) Woman seen every 2 weeks during first half of pregnancy (a) Assessments are especially important between weeks 28 and 30 (6) Weekly during second half of pregnancy b) Intrapartum period (1) Labor, birth exert tremendous stress on woman, fetus (a) Fatal to fetus if inadequate oxygen, blood supply (2) Nurse evaluates maternal vital signs frequently

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(a) A pulse rate >100 beats per minute or respirations > 24 per minute may indicate beginning cardiac decompensation, especially if accompanied by dyspnea, and require further evaluation (3) Encourage laboring woman to assume semi-Fowler position with lateral tilt, or sidelying position with head, shoulders elevated → ensure cardiac emptying, adequate oxygenation (a) Oxygen by mask, diuretics to reduce fluid retention, sedatives and analgesics, prophylactic antibiotics, and digitalis may also be used as indicated by the woman’s status (4) Remain with woman for support (5) Continuous electronic fetal monitoring c) Postpartum period (1) Significant changes → strain on heart, decompensation possible (2) Woman may remain in hospital longer than low-risk woman (a) Keep her in the semi-Fowler or side-lying position, with her head and shoulders elevated, and have her begin a gradual, progressive activity program (3) Nurse gives opportunity to discuss birth, deal with feelings, concerns (a) Provide opportunities to encourage maternal-newborn bonding (4) Only concern with lactation → related to medication (a) Nurse positions baby (5) Stress follow-up (6) Plan activity schedule that is gradual progressive, appropriate (7) Teaching 3. Evaluation a) Woman able to discuss condition and impact b) Woman participates in developing appropriate healthcare regimen c) Woman gives birth to healthy baby d) Woman does not develop congestive heart failure, thromboembolism, or infection e) Woman able to identify signs, symptoms of possible postpartum complications f) Woman able to care effectively for newborn infant

VII.

Other Medical Conditions and Pregnancy

A. Woman with preexisting medical condition should be aware of impact of pregnancy on condition B. See Table 17–5: Less Common Medical Conditions and Pregnancy, p. 381 1. Asthma a) Poor control associated with increased complications b) Prematurity, LBW more common 2. Epilepsy a) Majority of pregnancies uneventful; continue with medication b) Certain medications associated with increased incidence of congenital anomalies 25 Copyright © 2020 Pearson Education, Inc.

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3. Hepatitis B a) Does not usually affect course of pregnancy b) Perinatal transmission most often occurs at, near childbirth (1) Infants infected perinatally highest risk of chronic infection if not treated 4. Hyperthyroidism (thyrotoxicosis) a) Mild hyperthyroidism not dangerous (1) Increased incidence of preeclampsia, postpartum hemorrhage if not controlled b) Neonatal thyrotoxicosis rare (1) Low doses of antithyroid drug may produce fetal/neonatal hypothyroidism 5. Hypothyroidism a) Long-term replacement therapy usually continues at same dosage during pregnancy b) Mother untreated → fetal loss high 6. Maternal phenylketonuria (PKU) (hyperphenylalaninemia) a) Low phenylalanine diet mandatory before conception, during pregnancy b) Risk if maternal treatment not begun preconception 7. Multiple sclerosis (MS) a) Relapse rate reduced during second, third trimester → increased during 3 months following birth b) Some evidence for slightly lower birth weight infants, genetic predisposition 8. Rheumatoid arthritis (RA) a) Usually remission during pregnancy with relapse postpartum (1) Extra rest b) Woman taking prednisone during pregnancy → give birth slightly earlier 9. Systemic lupus erythematosus (SLE) a) Active management with surveillance of blood pressure, proteinuria, placental blood flow b) Increased incidence of caesarean birth, postpartum hemorrhage, blood transfusion, prematurity, smaller babies, congenital heart block 10. Tuberculosis (TB) a) Complications may be higher (1) Treat with isoniazid, rifampin, ethambutol b) Maternal TB inactive → mother may breastfeed, care for infant (1) TB active → newborn should not have direct contact with mother until noninfectious

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VIII.

Focus Your Study

IX.

Activities 1. Individual Have students prepare a teaching plan for injecting insulin for the pregnant woman who is newly diagnosed with gestational diabetes mellitus.

2. Small Group Divide the class into small groups of three to five students. Assign each group a medical condition covered in this chapter. Have each group prepare a teaching plan for the assigned medical condition, including diet, medication, and family teaching, and instruct the groups to cite resources for their research.

3. Large Group Facilitate a class discussion on pregnancy and sexually transmitted infections, including HIV/AIDS and tuberculosis. Be sure to include the social stigma of these medical conditions and the emotional issues facing the pregnant family. Invite the class to role-play for possible scenarios during assessment, teaching sessions, and diagnosis discussions.

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Chapter 18 Pregnancy at Risk: Gestational Onset Care of the Woman at Risk Because of Bleeding During Pregnancy.....................

2

Care of the Woman with Hyperemesis Gravidarum..............................................

8

Care of the Woman with a Hypertensive Disorder................................................

9

Care of the Woman with a Perinatal Infection Affecting the Fetus……………………

18

Care of the Woman Requiring Surgery During Pregnancy....................................

24

Care of the Woman Suffering Major Trauma ……………………………………………………

25

Care of the Pregnant Woman Experiencing Intimate Partner Violence………………

26

Care of the Woman at Risk for Rh Alloimmunization…………………………………………

27

Care of the Woman at Risk Due to ABO Incompatibility…………………………………….

30

Focus Your Study.....................................................................................................

30

Activities..................................................................................................................

30

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I.

Care of the Woman at Risk Because of Bleeding During Pregnancy

A. First and second trimesters 1. Abortion → pregnancy termination or loss prior to 20 weeks’ gestation or fetus weighing <500 g 2. Complications a) Bleeding in the first half of pregnancy (up to 20 weeks’ gestation) b) Ectopic pregnancy, gestational trophoblastic disease, and trauma c) Second half of pregnancy, particularly in the third trimester d) Placenta previa, abruptio placentae, trauma 3. See Table 18–1: Pregnancy-Related Bleeding by Trimester, p. 387

B. General Principles of Nursing Intervention 1. Vaginal bleeding relatively common during pregnancy a) Causes 2. Often nurse’s responsibility to make initial assessment a) Monitor blood pressure and pulse frequently b) Observe for indications of shock c) Count and weigh pads d) If pregnancy at 12 weeks or more → assess fetal heart tones with Doppler e) Prepare for intravenous (IV) therapy f) Obtain order to type and cross-match for blood g) Obtain an order for an obstetric ultrasound h) Prepare equipment for examination i) Have oxygen therapy available j) Collect and organize all data k) Assess coping mechanisms and support system of woman in crisis l) Assess family’s response to situation

C. Spontaneous Abortion (Miscarriage) 1. Describe both spontaneous and elective interruptions of a pregnancy 2. Many pregnancies end in first trimester (11 to 22%) a) Vaginal bleeding most common sign b) More than half related to chromosomal abnormalities c) Other causes d) Pathophysiology differs according to cause e) Spontaneous abortion can be extremely distressing (1) Chances for carrying next pregnancy to term still good (2) Following two to three consecutive losses → evaluate, candidates for genetic counseling 2 Copyright © 2020 Pearson Education, Inc.

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3. Classification (see Table 18–2: Classification of Abortions and Defining Characteristics, p.

388) a) Clinically silent abortion, “silent miscarriage,” chemical pregnancy b) Early abortion c) Late abortion d) Elective abortion e) Therapeutic abortion (TAB) f) Spontaneous abortion g) Threatened abortion h) Inevitable or imminent abortion i) Complete abortion j) Incomplete abortion k) Missed abortion l) Empty sac (preferred term), anembryonic pregnancy, blighted ovum m) Recurrent pregnancy loss (RPL), formerly called habitual abortion n) Septic abortion 4. Clinical therapy a) Indicators (1) Pelvic cramping and backache (2) Vaginal bleeding occurs in one-quarter of first trimester pregnancies (a) Approximately half → miscarriage b) Evaluations (1) Speculum examination (2) Ultrasound scanning (3) Laboratory determination of hCG level c) Therapy prescribed (1) Bedrest (2) Abstinence from coitus (3) Persistent bleeding → hospitalization (a) IV therapy or blood transfusions (b) Dilation and curettage (D&C) or suction evacuation of products of conception (c) Rh negative → Rh immune globulin within 72 hours

D. Nursing Management for the Woman Experiencing Spontaneous Abortion 1. Nursing Assessment and Diagnosis a) Assessment (1) Amount, appearance of vaginal bleeding, vital signs, pain (2) Blood type, antibody status (3) Fetal heart rate (FHR) if 10 to 12 weeks’ gestation or more b) Diagnoses include (1) Childbearing Process, Ineffective (2) Fear (3) Fluid Volume: Risk for Deficient 3 Copyright © 2020 Pearson Education, Inc.

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2. Nursing plan and implementation a) Community-based nursing care (1) Evaluate as outpatient (2) Emotional support (3) Woman may feel ambivalence → guilt (4) Psychologic support → encourage verbalizing feelings (5) Referrals to help deal with loss (6) Physical pain may be more severe than couple anticipates b) Hospital-based nursing care (1) Suction D&C for incomplete or missed abortion (2) Rh immune globulin before discharge (3) Monitor physical status (4) Emotional support (5) Answer questions c) Health promotion education (1) Post D&C instructions (a) Someone should remain with her for first 12-24 hours (2) Referrals d) Evaluation (1) Woman able to explain spontaneous abortion, treatment measures, long-term implications (2) Woman suffers no complications (3) Woman and partner begin verbalizing grief

E. Pregnancy of Unknown Location 1. Pregnancy of unknown location (PUL) a) when a pregnant woman undergoes an ultrasound without a definitive finding of either an intrauterine pregnancy or an ectopic pregnancy b) Not a diagnosis, but is an interim finding (1) Every effort needs made to determine correct diagnosis

F. Ectopic Pregnancy 1. Implantation of fertilized ovum in site other than endometrial lining of uterus a) Ectopic pregnancy (EP), also called extrauterine pregnancy or tubal pregnancy b) Risk factors (1) Tubal damage caused by pelvic inflammatory disease (PID) from a sexually transmitted infection or mixed bacterial infection; previous pelvic or tubal surgery; endometriosis; previous ectopic pregnancy; presence of an intrauterine device (IUD); high levels of progesterone, which can alter the motility of the egg in the fallopian tube; congenital anomalies of the tube; use of ovulation-inducing drugs; primary infertility; smoking; advanced maternal age c) Symptoms (1) Begin between 6 and 8 weeks’ gestational age (after the last menstrual period) 4 Copyright © 2020 Pearson Education, Inc.

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(2) 0.5 to 1.5% of pregnancies in US (3) Accounts for 3% of all pregnancy-related deaths d) Pathogenesis (1) See Figure 18–2: Various implantation sites in ectopic pregnancy, p. 391 (2) Normal symptoms of pregnancy may be present (3) Trophoblastic cells grow into adjacent tissues (4) Symptoms may not be obvious e) Internal hemorrhage (1) When embryo outgrows space → tube ruptures; bleeding into abdominal cavity (a) One-sided lower abdominal pain or diffuse lower abdominal pain and vasomotor disturbances such as fainting or dizziness (2) Slow → abdomen gradually rigid, tender (a) Adnexal tenderness or mass (3) Laboratory tests (a) β-hCG levels that do not rise as expected 2. Clinical therapy a) Differentiate from other disorders (1) Careful assessment of menstrual history, last menstrual period (LMP) (2) Careful pelvic exam → masses, tenderness (3) Laboratory testing (4) Transvaginal ultrasound (5) Serial measurements of serum hCG (6) Laparoscopy b) Confirmed (1) Therapy options (a) Medical management with methotrexate (i) Administered intramuscularly (IM), single dose, two dose, or multiple dose (ii) Monitor as outpatient for pain, hCG titers (b) Surgery (i) Preservation of tube if future pregnancy desired, tube not ruptured (ii) Assess risk for bleeding 3. Nursing Management for the Woman with an Ectopic Pregnancy a) Nursing Assessment and Diagnosis (1) Assess (a) Vaginal bleeding, vital signs (b) Emotional status, coping abilities (2) Diagnoses include (a) Childbearing Process, Ineffective (b) Fear (c) Pain, Acute (d) Fluid Volume: Risk for Deficient b) Nursing Plan and Implementation (1) Community-based nursing care 5 Copyright © 2020 Pearson Education, Inc.

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(a) Clinic office → alert to possibility if presents with abdominal pain, lack of menses for 1 to 2 months (b) Confirmed ectopic → methotrexate → education (i) Follow-up β-hCG testing (ii) Follow-up phone call between visits (iii) Nausea expected (iv) Severe pain → follow up warranted, treatment may have failed (2) Hospital-based nursing care (a) Surgery (i) IV, preoperative teaching (ii) Analgesics (3) Health promotion (a) Teaching (b) Emotional support c) Evaluation (1) Woman able to explain ectopic pregnancy, treatment alternatives, implications (2) Woman and caregivers detect possible complications early, manage appropriately (3) Woman and partner able to begin verbalizing loss

G. Gestational Trophoblastic Disease 1. Pathologic proliferation of trophoblastic cells a) Hydatidiform mole (molar pregnancy) (1) Proliferation of trophoblastic cells results in formation of an abnormal placenta characterized by hydropic grapelike clusters (a) Loss of pregnancy (b) Possibility of developing choriocarcinoma (c) Complete mole→ anuclear ovum that contains no maternal genetic material (i) Avascular hydropic vesicles (d) Partial mole → usually triploid karyotype (69 chromosomes) (i) Villi often vascularized (ii) Identifiable fetal parts may be present (2) 1 per 1000 to 1500 live births (3) Invasive mole → chorioadenoma destruens → involves uterine myometrium (4) Choriocarcinoma → invasive, malignant, trophoblastic disease, usually metastatic, can be fatal 2. Clinical therapy a) Signs (1) Vaginal bleeding (around fourth week)→ brownish to bright red (2) Anemia (3) Hydropic vesicles may be passed → diagnostic (4) Uterine enlargement greater than expected for gestational age (5) Absence of fetal heart sounds in presence of other signs of pregnancy (6) Markedly elevated serum hCG 6 Copyright © 2020 Pearson Education, Inc.

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(7) Very low levels of maternal serum α-fetoprotein (MSAFP) (8) Hyperemesis gravidarum may occur (9) Preeclampsia may be seen, especially in second trimester b) Diagnosis (1) Transvaginal ultrasound c) Therapy (1) Suction evacuation and curettage of uterus (2) Early evacuation decreases complications (3) Rh immune globulin if mother Rh negative d) Complications (1) Anemia (2) Hyperthyroidism (3) Infection (4) Disseminated intravascular coagulation (DIC) (5) Trophoblastic embolization of lung (6) Ovarian cysts e) Risk of choriocarcinoma (1) Extensive follow-up care (2) Baseline chest X-ray and repeat (3) Weekly β-hCG until negative three times, monthly for 6 to 12 months (4) If hCG plateaus or rises or metastases detected; treat appropriately 3. Nursing Management for the Woman with Gestational Trophoblastic Disease a) Nursing Assessment and Diagnosis (1) Observe for symptoms at each antepartum visit (a) Monitor vital signs, vaginal bleeding (b) Assess pain (c) Assess emotional state (2) Diagnoses include (a) Childbearing Process, Ineffective (b) Fear (c) Knowledge, Readiness for Enhanced b) Nursing Plan and Implementation (1) Community-based nursing care (a) Emotional support (b) Education (2) Hospital-based nursing care (a) Education (b) Type and cross-match blood (c) Oxytocin (d) Monitor urine output; signs of bleeding, infection (e) Rh immune globulin if Rh negative (3) Health promotion education (a) Woman needs to know importance of follow-up visits for 1 year 7 Copyright © 2020 Pearson Education, Inc.

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(b) Delay becoming pregnant for 1 year c) Evaluation (1) Woman has smooth recovery following successful evacuation of molar pregnancy (2) Woman able to explain GTD (3) Woman and partner able to begin verbalizing grief (4) Woman able to discuss importance of follow-up

II.

Care of the Woman with Hyperemesis Gravidarum

A. Nausea and vomiting so severe → affects hydration, nutritional status 1. Temporarily disabling a) Psychologic impact b) Nulliparous, adolescents, multiple gestation, increased body weight, certain ethnic groups, pregnancies complicated by GTD or fetal abnormalities, mother or sister experienced hyperemesis, woman’s history of hyperemesis 2. Cause unclear a) hCG may play a role b) Other potential factors: displacement of the gastrointestinal tract, hypofunction of the anterior pituitary gland and adrenal cortex, abnormalities of the corpus luteum, psychologic factors 3. Pathology begins with dehydration a) Hypovolemia b) Fluid-electrolyte imbalance

B. Diagnostic criteria 1. Intractable vomiting, dehydration, ketonuria, weight loss of 5% of pregnancy weight

C. Clinical Therapy 1. Control vomiting, correct dehydration, restore electrolyte balance, maintain nutrition a) Avoid triggers b) Frequent small meals c) Carbonated or sour beverages d) Ginger e) Acupuncture or acupressure f) Hypnosis g) Pyridoxine first-line pharmacologic treatment (1) 10 to 25 mg orally three times daily, 25 mg at bedtime (2) Diclegis, Promethazine (Phenergan), metoclopramide (Reglan), ondansetron (Zofran) h) IV fluids as outpatient i) See Complementary Health Approaches: Hyperemesis, p. 395

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2. Diagnosis a) Ultrasound to rule out molar pregnancy 3. Nothing by mouth, IV fluids 4. Total parenteral nutrition if no response to above management a) Start oral feeding when condition improved

D. Nursing Management for the Woman with Hyperemesis Gravidarum 1. Nursing Assessment and Diagnosis a) Assess (1) Emesis (2) Intake and output (3) Fetal heart rate (4) Maternal vital signs (5) Initial weight (6) Evidence of jaundice or bleeding (7) Emotional state b) Diagnoses include (1) Nutrition, Imbalanced: Less Than Body Requirements (2) Fluid Volume: Deficient 2. Nursing Plan and Implementation a) Community-based nursing care (1) Evaluate family and lifestyle stressors (2) Discuss strategies b) Hospital-based nursing care (1) Supportive, directed at maintaining relaxed, quiet environment (2) Oral hygiene (3) Monitor weight (4) Psychotherapy c) Health promotion education (1) Review actions to prevent, decrease nausea 3. Evaluation a) Woman able to explain hyperemesis gravidarum b) Woman’s condition corrected, complications avoided

III.

Care of the Woman with a Hypertensive Disorder

A. Most common medical disorder in pregnancy (10%) B. Classifications (see Table 18–3: Hypertensive Disorders in Pregnancy, p. 397) 1. Preeclampsia and Eclampsia Syndrome a) Preeclampsia → 5% of all pregnancies in United States

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(1) Syndrome that affects both mother and fetus (2) Increase in blood pressure after 20 weeks’ gestation accompanied by proteinuria in a previously normotensive woman b) Eclampsia → occurrence of a seizure in a woman with preeclampsia with no other cause for seizure 2. Pathophysiology of preeclampsia a) Eclampsia syndrome b) Impaired trophoblastic invasion and/or poor implantation (1) Abnormal immunologic response to paternal antigens (2) Imbalance in angiogenesis; an exaggerated systemic inflammatory response (3) Increased oxidative stress (4) Vascular endothelial dysfunction and coagulation abnormalities (5) Genetic propensity for the development of preeclampsia c) Key features (1) Failure of uterine spiral arteries to transform from thick-walled muscular vessels to saclike flaccid vessels (2) Loss of normal vasodilatation of uterine arterioles resulting in decreased placental perfusion (3) Systemic maternal vasospasm resulting in decreased perfusion to virtually all organs, including the placenta (Figure 18–5) (4) Decrease in plasma volume, activation of the coagulation cascade, and alterations in glomerular capillary endothelium (5) Increased sensitivity to pressor agents,imbalance between prostacyclin and thromboxane (6) Decreased NO production (7) Inappropriate endothelial-cell activation (8) Increased platelet activation can predate clinically evident disease (9) See Figure 18–5: Clinical manifestations and possible pathophysiology of preeclampsia-eclampsia, p. 399 (10) Women who develop preeclampsia more sensitive to pressor agents (a) Linked to ratio between prostaglandins (b) Prostacyclin-thromboxane (c) No effective intervention → low-dose aspirin results in modest risk reduction d) Risk factors e) First pregnancies (1) Adolescent pregnancies (2) Out-of-wedlock pregnancies (3) Conception with new partner (4) Paternal contribution (5) Other theories (a) Decreased renal perfusion associated with preeclampsia (i) Edema more profound than in normal pregnancy

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(a) Pathology→Higher salt retention draws out intravascular fluid→Plasma colloid osmotic pressure decreases → serum albumin loss 3. HELLP syndrome a) Hemolysis, elevated liver enzymes, low platelet count b) Associated with severe preeclampsia c) Usually manifests at 27–37 weeks’ gestation d) Hemolysis (1) Microangiopathic hemolytic anemia e) Blood flow obstructed in liver → hepatocellular injury→ hyperbilirubinemia and jaundice f) Symptoms (1) Nausea, vomiting, malaise, flulike symptoms, epigastric pain, swelling of liver (2) Misdiagnosis g) Require tertiary care center h) Maternal risks (1) Hypertensive disorders (2) Central nervous system (CNS) changes (3) Intracerebral hemorrhage rare → most common cause of death in women with severe preeclampsia and eclampsia (4) Acute tubular necrosis (5) Pulmonary edema (6) Thrombocytopenia (7) Subcapsular hematoma of liver rare (a) Rupture life-threatening event i) Fetal-neonatal risks (1) Small for gestational age (SGA) (2) Placental abruption (3) Prematurity (4) Oversedation due to medications used to treat j) Clinical manifestations and diagnosis k) Preeclampsia (1) After 20 weeks → blood pressure of 140 mm Hg systolic or 90 mm Hg diastolic (a) Two occasions 6 hours apart (2) Proteinuria generally between 300 mg/L (1+) and 1 g/L (2+) (a) 24-hour urine protein >300 mg abnormal (3) Edema (a) Puffy face, hands, dependent areas such as the ankles and lower legs (b) Weight gain of more than 4 lb in a week l) Preeclampsia with severe features (1) Can develop rapidly (2) Blood pressure of 160/110 mm Hg or higher on two occasions 4-6 hours apart while woman on bedrest (a) Oliguria <500 mL in 24 hours (3) Cerebral or visual disturbances 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(4) Pulmonary edema or cyanosis (5) Epigastric or right upper quadrant pain (6) Impaired liver function to at least twice normal (7) Thrombocytopenia (8) Intrauterine growth restrictions (9) Signs or symptoms (a) Severe headache (b) Blurred vision or scotomata (c) Narrow segments on retinal arterioles (d) Retinal edema (10) Dyspnea due to pulmonary edema (11) Pitting edema (12) Epigastric pain (13) Hyperreflexia (14) Nausea (15) Vomiting (16) Irritability (17) Emotional Tension (18) See Table 18–4: Signs and Symptoms of Worsening Preeclampsia, p. 401 m) Eclampsia (1) Convulsion or coma (2) Before onset of labor, during labor, early in postpartum period n) Clinical therapy (1) Goals are to prevent severe complications, birth of an uncompromised newborn as close to term as possible (2) Antepartum management (a) Cure = delivery of placenta (3) Home care of gestational hypertension and preeclampsia (a) Proteinuric preeclampsia → admitted to hospital (b) Management at home if: (i) BP ≤150/100 mm Hg, proteinuria less than 1 g/24 hours, platelet count greater than 120,000 mm3, normal fetal growth, no other complicating factors (ii) Must have understanding of condition (iii) Recognize signs, symptoms of worsening preeclampsia (iv) Be able to count fetal movements (c) Monitor blood pressure, weight, urine protein daily (d) Remote non-stress test on daily to biweekly basis (e) Nursing contact varies (f) Lab work o) Hospital care of gestation hypertension and preeclampsia (1) Bedrest, left lateral recumbent position (2) Diet well balanced and nutritious (3) Monitoring fetal well-being 12 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Fetal movement record (b) NST (c) Amniotic fluid index: normal is greater than 5 centimeters (d) Ultrasound at least every 2 to 4 weeks (e) Biophysical profile weekly (f) Amniocentesis to determine fetal lung maturity as necessary (g) Doppler velocimetry beginning 30 to 32 weeks (4) Monitoring maternal well-being (a) Blood pressure four times daily (b) Daily weight, evaluation for worsening edema, persistent headache, visual changes, epigastric pain (c) Daily urine dipstick for protein (d) Periodic assessment of laboratory values p) Hospital care of preeclampsia (1) Immediate hospitalization (2) Childbirth considered in all pregnant women who develop preeclampsia after 34 weeks’ gestation (3) Other therapies (a) Bedrest (b) Diet (c) Anticonvulsants (d) Corticosteroids (e) Fluid and electrolyte replacement (f) Antihypertensives (4) Therapeutic goal to maintain diastolic blood pressure between 90 and 100 mm Hg (a) Methyldopa → long-term control (b) Labetalol, hydralazine → IV bolus (i) Parenteral labetalol should be avoided in women with moderate to severe asthma, bradycardia, or congestive heart failure (c) Oral labetalol and nifedipine (d) Magnesium sulfate (e) Sodium nitroprusside in acute emergency q) Hospital care of eclampsia (1) Occurrence of either seizure of coma associated with pregnancy and not caused by other neurologic disease (2) Multifocal, focal, or generalized seizures (3) Nursing assessment includes (a) Time of onset (b) Progress of the seizure (c) Body involvement (d) Duration (e) Presence of incontinence (f) Status of the fetus (g) Signs of the placental abruption 13 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(h) Airway should be maintained (i) Oxygen administered during seizure (4) Treatment (a) Magnesium sulfate (i) Bolus of 4 to 6 g over 15 to 20 minutes in 100 ml of IV fluid (ii) 2 g/hour IV infusion (iii) Second seizure → additional bolus of 2 g (iv) Side effects (a) Loading dose: flushing, feeling of warmth, headache, nystagmus, nausea, dry mouth, dysphoria, dizziness (b) Lethargy, sluggishness, risk of pulmonary edema (v) Fetal side effects → hypotonia, lethargy, hypoglycemia, hypocalcemia (b) Antihypertensive agents (i) Used to keep diastolic blood pressure between 90 and 100 mm Hg (5) Fetal reaction to seizure → bradycardia, transient late decelerations, decreased variability, compensatory tachycardia (a) Stabilize mother → recover (b) If nonreassuring FHR for 10 to 15 minutes despite resuscitative efforts → consider birth (c) Nurse–patient ratio 1:1 (6) Nursing care (a) Frequent auscultation of maternal lungs (b) Watch for circulatory, renal failure and signs of cerebral hemorrhage (c) Administer meds as ordered (d) Indwelling catheter (e) May awaken confused, combative → family member (f) Environment (i) Avoid bright light, loud noises, and frequent disturbances (7) Uncontrolled hypertension → cerebral hemorrhage (a) Hydralazine, labetalol, nitroprusside r) Intrapartum management (1) Preeclampsia (a) Induction of labor by IV oxytocin (i) Cesarean birth if severe (b) Oxytocin and magnesium sulfate simultaneously (c) Narcotic for pain relief or regional anesthesia (d) Sims’ position for childbirth (i) Lithotomy with wedge under right buttock (e) Oxygen (2) Eclampsia (a) Intensive care unit until labor unless in tertiary care center (b) Invasive hemodynamic monitoring indications (i) Oliguria (ii) Severe cardiac disease 14 Copyright © 2020 Pearson Education, Inc.

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(iii) Severe renal disease (iv) Pulmonary edema resulting in impaired maternal oxygenation (v) Refractory hypertension with administration of vasoactive drug (c) Stabilize mother → consider birth of fetus (3) Pediatrician, neonatologist, neonatal nurse practitioner → available to care for newborn at birth s) Postpartum management (1) Usually improves rapidly after childbirth (2) Magnesium sulfate → continue for 24 hours (3) Possibility of worsening condition (4) Monitor for 4–6 weeks (5) Blood pressure remains above 160/100 mm Hg for 2 to 3 days → antihypertensive therapy (6) Hypertension remaining past the 84th day postpartum is classified as chronic hypertension (7) Risk of recurrence dependent on several factors 4. Nursing Management for the Woman with Preeclampsia a) Nursing Assessment and Diagnosis (1) Essential part of assessment → baseline blood pressure early in pregnancy (a) Taken, recorded each antepartum visit (b) Elevation based on two determinations (i) Seated, standing (c) Use Korotkoff phase V to measure diastolic (d) Calibrate mercury sphygmomanometer (e) If using electronic device, use one validated for pregnancy (2) Hospitalization → assessment (a) Blood pressure every 1 to 4 hours (b) Temperature every 4 hour (c) Pulse and respirations with BP (d) Fetal heart rate monitoring continuously (e) Urinary output should be 700 mL or greater in 24 hours, or at least 30 mL per hour (f) Urine protein hourly if catheter or with each void (g) Urine specific gravity: readings over 1.040 correlate with oliguria and proteinuria (h) Edema (i) Weight (j) Pulmonary edema (k) Deep tendon reflexes in the brachial, wrist, patellar, or Achilles tendons (Table 18–5, p. 405) (l) Clonus (m) Placental separation (n) Headache (o) Visual disturbance 15 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(p) Epigastric pain (q) Laboratory blood tests (i) Hematocrit, BUN, creatinine, uric acid, clotting studies, liver enzymes, electrolytes (r) Level of consciousness (s) Emotional response and level of understanding (t) Assess effects of medications (3) Diagnoses include (a) Fluid Volume: Risk for Imbalanced (b) Injury, Risk for (c) Maternal/Fetal Dyad, Risk for Disturbed b) Nursing Plan and Implementation (1) Community-based nursing care (a) Woman has several major concerns (i) Identify and discuss concerns (ii) Refer couple to resources (b) Health promotion education (i) Woman knows which symptoms are significant and should be reported (ii) Seen once or twice a week; come in earlier if with symptoms (iii) Understands diet plan (2) Hospital-based nursing care (a) Increased concern → worsening prognosis (i) Honest, hopeful information (b) Quiet low-stimulus environment (c) Nursing management of eclampsia (i) Frightening to family (ii) Tonic phase → turn to side, head turned face down (iii) Padded side rails (iv) Oxygen, oral airway (v) Physician, anesthesiologist notified (vi) Apply pulse ox and obtain IV access if not already done (vii) Monitor fetal heart tones continuously (viii) Monitor maternal vitals every 5 minutes until stable, then every 15 minutes (d) Nursing management during labor and birth (i) Plan of care depends on maternal and fetal condition (ii) Position on side as much as possible (iii) Monitor woman and fetus throughout labor (iv) Second stage → push on side or with wedge under hip (v) Family member with woman as is possible (e) Nursing management during the postpartum period (i) Monitor bleeding, pulse, urine output (ii) Blood pressure and pulse checked every 4 hours (iii) Lab work daily (a) Intake and output for 48 hours 16 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(iv) Monitor for postpartum depression (v) Combined oral contraceptives → progesterone-only pills c) Evaluation (1) Woman able to explain preeclampsia, implications, treatment, possible complications (2) Woman suffers no eclamptic seizures (3) Woman and caregivers detect signs of increasing severity of preeclampsia, complications (4) Woman gives birth to healthy newborn

C. Chronic Hypertension 1. Blood pressure 140/90 mm Hg or higher before pregnancy, before 20th week, persists 12 or more weeks following childbirth a) Challenge to differentiate hypertension from preeclampsia b) Early prenatal care important → risks to fetus 2. Counseling at first visit a) Nutrition b) Bedrest c) Medication (1) Methyldopa or labetalol first choice in pregnancy if medication required (2) Angiotensin-converting enzyme (ACE) inhibitors contraindicated during second and third trimesters d) Prenatal visits e) Blood pressure monitoring f) Fetal surveillance 3. First visit a) Thorough examination 4. More frequent prenatal visits a) 24-hour urine tests, serum creatinine, uric acid, hematocrit, ultrasound examinations at least once in second and third trimesters

D. Chronic Hypertension with Superimposed Preeclampsia 1. Preeclampsia develops in approximately 25% of women with chronic hypertension a) Difficult to diagnose b) After 20 weeks’ gestation, onset of proteinuria and worsening hypertension suggestive of superimposed preeclampsia

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E. Gestational Hypertension 1. Transient elevation of blood pressure without proteinuria, preeclampsia 2. Diagnosis- final determination that the woman has gestational hypertension is made retrospectively in the postpartum period

IV.

Care of the Woman with a Perinatal Infection Affecting the Fetus A. Perinatal infections are most likely to cause harm when embryo exposed during first trimester B. TORCH infections C. Toxoplasmosis 1. Protozoan Toxoplasma gondii (T. gondii) a) Feces of infected cat b) Eating raw or undercooked meat c) Drinking unpasteurized goat’s milk 2. Fetal-neonatal risks a) First-trimester infection → severe fetal damage → spontaneous abortion b) Highest rate of fetal infection (60%) → third trimester (1) Half of these infants will develop signs, symptoms if left untreated (2) Mild cases (3) Severe infection (4) Can cause chorioretinitis (inflammation of the retina and choroid layer of the eye), disseminated purpuric rash, hepatosplenomegaly, ascites, fever, seizures, periventricular calcifications, microcephaly, ventriculomegaly (5) Survivors are often blind, deaf, severely neurodevelopmentally impaired 3. Clinical therapy a) Goal of medical treatment → identify at-risk woman, treat promptly (1) Serologic testing IgM and IgG (2) Maternal infection established → spiramycin to decrease frequency of fetal transmission (3) Not treat fetal infection (a) Pyrimethamine/sulfadiazine/folinic acid after first trimester 4. Nursing Management for the Pregnant Woman with Toxoplasmosis a) Nursing Assessment and Diagnosis (1) Incubation 10 days (2) Asymptomatic or Symptoms myalgia, malaise, rash, splenomegaly, fever, headache, and enlarged posterior cervical lymph nodes (3) Diagnoses include (a) Knowledge, Readiness for Enhanced 18 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(b) Grieving b) Nursing Plan and Implementation (1) Education for prevention c) Evaluation (1) Woman able to discuss toxoplasmosis, transmission, implications, prevention (2) Woman implements health measure to avoid contracting toxoplasmosis (3) Woman gives birth to healthy newborn

D. Rubella 1. Mild illness in children, adults a) Infection in fetus → CRS → overwhelming consequences b) Immunize with live, attenuated virus c) Postpartum immunization 2. Fetal-neonatal risks a) Greatest risk during first trimester b) Maternal–fetal transmission 80% of cases c) Congenital cataracts, sensorineural deafness, congenital heart defects d) Intellectual disability, cerebral palsy e) Born with congenital rubella syndrome → infectious, isolated (1) Shed virus for up to 12 months 3. Clinical therapy a) Best therapy is prevention b) Live attenuated virus not given to pregnant women, vaccinate all children c) Recently vaccinated children safe to have contact with pregnant woman d) Pregnant woman becomes infected in first trimester → therapeutic abortion may be alternative 4. Nursing Management for the Pregnant Woman with Rubella a) Nursing Assessment and Diagnosis (1) Asymptomatic or mild infection (a) Titers (2) Diagnoses include (a) Coping, Ineffective (b) Health Maintenance, Ineffective b) Nursing Plan and Implementation (1) Support and understanding for couple contemplating abortion (2) Education c) Evaluation (1) Woman able to describe implications of rubella exposure during first trimester (2) If exposure occurs in woman not immune, able to identify options, make decision (3) Nonimmune woman receives rubella vaccine during early postpartum period (4) Woman gives birth to healthy infant

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E. Cytomegalovirus 1. CMV → belongs to herpes simples virus group → congenital and acquired disorders a) Found in urine, saliva, cervical mucus, semen, breast milk (1) Spread by close contact (2) Asymptomatic CMV common in children, gravid women (3) Cervix can harbor virus b) Accurate diagnosis → seroconversion c) Fetal diagnosis (1) Culture of amniotic fluid (2) Ultrasound findings may include fetal hydrops, growth restriction, hydramnios, cardiomegaly, fetal ascites d) No treatment for maternal CMV, congenital disease 2. Fetal-neonatal risks a) CMV most common viral infection in human fetus b) Congenital CMV leading cause of hearing loss in children c) Can result in extensive intrauterine tissue damage (1) Microcephaly, hydrocephaly, cerebral palsy, intellectual disability (2) Often small for gestational age (SGA) (3) No effective therapy exists

F. Herpes Simplex Virus 1. HSV-I or HSV-II 2. 1 in 6 ages 14–49 infected with genital herpes in United States 3. Fetal-neonatal risks a) Primary infection can increase risk of spontaneous abortion in first trimester b) Preterm labor (PTL), intrauterine growth restriction, neonatal infection c) Risk varies with route of birth, presence of lesion d) If HSV-I or HSV-II acquired close to time of labor → risk of transmission 30% to 50% for vaginal birth e) Exposure of newborn to recurrent lesion → risk of transmission 2% to 5% f) Outbreak during labor → preferred method of childbirth is cesarean g) Infected infant (1) Often asymptomatic at birth (2) Up to 4 weeks → symptoms (a) Vesicular skin lesions, respiratory distress, fever (or hypothermia), seizures, and poor feeding 4. Clinical therapy a) No history but partner with it → type-specific serology testing to determine risk of contracting b) Antiviral therapy after 36 weeks’ gestation (1) Acyclovir, famciclovir, valacyclovir 20 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

5. Nursing Management for the Pregnant Woman with Herpes Simplex Virus a) Nursing Assessment and Diagnosis (1) Initial prenatal visit → learn whether woman, partner have had previous herpes infections (2) Diagnoses include (a) Pain, Acute (b) Coping, Ineffective b) Nursing Plan and Implementation (1) Education c) Evaluation (1) Woman able to describe infection with regard to method of spread, expected medical therapy, comfort measures, implications (2) Woman has appropriate lab testing done as recommended throughout pregnancy (3) Woman gives birth to healthy infant

G. Group B Streptococcus Infection 1. Group B streptococcus (GBS) → bacterial infection found in lower gastrointestinal (GI), urogenital tract a) May transmit to fetus in utero or during childbirth b) Leading cause of infectious neonatal sepsis and mortality c) Estimated 10 to 40% pregnant women carriers d) Maternal morbidity → pyelonephritis, chorioamnionitis, postpartum endometritis, sepsis, wound infections, meningitis 2. Fetal-neonatal risks a) GBS may result in unexpected intrapartum stillbirths b) Vertical transmission → risk for GBS neonatal sepsis (1) Prematurity (2) Maternal intrapartum fever (3) Membranes ruptured for longer than 18 hours (4) Previously infected infant with GBS disease (5) GBS bacteriuria in the current pregnancy (6) Young maternal age (7) African American or Hispanic c) Severe, invasive disease in affected infants 3. Clinical therapy a) Guidelines (1) All women screened for vaginal, rectal GBS at 35 to 37 weeks (2) GBS carriers →intrapartum antibiotic prophylaxis (IAP) at onset of labor or rupture of membranes (ROM) b) GBS in urine → intrapartum antibiotic prophylaxis (1) Women who have given birth to newborn with invasive GBS → intrapartum antibiotic prophylaxis 21 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Prophylaxis indicated if results of GBS not known when labor begins (a) Gestation less than 37 weeks (b) Membranes ruptured ≥18 hours (c) Temperature >100.4°F (38°C) (3) Intrapartum prophylaxis not indicated (a) Cesarean birth, no labor, intact membranes (b) Positive GBS in previous pregnancy, negative result in current pregnancy (c) Negative vagina and rectal GBS screening (4) Figure 18–7, p. 414, provides an algorithm for assessing the need for intrapartum antibiotic prophylaxis (a) Intrapartum antibiotic therapy (i) Initial dose penicillin G 5 million units IV → 2.5 to 3.0 million units IV every 4 hours until childbirth (ii) Or ampicillin may be used (iii) Clindamycin if an allergy (5) If the GBS strain is resistant to clindamycin, vancomycin

H. Human B19 Parvovirus 1. Causes erythema infectiosum, fifth disease a) “Slapped cheek” rash b) Transmitted via hand-to-hand contact or respiratory droplets c) Symptoms in adults: myalgia, arthralgia, and coryza d) Low risk of fetal morbidity, transplacental transmission as high as 33% (1) Associated with spontaneous abortion, fetal hydrops, stillbirth (2) Before 20 weeks’ gestation → nonimmune hydrops, fetal anemia e) Weekly measurements of peak systolic velocity of the MCA (1) Fetal death → 4 to 12 weeks postinfection (2) Risk of fetal death remains several months post maternal infection, even when fetal hydrops is not evident

I. Zika Virus 1. Relatively new, no vaccine or cure a) Viral infection caused by a bite from the Aedes species of mosquito, or via blood, sex, handling specimens, or perinatal transmission 2. Congenital Zika syndrome (CZS) a) Microcephaly in 1:10 fetuses b) Decreased brain tissue with a specific pattern of brain damage c) Damage to the back of the eye d) Joints with limited range of motion, such as clubfoot e) Too much muscle tone, restricting body movement soon after birth f) Education (1) Follow CDC guidelines for women planning pregnancy

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(a) Delay conception at least 2 months from onset of symptoms in women, men for 6 months (b) Women of reproductive age who are planning a pregnancy in the upcoming year, or who are already pregnant, should absolutely avoid Zika-infested areas (c) Pregnant women with symptoms → If confirmed, refer to maternal-fetal medicine (i) Up to 2 weeks after symptom onset or last possible exposure, urine or serum RNA nucleic acid testing; a positive test confirms the diagnosis of recent maternal Zika virus infection (ii) From 2 to 12 weeks after symptom onset or last date of possible exposure, serologic assays can be offered to detect Zika virus–specific IgM antibodies

J. Other Infections in Pregnancy 1. See Table 18–6: Infections That Put Pregnancy at Risk, pp. 415–416 a) Urinary tract infections (1) Asymptomatic bacteruria (ASB) → oral sulfonamides early in pregnancy, ampicillin and nitrofurantoin in late pregnancy (2) Cystitis → oral sulfonamides early in pregnancy, ampicillin and nitrofurantoin in late pregnancy (3) Acute pyelonephritis → hospitalization, IV antibiotic therapy with carbenicillin, methenamine, cephalosporins (a) Follow-up urine cultures (b) Catheterization if no urine output b) Vaginal infections (1) Vulvovaginal candidiasis → intravaginal insertion of miconazole butoconazole, clotrimazole vaginal tablets (2) Bacterial vaginosis → metronidazole 250 mg orally (PO) TID × 7, metronidazole 500 mg PO twice daily (BID) × 7; clindamycin 300 mg PO BID × 7 (3) Trichomoniasis → single 2-g dose of metronidazole orally c) Sexually transmitted infections (1) Chlamydial infection → azithromycin or amoxicillin; repeat culture (2) Syphilis → follows regimen recommended for general population (a) Early latent → 2.4 million units benzathine penicillin G IM (b) Late latent, latent of unknown duration → 2.4 million units benzathine penicillin G IM once a week × 3 weeks (c) Desensitize allergic women then treat with penicillin (d) Sexual partners screened, treated (3) Gonorrhea → cephalosporin or spectinomycin (4) Condylomata acuminata → surgical or laser removal

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V.

Care of the Woman Requiring Surgery During Pregnancy A. Essential surgery can be undertaken 1. Risk for spontaneous abortion → less during early second trimester 2. Special considerations a) Shield fetus from radiation b) Nasogastric tube may be recommended before major surgery c) Indwelling urinary catheter d) Fetal heart tones monitored e) Increased respiratory secretion → may need endotracheal tube for respiratory support f) Position to allow optimal uteroplacental–fetal circulation g) Spinal or epidural anesthesia preferred h) Blood loss monitored carefully 3. Nursing Management for the Pregnant Woman Requiring Surgery a) Nursing Assessment and Diagnosis (1) Assess (a) Health status same as any preoperative patient (b) Consider impact of surgery on woman’s pregnancy (2) Pre/intra/postoperatively, fetal heart should be assessed (3) Diagnoses include (a) Anxiety (b) Fear b) Nursing Plan and Implementation (1) Educational needs (2) Support (3) Pre/intra/postoperatively, you are caring for two patients (4) Consider stage of pregnancy (5) Discharge teaching c) Evaluation (1) Woman able to explain procedure, risks and benefits, implications for pregnancy (2) Caregivers maintain adequate maternal oxygenation throughout surgery and postoperatively (3) Potential complications are avoided or detected early, treated successfully (4) Woman able to describe necessary postdischarge activities, limitations, follow-up (5) Woman maintains her pregnancy successfully

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VI.

Care of the Woman Suffering Major Trauma

A. Trauma from motor vehicle accidents leading cause of fetal and maternal death B. Violence next most common causes 1. Complicates 6 to 7% of all pregnancies 2. Early pregnancy → body changes increase potential for injury 3. Normal physiologic changes of pregnancy have clinical implications for victims of trauma 4. Trauma that causes concern includes blunt trauma, penetrating abdominal injuries 5. Complications a) maternal shock, premature labor, and spontaneous abortion b) Maternal mortality most often from head trauma or hemorrhage c) Fractures of pelvis can result in significant retroperitoneal hemorrhage (1) Cesarean birth may be necessary (2) Penetrating trauma → mother generally fares better than fetus 6. Clinical Therapy a) Stabilize injury, promote well-being for both mother and fetus b) Care to avoid development of supine hypotensive syndrome c) Noncatastrophic trauma → fetal monitoring for 4-24 hours if no vaginal bleeding, uterine tenderness, contractions, leaking amniotic fluid d) Abruption placenta → abdominal blunt force trauma (1) Fetomaternal hemorrhage (2) Kleihauer-Betke test → identify Rh negative unsensitized women who have experienced fetal–maternal trauma e) Cardiopulmonary resuscitation (CPR) on pregnant women in late gestation (1) Perimortem cesarean birth if CPR unsuccessful in first 5 minutes 7. Nursing Management for the Woman Suffering Major Trauma a) Nursing Assessment and Diagnosis (1) Assessed according to type and extent of injuries (a) Initial assessment → airway, breathing, existence of cardiovascular stability, extent of injury, brief neurologic assessment (b) Ongoing assessments → uterine tone, contractions, tenderness, fundal height, fetal heart rate, intake and output, indicators of shock, normal postoperative evaluation (2) Diagnoses include (a) Pain, Acute (b) Constipation (c) Fear b) Nursing Plan and Implementation (1) Ongoing assessment 25 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(a) Woman and fetus (b) Assess woman’s emotional state (2) Education (3) Support c) Evaluation (1) Woman and family able to understand effects of trauma on her, unborn child (2) Adequate maternal oxygenation maintained (3) Woman’s pain adequately relieved, trauma treated (4) Potential complications quickly identified, interventions instituted (5) Woman gives birth to healthy newborn (6) If trauma results in fetal demise → woman able to verbalize her feelings, begin working through grief process

VII.

Care of the Pregnant Woman Experiencing Intimate Partner Violence

A. True extent of domestic violence difficult to determine, estimates 6 to 22% 1. Violence may escalate during pregnancy 2. Complications more frequent 3. Pattern of violence may increase or decrease

B. Risk factors 1. Victim of physical, sexual, or psychologic abuse 2. Low socioeconomic status 3. Unemployment/ family financial difficulties 4. Heavy alcohol or drug use 5. Antisocial personality traits 6. Belief in strict gender roles (e.g., male dominance and aggression in relationships) 7. Negative or volatile family dynamics 8. Low social support 9. Weak community sanctions against IPV 10. May cause a) Psychologic distress b) Loss of pregnancy, preterm labor c) Low-birth-weight babies, injury to the fetus, and fetal death d) Poor maternal weight gain e) Infection f) Anemia 26 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

g) Second- and third-trimester bleeding seen more frequently h) Women who are battered may also experience sexual abuse and are at increased risk of contracting STIs 11. Identify a) Chronic psychosomatic symptoms b) Old scars c) Bruising (especially to breasts, abdomen, genitals) d) Decreased eye contact, silence when partner in room e) History (1) Nervousness, insomnia, drug overdose, alcohol problems (2) Frequent visits to emergency department, accidents 12. Goals a) Identify women at risk b) Increase decision-making abilities c) Provide safe environment for her and unborn child 13. Screening in private setting, direct questions 14. Determine immediate safety of woman a) Information available → community resources

VIII.

Care of the Woman at Risk for Rh Alloimmunization

A. Rh blood group present on surface of erythrocytes 1. Present → Rh positive 2. Absent → Rh negative a) If Rh-negative person exposed to Rh-positive blood → antigen-antibody response → sensitized (1) Subsequent exposure → serious reaction (2) Rh alloimmunization → Rh-negative woman carries Rh-positive fetus to term, termination (a) Transfusion, Rh-positive tubal pregnancy, amniocentesis, trauma (3) Screening of Rh-negative woman for D antibodies accepted (4) Duffy and Kell antibodies → irregular antibodies 3. Pathophysiology of RhD Alloimmunization a) During normal pregnancy → small amounts of fetal blood cross placenta (1) Rh-negative mother → anti-D antibodies (2) Develop IgM antibodies b) Subsequent exposure to RhD cells results in rapid production of IgM antibodies (1) If maternal hemorrhage → pregnancy termination, ectopic pregnancy, chorionic sampling (2) No problem during first pregnancy → subsequent pregnancies 27 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(3) Possibility → Rh-negative female fetus of Rh-positive mother sensitized in utero (a) Positive antibody screen

B. Fetal-Neonatal Risks 1. Hemolysis caused by maternal IgG antibodies → fetal anemia a) Increasing RBC production → nucleated RBCs erythroblastosis fetalis→ severe hemolytic disease of the fetus and newborn (HDFN) b) Anemia can cause fetal edema → hydrops fetalis, congestive heart failure c) RBC destruction → hyperbilirubinemia, jaundice d) Fetal death can be from severe anemia or hypoxia and cardiac arrest 2. Screening for Rh incompatibility and sensitization a) First prenatal visit (1) History of past pregnancies, sensitization, abortions, transfusions, children who developed jaundice or anemia during newborn period (2) Maternal blood type, Rh factor, Rh antibody screen (3) Medical complications b) Sensitization may occur antepartum → small transplacental bleeds (1) Repeat D antibody determination made at 28 weeks

C. Clinical Therapy 1. Goal prevention of Rh alloimmunization or, if alloimmunization has occurred, birth of a mature fetus that has not developed severe hemolysis in utero 2. Antepartum management of nonalloimmunized pregnant woman a) Four RhIg immune globulin products available: RhoGAM (the first approved for clinical use), HyperRHO, Rhophlac, WinRho-SDF b) Woman Rh negative, unsensitized and father Rh+ or unknown → Rh immune globulin given prophylactically at 28 weeks (1) After abortion, ectopic pregnancy, chorionic villus sampling, multifetal pregnancy reduction, partial molar pregnancy, amniocentesis, PUBS, antepartum hemorrhage, fetal death, blunt trauma, external cephalic version (2) Kleihauer-Betke test → determine amount of Rh(D) positive blood present in maternal circulation → calculate dosage (3) Standard dose of RhIg (300 mcg) can prevent alloimmunization after exposure of up to 30 mL of Rh-positive fetal whole blood or 15 mL of packed red cells 3. Antepartum management of the alloimmunization pregnant woman a) If father homozygous for Rh positive, all his offspring will be Rh positive b) If father heterozygous, 50% of offspring will be Rh positive; 50% Rh negative c) If woman alloimmunized for first time done at 14 to 16 weeks to determine gestational age d) If the father is heterozygous or if paternity is questionable or unknown, fetal DNA testing should be done to determine the fetal Rh status e) Maternal anti-D antibody titers monthly until 24 weeks 28 Copyright © 2020 Pearson Education, Inc.

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f) If titers higher than critical levels, Doppler ultrasound g) Intrauterine transfusion (1) Correct anemia → PUBS, intraperitoneally h) Intravascular transfusion → improved outcomes (1) Fetus temporarily paralyzed (2) Fetal hematocrit obtained (3) Leukocyte-poor Rh-negative packed red blood cells (PRBCs) transfused (4) Most transfused fetuses survive (5) Complications (a) Nonreassuring fetal status, umbilical vein hematoma, fetal-maternal hemorrhage, fetal death, chorioamnionitis (b) Birth delayed until 32 weeks if possible i) Postpartum management (1) Goals → prevent sensitization in unsensitized woman, treat isoimmune hemolytic disease in newborn (2) Rh-negative mother with no titer → gave birth to Rh+ fetus →IM injection of 300 mcg Rh immune globulin within 72 hours (a) Temporary passive immunity (3) Not given to newborn, father, previously sensitized woman 4. Nursing Management for the Woman with Alloimmunization a) Nursing Assessment and Diagnosis (1) Initial prenatal history (a) Asks blood type, Rh factor (i) If Rh negative → ask about Rh immune globulin, previous pregnancies, partner’s Rh factor (a) Uncertain paternity (ii) Lab work (b) Knowledge level and coping skills (c) Review data about Rh type of fetus (2) Diagnoses include (a) Knowledge, Readiness for Enhanced (b) Coping, Ineffective b) Nursing Plan and Implementation (1) Education (2) If sensitized → threat to any Rh+ fetus (3) Support (4) During labor → ensure woman’s blood assessed for antibodies (5) Rh immune globulin postpartum (6) See Key Points: Rh Alloimmunization, p. 407 c) Evaluation (1) Woman able to explain process of Rh sensitization, implications for unborn child, subsequent pregnancies

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(2) If woman not alloimmunized, able to explain importance of receiving Rh immune globulin when necessary, cooperates with recommended dosage schedule (3) Woman gives birth to healthy newborn (4) If complications develop for fetus (or newborn), they are quickly detected, therapy instituted

IX.

Care of the Woman at Risk Due to ABO Incompatibility A. Common with rare significant hemolysis 1. Most cases → type O mothers, type A, B fetus 2. Anti-A and anti-B antibodies naturally occurring 3. Once pregnant → maternal anti-A and anti-B antibodies cross placenta → hemolysis of fetal RBCs a) ABO incompatibility rarely has serious life-threatening scenarios because the antigen/antibody response is not as robust 4. Not treated antepartum a) Note if potential exists 5. Affected neonates → mild anemia

X.

Focus Your Study

XI.

Activities 1. Individual Have students prepare drug cards, including pregnancy category or risk and special considerations for the following drugs: Acyclovir Oxytocin RhoGAM Rhophylac Sodium amobarbital Spiramycin Valacyclovir WinRho-SDF

Nitroprusside Famciclovir Hydralazine HyperRHO Labetalol Magnesium sulfate Nicardipine Nifedipine

2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan, including community resources available for support or follow-up for one of the following conditions: • Hyperemesis gravidarum • Hypertension in pregnancy

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• • •

Rh incompatibility Motor vehicle accidents in pregnancy Physical violence in pregnancy

3. Large Group Invite a perinatal nurse from a tertiary care facility or perinatology practice to speak to the students in your class. Give the speaker a list of potential topics that may or may not have been covered in the text and encourage the speaker to bring case studies for presentation.

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Chapter 19 Processes and Stages of Labor and Birth Methods of Childbirth Preparation………………………………………………………………… …

2

Preparation for Childbirth That Supports Individuality………………………………………

3

Critical Factors in Labor..........................................................................................

4

Psychosocial Considerations……………………………………………………………………………..

7

Physiology of Labor…………………………………………………………………………………………..

8

Stages of Labor and Birth.......................................................................................

10

Maternal Systemic Response to Labor..................................................................

13

Fetal Response to Labor........................................................................................

15

Focus Your Study...................................................................................................

16

Activities.................................................................................................................

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I.

Methods of Childbirth Preparation

A. Programs share similarities 1. Usually taught by certified childbirth educators 2. Educational component to help eliminate fear, teach coping techniques 3. Relaxation techniques 4. What to expect in maternity cycle, labor and birth 5. Advantages → reduced need for analgesics, anesthetics; awareness of available options a) Helps understand choices b) Satisfaction of parents c) Shorten labor d) International Childbirth Education Association (ICEA) → education and resources to childbirth educators

B. Programs for Preparation 1. See Box 19–1: Most Commonly Used Childbirth Education Methods in the United States, p.

428 a) Lamaze → Psychoprophylactic b) Techniques (1) Disassociation relaxation (2) Controlled muscular relaxation (3) Breathing patterns (a) Used to promote birth as a normal process (i) Bradley → Partner-coached childbirth (4) Techniques (a) 12-week session (b) Controlled breathing and deep abdominopelvic breathing (c) Focus on achieving natural childbirth c) Hypnobirthing (1) Techniques (a) Breathing and relaxation techniques (b) Prepare body to work in neuromuscular harmony to make the birthing process easier, safer, more comfortable

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C. Body-Conditioning Exercises 1. Pelvic tilt 2. Pelvic rock 3. Kegel exercises 4. Strengthen abdominal muscles for expulsion phase

D. Relaxation Exercises 1. Conserve energy, uterine muscles work more effectively 2. Touch relaxation → pain relief measure where partner’s touch enhances the woman’s ability to relax 3. Light touching, stroking, massaging a) Combines abdominal breathing with focused touch relaxation b) See Box 19–2: Touch Relaxation Technique, p. 429 c) Disassociation relaxation (1) Woman taught to become familiar with contracting/relaxing voluntary muscle groups → learns to contract specific muscle group and relax rest of body (2) See Box 19–3: Visualization, Imagery, and Meditation, p. 429

E. Breathing Techniques 1. Key element to most childbirth preparation programs a) Increase the woman’s pain threshold, encourage relaxation, provide distraction, enhance the ability to cope with uterine contractions, allow uterus to function more efficiently 2. Lamaze uses partner-paced 3. Bradley encourages abdominopelvic breathing 4. Kitzinger uses chest breathing with abdominal relaxation 5. Hypnobirthing uses deep, slow breathing a) Pant-blow “quick method” to keep from breathing too rapidly

II.

Preparation for Childbirth That Supports Individuality

A. Encourage woman to incorporation her own natural responses to coping with the pain of labor and birth 1. Nurse can help couple by doing the following a) Identify the methods of childbirth preparation commonly used in your area b) Learn the basic relaxation and breathing c) Encourage making the birth a personal experience.

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d) Suggest the couple bring items from home that help create a more personal birthing space e) Encourage the couple to listen to soothing music on their cell phone or MP3 player or watch favorite DVDs to increase personalization of the childbearing experience

III.

Critical Factors in Labor

A. See Table 19–1: Critical Factors in Labor, p. 430 B. Birth Passageway 1. Pelvic types a) Size of maternal pelvis b) Diameters of pelvic inlet, midpelvis, outlet c) Type of maternal pelvis (1) Gynecoid (2) Android (3) Anthropoid (4) Platypelloid (5) Combination d) Ability of cervix to dilate, efface e) Ability of vaginal canal, introitus to distend

C. Birth Passenger (Fetus) 1. Fetal head a) Bony parts (1) Three major parts → face, base of skull, vault of cranium (2) See Figure 19–3: Lateral view of the fetal skull ..., p. 433 (3) Sutures → allow for molding of fetal head (a) Frontal (b) Sagittal (c) Coronal (d) Lambdoidal (e) See Figure 19–2: Superior view of the fetal skull, p. 432 (4) Intersection of several sutures forms fontanelle (a) Anterior (b) Posterior (5) Other landmarks a) Mentum → fetal chin b) Sinciput → brow c) Vertex → between anterior, posterior fontanelles d) Occiput → occipital bone (6) Diameters vary (a) See Figure 19–4A: Anteroposterior diameters of the fetal skull, p. 433

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D. Fetal Attitude 1. Relation of fetal body parts to one another (a) General flexion (b) See Figure 19–5: Fetal attitude, p. 433 2. Fetal lie a) Relationship of long (cephalocaudal) axis of fetus to that of mother (1) Longitudinal → cephalocaudal axis of fetus parallel to woman’s spine (2) Transverse → fetus is at right angle to woman’s spine b) See Table 19–3: Characteristics Associated with Longitudinal versus Transverse Fetal Lie, 434 3. Fetal presentation a) Body part that enters maternal pelvis first (1) Presenting part → felt through cervix on vaginal exam (2) Cephalic → head first (97% of term births) (a) Vertex (b) Sinciput (c) Brow (d) Face (e) See Figure 19–6: Cephalic presentation, p. 435 (3) Breech → lower extremities, buttocks first (a) Complete (b) Frank (c) Footling (4) Shoulder presentation (< 1%)

E. Relationship of maternal pelvis and presenting part 1. Engagement → largest diameter of presenting part reaches/passes through pelvic inlet a) See Figure 19–7: Process of engagement in cephalic presentation, p. 436 b) Can be determined by vaginal examination (1) Primigravida usually starts 2 weeks before term (2) Floating (ballottable) → freely movable above the inlet (3) Dipping → begins to descend into inlet before engagement (a) See Figure 19–7: C. Descending, p. 436 2. Station → relationship of presenting part to an imaginary line drawn between ischial spines of maternal pelvis a) Landmark designated as zero station b) Higher → negative number → centimeters above zero station c) Station –5 at inlet; station +4 at outlet d) See Figure 19–8: Measuring the station of the fetal head ..., p. 436

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3. Fetal position → refers to relationship of landmark on presenting fetal part to anterior, posterior, or sides of maternal pelvis a) Landmark for vertex presentation → occiput b) Landmark for face presentation → mentum c) Breech presentation → sacrum designated landmark d) Shoulder presentation → acromion process e) Three notations (1) Right (R) or left (L) side of maternal pelvis (2) Landmark of fetal presenting part (a) Occiput (O) (b) Mentum (M) (c) Sacrum (S) (d) Acromion (scapula [Sc]) process (A) (e) Anterior (A), posterior (P), or transverse (T) (3) Table 19–4 lists positions and abbreviations used for various fetal presentations, p.

437 f) Positions in vertex (1) ROA (2) ROT (3) ROP (4) LOA (5) LOT (6) LOP g) Positions in face presentation (1) RMA (2) RMT (3) RMP (4) LMA (5) LMT (6) LMP h) Positions in breech (1) RSA (2) RST (3) RSP (4) LSA (5) LST (6) LSP i) Dorsal added → fetal position in shoulder presentation (1) RADA (2) RADP (3) LADA (4) LADP j) Position influences labor and birth (1) Most common fetal position → occiput anterior 6 Copyright © 2020 Pearson Education, Inc.

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k) Determining fetal position → inspection, palpation

F. Physiologic Forces of Labor 1. Primary force → uterine contractions 2. Secondary force → use of abdominal muscles 3. Contractions a) Rhythmic tightening, shortenings of uterine muscles, three phases (1) Increment → building up (2) Acme → peak (3) Decrement → letting up b) Frequency → time in between beginning of one contraction to beginning of next contraction c) Duration → measured from beginning of the contraction to the end of the contraction d) Intensity → strength of uterine contraction during acme (1) Mild, moderate, strong (2) Beginning of labor usually mild, short, infrequent 4. Bearing down a) Cervix dilates completely → maternal abdominal musculature contracts → woman pushes (1) Cervix not completely dilated → causes cervical edema

IV.

Psychosocial Considerations A. Readiness includes: 1. Fears, anxieties 2. Birth fantasies 3. Level of social support 4. Preconceived ideas about birth a) See Table 19–5: Factors Associated with a Positive Birth Experience, p. 439 (1) Motivation for pregnancy (2) Attendance at childbirth education classes (3) A sense of competence or mastery (4) Self-confidence and self-esteem (5) Positive relationship with partner (6) Maintaining control during labor (7) Support from partner or other person during labor (8) Not being left alone in labor (9) Trust in the medical/nursing staff (10) Having personal control of breathing patterns, comfort measures (11) Choosing physician/certified nurse-midwife who has similar philosophy of care 7 Copyright © 2020 Pearson Education, Inc.

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(12) Receiving clear information regarding procedures b) Encourage to share dreams, fantasies c) Explore options, identify interventions to help cope with discomfort d) Support system e) Hindsight may have implications for mothering behaviors

V.

Physiology of Labor A. Possible Causes of Labor Onset 1. Between 38th and 42nd week 2. Hypotheses a) Progesterone withdrawal → decreased availability of progesterone to myometrial cells toward end of gestation b) Prostaglandin hypothesis → successful induction of labor after vaginal prostaglandin E c) Corticotropin-releasing hormone → corticotropin-releasing hormone (CRH) concentration increases throughout pregnancy → sharp increase at term

B. Myometrial Activity 1. Two portions → physiologic retraction ring a) Upper portion → contractile segment → thickens b) Lower portion → passive → expands, thins c) Effacement d) See Figure 19–11: Effacement of the cervix in the primigravida, p. 441 e) Fetal axis pressure → uterus elongates with contraction → straightens fetal body → thrusting presenting part down toward lower uterine segment and cervix f) Round ligament pulls fundus forward

C. Musculature Changes in the Pelvic Floor 1. Levator ani muscle, fascia of pelvic floor → draw rectum, vagina upward and forward with each contraction 2. Physiologic anesthesia from decreased blood supply to area

D. Premonitory Signs of Labor 1. Lightening → fetus begins to settle into pelvic inlet a) Leg cramps, pains due to pressure b) Increased pelvic pressure c) Increased venous stasis d) Increased urinary frequency e) Increased vaginal secretions 2. Braxton Hicks contractions → irregular, intermittent contractions a) Stronger, drawing sensation 8 Copyright © 2020 Pearson Education, Inc.

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3. Cervical changes a) Ripening (softening) 4. Bloody show a) Mucus plug expelled → softening, effacement of cervix (1) Pink-tinged secretions b) Sign of impending labor → 24 to 48 hours c) Rupture of membranes (ROM) (1) ROM → 12% of women before onset of labor (a) 80% of those → spontaneous labor within 24 hours (b) If ROM and labor doesn’t start in 12 to 25 hours, labor may need induced (2) Spontaneous rupture of membranes (SROM) → generally occurs at height of an intense contraction (a) Fetus not engaged → risk of umbilical cord expelled with fluid → prolapsed cord (b) Woman advised to notify healthcare provider, proceed to hospital, birthing center (3) Spontaneous rupture of membranes, leakage of fluid before labor → premature rupture of membranes (PROM) (4) Spontaneous rupture of membranes before 37 weeks → preterm premature rupture of membranes (PPROM) 5. Sudden burst of energy a) 24 to 48 hours before labor b) Prenatal teaching → warning about overexertion 6. Other signs 7. Weight loss of 1 to 3 lb a) Increased backache, sacroiliac pressure b) Diarrhea, indigestion, nausea, vomiting

E. Differences Between True Labor and False Labor 1. See Key Facts to Remember: Comparison of True Labor and False Labor, p. 442 2. True labor → progressive dilatation and effacement of cervix a) Regular contractions b) Intervals between contractions gradually shorten c) Contractions increase in duration and intensity d) Discomfort begins in back, radiates around abdomen e) Intensity usually increases with walking f) Cervical dilatation, effacement progressive g) Contractions do not decrease with rest, warm tub bath 3. False labor → does produce progressive cervical effacement, dilatation a) Contractions irregular b) Intervals usually do not change 9 Copyright © 2020 Pearson Education, Inc.

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c) Duration, intensity usually do not change d) Discomfort usually in abdomen e) Walking has no effect on or lessens contractions f) No cervical dilatation or effacement g) Rest and warm tub baths lessen contractions h) Nurse’s response to false labor (1) Education about characteristics of true labor (a) False labor common (2) Interventions to decrease anxiety, discomfort (a) False labor can last for several hours and can be exhausting

VI.

Stages of Labor and Birth

A. First Stage 1. Latent or early phase a) Onset of regular contractions b) Cervical dilation and effacement begins c) First labor → averages 7.3 to 8.6 hours d) Multiparas → average 4.1 to 5.3 hours e) Uterine contractions established (1) Increase in frequency, duration, intensity (2) Usually mild → woman able to cope (3) Lasting 20 to 40 seconds, frequency of 10 to 30 minutes (4) Excited, talkative, smiling 2. Active phase a) Anxiety tends to increase b) Contractions increase (1) 2 to 5 minutes, a duration of 40 to 60 seconds c) Support person important d) Cervix dilates from 4 to 7 cm 3. Transition phase a) Last part of first stage b) Woman entering transition → significant anxiety c) Increasing force, intensity of contractions d) Cervical dilatation slows → fetal descent increases e) Contractions more frequent, longer, stronger (1) From every 2 to 5 minutes to every 1½ to 2 minutes f) Dilatation approaches 10 cm → increased rectal pressure (1) Urge to bear down (2) Increase in bloody show (3) Rupture of membranes (ROM) g) Woman likely to withdraw into self h) Other characteristics include: 10 Copyright © 2020 Pearson Education, Inc.

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(1) Hyperventilation (2) Restlessness (3) Difficulty understanding directions (4) Sense of bewilderment and anger at contractions (5) Generalized discomfort (6) Increased sensitivity to touch (7) Increased need for partner’s and/or nurse’s presence or support (8) Increased apprehension and irritability (9) Statements that she “can’t take it anymore” (10) Requests for medication (11) Hiccupping, belching, nausea, vomiting (12) Beads of perspiration on upper lip (13) Increasing rectal pressure (14) Curling of her toes (15) Loss of control (16) Crying or yelling

B. Second Stage 1. Begins when cervix completely dilated a) Ends with birth of infant 2. As fetal head descends → woman has urge to push a) Intra-abdominal pressure exerted → fetal head descends → perineum begins to bulge, flatten, move anteriorly b) Labia begin to part c) Crowning → fetal head encircled by external opening of vagina d) Birth imminent e) May feel acute, increasingly severe pain, burning sensation f) Instruct to push through the pain and burning (1) Childbirth-prepared woman → relief that transition over (2) Woman may become frightened 3. Spontaneous birth (vertex presentation) a) Perineum thins, anus stretches, protrudes b) Extension under symphysis pubis → head is born c) Anterior shoulder meets underside of symphysis pubis → gentle push by mother d) Body follows e) See Figure 19–12: The birth sequence, p. 446 4. Positional changes of the fetus a) Descent → forces of pressure of amniotic fluid, fundus, contraction of abdominal muscles, straightening and extension of fetal body b) Flexion → fetal head descends, meets resistance → fetal chin flexes downward onto chest c) Internal rotation → fetal head rotates to fit diameter of pelvic cavity 11 Copyright © 2020 Pearson Education, Inc.

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d) Extension → resistance of pelvic floor, movement of vulva assist with extension of fetal head e) Restitution → shoulders enter pelvis obliquely when head rotates → neck twists → head emerges → neck untwists, head aligns with position of back in birth canal f) External rotation → as shoulders rotate to anteroposterior position in pelvis → head turned farther to one side g) Expulsion → anterior shoulder meets undersurface of symphysis pubis, slips under h) See Figure 19–13: Cardinal movements (mechanisms of labor), p. 448

C. Third Stage 1. Birth of infant until completed delivery of placenta 2. Placental separation a) After infant born → uterus contracts firmly b) Diminishes capacity, surface area of placental attachment c) Separation accompanied by bleeding → hematoma formation → accelerates separation d) Signs → usually 5 to 30 minutes to manifest (1) Globular-shaped uterus (2) Rise of fundus in abdomen (3) Sudden gush or trickle of bleed (4) Further protrusion of umbilical cord out of vagina e) Placental delivery (1) Woman may bear down (2) If fundus firm → CNM or physician may apply gentle traction to cord while pressure exerted on fundus (3) Retained → more than 30 minutes have elapsed from completion of second stage (4) Shiny side presenting → separates from inside to outer margins (a) Schultze mechanism → Shiny Schultze (5) Maternal surface delivers first → separates from outer margins inward (a) Duncan mechanism → Dirty Duncan (b) See Figure 19–14: Placental separation and expulsion, p. 448

D. Fourth Stage 1. 1 to 4 hours after birth a) Physiologic readjustment of mother’s body begins (1) Moderate drop in BP occurs, increased pulse pressure, moderate tachycardia b) Uterus remains contracted, midline c) Nausea and vomiting experienced during transition usually cease d) Shaking chill e) Bladder often hypotonic → may lead to urinary retention

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VII.

Maternal Systemic Response to Labor

A. Cardiovascular System 1. Contractions, pain, anxiety, apprehension 2. Increase in cardiac output with contractions 3. Maternal position affects cardiac output 4. Valsalva maneuver as she pushes → increased venous pressure 5. Next breath → intrathoracic pressure decreased, venous return increases 6. Cardiac output peaks immediately after birth → then decreases a) Remains elevated for at least 24 hours after the birth

B. Blood Pressure 1. Increased cardiac output → systolic blood pressure rises during uterine contractions 2. Blood pressure may drop precipitously when woman in supine position a) Women with hydramnios, multiple gestation, obese → highest risk of aortocaval compression

C. Fluid and Electrolyte Balance 1. Profuse diaphoresis, hyperventilation → insensible water loss 2. Parenteral intravenous fluids

D. Respiratory System 1. Oxygen demand and consumption increase → presence of uterine contractions a) 50% of increased oxygen used by placenta, uterus, fetus 2. Increased metabolism as labor progresses → mild increase in respiratory rate 3. By end of first stage → mild metabolic acidosis compensated by respiratory alkalosis a) Pushing in second stage → PaCO2 may rise → mild respiratory acidosis

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4. Changes quickly reversed in fourth stage

E. Renal System 1. During labor → increase in maternal renin, plasma renin activity, angiotensinogen 2. Polyuria common → increased cardiac output 3. Base of bladder pushed forward, upward with engagement 4. Pressure from presenting part → impair blood, lymph drainage → edema of tissues

F. Gastrointestinal System 1. Gastric motility, absorption of solid food reduced 2. Gastric volume remains over 25 mL → risk for aspiration if general anesthesia necessary 3. Fluid requirements not clear a) Oral hydration b) Saline lock for intravenous access

G. Immune System and Other Blood Values 1. White blood cell (WBC) count increases to 25,000/mm3 to 30,000/mm3 → labor, early postpartum 2. Maternal blood glucose decreases → decrease in insulin requirements a) Glucose levels can drop significantly during a prolonged or difficult labor

H. Pain 1. Pain during labor a) Accompanies normal physiologic process b) Pain during first stage of labor from (1) Dilatation of cervix (2) Hypoxia of uterine muscle cells (3) Stretching of lower uterine segment (4) Pressure on adjacent structures (5) See Figure 19–15: Pain pathways from uterus to spinal cord, p. 450 (6) Pain from uterus → directly referred to dermatomes supplied by 10th through 12th thoracic nerves (7) See Figure 19–16: Area of reference of labor pain during the first stage, p. 451 c) Second stage of labor (1) Pain due to: (a) Hypoxia of contracting uterine muscle cells (b) Distention of the vagina and perineum (i) Pressure on adjacent structures: Lower back, Buttock, Thighs

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(c) See Figure 19–17: Distribution of labor pain during the later phase of the first stage and early phase of the second stage, p. 451 d) Third stage of labor (1) Uterine contractions, cervical dilatation → placenta expelled (2) Pain felt above symphysis pubis bone, perineal area, lower back (3) See Figure 19–18: Distribution of labor pain during the later phase of the second stage and actual birth, p. 452 2. Factors affecting response to pain a) Preparation for childbirth shown to reduce need for analgesia during labor b) Individuals respond to painful stimuli → culturally acceptable way c) Families react to healthcare system based on own culture d) Nurse needs to identify cultural norms of family e) Fatigue and sleep deprivation → less energy and ability to use strategies for coping f) Previous experience with pain g) Anxiety h) Attention and distraction influence perception of pain i) Culture of healthcare → own expectations of woman and support person (1) Healthcare profession likely to interpret pain according to norms of healthcare culture (2) Accept and respect that pain is whatever the woman says it is

VIII.

Fetal Response to Labor

A. Normal fetus → normal labor has no adverse effects B. Heart Rate Changes 1. Decelerations → intracranial pressures of 40 to 55 mm Hg 2. Early decelerations harmless in normal fetus

C. Acid–Base Status in Labor 1. Blood flow to fetus slowed during acme of contraction a) Slow decrease in fetal pH 2. Second stage → more rapid decrease in fetal pH 3. Persistent acid–base imbalance → multi-organ dysfunction in infant

D. Hemodynamic Changes 1. Adequate exchange of nutrients, gases → depends on fetal blood pressure

E. Behavioral States 1. Human fetus develops behavioral states → 36 to 38 weeks’ gestation a) Quiet and active sleep states 15 Copyright © 2020 Pearson Education, Inc.

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b) Decreased fetal heart rate variability accompanies quiet sleep c) Quiet sleep state generally lasts less than 40 minutes

F. Fetal Sensation 1. 37 to 38 weeks’ gestation → fetus able to experience light, sound, touch 2. Hearing develops at 23 to 24 weeks → reliable at 28 weeks 3. Term baby aware of pressure sensations during labor

IX.

Focus Your Study

X.

Activities 1. Individual Using Table 19–5: Factors Associated with a Positive Birth Experience, p. 439, have students interview two to three (or more) women who have given birth. Instruct the students to ask the women to identify factors they felt most affected them and those factors that least affected them. Have the students identify the cultural identity of the women interviewed.

2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan for the pregnant woman. Assign each group a critical factor in labor or a specific stage of labor. The groups should use lay terms, diagrams, and pictures as appropriate in their teaching plans.

3. Large Group Show one of the short videos listed below that clearly shows the second stage of labor.

Facilitate a class discussion based on the video.

• http://www.medicanalife.com/watch_video.php?v=2803d92a3eac6ac • http://www.youtube.com/watch?v=u9xfu1qOJzs

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Chapter 20 Intrapartum Nursing Assessment Maternal Assessment...........................................................................................

2

Fetal Assessment..................................................................................................

8

Fetal Heart Rate Patterns.....................................................................................

12

Indirect Methods of Fetal Assessment................................................................

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Focus Your Study..................................................................................................

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Activities...............................................................................................................

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

Maternal Assessment

A. Accurate database 1. Goal → create an accurate database of information → healthcare providers to formulate an optimal plan of care 2. Patient history and screening 3. Varies with condition, stage of labor → triage a) Triage b) Vital signs, fetal heart rate (FHR) c) Contractions d) Abnormal symptoms or signs of distress 4. Suspected complications of labor, high risk, PROM, PPROM, preeclampsia, FHR abnormalities, vaginal bleeding → further assessment 5. No prenatal care → immediate complete assessment a) History and physical b) Obstetrical evaluation c) Laboratory tests d) Ultrasound e) Other indicated procedures 6. Well-being of mother and fetus primary concern

B. Prenatal Record 1. Perinatal guidelines a) Copy of prenatal record available → acute care facility at 36 weeks b) Foundation for intrapartum assessment

C. Historical Data 1. Pregnant patient the primary source 2. Foundation for intrapartum assessment 3. See Box 20–1: Historical Data for the Intrapartum Assessment, p. 457 a) Demographic information b) Socioeconomic factors c) Psychosocial assessment d) Medical, surgical histories e) Family history f) Obstetrical history (1) Past pregnancies (a) Complications during pregnancy (b) Labor complications 2 Copyright © 2020 Pearson Education, Inc.

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(c) Postpartum complications (d) High-risk factors (e) Previous abortions, etc. (f) Mode of birth (2) Current pregnancy (3) Gravidity, parity (4) High-risk factors (5) Blood type, Rh factor (6) Serology testing (7) Allergies (8) Drug, alcohol, smoking during pregnancy (9) Elevated blood pressure, bleeding problems, recurrent urinary tract infections (10) Medications (11) Method chosen for infant feeding (12) Type of prenatal education (13) Birth plan (14) Gestational age assessment (15) Fetal activity (16) Leopold maneuvers (17) Fetal positioning g) Clinical assessment (1) Maternal vital signs (2) Maternal weight, height, weight gain this pregnancy (3) Nutritional status (4) Uterine activity (5) Contraction assessment (6) Onset, duration, frequency of uterine contractions (7) Fetal response to uterine contractions (8) Membrane status (9) Status of membranes, color of amniotic fluid (10) Date and time of rupture (11) Vaginal examination (12) Vaginal bleeding and discharge (13) Cervical exam h) Biochemical examinations during pregnancy (1) Laboratory studies (2) CBC, blood type, Rh and antibody screen (3) Toxicology screening (if ordered) (4) Blood glucose screening (5) Urine for protein and sugar (6) Infectious disease evaluation (7) Chlamydia, gonorrhea, group beta strep, hepatitis B, rubella, syphilis (8) Optional infectious disease evaluation i) Fetal assessment 3 Copyright © 2020 Pearson Education, Inc.

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(1) Gestational age assessment (2) Last menstrual period (LMP) (3) Fetal movement (4) Ultrasound exams for dating (5) Fetal activity (6) Fetal movement by maternal report (7) Fetal movement by palpation (8) Antenatal assessments (9) Nonstress tests (NSTs) (10) Contraction stress tests (CSTs) (11) Biophysical profiles (BPPs) (12) Ultrasounds (13) Amniotic fluid index (AFI) (14) Method of monitoring (15) Auscultation (16) External (a) via ultrasound transducerPlaced on maternal abdomen over fetal back (17) Tocodynamometer (a) InternalVia fetal scalp electrode attached to fetal head (b) Cervix must be at least 2 cm dilated and membranes ruptured (c) Increases risk of infection transmission to fetus (18) Fetal spiral electrode (19) Intrauterine pressure catheter

D. Intrapartum High-Risk Screening 1. Integral part of assessment a) Physical conditions b) Psychosocial variables c) Cultural variables d) Communication problems e) Intimate partner violence 2. See Table 20–1: Intrapartum High-Risk Factors, p. 459 a) Abnormal presentation b) Multiple gestation c) Hydramnios d) Oligohydramnios e) Meconium staining of amniotic fluid f) Premature rupture of membranes (PROM) g) Induction of labor h) Abruptio placentae/placenta previa i) Failure to progress in labor j) Precipitous labor (less than 3 hours) k) Prolapse of umbilical cord 4 Copyright © 2020 Pearson Education, Inc.

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l) Fetal heart decelerations m) Uterine rupture n) Postdates (greater than 42 weeks) o) Diabetes p) Preeclampsia q) AIDS/STIs

E. Intrapartum Physical and Psychosociocultural Assessment 1. Physical exam → admission, ongoing 2. Physical assessment a) Critical assessments → maternal vital signs, labor status, fetal status, laboratory findings 3. Psychologic disorders a) Depression → fear, lack of energy, apathy, hopelessness, trouble concentrating, impaired immune function, impaired mother–baby interaction b) Panic disorder c) Obsessive-compulsive disorder d) Pregnancy further complicates psychiatric disorders 4. Psychosocial history a) Physical, sexual assault 5. Transcultural nursing assessment a) Starting point for plan → honors values, beliefs of laboring woman 6. Psychosocial a) Ideas, knowledge, fears about childbearing b) Adequacy of resources c) Information and resources 7. See Assessment Guide: Intrapartum—First Stage of Labor, p. 461

F. Evaluating Labor Progress 1. Ongoing accurate assessment → mother, fetus, responses 2. Method of monitoring a) Low tech b) Intermittent c) EFM d) Continuous 3. Guidelines with electronic fetal monitoring (EFM) a) Low-risk pregnancy (1) Nurse must perform a hands-on assessment, including auscultation of fetal heart tones (FHT) and palpation of uterine contractions (UC) 5 Copyright © 2020 Pearson Education, Inc.

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(2) Tracing reviewed every 30 minutes in first stage of labor (3) Every 15 minutes in second stage b) High-risk pregnancy (1) Every 15 minutes in first stage labor (2) Every 5 minutes in second stage labor c) See Table 20–3, p. 469 d) Document on same schedule 4. May be necessary to monitor more frequently a) Monitor before and after examination, rupture of membranes, certain procedures 5. EFM a) Originally in high-risk pregnancy, in 2002 85% of births used it 6. Intermittent assessment as appropriate a) Proper technique b) 1:1 nurse-to-patient ratio

G. Uterine activity assessment 1. Provides data regarding labor progress, fetal well-being a) Uterine contractions (UCs) reduce oxygen immediately available to fetus b) Adequate labor → 3 to 5 contractions in 10 minutes or a contraction every 2 to 3 minutes in active labor 2. UCs occur in wavelike patterns a) Begin at upper uterine segment → progress through lower segments of uterus b) Leads to cervical dilatation and effacement and the descent of the fetus c) Similar wave of relaxation d) During and between UCs → fundus changes shape, firmness e) Monitoring UCs (1) Palpation → fingertips of one hand on top of uterus (a) Frequency measured from beginning of one contraction to beginning of next (b) Duration from beginning of the contraction to end of same contraction (c) Acme (peak) evaluated subjectively (d) Benefits (i) Noninvasive (ii) Readily accessible (iii) Increases hands-on care (iv) Allows mother freedom of movement (e) Limitations (i) No quantitative measurement (ii) No permanent record (iii) Maternal size, positioning (2) Electronic monitoring with external tocodynamometer (a) Tocotransducer (toco) → pressure monitoring device 6 Copyright © 2020 Pearson Education, Inc.

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(b) Placed on maternal abdomen → at or near fundus (c) Held in place with elastic belt, belly band (3) Procedure (a) Palpation of uterus → locate fundus (b) Transabdominally (i) Frequency and duration (ii) Not accurate for UC intensity (c) Beltless tocodynamometer → remote telemetry (i) Adhesive transducer applied to abdomen (ii) More convenient (4) Advantages (a) Noninvasive (b) Easy to place (c) Before and after rupture of membranes (d) Intermittent (e) Permanent continuous recording (5) Disadvantages (a) Placement influences accuracy (b) Belt may be uncomfortable → need frequent readjustment (c) Nurse needs to palpate in addition (6) Electronic monitoring by internal pressure catheter (a) Intrauterine pressure catheter (IUPC) (i) Catheter inserted into uterine cavity → through cervical os (ii) Reflects pressure inside uterine cavity (iii) One of two types → fluid filled or solid tipped (iv) Can only be used after membranes have ruptured (7) Advantages (a) Near-exact pressure measurements (b) Accurate timing (c) Useful for vaginal birth after cesarean (VBAC) patients (d) Preferred when amnioinfusion indicated (e) Permanent record (8) Disadvantages (a) Membranes must be ruptured (b) Cervical dilation must be achieved (c) Invasive (d) Risk for infection, perforation, trauma (e) Contraindicated in known infections (f) Risk of placental puncture if low lying placenta 3. Cervical assessment a) Evaluated directly by vaginal exam (1) Dilatation (2) Effacement 7 Copyright © 2020 Pearson Education, Inc.

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b) See Clinical Skill 20–1: Performing an Intrapartum Vaginal Examination, p. 471

II.

Fetal Assessment

A. Determination of Fetal Position and Presentation 1. Position a) Inspection of woman’s abdomen (1) Observe abdomen for size and shape (2) Uterus projects up and down → longitudinal lie (3) Uterus projects left to right → transverse lie b) Palpation of the woman’s abdomen (Leopold maneuvers) (1) Systematic way to evaluate maternal abdomen (2) Procedure preparation (a) Empty bladder, positioned on back with abdomen uncovered (b) Shoulders raised slightly on pillow, knees drawn up little (c) Between contractions (d) Hands warm (3) Consider following questions: (a) Fetal lie longitudinal or transverse? (b) What is in fundus? Am I feeling buttocks or head? (c) Where is the fetal back? (d) Where are the small parts or extremities? (e) What is in the inlet? (f) Measuring the station of the fetal head while it is descending. (see Figure 19–8 in Chapter 19) (g) Is there fetal movement? (h) How large is the fetus? (i) Is there more than one fetus? (j) Is fungal height proportionate to estimated gestational age?

(4) First maneuver (a) Nurse palpates upper abdomen with both hands (b) See Figure 20–4: Leopold maneuvers ..., p. 475 (c) Fetal head is firm, hard, round, moves independently of trunk (5) Second maneuver (a) Determine location of fetal back → palpates abdomen with deep but gentle pressure (b) Right hand steady → left hand explores right side of uterus (c) Repeat on other side (d) Fetal back firm smooth, connect with what was found in fundus (e) See Figure 20–4: Leopold maneuvers ..., p. 475 (6) Third maneuver (a) Grasp lower portion of abdomen just above symphysis pubis with thumb, fingers of right hand (b) Opposite information from what was found in fundus 8 Copyright © 2020 Pearson Education, Inc.

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(c) Validates presenting part (d) See Figure 20–4: Leopold maneuvers ..., p. 475 (7) Fourth maneuver (a) Fingers of both hands moved gently down sides of uterus toward pubis (b) Cephalic prominence (brow) located on side where there is greatest resistance to descent of fingers toward pubis (c) Opposite side from fetal back → head well flexed (d) Fetal head extended → located on same side as back (e) See Figure 20–4: Leopold maneuvers ..., p. 475 c) Vaginal examination (1) Reveals → presentation, position, station, degree of flexion of head, swelling present on fetal scalp d) Ultrasound (US) (1) Real-time US → assess fetal lie, presentation, position (2) Obtain measurements of biparietal diameter to estimate gestational age (3) Assess for anomalies (4) Assess placement of placenta (5) Pinpoint fetal heart location (6) Diagnose fetal demise (7) See Chapter 16 for further discussion of the use of ultrasound for fetal assessment.

B. Auscultation of Fetal Heart Rate 1. Direct auditory monitoring 2. FHR = number of fetal heart beats per minute 3. Handheld instrument a) Fetoscope → magnify actual fetal heart sounds b) Ultrasound Doppler → converts fetal myocardial movement into sound waves 4. FHR heard best → a) Cephalic presentation → lower quadrant of maternal abdomen b) Breech presentation → just above or below umbilicus 5. After located → counted for 30 to 60 seconds a) Listen before, during, just after contraction (1) FHR over 160 beats/min → tachycardia (2) FHR under 110 beats/min → bradycardia (3) Decelerations (4) See Clinical Skill 20–3: Auscultation of Fetal Heart Rate and Table 20–4: Frequency of Auscultation: Assessment and Documentation, p. 477 (5) Auscultation used for years → valuable assessment technique (6) Low risk status → no pregnancy risk factors, no meconium-stained fluid, normal labor patterns, labor without augmentation or induction (7) Learned skill, requires practice 9 Copyright © 2020 Pearson Education, Inc.

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(8) Baseline, rhythms, increases, decreases in FHR (9) No permanent record b) Identify UCs, FHR simultaneously necessary → identify patterns c) Cannot determine baseline variability

C. Electronic Fetal Monitoring 1. EFM → provides continuous tracing of FHR a) Allows observation, evaluation (1) See Figure 20–7, Electronic monitoring by external technique, p. 478, and Clinical Skill 20–4: Electronic Fetal Monitoring, p. 479 b) Advanced assessment, clinical judgment skills c) Includes (1) Application of fetal monitoring components (2) Intermittent auscultation (3) Ongoing monitoring and interpretation of FHR data (4) Initial assessment of laboring woman and fetus (5) Ongoing clinical interventions and evaluations of woman, fetus d) Initiation of monitoring, ongoing clinical evaluation → healthcare professional with educations, skills (1) Registered nurse (2) Certified nurse midwives (CNMs) (3) Registered midwives (4) Other advanced practice nurses (nurse practitioners, clinical nurse specialists) (5) Physicians (6) Physician assistants (PAs) e) Standardized definitions for FHR tracings by ACOG, NICHD, and the Society for MaternalFetal Medicine (1) A three-tiered intrapartum categorization system was recommended 2. Indications for electronic fetal monitoring → see Table 20–5: Possible Indications for Electronic Fetal Monitoring, p. 480 a) Fetal factors (1) Decreased fetal movement (2) Abnormal auscultator FHR (3) Meconium passage (4) Abnormal presentations/positions (5) Intrauterine growth restriction (IUGR) or small–for-gestational-age (SGA) fetus (6) Postdates (greater than 41 weeks) (7) Multiple gestation b) Maternal factors (1) Fever (2) Infections (3) Preeclampsia (4) Disease conditions 10 Copyright © 2020 Pearson Education, Inc.

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(5) Anemia (6) Obesity (7) Rh alloimmunization (8) Previous perinatal death (9) Grand multiparity (10) Previous cesarean birth (11) Borderline/contracted pelvis c) Uterine factors (1) Dysfunctional labor (2) Failure to progress in labor (3) Oxytocin induction/augmentation (4) Uterine anomalies d) Complications of pregnancy (1) Prolonged rupture of membranes (2) Premature rupture of membranes (3) Preterm labor (4) Marginal abruptio placentae (5) Partial placenta previa (6) Occult/frank prolapse of cord (7) Amnionitis e) Regional anesthesia f) Elective monitoring 3. External monitoring a) Electronic monitoring can be done externally (1) Ultrasound transducer is a Doppler device (2) Placed on maternal abdomen over fetal back (3) Produces continuous graphic recording (4) Limited → susceptible to interference from maternal, fetal movement (5) Can show the baseline (BL), baseline variability (BL VAR), and changes in the FHR 4. Internal monitoring a) Internal fetal monitoring → fetal scalp electrode (FSE) (1) Fine surgical spiral wire attached to the fetal scalp b) Direct electrocardiogram (ECG) of FHR c) For spiral electrode to be inserted (1) Cervix must be dilated at least 2 cm (2) Presenting fetal part must be accessible by vaginal examination (3) Membranes must be ruptured (4) Electrode rotated clockwise → until attached to presenting part → disengaged from guide tube (5) See Figure 20–8: Techniques for internal, direct fetal monitoring, A, B, and C, p. 481 (6) Risk of transmission of known maternal infection exists (7) Spiral electrode provides instantaneous, continuous recording of FHR

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5. Telemetry a) FHR, uterine activity → may also be monitored by telemetry b) Less confining → US along with external uterine pressure transducers connected to a small battery-operated transmitter c) Direct, indirect monitoring of FHR, indirect monitoring of uterine pressure

III.

Fetal Heart Rate Patterns

A. Interval between two successive fetal heartbeats continually measured 1. Rate is displayed as if the beats occurred at the same interval for 60 seconds.

B. Fetal heart rate patterns → described by: 1. Baseline 2. Variability 3. Accelerations 4. Decelerations a) Categorized in three-tier system

C. Standardized terminology D. Baseline Fetal Heart Rate 1. BL FHR → determined by approximating mean FHR during 10-minute period → rounded to increments of 5 beats per minute a) Accelerations, decelerations, period of marked FHR variability excluded 2. Must be 2 minutes of identifiable baseline (BL) segments in any 10-minute window 3. Normal BL rate → 110 to 160 bpm a) As gestational age increases → FHR decreases as PNS matures

E. Tachycardia 1. Fetal tachycardia → BL FHR greater than 160 bpm for at least 10-minute period 2. Causes a) Idiopathic b) Maternal (1) Fever (2) Dehydration (3) Anxiety (4) Betasympathomimetic or sympathetic drugs (5) Maternal hyperthyroidism (6) Supraventricular tachycardia c) Fetal 12 Copyright © 2020 Pearson Education, Inc.

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(1) Early fetal hypoxia (2) Asphyxia (3) Fetal anemia (4) Infection (5) Prematurity (6) Prolonged fetal stimulation (7) Fetal heart failure d) Combined 3. Nonreassuring sign → accompanied by other FHR patterns a) Late decelerations b) Severe variable decelerations c) Decreased or absent variability 4. Intervention → treatment of underlying cause

F. Bradycardia 1. Fetal bradycardia → FHR baseline less than 110 beats/min for at least 10-minute period 2. FHR low as 90 beats/min → good variability → classified as benign, reassuring 3. Possible causes a) Maternal (1) Drugs that stimulate parasympathetic nervous system (PNS) or block sympathetic nervous system (SNS) (2) Maternal hypotension (3) Accidental monitoring of maternal pulse b) Fetal (1) Stimulation of vagus nerve (2) Prolonged umbilical cord compression (3) Fetal dysrhythmia associated with heart block in fetus (4) Hypoxemia or late fetal asphyxia (5) Occiput posterior or transverse position

G. Wandering baseline 1. Smooth, meandering, unsteady BL → fluctuates in the normal BL range without variability 2. Causes a) Congenital defect, metabolic acidosis

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H. Sinusoidal fetal heart rate pattern 1. Visually apparent, smooth, wavelike, undulating sine pattern that fluctuates in FHR baseline 2. Sinusoidal patterns → benign or pathological 3. Causes a) Fetal anemia b) Chronic fetal bleeding c) Fetal isoimmunization d) Twin-to-twin transfusion e) Umbilical cord occlusion f) Central nervous system (CNS) malformations 4. Interventions if uncorrectable → notify healthcare provider, expeditious delivery

I. Arrhythmias and dysrhythmias 1. Interchangeable terms 2. Disturbances in FHR pattern not associated with abnormal electrical impulse formation or conduction in the fetal cardiac tissue 3. Three categories a) Irregular rhythms b) Sustained tachycardia c) Sustained bradycardia 4. FHR dysrhythmia estimated in 2% to 14% of pregnancies a) 90% benign b) 10% → life threatening, require consultation c) Accurately diagnose abnormal FHR patterns 5. See Table 20–6: Common Causes or Various Types of Fetal Dysrhythmias, p. 484

J. Baseline Variability 1. BL VAR → reliable indicator of fetal cardiac and neurological function, well-being 2. Fluctuations in baseline FHR that are irregular in amplitude and frequency over 2 cycles per minute 3. Measured in beats per minute 4. Classified as follows: a) Absent FHR variability-amplitude range undetected b) Minimal FHR variability-amplitude range detectable but 5 beats/min or less c) Moderate FHR variability-amplitude range of 6 to 25 beats/min d) Marked FHR variability-amplitude range greater than 25 beats/min

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e) See Figure 20–12: A. and B. Moderate variability. C. Minimal variability. D. Absent variability and Figure 20–13: Marked variability, p. 485

K. Fetal Heart Rate Changes 1. FHR may exhibit intermittent, transient deviations → accelerations, decelerations a) Episodic changes → not associated with uterine contractions b) Periodic changes → occur with uterine contractions (1) If a periodic change occurs with > 50% of UCs in a 20-minute period → categorized as recurrent change/pattern c) Examine all changes in FHR → in relation to BL, uterine activity 2. Accelerations a) Acceleration (accel) → visually apparent increase in BL FHR (1) Onset-to-peak < 30 seconds, lasting less than 2 minutes overall (2) Peak must be 15 beats/min or more (3) Must last 15 seconds or more from onset to return to BL b) Prolonged acceleration → lasts 2 minutes or more, less than 10 minutes c) Episodic accelerations → not associated with contractions (1) Reassuring → fetal movement, stimulation, environmental stimulus d) Periodic accelerations → associated with uterine contractions (1) See Figure 20–14: Types of accelerations, p. 486 e) Generally associated with stimulation of autonomic nervous system (ANS) (1) Fetal movement, vaginal exams, application of fetal scalp electrode, occiput posterior presentation, uterine contractions, fundal pressure, abdominal palpation, VAS, scalp stimulation, other environmental stimuli f) Generally considered benign 3. Decelerations (decels) a) Decreases in the FHR below the BL b) Several components (1) Onset (2) Descent → time from onset to nadir (3) Nadir → lowest point of deceleration (4) Depth → level a deceleration reaches nadir (5) Recovery → time from nadir to return to BL (6) Duration → total length of time from onset to return to BL c) Classified (1) Early (2) Late (3) Variable (a) Accompanied by other characteristics (4) Prolonged (5) Based on shape, appearance, rate of decent, and timing in relation to uterine contractions 15 Copyright © 2020 Pearson Education, Inc.

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d) Characteristics of decelerations (1) See Figure 20–15: Types and characteristics of early, late, and variable decelerations, p. 487 (2) Early deceleration (a) Visually apparent, usually symmetrical, gradual decrease and return of FHR associated with uterine contraction (b) Gradual FHR decrease defined as on from the onset to the FHR nadir of 30 seconds or more (c) Decrease in FHR calculated from onset to nadir of deceleration (d) Nadir of deceleration occurs at same time as the peak of the contraction (e) Onset, nadir, recovery of deceleration → coincident with beginning, peak, ending of contraction (3) Late deceleration (a) Visually apparent, usually symmetrical, gradual decrease, return to FHR to BL, associated with uterine contraction (b) Gradual FHR decrease → defined from onset to nadir of 30 seconds or more Decrease in FHR calculated from onset to nadir of the deceleration (c) Deceleration delayed in timing, with nadir of deceleration occurring after peak of contraction (d) In most cases → onset, nadir, recovery of the deceleration occurs after beginning, peak, and ending of contraction (4) Variable deceleration (a) Visually apparent abrupt decrease in FHR (b) Abrupt FHR decrease defined as from onset of deceleration to beginning of FHR nadir of 30 seconds of less (c) Decrease in FHR is 15 beats/min or more → lasting 15 seconds or more, less than 2 minutes (d) Associated with uterine contractions → vary with successive uterine contractions (5) Early decelerations (Figure 20–17, p. 488) (a) Result of vagal nerve stimulation (i) Caused by fetal head compression occurs during UC (ii) Not associated with loss of variability, tachycardia, other FHR changes → viewed as reassuring unless seen with lack of descent of fetal head (6) Late decelerations (a) Lates or late decels → uteroplacental insufficiency → decreased blood flow and/or oxygen transfer to fetus (b) Reflexive → normal physiologic chemical response to low oxygen levels (c) Myocardial → repetitive, chronic episodes → metabolic acidosis → myocardial depression (d) Decrease in heart rate → usually shallow, 10 to 20 beats/min (e) Baseline variability minimal or absent → fetal hypoxia (f) Supine position (g) Immediate interventions (i) Position change → elevate trunk or turn on side 16 Copyright © 2020 Pearson Education, Inc.

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(ii) Increase intravenous fluids (iii) Oxygen via face mask (iv) Stop IV Pitocin if infusing (v) Notify physician, CNM immediately (7) Episodic or periodic decelerations (a) Episodic → without relationship to UCs, result of environmental stimuli (b) Periodic → direct association with UCs (i) Considered repetitive if they occur with 50% or more of UCs (8) Early or late decelerations (a) Periodic decelerations also classified by timing with respect to UCs (9) Prolonged decelerations (a) Visually apparent decrease in FHR (b) Lasts >2 minutes and <10 minutes (10) Variable decelerations (a) See Figure 20–22: Mechanism of variable deceleration, p. 491 (b) Have U or V shape, typically associated with cord compression (c) Not usually concerning unless: (i) Less than 70 beats/min (ii) Lasts more than 60 seconds (iii) Slow to return to baseline

L. Interpretation of Fetal Heart Rate Patterns 1. Systematic approach a) Determine uterine resting tone b) Assess contractions (1) What is the frequency?

(2) What is the duration?

(3) What is the intensity (if internal monitoring)? c) Evaluate FHR tracing (1) Determine baseline (a) Is the baseline within normal range? (b) Is there evidence of tachycardia? (c) Is there evidence of bradycardia?

(2) Determine FHR variability (a) Is variability absent, minimal, or moderate? (b) Is variability minimal or marked?

(3) Determine whether sinusoidal pattern present (4) Determine whether there are periodic changes (a) Are accelerations present? (b) Is there a reassuring tracing or FHR pattern? (c) Are decelerations present? (d) Are they uniform in shape? If so, determine if they are early or late decelerations. (e) Are they nonuniform in shape? If so, determine if they are variable decelerations.

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2. Categorize tracing a) See Table 20–7: Three-Tier Fetal Heart Rate Interpretation System, p. 492 b) Three-Tier Fetal Heart Rate Interpretation System (1) Category I: FHR tracings are normal (a) Baseline 110 to 160 beats/min (b) Baseline FHR variability moderate (c) Late or variable decelerations absent (d) Early decelerations present or absent (e) Accelerations present or absent (2) Category II: FHR tracings are indeterminate (a) Baseline rate (i) Bradycardia not accompanied by absent baseline variability (ii) Tachycardia (b) Baseline FHR variability (i) Minimal (ii) Absent without decelerations (iii) Marked baseline variability (c) Accelerations (d) Episodic decelerations (i) Recurrent variable decelerations (ii) Prolonged deceleration ≥2 minutes but <10 minutes (iii) Recurrent late decelerations with moderate baseline variability (iv) Variable decelerations with other characteristics → slow return to baseline, overshoots, shoulders (3) Category III: FHR tracings are abnormal (a) Absent baseline FHR and any of the following (i) Recurrent late decelerations (ii) Recurrent variable decelerations (iii) Bradycardia (b) Sinusoidal pattern 3. Provide information to laboring woman regarding FHR pattern 4. Labor and birth nurses → skilled, competent in evaluating FHR patterns and respond a) See Key facts to Remember: Guidelines for Management of Variable, Late, and Prolonged Deceleration Patterns, p. 494

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IV.

Indirect Methods of Fetal Assessment A. Scalp stimulation, acoustic stimulation, maternal abdominal palpation 1. Ongoing scalp stimulation is not recommended and should not be used by nurses

B. Cord Blood Analysis at Birth 1. Indications → significant abnormal FHR patterns have been noted before birth, amniotic fluid is meconium stained, or the newborn is depressed at birth 2. Analyze immediately after birth to assess respiratory status 3. Cord clamped prior to first breath a) 8- to 10-inch segment double clamped, cut b) Blood collected from umbilical arteries in heparinized syringe c) Should not be allowed to remain in the segment of cord longer than 30 minutes

V.

Focus Your Study

VI.

Activities 1. Individual Have students prepare a teaching plan for the laboring woman who does not understand fetal monitoring.

2. Small Group Divide the class into small groups of three to five students. Assign each small group a fetal heart rate pattern to describe and illustrate. The rubric should include the following: normal or abnormal patterns, causes, nursing interventions, and a teaching plan for the laboring woman who asks about the waveform pattern. The fetal heart rate patterns to include in the exercise are as follows: • Tachycardia • Bradycardia • Wandering baseline • Sinusoidal fetal heart rate pattern • Atrial dysrhythmias • Ventricular dysrhythmias • Accelerations • Decelerations 3. Large Group Review the monitor strip pictures from http://fetalmonitorstrips.com/learn_more.html or http://www.aafp.org/afp/990501ap/2487.html with the class. Project or print handouts for the students. Discuss reassuring and nonreassuring monitor strips.

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Chapter 21 The Family in Childbirth: Needs and Care Reality of Childbearing and Childrearing............................................................

2

Nursing Diagnoses During Labor and Birth........................................................

2

Nursing Care During Admission……………………………………………………………………..

3

Nursing Care During the First Stage of Labor.....................................................

6

Nursing Care During the Second Stage of Labor................................................

11

Nursing Care During the Third Stage of Labor....................................................

16

Nursing Care During the Fourth Stage of Labor.................................................

19

Nursing Care of the Adolescent..........................................................................

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Nursing Care During Precipitous Labor and Birth...............................................

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Evaluation............................................................................................................

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Focus Your Study.................................................................................................

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Activities..............................................................................................................

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

Reality of Childbearing and Childrearing

A. Meaningful, stressful event B. Concerns about care 1. Look to nurse for support

II.

Nursing Diagnoses During Labor and Birth

A. General plan to encompass whole process 1. First-stage diagnoses a) Anxiety related to discomfort of labor and unknown labor outcome b) Knowledge, Readiness for Enhanced c) Coping: Family, Compromised d) Pain, Acute e) Knowledge, Deficient f) Fear related to unknown birth outcome and anticipated discomfort 2. Second- and third-stage diagnoses a) Pain, Acute b) Knowledge, Deficient c) Coping, Ineffective d) Fear related to outcome of birth process 3. Fourth-stage diagnoses a) Pain, Acute b) Knowledge, Deficient c) Family Processes, Readiness for Enhanced

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III.

Nursing Care During Admission

A. Usually arrive at birth setting 1. Beginning of active phase of labor 2. Rupture of membranes (ROM) 3. Decreased fetal movement 4. Regular, frequent uterine contractions 5. Any vaginal bleeding

B. Patient teaching 1. What will occur during labor 2. Informed consent

C. Establishing a Positive Relationship 1. Initial interaction a) Increase or decrease anxiety 2. Create environment for family to ask questions a) Establish rapport, create supportive environment b) Provide opportunity for questions 3. Process of admission 4. Communicate in primary language 5. Cultural factors

D. Labor Assessment 1. Triage area, birthing room a) Admission history (1) Assist nurse in making effective nursing decisions (a) Is woman in labor or candidate to be sent home? (b) Are there factors that put woman or fetus at risk? (c) Should ambulation or bedrest be encouraged? (d) Is more frequent monitoring needed? (e) What are woman’s wishes and special requests? (f) Who will be with laboring woman for social support? b) Woman made comfortable c) Prenatal records 2. Intrapartum assessment a) Auscultate fetal heart rate (FHR) 3 Copyright © 2020 Pearson Education, Inc.

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b) Vital signs c) Contraction status d) Cervical dilation and effacement e) Fetal presentation and station (1) Early latent (2) Nullipara → sent home or ambulate f) Share findings with couple g) Advanced labor → physician, CNM notified immediately h) Signs of excessive bleeding, painless bleeding in last trimester, placenta previa → no vaginal exam 3. Results of comprehensive assessment determine if admission is routine or urgent 4. Notify physician or CNM if high risk a) If high-risk or emergency data identified → before or after completing admission process b) See Table 21–1: Indicators of Normal Labor Process on Admission, p. 500 5. Report should include a) Cervical dilation and effacement b) Station c) Presenting part d) Status of membranes e) Contraction pattern f) Fetal heart rate g) Vital signs that are not normal h) Response to labor by woman

E. Collecting Laboratory Data 1. Clean-voided midstream urine specimen a) Dipstick prior to sending to lab 2. Hemoglobin and hematocrit 3. Blood is typed and cross-matched 4. Syphilis if not done in last 3 months 5. HIV if not screened during pregnancy

F. Social Assessment 1. Detailed social history a) Risk factors including (1) Family violence or sexual assault (2) Drug, alcohol, tobacco use (3) Presence of sexually transmitted infections b) Current living situation 4 Copyright © 2020 Pearson Education, Inc.

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c) Resources available d) Preparedness for newborn e) Community resources f) Social support network 2. Provide information 3. Referrals to social services

G. Documentation of Admission 1. Nursing admission note a) Reason for admission b) Date, time, method of arrival c) Notification of physician/CNM d) Condition of woman and baby e) Labor and membrane status f) Current level of pain g) Pertinent social assessment information

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2. Interpreter 3. Comfort level

IV.

Nursing Care During the First Stage of Labor A. Plan of care to achieve nursing goals 1. Physical safety of woman and fetus 2. Emotional well-being of laboring couple 3. Support system 4. Continually assesses the effects and pattern of the UCs, FHR, and fetal well-being, maternal vital signs (VS), cervical changes, and intake and output

B. Labor support → primary role of nurse 1. Information 2. Pain management 3. Procedures and examinations 4. Reassurance 5. Positive reinforcement & praise 6. Assess individual preferences

C. Integration of Family Expectations 1. Assess expectations a) Birth plan 2. Expectations of nurse a) Highly involved b) Minimal involvement 3. Challenging to provide individualized care a) Cues from couple b) Direct questions

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4. Nurse serves as advocate for woman and support person

D. Integration of Cultural Beliefs 1. Values, customs, practices 2. Research → individual’s experiences in labor are highly dependent upon social and cultural norms 3. Cultural responses to labor a) Modesty b) Pain expression (1) Reactions (2) Korean culture → used to be important to be silent (3) European Americans → variety of behaviors 4. Examples of cultural beliefs a) Position b) Food and drink c) Hispancic women → partner with them (1) May fear loss of modesty, labor longer at home (2) Use less pain medications d) Muslim women (1) See case example on p. 462 5. European Americans demonstrate a wide variety of behaviors in response to pain 6. Need awareness of beliefs, values, practices → understand needs a) Demographics b) Stereotyping should be avoided

E. Provision of Care in the First Stage 1. Evaluate physical parameters of woman and fetus a) Maternal temperature every 4 hours unless elevated (1) 37.5°C (99.6°F) → taken every hour (2) Every 2 hours after amniotic fluid has ruptured b) Blood pressure, pulse, respirations → every hour c) BP > 30 systolic or 15 diastolic increase above prepregnancy readings or her pulse is more than 100 → notify provider Intrapartum vaginal examinations (1) To assess cervical changes, status of membranes, fetal position, and station (2) Increase risk of infection d) FHR every 30 minutes when between 110 and160 beats per minute (beats/min) without decels 2. Latent phase a) Anticipatory guidance b) Encourage ambulation 7 Copyright © 2020 Pearson Education, Inc.

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(1) If no ROM, no vaginal bleeding c) Offer clear liquids, ice chips, snacks at frequent intervals with low-risk pregnancies d) Tour birthing facility 3. Active phase a) Contractions frequency → 2 to 3 minutes, a duration of 50 to 60 seconds, and moderate intensity (1) Palpate contractions every 15 to 30 minutes b) Intrapartum vaginal exam → assess cervical dilation, effacement, fetal station and position (1) Cervix dilates from 4 to 7 cm, vaginal discharge and bloody show increase c) Encourage woman to void d) Vital signs every hour → low risk (1) Every 30 minutes for high risk e) FHR is auscultated every 30 minutes for women without complications (1) Every 15 minutes for women with complications f) Slow labor, not tolerating fluids → intravenous (IV) may be started (1) Encourage voiding every 1 to 2 hours to prevent bladder distention g) Amniotomy if membranes not ruptured (1) Document color, odor, time (a) Meconium staining may indicate fetal compromise (b) Increased incidence of amnionitis after membranes ruptured 24 hours (c) Monitor for cord prolapse 4. Transition phase a) Increase contraction frequency (1.5–2 min), duration (60–90 sec), intensity strong (1) Cervical dilatation increases 8 to 10 cm (2) Effacement 100%-nulliparous vs multiparous b) Contractions are palpated at least every 15 minutes c) Sterile vaginal examination can be done during this stage of labor to assess rapid changes in status d) Maternal blood pressure, pulse, and respirations are taken at least every 30 minutes, and FHR is auscultated every 30 minutes for low-risk women and every 15 minutes for high-risk women e) Woman’s center of focus turns inward (1) Ability to speak in coherent sentences may be impaired (2) Follow cues f) Encourage woman to rest between contractions g) Assist with breathing during contraction (1) Encouragement (2) Encourage to refrain from pushing until cervix dilated (3) Short breaths, pant like puppy h) Involuntary passage of flatus, stool, deepening voice → end of transition, beginning of second stage (1) Increasing pressure, feel need to bear down 8 Copyright © 2020 Pearson Education, Inc.

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F. Promotion of Comfort in the First Stage 1. Initial step → identify goals of woman, partner a) Identify factors that contribute to discomfort 2. Responses to pain a) Increased pulse, respiratory rate, dilated pupils, increased blood pressure, muscle tension b) Sounds important part of labor and birthing process (1) Naturally make sounds such as moans and grunts and feel that it helps them cope and do the work of labor (2) Screams → loss of ability to cope c) Touch may be soothing d) Nonverbal cues e) Nursing measures to decrease pain include (1) Encouraging position changes (2) Assisting with personal comfort measures (3) Decreasing anxiety (4) Providing information (5) Using specific supportive relaxation techniques (6) Encouraging paced breathing (7) Administering pharmacologic agents as desired 3. Position changes a) Ambulatory → fetal head, electronic fetal monitoring (EFM) reassuring FHR pattern (1) In bed if membranes ruptured, presenting part not engaged, bedrest recommended (2) See Figure 21–1: Woman and her partner walking in the hospital during labor, p. 504 (3) Use pillows to help b) Assume any comfortable position in bed (1) Side lying generally most advantageous (2) Frequent position changes, every hour 4. Personal comfort measures a) Vaginal discharge increases → change underpads frequently (1) Wash perineum with warm soap and water (2) Standard precautions b) Diaphoresis, constant leaking of amniotic fluid (1) Fresh, smooth, dry linen (2) Replace underpads frequently c) Cool washcloth to forehead, behind neck d) Encourage to void every 1 to 2 hours e) Assess bladder for retention of urine f) Dry mouth (1) Clear fluids, ice chips (2) Encourage nose breathing (3) A & D ointment or lip emollient to moisten dry lips 9 Copyright © 2020 Pearson Education, Inc.

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(4) Lollipops (5) Rinse mouth if vomits g) Cold feet → slippers, socks h) Birthing balls (1) Balance, safety issue (2) See Figure 21–2: The laboring woman is encouraged to choose a position of comfort, p. 506 i) Family, support person can assist with comfort measures j) Encourage family members to maintain own comfort 5. Reducing anxiety a) Related to combination of factors b) Anxiety not related to pain (1) Give information (2) Establish rapport (3) Express confidence in couple’s ability (4) Remain with woman as is possible (5) Praise for correct actions (6) Partner anxiety (a) Feeling helpless (b) Lack of knowledge (c) See Figure 21–3: The woman’s partner provides support and encouragement during labor, p. 507 c) History of sexual abuse or rape (1) Nonverbal cues 6. Providing information a) Stress intermittent nature b) Maximum duration of contractions c) Explanation of surroundings, procedures, equipment 7. Supportive relaxation techniques a) Tense muscles increase resistance to descent of fetus (1) Contribute to maternal fatigue, anxiety (2) Encouraged to use the periods between contractions to rest and relax muscles b) Distractions c) Touch (1) Hand available for touch d) Effleurage → abdominal comfort during contractions e) Pressure on lower back → back discomfort f) Visualization g) Encouragement and support for controlled breathing techniques 8. Breathing techniques a) Avoid hyperventilation b) Prenatal classes 10 Copyright © 2020 Pearson Education, Inc.

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c) Alternate relaxation and breathing exercises d) Hyperventilation → rapid breathing (1) Signs (a) Tingling, numbness nose, lips, fingers, toes (b) Dizziness (c) Spots before eyes (d) Spasms of hands, feet (2) Interventions (a) Encourage to slow breathing, shallow breaths (b) Relax (c) Count out loud (d) Remain with woman e) Assess interaction between woman and coach 9. Complementary and alternative therapies a) Hydrotherapy 10. Other comfort measures a) Analgesic agents, regional anesthesia blocks 11. See Evidence-Based Practice: Relaxation Therapies During Labor, p. 508

V.

Nursing Care During the Second Stage of Labor A. Provision of Care in the Second Stage 1. Sterile vaginal exams to assess fetal descent 2. Maternal blood pressure, pulse, FHR every 5 minutes 3. Fetus FHR every 5 to 15 minutes 4. Sensitive to sounds, changes woman makes 5. When to push a) Studies → rest up to 90 min and wait until urge b) Uncomfortable urge to push (bear down) → normal (1) Splitting apart, ring of fire → normal c) When contraction begins → take two short breaths → third breath → hold it while pulling back on knees, pushing down with abdominal muscles (1) May prefer to exhale slightly while pushing 6. Encourage to rest between contractions a) Assist into comfortable position b) Comfort measures

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7. Woman may want to change position 8. Fatigue, frustration → short rest period a) Inform provider of time spent pushing b) Provide information regarding progress 9. Prepared for birth a) Nullipara → perineum begins to bulge b) Multipara → cervix at 7 to 8 cm dilated 10. Monitor contractions, blood pressure, FHR a) Assist with pushing 11. Assist physician or CNM in preparing for birth a) Sterile gown, gloves b) Drapes over abdomen, legs

B. Promotion of Comfort in the Second Stage 1. Second-stage comfort measures that are appropriate are same as in first stage a) Cool cloths b) Dry gown c) Remove clothing if hot 2. Additional measures a) Warm compresses (1) Perineum (2) Abdomen (3) Back b) Perineal massage 3. Encourage rest of all muscles between contractions 4. Visualization techniques

C. Assisting the Woman and Physician/CNM During Birth 1. Equipment and materials into birthing room, delivery room a) Family → same clothes for birthing room, scrubs for delivery room b) Handwashing by nurses, physician, CNM c) Protective clothing for nurses 2. Labor, delivery, and recovery (LDR) rooms a) May all be done in one room depending on facilities 3. Birthing room a) If woman moved from one bed to another → between contractions b) Preserve privacy c) Family still together 12 Copyright © 2020 Pearson Education, Inc.

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d) Give simple directions on how to assist, be involved 4. Maternal birthing positions a) Bed, birthing chair, delivery table (1) Determined by woman and physician/CNM (2) Stirrups → padded, lift legs simultaneously (3) Upright position normal until modern times (a) women selected squatting, kneeling, standing, and sitting for birth b) See Table 21–4: Comparison of Birthing Positions, p. 513 c) Recumbent (1) Used to enhance asepsis, assessment of FHR, episiotomy and repair (2) Disadvantages (a) Decrease in blood pressure (b) Many women experience difficulty breathing (c) Uterine axis directed toward symphysis pubis instead of pelvic inlet (d) Increased risk of aspiration (e) May increase perineal pressure, making laceration more likely (f) Position may interfere with uterine contractions (g) Ensure stirrups do not cause excessive pressure on the legs (h) Woman works against gravity (i) Disadvantages lessened slightly if woman has back elevated 30 to 40 degrees d) Left lateral Sims (1) Left leg extended, right knee drawn against abdomen (2) Frequency of contractions may decrease → intensity increases (3) Increases overall comfort (4) Does not compromise venous return (5) Puts less stress and pressure on maternal neck (6) Diminishes chances of aspiration (7) Perceived as more natural (8) Fewer episiotomies → perineum tends to be more relaxed (9) Disadvantages (a) Difficult cutting, repairing episiotomies (b) Problems with difficult forceps births (c) Difficult for woman to see the birth (10) See Figure 21–5, Sidelying laboring or birthing position, p. 514 e) Squatting (1) Uses gravity (2) Abdominal wall relaxes (3) Aids in stretching cervix → stimulates myometrium to produce more intense uttering contractions (4) Birthing bar to increase balance, provide support (5) Increase size of pelvic outlet (6) Disadvantages (a) Difficult to control birth process 13 Copyright © 2020 Pearson Education, Inc.

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(b) Increases difficulty of administering analgesia (c) Increases difficulty of using instruments (d) Difficult to monitor fetal station (e) Perineal edema f) Semi-Fowler (1) Middle ground between recumbent & upright positions (2) Shorter first and second stages of labor (3) Enhances effectiveness of abdominal muscle efforts (4) Raising, supporting torso → helps woman view birth process (5) Birth attendant has access to perineum g) Sitting in birthing bed (1) Gravity aids descent and expulsion of the fetus.

(2) Does not compromise venous return from lower extremities.

(3) Woman can view the birth process.

(4) Leg position may be changed at will.

(5) Ensure legs and feet have support h) Sitting on birthing stool (1) Gravity aids descent and expulsion of the fetus.

(2) Does not compromise venous return from lower extremities.

(3) Woman can view the birth process.

(4) Leg position may be changed at will.

(5) Disadvantages (a) difficult to provide support to woman’s back (6) Encourage to sit in position that increases comfort i) Hands and knees (1) More comfortable for woman experiencing back labor (2) Extra pillows for forearms (3) Less pressure on perineum (4) Birth attendant has access to perineum for stretching (5) Access to fetal nose and mouth for suctioning (6) May increase placental and umbilical blood flow (7) May increase pelvic diameter → facilitate less traumatic birth of infant with shoulder dystocia (8) Disadvantages (a) Decreased eye contact between mother, birth attendant (b) Inability to use instruments (c) Necessity of repositioning mother for perineal repair (d) Maternal fatigue (e) Woman cannot view birth 5. Cleansing the perineum a) Position for birth b) Nurse washes hands c) Opens sterile prep tray 14 Copyright © 2020 Pearson Education, Inc.

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d) Dons sterile gloves e) Cleans vulva, perineum with cleansing solution f) Mons pubis up to lower abdomen g) Second sponge → inner groin, thigh of one leg h) Third sponge → other leg, moving outward i) Last three sponges → labia and vestibule → one downward sweep each j) May use a spray bottle with cleansing agent 6. Support during the second stage a) Assess partner/support person for comfort, knowledge b) Assists in activities that will support woman c) Keep support team informed 7. Assisting with the birth of the baby a) With fetal head distending perineum → clinician may support perineum (1) Woman asked to breathe rapidly, pant, blow to avoid too-rapid birth of fetal head b) After infant’s head born → clinician palpates for neck for presence of cord c) Restitution and external rotation → after head born (1) Suctioning (2) Gentle pull to release anterior shoulder d) Grasp posterior shoulder with one hand, palm toward perineum 8. Assisting with clamping the umbilical cord a) Controversy about when to clamp and cut cord b) Birth plan may express a preference (1) Delayed cord clamping for > 30 seconds in preterm infant may reduce transfusions, intraventricular hemorrhage, sepsis c) Clamped with two Kelly clamps, cut between them d) May be double clamped → collection of cord blood gases e) Examine newborn’s stump for two arteries, one vein f) Clamp 0.5 to 1 inch from abdomen (1) See Figure 21–6: Hollister cord clamp, p. 515 9. Cord blood collection for banking a) Immediately after cord is clamped and cut → before placenta expelled → physician/CNM withdraws blood from umbilical cord (1) Blood placed in special container (2) Special directions with container b) Recommendations for banking (1) Stem cell transplants for family history if illness, children with nontraditional lineage (2) Stem cell transplants used to treat many different types of diseases (3) Cord blood has advantages over bone marrow (4) Universal cord blood collection does not exist (5) Cord blood transfusions utilized to treat a number of disorders (6) Written consent required for both collection and storage of cord blood (7) Considered no-risk procedure 15 Copyright © 2020 Pearson Education, Inc.

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VI.

Nursing Care During the Third Stage of Labor

A. Provision of Initial Newborn Care 1. Physician/CNM places newborn on mother’s abdomen, chest for skin-to-skin, or radiantheated unit a) Skin-to-skin optimal for warmth, to promote breastfeeding, & fosters bonding 2. Respirations first priority a) Modified Trendelenburg to aid drainage of mucus b) Nasal pharyngeal suctioning (1) See Clinical Skill 21–1: Performing Nasal Pharyngeal Suctioning, p. 516 3. Provide, maintain warmth a) Dried immediately with warmed, soft blanket b) Dry head first c) Skin-to-skin contact with mother, both covered d) Stocking cap

B. Apgar scoring system 1. See Table 21–5: The Apgar Scoring System, p. 517 2. Evaluate physical condition of newborn a) 1 minute and 5 minutes after birth b) Total score of 0 to 10 based on five criteria 3. Five criteria evaluated a) Heart rate b) Respiratory effort c) Muscle tone d) Reflex irritability e) Skin color 4. Overall scores a) 7 to 10 → good condition, nasopharyngeal suctioning b) 4 to 7 → need for stimulation c) Less than 4 → need for resuscitation

C. Newborn physical assessment by the nurse 1. See Table 21–6: Initial Newborn Evaluation, p. 518 2. Abbreviated systematic physical assessment a) Size of newborn b) Contour, size of head in relationship to rest of body c) Posture, movements d) Muscle tone 16 Copyright © 2020 Pearson Education, Inc.

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e) Palpation of fontanelles f) Inspect face, ears, neck g) Skin inspected for discoloration, presence of vernix caseosa, lanugo (1) Evidence of trauma, desquamation h) Observe nares for flaring i) Inspect palate j) Suction as needed with bulb syringe k) Inspect chest for respiratory rate, retractions l) Auscultation m) Normal respiratory rate (RR) 30 to 60 breaths per minute n) Heart auscultated → 110 to 170 beats/min o) Inspect umbilical cord, abdomen p) Genital area, buttocks, anus noted q) Extremities inspected for symmetry r) Reflexes assessed

D. Newborn identification 1. Nurse gives mother and newborn identification codes in birthing or delivery room a) Mothers wrist, sometimes wrist of partner b) Newborn → two, one on wrist, one on ankle c) Security device on cord clamp, id bracelet (1) See Figure 21–8: A newborn with a security device in place on one ankle, p. 518 2. Security measures a) Identification b) Parent education c) Do not leave baby in room unattended, send to nursery d) Footprinting

E. Initiation of attachment 1. Emotional time for family a) Touching baby b) Talking to baby, often high-pitched voice 2. Lights can be dimmed → newborn open eyes wide a) First hour, newborn quiet 3. Complete assessments while baby is on mother’s chest or abdomen 4. Breastfeeding can be encouraged 5. Enhance attachment a) Minimize assessments b) Delay instillation of ophthalmic antibiotic for first hour c) Keep room slightly darkened, avoid loud noises

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d) Provide privacy per parents’ request (1) Parents may want immediate contact (2) Parents may want to wait until placenta expelled, episiotomy repaired e) Support wishes of parents f) Encourage to delay phone calls and visits for first hour

F. Delivery of the Placenta 1. Physician/CNM observes for signs of placental separation a) Uterus rises upward in abdomen → placenta settles downward into lower uterine segment b) As placenta proceeds downward → umbilical cord lengthens c) Sudden trickle, spurt of blood d) Uterus changes from discoid to globular shape 2. Nurse palpates uterus gently to check for ballooning 3. Expelling placenta a) Maternal bearing-down effort b) Controlled cord traction c) Fundal pressure 4. To assist in expelling placenta a) Ensure separation has occurred b) Place one hand above symphysis pubis → palm against anterior surface of uterus c) Elevation of uterus straightens birth canal d) Gentle traction → excessive traction increases risk of uterine, inversion, snapping of cord 5. Fundal pressure not method of choice a) Uncomfortable b) May damage uterine supports c) May invert uterus d) Mother → relax abdominal muscles e) Hand of physician/CNM scoops downward → contracted uterus is pressed downward in an arc 6. Inspection of placental membranes a) All cotyledons present → especially with Duncan mechanism (1) If there is a defect or a part missing from the placenta, a digital uterine examination is done b) Time and mechanism noted c) Vagina and cervix inspected for lacerations d) Fundus palpated; normal position is at the midline and below the umbilicus

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G. Use of Oxytocics 1. Stimulate uterine contractions after birth a) Reduce incidence of third-stage hemorrhage 2. May request 10 units of oxytocin be given intramuscularly to woman a) Anterior shoulder of infant at vaginal opening b) May be administered after placental expulsion 3. May add 10 to 20 units of oxytocin to IV fluids instead 4. Other medications a) Methylergonovine maleate (Methergine) b) Carboprost tromethamine (Hemabate) c) Misoprostol (Cytotec) → off-label use (1) Undesirable side effects including shivering, pyrexia, and diarrhea

VII.

Nursing Care During the Fourth Stage of Labor

A. Immediately after expulsion of placenta 1. Lasts 1 to 4 hours after birth until vital signs are stable 2. Episiotomy, vaginal lacerations repaired 3. Uterus palpated every 15 minutes → for hour, until firm and bleeding within normal limits a) Uterus sensitive to touch 4. Care of newborn next to mother 5. Behavioral characteristics of mother vary

B. Provision of Care in the Fourth Stage 1. After repairs completed, drapes removed 2. Clean absorbent pads beneath mother a) Maternity pads b) Cold pack on perineum c) Assist for shower as needed d) If stirrups used → clean perineum before removing legs from stirrups e) Legs removed from stirrups at same time f) Transfer to recovery room as appropriate 3. Encourage family celebration while assessing maternal bleeding, newborn stabilization a) Blood pressure, pulse → 5- to 15-minute intervals b) Firmness and position of fundus (1) Firm at the umbilicus or lower and in the midline c) Boggy uterus → feels soft → kneading motions → fundus will tighten to firm, hard object 19 Copyright © 2020 Pearson Education, Inc.

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(1) See Clinical Skill 21–2: Assessing the Uterine Fundus Following Vaginal Birth, p. 522 d) Inspect bloody vaginal discharge (1) Lochia (a) See Clinical Skill 32–2: Evaluating Lochia, p. 871 (2) Minimal, moderate, or heavy amount (3) Weigh maternity pads (a) 1 g is equivalent to approximately 1 mL of blood e) Continuous observation if perineal pad soaked in 15 minutes, or blood pools f) If fundus rises, displaces to right → palpate bladder for distension (1) Decreased sensations to void as a result of the decreased tone of the bladder (2) Catheterize if unable to void (3) Distended bladder → uterine atony → increasing postpartum bleeding g) Inspect perineum for edema, hematoma 4. Report the following to physician/CNM a) Hypotension b) Tachycardia c) Uterine atony d) Excessive bleeding e) Temperature > 38°C (100.4°F)

C. Promotion of comfort in the fourth stage 1. Tremors, shivering common a) Heated blanket b) Warm drink 2. Tired, hungry, thirsty a) Meal b) Sleep 3. Transfer to postpartum unit a) Per policy b) Vital signs stable c) Stable lochia d) Nondistended bladder e) Firm fundus f) Sensations fully recovered from any anesthetic agent received

VIII.

Nursing Care of the Adolescent

A. Adolescent patients 1. Ongoing support throughout labor and birth 2. Assess each patient a) Has young woman received prenatal care?

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b) What are her attitudes and feelings about the pregnancy? c) How does her developmental stage influence her behavior, and how are her specific needs different? d) Who will support her during birth, and what is person’s relationship to her? e) What preparation has she had for the experience? f) What are her expectations and fears regarding labor and birth? g) How has her culture influenced her? h) What are her usual coping mechanisms? i) Does she have adequate social support? j) Does she plan to keep the newborn? If so, does she need to learn parenting skills? k) Will the father of the baby be involved in the labor and birth experience?

3. Highest risk for pregnancy and labor complications a) If no prenatal care → close observation during labor b) Review record for risks c) More likely to have poor nutritional intake, preeclampsia, cephalopelvic disproportion (CPD), anemia, prematurity, drugs ingested during pregnancy, sexually transmitted infections, fetal death, and size–date discrepancies (gestation appears to be less than dates indicate because of minimal weight gain) 4. Support role depends on support system a) Establish trusting relationship b) Positive reinforcement c) Younger the adolescent → less able she may be to participate in process

B. Age-Related Responses to Labor and Birth 1. Very young adolescent (under age 14) → fewer coping mechanisms a) Needs someone to rely on at all times during labor b) More childlike and dependent c) Transition → withdrawn (1) Needs touching, soothing encouragement, nurturing 2. Middle adolescent (ages 14 to 16) a) May try to remain calm, unflinching 3. Older adolescent (ages 16 to 19) a) May feel they “know it all” b) Nurse needs to use reinforcement and nonjudgmental manner

C. The Adolescent Father 1. Important part of labor and birthing care 2. Early labor a) Talk about expectations for parenting, resources available b) May need encouragement to provide supportive care

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c) Use lay terms to answer questions honestly

D. Other Members of the Support Team 1. Adolescent mother may want parents, friends a) May want her parents b) May look to friends 2. Respect young woman’s privacy, honor her wishes 3. Advocate

E. Teaching the Adolescent Mother 1. Latent phase of labor a) Explain changes in body sensations, emotional reactions b) Teaching about possible procedures c) Assess for resources for infant, postpartum supplies, transportation, child care 2. Infant care information a) Breastfeeding information b) Support decision making 3. May relinquish newborn a) Seeing infant can facilitate grieving process, but is her choice

IX.

Nursing Care During Precipitous Labor and Birth A. Rapid labor → labor and birth last < 3 hours → nurse must manage birth of baby 1. Woman may feel disappointed, frightened, cheated, abandoned if physician/CNM not present 2. Keep woman informed

B. Imminent birth 1. Do not leave woman alone 2. Direct auxiliary personnel to retrieve precip pack and contact physician/CNM a) Pack contains (1) Small drape (2) Bulb syringe (3) Two sterile clamps (Kelly or Rochester) to clamp the umbilical cord before applying a cord clamp (4) Sterile scissors to cut the umbilical cord (5) Sterile umbilical cord clamp, either Hesseltine or Hollister (6) Baby blanket (7) Package of sterile gloves

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3. Remain calm a) Will reassure woman

C. Birth of the Baby 1. Encourage woman to assume comfortable position 2. Scrub hands, sterile gloves as time permits 3. Clear instructions to woman 4. Most vertex → when crowning instruct to blow, pant 5. If amniotic sac intact → tear with clamp 6. Index finger inside lower portion of vagina → stretching, “ironing the perineum” 7. Gentle pressure on head to maintain flexion a) Slows birth b) Do not force head back forcibly 8. Support perineum with the other hand and allow the head to be delivered between contractions 9. Woman continues to blow, pant → insert one or two fingers along back of fetal head to check for umbilical cord a) Grasp cord, pull over head, loosen, slip over shoulder b) If too tight → clamp with two clamps, cut between 10. Head typically rotates → nurse needs to let it rotate 11. After delivery of head → suction mouth, throat, then nose 12. Hand on each side of head of newborn → instruct mother to push down gently 13. Support as it emerges

D. Breech vaginal delivery 1. Rare (3%) 2. Most scheduled for cesarean birth 3. Primary concern → entrapment of head in cervix 4. Avoid intervention until buttocks born a) Pull loop of cord, support breech in both hands b) Lift slightly upward, shoulder passes under symphysis pubis c) Then lower and the anterior shoulder and arm will pass under the symphysis pubis d) Suprapubic pressure applied → maintain the normal flexion of the baby’s head → continued until the baby is born

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E. After birth 1. Newborn held at level of uterus to facilitate blood flow through cord 2. Infant slippery 3. Dry quickly 4. Head slightly lower to aid drainage of fluid, mucus 5. Apgar score assessed at 1 and 5 minutes 6. Alert for signs of placental separation a) Gentle downward traction on cord while instructing mother to push b) Inspect placenta 7. Assess firmness of uterus a) No palpation of uterus before separation of placenta 8. Cut umbilical cord a) Two clamps → 2 to 4 inches from newborn’s abdomen b) Cut between clamps with sterile scissors 9. Clean under mother’s buttocks a) Inspect for lacerations b) Bleeding from lacerations → pressing a clean perineal pad against the perineum → instruct woman to keep her thighs together

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10. Transport newborn to nursery if arrival of physician/CNM delayed, signs of respiratory distress

F. Record Keeping 1. Position of fetus at birth 2. Presence of cord around neck or shoulder (nuchal cord) 3. Time of birth 4. Apgar scores at 1 and 5 minutes 5. Gender of newborn 6. Time of expulsion of placenta 7. Method of placental expulsion 8. Appearance and intactness of placenta 9. Mother’s condition 10. Any medications that were given to mother or newborn (per agency protocol)

G. Postbirth Interventions 1. Same as those discussed in Nursing Care During the Third Stage of Labor section

X.

Evaluation A. Determine effectiveness of nursing care B. Anticipated 1. Mother’s physical needs and psychologic well-being of family have been maintained and supported 2. Baby’s physical and psychologic well-being has been protected and supported 3. Family has had input into birth process, and members have participated as much as they desired 4. Birth was safe and promoted family cohesiveness

XI.

Focus Your Study

XII.

Activities 1. Individual Have students prepare drug cards for the following medications, which are frequently used in labor:

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• • • •

Oxytocin Methylergonovine maleate Carboprost tromethamine Misoprostol

2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan for the adolescent in early labor. Instruct the students to include fetal heart rate (FHR) monitoring and potential interventions after delivery.

3. Large Group Show a video from the following link http://childbirthvideo.biz/. Stop as necessary to identify phases of the delivery process.

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Chapter 22 Pharmacologic Pain Management Medicated Birth....................................................................................................

2

Systemic Analgesia................................................................................................

3

Regional Anesthesia and Analgesia......................................................................

7

General Anesthesia...............................................................................................

18

Analgesic and Anesthetic Considerations for the High-Risk Mother and Fetus……………………………………………………………………………………………………..

20

Focus Your Study...................................................................................................

21

Activities................................................................................................................

21

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I.

Medicated Birth

A. Unmedicated versus medicated decisions involves many factors 1. Caregiver preference 2. Availability of analgesia & anesthesia 3. Fear of risks, complications 4. Past experiences 5. Previous pain experience 6. Culture

B. Increasing levels of pain 1. Interfere with coping

C. Decisions regarding medicates/unmedicated birth 1. Many factors 2. Support decision a) Offer alternatives if they do not want pharmacologic remedies 3. 2/3 of U.S. births receive regional anesthesia like an epidural 4. Offer alternative comfort measures 5. Pharmacologic agents affect fetus 6. Response to pain and stress also affects fetus

D. Unprepared for intense pain 1. Physiological and emotional responses to labor a) Increased respiratory rate b) Increased oxygen consumption c) Metabolic acidosis d) Release of catecholamines, leading to constriction of maternal blood vessels e) Fear and anxiety f) Feeling of being out of control g) Stalled labor progression.

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E. Goal is healthy, satisfying outcome for family

II.

Systemic Analgesia

A. Goal → maximum pain relief with minimal risk B. Systemic analgesia → pain medication given intravenously, intramuscularly, or via inhalation that does not result in complete loss of sensation or a reduction of motor functioning C. Multiple factors to consider 1. Effects on woman a) Adequate functioning of maternal cardiopulmonary system b) Fetal well-being dependent on woman 2. Effects on fetus a) All systemic analgesics → cross placental barrier by simple diffusion b) Crosses blood-brain barrier c) Fetal liver enzymes and renal systems are inadequate to metabolize analgesic agents (1) High doses remain active in fetal circulation for a prolonged period of time 3. Effects on labor contractions a) Lack of research and evidenced-based practice on pain management during labor for women with opioid dependencies b) Most physicians do not offer analgesics, direct to use an epidural 4. Medical status of woman 5. History of substance abuse; current use of substances, including alcohol 6. Progress of labor

D. Administration of Analgesic Agents 1. Optimal time determined after complete assessment of many factors a) In past → labor well established b) Current thinking → woman’s request for pain medications c) Too early → prolong labor d) Too late → no value e) Nurse observes woman for cues f) NO can be given at any point in labor, requires physician order 2. Maternal assessment a) Critical prior to administration (1) Woman willing to receive medication after being advised about it (2) Vital signs are stable (3) Contraindications are not present 3 Copyright © 2020 Pearson Education, Inc.

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(4) Knowledge of other medication being administered (5) See Box 22–1: What Women Need to Know About Pain Relief Medications, p. 531 3. Fetal assessment a) Fetal heart rate (FHR) is between 110 and 160 beats per minute b) Variability is present c) Late decelerations or recurrent variable decelerations are absent 4. Assessment of labor a) Contraction pattern b) Cervical dilatation c) Cervical effacement d) Fetal presenting part e) Station of the fetal presenting part 5. Routes of administration a) Oral analgesic not used b) Intramuscular (IM), intravenous (IV), subcutaneous (SC) c) IV preferred → prompt smooth predictable action d) IM, SC → takes a few minutes for effect to be felt e) NO self-administered by woman → rapid onset → leaves body quickly during exhalation

E. Sedatives 1. Primarily in early latent phase a) When the cervix is long, closed, and thick b) Relaxation and sleep for the expectant woman 2. Benzodiazepines a) Lorazepam (Ativan), midazolam (Versed) (1) No longer used for pain management in labor (2) May be used to treat anxiety after birth (3) Primary use in intrapartum setting → anticonvulsant (4) Flumanzenil → reverse benzodiazepine sedative effects b) H1-receptor antagonists → block action of histamines (1) Sedative effects (2) Anti-Parkinson, antiemetic effects (3) Seven subtypes (4) Used to promote sleep, decrease anxiety (5) Promethazine (Phenergan) (a) Often combined with opiates, antiemetic effects (b) Cross placental barrier → decreased beat-to-beat variability (c) IM injections painful (d) Does not cause lower APGAR scores (e) Can decrease variability

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(f) Binds to bilirubin → increases incidence of neonatal hyperbilirubinemia and jaundice (6) Diphenhydramine (Benadryl) (a) Over-the-counter to treat allergic rhinitis, urticaria (b) Sedative, antiemetic properties (c) Short half-life (d) Can cause agitation in some women 3. Nursing care a) Assessment before administering medications (1) Stage of labor (2) Frequency, duration, intensity of contractions (3) Vaginal exam (4) Fetal well-being established b) Education c) Ensure safe environment

F. Narcotic Analgesics 1. Injected into circulation → primary action at sites in brain 2. See Table 22–1: Analgesics Used in Labor, p. 533 3. Fentanyl (Sublimaze) a) Short-acting synthetic opioid, moderate analgesia, mild sedation b) Rapid onset c) Limited placental transfer d) Short half-life e) 50 to 100 mcg every hour f) Very useful in active labor, 5 cm dilated → helps over the hump to transition and second stage 4. Nursing care a) Prior to administration, confirm woman does not have any opioid dependency or addiction b) Evaluate respiratory and cardiac status (1) Vital signs, pulse oximetry (2) Level of consciousness checked frequently (3) Continuous EFM c) Naloxone (Narcan) can improve respiratory depression in mother, fetus/newborn 5. Nalbuphine hydrochloride (Nubain) a) Synthetic agonist-antagonist analgesic (1) May precipitate withdrawal if woman is physically dependent on narcotics b) Crosses placenta to fetus c) IM, SC, IV → most frequently IV in birth setting d) 10 mg/70 kg → onset 2 to 3 minutes → peak 15 to 20 minutes → 3 to 6 hour duration 5 Copyright © 2020 Pearson Education, Inc.

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e) Nursing care (1) Assess history for contraindications (a) Current narcotic drug dependence, sensitivity to sulfites, history of asthma (2) IV route frequently used during labor (a) Directly into tubing of running IV (b) 10 mg, over 3 to 5 minutes (3) Respiratory rate, quality of respirations, FHR (4) Urinary urgency (5) Experience dizziness and sedation 6. Opiate antagonist: Naloxone (Narcan) a) Antagonist with little or no agonistic effect b) Exhibits little pharmacologic activity in the absence of narcotic agent c) Can reverse mild respiratory depression, sedation, hypotension following small doses of opiates (1) Drug of choice when the depressant is unknown because it will cause no further depression d) Nursing care (1) When administered → resuscitative measures and trained personnel should be present as precaution additional respiratory support is needed (2) Inject undiluted, 0.4mg over seconds into tubing of running IV (a) Obtain maternal vital signs every 5 minutes until respiratory rate stable, then every 30 minutes (3) Neonatal dose can be given IV, IM, or ET (a) Dose 0.01mg/kg (4) Duration shorter than analgesics, monitor for return of respiratory depression 7. Nitrous oxide a) Making comeback in obstetrics b) Safe, effective and inexpensive c) Has not been shown to impact on rate of vaginal births, uterine activity, or risk of complication, breastfeeding, or Apgar scores d) Given in mixed concentration of 50% NO & 50% oxygen for obstetrics e) Apparatus uses a demand valve (1) Completely controlled by the woman f) Also has anxiolytic properties g) Rapid onset and offset h) Crosses placenta (1) Does not impact FHR pattern, depression i) Contraindications (1) Few (2) Inactives vitamin B12, do not give to women with B12 deficiency, Crohn’s, celiac, pernicious anemia, alcoholism, anorexia, recent bariatric surgery (3) Pneumothorax or obstructed bowel (4) Inability of woman to hold her own mask or tolerate potential side effects 6 Copyright © 2020 Pearson Education, Inc.

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j) Nursing Care (1) Assess (2) Consents and order (3) Education (4) Involve partner to cue to use NO with contraction use (5) No one else should hold mask for patient (6) Woman fall risk (7) Assess woman’s vital signs, FHR pattern (8) Document

III.

Regional Anesthesia and Analgesia

A. Regional anesthesia → temporary and reversible loss of sensation 1. Produced by injecting anesthetic agent into area that will bring agent into direct contact with nervous tissue 2. Local agent stabilizes cell membrane → prevents initiation, transmission of nerve impulses 3. Common in childbearing → epidural, spinal, combined a) Epidural → labor, vagina birth, cesarean birth (1) Relieves pain associated with first stage of labor (2) Can also be used in second stage, birth 4. See Figure 22–1: Schematic diagram showing pain pathways and sites of interruption, p. 536 5. See Table 22–2: Summary of Commonly Used Regional Blocks, p. 537 6. Regional anesthesia → less risk than general 7. Regional analgesia → temporary and reversible pain relief a) Inject analgesic into nervous tissue supplying region b) Using same agent as anesthesia problematic c) Use narcotic agent such as fentanyl along with small amount of local anesthetic (1) Pain relieved, blood pressure stable 8. Intrathecal injection a) Subarachnoid (spinal) space (1) Fentanyl citrate, preservative-free morphine (2) Pain relieved, urinary retention may occur 9. Informed consent a) Answer questions, address concerns early

B. Action and Absorption of Anesthetic Agents 1. Block nerve conduction by: a) Impairing propagation of action potential in axons b) Impairing transmission of nerve impulses by stabilizing cell membrane 7 Copyright © 2020 Pearson Education, Inc.

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2. Absorption depends on vascularity of area of injection a) Increase blood flow → cause vasodilation b) Higher concentration → greater vasodilation

C. Types of Local Anesthetic Agents 1. Esters a) Procaine hydrochloride (Novocain) b) Chloroprocaine hydrochloride (Nesacaine) c) Tetracaine hydrochloride (Pontocaine) d) Rapidly metabolized → toxic levels less likely to be reached 2. Amides a) Bupivacaine hydrochloride (Marcaine) b) Mepivacaine hydrochloride (Carbocaine) c) Ropivacaine hydrochloride (Naropin) d) Levobupivacaine (Chirocaine) e) Lidocaine hydrochloride (Xylocaine) f) More powerful, longer acting than ester types g) Readily cross placenta, affect fetus for prolonged period 3. Opiates a) Morphine (Duromorph) b) Fentanyl (Sublimaze) c) Used alone epidurally → less pain relief d) Combination achieves better pain control e) Pruritus f) Common with cesarean → effective with postpartum pain g) Fentanyl may interfere with early breastfeeding (1) Dose dependent

D. Adverse Maternal Reactions to Anesthetic Agents 1. Mild a) Palpitations, vertigo, tinnitus, apprehension, confusion, headache, metallic taste in the mouth 2. Common side effects a) Pruritus, vertigo, dizziness, urinary retention 3. Moderate reactions a) More severe degrees of mild symptoms plus b) Nausea, vomiting, hypotension, muscle twitching (may lead to convulsions and loss of consciousness)

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4. Severe reactions a) Sudden loss of consciousness, coma, severe hypotension, bradycardia, respiratory depression, cardiac arrest 5. Systemic toxic effects a) Most common with excessive dose 6. Women in labor a) Generally require less medication → hormonal factors, uterine compression, increased cardiac output, increased sensitivity of neural axons b) Imperative → close supervision with IV line in place 7. Epinephrine in anesthetic → differentiate reaction 8. Psychogenic reactions a) Severe anxiety, hallucinations, inability to move or speak, catatonic appearance 9. Allergic reactions a) Antigen-antibody reaction b) Urticaria, laryngeal edema, joint pain, swelling of the tongue, bronchospasm 10. Treatment of systemic toxicity a) Oxygen by mask, IV injection of short-acting barbiturate to decrease anxiety 11. Treatment of convulsions a) Establish airway, administer 100% oxygen b) Benzodiazepines or propofol c) Small doses to help avoid cardiorespiratory depression 12. Treatment of sudden cardiovascular collapse a) Airway, cardiopulmonary resuscitation, IV fluids, emergency cesarean birth b) Displace uterus during CPR c) After 4 minutes of resuscitative measures, a bedside cesarean birth must be started in order for delivery of the baby within 5 minutes

E. Lumbar Epidural Block 1. Injection of local anesthetic into epidural space a) See Figure 22–2: The epidural space lies between the dura mater and the ligamentum flavum, extending from base of the skull to the end of the sacral canal, p. 539 b) Space accessed through lumbar area c) Continuous block d) Complete pain relief → 85% of women 2. Common during labor and birth a) U.S. rates rising b) Demographic differences c) Does not pass through placenta to affect fetus

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3. Administration a) Single dose with epidural needle b) Single dose through epidural catheter with additional doses as needed c) Continuous epidural infusion via pump 4. Many women equate quality of labor to satisfaction with anesthesia 5. Guidelines a) Should be performed when woman experiences pain b) Asks for epidural 6. Complications a) Urinary catheterization b) Pitocin augmentation of labor c) Intrauterine pressure catheter use d) Fetal malpresentation associated with decreased maternal movement during labor e) Increased rates of assisted vaginal deliveries (forceps or vacuum assistance) f) Spinal headaches 7. Advantages a) Good analgesia b) Fully awake c) Adjustable d) Once pump off → wears off in 2 hours 8. Disadvantages a) Maternal hypotension → peripheral vasodilation (1) Preload with rapid infusion of IV fluids (2) Approaches (3) Single dose → gradual onset, less medication b) Postdural puncture seizures, meningitis, cardiorespiratory arrest, vertigo c) Onset of analgesia → 30 minutes d) Skilled personnel e) FHR → Variability may decrease f) Costly g) Decreased sensation and movement 9. Contraindications → absolute a) Maternal refusal b) Local or systemic infection c) Uncorrected hypovolemia d) Coagulation disorders e) Actual or anticipated maternal hemorrhage f) Increased intracranial pressure g) Allergy to a specific class of local anesthetic agents

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10. Contraindications → relative a) Platelet count less than 100,000/mm3 b) Severe anatomic abnormalities of the spine c) Uncooperative patient d) Sepsis e) Hypertension 11. Individual evaluation a) Previous back surgery b) Suspicion of neurologic disease c) Long-term use of aspirin, anti-inflammatory agents d) Abruptio placentae e) Acute infection at the epidural site f) Heart failure, aortic stenosis → may need invasive monitoring 12. Technique for continuous lumbar epidural block a) Maternal and fetal status, labor progress assessed b) Oxygen and resuscitative equipment readied c) IV infusion begun, preload of 500 to 1000 mL IV fluid given over 15 to 30 minutes d) Woman positioned on left or right side, at edge of bed, knees flexed or (1) Sitting on the edge of the bed, shoulders dropped, back rounded, chin on chest (2) Arch back like a cat (3) Assist with breathing, alert anesthesia provider when contraction occurs (4) See Figure 22–3: Positioning woman for epidural anesthesia block, p. 541 e) Skin prepared with antiseptic agent by the anesthesia provider f) Skin wheal of a small amount of local anesthesia given intradermally by anesthesia provider g) Anesthesia provider inserts short, beveled 16- to 18-gauge needle with stylet → to ligamentum flavum in widest interspace below second lumbar vertebra h) Anesthesia provider injects 5 mL preservative-free saline in order to pass catheter into epidural space more easily i) Catheter inserted approximately 1 to 2 cm into epidural space by anesthesia provider (1) Needle removed (2) Aspiration for blood or cerebrospinal fluid attempted j) If aspiration tests are negative → test dose injected (1) 1.5% lidocaine with epinephrine 1:200,000 concentration or (2) 3 mL of 0.23% bupivacaine with 1:200,000 concentration of epinephrine (3) Usually injected after aspiration, after a uterine contraction (4) If subarachnoid space has been entered → sensory and motor changes occur in woman’s extremities (5) If no untoward effects → additional anesthetic agent is injected (6) Catheter securely taped k) Nurse assists woman into semireclining position with lateral tilt of uterus → allows for distribution of block (1) Maintained in side-lying position to maximize uteroplacental perfusion 11 Copyright © 2020 Pearson Education, Inc.

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l) Anesthesia provider or nurse → monitor maternal blood pressure every 1 to 2 minutes for first 10 minutes (1) Every 5 to 15 minutes until block wears off (2) Nurse is responsible for documentation of assessment data obtained throughout the procedure m) Woman attended by nurse, nurse anesthetist, anesthesiologist for first 20 minutes following initial dose, after administration of any additional dose n) If hypotension (20% to 30% fall in systolic pressure, or below 100 mm Hg) → nurse ensures left lateral displacement of uterus maintained, IV fluids infused more rapidly (1) Oxygen by face mask (2) 10- to -20 degree Trendelenburg may be used (3) If blood pressure not restored within 1 to 2 minutes → vasopressor may be administered IV (a) Ephedrine, 5 to 15 mg o) Maternal blood pressure, pulse, FHR continue to be monitored by nurse p) If epidural not being administered by continuous pump → anesthesiologist aspirates catheter before administering subsequent doses 13. Technique for single-dose lumbar epidural block a) Same as lumbar block → instead of injecting 5 mL saline → test dose of 2 to 3 mL anesthetic agent to make sure dura mater has not been penetrated b) After checking again to confirm dura mater not perforated → clinician injects single dose of 10 to 12 mL to provide anesthesia for birth c) Subsequent care continues as for the procedure just described, from step 11 14. Problems and adverse effects a) Major (1) Maternal hypotension → results in uteroplacental insufficiency in fetus, manifested as late decelerations (a) Minimize risk → hydrating with 500 to 1000 mL IV solution before procedure (b) Intervention is to think of flip, flush, and O (i) Reposition to other side (ii) Increase fluids (iii) 10 L oxygen by non-rebreather facemask b) Inadequate block, unilateral block, block failure (1) One-sided block → have woman lie on unanesthetized side, inject more of local anesthetic agent (2) Continuous pump → turn from side to side (3) May have window of pain (4) Breakthrough pain c) Nurse assesses woman → calls anesthesia provider for additional medication d) Pruritus → diphenhydramine (Benadryl) e) Maternal temperature may be elevated to 37.8°C (100.4° F) or higher f) Headache, migraine headaches, neck aches, tingling of hands, fingers g) Short-term tenderness at puncture site 12 Copyright © 2020 Pearson Education, Inc.

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h) Urinary retention, shivering, nausea, vomiting 15. Complications a) Serious (1) Systemic toxic reaction → unintentional placement of drug in arachnoid, subarachnoid space, excessive amount of drug in epidural space, accidental intravascular injection (2) Likelihood of toxic reactions is higher than with some of the other regional procedures b) Pain during cesarean birth c) Spinal headaches 16. Nursing care a) Assess maternal vital signs, FHR for baseline information → within normal limits b) Document on EFM strips, nursing notes c) Labor progress assessed d) Procedure, expected results, questions answered (1) Nurse acts as advocate e) Nurse starts IV infusion, preloads per physician’s order or agency protocol (1) Usually dextrose free f) Void prior to block g) Support person present h) After block → semireclining position, head at 23 degrees, lateral uterine tilt (1) Then side-lying position i) Maternal blood pressure, pulse every 5 minutes → 30 minutes (1) Every 30 minutes thereafter (2) FHR monitored, assessed by continuous EFM j) Hypotension → corrective measures (1) Observe FHR k) Repeat regimen of assessing maternal blood pressure, etc. → additional local anesthetic agents injected l) If legs in stirrups → assess blood pressure when legs taken out m) Frequent bladder assessment n) Catheterization as necessary o) Shivering sensation suppressed → warmed blankets p) Assess level of pain relief q) Respiratory rate, quality of respirations assessed at least every 15 to 30 minutes r) Nurse asks if woman experiencing pruritus → alert for scratching (1) Benadryl as ordered s) Woman may require assistance pushing in second stage of labor → not feel contractions, urge to push t) Return of sensation prior to ambulation

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F. Spinal Block 1. Local anesthetic agent injected directly into spinal fluid in subarachnoid space to provide anesthesia for cesarean birth → blockade to the T4 dermatome a) Much higher level of anesthesia in pregnant woman than nonpregnant b) Low failure rate (1) Spinal blocks allow the anesthesia to mix directly with the cerebrospinal fluid → eliminates “windows” c) See Figure 22–5: Levels of anesthesia for vaginal and cesarean births, p. 546 2. Advantages a) Immediate onset of anesthesia b) Relative ease of administration c) Smaller drug volume d) Maternal compartmentalization of drug e) Frequently regional block or choice in acute obstetrical emergencies 3. Disadvantages a) Primary is intense blockade of sympathetic fibers → high incidence of hypotension b) Uterine tone maintained → manipulation difficult c) Short acting 4. Contraindications a) Severe hypovolemia b) Central nervous system disease c) Infection over the site of puncture d) Maternal coagulation problems e) Allergy to local anesthetic agents f) Sepsis, active genital herpes → relative contraindications g) Women who do not wish to have spinal procedure 5. Technique a) Nurse assists woman into sitting or left lateral position b) IV infusion checked for patency c) Nurse helps woman into same position as for lumbar epidural block d) Anesthesiologist/nurse anesthetist prepares skin carefully → maintaining sterility e) Skin wheal made over L3 or L4 f) 18- or 19-gauge needle introduced through the skin → into interspinous ligament (1) 24- to 27-gauge pencil-point needle introduced inside the larger needle → inserted into ligamentum flavum→ epidural space through dura mater → subarachnoid space g) The appropriate amount of anesthetic agent injected slowly → both needles removed h) Upon removal → drop of cerebrospinal fluid can be seen in hub of needle if subarachnoid space entered i) Hyperbaric solutions → woman sitting up for 45 seconds j) Nurse assists woman onto back with pillow under head 14 Copyright © 2020 Pearson Education, Inc.

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(1) Position changes can alter dermatome level if done within 3 to 5 minutes (2) After 10 minutes → position change will not affect level of anesthesia k) Nurse monitors blood pressure, pulse, respirations every 1 to 2 minutes for first 10 minutes, then every 5 to 10 minutes l) No direct effect on fetus 6. Complications a) Hypotension b) Drug reaction c) Total spinal neurologic sequelae d) Spinal headache e) Side effects (1) Nausea (2) Shivering (3) Urinary retention f) Prehydrate with 500 to 2000 mL of non–dextrose-containing fluids (1) Positioning woman in lateral, head-down position (2) Rapid IV fluids (3) Early detection → supplemental oxygen, assisted ventilation, measures to maintain blood pressure (a) Lateral, head-down position (b) If maternal hypotension has been reversed → delay the birth for 4 to 5 minutes to allow the fetus to recover (c) If doesn’t resolve → ephedrine IV g) Anesthesia in phrenic nerve or higher (1) Respiratory function impaired h) Complete spinal → respiratory assistance needed, loss of consciousness i) Total spinal → paralysis of respiratory muscles (1) Within 30 seconds to 45 minutes (2) Resuscitative treatment, airway control j) Inadequate anesthesia coverage → discomfort k) Neurologic complications → coincidental with preexisting disease l) Headache from leakage of spinal fluid (1) Postural headaches can last up to 7 days (2) Blood patch with severe headache 7. Nursing care a) Assist in positioning b) Provide oxygen c) Assess, record baseline vital signs of mother, fetus d) Start IV infusion with bolus e) Continue to monitor maternal blood pressure, pulse, respiration f) Monitor FHR at least every 5 minutes g) Positioning h) Detect contractions 15 Copyright © 2020 Pearson Education, Inc.

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i) Wedge pillow under right hip to displace uterus j) Inform woman of what is going on k) Continue to monitor maternal blood pressure, pulse, respiration l) Monitor FHR at least every 5 minutes m) Raising legs facilitates venous return n) Keep woman flat following birth (1) May avoid headache o) Monitor breathing and for hypotension closely

G. Combined Spinal–Epidural Block 1. CSE used for labor analgesia and cesarean a) Epidural needle into epidural space b) Pencil-point anesthesia needle through epidural needle through dura → into cerebrospinal fluid c) Small amount of local anesthetic agent, opioid, or both injected d) Epidural catheter through epidural needle into epidural space e) Needle removed → catheter securely placed against woman with tape 2. Advantages a) Spinal agent faster onset b) Medication can be added 3. Disadvantages a) Higher incidence of pruritus, urinary retention b) CSEs not as commonly used

H. Pudendal Block 1. Perineal anesthesia a) Second stage of labor b) Birth c) Episiotomy repair 2. Anesthetic agent injected below pudendal plexus a) See Figure 22–7: A. Pudendal block by the transvaginal approach. B. Area of perineum affected by pudendal block, p. 548 3. Advantages a) Ease of administration b) Absence of maternal hypotension c) Allows use of forceps or vacuum extraction 4. Disadvantages a) Urge to bear down decreased b) Burning sensation

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5. Complications a) Systemic toxic reaction from accidental vascular injection b) Broad ligament hematoma c) Perforation of the rectum d) Trauma to sciatic nerve 6. Nursing care a) Explain procedure, expected effect, answer questions

I. Local Infiltration Anesthesia 1. Injecting anesthetic agent into intracutaneous, subcutaneous, intramuscular area of perineum a) Usually at time of birth for episiotomy and repair b) After birth if laceration occurred c) See Figure 22–8: Local infiltration anesthesia, p. 549 2. Advantages a) Involves least amount of anesthetic agent b) Just before birth for episiotomy 3. Disadvantages a) Large amount of solution must be used b) Burning sensation at time of injection 4. Nursing care a) Explain procedure, expected effect, answer any questions

J. Transversus Abdominis Plane Block 1. TAP block → growing in use for postop pain after cesarean birth 2. Ultrasound guided local anesthetic injected into the space between the transverse abdominus and internal oblique muscles 3. AKA “fill block” 4. Advantages a) Provide up to 12 hours of analgesia without need for opioids b) Useful women who cannot or should not use opioids after surgery c) Reduce opioid-related side effects, use d) Improve woman's satisfaction with pain control 5. Contraindications a) Infection at site b) Refusal or inability to consent c) Allergies

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IV.

General Anesthesia A. Induced unconsciousness 1. Cesarean birth, surgical interventions with some obstetric complications 2. Use declining 3. Decrease exposure of fetus → woman fully prepped and OB fully ready before administering 4. Most common indication a) Perceived lack of time for regional anesthesia b) Contraindications to regional anesthesia c) Failure of regional anesthesia d) Patient refusal of regional anesthesia

B. Intravenous Anesthetics 1. Propofol (Diprivan) a) Short-acting sedative b) Narcosis within 30 seconds after IV administration c) Initiating unconsciousness → intubation 2. Ketamine → intermediate-acting barbiturate a) Effects typically last 20 to 60 minutes b) Contraindicated in women with preeclampsia or chronic hypertension c) Supplement spinal block d) Given with midazolam (Versed) → known hallucinogen

C. Inhales Anesthesia Agents 1. Nitrous oxide a) No significant uterine relaxation b) Fetal tissue uptake → 20 minutes after administration c) Dosage decreased to 50%, mixed with 50% oxygen 2. Halogenated agents a) Isoflurane, sevoflurane, desflurane b) Often combined with nitrous oxide c) Sevoflurane has been associated with uterine relaxation d) Increased maternal inspired oxygen 3. In combination with spinal, epidural techniques a) Ineffective regional b) Severe maternal anxiety

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D. Complications of General Anesthesia 1. Fetal respiratory depression a) Directly proportional to depth, duration of anesthesia b) Most anesthetics reach fetus in about 2 minutes 2. Uterine relaxation 3. Risk of aspiration a) Chemical pneumonitis → Mendelson syndrome

E. Care During General Anesthesia 1. Prophylactic antacid therapy 2. Wedge under hip → displace uterus 3. Preoxygenated with 3 to 5 minutes 100% oxygen 4. IV fluids 5. Nurse applies cardiac monitors, blood pressure cuff, oxygen saturation device; holds face mask for oxygenating the woman while anesthesiologist draws up needed medication 6. Emotional support 7. Rapid induction → nurse applies cricoid pressure until anesthesiologist has placed cuffed ET tube 8. See Figure 22–9: Proper position for fingers in applying cricoid pressure until cuffed endotracheal tube is placed …, p. 551

F. Neonatal Neurobehavioral Effects of Anesthesia and Analgesia 1. Neurobehavioral effects influenced by other factors a) Hunger, degree of hydration, time within the sleep–wake cycle, gestational age, birth weight

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V.

Analgesic and Anesthetic Considerations for the High-Risk Mother and Fetus A. Skill required 1. Difficult to separate maternal and fetal complications 2. Team approach

B. Preterm Labor 1. Immature fetus → more susceptible to depressant drugs 2. Analgesia avoided whenever possible 3. Emotional support to woman

C. Preeclampsia 1. Potential for chronic placental insufficiency or preterm birth is also present 2. Incidence of hypotension with epidural anesthesia increased a) Further stress on an already compromised cardiovascular system 3. Regional anesthesia preferred with severe hypotension a) IV fluids to raise CVP b) Woman at risk for heart failure c) Invasive cardiovascular monitoring d) Monitor fluid intake and output e) Vasopressors considered 4. General anesthesia may aggravate maternal hypertension a) Intubation safest → may cause hypertensive episode b) May be more difficult due to mucosal edema

D. Diabetes Mellitus 1. Fetus may have reduction in placental blood flow a) Continuous epidural 2. Cesarean birth → woman more likely to experience cardiovascular depression with regional block a) Acute hydration b) Left uterine displacement

E. Cardiac Disease 1. Mitral stenosis → continual epidural with low forceps birth a) Avoids Valsalva

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2. IV fluids, central venous pressure monitoring → avoid hypotension 3. Epidural, general anesthesia → cesarean 4. Ketamine avoided → tachycardia

F. Bleeding Complications 1. Trend → schedule cesarean 2. Epidural if maternal cardiovascular system stable 3. Treat hypovolemia immediately 4. Regional blocks contraindicated during active bleeding a) General anesthesia recommended b) Oxytocin should not be given IV bolus → dilute infusion 5. Resources on hand a) Large-bore IV catheters b) Fluid warmer c) Forced-air body warmer d) Woman’s specific blood type or O negative e) Trained personnel f) Equipment to infuse blood products rapidly

VI.

Focus Your Study

VII.

Activities 1. Individual Have students prepare drug cards for the following medications: Seconal Fentanyl Zolpidem Morphine sulfate Promethazine Naloxone Hydroxyzine Procaine hydrochloride Diphenhydramine Chloroprocaine hydrochloride Meperidine Bupivacaine hydrochloride Nalbuphine Lidocaine hydrochloride Butorphanol 2. Small Group Divide the class into small groups of three to five students. Ask each group to prepare teaching plans for the laboring woman who will be receiving anesthesia from the following list. For each anesthesia, the groups must include the advantages and disadvantages to the mother and the fetus or newborn. Instruct each group to include the expected nursing interventions needed for each anesthesia and to cite resources using APA format.

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• • • •

Pudendal block Epidural block General anesthesia Local anesthesia

3. Large Group Invite a nurse anesthetist or perinatal nurse to speak to the students in your class about anesthesia. Ask your speaker to include the perioperative nursing care considerations of the postpartum woman, and both vaginal delivery and cesarean delivery in the presentation.

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Chapter 23 Childbirth at Risk: Prelabor Onset Complications Care of the Woman at Risk Due to Preterm Labor.........................................

2

Care of the Woman with Premature Rupture of Membranes.......................

7

Care of the Woman and Fetus at Risk Because of Placental Problems.........

10

Care of the Woman with Cervical Insufficiency.............................................

15

Care of the Woman with a Multiple Gestation..............................................

16

Care of the Woman and Fetus at Risk Because of Amniotic Fluid-Related Complications.......................................................................................

19

Focus Your Study.............................................................................................

21

Activities..........................................................................................................

21

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I.

Care of the Woman at Risk Due to Preterm Labor

A. Early-term birth between 37 and 38 weeks 6 days B. Full-term birth between 39 and 49 weeks 6 days C. Late-term birth occurring after the 41st week D. Postterm birth occurring after 42 weeks E. Preterm labor (PTL) → labor that occurs between 20 and 37 completed weeks of pregnancy 1. Number one cause of neonatal mortality and long-term neurological disability 2. African American women 17.7%, 10% of Native American/Alaskan Native, and a little less than 10% of Caucasian American and Asian American 3. See Table 23–1: Risk Factors for Spontaneous Preterm Labor, p. 555

F. Maternal Risks 1. Previous preterm birth 2. Screening for risk factors help eliminate modifiable risk factors a) Smoking, substance abuse, stress, alcohol use, other behavioral factors b) Preconception teaching c) Prenatal teaching d) Monitoring

G. Fetal-Neonatal Risks 1. Mortality increases before 37 weeks’ gestation 2. Neonates < 32 gestational weeks are nine times more likely to die in the neonatal period compared to those at 39–40 weeks 3. Preterm birth accounts for 25% of neonatal deaths and 36% of infant death 4. Maturational deficiencies a) Respiratory system most critical b) Greater the gestational age the lower the incidence of RDS c) Periviable → 20 0/7 to 25 6/7 weeks’ gestation → 40% of infant deaths d) Extremely preterm births → prior to 28 weeks → 0.5% of all live births (1) Inform parents, consider palliative care vs resuscitation efforts (2) Realistic expectations on prognosis e) Severe maternal diabetes, serious isoimmunization → continuation of the pregnancy may be more life-threatening to the fetus than the hazards of prematurity (1) See Genetic Facts: Genetic Patterns and the Risk of Preterm Birth, p. 556 2 Copyright © 2020 Pearson Education, Inc.

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5. Tocolytic drug therapy a) Primary goal to delay birth for maximum benefit of glucocorticoids (1) Reduction in RDS, necrotizing enterocolitis, intraventricular hemorrhage, neonatal jaundice, admission NICU when given prior to 34 weeks’ gestation (2) See Table 23–2 Selected Interventions for Periviable Fetus in Preterm Labor, p. 557 6. Prompt diagnosis of PLT difficult a) Symptoms common in normal pregnancy (1) Uterine contractions that occur every 10 minutes or less, with or without pain (2) Menstral-like cramps felt low in abdominal (3) Constant or intermittent feelings of pelvic pressure that may feel like the (4) baby pressing down Rupture of membranes Low, dull backache, which may be constant or intermittent A change in vaginal discharge (an increase in amount, a change to more clear and watery, or a pinkish tinge)Urinary frequency, urgency, hesitancy, or hematuria Abdominal cramping with or without diarrhea b) No attempt is made to stop labor (1) Fetal demise (2) Lethal fetal anomaly (3) Severe preeclampsia/eclampsia (4) Hemorrhage/abruptio placentae (5) Chorioamnionitis (6) Severe fetal growth restriction (7) Fetal maturity (8) Category III fetal heart rate tracing (9) Gestational age less than 24 weeks (10) Oligohydramnios (less than normal amount of amniotic fluid) (11) Absent or reversed diastolic flow upon Doppler examination of umbilical blood flow (12) Repetitive severe variable decelerations (13) Significant vaginal bleeding consistent with abruption c) Some women have frequent contractions without cervical changes d) fFN in cervicovaginal fluid → normal first half of pregnancy (1) After 20 weeks → abnormal (2) Also in amniotic fluid (3) False positives (a) Recent sexual intercourse, vaginal examination, bacterial vaginosis, vaginal bleeding e) Contraction frequency alone not diagnostic of preterm labor (1) Electronic fetal monitoring (EFM) to detect uterine contractions for at least 1–2 hours (2) Digital exam after ROM ruled out (3) Endovaginal ultrasound exam for cervical length (a) Cervical length of 3 cm good evidence that woman not in PTL (b) Cervical length <20mm, 2 cm or more dilated, 50% or more effaced in presence of regular contractions → diagnostic of PTL 3 Copyright © 2020 Pearson Education, Inc.

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7. Interventions a) Primary (1) Diagnosis and treatment of infections (2) Cervical cerclage (a) Previous history of painless cervical dilatation that has resulted in a secondtrimester birth or a fetal loss that occurred in a previous pregnancy (3) Progesterone supplementation b) Secondary prevention (1) Antibiotics (2) Emergency cervical cerclage placement (3) Tocolysis 8. Bacterial infection → implicated as causative factor of PTL a) Sexually transmitted infection (STI), group B streptococcus (GBS), bacterial vaginosis (BV) b) BV (1) Most common lower genital tract infections (2) Associated with (a) Increased risk of PTL (b) Increased PPROM (c) Miscarriage (d) Chorioamnionitis (e) Endometritis (f) Cesarean section wound infection c) GBS can cause neonatal infection (1) Not associated with preterm birth d) Urinary tract infections (UTIs) associated with PTL (1) Positive culture → retest after therapy e) Preterm, low-birth-weight infants linked with gum disease f) Progesterone → promote uterine relaxation, suppress contractions, prevents gestational immune intolerance (1) Can be given prophylactically, not after labor has started 9. Tocolysis → use of medications in attempt to stop labor a) May delay 24 to 48 hours (1) May permit the administration of betamethasone for fetal surfactant induction or allow for the transport of the mother to a tertiary care facility b) Beta-adrenergic agonists (1) Magnesium sulfate (a) Do not use with calcium channel blockers, if mother has myasthenia gravis, or neuromuscular disorders (b) Loading dose of 4 to 6 g/hr intravenous (IV) in 100 mL IV fluid over 20 minutes (i) Maintenance 2 to 4 g/h titrated to deep tendon reflexes, serum magnesium levels (ii) Maternal serum level 5.5 to 7.5 mg/dl (iii) Side effects 4 Copyright © 2020 Pearson Education, Inc.

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(a) Flushing, warmth, headache, nystagmus, nausea, dry mouth, dizziness (b) Lethargy, sluggishness, risk of pulmonary edema (iv) Fetal side effects (a) Hypotonia for 1–2 days after birth, lethargy, hypoglycemia, lethargy (2) Calcium channel blockers (a) Nifedipine (i) Inhibits contractile activity (ii) Side effects (a) Hypotension, tachycardia, facial flushing, headache (iii) Coadministration with ritodrine or terbutaline may be beneficial (a) Not with magnesium sulfate (3) Prostaglandin synthetase inhibitors (a) Suppress muscle contraction (b) Maternal side effects are few (i) Dyspepsia, nausea, vomiting, depression, dizzy spells (ii) Not used in women with asthma, coagulation disorders, hepatic or renal insufficiency, peptic ulcer disease (c) Indomethacin, sulindac, celecoxib (d) Crosses placenta to fetus (e) Not used after 34 weeks → oligohydramnios, premature closure of fetal ductus arteriosus 10. National Institute of Child Health and Human Development (NICHD) a) Recommends corticosteroids be administered antenatally to women at risk of preterm birth

H. Nursing Management for the Woman at Risk for Preterm Labor 1. Nursing Assessment and Diagnosis a) Assessment (1) Predisposing factors (2) Educational needs b) Diagnoses include (1) Knowledge, Readiness for Enhanced (2) Fear (3) Coping, Ineffective (4) Anxiety 2. Nursing Plan and Implementation a) Community-based nursing care (1) Continued pharmacologic therapy b) Home care (1) Frequent office visits (2) Patient education (3) Ability to care for self, impact of changes 5 Copyright © 2020 Pearson Education, Inc.

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(4) Nursing management plan c) Health promotion (1) Signs and symptoms of preterm labor (a) Uterine contractions that occur every 10 minutes or less with or without pain for 1 hour (b) Mild menstrual-like cramps felt low in abdomen (c) Constant or intermittent feelings of pelvic pressure that may feel like the baby is pressing down (d) Rupture of membranes, leaking of clear fluid from vagina (e) Low, dull backache, which may be constant or intermittent (f) Change in the vaginal discharge (g) Urinary frequency, urgency, hesitancy or hematuria (h) Abdominal cramping with or without diarrhea (2) Taught to evaluate contraction activity one or twice a day (3) Taught when to report signs and symptoms (a) Any PTL symptoms for more than 15 minutes: (i) Empty her bladder (ii) Lie down tilted toward her side (iii) Drink 3 to 4 (8 oz) cups of fluid (iv) Palpate for uterine contractions, and if contractions occur 10 minutes apart or less for 1 hour, notify healthcare provider (v) Soak in a warm tub bath with the uterus completely submerged (vi) Rest for 30 minutes after the symptoms have subsided, and gradually resume activity (vii) Call healthcare provider if symptoms persist, even if uterine contractions not palpable d) Woman knowledgeable, attuned to changes in body → caregivers need to take her call seriously e) See Table 23–4: Self-Care Measures to Prevent Preterm Labor, p. 561 3. Hospital-based nursing care a) Supportive nursing care (1) Promoting rest (2) Monitoring vital signs (3) Measuring intake and output (4) Continuously monitoring FHR, uterine contractions (5) Place woman on left side (6) Vaginal examinations minimal b) Intense stress of woman and partner (1) Keep informed (2) Consultations as indicated or requested 4. Evaluation a) Woman can discuss cause, diagnosis, treatment of PTL b) Woman affirms that fears about early labor are decreased 6 Copyright © 2020 Pearson Education, Inc.

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c) Woman states she feels comfortable in ability to cope with situation and has resources to call on if needed d) Woman can identify signs and symptoms of PTL that need to be reported to her caregiver e) Woman can describe appropriate self-care measures to initiate in the event that she experiences any symptoms of PTL f) Woman successfully gives birth to a healthy infant

II.

Care of the Woman with Premature Rupture of Membranes

A. Spontaneous rupture of membranes before onset of labor → premature rupture of membranes (PROM) 1. After 37 weeks 2. Before 37 weeks → preterm PROM (PPROM) 3. Prolonged rupture of membranes → more than 24 hours before birth

B. PPROM → more frequently in lower socioeconomic status, previous preterm birth or PPROM 1. Multiple interrelated factors a) Cervicitis b) Urinary track infections c) Gonorrhea infections d) Asymptomatic bacteriuria e) Amniocentesis f) Placenta previa g) Abruptio placenta h) Hydramnios i) History of LEEP procedure j) Multiple pregnancy k) Maternal genital tract anomalies l) Smoking m) Substance abuse n) Connective tissue disorders o) Fetal anomalies 2. Unknown etiology

C. Maternal Risks 1. Infection a) Chorioamnionitis (1) Risk raises with earlier gestations (2) Gram stain, white cell count, glucose concentration, culture 7 Copyright © 2020 Pearson Education, Inc.

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b) Abruptio placentae

D. Fetal-neonatal risks 1. Associated complications: respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage 2. Infection (sepsis) 3. Fetal hypoxia 4. Early prolonged PPROM → fetal pulmonary hypoplasia, facial anomalies, limb position defects, fetal growth restriction 5. Clinical therapy a) Assessment (1) Time of initial loss of fluid (2) Continuous leaking (3) Color, consistency, amount, odor (4) Presence of blood, meconium, vernix b) Nitrazine testing of fluid (1) Amniotic fluid more alkaline (pH 7 to 7.5) than normal vaginal secretions (2) Blue-green, blue → suggestive of ruptured membranes c) Sterile speculum exam (1) Avoid digital exam d) Microscopic examination → ferning e) Fetal well-being (1) Fetal heart rate (FHR) tracing (2) Biophysical profile (3) Calculation of fetal age 6. Management a) No evidence of infection, gestation < 37 weeks → conservative (1) Hospitalized on bedrest (2) Fetal lung maturity studies near 34 weeks (3) Lab work (4) Non-stress tests (NSTs) every shift (5) Biophysical profile (BPP) every 24 hours b) Fetus not at viable stage (1) Home on bedrest (2) Monitor temperature 4x/day (3) Fetal movement record (4) Pelvic rest (5) Instructions on when to contact physician (6) Twice-weekly NSTs, complete blood counts (CBCs) (7) Weekly ultrasound, cervical visualization c) Prophylactic antibiotics 8 Copyright © 2020 Pearson Education, Inc.

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(1) Prevent ascending infection (2) Allow time for corticosteroids to enhance fetal lung maturity d) Immediate birth → fluid studies show (1) Low glucose level (2) High white blood cell (WBC) count (3) Positive Gram stain (4) Organisms in fluid e) Betamethasone (1) Decreases likelihood of several complications (a) Neonatal respiratory distress syndrome (b) Necrotizing enterocolitis (c) Intraventricular hemorrhage (d) Perinatal death (2) Single course → 12 mg IM with second dose in 24 hours (a) Or 6 mg every 12 hours for 2 doses f) Tocolytics (1) Generally not indicated (2) May be used to allow course of steroids 7. Health promotion education a) Counseling b) Accurate information about grave outcomes of very premature births

E. Nursing Management for the Woman with PROM or PPROM 1. Nursing Assessment and Diagnosis a) Assessment (1) Time, amount, color, odor, duration of ROM (2) Gestational age determined (3) Observe mother for signs and symptoms of infection (4) If fever, check hydration status (5) Fetal heart rate tracings monitored (6) Evaluate childbirth preparation, coping abilities of woman and partner b) Diagnoses may include (1) Infection, Risk for (2) Gas Exchange, Impaired (3) Coping, Ineffective 2. Nursing Plan and Implementation a) Focus on woman, partner, fetus (1) Uterine activity, fetal response to labor evaluated (2) Encourage to rest on side (3) Vaginal exams are not done unless absolutely necessary (4) Comfort measures (5) Ensure hydration is maintained 9 Copyright © 2020 Pearson Education, Inc.

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3. Health promotion education a) Education, implication of PROM/PPROM b) Treatment methods c) Accurate information about neonatal outcomes d) Provide psychologic support 4. Evaluation a) Woman’s risk of infection and cord prolapse decreased b) Couple is able to discuss implications of PROM/PPROM and treatment options c) Pregnancy is maintained without trauma to the mother or fetus

III.

Care of the Woman and Fetus at Risk Because of Placental Problems

A. Abruptio Placentae 1. Premature separation of a normally implanted placenta from the uterine wall a) More common in pregnancies complicated with (1) Smoking (2) PROM (3) Multiple gestation (4) Advanced maternal age (5) Cocaine use (6) Chorioamnionitis (7) Hypertension (8) Risk of recurrence is 10 times higher if a previous abruption has occurred 2. Cause unknown a) Hypertension b) Presence of fibroids c) Maternal trauma d) Domestic violence e) Abdominal trauma f) Overdistention of uterus g) Fetal growth restriction h) Alcohol consumption i) Short umbilical cord j) High parity k) More common in white and African American women than Asian and Latin American women 3. Pathophysiology a) See Figure 23–1: Abruptio placentae, p. 566 b) Types (1) Marginal (2) Central (3) Partial 10 Copyright © 2020 Pearson Education, Inc.

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(4) Complete c) Severe cases of central abruptio placentae → blood clot forms behind placenta (1) Blood invades myometrial tissue (2) Uterus contracts with difficulty → Couvelaire uterus → may necessitate hysterectomy (3) Large amounts of thromboplastin released into maternal blood supply → triggers disseminated intravascular coagulation (DIC) d) Grading (1) Grade 1 (mild) (2) Grade 2 (moderate) (3) Grade 3 (severe) 4. Maternal risks a) DIC b) Hypofibrinogenemia c) Moderate to severe hemorrhage → shock (1) Fatal if not reversed (2) Renal failure (a) Vascular spasm (b) Intravascular clotting 5. Fetal-neonatal risks a) Perinatal mortality 25% b) Complications: preterm labor, anemia, hypoxia (1) Irreversible brain damage, fetal demise 6. Clinical therapy a) Evaluate coagulation tests for DIC (1) Fibrinogen levels, platelet counts decreased (2) Prothrombin (PT), partial prothrombin (PTT) normal to prolonged b) Maintain cardiovascular status of mother (1) IV access with large-gauge cannula c) Continuous EFM d) Birth method depends on condition of woman and fetus (1) Induction of labor if separation mild, gestation near term (a) If rupture of membranes and oxytocin infusion by pump do not initiate labor within a short time, cesarean birth usually done (b) Supportive treatment (2) Moderate to severe separation → cesarean birth after hypofibrinogenemia treated (a) IV cryoprecipitate (b) IV fresh frozen plasma (FFP) (c) Vaginal birth impossible with Couvelaire uterus → cannot contract e) Hypovolemia (1) Life threatening → whole blood (2) Emergency cesarean with living fetus 11 Copyright © 2020 Pearson Education, Inc.

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(3) Stillborn fetus → vaginal birth preferable unless shock uncontrollable (4) IV fluids through 16- to 18-gauge cannula (5) Central venous pressure monitoring (6) Two venous lines if evidence of hypovolemia (7) Monitor urine output with indwelling catheter (8) DIC may preclude invasive hemodynamic monitoring (9) Laboratory testing for ongoing data (a) Hemoglobin, hematocrit, coagulation status (b) Clotting study f) Stimulate labor (1) Amniotomy, oxytocin stimulation (2) Kleihauer-Betke to determine amount of fetal–maternal hemorrhage in Rh-negative women → calculate appropriate dose of Rh D immunoglobulin

B. Nursing Management for the Woman with Abruptio Placentae 1. Nursing Assessment and Diagnosis a) Electronic monitoring of uterine contractions b) Uterine resting tone (1) Often increased with abruptio placentae c) Abdominal girth measurements hourly 2. Nursing diagnoses include a) Fluid Volume: Risk for Deficient b) Tissue Perfusion: Peripheral, Ineffective c) Anxiety d) Gas Exchange, Impaired 3. Nursing Plan and Implementation a) Factual reassurance b) Explanation of procedures c) Reinforce positive aspects 4. Evaluation a) Woman and baby have a safe labor and birth without further complications for the mother or child b) Woman and family verbalize understanding of reasons for medical therapy and risks

C. Placenta Previa 1. Placenta improperly implanted in the lower uterine segment a) See Figure 23–2: Grades of placenta previa, p. 569 b) Villi torn from uterine wall as lower uterine segment contracts and dilates in later weeks of pregnancy 2. Cause a) Unknown 12 Copyright © 2020 Pearson Education, Inc.

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b) 1:200 pregnancies c) Factors (1) Previous placenta previa (2) Multiparity (3) Increasing age (4) Placenta accreta (5) Defective development of blood vessels in the decidua (6) Prior cesarean birth (7) Cocaine use (8) Smoking (9) Recent spontaneous or induced abortion (10) Large placenta 3. Classifications a) Grade 1 → placenta lies over lower uterine segment but is lower edge does not abut the internal cerivical os b) Grade 2 → placental tissue raches the margin of the internal cervical os, but does not cover it c) Grade 3 → placenta partially covers the internal cervical os d) Grade 4 → placenta completely covers the internal cervical os 4. Vasa previa a) Fetal vessels course through amniotic membranes b) Present at cervical os 5. Clinical therapy a) History of abnormal placental placement diagnosed during pregnancy b) Review prenatal records c) Identify cause of bleeding d) Transabdominal scan to localize placenta e) Direct diagnosis → feeling placenta inside os → may cause profuse bleeding (1) Vaginal exam contraindicated f) If no ultrasound available (1) Double setup (a) Delivery room set up for vaginal exam, vaginal birth, cesarean birth (b) Adequate personnel g) Differential diagnosis (1) See Table 23–10: Differential Signs and Symptoms of Placenta Previa and Abruptio Placenta, p. 570 h) Care of woman with painless late gestational bleeding (1) Week of gestation (2) Amount of bleeding (3) Expectant management (a) Bedrest with bathroom privileges only as long as woman is not bleeding (b) No vaginal examinations 13 Copyright © 2020 Pearson Education, Inc.

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(c) Monitoring of blood loss, pain, uterine contractility (d) Evaluation of FHR with external monitor (e) Monitoring of maternal vital signs (f) Complete laboratory evaluation: hemoglobin, hematocrit, Rh factor, urinalysis (g) Administration of IV fluid (lactated Ringer’s solution) with drip rate monitored (h) Availability of two units of cross-matched blood for possible transfusion (i) Administration of betamethasone to facilitate fetal lung maturity (j) Administration of Rh D immunoglobin in Rh D negative women

D. Nursing Management for the Woman with Placenta Previa 1. Nursing Assessment and Diagnosis a) Ongoing to prevent, treat complications b) Painless, bright red vaginal bleeding best diagnostic sign of placenta previa c) No vaginal examinations d) Uterus soft, if labor begins, relaxed between contractions e) FHR stable unless profuse hemorrhage, maternal shock occurs f) Appraise blood loss, pain, uterine contractility g) Monitor maternal vital signs, results of blood and urine tests h) FHR monitoring with EFM 2. Diagnoses may include a) Fluid Volume, Deficient b) Tissue Perfusion: Peripheral, Ineffective c) Anxiety d) Gas Exchange, Impaired e) Fear 3. Nursing Plan and Implementation a) Monitor woman and fetus b) Emotional support for family c) Physical support with active bleeding d) Newborn assessment (1) Hemoglobin, cell volume, erythrocyte count → checked immediately after birth, monitored closely 4. Evaluation a) Cause of hemorrhage is recognized promptly, corrective measures are taken b) Woman’s vital signs remain in the normal range c) Woman and her baby have a safe labor and birth d) Family understands what has happened and the implications and associated problems of placenta previa

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IV.

Care of the Woman with Cervical Insufficiency A. Definition 1. Painless dilatation of the cervix without contractions because of a structural or functional defect of the cervix

B. Etiology multifactorial 1. Congenital 2. Acquired 3. Biochemical (hormonal)

C. Obstetric history may give risk indications 1. Multiple gestation 2. Repetitive second-trimester losses 3. Previous preterm birth 4. Progressively earlier births with each subsequent pregnancy 5. Short labors 6. Previous elective abortions or cervical manipulations 7. Diethylstilbestrol (DES) exposure 8. Other uterine anomaly

D. Endovaginal ultrasound measurements 1. Cervical length between 15 and 28 weeks identifies groups at risk a) At 16 to 24 weeks if at risk 2. Cerclage does not reduce risk of prematurity 3. Medical therapies used are serial cervical ultrasound assessments, progesterone supplementation, antibiotics, anti-inflammatory drugs

E. Cerclage Procedures 1. Surgical procedure a) Stitch placed in cervix to prevent spontaneous abortion, premature birth b) Elective (1) Placed in late first trimester, early second trimester (2) 93% success rate c) Emergent → dilation, effacement already occurred (1) Graver outcomes 15 Copyright © 2020 Pearson Education, Inc.

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(2) Preterm rupture of membranes (a) See Figure 23–3: A cerclage or purse-string suture is inserted in the cervix to prevent preterm cervical dilatation and pregnancy loss, p. 573 d) Uncomplicated (1) Outpatient and discharge when able to ambulate and void (2) Emergency → 5- to 7-day hospitalization or longer e) Serial ultrasounds weekly to monitor f) Cut sutures at 36–37 weeks’ gestation

V.

Care of the Woman with a Multiple Gestation A. Incidence of twins 1. 33 per 1000 live births 2. Increasing with advances in reproductive technologies 3. Twin birth most common

B. Pregnancy Loss in Multiple Gestation 1. 25% lost before end of first trimester a) Environmental factors b) Infectious organisms c) Trophoblast dysfunction d) Poor embryo quality e) Lower concentration of placentally produced substances f) Loss of one twin → more common in first trimester 2. Pregnancy loss in second trimester a) Congenital anomalies b) Growth restriction c) Chromosomal abnormalities d) Cervical insufficiency 3. Incidence of preterm birth higher a) 58.8% of twins b) 94.4% of triplets c) 98.3% quadruplets d) See Table 23–12: Guidelines for Timing of Birth in Multiple-Gestation Pregnancies, p. 575 4. Potential complications a) Spontaneous abortions are more common b) Gestational diabetes occurs more often in multiple gestations c) Hypertension is a major maternal complication d) Multiple gestations are more likely to acquire HELLP (hemolytic anemia, elevated liver enzymes, and low platelet count) syndrome 16 Copyright © 2020 Pearson Education, Inc.

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e) Women with multiple gestations more likely to develop acute fatty liver f) Pulmonary embolism six times more likely to develop during pregnancy with multiple gestations g) Maternal anemia occurs because of demands of the multiple gestation h) Hydramnios may be due to increased renal perfusion from cross-vessel anastomosis of monozygotic twins i) Premature rupture of membranes cervical insufficiency, and intrauterine growth restriction more common j) Rare complications associated with twins include twin-to-twin transfusion, conjoined twins, acardia k) Complications during labor include preterm labor, uterine dysfunction due to overstretched myometrium, abnormal fetal presentations, instrumental or cesarean birth, postpartum hemorrhage l) Pulmonary edema more common in multiple gestations m) Dermatologic complications n) Multiple births account for 21% of low-birth-weight infants o) More physical discomfort during pregnancy 5. Clinical therapy a) Goal → promote normal fetal development, prevent maternal complications and preterm birth, diminish fetal trauma during labor b) Ultrasound plays crucial role (1) Identification of multiple pregnancy (2) Detecting anomalies (3) Chorionicity (a) Essential in differentiating twin-to-twin transfusion from fetal growth restriction (4) Amnionicity (a) Ultrasound visualization or the lack of visualization of an intertwin membrane c) Preventing preterm labor (1) Early prenatal care, more frequent visits (2) Assessing cervical status (a) A cervical length < 25 mm between 14 and 20 weeks is associated with PTB prior to 32 weeks. (b) Cervical length < 25 mm for triplets between 15 and 20 weeks is associated with a 100% delivery rate by 28 weeks (3) fFN (4) Corticosteroids (a) 24 to 34 weeks if risk to deliver within next 7 days (b) Repeat dose if < 34 weeks and last dose was > 14 days prior (5) Insufficient evidence to support routine bedrest, cervical cerclage, reduced activity and work d) Intrapartum management and assessment (1) IV with large-bore needle (2) Anesthesia, cross-matched blood available 17 Copyright © 2020 Pearson Education, Inc.

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(3) Dual EFM (4) Method of birth depends on variety of factors (a) Presence of maternal complications (b) Fetal factors (c) Presentation (d) Three or more fetuses → cesarean (5) See Figure 23–5: Twins may be in any of these presentations in utero, p. 577 (6) Placentas examined after birth → laboratory for examination

C. Nursing Management for the Woman with Multiple Gestation 1. Nursing Assessment and Diagnosis a) Identify family history of twinning b) Medication taken to enhance fertility c) Each visit → measure fundal height (1) Growth, fetal movement, heart tone auscultation out of proportion to gestational age by dates → indicative of twins (2) See Figure 23-6: Leopold maneuvers in twin pregnancy …, p. 578 d) Determine family’s level of preparation e) Monitor each fetus during labor f) After multiple birth → mother closely monitored for postpartum hemorrhage 2. Diagnoses include a) Fear b) Coping, Ineffective c) Knowledge, Deficient d) Gas Exchange, Impaired 3. Nursing Plan and Implementation a) Community-based nursing care (1) Antepartum (a) Counseling about diet and daily activities (b) Meal plans (c) Prenatal vitamin and 1 mg folic acid, iron daily (d) Weight gain of 35 to 45 lb recommended (e) Prenatal vitamins with folic acid (f) Maternal hypertension treated with bedrest, lateral position (g) Pelvic rocking to alleviate back discomfort (h) Community support systems b) Hospital-based nursing care (1) Prepare to receive multiple newborns (a) Equipment, identification papers, bracelets (b) Staff 4. Evaluation a) Woman able to discuss implications and problems associated with multiple gestation 18 Copyright © 2020 Pearson Education, Inc.

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b) Woman feels she is able to cope with the pregnancy and birth c) Woman understands treatment plan and how to gain further information d) Mother, father, babies have a safe prenatal course, labor, and birth and safe postpartal and newborn course

VI.

Care of the Woman and Fetus at Risk Because of Amniotic Fluid-Related Complications

A. Hydramnios 1. Polyhydramnios → over 2000 mL of amniotic fluid a) Cause unknown b) Often occurs in cases of major congenital anomalies c) Anencephaly → fetus thought to urinate excessively d) Monozygotic twin manifests hydramnios → possible that twin with increased blood volume urinates excessively 2. Chronic → fluid gradually increases a) Problem of third trimester b) Most cases 3. Acute → volume increases rapidly a) Over a few days b) Usually between 20 and 24 weeks’ gestation 4. Amount of amniotic fluid over 3000 mL a) Shortness of breath and edema in lower extremities b) Can experience severe pain 5. Fetal malformation, preterm birth common a) Prolapsed cord can occur when membranes rupture 6. Clinical therapy a) Supportive treatment (1) Maternal dyspnea and pain → hospitalization, removal of excessive fluid (a) Artificial rupture of membranes → dangers (b) Needle amniotomy → slower release of fluid b) Prostaglandin synthesis inhibitor

B. Nursing Management for the Woman with Hydramnios 1. Nursing Assessment and Diagnosis a) Suspected when fundal height increases out of proportion to the gestational age b) Difficulty palpating fetus, auscultating FHR c) Abdomen tense, tight

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2. Diagnoses include a) Gas Exchange, Impaired b) Fear c) Pain, Acute 3. Nursing Plan and Implementation a) Amniocentesis (1) Sterile technique (2) Support (3) Education b) Fetus diagnosed with congenital defect (1) Psychologic support 4. Evaluation a) Woman and her partner can discuss the procedure, implications, risks and characteristics that need to be reported to the caregiver

C. Oligohydramnios 1. Less than normal amount of amniotic fluid → 500 mL considered normal a) Diagnosed when largest vertical pocket of amniotic fluid visible on ultrasound examination is 5 cm or less 2. Cause → unknown a) Cases of postmaturity b) Intrauterine growth restriction (IUGR) c) Fetal conditions with major renal malformations d) In first part of pregnancy (1) Fetal adhesions e) Fetal skin and skeletal abnormalities f) Pulmonary hypoplasia 3. Clinical therapy a) Suspected when uterus does not increase in size according to gestational dates b) Fetus easily palpated, not ballottable c) Biophysical profile d) NSTs e) EFM f) Amnioinfusion to replace some fluid volume

D. Nursing Management for the Woman with Oligohydramnios 1. Nursing Assessment and Diagnosis a) Fundal height less than gestational age b) Fetal parts easily palpated c) Continuous EFM in labor and birth d) Evaluate EFM tracing for nonreassuring signs 20 Copyright © 2020 Pearson Education, Inc.

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e) Position changes f) Newborn evaluated after birth g) Amniotic fluid index on ultrasound less than 5 cm 2. Diagnoses include a) Gas Exchange, Impaired b) Fear 3. Nursing Plan and Implementation a) Continuous monitoring during labor and birth b) Amnioinfusion c) Cesarean with nonreassuring FHR tracing 4. Evaluation a) Woman and her partner can discuss the diagnosis, implications, and risks to the caregiver b) Fetus remains uncompromised during labor and birth

VII.

Focus Your Study

VIII.

Activities 1. Individual Have each student prepare drug cards for the following medications: • Betamethasone • Ritodrine hydrochloride • Magnesium sulfate • Nifedipine • Cryoprecipitate • Fresh frozen plasma 2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan for the woman with one of the following nursing diagnoses: • Fear related to unknown outcome of pregnancy • Knowledge, Deficient related to lack of information about the problems associated with − Multiple gestation − Placenta previa − Oligohydramnios − Hydramnios 3. Large Group Invite a perinatal nurse or certified nurse-midwife (CNM) to speak to the students in your class, giving case studies related to prelabor complications.

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Chapter 24 Childbirth at Risk: Labor-Related Complications Care of the Woman Experiencing Dystocia Related to Dysfunctional Uterine Contractions.............................................................................................

2

Care of the Woman with Postterm Pregnancy..................................................

5

Care of the Woman and Fetus at Risk Because of Fetal Malposition...............

7

Care of the Woman and Fetus at Risk Because of Fetal Malpresentation ………………………………………………………………………………..

9

Care of Woman and Fetus at Risk Because of Macrosomia..............................

13

Care of the Woman and Fetus in the Presence of Nonreassuring Fetal Status………………………………………………………………………………………………….

15

Care of the Woman Experiencing Placental and Umbilical Cord Problems ……………………………………………………………………………………………

16

Care of the Woman and Fetus with a Prolapsed Umbilical Cord......................

18

Care of the Woman and Fetus at Risk Because of Anaphylactoid Syndrome of Pregnancy...........................................................................

20

Care of the Woman with a Uterine Rupture......................................................

21

Care of the Woman with Cephalopelvic Disproportion.....................................

22

Care of the Woman at Risk Because of Complications of Third and Fourth Stages of Labor……………………………………………………………………………………

24

Focus Your Study................................................................................................

25

Activities.............................................................................................................

25

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I.

Care of the Woman Experiencing Dystocia Related to Dysfunctional Uterine Contractions

A. Dystocia → abnormal labor pattern 1. Abnormalities occur with power, passenger, passage 2. Dysfunctional uterine contractions → prolongation of labor 3. See Figure 24–1: Comparison of labor patterns. A. Normal uterine contraction pattern … B. Tachysystole uterine contraction pattern C. Hypotonic uterine contraction pattern. p. 584 4. Risk factors a) Advanced maternal age b) Maternal obesity c) Nulliparity d) Short maternal height e) Pregnancy complications f) Labor induction g) Premature rupture of membranes h) Prolonged latent phase i) Epidural anesthesia j) Chorioamnionitis k) Postterm gestation l) Large-for-gestational-age (LGA) fetus m) Malposition n) Malpresentation

B. Tachysystole Labor Patterns 1. Contraction frequency of more than five contractions in a 10-minute period with less than 60 seconds of relaxation between contractions or uterine contractions lasting greater than 2 minutes 2. Risk factors a) High-dose oxytocin titration regimens b) Oxytocin incremental intervals less than 30 minutes c) Cocaine use d) Uterine rupture e) Placental abruption 3. Fetal-neonatal risks include a) Nonreassuring fetal status b) Category II and III fetal tracings c) Prolonged pressure on fetal head

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4. Clinical therapy a) Continuous fetal monitoring b) Oxytocin (Pitocin) infusion stopped immediately

C. Nursing Management for the Woman Experiencing Tachysystole Labor 1. Nursing Assessment and Diagnosis a) Monitor frequency, duration, intensity of labor contractions 2. Diagnoses include a) Pain, Acute b) Coping, Ineffective c) Anxiety 3. Nursing Plan and Implementation a) Comfort and support (1) Position change, sitting or left sidelying (2) Continuous fetal monitoring (3) Comfort measures (4) Oxytocin stopped immediately (5) Breast stimulation stopped (6) Relaxation exercises → quiet environment (7) Physician/CNM advised of patient status and contraction pattern (8) Maintain calm, understanding approach b) Patient education c) Nonreassuring fetal status often occurs with a tachysystole contraction pattern → intrauterine resuscitation measures may become warranted (1) Position the woman on her left side (2) Apply oxygen via face mask (3) Increase intravenous fluids by at least 500 mL bolus (4) Call for anesthesia provider for support (5) Call the physician/CNM to the bedside d) Evaluation e) Woman’s labor pattern normalizes with contractions of normal frequency, duration, and intensity f) Woman and partner able to cope with abnormal labor pattern and interventions g) Woman’s level of pain becomes tolerable

D. Hypotonic Labor Patterns 1. First stage and occur in nulliparous women, common 2. Clinical therapy a) Arrest of progress → irregular contractions, low amplitude (1) Commonly less than 1 cm cervical dilation per hour (2) Or no change of dilation for 2 hours b) Evaluate for cephalopelvic disproportion (CPD) 3 Copyright © 2020 Pearson Education, Inc.

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(1) Station (2) Size of maternal pelvis (3) Position, presentation of fetus (4) Fetal weight c) CPD ruled out → amniotomy (artificial rupture of membranes [AROM]) if membranes intact d) Other causes: induced labor with unripe cervix, false labor, early amniotomy, premature rupture of membranes e) Clinical therapy (1) Amniotomy (a) Active labor has been established (b) The presenting part is well applied to the cervix (c) Hypotonic labor patterns are present (d) Hypercontractibility is present (2) Oxytocin augmentation (a) Low-dose regimen → less uterine tachysystole (b) High-dose regimen → shorter length of labor, decreased second stage, reduced chorioamnionitis and neonatal sepsis, and reduced incidence of cesarean births related to dystocia → increased uterine tachysystole and adverse FHR changes (3) Continuous electronic fetal monitoring (EFM)

E. Nursing Management for the Woman Experiencing Hypotonic Labor 1. Nursing Assessment and Diagnosis a) Maternal vital signs, contractions, dilation, fetal descent, fetal heart rate (FHR) b) Signs and symptoms of infection, dehydration c) Vaginal exam → presenting part assessed d) See Figure 24–2: Effects of labor on the fetal head, p. 586 e) Woman’s stress and coping f) Adequate fluids and nourishment 2. Nursing diagnoses include a) Pain, Acute b) Coping, Ineffective c) Anxiety 3. Nursing Plan and Implementation a) Frequent maternal vital signs b) Note duration, frequency, strength of contractions c) FHR d) Assess amniotic fluid for meconium, blood, amount e) Intake and output f) Assess bladder every 2 hours for distention g) Ongoing evaluation for symptoms of infection h) Information 4 Copyright © 2020 Pearson Education, Inc.

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(1) Address the woman and her partner’s concerns and questions (2) Provide clear, accurate information (3) Keep the woman and her partner informed of labor progress (4) Advise the woman and her partner of possible treatment measures (5) Discuss disadvantages and treatment alternatives 4. Evaluation a) Woman and partner understand labor pattern and possible implications b) Woman and partner able to cope with labor c) Woman’s comfort increases and anxiety decreases d) Woman experiences more effective labor pattern

II.

Care of the Woman with Postterm Pregnancy

A. Extends more than 294 days or 42 completed weeks 1. 7th day of 42nd week elapsed 2. Associated with primiparity, previous postterm pregnancy, placental sulfatase deficiency, fetal anencephaly, male fetus, maternal obesity, genetic predisposition 3. Most causes related to inaccurate pregnancy dating a) Error in determining the time of ovulation and conception according to first day of last menstrual period b) Ultrasound in early pregnancy

B. Maternal Risks 1. Labor and birth may be affected a) Increased discomforts during pregnancy b) Maternal anxiety c) Insomnia d) Cesarean birth e) Operative vaginal birth f) Perineal trauma and damage g) Maternal hemorrhage 2. Fetal-neonatal risks a) Complications (1) Reduced placental blood supply (2) Decreased fetal oxygenation (3) Reduced nutritional supply (4) Oligohydramnios (5) Risk of umbilical cord compression (6) Small for gestational age (SGA) (7) Large for gestational age (LGA) (8) Macrosomia 5 Copyright © 2020 Pearson Education, Inc.

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(9) Higher incidence of birth trauma (10) Risk of shoulder dystocia (11) Cephalopelvic disproportion (CPD) (12) Meconium, which can be associated with nonreassuring fetal status and meconium aspiration at birth (13) Low umbilical artery pH (14) Low 5-minute Apgar scores (15) Nonreassuring fetal status (16) Increased category II and III FHR tracings (17) Hypoglycemia (18) Seizures (19) Respiratory distress b) Approximately 20% of all postterm infants experience dysmaturity syndrome associated with uteroplacental insufficiency 3. Clinical therapy a) Non-stress test (NST) b) Biophysical profile (BPP) c) Anytime tests indicate fetal problems or there is decreased amniotic fluid volume, induction of labor is recommended

C. Nursing Management for the Woman with Postterm Pregnancy 1. Nursing Assessment and Diagnosis a) Establish estimated date of birth (EDB), type of antenatal testing b) Continuous EFM c) Assess fluid for meconium d) Ongoing assessments of labor progress 2. Diagnoses include a) Fear b) Coping: Family, Compromised c) Injury, Risk for (Fetus) d) Injury, Risk for (Mother) e) Pain, Acute 3. Nursing Plan and Implementation a) Community-based nursing care (1) Education (a) Fetal activity monitoring b) Hospital-based nursing care (1) Continuous electronic monitoring (2) Assist with procedures c) Evaluation (1) Woman able to explain implications of postterm pregnancy (2) Woman and partner and family feel supported, able to cope with labor and birth 6 Copyright © 2020 Pearson Education, Inc.

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(3) Fetal problems identified quickly

III.

Care of the Woman and Fetus at Risk Because of Fetal Malposition

A. Persistent occiput posterior (OP) position 1. Head remains in direct OP position throughout labor 2. To rotate to occiput anterior (OA) position → rotate 135 degrees a) In most cases rotation is accomplished

B. Maternal-Fetal-Neonatal Risks 1. Fetal a) None unless protracted labor, operative birth 2. Maternal a) Intense pain in small of back b) Third- or fourth-degree perineal laceration c) Higher rates of cesarean birth d) Prolonged first and second stage of labor e) Oxytocin augmentation f) Anal sphincter injury g) Severe perineal lacerations h) Episiotomy i) Blood loss greater than 500 mL j) Postpartum infection k) Accidental lacerations of the lower uterine segment during cesarean l) Instrument delivery 3. Clinical therapy a) Close monitoring b) Vaginal versus cesarean birth safest (1) Spontaneous birth (2) Forceps-assisted birth with occiput directly posterior (3) Forceps rotation of the occiput to the anterior position and birth (Scanzoni maneuver) (a) See Figure 24–3, Scanzoni maneuver...

(4) Manual rotation to the anterior position followed by spontaneous or forcepsassisted birth (a) See Figure 24–4, Manual rotation of ROP to OA, p. 590 c) If pelvis is larger diameter, relaxed perineal muscles fetus may emerge spontaneously 4. Prolonged second stage with arrest of descent a) Lasts more than an hour in multiparas, > 2 hours nulliparas b) Forceps, manual rotation if no CPD c) Cesarean birth 7 Copyright © 2020 Pearson Education, Inc.

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C. Nursing Management for the Laboring Woman with a Fetus in Occiput Posterior Position 1. Nursing Assessment and Diagnosis a) First sign of OP position → intense back pain in first stage of labor b) Dysfunctional labor pattern c) Prolonged active phase d) Secondary arrest of dilatation e) Arrest of descent f) Depression in maternal abdomen above symphysis pubis g) FHR auscultated far laterally on maternal abdomen h) Vaginal exam → anterior fontanelle i) Intrapartum ultrasound, Leopold maneuvers 2. Diagnoses include a) Pain, Acute b) Coping, Ineffective 3. Nursing Plan and Implementation a) Forward leaning, hands and knees, straddling, kneeling, or side-lying positioning Pelvic rocking b) Whirlpool or shower c) Adequate fluid and hydration during labor d) Judicious use of anesthesia e) Oxytocin infusion f) Amniotomy g) Anticipate need for vacuum or forceps h) Use of birthing ball 4. Evaluation a) Woman’s discomfort is decreased b) Woman and her partner apply comfort measures and position changes to assist her c) Woman’s coping abilities are strengthened d) Woman and her partner state that they feel supported and encouraged

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IV.

Care of the Woman and Fetus at Risk Because of Fetal Malpresentation A. Normal cephalic presentation 1. Occiput presenting, head flexed 2. See Figure 24–5: Types of cephalic presentations, p. 591

B. Malpresentation 1. Military presentation → least difficult

C. Brow Presentation 1. Forehead is presenting part 2. Causes a) High parity, placenta previa, uterine anomaly, hydramnios, fetal anomaly, low birth weight, CPD, large-for-gestational-age (LGA) fetus 3. Prolonged labor, secondary arrest 4. Cesarean in presence of CPD 5. Episiotomy with vaginal birth 6. Clinical therapy a) No active intervention if dilation and descent occurring b) Expectant management → cesarean birth frequent

D. Nursing Management for the Laboring Woman with the Fetus in Brow Presentation 1. Nursing Assessment and Diagnosis a) Leopold maneuvers b) Vaginal examination → palpation of anterior fontanelle, orbital ridges c) See Figure 24–6: Brow presentation. A. Descent. B. Internal rotation in the pelvic cavity, p. 592 2. Nursing diagnoses include a) Anxiety or Fear b) Knowledge, Deficient c) Injury, Risk for (Fetus) 3. Nursing Plan and Implementation a) Close observation b) Education c) Reassurance d) Explanation of facial edema, excessive molding

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4. Evaluation a) Woman and partner understand the implications and associated problems of brow presentation b) Mother and baby have safe labor and birth c) Woman and baby initiate bonding process

E. Face presentation 1. Fetal head → hyperextended a) Multiparous, pendulous abdomen b) Macrosomia, nuchal cord, anencephaly, fetal malformations 2. Risks a) CPD b) Prolonged labor c) Infection d) Edema e) Petechiae, bruising 3. Clinical therapy a) If no CPD, mentum anterior, labor pattern effective → vaginal birth b) Oxytocin for hypotonic labor patterns c) Manual rotation should not be attempted d) If mentum wedged on anterior surface, or CPD → cesarean birth (1) See Figure 24–7: Face presentation. Mechanism of birth in mentoanterior position, p.

593 (2) See Figure 24–8: Face presentation. Mechanism of birth in mentoposterior position, p. 593

F. Nursing Management for the Laboring Woman with the Fetus in Face Presentation 1. Nursing Assessment a) Leopold maneuvers → fetus difficult to outline, furrow palpated b) Fetal heart tones on side where fetal feet palpated c) Vaginal exam → palpation of saddle of nose, gums should be attempted (1) See Figure 24–9: Face presentation. A. Palpation of the maternal abdomen with the fetus in right mentum posterior (RMP). B. Vaginal examination …, p. 594 2. Nursing diagnoses include a) Fear b) Injury, Risk for 3. Nursing Plan and Implementation a) Same as for brow presentation 4. Evaluation a) Woman and partner understand implications and problems of face presentation

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b) Mother and baby have safe labor and birth c) Woman and baby initiate bonding process

G. Breech Presentation 1. Most common of malpresentations a) Frank breech → 50% to 70% of breech presentations → flexed hips and extended knees b) Footling breech → 10% to 30% of breech presentations, preterm fetuses → single or double → one or both hips extended and foot presenting (1) See Figure 24–10: Breech presentation. A. Frank breech. B. Incomplete (footling) breech. C. Complete breech … D. On vaginal examination …, p. 594 c) Associated with (1) Placenta previa, implantation of placenta in cornual area, hydramnios, high parity, oligohydramnios, hydrocephaly, anencephaly, previous breech presentation, uterine anomalies, pelvic tumors, multiple gestation, fetal anomalies (2) Cord prolapse more likely (3) Neuromuscular disorders (4) Head trauma during vaginal birth (5) Entrapment of fetal head (6) Higher risks of meconium aspiration, fetal asphyxia d) Planned cesarean birth → lower risk of perinatal morbidity and mortality 2. Clinical therapy a) External cephalic version (ECV) usually attempted at 37 to 38 weeks b) Complementary and alternative therapies (1) Moxibustion (a) Acupoint BL67 → may increase fetal activity (2) Maternal positioning exercises 2 to 3 times daily → hips higher than torso c) Unsuccessful version, spontaneous return to breech (1) Evaluate possibility of vaginal birth versus cesarean (2) Cesarean in nulliparas d) Contraindications to labor and vaginal birth (1) Fetal weight less than 1500 g or more than 3800 g (2) Hyperextension of the fetal neck more than 90 degrees (3) Extension of the fetal arms over head (4) Anomalies such as hydrocephalus (5) Diminished maternal pelvic measurements e) Attempted vaginal birth → pain relief (1) Prevent sensation to push before full dilation → fetal head entrapped

H. Nursing Management for the Laboring Woman with the Fetus in Breech Presentation 1. Nursing Assessment and Diagnosis a) Leopold maneuvers → hard vertex in fundus, ballottement of head b) Fetal heart tones (FHTs) usually auscultated above umbilicus 11 Copyright © 2020 Pearson Education, Inc.

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c) Passage of meconium may occur d) Prolapsed cord if membranes ruptured 2. Nursing diagnoses include a) Self-Health Management, Readiness for Enhanced b) Injury, Risk for (Fetus) 3. Nursing Plan and Implementation a) Risk for cord prolapse b) Continuous EFM c) Ongoing assessments of labor progress d) Emotional support e) Assess FHR during vaginal birth 4. Evaluation a) Woman and partner can describe the implications and associated problems with breech presentation b) Mother and baby have a safe labor and birth c) Major complications are recognized early, and corrective measures are instituted

I. Transverse Lie (Shoulder Presentation) of a Single Fetus 1. Long axis lies across woman’s abdomen a) Associated conditions (1) Grand multiparity with lax uterine musculature, obstructions, hydramnios, preterm fetus b) Vaginal birth impossible (1) No labor attempted (2) Cesarean birth done quickly (3) See Figure 24–11: Transverse lie. A. Shoulder presentation. B. On vaginal examination, the nurse may feel the acromion process of the fetal presenting part, p. 596 2. Clinical therapy a) Leopold maneuvers → confirmed by ultrasound b) Management varies depending on length of gestation (1) ECV if close to term (2) No contraindication to vaginal birth (3) Fetal lung maturity confirmed (4) Tocolytics for procedure

J. Nursing Management for the Laboring Woman with the Fetus in Transverse Lie 1. Nursing Assessment and Diagnosis a) Inspection, palpation of abdomen b) FHTs in midline c) Vaginal examination 12 Copyright © 2020 Pearson Education, Inc.

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2. Nursing diagnoses a) Gas Exchange, Impaired b) Powerlessness, Risk for c) Fear 3. Nursing Plan and Implementation a) Evaluate fetal presentation b) Provide information, support to couple c) Interventions for induction if ECV accomplished 4. Evaluation a) Transverse lie is recognized promptly, crucial assessments are completed b) Measures to perform and ECV or cesarean birth are completed c) Mother and baby have a safe birth d) Couple can describe implications and associated problems of transverse lie

K. Compound Presentation 1. Two presenting parts a) Hand → generally not difficult birth 2. Cesarean birth indicated in presence of uterine dysfunction, nonreassuring fetal status

V.

Care of Woman and Fetus at Risk Because of Macrosomia A. Fetal macrosomia → weight more than 4000 g 1. Mean birth weight varies throughout world 2. Obese woman twice as likely to have macrosomic fetus 3. Association with pregestational, gestational diabetes 4. Other risk factors postterm pregnancy, multiparity, grand multiparity, previous macrosomic newborn, previous shoulder dystocia, male sex, and maternal birth weigh 5. Adequate pelvis may be small for oversized fetus 6. Complications a) Dysfunctional labor b) Postpartum hemorrhage c) Risk of perineal lacerations d) Infection e) Vacuum and forceps birth f) Shoulder dystocia (1) Obstetric emergency (2) Anterior shoulder does not emerge spontaneously g) Other injuries to fetus, brachial plexus injury

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7. Clinical therapy a) Identification of macrosomia before onset of labor (1) Diagnosis not precise (2) Fetus greater than 4500 g → cesarean (3) Fetus between 4000 and 4500 g → debated b) Vaginal birth attempted, shoulders not delivering (1) McRoberts maneuver (a) See Figure 24–12: McRoberts maneuver, p. 596 (b) Suprapubic pressure (2) Episiotomy (3) Woods screw maneuver (4) Elective clavicular break

B. Nursing Management for the Laboring Woman and the Fetus at Risk for Macrosomia 1. Nursing Assessment and Diagnosis a) Identifying factors associated with macrosomic infants b) FHR assessment c) Evaluation of cervical dilation, fetal descent 2. Nursing diagnoses a) Injury, Risk for (Fetus) b) Infection, Risk for c) Injury, Risk for (Mother) 3. Nursing Plan and Implementation a) Monitor labor closely for dysfunctional pattern b) Support for laboring woman, partner c) Provide information d) Additional staff if shoulder dystocia anticipated e) Evaluate newborn for cephalhematoma, Erb palsy, fractured clavicles f) Check uterus for potential atony, maternal vital signs 4. Evaluation a) Woman and partner can describe implications of macrosomia and possible associated problems b) Mother and baby have safe labor and birth

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VI.

Care of the Woman and Fetus in the Presence of Nonreassuring Fetal Status

A. Oxygen supply insufficient to meet physiologic demands of fetus B. Nonreassuring fetal status is the term used to identify data describing the fetal status C. Factors 1. Cord compression 2. Uteroplacental insufficiency 3. Preexisting maternal or fetal disease

D. Initial signs 1. Meconium-stained amniotic fluid 2. Changes in FHR a) Late, severe variable deceleration b) Decrease in or lack of variability c) Progressive acceleration in FHR baseline

E. Clinical therapy 1. Relieving hypoxia 2. Change mother’s position 3. Increase intravenous rates 4. Administer oxygen by mask 5. EFM if not in use 6. Oxytocin discontinued 7. See Table 24–1: Management of Nonreasssuring Fetal Status, p. 599

F. Nursing Management for the Laboring Woman and Fetus in the Presence of Nonreassuring Fetal Status 1. Nursing Assessment and Diagnosis a) Review prenatal history to anticipate possibility b) Assess FHR, observe for meconium staining when membranes rupture c) Assess changes in fetal movement activity 2. Nursing diagnoses a) Cardiac Output, Decreased (Fetus) 15 Copyright © 2020 Pearson Education, Inc.

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b) Anxiety 3. Nursing Plan and Implementation a) Assess fetal status b) Initiate corrective measures c) Provide explanations and emotional support to woman, partner, family 4. Evaluation a) Woman and family become less anxious and more able to cope with situation b) FHR remains in normal range, or alternatively, supportive measures maintain FHR as normal as possible

VII.

Care of the Woman Experiencing Placental and Umbilical Cord Problems

A. Placental Problems 1. Developmental a) Placental lesions, succenturiate placenta, circumvallate placenta, battledore placenta b) See Table 24–2: Placental and Umbilical Cord Variations, p. 601 2. Degenerative a) Infarcts, placental calcifications 3. Succenturiate placenta a) One or more accessory lobes of fetal villi have developed on placenta (1) Vascular connections of fetal origin (2) Risk of minor lobe being retained during third stage of labor b) Risks (1) Maternal → postpartum hemorrhage (2) Fetal/newborn → if vascular connections rupture → fatal fetal hemorrhage (a) Inspect newborn at birth for pallor, cyanosis, retractions, tachypnea, tachycardia, feeble pulse 4. Circumvallate placenta a) Fetal surface of placenta exposed through a ring opening around umbilical cord (1) Increased incidence of late abortion, fetal death (2) Antepartum hemorrhage (3) Prematurity (4) Abnormal maternal bleeding 5. Battledore placenta a) Umbilical cord inserted at or near placental margin b) Chances of preterm labor high c) Nonreassuring fetal status, bleeding during labor likely 6. Placental infarcts and calcifications a) Large enough → interfere with uterine–placental–fetal exchange b) Severe preeclampsia, women who smoke 16 Copyright © 2020 Pearson Education, Inc.

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B. Umbilical Cord Abnormalities 1. Congenital absence of umbilical artery a) Infants born with two vessel cords have increased rate of anomalies b) 15% have IUGR c) Inspect all cords after cut for three vessels at delivery 2. Insertion variations a) Velamentous insertion (1) Umbilical cord vessels divide some distance from placenta in placental membranes (2) More frequently in multiple gestations (3) Other placental anomalies accompany this condition (4) More easily compressed → lack of Wharton’s jelly (a) Increased risk of vessels tearing during birth (5) Risk of vasa previa b) Cord length variations (1) Average length 55 cm (2) Short cord associated with umbilical hernias, abruptio placentae, cord rupture (3) Long cords tend to twist, tangle around fetus (4) True knots 3. Clinical therapy a) Continuous EFM with any vaginal bleeding b) Nonreassuring heart rate pattern → report immediately c) Fetal hemorrhage → vaginal, cesarean birth, correct anemia d) Identify and treat neonatal complications

C. Nursing Management for the Laboring Woman and the Fetus with Umbilical Abnormalities 1. Nursing Assessment and Diagnosis a) May not be evident until birth of fetus b) Observe during labor 2. Diagnoses include a) Gas Exchange, Impaired (Fetus) b) Knowledge, Deficient 3. Nursing Plan and Implementation a) Alert for unusual amount of bleeding b) Inspect placenta c) Repositioning of woman 4. Evaluation a) Mother and baby have safe labor and birth b) Woman’s bleeding is assessed quickly, corrective measures taken c) Family is able to cope successfully with fetal or neonatal anomalies, if they exist 17 Copyright © 2020 Pearson Education, Inc.

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VIII.

Care of the Woman and Fetus with a Prolapsed Umbilical Cord

A. Umbilical cord that precedes fetal presenting part 1. Cord falls, washed down through cervix into vagina 2. Trapped between presenting part and maternal pelvis 3. Presenting part not firmly against cervix a) See Figure 24–13: Prolapse of the umbilical cord, p. 603 4. Occult cord prolapse 5. Incidence higher with a) 20x greater with abnormal axis lie, footling, shoulder presentations b) Low birth weight c) Multipara with more than five previous births d) Multiple gestation e) Polyhydramnios f) Unengaged presenting part g) Obstetric manipulation h) Long cord i) 80% occur in second stage of labor

B. Maternal-Fetal-Neonatal Risks 1. Maternal a) Reaction may cause stress 2. Fetus a) Compression of umbilical cord (1) Bradycardia (2) Persistent variable decelerations (3) Cord compressed further with each contraction (4) Pressure not relieved, fetus will die

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C. Clinical therapy 1. Prevention 2. Bedrest after rupture of membranes 3. Nurse usually finds, relieve pressure on cord 4. Knee-to-chest position (Figure 24–14)

D. Nursing Management for the Laboring Woman and the Fetus with a Prolapsed Umbilical Cord 1. Nursing Assessment and Diagnosis a) Review nursing history b) Is presenting part engaged c) Spontaneous or artificial rupture of membranes d) Assess FHR 2. Nursing diagnoses a) Gas Exchange, Impaired (Fetus) b) Fear 3. Nursing Plan and Implementation a) Few outward signs b) Call physician/CNM when membranes rupture c) Sterile vaginal examination d) Presenting part well engaged → risk minimal e) Membranes not ruptured → FHR monitored after spontaneous rupture, amniotomy f) EFM tracings show bradycardia, decelerations → vaginal exam g) Vaginal exam (1) Loop of cord → nurse’s gloved fingers in vagina, pushing presenting upward to lift fetal part off the cord (2) Oxygen administered (3) Large-gauge IV cannula inserted (4) Notify anesthesiology and neonatology (5) Insert indwelling bladder catheter → fill bladder with 500 mL warmed, sterile normal saline (6) Woman in side-lying position, assumes the knee-chest position (7) Maintain pressure on presenting part until fetus born via cesarean birth 4. Evaluation a) FHR remains in normal range with supportive measures b) Fetus is born safely c) Woman and partner feel supported d) Woman and partner understand problem and corrective measures that are undertaken

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IX.

Care of the Woman and Fetus at Risk Because of Anaphylactoid Syndrome of Pregnancy A. Amniotic fluid embolism, fetal cells, hair, other debris enters maternal circulation, then maternal lungs 1. Obstetric emergency

B. Clinical therapy 1. IV access quickly 2. Crash cart available 3. Stabilize mother, emergency cesarean birth 4. Symptoms occur rapidly a) Shortness of breath b) Hypoxia c) Cyanosis d) Cardiovascular and respiratory collapse 5. Supportive nursing measures a) Prepare for emergency birth b) Transfer of mother to ICU

C. Nursing Management for the Woman and Fetus at Risk Because of Anaphylactoid Syndrome of Pregnancy 1. Nursing Assessment and Diagnosis a) Gas Exchange, Impaired (Fetus) b) Gas Exchange, Impaired (Mother) c) Fear 2. Nursing Plan and Implementation a) Administer oxygen under positive pressure until medical help arrives b) IV line c) Cardiopulmonary resuscitation (CPR) d) Obstetrician, anesthesiologist, perinatologist, hospital intensivist called e) Prepare equipment for blood transfusion, insertion of central venous pressure (CVP) line f) Fetus continually monitored g) Emergent cesarean birth to save fetus (1) CPR continues through the cesarean procedure 3. Evaluation a) Mother treated with appropriate interventions to achieve stabilization b) Fetus is delivered safely via cesarean birth c) Family is informed and supported during emergency procedures 20 Copyright © 2020 Pearson Education, Inc.

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X.

Care of the Woman with a Uterine Rupture A. Nonsurgical disruption of uterine cavity 1. 1:2000 births 2. Complete → endometrium, myometrium, and serosa separated 3. Incomplete or partial → not all layers disrupted

B. Factors 1. Previous uterine incision 2. Uterine manipulation (version) 3. Operative vaginal delivery 4. Abdominal trauma 5. Interval of birth between deliveries less than 18 months 6. Postpartum fever during previous cesarean birth 7. One-layer closure performed with a previous cesarean birth

C. Clinical therapy 1. Only diagnosed via surgical incision 2. Pad count → vaginal bleeding 3. Preparations for emergency birth 4. Neonatal resuscitation should be anticipated

D. Nursing Management for the Woman with a Uterine Rupture 1. Nursing Assessment and Diagnosis a) Nonreassuring FHR commonly earliest sign b) Loss of fetal station on abdominal palpation c) Constant abdominal pain, uterine tenderness, change in uterine shape, cessation of contractions, hematuria, signs of shock 2. Nursing Plan and Implementation a) Nonreassuring fetal pattern identified → physician/CNM immediately contacted b) History of cesarean birth, uterine surgery at risk c) Maternal signs and symptoms assessed d) Leopold maneuvers, maternal vital signs e) Prepare woman for emergency cesarean birth f) Anesthesiologist called immediately

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3. Diagnoses a) Gas Exchange, Impaired (Fetus) b) Gas Exchange, Impaired (Mother) c) Fear d) Anxiety e) Coping, Ineffective 4. Evaluation a) Mother remains hemodynamically stable throughout emergency cesarean birth b) Fetus retains optimal oxygenation until safe birth is achieved

XI.

Care of the Woman with Cephalopelvic Disproportion

A. Birth passage 1. Bony pelvis through maternal soft tissues a) Contracture (narrowing) in any part of passage → CPD b) Abnormal fetal presentations and positions occur 2. Gynecoid, anthropoid pelvic types usually adequate for vertex birth 3. Android, platypelloid types predispose to CPD 4. See Table 24–3: Clues Suggesting Contractures of Maternal Pelvis, p. 605 a) Diagonal conjugate less than 11.5 cm, outlet less than 8 cm b) Unengaged fetal head in early labor in primigravidas c) Hypotonic uterine contraction pattern d) Deflexion of fetal head e) Uncontrollable pushing before complete dilation of cervix f) Failure of fetal descent g) Edema of anterior portion of cervix

B. Types of Contractures 1. Inlet a) Contracted if shortest anterior–posterior diameter < 10 cm b) Or greatest transverse diameter < 12 cm c) Bulging perineum and crowning indicate obstruction has been passed 2. Outlet a) Interischial tuberous diameter < 8 cm → outlet contracture b) Possibility of vaginal birth → depends on diameters and fetal posterosagittal diameter

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C. Implications of Pelvic Contractures 1. Labor prolonged 2. Premature rupture of membranes (PROM) can result 3. Obstructed labor can result in uterine rupture 4. Necrosis of maternal soft tissue → fistulas 5. Difficult forceps-assisted births a) Damage to fetus and mother

D. Clinical therapy 1. Fetopelvic relationships assessed a) Estimated weight of fetus from ultrasound measurements b) Pelvic measurements by manual examination and/or CT scan 2. If diameters borderline or questionable a) Trial of labor (TOL) b) Continued progress → TOL continues c) Progress ceases → decision for cesarean birth made

E. Nursing Management for the Woman with Cephalopelvic Disproportion 1. Nursing Assessment and Diagnosis a) Adequacy of maternal pelvis assessed intrapartum, antepartum b) Prolonged cervical dilation, effacement slow, delayed engagement 2. Nursing diagnoses a) Knowledge, Deficient b) Fear 3. Nursing Plan and Implementation a) During TOL → similar to care during any labor b) More frequent assessment of dilation, fetal descent c) Contractions monitored d) Positioning to increase pelvic diameters (1) Sitting, squatting e) Assist with coping with stresses f) Keep couple informed 4. Evaluation a) Woman’s fear is lessened b) Woman has additional knowledge regarding problems, implications, and treatment plans

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XII.

Care of the Woman at Risk Because of Complications of Third and Fourth Stages of Labor

A. Retained Placenta 1. Placenta retained beyond 30 minutes after birth 2. 2 to 3% of births 3. Manual removal by physician/CNM attempted 4. Failure to retrieve → surgical removal by curettage a) May be a symptom of an accreta, increta, percreta 5. General anesthesia if no epidural in place

B. Lacerations 1. Bright red blood in presence of well-contracted uterus 2. Incidence 3. Categorized in terms of degree a) First degree → limited to fourchette, perineal skin, vaginal mucous membrane b) Second degree → perineal skin, vaginal mucous membrane, underlying fascia, muscles of perineal body; may extend upward on one or both sides of vagina c) Third degree → through perineal skin, vaginal mucous membranes, perineal body and involves anal sphincter; may extend up the anterior wall of rectum d) Fourth degree → same as third and extends through rectal mucosa to lumen of rectum

C. Placenta Accreta 1. Chorionic villi attach directly to myometrium of uterus a) Placenta increta → myometrium invaded b) Placenta percreta → myometrium penetrated 2. Can be life threatening a) 1:2000 births 3. Risks a) Previous cesarean birth 4. Complications a) Maternal hemorrhage b) Failure of placenta to separate following birth of infant

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5. Abdominal hysterectomy may be necessary treatment

XIII.

Focus Your Study

XIV.

Activities 1. Individual Have each student prepare a teaching plan for the primigravida who is experiencing a postterm pregnancy.

2. Large Group Utilizing equipment from the skills lab, run an emergency drill/mock code for the woman with uterine rupture, amniotic fluid embolism, or placenta accreta with hemorrhage. Have students plan interventions. Evaluate and provide feedback on how they worked together.

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Chapter 25 Birth-Related Procedures Care of the Woman During Version....................................................................

2

Care of the Woman During Cervical Ripening....................................................

5

Care of the Woman During Induction or Augmentation of Labor…………………..

9

Care of the Woman During an Amniotomy........................................................

11

Care of the Woman During Amnioinfusion........................................................

13

Care of the Woman During an Episiotomy.........................................................

14

Care of the Woman During Forceps-Assisted Birth............................................

16

Care of the Woman During Vacuum Extraction.................................................

20

Care of the Family During Cesarean Birth..........................................................

21

Care of the Woman Undergoing Trial of Labor After Cesarean and Vaginal Birth After Cesarean....................................................................

25

Focus Your Study.................................................................................................

26

Activities..............................................................................................................

26

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I.

Care of the Woman During Version

A. Procedure used to change fetal presentation 1. External cephalic version (ECV) a) Fetus changed from breech, transverse, oblique lie (1) See Figure 25–1: External (or cephalic) version of the fetus, p. 609 (2) Success rates highest with transverse lie (3) Overall success rate 60% 2. Podalic version (internal version) a) Used only with second twin during a vaginal birth (1) Obstetrician places hand inside the uterus (a) See Figure 25–2: Use of podalic version and extraction of the fetus to assist in the vaginal birth of the second twin, p. 610

B. External Cephalic Version 1. If breech or shoulder presentation detected in later weeks of pregnancy a) ECV may be attempted b) May increase risk of intrapartum cesarean birth 2. Usually done after 36 to 37 weeks’ gestation a) Time for spontaneous change to vertex b) Risk of prematurity eliminated 3. Higher success rates a) Fetal weight estimated < 2500 g b) Higher parity c) Adequate amniotic fluid d) Lack of fetal engagement e) Transverse lie f) Palpable fetal head g) Relaxed uterus h) Anterior placenta i) Low station j) Maternal obesity k) Decreased amniotic fluid volume l) Anterior or posterior positioning of fetal spine 4. Criteria for external cephalic version a) Single fetus b) Fetal breech is not engaged c) Adequate amount of amniotic fluid must exist d) Reactive non-stress test (NST) should be obtained immediately before performing the version 2 Copyright © 2020 Pearson Education, Inc.

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e) Fetus must be 36 to 37 or more weeks’ gestation 5. Contraindications for external cephalic version a) Absolute contraindications (1) Suspected intrauterine growth restriction (2) Fetal anomalies (3) Presence of an abnormal fetal heart rate (FHR) tracing (4) Rupture of membranes (5) Planned cesarean birth (6) Maternal problems (7) Amniotic fluid abnormalities b) Relative contraindications for ECV (1) Previous lower uterine segment cesarean birth (2) Nuchal cord (3) Multiple gestation (4) Evidence of uteroplacental insufficiency (5) Significant third-trimester bleeding (6) Uterine malformation 6. External cephalic version procedure a) In birthing unit in case further intervention necessary b) Fasting for 8 hours preceding c) Ultrasound to confirm (1) Single fetus (2) Amount of amniotic fluid (3) Location of placenta (4) Position of umbilical cord (5) Breech presentation d) Maternal vital signs e) Continuous electronic fetal monitoring (EFM) f) Reactive NST g) Evaluate presence of uterine activity h) Blood work i) Explain procedure, patient signs consent form j) Intravenous line k) Beta-mimetic agent or magnesium sulfate administered to achieve uterine relaxation (1) Epidural or spinal analgesia increases success rate l) Woman positioned in supine or slight Trendelenburg m) Warmed ultrasound gel applied to abdomen n) Physician grasps fetal breech (1) Index finger, thumb o) Presenting part gently pushed out of maternal pressure p) Head and breech rotated or moved in opposite directions q) Direction similar to forward roll attempted initially r) Fails → opposite direction attempted 3 Copyright © 2020 Pearson Education, Inc.

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s) Procedure concluded when: (1) Fetal head is moved to a head-down position (2) Repeated failures have occurred (3) Woman has indicated that procedure has become too painful or stressful (4) Signs of maternal or fetal problems occur (a) Nonreassuring FHR pattern t) Beta-mimetic discontinued u) Nurse or physician holds fetus in new presentation until uterus regains tone v) Ultrasound performed to confirm fetal position

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7. Tocolysis likely to increase success rates of ECV 8. If failed, repeat attempt can be made within 1 week if tolerated well by mother and fetus

C. Nursing Management for the Expectant Woman During External Cephalic Version 1. Ensure that expectant woman understands procedure 2. Possibility of failure, slight risk to fetus discussed 3. Initial maternal, fetal assessments 4. Ongoing evaluation of FHR, NST 5. Blood work 6. Psychologic support 7. Monitor vital signs every 2 minutes during beta-mimetic use, 30 minutes after 8. FHR monitored for at least 30 minutes or longer 9. Provide information → aftercare instructions

II.

Care of the Woman During Cervical Ripening

A. Contraindications for ripening 1. Prematurity 2. Active herpes 3. Fetal malpresentation 4. Nonreassuring fetal surveillance 5. History of prior traumatic delivery 6. Regular contractions 7. Unexplained vaginal bleeding 8. Placenta previa 9. Vasa previa 10. Prior uterine myomectomy involving the endometrial cavity or classic cesarean delivery

B. Use of Misoprostol (Cytotec) 1. For cervical ripening 2. Synthetic prostaglandin PGE1 analogue a) Soften, ripen cervix, induce labor b) Tablet inserted into vagina 5 Copyright © 2020 Pearson Education, Inc.

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c) Oral or sublingual 3. More effective than oxytocin or prostaglandin agents, less costly 4. Adverse outcomes associated with doses beyond recommended 25 mcg 5. Guidelines a) Initial dosage should be 25 mcg b) Recurrent administration should not exceed dosing intervals of more than 3 to 6 hours c) Pitocin should not be administered less than 4 hours after the last Cytotec dose d) Misoprostol should only be administered where uterine activity and FHR can be monitored continuously for initial observation period 6. Contraindications a) Nonreassuring FHR tracing b) Frequent uterine contractions of moderate intensity c) Prior cesarean section or uterine scar d) Placenta previa e) Undiagnosed vaginal bleeding

C. Use of Prostaglandin Agents (Cervidil, Prepidil) 1. Prostaglandin gel a) Prepidil gel → 0.5 mg dinoprostone (1) Placed intracervically 2. Cervidil → intravaginal insert a) Resembles 2-cm-square piece of cardboard-like material b) Left in posterior vagina → slow release of 10 mg dinoprostone over 12 hours 3. Advantages and disadvantages of prostaglandin administration a) Cervidil → easily removed if uterine hyperstimulation occurs b) Both cause cervical ripening c) Shorten labor d) Lower requirements for oxytocin during labor induction e) Vagina birth achieved within 24 hours for most women f) Incidence of cesarean birth is reduced g) Complications (1) Uterine hyperstimulation (2) Nonreassuring fetal status (3) Hypotonous 4. See Table 25–1: Contraindications to Labor Induction or Augmentation, p. 614 a) Vasa previa or complete placenta previa b) Transverse fetal lie c) Umbilical cord prolapse d) Previous classical cesarean delivery e) Active genital herpes infection 6 Copyright © 2020 Pearson Education, Inc.

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f) Previous myomectomy entering endometrial cavity

D. Prostaglandin agent insertion procedure 1. Recommended that prostaglandin gel be used in hospital birthing unit a) Physician readily available in case of emergency cesarean birth b) Prepidil → introduced by means of prefilled syringe c) Dinoprostone available as gel or suppository d) Cervidil → insert placed in posterior vagina 2. Monitoring of contractions and fetal status 3. Hyperstimulation of uterus → insert removed 4. Active labor established → insert removed 5. Oxytocin started to facilitate birth

E. Mechanical Methods of Cervical Ripening and Labor Induction 1. Balloon catheters a) Promote mechanical dilatation b) Foley catheter with 30 to 50 mL balloon passed through undilated cervix, then inflated c) Weighted balloon applies pressure on internal os of cervix, ripens d) Can be used with other induction methods e) Extra-amniotic saline infusion (1) Additional saline inserted into Foley bulb, pulled snugly against cervical os

F. Use of Nitric Oxide Donor Agents 1. Being studied for their ripening of the cervix without producing contractions 2. Isosorbide mononitrate, isosorbide dinitrate, nitroglycerin, sodium nitroprusside 3. Use leads to little or no difference in the labor process and delivery outcomes 4. Associated with dizziness, nausea

G. Nursing Management for the Expectant Woman During Cervical Ripening 1. Administration of agents for cervical ripening a) Physicians, CNMs, labor and delivery nurses with special education and training 2. Baseline vital signs, EFM for 30 minutes 3. Reactive NST 4. Woman lying down after insertion a) Blanket or hip wedge under right hip b) 30 to 60 minutes c) Monitor for uterine tachysystole, FHR abnormalities 7 Copyright © 2020 Pearson Education, Inc.

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(1) 30 minutes to 2 hours if prostaglandin gel agent used d) More than five contractions in 10 minutes → woman positioned on left side, oxygen administered if fetal stress noted e) Gel removed for uterine tachysystole, severe nausea, vomiting, cardiac tachysystole develops 5. Balloon catheter → intermittent monitoring with maternal vital signs a) Do not need continuous fetal monitoring b) Note placement of catheter c) Avoid ambulation, woman should remain in a recumbent position d) No vaginal exams

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III.

Care of the Woman During Induction or Augmentation of Labor

A. Induction 1. Stimulation of uterine contractions before spontaneous onset of labor, with or without ruptured fetal membranes, for purpose of accomplishing birth

B. Labor augmentation 1. Artificial stimulation of uterine contractions when spontaneous contractions have failed to result in progressive cervical dilation or descent of fetus

C. May be indicated in presence of following 1. Maternal medical conditions 2. Preeclampsia, eclampsia 3. Premature rupture of membranes (PROM) 4. Chorioamnionitis 5. Fetal demise 6. Postterm pregnancy 7. Fetal compromise 8. Risk of rapid labor or extensive distance from hospital setting 9. Mild abruptio placentae 10. Nonreassuring FHR

D. Contraindications to Labor Induction or Augmentation 1. All contraindications to spontaneous labor, vaginal birth are contraindications to the induction or augmentation of labor

E. Assessment of individual patient, clinical situation 1. Fetal maturity 2. Amniotic fluid studies 3. See Table 25–2: Confirmation of Gestational Age, p. 615 a) Ultrasound measurement at less than 20 weeks b) Fetal heart tones (FHTs) documented for at least 30 weeks by Doppler ultrasonography c) 36 weeks since positive serum or urine human chorionic gonadotropin pregnancy test result 4. Bishop score a) Bishop prelabor scoring system 9 Copyright © 2020 Pearson Education, Inc.

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(1) See Table 25–3: Prelabor Status Evaluation Scoring System, p. 616 (2) Higher score → more likely labor will occur (3) Favorable cervix is most important criterion

F. Methods of Inducing or Augmenting Labor 1. Most frequent a) Stripping amniotic membranes b) Amniotomy c) Intravenous oxytocin infusion d) Complementary methods 2. Stripping the membranes a) CNM/physician inserts gloved finger into internal cervical ox b) Rotated finger 360 degrees, twice (1) Thought to release prostaglandin F2oc (PGF2oc) from the amniotic membranes or prostaglandin E2 (PGE2) from the cervix c) Discomfort d) Typically labor begins within 24 to 48 hours 3. Oxytocin infusion a) Effective method of initiating uterine contractions (1) Goal to achieve adequate uterine contraction pattern without tachysystole b) Augmentation of arrested labor → IV (1) Assessment of fetal station, maternal pelvis, fetal position before starting infusion c) Primary bottle of IV fluid prepared (1) Piggyback oxytocin solution into primary tubing port closest to catheter insertion with a device permits precise control of flow rate (2) 10 to 20 units oxytocin added to 1 L 5% dextrose in lactated Ringer’s solution (a) 10 or 20 milliunits of oxytocin per mL (b) High-dose and low-dose regimen d) Associated risks (1) Tachysystole of uterus with/without FHR changes (2) Uterine rupture (3) Water intoxication 4. Complementary health approaches a) Sexual intercourse/lovemaking (1) Female orgasm stimulates uterine contractions (2) Male ejaculate contains natural prostaglandins b) Self/partner stimulation of nipples, breasts (1) Stimulates release of endogenous oxytocin (2) Stimulate uterine contractions (3) Initiate spontaneous labor c) Herbs (1) Blue, black cohosh 10 Copyright © 2020 Pearson Education, Inc.

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(2) Evening primrose oil → oral, intravaginal (3) Red raspberry leaf teas d) Homeopathic solutions (1) Pulsatilla (2) Castor oil (3) Enemas (4) Acupressure/acupuncture

G. Nursing Management for the Expectant Woman During Labor Induction 1. Close observation 2. Accurate assessments a) Maternal vital signs b) Fetal monitoring (1) 20- to 30-minute electronic fetal monitor recording demonstrating a reassuring FHR c) Reactive NST d) Contraction status e) Physician should be readily available 3. Patient teaching a) Blood-tinged discharge from membrane stripping 4. Assess contraction pattern 5. EFM while breast pumping to stimulate breasts 6. Expected outcomes a) Woman and family fully informed; understand induction process; able to relate advantages, disadvantages, risks, possible outcomes; and have had opportunity to have questions answered b) Woman’s labor is successfully induced c) Labor progresses at normal rate, maternal vital signs remain in normal range d) Fetal status remains reassuring throughout the labor period

H. See Nursing Care Plan: For Induction of Labor, p. 619

IV.

Care of the Woman During an Amniotomy A. Artificial rupture of amniotic membranes (AROM) 1. Cervix must be dilated at least 2 cm 2. Stimulate or augment labor a) If labor progressing normally, not suggested as can increase risk of infection

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B. Advantages and Disadvantages of Amniotomy 1. Advantages a) Contractions similar to those of spontaneous labor b) Usually no risk of hypertonus or rupture of the uterus c) Woman does not require same intensive monitoring as with intravenous oxytocin d) EFM facilitated because once membranes ruptured: e) Fetal scalp electrode may be applied f) Intrauterine catheter may be inserted g) Scalp blood sampling for pH determinations may be done h) Color and composition of amniotic fluid can be evaluated i) Amniotomy less costly procedure 2. Disadvantages a) Once amniotomy done, risk of infections rise if labor proceeds beyond 24 hours b) Danger of prolapsed cord increased, especially if fetal presenting part not firmly pressed down against cervix c) Compression and molding of fetal head increased because of loss of cushioning effect of amniotic fluid d) Fetal injury can occur if amniohook causes laceration on presenting part e) Bleeding can occur if undiagnosed vasa previa present f) Severe variable decelerations can occur, which increases likelihood of cesarean birth g) Intervention can cause pain increase

C. Amniotomy Procedure 1. Fetus assessed for presentation, position, station, FHR before 2. Sterile vaginal examination → introduce amniohook into vagina against amniotic membrane 3. Small tear made in membrane made by provider with amnihook

D. Nursing Management for the Woman Undergoing Artificial Rupture of the Amniotic Membranes 1. Procedure explained 2. Fetal presentation, position, station assessed 3. Positioned in semireclining position, draped to provide privacy 4. Disposable underpads and/or towels to absorb amniotic fluid 5. FHR assessed before and after a) If markedly different, assess for cord prolapse

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6. Assess fluid for color, amount, odor, presence of meconium or blood 7. Clean and dry perineal area 8. Advise that fluid will continue 9. Patient comfort 10. Strict sterile technique 11. Minimize number of vaginal examination 12. Monitor vital signs every 2 hours 13. Provide information

V.

Care of the Woman During Amnioinfusion A. Amnioinfusion (AI) → volume of warmed, sterile, normal saline, Ringer’s lactate solution introduced into uterus through use of intrauterine pressure catheter (IUPC) 1. Increase volume of amniotic fluid volume 2. Relieve pressure on umbilical cord 3. Promote increased perfusion to fetus 4. Meconium dilution in presence of medium to heavy meconium staining

B. Contraindications 1. Contraindication to vaginal delivery 2. Amnionitis 3. Hydramnios 4. Uterine hypertonus 5. Multiple gestation 6. Known fetal anomaly 7. Uterine anomaly 8. Nonreassuring fetal status requiring immediate birth 9. Nonvertex presentation 10. Scalp pH below 7.2 11. Placenta previa 12. Vasa previa 13 Copyright © 2020 Pearson Education, Inc.

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13. Abruptio placentae

C. Can be associated with rare risk factors 1. Umbilical cord prolapse, amniotic fluid embolism, and uterine rupture

D. No one, accepted protocol 1. Infuse bolus of 500 to 800 mL of warmed saline through intrauterine catheter a) Infusion pump b) Approximate rate 3 mL per minute c) Repeat until indication resolves

E. Nursing Management for the Woman Undergoing Amnioinfusion 1. Suspect cord compression a) Assist woman into another position b) Apply O2 via face mask 2. Amnioinfusion considered 3. Monitor vital signs, contraction status 4. Continuous EFM 5. Provide ongoing information 6. Should not cause pain or discomfort 7. Ensure that fluid infused is being expelled 8. Advise that fluid will leak from vagina 9. Change absorbent pads, pericare on regular basis

VI.

Care of the Woman During an Episiotomy

A. Surgical incision of perineal body 1. Traditionally performed to prevent damage to soft tissues a) Prevent jagged tears from lacerations b) Reduce mechanical, metabolic risks to fetus/newborn c) Protect maternal bladder d) Prevent future perineal relaxation 2. Research indicates no maternal benefits a) Major perineal trauma more likely to occur if midline episiotomy is performed b) Additional complications associated with episiotomy (1) Blood loss (2) Infection (3) Pain 14 Copyright © 2020 Pearson Education, Inc.

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(4) Perineal discomfort (5) Dyspareunia (6) Flatal incontinence c) No evidence to support that it promotes shorter second stage, improved Apgar scores, or a decrease in perinatal asphyxia

B. Risk Factors That Predispose Women to Episiotomy 1. Overall factors a) Primigravid status b) Large or macrosomic fetus c) Occiput-posterior (OP) position d) Use of forceps or vacuum extractor e) Shoulder dystocia f) White race g) Physician provider h) Private practice physician i) Nocturnal birth times. j) Use of lithotomy position, other recumbent position k) Encouraging or requiring sustained breath holding during second-stage pushing l) Time limit placed on second stage

C. Episiotomy Procedure 1. Sharp scissors with rounded points a) Just before birth b) Approximately 3 to 4 cm of the fetal head is visible during a contraction 2. Two types a) Midline (1) Vertical incision that begins at the vaginal opening, extends downward to rectum (2) Vaginal orifice to fibers of rectal sphincter b) Mediolateral (1) Short perineum, macrosomia, instrument-assisted birth (2) Midline of posterior fourchette → 45-degree angle downward to right or left c) See Figure 25–3: The two most common types of episiotomies are midline and mediolateral. A. Right mediolateral. B. Midline, p. 624 3. Usually performed with regional or local anesthesia a) As crowning occurs

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4. Repair after birth before expulsion of placenta, or after expulsion of placenta

D. Nursing Management for the Woman Underoing an Episiotomy 1. Support 2. Distract from pain 3. Act as advocate 4. Note type of episiotomy on birth record, in report 5. Pain relief measures a) Ice pack b) 20 to 30 minutes, removed for at least 20 minutes before being reapplied 6. Inspect site every 15 minutes for first hour a) Redness, swelling, tenderness, and hematomas 7. Instructions on perineal hygiene

VII.

Care of the Woman During Forceps-Assisted Birth

A. Instrumented delivery, operative delivery, or operative vaginal delivery 1. Different types for specific functions

B. Criteria for Forceps Application 1. Outlet forceps application a) Forceps applied when fetal skull reaches pelvic floor and is at or on perineum b) Scalp is visible between contractions without separating labia c) Sagittal suture not more than 45 degrees from midline 2. Low forceps application a) Leading edge of fetal skull at +2 or below (+3) but not on pelvic floor b) Rotation of fetal head is less than 45 degrees 3. Midforceps application a) Fetal head engaged b) Leading edge of fetal skull is above +2 (+1, 0, –1, –2) c) Goal is to apply traction d) Rotate head, facilitate vaginal birth

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4. High forceps not indicated in current obstetric practice 5. See Figure 25–4: Forceps are composed of a blade, shank, and handle and may have a cephalic and pelvic curve, p. 625

C. Indications for Use of Forceps 1. Presence of any condition that threatens mother or fetus → can be relieved by birth 2. At risk a) Heart disease b) Acute pulmonary edema c) Pulmonary compromise d) Certain neurologic conditions e) Intrapartum infections f) Prolonged second stage g) Exhaustion h) Premature placental separation i) Prolapsed umbilical cord j) Nonreassuring fetal status k) Shorten second stage and spare pushing in exhausted mother, mother with heart disease 3. Risk factors a) Nulliparity b) Maternal age (35 and older) c) Maternal height of less than 150 cm (4 ft 11 in) d) Pregnancy weight gain of more than 15 kg (33 lb) e) Postdates gestation (41 weeks of more) f) Epidural anesthesia g) Fetal presentation other than occipitoanterior h) Presence of dystocia i) Presence of midline episiotomy j) Abnormal FHR tracing

D. Neonatal and Maternal Risks 1. Neonatal risks a) Ecchymosis or edema b) Forceps marks c) Caput succedaneum, cephalhematoma d) Hyperbilirubinemia e) Transient facial paralysis f) Low Apgar scores g) Retinal hemorrhage h) Corneal abrasions i) Descemet membrane tear j) Ocular trauma 17 Copyright © 2020 Pearson Education, Inc.

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k) Erb palsy l) Fractured clavicle m) Elevated neonatal bilirubin levels n) Prolonged infant hospital stay 2. Maternal risks a) Third- or fourth-degree Lacerations b) Extension of median episiotomy into the anus c) Increased bleeding or bruising d) Hematomas e) Pelvic floor injuries f) Increased perineal pain g) Sexual dysfunction in the postpartum period h) Postpartum infections i) Prolonged hospital stays j) Urinary and rectal incontinence, anal sphincter injury

E. Prerequisites for Forceps Application and Birth 1. Physician knowledgeable about advantages, disadvantages of different types of forceps and use 2. Cervix must be completely dilated 3. Fetal head must be engaged, stations, presentation, exact position of head must be known a) Vertex or face presentation, chin anterior 4. Amniotic membranes must be ruptured 5. Type of pelvis should be identified a) No disproportion between fetal head and maternal pelvis

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6. Maternal bladder should be empty 7. No obstructions to birth below fetal head 8. Adequate anesthesia

F. Trial or Failed Forceps Procedure 1. Attempts forceps with knowledge there could be degree of CPD 2. Setup for immediate cesarean birth available 3. If good application cannot be obtained, no descent → vacuum technique can be attempted 4. If yields no descent, cesarean birth method of choice

G. Nursing Management for the Woman Undergoing a Forceps-Assisted Birth 1. Variables a) Dystocia → maternal position b) FHR abnormalities → support ambulation, position changes, adequate fluids, monitoring 2. Forceps-assisted birth required a) Explain procedure b) Encourage to avoid pushing c) Monitor contractions d) With contraction, after forceps are in place, physician/CNM provides traction on forceps as woman pushed 3. Following birth a) Newborn assessed for facial edema, bruising, caput succedaneum, cephalhematoma, corneal abrasion, sign of cerebral edema b) Woman assessed for perineal swelling, bruising, hematoma, excessive bleeding, hemorrhage, signs of infection

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4. Answer questions 5. Provide reassurance

VIII.

Care of the Woman During Vacuum Extraction

A. Applying suction to fetal head 1. Soft suction cup placed against occiput of fetal head 2. No cervical or vaginal tissue trapped under cup

B. Negative pressure 50–60 mmHG suction applied for more than 10 minutes → associated with greater incidence of scalp injury 1. 20 to 30 minutes time limit on use 2. More than three pop-offs → discontinue

C. Indications 1. Prolonged second stage of labor, nonreassuring heart rate pattern 2. Preferred to forceps with borderline CPD

D. Contraindications 1. True CPD 2. Nonvertex presentations 3. Maternal or suspected fetal coagulation defects 4. Known or suspected hydrocephalus 5. Fetal scalp trauma 6. Relative contraindications a) Suspected fetal macrosomia b) High fetal station c) Face or breech presentation d) Gestation less than 34 weeks e) Incompletely dilated cervix f) Previous fetal scalp blood sampling 7. Complications a) Scalp lacerations b) Bruising c) Subgaleal hematomas d) Cephalhematomas e) Intracranial hemorrhages 20 Copyright © 2020 Pearson Education, Inc.

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f) Subconjunctival hemorrhages g) Neonatal jaundice h) Fractured clavicle i) Erb palsy j) Damage to sixth, seventh cranial nerves k) Retinal hemorrhage l) Fetal death 8. Maternal complications a) Perineal trauma b) Edema c) Third-, fourth-degree lacerations d) Postpartum pain e) Infection 9. Guidelines a) Same criteria as used to evaluate appropriateness of forceps birth b) Same indications and contraindications should be used for both forceps and vacuum births c) Presenting part must be vertex and must be at 0 station or below d) Vacuum-assisted births should be performed only by experienced practitioners e) Procedure should be terminated immediately if descent does not occur or if vacuum device pops off more than three times

E. Nursing Management for the Woman Undergoing a Vacuum-Assisted Birth 1. Inform woman about what is happening during procedure 2. Pump vacuum to appropriate level 3. FHR auscultated at least every 5 minutes, or continuous EFM 4. Inform parents that caput will disappear within 2 to 3 days 5. See Figure 25–6: Vacuum extractor traction, p. 628 6. Continue to assess newborn for complications

IX.

Care of the Family During Cesarean Birth A. Birth of infant through abdominal and uterine incision 1. One of oldest surgical procedures 2. 32% of all births in 2015 a) American College of Obstetricians and Gynecologists (ACOG) task force (1) Recommendations

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3. Factors affecting cesarean birthrate a) Rising number of nulliparous women b) Rise in maternal age c) Changing philosophies d) Interpretations of EFM tracings e) Decrease in use of forceps, vacuum extractors f) Rise in obesity g) Vaginal birth after cesarean h) Use of epidural anesthesia i) Physician convenience j) Type of provider k) Medical malpractice litigation l) Mother request over fear of labor, convenience, concern about pelvic floor damage

B. Indications 1. Complete placenta previa 2. Cephalopelvic disproportion (CPD) 3. Placental abruption 4. Active genital herpes 5. Umbilical cord prolapse 6. Failure to progress in labor 7. Proven nonreassuring fetal status 8. Benign, malignant tumors that obstruct birth canal 9. Previous cesarean birth 10. Breech presentation 11. Major congenital anomalies 12. Cervical cerclage 13. Severe Rh isoimmunization 14. Maternal preference 15. Dystocia

C. Maternal Mortality and Morbidity 1. Fourfold risk of death in United States 2. Perinatal morbidity a) Infection 22 Copyright © 2020 Pearson Education, Inc.

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b) Excessive blood loss c) Injury to maternal organs d) Increased hospital stay e) More negative emotions f) Lower Apgar scores g) Neonatal respiratory problems h) Reactions to anesthesia i) Blood clots

D. Surgical Techniques 1. Skin incision a) Transverse (Pfannenstiel) (1) Lowest, narrowest part of abdomen (2) Less bleeding, better healing (3) More time required b) Vertical (1) Quicker (2) Rapid birth indicated (3) In obese women 2. Uterine incisions a) See Figure 25–8: Uterine incisions for a cesarean birth, p. 631 b) Lower uterine segment (1) Transverse (2) Vertical incision (a) Lower uterine segment in certain circumstances c) Classic incision (1) Upper uterine segment (2) More blood loss, difficult to repair (3) Nearly never performed in modern obstetrics (4) Increased risk of uterine rupture in subsequent pregnancies (5) See Table 25–4: Types of Uterine Incisions for Cesarean Birth, p. 632

E. Analgesia and Anesthesia 1. Safety, comfort, emotional satisfaction

F. Nursing Management for the Woman Undergoing a Cesarean Birth 1. Preparation for Cesarean Birth a) Encourage all pregnant women, partners to discuss with physician/CNM 2. Possible preferences a) Participating in choice of anesthetic b) Presence of partner during procedure c) Audio or video recording/photographing birth 23 Copyright © 2020 Pearson Education, Inc.

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d) Delayed instillation of eye drops to promote eye contact between parent, newborn e) Physical contact or holding newborn while on operating table, recovery room f) Breastfeeding immediately after surgery completed g) Preparation that may be done h) Description or viewing operating room i) Types of anesthesia j) Sensations that may be experienced k) Roles of significant others l) Interaction with the newborn m) Immediate recovery phase n) Postpartum phase 3. Communication with couple 4. Preoperative teaching a) Nothing taken by mouth status b) Antacids c) Anesthesia d) Assist, monitor blood pressure e) Continuous EFM f) Prep g) Positioning on operating table h) “Time-out” i) Grounding source secured j) Suction k) Instrument count 5. Preparation for Repeat Cesarean Birth a) Encourage to identify what they would like altered b) Reassurance and support c) Provide opportunity to discuss anxieties, fears 6. Preparation for Emergency Cesarean Birth a) Time for privacy to assimilate information if possible b) Give couple opportunity for further clarification c) Before procedures explain (1) What is going to happen (2) Why it is going to happen (3) What sensation she may experience 7. Supporting the Father/Partner a) Include in the experience b) Gown and mask c) Sterile drape can be partition if viewing procedure not wanted d) Allow to be near operating room to hear first cry e) Encourage to carry/accompany infant to nursery for initial assessment 24 Copyright © 2020 Pearson Education, Inc.

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f) Involve in postpartum care in recovery room 8. Immediate Postpartum Recovery Period a) Assess Apgar score, complete initial assessment, identification procedures as after vaginal birth b) Assist with bonding c) Vital signs every 5 minutes until stable d) Every 15 minutes for 1 hour e) Every 30 minutes until discharged to postpartum unit f) Dressing, perineal pad checked every 15 minutes for at least an hour g) Fundus palpated to determine if remaining firm (1) Support fundus while palpating h) IV oxytocin i) If general anesthesia → positioned on side (1) Position on side (2) Assist with cough, deep breathing every 2 hours for 24 hours j) Check level of anesthesia every 15 minutes k) Monitor intake and output

X.

Care of the Woman Undergoing Trial of Labor After Cesarean and Vaginal Birth After Cesarean A. VBAC 1. Nonrecurring indications for cesarean 2. ACOG guidelines a) One previous cesarean birth and low transverse uterine incision b) An adequate pelvis c) No other uterine scars or previous uterine rupture d) Physician able to do cesarean available throughout active labor e) In-house anesthesia personnel available for emergency cesarean births if warranted 3. Debate and research: rise in cesarean birth and reduction in VBACs 4. Repeat cesarean deliveries associated with higher maternal and neonatal mortality rates 5. TOLAC carries some risks, but they are rare and isolated a) See Table 25–5: Risks Associated with Repeat Cesarean Delivery (1) Blood loss (2) Abnormal placentation (3) Surgical injury to bowel or bladder (4) Adhesions (5) Postsurgical complications (6) Longer hospitalization (7) Increased costs (8) Hysterectomy 25 Copyright © 2020 Pearson Education, Inc.

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B. Nursing Management for the Woman Undergoing Trial of Labor After Cesarean 1. Institutional protocols 2. Very low risk a) Blood count, type and screen b) Heparin lock inserted c) Continuous EFM d) Clear fluids e) NPO if higher risk f) Supportive and comfort measures g) Provide information and encouragement

XI.

Focus Your Study

XII.

Activities 1. Individual Have students prepare drug cards, including a dosing guide in milliunits/mL, on the following medications: • Misoprostol (Cytotec) • Dinoprostone (Cervidil) vaginal insert • Dinoprostone (Prepidil) • Oxytocin (Pitocin) 2. Small Group Divide the class into small groups of three to five students. Have each group prepare a nursing care plan for the patient who will be undergoing one of the following procedures: • Amniotomy • External cephalic version • Forceps-assisted birth 3. Large Group Watch the following videos and facilitate a class discussion on forceps- and vacuum-assisted births.

• Forceps-assisted birth (50 seconds): http://www.medicalvideos.us/videos/328/ • Forceps- and vacuum-assisted births (4 minutes 11 seconds): http://www.youtube.com/watch?v=YGYfia8oI34

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Chapter 26 Physiologic Responses of the Newborn to Birth Fetal Respiratory System......................................................................................

2

Cardiopulmonary Adaptation...............................................................................

3

Hematopoietic Adaptations..................................................................................

5

Thermoregulation……………………………………….…………………………………………………..

7

Hepatic Adaptations.............................................................................................

8

Gastrointestinal Adaptations................................................................................

11

Urinary Adaptations..............................................................................................

12

Immunologic Adaptations....................................................................................

13

Neurologic Adaptation.........................................................................................

14

Focus Your Study..................................................................................................

17

Activities................................................................................................................

17

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I.

Fetal Respiratory System

A. Fetal Lung Development 1. Continuous state of development during fetal life 2. 20 to 24 weeks → alveolar ducts begin to appear 3. Surfactant critical for alveolar expansion and stability a) 28 to 32 weeks gestation → type II cells increases → production starts b) Peaks at 35 weeks → lungs structurally developed c) Production and maintenance of normal volume of fetal lung fluid essential for normal lung growth d) See Figure 26–1: Process of absorption of fetal lung fluid during breathing at birth, p.

639

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B. Fetal Circulation 1. In utero, placenta is organ of gas exchange 2. From placenta, highly oxygenated blood (65–70%) flows through umbilical vein 3. Small amount perfuses liver, majority volume flowing through inferior vena cava to right atrium 4. Blood directed to right atrium across the foramen ovale (FO) 5. 60% of right ventricle output bypasses the lung and flows through ductus arteriosus (DA) 6. In fetal circulation, right and left ventricles function together, in parallel, rather than sequentially 7. See Key Facts to Remember: Fetal and Newborn Circulation, p. 640

II.

Cardiopulmonary Adaptation

A. Marked changes at birth 1. During late gestation, lung fluid secretion decreases 2. Onset of labor stimulates catecholamines and other hormones, causing fetal pulmonary epithelial cells to begin reabsorption of fluid from alveolar spaces 3. With birth, changes in sensory environment from warm to cold is stimulus for initiation of breathing 4. Neonate’s first breaths of air empties the airways of fluid, establishes volume and function of newborn’s lungs, causes fetal circulation to convert to neonatal circulation 5. See Figure 26–2: Initiation of respiration in a newborn, p. 640 6. When umbilical cord clamped, placenta is excluded from circulation, cessation of blood flow through umbilical vein facilitates collapse of ductus venosus (DV), systematic vascular resistance increases 7. Fetal pulmonary to systemic pressure relationships are reversed 8. Closure of fetal shunts →systemic pressure b>pulmonary pressure→foramen ovale closes→establishes serial arterial-venous circulation indicative of neonatal circulation 9. See Figure 26–3: Transitional circulation: Conversion from fetal to neonatal circulation, p.

641 10. Four major cardiopulmonary changes a) See Figure 26–4: Major changes that occur in the newborn’s circulatory system, p. 642 b) Increased systemic vascular pressure and decreased pulmonary vascular pressure c) Closure of foramen ovale d) Closure of the ductus arteriosus 3 Copyright © 2020 Pearson Education, Inc.

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e) Closure of ductus venosus f) See Figure 26–5: Fetal-newborn circulation, p. 642

B. Maintaining Respiratory Function 1. Ability of the lung to maintain oxygenation and ventilation influenced by lung compliance and airway resistance 2. Lung compliance influenced by elastic recoil of lung tissue and anatomic differences in the newborn 3. Airway resistance depends on the radius length and number of airways

C. Characteristics of Newborn Respiration 1. Normal newborn respiration rate is 30 to 60 breaths per minute 2. Initial respirations largely diaphragmatic, shallow, and irregular in depth and rhythm 3. Periodic breathing: vigorous respiration followed by a pause for up to 20 seconds alternating with breathing 4. Apnea: cessation of breathing lasting more than 20 seconds a) May or may not be associated with changes in skin color or heart rate < 100 beats per minute 5. Newborns are obligatory nose breathers because nasal route is primary means of air entry 6. Immediately after birth and for next 2 hours, respiratory rates 60 to 70 breaths per minute 7. Acrocyanosis normal for first 24 hours 8. Primary care provider should be notified if: a) Respiration drop below 30 or exceed 60 per minute when baby is at rest b) Retractions c) Central cyanosis d) Nasal flaring e) Expiratory grunting f) Increase use of intercostal muscles 9. Pulse oximetry a) Should be > 95% in term newborns b) Takes about 10 minutes on average for pulse ox saturation to be > 90% c) See agency protocols

D. Characteristics of Cardiac Function 1. Heart rate a) Average resting heart rate in first week of life → 110 to 160 beats/min b) May drop to low of 70 to 90 beats/min during deep sleep

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c) Take via apical pulse with auscultation for one full minute, preferably when newborn is asleep 2. Blood pressure a) Highest immediately after birth → lowest about 3 hours of age b) 4 to 6 days of life → rises, plateaus c) Peripheral perfusion pressure sensitive indicator of ability to compensate d) Average mean blood pressure is 50 to 55 mmHg in full-term, resting newborns over 3 kg during first 12 hours of life e) Preterm newborn → average varies with weight, degree of illness f) See Figure 26–7: Response to blood pressure changes in newborn blood volume, p. 643 3. Cardiac murmurs a) Turbulent blood flow b) 90% of murmurs in newborns transient, not associated with anomalies c) Transition period d) Clicks at lower left sternal border → first few hours of life e) Early discharge → murmurs related to VSD and PDA not picked up until first well-baby checkup at 4 to 6 weeks of age.

4. Cardiac workload a) Before birth → right ventricle does 2/3 of cardiac work → increased size and thickness b) After birth → left ventricle must assume work → progressively increases in size and thickness

III.

Hematopoietic Adaptations

A. Mean hemoglobin level in cord blood at term is 17 g/dL B. Hemoglobin and hematocrit values rise in the first several hours after birth → movement of plasma from the intravascular to the extravascular space C. 3 to 5 days after birth, nucleated red blood cells (RBCs) are normally no longer found 1. May be present if hemolysis or hypoxic stress

D. Oxygen Transport 1. Transportation of oxygen to peripheral tissues depends on type of hemoglobin in red blood cells 2. 70% to 90% of hemoglobin in fetus and newborn is fetal hemoglobin (HbF) 3. Greatest difference between HbF and HbA (adult hemoglobin) relates to transport of oxygen a) Absolute oxygen-carrying capacity of fetal blood is greater than adult blood, which allows fetus to tolerate hypoxic intrauterine environment 5 Copyright © 2020 Pearson Education, Inc.

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4. Hypoxia causes increased amounts of erythropoietin to be secreted, resulting in active erythropoiesis 5. Fetal hemoglobin concentration in blood decreases after birth a) 3 to 5% per week, only 5 to 8% of total hemoglobin at 6 months of age 6. Initial decline in hemoglobin creates phenomenon known as physiologic anemia of the newborn a) Lowest level of hemoglobin at 3 months (physiologic nadir) 7. Once erythropoiesis resumes, iron stores used to produce new RBCs 8. By 3 to 5 days after birth, nucleated red blood cells normally no longer found in blood of term or preterm infants 9. Number of maternally administered pharmacologic agents implicated in hematologic abnormalities of fetus or newborn 10. Obtain accurate maternal history including medications 11. Newborn blood volume amount varies based on a) Amount of placental transfusion during delivery b) Gestational age c) Prenatal and/or postnatal hemorrhage d) Site of blood sample

E. Delayed Cord Clamping 1. If the umbilical cord is left unclamped for a short period of time after birth, blood from the placenta passes to the newborn (placental transfusion) 2. Increases neonates blood volume, improve blood flow to organs 3. Previous standard was immediate clamping at birth, WHO recommends delayed as standard of care 4. Placental blood rapidly transferred to newborn → 80mL of blood transferred in 1 min, 100mL at 3 minutes→ may facilitate transition 5. Positive effects a) Significantly higher levels of hemoglobin, higher ferritin levels until 6 months of age, fewer suffered from iron deficiency anemia, less need for blood transfusions, decreased rate of intraventricular hemorrhage 6. Negative a) Increased need for phototherapy for jaundice

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F. Coagulation 1. Platelet count of newborn comparable to adult values 2. Newborn may have transient diminished platelet function 3. Transient neonatal thrombocytopenia may occur in infants born to mothers with severe hypertension or HELLP syndrome 4. See Table 26–1: Normal Term Newborn Cord Blood and Cord Blood Gas Values, p. 645

IV.

Thermoregulation A. Newborns are homeothermic → physiologic response to changes in ambient temperature in and attempt to maintain a normal core temperature B. Thermoregulation is balance of heat loss, heat gain, and heat production 1. Neutral thermal environment (NTE) → temperature range in which heat production is at the minimum needed for normal body temperature

C. Establishment of thermal stability 1. Heat transfer from newborn organs to skin surface is increased 2. Nonshivering thermogenesis for heat production via metabolism of brown adipose tissue 3. Blood vessels closer to skin 4. Flexed posture decreases surface area exposed to environment 5. Preterm infants have increased heat loss via evaporation due to increased total body water and thin skin

D. Heat Loss 1. Large body surface in relation to mass, less insulating subcutaneous fat a) Loses about four times as much heat as adult b) The greater the difference between core and skin temps, heat transfer increases rapidly (1) Increase in oxygen consumption (2) Increased metabolism of brown fat (3) Depletion of glycogen stores and acidosis c) Heat loss mechanisms (1) Convection → warm body surface to cooler air currents (2) Radiation → body heat transferred to cooler surfaces, objects not in direct contact with body (3) Evaporation → loss of heat incurred when water converted to vapor (4) Conduction → loss of heat to cooler surface by direct skin contact d) See Figure 26–8: Methods of heat loss. A. Convection. B. Radiation. C. Evaporation. D. Conduction, p. 646 7 Copyright © 2020 Pearson Education, Inc.

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E. Heat Production (Thermogenesis) 1. Nonshivering thermogenesis (NST) a) Skin receptors perceive drop in environmental temperature → transmit sensations to stimulate sympathetic nervous system (1) Uses brown adipose tissue (BAT) to provide heat (2) BAT = brown fat (a) Found at midscapular area, around the neck, axillae, with deeper placement around the trachea, esophagus, abdominal aorta, kidneys, adrenal glands b) Shivering rarely seen in newborns (1) SGA, intrauterine growth restricted (IUGR), premature → inadequate brown fat stores c) Increase metabolism result of hypothermia (1) Increase oxygen and glucose consumption → show signs of respiratory distress (2) Exposed to cold → preterm newborn unable to increase ventilation (3) Effect of drugs

V.

Hepatic Adaptations A. Neonate less than 20% of hepatocytes than in adult liver B. Iron Storage 1. As RBCs destroyed after birth → iron content stored in liver 2. Term newborn 270 mg of iron at birth, 140 to170 mg of this amount is in the hemoglobin 3. Iron intake of mother adequate → iron stored to last until 5 months of age

C. Glucose Homeostasis 1. Glucose not used for immediate energy needs converted to glycogen 2. Stored in liver, heart, skeletal muscles as glycogen 3. Fetal glucose levels approximately 80% of mother’s glucose level 4. Glycogen storage for postnatal energy needs begins early in gestation; most glycogen stores accumulate in third trimester 5. After umbilical cord clamping, neonate’s blood glucose level fall a) Reaching a nadir at about 1 to 2 hours of ages

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6. First hours after birth, neonatal brain metabolizes newborn’s abundant stores of lactate 7. By secreting glucagon and suppressing insulin release, newborn mobilizes glucose to meet energy needs 8. If healthy term infant not fed soon after birth, blood glucose levels rise at 3 to 4 hours of age 9. Hepatic glycogen rapidly depleted if feeding is not established early

D. Conjugation of Bilirubin 1. Bilirubin is primarily the metabolic end product of erythrocyte 2. Bilirubin: metabolic end product of erythrocyte (RBC) breakdown 3. Conjugation → conversion of yellow lipid-soluble pigment into water soluble pigment a) Unconjugated bilirubin → fat soluble, not excretable, potential toxin 4. Total serum bilirubin → sum of conjugated (direct) and unconjugated (indirect) bilirubin a) At birth → less than 3 mg/dl 5. After birth → newborn’s liver must begin to conjugate bilirubin 6. Unconjugated bilirubin formed → transferred to liver for uptake or change to direct bilirubin → through bile ducts → intestines → not reabsorbed → yellow brown stool 7. Can be changed back to unconjugated → in intestine enzyme deconjugate bilirubin → reabsorbed through intestinal wall → back to liver 8. See Figure 26–9: Conjugation of bilirubin in newborns, p. 649 a) Babies with delayed bacterial colonization of gut 9. Infants who establish gut motility, active stooling → early and frequent feedings 10. Less hepatic activity → increases susceptibility to jaundice 11. Hyperbilirubinemia is elevated total serum bilirubin level

E. Physiologic Jaundice 1. Nonpathologic unconjugated hyperbilirubinemia 2. 60% term newborns; 80% preterm neonates intestinal tract 3. Normal biologic response 4. Because of shorter lifespan of fetal RBCs, newborns have two to three times greater production or breakdown of bilirubin 5. Signs of physiologic jaundice appear after the first 24 hours postnatally (yellowing of skin) a) Differentiates physiologic jaundice from pathologic jaundice b) Physiologic jaundice (nonpathologic unconjugated hyperbilirubinemia) 9 Copyright © 2020 Pearson Education, Inc.

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(1) 60% of term newborns (2) 80% of preterm newborns (3) Visible when the serum bilirubin concentration is greater than 4 to 6 mg/dL 6. Unmonitored and untreated severe hyperbilirubinemia may progress to excessive levels that are associated with bilirubin neurotoxicity 7. Jaundice detected by blanching skin with digital pressure on forehead, midsternum, or knee to reveal underlying color of the skin a) Develops in cephalocaudal progression b) Maintain newborn’s skin temperature at 36.5°C (97.8°F) or above c) Monitor stool for amount and characteristics d) Encourage early feedings 8. Absence of jaundice is not indication of absence of hyperbilirubinemia 9. Clinical risk factors a) Exclusive and insufficient breast milk feedings b) Family history of neonatal jaundice c) Bruising d) Assisted delivery with vacuum or forceps e) Cephalhematoma f) Asian ethnicity g) Maternal age > 25 years h) Male gender i) Gestational age

F. Breastfeeding Jaundice 1. Breastfeeding jaundice → in first days of life a) Inadequate fluid intake b) Dehydration c) Self-limiting d) Prevention & treatment (1) Encouraging frequent (every 2 to 3 hours) breastfeeding (2) Avoiding supplementation in nondehydrated newborns (3) Accessing maternal lactation counseling

G. Breast Milk Jaundice 1. Exact mechanism unknown, 1:200 term newborns 2. Onset 3 to 5 days, peaks at 2 weeks of life 3. Bilirubin metabolism causes exaggerated physiologic jaundice 4. Breast milk jaundice related to milk composition promotes increased bilirubin reabsorption a) Appear well 10 Copyright © 2020 Pearson Education, Inc.

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b) May need temporary cessation of breastfeeding 5. See Key Facts to Remember: Factors in Physiologic, Breast Milk, and Breastfeeding Jaundice, p. 650

VI.

Gastrointestinal Adaptations

A. Digestion and Absorption 1. Adequate intestinal, pancreatic enzymes to digest most simple carbohydrates, fat, proteins a) Lactose primary carbohydrate in breastfeeding newborn b) Only enzyme lacking is pancreatic amylase 2. Proteins require more digestion 3. Absorbs and digests fats less efficiently 4. Fetal gastrointestinal tract is sterile a) Microbes begin → newborn’s oral mucosa is exposed to the environment 5. Infants born by vaginal delivery become colonized by microbes present in the birth canal and mother’s gastrointestinal tract 6. Infants born by cesarean section initially colonized by skin flora 7. Air enters stomach immediately after birth a) Small intestine is air filled within 2 to 12 hours, large bowel within 24 hours 8. Salivary glands immature at birth 9. Newborn’s stomach has capacity of 50 to 60 mL

B. Cardiac sphincter immature → regurgitation may be noted 1. Monitor continuous vomiting or regurgitation 2. Bilious vomiting abnormal → evaluated 3. Digestion and absorption → growth and development a) Requires 120 kcal/kg/day b) May be weight loss of 5% to 10% → shift of intracellular to extracellular space

C. Elimination 1. Meconium within 24 to 48 hours a) Formed in utero b) Thick, tarry, black to dark green

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2. Transitional stools 3. Breastfed → pale yellow, more liquid, more frequent 4. Formula → pale, consistency of peanut butter 5. Frequency varies a) One every 2 to 3 days to 10 daily b) Not constipation if bowel movement remains soft c) See Key Facts to Remember: Physiologic Adaptations to Extrauterine Life, p. 652

VII.

Urinary Adaptations

A. Kidney Development and Function 1. Kidneys have full complement of functioning nephrons by 34 to 36 weeks’ gestation a) Glomerular filtration doubles in first few days of life b) Ability to concentrate urine fully attained by 3 months of age c) Feeding practices can affect osmolarity

B. Characteristics of Newborn Urinary Function 1. Normal newborn → 90% void within 24 hours after birth, 99% by 48 hours a) Assess for fluid intake, bladder distention, restlessness, symptoms of pain if no void by 48 hours b) Initial bladder volume → 6 to 44 mL of urine 2. First 2 days → 2 to 6 times daily → 15 mL/kg/day a) Subsequently 5 to 25 times/24 hours → volume 25 mL/kg/day 3. Frequently cloudy, high specific gravity a) Urine straw colored, almost odorless

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4. See Table 26–2: Newborn Urinalysis Values, p. 652

VIII.

Immunologic Adaptations

A. Neonatal defense against infections dependent upon maternal immunity 1. Maternal–fetal infection transmission major cause of morbidity and mortality in newborns

B. Defense, homeostasis, surveillance C. Nonspecific immune mechanisms 1. Phagocytosis 2. Inflammatory response 3. Complement 4. Coagulation 5. Function without prior exposure, identified early in gestation, reach functional development at 32 to 33 weeks’ gestation

D. Humoral Immunity 1. Specific antibody-mediated response that functions effectively if there has been recent exposure a) Maturation of specific immune responses begins in utero, 7 to 12 weeks’ gestation 2. Active immunity: woman forms antibodies in response to illness or immunization 3. Passive acquired immunity: antibodies transferred to fetus in utero 4. Immunoglobulin G (IgG) major immunoglobulin of serum and interstitial fluid and provides immunity against bacterial and viral pathogens a) Other immunoglobulins: IgM, IgA, IgE

E. Cellular Immunity 1. Mediated by T lymphocytes 2. Three types of active T cells a) Cytotoxic b) Helper c) Suppressor

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3. T lymphocytes modify behavior of phagocytic cells and increase their antimicrobial activity

IX.

Neurologic Adaptation A. Neuronal organization 1. Basis of brain function and its complex circuitry 2. Peaks at 20 weeks’ gestation and continues into adult life

B. Myelination 1. Enhances intracellular communication 2. Begins second trimester and continues into adult life

C. Intrauterine Environmental Influence on Newborn Behavior 1. Intrinsic factors → nutrition and drug exposure 2. External factors → mother’s physical environment 3. Responses to different stresses vary a) Quietly, overreact, combination 4. Intense auditory stimuli in utero → manifested in behavior of newborn

D. Characteristics of Newborn Neurologic Function 1. Perinatal factors a) Labor and delivery, drugs given to mother, overall infant health, gestational age 2. Environment a) A quiet, dim, warm, calming environment versus noisy, bright or cold 3. Usually partially flexed extremities, legs near abdomen 4. Organization and intensity of newborn motor activity influence by several factors a) Sleep–wake states b) Presence of environmental stimuli c) Conditions causing chemical imbalance, such as hypoglycemia d) Hydration status e) State of health f) Recovery from stress of labor and birth

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5. Muscle tone should be symmetric 6. Reflexes, including Moro, grasping, rooting, sucking reflexes, characteristics of neurologic integrity 7. Self-quieting ability: ability of newborn to use their own resources to quiet and comfort themselves 8. Habituation: newborn’s ability to process and respond to complex stimulation

E. Periods of Reactivity 1. First period → birth to about 30 minutes after birth a) Indicate readiness for feeding → sucking, rooting, and swallowing (1) Initiate breastfeeding b) Respirations rapid, heart rate rapid, bowel sounds usually absent 2. Period of inactivity to sleep phase a) Heart rate, respirations decrease b) Sleep phase may last a few minutes to 2 to 4 hours c) Difficult to arouse, no interest in sucking 3. Second period of reactivity a) Awake and alert b) 4 to 6 hours c) Physiologic responses vary (1) Alert for apneic periods d) Close observation e) Gastrointestinal tract more active (1) Secretions can cause gagging, choking, and regurgitating f) Maintain clear airway g) May suck, root, swallow

F. Behavioral States of the Newborn 1. Sleep states a) Deep or quiet sleep (1) Closed eyed, no eye movements (2) Regular, even breathing b) Active of light sleep (rapid eye movement [REM] sleep) (1) Irregular respirations, eyes closed with REM (2) Irregular sucking motions 2. REM active sleep, quiet sleep → intervals of 50 to 60 minutes a) 45% to 50% of total sleep is active b) 35% to 45% is quiet sleep c) 10% transitional d) Any disturbance of the sleep–wake cycle → irregular spikes of growth hormone 15 Copyright © 2020 Pearson Education, Inc.

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e) Over time → become diurnal 3. Alert states a) First 30 to 60 minutes after birth b) Periods of alertness short first 2 days after birth c) Subcategories of alert state (1) Drowsy or semidozing (2) Quiet alert (3) Active alert (4) Crying

G. Sensory/Perceptual Capacities of the Newborn 1. Visual capacity a) Orientation → ability to be alert to, to follow, fixate on complex visual stimuli b) Prefers human face; eyes; bright, shiny objects 2. Auditory capacity a) Definite, organized behavior repertoire b) Stimulus used → selected to match the state of the newborn c) Prefers sound of human voice d) Evaluate newborn hearing prior to discharge 3. Olfactory capacity a) Develops rapidly b) Can differentiate mother by smell within first week of life 4. Taste and sucking a) Distinguish between sweet and sour at 3 days of age b) Newborn sucks in bursts with frequent regular pauses (1) Sucking pattern variations between bottle and breastfeeding c) Rooting reflex → awake and hungry d) Feeding → sucking pattern e) Nonnutritive sucking as self-quieting activity 5. Tactile capacity a) Very sensitive to being touched, cuddled, held b) Swaddling, placing a hand on the abdomen, or holding the arms to prevent a startle reflex → soothe baby c) Touch may be most important for newborn

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X.

Focus Your Study

XI.

Activities 1. Individual Have students develop a teaching plan for the mother of a term infant that is small for gestational age. Instruct to students to base their information on normal newborn indicators and to cite their resources in APA format.

2. Small Group Divide the class into small groups of three to five students. Have each group develop a sensory assessment plan for the normal newborn for the assigned sense: • Taste • Smell • Hearing • Sight • Touch 3. Large Group As a class, watch the following videos and facilitate class discussions on the subject matter presented: 1. Normal newborn circulation (2 minutes 50 seconds): http://www.dailymotion.com/video/xavrnu_normal-newborn-circulation_creation 2. Newborn normal behavior (1 minute 38 seconds): http://www.youtube.com/watch?v=AlRnKt6q1T8

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Chapter 27 Nursing Assessment of the Newborn Timing of Newborn Assessments........................................................................

2

Estimation of Gestational Age.............................................................................

2

Physical Assessment............................................................................................

5

Focus Your Study.................................................................................................

15

Activities...............................................................................................................

15

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I.

Timing of Newborn Assessments

A. First 24 hours → mortality and morbidity statistically high B. Delivery room disposition: first assessment → birthing area immediately after birth 1. Need for resuscitation 2. Stable → placed with parents

C. Nursery or couplet care admission examination: second assessment → routine assessment to nursery 1. No later than 2 hours after birth 2. Progress of adaptation to extrauterine life 3. Determination of gestational age 4. Ongoing assessment for newborn at risk

D. Before discharge examination 1. Complete physical examination 2. Detect any emerging or potential problems 3. Behavioral assessment

E. See Key Facts to Remember: Timing and Types of Newborn Assessments, p. 659

II.

Estimation of Gestational Age

A. Establish in first 4 hours after birth B. Gestational age tools 1. External physical characteristics a) Sole creases b) Amount of breast tissue c) Amount of lanugo d) Cartilaginous development of the ear e) Testicular descent and scrotal rugae in the male f) Labial development in the female.

2. Neurologic development a) Nervous system unstable during first 24 hours of life b) Second assessment in 24 hours c) Between 26 and 34 weeks significant neurologic changes

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3. Ballard tool a) Each finding given a point value b) Physical characteristic and neurologic characteristics 4. New Ballard Score → assessment of newborns between 20 and 28 weeks’ gestation, less than 1500 g a) Do assessment in first 12 hours of life, especially if <26 weeks’ gestation 5. Maternal conditions may affect certain components a) Diabetes b) Preeclampsia c) Maternal analgesia and anesthesia

C. Assessment of Physical Maturity Characteristics 1. Resting posture a) See Figure 27–1: Resting posture, p. 661 2. Skin 3. Lanugo a) See Figure 27–2: Lanugo, p. 662 4. Sole (plantar) creases a) See Figure 27–3: Sole creases, p. 662 5. Areola and breast bud tissue a) See Figure 27–4: Breast tissue., p. 663 b) As gestation progresses, breast tissue mass and areola enlarge 6. Ear form and cartilage a) See Figure 27–5: Ear form and cartilage, p. 663 7. Male genitals a) See Figure 27–6: Male genitals, p. 664 8. Female genitals a) See Figure 27–7: Female genitals, p. 664 9. Vernix a) Note in birthing area prior to drying infant

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10. Hair 11. Skull firmness 12. Nails

D. Assessment of Neuromuscular Maturity Characteristics 1. Central nervous system matures at constant rate a) Caudocephalic progression, lower to upper extremities 2. Characteristics evaluated a) Square window sign (1) See Figure 27–8: Square window sign, p. 665 b) Recoil (1) Test of flexion development (2) First tested in legs (a) Newborn is placed on back on flat surface (b) Legs are placed in flexion then extended parallel to each other on flat surface (c) Response is recoil of legs (i) Preterm infants have less muscle tone → less recoil (3) Arm recoil tested by flexion at the elbow and extension of arms at newborn’s side (4) Bilateral to rule out brachial palsy (5) See Figure 27–9: Arm recoil, p. 665 c) Popliteal angle d) Scarf sign (1) See Figure 27–10: Scarf sign, p. 665 e) Heel-to-ear extension (1) See Figure 27–11: Heel-to-ear. No resistance. Leg fully extended. Score 0, p. 666 f) Ankle dorsiflexion (1) See Figure 27–12: Ankle dorsiflexion …, p. 666 g) Head lag (1) Pulling baby to sitting position (2) Noting degree of head lag h) Ventral suspension (1) Holding newborn prone on examiner’s hand (2) Note position of head, back, degree of flexion in arms and legs i) Major reflexes j) Supplementary method k) View cornea with ophthalmoscope 3. Gestational age determination and birthweight considered together a) Below 10th percentile → small for gestational age (SGA) b) Appropriate for gestational age (AGA) c) Above 90th percentile → large for gestational age (LGA)

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d) See Figure 27–13: Select reference percentiles for birth weight at each gestational age from 22 to 44 completed weeks …, p. 668 e) Use information in conjunction with physical examination

III.

Physical Assessment

A. Complete with parents → systematic, head-to-toe manner B. General Appearance 1. Head large for body 2. Prominent abdomen, sloping shoulders, narrow hips, rounded chest 3. Tend to stay in flexed position

C. Weights and Measurements 1. Average full-term Caucasian newborn 3405 g (7 lb 8 oz) a) African, Asian, and Hispanic heritage are usually smaller 2. 70% to 75% of newborns’ body weight water 3. Length of normal newborn difficult to measure a) See Figure 27–14: Measuring the length of the newborn, p. 669 4. Head circumference a) Approximately 2 cm greater than circumference of chest b) See Figure 27–15: A. Measuring the head circumference of the newborn, p. 670 5. Chest circumference a) See Figure 27–15: B. Measuring the chest circumference of the newborn, p. 670 b) See Key Facts to Remember: Newborn Measurements, p. 669 6. Temperature a) Critical b) Heat conservation measures → or core temp falls 0.1°C (0.2°F) per minute (1) Skin temperature 0.3°C (0.5°F) per minute (2) Stabilizes at 8 to 12 hours c) Assess temperature on admission to nursery (1) Every 30 minutes until stable for 2 hours (2) Then once every 8 hours (3) Exposed to group B hemolytic streptococcus → more frequently d) Axillary, skin probe, rectal (1) Continuous skin probe (2) See Figure 27–16: Axillary temperature measurement, p. 670 (3) See Figure 27–17: Temperature monitoring for the newborn …, p. 670 e) Temperature instability may indicate: (1) Infection 5 Copyright © 2020 Pearson Education, Inc.

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(a) Subnormal or deviation of more than 1°C (2°F) from one reading to the next (2) Reaction to too many blankets (3) Too hot a room (a) May increase respiratory and heart rates (4) Dehydration

D. Skin Characteristics 1. Pink tinge to skin in all babies a) Pigmentation deepens over time b) Cyanotic at rest, pink when crying, may have choanal atresia c) Crying increases cyanosis → heart or lung problems suspected 2. Acrocyanosis a) See Figure 27–18: Acrocyanosis, p. 671 b) Bluish coloration of hands and feet c) First 24 hours 3. Mottling a) Related to chilling, prolonged apnea, sepsis, or hypothyroidism 4. Harlequin sign a) See Figure 27–19: Harlequin sign, p. 671 b) Deep color on one side of body, other side pale 5. Jaundice a) Yellowish discoloration of skin and mucous membranes b) First detectable on face c) Advances from head to toe d) May be related to hematomas, immature liver function, poor feeding, blood incompatibility, oxytocin, augmentation or induction, severe hemolysis process e) See Clinical Skill 27–1: Assessing Jaundice in the Newborn, p. 672 6. Erythema toxicum a) Eruption of lesions on area surrounding a hair follicle b) Appear suddenly, usually trunk and diaper area c) See Figure 27–20: Erythema toxicum, p. 672 7. Milia a) Exposed sebaceous glands b) See Figure 27–21: Facial milia over bridge of nose, p. 673 8. Skin turgor a) Abdomen, forearm, thigh 9. Vernix caseosa a) White, cheeselike substance

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10. Forceps marks a) Reddened areas over cheeks and jaws b) Reassure parents 11. Sucking blisters a) See Figure 27–22: Sucking blister in middle of upper lip, p. 673

E. Birthmarks 1. Telangiectatic nevi → stork bites a) Eyelids, nose, lower occipital bone, nape of neck b) See Figure 27–23: Stork bites …, p. 673 2. Congenital dermal melanocytosis (Mongolian blue spots) a) Bluish-black or gray-blue, dorsal area, buttocks b) See Figure 27–24: Mongolian spots, p. 673 3. Nevus flammeus (port wine stain) a) Capillary angioma directly below epidermis b) Nonelevated, sharply demarcated, red to purple c) Commonly on face d) Neurologic problems → suggestive of Sturge-Weber syndrome e) See Figure 27–25: Port wine stain over temple area, p. 674 4. Nevus vasculosus (strawberry mark) a) Capillary hemangioma b) Enlarged capillaries in dermal, subdermal layers c) Raised, clearly delineated, dark red, rough-surfaced d) Grow until about 6 months of age e) Shrink, resolve spontaneously f) Information, reassurance g) See Figure 27–26: Nevus vasculosus, also called strawberry mark, on leg, p. 674 5. Note bruises, abrasions, birthmarks on admission

F. Head 1. General appearance a) One-fourth of body size; soft, pliable skull bones b) Normal occipital-frontal circumference 32 to 37 cm for term newborns c) Asymmetry → molding with vaginal birth d) Extreme differences (1) Microcephaly (2) Hydrocephalus (3) Craniosynostosis (4) Plagiocephaly e) Fontanelles

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(1) Anterior → openings at junction of cranial bones (a) Diamond-shaped (b) 3 to 4 long  2 to 3 cm wide (c) Closes within 18 months (2) Posterior → parietal, occipital bone (a) Triangular, smaller (b) 0.5  1 cm (c) Closes at 2 to 3 months (3) Indicator of newborn’s condition 2. Cephalhematoma a) Collection of blood between surface of a cranial bone, periosteal membrane b) See Figure 27–28: A. Cephalhematoma is a collection of blood between the surface of the cranial bone and periosteal membrane …, p. 675 c) Feels loose, slightly edematous 3. Caput succedaneum a) Localized, easily identifiable soft area of scalp b) Long labor, vacuum extraction c) See Figure 27–29: Caput succedaneum is a collection of fluid (serum) under the scalp, p.

676

G. Hair 1. Term newborn → smooth, ethnic texture variations

H. Face 1. Designed to help with suckling 2. Symmetry a) Eyes, nose, ears b) Facial movement c) See Assessment Guide: Newborn Physical Assessment, pp. 685–696

I. Eyes 1. Color a) Scleral color white to bluish white 2. Check for size, equality of pupil size, reaction of pupils to light, blink reflex, edema, inflammation of eyelids 3. Erythromycin, tetracycline used prophylactically 4. Silver nitrate → may cause chemical conjunctivitis 5. Infectious conjunctivitis a) Greenish yellow 8 Copyright © 2020 Pearson Education, Inc.

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6. Subconjunctival hemorrhage 7. Transient strabismus a) See Figure 27–30: Transient strabismus in the newborn may be due to poor neuromuscular control, p. 677 8. Observe for opacities, absence of red retinal reflex 9. Cry commonly tearless 10. Peripheral vision, can fixate on near objects

J. Nose 1. Small, narrow 2. Nose breathers for first few months 3. Choanal atresia 4. Has ability to smell

K. Mouth 1. Lips → pink, touch should produce sucking motions 2. Stimulate to cry → depress tongue a) Examine entire mouth for cleft palate b) See Figure 27–31: The nurse inserts the index finger or pinky into the newborn’s mouth and feels for any openings along the hard and soft palates, p. 677 3. Precocious teeth 4. Epstein’s pearls 5. Thrush → candida albicans → treated with nystatin 6. Tongue-tied → ridge of frenulum tissue

L. Ears 1. Soft, pliable, should recoil 2. Top of ear should be parallel to outer, inner canthus of eye 3. Low-set ears → characteristic of many syndromes a) See Figure 27–32: The position of the external ear may be assessed by drawing an imaginary line across the inner and outer canthus of the eye to the insertion of the ear …, p. 678

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4. Preauricular skin tag 5. Hearing acute as mucus absorbed, eustachian tube aerated, tympanic membrane visible 6. Evaluate response to loud, moderately loud noises 7. AAP has endorsed universal newborn screening in birthing units as standard care

M. Neck 1. Short, creased with skin folds 2. Cannot support full weight of head 3. Palpate for masses, lymph nodes 4. Range of motion 5. Clavicles evaluated for evidence of fractures

N. Chest 1. Thorax cylindric, symmetric at birth, ribs flexible 2. Engorged breasts common → hormones a) See Figure 27–33: Breast hypertrophy, p. 678 b) Whitish secretions

O. Cry 1. Strong, lusty, medium pitch 2. High-pitched, shrill cry abnormal 3. Important method of communication

P. Respiration 1. Normal 30 to 60 respirations per minute, predominantly diaphragmatic 2. Note a) Hyper- or hypoexpansion b) Airway noises 3. Episodic breathing (apnea) may occur with no color, heart rate change

Q. Heart 1. Normal 110 to 160 beats/min a) Up to 180 beats/min b) Note rate, rhythm (1) Pulse rate variable, influenced by physical activity, crying, state of wakefulness, body temperature 10 Copyright © 2020 Pearson Education, Inc.

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2. Auscultation over entire heart region a) Placement of heart determined (1) Shift of heart tones → pneumothorax, dextrocardia, diaphragmatic hernia (2) Presence of murmur b) Apical pulse rates by auscultation for a full minute, preferably while asleep 3. Peripheral pulses a) Brachial b) Femoral c) Pedal (1) See Figure 27–34: A. Bilaterally palpate the femoral arteries for rate …. B. Compare the femoral pulses to the brachial pulses …, p. 679 4. Measurement of blood pressure a) See Figure 27–35: Blood pressure measurement using the Dinemapp and Doppler devices. The cuff can be applied to either the newborn’s upper arm or the thigh, p. 680 b) Immobilize extremity c) Crying, movement, inappropriate size → give inaccurate measurements d) If cardiac anomaly suspected → all extremities 5. See Key Facts to Remember: Normal Vital Signs, p. 680 a) Pulse 110 to 160 beats/min (1) During deep sleep as low as 70 beats/min; if crying, up to 180 beats/min (2) Apical pulse counted for 1 full minute b) Respirations 30 to 60 respirations/minute (1) Predominantly diaphragmatic but synchronous with abdominal movements (2) Respirations are counted for 1 full minute c) Blood pressure 70 to 50/45 to 30 mm Hg at birth (1) 90/50 mm Hg at day 10 d) Temperature → normal range: 36.5°C to 37.5°(97.7°F to 99.4°F) (1) Axillary: 36.5°C to 37.2°C (97.7°F to 99°F) (2) Skin: 36°C to 36.5°C (96.8°F to 97.7°F) (3) Rectal: 36.6°C to 37.2°C (97.8°F to 99°F)

R. Abdomen 1. Cylindrical, protrudes slightly, moves with respiration a) Scaphoid abdomen 2. No cyanosis, few blood vessels apparent a) No distention or bulging 3. Auscultate for bowel sounds → by 1 hour after birth a) Auscultate before palpating 4. Palpation systematic a) Liver large in proportion 11 Copyright © 2020 Pearson Education, Inc.

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S. Umbilical cord 1. Initially white, gelatinous, two arteries, one vein a) Dry, shriveled, blackened by second, third day 2. Cord bleeding abnormally 3. Foul-smelling drainage abnormal 4. Patent urachus 5. Umbilical cord hernia a) See Figure 27–36: Umbilical hernia, p. 681

T. Genitals 1. Female newborns a) Note labia and clitoris b) Discharge c) Pseudomenstruation 2. Male newborns a) Urinary orifice correctly positioned (1) Hypospadias (2) Epispadias b) Phimosis c) Scrotum inspected for size, symmetry (1) Presence of both testes (2) Cryptorchidism (3) Hydrocele

U. Anus 1. Verify patent anus that has no fissure a) Imperforate anus, rectal atresia 2. Note passage of meconium

V. Extremities 1. Note gross deformities 2. Arms and hands a) Polydactyly b) Syndactyly c) Palmar crease d) Brachial palsy (1) Partial or complete paralysis of portions of the arm (2) From trauma to the brachial plexus during a difficult birth

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(3) Erb-Duchenne paralysis (Erb palsy) → arm lies limply at side (a) Lower arm (b) Whole arm (4) Prognosis related to degree of nerve damage 3. Legs and feet a) Equal, symmetric skin folds b) Barlow and Ortolani maneuvers for hip dislocation/instability (1) See Figure 27–37: A. The asymmetry of gluteal and thigh fat folds …, B. Barlow (dislocation) maneuver …, C. Dislocation is palpable …, D. Ortolani maneuver …, p.

682 c) Feet examined for evidence of talipes (1) See Figure 27–38: A. Unilateral talipes equinovarus (clubfoot) ..., p. 683

W. Back 1. Examine in prone position 2. Should be straight, flat 3. Examine for dermal sinus 4. Pilonidal dimple

X. Assessment of neurologic status 1. Important behaviors to assess are: a) State of alertness b) Resting posture c) Cry d) Quality of muscle tone e) Motor activity 2. Position a) Partially flexed extremities, legs abducted to abdomen b) Purposeless, uncoordinated bilateral movements c) Eye movements d) Fixate on faces e) Evaluate muscle tone (1) Slightly hypertonic (2) Symmetric (3) Differentiate tremors from convulsions (4) Neonatal seizures may be: (a) Chewing, swallowing, deviations, rigidity, flaccidity (5) Specific deep tendon reflexes (6) Immature central nervous system

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3. Tonic neck reflex a) See Table 27–1: Common Newborn Reflexes, Tonic neck reflex, p. 667 4. Palmar grasping reflex a) See Table 27–1: Common Newborn Reflexes, Tonic neck reflex, p. 667 5. Moro reflex a) See Table 27–1: Common Newborn Reflexes, Tonic neck reflex, p. 667 6. Rooting reflex a) See Table 27–1: Common Newborn Reflexes, Tonic neck reflex, p. 667 7. Sucking reflex a) See Table 27–1: Common Newborn Reflexes, Tonic neck reflex, p. 667 8. Protective reflexes a) Blink b) Gag c) Yawn d) Cough e) Sneeze f) Draw back from pain 9. Trunk incurvation (Galant reflex) 10. Stepping reflex a) See Table 27–1: Common Newborn Reflexes, Tonic neck reflex, p. 667 11. Steps to assess central nervous system (CNS) integration a) Unpowdered gloved finger into mouth to elicit sucking reflex b) As soon as newborn sucking vigorously (1) Assess hearing, vision responses by noting sucking changes (2) Should be brief cessation of sucking

Y. Newborn Behavioral Assessment Scale 1. See Assessment Guide: Newborn Physical Assessment, pp. 685–696

Z. The Brazelton Neonatal Behavioral Assessment Scale 1. Third day after birth in quiet, dimly lit room 2. Determine state of consciousness 3. Observe sleep–wake cycle a) Transitions

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4. Newborn’s style and ability to adapt indicate need for parental interventions?

5. Parental interventions necessary to lessen outside stimuli?

6. Can baby control amount of sensory input to be dealt with?

7. Behaviors and sleep–wake states a) Habituation b) Orientation to inanimate and animate visual and auditory assessment stimuli c) Motor activity d) Variations e) Self-quieting activity f) Cuddliness or social behaviors

IV.

Focus Your Study

V.

Activities 1. Individual Have students prepare a newborn maturity rating and classification for a newborn in the nursery. Instruct students to use the Ballard assessment tool.

2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan for the new parent on the assigned physical assessment area: • Temperature • Birthmarks • Hair • Mouth • Heart • Extremities • Neurologic status • Skin • Head • Face • Chest and respirations • Abdomen and umbilical cord • Reflexes 3. Large Group As a class, view the following three short videos and facilitate a class discussion on the physical examination of the normal newborn: 1. Behavior (1 minute 38 seconds) http://www.youtube.com/watch?v=AlRnKt6q1T8 2. Tone: Scarf Sign (37 seconds) http://www.youtube.com/watch?v=Lx_4DglwmIE&NR=1 15 Copyright © 2020 Pearson Education, Inc.

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3. Tone: Arm Recoil (29 seconds) http://www.youtube.com/watch?v=97I03A8eg_Y&NR=1

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Chapter 28 The Normal Newborn: Needs and Care Admission and the First 4 Hours of Life..................................................................

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The Newborn Following Transition.........................................................................

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Preparation for Discharge.......................................................................................

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Focus Your Study.....................................................................................................

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Activities...................................................................................................................

10

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

Admission and the First 4 Hours of Life

A. Nursing Management for the Newborn During Admission and the First 4 Hours of Life 1. Nursing Assessment and Diagnosis a) Review prenatal record for possible risk factors (1) Infectious disease screening results, drug or alcohol use by the mother, gestational diabetes, other data related to needs of the newborn or their transition b) Review birth record (1) Prolonged rupture of membranes, instrument or vacuum delivery, use of narcotic analgesia, presence of meconium c) Preliminary physical examination (1) Notify physician/nurse practitioner of deviations from normal d) Diagnoses include (1) Airway Clearance, Ineffective (2) Body Temperature: Imbalanced, Risk for (3) Pain, Acute

B. Planning and Implementation 1. Initiation of admission procedures a) Evaluates newborn’s need to remain under evaluation (1) Maternal and birth history (2) Airway clearance (3) Skin color (4) Vital signs (5) Measurements (head circumference, body length, body weight) (6) Neurologic status (7) Ability to feed (8) Evidence of complications and/or illness (9) Other evaluations as needed or directed b) Initial assessment indicates newborn not at risk → routine admission procedures (1) In presence of parents (2) No later than 2 hours after birth c) Check, confirm newborn’s identification with mother’s identification 2. Essential data to be recorded a) Condition of newborn b) Labor and birth record c) Antepartum history d) Parent–newborn interaction information e) Weigh newborn in grams and pounds (1) See Figure 28–1: Weighing a newborn. The scale is balanced before each weighing, with a protective pad in place, p. 700 2 Copyright © 2020 Pearson Education, Inc.

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(2) Length, circumference of head, circumference of chest (3) Rapidly assess color, tone, alertness, general state f) Vital signs g) Hematocrit, blood glucose evaluations on at-risk newborns (1) See Procedure 31–1: Performing a Heel Stick on a Newborn in Chapter 31 3. Maintenance of a clear airway and stable vital signs a) Free-flow oxygen available b) Position on back c) Bulb syringe or DeLee wall suction (1) See Clinical Skill 21–1: Performing Nasal Pharyngeal Suctioning in Chapter 21 d) Initial vital signs (1) Initial temp taken by axillary method (2) Brief periods of apnea, lasting only 5 to 10 seconds with no color or heart rate changes, are considered normal. The normal pulse range is 110 to 160 beats per minute (beats/min), and the normal respiratory range is 30 to 60 respirations per minute e) Monitor core temperature at intervals (1) Every 30 minutes until stable for 2 hours 4. Maintenance of a neutral thermal environment a) Essential to minimize need for increased oxygen (1) Hypothermia → lead to metabolic acidosis, hypoxia, shock b) Assessment and interventions under radiant warmer c) Cap d) Bathe while under warmer with parents e) Recheck temperature after bath f) Protect from drafts g) See Clinical Skill 28–1: Thermoregulation of the Newborn, p. 701 h) See Key Facts to Remember: Maintaining a Stable Temperature in the Newborn, p. 702 5. Prevention of vitamin K deficiency bleeding a) Prophylactic injection of vitamin K1 given b) Intramuscularly in vastus lateralis muscle (1) See Figure 28–2: Injection sites, p. 703 (2) See Figure 28–3: Procedure for vitamin K injection ..., p. 703 6. Prevention of eye infection a) Legally required prophylactic eve treatment for Neisseria gonorrhoeae (1) Topical agents (2) 0.5% erythromycin ophthalmic ointment (3) 1% tetracycline (4) Also effective for chlamydia b) See Figure 28–4: Ophthalmic ointment …, p. 704 c) Massage eyelid gently to distribute ointment d) Can cause chemical conjunctivitis 3 Copyright © 2020 Pearson Education, Inc.

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7. Early assessment of neonatal distress a) Constantly alert b) Teach parents to recognize hallmarks of distress (1) How to maintain temperature (2) See Table 28–1: Signs of Neonatal Distress, p. 704 (3) Increased respiratory rate or difficult respirations (4) Sternal, substernal, intercostal retractions (5) Nasal flaring (6) Excessive mucus (7) Cyanosis (8) Pallor (9) Mottling (10) Plethora (11) Jaundice of the skin within 24 hours of birth or because of hemolytic process (12) Abdominal distention or mass (13) Vomiting of bile-stained material (14) Absence of meconium elimination within 48 hours of birth (15) Absence of urine elimination within 24 hours of birth (16) Temperature instability (17) Jitteriness, irritability, or abnormal movements (18) Difficult to waken, lethargy, or hypotonicity (19) Weight change greater than anticipated c) Early onset GBS disease (1) At-risk mothers receive intrapartum antimicrobial prophylaxis (IAP) 8. Initiation of first feeding a) Timing varies b) Breastfeed → encourage to put to breast during first period of reactivity c) Formula fed → by 5 hours of age (1) During second period of reactivity 9. Facilitation of parent–newborn attachment a) Eye-to-eye contact extremely important (1) When the newborn is in the first period of reactivity (2) Optimal range for visual acuity (7 to 8 inches) b) Emergent parent–baby bond c) Interactive bath

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C. Evaluation 1. Newborn baby’s adaptation to extrauterine life supported and complete 2. Baby’s physiologic and psychologic integrity supported 3. Positive interactions between parent and infant supported

II.

The Newborn Following Transition

A. Nursing Management for the Newborn Following Transition 1. Nursing Assessment and Diagnosis a) Breathing Pattern, Ineffective b) Nutrition, Imbalanced: Less Than Body Requirements c) Urinary Elimination, Impaired d) Infection, Risk for e) Knowledge, Readiness for Enhanced f) Family Processes, Readiness for Enhanced

B. Planning and Implementation 1. Maintenance of cardiopulmonary function a) Assess vital signs every 6 to 8 hours or more b) Place on back for sleeping c) Bulb syringe within reach d) Indicators of risk (1) Pallor, cyanosis, ruddy color, apnea, or other signs of instability 2. Maintenance of a neutral thermal environment a) Maintain within normal range (1) Dried completely → dressed, head covering b) Temperature that falls below optimal levels → use calories to maintain body heat (1) Increased respiratory rate → increased insensible fluid loss 3. Promotion of adequate hydration and nutrition a) Record caloric and fluid intake b) Early and frequent feedings c) Record voiding and stooling patterns d) First voiding within 24 hours, stool within 48 hours e) Weigh at same time each day (1) Birth weight should be regained by 2 weeks f) Excessive handling can increase metabolic rate, calorie use, fatigue (1) Cues of fatigue (2) Decrease in muscle tension and activity in extremities and neck (3) Loss of eye contact g) Assess woman’s comfort, latching-on techniques

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4. Promotion of skin integrity a) Skin care important for health and appearance, infection control b) Umbilical cord assessed for signs of bleeding or infection (1) Clamp removed within 24 to 48 hours of birth (2) Keep clean and dry (3) See Figure 28–5: The umbilical cord base is carefully cleaned and Figure 28–6: The umbilical cord looks dark and dries up prior to falling off, p. 706 c) Fold diaper down to prevent coverage of cord stump d) Observe for signs, symptoms of infection (1) Instruct parents in care 5. Promotion of safety a) Threat of infant abduction requires hospitals to have active programs for prevention b) Security (1) Checking identification bands in place (2) Electronically tagged band (3) Allowing only people with proper birthing unit identification to remove their baby from room (4) Reporting the presence of any suspicious people on the birthing unit c) Safety (1) Never leaving newborn alone in room (2) Never lifting newborn if a parent feels weak, faint, or unsteady on his or her feet (3) Always keeping an eye and hand on the newborn when he or she is out of crib (4) Protecting from infection, even though newborns possess some immunity 6. Prevention of complications a) Newborns at continued risk for complications (1) Hemorrhage (2) Late-onset cardiac symptoms (3) Jaundice (4) Infection (5) Cyanosis b) Infection best prevented with 2- to 3-minute scrub of all personnel c) Parents instructed d) Jaundice in most newborns benign (1) Monitor to identify 7. Circumcision a) Surgical procedure (1) Prepuce separated from glans penis, excised (2) Religious, ethical, cultural beliefs and practices (3) Informed consent b) Current recommendations (1) AAP and ACOG do not recommend routine circumcision but acknowledge that medical indications for circumcision still exist 6 Copyright © 2020 Pearson Education, Inc.

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(a) Medical indications exist (2) Recommend analgesia (3) Not performed if newborn premature, compromised (a) Bleeding problem, born with genitourinary defect c) Care of uncircumcised newborn (1) Parents education on hygiene, foreskin and glans (2) Separation of foreskin and glans normally complete at 3 to 5 years (3) Smegma d) Care of the circumcised newborn (1) Allay parents’ anxiety by sharing information (2) Allow to express concerns (3) Potential risks and outcomes (4) Information about good hygiene practices (5) If desired performed after newborn well stabilized (6) Nurse ascertains that physician has explained procedure, parents have any questions (7) Verify circumcision permit signed (8) Preoperative procedures (a) Identification band (b) Gather equipment (c) Remove diaper, place newborn on padded circumcision board (d) Variety of devices used → all produce minimal bleeding (e) Assess newborn’s response (f) Anesthesia (i) Topical analgesia (g) Comfort procedures (h) Assess for signs of hemorrhage, infection (i) Every 30 minutes for at least 2 hours (ii) Observe for first void (9) Teach family members how to assess for bleeding, stress to parents to report any signs or symptoms of infection (a) Newborn circumcision care (i) Clean with warm water with each diaper change (ii) Apply petroleum ointment for next few diaper changes (iii) If bleeding does occur, apply light pressure with a sterile gauze pad (iv) Glans normally has granulation tissue during healing (v) Continued application of petroleum ointment can help protect granulation tissue (vi) If Plastibell: should fall off in 8 days, no ointments or creams while bell is on (vii) Ensure diaper not loose enough to cause rubbing with movement (b) See Figure 28–7: Circumcision using the Yellen or Gomco clamp, p. 708 (c) See Figure 28–8: Circumcision using the Plastibell …, p. 708 (d) See Figure 28–9: Following circumcision, petroleum ointment may be applied to the site for the next few diaper changes, p. 709

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8. Enhancement of parent–newborn attachment a) Promoted by encouraging all family members to be involved with new member of family (1) See Teaching Highlights: What Parents Need to Know About Enhancing Attachment, p. 709 b) Infant massage c) Discuss waking activities (1) Talking (2) Holding (3) Gently bending baby back and forth while grasping under the knees d) Quieting activities (1) Swaddling (2) Using slow, calming movements (3) Talking softly, singing or humming e) Cultural competence

C. Evaluation 1. Baby’s physiologic and psychologic integrity supported 2. Newborn feeding pattern satisfactorily established 3. Parents express understanding of the bonding process and display attachment behaviors

III.

Preparation for Discharge

A. Crucial transition for family B. Nursing Management for the Newborn in Preparation for Discharge C. Nursing Assessment and Diagnosis 1. Assess whether parents have realistic expectations of newborn’s behaviors 2. Assess depth of knowledge in caring for newborn 3. Diagnoses include a) Parenting, Readiness for Enhanced b) Family Processes, Readiness for Enhanced

D. Planning and Implementation 1. Parent teaching a) Every contact presents opportunity for sharing information b) Observe how parents interact with infant c) Provide mother–baby care and home-care instruction d) One-to-one teaching shown to be most effective

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2. General instructions for newborn care a) Picking up baby → hand under neck and shoulders, other hand under buttocks or between legs b) Safety topics (1) Back to sleep, bulb syringe c) Alone only in crib d) Demonstrating bath, cord care, temperature assessment e) When to call healthcare provider f) Nurse demonstrates, reviews taking of temperature 3. Nasal and oral suctioning a) Obligatory nose breathers for first months of life b) Demonstrate use of bulb syringe (1) Bulb syringe compressed and tip placed in nostril (2) Take care not to occlude passageway (3) Expand bulb slowly by releasing compression (4) Remove from nostril (5) Drainage compressed out of bulb (a) See Figure 28–11: Nasal and oral suctioning …, p. 712 (6) Suctioning mouth (a) Bulb compressed (b) Tip placed about 1 inch to one side of the newborn’s mouth and compression released (c) Draws up excess secretions (d) Repeat on other side of mouth (e) Avoid roof of mouth, back of throat (f) Wash in warm, soapy water daily and as needed c) Transient edema of nasal mucosa (1) Use of normal saline to loosen secretions 4. Sleep and activity a) Healthy term infants should be placed on backs to sleep (1) Reduces incidence of sudden infant death syndrome (SIDS) (2) Nurses demonstrate in hospital b) Recognize variations of each newborn, assist parents 5. Car safety considerations a) Car seat adapted to fit newborns (1) Half of children killed or injured in automobile accidents could have been protected by the use of a federally approved car seat (2) See Figure 28–12: Infant car restraint for use from birth to about 12 months of age, p. 713

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6. Ensure parents are knowledgeable, encourage seats are checked by local specially trained groups 7. Newborn screening and immunization program a) Newborn screening tests (1) Blood spot screening (2) Hearing screening (3) Hyperbilirubinemia screening (4) Critical congenital heart disease screening (5) Specific disorder tested for each state b) Hearing screenings (1) Hearing loss in 1–3:1000 babies in normal newborn population (2) Accomplished before discharge (3) Follow-up if newborn fails to pass initial screen (4) See Figure 28–13: Newborn hearing screen, p. 713 c) Immunization programs (1) Hepatitis B d) Checklist for caregiving methods 8. Community-based nursing care a) Discuss ways to meet newborn’s needs, ensure safety, appreciate unique characteristics and behaviors (1) Checklist may be helpful b) Signs of illness c) How to reach care provider or after-hours clinic d) Importance of follow-up after discharge (1) Should be scheduled within 48 hours of discharge (2) See Key Facts to Remember: What Parents Need to Know About Newborn Care, p.

716 e) Routine well-care baby visits scheduled

E. Evaluation 1. Parents demonstrate safe techniques for caring for newborn 2. Parents verbalize developmentally appropriate behavioral expectations of newborn and knowledge of community-based newborn follow-up care

IV.

Focus Your Study

V.

Activities 1. Individual Have students prepare drug cards on the following medications: • Erythromycin ophthalmic ointment • Vitamin K1 phytonadione

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•

Hepatitis B vaccine

2. Small Group Divide the class into small groups of three to five students. Have each group research the cultural beliefs of a population in their area. Assign each group a particular group to research and have groups give 10-minute presentations to the class. The groups should include handouts with their presentations and their references should be cited in APA format.

3. Large Group Invite a local resource (law enforcement or another community resource) to come to class to demonstrate the proper installation and use of a car seat.

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Chapter 29 Newborn Nutrition Nutritional Needs and Breast Milk/Formula Composition..............................

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Breastfeeding...................................................................................................

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Breastfeeding Technique…………………………………………………………………………….

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Timing of Newborn Feedings...........................................................................

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Formula Feeding...............................................................................................

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Community-Based Nursing Care......................................................................

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Nutritional Assessment....................................................................................

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Focus Your Study..............................................................................................

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Activities...........................................................................................................

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

Nutritional Needs and Breast Milk/Formula Composition

A. Diet 1. Hydration, calories, protein, carbohydrates, fat, minerals, vitamins 2. Exclusive breast milk is sufficient from birth up to 6 months of age.

3. Breastfeeding with solid foods for the next 6 months is recommended.

4. > 1 year, breastfeeding may be continued for as long as mutually desired by mother and baby

B. Dietary Reference Intakes 1. DRI encompasses four aspects a) Estimated average requirement (EAR) b) Recommended daily allowance (RDA) c) Adequate intake (AI) d) Tolerable upper intake level (UL) 2. Framework → links nutrition and health across lifespan

C. Growth 1. All infants lose weight after birth a) Not a concern unless 7 to 10% of birth weight loss b) In 7 to 14 days should regain their weight c) Weight loss does not result in dehydration 2. Different growth rates due to different composition of human milk, formula a) See Table 29–1: Comparison of Nutrients in Milk, pp. 720–721 b) Breastfeeding “gold standard” for neonatal nutrition c) Formula-fed infant tends to regain birth weight earlier d) Breastfed only same or slightly higher weight gain for 3 to 4 months e) After 3 to 4 months → formula- and combination-fed have greater gain 3. Infants generally double birth weight by 5 months a) Triple birth weight by 1 year b) Quadruple birth weight by 2 years c) Tracking by growth chart d) See Key Facts to Remember: Newborn Caloric and Fluid Needs, p. 721

D. Fluid 1. Requirements high a) 140 to 160 mL/kg/day b) Decreased ability to concentrate urine, increased overall metabolic rate c) High water content 2 Copyright © 2020 Pearson Education, Inc.

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d) More susceptible to dehydration (1) Insufficient fluid intake (2) Increased fluid loss from diarrhea, vomiting 2. Signs of dehydration a) Fontanelle in addition to other signs (1) See Box 29–1: Signs of Dehydration in the Newborn, p. 722

E. Energy 1. Basal metabolic rate (BMR) a) Energy needed for thermoregulation, cardiorespiratory function, cellular activity, growth b) 100 to 115 kcal/kg/day at 1 month c) 85 to 95 kcal/kg/day from 6 to 12 months

F. Fats 1. Approximately 50% of calories from fat 2. Milk composition a) 98% of human milk fat in form of triglycerides b) Fatty acids key component to brain development c) Needed for myelination of spinal cord d) Fat content variable (1) 30 to 50 gm/L of human milk (2) Influences e) Phospholipids, cholesterol higher in colostrum 3. Fats in milk-based formulas modified to parallel fat profile of human milk

G. Carbohydrates 1. Other main source of energy a) 40% of calories in diet 2. Milk composition a) Breast milk → primary carbohydrate is lactose b) Also contains trace amounts of other carbohydrates

H. Proteins 1. Building blocks for muscle and organ structure 2. Key to almost every metabolic processes 3. Milk composition a) Casein and whey proteins b) Whey predominant protein in human milk (1) Easily digested → more frequent feedings

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Casein predominant in cow milk → 20:80 whey/casein ratio (1) Less easily digested, forms curds d) Cow’s milk–based formulas modified to get closer to mature human milk (1) Human milk 60:40 whey/casein ratio (2) Formulas 48:52 whey/casein ratio 4. Human milk whey protein a) Alpha-lactalbumin b) Serum albumin c) Lactoferrin d) Immunoglobulins e) Lysozyme f) Nonnutritional elements

I. Vitamins, Minerals, and Trace Elements 1. Vitamins a) Adequate vitamin intake important to support growth and metabolism (1) Fat-soluble → A, D, E, K → possibility of toxicity b) Milk composition (1) Influenced by mother’s vitamin intake, general nutritional status, genetic differences → varies as lactation progresses (a) Prenatal vitamins continued (2) Human milk low in vitamin D (a) All infants and children receive 400 international units daily (3) Vitamin K present in breast milk, but in small quantity (a) Standard care to give vitamin K prophylaxis (4) Vitamin B complex and C are water soluble (a) Exclusively breastfed should receive vitamin B12 supplementation (b) Formula is fortified with adequate amounts (5) Vitamin A (a) Healthy skin, hair, nails, gums, glands, bones, teeth, helps prevent infections (6) Vitamin E (a) Antioxidant and free radical scavenger (b) Naturally present in breast milk 2. Minerals a) Diverse regulatory functions throughout body (1) Calcium → clotting (2) Phosphorus → adenosine triphosphate (ATP), deoxyribonucleic acid (DNA), ribonucleic acid (RNA), phospholipids (3) Sodium → fluid balance (4) Calcium, sodium, potassium → nerve and muscle function (5) Chlorine → acid–base balance (6) Cobalt → with vitamin B12 to form blood cells 4 Copyright © 2020 Pearson Education, Inc.

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(7) Copper and iron → blood production (8) Iodine → thyroid hormone synthesis (9) Magnesium, manganese, zinc → enzymatic processes b) Milk composition (1) Human milk and formulas contain major, trace minerals → satisfy needs (2) Mineral content of milk does not appear to be influenced by maternal diet (3) Iron in human milk more completely absorbed—infant absorbs 50% to 80% of iron compared with less than 12% of iron in formula (4) Nurse educates parents → iron added to formula is in ionic form and does not cause constipation 3. Trace elements a) Nucleotides → building blocks for DNA, RNA b) Carnitine → transport fatty acids to mitochondria for oxidation c) Taurine → growth, central nervous system, auditory function development

J. Feeding Intolerances 1. Evaluate true lactose intolerance versus cow’s milk protein allergy 2. Develops after 2 to 5 years and not a condition affecting infants 3. Eliminate bovine protein from mother’s diet, mother can continue breastfeeding

K. Specialty Formulas 1. American Academy of Pediatrics and ACOG recommend breastfeeding all infants a) Rare exceptions 2. First choice → cow’s milk-based formula 3. Milk-based lactose-free formulas 4. Soy-based formulas a) For infants with primary lactose deficiency b) For infants with galactosemia c) Term infant of formula-feeding vegan parents d) For infants who develop secondary transient lactose deficiency following acute diarrhea e) Sometimes switched for colicky symptoms → will not always solve the cause 5. Hydrolyzed (hypoallergenic) formulas a) For infants who have formula intolerance not related to cow’s milk-based formulas → protein broken down into smaller components b) Nestle Good Start HMO c) Documented cow’s milk-based allergies, metabolic disorder, malabsorption syndrome → hypoallergenic formulas (1) Nutramigen, Alimentum

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L. Choice of Feeding 1. Meet essential needs of newborn is priority 2. Mothers usually decide by 6 months of pregnancy on feeding method a) Decision influenced by others 3. Educate to help make informed choice 4. Healthy People 2020 a) 82% will initiate breastfeeding b) At least 61% will continue until infant 6 months old c) At least 34% continue until infant 12 months old d) Goal for exclusive breastfeeding at 3 months is 46%, 6 months is 26%

II.

Breastfeeding

Breast Milk Production 1. Breast divided into 15 to 20 lobes a) Separated by fat, connective tissue b) Interspersed with blood vessels, lymphatic vessels, nerves c) Lobules → alveoli → where milk synthesized d) Range ]4-18 milk ducts exiting the nipple e) See Figure 29–1: Anatomy of the breast, p.724 f) Oxytocin

Physiologic and Endocrine Control of Lactogenesis 1. Increased levels of estrogen → stimulate breast duct proliferation, development a) Elevated progesterone levels promote development of lobules, alveoli b) Prolactin levels rise c) Lactation suppressed during pregnancy → elevate progesterone levels secreted by placenta (1) Placenta delivered → progesterone falls, inhibition removed → milk production triggered → lactogenesis II 2. Prolactin released by anterior pituitary → response to breast stimulation from suckling, breast pump a) Stimulates milk-secreting cells b) Stimulates milk production → breastfeed/pump more frequently c) Established during first 2 weeks postpartum 3. Start of feeding → foremilk a) Watery, high in lactose, protein, low in fat (1 to 2%) b) Stretching of nipple, compression of areola → triggers release of oxytocin → myoepithelial cells around alveoli contract → eject milk

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4. Oxytocin → milk-ejection reflex or let-down reflex → hindmilk (rich in fat) a) Initial let-down → about 2 minutes after feeding starts b) Hindmilk → rich in fat and high in calories 5. By 6 months → prolactin levels 5 to 10 ng/mL → milk production continues a) Feedback inhibitor of lactation (FIL) (1) Negative feedback loop → the more milk left in breast, longer it remains → more milk production decreased (2) Autocrine control 6. Delay or impair lactogenesis a) Maternal factors b) Lifestyle factors

Stages of Human Milk 1. Colostrum a) Initial milk → begins to be secreted mid-pregnancy (1) Immediately available at delivery (2) Small volume → newborn nurses frequently → helps stimulate milk production (3) Thick, creamy, yellowish b) Concentrated amounts protein, fat-soluble vitamins, minerals, antioxidants, lactoferrin, IgA c) Promotes establishment of Lactobacillus bifidus flora d) Laxative effect → pass meconium → decrease hyperbilirubinemia 2. Transitional milk a) “Coming in” b) 48 to 96 hours postpartum, most on day 3 c) Yellow, more copious than colostrum, more fat, lactose, water-soluble vitamins, calories d) See Figure 29–2: Transitional human milk, p. 726 3. Mature milk a) White to slightly blue-tinged b) By 2 weeks postpartum and continues for remainder of breastmilk production c) 13% solids d) 87% water e) Gradual change in composition to accommodate needs of newborn

Advantages of Human Milk 1. American Academy of Pediatricians (AAP) recommends as exclusive feeding for first 6 months 2. Nutritional advantages a) Species specific

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b) Lactose primary carbohydrate → galactose → brain, central nervous system (CNS) development (1) Energy source, enhances absorption of calcium, magnesium, zinc c) Mineral content constant d) Iron more readily and fully absorbed than that of formula (1) Lactoferrin e) Reduced risk of specific diseases f) Mother benefits (1) Decreased risk for postpartum bleeding → rapid uterine involution (2) Protective function possible against premenopausal breast cancer, ovarian cancer (3) Decrease in type 2 diabetes, rheumatoid arthritis, and hypertension 3. Immunologic advantages a) Varying degrees of protection from respiratory tract and GI infections (1) Urinary tract infections, otitis media, bacterial meningitis, bacterium, allergies b) Secretory IgA → role in decreasing permeability of small intestine c) Breastfeeding does not adversely affect immunization (1) Should be vaccinated as scheduled 4. Psychosocial benefits of breastfeeding a) Self-esteem (1) Providing perfect food for baby, protection with antibodies b) Enhanced bonding (1) Close contact → tactile stimulation 5. See Table 29–2: Comparison of Breastfeeding and Formula-Feeding, p. 727

Potential Challenges to Breastfeeding 1. Challenges a) Pain with breastfeeding b) Concern over adequacy of milk volumes c) Leaking milk d) Embarrassment e) Stress f) Unequal feeding responsibilities/fathers left out g) Diet restriction h) Limited hormonal birth control options i) Vaginal dryness associated with breastfeeding 2. Medications a) Most drugs penetrate into human milk b) Almost all medications appear in only small amounts in human milk c) Very few drugs are contraindicated for breastfeeding women d) Healthcare provider should consider the following: (1) Mother’s need for medication 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(2) Drug’s potential effect on milk production (3) Amount of drug excreted into the milk (4) Extent of baby’s oral absorption of the drug (5) Drug’s potential adverse effects to the infant (6) Baby’s age and health e) Adjustments to be made (1) Avoid long-acting forms of drugs (2) Consider absorption rates, peak blood levels in scheduling administration of drugs (3) Use preparations that can be given at longer intervals (4) Select drug with least tendency to pass into breast milk (5) Use single-symptom drugs versus multi-symptom drugs

Potential Contraindications to Breastfeeding 1. HIV positive or as AIDS → counseled against breastfeeding 2. Mother has active, untreated tuberculosis, varicella, human T-cell leukemia virus type 1 (HTLV1)-positive, or another illness on case by case basis 3. Mother has active herpes on breast 4. Mother uses illicit drugs or is an alcoholic 5. Maternal smoking poses health risks to mother, potential second-hand exposure to baby 6. Specific medications, radioactive isotopes, antimetabolites, chemotherapy drugs a) Mother with diagnosis of breast cancer should not breastfeed to start treatment immediately 7. Infant has galactosemia

Cultural Considerations in Newborn/Infant Feeding 1. Ask questions in a sensitive and respectful way 2. Correct misconceptions a) “Spoiling their milk” b) Do not throw out “dirty” colostrum 3. Best to have a female, non–family member translator 4. Galactagogues used to increase milk production, reestablish supply, assist in initiating lactation when adoptive mother wished to nurse 5. Some of these herbs not recommended if nursing mother also pregnant a) Most notice increase in milk supply → 1 to 3 days b) Also needs to increase frequency c) Hydrate d) Eat well

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6. Herbal galactagogues → tea, capsule, tincture 7. Fenugreek 8. Others a) Alfalfa, dandelion, fennel, horsetail, red raspberry, caraway, anise

Breastfeeding Technique 1. Breastfeeding position and latching on a) Not instinctive → learned 2. Positioning a) Multiple positions (1) Cross-cradle (a) See Figure 29–5: Cross-cradle position, p. 733 (2) Cradle (a) See Figure 29–6: Cradle position, p. 733 (3) Football-hold (a) See Figure 29–7: Football hold position, p. 734 (4) Side-lying (a) See Figure 29–8: Side-lying position, p. 734 3. Latching on a) Position for an optimal attachment b) Infant needs to attach lips far back on areola, not on actual nipple (1) Sore nipples c) Elicit rooting reflex → infant opens mouth wide → draw baby toward her (1) See Figure 29–9: C-hold hand position, p. 735 (2) See Figure 29–10: Scissor-hold hand position, p. 735 (3) See Figure 29–11: Nose to nipple, p. 736 (4) See Figure 29–12: Initial attempt to elicit the rooting reflex, p. 736 (5) See Figure 29–13: Continued attempt to elicit the rooting reflex, p. 736 (6) See Figure 29–14: Baby is latched on, p. 737 4. Breastfeeding assessment a) Monitor progress with systematic assessment of several feeding episodes (1) Anticipatory guidance (2) Maternal response to infant cues (3) Latch-on technique (4) Positioning (5) Signs of active feeding (6) Let-down response (7) Nipple condition (8) Maternal comfort during feeding (9) Infant’s weight from previous measurement (10) Infants report of intake and output 10 Copyright © 2020 Pearson Education, Inc.

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(11) LATCH Scoring Tool 5. Breastfeeding efficiency a) No visual assurance of amount of breast milk consumed b) Other signs of effective, active breastfeeding (1) Rhythmic suckling pattern (2) Suckling with jaw compressions (3) Feeding 10 to 20 minutes on first breast, few minutes or not at all on second (4) Observe for swallowing (5) Infant will pull away, fall asleep when satiated (6) Extremely relaxed (7) Characteristic output (8) Pre- and postfeeding weights c) See Figure 29–15: Breastfeeding intake and output expectations, p. 739 d) Minimum output (1) Day 1 (a) Infant should produce at least one wet diaper and one meconium stool by 24 hours of age (b) Note pinkish-red “brick dust” appearance on the diaper (c) Uric acid crystals produced by kidneys (i) Associated with concentrated urine (ii) Red flag raised if presence continued beyond day 2 or 3 of life (2) Day 2 → Infant should produce at least two wet diapers and two early transitional stools in a 24-hour period by 48 hours of age (3) Day 3 → Infant should produce at least three wet diapers and three transitional stools in a 24-hour period by 72 hours of age (a) When a mother’s milk supply is abundant on day 2, some babies will have transitioned to yellow milk stools as early as day 3 (4) Day 4 → Infant should produce at least four wet diapers and three to four yellowgreen transitional stools or yellow milk stools in a 24-hour period by 96 hours of age (5) Day 5 → Infant should produce at least five wet diapers and three to four yellow milk stools per day; stools typically explosive with curdy or seedy appearance (a) Hereafter, breastfeeding infants will consistently produce at least six wellsaturated wet diapers per day (b) These infants will typically continue to produce at least three to four yellow milk stools daily, but may have up to 10 stools per day until they are about a month old (c) Infants 4 weeks or older may suddenly decrease their stool frequency, even skipping days 6. Bottle-Feeding Human Milk a) Hand expression (1) Teach all mothers the skill (a) Be sure breasts are clean (b) Hands are washed before preparing to pump 11 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(c) Take a few minutes to massage the breasts and relax (d) Sit up straight or lean slightly forward (e) Position thumb at 12 o’clock position on top edge or areola, forefinger, middle finger pads at 6 o’clock position on bottom edge of areola (f) Mother will stretch areola back toward her chest wall without lifting her fingers off her breast (g) Now mother rolls thumb and fingers simultaneously forward (h) Repeat sequence multiple times to completely drain breasts (i) Move fingers to other positions on same breast when milk flow slows (2) Should not be painful (3) See Figure 29–16: Hand expression, p. 740 b) Breast pumps (1) Not all breast pumps of same quality (2) Should be able to cycle from low to high suction 45 to 60 cycles per minute (a) See Figure 29–18: Manual breast pump, p. 742 (b) See Figure 29–19: Individual double electric breast pump, p. 742 (c) See Figure 29–20: Hospital-grade multi-user breast pump, p. 742 (3) Breast flange fit and comfort important c) Storing human breast milk and formula (1) See Table 29–3: Pumping Instructions and Breast Milk Storage Guidelines, pp. 740– 74139 (a) Once a day, rinse breasts with water (b) Wash hands well with soap and water before pumping (c) Take a few minutes to massage breasts and relax (d) Sit up strait or lean slightly forward (e) For hand-expressing, use Marmet technique (i) Thumb at 12 o’clock position at top of areola and forefinger and middle finger at 6 o’clock (ii) Stretch areola back towards chest (iii) Roll thumb and fingers simultaneously forward (iv) Repeat sequence (f) For single sided pumping (i) Pump each breast for 10-20 minutes (ii) Pump expressed milk into glass or plastic bottles (iii) Feed freshly expressed milk whenever possible. (iv) Store expressed human milk (v) Never thaw in microwave or in a pan on the stove (a) For quick thaw, place container in a bowl in the sink and run warm water over it for no longer than 15 minutes (b) For slow thaw overnight, take frozen container from freezer day or several hours before and defrost in refrigerator (vi) Check temperature of milk before feeding to baby (2) Feeding (a) Human milk or formula 12 Copyright © 2020 Pearson Education, Inc.

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(i) Opened/reconstituted (ii) Being fed (iii) Finish feed within 1 hour (b) Fresh human milk (i) Room temperature (ii) 72°F to 79°F (iii) 4 hours (c) Fresh human milk (i) Room temperature (ii) 66°F to 72°F (iii) 6 to 10 hours (d) Fresh human milk (i) Cooler w/ frozen ice packs (ii) 59°F (iii) 24 hours (e) Formula (i) Opened/reconstituted (ii) Room temperature (iii) 2 hours (f) Thawed human milk (i) Refrigerator (ii) 24 hours (g) Formula (i) Opened/reconstituted (ii) Refrigerator (iii) 24 to 48 hours (see label) (h) Fresh human milk (i) Refrigerator (ii) 8 days (i) Formula powder (i) Opened can (ii) Room temperature (iii) 1 month (j) Fresh human milk (i) Freezer (ii) 3 to 4 months (k) Formula/powder in sealed container (i) Avoid excessive heat (ii) Printed expiration date (l) Thawed human milk (i) Freezer (ii) Do not refreeze (m) Formula (i) Freezer 13 Copyright © 2020 Pearson Education, Inc.

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(ii) Do not freeze d) Supplementary formula-feeding (1) Only when medically indicated (2) May cause infant to develop incorrect sucking pattern (3) Nipple confusion/nipple preference (a) Latching different, tongue movement different (4) Valid medical indication (a) Mother’s own milk (b) Pasteurized donor milk (c) Formula (5) See Table 29–6: Factors Requiring Consideration of Supplementation, p. 743 (6) Risk factors for inadequate intake (a) Maternal/infant separation (b) Maternal barriers to breastfeeding (e.g., medications, fatigue, pain, cultural) (c) Congenital malformation or illness interfering with ability to breastfeed (d) Delayed lactogenesis after day 3 or 4 (e) Primary lactation failure (usually due to breast pathology or prior breast surgery) (f) Low birth weight or infant with illness/disorder requiring nutrient requirements that may exceed that available through breastfeeding (7) Signs of potential inadequate intake: (a) Weight loss >7% from birth weight (b) Delayed bowel movements or continued meconium stools beyond day 2 (c) Hypoglycemia not responding to frequent breastfeeding attempts (d) Hyperbilirubinemia due to breastfeeding jaundice

III.

Timing of Newborn Feedings

A. Ideally determined by physiologic, behavioral cues B. Initial Feeding 1. Infant should be placed on mother’s chest a) Skin-to-skin contact helps maintain body temperature, self-regulation, increases maternal oxytocin levels, helps mother to notice subtle feeding cues, promotes bonding b) First 2 hours of life → alert and ready to breastfeed 2. Plans to bottle-feed → still skin to skin a) Formula-feeding not typically initiated in birthing room 3. Assessment of newborn’s physiologic status primary, ongoing concern a) Watch for complications when eating b) Wet burps normal, with some degree of reflux c) Holding baby upright on parent’s chest for 15 to 20 minutes after feeding

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C. Establishing a Feeding Pattern 1. “On-demand” feeding program facilitates own rhythm, helps mother establish lactation a) Rooming in → 24-hour access b) Following initial alert period, newborn typically sleeps for several hours c) Cluster feeding 5 to 10 episodes over 2 to 3 hours d) Uninterested in nursing → prolonged pushing, medications in labor 2. Waking sleepy baby a) Late-preterm tend to be very sleepy, less stamina, greater difficulty with suck/latch/swallow b) Remove blanket, clothing → infant in diaper, T-shirt c) Blanket over baby after latching d) Encourage mother to use tactile stimulation while newborn attached to breast 3. Feeding pattern may change when milk comes in a) Every 1½ to 3 hours around the clock b) May struggle with latch-on with engorged breasts c) Express milk to soften breast 4. Rates of digestion differ between breast milk and formula a) Formula-fed newborns sleep longer b) Awaken to feed every 3 to 4 hours 5. Normal feeding pattern erratic 6. Satiety behaviors a) Longer pauses toward end of feeding b) Noticeable total body relaxation c) Infant may release his mother’s nipple, bottle nipple, fall asleep d) Breastfed newborn awakens → feed no matter how long it has been (1) Pacifier inappropriate at this time, wait to 3 to 4 weeks 7. Growth spurts require increased feeding volume

IV.

Formula Feeding A. Formula-Feeding Guidelines and Technique 1. Commercial formulas a) Powder (1) Least expensive (2) Use within 24 to 48 hours once prepared (3) Standard → one level unpacked scoop to 60 mL water (4) Not sterile b) Formula concentrate (1) More expensive than powder (2) Dilute with equal part of water 15 Copyright © 2020 Pearson Education, Inc.

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c) Ready-to-feed formula (1) Easiest (2) Most expensive 2. Underscore importance of proper preparation a) Follow directions on package precisely b) Recommended sanitary and safety precautions include: (1) Check the expiration date on the formula container (2) Ensure good hand washing before preparing formula; never dip into the can without clean hands (3) Clean bottles, nipples, rings, disks, and bottle caps (4) Wash in a dishwasher when available (small items and heat-sensitive items on top rack secured in a basket), or boil briefly (1 to 2 minutes) in a pot of water, or (5) Clean using a microwave sterilization kit, or (6) Clean using very warm soapy water and a nipple and bottle brush (7) Inspect and replace bottle nipples as soon as they show wear (8) Wash the top of the formula container before piercing the lid, and shake the liquid formulas well before pouring out desired amount (9) Shake prepared milk that has been sitting in the refrigerator before feeding (10) Use hot water (158°F or higher) to make powdered formula (11) Use only the scoop supplied in the can of formula when formula preparation instructions call for a “scoop” of powdered formula; a scoop should not be “packed” and should be leveled off (12) Do not add anything else to the bottle, except under direction of baby’s healthcare provider (13) Warm up formula in a bottle by placing the bottle in a bowl of warm tap water for no longer than 15 minutes; do not fill the bowl with water higher than the rim of the bottle (14) Allow freshly prepared (unused) formula to sit out at room temperature for no longer than 2 hours; use an insulated pack to transport formula; milk left over in the bottle after a feeding should be discarded (15) In warm weather, transport reconstituted or formula concentrate from an open can in an insulated pack with frozen gel packs (16) Travel with water and formula separated (17) Hold the infant during feedings (18) Do not allow the infant to bottle feed in a supine position → increases the risk of otitis media, dental caries (19) Never prop a bottle—this is a choking hazard (20) Allow infants to take what they want and to stop when they want 3. Guidance about water for reconstitution a) If boiling → boil for 1 to 2 minutes after reaching rolling boil b) Allow the water to cool before using it to reconstitute the formula c) Distilled, filtered water → fluoride concerns d) See Table 29–7: Water Sources, p. 746 16 Copyright © 2020 Pearson Education, Inc.

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4. Bottles and nipples a) Based on preference b) Feeding technique is emphasis c) Burp frequently d) Vented bottle, tilting bottle at 45-degree angle e) Slow-flow nipple to start → graduate to medium-flow to high-flow f) Observe bottle for bubbles (standard bottle), liner retracts g) Infants who persistently leak from side of mouth may be getting fluid too quickly (1) See Figure 29–22: Burping baby sitting up on lap, p. 747 (2) See Figure 29–23: Burping baby over the shoulder, p. 747 (3) See Figure 29–24: Bottle-feeding, p. 747 h) Concern regarding chemicals in plastic baby bottles (1) Bisphenol A (BPA) (2) Read labels (3) Limit heating bottles (4) Throw out old bottles with scratches

B. Involving Fathers and Partners 1. Speak to both parents when entering room 2. If breastfeeding a) Ask to wait to give bottles until breastfeeding is established b) Help mother position, help reposition latch c) Massage breasts to help stimulate sleepy baby d) Burp baby e) Skin-to-skin contact (1) See Figure 29–25: Father and newborn skin to skin, p. 748

V.

Community-Based Nursing Care A. Promotion of Successful Newborn/Infant Feeding 1. Baby-Friendly Hospital Initiative a) Promoting hospitals, birthing centers that offer optimal lactation services 2. Community resources a) La Leche League International (LLLI) b) Peer counseling 3. WIC a) Supplemental Nutrition Program for Women, Infants, and Children (WIC) b) Provides low-income women and children with nutritious foods

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VI.

Nutritional Assessment

A. Includes 1. Nutritional intake and output 2. Infant’s measurements (length, head circumference, weight) 3. Physical examination a) Head-to-toe physical

B. Nursing Management for a Newborn with Significant Weight Loss 1. Nursing Assessment and Diagnosis 2. Breastfeeding, Ineffective, related to a) Mother’s lack of knowledge about breastfeeding b) Mother’s not responding to infant’s feeding cues c) Mother’s inability to facilitate effective breastfeeding 3. Breastfeeding, Ineffective, related to a) Insufficient knowledge regarding newborn’s reflexes and breastfeeding techniques b) Lack of support by father of baby or other support persons c) Lack of maternal self-confidence d) Maternal self-confidence e) Maternal fatigue f) Possible maternal ambivalence g) Poor infant sucking reflex h) Difficulty waking the sleepy baby 4. Nutrition, Imbalanced: Less Than Body Requirements, related to a) Mother’s increased caloric and nutrient needs status post-cesarean section b) Newborn’s inability to correctly latch on and transfer milk

C. Nursing Plan and Implementation 1. Review the mother’s history 2. Maternal assessment 3. Newborn assessment 4. Newborn feeding history 5. Pre- and postbreastfeeding weight check a) Calculate milk transfer during breastfeeding 6. Observation of breastfeeding technique 7. Review feeding requirement/caloric requirement based on infant’s birth weight a) Fluid requirement: 140 to 160 mL/kg/day 18 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

(1) 496 to 567 mL/day b) Infant should feed 8 to 12 times per day (1) 496/10 = 49.6 mL/feeding (2) Day 3 feeds less c) Caloric requirement 100 to 115 kcal/kg/day (1) Up to full caloric requirement about day 6 8. Assess teaching needs and provide verbal and written instructions a) Review benefits of breastfeeding b) Review breastfeeding technique c) Watch infant for early feeding cues d) Provide breast pump instructions and review collection and storage e) May start pumping to increase breast stimulation f) Review process of breastfeeding and practice proper breastfeeding technique g) Review infant intake and output, weight gain expectations h) Provide information on maternal nutrition and fluid requirements 9. Arrange for follow-up lactation consultation visit in 2 days to reassess 10. Evaluation a) Newborn will rouse to feed at least every 3 hours and will stay awake until end of feeding b) Newborn will correctly latch onto breasts, effectively breastfeed 8 to 12 times per day c) Newborn will gain at least 10 g/kg/day and be back to birth weight no later than day 14 of life d) Newborn will have four wet diapers, three to four bowel movements on day 4; five wet diapers, three to four bowel movements on day 5; and six to eight wet diapers, three to four bowel movements every day thereafter during the first month of life e) Newborn’s stools will transition from black to yellow by day 5 and will change in consistency from thick and sticky to loose and explosive with small curds or seedy appearance f) Newborn will not have any uric acid crystals in her diaper after day 3 or 4 g) Newborn will be satiated after feeding, as evidenced by relaxed muscle tone and sleepiness 11. Expected outcomes for the mother include: a) Mother will verbalize/demonstrate an understanding of breastfeeding technique, including positioning and latch on, signs of adequate feeding, self-care b) Mother will breastfeed pain-free c) Mother will express satisfaction with the breastfeeding experience d) Mother will consume a nutritionally balanced diet with appropriate caloric and fluid intake to support breastfeeding

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VII.

Focus Your Study

VIII.

Activities 1. Individual Have students prepare a teaching plan for the partner who will assist the new mother with breastfeeding. Have students focus their plans on one of the following: • Adolescent father • Primipara • Multipara who is breastfeeding for the first time • Multipara with first cesarean birth 2. Small Group Divide the class into small groups of three to five students. Have each group prepare a teaching plan for the woman who will be bottle feeding. Instruct the groups to include comparisons of specific bottles, nipple types, etc. The groups can then prepare a resource list for new mothers.

3. Large Group Invite speaker from the La Leche League or another lactation consultant to speak with students.

Ask the speaker to bring a variety of breast pumps and assistive devices to demonstrate to students.

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Chapter 30 The Newborn at Risk: Conditions Present at Birth Identification of At-Risk Newborns.....................................................................

2

Care of the Small-for-Gestational-Age/Intrauterine Growth Restriction Newborn………………………………………………………………………………………………

3

Care of the Large-for-Gestational-Age Newborn...............................................

5

Care of the Newborn of a Mother with Diabetes...............................................

6

Care of the Postterm Newborn...........................................................................

8

Care of the Preterm (Premature) Newborn........................................................

9

Care of the Newborn with Congenital Anomalies..............................................

19

Care of the Newborn with Congenital Heart Defect………………………………………

19

Care of the Newborn of a Substance-Abusing Mother......................................

20

Care of the Newborn Exposed to HIV/AIDS........................................................

24

Care of the Newborn with an Inborn Error of Metabolism................................

25

Focus Your Study.................................................................................................

27

Activities..............................................................................................................

27

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

Identification of At-Risk Newborns

A. At-risk newborn often involves one or more predictable risk factors 1. Low socioeconomic level of the mother 2. Limited access to health care or no prenatal care 3. Exposure to environmental dangers, such as toxic chemicals and illicit drugs 4. Preexisting maternal conditions 5. Maternal factors such as age or parity 6. Medical conditions related to pregnancy and their associated complications 7. Pregnancy complications

B. Birth of at-risk newborns can often be anticipated 1. Even if identified → labor cannot be predicted 2. Apgar score is a helpful tool

C. Newborn classification and neonatal mortality risk chart 1. Preterm: less than or equal to 36 weeks, 6 days 2. Late preterm: 34 weeks, 0 days through 36 weeks, 6 days 3. Early term: 37 weeks, 0 days through 38 weeks, 6 days 4. Full term: 39 weeks, 0 days through 40 weeks, 6 days 5. Late term: 41 weeks, 0 days through 41 weeks, 6 days 6. Postterm: 42 weeks, 0 days and beyond 7. Large-for-gestational-age (LGA) → above 90th percentile 8. Appropriate-for-gestational-age (AGA) → between 10th and 90th percentile 9. Small-for-gestational-age (SGA) → below 10th percentile 10. Chart should correlate with characteristics of the patient populations 11. Neonatal mortality risk → chance of death within neonatal period 12. Neonatal morbidity → can also be anticipated based on birth weight and gestational age

D. Identifying nursing care needs 1. Decreasing physiologically stressful situations

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2. Constantly observing for subtle signs of change in clinical status 3. Interpreting laboratory data and coordinating interventions 4. Conserving the infant’s energy for healing and growth 5. Providing for developmental stimulation and maintenance of sleep cycles 6. Assisting the family in developing attachment behaviors 7. Involving the family in planning and providing care

II.

Care of the Small-for-Gestational-Age/Intrauterine Growth Restriction Newborn

A. Terminology 1. SGA → less than 10th percentile for birth weight 2. Intrauterine growth restriction (IUGR) → advanced gestation and decreased growth potential for the fetus

B. Factors Contributing to IUGR 1. Maternal factors a) Primiparity, grand multiparity, multiple gestation pregnancy, lack of prenatal care, age extremes, low socioeconomic status b) Nutritional supply in third trimester 2. Maternal disease 3. Environmental factors a) High altitude, exposure to x-rays, excessive exercise, work-related exposure to toxins, hyperthermia, use of teratogenic drugs 4. Placental factors 5. Fetal factors

C. Patterns of IUGR 1. Growth failure early → organs small, weight subnormal 2. Growth failure late → organs normal, size diminished 3. Symmetric (proportional) IUGR → long-term maternal conditions, fetal genetic abnormalities a) Noted by ultrasound in first half of second trimester 4. Asymmetric (disproportional) IUGR → acute compromise of uteroplacental blood flow a) May not be evident before third trimester b) Decrease in growth rate of abdominal circumference 3 Copyright © 2020 Pearson Education, Inc.

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c) Particularly at risk for perinatal asphyxia, pulmonary hemorrhage, hypocalcemia, hypoglycemia in newborn period 5. Physiologic maturity develops according to gestational age

D. Common Complications of the SGA or IUGR Newborn 1. Fetal hypoxia a) Little reserve to withstand demands of labor and birth 2. Aspiration syndrome a) Fetus gasps during birth → amniotic fluid into lower airways, meconium 3. Hypothermia a) Diminished subcutaneous fat, depletion of brown fat in utero 4. Hypoglycemia a) Increased metabolic rate in response to heat loss, poor hepatic glycogen stores 5. Polycythemia a) Number of red blood cells increased

E. Factors contributing to poor outcome include: 1. Congenital malformations a) 5% of SGA infants 2. Intrauterine infections a) Rubella, cytomegalovirus (CMV) 3. Continued growth difficulties 4. Cognitive difficulties a) Subsequent learning disabilities

F. Clinical therapy 1. Early recognition, medical management of potential problems

G. Nursing Management or the SGA/IUGR Newborn 1. Nursing Assessment and Diagnosis a) Gestation age b) Identify signs of potential complications c) Symmetric IUGR → in proportion, below normal size (1) Generally vigorous d) Asymmetric IUGR → long, thin, emaciated, loose skin folds, dry, desquamating skin (1) Head appears large because chest, abdominal girth decreased (2) See Figure 30–1: Thirty-one week-gestational age, SGA 2-day-old baby girl, p. 756

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2. Nursing diagnoses include: a) Gas Exchange, Impaired b) Injury, Risk for c) Tissue Perfusion: Peripheral, Ineffective d) Parenting, Risk for Impaired (1) See Nursing Care Plan: For the Small-for-Gestational-Age Newborn, pp. 758–761 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Hypoglycemia (2) Other conditions b) Community-based nursing care (1) Long-term needs (2) Promote positive atmosphere to enhance growth and outcomes 4. Evaluation a) SGA/IUGR newborn free from respiratory compromise b) SGA/IUGR newborn maintains stable temperature c) SGA/IUGR infant free from hypoglycemic episodes and maintains glucose homeostasis d) SGA/IUGR newborn gains weight and takes breast or formula feedings without physiologic distress or fatigue e) Parents verbalize concerns surrounding baby’s health problems and understand rationale behind management of their newborn

III.

Care of the Large-for-Gestational-Age Newborn

A. LGA at or above 90th percentile 1. Best-known condition → maternal diabetes a) 3% to 10% all pregnancies complicated by diabetes b) 60% gestational diabetes; 33% insulin-dependent diabetes c) Directly proportional to high, unstable glucose concentrations d) Multiparous women → two to three times number of LGA infants as primigravidas e) Male infants typically larger than female infants f) Babies with erythroblastosis fetalis, Beckwith-Wiedemann syndrome, transpositions of great vessels usually large 2. Characteristically proportional a) Diabetic mother may have higher body weight b) Tend to be more difficult to arouse c) Problems maintaining quiet, alert state

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B. Common Complications of the LGA Newborn 1. Birth trauma due to cephalopelvic disproportion (CPD) and macrosomia 2. Hypoglycemia, polycythemia, hyperviscosity

C. Nursing Management for the Large-for-Gestational-Age Newborn 1. Perinatal history in conjunction with ultrasonic measurement of biparietal diameter a) Gestational age testing b) Monitoring vital signs c) Screening d) Address parental concerns 2. Similar to care of infant of diabetic mother

IV.

Care of the Newborn of a Mother with Diabetes A. IDMs → at risk 1. Close observation first few hours of the first few days of life 2. Macrosomic, ruddy in color, excess adipose tissue 3. Decreased total body water 4. Excessive weight due to increased weight of visceral organs, cardiomegaly, increased body fat 5. Caused by exposure to high levels of maternal glucose a) May be obese as children b) See Figure 30–2: Macrosomic newborn of an undiagnosed diabetic mother born at 35 weeks’ gestation weighing 3775 g …, p. 762

B. Common Complications of the Infant of a Diabetic Mother 1. Low glucose concentrations (hypoglycemia) a) Blood sugar less than 40 mg/dl b) IDM continues to produce high levels of insulin c) Deplete infant’s blood glucose within hours after birth d) Signs and symptoms of hypoglycemia 2. Hypocalcemia a) Tremors b) Secondary hypoparathyroidism c) Treatment rarely necessary 3. Hyperbilirubinemia a) 48 to 72 hours after birth

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4. Birth trauma a) Trauma may occur during labor and vaginal birth 5. Polycythemia a) Fetal hyperglycemia, hyperinsulinism → increased oxygen consumption 6. Respiratory distress syndrome (RDS) a) More frequently in newborns of diabetic mothers who are not well controlled b) Lungs less mature than expected c) RDS not as problematic for infants born to diabetic mothers who have decreased placental perfusion 7. Congenital birth defects

C. Nursing Management for the Infant of a Mother with Diabetes 1. Nursing Assessment and Diagnosis a) IDM will appear older than gestation age scoring b) Assess for signs of respiratory distress, hyperbilirubinemia, birth trauma, congenital anomalies 2. Nursing diagnoses include: a) Nutrition, Imbalanced: Less Than Body Requirements b) Gas Exchange, Impaired c) Tissue Perfusion. Peripheral, Ineffective d) Tissue Integrity, Impaired e) Family Processes, Interrupted 3. Nursing Plan and Implementation a) Ongoing monitoring of: (1) Hypoglycemia (2) Polycythemia (3) Hyperbilirubinemia (4) Birth injuries (5) Congenital malformations b) Parental teaching 4. Evaluation a) Newborn’s respiratory distress and metabolic problems are minimized b) Parents understand the etiology of the baby’s health problems and preventive steps they can initiate to decrease the impact of maternal diabetes on subsequent pregnancies c) Parents verbalize their concerns surrounding their baby’s health problems and understand the rationale behind management of their newborn

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V.

Care of the Postterm Newborn A. Any newborn born after 42 weeks’ gestation 1. 6% of all pregnancies 2. Most normal size and health 3. Some keep growing, > 4000g 4. Potential intrapartum problems → CPD, shoulder dystocia

B. Common Complications of the Newborn with Postmaturity Syndrome 1. Truly postmaturity → high risk for morbidity, mortality rate 2 to 3 times that of term infants a) Majority of deaths occur during labor 2. Characteristics of postmaturity syndrome newborn a) Hypoglycemia b) Meconium aspiration in response to in-utero hypoxia c) Oligohydramnios d) Polycythemia e) Congenital anomalies f) Seizures g) Cold stress 3. Long-term effects unclear 4. Combination of placental aging and subsequent insufficiency

C. Clinical therapy 1. Differentiate fetus with postmaturity syndrome from large, well nourished, active fetus 2. Antenatal testing 3. Monitor hypoglycemia 4. SGA → peripheral and central hematocrits 5. Fluid resuscitation, partial exchange transfusion 6. Oxygen for respiratory distress

D. Nursing Management for the Newborn with Postmaturity Syndrome 1. Nursing Assessment and Diagnosis a) Newborn with postmaturity syndrome appears alert b) Dry, cracking, parchment-like skin c) No vernix, lanugo d) Fingernails long 8 Copyright © 2020 Pearson Education, Inc.

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e) Meconium staining → yellow to green (green is recent) f) See Figure 30–4: The skin of the postterm infant exhibits deep cracking and peeling of skin, p. 765 2. Nursing diagnoses include: a) Hypothermia b) Nutrition, Imbalanced: Less Than Body Requirements c) Gas Exchange, Impaired d) Tissue Perfusion: Peripheral, Ineffective 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Monitor cardiopulmonary status (2) Provide warmth (3) Frequently monitor blood glucose, initiate early feeding (4) Obtain central hematocrit 4. Evaluation a) Postterm newborn establishes effective respiratory function b) The postmature baby is free of metabolic alterations (hypoglycemia) and maintains a stable temperature

VI.

Care of the Preterm (Premature) Newborn

A. Infant born prior to the start of the 37th week 1. 1 in 10 neonates born in United States 2. Rise in multiple birth rates 3. Variable immaturity of all systems

B. Alteration in Respiratory and Cardiac Physiology 1. Preterm infant unable to produce adequate amounts of surfactant 2. Muscular coat of pulmonary blood vessels is incompletely developed a) Left to right shunting through ductus arteriosus → increases blood flow back into lungs 3. Ductus may remain open → increases blood volume to lungs

C. Alteration in Thermoregulation 1. Five physiology and anatomic factors increase heat loss in preterm newborn a) Higher ratio of body surface to body weight b) Very little subcutaneous fat c) Thinner, more permeable skin d) Gestational age→ amount of flexion of extremities e) Decreased ability to vasoconstrict superficial blood vessels and conserve heat 9 Copyright © 2020 Pearson Education, Inc.

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2. More preterm baby is less able to maintain heat balance 3. Provide neutral thermal environment (NTE)

D. Alteration in Gastrointestinal Physiology 1. Gastrointestinal (GI) immaturity a) Danger of aspiration due to poorly developed gag reflex, incompetent esophageal cardiac sphincter, inadequate suck/swallow/breathe reflex b) Difficulty in meeting high caloric and fluid needs for growth (1) Small gastric capacity c) Limited ability to convert certain essential amino acids to nonessential amino acids d) Inability to handle increased osmolarity of formula protein due to kidney immaturity e) Difficulty absorbing saturated fats due to decreased bile salts and pancreatic lipase f) Difficulty with lactose digestion initially (1) Processes may not be fully functional during the first few days of preterm infant’s life g) Deficiency of calcium, phosphorus → deposited in last trimester (1) Rickets, bone demineralization h) Increased basal metabolic rate, increased oxygen requirements i) Feeding intolerance, necrotizing enterocolitis (1) Diminished blood flow, tissue perfusion to bowel

E. Alteration in Hepatic and Hematologic Physiology 1. Decreased glycogen stores → frequently experiences stress a) High risk for hypoglycemia 2. Iron stored in liver → lower iron stores a) Many require transfusions of packed cells b) Oral iron supplementation c) Erythropoietin 3. Conjugation of bilirubin in liver impaired → bilirubin levels increase more rapidly 4. Normal cord hemoglobin in infant 34 weeks’ gestation → 16.8 g/dl, 80 to 100 mL/kg total blood volume a) Blood loss significant

F. Alteration in Renal Physiology 1. Glomerular filtration rate (GFR) lower → low renal blood flow a) Related to lower gestational age

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2. Preterm infant’s kidneys limited in ability to concentrate urine, excrete excess amounts of fluid → blunted response to antidiuretic hormone (ADH) 3. Preterm kidneys begin excreting glucose at lower serum glucose level than term infant 4. Kidney’s buffering capacity reduced 5. Immaturity of renal system affects ability to excrete drugs

G. Alteration in Immunologic Physiology 1. Preterm infant increased susceptibility to infections acquired in utero 2. In utero, fetus receives passive immunity from maternal IgG immunoglobulins a) Last trimester → preterm infant has few antibodies 3. IgA → found in breast milk 4. Skin surface easily excoriated → with invasive procedures → risk for nosocomial infections a) Hand-washing technique vital

H. Alteration in Neurologic Physiology 1. Most rapid brain growth and development occurs in third trimester of pregnancy a) Closer to term a baby is born, the better the neurologic prognosis 2. Intraventricular hemorrhage (IVH) a) Hydrocephalus may develop as consequence of IVH

I. Alteration in Reactivity Periods and Behavioral States 1. Preterm periods of reactivity delayed a) Hypotonic, unreactive for several days after birth b) Disorganized in sleep-wake cycles c) Neurological responses weaker

J. Management of Nutrition and Fluid Requirements 1. Early feedings extremely valuable for premature newborn 2. Nutritional requirements a) Uncompromised, healthy preterm infant → 95 to 130 kcal/kg/day b) Fortified breast milk, preterm formula (1) Human donor milk option (2) Feeding protocol based on infant’s weight, estimated stomach capacity c) More protein d) Supplemental multivitamins (1) Vitamins A, D, E, iron, trace minerals (2) Vitamin E e) Considered adequate with consistent weight gain of 20 to 30 g/day 11 Copyright © 2020 Pearson Education, Inc.

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3. Methods of feeding a) Bottle feeding (1) Coordinated, rhythmic suck-swallow-breathing pattern → bottle (2) Readiness to feed → engagement and hunger cues (a) Ability to suck (b) Bringing hands to the mouth (c) Being alert (d) Exhibiting fussiness (e) Sucking on fingers or pacifier (f) Exhibiting rooting behavior (g) Showing relaxed facial expression and good tone (3) Observe for tachypnea, decrease in oxygen saturation levels, bradycardia, lethargy, uncoordinated suck and shallow b) Breastfeeding (1) As soon as infant demonstrates (a) Coordinated suck and swallow reflex (b) Showing consistent weight gain (c) Control body temperature outside incubator (2) Allows mother to contribute actively to infant’s well-being (3) Skin-to-skin holding of low-birth-weight (LBW) infants → mothers can significantly increase milk volume (4) Football hold (a) Feeding time may be up to 45 minutes (b) Burp in between breasts (c) Coordinate flexible feeding schedule (5) Pumping (a) Double-pumping system c) Gavage feeding (1) Tube feeding (a) Lack of, or poorly coordinated, suck-swallow-breathing pattern, respiratory compromise, ventilator dependent (b) < 34 weeks’ gestation (2) Intermittent bolus or continuous drip, nasogastric or orogastric (3) Minimal enteral nutrition (MEN) → small-volume feedings of formula, human milk (a) Prime intestinal tract (b) No increased in incidence of necrotizing enterocolitis (c) Fewer days on total parental nutrition (TPN) (d) Increased weight gain and muscle maturation (e) Increased gut peristalsis (f) Increased gut hormone levels (g) Shorter time required to reach full-volume enteral feedings (h) Lower risk of osteopenia (i) Possible decrease in hospital stay (4) See Clinical Skill 30–1: Performing Gavage Feeding, p. 772 12 Copyright © 2020 Pearson Education, Inc.

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d) Fluid requirements (1) Based on weight, postnatal age (2) Recommendations for preterm infant weighing 1500 g (a) 60 to 80 mL/kg/day → day 1 (b) 80 to 100 mL/kg/day → day 2 (c) 100 to 160 mLkg/day → day 3 (d) Increased up to 190 mL/kg/day if (i) Very small (ii) Phototherapy (iii) Radiant warmer (3) Daily weights (a) Weights every 6 to 8 hours sometimes if < 1000g (b) Weight loss expected first 5 to 6 days, 15 to 20% of birth weight

K. Common Complications of Preterm Newborns and Their Clinical Management 1. Apnea of prematurity a) Refers to cessation of breathing for 20 seconds or longer b) Etiology multifactorial (1) Neuronal immaturity (2) Obstructive apnea c) Onset often insidious d) Document all episodes of apnea (1) Activity, length, treatment e) Assess quickly f) Interventions (1) Gentle stimulation (2) Respiratory support (3) Pharmacologic intervention (a) Caffeine citrate (4) Conservative management of gastroesophageal reflux 2. Patent ductus arteriosus (PDA) a) Functional closure of ductus arteriosus related to birth weight b) Pulmonary vascular resistance (PVR) falls and systemic vascular resistance (SVR) rises, a left-to-right shunt via the PDA results c) Blood flows from aorta into pulmonary artery, increasing pulmonary blood flow d) Leads to left ventricular volume overload, pulmonary edema, congestive failure e) Oxygenation is compromised, and ventilator requirements will increase, leading to possible difficulty in weaning from ventilator and long-term pulmonary sequelae 3. Early identification with prompt intervention → minimize long-term complications a) Adequate respiratory support b) Restricting fluids c) Diuretics 13 Copyright © 2020 Pearson Education, Inc.

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d) Digoxin e) Prostaglandin synthetase inhibitors can cause ductal closure (1) Indomethacin → short course or long course (2) Ibuprofen lysine → short course f) Surgical ligation 4. Respiratory distress syndrome (RDS) a) Results from inadequate surfactant production 5. Intraventricular hemorrhage a) Most common type if intracranial hemorrhage in small preterm infant b) Most common site → periventricular subependymal germinal matrix (1) Before 34 weeks’ gestation & <1500g → tiny vessels fragile (2) Highly susceptible to hypoxic events, respiratory distress, birth trauma, birth asphyxia (3) Germinal matrix vessel ruptures

L. Long-Term Needs and Outcomes 1. Follow-up care important 2. LBW preterm infants face higher mortality rates a) Sudden infant death syndrome (SIDS) b) Respiratory infections c) Neurologic defects 3. Higher morbidity if < 1500g 4. Retinopathy of prematurity (ROP) a) Susceptible to injury of delicate capillaries of retina (1) Ischemia → results in hemorrhage, scarring, retinal detachment, impaired vision, eventual complete blindness b) Multifactorial in origin (1) Hyperoxemia (2) Other factors c) Judicious use of supplemental oxygen therapy d) Treatment (1) Laser photocoagulation, cryotherapy e) Parental support and education for parents of visually impaired infant 5. Bronchopulmonary dysplasia (BPD) a) Long-term lung disease from damage to alveolar epithelium secondary to positive pressure respiratory therapy 6. Speech defects a) Delayed development

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7. Neurologic defects a) Most common include (1) Cerebral palsy, hydrocephalus, seizure disorders, lower IQ scores, learning disabilities 8. Auditory defects a) 1 to 4% incidence of moderate to profound hearing loss (1) Formal audiologic examination before discharge, 3 to 6 months b) Evoked otoacoustic emissions test (EOAE) c) Automated auditory brain response (AABR) (1) See Figure 30–12: Preterm newborns should have a formal hearing test prior to discharge, p. 776 9. Speech defects a) Delayed development (1) Receptive and expressive ability

M. Nursing Management for the Preterm Newborn 1. Nursing assessment a) Assess physical characteristics, gestational age (1) Color (2) Skin (3) Lanugo (4) Head size (5) Skull (6) Ears (7) Nails (8) Genitals (9) Posture (10) Cry (11) Reflexes (12) Activity b) Gestational age assessment tools 2. Nursing diagnoses a) Gas Exchange, Impaired b) Breathing Pattern, Ineffective c) Tissue Perfusion: Cardiac, Risk for Decreased d) Tissue Perfusion: Peripheral, Ineffective e) Nutrition, Imbalanced: Less Than Body Requirements f) Thermoregulation, Ineffective g) Fluid Volume, Deficient h) Family Processes, Dysfunctional

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3. Nursing Plan and Implementation a) Maintenance of respiratory function (1) Increased danger of respiratory obstruction (a) Positioning (b) Supine → slightly elevate infant’s head (c) Prone → splints chest wall, decreases amount of respiratory effort (i) Facilitates chest expansion (2) Monitor for signs of respiratory distress (a) Cyanosis → serious sign when generalized (b) Tachypnea → sustained respiratory rate greater than 60/minute after first 4 hours of life (c) Retractions (d) Expiratory grunting (e) Nasal flaring (f) Apneic episodes (g) Presence of crackles or rhonchi on auscultation (h) Diminished air entry (3) Administer oxygen per physician/nurse practitioner order if respiratory distress occurs (4) If hypoxemia not treated (a) May result in PDA, metabolic acidosis (b) Periodic arterial blood gas sampling (5) Consider respiratory function before initiation of feedings b) Maintenance of neutral thermal environment (1) Minimizes oxygen consumption (a) Allow skin-to-skin contact (b) Warm and humidify oxygen (c) Place baby in double-walled incubator (d) Avoid placing baby on cold surfaces (e) Use warmed ambient humidity (f) Keep the skin dry, place cap on the baby’s head (g) Keep radiant warmers, incubators, cribs away from windows, cold external walls (h) Open incubator portholes, doors only when necessary (i) Use a skin probe to monitor baby’s skin temperature (j) Warm formula, stored breast milk before feeding (k) Use reflector patch over skin temperature probe (2) When stable → clothed with double-thickness cap, cotton shirt, diaper, swaddled c) Maintenance of fluid and electrolyte status (1) Hydration based on weight, gestational age, chronologic age, volume of sensible, insensible water loss (2) Assess and record signs of dehydration (3) Assess and record signs of overhydration (a) Excessive weight gain (b) Intake and output 16 Copyright © 2020 Pearson Education, Inc.

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Infant weighed once daily at same time of day Weigh diapers, 1 ml = 1 g d) Provision of adequate nutrition and prevention of fatigue during feeding (1) Feeding method depends on preterm newborn’s feeding abilities and health status (a) Nipple and gavage methods initially supplemented with IV therapy (b) MEN via gavage (c) Measure abdominal girth, auscultate abdomen (d) Check for residual formula (e) Preterm infants who are ill, fatigue easily → fed by gavage (2) Readiness to feed (a) Gradual nipple-feeding program (3) Monitor weight (4) Nurse involves parents in feeding e) Prevention of infection (1) Minimize preterm newborn’s exposure to pathogenic organisms (a) Strict hand washing, use of separate equipment for each infant (b) Standard precautions, short-trimmed nails (no artificial nails) (c) 2- to 3-minute scrub (d) Nurse may be first to identify subtle clinical signs (i) Apnea, bradycardia (e) Other potential interventions (i) Limiting visitors, requiring visitors to wash their hands, maintaining strict aseptic practices when changing IV tubing and solutions, change incubators and radiant warmers weekly, prevent skin break down f) Promotion of parent–newborn attachment (1) Preterm newborns may be separated from parents for prolonged periods (2) Take measures to promote positive parental feelings toward newborn (3) Early involvement in care and decisions regarding baby provides parents with realistic expectations for baby (a) Daily participation, early, frequent visits (4) Skin-to-skin (kangaroo) care (a) See Figure 30–14: Kangaroo (skin-to-skin) care facilitates a closeness and attachment between mother and her premature newborn, p. 780 (b) Improved oxygenation (c) Enhanced temperature regulation (d) Decline in episodes of apnea and bradycardia (e) Increased periods of quiet sleep (f) Stabilization of vital signs (g) Positive interaction between parent and infant; enhances attachment and bonding (h) Increased growth parameters (i) Early discharge (5) Plan nursing care around times when infant is alert (6) Some parents will progress easily; others will not 17 Copyright © 2020 Pearson Education, Inc.

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g) Promotion of developmentally supportive care (1) Prolonged separation and the NICU environment necessitate individualized baby sensory stimulation programs (2) Preterm newborns are not developmentally able to deal with more than one sensory input at a time (3) Prove developmentally and supportive, family-centered care → improved outcomes (4) Noise levels reduced (5) Dimmer switches (6) Blankets over incubators (7) Plan nursing care to decrease number of times disturbed (8) Developmental techniques (a) Containment measures (b) Gentle touch, no sudden postural changes (c) Promote soothing activities (d) Simulate kinesthetic advantages (e) Nonnutritive sucking 4. Preparation for home care a) Parents often anxious when transferred out of NICU, discharged home (1) Instructions include breastfeeding, formula-feeding techniques, formula preparation, medication administration (2) Information on bathing, diapering, hygiene, normal elimination patterns (3) Referrals may be necessary for severe abnormalities, feeding problems, complications (4) Normal growth and development expectations b) Preterm, LBW infants at greater risk of increased morbidity from vaccine-preventable diseases (1) Full doses of: (a) Diphtheria (b) Tetanus (c) Acellular pertussis (d) Haemophilus influenzae type b (Hib) (e) Hepatitis B (f) Inactivated poliovirus (g) Rotavirus (h) Pneumococcal conjugate vaccine (PCV) (i) Influenza at 6 months of age 5. Evaluation a) Preterm newborn is free of respiratory distress and establishes effective respiratory function b) Preterm newborn gains weight and shows no signs of fatigue or aspiration during feedings c) Preterm newborn demonstrates a serial head circumference growth rate of 1 cm per week 18 Copyright © 2020 Pearson Education, Inc.

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d) Parents are able to verbalize feelings, show positive attachment behavior such as frequent visits and growing confidence in participatory care activities

VII.

Care of the Newborn with Congenital Anomalies

A. Newborn and family at risk 1. Life threatening or visible and cause emotional distress 2. If one found, look for others 3. See Table 30–4: Congenital Anomalies: Identification and Care in Newborn Period, p. 783– 787

VIII.

Care of the Newborn with Congenital Heart Defect

A. Congenital heart defect (CHD) most common congenital defect B. Overview of Congenital Heart Defects 1. Only 25% identified on prenatal ultrasound 2. Early treatment → identified in first days of life with pulse oximetry a) Post ductal on foot b) Accurate probe placement (1) Light probe emitter directly opposite the light emitter (2) Avoiding placing probes on an extremity with the automatic blood pressure cuff (3) Cleaning and drying skin prior to placement of the probe (4) Covering the probe with an opaque covering 3. Multifactorial cause with no specific trigger a) Environmental or genetic 4. Common defects seen in first 6 days of life a) Left ventricular outflow obstructions (1) Mitral stenosis, aortic stenosis, atresia b) Hypoplastic left heart c) Coarctation of the aorta d) Patent ductus arteriosus (PDA) e) Transposition of the great vessels f) Tetralogy of Fallot g) Large ventricular septal defect h) Atrial septal defects

C. Nursing Management for the Newborn with a Cardiac Defect 1. Nursing Assessment and Diagnosis a) Early identification of cardiac defects b) Cyanosis 19 Copyright © 2020 Pearson Education, Inc.

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c) Heart murmur d) Congestive heart failure (CHF) e) See Table 30–6: Cardiac Defects of the Early Newborn Period, pp. 789–791 2. Initial repair in newborn becoming more common a) Stabilize → decisions about ongoing needs 3. Careful and complete explanations 4. Emotional support of parents 5. Allow parents to verbalize concern

IX.

Care of the Newborn of a Substance-Abusing Mother A. Infant of a substance-abusing mother (ISAM) → exposed to licit or illicit drugs B. See Table 30–7: Common Drugs of Abuse, p. 792 C. The Newborn with Fetal Alcohol Spectrum Disorders 1. Fetal alcohol syndrome (FAS) a) Leading cause of preventable nongenetic intellectual disability b) FASD now includes all categories of prenatal alcohol exposure (1) Clinical manifestations of FAS (2) Social & family environment (3) Maternal alcohol history (a) Ethanol crosses placenta (b) Characteristics (i) Abnormal structural development and CNS dysfunction (ii) Growth deficiencies (iii) Distinctive facial abnormalities (iv) Associated anomalies

D. Long-term complications for the infant with FAS 1. Delay in oral feeding development a) Persistent vomiting until 6 to 7 months of age b) Difficulty adjusting to solid foods 2. CNS dysfunctions most common and serious a) Increased placidity, hypotonicity, decreased ability to block out repetitive stimuli 3. Impulsivity, cognitive impairment, speech and language abnormalities 4. Thin, underweight children 5. Learning disabilities indicative of CNS involvement a) Severe intellectual disabilities or normal intelligence

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E. Nursing Management for the Newborn with Fetal Alcohol Spectrum Disorders 1. Nursing assessment a) Abnormal structural development, CNS dysfunction b) Growth deficiencies c) Patience with feeding (1) Breastfeeding not contraindicated, but excessive alcohol intake can lead to infant intoxication d) Symptoms in first week of life (1) Sleeplessness, excessive arousal states, inconsolable crying, abnormal reflexes (2) Hyperactivity (3) Seizures (4) Reinforce positive parenting, parents can get easily frustrated

F. Opiate Dependency 1. Drugs of abuse of opiates include heroin, morphine, codeine, prescription narcotics a) Obstetric complications for the fetus and substance-abusing mother include: (1) Intrauterine asphyxia (2) Intrauterine infection (3) Intrauterine growth restriction (IGR) (4) Low Apgar scores 2. Common complications of the drug-exposed newborn a) Respiratory distress b) Jaundice c) Congenital anomalies and growth restriction d) Behavioral abnormalities e) Withdrawal 3. Long-term effects a) Behavior lability, unable to express strong feelings (1) Poor social interaction skills, cannot habituate, easily overstimulated, difficulty sleeping b) Higher incidence of GI and respiratory illness 4. Clinical therapy a) Complete prenatal care b) Methadone or buprenorphine maintenance c) Newborn treatment (1) Management of complications (2) Serologic tests (3) Urine drug screen (4) Meconium analysis (5) Social service referral (6) Pharmacologic management for withdrawal 21 Copyright © 2020 Pearson Education, Inc.

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(7) Nutritional support

G. Nursing Management for the Substance-Exposed Newborn 1. Nursing Assessment and Diagnosis a) Discovering mother’s last drug intake b) Assessing for congenital malformations, complications related to intrauterine withdrawal c) Identifying signs and symptoms of newborn withdrawal/neonatal abstinence syndrome (1) See Table 30–9: Clinical Manifestations of Newborn Withdrawal, p. 794 (2) Central nervous system signs (3) Cutaneous signs (4) Gastrointestinal signs (5) Autonomic signs d) Neonatal abstinence syndrome (NAS) (1) Systematic scoring for assessing severity (2) Helps guide need for pharmacologic treatment (3) See Table 30–9: Scoring of Neonatal Abstinence Syndrome Signs and Symptoms, p.

795 2. Nursing diagnoses include: a) Infant Behavior: Disorganized b) Breathing Pattern, Ineffective c) Skin Integrity, Impaired d) Parenting, Impaired 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Reducing withdrawal symptoms (2) Promote adequate respiration, temperature, nutrition (3) General nursing care measures include: (a) Performing neonatal abstinence scoring per hospital protocol (b) Monitoring temperature for hypothermia (c) Carefully monitoring pulse and respirations every 15 minutes and pulse oximetry until stable (d) Providing small, frequent feedings, especially in the presence of vomiting, regurgitation, and diarrhea (e) Breastfeeding recommended for women who are not using additional drugs or who are in methadone treatment (f) Positioning on the right side-lying or semi-Fowler’s to avoid possible aspirations of vomitus or secretions (g) Monitor weight-gain pattern daily to assess for the need for increased calorie content of formula (h) Administering medications as ordered, such as oral morphine elixir, methadone, and deodorized of tincture of opium.

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(i) Monitoring frequency of diarrhea and vomiting and weighing infant every 8 hours during withdrawal (j) Swaddling with hands near mouth to minimize injury and achieve more organized behavioral state (k) Gentle, vertical rocking can be successful in calming an infant who is out of control (l) Protecting face and extremities from excoriation by using mittens and soft sheets or sheepskin (m) Applying protective skin emollient to the groin area with each diaper change (n) Placing newborn in quiet, dimly lighted area of nursery b) Community-based nursing care (1) Parents need to prepare for what to expect (a) NAS infants may be jittery, irritable from 6 days to 8 weeks (b) Higher risk for SIDS with heroin, cocaine, or opiate use (c) Apnea monitoring (d) Demonstrate feeding techniques, comforting measures, how to recognize cues, appropriate parenting responses (e) Available resources (f) Follow-up and ongoing evaluation 4. Evaluation a) Newborn tolerates feedings, gains weight, decreased number of stools b) Parents learn innovative ways to comfort newborn c) Parents able to cope with frustrations, begin to use outside resources

H. Newborns of Mothers Who Are Tobacco Dependent 1. Risks of tobacco to the fetus and newborn a) Preconceptual cigarette smoking decreases fertility b) During pregnancy → associated with spontaneous abortion, placenta previa, abruptio placentae 2. Carbon monoxide binds hemoglobin → decreases oxygen-carrying capacity of blood a) Chronic hypoxia b) Polycythemia/hyperviscosity c) Intrauterine growth restriction (IUGR) d) Prematureinfants e) Neuroteratogen 3. Greatest risks a) IUGR and/or prematurity b) Intrauterine distress c) Neonatal neurobehavioral abnormalities d) Hypertonia or hypotonia, tremors, increased Moro reflex e) Signs of nicotine toxicity (tachycardia, irritability, poor feeding) f) SIDS 23 Copyright © 2020 Pearson Education, Inc.

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4. Clinical therapy a) Prenatal history → inquiry into tobacco use, exposure b) Cotinine found in fetal blood fluids → correlation between cigarettes smoked and cotinine concentration c) Newborns may be screened with the NICU Network Neurobehavioral Scale (NNNS) to assess their neurologic, behavioral, and stress/abstinence neurobehavioral function d) Hearing impairment risk increased e) Long-term respiratory problems such as asthma, cognitive and receptive language delays that may persist into school age, should be evaluated

X.

Care of the Newborn Exposed to HIV/AIDS A. Preventative strategies have reduced risk of maternal–child transmission 1. 1% to 2% 2. Transmission occurs through placenta, breast milk–contaminated blood 3. Vertical transmission in mothers not receiving antiretroviral therapy → 25% to 40% 4. Universal testing (with notification) of pregnant women

B. Early identification of babies with/at risk essential 1. bDNA polymerase assay and HIV RNA assay a) Positive result with 48 hours suggests utero transmission b) Repeat 14 to 21 days c) Repeat at 1 to 2 months d) Repeat 4 to 6 months

C. Full-term newborns 1. 4 week ZDV/AZT started prophylactically as soon after birth as possible → 6 weeks 2. Confirmed positive HIV → combination antiretroviral therapy 3. Breastfeeding avoided with HIV-positive mother in developed countries

D. Nursing Management for the Newborn Exposed to HIV/AIDS 1. Nursing Assessment and Diagnosis a) Many newborns exposed to HIV/AIDS premature, SGA, both (1) May show signs, symptoms within days of birth (a) Enlarged spleen and liver, swollen glands, recurrent respiratory infections, rhinorrhea, interstitial pneumonia (rarely seen in adults), recurrent GI (diarrhea and weight loss) and urinary system infections, persistent or recurrent oral candidiasis infections, loss of achieved developmental milestones (2) High risk of acquiring Pneumocystis jirovecii pneumonia

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2. Nursing diagnoses a) Nutrition, Imbalanced: Less Than Body Requirements b) Skin Integrity, Impaired c) Infection, Risk for d) Mobility: Physical, Impaired e) Development: Delayed, Risk for f) Parenting, Impaired 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Normal care given to newborns (2) Plus use standard precautions for bloodborne pathogens (3) See Table 30–10: Issues for Caregivers of Newborns at Risk for HIV/AIDS, p. 800 b) Community-based nursing care (1) Hand hygiene (a) Parent teaching (2) Nutrition essential (3) Baby has own skin care items (a) Wash separate linens soiled with blood or body fluids (4) Diaper changing area separate from food prep and serving areas (5) Parent teaching signs of infection, disease transmission c) Regular clinical, immunologic, virologic monitoring 4. Evaluation a) Parents are able to bond with their infant and have realistic expectations about the baby b) Potential opportunistic infections are identified early and treated promptly c) Parents verbalize their concerns surrounding their baby’s existing and potential health problems and accept outside assistance as needed

XI.

Care of the Newborn with an Inborn Error of Metabolism

A. Inborn errors of metabolism (IEM) are hereditary disorders transmitted by mutant genes 1. Enzyme defect → blocks a metabolic pathway → accumulation of toxic metabolites 2. Newborn screening a) Phenylketonuria, congenital hypothyroidism, sickle cell disease, congenital adrenal hypoplasia, s-beta thalassemia, and galactosemia required in all states b) Mandatory newborn screening for other inborn errors of metabolism varies among states and often includes maple syrup urine disease (MSUD), homocystinuria, and cystic fibrosis (CF).

B. Selected Inborn Errors of Metabolism 1. Phenylketonuria (PKU) most common of amino acid disorders a) Phenylalanine essential amino acid → converted into tyrosine 25 Copyright © 2020 Pearson Education, Inc.

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b) PKU → lacks converting ability → accumulate in blood and brain tissue → progressive intellectual disability c) Guthrie blood test for PKU (1) See Figure 30–18: Guthrie card for newborn testing, p. 801 (2) Done at least 24 hours after initiation of feedings 2. Congenital hypothyroidism (CH) a) Elevated thyroid-stimulating hormone (TSH), low T4 → premature infant

C. Clinical therapy 1. Screening and early clinical intervention a) Early discharge can make a challenge b) False positives

D. Nursing Management for the Newborn with an Inborn Error of Metabolism 1. Nursing Plan and Implementation a) Newborn with phenylketonuria (1) Normal appearing newborn → blond hair, blue eyes, fair complexion (2) Fails to thrive → vomiting, eczematous rashes (3) By 6 months → intellectual disability, other CNS involvement b) PKU infant treated with special diet limits ingestion of phenylalanine (1) Food lists (2) Special formula (3) If treatment is begun before 1 month of age, CNS damage can be minimized c) Newborn with congenital hypothyroidism (1) Recognizable features at birth (a) Large tongue (b) Umbilical hernia (c) Cool and mottled skin (d) Low hairline (e) Hypotonia (f) Large fontanelles (g) Prolonged newborn jaundice, poor feeding, constipation, low-pitched cry, poor weight gain, inactivity, early sleeping through the night, delayed motor development (h) < 30 weeks’ gestation→ lower T4 and TSH values than term babies (2) Managed (a) Adjustment of thyroid medication to accommodate growth and development (b) Laboratory monitoring

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E. Evaluation 1. Risk of inborn errors of metabolism promptly identified, early intervention initiated 2. Parents verbalize concerns about baby’s nutritional status, health problems, long-term care needs, and potential outcomes 3. Parents are aware of available community health resources and use them as indicated

XII.

Focus Your Study

XIII.

Activities 1. Individual Have each student prepare drug cards on the following medications specific to newborns at risk: • Caffeine citrate • Phenobarbital • Vitamin K • Iron supplementation • Erythropoietin • Diphtheria • Tetanus • Acellular pertussis • Haemophilus influenzae type b (Hib) • Hepatitis B • Inactivated poliovirus • Rotavirus • Pneumococcal conjugate vaccine 2. Small Group Divide the class in to small groups of three to five students. Have the groups prepare a teaching plan for parents of a preterm newborn. Each group will present one of the following areas: • Respiratory distress syndrome (RDS) • Patent ductus arteriosus (PDA) • Hypothermia and cold stress • Necrotizing enterocarditis (NEC) and feeding difficulties • Chronic lung disease • Sensorineural hearing loss • Neurologic sequelae 3. Large Group Present and review the following video (4 minutes 44 seconds) on premature triplets. Have students assess the characteristics presented. Consider presenting the video without audio: http://www.youtube.com/watch?v=Q6jEKv0Kp_w

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Chapter 31 The Newborn at Risk: Birth-Related Stressors Care of the Newborn at Risk Due to Asphyxia......................................................

2

Care of the Newborn with Respiratory Distress...................................................

7

Care of the Newborn with Meconium Aspiration Syndrome...............................

9

Care of the Newborn with Complications Due to Respiratory Therapy............. .

12

Care of the Newborn with Cold Stress..................................................................

14

Care of the Newborn with Hypoglycemia.............................................................

15

Care of the Newborn with Jaundice......................................................................

16

Care of the Newborn with Anemia.......................................................................

20

Care of the Newborn with Infection.....................................................................

21

Care of the Family with Birth of an At-Risk Newborn...........................................

23

Considerations for the Nurse Who Works with At-Risk Newborns……………………

27

Focus Your Study...................................................................................................

27

Activities................................................................................................................

27

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

Care of the Newborn at Risk Due to Asphyxia

A. Neonatal asphyxia → deprivation of oxygen to the baby’s brain and organs during the birth process B. Incidence increases as gestational age decreases 1. Results from several factors 2. Circulatory → inability to transition to extrauterine circulation 3. Respiratory → failure of lung expansion 4. Biochemical → hypoxemia, metabolic acidosis, hypercapnia → cause a) Pulmonary vasoconstriction, high pulmonary vascular resistance b) Hypoperfusion of the lungs → failure to achieve FRC c) Large right-to-left shunt in heart (1) Right atrial pressure > left atrial pressure → foramen ovale reopens d) Change from aerobic to anaerobic metabolism (1) Buildup of lactate (2) Metabolic acidosis (3) Respiratory acidosis (4) Glycogen stores mobilized 5. Protective mechanisms a) Relatively immature brain b) Resting metabolic rate lower than that observed in the adult c) Ability to mobilize substances within the body for anaerobic metabolism and to use energy more efficiently d) Intact circulatory system able to redistribute lactate and hydrogen ions in tissues still being perfused

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6. Severe prolonged hypoxia will overcome protective mechanisms

C. Risk factors Predisposing to Asphyxia 1. Nonreassuring fetal heart rate pattern/sustained bradycardia 2. Impairment of maternal oxygenation 3. Alteration of blood flow through placenta or cord 4. Significant intrapartum bleeding 5. Difficult birth, prolonged labor 6. Pregnancy-induced hypertension or preeclampsia 7. Difficult birth, prolonged labor, malposition, PROM 8. Narcotic use in labor 9. History of meconium in amniotic fluid 10. Prematurity 11. Male newborn 12. Intrauterine growth restriction (IUGR) 13. Small for gestational age (SGA) 14. Large for gestational age (LGA) or macrosomia 15. Multiples 16. Structural lung abnormality/oligohydramnios 17. Congenital heart disease 18. Maternal fever 19. Anemia: Isoimmunization, intrapartum hemorrhage, maternal viral illness 20. Not always apparent 21. Antenatal neuroprotection

D. Clinical therapy 1. Fetal biophysical assessment a) Monitoring of fetal pH b) Fetal acidosis via three factors (1) Excess CO2 (2) Lactic, uric or keto acids (3) Both carbonic and noncarbonic acids 3 Copyright © 2020 Pearson Education, Inc.

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c) Fetal heart rates (FHRs) d) Fetal oximetry 2. Assess newborn’s need for resuscitation a) Color b) Heart rate c) Respirations d) Cry e) Apgar score (1) Score < 7 at 5 minutes requires additional scores every 5 minutes for 20 minutes 3. Resuscitative efforts a) 10% all newborns to begin breathing → 3% require positive pressure ventilation → < 1% requiring more b) Identification of newborns who do not require resuscitation rapid assessment (1) What is the gestational age?

(2) Is amniotic fluid clear of meconium, evidence of infection?

(3) How many babies are expected?

(4) Are there any other risks? c) Questions following birth (1) Is the baby full term?

(2) Is the baby breathing and crying?

(3) Does the baby have good muscle tone? d) If all yes → no resuscitation e) If any answer no → resuscitative assistance (1) Initial steps in stabilization (a) Warming, positioning, clearing the airway as necessary, drying, stimulating, and repositioning (2) Oxygen administration while monitoring pulse oximetry (3) Positive pressure ventilation/intubation (4) Chest compressions (5) Administration of epinephrine, volume expansion, or both (6) Neonatal therapeutic hypothermia (7) Newborn blood gas to follow up cord gas values and response to resuscitation efforts

E. Resuscitation Management 1. Suctioning a) Head-down sniffing position → avoid aspiration b) Establish patent airway 2. Level position under preheated radiant heat source, dries baby a) Stable baby → mother’s chest, abdomen b) Extremely preterm newborn → temperature of the delivery room be raised to 23° to 25°C (74° to 77°F), plastic wrap, bag to prevent evaporative heat loss 4 Copyright © 2020 Pearson Education, Inc.

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c) Heat loss through evaporation tremendous first few minutes of life 3. Ventilation established a) Simple to complex progression of interventions b) Position and clear airway, simple stimulation c) Positive pressure if respiration not initiated, inadequate (1) Sniffing position (2) Mask positioned securely on face (3) Avoid hyperextension (a) See Figure 31–1: Demonstration of resuscitation of a newborn with flow inflating/anesthesia bag and mask .., p. 808 d) Devices used (1) Self-inflating bag (2) Flow inflating/anesthesia bag (3) T-Piece resuscitator e) Chest movement observed for proper ventilation (1) Air entry, heart rate checked by auscultation (2) Ventilation adequate → chest moves symmetrically f) Endotracheal intubation may be needed (1) See Figure 31–2: Endotracheal intubation is accomplished with the newborn’s head in the “sniffing position …, p. 809 4. Heart rate absent or < 60 beats per minute after 30 seconds of 100% oxygenation given via effective PPV → external cardiac massage a) Positioned on firm surface b) Resuscitator stands at foot or head of infant (1) Both thumbs over lower third of sternum, hands wrapped around newborn to support back (2) Two fingers instead of thumbs (3) Sternum depressed sufficiently to generate palpable pulse (4) Rate of 90 beats per minute (5) Ratio of 3:1 heartbeat/assisted ventilation (a) 90:30 (6) See Figure 31–3: External cardiac massage …, p. 810 5. Available drugs a) Oxygen b) Epinephrine → 0.1 to 0.3 mL/kg of 1:10,000 solution (0.1 mg/mL) (1) IV → umbilical vein (2) Endotracheal → higher dose c) Naloxone hydrochloride → not recommended d) Volume expanders for shock (1) Normal saline → 10 mL/kg via umbilical vein (2) Known fetal hemorrhage → packed red blood cells

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6. Neonatal therapeutic hypothermia (therapeutic cooling) a) Standard of care in the newborn with asphyxia → decrease injury to the brain during reperfusion (1) Decrease cell death, improve long-term outcomes (2) Cooling blanket (3) Criteria (a) 5-minute Apgar < 5 (b) Cord pH or newborn pH 7.0, base deficit > -15 (c) Abnormal neurologic exam (d) Initiate within 6 hours of delivery

F. Nursing Management for the Newborn Needing Resuscitation 1. Nursing Assessment and Diagnosis a) Identification of newborns who may be in need of resuscitation b) Ongoing monitoring as labor progresses c) Assisting with fetal scalp blood sampling d) Observing for presence of meconium e) Alert interdisciplinary resuscitation team 2. Nursing diagnoses include: a) Breathing Pattern, Ineffective b) Cardiac Output, Decreased c) Coping: Family, Compromised 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Identification of possible high-risk situations (2) Effective resuscitation (a) Check and maintain equipment before emergency (b) Systematic check each shift (3) Dry newborn quickly with warmed towels, blankets, place hat on infant (4) Under radiant warmer (5) Neonatal Resuscitation Program (NRP) certification b) Supporting parents (1) Procedure may be distressing to parents who are present (2) Support person for parents 4. Evaluation a) Newborn requiring resuscitation is promptly identified, intervention started early b) Newborn’s metabolic and physiologic processes stabilized, recovery proceeds without complications c) Parents can verbalize reason for resuscitation, and what was done to resuscitate their newborn d) Parents can verbalize fears about resuscitation process and potential implications for their baby’s future 6 Copyright © 2020 Pearson Education, Inc.

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II.

Care of the Newborn with Respiratory Distress

A. Respiratory distress syndrome (RDS) 1. Former name was hyaline membrane disease (HMD)→ primary absence, deficiency, alteration in production of pulmonary surfactant a) “Golden hour” b) Higher in newborns exposed to infection and without antenatal steroids 2. Factors associated with development of RDS a) Prematurity b) Surfactant deficiency disease 3. Development of RDS indicates failures to synthesize adequate surfactant a) Instability of alveoli b) See Figure 31–4: Cycle of events of RDS leading to eventual respiratory failure, p. 813 c) Increasing amounts of energy to reopen collapsed alveoli d) Lung compliance decreases e) Physiologic alterations of RDS produce (1) Hypoxia (2) Respiratory acidosis (3) Metabolic acidosis f) Radiologic picture of RDS → diffuse bilateral reticulogranular density (1) See Figure 31–5: RDS chest x-ray …, p. 814 4. Clinical therapy a) Prenatal (1) Prevent preterm birth (2) Antenatal steroids b) Postnatal (1) Surfactant replacement therapy → delivered via endotracheal tube or continuous positive airway pressure (CPAP) (a) Low birthweight, >30 weeks’ gestation (2) Supportive medical management (a) Establishing PEEP to transition to FRC (b) Ventilatory therapy (c) Blood gas monitoring (d) Pulse oximetry monitoring (e) Correction of acid–base imbalance (f) Environmental temperature regulation (g) Adequate nutrition (h) Protection from infection (3) Mild → increased humidified oxygen (a) CPAP (b) Heated high-flow O2 via nasal cannula (4) Ventilator 7 Copyright © 2020 Pearson Education, Inc.

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(a) Pressure control mode (b) See Figure 31–6: One-day-old …, p. 814 (5) High-frequency ventilation (HFV) (a) When ventilator not successful 5. Nursing Management for the Newborn with Respiratory Distress Syndrome a) Nursing Assessment and Diagnosis (1) Characteristics of RDS (a) See Table 31–2: Clinical Assessments Associated with Respiratory Distress, p. 815 (b) Skin color (c) Respiratory (i) Increasing cyanosis (ii) Tachypnea (iii) Apnea (d) Chest (i) Grunting respirations (ii) Nasal flaring (iii) Significant retractions (e) Cardiovascular (i) Systolic murmur (ii) PMI 4th or 5th intercostal space (f) Hypothermia (g) Muscle tone (2) Silverman-Anderson index b) Nursing interventions (1) Per institutional protocol (2) Noninvasive oxygen monitoring (3) Ventilatory assistance (4) NICU

B. Transient Tachypnea of the Newborn 1. Progressive respiratory distress that resembles RDS a) Due to maternal diabetes and asthma, male sex of fetus, macrosomia, cesarean-section delivery b) Typically < 40% oxygen relieves hypoxia c) Fails to clear lung mucus and other debris from airways d) Mild respiratory at first → grunting, nasal flaring, retractions, desaturation, mild cyanosis on room air e) Tachypnea at 6 hours, respirations > 60 breaths/minute f) Improve within 12 to 24 hours, up to 48 to 72 hours 2. Clinical therapy a) Initial x-ray may be identical to RDS (1) But will also have generalized overexpansion of the lungs (hyperaeration of alveoli) 8 Copyright © 2020 Pearson Education, Inc.

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(2) Dense streaking b) Ambient oxygen concentrations of 30 to 50% c) IV fluids during acute phase 3. Hypoxemia is severe and tachypnea continues → persistent pulmonary hypertension of the newborn (PPHN) a) See Nursing Care Plan: For the Newborn with Respiratory Distress Syndrome, pp. 819– 821

C. Persistent Pulmonary Hypertension of the Newborn 1. PPHN → serious disorder, 1–2:1000 live newborns 2. Failure to transition mediators from iNO to O2 → cycle of pulmonary constriction starts → right to left shunting in heart → blood bypasses lungs and fails to get oxygenated 3. Clinical therapy a) Diagnosis → assessment, ECG b) Perinatal asphyxia precursor c) Goal to lower pulmonary vascular resistance (1) Excellent ventilation (2) Elevated oxygenation (3) 20ppm of iNO (4) Volume expanders (5) Drug therapy-analgesics, sedatives, vasopressors, hydrocortisone, afterload reducters 4. Nursing Management for the Newborn with Persistent Pulmonary Hypertension a) Assess for signs in first hours of life b) Fail to respond to therapies c) Critically ill, NICU

III.

Care of the Newborn with Meconium Aspiration Syndrome

A. Body’s physiologic response to asphyxia/hypoxia → increased intestinal peristalsis, relaxation of anal sphincter 1. Meconium indicates asphyxia 2. 10 to 15% live-born, late-preterm, term infants → born through meconium-stained amniotic fluid (MSAF) a) 4 to 5% will develop meconium aspiration syndrome (MAS) 3. Presence of meconium in lungs produces: a) Mechanical obstruction of airways → air allowed in but not exhaled b) Chemical pneumonitis leading to possible development of secondary bacterial pneumonias c) Inactivation of natural surfactant 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

B. Clinical Manifestations of MAS 1. Fetal hypoxia in utero a few days, few minutes before birth 2. Presence of signs of distress at birth a) Pallor, cyanosis, apnea, slow heartbeat, low Apgar (<6) 3. After initial resuscitation → severity of clinical symptoms correlates with extent of aspiration a) Overexpansion of lungs, barrel shape chest b) Diminished air movement c) Displaced liver d) Yellowish/pale green staining of skin, nails, umbilical cord e) MAS chest x-ray → asymmetric, coarse, patchy densities/infiltrates 4. Biochemical alterations a) Metabolic acidosis b) Respiratory acidosis c) Hypoxia d) If meconium pH 7.0–7.2 → chemical pnuemonitis e) Bile acids inactivates natural surfactant f) Hypoxia → cardiopulmonary shunting → PPHN 5. Clinical therapy a) Prevention management b) Vigorous infant with meconium stained amniotic fluid → no special action c) Absent, depressed respirations, heart rate (HR) < 100, poor muscle tone → direct tracheal suctioning by specially trained personnel d) Further resuscitative efforts as indicated e) Transfer to nursery (1) Neutral thermal environment (2) Umbilical arterial line (3) Umbilical venous catheter f) Treatment (1) Oxygen (2) Low positive end-expiratory pressure (PEEP) (3) Providing exogenous surfactant (4) Dopamine, dobutamine (5) High-frequency ventilation, nitric oxide therapy, extracorporeal membrane oxygenation (ECMO) (6) Chest physiotherapy (7) Prophylactic antibiotics (8) Continuous infusion of sodium bicarbonate

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C. Nursing Management for the Newborn with Meconium Aspiration Syndrome 1. Nursing Assessment and Diagnosis a) Intrapartum → signs of fetal hypoxia, meconium staining b) Birth → signs of distress c) Ongoing assessment → signs of complications 2. Nursing diagnoses include: a) Gas Exchange, Impaired b) Nutrition, Imbalanced: Less Than Body Requirements c) Coping: Family, Compromised 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Early identification (2) Maintaining adequate oxygenation, ventilation (3) Regulating temperature (4) Glucose testing, hypoglycemia (5) Calculating necessary fluids (a) May restrict in first 48 to 72 hours (6) Providing caloric requirements possibly with TPN (7) Monitoring IV antibiotic therapy 4. Evaluation a) Newborn at risk of MAS promptly identified, early intervention initiated b) Newborn is free of respiratory distress and metabolic alterations c) Parents verbalize their concerns about their baby’s health problem and survival and understand the rationale behind management of their newborn

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

IV.

Care of the Newborn with Complications Due to Respiratory Therapy A. Oxygen, mechanical ventilation can have harmful effects 1. Ventilator-associated lung injury (VALI) 2. Barotrauma, volutrauma

B. Pulmonary Interstitial Emphysema 1. PIE → accumulation of air in lung tissues 2. Air collects outside lung 3. As air collects → blood vessels constricted → blood gas exchange impaired 4. May precede pneumothorax, pneumopericardium, air embolism, pneumomediastinum

C. Pneumothorax 1. Accumulation of air in thoracic cavity a) Between the parietal and visceral pleura b) Precedes collapse of lung 2. In newborn causes several challenges a) Collapse of the lung b) Compression of heart and lungs c) Compromise of venous return to right heart with mediastinal air d) Development of pleural space 3. Symptoms a) Sudden, unexplained deterioration in newborn’s condition b) Decreased breath sounds c) Apnea d) Bradycardia e) Tachypnea f) Nasal flaring g) Grunting h) Palpable liver or spleen i) Cyanosis j) Increased oxygen requirements k) Higher PCO2 l) Decreased pH m) Mottled, asymmetric chest expansion n) Decreased arterial blood pressure o) Mottled asymmetric chest expansion p) Decreased arterial blood pressure q) Shocklike appearance 12 Copyright © 2020 Pearson Education, Inc.

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r) Shift of apical cardiac impulses 4. Transillumination of chest for rapid evaluation 5. X-ray a) See Figure 31–9: Chest x-ray of a left-sided pneumothorax .., p. 824 6. Potentially life threatening a) Removal of accumulated air → thoracentesis

D. Bronchopulmonary Dysplasia/Chronic Lung Disease 1. BPD → chronic lung disease of prematurity (CLD) a) Oxygen therapy → causes injury 2. Definition of BPD → dependence on oxygen at or longer to 28 days of age following mechanical ventilation with subsequent x-ray changes and dependence on supplemental oxygen longer than 36 weeks’ corrected gestational age 3. Clinical therapy a) Therapeutic interventions (1) Oxygen levels adjusted to keep saturation at a percentage between the low and mid-90s (2) Diuretics and fluid restrictions (3) Electrolyte supplementation (4) Bronchodilators (5) Long-term steroids (6) Serial echocardiography to monitor cardiac response

E. Nursing Management for the Newborn with Complications Due to Respiratory Therapy 1. Hospital-Based Nursing Care a) Observe for changes in oxygenation b) Blood gases based on chronic blood gas protocol c) Maintain body temperature d) Bronchodilators e) Diuretics f) Steroids g) Electrolyte supplements h) Nutrition i) Monitor for infection (1) Keep visitors with early signs of infection away (2) Help family coping 2. Health promotion education a) Family becomes aware of implications of chronic illness and prolonged hospitalization (1) Involve them in plan of care 13 Copyright © 2020 Pearson Education, Inc.

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b) Demonstrate ability to provide all care for their child (1) Feeding (2) Adjusting oxygen, oxygen saturation monitoring, suctioning, airway management, CPT, bathing, giving medications (3) When to call home health nurse, care provider (4) How to assess infant’s respiratory condition

V.

Care of the Newborn with Cold Stress A. Excessive heat loss resulting in use of compensatory mechanisms to maintain core body temperature 1. Major source of heat production in nonshivering thermogenesis (NST) → brown fat metabolism 2. Ability of infant to respond to cold stress impaired a) Hypoxemia b) Intracranial hemorrhage or any central nervous system abnormality c) Hypoglycemia 3. Monitor temperature more closely a) Neutral thermal environment conscientiously maintained b) See Figure 31–11: Cold stress chain of events .., p. 826 4. Consequences of cold stress can be devastating and potentially fatal

B. Nursing Management for the Newborn with Cold Stress 1. Prevention of hypothermia is critical in very-low-birth-weight and ELBW newborns 2. Observe for signs of cold stress a) Increased movements and respirations, decreased skin temperature and peripheral perfusion, development of hypoglycemia, development of metabolic acidosis 3. Decrease in rectal temperature means long-standing cold stress 4. Determine if hypoglycemic 5. Hypothermia → nursing interventions include: a) Maintain neutral thermal environment (NTE) b) Warm the newborn slowly c) Increase air temperature in hourly increments of 1°C until infant’s temperature stable d) Monitor skin temperature every 15 to 30 minutes e) Remove plastic wrap, caps, heat shields while rewarming f) Warm IV fluids before infusion g) Initiate efforts to block heat loss by evaporation radiation, convection, conduction (1) Maintain newborn in NTE h) Assess for presence of anaerobic metabolism 14 Copyright © 2020 Pearson Education, Inc.

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i) Initiate interventions for resulting metabolic acidosis

VI.

Care of the Newborn with Hypoglycemia

A. Low blood sugar 1. Plasma glucose concentration < 45 to 47 mg/dl a) Values <20 to 25 mg/dL treated with parenteral glucose D10W → raise >45 mg/dl 2. Most at risk a) Symptomatic newborn b) Newborns of mothers with diabetes c) LGA newborn d) SGA or IUGR newborns e) Neonates with perinatal stress f) Preterm → not in utero for sufficient time to store glycogen and fat g) Infants of White’s classes A through C, type 1 diabetic mothers → increased stores of glycogen and fat h) Infants with recurrent episodes of hypoglycemia have long-term neurologic deficits i) SGA infant used up glycogen, fat stores j) Newborn stressed at birth → asphyxia, cold → uses up available glucose stores

B. Clinical therapy 1. Identification → symptoms may include: a) Lethargy, sleepiness, limpness b) Poor feeding, poor/inadequate sucking reflex, vomiting c) Hypothermia or temperature instability d) Pallor, cyanosis e) Apnea, irregular respirations, respiratory distress, cyanosis, tachypnea f) Hypotonia, possible loss of swallowing reflex g) Tremors, jerkiness, seizure activity, irritability, eye rolling h) High-pitched cry i) Exaggerated Moro reflex j) Temperature instability 2. Aggressive treatment recommended after single low blood glucose level a) Glucose oxidase reagent strip with reflectance meter below 40 mg/dl b) See Clinical Skill 31–1: Performing a Heelstick on a Newborn, pp. 829–830 c) Must confirm with laboratory determination (1) Venous blood glucose concentrations are approximately 15% to 19% lower than arterial blood glucose d) Adequate caloric intake → early feeding → likely to remain above hypoglycemic level e) IV infusions of a dextrose solution begun immediately after birth → prevent hypoglycemia (1) May cause hyperglycemia 15 Copyright © 2020 Pearson Education, Inc.

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C. Nursing Management for the Newborn with Hypoglycemia 1. Nursing Assessment and Diagnosis a) Identify and screen infants (1) Glucose strips, urine dipsticks, urine volume 2. Nursing diagnoses include: a) Nutrition, Imbalanced: Less Than Body Requirements b) Breathing Pattern, Ineffective c) Pain, Acute d) Coping: Family, Compromised e) Parenting, Risk for Impaired 3. Nursing Plan and Implementation a) Monitor all at-risk groups within 30 to 60 minutes after birth b) Method of feeding influences glucose and energy requirements (1) Monitoring during transition from IV to oral feedings c) Complementary health approaches (1) Assist infants to cope with, recover from, painful clinical procedures (2) Avoid unnecessary stimuli as possible (3) Containment with swaddling, facilitated tucking (4) Nonnutritive sucking → thought to produce analgesia through stimulation of orotactile and mechanoreceptors (5) Wide range of oral sucrose used for procedural pain relief → calming effect

VII.

Care of the Newborn with Jaundice

A. Most common abnormal physical finding → icterus neonatorum 1. 80% healthy newborns 2. Total bilirubin levels > 6–9 mg/dL 3. Jaundice → yellowish coloration of skin, sclera that develops from deposit of bilirubin in lipid/fat-containing tissues a) Infant must conjugate bilirubin → rate depends on rate of hemolysis, bilirubin load, maturity of liver, presence of albumin-binding sites 4. Pathologic jaundice a) Newborns who exhibit jaundice within first 24 hours of life b) Total serum bilirubin concentration increase > 0.2 mg/dl/hour c) Surpass 95th percentile on nomogram for age in hours d) Persistent visible jaundice after 1 week of age in term infants, 2 weeks in preterm

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B. Physiologic Jaundice 1. Normal process that occurs during transition from intra- to extrauterine life, appears after 24 hours of life 2. Differs between breast- and bottle-fed newborns

C. Pathophysiology of Hyperbilirubinemia 1. Serum albumin-binding sites usually able to conjugate enough bilirubin a) Conditions that decrease number or quality of binding sites (1) Asphyxia (2) Neonatal drugs (3) Acidosis (4) Hypothermia (5) Hypoglycemia (6) Maternal use of sulfa drugs and salicylates (7) Less albumin 2. Bilirubin not bound crosses blood-brain barrier a) Kernicterus or acute bilirubin encephalopathy b) Can cause permanent neurologic sequelae 3. Screen all newborns

D. Causes of Hyperbilirubinemia 1. Hemolytic disease of the newborn a) Alloimmune hemolytic disease → erythroblastosis fetalis (1) Rh-negative mother pregnant with Rh-positive fetus → maternal antibodies cross placenta b) Hydrops fetalis → maternal antibodies attach to Rh site on fetal red blood cells (RBCs) (1) Severe anemia, multiple organ system failure result (2) Severe generalized massive edema develops 2. ABO incompatibility → may result in jaundice, rarely severe 3. Predisposing maternal conditions 4. Prognosis depends on extent of hemolytic process, underlying cause a) May lead to kernicterus if not aggressively treated (1) Exchange transfusion required (a) Poor tone, lethargy, feeding/sucking issues 5. Clinical therapy a) Prevention b) Laboratory and diagnostic assessments (1) Maternal and neonatal blood types tested (2) Coombs test 17 Copyright © 2020 Pearson Education, Inc.

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(3) Serum bilirubin levels (4) Hemoglobin (5) Reticulocyte percentage (6) White cell count (7) Positive smear for cellular morphology c) Neonatal hyperbilirubinemia considered pathologic if: (1) Clinically evident jaundice appearing before 24 hours of life or if jaundice seems excessive for the newborn’s age in hours (2) Serum bilirubin concentration rising by more than 0.2 mg/dl per hour (3) Symptoms of primary illness (4) Conjugated bilirubin concentrations greater than 2 mg/dl or more than 20% of the total serum bilirubin concentration (5) Clinical jaundice persisting for more than 8 days in a term newborn and 14 days in premature newborn d) Transcutaneous bilirubin (TcB) measurements are noninvasive method of assessing bilirubin levels and may be used for predischarge risk assessment (1) See Figure 31–14: A newborn being screened with a transcutaneous bilirubinometer, p. 833 e) Coombs test determines whether jaundice is due to Rh or ABO compatibility f) Rh sensitization (1) Rh-positive newborn with positive Coombs test (2) Increased erythropoiesis with many immature circulating RBCs (3) Anemia (4) Elevated levels of bilirubin in cord blood (5) Reduction in albumin binding capacity g) ABO incompatibility (1) Increase in reticulocytes (2) Indirect Coombs strongly positive h) Prevention i) Any cause → management similar (1) Alleviate anemia, remove maternal antibodies and erythrocytes, reduce serum bilirubin levels, minimize consequences of hyperbilirubinemia (2) Phototherapy, exchange transfusion, drug therapy (3) If newborn has hemolysis, unconjugated bilirubin level of 14 mg/dl, weighs less than 2500 g, less than 24 hours old → exchange transfusion may be best (4) Over 24 hours old → phototherapy j) Phototherapy (1) Exposure of newborn to high-intensity light → photoisomerization (a) Alone or with exchange transfusion (b) Changes bilirubin from non-water soluble to water soluble (c) Excreted in urine and bile (2) Used for prevention of hyperbilirubinemia (3) Halogen light source, phototherapy lights, fiber-optic blanket LEDs, or combination (a) Blanket → light on at all times, infant accessible 18 Copyright © 2020 Pearson Education, Inc.

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(b) Used with standard light source → intensive phototherapy (4) Nurse tracks hours each lamp used (5) See Clinical Skill 31–2: Newborn Receiving Phototherapy, pp. 834–835 k) Exchange transfusion (1) Withdrawal and replacement of newborn’s blood with donor blood (2) Monitor total serum bilirubin (TSB) (3) Type and cross-match (4) Use modified whole blood → red cells and plasma

E. Nursing Management for the Newborn with Jaundice 1. Nursing Assessment and Diagnosis a) Identify prenatal, perinatal factors that predispose b) Often due to multitude of causes including genetic basis c) Note behavior, evidence of bleeding (1) Suspect hemolytic disease if (a) Placenta is enlarged (b) Newborn is edematous, with pleural and pericardial effusion plus ascites. (c) Pallor or jaundice is noted during the first 24 to 36 hours. (d) Hemolytic anemia is diagnosed (e) Spleen and liver are enlarged. d) Visual inspection (1) Blanch skin over bony prominence → yellow before normal color returns (a) Conjunctival sacs in darker skinned baby (b) Progresses cephalocaudal 2. Nursing diagnoses include: a) Fluid Volume: Risk for Deficient b) Injury, Risk for c) Neurovascular Dysfunction: Peripheral, Risk for d) Parenting, Risk for Impaired 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Phototherapy success measured every 12 hours, or daily (a) Turn off lights when drawing blood (2) Eye patches over newborn’s closed eyes (a) Assess eyes for conjunctivitis at least one shift (b) Removed for feeding (3) Photometer to measure, maintain desired irradiance levels (4) Parents need explanations repeated, clarified (5) Education if rooming in (a) Keep baby in the room 24 hours a day (b) Take emergency action if necessary (c) Complete instruction checklists 19 Copyright © 2020 Pearson Education, Inc.

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(d) Sign a consent b) Community-based nursing care (1) Early discharge → increase hospital readmission (2) Home therapy only if nomogram indicates optional phototherapy (3) Generates feelings of guilt, fear (4) Reassurance and support (5) Cultural beliefs (a) Interpret illness within cultural framework (6) Education to record temperature, weight, fluid intake and output, stools, feedings, use of equipment (7) Lights versus blanket (8) Ongoing monitoring of bilirubin levels c) See Nursing Care Plan: For the Newborn with Hyperbilirubinemia, pp. 837–839 4. Evaluation a) Newborns at risk for development of hyperbilirubinemia identified, action taken to minimize potential impact of hyperbilirubinemia b) Newborn will not have any corneal irritation or drainage, skin breakdown, or major fluctuations in temperature c) Parents understand rationale for, goal of, and expected outcome of therapy d) Parents verbalize their concerns about their baby’s condition and identify how they can facilitate their baby’s improvement

VIII.

Care of the Newborn with Anemia

A. Normal full-term hemoglobin → 13 to 16 g/dl B. Physiologic anemia of infancy exists as a result of the normal gradual drop in hemoglobin C. Nadir → lowest point 1. Most common causes of anemia → blood loss, hemolysis, impaired RBC production a) Blood loss in utero, fetomaternal, fetofetal, umbilical cord, birth trauma b) Excessive hemolysis c) Physiologic anemia of infancy → normal gradual drop in hemoglobin d) In preterm newborns seen earlier, more severe

D. Clinical therapy 1. Initial lab workup a) Should determine (1) Hemoglobin and hematocrit (2) Reticulocyte count (3) Examination of maternal blood smear (4) Bilirubin levels 20 Copyright © 2020 Pearson Education, Inc.

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2. Mild or chronic anemia → iron supplements, iron-fortified formula a) Severe → transfusions b) Anemia of prematurity → treat causative factor, supplemental iron

E. Nursing Management for the Newborn with Anemia 1. Assessment a) Symptoms of anemia (1) Signs of shock (a) Capillary filling time greater than 3 seconds (b) Decreased pulses (c) Tachycardia (d) Low blood pressure. b) Signs of longer term compromise (1) Poor weight gain (2) Pallor (3) New onset of jaundice or recurrent jaundice (4) Tachycardia (5) Tachypnea Apneic episodes. c) Constant cardiac and respiratory monitoring d) Report symptoms e) Limit phlebotomy losses f) Document blood losses, replacement

IX.

Care of the Newborn with Infection A. Sepsis neonatorum → caused by organisms that do not typically cause significant disease in older children 1. Early-onset neonatal sepsis (EONS) 2. Late-onset sepsis (LOS) 3. Nosocomial infections → methicillin-resistant Staphylococcus aureus (MRSA), Candida a) Full-term infants susceptible → immunologic systems immature b) See Figure 31–17: Term newborn with suspected sepsis, p. 841 4. Present as bacteremia/sepsis, urinary tract infection, meningitis, pneumonia 5. Maternal antepartum, intrapartum infections, PROM 6. More common in VLBW, and newborns of African heritage 7. Gram-negative and gram-positive β-hemolytic streptococcus most common a) Pseudomonas common with ventilator support and oxygen therapy equipment 8. Protections starts prenatally a) Screening 21 Copyright © 2020 Pearson Education, Inc.

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b) Sterile technique c) Antibiotic prophylaxis

B. Health care prevention education: preventing newborn infections 1. During the prenatal period 2. During the intrapartum period 3. During the postpartum period

C. Clinical therapy 1. Cultures as soon after birth as possible, before antibiotic therapy a) Anaerobic, aerobic blood cultures b) Spinal fluid culture c) Urine culture d) Skin or mucus membrane cultures e) Tracheal aspirate cultures f) Placental cultures g) Complete blood count, C-reactive protein (CRP), procalcitonin (PCT) chest x-ray, serology, Gram stains of fluids, white blood cell (WBC) count (1) WBC count may be normal or low (2) Serum IgM → elevated h) Neonatal infection correlates with high mortality→institute therapy while sepsis workup is begun 2. Institute therapy before results return a) Combination of two broad-spectrum antibiotics until culture results obtained b) Appropriate specific antibiotic therapy c) Cephalosporins 3. Supportive physiologic care 4. See Table 31–6: Neonatal Sepsis Antibiotic/Antiviral Therapy, p. 845

D. Nursing Management for the Newborn with Infection 1. Nursing Assessment and Diagnosis a) Subtle behavioral changes b) Temperature instability, commonly hypothermia c) Feeding intolerance d) Hyperbilirubinemia, petechial hemorrhages, hepatosplenomegaly e) Tachycardia initially, followed by spells of apnea, bradycardia 2. Nursing diagnoses include: a) Infection, Risk for b) Fluid Volume: Deficient c) Coping: Family, Compromised 22 Copyright © 2020 Pearson Education, Inc.

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3. Nursing Plan and Implementation a) Controlling environment, preventing infection b) Strict hand-washing techniques c) Aseptic collection of specimens d) Care of equipment e) Provision of antibiotic therapy (1) Proper dose, based on weight, desired peak and trough levels (2) Appropriate route, method, timing (3) Admixture incompatibilities (4) Side effects and signs of toxicity (5) Term infants → neonatal home infusions f) Provision of supportive care (1) Observes for resolution of symptoms or development of other symptoms (2) Maintain neutral thermal environment (3) Provide respiratory support (4) Provide cardiovascular support (5) Provide adequate calories (6) Provide fluids, electrolytes to maintain homeostasis (7) Observe for hypo-, hyperglycemia, acidosis, hyponatremia, hypocalcemia g) Instruction for parents for daily care 4. Evaluation a) Risks for development of sepsis are identified early and immediate action taken b) Appropriate use of aseptic technique protects newborn from further exposure to illness c) Baby’s symptoms relieved, infection is treated d) Parents verbalize concerns about baby’s illness, understand rationale behind the management of their newborn

X.

Care of the Family with Birth of an At-Risk Newborn A. Parental Responses 1. Acute grief reaction to loss of idealized baby a) Attachment fragile b) Feelings of guilt and failure c) Waiting between suspicion, confirmation of abnormality or dysfunction anxious 2. During waiting period → support, acknowledgement that it is an anxious time a) Discussion of problem, anticipatory management (1) Maintain trust (2) Appreciate reality of situation (3) Begin grieving process (4) Mobilize internal, external support b) Anger common (1) Direct at physician, nurse, hospital, routine

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(2) Posttraumatic stress disorder (PTSD) in mothers spending time in neonatal intensive care unit (NICU) 3. Grief and mourning mark parental reactions to infant with abnormalities a) Grief work b) Parental detachment precedes parental attachment c) A healthy parent–child relationship can occur

B. Developmental Consequences 1. Baby at risk for emotional, intellectual, cognitive development delays 2. Parents must understand reality of disability, hurdles ahead a) Interprofessional team b) Early and continued involvement of parents

C. Nursing Management for the Family of an At-Risk Newborn 1. Nursing Assessment and Diagnosis a) Level of understanding b) Behavioral responses c) Difficulties with communication d) Paternal and maternal education level e) Documentation of information gathered (1) Recording of visits, caretaking, affect toward newborn (2) Telephone calls (3) Serial observations f) If distancing behaviors evolve → interventions g) See Table 31–7: Adaptive and Nonadaptive Parental Responses to a Newborn’s Health Crisis, p. 848 2. Diagnoses may include: a) Grieving, Complicated b) Fear c) Parenting, Impaired 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Parents acutely perceptive about other’s responses, reactions to child (2) Nurse must work out personal reactions (a) Therapeutic questions (b) Grief is individual and the child and situation are what is important (3) Support of parents in initial viewing or the newborn (a) Prepare for visit → realistic, positive attitude (b) Observe baby → present strengths and deficiencies (c) NICU booklet prior to entering unit (d) May be overwhelmed with sounds, language, atmosphere 24 Copyright © 2020 Pearson Education, Inc.

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(e) Primary nurse and physician with parents (f) Slow, complete simple explanations (g) Concerns may be voiced, or may not be (i) Anticipate questions (ii) Concerns about physical appearance common (h) Set tone → safe, trusting environment (i) Parents as essential caregivers (i) Trusting relationship → one-to-one basis (j) Nurses invest baby with value in eyes of parents (4) Facilitation of attachment if neonatal transport occurs (a) Essential that mother see, touch infant before transport (b) Explanations and support (i) Photographs (5) Promotion of touching and parental caretaking (a) See Figure 31–20: Mother of this 26-week …, p. 850 (b) Several visits to become comfortable, confident (c) Eye contact, touching may take several visits (d) Facilitate touching → getting to know infant, establishing bond (e) Encourage parents to meet newborn’s need for stimulation (i) See Figure 31–21: This mother of a 31-week …, p. 850 (f) Encourage visiting, involvement in care (g) Refer to infant by name (h) Promote parental success → demonstrate caretaking → positively reinforce behavior (i) Parents may be ambivalent toward nurse → criticism, manipulation (i) Recognize feeling of mothers → enhance bonding (ii) Positive remarks about breast milk, weight gain, etc. (iii) Encourage parents to talk about hopes, fears → involve in parent groups (iv) Detachment easier after attachment → comforted that they did all they could (6) Facilitation of family adjustment (a) Maintaining interpersonal relationships difficult → primary nurse to coordinate continuity (b) Transfer to step-down nursery, regular unit difficult → new healthcare professionals (c) Liaison between parents and wide variety of professionals (d) Encourage to use support system (i) Friends, neighbors, as well as family (e) Impact of crisis on family varies (f) Encourage open communication between spouses → no secrets (i) Important if mother hospitalized apart from infant (ii) Give parents information together (g) Sibling responses (i) Not to be overlooked (ii) Hostility, shame if infant has anomaly → guilt over reaction 25 Copyright © 2020 Pearson Education, Inc.

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(iii) Family tension (h) Respect and facilitate desires, needs of individuals → elicit feelings (7) Cultural barriers → increase feelings of isolation uncertainty (a) Language barriers (b) Cultural differences (8) Families with children in NICU become friends → support one another (a) Early one-to-one contact b) Community-based nursing care (1) Predischarge planning begins once condition stable (a) Collaborative care team approach (b) Adequate teaching helps transform feelings of inadequacy → self-assurance, attachment (c) Sudden infant death syndrome (SIDS) risk-reduction practices (d) Home care instruction in optimal learning environment over time (e) Interact with staff while transitioning to sole caretakers (2) Basic elements of home care instruction (a) Teach parents routine well-baby care (b) Help parents learn to do special procedures as needed by newborn (i) Written tools as well (c) Make sure all screening tests, immunizations done (d) Refer parents to community health and support organizations (e) Help parents recognize growth and development needs of infant (f) Arrange follow-up care before discharge (g) Evaluate need for durable medical equipment for infant care in the home (h) Arrange for neonatal hospice for parents of medically fragile infant (3) Teaching not always perceived as adequate → stress levels of family 4. Evaluation a) Parents are able to verbalize feelings of grief and loss b) Parents verbalize concerns about their baby’s health problems, care needs, potential outcome c) Parents able to participate in infant’s care and show attachment behaviors

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XI.

Considerations for the Nurse Who Works with At-Risk Newborns

A. NICU staff nurses never see long-term results B. Emotional environment → lots of living and lots of dying C. NICU nurses need supported D. Ability to cope with stress key to creating emotionally healthy environment 1. Caregivers may be unaware of need to grieve 2. Group meetings 3. Individual support 4. Primary care nursing

XII.

Focus Your Study

XIII.

Activities 1. Individual Have students prepare drug cards for the following medications used for the newborn at risk: • Epinephrine • Oxygen • Dextrose • Naloxone hydrochloride • Surfactant • Dopamine • Dobutamine • Nitric oxide • Albuterol 2. Small Group Divide the class into small groups of three to five students. Have each group interview a separate NICU nurse or other NICU staff member. Instruct the groups to develop a set of questions they want answers to prior to the appointment. Advise the groups to make appointments rather than showing up unexpectedly at the NICU. They can ask questions that include the topics covered in this chapter or other topics with the approval of the instructor.

Their questions should include those about the emotional support of families, siblings, and staff. Have the groups write up the results of their interviews for discussion by and distribution to the class.

3. Large Group Review the interview results with the class. Facilitate a discussion about the emotional support needed for family and siblings of at-risk newborns.

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Chapter 32 Postpartum Adaptation and Nursing Assessment

Postpartum Physical Adaptations.....................................................................

2

Postpartum Psychologic Adaptations...............................................................

6

Development of Family Attachment.................................................................

7

Postpartum Nursing Assessment......................................................................

8

Discharge Assessment and Follow-Up..............................................................

12

Focus Your Study...............................................................................................

12

Activities............................................................................................................

12

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Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

I.

Postpartum Physical Adaptations

A. Reproductive System 1. Involution of the uterus → rapid reduction in size of uterus a) Return to condition similar to non-pregnant state → slightly larger b) Decidua irregular, jagged, varied in thickness → cast off as lochia c) Process complete by 3 weeks except placental site takes up to 6 weeks d) Heals by exfoliation → no scar e) Estrogen, progesterone levels decrease → uterine cells atrophy f) Involution enhanced by: (1) Uncomplicated labor and birth (2) Complete expulsion of amniotic membranes and placenta (3) Breastfeeding (4) Manual removal of placenta during cesarean (5) Early ambulation g) See Table 32–1: Factors That Slow Uterine Involution, p. 857 (1) Prolonged labor (2) Anesthesia (3) Difficult birth (4) Grandmultiparity (5) Full bladder (6) Incomplete expulsion of placenta or membranes (7) Infection (8) Overdistention of uterus h) Changes in fundal position (1) Uterus contracts firmly immediately following expulsion of placenta (2) Fundus midline of abdomen, between symphysis pubis and umbilicus (a) See Figure 32–1: Involution of the uterus …., p. 857 (3) Above umbilicus, boggy → associated with bleeding (4) Full bladder → fundus higher, not midline (deviated to right) (a) See Figure 32–2: The uterus becomes displaced …, p. 858 (b) Void immediately, in-and-out catheterization (5) Top of fundus descends approximately 1 fingerbreadth (1 cm) per day (6) Breastfeeding → may hasten involution (7) Infection, oversized uterus during pregnancy, etc. → slow involution (subinvolution) 2. Lochia a) Discharge of debris remaining in uterus after birth (1) Lochia rubra → dark red → first 2 to 3 days postpartum (2) Lochia serosa → pinkish color → 1 to 2 weeks (3) Lochia alba → creamy or yellowish b) Trend of flow should be toward a lighter color c) Musty, stale odor, not offensive 2 Copyright © 2020 Pearson Education, Inc.

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(1) Foul smell → suggests infection (2) Total volume approximately 225 mL (3) Amount may increase by exertion, breastfeeding (4) Less lochia with cesarean birth d) Evaluation to determine hemorrhage, assess involution e) Continuous seepage of blood immediately after birth → consistent with lacerations 3. Cervical changes a) Following birth → spongy, flabby, formless, may appear bruised b) Admits two fingers → end of first week to one fingertip c) Shape of os permanently changed by first childbearing d) Cervical os permanently changed → dimple to slit appearance 4. Vaginal changes a) Appears edematous, gaping, may be bruised b) Size decreases, rugae begin to return within 3 weeks c) Nonlactating → appears normal d) Lactating → hypoestrogenic due to ovarian suppression → dyspareunia e) Kegel exercises improve tone, contractibility of vaginal opening 5. Perineal changes a) Early postpartum → edematous with some bruising b) Episiotomy, laceration edges → approximated c) Ecchymosis may delay healing d) Complete healing 4 to 6 months 6. Recurrence of ovulation and menstruation a) Varies (1) Nonbreastfeeding → 7 to 10 weeks (a) First ovulation 70 to 75 days (2) Breastfeeding → 3 or more months (a) Rise in serum progesterone (b) Return of menstruation and ovulation directly related to length of time breastfeeding (c) LAM

B. Abdomen 1. Uterine ligaments stretched, abdominal wall loose and flabby 2. Diastasis recti abdominis → separation of rectus abdominis muscles a) Tone may be regained → responds well to exercise within 2 to 3 months b) See Figure 32–3: Diastasis recti abdominis, a separation of the musculature, commonly occurs after pregnancy, p. 860 3. Striae (stretch marks) → stretching, rupture of elastic fibers in skin a) Differ based on mother’s skin color 3 Copyright © 2020 Pearson Education, Inc.

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C. Lactation 1. Breasts develop in preparation for lactation from estrogen and progesterone changes 2. After birth → hormonal changes lead to establishment of milk production

D. Gastrointestinal System 1. Hunger following birth common, thirsty a) Light meal 2. Bowels tend to be sluggish → progesterone, decreased abdominal muscle tone, bowel evacuation associated with labor and birth 3. Episiotomy, lacerations, hemorrhoids → woman may delay elimination a) Actually may increase constipation, pain by waiting b) Cesarean birth → may start with clear liquids until bowel sounds 4. Flatulence → early ambulation

E. Urinary Tract 1. Increased bladder capacity, swelling and bruising of tissues around urethra, decreased sensitivity to fluid pressure, decreased sensation of bladder filling 2. Urinary output increases during early postpartum period → puerperal diuresis a) 2000 to 3000 mL 3. Stasis → increased risk for urinary tract infection 4. Hematuria occasionally occurs → in week 2 or 3 may indicate infection

F. Vital Signs 1. Afebrile except for first 24 hours → 38°C (100.4°F) due to exertion, milk coming in 2. Transient rise in systolic and diastolic blood pressure a) Orthostatic hypotension → first 48 hours b) Monitor late preeclampsia → blood pressure if woman complains of headache 3. Bradycardia common first 6 to 10 days a) Pulse >100 beats/min may indicate hypovolemia, infection, fear, pain

G. Blood Values 1. Return to pre-pregnant state by end of postpartum period a) Coagulation factors may continue b) Nonpathologic leukocytosis → up to 20,000 to 25,000/mm3 → normal by end of first week 2. Hemoglobin, hematocrit difficult to interpret in first 2 days a) Blood loss 4 Copyright © 2020 Pearson Education, Inc.

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(1) Average blood loss is 200 to 500 mL with vaginal birth, > 1000 mL cesarean birth (2) 2 to 3 percentage point drop in hematocrit equals a blood loss of 500 mL b) Lochia c) Extracellular fluid decreases d) Hemodilution after 3 to 4 days e) Platelets typically fall with placental separation → increase gradually

H. Cardiovascular Changes 1. Increased cardiac output during birth → stabilizes within 1 hour of birth 2. Cardiac output declines by 30% in first 2 weeks → normal by 6 to 12 weeks

I. Neurologic Changes and Conditions 1. Headaches most common → fluid shifts, spinal anesthesia, pregnancy-induced hypertension (PIH), stress, leakage of spinal fluid 2. Migraines tend to resume postpartum 3. Women with epilepsy nine times more likely to have seizure in labor, first 24 hours a) Retitration of antiepileptic drugs (AED) b) More likely to be diagnosed with depression 4. Multiple sclerosis (MS), Guillain-Barré syndrome → more likely to have symptoms

J. Weight Loss 1. Initial loss of 10 to 12 lb → birth of infant, placenta, amniotic fluid 2. Puerperal diuresis → additional 5 lb 3. By 6 to 8 weeks → back to approximate pre-pregnant weight if had 25 to 30 lb gain

K. Postpartum Chill 1. Intense tremors after birth → theories offered 2. If no fever → no clinical concern 3. Warmed blankets, warm drink

L. Postpartum Diaphoresis 1. Elimination of fluid, waste products via skin

M. Afterpains 1. More common in multipara → intermittent uterine contractions a) Lost tone results in alternate contraction and relaxation b) Can cause severe pain 2 to 3 days after birth c) Oxytocic agents, breastfeeding → stimulates uterine contractions 5 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

d) Ibuprofen, warm water bottle (1) Breastfeeding → mild analgesic 1 hour before feedings

II.

Postpartum Psychologic Adaptation

A. Readjustment and adaptation 1. Changes in body image, reality that she is no longer pregnant

B. Taking-In and Taking-Hold Periods 1. Taking in → passive, somewhat dependent a) Talk about perceptions of labor, birth b) Food and sleep 2. 2 to 3 days → taking hold → ready to resume control of body, mothering, life in general a) Worries about breastfeeding techniques b) May feel demoralized by nurse, older family member holds baby proficiently

C. Becoming a mother 1. Maternal role attainment (MRA) a) Process by which woman learns mothering behavior, becomes comfortable with identity as a mother b) 3 to 10 months after birth 2. Becoming a mother (BAM) → dynamic transformation, evolution of persona 3. Nurses aware of long-term adjustments and stresses childbearing family faces 4. Nursing interventions to foster process of becoming a mother a) Instructing about newborn/infant caregiving b) Building awareness of and responsiveness to newborn/ infant interactive capabilities c) Promoting maternal–newborn attachment d) Preparing the woman for the maternal social role e) Encouraging interactive therapeutic nurse–patient relationships

D. Postpartum Blues 1. Transient period of depression during first few days of puerperium a) Mood swings, anger, weepiness, anorexia, difficulty sleeping, feeling of letdown b) Fatigue, discomfort, overstimulation may play a part 2. Hormonal, environmental, fatigue, overstimulation all factors a) Resolves naturally in 10 to 14 days b) Persistent or if symptoms worsen → evaluate for postpartum depression

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E. Importance of Social Support 1. Network a) Family interaction can be source of stress b) Increasing contact with parents of small children c) New mother support group 2. Postpartum doula a) Tailored to help new mother feel rested, well nourished, place house in order

III.

Development of Family Attachment

A. Maternal–Newborn Attachment Behavior 1. Personal characteristics important a) Level of trust b) Level of self-esteem c) Capacity for enjoying herself d) Adequacy of knowledge about childbearing and childrearing e) Prevailing mood or usual feeling tone f) Reactions to present pregnancy

B. Initial Attachment Behavior 1. Regular pattern a) Progression of touching activities b) Increases en face position time (1) See Figure 32–4: The mother has direct face-to-face and eye-to-eye contact in the en face position, p. 864 c) Relies heavily on sight, touch, hearing (1) Responds verbally to sounds d) May be experiencing shock, disbelief, denial 2. Acquaintance phase a) Infant gives behavioral cues → responds to mothering b) Newborn also becoming acquainted 3. Mutual regulation phase a) Balance sought between needs of mother, needs of infant b) Primarily enjoying each other → reciprocity 4. Reciprocity a) Interactional cycle, involves mutual cuing behaviors 5. Father–newborn interactions a) Engrossment → sense of absorption, preoccupation, interest in infant demonstrated by fathers

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(1) See Figure 32–5: The father experiences strong feelings of attraction during engrossment, p. 865 6. Siblings and others a) Infants capable of maintaining number of strong attachments without loss of quality

C. Cultural Influences in the Postpartum Period 1. Western culture emphasizes events of birth, many other cultures place emphasis on postpartum period 2. Expectations influenced by beliefs, values of family and cultural group a) Influences needs regarding food, fluids, rest, hygiene, medications, relief measures, support, counsel 3. Nurses belong to own ethnoculture a) Important to understand approaching care from own perspective 4. Describing practices involves some generalization a) European heritage → full meal, large amount of iced fluids following birth b) Women of Islamic faith may have modesty requirements (1) Coverings (2) No man, other than her husband or a family member, may be alone with her c) Hispanic, African, Asian cultures → may avoid cold after birth d) Beliefs related to hot and cold

IV.

Postpartum Nursing Assessment A. Risk Factors 1. Ongoing assessment and patient education a) See Table 32–2: Postpartum High-Risk Factors, p. 867 (1) Preeclampsia (2) Diabetes (3) Cardiac disease (4) Cesarean birth (5) Overdistention of uterus (6) Abruptio placentae, placenta previa (7) Precipitous labor (8) Prolonged labor (9) Difficult birth (10) Extended period of time in stirrups at birth (11) Retained placenta

B. Physical Assessment 1. Principles to remember in preparing/completing postpartum assessment a) Select time that will provide most accurate data 8 Copyright © 2020 Pearson Education, Inc.

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b) Consider patient’s need for possible premedication before painful assessments c) Provide an explanation of the purposes of regular assessment d) Ensure woman is relaxed before starting e) Document and report results according to hospital/unit policy f) Take appropriate precautions to prevent exposure to body fluids 2. Excellent opportunity for patient teaching a) See Key Facts to Remember: Common Postpartum Concerns, p. 868 (1) Gush of blood that sometimes occurs when she first arises (2) Passing clots (3) Night sweats (4) Afterpains (5) “Large stomach” after birth and failure to lose all weight gained during pregnancy 3. Use opportunities for teaching regarding self-care 4. Vital signs a) Begin assessment with vital signs b) Temperature elevation → only last 24 hours (1) Identify risk factors c) Alterations may indicate complications → assessed at regular intervals d) Inform woman of results 5. Auscultation of lungs a) Should be clear b) Preterm labor or preeclampsia → risk for pulmonary edema 6. Breasts a) Don gloves → assess fit, support of bra (1) Support, maintains shape b) Breastfeeding → straps cloth, easily adjustable (1) Wide back, three rows of hooks (2) Nursing bra (3) Have woman remove bra so breasts can be examined (4) Palpate lightly for softness, slight firmness, firmness (5) Warmth, tenderness (6) Assess for fissures, cracks, soreness, inversion (7) Teach woman how to recognize problems c) Nonbreastfeeding mother (1) Evidence of discomfort → relief measures 7. Abdomen and fundus a) Void prior to examination b) Determine relationship of fundus to umbilicus, firmness c) Midline or displaced

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(1) See Clinical Skill 32–1: Assessing the Status of the Uterine Fundus After Vaginal or Cesarean Birth, pp. 869–870 d) Teaching woman as assessment completed e) Cesarean birth → abdominal incision exquisitely tender (1) Palpate fundus with extreme care (2) Inspect incision for signs of healing f) Feels firm, not overly tender (1) If boggy → massage gently with finger tips (2) Observe perineal pad for results of massage g) Postpartum uterine atony nursing interventions (1) Reevaluate for full bladder (2) Question woman on bleeding history since birth, last examination (3) Put newborn to breast for feeding to stimulate oxytocin production (4) Assess maternal blood pressure and pulse to identify hypotension (5) Reassess fundus → if still boggy, alert physician/CNM physician immediately → further intervention needed 8. Lochia a) Assessed for character, amount odor, presence of clot b) Don gloves c) Rubra with clots normal days 1 to 3 → after 2 to 3 days serosa d) Should never exceed a moderate amount → partially saturate 4 to 8 pads daily e) See Figure 32–7: Suggested guidelines for assessing lochia volume, p. 870 (1) Weigh pads → 1 g = 1 mL f) Clots, heavy bleeding → atony, retained placental fragments, unknown laceration (1) Assess vital signs (2) Possible medication (3) See Key Facts to Remember: Changes in Lochia That Cause Concern, p. 871 g) If odor is present → infection h) Hygienic measures 9. Perineum a) Inspected with woman in Sims position b) Assess wound if episiotomy, laceration repair c) Evaluate state of healing d) Assess hemorrhoids for size, number, pain or tenderness e) Talk to woman about comfort measures, information about episiotomy, dissolvable sutures f) See Figure 32–8: Intact perineum with hemorrhoids, p. 872 g) See Clinical Skill 32–3: Postpartum Perineal Assessment, pp. 872–873 10. Lower extremities a) Risk for thrombophlebitis, thrombus formation, inflammation of vein b) Hypercoagulability, severe anemia, obesity, traumatic delivery c) Homans sign (1) See Figure 32–9: Homans sign ..., p. 874 10 Copyright © 2020 Pearson Education, Inc.

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d) Edema → compare both legs e) Early ambulation, passive range-of-motion exercises f) Patient teaching g) Record results 11. Elimination a) Signs of bladder distention → postpartum diuresis b) Assess frequently c) Techniques to facilitate voiding d) Catheterization e) Assess fluid intake, signs of UTI f) Intestinal elimination status (1) Stool softeners (2) Encourage ambulation, force fluids, fresh fruits, roughage g) Provide information 12. Rest and sleep status a) Physical fatigue concern b) Significant factor in apparent disinterest in newborn → tired c) Evaluate amount of sleep woman getting d) Daily rest period should be encouraged 13. Nutrition a) Nonbreastfeeding → dietary requirements to pre-pregnancy levels → reduce intake by 300 kcal b) Lactating mothers → increased requirements → increase 200 kcal over pregnancy requirements → 500 kcal over non-pregnant requirements c) Iron supplement (1) Inform dietitian → special needs

C. Psychologic Assessment 1. Physical and developmental tasks of postpartum weeks a) Restoring physical condition b) Developing competence in caring for, meeting needs of infant c) Establishing relationship with new child d) Adapting to altered lifestyles and family structure resulting from the addition of a new member e) Little or no experience → may be feeling overwhelmed f) Characteristics (1) Excessive, continued fatigue; marked depression; excessive preoccupation with physical status or discomfort; evidence of low self-esteem; lack of support systems; marital or relationship problems; inability to care for or nurture the newborn; current family crises g) Referrals

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D. Assessment of Early Attachment 1. Assess progress toward attachment a) Is mother attracted to newborn? b) Is mother inclined to nurture infant? c) Does mother act consistently? d) Is mothering consistently carried out? e) Is mother sensitive to newborn’s needs as they arise? f) Does mother seem pleased with appearance and sex? g) Are there any cultural factors that might modify mother’s response?

2. Is there a problem in attachment?

3. See Assessment Guide: Postpartum—First 24 Hours After Birth, pp. 876–878

V.

Discharge Assessment and Follow-Up A. Include: 1. Physical examination 2. Discharge teaching

B. Home visit, follow-up phone call C. 3 to 4 days after birth 1. Assessment and teaching

VI.

Focus Your Study

VII.

Activities 1. Individual Have students prepare a teaching plan for the woman who is 2 weeks postpartum, detailing normal changes in the physical assessment. Students should cite their references in APA format.

2. Small Group Divide the class into small groups of three to five students. Have each group prepare a list of questions for a follow-up phone call from the postpartum unit. The groups should include appropriate questions regarding physical assessment, attachment, feelings about the baby, and family adjustment. Have the groups include an assessment for postpartum depression.

3. Large Group Have the entire class watch the following video (4 minutes 54 seconds) on postpartum depression and discuss the appropriate assessment questions: http://www.youtube.com/watch?v=MJ6ALUrwSRM

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Chapter 33 The Postpartum Family: Needs and Care Nursing Care During the Early Postpartum Period.............................................

2

Community-Based Nursing Care.........................................................................

3

Health Promotion Education …………………………………………………………………………

3

Promotion of Maternal Comfort and Well-Being...............................................

5

Promotion of Maternal Nutrition, Rest, and Activity.........................................

9

Promotion of Family Wellness and Shared Parenting........................................

10

Nursing Care Following Cesarean Birth..............................................................

12

Nursing Care of the Obese Postpartum Mother................................................

14

Nursing Care of the Adolescent Postpartum Mother .......................................

15

Nursing Care of LGBTQ Postpartum Mothers………………………………………………..

16

Nursing Care of the Postpartum Mother with Special Needs...........................

16

Nursing Care of the Postpartum Mother with a History of Sexual Abuse…………………………............................................................................

16

Nursing Care of the Woman Who Relinquishes Her Newborn..…………………….

16

Discharge Information........................................................................................

17

Evaluation of the Postpartum Family.................................................................

18

Focus Your Study................................................................................................

19

Activities.............................................................................................................

19

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I.

Nursing Care During the Early Postpartum Period

A. Nursing Diagnoses 1. Maternal a) Urinary Elimination, Impaired b) Skin Integrity, Impaired c) Pain, Acute d) Infection, Risk for e) Constipation, Risk for 2. Wellness diagnoses include a) Knowledge, Readiness for Enhanced b) Coping: Readiness for Enhanced c) Breastfeeding, Readiness for Enhanced

B. Nursing Plan and Implementation 1. Individualized to woman, newborn, family 2. Patient teaching a) Self-care b) Effective newborn care 3. Desired patient outcomes include a) Mother and baby remain healthy, safe, and free of injury or complications b) Mother verbalizes comfort c) Mother tells birth story and verbalizes feelings and concerns regarding the event d) Mother reviews educational resources for self- and infant care e) Mother performs appropriate self- and infant care f) Parent(s) and newborn demonstrate positive bonding behaviors g) Parents practice principles of infant safety h) Mother verbalizes understanding of and demonstrates successful breastfeeding and breast care; or mother describes accurate preparation of infant formula, demonstrates safe bottle-feeding techniques, and verbalizes understanding of lactation suppression care i) Mother verbalizes sources of support to assist in newborn care and family responsibilities j) Mother states plan for follow-up health care for self and infant k) Mother identifies signs and symptoms of maternal or newborn complications and reasons to seek care before routine follow-up visits 4. Additional outcome for cesarean birth mother include: a) Mother states in own words the reason for the cesarean birth and verbalizes feelings related to the event b) Mother maintains desired comfort level (pain level less than 4 on 1 to 10 scale) c) Mother maintains mobility (up in chair within 12 hours; ambulates within 24) 2 Copyright © 2020 Pearson Education, Inc.

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5. Care designed to achieve outcome for woman and family 6. See Key Facts to Remember: Postpartum Assessment, p. 883

II.

Community-Based Nursing Care

A. Services 1. Education opportunities a) Nutrition counseling b) Breastfeeding assistance c) Maternal exercise d) Newborn/infant care e) Newborn/infant development f) Parenting courses 2. Healthcare programs a) Well-baby clinics b) Immunization clinics c) Lactation centers d) Family planning agencies e) New mother support groups 3. Different locations

B. Home health care 1. See Evidence-Based Practice: Postnatal Support from the Midwife, p. 883

III.

Health Promotion Education

A. Meeting educational needs primary responsibility of postpartum nurse 1. Assess learning needs through observation, sensitivity, questions

B. Timing and Methods of Teaching 1. Provide education efficiently and effectively → shortened postpartum stays 2. Assessment begins at first access to healthcare system 3. Variety of educational options a) Structured group classes b) Individualized instruction c) Printed materials d) Online materials e) Educational television channels f) Approved streaming videos produced by professional organizations

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4. Streamlined to meet individual needs of patients 5. Nurse to be available for clarification and ongoing communication 6. Continued learning through printed materials accompanied by verbal explanations

C. Content of Teaching 1. Expected physiologic changes 2. Activity level 3. Self-care 4. Maternal nutrition 5. Exercise 6. Sexuality and contraception 7. Emotional responses to childbearing 8. Newborn care 9. Newborn safety 10. Newborn immunizations 11. Signs of maternal and newborn complications 12. Emergency contact information 13. Psychosocial support 14. Specific follow-up for high-risk patients 15. Healthcare team roles and follow-up appointments

D. Maternal learning needs vary 1. Not limited to how-to activities

E. Anticipatory guidance 1. Colic 2. Postpartum health issues 3. Discussion groups 4. Complications and discomforts in first-year postpartum common a) Pain, fatigue, urinary incontinence, sleep deprivation, changes in mental health status 5. Special concerns → adolescent mothers, cesarean delivery, congenital anomalies a) See Table 33–1: Areas to Include in Postpartum Teaching, pp. 885–888 4 Copyright © 2020 Pearson Education, Inc.

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b) Include partner or other family member in teaching c) Critical concepts to review: (1) Headache (2) Leg pain (3) Abnormal vaginal bleeding (4) Swelling of face or extremities (5) Chest pain or shortness of breath (6) Thoughts of harming self or baby (7) Oral temperature of 100.4°F or higher (8) Excessive incisional pain or discharge

F. Evaluating Learning 1. Methods vary according to objectives, teaching methods a) Return demonstration, discussion 2. Less concrete learning evaluation more difficult a) Follow-up phone calls, home visits

IV.

Promotion of Maternal Comfort and Well-Being A. Assess patient on regular basis, providing care per protocol 1. Relieving specific discomforts 2. Medications for comfort, anemia, immunizations

B. Monitoring Uterine Status 1. Institutional protocols a) Presence of bogginess b) Positioning out of midline c) Heavy lochial flow d) Presence of clots e) Formation of hematoma 2. Monitor amount, consistency, color, odor of lochia 3. Breastfeeding or medication to promote uterine contractions 4. Teaching for self-care a) Teach woman to assess fundus and massage b) Teach to monitor lochia c) When to call healthcare provider

C. Relief of Perineal Discomfort 1. Assess perineum for edema, other problems a) Special measures woman would like 5 Copyright © 2020 Pearson Education, Inc.

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2. Hygienic practices 3. Perineal care a) After each elimination → cleanses, promotes comfort (1) Peri-bottle with warm tap water (2) Towelettes (3) Patting motion with toilet paper b) Front to back c) Teaching for self-care (1) Demonstrate and assist as necessary 4. Local perineal cooling a) Episiotomy or laceration (1) Reduce edema, numb tissue (2) Ask permission and consider cultural norms (3) Cooling packs or cold gel pads (4) Most often used in first 24 hours, continue as long as necessary (5) Apply for 10 to 20 minutes b) Teaching for self-care (1) Purpose, anticipated effects, benefits, possible problems 5. Sitz bath a) Warmth provides comfort, decreases pain, increases circulation to tissues (1) Promotes healing, reduces incidence of infection (2) May be used as needed (PRN) for 20 minutes (3) Clean towel, peripad ready to apply (4) See Figure 33–1: A sitz bath promotes …, p. 891 b) Teaching for self-care (1) Purpose, anticipated effects, benefits, possible problems, safety measures (2) 4 to 6 inches of water (3) Assess for temperature (4) Soak for 15 to 20 minutes 6. Topical agents a) Apply after sitz bath or perineal care (1) Anesthetic sprays, foams, ointments, Tucks pads b) Teaching for self-care (1) Purpose, use, anticipated effects, benefits, possible problems, safety measures (2) Return demonstration 7. See Clinical Skill 33–1: Use of Perineal Hygiene, Perineal Cooling, and Sitz Baths, pp. 892– 893

D. Relief of Hemorrhoidal Discomfort 1. Use of sitz baths, topical anesthetics, cool packs, witch hazel pads (Tucks) a) Short-term use of topical creams, rectal suppositories may be helpful 6 Copyright © 2020 Pearson Education, Inc.

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b) Increase fiber, fluid 2. Teaching for self-care a) Side-lying position, tighten buttocks when sitting down b) Diet and fluids c) Walking d) Assure hemorrhoids usually disappear a few weeks after birth

E. Relief of Afterpains 1. Intermittent uterine contractions a) Multiparous women frequently (1) Breastfeeding can initiate (2) Pillow under lower abdomen → intensifies for 5 minutes, then diminishes (3) Ambulation (4) Analgesics b) Mother’s description most reliable method of determining analgesic (1) Mild analgesics pose little risk to newborn c) Teaching for self-care (1) Cause and methods to decrease discomfort (2) Explains medications

F. Relief of Discomfort from Immobility and Muscle Strain 1. Pushing during labor 2. Early ambulation a) Assist first few times woman gets up b) Dizziness a concern 3. Teaching for self-care a) Importance of ambulation, monitoring signs of dizziness, weakness

G. Postpartum Diaphoresis 1. Fresh linens, dry gown 2. Cultural considerations for showering 3. Offer fluids 4. Teaching for self-care a) Information about normal physiologic changes

H. Suppression of Lactation in the Nonbreastfeeding Mothers 1. Engorgement → leakage, discomfort a) Nonpharmacologic means (1) Support bra continuously

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(2) Avoid breast stimulation (3) Applying cold packs (4) Apply cabbage leaves b) Signs peak by 4 days → spontaneously resolve by 10th day c) Analgesics d) Acupuncture, acupressure, ultrasound, Gua Sha scraping therapy are used in some settings 2. Teaching for self-care a) Avoid stimulation of breasts, nipples b) Heat avoided → water over back in shower c) 24-hour support bra d) Analgesics e) Cold compresses

I. Pharmacologic Interventions 1. See Table 33–2: Essential Information for Postpartum Immunizations, p. 896 2. Immunizations a) Pertussis in Tdap (1) Administer to pregnant woman at 27 to 36 weeks 3. Influenza a) Prior to discharge 4. Rubella a) If not rubella immune on lab test b) Use with caution in breastfeeding mothers 5. MMR II 6. Rho immune globulin a) Rh– woman with Rh+ baby (1) Within 72 hours after childbirth (2) Woman needs to understand implications of Rh– status in future pregnancies 7. Analgesics a) Variety of drugs used alone or in combination to provide relief of postpartum pain (1) Acetaminophen (2) Nonsteroidal anti-inflammatory agents (3) Narcotic b) Nurse should assess level of consciousness, vital signs 1 hour after administering

J. Support of Maternal Psychosocial Well-Being 1. Emotional stress a) Tremendous physiologic changes 8 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

2. Becoming a mother (BAM) a) Life-transforming process (1) Commitment, attachment, preparation → pregnancy (2) Acquaintance, learning, physical restoration → first 2 to 6 weeks after birth (3) Moving toward a new normal → 2 weeks to 4 months (4) Achievement of the maternal identity → around 4 months 3. Taking-in period → dependent, inwardly focused a) Promote skin-to-skin contact (SSC) early postpartum 4. Taking hold → self-care needs met → will shift to care of newborn, parenting a) Positive feedback b) Tell birth story c) Adjust to reality of child 5. Postpartum mood disturbances a) Often discharged before onset (1) Postpartum baby blues for up to 2 weeks following delivery (2) Immediate postpartum period predictor of postpartum depression (3) Individually assess b) Teaching for self-care (1) Advise mother of physical, psychologic, hormonal factors influencing response to childbirth (2) Discuss normal adaptations (3) Symptoms relatively mild and self-limiting, usually resolving within 10 days (a) If severe or last > 14 days, contact healthcare provider (4) Advise families about symptoms of postpartum depression

V.

Promotion of Maternal Nutrition, Rest, and Activity A. Promotion of Nutrition 1. Hungry and thirsty immediately following delivery a) Eat and drink as desired 2. Breastfeeding → 500 kcal/day additional calories from prepregnant intake 3. Nonbreastfeeding → normal nonpregnant caloric requirements 4. Prenatal vitamins and iron supplementation until postpartum checkup

B. Relief of Fatigue 1. Following birth → exhaustion or euphoric with energy a) Evaluate individual needs 2. Fatigue common a) Expected resolve over first few postpartum weeks b) Sleep deprivation contributes to problem 9 Copyright © 2020 Pearson Education, Inc.

Davidson/London/Ladewig, Olds’ Maternal–Newborn Nursing and Women’s Health Across the Lifespan 11th Ed. Instructor’s Resource Manual

c) Mother sleeps → adult in room or newborn to nursery d) Severe → complicate recovery process, parental self-efficacy, parenting behaviors 3. Teaching for self-care a) Nearly all new mothers (1) Cesarean birth → newborn and own recovery b) Counsel to sleep when baby sleeps c) Ask for help d) Call provider if signs of anemia, infection, thyroid dysfunction, unrelenting fatigue

C. Resumption of Activity 1. Gradually increase ambulation and activity a) Naps, avoid heavy lifting, avoid excessive stair climbing b) Week 2 → light housekeeping c) All activities when lochial flow stopped, around 4 to 5 weeks 2. Teaching for self-care a) Suggestions to limit number of activities b) Increase in lochia → increase rest periods, decrease extra activities

D. Postpartum Exercise 1. Simple exercises in birthing unit 2. Promotes well-being and less fatigue 3. Teaching for self-care a) Kegel exercises immediately after birth b) Short walks c) Abdominal exercises d) Regular exercise after 6-week postpartum examination

VI.

Promotion of Family Wellness and Shared Parenting

A. Satisfactory maternity experience → positive for whole family 1. Family-centered care a) Mother–baby care, couplet care b) Skin-to-skin (SSC) care positive effects on infants c) Crib near mother’s bed (1) Self-contained unit (2) On-demand feeding d) Flexible to permit baby to nursery e) Involved fathers → may not have role model, support, resources (1) Anticipatory guidance

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B. Reactions of Siblings 1. Sibling visitation meets needs of siblings, mother a) Visiting hours more flexible b) See Figure 33–3: This young girl visits her mother …,p. 901 c) Sibling prepared → arrival requires adjustments d) Have father carry baby inside → mother’s arms free to immediately hug, hold older children e) Working with parents to care for newborn (1) Constant supervision f) Regression common g) Reassurance that older sibling still special, truly loved, valued h) Patent–child time, one-on-one i) Genital differences → simple explanation

C. Resumption of Sexual Activity 1. Risks minimal after 2 weeks a) Abstain from intercourse until perineum healed, lochial flow stopped b) Vaginal dryness → water-based lubrication c) Breastfeeding couples should be forewarned → milk may spurt from nipples 2. Other factors may inhibit satisfactory sexual experience a) Baby’s crying b) Body image c) Sleep deprivation d) Libidinal changes 3. Fatigue 4. Most couples resume sexual activity within 3 months 5. Health promotion education a) Discuss normal sexual changes that frequently occur b) Facilitate open dialog

D. Contraception 1. Family planning information before discharge a) Consistency of use outweighs absolute reliability b) Method appropriate for couple 2. Health promotion education a) Discuss available contraceptive methods b) Written information c) Stress that pregnancy can occur before first menstrual period

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E. Parent–Newborn Attachment 1. Interventions designed to promote feelings of well-being, comfort, satisfaction a) Determine the childbearing/childrearing goals of the infant’s parents (1) Incorporate them when planning nursing care for the family b) Postpone eye prophylaxis for 1 hour after birth to facilitate eye contact c) Provide private time in first hour after birth for the new family, encourage SSC d) Arrange setting so nurse–patient relationship can be developed and maintained e) Encourage the mother to tell her birth story f) Encourage the parents to involve the siblings g) Use anticipatory guidance from conception through the postpartum period h) Include parents in any nursing intervention, planning, and evaluation i) Initiate and support measures to alleviate fatigue in the parents j) Help parents identify, understand, accept both positive and negative feelings related to the birth, the newborn, and the overall parenting experience k) Support and assist parents in determining the personality and unique needs of their infant 2. Allow parent to care for baby as soon as possible a) Observe beginnings of parent–newborn attachments b) Remember cultural values, beliefs, practices 3. Health promotion education a) Advise parents that they may experience feelings of uncertainty b) Provide reassurance c) Normal infant behavior and activity d) Explain that new attachments, new relationships have discovery

VII.

Nursing Care Following Cesarean Birth

A. 32% women delivered by cesarean birth in United States in 2014 1. Similar postpartum needs with surgical needs

B. Promotion of Maternal Physical Well-Being After Cesarean Birth 1. Promotion of comfort, safety, prevention of postoperative complications a) Routine postpartum assessments (1) Inspection of dressing, incision (2) Lung sounds (3) Gastrointestinal status (4) Genitourinary status b) Immobility → increases chances of pulmonary infection (1) Incentive spirometry, cough and deep breathe every 2 to 4 hours (2) Increases risk of abdominal distention, deep vein thrombosis, pulmonary embolism (a) Dangle legs on side of bed, early ambulation

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2. Assess pain level, provide relief as needed a) Administer analgesic medications b) Promote comfort through positioning, back rubs, oral care, reduction of noxious stimuli c) Encourage presence of father or partner, newborn d) Encourage use of breathing, relaxation, distraction e) Instruct woman to splint incision with pillow f) Encourage adequate rest periods g) Encourage early ambulation h) Allow woman to begin judiciously consuming food and fluids as desired when awake and alert 3. Neuraxial analgesia a) Administered first 24 hours following birth 4. Patient-controlled analgesia (PCA) a) PCA → woman given bolus at beginning of therapy, presses button to self-administer small doses as needed (1) Preset with time lockout (2) Feel less anxious 5. Oral analgesics 6. General anesthesia → abdominal distention may occur a) Leg exercises, abdominal tightening, avoiding carbonated beverages, avoid straws b) Mylicon 7. Positioning for activities a) Feeding, holding b) Pillow in lap c) Football hold d) Demonstrate body mechanics for getting out of bed 8. Special needs following discharge a) Sleep, rest b) Incisional care c) Assistance with household chores d) Infant care e) Self-care f) Pain relief 9. Teaching for self-care a) Assist in identifying interventions to relieve pain b) Encourage to take medication regularly c) Avoid prolonged activity d) Frequent rest e) Help identify resources for assisting mother

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C. Promotion of Parent–Newborn Interaction After Cesarean Birth 1. Factors may hinder successful interactions a) Physical condition of mother and newborn, reactions of mother b) Condition of infant c) Skin-to-skin contact (SSC) as soon as possible → father or mother d) Signs of grief response to loss of fantasized vaginal birth experience e) Positive support to couple (1) Allow to tell story (2) Allow them to make choices (3) Presence of father positively influences woman’s perceptions of birth event f) Perception of and reactions to birth (1) Mothering role perceived as extension of childbearing role (2) Might lead to feelings of failure, frustration g) Teaching for self-care (1) Advise mother she can hold, cuddle, lift, feed infant (2) Assist with positioning (3) Advise to care for infant → delegate other household duties

VIII.

Nursing Care of the Obese Postpartum Mother

A. Increasing in United States 1. Special needs a) Risk for postpartum hemorrhage, increased risk of postpartum mortality (1) Vigilant assessment of the fundus b) Assess for airway obstruction, hypoxia c) Encourage early ambulation d) Sequential compression devices (SCDs) e) Mother to demonstrate incision care f) Mother needs to recognize signs of infection, dehiscence g) Safety needs with transfer, position changes, ambulation h) Emotional needs (1) Sometimes experience prejudice, psychologic distress, and humiliation (2) Bed size, transport equipment, etc.

2. Teaching for self-care a) Advise to ambulate as early as possible b) Teach symptoms of infection, what to report c) Children at risk for obesity, impaired glucose tolerance, cardiometabolic complication

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IX.

Nursing Care of the Adolescent Postpartum Mother A. Transition to motherhood stressful for adults → teen mothers with fewer resources 1. Newborns more likely to be low birth weight, preterm, die in infancy

B. Same basic physical care needs 1. May not have working knowledge of their own anatomy and physiology 2. Demonstrate self-care 3. Detailed teaching on contraception

C. Nurse–patient relationship 1. Sensitivity, nonjudgmental 2. Still trying to meet educational goals 3. Relying on others

D. Opportunities for teaching 1. Serve as role model 2. Ensure adolescent mother has knowledge and skills to care for newborn 3. Newborn physical exam at bedside a) Gives adolescent permission to explore baby b) Group classes with other adolescent mothers 4. Information about options in community a) Adolescent clinics b) Support groups and programs c) Group classes

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X.

Nursing Care of LGBTQ Postpartum Mothers A. Body of knowledge growing for care of lesbian, gay, bisexual, transgender, and queer (LGBTQ) families 1. Role of nonbiological lesbian co-mothers 2. Follow cue of family

B. Maintain attitude that is respectful, caring, open 1. Quality, patient-centered care for any woman 2. Ask for guidance regarding special needs or requests 3. Postpartum instructions on intercourse and contraception might need to be individualized and amended

XI.

Nursing Care of the Postpartum Mother with Special Needs

A. Women with physical, developmental, or intellectual disabilities, those suffering from chronic health conditions → at risk during this time period B. Postpartum time period → great growth, challenges, learning opportunities 1. Developmental or intellectual disabilities → risk 2. Present information in easy-to-understand format

C. Needs assessment 1. Community and private resources

XII.

Nursing Care of the Postpartum Mother with a History of Sexual Abuse

A. Tend to have more anxiety and stress related to procedures, interactions, and being touched in general 1. Difficulty establishing trust

B. Ensure privacy, safety, trust C. Screened for PPD prior to discharge D. Support groups E. Privately question all patients regarding feeling safe returning to home environment

XIII.

Nursing Care of the Woman Who Relinquishes Her Newborn 16 Copyright © 2020 Pearson Education, Inc.

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A. Relinquishing mother → chooses an adoption plan or one who has conceived via traditional or gestational means and is acting as a surrogate mother 1. Traditional adoption becoming more rare 2. Reasons for choosing adoption vary a) Single parenting b) Inability to care financially for child c) Unable to care for another child, multiple children d) Do not have desire, maturity to be mothers e) Complicated psychosocial issues f) Personal and complex 3. Private and public agencies 4. Adoptive parents may be openly involved in the labor and birth 5. Use critical thinking and flexibility

B. Compassionate patient-centered care 1. Communicate plan to other staff 2. Act as primary support if woman alone 3. Respect amount of contact requested 4. Respectful communication a) Adoption plan b) Finding family to parent your child 5. Acknowledge significance of birth mother’s experience a) Loss and grief b) At risk for disenfranchised grief → grieving process, resolution c) Refer to support group, organization, therapist, clergy

XIV.

Discharge Information A. Frequently discharge within 24 to 48 hours 1. Home health services

B. Preparation for discharge begins on admission 1. See Key Facts to Remember: Discharge Teaching, p. 910 2. Woman should contact caregiver if she develops any signs of possible complications: a) Fever b) Change in lochia c) Evidence of mastitis 17 Copyright © 2020 Pearson Education, Inc.

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d) Evidence of thrombophlebitis e) Evidence of urinary tract infection f) Evidence of infection g) Continued mood changes, signs of postpartum depression h) Severe pelvic pain, abdominal tenderness i) Chest pain or shortness of breath j) Signs of preeclampsia such as headache or swelling of the face or extremities 3. Woman should review literature she has received 4. Woman should be given phone numbers of postpartum unit, lactation consultant, nursery 5. Woman should be given information on local agencies, support groups 6. Information regarding feeding methods 7. Scheduled appointments 8. Woman should understand procedure for obtaining copies of birth certificate 9. New parents should be able to provide home care 10. Parents should be aware of signs, symptoms in infant that indicate possible problems 11. Parents should be given information about postpartum mood and anxiety disorders

C. Reassurance of couple’s ability to be successful parents 1. Address follow-up visits as appropriate 2. Family approach as appropriate, with father, siblings

XV.

Evaluation of the Postpartum Family 1. Mother and infant remain healthy, safe, free of injury or complications 2. Mother verbalizes comfort, uses self-comfort measures as appropriate 3. Mother verbalizes feelings, concerns related to birth event and newborn 4. Mother performs appropriate self-care measures 5. New parents demonstrate safe, effective care of baby 6. Parents and newborn display positive bonding behaviors 7. Mother–newborn dyad demonstrates successful breastfeeding a) Parents describe safe formula preparation; demonstrate safe bottle feeding b) Mother describes appropriate breast care

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8. Mother is rested, verbalizes understanding of importance of gradual return to activities 9. Mother identifies sources of support to assist with newborn care and family responsibilities 10. Mother states plan for follow-up healthcare for herself and infant 11. Mother identifies signs, symptoms of maternal newborn complications and reasons to seek care before routine follow-up visits 12. Cesarean birth mother states in own words reason for cesarean birth, verbalizes feelings 13. Cesarean birth mother verbalizes comfort and maintains mobility 14. Obese patient remains free of injury or complications 15. Adolescent mother expresses her feelings about the childbearing experience and verbalizes knowledge of resources for continued support 16. Woman relinquishing newborn verbalizes rationale for decision a) Demonstrates acceptance of decision 17. All women and their husbands or partners have been supported a) Culturally (1) Special considerations related to age, sexual preference, ethnic background b) Abilities c) Histories 18. The mother and father/partner are aware of symptoms of postpartum mood and anxiety disorders 19. All components of nursing care designed to achieve outcomes identified for the woman and her family

XVI.

Focus Your Study

XVII.

Activities 1. Individual Have students prepare drug cards for the following medications: • Percocet 5/325 • Vicodin • Rubella virus vaccine • RhoGAM • Ibuprofen • Lortab • Mylicon 2. Small Group Divide the class into small groups of three to five students. Have each group brainstorm and pick two areas of new-mother teaching the group feels are often left out or underemphasized.

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Encourage the groups to draw on personal experience, if possible. Have each group prepare a teaching plan for the new mother on these two areas and cite their references in APA format.

3. Large Group Lead a class discussion on diversity in parenting. Focus on the cultures and ethnic groups common to your area. Be sure to include alternative lifestyle, surrogacy, and single parenting by choice in your discussion. The goal of the discussion is the following: • Identify areas of education that might be different for the new family.

• Identify areas of education that might be necessary for nurses.

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Chapter 34 Home Care of the Postpartum Family Role of Length of Stay and Professional Guidelines for Discharge………………

2

Considerations for the Home Visit..................................................................

2

Home Care: The Newborn...............................................................................

4

Home Care: The Mother and Family...............................................................

12

Other Types of Follow-Up Care.......................................................................

16

Focus Your Study.............................................................................................

17

Activities..........................................................................................................

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I.

Role of Length of Stay and Professional Guidelines for Discharge

A. 1998 Newborns’ and Mothers’ Health Protection Act (NMHPA) 1. Provides minimum stay of 48 hours for uncomplicated vaginal birth a) 96 hours following uncomplicated cesarean birth b) American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) → decision to discharge made by providers caring for newborn and mother in consultation with family c) See Table 34–1: Minimal Criteria for Discharge of Healthy Term Newborns, p. 916

II.

Considerations for the Home Visit

A. Purpose and Timing of the Home Visit 1. 60% of women attend postpartum visit at 4 to 6 weeks after birth 2. Focuses on assessment, teaching, counseling a) Days 3 to 6 (1) Peak potential for newborn jaundice, weight loss, dehydration 3. Postpartum home care → expanding information, reinforcing self- and infant care a) Assess home safety b) Exercise critical thinking, creativity

B. Fostering a Caring Relationship with the Family 1. Birthing center strives to enhance family autonomy → institutional constraints a) Home visit very different b) Nurse is visitor 2. Goals a) Regard for patient b) Genuineness c) Empathy d) Trust and rapport 3. See Table 34–2: Fostering a Caring Relationship, p. 917

C. Planning the Home Visit 1. Identify purpose of visit 2. Gather anticipated materials and equipment 3. Communicate with primary healthcare provider(s), review inpatient records 4. Personal contact to arrange appointment a) Identify purpose and goals 2 Copyright © 2020 Pearson Education, Inc.

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D. Maintain safety 1. Nurses exposed to safety hazards with traveling and during home visits 2. Risks 3. Basic safety rules a) Confirm address b) Outline route vis GPS if available c) Provide schedule of visits to supervisors d) Notify when leaving for visit, when finished with visit e) Carry cellular phone with battery charged f) Carry hard copy of agency, emergency phone numbers g) Ensure vehicle well maintained h) Wear a name tag, carry identification i) Carry flashlight j) Avoid wearing any jewelry k) Lock personal belongings in trunk, out of sight l) Call patients to confirm at home, expecting nurse m) Identify all individuals present in home at start of visit n) Pay attention to body language of all present during visit o) If any threatening, sexually inappropriate behavior, presence of weapons, threatening pets, illegal substance use, or issues that make the nurse feel unsafe occur, terminate p) Be aware of personal body language and how it might be interpreted q) Have car keys in hand before returning to vehicle r) Lock the doors and drive away upon return to the vehicle at the completion of visits s) Inform supervisor immediately of any threatening situation, assault, or injury t) Notify authorities if a crime has been committed 4. Drive neighborhood before visit a) Two nurses together b) Violence in progress → do not enter, call 911 5. Home care agencies → violence protection programs a) Policies, safety education b) Escort as necessary c) Code phrases, set plan for unsafe situations d) Independent personal safety training 6. Review plans before accepting employment 7. Be aware of surroundings

E. Carrying Out the Home Visit 1. Introduce self, confirm location a) Introductions to others

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b) Where to sit 2. Uniform assessment tool → determine actions a) Direct physical care b) Conduct patient and family teaching c) Consult with physician, midwife, specialist d) Refer woman or family to appropriate community agencies e) Schedule additional home visits or telephone follow up 3. Nurse needs excellent assessment skills a) Observing variations from norm b) Critical thinking c) Problem solving d) Effective communication

III.

Home Care: The Newborn

A. Can provide positive feedback, suggest alternatives 1. Each newborn has variations 2. Birthing unit nursery staff available 3. Should have been taught caregiving methods before discharge a) Complete teaching, review of initial teaching b) Questions regarding infant care, feeding, signs of illness

B. Home visits associated with reduction in adverse undetected health issues and cost savings C. Physical Assessment of the Newborn at Home 1. Newborn physical exam a) General appearance b) Vital signs c) Skin d) Respiratory e) Cardiovascular f) Neurologic g) Gastrointestinal h) Genitourinary i) Musculoskeletal j) Behavioral state k) Parent–newborn interaction

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2. Screening exams done 3. Assessment of late preterm infants a) Born between 34 and 36 6/7 gestational weeks 4. Risk for complications 5. Home health visit within 24 to 48 hours of discharge a) Assess frequency, duration of breastfeedings b) Frequency and amount of formula c) Input, output, weight, hydration status d) Parent education e) Hyperbilirubinemia more likely f) Instructions on hand washing, avoiding infection g) Ongoing assessment

D. Positioning and Handling of the Newborn 1. Demonstrate methods of positioning, handling newborn a) See Figure 34–2: Various positions for holding a newborn …, p. 921 2. Cradle hold 3. Upright position 4. Football hold

E. Skin Care and Bathing 1. Maintains temperature, barrier a) Port of entry 2. Bath demonstration best way to provide information a) Bathing every other day → avoid drying skin b) Neutral pH cleansing agents c) Immersion baths safe prior to cord separation d) See Box 34–1: Bath Supplies, p. 921 e) May use dishpan, kitchen sink, large bowl f) Washcloths (2) (1) Towels (2) (2) Blankets (2) (3) Unperfumed mild skin cleanser (4) Shampoo (5) Petrolatum product or diaper ointment, if indicated (6) Diapers (7) Clean clothes g) Silence phone, don’t answer door—never leave baby unattended

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3. Sponge bath →Tub/container filled with 5 inches of water → warm to touch: a) 38°C to < 40°C (100°F to < 104°F) b) Flat, protected surface → never leave unattended c) Wrap dampened washcloth around index finger once d) Eye wiped from inner to outer canthus e) Different portion for each eye f) Then ears → washcloth around index finger, external ear, behind ear g) Rinse washcloth → wipe remainder of face h) Neck washed carefully → mild soap i) Bathe upper and lower body separately j) Neck, face clean, dry → unwrap blanket, remove T-shirt, wet chest, back, arms with washcloth k) Lather hands → wash → rinse → dry → wrapped l) Unwrap legs → wet → lather → rinse → dry m) Dry skin → emollient (1) Avoid baby oil, baby powder n) Genital area cleansed after each diaper o) Uncircumcised males → clean penis daily p) Wrapped in terry cloth towel, patted dry q) Wash hair last r) Football hold, head tilted downward s) Moisten hair, lather t) Rinse, towel dry 4. Tub bath a) Wash face, eyes, ears, neck as in sponge bath b) Immerse in sink, baby tub c) Hold securely d) Slippery when wet e) Sock over supporting arm f) See Figure 34–3 When bathing the newborn …, p. 922 g) Double blanket in clean, dry blankets h) Dress when dry

F. Cord Care 1. Teaching a) Wash hands before and after handling cord b) Keep cord clean and dry c) Keep cord exposed to air, loosely covered d) Keep diaper folded below cord e) Clean cord if it becomes soiled with urine or stool f) Dry cord thoroughly after cleansing

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2. Inspect cord during each diaper change, bath a) May smell earthy, small amount of mucus present → normal b) Notify healthcare provider if any drainage, foul smell, redness, swelling, discoloration

G. Nail Care 1. May adhere to skin within first days of life 2. Cutting is contraindicated 3. Separate, break off 4. File with newborn file when infant asleep 5. Socks or mittens on hands

H. Dressing the Newborn 1. Needs to wear T-shirt, diaper, sleeper a) Dress more warmly if home maintained at 60°F to 69°F b) Cover head outdoors c) Protect with shade from sun 2. Diaper shapes vary a) Prefolded, disposable → rectangular b) Cloth diapers → triangular or kite-folded c) See Figure 34–4: Two basic cloth diaper shapes ..., p. 924 d) Launder separately with mild soap e) Presoak diapers 3. Swaddling the newborn a) Helps newborn maintain body temperature b) Provides feeling of closeness and security c) Effective in quieting crying baby d) See Figure 34–5: Steps in wrapping a baby, p. 924

I. Temperature Assessment, Fever, and Illness 1. Provide opportunities for discussion and demonstration for taking temperature 2. Take only when signs of illness are present 3. 36.5°C to 37.4°C (97.7°F to 99.3F°) considered normal 4. Rectal method considered gold standard → risk of trauma 5. Tympanic not recommended or found accurate in young infants 6. Axillary safe for babies < 4 weeks a) Add 0.4 C to estimate rectal temperature

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7. Infrared scanning thermometers commercially available 8. Recommend purchasing thermometer designed to measure infant temperature a) Ensure no mercury thermometer 9. Use same thermometer and measurement site during the course of one illness 10. Under 90 days of age → see provider if newborn has a rectal temperature of 100.4°F or axillary of 99.4 F 11. Other signs of systemic infection a) Subtle manifestations b) Temperature instability c) Poor feeding d) Abdominal distention e) Inability to tolerate feedings f) Apnea g) Alterations in behavior h) “Just not acting right”

J. Stools and Urine 1. Appearance, frequency of newborn’s stools concern a) Babies expected one meconium stool on first day b) One to two stools on day 2 c) One to three stools daily by days 3 to 4 d) One to four stools daily on days 4 to 7 e) Formula-fed babies may have one to two stools daily f) Stools darker, more formed 2. Show pictures so family knows what to expect 3. Urination a) One in first 24 hours b) Twice in second 24 hours c) Three to five voids days 3 to 5 d) By day 5, five or more wet diapers per day 4. Diaper area care a) Diaper area cleansed, well dried with each diaper change b) Diaper dermatitis (1) Short periods of time air-drying with no diaper (2) Minimal soap required (3) Alcohol-free wipes c) Irritant diaper dermatitis (IDD) → Localized, nonimmunologic reaction to the friction, occlusion, moisture, urine, feces, chemicals in the diaper environment d) Even with proper care → some type of diaper rash e) Petrolatum provides protection from wetness, promotes healing 8 Copyright © 2020 Pearson Education, Inc.

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f) Commercial products g) Petrolatum, zinc oxide h) Lanolin may be allergenic i) If rash persists more than 2 to 3 days contact healthcare provider

K. Sleeping 1. Sudden infant death syndrome (SIDS) preventions 2. Sudden unexpected death of an infant less than 12 months of age not explained by autopsy, site investigation, clinical history 3. 2011 “Back to Sleep” guidelines 4. Preventions a) Babies should sleep on their backs (1) See Figure 34–6: Babies should be placed on their backs when sleeping, p. 926 b) Firm crib mattress c) Room sharing without bed sharing d) Loose bedding and soft objects removed from crib e) Smoking exposure should be avoided before and after birth f) Alcohol and illicit drug exposure avoided g) Babies should be breastfed unless contraindicated (1) Exclusive breastfeeding for at least 6 months ideal h) Babies should not be offered a pacifier while falling asleep i) Babies should not be overheated j) Babies should receive their immunizations k) Positioning devices not recommended l) Babies should not sleep with cardiorespiratory monitors attached unless prescribed m) Babies should have tummy time n) Pregnant women should follow the recommended schedule for prenatal care 5. AAP guidelines for healthy infants 6. Crib safety a) Observe crib, bassinet, cradle, mat, other devices b) Crib should be a recent model with mattress that fits snugly and designed to prevent entrapment and suffocation c) Consumer Product Safety Commission (CSPC) updated requirements for crib safety in 2010

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L. Proper Positioning 1. Placed in supine position to sleep 2. Encourage to hold infants upright for 10 to 15 minutes after feedings 3. Remind parents to teach caregivers

M. Sleep–Wake States 1. Several periods of reactivity 2. Deep sleep 3. Light sleep 4. Drowsy awake state 5. Quiet alert state 6. Active alert state 7. Crying state 8. Response to unpleasant stimuli → Individual patterns after 2 to 3 days 9. Comfort by swaddling, rocking, or other reassuring activities 10. See Figure 34–7: Picking up babies and consoling them …, p. 929

N. Injury Prevention 1. Accidental injuries fifth leading cause of death in infants under 1 year a) Suffocation b) Homicide c) Motor vehicle accident d) Drowning e) Fire/burns f) Natural/environment g) Most common nonfatal accidental injuries < 1 year of age in 2014 were falls, strikes, bites or stings, foreign bodies, inhalation/suffocation, fires/burns 2. Share information regarding common injuries, accidents 3. Care seat safety 4. Observe environment → observe for childproof changes to be made 5. Abusive head trauma (AHT) a) Previously called shaken baby syndrome (SBS) → non-accidental traumatic brain injury that results from violent shaking

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(1) Swelling, increased cranial pressure, bleeding result → may sustain permanent neurologic damage b) Risks (1) Infant crying (2) If male caregiver; less educated, young, substance-abusing, poorly supported, (3) Single parent; history of poor impulse control; history of prior military service; history of abuse as a child; and living in poverty c) The Period of PURPLE Crying (1) P: Peak of crying (2) U: Unexpected/unexplained (3) R: Resists soothing (4) P: Pain-like face (5) L: Long lasting (6) E: Evening and late afternoon d) Educate parents on techniques (1) Singing, swaddling, gentle rhythmic movements, white noise, offering a pacifier before the baby is crying vigorously 6. Colic as a parental stressor a) Manifested by persistent, unexplained, inconsolable crying b) Can continue for several hours each day, often in evening (1) Can start 2 to 3 weeks of age through 4 to 6 months (2) Etiology unknown; gastrointestinal in nature c) Interventions (1) Dietary (a) Maternal hypoallergenic diet may be helpful for breastfed babies (b) Switching from cow’s-milk formula to a soy or hydrolyzed formula for those who are formula-fed (2) Pharmacologic agents (a) Simethicone, herbal agents, sugar dicyclomine, cimetropium bromide (3) Manipulative techniques (a) Infant massage (4) No definitive treatment d) Guidance (1) Strain on family relationships (2) Risk for abuse (3) Lay baby down safely to take a break

O. Newborn Screening and Immunization Program 1. Screening tests a) Detect disorders than can cause physical, intellectual, and developmental complications, death b) Second blood specimen after 7 to 14 days

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2. Newborn hearing screenings administered prior to discharge 3. Ensure family has information on childhood immunization schedule 4. Confirm Tdap status of mother

IV.

Home Care: The Mother and Family A. Assessment of Mother and Family at Home 1. Specifically 2. Progression of lochia 3. Fever or malaise 4. Dysuria or difficulty voiding 5. Pain in the pelvis or perineum 6. Painful, reddened hot spots or shooting pains in the breasts during or between feedings 7. Areas of redness, edema, tenderness, warmth of legs 8. Also discuss diet, fatigue, ability to rest, sleep, pain management, signs of postpartum complications, activity, sexuality issues, self-care ability, social support system, cultural or religious practices 9. Physical assessment 10. Psychologic assessment 11. Attachment, adjustment to parental role, maternal emotions, sibling adjustment, educational needs 12. Provide teaching to mother and family

B. Postpartum Fatigue 1. Inform mothers it may be significant problem 2. Emphasize nutrition, periods of uninterrupted sleep 3. Continued vitamins and iron

C. Breastfeeding Concerns Following Discharge 1. Healthy People 2020 goal to increase infants breastfed from 74 to 89.1% exclusively until 3 to 6 months of age and increase number breastfed until 6 to 12 months 2. Benefits to mother, infant, society 3. Anticipatory guidance and support a) Home visit time to promote continued breastfeeding 12 Copyright © 2020 Pearson Education, Inc.

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b) Infant to be seen by 3 to 5 days of age → assess weight, jaundice, hydration, elimination 4. Breastfeeding assessment a) Observe feeding episode (1) Positioning (2) Latch on (3) Let-down (4) Sucking pattern (5) Nipple condition (6) Infant response (7) Maternal response (8) Use tool to assess, like LATCH Scoring 5. Concerns related to the breastfeeding baby a) Infant weight remain within 10% of birth weight b) Assist with techniques to increase milk production, promote milk transfer (1) Every 2-hour feedings (2) Nurse can assist with pumping or hand expressing c) Assistance in awakening to feed at least eight times/day in first week of life d) Feeding cues e) Concerns related to breast milk supply (1) Audible swallowing (2) Milk at mouth f) Continue nursing on demand at least every 3 hours 6. Concerns related to maternal breastfeeding difficulties a) Newborn should maintain weight within 10% of birth weight (1) If experiencing a 7 to 9% newborn weight loss with techniques to increase milk production and promote better milk transfer (2) Encourage feeding every 2 hours (3) Assess milk production (4) Quiet alert state is ideal for latch-on b) Signs of adequate milk transfer during the first week of life (1) Baby swallows audibly during feedings.

(2) Mother’s nipple is moist after feedings.

(3) Baby has moist mucous membranes and skin is elastic.

(4) Mother and baby both appear satisfied and comfortable after feedings.

(5) Baby passes three to five loose yellow stools per day by day 4 or 5 (6) Six or more diapers are saturated with clear urine each day by the end of the first week (7) Baby actively suckles eight or more times in 24 hours for a total of 140 minutes or more c) Concerns related to maternal breastfeeding difficulties d) Nipple soreness (1) Sensation of massaging, stretching as infant elongates nipple 13 Copyright © 2020 Pearson Education, Inc.

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e) Erythema, edema, abrasions, fissures, cracks, bruises, blisters, bleeding → mechanical trauma f) Observe latching g) Rotate positions when feeding infant h) Observe baby’s oral cavity for anatomical concerns i) Baby will suck rapidly at beginning of feeding j) Nipple elongated at end of feeding k) Comfort measures l) Warm water compresses, avoiding soap on breasts m) Gently massage before feeding stimulates let-down n) Air-drying (1) See Figure 34–9: Air-drying the nipples can help prevent cracking and fissures, p. 937 o) Breast shells over nipples between feedings p) Talk with lactation consultant or provider q) Home-care nurse can make recommendations 7. Flat or inverted nipples a) Most able to breastfeed b) Cold pack will evert a flat nipple c) Side-lying position d) Use of a pump before latch-on 8. Breast engorgement a) Fullness versus engorgement b) Engorgement → hard, painful, warm, taught and shiny c) May be accompanied by fever d) Warm compresses, showers before nursing e) Breast massage f) Cold compresses applied after nursing g) Cabbage compresses h) Ultrasound i) Milk expression j) Anti-inflammatory medication effective k) Acupuncture l) Pumping m) Unrelieved → involution, decreased milk synthesis 9. Plugged ducts a) Areas of tenderness, redness, heat, palpable lump b) May be relieved by massage c) Frequent feedings 10. Mastitis a) Plugged ducts, milk stasis → increase risk for mastitis b) Stress, cracked nipples, fatigue, abundant milk supply c) Symptoms: 14 Copyright © 2020 Pearson Education, Inc.

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d) Fever e) Hot, red, tender area on breast f) Flulike symptoms g) Treatment h) Continue breastfeedings i) Moist heat j) Increased fluids k) Rest l) Analgesics m) Antibiotics 11. Effects of medications and alcohol a) Analgesics as directed by primary healthcare provider b) Acetaminophen or nonsteroidal anti-inflammatory (NSAIDs) safe for use during breastfeeding c) Alcohol passes into breast milk d) Not recommended for breastfeeding women e) Consume after breastfeeding 12. Breastfeeding and the working mother a) Help woman to explore options, solve problems related to breastfeeding b) If not pumped supply will decrease c) Begin pumping before returning to work d) Methods of maintaining breast milk e) Use of side-lying position when nursing before, after work f) Normal to have feelings of anxiety, guilt, doubt when returning to work 13. Weaning a) Process that begins with introduction of sources other than breast milk b) Ends when child no longer breastfeeds c) Provide anticipatory guidance and support to extend breastfeeding as long as possible d) Gradual approach physically, emotionally comfortable for mothers, babies 14. Developing cultural competence a) Cultures vary tremendously b) Home-care nurse needs to individualize care 15. Breastfeeding referrals and social support a) Support from family, social contacts important b) Providers of care need to be knowledgeable c) Local support groups

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D. Formula Feeding 1. AAP recommends iron-fortified formula until 1 year if not breastfed 2. Human milk substitute 3. Ready-to-feed 4. Liquid concentrates 5. Powder forms 6. Mix formula exactly as package directs 7. World Health Organization (WHO) guidelines for preparation of powdered formula

V.

Other Types of Follow-Up Care A. Return Visits 1. Up to three visits 2. At 24 hours after discharge, 2 visits over next week

B. Telephone Follow-Up 1. Additional information, address questions 2. Telephone assessment a) Listen skillfully, open-ended questions b) Typically within 3 days of discharge or earlier c) Caring attitude d) Plan of care include e) Counseling f) Teaching g) Referral h) High level of learning readiness i) Advice line

C. Postpartum Classes and Support Groups 1. More common 2. Series of structured classes a) Socialize b) Provide support c) Parenting topics d) Nutrition e) Exercise f) Concerns

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D. Support Programs Utilizing Technology 1. Use of phone apps, online support groups, internet discussion boards, social media, and peer support online technologies 2. Evaluate reliability 3. Encourage websites affiliated with government organizations, universities, healthcare organizations

VI.

Focus Your Study

VII.

Activities 1. Individual Have students make a list of equipment that might be appropriate for the home-care nurse to carry into the day 5 postpartum home visit. Instruct students to include sources, if any.

2. Small Group Divide the class into small groups of three to five students. Have each group research the community for new-parent resources of any kind and prepare a list in a format to share with the class.

3. Large Group Invite a home-care agency nurse to speak to the class about the job and the following particulars: equipment, hours, patient care, the positives of the job, and the negatives of the job.

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Chapter 35 The Postpartum Family at Risk Care of the Woman with Postpartum Hemorrhage.......................................

2

Care of the Woman with a Reproductive Tract Infection or Wound Infection…………………………………………………………………………………………..

7

Care of the Woman with a Urinary Tract Infection…………………………………….

9

Care of the Woman with Postpartum Mastitis...............................................

11

Care of the Woman with Postpartum Thromboembolic Disease..................

13

Care of the Woman with a Postpartum Psychiatric Disorder........................

17

Focus Your Study.............................................................................................

20

Activities..........................................................................................................

20

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I.

Care of the Woman with Postpartum Hemorrhage

A. Early (immediate or primary) postpartum hemorrhage (PPH) → first 24 hours after childbirth B. Late (secondary) postpartum hemorrhage → 24 hours to 6 weeks after birth 1. PPH cause of significant maternal mortality and morbidity a) Blood loss greater than 500 mL following childbirth vaginal delivery; 1000 mL following cesarean delivery; 1500 mL during repeat cesarean birth b) Drop in maternal hematocrit levels of more than 10% or more from predelivery baseline or excessive bleeding that causes hemodynamic instability or need for blood transfusion c) Can occur intra-abdominally

C. Early (Primary) Postpartum Hemorrhage 1. Blood volume and cardiac output increased 2. Normal mechanism for hemostasis after expulsion of placenta → contraction of interlacing uterine muscles a) Uterine atony → 80% of PPH cases b) Lacerations c) Retained placental fragments d) Hematomas e) Uterine inversion or rupture f) Problems of placental implantation g) Coagulation disorders 3. Uterine atony a) Contributing factor (1) Overdistention of uterus (2) Prolonged or precipitous labor (3) Oxytocin augmentation or induction of labor (4) Grand multiparity (5) Use of anesthesia (6) Prolonged third stage of labor (7) Preeclampsia (8) Asian or Hispanic heritage (9) Operative birth (10) Retained placental fragments (11) Placenta previa or accrete, placental abruption (12) Obesity b) 4 Ts (1) Tone (2) Trauma 2 Copyright © 2020 Pearson Education, Inc.

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(3) Tissue (4) Thrombin c) May be slow and steady or sudden and massive (1) Vaginally or large clots (2) Maternal vital signs may not change until significant blood loss has occurred d) Ideally prevented e) Prior history of PPH increases the woman’s risk by double in subsequent pregnancy (1) Active management of third stage of labor, controlled traction on umbilical cord, uterine massage → prevent half of cases of postpartum hemorrhage f) Clinical therapy (1) Stop hemorrhage, correct hypovolemia, treat underlying cause (2) Excessive bleeding → bimanual massage (a) See Figure 35–1: A. Manual compression of the uterus and massage with the abdominal hand will usually effectively control hemorrhage from uterine atony.

B. Manual removal of placenta ..., p. 948 (3) Uterine stimulants (a) Oxytocin (b) Ergotamine (c) Prostaglandin analog (d) Misoprostol (e) See Table 35–1: Uterine Stimulants Used to Prevent and Manage Uterine Atony, p. 949 (4) Management by uterine tamponade (a) Use of Bakri balloon (i) Inserted into the uterine cavity and inflated with 300–500 mL of isotonic saline to provide pressure against the uterine walls (b) Permits any continuous bleeding from uterus to be visualized (c) Antibiotics administered while balloon in place (d) If bleeding controlled, tamponade removed after 24 hours (e) Uncontrolled, uterus packed with 4-inch-wide sterile gauze (5) Management by uterine artery embolization (a) Vaginal delivery with unsuccessful tamponade effort → uterine artery embolization (b) Catheter inserted to embolized bleeding vessel → alternative to hysterectomy (6) Surgical management of postpartum hemorrhage (a) Exploratory laparotomy with variety of uterine compression techniques (b) B-Lynch compression (brace suture) (c) Uterine artery surgically ligated to control bleeding (d) Hysterectomy is procedure of last resort (i) Ends childbearing (ii) Emotional distress 4. Lacerations of the genital tract a) Factors that predispose 3 Copyright © 2020 Pearson Education, Inc.

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(1) Nulliparity (2) Epidural anesthesia (3) Precipitous childbirth (4) Macrosomia (5) Forceps- or vacuum-assisted birth (6) Use of oxytocin b) Bright red blood in presence of firmly contracted uterus c) Episiotomies → blood loss slow, steady bleeding 5. Retained placental fragments a) Can be cause of early PPH → generally most common cause of late PPH b) Partial separation of placenta during massage of fundus before spontaneous separation c) Inspect placenta for intactness after delivery d) Uterine exploration e) Sonography may be used f) Curettage may be necessary 6. Vulvar, vaginal, and pelvic hematomas a) Result of injury to blood vessel from birth trauma b) May happen rapidly with 250–200 ml of blood c) Risks factors (1) Episiotomy (2) Forceps- or vacuum-assisted births (3) Genital tract laceration (4) Primiparity (5) Macrosomia (6) Prolonged second stage of labor (7) Preeclampsia (8) Clotting disorder (9) History of vulvar varicosities d) Small → ice packs, analgesia → may resolve over a few days (1) Heat after 24 hours e) Larger → evacuated with incision and drainage, broad spectrum antibiotics (1) Ligation of vessel (2) Urinary catheter due to packing (3) Risk for infection 7. Uterine inversion a) Prolapse of uterine fundus to, or through, cervix b) Often associated with: (1) Abnormal adherence of the placenta (2) Weakness of uterine musculature or uterine abnormalities (3) Rapid labor (4) Uterine relaxation secondary to anesthesia, drugs (5) Excess traction of cord or vigorous manual removal of placenta 4 Copyright © 2020 Pearson Education, Inc.

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c) Immediate repositioning of uterus within pelvis (1) Under intravenous tocolysis or general anesthesia 8. Coagulation disorders a) Postpartum bleeding with no identifiable cause b) Disseminated intravascular coagulation (DIC) → preeclampsia, amniotic fluid embolism, sepsis, abruptio placentae, prolonged intrauterine fetal demise syndrome

D. Late Postpartum Hemorrhage 1. Hemorrhage 24 hours to 12 weeks after birth 2. Subinvolution → failure to return to normal size of placental site, retention of placental tissue a) Site of placental implantation last area of uterus to regenerate (1) Postpartum fundal height greater than expected (2) Lochia often fails to progress normally (3) Retained placental tissue → confirm with pelvic ultrasonography b) Commonly diagnosed during routine postpartum examination (1) Enlarged, softer-than-normal uterus c) Oral administration of methylergonovine maleate (1) 0.2 mg every 3 to 4 hours for 24 to 48 hours d) Antibiotics if infection present

E. Nursing Management for the Woman with Postpartum Hemorrhage 1. Nursing Assessment and Diagnosis a) Regular and frequent assessment of fundal position, evidence of uterine tone, contractility b) Monitor bladder for evidence of increasing distention c) Assessment for bleeding → peripads d) Examine perineal area for signs of hematomas e) Notify physician/CNM if hematoma suspected f) Ice packs during first hour after birth → for 8 to 12 hours g) Alert for signs of impending hypovolemic shock 2. Diagnoses may include: a) Fluid Volume: Deficient b) Tissue Perfusion: Peripheral, Risk for Ineffective c) Bleeding, Risk for 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Boggy, soft uterus → massaged until firm, clots removed (2) Weigh perineal pads (3) Catheterize if unable to void (4) Risk factors, frequent massage → maintain vascular access 5 Copyright © 2020 Pearson Education, Inc.

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(5) Elevate legs to 30 degrees → promote oxygenation, venous return (6) See Key Facts to Remember: Nursing Actions During Postpartum Hemorrhage, p. 951 (7) Call for assistance per protocol (8) Administration of fluid replacement and transfusion, prescribed medications (9) Keep woman comfortable (10) Nothing by mouth (NPO) in case of surgery (11) Anticipate intensive monitoring → prepare woman and family for transfer to intensive care setting (12) Anticipate, request additional resources (13) Provide family with information (14) Collaboration and communication with team (15) Preparing for medical interventions such as IV infusions, blood transfusions, oxygen therapy, medications (16) Monitor urinary output (17) Blood and blood products b) Fluid replacement (1) Normal saline and lactated ringers (2) Rapid administration of warmed crystalloids (3) 3 mL solution per 1 mL of estimated blood lost ratio (4) Careful monitoring c) Monitor for transfusion reactions d) Evaluate for signs of anemia e) Plan activities for adequate rest f) Fatigue associated with blood loss → may need additional assistance caring for infant g) Father can support recovery 4. Health promotion education a) Woman and family need clear written explanations of normal postpartum course (1) Signs of abnormal bleeding (2) Fundal massage (3) Perineal care 5. Community-based nursing care a) Routine discharge instructions (1) Manage fatigue and weakened condition (2) Mother to take care of baby, delegate everything else b) Rise slowly to minimize risk of orthostatic hypotension c) May need assistance caring for newborn d) Needs rest, extra time to rest after activities e) Risk for depression f) Nutritional needs including high in iron g) Count perineal pads for several days h) Risk for infection i) Assess coping strategies j) Realistic information 6 Copyright © 2020 Pearson Education, Inc.

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6. Evaluation a) Signs of postpartum hemorrhage are detected quickly, managed effectively b) Maternal–infant attachment maintained successfully c) Woman able to identify abnormal changes that might occur following discharge (1) Understands importance of notifying caregiver if they develop

II.

Care of the Woman with a Reproductive Tract Infection or Wound Infection

A. Puerperal infections 1. Infection of reproductive tract associated with childbirth that occurs at any time up to 6 weeks postpartum a) Occurs at any time up to 6 weeks postpartum b) Most common → endometritis c) Peritonitis d) Respiratory complications e) Acute pyelonephritis f) Thrombophlebitis g) Breast engorgement 2. Preventive measures 3. Prognosis directly related to stage of disease at diagnosis, causative organism, appropriateness of treatment, state of health and immune system 4. Puerperal morbidity → temperature of 38°C (100.4°F) or higher, with temperature occurring on any 2 of first 10 days postpartum, exclusive of the first 24 hours, and when taken by mouth by a standard technique at least four times a day 5. Normal vaginal, cervical bacteria pathogenic a) Following rupture of membranes, during labor and delivery → contamination of cavity can easily occur

B. Postpartum Endometritis 1. Metritis → inflammation of the endometrium portion of the uterine lining a) 1 to 3% of vaginal births b) Primarily affects placental implantation side c) 30% to 35% cesarean births d) Same pathogenesis as vaginal delivery e) Aerobic and anaerobic organisms f) Initial 24 to 36 hours postpartum → group B streptococcus g) Late-onset postpartum endometritis/metritis → genital mycoplasmas and Chlamydia trachomatis

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2. Risks factors for postpartum uterine infection a) Cesarean birth b) Premature rupture of amniotic membranes (PPROM) c) Prolonged labor preceding cesarean birth d) Multiple vaginal examinations during labor e) Compromised health status f) Use of fetal scalp electrode or intrauterine pressure catheter for internal monitoring during labor g) Obstetric trauma h) Chorioamnionitis i) Preexisting bacterial vaginosis or Chlamydia trachomatis j) Instrument-assisted childbirth—vacuum or forceps k) Manual removal of the placenta or uterine exploration after delivery l) Retained placental fragments m) Lapses in aseptic technique by surgical staff n) Diabetes mellitus o) Immunocompromised status 3. Foul-smelling lochia, fever, uterine tenderness on palpitation, lower abdominal pain, tachycardia, chills 4. Antibiotics prior to surgery decreases incidence by up to 60%

C. Postpartum Wound Infections 1. Classic signs a) Redness, warmth, edema, purulent drainage, gaping of previously approximated wound, pain b) Cesarean delivery → concurrent endometritis (1) May have cellulitis without exudate (2) Culture exudate 2. Clinical therapy a) History and physical, cultures, blood tests, urinalysis b) Localized infection treated with broad-spectrum antibiotics, sitz baths, analgesics c) Evidence of pus → opened and drained (1) Packed and repacked two to three times daily d) Antibiotics with coverage against Staphylococcus aureus (1) Intravenous antibiotics for endometritis (2) Generally improve within 2 days of starting (a) If afebrile and asymptomatic for 24 hours → discontinue (i) If fever continues after 48 hours → continue workup

D. Nursing Management for the Postpartum Woman with Puerperal Infection 1. Nursing Assessment and Diagnosis a) Inspect perineum or abdominal wound site every 8 to 12 hours 8 Copyright © 2020 Pearson Education, Inc.

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b) REEDA scale (1) Redness, edema, ecchymosis, discharge, approximation c) Fever, malaise, abdominal pain, foul-smelling lochia, larger than expected uterus, tachycardia, other signs of infections → noted and reported 2. Diagnoses may include: a) Injury, Risk for b) Pain, Acute c) Parenting, Risk for Impaired 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Standard precautions (2) Aseptic technique (3) Teaching self-care to prevent infection (4) Draining wound → clear instructions about wound care, hand washing, linens (a) Ongoing assessment of urine specific gravity, intake and output (5) Medications and IVs as ordered (6) Promoting maternal–infant attachment (7) Breastfeeding mother can pump (8) Bonding with father (a) See Nursing Care Plan: For the Woman with a Puerperal Infection, p. 956 b) Community-based nursing care (1) Assistance when discharged from hospital (2) Instruction in care of newborn including feeding, bathing, cord care, immunizations, significant observations that should be reported (3) Instructions regarding activity, rest, medications, diet, signs and symptoms for complications c) Evaluation (1) Infection quickly assessed, treatment instituted successfully without further complications (2) Woman understands nature of infection and purpose of therapy (a) Carries out any ongoing antibiotic therapy necessary after discharge (3) Maternal–newborn attachment maintained

III.

Care of the Woman with a Urinary Tract Infection

A. Overdistention of the Bladder 1. Trauma, effects of anesthesia, nulliparity, instrumental childbirth, prolonged labor 2. Clinical therapy a) Draining bladder with straight catheter one time (1) Recurs → indwelling catheter for 24 hours

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B. Nursing Management for the Postpartum Woman with a Urinary Tract Infection 1. Nursing Assessment and Diagnosis a) Overdistended bladder appears as large mass, reaching to umbilicus, displacing uterine fundus upward and to one side 2. Diagnoses include: a) Infection, Risk for b) Urinary Retention 3. Nursing Plan and Implementation a) Diligent monitoring of bladder b) Encourage to void c) Medicate for pain prior to voiding d) Ice packs to perineum to minimize edema e) Warm water, sitz bath f) Aseptic technique if catheterization necessary g) Clamp catheter if urine amount reaches 800 mL (1) Document, vital signs (2) Unclamp place on gravity drainage 4. Evaluation a) Woman voids adequately to meet demands of increased fluid shifts during postpartum period b) Woman does not develop infection due to stasis of urine c) Woman actively incorporates self-care measures to decrease bladder distention

C. Cystitis (Lower Urinary Tract Infection) 1. Retention of residual urine, bacteria, bladder traumatized by childbirth a) Ascends from urethra to bladder b) Escherichia coli → most common cause 2. Clinical therapy a) Clean-catch, midstream urine sample b) Assist woman c) Antibiotic therapy before culture and sensitivity (1) Frequently trimethoprim-sulfamethoxazole-double strength (Bactrim DS, Septra DS) d) Antispasmodic or urinary analgesic agents, such as phenazopyridine hydrochloride (Pyridium)

D. Nursing Management for the Postpartum Woman with Cystitis 1. Nursing Assessment and Diagnosis a) Void every 2 hours to prevent urinary stasis b) Report symptoms of incomplete emptying of bladder or dysuria c) Symptoms of acute cystitis 10 Copyright © 2020 Pearson Education, Inc.

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(1) Usually start 2 to 3 days after birth (a) Pyelonephritis → systemic symptoms 2. Diagnoses may include: a) Pain, Acute b) Health Management, Ineffective 3. Nursing Plan and Implementation a) Screening for asymptomatic bacteriuria in pregnancy b) Frequent emptying of bladder during labor and postpartum c) Catheterization technique (1) Nursing actions to prevent overdistention 4. Health promotion education: avoiding postpartum UTIs a) Postpartum perineal hygiene b) Maintain good fluid intake c) Empty bladder frequently d) Void before and following intercourse e) Cotton-crotch underwear f) Evaluation (1) Woman identifies signs of UTI (a) Condition treated successfully (2) Woman uses self-care measures to prevent the recurrence of UTI (a) Part of her personal hygiene routine (3) Woman continues with any long-term therapy or follow up as appropriate for the diagnosis (4) Maternal–newborn attachment maintained (a) Woman able to care for newborn effectively

IV.

Care of the Woman with Postpartum Mastitis A. Infection of interlobar connective tissue in the breast that occurs primarily in lactating women 1. Onset is usually between the third and fourth week postpartum or any other time that nursing frequency decreases 2. Local to abscess, septicemia 3. Staphylococcus aureus, Haemophilus parainfluenzae, H. influenzae, E. coli, Streptococcus 4. Fever; chills; headache; flulike symptoms; warm reddened, painful area of breast, often wedge shaped a) See Figure 35–2: Mastitis, p. 960 b) Bacteria invade breast tissue after it has been traumatized in some way c) Milk stasis: milk favorable medium d) See Table 35–4: Factors Affecting Development of Postpartum Mastitis, p. 961 11 Copyright © 2020 Pearson Education, Inc.

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e) See Concept Map: Medical Diagnosis: Milk Stasis, p. 962 5. Candida albicans causative organism → baby will often have thrush 6. Clinical therapy a) Clinical diagnosis in most cases b) Midstream milk collection c) Frequent and complete emptying of the breasts d) Antibiotics (penicillinase-resistant penicillins) e) Rest f) Increased fluid intake (1) At least 2 to 2.5 L/day g) Supportive bra h) Local application of warm, moist heat or ice packs i) Analgesics (1) Nonsteroidal anti-inflammatory agents j) Continue breastfeeding (1) Increasing cases of methicillin-resistant Streptococcus aureus (MRSA) → breast milk culture if first round of antibiotic therapy not effective k) Candida infections (1) Antifungal creams or ointments (2) Oral fluconazole (Diflucan) l) Abscess formation (1) Incision and drainage (2) Continued breastfeeding recommended

B. Nursing Management for the Postpartum Woman with Mastitis 1. Nursing Assessment and Diagnosis a) Daily assessment of breast consistency, skin color, surface temperature, nipple condition, presence of pain b) Observe breastfeeding for technique c) Consultation with lactation specialist d) Assess for contributing factors 2. Diagnoses may include: a) Trauma, Risk for b) Breastfeeding, Ineffective 3. Nursing Plan and Implementation a) Prevention easier than treatment b) Meticulous hand washing c) Prompt attention to blocked milk duct d) Rotate position of infant for feeding e) Manually express milk f) Apply warm, moist compresses prior to breastfeeding 12 Copyright © 2020 Pearson Education, Inc.

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g) Switch breasts h) Early identification of, and intervention for, sore nipples essential 4. Discharge planning and home care teaching a) Woman to be aware of importance of: b) Regular, complete emptying breasts & stasis (1) Role of letdown (2) Correct positioning of infant (3) Proper latch on (4) Complete course of antibiotics c) All flulike symptoms considered sign of mastitis d) See Table 35–4: Symptoms of Engorgement, Plugged Duct, and Mastitis, p. 962 5. Community-based nursing care a) Home care nurse may suspect mastitis b) Assist mother to obtain appropriate breast pump c) Referral to lactation consultant, La Leche League 6. Evaluation a) Woman aware of signs and symptoms of mastitis b) Woman reports signs and symptoms of mastitis early (1) Treated successfully c) Woman can continue breastfeeding if she chooses d) Woman understands self-care measures she can use to prevent recurrence

V.

Care of the Woman with Postpartum Thromboembolic Disease A. Venous thromboembolism (VTE) 1. Formation of blood clot (thrombus) at an area of impeded blood flow in a superficial or deep vein 2. Thrombophlebitis: inflammation in vein wall a) Pulmonary embolism (1) Rare, life threatening (2) Thrombi formed in deep leg veins, carried to pulmonary artery, obstructing blood flow to one or both lungs 3. Three major causes (Virchow’s triad) a) Hypercoagulability of blood b) Venus stasis c) Injury to the epithelium of blood vessel 4. Risk factors include: a) Cesarean birth b) Immobility (prolonged) c) Obesity 13 Copyright © 2020 Pearson Education, Inc.

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d) Cigarette smoking e) Previous thromboembolic disease or strong family history f) Trauma to extremity g) Varicose veins h) Diabetes mellitus i) Advanced maternal age j) Multiparity k) Anemia l) Malignancy m) Inherited coagulation pathway deficiency n) Proteins C and S deficiency 5. Direct factors a) Increased amounts of certain blood clotting factors b) Postpartum thrombocytosis c) Release of thromboplastin substances from tissue of the decidua, placenta, fetal membranes d) Increased amounts of fibrinolysis inhibitors

B. Superficial vein disease 1. SVD → most common clot involves saphenous vein 2. More common in postpartum women than during pregnancy a) Preexisting varices 3. Tenderness in portion of vein, local heat and redness, normal temperature or low grade fever 4. Palpable cord 5. Local heat, elevation of affected limb, analgesic agents

C. Deep Vein Thrombosis 1. Women with history of thrombosis a) Obstetric complications (polyhydramnios, preeclampsia, and operative birth) increase incidence 2. Clinical manifestations may include: a) Edema of ankle and leg b) Initial low-grade fever c) Tenderness or pain d) Palpable cord e) Changes in limb color f) Difference in limb circumference (1) >2 cm g) Pain depending on location of vein involved 14 Copyright © 2020 Pearson Education, Inc.

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h) Positive Homans sign i) Diagnosis confirmed by objective testing.

D. Pulmonary Embolism 1. PE → thrombus from lower extremity or pelvis lodges in pulmonary vascular bed a) Restricts circulation to corresponding area of lung b) Catastrophic event with high mortality rate c) Size of the clot may be microscopic or large enough to occlude the branches of the pulmonary artery 2. Diagnosis difficult a) Nonspecific dyspnea b) Pleuritic chest pain c) Cough d) Cyanosis e) Tachypnea and tachycardia f) Panic g) Syncope h) Sudden hypotension 3. Clinical emergency a) Elevate head of bed b) Oxygen by face mask at 8 to 10 L per minute c) Narcotics for pain d) Imaging tests 4. Clinical therapy a) Immediate administration of anticoagulants (1) Unfractionated heparin drug of choice (2) International normalized ratio (INR) 2.0 to 3.0 with oral warfarin for 2 days (3) Strict bedrest (4) Elevation of leg (5) Analgesics b) Walking when symptoms subside c) Continue warfarin sodium for 3 months or more d) Elastic support stocking e) Vena cava filtering device if woman cannot be anticoagulated

E. Nursing Management for the Postpartum Woman with Thromboembolic Disease 1. Nursing Assessment and Diagnosis a) History b) Factors predisposing to development of thrombosis c) Alert to complaints of pain in leg, inguinal area, lower abdomen d) Assess legs for edema, temperature change, pain with palpation

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2. Diagnoses include: a) Tissue Perfusion: Peripheral, Ineffective b) Pain, Acute c) Parenting, Risk for Impaired d) Family Processes, Interrupted e) Knowledge, Deficient 3. Nursing Plan and Implementation a) Hospital-based nursing care (1) Evaluate women with varicosities for need for support hose during labor and postpartum b) Maintain heparin therapy c) Provide for comfort measures d) Monitor for signs of PE e) Assess for bleeding related to heparin f) Instruct to avoid prolonged sitting, standing g) Avoid crossing legs h) Frequent breaks when traveling i) Identify history 4. Health promotion education a) Taught drug and safety factors re: Coumadin b) Educated about foods high in vitamin K 5. Community-based nursing care a) Answer questions, clarify instructions b) Assess plans couple has for bed rest for mother c) Father may be assuming multiple roles d) Other concerns e) Resources as required f) All couples taught about signs and symptoms 6. Evaluation a) Woman seeks treatment for thrombophlebitis early (1) Managed successfully without further complications b) At discharge, woman able to explain purpose, dose regimen, necessary precautions associated with any prescribed medications c) Woman can discuss self-care measures and ongoing therapies indicated d) Woman has bonded successfully with newborn (1) Able to care for baby effectively

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VI.

Care of the Woman with a Postpartum Psychiatric Disorder

A. Types of Postpartum Psychiatric Disorders 1. Adjustment reaction with depressed mood 2. Postpartum mood episodes with psychotic features 3. Peripartum major mood episodes 4. Also known as postpartum depression 5. Adjustment reaction with depressed mood is the mildest condition a) Disrupted mood, commonly known as postpartum blues, or as maternal or baby blues b) Up to 85% characterized as mood lability and emotional hypersensitivity c) Does not consistently affect woman’s ability to function d) Self limiting e) Lasts from a few hours to 1 to 14 days f) Factors contributing (1) Primiparas (2) Emotional letdown that follows labor and childbirth (3) Physical discomfort typical in early postpartum (4) Fatigue (5) Anxiety about caring for newborn after discharge (6) Depression during pregnancy or previous depression unrelated to pregnancy (7) Severe premenstrual syndrome (PMS) g) Provide reassurance, validate existence h) Anticipatory guidance i) Partner encouraged to watch for and report signs that new mother not returning to more normal mood 6. Peripartum major mood episodes a) Postpartum depression (PPD) (1) Clinical depression b) Risk factors (1) History of major depression (2) Depression during pregnancy (3) History of postpartum depression or bipolar illness (4) Stressful life events (5) Primiparity (6) Ambivalence about maintaining pregnancy (7) Occurrence of postpartum blues (8) Lack of social support (9) Lack of stable, supportive relationship with parents or partner (10) Woman’s dissatisfaction with herself, including body image problems, eating disorders

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(11) Complications of delivery (12) Loss of newborn (13) Age (adolescence increases risk) c) First 4 weeks after childbirth → period of greatest risk (1) See Figure 35–3: Postpartum depression occurs in 10 to 20% of all postpartum women, p. 970 d) Women with postpartum depression at risk for suicide e) Screen for PPD f) Safety priority (1) Woman’s and her child(ren) (2) Question about depression, suicidal thoughts, infant at risk (3) May attempt suicide g) Woman and family need information about illness, course, risk of recurrence h) Outcomes good with antidepressants and psychotherapy (1) Serotonin reuptake inhibitors (SSRIs) (2) Monoamine oxidase inhibitors (MAOIs) rarely used (3) Medications excreted into breast milk (a) Prozac not recommended (4) Electroconvulsive therapy (ECT) for more rapid treatment of severe depression, mania, high risk for suicide 7. Postpartum mood episodes with psychotic features (postpartum psychosis) a) Usually evident first few days after childbirth b) Rare → considered emergency → risk of suicide, infanticide c) Clinical features (1) Sleep disturbances (2) Depersonalization (3) Confusion; irrational, disorganized thinking; bizarre behaviors; delusions; hallucinations (4) Psychomotor disturbances d) Risk factors (1) Previous postpartum psychosis (2) History of bipolar disorder (3) Family history of mood disorder e) May experience delusions, auditory ortactile hallucinations (1) Infant “better off dead” (2) Terrible crazy mother (3) Child may appear neglected f) Provision for safety of woman and infant (1) Immediate referral to psychiatric care (2) Inpatient admission g) Breastfeeding with psychotropic medications (1) Evaluate risk (a) Severity of symptoms 18 Copyright © 2020 Pearson Education, Inc.

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(b) Benefits of breastfeeding (c) Potential risks to baby if psychotropics used (d) Preferences of woman (2) Monitor infant 8. Posttraumatic stress disorder (PTSD) a) Development of characteristic symptoms following exposure to one or more traumatic events b) At risk (1) Prior psychiatric histories (2) Facts of labor and birth distorted c) Clinical features (1) Feeling numb (2) Dazed, unaware of environment (3) Intrusive thoughts (4) Flashbacks (5) Difficulty thinking (6) Difficulty sleeping (7) Irritability (8) Avoidance of others, reminders of traumatic event d) Clinical therapy (1) Medications (2) Individual or group psychotherapy (3) Practical assistance with child care (4) Support groups

B. Nursing Management for the Postpartum Woman with a Psychiatric Disorder 1. Nursing Assessment and Diagnosis a) Factors predisposing woman b) Prenatal questionnaire c) Anticipatory guidance of challenges of new motherhood d) Screening tools (1) Edinburgh Postnatal Depression Scale (EPDS) (a) Early management (2) Postpartum Depression Screening Scale (PDSS) e) Observe for objective signs of depression f) Listen for statements (1) Anxiety prominent feature for some women (2) Fatigue (3) Assessment of suicide risk (a) SAL → specific plan, accessible weapon or means, lethality of weapon g) Family members of depressed woman should be alert to signals

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2. Nursing diagnoses include: a) Coping, Ineffective b) Parenting, Risk for Impaired c) Violence: Self-Directed, Risk for 3. Nursing Plan and Implementation a) Offer realistic information b) Anticipatory guidance c) Social support teaching guides d) Alert mother, partner, family members to possibility of postpartum blues e) Information, emotional support, assistance providing care for infant 4. Community-based nursing care a) Home visits, especially early discharge b) Telephone follow-up c) Screening at well-child follow-ups d) Family problem e) Harder to understand → education of partner and family f) Practical matters of running household 5. Evaluation a) Woman’s signs of depression identified (1) She receives therapy quickly b) Newborn is cared for effectively by father/partner or another support person until mother able to provide care c) Mother and newborn remain safe d) Newborn integrated into family

VII.

Focus Your Study

VIII.

Activities 1. Individual Have students prepare drug cards on the following medications: • Oxytocin • Ergotamine • Prostaglandin • Misoprostol • Gelfoam • Polyvinyl alcohol • Ampicillin • Bactrim DS • Septra DS • Dicloxacillin • Cephalexin • Diflucan • Heparin • Warfarin sodium

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2. Small Group Divide the class into small groups of three to five students. Have each group role play telephone follow-up conversations for depression assessment in the postpartum woman. Have the groups document the questions asked.

3. Large Group Lead the class through the following two drills. At the closure of each drill, review the group’s performance and facilitate a class discussion on the drill.

A. Mock postpartum hemorrhage drill: • Identification of bleeding • Delegations of tasks • Documentation of tasks • Vital signs • IV infusions • Notification of provider • Positioning on bed • Oxygen therapy • Massaging fundus B. Mock pulmonary embolus drill: • Assessment of symptoms • Delegation of tasks • Documentation of tasks • Vital signs • IV infusions • Notification of provider • Positioning on bed • Oxygen therapy

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Chapter 36 Grief and Loss in the Childbearing Family Common Causes of Perinatal Loss.....................................................................

2

Maternal Physiologic Implications.....................................................................

4

Postbirth Evaluation...........................................................................................

4

The Experience of Loss.......................................................................................

5

Frameworks for Understanding Perinatal Loss..................................................

5

Special Issues for Consideration.........................................................................

7

Focus Your Studies..............................................................................................

17

Activities..............................................................................................................

17

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I.

Common Causes of Perinatal Loss

A. Occur from 20 weeks gestation up to 7 days after birth B. Incidence of fetal death after 20 weeks → 5.96/1000 total births C. Perinatal mortality rate (PMR) is defined as death around the time of delivery and includes both fetal deaths and early infant deaths D. Causes 1. Unknown 2. Physiologic maladaptations including asphyxia 3. Congenital malformations 4. Pregnancy complications a) Preeclampsia or eclampsia, diabetes, systemic lupus erythematosus, renal disease, thyroid disorders, cholestasis of pregnancy, abruptio placentae, placenta previa, diabetes, renal disease, cord accidents, fetal growth restriction, and alloimmunization 5. Inaccurate gestational age designation 6. Infections a) Especially in developing countries

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7. Multiple gestations 8. Lower education attainment 9. Advanced maternal age 10. Obesity

E. Risk factors 1. Previous still birth or IUGR 2. Maternal race or ethnicity 3. Age 4. Multiple gestation 5. Number of previous pregnancies 6. Twin pregnancies 7. Teenagers 8. Unmarried women 9. Maternal overweight and obesity

F. Early diagnosis of congenital anomalies 1. Increased use of elective termination

G. Reproductive advances → increase incidence of fetal death H. Infection 1. Causal factors a) Severe maternal illness b) Infecting placenta c) Infecting fetus causing congenital deformity incompatible with life d) Infecting fetus, damaging vital organ e) Precipitating preterm labor fetus dying in labor

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2. Ascending bacterial organisms

I. Maternal conditions 1. Hypertensive disorders 2. Diabetes mellitus 3. Thyroid, liver, or renal disease 4. Connective tissue disease (lupus) 5. Cholestasis

J. Maladaptations that can cause still birth 1. Antiphospholipid syndrome 2. Heritable thrombophilias 3. Red cell and/or platelet alloimmunization 4. Congenital anomaly and malformations 5. Chromosomal abnormalities 6. Fetomaternal hemorrhage 7. Fetal growth restriction 8. Placental abnormalities 9. Umbilical cord pathology 10. Multifetal gestation 11. Amniotic band sequence 12. Central nervous system lesions

II.

Maternal Physiologic Implications

A. Greatest maternal risks are from prolonged retention of deceased fetus 1. Disseminated intravascular coagulation (DIC) 2. Infection → endometritis, sepsis 3. Acute renal failure 4. Shock or hypotension 5. Maternal death

B. Multiple gestation 4 Copyright © 2020 Pearson Education, Inc.

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1. May retain live fetus 2. Follow prothrombin time (PT), partial prothrombin time (PTT), fibrinogen, platelet count

C. Clinical therapy 1. Woman may report absence of fetal activity 2. Diagnosis of IUFD confirmed by ultrasound a) Fetal heart with absence of heart action b) Maternal estriol levels fall c) Spontaneous labor within 2 weeks of fetal death 3. Induction within few days or weeks a) Wait until emotionally prepared if possible, schedule an induction b) Mode dependent on gestational age, readiness of cervix c) Laminaria tents → less than 16 gestational weeks d) Misoprostol 800 mcg vaginally e) repeated for second dose no earlier than 3 hours and typically within 7 days if no response to first doseOr Oxytocin (1) Preferred in women with prior uterine surgery f) Previous low transverse incision cesarean birth over 28 gestational weeks (1) Recommend cervical ripening

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III.

Postbirth Evaluation

A. Causative factor identification through postmortem exam assists families to progress through mourning B. Maternal, fetal, placental testing 1. See Table 36–1: Tests to Determine Cause of Fetal Loss, p. 979 2. Blood tests, x-rays 3. Ultrasound 4. Autopsy/MRI 5. Cultures 6. Chromosomal studies

C. Visual inspection of baby, umbilical cord & placenta D. Autopsy 1. Best to determine cause 2. If parents decline, MRI study

IV.

The Experience of Loss 1. Bereavement → suffered event of loss 2. Grief → individual’s reaction to the loss 3. Mourning → process by which individuals incorporate the experience into their lives 4. Unanticipated loss can be devastating, traumatic 5. Perinatal loss → disenfranchised grief a) Silent loss

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V.

Frameworks for Understanding Perinatal Loss A. Models and theories 1. No consensus for which model is cornerstone

B. Grieving process variable 1. Dependent on many factors 2. Nonlinear 3. Intensity of experience

C. Dual process model 1. Two competing sphere: Loss and restoration

D. Attachment theory 1. Nine events a) Planning pregnancy b) Confirming pregnancy c) Accepting pregnancy d) Feeling fetal movement e) Accepting the fetus as individual f) Giving birth g) Seeing baby h) Touching baby i) Giving care to baby j) See Table 36–2: Psychologic Process of Becoming a Parent, p. 980 2. First five levels a) Naming baby, future plans, nursery preparations, personal stories b) Continuing bonds to be connected to deceased infant 3. Meaning reconstruction a) Redefining ourselves, interactions with words after significant loss (1) Why me?

(2) 70 to 85% find themselves searching for meaning early in the los (3) Are we still parents? b) Facilitate process if struggling with meaning (1) Caregiver should not initiate process 4. Understand framework for process manifestations can be explored a) Early responses (1) Shock (2) Numbness (3) Denial 7 Copyright © 2020 Pearson Education, Inc.

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(4) Protest (5) Disorientation (6) Guilt (7) Confusion b) Denial protective mechanism to prevent meltdown (1) Hope second opinion will be different c) Move quickly from shock, confusion, denial into intense emotions d) Anger is common (1) Despair, longing for event not to have occurred e) See Evidence-Based Practice: Perinatal Grief Intensity Scale, p. 981

VI.

Special Issues for Considerations

A. Factors will influence couple’s response to perinatal loss 1. Gender 2. Age 3. Personality type 4. Family dynamics 5. Cultural and religious beliefs 6. Socioeconomic status 7. Early pregnancy 8. Multifetal pregnancy loss 9. Grief from infertility

B. Individual and Family Issues 1. Age a) Couples in 30s → may feel running out of time (1) May have living children as well b) Couples in 20s → may be first significant death c) Adolescent → physical, emotional responses (1) Adolescent who attaches meaning to her pregnancy has the highest rate of grief reaction and life impact (2) Younger the adolescent, greater physical and emotional responses to the loss were experienced as compared to older adolescents (3) Rely on peer support 2. Family dynamic a) Presence or lack of cohesion b) Strong family ties fare better

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c) “Lie and deny” family difficult to assess (1) Family deals with bad news and loss events as though they have not occurred d) Persistent denial → gentle review of facts 3. Gender issues a) Intuitive styles of coping (1) Feel way through loss (2) Prefer care with emphasis on emotional, psychosocial support (3) Initiate discussion of thoughts, feeling concerning loss (4) Share that spouses commonly unable to be emotionally available to each others b) Instrumental styles of coping (1) More cognitive skills to navigate loss (2) Value care with emphasis on problem solving (3) Address that parent who seems detached, unaffected by loss is not uncaring (a) More men fall into this category (4) They value acceptance, acknowledgment of pain, information regarding loss c) Inform couples that both styles are acceptable d) Reassure couples that the feelings will not always remain so intense 4. Other features of bereaved individuals a) Overall features that place them at increased risk (1) Insecurity (2) Anxiety (3) Low self-esteem (4) Previous psychiatric history (5) Excessive anger or guilt (6) Physical disability or illness (7) Previous unresolved losses (8) Inability to express emotion (9) Concurrent problems of living

C. Societal Issues 1. Spirituality → a) May bring comfort or precipitate spiritual crisis 2. Spirituality → human search for meaning and connectedness to life, others, God, universe 3. Religion → structured efforts conducted in a systematic approach to attain holiness 4. Six themes affecting spiritual needs a) Honest exchange of information b) Empathy and presence c) Continuing bonds d) Spiritual rites e) Attachment with others f) Grief support 9 Copyright © 2020 Pearson Education, Inc.

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5. Important for nurse not to answer rhetorical questions 6. Act as family advocate → contact clergy, spiritual advisor, hospital chaplain 7. Some commonalities within culture groups a) Grieving and rituals 8. Culture a) Culture can influence needs, beliefs b) See Table 36–4: Common Cultural Practices: Grief, Bereavement, and Perinatal Loss, pp.

984–986

D. Specific Circumstances 1. Infertility a) Ongoing struggle and face difficulties and decisions (1) Treatment available (2) Waiting (3) Psychologic roller coaster (4) When to discontinue treatment b) Assess where woman is in process c) Support decisions d) Finally experiencing a pregnancy → heightened anxiety, additional reassurances will need to be offered 2. Early pregnancy loss a) Ectopic, molar, blighted ovum, spontaneous abortion b) Devastating for many couples c) Attachment based on the level of emotional bonding d) May have guilt, especially mother e) Assessment of future pregnancies (1) Couples may have no desire to try again f) Prepare couples for fact that others will often underestimate impact of loss g) Early pregnancy remembrance box h) See Figure 36–1: Early pregnancy remembrance box, p. 987 3. Multifetal pregnancy loss a) MPL → statistics for increased prematurity rates, death during infancy for twins, higher order multiples (1) Twins 2.5 times higher mortality rate, triplets or higher 5 times b) MPL can be spontaneous, elective termination or selective reduction c) Loss of one baby can be from intrauterine demise, twin-to-twin transfusion, complications of monoamniotic twinning, placental problems, adverse intrapartum events, delayed interval delivery, postoperative complications, prematurity d) Issues affecting parents (1) Malformation, birth defects (2) Options and impact of difficult decisions 10 Copyright © 2020 Pearson Education, Inc.

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(3) Sudden death of infant fear and anxiety for surviving infants (4) Prospect of infertility because of previous abortions (5) Last attempt at in vitro fertilization (6) Guilt (7) Cohabitation of mourning and joy e) Resist urge to focus on positive of surviving sibling (1) Couple imagines what lost child might have looked like, personality, etc. f) Visual memories (1) Pictures of multiples together (2) Funeral or not, may delay until mother can attend 4. Maternal death a) Death of a woman while pregnant or within 42 days of termination of pregnancy (1) Irrespective of duration and site of pregnancy (2) From any cause related to or aggravated by the pregnancy or its management (3) Not from accidental or incidental causes b) Common causes (1) Hemorrhage, hypertensive disorders, amniotic fluid embolism, infection, preexisting chronic conditions, such as diabetes and cardiovascular disease (2) Obesity playing bigger role in risks (3) Homicide, suicide c) Husband, partner, or father of child (1) Shocking and traumatic (2) Complicated by number of factors (3) May be extremely intense d) Traumatic for staff on perinatal unit (1) Nursing care continues (2) Professional debriefing Take care of self and own reactions

E. Nursing Management for a Family Experiencing Perinatal Death 1. Nursing Assessment and Diagnosis a) Clinical setting (1) Cessation of fetal movement, decrease in signs and symptoms of pregnancy (2) Establish fetal demise (3) Assess family member’s ability to adapt to loss (4) Intrapartum complication (5) Assist family in mourning process b) Diagnoses that may apply include: (1) Grieving (2) Powerlessness (3) Family Processes, Dysfunctional (4) Hopelessness (5) Spiritual Distress, Risk for 11 Copyright © 2020 Pearson Education, Inc.

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2. Nursing Plan and Implementation a) Protocol of facility → holistic focus (1) Notify entire healthcare team (2) Symbol so staff aware of loss (3) Allow family to dictate own experience b) Avoiding use of clichés (1) Inappropriate remarks (a) See Table 36–5: Unhelpful Versus Helpful Interactions with Grieving Families, p.

990 (2) Facilitate healthy mourning → active listening c) Facilitating the family’s mourning process (1) Paradigm shift → normal mourning (2) From encouraging intense grief response to naturally resilient, will recover in their own time (3) Stoic response not always counterproductive (a) Not only is early intervention not always necessary, it can even be harmful (4) Simple caring guidelines (5) Goals (a) Help family navigate medical/healthcare system (b) Facilitate process by allowing them to dictate their own experience d) The caring theory (1) Five attributes of caregiver (a) Knowing (i) Attempting to understand event as it has meaning in life of parents (b) Being with (i) Emotionally present, as a human being (c) Doing for (i) Restating of the golden rule (d) Enabling (i) Facilitation of parents’ passage through life transitions and unfamiliar events (e) Maintaining belief (i) Believing in parents’ capacity to get through event and face future with meaning e) The art of responding (1) See Table 36–6: The Essential Elements of Responding Effectively to the Needs of Grieving Families, p. 991 3. Preparing the family for the birth and death a) Known or suspected fetal demise → private room away from other laboring women (1) Sit down, introduce self, simple statement (a) “I’m so sorry. This must be hard for you. I’d like to help you through it.”

(2) Allow couple to stay together as much as they wish b) Complete information about what to expect (1) See Figure 36–3: St. Joseph perinatal comfort care program …, p. 991 12 Copyright © 2020 Pearson Education, Inc.

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c) Stay with couple or respect cues to be left alone d) Same nurse → therapeutic relationship e) May ask same questions repeatedly f) Interprofessional team g) Offer to contact chaplain, social worker h) Explain details of plan of care (1) Allow to make decisions (2) See Figure 36–4: St. Joseph Hospital neonatal comfort care orders, p. 993 i) Birth of terminal or stillborn infant marks beginning and end j) Help couple explore feelings, make decisions k) Birth preferences (1) Music, lights (2) Specific position (3) Have baby placed on mother’s chest immediately after birth (4) Allow father to cut umbilical cord (5) Including family members/friends at birth l) May be concerned about strange preferences (1) Reassure no right or wrong feelings m) Waves of overwhelming grief, disbelief, sadness 4. Supporting the family in decision making a) Guidance throughout process b) Simple choices c) Advocate d) Careful listening e) Any decision couple makes for themselves is the right one f) If hesitant to view infant, offer a picture to help allay fears 5. Postmortem care a) Preparing for viewing and holding (1) Maceration (a) Tissue breakdown → sloughing of the skin (b) Gloved hand for washing → disrupt skin as little as possible (2) Place in gown (3) Wrap in blanket (4) Hat to cover birth defects b) Allow parents opportunity to see the baby before seeing birth defects c) Monitor own personal reactions to infant d) Dying infant (1) Bathe quickly → return to parents (2) Allow to remain with parents as long as they desire e) See Table 36–7: Postmortem Care, p. 995 6. Supporting siblings and extended family members a) Advocate for family’s wishes 13 Copyright © 2020 Pearson Education, Inc.

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b) Children included as parents wish (1) Children respond according to their age and maturity level c) Avoid euphemisms d) Children will need reassurance (1) That they are still going to be taken care of (2) That nothing they did caused the event to happen e) Extended family members → “doubly” grieving f) Family support major comfort with open communication, honest interaction 7. Actualizing the loss: Providing memories a) Mementos (1) See Figure 36–5: Foot- and handprint molds, p. 996 b) Pictures c) Hand- or footprint molds and cards d) Remembrance box (1) See Figure 36–6: Personal memory box, p. 996 8. Providing discharge care a) Three options for disposition (1) Traditional burial via funeral home (a) Family contacts funeral home directly to make arrangements (b) Burial on private land (i) State and locally dictated b) Cremation at a funeral home c) Hospital disposition (1) Not recommended d) Support decision e) Option of early discharge f) Facility protocol (1) Birthing unit, postpartum or medical unit (2) All staff notified of mother’s status g) Physical considerations, adaptation of mother h) Emotional considerations of couple i) Prepare couple for home (1) Others will not know how to respond (2) Age appropriate grieving for siblings (3) Depression common (4) Cope better if adequately prepared j) Nurse experiences many of grief reactions as parents k) Closure of intrapartum event to continue process l) Refer for counseling m) Schedule follow-up phone calls to assess family’s functioning 9. Referring the family to community services a) Established protocol for families 14 Copyright © 2020 Pearson Education, Inc.

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b) Specialized groups c) Internet technology allowed large numbers of individuals to share resources 10. Perinatal hospice a) Compassionate structured program providing context to find meaning b) Offer parents support and guidance c) Interprofessional team 11. Care of the couple who has experienced loss in a previous pregnancy a) Previous loss → enters subsequent pregnancy with conflicting feelings b) May relive experience c) Kind, compassionate, and patient d) Potential of unresolved grief e) Interventions to decrease anxiety (1) Early ultrasound (2) Weekly visits for a period of time to hear fetal heartbeat (3) Additional antepartum testing (4) Non-stress test, biophysical profiles f) See Nursing Care Plan: For a Family Experiencing Perinatal Loss, p. 999 12. Evaluation a) Challenging and rewarding b) Expected outcomes include: (1) Family members feel free to express their feelings about the death of their baby if they desire to do so (2) Family members participate in decision making regarding preferences for labor, birth, and immediate postpartum period (3) Family members participate in decision of whether to see their baby and other decisions about the baby (4) The family has resources available for continued support (5) Family members know the community resources available and have names and phone numbers to use if they choose

VII.

Focus Your Studies

VIII.

Activities 1. Individual Have students research the perinatal morbidity and mortality statistics for selected cities in your state. Have each student prepare a short report on the demographics.

2. Small Group Divide the class into small groups of three to five students. Have each group research perinatal grieving. Next, have each group brainstorm on their findings to develop the appropriate therapeutic communications for difficult scenarios such as the following: • What will baby look like?

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• • •

Why did this happen to me?

I feel like such a failure.

I will never get over this.

3. Large Group Invite a member of the clergy, social worker, or grief counselor who works with perinatal loss to speak with the class.

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