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Chapter 1- contraception Contraception refers to strategies or device used to reduce the risk of fertilization or implantation in an attempt to prevent pregnancy Natural family planning: behavioral methods o Abstinence – no gentialia contact o Withdrawal (coitus interruptus) Choice for monogamous couple Least effective methods Risk for pregnancy o Calendar methods ovulation occurs about 14 days before the onset of her next menstrual cycle, and avoid intercourse during that period count at least 6 cycles o basal body temperature body temperature can drop slightly at the time of ovulation measure oral temperature prior to getting out of bed each morning to monitor ovulation inexpensive, convenient, and no adverse effects Basal body temperature and the symptothermal method are fertility awareness methods. o Lactational amenorrhea method Barrier o Condoms Only water-soluble lubricants should be used with latex condoms to avoid condom breakage o Diaphragm Dome-shaped cup with a flexible rim made of silicon that fits snugly over the cervix with spermicidal cream or gel placed into the dome and around the rim Client should be properly fitted with a diaphragm by a provider Replaced every 2 years and refitted for a 20% weight fluctuation, after abdominal or pelvic surgery and after every pregnancy Prior to coitus, the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim The diaphragm can be inserted up to 6 hours before intercourse and must stay in place 6 hour after intercourse but for no more than 24 hrs. Spermicide must be reapplied with each act of coitus Patient should empty bladder before insertion Wash with soap and water after use o Cervical cap o Contraceptive sponge o Question
IUD can maintain effectiveness for 1 to 10 years Contraception can be reversed Can increase the risk of pelvic inflammatory disease, uterine perforation, or ectopic pregnancy and can be expelled A client should report to the provider later or abnormal spotting or bleeding, abdominal pain or pain with intercourse, abnormal of foul-smelling vaginal discharge, fever, chills, a change in string length or if IUD cannot be located IUD can cause irregular menstrual bleeding Must be removed in the event of pregnancy o Emergency contraception Morning-after pill that prevents fertilization from taking place Pill is taken within 72 hr after unprotected coitus Surgical methods o Tubal ligation Sterilization for women A laprascope is inserted; fallopian tubes are grasped and sealed o Vasectomy Sterilization for men Usually performed under local anesthesia Involves cutting the vas deferens, which carries the sperm Chapter 3 – Expected physiological changes during pregnancy Signs of pregnancy o Presumptive, probable, positive Presumptive: those changes felt by the woman o e.g., breast changes (darkened areolae, enlarged Montgomery’s glands), uterine enlarged, quickening (slight fluttering movements of the fetus feld by a woman, usually between 16 to 20 seeks of gestation) o Skipping period is not reliable sign of pregnancy by itself but if it accompanied by nausea, fatigue, breast tenderness, and urinary frequency, pregnancy would see very likely Probable: those changes observed by an examiner o Hegar’s sign – softening and compressibility of lower uterine segment or isthmus o Ballottement examiner pushes against the women's cervix during a pelvic exam and feels a rebound from the floating fetus rebound of unengaged fetus o abdominal enlargement o Chadwick’s sign – deepened violet-bluish color of cervix and vaginal mucosa o Broxton Hicks contractions – falls contractions that are painless, irregular, and usually relieved by walking o Positive pregnancy test Hasan Chowdhury - 3
Human chorionic gonadotropin (HcG) is earliest biochemical marker for pregnancy Production begins as early as day of implantation Can be detected in maternal serum or urine as soon as 7 to 8 days before the expected menses Urine sample should be first-voided morning specimens and follow the direction for accuracy o Fetal outline felt by examiner Positive: those signs attributed only to the presence of the fetus o Confirm that fetus is growing in the uterus o Fetal heart sound - hearing fetal heart tones (via Doppler) o visualizing the fetus by ultrasound o palpating fetal movements (20 weeks) by examiner o Pulse sock on mom to get mom’s HR to ensure it’s not baby’s heart sound Calculating delivery date and determine number of pregnancies for pregnant client o Nagele’s rule Date of last menstrual period (LMP) Calculation of estimated or expected date of birth (EDB) or delivery (EDD) Nagele’s rule Use first day of LNMP 11/21/ Subtract 3 months 8/21/ Add 7 days 8/28/ Adjust year 8/28/08 = EDB Ultrasound is the best method of dating a pregnancy o Kathy’s rule Add 9 months and 7 days o Measurement of fundal height In centimeters form the symphysis pubis to the top of the uterine fundus (between 18 and 32 weeks of gestation) Approximates the gestational age o Gravidity – number of pregnancies Nulligravid – never been pregnant Primigravida – first pregnant Multigravida – two or more pregnant o Parity – number of pregnancies in which the fetus or fetuses reach 20 weeks of pregnancy Nullipara – no pregnancy beyond the stage of viability Primipara – has completed one pregnancy to stage of viability Multi para o Viability – infant has capacity to survive outside of uterus (22 to 25 weeks) o GTPAL acronym Gravidity Term birth (38 weeks or more) Preterm birth (from viability up to 37 weeks) Abortions/miscarriages (prior to viability) Living children Hasan Chowdhury - 4
High in folic acid is important for neurological development and prevent fetal neural tube defects Foods – green leafy vegetables, dried peas and beans, seeds, orange juice Women who wish to become pregnant of childbearing age take 400 mcg of folic acid Women who become pregnant take 600 mcg of folic acid to prevent fetal neural tube defects o Iron supplements Best absorbed between meals and when given with a source of vitamin C (orange juice) Foods – beef liver, red meat, fish, poultry, dried peas and beans and fortified cereals Stool softener might need to be added to decrease constipation with iron supplement o Calcium Foods – milk, nuts, legumes and dark green leafy vegetables Postpartum women who are breastfeeding should continue taking calcium supplement during lactation o Fluid 8 to 10 glasses (2.3 L) of fluids are recommended daily o Limit caffeine Recommend daily intake of no more than 200 mg of caffeine It is recommended that women abstain form alcohol consumption during pregnancy Chapter 6 – Assessment of fetal well-being Ultrasound o client should have full bladder for the procedure o fetal and maternal structures can be pointed out to the client as the US procedure is performed Biophysical profile o Uses a real-time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli o Client presentation Premature rupture of membranes Maternal infection Decreased fetal movement Intrauterine growth restriction o Variables FHR Fetal breathing movements Gross body movements Fetal tone Qualitative amniotic fluid volume o Total score findings 8 to 10 is normal – low risk of chronic fetal asphyxia Kasan Cho×1hury - h
4 to 6 is abnormal – suspect chronic fetal asphyxia Less than 4 is abnormal – strongly suspect chronic fetal asphyxia Nonstress test o Most widely used technique for antepartum evaluation of fetal well-being performed during the 3rd^ trimester o Noninvasive procedure that monitors response of the FHR to fetal movement o Disadvantage of an NST include a high rate of false nonreactive results with the fetal movement response blunted by sleep cycles of the fetus, fetal immaturity, maternal medications and nicotine use disorder The acoustic vibration device is activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus Contraction stress test o Nipple-stimulated contraction test Consists of a woman lightly brushing her palm across her nipple for 2 min, which cause the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins o Oxytocin-stimulated contraction test IV administration of oxytocin to induce uterine contractions Oxytocin is used to induce uterine contraction Contraindicated for placenta previa, vasa previa, preterm labor, multiple gestations, previous classic incisions for C-section, reduced cervical competence Can be difficult to stop and may lead to preterm labor Negative results are a normal finding Positive result is an abnormal finding o Indication for contraction stress test (CST) Decreased fetal movement Intrauterine growth restriction (IUGR) Postmaturity Amniocentesis o Aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client’s uterus and amniotic sac under ultrasound guidance locating the placenta and determining the position of the fetus o It may be performed after 14 weeks of gestation o Indications Prenatal diagnosis of genetic disorder or congenital anomaly of the fetus Alpha-fetoprotein (AFP) level for fetal abnormalities High AFP – neural tube defect Low AFP – down syndrome Lung maturity assessment o Instruct the client to empty her bladder prior to the procedure to reduce its size and reduce the risk of inadvertent puncture o Post procedure Administer Rho(D) immune globulin to the client if she is Rh-negative (standing practice after an amniocentesis for all women who are Rh- negative to protect against Rh isoimmunization) Kasan Cho×1hury - 7
Corticosteroids, such as betamethasone, promote fetal lung maturation if early delivery is anticipated (cesarean birth) Abruptio placentae o Abruptio placentae is the premature separation of the placenta from the uterus o It has significant material and fetal morbidity and mortality and is a leading cause of maternal death o Sudden onset of intense localized uterine pain with dark red vaginal bleeding o Risk factors Blunt external abdominal trauma (motor-vehicle crash, maternal battering) Cocaine use resulting in vasoconstriction Smoking cigarette Maternal hypertension (chronic or gestational) Previous incidence of abruptio placentae Premature rupture of membrane Multifetal pregnancy Chapter 9 – Medical conditions Cervical insufficiency (premature cervical dilation) o The client can require cervical cerclage (indicated for women who have singleton pregnancy) o Often placed at 12 to 14 weeks gestation and removed at 37 weeks gestation o Provide education about clinical findings to report to the provider for preterm labor rupture of membranes, infection, strong contractions less than 5 min apart, severe perineal pressure, and an urge to push Hyperemesis gravidarum o hyperemesis gravidarum is excessive nausea and vomiting (possibly related to elevated hCG levels) that is prolonged past 12 weeks gestation and results in 5% weight loss from pre-pregnancy weight, electrolyte imbalance, acetonuria and ketosis o Risk factors maternal age younger than 30, history or migraines, obesity, first pregnancy, diabetes, multi-gestation, GI disorders, or family history of hyperemesis monitor patient I&O, assess skin turgor, weight and vital signs o laboratory test Urinalysis for ketones and acetones (breakdown of PR and fat) is the most important lab test
- Elevated urine specific gravity, urine ketone present Chemistry profile Thyroid test – indicate hyperthyroidism CBC (complete blood count) – elevated Hct o Nursing care Monitor I&O Assess skin turgor and mucous membranes Monitor vital signs Monitor weight Have the client remain NPO for 24 to 48 hours Kasan Cho×1hury - 9
Clear liquid after 24 if no vomiting and increase diet if tolerated o Medications Give the client IV lactated ringer’s for hydration Give pyridoxine (vitamin B6) and another vitamin supplement s as tolerated Use antiemetic medications (ondansetron, metoclopramide) cautiously for uncontrollable nausea and vomiting Use corticosteroid to treat refractory hyperemesis gravidarum o Advance the client’s diet as tolerated, with frequent small meals – start with dry toast, crackers, or cereal; then move to a soft diet; and finally, to a normal diet as tolerated Iron-deficiency anemia o Occurs during pregnancy due to inadequacy in maternal iron stores and consuming insufficient amounts of dietary iron o Foods – legumes, fruits, green leafy veggies, and meat o Medications Ferrous sulfate iron supplements Instruct the client to take the supplement on an empty stomach and take with orange juice to increase absorption Encourage a diet rich in vitamin C- containing foods to increase absorption Gestational diabetes mellitus o Gestational diabetes mellitus (GDM) is an impaired tolerance to glucose with the first onset or recognition during pregnancy Normal glucose during pregnancy – 70 to 110 mg/dL Women will develop type II diabetes mellitus within 5 years of delivery o Laboratory tests Glucola screening test/1-hr glucose tolerance test 50 g oral glucose load, followed by plasma glucose analysis 1 hour later perforated 24 to 28 weeks of gestation Fasting is not necessary Positive blood glucose screening is 130 to 140 mg/dL or greater Additional testing with a 3-hr oral glucose tolerance test (OGTT) is indicated Oral glucose tolerance test (OGTT) Following overnight fasting Avoid caffeine and abstinence from smoking for 12 hr prior to testing Fasting glucose is obtained, a 100g glucose load is given and serum glucose levels are determined at 1,2, and 3 hr following glucose ingestion o Diagnostic procedures Biophysical profile to ascertain fetal well-being Nonstress test to assess fetal well-being o Medication Oral hypoglycemic therapy is an alternation to insulin in women who have GDM who require medication in addition to diet for blood glucose control Kasan Cho×1hury - 10
Medication of choice for prophylaxis or treatment to lower blood pressure and depress the CNS Monitor for signs of magnesium sulfate toxicity o Absence of patella deep tendon reflexes o Urine output less than 30 mg/hr o RR less than 12/min o Decrease level of consciousness o Cardiac dysrhythmias Antidote – calcium gluconate or calcium chloride o Client education Maintain bed rest and encourage side-lying position Promote diversional activities (TV, visits form family or friends, gentle exercise) Avoid foods that are high in sodium Avoid tobacco and alcohol and limit caffeine intake Drink 6 to 8 oz glasses of water a day Maintain dark, quiet environment to avoid inducing a seizure Maintain a patent airway in the event of seizure Administer antihypertensive medications as prescribed Chapter 10 – Early Onset of Labor Preterm labor o Preterm labor is uterine contraction and cervical changes that occur between 20 and 37 weeks of gestation o Assessment of preterm labor Previous preterm birth Multifetal pregnancy Substance use History of multiple miscarriages or abortions Diabetes mellitus Chronic hypertension Second trimester bleeding History of UTI o o Expected findings – uterine contraction o Diagnostic procedures Obtain swab of vaginal secretions for fetal fibronectin between 24 and 34 weeks of gestation This protein can be found in vaginal secretions and can be related to inflammation of the placenta and that can lead to preterm birth This test is used to determine preterm labor o Nursing care Focusing on stopping uterine contraction Activity restriction Strict bed rest can have adverse effects Kasan Cho×1hury - 12
Encourage the client to rest in the left lateral position to increase blood flow to the uterus and decrease uterine activity Ensuring hydration Dehydration stimulate the pituitary gland to secret and antidiuretic hormone and oxytocin o Medication Nifedipine Calcium channel blocker Used to suppress contractions by in habiting calcium form entering smooth muscles Nursing consideration o Monitor for headache, flushing, dizziness and nausea o These usually are related to orthostatic hypotension that occurs with administration Magnesium sulfate Commonly used tocolytic that relaxes the smooth muscle of the uterus and thus inhibits uterine activity by suppressing contraction Nursing consideration o Contraindications for tocolysis include active vaginal bleeding, dilation of the cervix greater than 6 cm, chorioamnionitis, greater then 34 weeks gestation and acute fetal distress o Monitor for client for magnesium toxicity and discontinue for any of the following adverse effects Loss of deep tendon reflexes Urinary output less than 30 ml/hr Respiratory depression (less than 12/min) Pulmonary edema and chest pain o Administer gluconate of calcium chloride as and antidote for magnesium sulfate toxicity Notify provider – blurred vision, headache, nausea, vomiting, or difficulty breathing Indomethacin Non-steroidal anti-inflammation drug (NSAID) Suppress preterm labor by blocking the production of prostaglandins This inhibition of the prostaglandins suppresses uterine contraction Betamethasone Enhance fetal lung maturity and surfactant production in fetuses between 24 to 34 weeks gestation Premature rupture of membranes o Client reports a gush or leakage of clear fluids from the vagina Temperature elevation Increased maternal hear rate or FHR Foul-smelling fluid or vaginal discharge Abdominal tenderness Kasan Cho×1hury - 13
Immediately following the rupture of membranes, a nurse should assess the FHR for abrupt decelerations, which are indicative of fetal distress to rule out umbilical cord prolapse o Assessment of amniotic fluid Amniotic fluid is alkaline – Nitrazine paper is deep blue, indicting pH of 6. to 7. Laboratory analysis o Group B streptococcus Screening at 35 to 37 weeks If positive, IV prophylactic antibiotic is prescribed, exceptions are planned cesarean birth and membranes intact o Urinalysis Proteinuria, UTI (common diabetic pregnancy) Characteristics^ of^ False^ Labor o Contraction -Painless,^ irregular frequency, and intermittent contractions -Contractions decrease in frequency, duration, and intensity with walking or position changes -Contractions are felt in lower back or abdomen above umbilicus -Contractions often stop with sleep or comfort measures such as oral hydration or emptying of the bladder o Cervix^ (assessed by vaginal exam) -The^ cervix has no significant changes in dilation or effacement -The cervix often remains in posterior position -The cervix has no bloody show o Fetus^ -The presenting part of the fetus is not engaged in the pelvis. Nursing^ Care^ During^ Stages^ of^ Labor:^ Identifying^ the^ Need^ for^ Reassessment o If^ there are late declarations o if^ baby is tachycardic or bradycardia Chapter 12 – pain management nonpharmacological o Reduce anxiety, fear and tension which are major contributing factors to pain in labor o Hypnosis, biofeedback, music therapy o Cutaneous stimulation strategies Effleurage – light, gentle circular stroking of the client’s abdomen with the fingertips in rhythm with breathing during contractions o Sacral counterpressure using the heel of the hand or fist against the client’s sacral area to counteract pain in the lower back o hydrotherapy (whirlpool or shower) increases maternal endorphin levels o frequent maternal position changes to promote relaxation and pain relief supine position only with the placement of a wedge under one of the client’s hip to tilt the uterus and avoid supine hypotension syndrome pharmacological Kasan Cho×1hury - 15
o To avoid slowing the progress of labor, prior to administering analgesic medications, the nurse should verify that labor is well established by performing a vaginal exam and evaluating uterine contraction pattern o Analgesia Sedatives (barbiturates) Secobarbital pentobarbital and phenobarbital can be used during the early or latent phase of labor to relieve anxiety and induce sleep Side effect - Neonate respiratory depression secondary to the medication crossing the placenta and affecting the fetus. This medication should not be administered if birth is anticipated within 12 to 24 hours Nursing action Assist the mother to cope with labor Assess the neonate for respiratory depression Opioid analgesics Meperidine hydrochloride, fentanyl, butorphanol, nalbuphine act in CNS to decrease the perception of pain without the loss of consciousness Client can receive opioid analgesics IM or IV but the IV route is recommended during labor because the action is quicker these given early part of active labor Butorphanol and nalbuphine o Adverse effect Opioid analgesics can cause respiratory depression in the neonate Sedation Hypotension Decreased FHR variability o Nursing action Performing a vaginal exam that reveals cervical dilation of at least 4 cm with a fetus that is engaged Administer antiemetics as prescribed Prepare administer antidotes Naloxone, an opioid antagonist, should be readily available for reversal of opioid- induced respiratory depression Epidural and spinal regional analgesia o Fentanyl and sufentanil o Adverse effect Bradycardia or tachycardia Hypotension Respiratory depression o Nursing action Putting side rails up on the client’s bed – client can experience dizziness and sedation, which increases maternal risk for injury Administer Antiemetics as prescribed Kasan Cho×1hury - Th
o Manage maternal hypotension by administering an IV fluid bolus as prescribed, position the mother laterally, increasing the rate of IV fluid administration and initiating oxygen o To relieve postpartum headache resulting from cerebrospinal fluid leak, placing the client in a supine position, promoting bed rest in a dark room, and administering oral analgesics, caffeine and fluids. An autologous blood patch is the most beneficial and reliable relief measure for cerebrospinal fluid leaks General anesthesia Delivery complication or emergency General anesthesia produces unconsciousness Nursing action o NPO o Apply antiembolic stockings or sequential compression devices o Administer histamine-receptor antagonist – ranitidine to decrease gastric acid production o Administer metoclopramide to increase gastric emptying as prescribed o Assess the client postpartum for decreased uterine tone, which can lead to hemorrhage and be produced by pharmacological agents used in general anesthesia Chapter 13 – Fetal Assessment during labor Leopold maneuvers o Leopold maneuvers consist of performing external palpations external palpations of the maternal uterus through the abdominal wall to determine the following o Place a small, rolled towel under the client’s right or left hip to displace the uterus off the major blood vessels to prevent supine hypotensive syndrome Continuous electronic fetal monitoring o A normal fetal heart rate breathing at term is 110 to 160/min excluding accelerations, decelerations and periods of marked variability within a 10 min window. o Fetal heart rate baseline variability is described as fluctuations in the FHR baseline that that irregular in frequency and amplitude FHR patterns o Accelerations o Fetal bradycardia FHR less than 110/min or 10 min or more Causes/complications Uteroplacental insufficiency Umbilical cord prolapses Anesthetic medications Nursing intervention Discontinue oxytocin if being administered Kasan Cho×1hury - T
Assists the client to a side-lying position Administer oxygen by mask at 10 L/min via nonrebreather face mask Notify the provider o Fetal tachycardia FHR greater than 160 /min for 10 min or more Causes/complication Maternal infection, chorioamnionitis Nursing interventions Administer prescribed antipyretics for maternal fever Administer oxygen by nonrebreather face mask o Early deceleration of FHR Causes/complication Compression of the fetal had resulting form uterine contraction o Later decelerations of FHR Uteroplacental insufficiency causing inadequate fetal oxygenation Nursing intervention Place client in side-lying position IV fluid administration Discontinue oxytocin if being infused Administer oxygen by mask at 8 to 10 L/min via nonrebreather face mask Elevate the client’s leg Notify the provider o Variable deceleration of FHR Umbilical cord compression Nursing interventions Reposition client form side to side or into knee-chest Discontinue oxytocin if being infused Administer oxygen by mask at 8 to 10 L/min via nonrebreather face mask Chapter 14 – Nursing care during stages of labor Identifying the needs for reassessment each different stage of labor calls for different assessments of the mom stage^ one^ should^ focus^ on^ rupture^ of^ membranes,^ bladder^ distention,^ temperature, and FHR stage^ two^ should^ focus^ on^ BP,^ HR,^ and^ RR^ every^ 5-30 minutes,^ uterine^ contractions, pushing efforts by client, increase in bloody show, shaking of extremities stage three is focused on BP, HR, and RR every 15 min, clinical findings of separation of placenta, vaginal fullness exam stage^ four^ should^ focus^ on^ assessing^ maternal^ vital^ signs^ to^ a^ steady^ state Chapter 15 – Therapeutic procedures to assist with labor and delivery Kasan Cho×1hury - T
