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Maternal Exam and Prenatal Care, Exams of Nursing

Chamberlain College of Nursing Nursing

Information on postpartum hemorrhage, prenatal care, and fetal heart tones. It explains the causes of PPH, how to assess fundus, and the medications used to treat it. It also lists the things that need to be checked during a prenatal visit and the changes in body systems during pregnancy. the three stages of maternal role transition and the fetal heart tones. It also provides information on the different types of decelerations and what to do in case of a late deceleration.

Typology: Exams

2022/2023

Available from 11/22/2023

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MATERNAL EXAM, CORRECT. Rated

Postpartum Hemorrhage (PPH)

•From delivery up to 6wks postpartum

•SVD Spontaneous vaginal delivery: greater than 500ml (considered PPH)

oEstimated blood loss

oQuantitative blood loss (weighing everything)

•CS C-Section: greater than 1000ml

Two main reasons for PPH

•Full bladder

•Retained placenta

What you will assess when you walk into a patient’s room for PPH

1. Assess Fundus

-should always be right at umbilicus

If it feels like your cheek: boggy; (massage it) Don’t stop unless it firms up

2. Call for help

3. Call Dr.

4. Meds

5. VS and O2 stat

6. Weigh under pads (add this amount of blood loss to what she lost at delivery

7. Change under pads

8. Empty bladder (foley)

9. Start 2nd IV; may need to give patient blood

oOnce you start to feel the fundus firm up you can stop massaging

oOnly thing that can misplace the fundus is a full bladder

•The uterus has to contract to stop bleeding

Meds (all usually standing orders)

Discover Exams of Nursing Chamberlain College of Nursing

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Postpartum Hemorrhage (PPH)

From delivery up to 6wks postpartum
SVD Spontaneous vaginal delivery: greater than 500ml (considered PPH) o Estimated blood loss o Quantitative blood loss (weighing everything)
CS C-Section: greater than 1000ml Two main reasons for PPH
Full bladder
Retained placenta What you will assess when you walk into a patient’s room for PPH

Assess Fundus -should always be right at umbilicus If it feels like your cheek: boggy; (massage it) Don’t stop unless it firms up
Call for help
Call Dr.
Meds
VS and O2 stat
Weigh under pads (add this amount of blood loss to what she lost at delivery
Change under pads
Empty bladder (foley)
Start 2 nd^ IV; may need to give patient blood o Once you start to feel the fundus firm up you can stop massaging o Only thing that can misplace the fundus is a full bladder

The uterus has to contract to stop bleeding Meds (all usually standing orders)

Pitocin : usually IV sometimes IM every patient after they deliver will get this drug (immediately) o If there is a fetus in the uterus; has to be on pump and is piggybacked o If not given wide open
Methergine : given IM; if patient has HTN CANNOT be given this drug
Hemabate : given IM; CANNOT give if patient has asthma (can cause explosive diarrhea)
Cytotec : rectally; given 800-1000 mcg *Methergine and Hemabate: work within 2-3 minutes If all of this doesn’t work then back to the OR
Should be dark brown
Firm w/ Bright red blood- laceration
After delivery check every 15 minutes x 4
Every 30 minutes x 4

Conception – 13 6/7 weeks (13 weeks & 6 days) 2 nd^ trimester
14 weeks -26 6/7 weeks (26 weeks & 6 days) 3 rd^ Trimester
27 weeks-40 6/7 weeks (40 weeks & 6 days) Term: 37 weeks or greater 20 weeks gestation when the organs are done being formed G- # of pregnancies T- # of term deliveries P- # of preterm deliveries (20- 36 6/7 weeks) A- # of abortions (less than 20 weeks)

L- # of living children Fetus cannot survive before 20 weeks Antepartum o fetus in uterus Prenatal Visit (1st^ things that need to be checked)

Vital signs
Estimated Date of Confinement (Estimated Due Date)
Medical hx
CBC
Hep B
HIV
VDRL- STI
Blood type- Rh factor
Rubella titters; drawn at prenatal visit (if nonimmune she needs Rubella titters w/in 72hrs after delivery)
TB skin test
Pap smear
Weight
UA- urinalysis
Fetal heart tones (can be heard at 6 weeks) If mother is Rh-(negative), she needs Rhogam (26-28wks), she needs that because negative antigens may try to fight off pregnancy
If mom is negative and baby blood positive; mom needs Rhogam within 72hrs after delivery to protect next pregnancy *Only run babies cord blood to find out blood type if moms blood type is negative Next visits
VS

Changes in Body Systems: Reproductive

Uterus o F
Cervix o Chadwick signs: bluesish/purplish o Goodell’s sign: cervix softening o Mucus plug: keeps the uterus safe from any germs getting into uterus; can cause some spotting as separating from cervix wall o Hrg’s sign: softening of lower segment of the uterus
Vagina and vulva o Increased vascularity o Vaginal mucosa thickens o Vaginal rugae becomes prominent o Increased roiduction
Breast o Grow larger o Areola gets darker o Colostrum- thick yellow discharge; body getting ready for breast home
Heart
Blood o Blood volume increase o Plasma volume increases: o Cardiac output increase
Relaxin:

o body releases during pregnancy; smooth muscle relaxer; keeps BP normal

Has clotting factors in it
Oxygen needs increase o RR will go up about 20%
Appetite o increase after 1 st^ trimester
Mouth o gums may bleed, can get gingivitis, ptyalism
Esophagus o acid reflux; heart burn
Large and small intestines

*Normal for pregnant women to have a trace of glucose in urine o Moms become insulin resistant to make more glucose for baby Conformation of pregnancy:

Presumptive (subjective) o Amenorrhea o N/V o Fatigue o Urinary frequency o Breast changes o Vaginal & cervical color changes

o Quickening (fetal movement)- flutter of gas

Probable (objective) o Abdominal enlargement o Goodell’s sign softening of the lower part of the cervix-soft like your cheek. o Hagar’s sign (softening of the lower uterine segment) o Ballottement- Dr. does a dig vag exam & can push up on cervix. Fetus will go up & come back down o Braxton Hicks pre-contractions ATI o Palpation of fetal outline- Enlarged abdomen o Positive pregnancy test o Chadwick sign- - bluish purple color of the cervix
Positive o Fetal heart sounds o Fetal movement detected by provider o Visualization of the embryo or fetus First Trimester
Uncertainty Second Trimester
Physical evidence of pregnancy
Fetus as the primary
Narcissism and introversion
Body image
Changes in sexuality; changes in sex drive Third Trimester

Things to know: o Mom needs 600mcg/day of folic acid o Mom: needs extra calcium o hCG: levels go up when pregnant o Moms should gain 25-35lbs: normal weight gain o Should drink 6-8liters/day o DO NOT ovulate during pregnancy o Never lie a pregnant women supine/flat on back; always needs to have a pillow wedged behind her back Week 2 Notes Effects of the birth process: Maternal Response Variability- (goes up & down) when we look at a fetal monitor strip. We’re always going to look for variability It’s the babies hear beat from beat to beat Absent- 0 BPM Minimal 0-5 BPM Moderate 5-25 BPM—Always want Marked >25 BPM Characteristics of contractions:
Coordinated o Frequency ▪ Beginning of one uterine contraction to the beginning of the next ▪ Range in minutes; how often (ex. 1.5- 2 minutes) ▪ Don’t want a frequeny to be any more than 2 min’s lasting about 60-

90 sec’s o Duration ▪ Beginning of a uterine contraction to the end of the same contraction when it comes back to baseline ▪ Range in seconds; how long is last (ex. 60-90 sec’s)

Involuntary
Intermittent- relaxation of the contraction (we must have this relaxation period, because if not. That means the uterus is not contracting & it’s where the fetus is getting most nutrients & oxygen. During that resting tone) Contraction Cycle o Increment ▪ Period of increasing strength o Acme ▪ Period during which the contraction is most intense

Baby heart tone always at top
Mom contractions at the bottom Variable (type of deceleration) Cord Compression -Sudden drop with a quick return to baseline -Reposition mom w/in 30 seconds. V or W appearance Early (starts right w/contraction) Head Compression (usually est. 8cm) -mirrors mom contraction -Sterile vaginal exam (find out dilation)
reposition mom Acceleration (above baseline)-lack of baseline Oxygenated -Baby is saying he is ok

Late (declaration and contraction don’t match) Placental insufficiency -Baby suffering -Not getting enough oxygen & nutrients Characteristics of late- beginning, middle, & end are off LATE deceleration (what to do)

Reposition mom
Shut off Pitocin (causes contractions)
Increase IV fluids
o2 via nonrebreather mask (8-10/L)
Sterile vaginal exam-
Call provider *Anything goes below baseline; deceleration *Want to see lots & lots of acceleration (when baby moves HR should go up) *NEVER nasal cannula in L&D Accelerated Increase in fetal heart rate

15 beats by 15 beats above baseline (32+weeks)
10 beats by 10 beats above baseline (under 32 weeks) Fetus well oxygenated Uterine body
Upper two thirds of the uterus contracts actively to push fetus down
Lower one third remains less active

Powers o Contractions o Maternal pushing
Passage o Pelvis
Passenger o Baby o Placenta o Membranes Baby can’t come out if it’s extended or hyperextended
Psyche (how mom feels about pushing) o Anxiety o Culture and expectation o Birth as an experience o Support o Impact of technology
Position o Fetal head position o Want baby to be in an anterior position (occipital) OA o OT- occipital transverse Presentation
Fetal part that first enters the pelvis
Cephalic o Vertex, military, brow, face
Breech o Frank, full, footling
Shoulder - Cephalic Presentation

The cephalic presentation is more favorable than others for the following reasons:
• The fetal head is the largest single fetal part, although the breech (buttocks), with the legs and feet flexed on the abdomen, is collectively larger than the head. After the head is born, the smaller parts follow easily as the extremities unfold.
• During labor, the fetal head can gradually change shape, molding to adapt to the size and shape of the maternal pelvis.
• The fetal head is smooth, round, and hard, making it a more effective part to dilate the cervix, which is also round.
Cephalic presentation has the following four variations (Fig. 12.8):
• Vertex—This is the most common type of cephalic presentation, in which the fetal head is fully flexed. It is called a vertex or occiput presentation and is the most favorable for normal progress of labor because the smallest suboccipitobregmatic diameter is presenting.
• Military—The head is in a neutral position, neither flexed nor extended. The longer occipitofrontal diameter is presenting.
• Brow—The fetal head is partly extended. The brow presentation is unstable, usually converting to a vertex presentation if the head flexes or to a face presentation if it extends. The longest supraoccipitomental diameter is presenting. C-section
• Face—The head is extended, and the fetal occiput is near the fetal spine. The submentobregmatic diameter is presenting. C-section

Maternal Exam and Prenatal Care, Exams of Nursing

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