LABOR AND DELIVERY SKILLS
Bloodborne pathogens / Standard Precautions The Center for Disease Control (CDC) defines Standard Precautions Precautions as a set of precautions designed to prevent or reduce the risk of transmission of HIV, HBV, HCV and other blood-borne pathogens from both recognized and unrecognized sources of infection in health-care workers (HCWs). HCWs are defined as persons, including students and trainees, whose activities involve contact with patients or with blood or other body fluids from patients in a health-care setting. Nurses employed in labor and delivery are exposed to blood, vaginal secretions and amniotic fluid, which are carriers of infectious diseases. Blood is the single most important source of HIV, HBV and other bloodborne pathogens. The blood does not have to be visible to the human eye to be capable of transmitting disease. Handwashing Wash the hands thoroughly, with soap and water, after contamination with blood or other body fluids, between patients and immediately after gloves are removed. Gloves do not replace the need to wash the hands. There may be minuscule puncture marks on the gloves that can aid in spreading infectious diseases. Gloves In labor and delivery, gloves must always be worn when touching body fluids that contain blood or when handling items or surfaces with blood or body fluids what are potentially infectious. (CDC, 1999) Non sterile gloves can be used when starting the intravenous, phlebotomy, intravenous, phlebotomy, washing used instruments, cleaning a patient before or after a vaginal delivery, obtaining various body fluids for diagnostic purposes (peritoneal or amniotic fluids), handling the placenta and umbilical cord, and when handling the infant after the delivery until blood and amniotic fluid is washed off. Non-sterile gloves can also be used for procedures involving contact with mucous membranes and other non sterile examination, for example: digital examination of mucous membranes or when performing heel sticks on infants. Sterile gloves must be used for procedures that involve contact with normally sterile areas of the body. In obstetrics this includes the use of sterile gloves during vaginal examinations to protect the transmission or introduction of infection into the vagina. Gloves should be changed between each patient contact. Never wash gloves for reuse. Protective Barriers The Center for Disease Control (CDC) states that all health care workers who participate in invasive procedures must use appropriate barrier precautions. (CDC, 1999).The CDC recommends that for both vaginal and cesarean deliveries gloves, gown (with protective front), front), plastic disposable overshoes, eyeguard and mask be worn. Both in a vaginal or cesarean section, the floor or ground is likely to be contaminated and when the placenta is delivered, the blood may splatter. Human Milk Although HIV and outer surface antigens (HBsAg) have been found in the milk of mothers infected with HIV and HBV, health care workers do not have the same type of exposure as the infant. Therefore, universal precautions do not apply to breast milk.
Source: The Center for Disease Control (CDC) the prevention of transmission of blood-borne diseases in the health-care setting 1999. setting 1999.
HISTORY AND INITIAL ASSESSMENT As with any evaluation the first and perhaps most essential component is the history. The patient should be specifically queried about the presence or absence of leaking or ruptured membranes and the presence or absence or vaginal bleeding. A history history of recent illnesses should be sought and any prenatal complications should be reviewed. Finally, Finally, an inquiry should be made about the patient's expectations and preparation for the labor and delivery process (childbirth classes, preferred pain management, plans for infant feeding). A careful review of the prenatal record should be supplemented by the patient interview with regard to recent illnesses and obstetrical complications.
PHYSICAL EXAMINATION OF THE LABORING WOMAN
Steps you should take to prepare for the examination: Ask woman to empty bladder (collect urine for testing). Prepare to follow a logical order. Prepare to chart logically immediately after exam (make notes). Remember to use all your senses during assessment. Remember to explain everything you are doing. Exam should be carried out immediately and as quickly as possible.
Urine tests used during intrapartum
Ph
Measures acidity/alkalinity of the urine, Levels below normal indicate high fluid intake, levels above the norm indicate inadequate fluids & dehydration.
Protein Normal = Negative, Small amounts may be in urine from vaginal secretions & dehydration, Amounts of 2+ to 4+ may indicate be one indicator of possible UTI, Kidney Infection or PIH.
Glucose Normal = Negative or + I. High levels of glucose may be one indicator of high blood sugar, gestational diabetes or diabetes mellitus. Always ask what woman has recently eaten if her BS is high.
Ketones
Normal = Negative. Ketones are products of the breakdown of fatty acids caused by fasting. The body breaks down fats because there are not enough carbohydrates and proteins available. Ketones may be deleterious to fetus.
Techniques to be used in performing a physical examination: Inspection Palpation Auscultation...
For more information go to: The Auscultation Assistant - Hear Breath Sounds, Heart Murmurs, Heart Sounds, and ...
Perform Examination: Examination:
General appearance: Edema, skin color, hygiene, pain, distress, mood
Measure vital signs: Blood pressure, pulse, respiration, temperature
Blood pressure Take blood pressure with woman in sitting or side lying position Compare blood pressure with prenatal blood pressure
At what point would you determine if the patient were hypertensive? hypertensive? What additional assessments and interventions would you take if patient were hypertensive? Test for proteinuria. Assess for facial and general edema. Test for hyperreflexia. Ask if patient is having headaches, blurred vision, spots in vision. Notify provider of any pathologic results
Pulse Rate: 60 - 90 Increased pulse can be dehydration, anxiety.
Always question possibility of cardiac problems. What is the most common cardiac problem problem in a young female?
Respiration Don’t count during a contraction
Temperature Think about infection and dehydration
Abdominal examination An abdominal examination should include a measurement of fundal height as well as an assessment of fetal size (estimated fetal weight), presentation and position using Leopold's maneuvers. Inspect: Scars, linea, striae, symmetry Palpate: Palpate: fundal height, fetal position Osculate: fetal heart tones Determine and palpate contractions
Inspect and palpate lower extremities Press firmly with thumbs about 5 seconds over shin If any signs of elevated blood pressure, elicit DTR If reflexes are hyperactive, check for clonus
Measuring fundal height
Place the zero line of the tape measure on the anterior border of the symphysis pubis and stretch tape over midline of abdomen to top of fundus. The tape should be brought over the curve of the fundus. The height of the fundus in centimeters equals the number of weeks gestation plus or minus 2. After 32 weeks the relationship is less accurate. Perform Leopold maneuver.
Leopold's Leopold's Maneuver Abdominal Examination for Position and Presentation and Size
Hands have an acute sense of touch especially when attached to a well-trained well-trained mind. You should always assess for position, presentation, presentation, engagement and size by abdominal examination. examination. With warm hands and gentle pressure palpate the abdomen for soft consistency, fluctuating fluctuating amniotic fluid, indefinite outlines and baby’s small knobby parts.
Leopold's maneuvers are used to determine the orientation of the fetus through abdominal palpation.
1. Palpation of the uterine fundus to determine which fetal pole "head or breech" is present in the fundus. Using two hands and compressing the maternal abdomen, a sense of fetal direction is obtained (vertical or transverse). transverse).
2. The lateral sides of the fundus are palpated to determine the position of the fetal back and small parts. . The fetal spine will palpate as firm, flat and linear. The fetal extremities are palpable by their varying contour and movements. The purpose of this maneuver is to determine whether the fetal back is left or right.
3. The purpose of this maneuver is to determine the pelvic position of the presenting part. The presenting part (head or breech) is palpated above the symphysis and degree of engagement determined. The examiner uses the thumb the fingers of one hand in the suprapubic region (similar to palming a basketball) and attempts to move the presenting part from side to side. If little movement occurs or only the fetal neck is palpable the presenting part is engaged.
4. The fetal occipital prominence and f lexion lexion of the vertex is determined. If the fetal vertex is flexed, the cephalic prominence may be palpable on a same side as the fetal small parts. If a distinct cephalic prominence is noted on the same side as the spine and head the vertex is not very well flexed.
Use Leopold's to locate fetal back and as a reason to "lay hands" on your patient. slowly “walk” fingers over the abdomen looking for the resistance of baby’s back, which may be in the center of the abdomen or deflected off to either either side. Palpating the fundus (top) of the abdomen along with the symphysis pubis area (bottom) of the abdomen, the hands will be feeling for the firm irregular buttocks of baby or baby’s even firmer regular and smooth head as you ‘visualize’ the size of b aby. aby. While locating fetal position and heart tones, talk to the patient. Assess abdominal tenderness as well as contractions and ascertain fetal movement. Sometimes just taking those few minutes to touch, talk to and listen to the patient goes a long way to establishing the tone of the whole labor. labor. The monitors m onitors are great but do remove that human touch. Always remember remember there there is a human being attached attached to that monitor and treat her as such. She has a lot of information to impart if you ask the right questions and make astute observations Leopold's maneuvers just are a part of a whole-person assessment. Develop a skill for this by practicing and learn it well. It CAN help you determine a lot of things and help establish a warmer relationship with a mom-to-be---especially if you provide her with the information you find. It just makes it all much more personal. Technology Technology is a wonderful thing but NEVER takes the place of this touch and YOUR assessment skills.
Monitoring the Mother and Fetus During Labor •
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A 20 minute fetal monitor strip is done for all patients on admission. As long as the patient is healthy, healthy, the presentation normal, the presenting part well engaged, and the fetus in good condition, the woman may walk about or be in bed as she wishes. The patient's condition and progress is checked periodically. periodically. FHT's are checked q 30 min in latent phase, q 15min. in active phase, and q 5min. in second stage. The maternal temp is taken q 4 hrs., q 2 hours if ROM. Variations to this timing depend on the maternal-fetal situation. The progress of labor is followed b y abdominal or vaginal examination to note the position of the baby, baby, the station of the presenting part, and the dilatation of the cervix. These examinations should be done only often enough to ensure the safe conduct of labor, i.e., to determine that the rate of dilatation is within the normal range or to evaluate the patient if she is requesting medication. Over distension of the bladder is obviated b y urging the patient to void every few hours. If she is not able to do so, catheterization may be necessary, necessary, since a full bladder impedes progress. Adequate amounts of fluids and nourishment are essential. If the patient is unable to take enough orally, orally, a intravenous of Lactated Ringers solution may be given. During the first stage, the patient should be impressed with the important of relaxing with the contractions. Help the couple as much as possible to work with the contractions and compliment them for a good job. The passage of meconium stained fluid in a cephalic presentation is a possible sign of fetal distress and if present, the patient should be continually monitored during active labor. labor.
Ausculate fetal heart tones. ROA is best heard in mother's right lower quadrant. ROP or LOP is best heard in mother’s left side.
For more information go to: Should Women be Given a Choice About Fetal Assessment in Labor? MCN, The American Journal of Maternal/Child Nursing September / October 2003
Abdominal Examination for Contractions
An initial abdominal examination is carried out on admission by laying a hand on the uterus and palpating, noting the degree of hardness during a contraction and timing its length. This should be repeated at intervals throughout labor in order to assess the length, strength and frequency of contractions and the descent of the presenting part. The uterus should always feel softer between contractions. contractions.
The monitor should never be relied on; the mother’s abdomen should be regularly palpated by hand.
Uterine contractility can be quantified subjectively by palpation or objectively by the use of an external tocodynamometer or an intrauterine pressure catheter (IUPC). The external tocodynamometer can generally provide reliable information about the frequency of uterine contractions and their approximate duration. The actual amount of intrauterine pressure generated with each contraction must be measured by internal devices, such as the intrauterine pressure catheter. The traditionally traditionally used measure of uterine work is called the Montevideo method. Montevideo units are calculated by totaling the peak uterine pressures (in mm/Hg) minus the baseline pressures over a ten minute period. at least 200 Montevideo units are required before the forces of labor can be considered adequate (i.e., when a protraction or arrest disorder is noted measures should be taken to ensure that contractions at least 200 Montevideo units exist before a cesarean delivery is undertaken).
Uterine Contractions
Vaginal examination A fetal heart check and an abdominal palpation for fetal position and presentation presentation should always precede initial vaginal examination. The vulva should be carefully inspected for lesions (e.g., herpes, etc), some assessment of the superpubic angle, prominence of the iliac spine and size of the pelvis in relation to the fetal head should be made. Purpose of exam is to assess the status of membranes, fetal presentation presentation and position, engagement, effacement, cervical dilatation and station.
Lie and presentation
Lie and Presentat Presentation ion
Engagement
Engagement
Effacement
Effacement
Station
Station
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Procedure Prepare client the same way as for a speculum examination. Lubricate index and middle finger of examining hand generously. Separate the labia with gloved fingers. Inspect vaginal opening (introitus). Observe Observe for: Amount of bloody show: advanced labor Ruptured membranes Discharge that is malodorous Discharge that is deep yellow or greenish brown: Meconium Ulcerated areas on perineum: Herpes, Syphilis
Examinations are done with aseptic technique (sterile gloves and antiseptic solution). You insert two fingers into the vagina and feel the cervix and the top of the baby’s head to gather information about the dilation and the presentation of the baby. baby. This may be uncomfortable, especially especially during a contraction.
There is no place for routine vaginal examinations in any labor. labor. Vaginal examination should only be done when there is doubt about the clinical situation or symptoms, and the information gathered is necessary or likely to be of use in making a clinical decision.
Excessive vaginal examinations carry with it the risk of increased infection. You should rely on behavior and emotional responses and physical sensations rather than vaginal exams.
Reasons to defer or avoid digital vaginal examination: The vaginal examination should be avoided or deferred in certain circumstances. In most of these situations a careful speculum examination is acceptable: (1) Significant vaginal bleeding of unknown etiology (delay examination until placenta previa has been ruled out by ultrasonography), (2) Presence of placenta previa, (3) Ruptured membranes in patients who are not in labor and for whom immediate induction of labor is not anticipated, (4) Presence of active HSV lesions in a p atient with ruptured membranes.
Dilatation chart (actual size)
Cervical dilation: 1 finger represents aprox 1.5 cm.
Questions to ask yourself as you perform a Vaginal Vaginal Examination
Status of amniotic membranes:
Are they intact. Bulging through the cervix? Status of cervix:
Is it soft or firm (the cervix must be soft before it can efface and dilate), anterior or posterior? (the cervix must be anterior before it can really start to dilate) How much effacement?
0%/long and thin to 100%/completely thinned out. How much dilation?
0 (closed) to 10 cm. (dilation complete). Fetal presentation:
What is the presenting part? (head, breech, other fetal part) What is the fetal position? (left/right, anterior/posterior/transverse) anterior/posterior/transverse) Fetal station:
What is the presenting part in relation to the ischial spines? Engagement:
Is the presenting part engaged and well well applied to the cervix? cervix? stabilized in the middle of the pelvis below the level of the ischial spine [zero station].
How to palpate presenting part: Palpate the hard skull; palpate for sagital suture; follow to anterior or posterior
fontanel If what you feel is soft it may be breech or face.
Assessing Cervical effacement Cervical effacement: Palpate degree of thickness; normal cervix about 1 inch thick
How to determine station: Station is the relationship relationship of the presenting part to the ischial spines. Locate the lowest portion of presenting part, then sweep the fingers deeply to one side of pelvis to feel for ischial spines.
To determine station estimate in centimeters, the tip of presenting part is above the ischial spine. Tell the mother your findings.
Speculum examination A speculum examination will be necessary in cases of suspected "leaking" or ruptured membranes. The presence of "leaking" or ruptured membranes can be confirmed by performing a nitrazine test, inspecting the posterior fornix for pooling of fluid and by obtaining a sample of the fluid with a sterile applicator and applying the fluid to a glass slide. The glass slide is allowed to air dry and is subsequently inspected for an arborization pattern ("ferning").
Procedure: Select speculum Speculum is made of 2 blades and a handle There is a thumb piece attached to top blade The bottom blade is fixed The top blade is hinged and thumb piece controls movement Comes in both metal and plastic
Explain what you will do. Have client empty bladder. Assist client to bend legs, feet resting either flat on table or in stirrups. Place pillow under her head and under her hip. Drape client’s legs.
Place a minimum amount of lubricant on speculum. Sterile water may be used as lubricant.
Using dominant hand, place 2 fingers just inside the introitus and gently press down on base of vagina. With other hand, introduce the closed speculum past your fingers at about 45-degree angle downward. Keep a downward pressure on blade to avoid upward pressure on sensitive bladder and top of vaginal wall. After speculum in vagina, remove finger. Turn blades into a horizontal plane while keeping moderate downward pressure. Move your thumb to the thumb piece and press to open blades so that the cervix is in view. Sweep the blades upward and gently press on the handle. When cervix in view, tighten the thumbscrew to keep blades open.
If membranes are ruptured, you will see fluid leaking from cervix. Place sterile cotton tipped applicator in pool of fluid. Touch applicator to nitrazine paper or glass slide. Release thumb screw. screw. Hold blades apart by pressing on thumb piece and begin withdrawing the speculum until cervix is released. Release pressure on thumb piece and allow blades to close. Rotate the blades to a sideways position; exert downward pressure. Gently and slowly remove.
Fern testing for ruptured membranes Amniotic fluid contains a high amount of salt. If drops of fluid are spread on glass slide, allowed to dry and examined through microscope, a characteristic fern pattern can be seen.
Mechanisms of Labor
The following definitions must be mastered to be able to discuss and understand the mechanism of labor: Attitude. This refers to the posturing of the joints and relation of fetal parts to one another. The normal fetal attitude when labor begins is with all joints in flexion. Lie. This refers to the longitudinal axis of the fetus in relation to the mother's longitudinal axis; i.e., transverse, oblique, or longitudinal (parallel).
Presentation. This describes that part on the the fetus lying over the inlet inlet of the pelvis or at the cervical os.
Point of Reference or Direction. This is an arbitrary point on the presenting part used to orient it to the maternal pelvis [usually occiput, mentum (chin) or sacrum]. Position. This describes the relation of the point of reference to one of the eight octanes of the pelvic inlet (e.g., LOT: LOT: the occiput is transverse and to the left). Engagement. This occurs when the biparietal diameter is at or below the inlet of the true pelvis. Station. This references the presenting part to the level of the ischial spines measured in plus or minus centimeters.
Normal mechanisms of labor/ Cardinal Movements - Occiput anterior positions •
Definition: A mechanism of labor is a series of passive, adaptive movements of the fetal head and shoulders through the birth canal.
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Related factors Passage: Size and morphology of the pelvis o Passenger: Size of the baby and moldability of the fetal skull o Powers: Quality (efficiency) (efficiency) of uterine contractions and voluntary expulsive forces and o quality and direction of soft tissue resistance, especially of the levator ani muscles o Psyche: Mom’s attitude
Cardinal Movements of Labor o
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Engagement: Mechanism by which the greatest transverse diameter of the head in vertex (biparietal diameter) passes through the pelvic inlet (usually 0 station). The head usually enters the pelvis in the transverse or oblique - the inlet is a transverse oval. Descent: This occurs intermittently with contractions contractions and is brought about by one or more forces: Pressure of the amniotic fluid, direct pressure of the fundus upon the breech, contractions of abdominal muscles (2nd stage) and extension and straightening of the fetal body. body. Flexion: As soon as the vertex meets resistance from the cervix, walls of the pelvis or the pelvic floor, flexion flexion results. The chin is brought into contact with the fetal thorax and the resenting diameter is changed from occipitofrontal to suboccipitobregmatic (9.5 cms.) Internal Rotation: After engagement, as the head descends, the lowermost portion of the head (usually the occiput) meets resistance from one side or the other of the pelvic floor and is rotated about 45 degrees anteriorly to the midline under the symphysis. Internal rotation brings the AP diameter of the head in line with the AP diameter diameter of the pelvic outlet. Extension: With With further descent and full flexion of the head, the nucha (the base of the occiput) becomes impinged under the symphysis. Upward resistance from the pelvic floor causes the head to extend, with the bregma, brow, brow, nose, mouth and chin being born successively. Restitution: When the head is free of resistance, it untwists, causing the occiput to move about 45 degrees back to its original left or right position. The sagittal suture has now resumed its normal right angeled relationship to the transverse (bisacromial) diameter of the shoulders.
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External Rotation: While the head has been descending to the pelvic floor, the shoulders have entered the pelvis and engaged with the bisacromial diameter in the transverse or in an oblique diameter. diameter. With the descent, the leading (anterior)shoulder meets the resistance of the side of the pelvic floor and is rotated anteriorly toward the midline under the symphysis. This This movement brings the long axis of the shoulders in line with the long axis of the pelvic outlet. The movement of the shoulders causes the occiput to rotate another 45 degrees, to the transverse position. Expulsion: Delivery of the anterior shoulder, posterior shoulder, and the rest of the body.
Expulsion
The Six Steps of Labor Progression
Labor can be defined as regular, painful uterine contractions that result in progressive cervical change. The diagnosis of labor progression may be dependent upon the patient's history of uterine contractions as well as information gathered from abdominal palpation and vaginal examination. Evidence of progressive cervical effacement and/or dilation is necessary in order to distinguish true labor from false labor.
Labor progresses in six ways and all are equally i mportant. Frequency, duration and intensity of contractions cannot be relied upon as measures of progression in labor.
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Cervical dilatation and fetal descent are the only indicators that labor is progressing.
Cervical Ripening
The cervix ripens or softens. As a woman’s body gets ready to labor it produces prostaglandin. This causes the cervix cervix to soften from the consistency consistency of rubber to something that feels like a marshmallow.
Cervical Position
The cervix moves from a posterior to an anterior position. During most of the pregnancy, pregnancy, the cervix points toward the back (posterior), but during the last few weeks of pregnancy or in early labor, it moves forward forward (anterior). The uterus may contract for several days intermittently before true labor begins to accomplish these
first two things, softening the cervix and bringing the cervix from the back of the vagina to the front of the vagina.
Cervical Effacement
The cervix effaces About two inches in length is average size, but in early labor, the the cervix begins to get shorter and thinner (effacement). (effacement). By the active part of labor the cervix will be completely effaced and be paper-thin.
It is vital to understand that when the cervix has not undergone undergone the first three steps (ripening, effacement, and anterior movement of the cervix), significant dilation (beyond 3-4 cm in the nullipara, more in the multipara) rarely occurs), occurs) , but that pre-labor contractions are accomplishing the important job of pre-paring the cervix to dilate.
Cervical Dilatation
The cervix dilates and active labor begins. Not much dilatation can occur until the cervix has completed the above three processes . Remember the cervix cervix needs to get very soft, move to an anterior position and get paper-thin before it will dilate much past 3-4 centimeters.
Fetal Head Rotation, Flexion and Molding
The fetal head rotates, flexes, and molds. The head begins to change shape to fit through the pelvis. Remember, Remember, this is called molding. Rotation, flexion, molding, molding, and descent of the fetal head take place in active labor and second stage
Fetal Descent and
The fetus descends and is born. Descent occurs as the baby lowers itself into your pelvis. Remember, Remember, descent is measured in terms terms of "stations."
Birth
Stages of Labor Chart
The first stage of labor begins when uterine contractions of sufficient frequency, intensity and duration result in effacement and dilation of the cervix. The first stage is completed when the cervix reaches 10 cm. The second stage involves descent of the fetus and its eventual expulsion from the vagina. It begins with complete cervical dilation (10 cm) and ends with delivery of the infant. The third stage of labor involves delivery of the placenta. It begins with the completion of the infants' delivery and ends with delivery of the placenta and membranes.
LATENT-EARLY LABOR FIRST STAGE
ACTIVE LABOR (4-8 cm.)
TRANSITION LABOR
SECOND STAGE LABOR
THIRD STA Delivery of t Placenta
LABOR LATENT (0-3 cm.)
(8-10 cm)
(10 cm. -Birth)
Pre-labor
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Ripening and Contractions: effacement of the cervix 5-20 minutes ♥ apart
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30-45 seconds long
Contractions:
Contractions:
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2-5 minutes apart
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1 -2 minutes apart
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45-60 seconds long
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45-90 seconds long
Contractions: ♥
3-5 minutes apart
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60-120 seconds long
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A feeling of fullness and cramping as placenta sepa
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A time for m to hold and e baby.
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Mild, feel like cramps, back pain, pressure
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Stronger and more intense
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The strongest they will get
Contractions: Irregular
Less aware of contractions, more aware of urge to push and fullness in vagina as baby moves down
Diagnosis of Abnormal Labor
Review Friedman Curve Cervical dilation usually follows a sigmoid curve over time. In the 1970s, Friedman (Friedman EA 1978, labor: clinical evaluation and management. Appleton and Lange, E. Norwalk, CT) plotted the labor curves of over 10,000 normal pregnant women. In addition to noting that cervical dilation
progressed on a sigmoid curve, he noted that labor progressed faster in parous women. Patients whose labor is excessively long in duration or slow in rate of progress require special attention and may be treated with various forms of intervention aimed at improving the progress of labor.
Friedman Curve
For more information go to: Diagnosis of Abnormal Labor
Prolonged or Protracted Latent Phase: A prolonged latent phase is present when the active phase of labor is not achieved after 14 hours in multiparous patients and 20 hours in nulliparous patients. This diagnosis may be difficult to make since the onset of labor is very often dependent upon the patient's perception of when labor actually began. There are two basic methods for prolonged latent phase, narcotic analgesia or oxytocin augmentation of labor. In cases where the fetal heart rate tracing is normal and the patient is at low risk a large dose of narcotic plus antihistamine may be administered in order to allow the patient to rest for several hours. Typically, Typically, when the parturient awakens she will either find that she has entered the active phase or the contractions will completely dissipate during the hours of sleep. In the later case, false labor would be diagnosed and the patient would be subsequently discharged to home. Prolonged or Protracted Active Phase A protracted active phase is defined as progression at less than 1.2 cm an hour in nulliparous patients and less than 1.5 cm and hour in parous patients during the active phase. This disorder is associated with a higher incidence of occiput posterior and occiput transverse fetal positions. It may also be indicative of true cephalopelvic disproportion or it may result from inhibitory effects of narcotics anagelsia. Generally this condition is treated by first assessing the adequacy of labor (i.e., placing an intrauterine pressure catheter and determing the number of Montevideo units). Additionally Additionally,, the size of the fetus in relation to the pelvis must also be determined. When addressing active phase labor abnormalities most Obstetricians refer to "the three P's". The power refers to the a dequacy of labor, passenger refers to the size and attitude of the fetus and the pelvis refers to the size and shape of the maternal boney pelvis. In most instances the laboring patient has a relatively normal pelvis d fetus but uterine contractile forces are found to be inadequate. In these cases labor augmentation with oxytocin is indicated. Most center's begin oxytocin at 1-2 mL per minute and increase the dose by 1/2 to 1 mL every 20-40 minutes. Active Phase Arrest: This This is the most common abnormality of labor in women who are ultimately delivered by cesarean section. It is defined as a lack of cervical progress over 2 or more hours, despite adequate uterine contractions (> 200 Montevideo units). As with Protracted Active Active Phase, the three P's must be assessed and in most cases a trial of oxytocin augmentation given. Second Stage Disorders: The average primigravida can expect to spend one to two hours in the second stage of labor while the multiparous women will typically have a second stage of 30
minutes duration or less. These times may be significantly increased in patients who have epidural anesthesia. In the presence of an epidural anesthetic the second stage may last as long as three hours in a nulliparous patient and as long as 1-1/2 hours in a parous patient. Protracted Descent: Common causes of protracted descent include poor maternal expulsive effort and excessive fetal size relative to the maternal pelvis. A common management approach to protracted descent is to simply allow a longer period of time for the patient to push. Alternatively Alternatively,, in a patient with epidural anesthesia who has poor effort initially, initially, expectant management can be undertaken while the patient is allowed to relax for the first 1 to 1-1/2 hours after becoming completely dilated (laboring down). When the fetal vertex reaches a +2 station or more a forceps or vacuum delivery may be used. Arrested Descent: Arrested Arrested Descent occurs when there is no ad vancement of the presenting part for more than an hour. The criteria are the same in both the nulliparous and multiparous patients. The reasons for this disorder are the same as Protracted Descent. Reducing the level of maternal epidural anesthesia may be helpful in some cases. Additionally, Additionally, changes in maternal position such as having the mother assume the "squatting" position may be helpful.
Fluids
As part of the altered anatomy and physiology during pregnancy, pregnancy, laboring women are considered to have a full stomach. The enlarged gravid uterus physically obstructs gastric emptying and increases intragastric pressure. Pregnancy hormones decrease intestinal motility and gastroesophageal barrier pressure, as evidenced by the common complaints of constipation and acid reflux or heartburn. The policy of NPO (nothing by mouth) is, regrettably, regrettably, a well-established well-established routine in many hospitals. Reducing the risk of maternal morbidity and mortality by reducing stomach contents, thus eliminating the acidic contents for pulmonary aspiration, is given as the rationale. However, surveys of literature from anesthesia and obstetrics show no compelling scientific basis for maintaining NPO policies (although aspiration can be a complication of inadvertently high spinal or epidural blocks).
Choices for fluids in labor include water or ice, juices (less acidic are preferable; may be frozen in ice cubes), popsicles, and hydrating fluids such as Gatorade.
Intravenous Hydration
IV fluids (usually dextrose and water or lactated Ringer's solution) are indicated when the mother is NPO status and should be run at a rate of 125 mL per hour, which ensures that the mother receives 1,000 mL of fluid every 8 hours.
IV therapy is not needed routinely, especially in the first hours of labor. A normal healthy woman, who already has approximately 2 L of stored body water in extravascular spaces. Routine IV fluid administration can induce fluid overload, hyperglycemia hyperglycemia in the fetus, and hypoglycemia in the newborn, and can alter plasma sodium levels.
Comfort Measures for the Laboring Woman.
Do not leave alone in active labor. Change soiled and damp linen promptly. promptly. Provide mouth care. Ice chips, lubricate lips. Keep room cool, uncluttered, quiet and privacy. privacy. Promote participation of coach.
For more information go to: Therapeutic Choices for the Discomforts of Labor Journal of Perinatal and Neonatal Nursing, October / December 2003
Slow-Paced Breathing
Every woman beginning labor should be taught this simple technique for coping with labor. The use of a specific breathing pattern during labor contractions has two objectives: Helping the woman relax by distracting her from the intense contraction sensations. Ensuring a steady, adequate intake of oxygen.
Begin the Breathing Technique Technique
This technique is done only during contractions. Rest and sleep between contractions is important. Instruct the laboring woman to do the following: Assume a comfortable position. Try to maintain a relaxed state throughout the contraction. Close her eyes or Concentrate on a focal point while doing the breathing (e.g., a pretty picture, a button on someone's shirt).
Cleansing Breath
Begin and end each breathing technique with a cleansing breath. This is simply a deep quick breath, like a big sigh. Inhalation is through the nose; exhalation is through slightly pursed lips.
Slow-Paced Breathing
This technique can be used in early labor and for as long as the mother is comfortable with it. For some women, this may last throughout the entire first stage of labor. labor. 1. Take Take a cleansing breath as soon the contraction begins.
2. Breathe slowly and deeply in through the nose and out through slightly pursed lips or the nose over the duration of the contraction.
3. Maintain a steady rate of approximately 6 to 9 breaths during a 60-second contraction (the cleansing breaths do not count).
For more information go to:
AWHONN Clinical Position Statement Professional Nursing Support of Laboring Women
Epidural Anesthesia
Pain management options for woman in labor have changed dramatically over the last decade. Systemic Systemic analgesia and dense-motor-blockade regional analgesia/anesthesia have become less common for childbirth while the use of newer neuraxial and regional techniques, with minimal motor blockade, have become more popular. Neuraxial analgesia is defined as intrathecal or epidural administration of opioids and/or local anesthetics for treatment of postoperative pain or other acute pain problems. Neuraxial analgesia includes epidural, spinal and combined spinal-epidural techniques. Patients receive a 1000cc Lactated Ringers IV bolus (unless on a fluid restriction), and an oral antacid (Bicitra) prior to the placement of the epidural. The fluid bolus potentially alleviates alleviates any precipitous drops in the patient’s blood pressure. L&D RN's assist with patient positioning during the procedure. Blood pressures are recorded prior to the start of the epidural, when a test dose is administered, when a bolus dose is administered, and q 5-15 minutes until stable pe r the RN's and anesthesiologists discretion. The anesthesiologist gives BP parameters parameters to be notified if abnormal. After one hour of stable BP's, BP's can be recorded q 30 min until delivery. delivery. FHR and contractions are recorded at these intervals also. Patients are kept NPO or ice chips only after placement.
Education and certification of nurses. A standardized educational program should be established for initial training and certification of nurses caring for patients receiving neuraxial analgesia and for maintenance of competence. Nursing personnel should understand •
• • •
•
The risk of respiratory depression, including delayed respiratory depression when hydrophilic opioids are used Assessment and management of respiratory depression Assessment of motor and sensory blockade Assessment and management of hypotension in patients receiving neuraxial analgesia Signs and symptoms of the rare, but catastrophic, complications of neuraxial analgesia.
For more information go to:
Nursing Responsibilities in Preventing, Preparing for, and Managing Epidural Emergencies Journal of Perinatal and Neonatal Nursing, January/March 2003 The Role of the Registered Nurse (RN) in the Care of Pregnant Women Women Receiving Analgesia/Anesthesia by Catheter Techniques (Epidural, Intrathecal, Spinal, PCEA Catheters)
Guidelines for the Epidural Procedure
Adapted from the AWHONN's Evidence-Based Clinical Practice Guideline, Nursing Care of the Woman Receiving Regional Analgesia/Anesthesia in Labor.
The purpose of these guidelines is to provide principles of management, so that neuraxial analgesia is provided in a fashion that maximizes its benefit-risk ratio. Adequate nursing support is essential to the safe provision of an epidural. Evidence is lacking regarding the safety of nurses administering bolus medications during labor. However, However, the significance of potential side effects has necessitated standards that preclude this activity from nursing functions currently.
The AWHONN AWHONN position statement maintains that the insertion of epidural catheters and injection or rebolus of regional analgesic/anesthetic agents remains within the scope of the licensed, credentialed anesthesia care provider. provider.
During the first stage of labor, anesthetic dosages are given to limit the block to the lower thoracic (T10) and upper lumbar segments. This allows perineal tone to be maintained to avoid interfering with internal rotation of the fetal head to the occiput anterior position. When Stage II labor is reached, the block can be extended to the sacral area to promote perineal relaxation, delivery, and episiotomy repair.
Special techniques include the following: •
•
Patient-controlled Patient-controlled epidural anesthesia (PCEA): allows the patient to self-titrate periodic amounts of anesthetic So called walking epidural: patients who have intentional motor function and semi-mobility semi-mobility with a bolus or continuous infusion via an indwelling epidural
catheter preceded by an injection of local anesthetic into the subarachnoid space.
Actions Before the Procedure Remarks Consult with anesthesia and obstetric providers The physician, anesthesiologist, or nursewhen epidural anesthesia is requested by client anesthetist is responsible for explaining complications. Docume Document nt inform informed ed consen consentt by the the woma woman n The The nurse nurse clarif clarifies ies and elabor elaborate ates s on inform informati ation on regarding the purpose, the desired effect, possible side effects, the procedure itself, and recovery. Note contraindications, such as maternal fear Sympathetic blockade worsens some of these. or refusal, local infection at the injection site, coagulation defects, and maternal hypotension or shock. Move ove the the cras crash h car cart to an are area near nearby by.. This prov provid ides es for any emerge ergenc ncy y. Obtain maternal baseline BP, pulse rate, Anesthetic effects include vascular vasodilatation, respiratory rate, and fetal baseline heart rate decreased BP, and possible fetal heart rate and variability. variability. Confirm a reassuring fetal heart accelerations that could exacerbate a preexisting tracing before the procedure. problem. Have Have the the woman woman void void befor before e the the proce procedur dure. e. The The epidur epidural al bloc block k can reduce reduce or or elim elimina inate te bladder sensation. Administer an IV fluid bolus of 500 to 1,000 ML A preprocedure bolus will help prevent balanced saline or lactated Ringer's solution 10 hypotension caused by vasodilatation from the to 30 minutes before the epidural procedure. anesthetic. NOTE: IV glucose solutions are not recommended because of the potential impact of fetal hyperglycemia with subsequent and rebound newborn hypoglycemia. This promotes moderate spinal flexion to assist in locating the appropriate site.
Assist the woman to a side-lying position with legs slightly flexed or to a sitting position with the mother's head flexed forward, elbows resting on her knees, and feet supported on a chair. Support the mother throughout the procedure Breathing techniques appropriate to the phase of of local infiltration and catheter threading. labor can be encouraged to promote relaxation. A high-pressure volumetric volumetric pump is required for This is important to overcome catheter resistance. continuous epidural infusion. Check frequently to ensure that the proper hourly rate is according to the prescribed orders. Ensure that all connections along the epidural route are secure. Note maternal BP and pulse rate before and Epinephrine is added to the test dosage. If the after the test dosage. Repeat at least every 5 catheter is misplaced and is in the dilated epidural minutes throughout administration of the vein, maternal pulse rate will increase 20% to anesthetic dose and for 15 minutes afterwards. 30%. A normal rate reflects reflects that the drug was was not injected intravascularly. Thereafter, record BP, pulse, and respiration Systolic drops below 90 mm Hg are considered rate regularly based on institutional protocol inadequate to maintain uterine blood flow for fetal and patient's status. oxygenation. Never leave a mother unattended during the first 20 minutes following administration of the initial anesthetic or any bolus dose.
Actions Following the Procedure You need to reassure the mother if she feels a warm tingling sensation down her legs when the initial bolus loading dose is given.
Remarks This is a normal preanesthetic effect.
Avoid maternal hypotension by promoting uterine displacement with a pillow/wedge or placing the mother in a full lateral position or in a supine position, with the head of the bed elevated. Assist the mother in turning every hour.
Promote and maintain uterine displacement. Avoid the supine position.
Evaluate the mother's bladder every 30 minutes. Periodically assess for level of anesthesia before administration of any bolus dose. (One way to do this is to move an ice cube from the mother's groin area upward. Mark with a skin marker the level at which the mother becomes aware of the cold; repeat on other side.) Determine the level of pain relief u sing institutional pain assessment scales.
This allows the drug to defuse bilaterally.Avoid bilaterally.Avoid excessive pressure in one area. The woman can lose the sensation to void. A full bladder not only is subject to trauma but also can impede descent of the fetus. This is important to avoid potentially high levels of anesthesia. This is also done to assess the fading of anesthesia.
Avoid anesthesia receding too far bfore a (bolus dose) is needed.
Continually monitor for maternal maternal complications. complications. Nausea, vomiting, itching, and urinary retention are possible. Nausea and vomiting can occur in up to 50% of women having epidural anesthesia.
Document the following per institutional policy:
Can be rapidly reversed by administering naloxone hydrochloride (Narcan). This documentation is placed on the fetal monitor strip and becomes part of the medical record.
Times, Times, types, and amounts of anesthetic Maternal BP and pulse rates Position changes
Document the same information in the nursing notes, including description of the following:
Oxygen administration
The woman's responses to the procedure
IV rate changes
Any complications
Maternal response
Use of oxygen Other supportive interventions, should they be necessary During Stage II of labor, in preparation for delivery, delivery, assist the mother to a semi-upright position, an upright position, or a sidelying position.
A semi-upright position allows the anesthetic to migrate into the sacral area. If fetal heart rate decelerations occur, a lateral position optimizes blood flow to the fetus.
Under the influence of epidural anesthesia, Stage II of labor is sometimes delayed. The American College of Obstetricians and Gynecologists (ACOG) defines a prolonged Stage II as being greater than 3 hours in a nullipara with regional anesthesia and greater than 2 hours without regional anesthesia. For the multipara, a prolonged Stage, II is greater than 2 hours with regional anesthesia and greater than 1 hour with anesthesia.
Continue to monitor for maternal complications complications and evaluate and document maternal pain levels using standard assessment tools such as visual and verbal analog scales
Actions to Respond to Complication Maternal Hypotension
Remarks
Maternal hypotension is defined as a systolic Maternal hypotension may result in a fetal blood pressure less than 100 mm Hg or a 20% hypotensive response showing fetal bradycardia decrease from preanesthesia levels. and/or late decelerations.
Place the mother in a full lateral or upright position. Give oxygen by face mask Give 250 to 500 ML IV bolus of non-glucosebalanced saline solution. If vasopressors are needed, 5 to 10 mg IV ephedrine is recommended. Pruritus
These supportive measures are intended to restore uterine blood flow. This is the vasopressor of choice because it targets cardiac muscle, thus increasing uterine blood flow by enhancing cardiac output.
Pruritus is a common and mild reaction to anesthetic, usually begins within 10 to 30 minutes of epidural initiation and medication administration.
Diphenhydramine or naloxone is used for treatment. Usually, Usually, the pruritus resolves within an hour of onset. Urinary retention Urinary retention is a side e ffect of epidural anesthesia in a large percentage of women.
Urinary catheterization will be necessary in some women
The use of opioids may increase the risk of pruritus by 40% to 90%. Less than 20% of women require medication to alleviate it.
Assessment of bladder status is critical to avoid overdistension of the bladder, which the mother cannot feel. Urinary displacement relieves pressure on the vena cava and aorta, promoting better venous return to the heart.
High Spinal Prevailing symptoms:
Inadvertent intravenous catheter placements can occur in up to 5% of pregnant women.
Profound motor and sensory block within 1 to 5 minutes of the epidural injection Severe hypotension Cessation of respirations Cardiac arrest
Take steps to do the following: Establish a patent airway. Give 100% oxygen at a high flow rate. Intubate if necessary. Administer vasopressors. Manually push the gravid uterus to one side. Intravascular Injection of Local Anesthetic Signs of this include the following: Change in maternal heart rate (tachycardia or bradycardia)
Inadvertent dural punctures occur in approximately 2% of pregnant women.
Maternal hypertension Dizziness, tinnitus, or metallic taste Loss of consciousness.
Intravascular injection of a local anesthetic may result in seizure or cardiac arrest and requires an immediate response, including cardiopulmonary resuscitation, 02 administration, and assisted ventilation. Spinal Headaches If the dura is accidentally punctured, women may experience spinal headaches 24 to 48 hours after the puncture.
Headaches develop in 1% to 3% of women who receive epidural anesthesia.
Conservative treatment involves: Maintaining a flat position, hydration, and an abdominal binder and administering analgesics.
As cerebrospinal fluid is lost, pressure is diminished throughout that compartment and the brain descends somewhat, especially when the A blood patch is used to seal the puncture site, mother is in an upright position. using 15 mL of the patient's unanticoagulated blood. As the blood clots, it "patches" the area, usually affording quick relief
Actions During Recovery From Epidural/Delivery During the mother's recovery, keep the side rails up and the bed in a low position.
Remove the catheter once the placenta has been delivered and the mother begins her recovery period. A registered nurse with training may remove the catheter.It catheter.It is preferable to remove the catheter with the
Remarks
The maternal position increases the intervertebral space.
mother in the same position used during placement.
Inspect the catheter carefully to make sure it is intact. If you suspect breakage, alert the anesthesiologist immediately. immediately. Always save the catheter for the anesthesiologist's inspection.
Assess for motor and sensory return by asking the mother to move her legs up and down and side to side; perform plantar flexion and dorsiflexion of the feet. The mother must be able to support her knees in an upright position, as in a standing position.
Actions to Respond to Neonatal Complication
Remarks
Neonatal respiratory depression as a result of Monitor all neonates for signs of neurobehavioral opioids can be treated with narcotic antagonists change associated with the use of epidurals i.e. Narcan
For more information go to:
American Family Physician The Nature and Management of Labor Pain: Part II. Pharmacologic Pain Relief [2003] The Nature and Management of Labor Pain: Part I. Nonpharmacologic Pain Relief [2003] Contemporary OB/GYN Do epidurals increase risk of C/S? Yes. [2003]
Do epidurals increase risk of C/S? No. [2003] Epidural analgesia: 2002 update [2002] Epidural Cochrane Reviews Types of intra-muscular opioids for maternal pain relief in labour (Cochrane Review) [2004] Spinal versus epidural anaesthesia for caesarean section (Cochrane Review) [2004] Prophylactic intravenous preloading for regional analgesia in labour (Cochrane Review) [2004] Epidural versus non-epidural analgesia for pain relief in labour (Cochrane Review) [2004] Complementary and alternative therapies for pain management in labour (Cochrane Review) [2004] Combined spinal-epidural spinal-epidural versus epidural analgesia in labour (Cochrane Review) [2004]
Amnioinfusion
Guidelines for the Amnioinfusion Procedure Adapted from the AWHONN's Evidence-Based Clinical Practice Guideline, Nursing Care of the Woman Receiving Amnioinfusion in Labor.
• •
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Obtain informed consent, including purpose, risks, and benefits, and explain the procedure to the mother. With With the mother's permission, perform a vaginal examination to rule out cord prolapse. Determine cervical dilatation, effacement, effacement, station, status of membranes, and presentation. Ask the woman to position herself on her side. With the mother's consent, insert a fetal scalp electrode and an intrauterine pressure catheter.
New-generation pressure catheters are equipped with dual lumens, internal transducers, and amnioports (sites for injecting the amnioinfusion fluid). Connect the catheter to the amnioinfusion system. Double-lumen uterine catheters permit monitoring of uterine activity while amnioinfusion is being performed. Otherwise, use a separate uterine catheter to monitor uterine activity throughout the procedure.
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Prepare the infusion (an initial bolus of normal saline or lactated Ringer's), by either gravity flow or an infusion pump.
NOTE: A literature literature survey revealed no demonstrable benefits using infusion pumps or solution warmers during amnioinfusion. Warming Warming is accomplished by using a standard blood-warming unit. Extremes of temperature should be avoided. Do not use a microwave oven to warm the fluid
•
Infuse the stipulated infusate at the rate determined by protocols and by primary care provider orders.
Infusion rates vary among recent reports in the literature. An initial bolus of 250 to 600 mL and an hourly maintenance rate of 150 to 180 mL has been suggested. Recent studies show initial bolus ranges from 250 to 600 mL followed by a maintenance infusion rate of 150 to 180 mL per hour.
•
•
Observe for fluid return; if 250 m L infuses with no evidence of return, discontinue the infusion and wait to see fluid. Continue the infusion until either the variable decelerations cease or 800 mL of normal saline or lactated Ringer's infuse.
Resolution of variable decelerations might not occur. occur. The woman's primary care provider should be contacted if resolution is not achieved within the time frame stipulated in nursing protocols.
• • •
Reduce the infusion rate to the hourly maintenance rate designated by nursing and institutional protocols. Carefully monitor uterine activity throughout the procedure. Watch uterine resting tone.
Artificially increased uterine resting pressures higher than the preinfusion baseline can occur. A resting resting baseline pressure of less than 25 mm Hg should be maintained.
•
Carefully calculate fluid output during the amnioinfusion.
Fluid output can be evaluated b y comparing a dry-weight item with a wet-weight item; 1 mL of fluid is equal to 1 g of weight. Therefore, all vaginal fluid should be captured in whatever padding is kept under the mother. mother.
•
Document the procedure on the fetal monitor tracing and in nursing progress notes.
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Be attentive to other possible complications associated with amnioinfusion.
Iatrogenic polyhydramnios can occur if the fetal head is pressed closely against the cervix. Too much retained fluid may result in maternal symptoms of shortness of breath, h ypotension, or tachycardia. tachycardia.
Abruptio Placentae. Signs and symptoms of abruptio placentae include a hard, board like abdomen; vaginal bleeding; and pain. NOTE: Vaginal Vaginal bleeding does not always occur with abruptions of the placenta.
Umbilical cord prolapse can occur if the cord is carried down with fluid output.
Intrauterine Resuscitation
What is intrauterine resuscitation? Interventions undertaken to attempt to change the relationship of the uterus, placenta, cord, and fetus to improve placental and fetal oxygenation. These are empirically empirically designed to overcome uteroplacental insufficiency or to decrease cord compromise.
These include the following: •
• •
Positioning the mother to right/left side lying recumbent or knee-chest to improve blood flow to the uterus Repositioning the mother to alleviate cord compression Discontinuing oxytocin
•
• •
•
Tocolysis with subcutaneous Terbutaline to decrease/moderate uterine activity and improve blood flow Increasing intravenous (IV) fluids to enhance maternal blood flow volume Administering oxygen to the mother in an effort to promote ox ygen flow across the placental membrane Performing amnioinfusion-fluid amnioinfusion-fluid instillation into the amniotic cavity through a catheter; usually performed transcervically during the intrapartum period.
Fetal Pulse Oximetry
Current techniques for evaluating fetal status in labor are limited in their ability to predict outcome. Fetal oxygen saturation monitoring provides a continuous measure of fetal ox ygenation and is used to evaluate peripheral tissue perfusion to provide additional information when a nonreassuring fetal heart rate pattern occurs and a management decision cannot be made without benefit of additional information information regarding fetal oxygenation.
Procedure
A sensor is inserted into the uterus and placed next to a fetal vascular bed (e.g., temple, cheek, forehead).
Measurements are based on a fraction that represents the rate of hemoglobin that is oxygenated (oxyhemoglobin), as measured by differences in light absorption, and are displayed on the electronic fetal monitoring strip providing continuous real-time data.
The normal range of fetal ox ygenation in labor is between 30% and 70%. Values Values greater than 30% provide reassurance.
Indications
Single fetus at term Vertex presentation Nonreassuring fetal heart rate pattern Ruptured membranes Cervix dilated at least 2 cm with station -2 or below
Contraindications
Placenta previa Nonreassuring fetal heart rate pattern necessitating immediate delivery Infectious diseases that preclude internal fetal heart rate monitoring (e.g., HIV; active herpes virus; hepatitis B, C, and E)
Amniotomy Artificial rupture of membranes is a commonly used practice in obstetrics performed at or beyond 3 cm dilation. The technique involves perforation of the fetal membranes with a sterile plastic instrument (amnihook) or by applying a fetal scalp electrode through the membranes onto the
fetal scalp. Amniotomy Amniotomy results and local release of arachidonic acid from the membranes and the subsequent prostaglandin formation is thought to be one of the mechanisms responsible for labor augmentation and induction. The procedure may be associated with changes in the fetal heart rate (e.g., accelerations or bradycardia) secondary to prolonged uterine contraction, secondary to release of a large quantity of fluid or in some cases prolapse of the umbilical cord.
For more information go to: Amniotomy and Placement of Internal Fetal Spiral El ectrode
AWHONN Clinical Position Statement Amniotomy and Placement of Internal Fetal Spiral El ectrode through Intact Membranes
Induction of Labor
Induction of labor is the deliberate starting of uterine contractions before they begin on their own.
oxytocin to enhance existing labor. Augmentation is the administration of synthetic oxytocin
For more information go to: Methods for Cervical Ripening and Induction of L abor http://www.aafp.org/afp/20030515/2123.html http://www.aafp.org/afp/20030515/editorials.html
Indications
The benefits of delivering the fetus at a specific point in time must outweigh the benefits of permitting the pregnancy to continue. Induction is appropriate when delivery is indicated but immediate delivery by cesarean is not necessary
Indications include.
Pregnancy induced hypertension (PIH) Fetal demise PROM, with or to prevent chorioamnionitis Suspected fetal jeopardy Macrosomia Relative contraindications include. Previous classical uterine incision Placenta previa Active genital herpes Fetal malposition; abnormal lie Cephalopelvic disproportion Invasive cervical carcinoma
Pre-requisites
Accurate estimation of gestational age Favorable Bishop score Available personnel and resources for observation and immediate intervention
Methods Cervical ripening Hygroscopic dilators
Prostaglandin gel Amniotomy Oxytocin
Oxytocin Pharmacology
Posterior pituitary hormone/ Half life = 3-6 minutes /Causes uterine contractions/Antidiuretic/Causes contractions/Antidiuretic/Causes milk ejection reflex
Policy and prerequisites Physician availability Nursing personnel Monitoring ACOG guidelines
Induction Procedure Intravenous LR infusion Use volumetric pump Piggy back oxytocin solution
Dosage
Induction -start at 0.5-1.0 mU/min, increasing every 15-4(minutes by 1-2 mU/min Augmentation- start at 0.5 mU/min Active management (nulliparous patients) -start at 4.0-6.0 mU/min, increasing every 15 minutes b y 4.0-6.0 mU/min
Indications for reducing or discontinuing oxytocin include:
Non-reassuring fetal heart rate Uterine hyperstimulation hyperstimulation Persistent uterine hypertonus
Nursing responsibilities Assess and document fetal presentation Explain procedure to patient; obtain consent Document maternal and fetal assessment at the time of each change in infusion rate Notify physician of abnormal FHR, abnormal contraction pattern, or discontinuance Monitor Intake and Output
For more information go to: Active management of labor
Vacuum Extraction
In vacuum extraction, a properly sized silastic cup is attached to a source of suction (manual or electric). The physician determines the position position of the fetal head, and places the cup on the head of the fetus in the area of the posterior fontanel. The practitioner then uses gentle downward traction to deliver the fetal head. Continuous or intermittent suction is used. Once the baby's head is delivered, the suction is discontinued and the cup removed.
The nurse's involvement in vacuum extraction is primarily on the side of patient education. The nurse is responsible for assessing the patient's level of pain, assisting the physician and reassuring the patient throughout the procedure.
Additionally, Additionally, the nurse must be prepared to resuscitate the newborn if necessary and explain any marks that may be caused by either forceps delivery or vacuum extraction.
For more information go to:
Vacuum Extraction
Shoulder Dystocia
Most of the time, an infant's shoulders present in the proper alignment across the mother's pelvic outlet. However, However, occasionally the shoulders present transverse to the pelvic outlet. As a result, shoulder d ystocia may occur. In shoulder dystocia, the baby's shoulder becomes lodged under the mother's symphysis symphysis pubis, making delivery difficult. In such cases, the nurse-midwife or obstetrician will require assistance. When the physician identifies a shoulder dystocia, the nurse's first response is to call for additional assistance. The nurses help the physician with either the McRobert's maneuver or applying suprapubic pressure, if required.
The McRobert's Maneuver
First try the McRobert's maneuver. maneuver. In this maneuver, one nurse stands on each side of the patient and help her to hyperflex her legs. If possible, the patient must keep her knees bent back to her abdomen. When the patient's legs are hyperflexed, the birth canal opens to its maximum, facilitating the delivery of her baby's anterior shoulder. shoulder.
Suprapubic Pressure
In applying suprapubic pressure, the nurse must feel the infant's shoulder above the symphysis pubis and press directly down on it with the heel of her hand. This action c an help to dislodge the baby's shoulder to facilitate easier delivery of the baby.
Perineal Skin Prep
Crowning and birth of the baby and placenta
Father or SO Cuts the Cord
Hand baby to mom: if baby is stable
For more information go to:
Management of the Third Stage of Labor
Newborn Management
Review of Newborn ABC Management
A
Airway
B Breathing
C Circulation
When the head is delivered, the mouth is suctioned first and then the nose to reduce the risk of aspiration. The caregiver will inspect to see if the umbilical cord is wrapped around the neck. If the cord is around the infant’ infant’ss neck, it is loosened, and slipped over the infant’s infant’s head. If it is impossible to slip the cord over the head, the cord is clamped in two places and cut between the clamps. Then the body of the baby is delivered and the mouth and nose are suctioned again. If breathing is not spontaneous, the caregiver gently rubs the baby’s back with a towel to stimulate breathing.
Dry the baby, cover, and put in a warm environment. If baby is stable placing the infant on the mother’s abdomen is a warm and appropriate place. Determine the Apgar score at delivery and then again 5 minutes after delivery. delivery. Apgar Score 0
1
2
Appearance
Blue
Blue limbs, pink body
Pink
Pulse
Absent
< 100 beats/min.
> 100 beat/min.
Grimace
Limp
Some flexion
Good flexion
Activity
Absent
Some motion
Good motion
Respiratory
Absent
Weak cry
Strong cry
Assign a score to appearance, pulse, grimace, activity, activity, and respiratory. respiratory. Add them together. together. A score 7 to 10 is good; 4 to 6 is depressed; 0 to 3 is severely depressed.
C
Clamp the Cord
C
Cover
C
Continue the assessment
When the cord has stopped pulsating, the caregiver clamps the cord in two places, and cut between the clamps.
Continue to dry the baby, baby, cover and keep warm, again if baby is stable the mother’s abdomen is a warm and appropriate place, encourage the mother to breastfeed the infant. Breastfeeding stimulates the uterus to contract. . If the baby is not stable the baby must be transferred to the radiant warmer. warmer. Continue the assessment. Reassess the airway. If the airway is not clear, suction the nose and then the mouth, reposition the newborn, and perform a slight chin lift. Do not hyperextend the neck. If breathing is absent or heart rate is < 80 beats/min. begin resuscitation.
Provide oxygen, establish effective ventilation with a bag-valve mask or endotracheal intubation, and perform chest compressions. Medications are infrequently needed. A blood glucose level of 40 mg/dl is critical in a newborn. Administer a 25% solution at Resuscitation 0.5 g/kg.
CPR Neonatal
Obstetrical Complications
Breech
Breech presentations are categorized into three types: A complete breech is presentation with the infant’s infant’s knees and hips flexed. An incomplete breech is presentation with one or both of the infant’s feet or knees first. A frank breech is presentation with the infant's hips flexed and the legs extended.
For more information go to: Breech Presentation
Abruptio placentae
Abruptio placenta is premature separation of the placenta. The cause is unknown. Symptoms may include vaginal bleeding and abdominal pain or contractions. Diagnostic Diagnostic tests include hemogram and crossmatch of 4 units of PRBC. Management includes fluid resuscitation with normal saline, fetal monitoring, and STAT C-section.
For more information go to:
Ultrasound of Placental Abruption Abruptio placentae: Fetal tracing Abruptio Placentae
Gross: abruptio placenta Microscopic: abruptio placenta Abruptio placenta Characteristic findings of placental abruption (list) Risk factors for placental abruption (list)
.
Amniotic fluid embolism
An amniotic fluid embolism is amniotic fluid that leaks into the mother ’s vascular system and is associated with abruptio placentae, placenta previa, and cases of fetal demise. Symptoms may include profound hypotension, cardiopulmonary comprise and/or cardiac arrest. Management may include rapid endotracheal intubation, mechanical ventilation, fluid resuscitation with normal saline and blood products, and evaluation of coagulopathy. coagulopathy.
Cord prolapse
There are three variations of cord prolapse: • • •
The cord is compressed by the fetus and not visible externally. externally. The cord may not be visual but is felt in the vaginal canal. The cord is protruding from the vagina.
The goal is prevention of fetal anoxia. Management includes positioning the mother on the left side in trendelenberg or in a knee-chest position and administering 100% oxygen. If the cord is exposed, cover it with saline moistened sterile gauze. STAT C-section is performed.
For more information go to: Umbilical Cord Complications "Velamentous" "V elamentous" insertion of the umbilical umbili cal cord
Placenta previa
Placenta previa is a disorder where the placenta presents before the fetus. The amount of coverage of the os is used to determine the type of placenta previa: total completely covers the os, partial partially covers the os, and marginal is beside the os. Symptoms may include hemorrhage not accompanied by labor. Diagnostic tests may include hemogram, type and crossmatch for four units of PRBC, clotting studies, and ultrasound. Management may include fluid resuscitation with normal saline, blood replacement, and transfer to labor and delivery. delivery. Pelvic examination is contraindicated.
For more information go to: Placenta Previa
Total Placenta previa: schematic s chematic of complete placenta previa Total Placenta previa: placenta accreta in uterine specimen Partial placenta previa Low lying posterior placenta previa
Pre-Eclampsia/Eclampsia
Cardinal signs of pre-Eclampsia are elevated blood pressure, sudden weight gain with generalized edema, decreased urine volume, and proteinuria. Eclampsia symptoms may include seizures and coma. Signs and symptoms usually occur in the third trimester, trimester, but can occur up to two months post delivery. delivery. Treatment includes oxygen, intravenous access, and fetal monitoring. Magnesium sulfate is used to control seizures. Hydralazine and nitroprusside sodium may be used to control hypertension. The problem commonly occurs in primagravida women and is associated with diabetes, hypertension, and renal disease.
For more information go to: Obstetrical Accidents Involving Intravenous Magnesium Sulfate: Recommendations to Promote Patient Safety MCN, The American Journal of Maternal/Child Nursing, May/June 2004
Eclampsia
Edema Risk factors for preeclampsia (table) PIH is a multi-org multi-organ an pathologic state with various subsets: (list) Signs and symptoms of mild and severe pregnancy induced hypertension (table)
Cesarean Section
In the case of severe obstetric emergencies, the time from decision to delivery is ideally within 30 minutes
For more information go to:
Cesarean Delivery
Nursing Responsibilities in the O.R. •
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The labor and delivery nurse is responsible for informing the physician of complications and calling the anesthesiologist. If the physician is present, he will order the C-section. If he is not present, the nurse phones the ph ysician, who confirms the necessity of the C-section. The anesthesiologist is then called. Notifying the pediatrician and resuscitation team (usually an RN from the nursery and a respiratory therapist). therapist). If the C-section is not immediate, the resuscitation team may arrive in the OR after the patient is taken to the OR. Informed consent must be obtained. The JCAHO states that this is to be obtained by the ph ysician, who is also responsible for explaining the procedure as well as the risks and benefits. The labor and delivery nurse witnesses the patient's signature and asks the patient if she understands what the physician has told her. The nurse also answers questions the patient may have about the procedure at this point. The nurse can then prepare the patient appropriately. appropriately. Inserting a Foley catheter. catheter. This may occur before leaving the birthing room or when patient arrives at the OR, according to emergency and timing. If the patient has had an epidural, she may already have a Foley in place. Administering ordered meds. Take patient to the OR and transfer to the operating table. Positioning the patient with a wedge under the patient's right hip to keep the weight of the uterus off of her large blood vessels. This occurs as soon as the patient arrives at the OR. Assuring Infant resuscitation equipment is present and in good operating condition prior to delivery. delivery. In preparing equipment for delivery, the nurse turns the infant warmer on, as well as the sources for oxygen and suction. Obtaining a fetal heart rate (unless the C-section is a critical emergency). emergency).
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Placing a grounding pad under her thigh and attaching the electrocautery unit. The grounding pad or return electrode for the electrocautery unit must be placed on the patient's thigh and attached to the unit before being turned on. It is important not to place place the grounding pad over a wet surface. surface. The nurse must be careful to assure that the prep solution does not run down over the area where the pad will be placed. Prepping the patient's abdomen for surgery. surgery. Abdominal prep varies from institution to institution and from physician to physician. Under normal circumstances, the area directly over and immediately surroundi surrounding ng the surgical site is shaved or clipped. Then, one of several types of prep solutions is applied. Although these solutions differ, their application process is consistent. Working from the side of the patient tilted toward the nurse, the nurse starts at the incision site and works outward (cleanest area to dirtiest) in a circular motion, never going back over a previously prepped site with a used applicator. applicator. In a crash C-section, the prep does not include a shave and the solution is poured over the belly, or sprayed. Counting instruments, sponges and sharps prior to surgery. surgery. The circulating nurse is responsible for making sure the counts of these items are accurate. The scrub tech or nurse and circulating nurse counts the instruments together. together. It is important for the circulating nurse and scrub tech to count instruments aloud and simultaneously. simultaneously. The number of each item must be determined with utmost certainty. certainty. At the end of each count, the circulating nurse informs the physician of the results, and the physician verbally acknowledges this information. These These counts occur at the beginning of the surgery, surgery, when a body cavity is closed, and prior to skin closure. During emergency surgeries, surgeries, as in a crash c-section, the instrument count is forgone, while attempts are usually made to count sponges and needles. A post op x-ray is then taken to confirm the absence of any instrument or foreign body left in the abdominal cavity. Providing patient education, explaining to the patient what is happening to the extent that time allows just prior to emergency surgery. It is important to remember that an emergency C-section can be very frightening for the patient and her birth partner. That's why, even while preparations are being made, it is imperative for the nurse to explain what is happening and reassure the patient as much as possible. Once preparations are complete, the surgeon(s) and anesthesiologist are called to the O.R.
For more information go to: Common Areas of Litigation Related to Care During Labor and Birth: Recommendations to Promote Patient Safety and Decrease Risk Exposure Journal of Perinatal and Neonatal Nursing, April/Jun April/June e 2003
CRITICAL THINKING: Labor and Delivery •
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IV Nubain/Stadol is ordered for pain to the mother in active labor. labor. What measures do you need to take before giving pain medication to a laboring woman? When should an IV medication be given in relation to her contractions? List four possible causes of fetal tachycardia. List three possible causes of fetal bradycardia.
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What should you do if you discover fetal bradycardia? What are common causes of early decelerations? What are common causes of late decelerations? What are common causes of variable decelerations? What are the nursing responsibilities for a patient receiving Terbutaline? Terbutaline?
CRITICAL THINKING: Labor and Delivery •
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A childbirth childbirth coach can sometimes feel "in the way". How can you make the coach feel more welcome and comfortable? Take a minute and draw a fetus inside a uterus. Draw the fetus in a longitudinal lie, cephalic lie, extended attitude.
CRITICAL THINKING: Unknown Obstetrical Complication Mary, G3, P0 presents to L&D complaining of vaginal bleeding and abdominal pain. She appears reluctant to answer questions. She is 38 weeks pregnant with a history of no prenatal care. Her fundal height measures 30cm. Her monitor pattern reveals fetal heart rate of 180 and decreased variability. variability. Her abdomen is rigid and a hypertonic pattern appears on the monitor. monitor. BP 100/60, P 120, R 24. Mary is slow to respond to questions and appears weak and diaphoretic. Describe Mary’s obstetrical history? What emergency obstetrical complication do you suspect Mary has? Support your choice with clinical findings. What data support your suspicion that Mary is a substance abuser? What common pain meds should be avoided in drug addicted persons?
CRITICAL THINKING: Labor Mary has an emergency emergency cesarean section for abruptio placenta. She is in the recovery room and you notice bloody urine in the Foley catheter and a 2cm area of bright red blood on her abdominal dressing. What should you do, and what serious complication would Mary be at risk for?
Mary’s baby weighs 3 pounds and is severely growth restricted. Explain why these babies are prone to hypothermia, hypoglycemia and hyperbilirubinemia. What symptoms will you look for in Mary’s baby due to Mary’s use of drugs?
CRITICAL THINKING: Labor Sarah is at 42 weeks’ gestation. Her physician has ordered a b iophysical profile (BPP). She is very upset and tells the nurse: "All my doctor told me is that the test will see if my baby is O.K. I don’t know what is going to happen next and if it will be painful to me or harmful to my baby." Sarah receives a score of 8 for the BPP.
Describe how you would be respond to Sarah’s concerns. List the factors that were evaluated to obtain this score. Specify the meaning of Sarah’s test result of 8.
Thermoregulation Using a Radiant Warmer
Assessment • •
Assess infant's axillary temperature. If below 36.4176C (97.5° F), may lead to cold stress. Assess skin integrity.
Implementation • • • •
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Prewarm the radiant warmer to between 36° and 37° C (96.8° and 98.6° F). Remove shirt from infant, leaving a diaper on. Place infant under the heater Place thermal skin probe on the abdomen and attach by an aluminum heat deflector patch. Set the radiant warmer controls according to agency protocol.
Evaluation •
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Evaluate axillary temperature to verify stability between 36.4° and 37.2° C (97.5° and 99° F). Inspect infant's skin for absence of redness and irritation. Assess infant's axillary and skin probe temperature every 30 minutes or according to agency protocol. As the infant's temperature stabilizes, prewarm blankets. When the infant's temperature reaches 37° C (98° F), dress and wrap in prewarmed blankets with a dry cap on head. Place in an open crib. Recheck axillary temperature in 1 hour.
Identify Unexpected Outcomes and Nursing Interventions …Report and Record • • • •
Temperature of infant before and after warming. Length of time under the warmer. Temperature of infant 1 hour after removing from the warmer. Condition of skin after warming process
Infant Bathing || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities |
Assessment • • • • • •
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Assess the infant's skin for dryness, peeling, or signs of infection. Assess the site of the umbilical cord for redness, drainage, drying, and intactness. Assess the infant's temperature if at high risk for hypothermia. Shampooing infant's hair: Wrap the infant in the blanket using a swaddling technique. Hold the infant in a "football" hold over the washbasin, or leave infant in crib and gently pick up head, supporting it in one hand. Lather scalp with a small amount of mild soap. A soft washcloth may be used to wash the scalp if there is excess soiling. Rinse the scalp thoroughly by pouring water from a small cup over the infant's scalp into the washbasin. Dry thoroughly with a towel. Comb or brush infant's hair gently. Replace the damp blankets. Implementation Prepare washbasin with warm water at about 36.6° to 37.8° C (98° to 100° F), which is comfortably warm. Place infant in crib or bassinet with sides and have all supplies within reach. Use clean gloves for first newborn bath or if in contact with body secretions during any bath. Keep infant covered with a blanket to maintain warmth. Cleanse the eyes with plain water from the inner to the outer canthus, using a clean portion of the washcloth with each wipe. Apply a moistened washcloth for 1 to 2 minutes before cleansing to soften crusts if present. Cleanse the external ears with plain water and a twisted end of the washcloth. Cleanse the face and neck with plain water, with attention to areas behind ears and creases in neck. A small amount of soap may be used for soiled creases, rinsing well after washing. Dry face and neck with a towel using a gentle patting motion. With fresh washcloth dampened with plain water, cleanse the infant's mouth, including inside lips, cheeks, dorsal surface of tongue, roof of mouth, and along upper and lower gum pads. Cover infant's lower body with blanket. Cleanse infant's upper body with soap and washcloth. Quickly rinse soap from the infant's hands. Thoroughly rinse the rest of the upper body and dry completely by using a patting motion. Cleanse the abdomen around the umbilicus with soap and water, keeping the cord dry. dry. Dry the area. Apply cord care product according to agency protocol until area is healed. Cover the upper body with a dry towel or blanket. Cleanse the legs and outer buttocks with soap and water. Rinse Rinse and dry dr y thoroughly. thoroughly. With a fresh washcloth, cleanse the genitalia with plain water. For a female infant: Gently retract labia and wash from front to back toward the anus. Use separate portions of the washcloth for each wipe. Wash the other portions of the labia and the folds in the groin. For an uncircumcised male infant: Wash from the urethra outward and down toward the scrotum. Wash scrotum and folds of the groin. In uncircumcised newborns, the foreskin may be adhering to the glans and should not be retracted. In a circumcised newborn, circumcision care is done. Assess area for bleeding. Cleanse the area gently with warm tap water and cotton gauze or cotton balls. Place sterile gauze dressing with sterile petroleum jelly added between the penis and diaper. Change this dressing with each diaper change. Cleanse anal area with soap, rinse, and dry.
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Apply clean diaper.
Identify Unexpected Outcomes and Nursing Interventions Record and Report • •
Temperature on the graphic sheet. Description of skin condition.
Parent Teaching and Evaluation Communication Tip: Assess parents' parents' knowledge of how to give a bath and any cultural deviations that may alter the care of the infant. Incorporate specific bathing techniques important to their family or culture. •
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Evaluate parents' ability to bathe, handle, and dress the infant during a return demonstration. Observe parents' interactions with infant in relation to sensory and social stimulation. Document parent teaching and response.
Infant Feeding || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities |
Assessment • • • •
Assess for feeding readiness cues Determine when the infant was last fed, and the quality of that feeding time. Assess physical development of infant and suck reflex. Assess for tolerance of last feeding of formula.
Implementation • • •
Identify the infant using identification bracelet. Prepare the infant by providing clean diaper and clothing and wrap snugly. snugly. Encourage mother to implement thorough hand washing before infant feeding.
Assisting with Breast-Feeding
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Assist the mother to a comfortable position supported with pillows in the bed or chair. Assist the mother to position the infant in one of four positions (The football hold; The cradle hold; Across Across the lap; Lying down) and encourage her to to use a variety of positions Assist the baby to latch on effectively. Have the mother support the breast in one hand with the fingers underneath and the thumb on top. Have the mother lightly touch the baby's lower lip and the tip of the tongue with her nipple. When the mouth is open wide and the tongue is down, have the mother pull the baby quickly to the breast, bringing the baby to the breast and not the breast to the baby. Evaluate for a proper latch on. The mother feels a firm tug on her nipple and no pinching or sliding sensation. Ask if nursing hurts after the first few sucks. If there is pain, have her release the suction with her finger and remove the infant from the breast and start over. Assess for the following evidence of success: After the milk comes in at least one breast softens with each feeding. The baby has bursts of 10 or more sucks and swallows at the beginning and slows down to 2 to 3 sucks and swallows as the breast softens. The swallowing can be heard. As the let-down reflex occurs, there may be leaking from the other breast. After the breast has softened, encourage the mother to burp the infant and, if possible or desired, continue nursing on the opposite breast. Encourage the mother to begin feedings on the opposite breast each time.
Assisting with Formula Feeding • • • • • • • •
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Identify and prepare the appropriate type and amount of formula. Position the infant: cradle head in one hand or on one arm, support body on the other. Place bib or small cloth under infant's chin. Touch the corner of infant's mouth with nipple. Insert nipple into mouth and hold bottle so that nipple is completely filled with formula. Allow infant to suck, observing for suck-swallow-breathe reflex. Observe for choking, gagging, or regurgitation during feeding. Burp infant about halfway through feeding. Place infant in prone position across lap and gently pat infant's back. Observe infant's face for signs of choking or vomiting. The infant may also be placed on the shoulder of the caregiver or in a sitting position. Continue to feed remainder of formula. Burp infant at the end of the feeding. Check diaper and change if needed. Place infant in bed on right side, never on the abdomen. Observe for choking, gagging, or regurgitation after feeding.
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Dispose of bottle and unused formula in an appropriate container.
Evaluation •
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Evaluate the amount of formula or, if breast-feeding, the time in minutes and note if infant softens at least one breast each feeding. The infant is content for at least 2 to 2½ hours between feedings. The infant has at least six wet diapers and two bowel movements each 24 hours by 4 days of age. The infant regains birth weight in 7 to 10 days and doubles the birth weight in 6 months.
Identify Unexpected Outcomes and Nursing Interventions Record and Report • • • • •
Amount of formula infant drank. Length of feeding. How infant sucked. Infant's tolerance of formula. Positive/negative bonding response of parents.
Newborn Exam Physical Assessment Assessment of the Newborn
|| TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities |
Measure and record height, weight, and head circumference. If the infant appears premature or is unusually large or small, perform a Dubowitz/Ballard Dubowitz/Ballard exam to assess gestational age (see Dubowitz/Ballard Dubowitz/Ballard scoring grid). The exam is divided into two parts: an external characteristics score, which is best done at birth, and a neuromuscular score, which should be done within 24 hours after birth.
SKIN Color • • • • •
Pallor - associated with low hemoglobin Cyanosis - associated with hypoxemia Plethora - associated with polycythemia Jaundice - Elevated bilirubin Slate grey colour - associated with methemoglobinemi methemoglobinemia a
Lesions •
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Milia - pinpoint white papules of keratogenous material usually on nose, cheeks and forehead, last several weeks. Miliaria - obstructed eccrine sweat ducts. Pinpoint vesicles on forehead scalp and skinfolds. Clear within 1 week. Transient neonatal pustular melanosis - small vesicopustules, generally present at birth, containing WBCs and no organisms. Erythema toxicum - Most common newborn rash. Variable, irregular macular patches. Lasts a few days. Cafe au lait spots - suspect neurofibromatosis if there are many large spots. Junctional nevi - if large numbers suspect tuberous sclerosis, xeroderma pigmentosus, generalized generalized neurofibromatosis. neurofibromatosis.
NEUROLOGICAL EXAM || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities | State of alertness Check for persistent lethargy or irritability. irritability. Posture In term infant, normal position is one with hips abducted and partially flexed and with knees flexed. Arms Arms are adducted and flexed at the elbow. The fists are often clenched, with fingers covering the thumb. Tone Support the infant with one hand under his chest. The neck extensors should be able to hold the head in line for 3 seconds. Should not h ave more than 10% head lag when moving from supine to sitting position. Reflexes
Reflexes must be symmetrical. Biceps jerk test C5 and C6 Knee jerk tests L2-L4 Ankle jerk tests S1, S2 Truncal incurvation reflex tests T2 through S1 Anal wink test S4, S5 Other primitive reflexes include the Moro, palmer and planter grasps, sucking and rooting reflexes, and the asymmetric tonic neck reflex (ATNR). (ATNR).
Neonatal Primitive Reflexes
Newborn and infant reflex tests and b ehaviors. BABINSKI
BABKIN
DOLL'S EYE
Baby's foot is stroked from heel toward the toes. The big toe should lift up, while the others fan out.
When both of baby's palms are pressed, her eyes will close, mouth will open and her head will turn to one side.
While manually turning baby's head, his eyes will stay fixed, instead of moving with the head.
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Absence of reflex may suggest immaturity of the CNS, defective spinal chord, or other problems. Reflex may be seen up to age one, then reaction will be reversed with the toes curling downward.
GALANT
While normally vanishing around one Absence of this reflex month of age, if it or if it reappears after reappears later, there vanishing around 3-4 may be damage to the mos., it may signify a CNS. malfunctioning CNS.
MORO
While stroking Baby is held horizontally, horizontally, then swiftly baby's back to lowered a few inches, or the head may one side, her be lowered a few inches, or a loud spine and trunk sudden noise will make baby's arms will arch toward fling out and then come together as that side. hands open then clutch.
PALMAR GRASP By pressing just one of baby's palms, fingers should grasp the object.
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Absence may Absence or weakness of this reflex may Absence or indicate spinal suggest a severely disturbed CNS. weakness of injury or this reflex depression of could reflect an the CNS. injured spinal chord or depressed CNS. PEREZ Firmly stroking baby's spine from tail to head, will make her cry out and head will rise.
PLANTERS GRASP Pressing thumbs against the balls of baby's feed will make his toes flex.
STEPPING Holding baby upright with feet touching a solid surface and moving him forward should elicit stepping movements.
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If this reflex does not vanish in 4-6 months, baby's CNS may be severely depressed.
**** Absence of this reflex may indicate damage to After 3-4 months, this reflex the spinal chord. should vanish. If it reappears, there may be an injury of the upper spinal chord.
SUCKING
ROOTING
WITHDRAWAL
A finger or nipple When baby's cheek is A pinprick to the sole of placed in baby's stroked at the corner of her baby's foot will make mouth will elicit mouth, her head will turn baby's knee and foot flex. rhythmical toward finger and she will sucking. make sucking motions. **** ****
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Absence of this reflex could indicate a damaged sciatic nerve.
Depressed If this reflex doesn't vanish sucking may be in 3-4 months, the CNS due to may be malfunctioning. medication given during childbirth When reflexes appear and disappear: Reflex
Appears
Disappears
Moro
Newborn
3 months
Grasp
Newborn
3 months
LE crossed extensors
Birth
1 month
Extensor plantar
Newborn
8-12 months
Placing/stepping
Birth
1-2 months
ATNR
Newborn
3 months
HEAD AND NECK || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities |
Head Check for overriding sutures, the number of fontanelles and their size. Check for abnormal shape of head. Check for encephalocoeles. Measure the head circumference. • • • •
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Eyes Check for colobomas, heterochromia. heterochromia. Cornea - Check for cloudiness. Conjunctiva - Inspect for erythema, exudate, edema, jaundice and hemorrhage. Silver nitrate prophylaxis can cause a chemical conjunctivitis. Check for pupillary size and reactivity to light. Red Reflex - Hold the ophthalmoscope 6-8" from the eye. Use the +10 diopter lens. The normal newborn transmits a clear red colour back to the observer. Black dots may represent cataracts. A whitish color may be suggestive of retinoblastoma.
Ears Check for asymmetry, irregular shapes. Look for auricular or pre-auricular pits, fleshy appendages, lipomas, or skin tags. Nose Look for flaring of the alae nasi as a sign of increased respiratory effort. Look for hyper- or hypotelorism. Check for choanal atresia (CA) as manifested by respiratory distress (neonates are obligate nose breathers). A soft NG tube should be passed through each nostril to confirm patency if choanal atresia is suspected. Palate Check for cleft lip and palate. Mouth
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Observe the size and shape of the mouth. Microstomia - seen in Trisomy 18 and 21. Macrostomia Macrostomia - seen in mucopolysaccharidoses. mucopolysaccharidoses. Fish mouth - seen in fetal alcohol syndrome. Epstein pearls - small white cysts that th at contain keratin, frequently frequently found on either side of the median raphe of the palate. Ranulas - small bluish white swellings swellings of variable size on the floor of the mouth representing representing benign mucous gland retention cysts.
Tongue Macroglossia - Hypothyroidism, mucopolysaccharidoses Teeth Natal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk of aspiration if loosely attached. Chin Micrognathia - occurs with Pierre-Robin syndrome, Treacher-Collins Treacher-Collins syndrome, Hallerman Streiff syndrome. Neck Palpate over all muscles, palpate clavicles for possible fractures. Web neck found in Turner's Turner's and Noonan's syndromes. Torticollis Torticollis usually secondary to sternocleidomastoid hematoma. Cystic hygromas most common neck mass. Lymph nodes are unusual at birth and their presence usually indicates congenital infection.
CHEST AND LUNGS Observe respiratory rate, respiratory pattern (periodic breathing, periods of true apnea). Observe chest movements for symmetry and for retractions. Listen for stridor, grunting. Note that there may be some enlargement of the breasts secondary to maternal hormones. Cardiovascular System Measure heart rate, blood pressure in upper and lower extremities, respiratory rate.
Inspection Check baby's color for pallor, pallor, cyanosis, and plethora. Palpation Check capillary refill. Check pulses; note any decrease in femoral pulses or radio-femoral delay as a sign of possible coarctation of the aorta, note character of pulses (bounding or thready). Locate PMI with single finger on chest; abnormal location of PMI can be clue to pneumothorax, diaphragmatic hernia, situs inversus, or other thoracic problem.
Auscultation Note rhythm and presence of murmurs that may be pathologic. Before birth, there is a natural opening between the aorta (the main artery to the body) and the pulmonary artery (the main artery to the lungs) called the ductus arteriosus. This opening usually closes shortly after birth. PDA occurs when this opening fails to close; PDA occurs in about 10% of infants. PDA is often treated initially with a medication called indomethacin. If the ductus fails to close on its own or with indomethacin, surgery is performed. A small incision is made on the left side of the chest. The ductus is either ligated (tied off) or cut. Patent Ductus Arteriosis
Atrial septal defect (ASD) is a congenital heart defect. In fetal circulation there is normally an opening between the two atria (the upper chambers of the heart) to allow blood to bypass the lungs. This opening usually closes about the time the baby is born. If the ASD is persistent, blood continues to flow from the left to the right atria. This is called a shunt. Atrial Septal Defect
Before a baby is born, the right and left ventricles of its heart are not separate. As the fetus grows, a muscular wall forms to separate these lower heart chambers. If the wall does not completely form, a hole remains. This is what is known as a ventricular septal defect, or a VSD. It is estimated that up to 1% of babies are born with this condition. In the vast majority (80-90%) of babies born with this condition, t he hole is small. They will have no symptoms, and the hole will close spontaneously as the muscular wall continues to grow after birth. If the hole is large, then too much blood will be pumped to the lungs, leading to congestive heart failure. These babies are often have symptoms rel ated to the problem and m ay need medicine or surgery to close t he hole. Ventricular Septal Defect
ABDOMEN Note shape of abdomen. Flat abdomens signify decreased tone, abdominal contents in chest, or abnormalities in abdominal musculature. Note abdominal distension. Observe for diastasis recti. Observe for any obvious malformations e.g. omphalocoele. An omphalocoele has a membrane covering (unless it has been ruptured during the d elivery) whereas a gastroschisis does not.
Examine umbilical cord and count the vessels. Note color of cord. Palpate liver and spleen. It may be normal for the liver to be about 2 cm below the right costal margin. The spleen is not usually palpable; if the spleen is felt, be alert for congenital infection or extramedullary hematopoeisis. After locating these organs (checking for situs inversus), palpate for any abnormal masses. • • •
Auscultate for bowel sounds. Examine for hernias - umbilical or inguinal. Inspect anal area for patency and/or presence of fistulas.
Genitourinary Exam || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities | Kidneys Examined by palpation. The kidneys should be about 4.5-5.0 cm vertical length in the full term newborn. The technique for palpation is either a) one hand with four fingers under the baby's back, palpation by rolling the thumb over the kidneys, or b) palpate the left kidney by placing the right hand under the left lumbar region and palpating the abdomen with the left hand (do the reverse for the right kidney). Male genitalia Term normal penis is 3.6±0.7 cm stretched length. Inspect glans, urethral opening, prepuce and shaft. Normally difficult to completely retract foreskin. Observe for hypospadias, epispadias. Inspect circumcised penis for edema, incision, bleeding. Full term infant should have brownish pigmentation and fully rugated scrotum. Palpate the testes. Female genitalia Inspect the labia, clitoris, urethral opening and external vaginal vault. Often a whitish discharge is present; this is normal, as is a small amount of bleeding, which usually occurs a few days after birth and is secondary to maternal hormone withdrawal. Hymenal tags may be present normally. normally.
Extremities and Skeletal System || TOP || Thermoregulation | Bathing | Feeding | Newborn Exam | Neurological | Genitourinary | Extremities | Spine Scoliosis, kyphosis, lordosis, spinal defects, meningomyelocoeles.
Upper extremity Look for clavicular fracture, absence of radius or ulna. Inspect creases and fingers. Lower extremity See posture above. Do Ortolani maneuver to check for congenital hip dislocation. Check toes.
Problems in the Neonate Cueing Into Infant Pain MCN, The American Journal of Maternal/Child Nursing , March/April 2004
Newborn Behavioral and Psychological Responses to Circumcision MCN, The American Journal of Maternal/Child Nursing , September/October 2003
Small for gestational age (SGA) Symmetric (HC = Wt = L, all <10 %) -- 33% of SGA infants •
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Genetic Small maternal size o Chromosomal abnormalities (Trisomies 13, 18, 21, and Turner's o syndrome) Congenital abnormalities o Intrauterine infections Viruses (rubella, CMV, varicella, HIV) o Bacteria (tuberculosis) o o Spirochete (syphilis) Protozoan (toxoplasmosis, malaria) o Inborn errors of metabolism o Hypophosphatasia Leprechaunism o Some amino acidurias o Environmental Drugs (heroin, methadone, ethanol, diphenylhydantoin) o X-rays (therapeutic) o o Smoking
Small for gestational age (SGA) Asymmetric (HC = L > Wt, Wt <10 %) -- 55% of SGA infants •
Uteroplacental insufficiency -- onset usually after 24 weeks o Chronic hypertension
o o o o o
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Preeclampsia Renal disease Cyanotic heart disease Hemoglobinopathies Placental infarcts or chronic abruption, velamentous insertion, circumvallate circumvallate placenta, multiple gestation. Altitude
Small for gestational age (SGA) Combined (symmetric or asymmetric) -- 12% of SGA infants infants •
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Environmental Drugs (including ethanol) o Smoking o Placental unit insufficiency Placental infarcts or chronic abruption, velamentous insertion, o circumvallate circumvallate placenta, multiple gestation.
Large for gestational age (LGA) • • • •
Infants of diabetic mothers Beckwith-Wiedemann syndrome Hydrops fetalis Large mother
POSTPARTUM PHYSICAL ASSESSMENT: VS, amount of lochia, presence of edema, fundal height and firmness, status of perineum, bladder distension
First hour: every 15 minutes Second hour: every 30 minutes First 24 hours: every 4 hours After 24hours: every 8 hours
Postpartum Beliefs and Practices Among Non-Western Non-Western Cultures MCN, The American Journal of Maternal/Chil Maternal/Child d Nursing , March/April 2003
KNOW YOUR PATIENT --- DELIVERY HISTORY /ADMISSION/TRANSITION ASSESSMENT: Gravida, parity / Time and type of delivery Anesthesia or medications / Risk factors for PPH Medical history / Routine medications / Allergies Infant status / Breast/bottle Breast/bottle Rho (D) / Rh-? (72h) / Rubella immune?
VITAL SIGNS Heart Rate
DAY DAY 1 40-70 BPM
DAY DAY 2 AND AFTER Bradycardia or normal
Respiratory
Normal
Normal
Blood Pressure
Normal
Norma
Temperature Temperature 100.4 is considered normal for first 24 hours due to muscular exertion, exertion, dehydration .
POSTPARTUM PHYSICAL ASSESSMENT
B - breast U - uterus B - bowels B - bladder L - lochia E - episiotomy
BREAST ASSESSMENT ASSESSMENT Breasts – Soft, engorged, filling, swelling, redness, tenderness. Nipples – Inverted, everted, cracked, bleeding, bruised, presence presence of colostrum or breastmilk.
AWHONN Clinical Position Statements
Breastfeeding The Role of the Nurse in the Promotion of Breastfeeding Drugs in Nursing Mothers
FUNDAL ASSESSMENT ASSESSMENT Location in relation to umbilicus Degree of firmness Midline or deviated to one side
ASSESSING THE UTERINE FUNDUS The uterus is best evaluated with the patient in a supine position and with an empty bladder. The nurse should support the lower uterine segment just above the symphysis pubis with the non-dominant hand and palpate the uterine fundus for degree of involution. Fundal descent is measured in relationship to the umbilicus in fingerbreadths or centimeters.
PERINEAL ASSESSMENT ASSESSMENT Assessment of the episiotomy/perineum should occur with the woman in lateral Sims (side lying) position. Use the acronym REEDA (redness, edema, ecchymosis, discharge, approximation of edges of episiotomy) to guide assessment. Even if there is no episiotomy, the perineum should still be assessed.
Unusual perineal discomfort may be a symptom of impending infection or hematoma. Hemorrhoids ?
LOCHIA ASSESSMENT Assessment of lochia includes noting color, presence of clots and foul odor. odor. Day 1- 3 - lochia rubra Day 4-10 - lochia serosa Day 11- 21 - lochia alba
BLADDER ASSESSMENT ASSESSMENT Voiding pattern, complete emptying, pain burning on urination Record Record first three voids with the amount and times voided A full bladder displaces the uterus upwards and laterally and prevents contraction of the uterus = UTERINE ATONY ATONY = > risk of postpartum hemorrhage.
UTERINE ATONY Normal pregnancy is associated with an increase in extracellular H20. Postpartum diuresis is a reversal of that process and occurs post delivery. The bladder has increased increased capacity and decreased decreased muscle tone. This leads to over-distension over-distension of the bladder, incomplete emptying of bladder, retention of residual urine and increased increased risk of UTI and postpartum hemorrhage.
UTERINE INVOLUTION –at delivery fundus at umbilicus –1-2 hours midway between umbilicus and symphysis pubis --12 hours 1 cm above or at umbilicus After that the height of the uterine fundus decreases (involutes) by approximately 1 cm per day.
POSTPARTUM CESAREAN Incision site…approximated redness swelling, discharge. If lochia indicates excessive bleeding, combine palpation and pain management measures.
Rh Factor
The Rh factor is blood group present on the surface of erythrocytes of the rhesus monkey. monkey. It is found in variable degrees in the human population. When the factor is present a person is designated Rh+ (positive). A person without the factor is Rh - (negative). The blood of an Rh + fetus can sensitize a pregnant female and form anti-Rh agglutinin. In subsequent pregnancies, if the fetus is Rh + the material blood may cross the placenta and destroy fetal cells. RhoGAM immune globulin is prepared from the plasma of a person with high Rh antibodies. It is given to an Rh- mother within 72 hours after delivery of an Rh+ infant or if the Rh is unknown. The dose must be repeated after each subsequent delivery. delivery. RhoGAM 300 mcg is the standard dose.
RhoGAM Rho (d) immune globulin, human Indi Indica cati tion onss
Prev Preven enti tion on of isoi isoimm mmun uniz izat atio ion n in Rh- females after delivery of an Rh + infant or if the Rh is unknown.
Adul Adultt dos dosee
1 via viall IM IM giv given en with within in 72 hour hourss of of ter termi mina nati tion on of preg pregna nanc ncy y
Onset
IM onset rapid, peak and duration unknown
Side Side effe effect ctss
Irri Irrita tati tion on at inje inject ctio ion n sit site, e, feve feverr, let letha harg rgy y
Prec Precau auti tion onss
Made Made fro from m huma human n plas plasma ma.. Prod Produc ucts ts mad madee from from hum human an pla plasm smaa may may contain infectious agents.
Postpartum Emergencies
DIC is characterized by the increase of clotting mechanisms. Clotting factors are consumed before the liver can replace them. Hemorrhage Postpartum DIC ensues. (disseminated intravascular coagulation) Causes may include amniotic fluid embolus, f etal demise, and abruptio placentae.
Diagnostic monitor is the fibrinogen level.
Management may include replacement of clotting factors, platelets, fresh frozen plasma, and cryoprecipitate. Heparin may be used.
Postpartum hemorrhage
Postpartum hemorrhage is excessive bleeding of more than 1000 ml within 24 hours of delivery.
The cause is often failure of the uterus to return to normal size,
retrained products of conception, and vaginal or cervical lacerations.
Management may include CBC, sedimentation rate, type and cross, fluid resuscitation with normal saline and blood, vaginal examination, diagnosis, and correction of the underlying cause.
Complete pelvic examination under anesthesia and/or surgical repair, may be required.
Postpartum depression
AWHONN Clinical Position Statement The Role of the Nurse in Postpartum Depression
Postpartum depression is a nonpsychotic depressive episode that begins in the postpartum period, includes a period of at least 2 weeks of depressed mood or loss of interest in almost all activities, and at least four of the following symptoms: *changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feeling of worthlessness or guilt; difficulty thinking, concentrating or making decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts. Postpartum depression prevalence rates are estimated to be 10-15%.
STUDY GUIDE NEWBORN EXAMINATION
Physical Assessment Assessment of the Newborn
Measure and record height, weight, and head circumference. If the infant appears premature or is unusually large or small, perform a Dubowitz/Ballard exam to assess gestational age (see Dubowitz/Ballard scoring grid). The exam is divided into two parts: an external characteristics score, which is best done at birth, and a neuromuscular score, which should be done within 24 hours after birth.
| Skin | Neurological Exam | Head & Neck | Chest & Lungs | Abdomen | | Extremities & Skeletal | Neonatal Primitive Reflexes | Exam for Gestational Age | | Physical Maturity | Maturity Rating | Administering & Enema | Urinary Catheterization |
SKIN Color • • • • •
Pallor - associated with low hemoglobin Cyanosis - associated with h ypoxemia ypoxemia Plethora - associated with polycythemia Jaundice - Elevated bilirubin Slate grey colour - associated with methemoglobinemia
Lesions •
•
•
• •
Milia - pinpoint white papules of keratogenous material usually on nose, cheeks and forehead, last several weeks. Miliaria - obstructed eccrine sweat ducts. Pinpoint vesicles on forehead scalp and skinfolds. Clear within 1 week. Transient Transient neonatal pustular melanosis - small vesicopustules, generally present at birth, containing WBCs and no organisms. Erythema toxicum - Most common newborn rash. Variable, Variable, irregular macular patches. Lasts a few days. Cafe au lait spots - suspect neurofibromatosis neurofibromatosis if there are many large spots. Junctional nevi - if large numbers suspect tuberous sclerosis, xeroderma pigmentosus, generalized neurofibromatosis.
NEUROLOGICAL EXAM
State of alertness Check for persistent lethargy or irritability. irritability. Posture In term infant, normal position is one with hips abducted and partially flexed and with knees flexed. Arms Arms are adducted and flexed at the elbow. The fists are often clenched, with fingers covering the thumb. Tone Support the infant with one hand under his chest. The neck extensors should be able to hold the head in line for 3 seconds. Should not h ave more than 10% head lag when moving from supine to sitting position. Reflexes Reflexes must be symmetrical. see below) Head Check for overriding sutures, the number of fontanelles and their size. Check for abnormal shape of head. Check for encephalocoeles. Measure the head circumference. Eyes • • •
•
Check for colobomas, heterochromia. Cornea - Check for cloudiness. Conjunctiva - Inspect for erythema, exudate, edema, jaundice and hemorrhage. Silver nitrate prophylaxis can cause a chemical conjunctivitis. Check for pupillary size and reactivity to light. Red Reflex - Hold the ophthalmoscope 6-8" from the eye. Use the +10 diopter lens. The normal newborn transmits a clear red colour back to the observer. Black dots may represent cataracts. A whitish color may be suggestive of retinoblastoma.
Ears Check for asymmetry, irregular shapes. Look for auricular or pre-auricular pits, fleshy appendages, lipomas, or skin tags. Nose Look for flaring of the alae nasi as a sign of increased respiratory effort. Look for hyper- or hypotelorism. Check for choanal atresia (CA) as manifested by respiratory distress (neonates are obligate nose breathers). A soft NG tube should be passed through each nostril to confirm patency if choanal atresia is suspected.
Palate Check for cleft lip and palate. Mouth • • • • •
•
Observe the size and shape of the mouth. Microstomia - seen in Trisomy 18 and 21. Macrostomia - seen in mucopolysaccharidoses. mucopolysaccharidoses. Fish mouth - seen in fetal alcohol syndrome. Epstein pearls - small white cysts that contain keratin, frequently found on either side of the median raphe of the palate. Ranulas - small bluish white swellings of variable size on the floor of the mouth representing benign mucous gland retention cysts.
Tongue Macroglossia - Hypothyroidism, mucopolysaccharidoses Teeth Natal teeth - occur in 1/2,000 births. Mostly lower incisors. Risk of aspiration if loosely attached Chin Micrognathia - occurs with Pierre-Robin syndrome, Treacher-Collins Treacher-Collins syndrome, Hallerman Streiff syndrome. Neck Palpate over all muscles, palpate clavicles for possible fractures. Web neck found in Turner's Turner's and Noonan's syndromes. Torticollis Torticollis usually secondary to sternocleidomastoid hematoma. Cystic hygromas most common neck mass. Lymph nodes are unusual at birth and their presence usually indicates congenital infection.
CHEST AND LUNGS
Observe respiratory rate, respiratory pattern (periodic breathing, periods of true apnea). Observe chest movements for symmetry and for retractions. Listen for stridor, grunting. Note that there may be some enlargement of the breasts secondary to maternal hormones. Cardiovascular System Measure heart rate, blood pressure in upper and lower extremities, respiratory rate.
Inspection Check baby's color for pallor, pallor, cyanosis, and plethora. Palpation Check capillary refill. Check pulses; note any decrease in femoral pulses or radio-femoral delay as a sign of possible coarctation of the aorta, note character of pulses (bounding or thready). Locate PMI with single finger on chest; abnormal location of PMI can be clue to pneumothorax, diaphragmatic hernia, situs inversus, or other thoracic problem. Auscultation Note rhythm and presence of murmurs that may be pathologic.
ABDOMEN
•
•
•
• • •
Note shape of abdomen. Flat abdomens signify decreased tone, abdominal contents in chest, or abnormalities in abdominal musculature. Note abdominal distension. Observe for diastasis recti. Observe for any obvious malformations e.g. omphalocoele. An An omphalocoele has a membrane covering (unless it has been ruptured during the delivery) whereas a gastroschisis does not. Examine umbilical cord and count the vessels. Note color of cord. Palpate liver and spleen. It may be normal for the liver to be about 2 cm below the right costal margin. The spleen is not usually palpable; if the spleen is felt, be alert for congenital infection or extramedullary hematopoeisis. hematopoeisis. After locating these organs (checking for situs inversus), palpate for any abnormal masses. Auscultate for bowel sounds. Examine for hernias - umbilical or inguinal. Inspect anal area for patency and/or presence of fistulas.
GENITOURINARY EXAM
Kidneys Examined by palpation. The kidneys should be about 4.5-5.0 cm vertical length in the full term newborn. The technique for palpation is either a) one hand with four fingers under the baby's back, palpation by rolling the thumb over the kidneys, or b) palpate the left kidney by placing the right hand under the left lumbar region and palpating the abdomen with the left hand (do the reverse for the right kidney).
Male genitalia Term normal penis is 3.6±0.7 cm stretched length. Inspect glans, urethral opening, prepuce and shaft. Normally difficult to completely retract foreskin. Observe for hypospadias, epispadias. Inspect circumcised penis for edema, incision, bleeding. Full term infant should have brownish pigmentation and fully rugated scrotum. Palpate the testes. Female genitalia Inspect the labia, clitoris, urethral opening and external vaginal vault. Often a whitish discharge is present; this is normal, as is a small amount of bleeding, which usually occurs a few days after birth and is secondary to maternal hormone withdrawal. Hymenal tags may be present normally. normally.
EXTREMITIES AND SKELETAL SYSTEM
Spine Scoliosis, kyphosis, lordosis, spinal defects, meningomyelocoeles. Upper extremity Look for clavicular fracture, absence of radius or ulna. Inspect creases and fingers. Lower extremity See posture above. Do Ortolani maneuver to check for congenital hip dislocation. Check toes.
NEONATAL NEONATAL PRIMITIVE REFLEXES
| TOP | Skin | Neurological Exam | Head & Neck | Chest & Lungs | Abdomen | | Extremities & Skeletal | Neonatal Primitive Reflexes | Exam for Gestational Age | | Physical Maturity | Maturity Rating | Administering & Enema | Urinary Catheterization | Newborn and infant reflex tests and behaviors. BABINSKI Baby's foot is stroked from heel toward the toes. The big toe should lift up, while the others fan out.
BABKIN When both of baby's palms are pressed, her eyes will close, mouth will open and her head will turn to
DOLL'S EYE While manually turning baby's head, his eyes will stay fixed, instead of moving with the head.
one side. ****
**** ****
Absence of reflex may suggest immaturity of the CNS, defective spinal chord, or other problems. Reflex may be seen up to age one, then reaction will be reversed with the toes curling downward. GALANT
While normally vanishing around one Absence of this reflex month of age, if it or if it reappears after reappears later, there vanishing around 3-4 may be damage to the mos., it may signify a CNS. malfunctioning CNS.
PALMAR GRASP
MORO
While stroking Baby is held horizontally, horizontally, then swiftly baby's back to lowered a few inches, or the head may one side, her be lowered a few inches, or a loud spine and trunk sudden noise will make baby's arms will arch toward fling out and then come together as that side. hands open then clutch. ****
By pressing just one of baby's palms, fingers should grasp the object.
****
****
Absence may Absence or weakness of this reflex may Absence or indicate spinal suggest a severely disturbed CNS. weakness of injury or this reflex depression of could reflect an the CNS. injured spinal chord or depressed CNS. PEREZ Firmly stroking baby's spine from tail to head, will make her cry out and head will rise.
PLANTERS GRASP Pressing thumbs against the balls of baby's feed will make his toes flex.
STEPPING Holding baby upright with feet touching a solid surface and moving him forward should elicit stepping movements.
**** ****
If this reflex does not vanish in 4-6 months, baby's CNS may be severely depressed. SUCKING
**** Absence of this reflex may indicate damage to After 3-4 months, this reflex the spinal chord. should vanish. If it reappears, there may be an injury of the upper spinal chord. ROOTING
A finger or nipple When baby's cheek is
WITHDRAWAL A pinprick to the sole of
placed in baby's mouth will elicit rhythmical sucking. ****
stroked at the corner of her baby's foot will make mouth, her head will turn baby's knee and foot flex. toward finger and she will make sucking motions. **** ****
Absence of this reflex could indicate a damaged sciatic nerve.
Depressed If this reflex doesn't vanish sucking may be in 3-4 months, the CNS due to may be malfunctioning. medication given during childbirth
Dubowitz/Ballard Dubowitz/Ballard Exam for Gestational Age Neuromuscular Maturity
Posture: With the infant supine and quiet, score as follows: • • • • •
Arms and legs extended = 0 Slight or moderate flexion of hips and knees = 1 Moderate to strong flexion of hips and knees = 2 Legs flexed and abducted, arms slightly flexed = 3 Full flexion of arms and legs = 4
Square Window: Flex the hand at the wrist. Exert pressure sufficient to get as much flexion as possible. The angle between the hypothenar eminence and the anterior aspect of the forearm is measured and scored: • • •
>90 degrees = -1 90 degrees = 0 60 degrees = 1
• • •
45 degrees = 2 30 degrees = 3 0 degrees = 4
Arm Recoil: With the infant supine, fully flex the forearm for 5 seconds, then fully extend by pulling the hands and release. Score the reaction: • • • • •
Remains extended 180 degrees, or random movements = 0 Minimal flexion, 140-180 degrees = 1 Small amount of flexion, 110-140 degrees = 2 Moderate flexion, 90-100 degrees = 3 Brisk return to full flexion, <90 degrees = 4
Popliteal Angle: Angle: With the infant supine and the pelvis flat on the examining surface, the leg is flexed on the thigh and the thigh fully flexed with the use of one hand. With the other hand the leg is then extended and the angled scored: • • • • • • •
180 degrees = -1 160 degrees = 0 140 degrees = 1 120 degrees = 2 100 degrees = 3 90 degrees = 4 <90 degrees = 5
Scarf Sign: With the infant supine, take the infant's hand and draw it across the neck and as far across the opposite shoulder as possible. Assistance Assistance to the elbo w is permissible by lifting it across the body. Score according to the location of the elbow: • • • • • •
Elbow reaches or nears level of opposite shoulder = -1 Elbow crosses opposite anterior axillary line = 0 Elbow reaches opposite anterior axillary line = 1 Elbow at midline = 2 Elbow does not reach midline = 3 Elbow does not cross proximate axillary line = 4
Heel to Ear: With the infant supine, hold the infant's foot with one hand and move it as near to the head as possible without forcing it. Keep the pelvis flat on the examining surface. Score as shown in the diagram above.
PHYSICAL MATURITY
| TOP OF PAGE |
Sign
-1
0
Skin
Sticky, friable, Gelatinous transparent red, translucent
Smooth pink, Superficial Cracking, visible veins peeling and/or pale areas, rash, few rare veins veins
Lanugo
None
Abundant
Plantar Creases
Sparse
1
2
3
4
Parchment, Leathery, deep cracked, cracking, no wrinkled vessels
Thinning
Bald areas Mostly bald
Heel-toe 40-50 Heel-toe >50 Faint red mm = -1, <40 mm, no marks mm = -2 creases
Anterior transverse crease only
Creases Creases over over entire sole anterior 2/3
Breast
Imperceptible
Barely perceptible
Stippled areola, 1-2 mm bud
Raised Full areola, 5areola, 3-4 10 mm bud mm bud
Eye & Ear
Lids fused, loosely = -1, tightly = -2
Lids open, Slightly Well-curved pinna flat, curved pinna, pinna, soft but stays folded soft with ready recoil slow recoil
Formed and Thick firm, with cartilage, ear instant stiff recoil
Scrotum Testes in Testes empty, faint upper cannal, descending, rugae rare rugae few rugae
Testes Testes down, good pendulous, rugae deep rugae
Genitals, Scrotum flat, male smooth
Flat areola, no bud
Genitals, Clitoris Prominent Prominent female prominent, labia clitoris, small clitoris, flat labia minora enlarging minora
Majora and minora equally prominent
Majora large, minora small
5
Majora cover clitoris and minora
Maturity Rating Add up the individual Neuromuscular and Physical Maturity scores for the twelve categories, then obtain the estimated gestational age from the table below. Total Score Gestational Gestation al Age, Weeks -10
20
-5
22
0
24
5
26
10
28
15
30
20
32
25
34
30
36
35
38
40
40
45
42
50
44
ADMINISTERING AN ENEMA | TOP OF PAGE | Skin | Neurological Exam | Head & Neck | Chest & Lungs | Abdomen | | Extremities & Skeletal | Neonatal Primitive Reflexes | Exam for Gestational Age | | Physical Maturity | Maturity Rating | Administering & Enema | Urinary Catheterization |
Assessment 1.
Determine last bowel movement and presence of bowel sounds or abdominal pain. __ ___ ___ ____________
2.
Assess ability to control external sphincter. sphincter. ___ ___ ___ ____________
3.
Determine presence of hemorrhoids. ___ ___ ___ ____________
4.
Assess abdominal pain. ___ ___ ___ ____________
5.
Assess client's understanding of procedure. ___ ___ ___ ____________
6.
Assess client's mobility status. ___ ___ ___ ____________ Implementation
1.
Use Standard Protocol. ___ ___ ___ ____________
2.
3.
Assist client to side-lying (Sims') position with right knee flexed. ___ ___ ___ ____________ Place waterproof pad under hips and buttocks. ___ ___ ___ ____________
4.
Cover client with bath blanket, exposing only rectal area. ___ ___ ___ ____________
5.
Ensure that toilet, bedpan, or commode is available. ___ ___ ___ ____________
6.
7.
8.
Prepackaged container: A.
Remove plastic cap from rectal tip, applying more lubricant to cap if needed. ___ ___ ___ ____________
B.
Gently separate buttocks and locate anus. Instruct client to take deep breaths through mouth. ___ ___ ___ ____________
C.
Insert lubricated tip into rectum 3 to 4 inches (adult). ___ ___ ___ ____________
D.
Squeeze bottle continuously until all fluid is expelled. ___ ___ ___ ____________
Enema bag: Fill enema bag with 750 to 1000 ml warm tap water. water. Check temperature of water. Fill tubing with solution, removing air, air, and clamp. ___ ___ ___ ____________ Add soap to water if ordered. ___ ___ ___ ____________ A.
Lubricate 3 to 4 inches of tip of tubing. ___ ___ ___ ____________
B.
Gently separate buttocks and locate anus. ___ ___ ___ ____________
C.
D. E.
F.
G.
H.
Insert tip of tube slowly, slowly, pointing tip toward umbilicus, for 3 to 4 inches (adult). ___ ___ ___ ____________ Hold tubing until fluid is instilled. ___ ___ ___ ____________ With container at hip level, open clamp and begin instillation. ___ ___ ___ ____________ Raise height of container to 12 to to 18 inches inches above anus anus and hang on IV IV pole. ___ ___ ___ ____________ Lower height of container if client experiences cramping. ___ ___ ___ ____________ Clamp tubing after solution instilled and inform inform client that tubing tubing will will be removed. ___ ___ ___ ____________
9.
Explain to client that a feeling of distention is expected. Ask client to retain solution as long as possible (5 to 10 minutes). ___ ___ ___ ____________
10. Discard enema container container (and tubing). ___ ___ ___ ____________ 11. 11. Assist client client to use bathroom, bedpan, or commode. ___ ___ ___ ___ ____________ 12. Instruct clients clients with history history of cardiovascular cardiovascular disease to exhale during during defecation (Valsalva (Valsalva maneuver can cause cardiac arrest). ___ ___ ___ ____________ 13. Instruct client client to call for nurse to inspect results before discarding. ___ ___ ___ ____________ 14. Assist client client with perineal perineal care as necessary. necessary. ___ ___ ___ ____________ 15. Use Completion Protocol. ___ ___ ___ ____________ ____________
Evaluation 1.
2.
Evaluate results of enema (decreased abdominal discomfort; palpate abdomen). __ ___ ___ ____________ Observe characteristics of stool. ___ ___ ___ ____________ Identify Unexpected Outcomes and Intervene as Necessary Report and Record
1.
Type of enema given ___ ___ ___ ____________
2.
Results (color, amount, and appearance of stool) ___ ___ ___ ____________
3.
Subjective response
URINARY CATHETERIZATION: CATHETERIZATION: FEMALE
| TOP OF PAGE | Skin | Neurological Exam | Head & Neck | Chest & Lungs | Abdomen | | Extremities & Skeletal | Neonatal Primitive Reflexes | Exam for Gestational Age | | Physical Maturity | Maturity Rating | Administering & Enema | Urinary Catheterization |
Assessment 1.
Assess client's weight, age, level of consciousness, ability to cooperate, and mobility of lower extremities. ___ ___ ___ ____________
2.
3.
Assess client's knowledge and prior experience with catheterization. ___ ___ ___ ____________ Palpate for bladder over symphysis pubis. ___ ___ ___ ____________
4.
Inspect perineal region, observing for perineal landmarks, erythema, drainage, or discharge. ___ ___ ___ ____________
5.
Ask client the time of last voiding and to describe urine (if nurse did not observe). Check I&O flow sheet. ___ ___ ___ ____________
6.
Ask client and check chart for allergies. ___ ___ ___ ____________
7.
Assess any pathological condition that may impair passage of catheter ___ ___ ___ ____________
8.
Review client's medical record, including physician's order and nurse's notes. Note previous catheterization, including catheter size, response of client, and time of last catheterization. ___ ___ ___ ____________ Implementation
1.
Use Standard Protocol. ___ ___ ___ ____________
2.
Cleanse perineal area with soap and water, water, rinse and dry. dry. ___ ___ ___ ____________
3.
Position and drape client in dorsal recumbent position with soles of feet together and knees abducted as far as possible. (Option: if unable to lie supine, use sidelying position with upper leg flexed at knee and hip and supported by another caregiver). ___ ___ ___ ____________
4.
Position overhead light to illuminate perineum. ___ ___ ___ ____________
5.
Place catheter kit on overbed table and open outer wrap using sterile technique. ___ ___ ___ ____________
6.
Open package containing drainage system; place bag over edge of bottom bed frame and bring tube up between siderail. ___ ___ ___ ____________
7. 8.
9.
Put on sterile gloves. ___ ___ ___ ____________ Organize supplies on sterile field, maintaining sterility of gloves. ___ ___ ___ ____________ Prepare equipment: A.
Check bag clamp. ___ ___ ___ ____________
B.
Test balloon by injecting saline solution into balloon port. Withdraw fluid if no leakage is noted. If balloon leaks, replace with another catheter set. ___ ___ ___ ____________
C.
Lubricate catheter 1 to 2 inches. ___ ___ ___ ____________
D.
Open specimen container if needed. ___ ___ ___ ____________
E.
Pour antiseptic solution over all but one cotton ball. ___ ___ ___ ____________
10. Draping and Cleansing: A.
Allow top edge of sterile drape to form cuff over both gloved hands. ___ ___ ___ ____________
B.
Place drape on bed between thighs, ask client to lift buttocks, and slip drape under buttocks, taking care not to contaminate sterile gloves. ___ ___ ___ ____________
C.
Place sterile tray and contents on sterile drape between thighs. ___ ___ ___ ____________
D.
Separate labia with fingers on nondominant hand (now contaminated). This hand remains in this position for remainder of the procedure. ___ ___ ___ ____________
E.
Cleanse labia and meatus using forceps to hold cotton balls and one cotton ball for each stroke, moving anterior to posterior. The first stroke is on one side of meatus, down the center, then on opposite side. ___ ___ ___ ____________
11. 11. Holding catheter with with dominant hand near tip, slowly insert insert catheter until urine flows, then advance another 1 to 2 inches. ___ ___ ___ ____________ 12. For straight catheterization, place end of catheter in urine tray and allow to drain until bladder is empty. If specimen is needed, it is collected during this drainage process. Remove catheter, pulling slowly but evenly after drainage stops. ___ ___ ___ ____________ 13. For indwelling catheter, while continuing to hold catheter in place with nondominant hand, use prefilled syringe to inflate balloon. ___ ___ ___ ____________ 14. If necessary, necessary, secure catheter catheter to drainage bag. (Some sets sets come pre-attached). pre-attached). ___ ___ ___ ____________ 15. Secure catheter to inner thigh with nonallergenic nonallergenic tape or catheter strap, allowing some slack to prevent tension of the balloon on the internal sphincter. ___ ___ ___ ____________ 16. Position drainage drainage bag with tubing coiled on the bed (not (not in dependent loops). ___ ___ ___ ____________
17. Cleanse and dry perineal area. Position for comfort. ___ ___ ___ ____________ 18. Measure urine, noting color and clarity. clarity. ___ ___ ___ ____________ 19. Use Completion Protocol. ___ ___ ___ ____________ ____________
EVALUATION
1.
Observe urine in catheter bag for amount, color, and clarity. clarity. ___ ___ ___ ____________
2.
Palpate bladder and determine client's comfort level. ___ ___ ___ ____________ Identify Unexpected Outcomes and Nursing Interventions Record and Report
1.
Type and size of catheter inserted ___ ___ ___ ____________
2.
Amount of fluid used to inflate balloon ___ ___ ___ ____________
3.
Characteristics of urine and amount of urine ___ ___ ___ ____________
4.
5.
Reasons for catheterization and specimen collection ___ ___ ___ ____________ Client's response to procedure ___ ___ ___ ____________
