1st Trimester: weeks 1-13 2nd trimester: weeks 14-26 3rd Trimester: weeks 27-40 School of nursing auditorium;

where patho was (4-6) Exam 1: labor, post-partum, newborn feeding, newborn, analgesia/anesthesia, feeding, fetal development, fetal-wellbeing, genetic 1. Pregnancy hormones: a. Human chorionic gonadotropin (hcg): stimulates estrogen and progesterone by corpus luteum to maintain pregnancy until placenta can do so b. Estrogen: stimulates uterine development c. Progesterone: maintains endometrium, relaxes uterus, inhibits uterine contractility d. Relaxin: inhibits uterine activity, softens cervix e. Oxytocin: contracts uterus; lets down milk f. Prolactin: prolacts/produces milk 2. Labor a. Position: relationship between babys presenting part and moms pelvis i. LOA: babys back is on moms anterior left side; want vertex (chin on chest) b. Presentation: what part is coming first i. Cephalic: head first ii. Breech: head last; FHT heard above abdomen 1. Frank breech: babys legs to chest 2. Incomplete: one leg is up and one is outstretched c. Lie: relationship of babys backbone to moms backbone (horizontal = bad) d. Station: relationship of presenting part to ischial spines; engaged at station 0; decends from -4 to +4 e. Internal monitor: cervix must be dilated at least 2cm, presenting part must be assessable via vaginal exam, ruptured membranes f. Contractions: eventually want 60-90 sec q2-3min; at least 40seconds between (every1.5min not good) i. With real labor will start in back and radiate forward and will be productive ii. If not enough rest times; turn off pitocin; hydrate; could give tocalytic to calm uterus 3. Stages of labor: a. First: onset of true labor to full dilation i. Latent: excited; 0-3cm; irregular contractions; mild moderate intensity ii. Active: pain increases; serious; 4-7cm; contractions every 2-3 minutes; 45-60 seconds; mod-strong intensity iii. Transition: intense; 8-10cm; contractions every 2-3 minutes; 60-90 seconds b. Second: dilation to birth c. Third: birth to placenta 4. Fetal Well-being a. Baseline: 110-160 b. Variability: 5-25bpm; 15bpm above baseline for >15 seconds two times in twenty min c. Possible fetal compromise: late decelerations, decreased variability i. Late decelerations: caused by uteroplacental insufficiency, decreased O2 1. Turn off pitocin 2. Have mom lie on left side, then right side, then knee-chest position 3. Call for help 4. Give 10-12L Oxygen mask 5. Increase IV fluid (increase maternal blood volume) 6. Sterile vaginal exam (check for prolapse) 7. Notify physician ii. Significant prolonged late decels: turn off pitocin first! iii. Early decelerations: begin and end with contractions; caused by fetal head compression iv. Variable decelerations: caused by cord compression; same intervention as decels v. Increase in baseline FHR: could be an indication of early fetal distress or maternal fever vi. Fetal tachycardia: infection, may be acidotic, need to get them out d. Trimester: i. First: 1. Routine screening: cystic fibrosis 2. HCG testing (pregnancy hormone) 3. Progesterone (calms uterus) 4. First trimester screen: Hcg blood test, ultrasound, nucal fold for downs, pap A (neural tubes/downs)

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6. ii. Second: 1. Ultrasound for dates/well-being (18-24 weeks) 2. MSAFP (increased neural tube defects; decreased downs) 3. Amniocentesis: genetic abnormalities, LS ratio; cant be done until 14 weeks 4. Fundal height = GA iii. Third: 1. Fetal movement/weight 2. NST (28wks) 3. CST 4. Baseline variability 5. Biophysical profile (assess fetal movement, tone, FHR, amniotic fluid and breathing; 8-10 is normal) 6. Doppler flow (looks at blood flow in umbilical cord) 15 weeks 7. Amniocentesis, L/S ratio, 14-16 weeks, genetic disorder, iv. Labor: electronic monitoring, decelerations, fetoscope 1. Leopolds maneuver: place hands at fundus of uterus, move hands along sides of fetus, estimate size and position v. After birth: Torch screen: done if any vague signs of sepsis; looks for viruses not shown in mom; toxocyclis? Post-partum a. Immediately after placenta comes out: uterus contracts to grapefruit, two fingers below umbilicus i. 6-12 hours after: fundus is at umbilicus, decreases 1cm per day (in pelvis by 10 th day) b. Episiotomy healing: 2-3 weeks initially, 4-6 months completely; apply ice packs 20-30 min and remove for at least 20 (first 24 hours; then heat) c. Lacerations: 1st (epidermal), 2nd (epidermal and muscle); 3rd (rectal sphincter); 4th (rectal mucosa) d. Menstruation: i. Non-breast-feeding: 6-10 weeks ii. Breast-feeing: 3 months e. Breasts: not full until 3rd/4th day f. Lochia: lasts six weeks g. Bowel: returns in 2-3 days; sluggish d/t progesterone, decreased tone; c-section pt receives clear liquids until bowel sounds present h. Uterus: decreased sensation from increased capacity and decreased tone; increased risk of urinary retention; diuresis helps rid body of extra fluid and blood volume i. Increased voiding first 24 hours d/t rapid bladder filling from stopping oxytocin j. Temp: up to 38(100.4) first 24 hours d/t dehydration/exertion k. Blood loss (Hgb drops by 1 for every 500cc blood loss) i. Vaginal: 500mL ii. C-section: 1000mL l. Weight-loss: 10-12 from baby, placenta, amniotic fluid m. Nutrition: i. Non-breast-feeding: reduce calories by 300 ii. Breast-feeding: increase calories by 200 (total of 500) n. Labs: i. WBC: up to 25,000 ii. Hgb decrease by 1 for every 500cc blood loss iii. Hct can be as low at 34% o. Psychosocial: i. Taking in phase: first three days; needs to discuss labor; focused on own needs ii. Taking hold phase: 3rd to 10th day; obsessed w body functions; needs anticipatory guidance iii. Letting go phase: after 10 days; mothering functions established p. *Administer rhogam at 28 weeks and within 72 horus of delivery is 0i. Placenta separates; placenta is fetal blood; when separates there is liklihood of fetal and maternal blood; dont want mom to make antibodies so give within 72 hours ii. Coombs: is there exposure of antibodies; dont want maternal antibodies in babys system, will break down RBC and cause anemia (if positive; cant give rhogam too late) iii. If positive: assess fetal well-being early, often, watch for growth, cord velocity ultrasound to measure pressure in umbilical cord, amnio to measure bili in amniotic fluid

CVS (chorionic villi samples babys tissues to look for problems with baby; can be done at 10 weeks; do later to decrease risks) Nuchal cord thickness

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Newborn assessment: a. Void: within 24 hours; 6 diapers per day b. Bowel: mec within 48 hours; if not assess stomach for distention/obstruction c. APGAR: absent is always 0 i. Appearance (blue extremities=1, pink =2) ii. Pulse (<100=1, >100=2) iii. Grimace/reflexes (grimace=1, vigorous cry=2) iv. Activity (some flexion of extremities=1, active motion=2) v. Respiration (slow, irreg=1, good cry =2) d. Respirations: 30-60 e. HR: 110-160 f. Temp: >36.6-37.5 g. Cord: 2 arteries, 1 vein; clean 2-3 times/day h. Creases: only one crease on hand could be down syndrome i. Newborn screening: pku, metabolic newborn screening; five blood spots tests for sickle cell, metabolic/hormonal j. Cord falls off within 2 weeks k. Weight: 3405g (7lbs, 8oz) l. Length: 50cm (18-22in) m. Head circumference: 32-37cm (12.5-14.5) n. Ballard scale: looks at neuromuscular activity and gestational age (foot creases, buds) o. Erythromycin give for gonorrhea p. Reflexes: i. Tonic: newborn is supine, head is turned to one side, extremities straighten to same side; other side flexes ii. Moro: newborn abducts and extends arms w fingers fanning when startled iii. Babinski: fanning of toes 7. Normal occurrences a. Caput succedaneum: swelling of soft tissue of presenting part; crosses suture line, goes away in 24 hours b. Cephalhematoma: between bone and lining of bone, doesnt cross suture line, takes a while to go away c. Mongolian spots: dark pigment on lower back 8. Physiologic responses of newborn: a. Lungs are well-developed at 35 weeks; surfactant prevents collapse of alveoli and promotes lung compliance b. Fetal Hgb: lower O2 carrying capacity but more greatly saturated c. Glucose = main source of energy first 4-6 hours (normal >45) d. Can synthesize vitamin K on 8th day e. Rhogam given at 26-28 weeks, lasts 90 days f. Ductus arteriosis (shunts blood from pulmonary artery to aorta) closes in 1-2 days; newborn circulation is RL because of increased left ventricle pressure (changes after birth; lung pressure drops) g. Foreamen ovale: hole between left an right atrium; lets blood bypass pulmonary artery and lungs 9. Newborn feeding: 90-120kcal per day; need 1-2oz more per feeding than babys age in months a. Formula: 20cal per oz; 2oz every 3-4 hours b. Breast-feeding: >20cal per oz; prolactin makes milk i. LATCH score (want 10): latch, audible swallowing, type of nipple, comfort (maternal), hold ii. Every 2-3 hours c. Weight loss 1st week: 5-10% 10. Pain management a. Barbiturate: given in early labor (latent), not during labor because stops/slows GI b. Anesthesia blocks nerve sensation c. Caudal: given at lower part d. Epidural: space outside spinal cord; higher, helps with contractions, can choose effects; can be given after 2nd stage i. Cannot have epidural if platelets <100,000 ii. Give 500-1000cc fluid before cuz of risk of vasodilation/hypotension iii. Watch for lightheadedness from hypotension decreases FHR (less placental perfusion) turn on side, give fluid, let her ride it out iv. Needs foley, cant get out of bed v. If BP falls: put mom on side, IV fluids vi. Direct effect on temp; shouldnt cause fever vii. Deromorph = itchy, N/V, urinary retention = give Benadryl or piggyback narcan e. Spinal: injected into intrathecal space; deeper than epidural; affects pain, touch, movement

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i. Spinal headache: spinal fluids oozes into epidural space, non-existent when laying down but horrible when gets up Narcotic: have Narcan on hand to prevent respiratory distress in kid

Exam 2: Pregnancy loss, antepartum, pregnancy complications, hemorrhage, labor and delivery complications 1. Antepartum: a. Prostaglandins irritate uterus and bowel loose bowel movements b. Vitamins: folic acid 400mcg 3 months before pregnant c. Labs: i. WBC: up to 18,000 during pregnancy; up to 20,000 during labor, between 25,000 and 30,000 postpartum (look at if 30,000) d. Lung expansion grows; increased tidal amount; cant drop diaphragm (SOB) e. TPAL i. T: #term infants (after 37 weeks) ii. P: #preterm infants (after 20 weeks) iii. A: abortion before 20 weeks 1. 24 weeks = age of viability 2. Symptoms: early vaginal bleeding, cramps, bloating, pressure, early dilation of cervix (inevitable) iv. L: # living children Signs of pregnancy a. Early symptoms: i. Morning sickness: d/t change in hormones; Hcg from progesterone; Hcg from embryo tells corpus luteum to stay open and keep producing progesterone until placenta can at 3 months ii. Fatigue: plasma increases 50%, dilutes Hgb pseudoanemia; rbc never fully catch up (only increase 30%) iii. Breast tenderness, urinary frequency (uterus pushes on bladder), pica iv. Back pain (lordosis/forward curve): shouldnt lie flat, lay on left side, crunch body v. Nasocongestion: progesterone vasodilates; take antihistamine but no decongestant b. Probable signs: i. Chadwicks sign, vascular vagina (purple), soft cervix, growing uterus, stretch marks, pregnancy tests, linea negra, dark areolas ii. Ballotment: vag exam, push on cervix, will bounce on top of uterus and come back down iii. Uterine souffl: swishing of blood through larger than normal blood vessel iv. Fetal souffl: swishing sound of umbilical cord v. Melasma: blotchy face from increased melanin vi. Laukorrhea: normal clear vaginal discharge vii. Heart burn: progesterone relaxes cardiac sphincter; acid comes up viii. Gum hyperplasia: increased vasculature from progesterone (chew gum) c. Definitive signs: FHT, ultrasound, fetal movement felt by examiner Nutritional needs: i. Iron: increase from 18 to 30mg (spinach, meat, w vit c); SE: constipation ii. Protein increase serving iii. Calcium: 4-5g iv. No-nos: mercury fish, cheese, cat litter, uncooked meat v. Weight gain: 25-50lbs (skinny ppl should gain more and fat ppl less) 1. 1st trimester: 2-5lbs 2. 2nd trimester: 1lb per week Visits: a. First 7 months: every 4 weeks b. 28-36 weeks: every 2 weeks c. 36-40 weeks: every week First prenatal visit: a. Vitals, cbc, blood type/screen b. Urine dip: protein to rule out preeclampsia, nitrites/leukocytes to rule out infection, ketones to rule out diabetes c. Genetic screens: first semester screen (trisomy 18 and 21); ethnic screens: sickle cell (blacks), thalassemia/hgb disorder (mediteraneans), cystic fibrosis (whites), taysachs (jews) d. Flu shot in first trimester (not rubella) Progression of pregnancy:

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BP decreases; lowest point in second trimester Ambivolence common into 2nd trimester Can hear fetoscope within 18 weeks Syphilis doesnt cross placenta until 20 weeks; treat mom Heart rate: 12-16 weeks i. Doppler: 10-12 weeks ii. Fetoscope: 16-20 weeks f. Quickening, baby movement felt: 16-20 weeks (changes to its all about me to all about baby) g. FH at belly button at 20 weeks h. Rhogam 28 weeks i. Glucola 24-28 weeks (placenta releases insulin resistant hormones) i. Give sweet stuff; wait 1 hour; if >140 needs 3 hour test (fasting) j. Amniocentesis: done early to look for genetic abnormalities and lung maturity k. NST: want to be reactive; if not reactive biophysical profile l. Want negative contraction stress test m. Proteinuria normal trace to +1 Danger signs to report: a. Gush of fluid (ROM), vaginal bleeding (abruptio, previa, bloody show), abdominal pain (premature labor, abruption), fever (infection), persistent vomiting (hyperemesis gravidarum), visual disturbances, edema of hands/face and severe headache (htn, preeclampsia), epigastric pain (preeclampsia), dysuria (uti), decreased fetal movement (compromised fetal well-being) Diabetic moms: insulin resistance increases 2-3 times during pregnancy; want very controlled a. Symptoms: i. Ketones from burning fats/proteins because sugar is going to baby b. Causes: drugs given to stop preterm labor; c. Risks: cardiac and brain problems; last month of pregnancy is highest risk; hydramnios(increase fluid) i. Hypoglycemia (still has moms increased insulin) 1. Symptoms: jittery, lethargic, cyanotic, decreased temp, polycythemia (sweet hgb doesnt hold oxygen well so baby has extra), prone to jaundice ii. Small baby (Micronesia) from non-functional placenta iii. Larger baby (macronesia): moms sugar goes to baby iv. More rbc: O2 not carried well v. Placenta will age too fast vi. Hydramnios vii. Preeclampsia viii. Baby will have decreased calcium and magnesium (arrythmias is really low Ca+) ix. Birth trauma: 1. Baby: bruising, broken clavicle 2. Mom: hemorrhage (long labor), tearing, risk of c-section (want out early) d. Prone to preeclampsia, infections, keto-acidosis e. Testing i. Glucola testing: 24-28 weeks; women >26, diabetics, previous big baby/loss ii. Blood sugars upon rising, before meals, before bed iii. A1c should be 7 iv. 24 hour urine test f. Plan: want baby out early; look at maturity i. Lung maturity: normally want 2:1; want diabetic infants 3:1 ii. Give betameth (steroid) up to 34 weeks to increase lung maturity; baby develops more surfactant at 34 weeks to decrease surface tension; increases infection risk g. Draw up regular insulin first Pregnancy complications: a. Previa: implantation of placenta in lower uterine segment, zone of diliation; partial (some component in zone of diliation; may or may not be vaginal birth); marginal (some portion over dilatation, could be okay for labor); complete (significantly over internal os) i. Risks factors: breech, grand mal, older mom, previous c-sections, smokers, twins, short time btwn pregnancies ii. Can see at 20 week exam iii. Painless bright red vaginal bleeding towards end of third trimester (uterus begins to soften and stretch; attachment site becomes compromised = bleeding) iv. May present after vaginal intercourse (irritation on cervical os); no sex or vag exams v. Bleeding could be little to moderately significant

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vi. Prone to hemorrhage (lower uterus doesnt contract well vii. Tx: judgment and degree; ultrasound determines x amount; decides either c-section or vaginal deliver; if marginal, will note, pay attention, watch labor progression and heart tones; if concerns about bleeding c-section; bed rest, bathroom privileges Placental abruptions: partial or complete premature separation of normally implanted placenta i. Risk factors: htn, smoking, substance abuse, trauma, uterine hyperstimulation (more than 3 contractions in 10 minutes), induction of labor, preeclampsia, prior uterine surgery ii. Symptoms: 1. Mild: cant tell until placenta is born; maternal side shows infarct 2. Significant: rigid uterus, relaxation tone is harder; monitor may show increased resting tone; uterine pain unrelated to contractions, hypertonic labor pattern, decels, fetal distress, possible vaginal bleeding, heart tones may decelerate (placenta can lose some sections and still work) iii. Interventions for prolonged late decelerations: 1. IV access 2. Call for help 3. Fluid bolus 4. O2 5. Position change 6. Call provider iv. Tx: quick c-section, general anesthetic, classical incision on belly/uterus (belly button to symphysis pubus) Molar pregnancy (hydratiform mole): not good; abnormal union of either two sperm one egg (instead of 46 csomes, have 69); or sperm going into egg with nothing in it (23 csomes); results in rapid reproduction of cells ultrasound confirms i. Symptoms: enlarged uterus greater than dates; absent tones, increased Hcg from bad tissue growth, greater nausea/positive pregnancy test, dirty brown discharge, ii. Treatment: evacuate fetus; risk of uterine cancer if not removed, serial Hcg levels, suggest dont get pregnant for 1 year; want to make sure everythings out Cervical incompetence: premature dilation of cervix, i. Tx: cerclage: sew cervix shut around 12 weeks before it dilates (when pressure increases), pelvic rest (no sex), come in with first sign of labor to clip sutures and tear cervix ii. Risks: infection, irritable uterus Infections i. Corioamnitis: infection of amniotic sac 1. Symptoms: abdominal tenderness, smelly amniotic fluid, high temp; tachy baby; will have to deliver preterm 2. Risk factors: lots of vag exams, hours since rupture, GBS+ 3. Tx: IV antibiotics; preterm delivery (increased risk of c-section/sepsis) ii. GBS: test at 35-37 weeks (vag swab) 1. Mom: preterm labor, chorioamnionitis, PROM, UTI 2. Baby: preterm, can get sepsis: decreased, sometimes elevated temp, feeding change, lethargy, increased wbc, decreased reflexes (hypotonia), jaundice iii. Rubella: baby at highest risk for miscarriage and anomalies during 1st trimester iv. Hep B: HbIg and vaccine v. Symphillis: baby is protected before 20 weeks; can treat mom vi. Gonorrhea, chlymydia: caught through birth Bleeding: depends on gestational age i. 1st trimester 1. Threatened abortion: early membrane rupture, vaginal bleeding, cramps, bloating, pressure, back ache drink fluids, rest, time will tell 2. Spontaneous abortion: same as threatened; along with dilation of cervix early on; everything may come out or may need a DNC; most common cause of bleeding in 1st trimester 3. Missed abortion: baby died unknowingly, nothing passed, possible spotting, scan and see uterus is too small for gestational age 4. Ectopic pregnancy: out of place; egg doesnt travel quickly enough a. Symptoms: normal early on; then ton of pain in abdomen and right shoulder once starts growing in tube (8-12 weeks) b. Diagnosed via ultrasound c. Tx: if hasnt ruptured, get rid of it; if ruptures, can hemorrhage ii. 2nd trimester: placenta previa, threatened abortion

iii. 3rd trimester: previa, abruption, early labor, cervical issue 10. Preeclampsia: 20 weeks to 48 hours postpartum a. What puts mom at risk? First child, multiple gestations, first time dad, under 20, over 35, previous preeclampsia, obesity, black renal disease, stress, women born small, UTI b. Symptoms: show in 3rd trimester (hyper-reflexes, headache, epigastric pain, visual changes, flu-like symptoms) i. Increased bp (above 140/90) on at least two occasions >6 hours apart ii. Hyper-reflexes greater than +2 iii. Edema (vasospasms increase bp damages blood vessel lining plasma leaks into interstitial space edema); weight gain 5lb per week iv. Proteinuria >300mg/day (altered absorption of protein and salts; protein escapes thro damaged blood vessels) v. Lowered platelets <100,000 (no protein to hold fluids body lays down platelets to protect self clot formation/disseminated intervascular coagulation) vi. Headache (brain edema) report if unrelieved by tylonel vii. Blurred vision viii. Epigastric pain (report if RUQ pain not relieved with medication) ix. Low blood sugar x. Oligohydramnios: decreased functioning of placenta xi. Elevated liver enzymes amd hgb/hct; unless hemolysis then Hct will decrease c. Risks: seizure, placental abruption, stroke, HELLP syndrome d. Monitoring i. Vitals q2hours ii. Hourly for urine: 30cc/hour; 720cc/day iii. Monitor baby more closely (NST) iv. BUN and creat for kidney functioning (serum value will increase) 1. Dont aggressively limit sodium v. Monitor for seizures vi. Lung sounds (risk for pulmonary edema) e. Treatment i. Delivery ii. Bedrest iii. Diet: high protein iv. Betameth: increases surfactant; works for 7 days; 2 doses (2nd one 24 hours later); dont regive after a week 1. Suppresses immune response and messes with sugar metabolism v. Magnesium sulfate: given as anticonvulsant to prevent seizure, smooth muscle relaxant initial bp decrease; sedates to increase threshold for convulsion 1. Give 4 grams over 15-30 minutes piggybacked into main line on pump own Y line a. Increase 1-2g over one hour 2. Normal side effects: dizziness (bedrest order), blurred vision, feeling hot, reduction in flexes (not total loss), sweating 3. Crosses placenta sluggish baby (may lose variability); risk of neonatal respiratory depression & decreased suck reflex 4. Monitor for: a. Vitals q1min b. Loss of reflexes (dont want absent) c. Respiratory depression (death) >12 d. Place foley or watch voids very closely (want urine > 30ml) renal failure (is excreted in the urine; if no urine; not excreting mag) e. Blood levels (4-8) f. Postpartum hemorrhage g. Hypocalcemia 5. Contraindications: hypocalcemia, myasthenia gravis, renal failure 6. Antidote: calcium glutinate vi. Antihypertensives: hydralazine, labetalol, nifedipine f. HELP Syndrome: Hemolysis, Elevated liver enzymes, Low platelets (bleeding and malaise), associated with Preeclampsia; risk for hemorrhage, pulmonary edema i. Tx: dont induce immediately; want to give all betameth; if cant stabilize deliver g. Severe preeclampsia: BP increase of 30/15; proteinuria 3+ (160/110) h. Eclampsia: convulse and go into coma; first 48 hours after birth is high risk

i. Dont want a lot of ppl 11. Induction: a. Indication for fetal stress: variability <6, decreased fetal movement, nonreactive NST, reactive CST (late decels), decreased amniotic fluid volume b. Risks: infection, cord prolapse, abruption c. Types i. Mechanical (membrane sweeping): if unripe mom isnt candidate for other modalities; irritation of cervix releases prostaglandins; risk of prolapse and infection; listen through amniotomy ii. Strip membranes: separate amniotic sac from wall iii. Cervidil/cytotec: prostaglandins, ripen cervix (soften); may cause diarrhea 1. Place in posterior fornix; 12 hour dosing 2. Bishop score: assesses mothers readiness for labor; measures dilation, effacement, consistency, position, station (want 8-10) iv. Pitocin (oxytocin): high risk med; only if cervix is ripe 1. Run: piggyback Y site closest to patient via IV pump w LR, have doubled check by other RN, a. At the U: 30u/500mL (1mL/hr = 1mu/min) b. Not at the U: 20u/1000ml (3cml/hour = 1mu/min) 2. Wont know effect for 20 minutes 3. Continually monitor fetus 4. Give until contractions q2-3min; 60sec a. need 40 sec btwn to replenish placenta between contractions b. receptor sites may get overstimulated turn off pit, let regroup and then turn back on later 5. Risks: a. Hyperstimulation: fetal distress, abruption, uterine rupture (sudden sharp pain, shock, cessation of contraction/FHR) b. Water intoxifcation: antidiuretic i. Watch for decreased urine output c. Blood pressure drop if given too fast d. Hemorrhage 6. Have terbutaline available 12. Hemorrhage: loss of more than 15% blood a. Causes? i. Intrapartum: abruption, previa ii. Postpartum: 1. Risk factors for early postpartum hemorrhage: *uterine atony, short/long labors, multiple gestation, corioamnitis, prolonged rupture of membranes, pitocin, magnesium, lacerations, clotting disorder, preeclampsia, decreased hct (more significant sooner), big babies; retained placental fragments (late postpartum) 2. Risk factors for late postpartum hemorrhage: retained placental fragments, endometritis b. Symptoms: trickle of blood with firm fundus could be laceration, fatigue, vitals are late change (orthostatic hypotension, tachycardia); more prone to infection c. Interventions: vitals, IV access, call for help, Pitocin or misoprostol, reassure family i. Call for another nurse, then call provider ii. Uterine massage to express clots and stop bleed iii. Methergine: .2mg, causes uterine contraction, 5-6 doses q 4 hour for 24 hours; may cause cramps give motrin/tylonel 13. Labor complications: a. Prolapsed cord: delivery of cord before baby; umbilical cord precedes presenting part; call for help and transport to OR i. Risk factors: higher station (-2, -3) ii. Symptoms: feels like something is falling out, decelerations, iii. First priority; counter pressure to presenting part to take pressure off cord; want to push up presenting part to get pressure off cord iv. Call for help, put O2 on mom, check fetal heart tones; put fingers in vag and keep there until OR arrival, want presenting part off cord b. Hypertonic labor pattern: early part of labor (latent phase), contractions mid-uterus instead of fundus, long strong contractions, little resting time between i. Increased uterine tone impedes placental blood flow; if untreated abruption ii. Tx: calm uterus morphine, rest, sedation

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Hypotonic labor pattern: labor slows over time, contractions are further apart, less intense, shorter (active phase of labor) i. Tx: assess for full bladder, induce labor, amniotomy, oxytocin Preterm labor: regular uterine contractions 20- 37 weeks gestation i. Risk factors: previous preterm birth, multiple pregnancies (uterine distension), polyhydramnios, cervical incompetence, chorioamnionitis, GBS, UTIs, hemorrhage, htn, abruption, stress, diabetes, uterine anomalies, smoking, age <16 >40 ii. Can cause infection, hemorrhage, heart & respiratory problems, poor feeding, temp & neuro instability iii. Symptoms: contractions, low abdominal cramping, pelvic pressure, low backache, cervical changes, pink vag discharge, engagement, nitrites leukocytes rbc in urine, fetal tachycardia iv. Instruct client to empty bladder, lie down on side, drink 3-4 cups water, if symptoms dont disappear call physician v. Tx: empty bladder, rest, hydrate, position on left side, avoid nipple stimulation, monitor contractions and FHT, tocalytics (mag/terbutaline) 1. Terbutaline: B-aderneric agonist; SQ or PO a. SE: tachycardia, nervous, tremors, n/v, elevated BP, decreased K+, pulmonary edema, alteration in blood glucose b. Dont give if pregnancy induced hypertension, intrauterine growth restriction, poorly controlled diabetes, cardiac disease Premature rupture of membranes: i. PROM: rupture of membranes >24 hours before onset of labor ii. PPROM: rupture of membranes >24 hours before labor before 37 weeks iii. Interventions: 1. Limit exams 2. Asses temp, WBC increase, abdominal pain, smelly fluid, fetal tachycardia Amniotomy: artificial rupture of membranes; look at color/consistency and FHT; increases risk for infection so watch moms tempp q2 Postterm: aging placenta doesnt function well; results in big babies, risk of c-section, laceration; oligohydramnios, mec aspiration Shoulder Dystocia: shoulder doesnt deliver within 3 minutes of head i. Risk factors: obesity, big baby, diabetes, prolonged second stage, hx of dystocia ii. Risks: asphyxia from cord compression; intraventricular hemorrhage, fractures iii. Interventions: 1. Call for help 2. Maneuvers: look at clock for documentation, call for help a. Mcroberts: pull legs back as far as possible, flatten pelvis, change fetal orientation b. Suprapubic pressure: rotate anterior shoulder transversely to relieve impaction, push down on pubic bone on babys back, pop shoulder out c. Gaskin: hands and knees Cephalic pelvic disproportion: fetal head is larger than mother pelvis; cant pass through; lack of progress notify physician i. Pelvis <9 is small, but must account for head size ii. Fetal head doesnt descend despite strong contractions iii. Rest, observation, possible pitocin

Exam 3: post-partum complications, infertility, adoption, abortion, contraception 1. Postpartum complications: a. Infection: i. WBC can be up to 25,000 ii. Risk factors: c-section, laceration, decreased hgb, prolonged rupture of membranes, UTI, foley, internal monitor, breastfeeding iii. Types: mastitis, UTI (from prolonged 2nd stage), endometritis 1. Infection of Endometrium of uterus a. Risks: PROM, diabetes, lots og vag exams b. Symptoms: smelly lochia, tender abdomen, fever after 24 hours taken on two consecutive days 24 hours apart (day 2 and 3); not first 24 b/c may be elevated from dehydration, epidurals, vasodilation) c. Tx: early oral antibiotics, late iv antibiotics 2. Phlebitis: inflammation of lining; thrombophlebitis (blood clot) a. Risk facors: >35, smokers, post-op, obese, clotting disorder

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Superficial veins: elevate, warmth Deep veins: heparin (no Coumadin when breastfeeding), bed rest, no razors if on heparin Infertility: 1 year of unprotected intercourse (2-3x/wk) without conception; 15% of all pregnancies (male should be on top) a. Hormones: estrogen high in first half of cycle, then it decreases, and the progesterone dramatically increases b. Ovulation occurs 14 days before onset of period c. Early things to assess for/with i. Woman (50%): normal female sexual characteristics, PCOS, menstrual cycle history (reg/ireg), hormonal evaluations (FSH), reproductive history, cervical mucus changes, previous miscarriages (woman can develop antibodies against male sperm) 1. Basic labs ii. Man (35%): sexual hx, previous children, meds, undescending testicle 1. Varicocele: most common cause of overheating sperm, varicose veins in scrotum, penis valves prevent proper blood flow; pools/swells; needs repair for sperm count to normalize 2. Sperm count analysis: after 3 days of no ejaculation medicated condoms, semen stored at body temp, brought in immediately (within 2 hours), keep in armpit to keep warm iii. Go into invasive measures d. Reasons for infertility: smoking, alcohol, STIs i. Timing of intercourse isnt during ovulation; too much sex dilutes sperm ii. Abnormal reproductive tract iii. Diet: need fat to make sex hormones iv. Stress, endocrine imbalance (hypo/per thyroidism), cancer tx, marijuana v. Women: egg lasts 24 hours 1. Age >35 (prime is 18-21); less eggs 2. Endometriosis: endometrium lining leaves uterus and settles somewhere else in body; the tissue secretes hormones that conflict with a normal cycle a. Tx: shut down hormonal system then try and get pregnant quickly once off meds 3. Polycystic ovarian syndrome: imbalance of hormonal structure; too many androgens, insulin resistance (high bg), increased LH difficult to ovulate a. Increased body hair, weight gain, missing periods 4. Hostile uterus: poorly shaped (septum down middle, fibroids);; egg could fertilize but not implant vi. Men: at least half of sperm need to be of proper morphology (character) 1. Environmental: radiation decreases sperm, pesticides/teratogens affect sperm motility, heat (hot tubs) 2. Antidepressants, steroids, & antihypertensives affect sperm, erection, libido 3. Hypospadius: mans urethra is on underside of penis and not tip 4. Epospadius: mans urethra is on top on penis, not tip; sperm doesnt go where you want it 5. Testicular cancer: young men, affects sperm production/quality, need to bank sperm 6. Undescended testicles: abdominal cavity is too warm; surgery to bring down 7. Retrograde ejaculation: ejaculates into bladder e. How to test fertility: i. Basal body temp: good for fertility enhancement, not contraception 1. Know baseline temp; temp increases 1 degree before ovulation and drops 1 degree after ovulation (sperm lives 72 hours) 2. Natural family planning ii. Cervical mucus: gets elastic and slimy during ovulation f. How to test patency of reproductive tract i. Historsalpistogram: insert dye in uterus, want to know if system is patent, look for abnormalities; uncomfy, expensive 1. Dont do after ovulation, if possibly pregnant could dislodge fetus ii. Endometrial biopsy: done if possible endometrial build-up, looks at lusciousness of uterus; do after ovulation g. Treatment of infertility: 6 months of clomid (oral), then add gonanotropin (SQ) for six months, then IVF i. Tube stenosis: inducing ovulation wont matter b/c egg cant pass through fallopian tube 1. In-vitro stimulation: hyperstimulate ovulations; go in with needle, harvest/aspirate eggs from someone, fertilize/mix with sperm, wash them back into uterus at proper time; hope implants a. Can freeze embryos but not just eggs b. Can force sperm into egg and hope it works

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c. $40,000 per cycle ii. If not ovulating: 1. Clomid: hopefully triggers multiple ovulations; estrogen agonist; makes body think it has a lot of estrogen; woman will make more FSH (regulates reproduction) a. Works better in young b/c more eggs (possible multiple gestation) 2. If doesnt work give something more potent (gonanotropins from urine) 3. Adoption: a. Safe Haven Law: mom can drop off newborn to state within 72 hours without consequence (hard to get kid back) b. Closed adoption: no info about birth parent shared to adoptive parent; cant contact them c. Process: criminal record, application form, reference letters, financial record, information session, household evaluation (several occasions) i. Takes about 6 months; fees for each stage ii. Birth parents have 6 months to change mind iii. Single mom still needs fathers permission to put child up for adoption iv. If mother is a minor; needs a state advocate; attempt to find dad before rights are terminated v. Foster family cant adopt child until parental rights are terminated Abortion: most common surgical procedure in world a. Stats: pregnancies are planned (Hispanics, blacks); unplanned end up in abortion i. Protestant women in 20s ii. Almost 90% occur in 1st trimester iii. Decline in providers in past two years iv. Mainly done in clinics b. Main reason: child would limit mothers ability to meet responsibilities; cant afford one c. Abortion related death: infection, hemorrhage i. 1st trimester: 1 in 500,000 interferes w responsibilities ii. 2nd trimester: 1 in 300,000 didnt realize pregnant d. Restrictions: i. Woman receives mandatory state-directed counseling, 24 hours before abortion ii. Medicaid only available w life endangerment, rape, incest (32 states, 4 in 10 women) iii. Required to offer ultrasound iv. Only by physicians e. First trimester surgical abortion: (3-5 min is intense) i. Lidocain to cervix ii. Cervix is dilated w metals rods (dilation depends on gestation) iii. Once dilated, pregnancy is removed with manual vacuum aspirator (3x) iv. Pain: really strong menstrual cramps f. Second trimester surgical abortion: pregnancy is larger, make sure fetal heart isnt beating; sedation i. Need to prepare cervix w laminara, cytotex, digoxin ii. Uses suction machine and instruments to remove pregnancy iii. Utilizes cord compression until heart stops beating, dismemberment b/c of partial birth abortion ban iv. Recovery for at least 45 min g. Abortion pill: 98-99% effective, 450$ i. One pill is progesterone inhibitor that detaches pregnancy from uterine wall ii. 24 hours later, four pills placed btwn cheek/gum, cause uterus to contract, pregnancy is passed iii. Bleeding 4-10hours after: really heavy period, clots size of golf ball Birth control: a. Menstruation stages: if you get pregnant the corpus luteum lives for 10 weeks and the hormone levels continue to rise; if you dont get pregnant the corpus luetum dies and hormone levels decline i. First stage (follicular phase): 10-14 days 1. Starts w first day of menstruation hypothalmus releases hormone 2. Growth/thickening of endometrium in preparation for pregnancy 3. FSH rises 4. Signals ovaries to produce estrogen estrogen rises 5. Stimulates LG 6. Egg is released into fallopian tube ovulation 7. Estrogen and progesterone are lowest during this cycle ii. Second half of cycle (ovulation/premenstrual): 14 days after ovulation (18th day if 32-day cycle) 1. LH causes corpus luteum to produce progesterone 2. Estrogen and progesterone rise to prepare uterine lining for pregnancy; make thick blanket of blood vessels to support possible fertilized egg (ovulation)

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If egg is fertilized, hormones will continue to increase, wall thickens and blanket becomes placenta 4. If not fertilized, progesterone and estrogen decrease, corpus luteum dies, and endometrial lining sheds Estrogen-progesterone combination type: i. Action: prevent ovulation, thickens womans cervical mucous (sperm cant penetrate), thins endometrium (doesnt allow egg to attach) 1. Makes pituitary think body is pregnant so hormones arent given off no ovulation 2. Estrogen and progesterone compete so if you give estrogen may not make progesterone ii. Pros: most effective type; stops woman from ovulating, decreases acne, can lower ovarian cancer and PID, decrease menstrual cramps and bleeding iii. Cons: risk of blood clots, spotting, breast tenderness, nausea (not for women who smoke, have diabetes, over 35, or at risk for clots) iv. Types:
1. Oral contraceptive pills: 1958; have 25-30mg estrogen; stops woman from ovulating; work for 36 hours (have a 12 hour window to take); keeps estrogen from rising and dipping a. Bicyclic: equal amounts of estrogen and progesterone; stops when woman gets her period b. Tricyclic: increased progesterone; good for acne c. Risk of blood clots, spotting, breast tenderness, nausea d. Decreases ovarian cancer by 40% e. If forget once; wear condom for week; if forget 3 times; start over Nuva-ring: 99% effective, lasts 30 days, can take out for week on period Patch-orthevra: stopped prescribing b/c 2 x more likely to cause clot; stays on for 7 days then change it

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Progesterone only: i. Pros: can be taken by almost all women women breast feeding, w blood clot risk, w migraines ii. Cons: must be taken at the same time to be effective, may cause spotting, acne, weight gain, bleeding iii. Types:
1. 2. 3. 4. 5. Mini pill: 95% effective, 35mg progesterone, makes mucus thick and sticky a. Who for? Ppl that cant take birth control pills, at risk for blood clot, have migraines, breastfeeding Mirena: 99.8% effective a. Who for? Women w babies b/c easier b. SE: spotting 2-3 months, comes out easier in women who havent had babies Depo-provera: 99.7% effective; shot; 150 mg a. SE: acne, weight gain (10lb) Implanon: tube in arm so you dont make estrogen or progesterone a. SE: weight gain, bleeding Plan B: after unprotected sex, 150mg PO, no SE, stops ovulation w whooping dose of progesterone

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Conversions: - 2.54cm = 1in - 1lb = 16oz - EDD: subtract 3 months, add 7 days - 2.22lbs = 1kg - Celsius = (5/9)(F-32) - Farenheit = (9/5) (C+32) - Failure of NST; do BPP (want 8-10) cuz lower risk for kid than CST - Gush of fluid: look at perineum and fluid to see if amniotic fluid (assess data) o If membranes ruptured (known): check fetal heart tones - If mom is GBS positive and not treated: term: observe baby 24 hours; preterm: observe 48 hours o GBS is associated with preterm birth - Diabetes affects infertility

Mechanical: i. IUD copper: 99% effective 98% may spontaneously come out; easy for moms; copper changes ionization of sperm ii. Condoms: male: 97% effective; female: 94% effective; possible latex allergy iii. Diaphragms: 94-96% effective, put spermicide in center; need it to stay there for 6-8 hours after sex iv. Natural family planning (calendar method): know period lengths for at least 6 months; subtract 18 days from shortest period length and 11 days from longest period length = those are the days to abstain from vaginal intercourse; first day is first day of bleeding Periods range from: 26 days to 30 days Subtract -18 -11 Can get pregnant from day 8 to day 19 =8 =19 v. Sponge: 90% effective, taken off market (toxic shock); spermicidal in it vi. Breast feeding: prolactin competes/inhibits the LH (triggers ovulation); only effective if prolactin is stimulated every 3 hours (cant supplement at all)