TEST PREVIEW: 316 Maternal Infant Exam #2 Spring 2019.

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TEST PREVIEW: 316 Maternal Infant Exam #2 Spring 2019 Pregnancy: conception, biophysical changes, and physiology— • Review various Hormones of Pregnancy and their influence: Progesterone, ... Estrogen, HCG; know Presumptive, Probable, and Positive signs of pregnancy o Progesterone: secreted by corpus luteum for 2 months. Thereafter is produced by placenta and corpus luteum  Diminishes uterine contractions  Prepares breasts for lactation  Reduces gastric motility and relaxes cardiocosphincter  Increase Na excretion  Reduce tone of smooth muscles o Estrogen causes  Enlargement of uterus and breast  Increased elasticity of connective tissues  Cervical enlargement and softening  Secretion of HCL and pepsin  Retention of NA and H2O by kidney tubules  Hypercoagulability of blood (possibility of thrombus)  Increased pigmentation o HCG secreted by chorionic villi:  Supports corpus luteum, stimulates estrogen, and progesterone production  Level peaks at 60-70 days gestation; falls after the 4th month; gone 2 weeks postpartum  Raises body temperature  May have immunologic properties preventing a lymphocytic reaction to the fetus  May cause allergic reaction (hyperemesis) o Presumptive signs of pregnancy (subjective)  Menstrual suppression (amenorrhea, menstruation may occur after conception)  Nausea, vomiting, and “morning sickness” (due to increased HCG levels)  Frequency of micturition (uterus stretches base of bladder)  Tenderness and fullness of the breasts, breast pigmentation, and discharge (due to increased progesterone and estrogen)  “quickening” (usually 18-20 weeks, may be 16 weeks in multigravida)  Fatigue o Probable signs (objective)  CHADWICK'S Sign--Dark blue discoloration of the vaginal mucous membrane   pigmentation of the skin, LINEA NIGRA, CHLOASMA and abdominal striae gravidarum (stretch marks)  HEGAR'S SIGN - (lower part of the body of uterus much softer than cervix)  GOODELL'S SIGN - cervix softens due to increased vascularity edema  POSITIVE PREGNANCY TEST(increased HCG levels, blood/serum 8-9 days after ovulation and fertilization and urine test within 2 weeks of gestation)  Changes in the size, shape, and consistency of the uterus  ballottement (sudden tap on presenting part makes it rise in amniotic fluid)  BRAXTON HICKS contractions (painless, cause of false labor) o Positive signs (diagnostic)  Fetal heart sounds (audible with doppler 8-10 weeks gestation, or ultrasound)  Fetal movements felt by examiner  X-ray: outline of fetal skeleton  Ultrasound: presence of a conceptus (6-8 weeks)  Fetal movements visible • Normal variations in pregnancy for lab values, and GI system. Chadwicks sign, Chloasma, Goodell’s sign, friability of mucus membranes o Cardiac output  10-15% in 1st stage, 30-50% in 2nd stage o Position change affects CO, side lying increases CO by 22% o BP: systolic  during contraction in 1st stage; systolic & diastolic  during contractions in 2nd stage o WBC  25-30000 during labor due to increase in neutrophils resulting from a physiologic response to stress o Gastric motility is decreased (emptying is delayed, risk for aspiration) Newborn Nutrition • Pros of breastfeeding o Provide antiviral, anti-protozoan, anti-inflammatory antibodies o Colostrum contains macrophages o No allergic reactions o Easily digested o IgA present (protective anti-absorptive effect keeps protein molecules from passing through intestines) o No need to use vitamin supplements o No vitamins lost during reheating o Optimal food for first 4 to 6 months/first year o Promotes good jaw and tooth development o Low pH of stools o Inhibits growth of bacteria o Natural laxative for babies o Natural emollient to heal tender nipple tissue o Promotes uterine involution (oxytocin production uterine contraction and letdown reflex) • Cons of breastfeeding o High maternal demand o Maternal inconveniences (milk leakage, sore nipples, and time demand) o Food intolerance and drugs transmitted through breast milk o Father may feel excluded from feeding process o Increase possibility of breast milk jaundice o Easily digested infant may nurse every 2-3 hours or more o Demanding for first time mothers • How is colostrum different than mature breastmilk? o Colostrum  Yellow colored fluid, present from end of pregnancy until 2 days post-partum  Higher proteins and lower fast/lactose than mature breastmilk  Rich in antibodies and has a laxative effect for baby o Transitional milk  Produced from the end of colostrum production until approximately 2 weeks postpartum  This is where engorgement occurs  Consists of fat, lactose, and water soluble vitamins o Mature breast milk  Decrease in concentration of immunoglobulins  Decreased in total protein  Increase in lactose, fat and total calories  10% solids, rest is water for maintaining hydration o Notes:  Cannot add immunoglobins and antibodies to formula  Colostrum is what they get right off the back, easily digestive, good for premature babies (save and freeze every drop for them) have antibodies (higher in protein)  Transitional has more calories  Mature has more lactose fat and total calories (less protein) • Breastfeeding nursing interventions to foster success, prevent engorgement & sore nipples o Engorgement  Painful firmness as milk comes, hard to touch, skin is shiny, and taut  Usually disappears within 24-48 hours  Wear support bra, empty breast fully, frequent feedings  Keep nursing, use ice bags between feeding, hot shower and manual expression to soften nipples, pumps to soften nipples, increase feedings to 20 min, apply warms compresses, cabbage leaves on side of bra (reduces edema), analgesics shortly before feeding o Foster success  Provide reassurance, allow time to learn  Provide adequate nutrition for baby  Prevent trauma to the nipples  Create comfortable space • Arrange for privacy • Assist in finding a comfortable position • Use additional pillows for support, evaluate baby’s mouth position  Initiate breast feeding within the first hour after birth in the quiet alert stage- first stage of reactivity  Promotes bonding, increases oxytocin levels to reduce maternal bleeding, helps maintain baby’s glucose level  Assess effectiveness of newborns suck, swallow and gag reflex  Watch for circumoral cyanosis, rapid respirations, diaphoresis which may indicate cardiovascular complications  Assess for tracheoesophageal fistula and esophageal atresia (look for increased oral mucus or history of maternal polyhydramnios  Pumping and expression: start after 24 hours if nursing is not well established is recommended o Sore Nipples  Common causes are poor positioning and improper latch  To treat: warm compressions, air dry, lanolin, breast milk on areola a natural emollient, frequently change position  Change positions while breastfeeding to avoid nipple discomfort (so they do not press on the same parts each time) • Hormones that facilitate preparation for breastfeeding during pregnancy. o Hormonal pathways (postpartum)  Birth results in a rapid  in estrogen and progesterone and an  in the secretion of prolactin. Prolactin promotes milk production by stimulating the alveolar cells of the breast. Prolactin levels rise in response to suckling. o Let-down reflex (postpartum)  Suckling also stimulates the release of oxytocin from the pituitary gland.  Oxytocin increases the contractility of the myoepithelial cells lining the walls of the mammary ducts, and a flow of milk results this is called the letdown reflex.  Often described as a tingling, prickling sensation as milk comes down, mothers may feel increased cramping, increased lochia, leaking from other breast, and a sense of relaxation. Letdown reflex is stimulated by infants cry, infants presence, suckling, mothers thoughts of infant, and sexual orgasm. o Know the two hormones  Prolactin deals with production  Oxytocin is used to stimulant contractions, and let down reflex (releases milk from breast) • How does breastfeeding promote the infant’s immune system? o Fetal Assessment Worksheet: • Know the expected results for a non-stress test (NST), contraction stress test (CST), how results are determined. o NST (noninvasive)  Looking at the late decelerations w/ contractions and how baby responds to oxytocin  Fetal heart monitor  Want to get a baseline  Looking of 2 or more accelerations of 15 beats per minute lasting for 15 seconds having this = reactive (normal) o CST (invasive)  Fetal heart monitor, iv pump (Pitocin)  Looking for the absence of any late decelerations in response to uterine activity  Want baseline to stay variable, no reflection of utero in sufficiency  Want Negative result (no reaction)  The presence of any deceleration is not good • Differentiate purpose, implications of results, and timing of chorionic villi sampling (CVS), Amniocentesis, PUBS, MS-AFP. o CVS:  A procedure used to detect genetic, metabolic, and DNA abnormalities and is done for first trimester diagnosis after 9 completed weeks.  Benefits  early diagnosis and decreased waiting time for results; CVS is done at 10-12 weeks o Amniocentesis  Early (15-20 weeks): chromosomal abnormalities, validate abnormalities, biochemical determinations  Late (30-39 weeks): lung maturity studies (L/S ratio) o PUBS  Obtains pure fetal blood from the umbilical cord to diagnosis hemophilia’s, hemoglobinopathies, fetal infections, hemolytic disorders, assessment of fetal HGB and HCT for calculation of transfusion requirements in the second and third trimesters. o MS-AFP  Maternal serum alpha fetal protein  Screens for NTD, trisomy 21, and trisomy 18. Using an ultrasound along with MSAFP has a higher detection rate than the quadruple check alone. If an abnormal result is obtained, an amniocentesis may be done and risk of pregnancy will be counseled. • Understand pathophysiology and description of Variability o Baseline variability is a measure of the interplay effect between the sympathetic nervous system and the parasympathetic nervous system o Fluctuations in the FHR of two cycles per min or greater o Variability is visually quantitated as the amplitude of peak-to-trough in bpm  Absent – amplitude range undetectable  Minimal – amplitude range detectable but 5 bpm or fewer  Moderate(normal)- amplitude range 6-25 bpm  Marked – amplitude range greater than 25 bpm o Beat to beat variability is probably the most accurate indicator of fetal well being that the nurse has, if BTBV is poor, the fetus is probably in distress and needs to be delivered SOON • Accelerations, Early decelerations, Variable Decelerations, Late decelerations and appropriate nursing interventions. o Accelerations  A visually apparent abrupt increase (onset to peak less than 30 seconds) in the FHR from the most recently calculated baseline  The duration of an acceleration is defined as the time from the initial change in FHR from baseline to the return of the FHR to baseline  At 32 weeks of gestation and beyond, an acceleration has an acme of 15 bpm or more above baseline, with duration of 15 sec or more but less than 2 min  Before 32 weeks, an acceleration has an acme of 10 bpm or more above baseline, with a duration of 10 seconds or more but less than 2 min  If an acceleration lasts 10 min or longer it is a baseline change • Cause: stimulation of autonomic nervous system of the fetus seen with fetal movement, vaginal exams, abdominal palpations, uterine contractions – usually signs of fetal well being • No NI’s o Early Deceleration  “mirrors” contraction  In association with uterine contraction, a visually apparent, gradual (onset to nadir 30 sec or more) decrease in FHR with return to baseline. **Nadir of the deceleration occurs at the same time as the peak of the contraction  Cause – head compression after uterine contraction (because baby is moving down), vaginal exam, fundal pressure, placing internal fetal scalp electrode  NI’s – benign pattern, no intervention required o Variable Deceleration  V,U or W shaped  An abrupt (onset to nadir less than 30 sec) visually apparent decrease in the FHR below the baseline. The decrease in FHR is 15 bpm or more, with duration of 15 seconds or more but <2 minutes  Cause – umbilical cord compression, if repetitive in may indicate nuchal cord (neck)  NI’s – change maternal position, if severe may need to try amnioinfusion o Late Deceleration  In association with uterine contraction, a visually apparent, gradual (onset to nadir 30 sec or more) decreases in FHR with return to baseline. Onset, nadir and recovery of the deceleration occur after the beginning, peak and end of the contraction, respectively  Very ominous when associated with loss of variability, rising baseline or tachycardia  Repetitious  Cause- uteroplacental insufficiency or decreased maternal fetal exchange during contradictions causing hypoxemia • See with – hyperstimulation of uterus with oxytocin, toxemia, posterity, SGA, maternal diabetes, anemia or cardiac disease, placenta previa or abruption  NI’s – change maternal positions to left lateral, stop Pitocin/oxytocin if being used, O2/mask at 7-10L/min, correct maternal hypotension, increase mainline IV rate (Bolus), elevate legs • Recognize reassuring and non-reassuring FHR patterns o VEAL CHOP V – variable deceleration is caused by the C-cord E – early deceleration is caused by H – head compression A – acceleration is O – okay L- late deceleration P- placental insufficiency • Nurse’s responsibility in fetal monitoring and care of the mother and fetus. o Ital signs every 15 minutes o FHR every 15 minutes o Strict bed rest o Comfort reassure o Contracting pattern o Uterine resting tone o Danger: rising resting tone uterine rupture • Parameters of significance in ultrasound testing for gestational age, nurse’s role in preparation of patient and assisting with ultrasound, parameters for BPP (biophysical profile). 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