Objective 1 The Student will analyze labor.

a) Explain physiologic and psychological responses to labor Normal contractions are coordinated, involuntary and intermittent. Coordinated: The uterus contracts and relaxes like the heart or other smooth muscle..They are low in intensity and uncoordinated. As the woman becomes full term the contractions become organized and gradually assume a pattern of increased frequency, duration and intensity. Involuntary: Uterine contractions are not under conscious control (involuntary). The mother cannot start or stop labor by conscious effort. Some activities though can stimulate labor to begin. Anxiety and stress can diminish them. Intermittent: Labor contractions are intermittent rather than sustained, allowing relaxation of the uterine muscle and resumption of blood flow to and from the placenta to permit gas, nutrient and waste exchange for the fetus. There are three phases of contractions. They are described in terms of frequency, duration, intensity. Frequency: the period from the beginning of one uterine contraction to the beginning of the next. Expressed in minutes and fractions of minutes (3 1/2 to 4 min apart) Duration: the length of each contraction from beginning to end. Usually expressed in seconds, (contractions lasted 55 to 65 seconds) intensity: the strength of the contractions in terms of mild, moderate and strong on palpation by the nurse. Different descriptions of intensity apply when fetal monitoring is used to record contractions. An interval is the, period between the end of one contraction and the beginning of the next.. Uterine activity during labor is characterized by opposing features. Upper 2/3 contracts actively to push the fetus down. Lower 2/3 remains less active, promoting downward passage of the fetus. The cervix is passive. Opposing characteristics of contractions in the upper and lower uterine segments change the shape of the uterus becoming elongated and narrow as labor progresses which ultimately directs the fetus downward in the pelvis. Effacement and Dilation are the major cervical changes during labor. They occur concurrently but at different rates. Effacement is estimated as a percentage of the original cervical length.. A fully thinned cervix is 100% effaced. Dilation is expressed in centimeters. Full dilation is approximately 10 cm, to allow passage of athe average-sized full-term fetus. Sytem changes: Reproductive system- Contractionsnormal labor contractions are coordinated, involuntary and intermittent Contraction Cycleeach contraction consists of three phases(frequency, duration, intensity. Uterine Bodyuterine activity during labor is characterized by opposing features Cervical changeseffacement and dilation Cardiovascularly, during each uterine contraction, blood flow to the placenta gradually decreses, causing a selative increase in the woman's blood volume, increasing her blood pressure slightly and slowing her pulse.

Respiratory depth and rate increase especially if the woman is anxious or in pain. They may hyperventilate causing respiratory alkalosis from exhaling too much CO2. Gl motility is reduced during labor which can result in nausea and vomiting. Most women are not hungry but thirsty and have dry mouths. Urinary-reduced sensation of a full bladder occurs in labor. A full bladder can inhibit fetal descent because it occupies space in the pelvis. Hematopoetic -500ml is the maximum normal blood loss during vaginal birth. This is acceptable and tolerable since the blood volume increases during pregnancy by 1-2 L. The levels of certain clotting factors are elevated during pregnancy and continue to be higher during labor and after delivery. This provides protection from hemorrhaging but increases the risk for DVT during pregnancy and after birth. Pvschologically-mild anxiety and fear decrease a womans ability to cope with pain in labor. Preparation for childbirth can enhance a womans ability to work with her body's efforts rather that resist the natural forces. A womans culture affects her views of birth and practices surrounding it. I can influence her reaction to labor and her expectations of interaction with her newborn. A woman who has a more realistic expectation about the birth is more likely to have a postitive experience. b) Discuss premonitory signs of labor Braxton Hicks: contractions throughout pregnancy, irregular and mild. Lightening: as the fetus descends toward he pelvic inlet the woman notices that she breaths more easily because the upward pressure on her diaphragm is reduced, but the pressure on the bladder increases. increased vaginal mucous secretions: occurs as fetal pressure causes congestion in the vaginal mucosa Cervical ripening and bloody show: cervix softens from hormone relaxin and increased water content, allowing the cervix to yield more easily to the forces of labor contractions. As the fetal head descend it puts pressure on the cervix starting the process of effacement and dilation. This causes expulsion of the mucous plug that seals the cervix during pregnancy. Energy spurt: energy spurt that causes women to "nest". Weight loss: a small weight loss of 2.2 to 6.6 kg may occur because of altered estrogen and progesterone ratio causing excretion of some of the extra fluid that accumulates during pregnancy. c) Distinguish between true and false labor True Labor: Contractions cause progressive change in the cervix. An increase in effacement and dilation occur. Contractions are consistent and increase in frequency, duration and intensity. Pain is felt in lower back gradually sweeping around the lower abdomen. False Labor: false contractions are inconsistent in frequency, duration, and intensity...do not change of may decrease with activity. Discomfort is felt in the abdomen and groin. Cervix does not change significantly d) Discuss the role of passage, passenger, powers and psyche in the labor process

The four P's of labor : Passage (pelvis, soft tissue) During birth, the true pelvis functions like a curved cylinder with different dimensions at different levels -Passenger (fetus, membranes and placenta) Several fetal anatomic and positional variables influence the course of labor

Powers (uterine contractions, bearing down efforts) These are the primary forces that moves the fetus through the maternal pelvis Psyche (psychological elements) Mild anxiety, and fear decrease the woman's ability to cope with pain in labor. Preparation for childbirth can enhance a woman's ability to work with her body's efforts rather than resist the natural forces. e) Identify factors that can indicate a greater than normal risk to the mother and fetus during labor.

Breech presentation: more likely to occur with abnormalities of the maternal uterus and pelvis and with placenta previa. The fetal head is the last part to be born which can cause the umbilical cord to compress and the fetus unable to breath. Fetal heart rate outside the normal range for a term fetus (110-160bpm for a term fetus) Meconium stained amniotic fluid Cloudy, yellowish or foul-smelling amniotic fluid (can indicate infection) Excessive frequency or duration of contractions (can reduce placental blood flow) Incomplete uterine relaxation and intervals <30sec between contractions (reduces placental blood flow) Maternal hypotension (may divert blood flow away from placenta to ensure adequate perfusion of the maternal heart and brain Maternal hypertension (associated with vasospasm in spiral arteries which supply the intervillous spaces of the placenta) Maternal fever (100.4 or >) f) Explain the stages and phases of labor

f*~..Divided into 4 stages: First Stage: Effacement and dilation in three phases: 1) Latent- first 3cm of cervical dilation 8.6 to 5.3 hours duration. Can be unnoticed but eventually can be realized as the real thing. Contractions build in frequency, duration and intensity. 2) Active-pace of labor increases. Dilation is 4-7cm at 4.6 to 2.4 hours duration. The fetus descends into the pelvis and internal rotation begins. Contractions are 2-5 min apart and last 40-60 sec. Intensity ranges from moderate to severe. 3) Transition-cervix dilates from 8-1 Ocm and fetus descends further in to the pelvis. Contractions are strong and are 1.5 to 2 min apart, lasting 60-90 sec. May cause the woman to push and bear down during contractions. Second Stage: Expulsion with complete 10cm dilation and full (100%) effacement of the cervix ending with the birth of the baby. Duration last SOmin to 3 hours. Contractions are strong 2 to 3 min apart and lasting 40-60 sec. Duration last SOmin to 3 hours. Contractions are strong 2 to 3 min apart and lasting 40-60 sec. The woman exerts physical effort to push the baby out. This stage ends with the birth of the baby. Third Stage: Placental. Begins with the birth of the baby and ends with the expulsion of the placenta. Shortest stage lasting up to 30 min with an average length of 5-10 min. Placenta is expelled in two ways: Schultz which is shiny fetal side presenting first or Duncan, which is less common and the maternal side is presenting first. Fourth Stage: Physical recovery for the mother and infant. Lasts from the delivery of the placenta through the first 1-4 hours after birth.

Objective 2 The student will evaluate the intrapartum patient's needs a) Incorporate physiological, psychological and cultural factors

Physiological factors: Labor is work and therefore women often get hot and perspire. Offer cool damp washcloths. Offer ice chips, frozen juice bars. A full bladder can intensify pain during labor and delay fetal descent. Remind the woman to empty her bladder frequently. Positioning is helpful to reduce discomfort and assist the labor process. Encourage proper breathing techniques. Psychological factors: Provide encouragement to the woman and tell her when her labor is progressing. Praise her for correct breathing and reinforce her self control efforts. Soft indirect lighting is soothing as opposed to bright overhead lighting. Simply reassure that all is going well. Cultural factors: Arrange for a culturally acceptable interpreter who is fluent in the woman's language if needed. Cultural beliefs and practices give structure, meaning and richness to the birth experience. Incorporate the family' cultural practices into care as much as possible. Women who do not usually welcome touch may appreciate it during labor, but don't assume that, make sure you ask. b) Explain oxytocin in the post delivery period Reduces bleeding after expulsion of the placenta. Stimulates sustained contraction of the uterus and causes arterial vasoconstriction. c) Develop a nursing care plan for the intrapartum patient

Refer to page 301 to 303 for care plan d) Calculate an Apgar score Apgar score is assessed at 1 and 5 minutes (10 minutes if response is poor) after birth for rapid evaluation of early cardiopulmonary adaption. If the Apgar score is 8 or higher, no intervention is needed. Arranged as most important (heart rate) to least important (color). Assigned a score of 0-2 in 5 areas and the scores are totaled. Heart rate 0=absent, 1 =below 100/bpm 2=100/bpm or higher, 0=no spontaneous respirations 1= slow resp. or weak cry 2= spontaneous resp and strong, lusty cry 0=limp 1=minimal flexion of extremities; sluggish movement 2=flexed body posture; spontaneous and vigorous movement 0=no response to suction or gently slap on soles 1=minimal response (gimace) to suction or gentle slap on soles 2=Responds promptly to suction or a gentle slap to the sole with cry or movement 0=pallor or cyanosis 1=bluish hands and feet only 2=pink (light skin) or absence of cyanosis (dark skin), pink mucus membranes

Respiratory rate:

Muscle tone:

Reflex response:

Color:

If score is:

0-3 4-7 8-10

Patient needs resuscitation Gently stimulate by rubbing the infant's back while administering oxygen. Determine whether mother received narcotics, which may have depressed infant's respirations Have Narcan available for administration Provide no action other than support the infant's spontaneous efforts and continued observation.

Objective 3 The Student will analyze extra uterine adaptation. a) Describe changes from fetal to newborn circulation During fetal life three shunts carry blood away from the lungs and liver. At birth, changes in blood oxygen level shifts pressure within the heart and pulmonary systemic circulation, and clamping of the umbilical cord allow the infants blood to circulate to the lungs for oxygenation and to the liver for filtration. Occur simultaneously within the first few minutes after birth. Ductus Venosus Blood flow occluded with end of umbilical circulation. Caused by occlusion of cord stops flow of blood from the placenta through umbilical vein to ductus venosus. The results are that blood travels through the liver to be filtered as in adult circulation. Occurs when cord is clamped and permanent at 1-2 weeks. It becomes ligamentum venosum. Foramen Ovale Closes when pressure in the LA becomes higher that pressure in the RA. Caused by cord occlusion elevates systemic resistance. Blood returns from PV to LA. Both increase L heart pressure. Decreased pulmonary resistance allows free flow of blood into lungs and decreased pressure in RA. This results in the blood entering RA can no longer pass through to LA; instead it goes to RV and through PA to the lungs. Occurs within minutes and becomes permanent at 3 mos. It becomes fossa ovale. Ductus Arteriousus Constriction preventing entrance of blood from PA. Caused by increased oxygen level in the blood. Results from blood in the PA is directed to lungs for oxygenation. Occurs within minutes after birth with complete closure in 15 to 24 hours. It is permanent at 3 to 4 weeks. It becomes ligament arteriosum. b) Describe respiratory changes at birth At 22 weeks gestation the lungs begin to produce surfactant which lines the inside of the alveoli and reduces surface tension within. This allows the alveoli to remain partially open when the infant begins to breathe at birth. Once the alveoli expand, surfactant acts to keep them partially open between respirations. With each cry, the pressure within the lungs increases, keeping alveoli open and causing remaining fetal lung fluid to move into the interstitial spaces where it is absorbed by the pulmonary circulatory and lymphatic systems. Pulmonary blood vessels Dilation of all vessels in the lungs caused by increase of oxygen level in the blood. Results from Decreased pulmonary resistance allowing blood to enter freely to be oxygenated. Begins with first breath. c) Describe mechanisms and effects of heat loss after birth Because the skin of an infant is thin and the blood vessels are close to the surface they can lose heat. Newborns have three times more surface area to body mass than adults do which gives them more area for heat loss. Some methods of heat loss are: Conduction -occurs when the infant comes in contact with cold objects or surfaces such as a scale. Evaporation-occurs during birth or anytime the infant is wet and from insensible water loss. Convection- occurs when drafts come from open doors, air conditioning, or even air currents created by people moving about. Radiation-occurs when the infant is near a cold surface. Thus the heat is lost from the infant's body to the sides of the crib or incubator and to the outside walls and windows.

Effects: Thermogenesis Newborns rarely shiver except at low temperatures, and shivering is not an effective method of heat production. Instead they cry and become restless. Exposure to cool temperatures also results in decreased flow of warm blood to the skin because of vasoconstriction. Acrocynosis can occur and in addition a drop in temperature increasing metabolic rate and markedly causing above-normal oxygen and glucose use. Cold Stress Can cause many body changes. Increases the need for oxygen due to the metabolism of brown fat. Can cause diminished production of surfactant impeding lung expansion, and respiratory difficulty. Mild respiratory distress can become severe hypoxia if oxygen must be used for heat production. Glucose demands are higher when the metabolic rate increases in efforts to produce heat. Metabolism of brown fat and glucose in the presence of insufficient oxygen causes production of acids and metabolic acidosis can occur. d) Describe body system changes after birth to include the immune, hematologic, renal, endocrine, gastrointestinal, hepatic and neurological systems Immune: WBC's respond slowly and inefficiently when the body is invaded by organisms. Leukocytes rise during the first 12 hours after birth and then decline slowly. The increase in WBC does not necessarily indicate infection, actually may decrease in infections. An increased number of immature leukocytes are a sign of infection or sepsis in the neonate, along with a decrease in platelets. IGg is the only immunoglobulin that crosses the placenta providing the fetus with passive temporary immunity to bacteria, bacterial toxins ad viruses which the mother is immune to. IgM is the first immunoglobulin produced by the body when the newborn is challenged. IgA does not cross the placenta and must be produced by the infant, and is available in colostrums and breast milk. Hematologic: Higher RBC's and higher Hgb and Hct than adults. RBC's have a shorter life span. Hemolysis occurs and Hgb is broken down releasing bilirubin. Excess bilirubin can cause jaundice. Newborns are at risk for clotting deficiencies during the first few days of life because they lack vitamin K which is necessary to activate several of the clotting factors II, VII, IX, X. Renal: Full kidney function does not occur until after birth when the kidneys take over the elimination of waste. Blood flow to the kidneys increases after birth due to the decreased resistance in the renal vessels. The GFR does not reach adult levels until 1 to 2 years of age therefore infants have a decreased ability to remove waste products from the blood. The fist voiding occurs within 12 hours of birth and within 24 hours in 95% of all newborns. Insensible water loss is increased in the newborn because of the large surface area of the body and rapid respiratory rate. Newborns tend to lose bicarb at lower levels than adults, increasing their risk of acidosis. Endocrine: Glucose that has been supplied by the placenta is stored as glycogen in the fetal liver and skeletal muscle for use after birth. Until newborns begin regular feedings and their intake is adequate to meet energy requirements, the glucose present in the body is used. Glucose usually falls to the lowest level by 60 to 90 minutes after birth and rises within hours. Gastrointestinal: Capacity is about 6mi/kg at birth to 90ml within the first week. The cardiac sphincter between the esophagus and the stomach is relaxed causing the tendency to regurgitate feedings easily. Digestive tract is sterile at birth. Once the infant is exposed to the external environment and begins to take in fluids, bacteria enter the Gl tract. Normal intestinal flora is established within a few days of life. Pancreatic amylase is excreted by the infant. Usually passed within 12 hours of life and 99% neonates pass meconium within 48hrs. The second type of stool passed is called transitional stool. They are a combination of meconium and milk stool

Hepatic: Conjugating of bilirubin is a major function of the liver and some newborns liver's are not mature enough to prevent jaundice during the first week of life. Prothrombin and coagulation factors II, VII, IX, and X are produced by the liver and activated with Vitamin K which is deficient in newborns. The liver metabolizes drugs inefficiently in the newborn and certain drug amounts can be carried from breast milk to the infant. Neurological: Relfexes are tested...Babinski (lateral stroke on the foot from heel to across), Gallant (stroke the Back lateral to the vertebral column), Grasp (press finger against base of fingers and toes), Moro (drop head back 30 degrees), Rooting (stroke side of cheek), Startle (make loud noise), Stepping (hold infant so feet touch solid surface), Sucking (place nipple or finger in mouth rub & against the palate), Swallowing (place fluid at the back of the tongue), Tonic neck (turn infants head to one side while he or she is supine. Siezures indicate CNS abnormality. High pitched, shrill, hoarse, or catlike, may indicate neurologic disorders. e) Describe signs and symptoms of respiratory distress, jaundice, hypoglycemia, hypothermia, hyperthermia and birth injuries

Respiratory distress: Tachypenea within the first hour. Retractions Nasal flaring, grunting, gasping, moments of apnea>20sec, seesaw respirations, cyanosis Jaundice: Yellow skin and eyes Hypoglycemia: Jitteriness, poor muscle tone, diaphoresis, poor suck, tachypnea, resp. distress, tachycardia Dyspnea, cyanosis, apnea, low temp, high-pitched cry, irritability, lethargy, seizures, coma, may be asymptomatic

Hypothermia: Crying and restlessness, Acrocyanosis, (95 to 96.8 F) Hypoglycemia, resp. distress, metabolic Acidosis, jaundice Hyperthermia: Elevated temp, increased need for oxygen, increased glucose needs, and peripheral vasodilation occurs and may lead to fluid loss Birth Injuries: Absence of relflexes or asymmetric responses. Unilateral drooping of the mouth, one-sided cry No rooting reflex on the affected side, f) Describe periods of reactivity and behavioral states

Early hours after birth the infant goes through changes called the periods of reactivity. These two periods are separated by a period of sleep. After the first period of reactivity the infant becomes quiet and fall into a deep sleep that can last as long as 2-4 hours. Pulse and RR drop into normal range and temp may be low. When the infant awakes they enter the second period of reactivity which lasts for a short time or several hours. They are alert, and interested in feeding and may pass meconium. Pulse and RR increase and may have periods of apnea. 6 behavioral states: 1) Quiet Sleep Statedeep sleep with closed eyes and no eye movements. RR is slow and regular, no body movement. No response to stimuli or noise 2) Active Sleep Statelighter sleep. Moves extremeties, stretches, change facial expressions and sucking movements. RR rapid, irregular and REM occur. Startled by noise or disturbances. 3) Drowsy Statebetween sleep and waking. Eyes may remain closed or if open appear glazed and unfocused. Move extremities slowly and whimper...may gradually awaken. I 4) Quiet Alert Statefocus on objects or people, respond to parents with intense gazing. Body movements are minimal and seem to concentrate on the environment.

5) Active Alert Stateoften fussy, restless and have faster and more irregular RR and seem more aware of feelings of discomfort from hunger or cold. 6) Crying State may quickly follow the alert state is no intervention occurs to comfort the infant.

g) Discuss initial assessment of the newborn The initial assessment is done to determine the neonates health status. It should include, cardiorespiratory status, thermoregulation, and the presence of abnormalities, measurements. When the infant is stable and oxygenating well, a more thorough assessment can be performs. Cardiorespiratory Status: RR, Breath sounds, Signs of resp. distress. Color Heart sounds Brachial and femoral pulses Blood pressure Capillary refill Temperature (axillary) Head and neck (fontanels, molding, caput succedaneum, cephalhematoma) Neck and clavicles Cord Extremities (hands, feet, hips) Vertebral column Weight, Length Head and chest circumference.

Thermo regulation: Presence of abnormalities:

Measurements:

Objective 4 The student will analyze ongoing newborn needs

a)

Discuss ongoing assessment of the newborn

Ongoing assessment of the newborn focuses on more specific areas and body systems. Neurological: Reflexes, sensory assessment Hepatic system: Blood glucose, bilirubin, Gl System: Mouth, suck, initial feeding, abdomen and stools. Gentouhnary: Kidney palpation, urine, genitalia Integumentary system: Skin (color, lanugo, vernix,erythema toxicum, birth marks, delivery Marks) Breasts, hair, nails Neuromuscular. Posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear, b) Discuss dietary and fluid needs Daily calorie and fluid needs of the newborn are: Calories =110-120 Kcal/kg (50-55 kcal/lb) Fluid = 40 to 60 ml/kg (18-27 ml/ib) for the first two days of life 100 to 150 ml/kg (45-68 ml/lb) by the end of the first week. Breast milk is species specific and the nutrients are proportioned appropriately for the neonate and vary to meet the newborns changing needs. Can provide protection against infection and is easily digested. Breast milk and formula provide the infants fluid needs and additional water is unnecessary. c) Discuss neonatal pathogens and their effect on the newborn

Bacterial infection of the newborn affects 1 to 4 in every 1000 live births. And is the leading cause of death in the neonatal period. They can acquire infections before, during and after birth. Vertical infections are acquired before or during birth from the mother. Some of these organisms are: Cytomegalovirus infection Syphilis Toxoplamosis During labor and birth, organisms in the vagina such as group B streptococci, herpesvirus, and Hepatitis B virus may enter the uterus after rupture of membranes or can affect the infant as he passes through the birth canal. Infections that occurs after birth may result in sepsis neonatorum; systemic infection from bacteria in the blood stream. The blood brain barrier may be ineffective in keeping our organisms so a CNS infection can occur. The most common causative agents of neonatal sepsis are group B streptococci and E-coli. d) Discuss common medications/vaccines used in the neonatal period to include vitamin K, erythromycin, Hep B vaccine, Hep B immunoglobulin

Vitamin K vaccine: Promotes formation of factors II, VII, IX, X by the liver for clotting; provides Vitamin K which is not synthesized in the intestines for the first 5-8 day after birth. Erythromvcin drops: Antibiotic used in the eyes as prophylaxis against the organisms Neisseria gonorrhoeae, & Chlamydia trachomatis. Required by law whether or not the mother is known to be Infected.

Hepatitis B vaccine: Used to immunize against Hepatitis B in exposed and unexposed infants. Usually given The day of discharge (or within 12 hours of birth) with the second dose is due at 1-2 Hep B Immune Globulin (HBIG): Prophylaxis for infants of hepatitis B surface antigen-positive mothers. Given within 12 hours of birth. Provides antibodies and passive immunity to Hep B. e) Discuss appropriate circumcision and unbilical cord care

Umbilical cord care: should be checked for bleeding or oozing during the early hours after birth. Cord clamp must be securely fastened with no skin caught in it. It will become brownish black within 2 to 3 days and fall off within 10-14 days. It may be treated with bateriacidal substance such as triple-dye solution, antibiotic ointment, or alcohol and cleaned with at mild soap solution and allowed to dry naturally. Parents can clean the cord with alcohol 3 times a day and keep the diaper fold below the cord to keep it free of urine and dry. Circumcision care: a small piece of guaze may be placed over the area. The diaper is loosely replaced to prevent pressure. The nurse watches closely over the next few hours for complications after the procedure. If excessive bleeding occurs the physician is notified. Noting the first urination after circumcision is important to detect any obstruction. f) Discuss common laboratory studies performed on the newborn

Blood glucose: levels below 40-45 mg/dl have potential for hypoglycemia. PKU: Condition where the infant cannot metabolize amino acid phenylalanine which is common in protein foods and milk products. Accumulation of phenylalanine can result in severe mental retardation. Congenital hypothyroidism (CH): Most common preventable cause of mental retardation. Thyroid does not produce thyroxine hormone Galactosemia: Absence of the enzyme needed for the conversion of milk sugar galactose to glucose. Results in liver damage, brain damage, damage to the eyes and eventually causes death. Hemoglobinopathies: Include sickle cell anemia, thalassemia and other disease. These disease cause chronic anemia, sepsis and other serious conditions. Congenital adrenal hyperplasia: refers to a group of disorders with an enzyme defect that prevents adequate adrenal corticosteroida and aldosterone production, increasing the production of androgens. S/S ambiguous genitalia at birth, masculinized females infants. Salt wasting crisis. g) Discuss the Texas newborn screening program The program currently screens every infant born in Texas, testing for 27 disorders. Early detection and management of these disorders, which are caused by inherited genetic defects (with the exception of Hypothyroidism where only 15% of cases are inherited), prevents mental retardation and other catastrophic health problems in affected children. In most instances, the parents are unaware of being "silent carriers" for the genetic defect, and the diagnosis of a genetic disease in their newborn infant is unanticipated. h) Discuss methods to promote newborn safety in the hospital

Indentifying the Infant- Two bracelets are placed on the infant, one on the mother and one on the father. Information on the band is identical and includes the infants sex, date, and time of birth, delivering doctor, mother's name, mother's hospital number and a number imprinted on the plastic band. Other methods to identify the infant are footprints, fingerprints of the mother or photographs of the infant. Birthmarks or other distinguishing features are carefully documented in the nurses notes. Preventing Infant Abduction- teach parents how to recognize picture identification badges worn by the birth facility personel. Never give an infant to someone who does not have proper identification. People entering and leaving maternity units should be observed at all times. Remote exits are locked and often equipped with video cameras and alarms. Preventing infection- wash hands frequently and arms thoroughly throughout the day and before and after any infant is touched. A special disinfectant for cleansing the hands may be used in place of handwashing when the hands are not visibly soiled. Parents should discourage visitors with colds or other infections. Each infants supplies should be kept separate to avoid cross-contamination. If the mother has an infection it is up to the doctor to determine if it is safe for the newborn to remain with her. Nurses must be vigilant for signs of infection during assessment and infant care. j) Develop teaching plan for parents

Most new mothers feel unprepared, physically and emotionally to take over total care of their newborn and themselves. Topics to cover in teaching are: Newborn characteristics and behavior. Use of a bulb syringe Breastfeeding (frequency/length, positioning, latch on, supply and demand, supplementing, potential problems) Formula feeding (frequency/length, positioning, avoiding propping, formula preparation) Burping Cord care Care of the penis after circumcision or care of uncircumcised penis Holding and positioning Sleep patterns Elimination patterns Bathing and skin care Clothing Signs of problems Taking a temperature Infant safety Car seat use

Objective 5 The Student will discuss postpartum physiological needs.

a) Describe physiological changes and needs Reproductive system: Involution of the uterusProcess involves: contraction of muscle fibers, catabolism, and regeneration of uterine epithelium. Begins immediately after birth of the placenta. Healing at the placenta! site takes 6-7 weeks. Descent of the uterine fundus-usually has descended into the pelvic cavity by the 10th day and cannot be palpated abdominally. Afterpainsintermittent uterine contractions. Lochiaconsists mostly of blood with small particles of deciduas and mucos. Lasts usually for 3 weeks but can last as long as 6 weeks. CervixRapid healing takes place after birth and by the end of the first week, the cervix feels firm and the external os is the width of a pencil. The internal os is permanently changed an appears slit like. Vaginaafter birth the vaginal walls appear edematous and multiple lacerations may be present. Very few rugae (folds) are present and the hymen is permanently torn. Vaginal mucosa heals and rugae regained by 3 weeks. It takes 6 weeks for the vagina to complete involution and gain the same size and contour it had before pregnancy, but does not entirely gain its nulliparous size. Perineummay appear edematous and bruised. Episiotomy site takes 4-6 months to completely heal. Cardiovascular system: Cardiac outputdespite blood loss, a transient increase in maternal cardiac output occurs after childbirth. The rise in output which persists for 48 hours after childbirth is caused by an increase in stroke volume, therefore bradycardia may be noted in the early postpartum period, returning to normal within 6 to 12 weeks after childbirth. Plasma volumethe body rids itself of excess plasma volume that was necessary during pregnancy by two methods: Diuresis (increased excretion of urine) and Diaphoresis (profuse perspiration) Coagulationcontinuing elevations in clotting factors continue for several days or longer causing continued risk for thrombus formation. It takes 3-4 weeks for normal levels to return. Blood valuesleukocytosissss occurs while the WBC count increases to as high as 30,000/mm3. Values fall to normal within 4 to 7 days after birth. Hematocrit may return to normal within 4 to 8 wks. Gl sytem: Digestion- begins to be active again soon after childbirth. Constipation is a common problem during postpartum period because of bowel tone and restricted food intake and fluid during labor. Perineal trauma, episiotomy, and hemorrhoids cause discomfort that interfere with bowel elimination. Normal patterns of elimination return within 8 to 14 days. Urinary system: Kidneys return to normal function by 4 to 6 weeks after delivery. Urinary retention may be caused by complications from childbirth such as UTI and postpartum hemorrhage. Stress incontinence that occurs during pregnancy improves within 3 months after birth. Musculoskeletal system: Muscles and joints1 to 2 days after childbirth may experience muscle fatigue and aches because of the exertion during labor. Levels of hormone relaxin gradually subside and ligaments and cartilage of the pelvis return to their pre-pregnancy positions. Abdominal walllongitudnal muscles of the abdomen may separate during pregnancy. May return to normal position within 6 wks after birth.

Integumentary system: Skin changes that occur during pregnancy are caused by increase in hormones. Skin gradually reverts to pre-pregnancy state after hormones decline following childbirth. Striae gravidarum (stretch marks) gradually fade to silvery lines but do not disappear. Hair loss peaks at 3-4 mo and regrowth begins at 9 mo after birth. Neurologic sytem: Analgesics and anesthesia can produce temporary changes in neurological status (lack of feeling in the legs, and dizziness). Complaints of headache require careful assessment. Frontal headaches are not unusual in the first week postpartum, but severe headaches are not common and could be postpuncture headaches resulting from regional anesthesia. Endocrine system: Adrenal hormones return to prepregnancy levels. Resumption ofovulation and menstruationnon-nursing mothers resume menstruation within 7 to 9 weeks after childbirth. The first few cycles for both lactating and non lactating women are often anovulatory but ovulation may occur before the first menses. Breastfeeding delays the return of both ovulation and menstruation (within 12 wks or as late as 18 months). Lactationafter expulsion of the placenta, estrogen and progesterone decline rapidly and prolactin initiates milk production within 2 to 3 days after childbirth. Once milk is established, it continues because of frequent removal of milk from the breast...the more the infant nurses, the more milk is produced. Weight lossapprox. 4.5 to 5.5 kg are lost during childbirth. This include the weight of the fetus, placenta and amniotic fluid and blood lost. An additional 2.3 to 3.6 kg is lost from dieresis in the early days following birth. Most women approach their pre-pregnancy weight about 6 months after childbirth. Prenatal and neonatal records are checked to determine if Rh(D) immune globulin (RhoGAM) should be ^administered, if the mother is Rh negative and the newborn is Rh positive and the mother is not already desensitized. If not immune, rubella vaccine is recommended after childbirth to prevent her from acquiring rubella during subsequent pregnancies. Both cold and warmth are used to relieve perineal pain after childbirth. Ice packs can be used to treat edema in the perineal area, while sitz baths can increase circulation to the area and promote healing within the first 24 hours. Analgesics such as Tylenol are given for pain and NSAID for inflammation and mild to moderate pain.. Bladder elimination should be encouraged as soon as they are able to ambulate. Approximately 2500ml of fluid should be encouraged a day. Meals and snacks should be available at all times. Assist with ambulation early after childbirth to avoid and prevent thombi b) Compare cesarean birth and vaginal birth in terms of nursing assessments and care Cesarean birth must be assessed like any other post operative patient. Pain relief is provided with a PCA. Respirations must be assessed frequently due to anesthesia and narcotics used for delivery. In addition to observing RR, the mother's breath sounds should be auscultated because of longer periods of immobility. Ausculate for bowel sounds until normal peristalsis returns. If surgical dressing is present, it should be observed for intactness and discharge. Incision is observed for signs of infections. Palpation of the fundus should be done gently with cesarean birth. IV site and rate should be assessed and signs of infiltrations such as edema and coolness at the site. The amount, color and clarithy of urine should be monitored.

c) Describe use of oxytocin, analgesics, Rh immune globulin, and rubella vaccine, methergine Prenatal and neonatal records are checked to determine if Rh(D) immune globulin (RhoGAM) should be administered, if the mother is Rh negative and the newborn is Rh positive and the mother is not already desensitized. If not immune, rubella vaccine is recommended after childbirth to prevent her from acquiring rubella during subsequent pregnancies Oxytocin can be used for reduction of bleeding after expulsion of the placenta. Methergine is used to prevent and treat hemorrhage caused by uterine atony. d) Develop nursing care to support the physiologic well being of the new mother during the postpartum period. Promote rest and sleep. Make every attempt to allow the mother adequate time for uninterrupted rest periods. Provide Nourishment- low-fat diet with adequate protein, complex carbs, fruits and veggies provide energy and nutrients needed. Promote regular bowel elimination-increase fiber and drinking at least 8 glasses of water a day. Promote good body mechanics- exercise has beneficial physical and psychological effects. Counsel about sexual activity- anticipatory guidance. Instructions about follow up appts-remind the mother to make an appt with her physician for a postpartum exam (usually between 2 to 6 weeks after childbirth)

Objective 6 The student will evaluate postpartum psychosocial needs.

a) Indentify parent behaviors that indicate bonding and attachment Behaviors that indicate bonding and attachment refer to the rapid initial attraction felt by parents soon after childbirth. Bonding is unidirectional, from parent to child. This bonding takes place during interaction in the sensitive period extending through the first 30 to 60 minutes after birth. The newborn is quiet and alert and responds to the mothers voice and touch. Attachment is the process in which an enduring bond between parent and child is developed through pleasurable and satisfying interaction. Attachment is reciprocal. Alert infants have a repertoire of responses called reciprocal attachment behaviors. An infant's grasp around the mother finger means "I love you" to the parent. Other reciprocal attachment behaviors are: Make eye contact and engage in prolonged, intense, mutual gazing Move their eyes and attempt to "track" the parent's face Grasp and hold the parent's finger Move synchronously in response to rhythms and patterns of the parent's voice Root, latch onto the breast and suckle Be comforted by the parent's voice or touch.

b) Describe progressive phases of maternal adaptation (taking in, taking hold, letting go) Taking-ln: First phase of maternal adaption during which the mother passively accepts care, comfort, and details about the newborn. and initiates care of the infant. Letting-Go: A phase of maternal adaption that involves relinquishment of previous roles and assumption of a new role as a parent. c) Explain process of family adaptation to the birth of a new infant The birth of an infant requires the reorganization of roles and relationships within the family Fatherfacilitated by engrossment. Characterized by intense interest in how the infant looks and responds, along with the desire to touch and hold. Attachment behaviors of the father increase when the infant is awake, makes eye contact, and responds to the father's voice. Some fathers have difficulty adapting to the changes in role the birth brings. Those with unsteady or part time jobs and those whose relationship with the mother is of shorter length or is less satisfactory are more likely to experience distress than those with steady jobs and longer relationships. One study shows that fathers maintain the same level of functioning in child care and household tasks as they had before the birth, but did not increase participation even though the need was greater. Siblingsadjustment depends on the age and developmental level. Toddlers usually are not completely aware of the impending birth. They may view the infant as competition or fear that they will be replaced in the parent's affection. Negative behaviors may indicated the degree of stress experienced by the youngster. Preschool siblings may engage in more looking than touching. Older children may adapt more easily. All Jsiblings need extra attention from the parents and reassurance that they are loved and important. Parents can encourage older siblings to participate in appropriate aspects of infant care.

C Taking-Hold: Second phase of maternal adaption during which the mother assumes control of her own care

GrandparentsGrandparents who live near the child frequently develop strong attachment that evolves into unconditional love and a special relationship that brings joy to the grandparents. Grandparents must try to devise ways to foster a relationship with grandchildren they seldom see. Many grandparents strive to be fully involved in the care and upbringing of the grandchild while others desire less involvement. The degree of involvement my cause some conflict with parents, or it may be a comfortable arrangement for both families. d) Develop nursing care to support the psychosocial needs of the family Teach the family about the newborn. Some parents have unrealistic expectation of the newborn. Provide information about the infant's capabilities as well as the infants physical and emotional needs. Discuss the importance of responding promptly and gently to the cues such as crying and fussing that may indicate the infant needs attention Provide aniticipatory guidance about stress reduction and the demands of the first weeks at home. Help the father or co-parent become involved by including him in teaching and providing opportunities for him to participate in diapering, comforting and feeding the infant. Provide ways to reduce sibling rivalry. Suggest the parents plan time alone with other children and older siblings. Indentify resource for the mother to help with the division of labor. Community resources such as daycare centers, parenting classes,and breastfeeding support are available. Remind the mother that resources are available when she begins to feel isolated and exhausted. e) Identify maternal concerns of body image and postpartum blues. Some mothers have unrealistic expectations of weight loss and the time it takes for their body to regain its nonpregnant shape. Should be emphasized that weight loss should be gradual and that about 6-12 months is usually required to lose most of the pregnancy weight. Mild depression a.k.a. postpartum blues is a frequently expressed concern. The mild transient condition affects more than 70% of the US women who give birth. The condition begins in the first week and usually lasts no longer than 2 weeks. Characterized by insomnia, irritability, fatigue, tearfulness, mood instability and anxiety. Usually cause by the emotional let down after birth. Hormonal fluctuations are often considered to be the source of the problem, but not the cause. Post partum blues is self-limiting and mothers benefit greatly when empathy and support are given by their family and health care team.

Objective 7 The student will explain pregnancy changes a) Differentiate presumptive, probable and positive signs of pregnancy Presumptive indications of Pregnancy Mainly subjective changes that are experienced and reported by the woman. They include: Amenorrhea Nausea and Vomiting Fatigue Urinary Frequency Breast and skin changes Cervical color changes Quickening Probable indications of Pregnancy Objective findings that can be documented by an examiner. They are primarily related to physical changes in the reproductive organs: Abdominal enlargement Cervical softening Changes in uterine consistency Ballottement Braxton Hicks contractions Palpation of fetal outline Postive result of pregnancy tests

C'

Positive indications of Pregnancy Only three signs are accepted as positive confirmation of pregnancy: Auscultation of fetal heart sounds, Fetal movement felt by an examiner, Visualization of the fetus with sonography b) Describe physiological changes which occur during pregnancy Physiological changes Changes in the reproductive system Uterusthe most dramatic change occurs in the uterus and its growth potential. Before pregnancy the uterus is contained entirely in the pelvic cavity and weighs about 50-70g with 10 ml capacity. By 36 weeks of gestation the uterus weight 800-1200g and has a 5000ml capacity. As it enlarges, there is an increase in the number and size of blood vessels which expands the blood flow dramatically. It becomes contractile and by the 12th week of gestation, expands beyond the pelvic cavity and can be palpated above the symphysis pubis. Cervixchanges occur in color and consistency in response to increasing levels of estrogen. It becomes congested with blood resulting in characteristic bluish purple color that extends to the labia and vagina (a.k.a. Chadwicks sign) Vagina and Vulvaincreased vascularity and somewhat similar to those of the cervix. Softening of the connective tissue allow the vagina to stretch during childbirth. pH changes occur to help prevent growth of harmful bacteria found in the vagina . Edema, vascularity and connective tissue changes make the tissues of the vulva and perineum more pliable Ovariesonce conception occurs the main function of the ovaries is to produce progesterone for the first 6-7 weeks of pregnancy.

Breastschange in size and appearance. Estrogen stimulates growth of mammary ductal tissue and proteserone promotes the growth of lobes, lobules and alveoli. Nipples increase in size and become more erect and the areolae become larger and more pigmented. Changes in the cardiovascular system: Heartchanges are minor and reverse soon after childbirth. The muscles of the heart enlarge slightly because of the increased workload during pregnancy. The heart is pushed upward and to the left as the uterus elevates the diaphragm (3rd trimester). Heart sounds may be altered. The most common are the splitting of the first heart sound and a systolic murmur found in 90% of all pregnant women. Blood volumetotal blood volume (RBC's, WBC's, platelets, and plasma) increase about 40-50% during pregnancy Plasma volumebegins at 6-8 weeks of gestation and peaks at 4700 to 5200 ml at 32 wks. 50% above non pregnant values. Cardiac outputconsequence of the expanded blood volume. Rises rapidly during the first trimester and increased 30-50% by the third trimester. Primarily the result of a gain in the stroke volume but the heart rate also rises 10-20 bpm by 32 wks gestation. Peripheral vascular resistancefalls during pregnancy because 1) smooth muscle relaxation in vessel walls resulting from progesterone effects; 2) addition of the uteroplacental unit providing greater area for circulation; 3) fetal heat production which may produce vasodilation; 4) synthesis of prostaglandins that cause resistance to circulating vasoconstrictors such as angiotensin II and norepinephrine; 5) increased nitric oxide levels causing vasodilation. Blood pressureremains stable despite the increase in blood volume. BP is affected by maternal position Blood flowchanges during pregnancy: 1) Altered to include the uteroplacental unit. 2) About 50% more blood must circulate through the maternal kidneys to remove increased metabolic waste generated by the mother and fetus. 3) Skin requires increased circulation to dissipate heat generated by increased metabolism 4) Blood flow to the breasts is increased two to three times by the end of pregnancy 5) The weight of the expanding uterus on the inferior vena cava and iliac veins partially obstructs blood return from veins in the legs and blood pools in the deep and superficial veins in the legs. Blood componenetsincrease in erythrocytes (25-33%), leukocytes (12,000 to 25,000 cell/mm3), and clotting factors (Factor I: plasma fibrinogen; 50%) Factors II, VII, VIII, X and XII are also increased. Changes in the respiratory system: Oxygen consumptionincreases by 15-20% in pregnancy. Half is used by the fetus and placenta and the rest is consumed by the uterus, breast tissue, and increased maternal respiratory and cardiac demands. Hormonal factorsprogesterone is the major factor in the respiratory changes of pregnancy. Causes mild hyperventiiation and along with prostaglandins, it helps decrease airway resistance by relaxing smooth muscle in the respiratory tract. Estrogen causes increased vascularity of the mucous membranes of the upper respiratory tract.

Physical changesby the third trimester, the enlarging uterus lifts up the diaphragm by about 4 cm preventing the lungs from expanding as fully as they normally do. Changes in the gastrointestinal system: Appetiteoften increased during pregnancy unless the mother is nauseated. This helps to take in additional calories required. Mouthelevated levels of estrogen cause hyperemia of the tissues of the gums and mouth and may lead to gingivitis and bleeding gums. Esophaguslower esophagus sphincter tone decreases during pregnancy primarily because of the relaxant activity of progesterone on the smooth muscle. GERD can occur more easily Stomach and small intestineelevated levels of progesterone cause smooth muscle to relax and decrease tone and motility of the Gl tract. Large and small intestinethe small intestine may not empty durning pregnancy, which may allow additional time for nutrient to be absorbed. This slowed process benefits the growing fetus but may cause bloating and abdominal distention. Decreased motility may lead to constipation. Liver and gallbladderfunctional changes occur. The enlarging uterus pushes the liver upward and backward during the last trimester and liver function is also altered. Serum alkaline phosphatase rises two to four times the normal level and serum albumin level falls gradually. The gallbladder becomes hypotonic and emptying time is prolonged; bile becomes thicker and cholesterol crystal may be retained predisposing to the development of gallstones. Changes in urinary system: Bladderfrequency and urgency of urination. Uterus begins to exert pressure on the bladder as it enlarges and bladder capacity doubles by term. Kidneys and ureterskidneys change in size and shape because there is dilation of the renal pelves and calyces. The ureters also dilate above the pelvic brim. Functional changes of the kidneys due to increase in renal plasma flow or the total amount of plasma to flow through the kidneys. This change results from increase in plasma volume and cardiac output. GFR rises by as much as 50% by the end of the first trimester. Changes in the integumentary system: Skincirculation to the skin increases and encourages activity of the sweat and sebaceous glands. Hyperpigmentation increase in 90% of pregnant women as a result of increase progesterone and estrogen levels. Areas include brownish patches called chloasma, melasma. The linea alba, the line that marks the longitudinal division of the midline of the abdomen darkens to become linea nigra. Cutaneous vascular changes occur due to blood vessel dilation and proliferation during pregnancy. Angiomas (vascular spiders) occur on the face, neck upper chest and arms Connective tissuelinear tears occur on the abdomen, breast, and buttocks appearing as slightly depressed pink to purple streaks called striae gravidarum (stretch marks). Hair and nailsfewer follicles that are now in the resting phase so hair grows more rapidly and less hair falls out during pregnancy. Nail growth increases during pregnancy and nails thin and get soft as pregnancy progresses.

Changes in the musculoskeletal system: Calcium storagefetal demands for calcium increase especially in the third trimester. Absorption of calcium from the intestine doubles during pregnancy. Calcium is stored to meet the later needs of the fetus. Postural changeschanges are progressive. Loosening and widening of the symphysis pubis and the sacroiliac joint creates pelvic instability and may cause pain at the symphysis and inner thighs. During the last trimester the mother must lean backward to maintain balance. Abdominal wallabdominal muscles are stretched beyond their capacity during the 3rd trimester causing the rectus abdominus muscles to separate. Changes in the endocrine system: Pituitary glandprolactin increases to prepare the breast to produce milk. Oxytocin stimulates the milk ejection reflex after birth and stimulates contractions of the uterus. This action is inhibited during pregnancy by progesterone which relaxes smooth muscle fiber of the uterus. Thyroid glandrise in total thyroxine (T-4) occurs along with corresponding gain in thyroxine binding globulin. The basal metabolic rate increase up to 25% primarily because of the metabolic activity of the fetus. Parathyroid glandparathyroid hormone is slightly decreased or at a low normal level during pregnancy. Pancreassignificant changes due to the alterations in maternal blood glucose levels and consequent fluctuation in insulin production. Blood glucose levels during pregnancy are 10-20% lower and hypoglycemia may develop between meals and at night as the fetus continuously draws glucose from the mother. Adrenal glandssignificant changes occur in two adrenal hormones: cortisol and aldosterone. Level of both total cortisol and free cortisol. Cortisol regulates carbohydrate and protein metabolism and stimulates gluconeogenesis whenever the supply of glucose is inadequate to meet the body's need for energy. Aldosterone increases to maintain the necessary level of sodium in the greatly expanded blood volume and to meet the needs of the fetus. Placental hormones hCG is produced by trophoblastic cells surrounding the developing embryo. It is produced to prevent deterioration of the corpus luteum so that it can continue producing progesterone until the placenta is suffieciently developed to assume the function. Estrogenstimulates uterine growth, increases blood supply to the uterine vessels, increases uterine contractions near term, aids in the development of the glands and ductal system of the breasts for lactation, causes hyperpigmentation, vascular changes in the skin and increased activity of the salivary glands Progesteronemaintain the endometrial lining of the uterus for implantation, prevents spontaneous abortion by relaxing smooth muscle of the uterus, helps prevent tissue rejection of the fetus, stimulates development of lobes, lobules in the breast for lactation, facilitates the deposit of maternal fat stores which provide energy reserve. hPLincreases availability of glucose for the fetus. Relaxininhibits uterine contractions, softens connective tissue in the cervix and relaxes cartilage and connective tissue of the pelvic joints.

Metabolismweight gain should average 25-35 Ibs during pregnancy. The fetus, amniotic fluid, and placenta make up less than half the recommended gain. The rest is composed of uterus, breasts, increase blood volume, interstitial fluid and maternal fat stores. Changes in sensory organs: Eyecornea thickens because of edema. Intraocular pressure decreases requiring less medication in women with glaucoma Earschanges in the mucous membranes of the Eustachian tubes causing women to have blocked ears and a mild hearing loss that is temporary. Immune systemaltered to allow for the fetus which is a foreign tissue for the mother, to grow undisturbed without being rejected by the woman's body. Resistance to infection is decreased due to WBC functioning. c) Describe psychological changes which occur during pregnancy Psychological changes First Trimester Uncertaintytries to confirm pregnancy with physician, nurse mid-wife or LNP. Reactions to pregnancy depends on the individual Ambivalencehalf of all pregnancies are unintended and unexpected. Conflicting feelings about being pregnant because it may not be the right time, even if the pregnancy is planned and wanted. Some women wish they had completed a specific goal before becoming pregnant. "Self as a primary focusearly pregnancy comes with nausea, vomiting fatigue and the concept of the fetus seems vague. Second Trimester Physical evidencefetus is now considered "real". Fetal movement can be felt at this time. "Fetus" as primary focusbecomes the womans major focus and producing a healthy infant, disinterested in information about diet and fetal development. Narcissism and introversionworry about being able to protect and provide for the fetus. Selecting the right foods to eat, the right clothes to wear may assume more importance now. Loss of interest in jobs and more on events taking place inside them. Daydreams about what life will be like with the baby. Body imagesome find the changes welcomed because it signifies the fetus is growing and gives a sense of pride, while others find it negative and affect the self image. Sexualityunpredictable and may increase or decline. Physical comfort and sense of well being are closely linked to her interest in sexual activity. Some fear of miscarriage and may avoid sexual activity especially if a miscarriage has occurred before Third Trimester Vulnerabilitymay feel the baby will be lost or harmed if not protected at all times. Nightmares about losing the baby or having a deformed baby cause them to become very cautious. They avoid crowds, or potential physical dangers.

Increasing dependencedependence on the partner is significant and she may insist that he be easy to reach at all time and may call him several times a time just to be sure that is is available. They fear that something will happen to their partner. Preparation for birththe relationship between the fetus and the mother changes and she realizes that she and the fetus are interrelated, and the baby is a passive presence and not a part of herself. She longs to see the baby and get acquainted with him. They are often tired of being pregnant and want the pregnancy over. Some fear the process of childbirth (pain). Nesting takes place and negotiations with the partner or sharing care and household tasks (yeah, right!!) d) Describe each component of initial prenatal visit Primary objectives for the first prenatal visit are: Verify or rule out pregnancyblood test Evaluate the pregnant woman's physical health relevant to childbearinghealth history, menstrual history, contraceptive history, family history, psychosocial history, partners health history. Assess the growth and health of the fetusultrasound Establish baseline data for comparison to future observationsVS, urinalysis, blood sugar, weight Establish trust and rapport with the childbearing familyanswer questions, provide information, teach Evaluate the psychosocial needs of the woman and her family, childbirth classes, support groups for multipara pregnancy Assess the need for counseling and teaching Negotiate a plan of care to ensure both a healthy mother and a healthy baby.

e) Describe each component of return prenatal visits Usual schedule for return visits are : Conception to 28wks every 4 weeks 29-36 wksevery 2-3 weeks 37 wks to birthweekly Assessment focuses on the following; Vital Signs: BP, Respirations, temperature, pulse Urinalysis: detect presence of ketones, protein, glucose, and bacteria Fundal height: evaluates fetal growth and confirms gestational age Leopold's maneuver: Palpation of the fetus through the abdominal wall Fetal heart rate: Doppler transducer or with a fetoscope Fetal activity: kick count, indicates a physically healthy fetus Ultrasound screen: 12 -20 wks, determines gestational age and some fetal anomalies and sex. Glucose screen: 24-28wks Isoimmunization: 28wks for Rh factor... RhoGAM is given. Pelvic exam: determines cervical changes, descent of the fetus and presenting part f) Determine rationales and normal values for prenatal laboratory studies See Table 7-3 on page 134 of the text. g) Identify substances which have teratogenic effects

jMcohol Aminoglycosides Anticonvulsant agents

Antihyperlipidemic agents (statins) Antineoplastic agents

Antithyroid drugs

Cocaine Lithium /^Mercury

V.,

Diethylstibestrol (DES) Retinoic acid Tetracycline

Folic acid antagonist Tobacco Warfarin

Infections . CMV Herpes simplex virus HIV Rubella h) Explain the nurse's role in prenatal care i) Discuss teaching needs in pregnancy

Syphilis Toxoplasmosis Varicella

Teach necessary lifestyle changes to ensure the health of the mother and fetus (prescription, over the counter drugs, tobacco, alcohol, illegal drugs, alternate and complementary therapies (herbal therapy) j) Calculate obstetrical history using 3 & 5 digit systems

The method for calculating gravid and para is to separate pregnancies and their outcome using the acronym GTPAL: G=gravid T=term P=preterm A=abortions L=living children Each letter will correspond with a number (# of pregnancies, #abortions, # of living children etc.) with a minimum of 3 and a maximum of 5 numbers Example: Kathleen Eber gave birth to twins at 32 weeks gestation and to a stillborn infant at 24 weeks gestation. Approximately 2 years later, she experienced a spontaneous abortion at 12 weeks gestation. If pregnant now, she is gravida 4, para 2 (twins count as one parous experience and the stillborn counts as one parous experience). Using the GTPAL acronym, to refer to pregnancies delivered, T=0 (no term babies) P=2 (two pregnancies ending in pretermtwin 32wks, stillborn 24wks) A=1 (one spontaneous abortion) L=2 (two live birthstwins) GTPAL would be 4-0-2-1-2 k) Calculate EDO using Naegele's rule Take the date of the last menstrual cycle, add /days, subtract 3 months and add the following year. March 14, 2006 LNMP + 7 days f ) "March 21, 2006 Subtract 3 months December 21,2005 Add the following year = December 21, 2006 EDD

Objective 8 The student will analyze pregnancy needs a) Determine physiological and psychosocial and cultural needs

Physiological needs: A/auseaA/om/f/ngH-Reassurance that this is usually temporary and will not harm the fetus. Taking a multivitamin at the time of conception may decrease symptoms. Several antihistamines can be prescribed safely for more severe nausea. Nonpharmacological remedies like ginger may also be used for nausea. Heartburnavoid drinks high in phosphorous such as soft drinks Maintain a well balance diet. Avoid laying down after meals. Eat several small meals a day instead of one large meal. Use antacids that are low in sodium. Eliminate smoking and curtail intake of caffeine. Backacheavoid high heel shoes and wear comfortable shoes. Do not bend at the waist when picking up item; squat instead. Get regular exercise and maintain correct posture. A maternity back binder for use in pregnancy is helpful. Round ligament painTry a heating pad if pain persists. Avoid stretching and twisting at the same time. When getting out of bed, turn to the side and then get up slowly Urinary frequencyPerform kegel's often to maintain bladder control; 30 times a day if possible. VaricositiesApply support hose or elastic stockings that reach above the varicosities before getting out of bed each morning. Take frequent rest periods with the legs elevated above the level of the hips. HemorrhoidsTake frequent tepid baths. Drink plenty of water. External hemorrhoids can be pushed back into the rectum using a lubricated gloved index finger. Apply witch hazel or anesthetic ointments. ConstipationAdditional fiber is necessary in the diet. Restrict consumption of cheese. Drink at least 8 glasses of water each day (not tea, coffee, or carbonated drinks...these cause diuretic effect) Psvchosocial needs: First Trimester (period of maternal self-focus). Teaching should be aimed at the common early changes in pregnancy and their normality. Coping with morning sickness, sexuality and mood swings are important subjects to explore with the couple. It should be explained that these changes are normal and generally do not indicate problems. Second Trimester (the fetus is the primary focus) Ultrasound allows a visual confirmation of the fetus. Quickening, the feeling of fetal movement occurs during this time. This experience is important because it confirms the presence of the fetus with each movement. Teaching should be aimed at body image changes, diet and fetal development and changes in sexuality, Third Trimester (Preparation for the infant...nesting) Many couples complete childbirth classes at this time . Negotiation of changes in how she and her partner will share household task are among the plans. Teaching should be aimed supporting the womans fears of labor, and preparing for the delivery. Cultural: Culture often determines the health beliefs, values and expectations of the family when a woman becomes pregnant. A woman who does not normally follow certain beliefs of her culture may adhere to them (during pregnancy. Cultural differences that cause conflict between health care providers and families during pregnancy are observed most often in the area of health care beliefs, communication, and time orientation.

When health professionals violate cultural norms, women are less likely to follow health instructions and education given.

b) Discuss danger signs during pregnancy Vaginal bleeding Rupture of membranes Swelling of the fingers orpuffiness around the eyes Continuous pounding headache Visual disturbancesflashing light, spots before the eyes, blurred vision Perisistant or severe abdominal pain Chills or fever Painful urination Persistent vomiting Change in frequency or strength of fetal movements Signs ofpreterm laboruterine contractions, cramps, constant or irregular backache, pelvic pressure c) Develop nursing care for the antepartal woman

Discuss and practice self care measures taught to promote safety and health of the mother and fetus. Explain methods to help relieve common discomforts of pregnancy. Identify a plan early in pregnancy to modify habits that could adversely affect health, such as curtailing the use of alcohol and tobacco.

Objective 9 The student will evaluate pregnancy nutritional needs.

I

a) Identify special nutritional needs and b) Describe rationales for special nutritional needs Nutritional needs increase during pregnancy but the amount varies. Extra food needed to meet pregnancy requirements are: 1 carrot, 1 slice of whole wheat bread, 14 banana, and 1 glass of low-fat Energy (kcai): milk; second trimester. Add Yz banana in the third trimester. Rationale: kcals are obtained from carbs and proteins which provide 4 calories to each gram and fats which provide 9 calories to each gram. Extra calories are needed during pregnancy to provide maintenance of the fetus, placenta and added maternal tissue and increased basal metabolic rate. Protien: 1-2 oz. meat, fish, or poultry or 3 C. of milk, or3 oz. cheese, or 1C cottage cheese or 1 block(4oz) of tofu or 1C. brown rice and 1 1/4 C. beans Rationale: necessary for metabolism, tissue synthesis, and tissue repair during pregnancy. If calories are too low and protein is used for energy, fetal growth is impaired. Iron: 1oz red meat and 1C lima beans and Yz C spinach and 1C broccoli Rationale: needs for iron are increased during pregnancy. 200mg for normal daily losses, 300mg for transfer to fetus for production of RBC's and iron storage. If the transfer of iron to the fetus is inadequate due to decrease in maternal intake of iron, then the fetus will use the maternal stored iron. Thiamine: Yz C. bran flakes or % C. peanuts or 1 14 oz pecans or 1oz ham or 1 14 C rice or 1C macaroni Rationale: Needs to be increased because of intake of calories. They form coenzymes needed to release energy. Riboflavin:
3A

C. milk or cottage cheese or 2oz oatmeal or 1 14 oz beef or 1C broccoli or 1C spinach

Rationale: Needs to be increased because of greater intake of calories. Forms coenzymes necessary to release energy Niacin: 1T peanut butter or 4 slices of bread or 1oz meat; also made by body from tryptophan Rationale: Needs to be increased because of greater intake of calories. Forms coenzymes necessary to release energy. Vitamin C: 2tsp orange juice or 14 C peaches or Yz C apple or 1 14 T tomato juice

Rationale: Not stored in the body, therefore need to supplement. Necessary for the formation of fetal tissue. The need is increased in smoking, drug or alcohol abuse and aspirin use in mother. c) Describe nutritional status on the course and outcome of pregnancy

Age, knowledge about nutrition, exercise habits and cultural background influence the food choices women make and their nutritional status. Meeting nutritional requirements for pregnancy should focus on "energy needs, protein, calcium, iron, zinc, vitamin B12, vitamin A. Morning sickness is usually temporary and most women can consume enough food to maintain nutrition sufficiently. In addition to teaching dietary needs and changes, it is important to be alert to abnormal prepregnancy weight. Obese woman may have other health problems such as HTN that may affect the nurse's nutritional status. d) Describe fetal nutritional needs ???? not sure e) Analyze weight gain

Women should meet the RDA for pregnancy by eating the recommended number of servings of foods from each food group. She should gain 1.6kg during the first trimester and 0.4kg per/week during the second and third trimester. Total weight gain should be 11.5 to 16kg. Weight is assessed at the initial visit and subsequent visits. Other indication of nutritional status include any signs of deficiency (bleeding gums) Even though food intake may not be enough to allow for optimal health and storage of nutrients, most women obtain enough nutrients to avoid signs of deficiency. S/S include: pallor, low Hgb, fatigue, and increase susceptibility to infection. f) Describe common methods of nutritional assessment

Assessment begins with discussion of the woman's appetite; has it changed? Eating habits, food preferences, psychosocial influences (cultural or religious), diet history, physical assessment, laboratory tests. Reassessing nutritional status includes dietary status, any difficulty with the womans diet, check weight to see if it is in the expected range, evaluate Hgb and Hct level to check anemia. g) Discuss appropriate nutritional supplements Ironnot supplied completely and easily by diet during pregnancy. Approximately 1000mg of iron is needed during pregnancy, of this 500mg is used by the maternal RBC's, 200mg for daily losses, and SOOmg for transfer to the fetus for production of RBC's and iron storage. Folic acidnot obtained in adequate amounts through normal food intake. Especially important before conception and in the first trimester after conception. 400mcg (0.4mg) of folic acid is required daily before pregnancy and 600mcg (0.6mg) during pregnancy. Deficiency in the first trimester can lead to spontaneous abortion and neural tube defects. h) Develop nursing care to meet the nutritional needs of the pregnant patient

Identify problems with nutrition. Explain nutrient needs. Provide reinforcement for eating appropriately. Evaluate weight gain, encourage supplement intake, and make referrals to dietician or public assistant programs.