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Objective 18

The student will analyze antepartal complications a) b) c) d) e) Describe common antepartal complications Describe pathophysiology of each complication Describe multi-disciplinary management of the each complication Discuss medications used to treat the various complication Explain maternal and fetal risk associated with the complication

Hemorrhagic conditions: Early pregnancy 1. Abortionspontaneous abortion is a termination of pregnancy without action taken by the mother or another person. Most common cause is congenital abnormalities that are often incompatible with life. Management: Exam of the reproductive system to determine whether anatomic defects are the cause. If anatomically normal then referral to genetic screening is given. 2. Ectopic Pregnancyimplantation of a fertilized ovum in an area outside the uterine cavity. Aka "a disaster of reproduction" for two reasons: it remains a significant cause of maternal death from hemorrhage, it reduces the woman's chance of subsequent pregnancies because of extensive damage to fallopian tubes Management: Depending on whether the tube is intact or ruptured. May not be managed if tube is ruptured. The goal is to preserve the tube and improve the chance of future fertility. Surgical management of a tubal pregnancy that is unruptured may involve a linear salpingostomy to salvage the tube. When the tube is ruptured the management is to control the bleeding and prevent hypovolemic shock. 3. Gestational Trophoblastic Disease(aka hydatidiform mole) occurs when trophoblasts develop abnormally, as a result the placenta but not the fetal part of the pregnancy develops. Grapelike clusters of tissue rapidly fill the uterus to the size of an advanced pregnancy. Can be with no fetus present of with partial in which fetal tissue of membranes are present. Management: Two phases: 1) evacuation of the trophoblastic tissue of the mole. 2) continuous follup of the woman to detect malignant changes of any remaining trophoblastic tissues. Treatment for any other problems such as HEG or preeclampsia. Late pregnancy 1. Placenta PreviaImplantation of the placenta in the lower uterus. Resulting in the placenta being closer to the internal cervical os thatn the presenting part (usually the head) of the fetus. Can be Marginal; 3cm from the os, Partial: within 3cm of os, Total', completely covers the os. Only 10% of placenta previa in the second trimester remain a previa at term. Management: evaluated to determine the amount of hemorrhage and electronic fetal monitoring is initiated to evaluate the fetus. Conservative management may take place in the home or hospital. 2. Abruptio Placentaeseparation of a normally implanted placenta before the fetus is born. Occurs in cases of bleeding and formation of a hematoma on the maternal side of the placenta. As the clot expands, further separation occurs. Hemorrhage may be apparent or concealed.

Management: Hospitalized is incurred and evaluation is done. If the condition is mild and the fetus is immature and shows no signs of distress, conservative management may be initiated. Best rest, and administration of tocolytic meds to decrease uterine activity are given. Immediate delivery of the fetus is necessary if signs of fetal compromise exists or if the mother exhibits signs of excessive bleeding (obvious or concealed) Pathophysiology of Hemorrhagic Conditions: Abortionfetus is not viable and able to live outside the uterus. Usually < 20wks gestation or weighing < 500g is not viable. Mostly caused by congenital abnormalities that are incompatible with life. Can be chromosomal (50-60%) Gestational Trophoblastic Diseasetrophoblasts develop abnormally, as a result the placenta but not the fetal part of the pregnancy develops. Grapelike clusters of tissue rapidly fill the uterus to the size of an advanced pregnancy. Can be with no fetus present of with partial in which fetal tissue of membranes are present. Placenta Previaimplantation of the placenta in the lower uterus. Resulting in the placenta being closer to the internal cervical os than the presenting part (usually the head) of the fetus. Abruptio Placentaeseparation of a normally implanted placenta before the fetus is born. Occurs in cases of bleeding and formation of a hematoma on the maternal side of the placenta. As the clot expands, further separation occurs. Medications used in treatment: After abortion, Oxytocin, Methergine or Prostiglandis is given to stimulate uterine contractions. Risk to Mother and Fetus: following spontaneous abortion, maternal risk for DIG (consumptive coagulopathy), a life threatening defect in coagulation that may occur with several complications of pregnancy. Ectopic pregnancy is the #1 cause of maternal death from hemorrhage and reduces the chance of subsequent pregnancies. Persistent gestational trophoblastic disease may undergo malignant change and may metastasize to distant sites such as the lung, vagina, liver and brain. Placenta previa can cause fetal compromise if maternal bleeding is excessive, then delivery is mandatory regardless of gestational age of the fetus. Maternal hypovolemia can occur with preterm labor. Abruptio placentae causes hemorrhage and hypovolemic shock in the mother. Fetal vessels are disrupted as placental separation occurs resulting in fetal and maternal bleeding. Major dangers for the fetus are asphyxia, excessive blood loss and prematurity. Hyperemesis qravidarum: (HEG) Persistent, uncontrolled vomiting that begins before the twentieth week of pregnancy. May continue throughout pregnancy although its severity usually lessens. Unlike morning sickness which usually lessens and is self-limited and causes no complications, HEG can have serious consequences. Management: R/O other cause of N/V. Lab studies include determining the Hgb/Hct which may be elevated as a result of dehydration which results in hemoconcentration. Electrolyte studies may reveal reduced sodium, potassium and chloride. Elevated creatinine levels indicate renal dysfunction. Drug therapy may be required. Pathophysiology of Hyperemesis Gravidarum: Cause is unknown but the condition is common among unmarried white women during first pregnancies and in multifetal pregnancies. Some theories include possible allergy to fetal proteins. Some hormones that are elevated during pregnancy (estrogen and hCG) are considered a possible cause along with thyroid dysfunction and most recently association with HelioBacter Pylori.

C.

replacement is managed to avoid worsening the woman's reduced intravascular volume without giving her too much which could cause pulmonary edema or ascites. Labor induction is done if the gestation is at least 34 weeks. Pathophysiology of HELLP Syndrome: Hemolysis is thought to occur as a result of the fragmentation and distortion of erythrocytes during passage through small damaged blood vessels. Liver enzyme levels increase when hepatic blood flow is obstructed by fibrin deposits. Hyperbilirubinemia and jaundice amyoccur as a result of liver impairment. Low platelet levels are cause by vascular damage resulting from vasospasm; plateles aggregate at sites of damage, resulting in thrombocytompenia, which increases the risk for bleeding, usually in the liver. Medications used in treatment: magnesium sulfate to control seizures and hydralazine to control blood pressure. Risk to Mother and Fetus: Maternal risks are great, A sudden increase in intraabdominal pressure, including a seizure could lead to rupture of a subcapsular hematoma, resulting in internal bleeding and hypolovemic shock. Hepatic rupture can lead to fetal and maternal mortality Chronic Htn: whenever evidence suggests that htn preceded the pregnancy or when a woman is hypertensive before 20 weeks gestation. Management: a dietician should be consulted about approprieat dies and weight gain. Reduce salt intake. More frequent prenatal visits and monitoring of fetal kicking used to assess growth and development of fetus. Pathophysiology of Chronic Htn: Because the natural fall in blood pressure occurs during early prengnancy, the woman's blood pressure may appear normal when she enters prenatal care. Medications used in treatment: If diastolic pressure remains higher than lOOmmHg in early pregnancy, Aldomet (methyldopa) is the drug of choice. B-blockers and calcium channel blockers may also be used if Aldomet is not effective. Risk to Mother and Fetus: Maternal hazard is the development of preeclampsia which occurs in 20% of women with chronic Htn. Poor fetal growth patterns or signs that are nonreassuring such as falling amount of amniotic fluid compromise the fetus.

Rh Factor: incompatibility between maternal and fetal blood. Possible only when two specific circumstances co-exist: 1. The expectant mother is Rh-negative 2. The fetus is Rh-postive The Rh factor affects the fetus and causes no harm to the expectant mother. Management: blood test done on initial prenatal visit to determine blood type and Rh factor. Coombs test is done in Rh neg women to determine whether they are sensitized (developed antibodies) as a result of previous exposure to Rh-pos. blood. RhoGAM is given at 28 weeks to prevent sensitization and then abain within 72hrs after delivery. Amniocentesis may be performed to determine the Rh factor of the fetus or to evaluat change in the optical density of amniotic fluid. Pathophysiology of Rh Factor. Rh incompatibility can occur if the Rh-neg woman conceives a child who is Rh-positive. As a result of exposure to the Rh-postitive antigen, maternal antibodies may develp that cause 5hemolysis of fetal Rh-positive red blood cells in subsequent pregnancies.

Medications used in treatment: RhoGAM (Rh (D) immunoglobulin) injection is given to the mother at 28 weeks gestation and within 72 hrs after birth.
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Risk to Mother and Fetus: If antibodies to the Rh factor are present in the expectant mother's blood, they cross the placenta and destroys fetal erythrocytes. The fetus becomes deficient in RBC's which are needed to transport oxygen to fetal tissue. As fetal RBC's are destroyed, fetal bilirubin levels increase which can lead to neurologic disease. This hemolytic process results in rapid production of erythroblasts which cannot carry oxygen. This syndrome is known as erythroblastosis fetalis. The fetus can become so anemic that generalized fetal edema results and can end in fetal congestive heart failure.

ABO incompatibility: occurs when the mothers blood type is O and the fetus is blood type A, B or AB. These types contain a protein component (antigen) that is not present in type O blood. Management: No specific prenatal care is needed. During delivery the cord blood is taken to determine the blood type of the newborn and the antibody liter. Pathophysiology of ABO incompatibility: ABO incompatibility usually occurs when the mother has type O blood and naturally occurring anti-A and anti-B antibodies, which cause hemolysis if the fetus's blood is not type O. ABO incompatibility may result in hyperbilirubinemia of the infant, but usually presents no serious threat to the health of the child. Risk to Mother and Fetus: ABO incompatibility may result in hyperbilirubinemia of the infant, but it usually presents no serious threat to the health of the child.

f)

Develop nursing care to meet the needs of the antepartal patient who is experiencing: An adolescent pregnancy, diabetes mellitus, hyperemesis gravidarum, domestic violence, substance abuse, RH incompatibility, and infection

Care plan for Preeclampsia is on pg. 650-651 of the text. Care plan for Antepartum bleeding is on pag. 637-638 of the text.

Objective 19 The student will analyze pregnancy induced hypertension

a) List characteristics

Increased blood pressure; systolic increase of SOmmHg, diastolic increase of 15mmHg over the baseline pressure for the individual woman on two assessments at least 6-hr apart. Occurs mostly in the last trimester Proteinuria Edema b) Define classifications of hypertension during pregnancy Preeclampsiasystolic BP >= 140mmHg or diastolic BP >= QOmmHg that develops after 20wks gestation and is accompanine by proteinuria >0.3g ub a 24 hr urine collection (random urine dipstick is usually >=1+) EcclampsiaProgression of preeclampsia to generalized seizures that cannot be attributed to other causes. Gestational hypertensionSystolic BP >=140mmHg or diastolic BP >=90mmHg that develops after 20 wks gestation but without significant proteinuria (neg or trace on a random urine dipstick) Chronic HypertensionSystolic BP >=140mmHg or diastolic BP >=90mmHg that was known to exist before pregnancy or develops before 20 wks gestation. Also diagnosed if the hypertension does not resolve during the postpartum period.

Preeclampsia superimposed on chronic hypertensionDevelopment of new-onset proteinuria >0.3g in a 24hr collection in a woman who has chronic hypertension. I a woman who had proteinuria before 20wks, preeclampsia should be suspected if the woman has a sudden increase in proteinuria from her baseline levels, a sudden increase in BP when it had been previously well controlled, development of thrombocytopenia (platelets < 100,000/mm3) or abnormal elevations of liver enzymes (AST or ALT). c) Explain pathophysiology In normal pregnancy vascular volume and cardiac output increase significantly. Despite these increase, blood pressure does not rise in normal pregnancy. This is probably because pregnant women develop resistance to the effects of vasoconstrictors such as angiotensin II. Peripheral vascular resistance decreases because of the effects of certain vasodilators such as Prostacyclin and endothelium derived relaxing factors (EDRF). In preeclampsia, however, peripheral vascular resistance increases because some women are sensitive to angiotensin II. They also may have a decrease in vasodilators. Vasospasm decrease the diameter of blood vessels which results in endothelial cell damage and decreased EDRF. Vasocontriction also results in impeded blood flow and elevated BP. As a result, circulation to all body organs including kidneys, liver, brain and placenta is decreased. d) Determine genetic risk factors Family history of PIH, Mother or sister who had preeclampsia Expectant father previously fathered a pregnancy in another woman who had the disorder e) Discuss maternal and fetal risks Major cause of prenatal death and is often associated with intrauterine fetal growth restriction (IUGR), persistent hypoxemia and acidosis when maternal blood flow through the placenta is reduced.

Pulmonary edema, circulatory or renal failure and incracranial hemorrhage are additional risks associated with preeclampsia or eclampsia. Aspiration may cause maternal morbidity after an eclamptic seizure. f) Describe multi-disciplinary management Preeclampsia can progress to eclampsia very quickly. The only cure is to deliver the baby. However, the decision is based on gestational age and the severity of the hypertensive disorder. If the fetus is <34 wks, steroids to accelerate fetal lung maturity will be given and an attempt made to delay birth for 48hrs. If maternal or fetal condition deteriorates, the infant will be delivered regardless of gestational age or administration of steroids. If preeclampsia is mild then activity restrictions and bed rest with 1 1/2 hours of lateral positioning a day. Blood pressure is monitored 2-4 X a day and weight should be taken daily at the same time each day. Urinalysis is tested for protein using a urine dipstick and the first voided midstream specimen daily. Fetal assessment is done via "kick counts". Diet should have ample protein and calories with restriction of sodium. If preeclampsia is severe, delivery is necessary even if gestational age is <34 weeks. A decrease in amniotic fluid is considered significant because is suggests reduced placental blood flow even if the BP is not high. Management during antepartum is to improve placental blood flow and fetal oxygenation and to prevent seizure and other maternal complications such as stroke. g) Explain pharmacological agents used in treatment Anti-hypertensive medication is given if the systolic BP is >= 160mmHg or diastolic BP is >=110mmHg. Hydralazine (Apresoline) is often used because of it's safety. Relaxes arterial smooth muscle to reduce blood pressure. Niphedipine B-blocker Calcium channel blockers Care is given with administering anti-hypertensive meds for the woman on magnesium sulfate to avoid hypotension. Anti-convulsants are given to prevent seizures. Magnesium Sulfate most commonly given Dilantin Diphenylan h) Develop nursing care for the patient who has PIH or preexisting hypertension Care plan for patient with PIH on pg 650-651 in the text.

Objective 20 The student will analyze pregnancy hemorrhagic conditions a) Describe common hemorrhagic conditions during early pregnancy d) describe multi-disciplinary management for each condition Hemorrhagic conditions: Early pregnancy 1. Abortionspontaneous abortion is a termination of pregnancy without action taken by the mother or another person. Most common cause is congenital abnormalities that are often incompatible with life. Management: Exam of the reproductive system to determine whether anatomic defects are the cause. If anatomically normal then referral to genetic screening is given. 2. Ectopic Pregnancyimplantation of a fertilized ovum in an area outside the uterine cavity. Aka "a disaster of reproduction" for two reasons: it remains a significant cause of maternal death from hemorrhage, it reduces the woman's chance of subsequent pregnancies because of extensive damage to fallopian tubes Management: Depending on whether the tube is intact or ruptured. May not be managed if tube is ruptured. The goal is to preserve the tube and improve the chance of future fertility. Surgical management of a tubal pregnancy that is unruptured may involve a linear salpingostomy to salvage the tube. When the tube is ruptured the management is to control the bleeding and prevent hypovolemic shock. 3. Gestational Trophoblastic Disease(aka hydatidiform mole) occurs when trophoblasts develop abnormally, as a result the placenta but not the fetal part of the pregnancy develops. Grapelike clusters of tissue rapidly fill the uterus to the size of an advanced pregnancy. Can be with no fetus present of with partial in which fetal tissue of membranes are present. Management: Two phases: 1) evacuation of the trophoblastic tissue of the mole. 2) continuous follup of the woman to detect malignant changes of any remaining trophoblastic tissues. Treatment for any other problems such as HEG or preeclampsia. b) Describe common hemorrhagic conditions during late pregnancy Late pregnancy 1. Placenta PreviaImplantation of the placenta in the lower uterus. Resulting in the placenta being closer to the internal cervical os thatn the presenting part (usually the head) of the fetus. Can be Marginal; 3cm from the os, Partial] within 3cm of os, Total] completely covers the os. Only 10% of placenta previa in the second trimester remain a previa at term. Management: evaluated to determine the amount of hemorrhage and electronic fetal monitoring is initiated to evaluate the fetus. Conservative management may take place in the home or hospital. 2. Abruptio Placentaeseparation of a normally implanted placenta before the fetus is born. Occurs in cases of bleeding and formation of a hematoma on the maternal side of the placenta. As the clot expands, further separation occurs. Hemorrhage may be apparent or concealed.

Management: Hospitalized is incurred arid evaluation is done. If the condition is mild and the fetus is immature and shows no signs of distress, conservative management may be initiated. Best rest, and administration of tocolytic meds to decrease uterine activity are given. Immediate delivery of the fetus is necessary if signs of fetal compromise exists or if the mother exhibits signs of excessive bleeding (obvious or concealed) c) Determine signs and symptoms for each condition Signs and symptoms are: AbortionVaginal bleeding followed by rhythmic uterine cramping, persistent backache, or feelings of pelvic pressure. Symptoms increase the chance that the threatened abortion will progress to inevitable abortion. Ectopic PregnancyMissed menstrual period, abdominal pain, vaginal spotting. If implantation occurs, early signs of pregnancy will be noted. Several weeks into the pregnancy, intermittent abdominal pain and small amounts of vaginal bleeding occur that initially are mistaken for threatened abortion. Gestational Trophoblastic DiseaseElevated hCG Absence of fetal sac or fetal heart activity Uterus is larger than one would expect based on duration of pregnancy Vaginal bleeding varying from dk brown spotting to profuse hemorrhage Excessive N/V Early development of preeclampsia Placenta Previasudden onset of painless uterine bleeding in the last half of pregnancy. May be scanty or profuse and may cease spontaneously and then reappear later. Abruptio PlacentaeBleeding vaginally or concealed behind the placenta Uterine irritability with frequent low intensity contractions Abdominal or low back pain described as dull or aching High uterine resting tone identified with use of an intrauterine pressure catheter Signs of concealed hemorrhage in Abrupto Placentae Increase fundal height Hard, boardlike abdomen High uterine baseline tone on electronic monitoring strip when intrauterine pressure catheter is used Persistent abdominal pain Systemic signs of early hemorrhage (tachycardia in mother and fetus), tachypnea, falling BP, falling urine output, restlessness Persistent late deceleration in fetal heart rate or decreasing baseline variability; absence of accelerations Slight or absent vaginal bleeding e) Develop nursing care for the woman who has a hemorrhagic condition Nursing care plans on pg 637-638 in the text.

Objective 21 The student will explain newborn complications

a) Identify newborns who are at risk Preterm infantsborn before the beginning of the 38th week of gestation Postterm infantsborn after 42 weeks gestation LGA infants (large-for-gestational age)infant whose size is above the 90th percentile for gestational age SGA infants (small-for-gestational age)infant whose size is below the 10th percentile for gestational age Low birth weight infantsweighing less than 2500g (5lb, 8oz.) at birth Extremely low birth weight infantsweighing 1000g (2lb, 3oz.) or less at birth Drug exposed infantsmaternal drug abuse/use/exposure b) Identify the newborn problems associated with pre-term and post-term birth Problems associated with Preterm birth: Respiration: The presence of surfactant in adequate amounts is of primary importance. Surfactant reduces surface tension in the alveoli and prevents their collapse with expiration. Infants born before surfactant production is adequate develop respiratory distress syndrome. Also have premature cough reflex and narrow respiratory passages which increase respiratory difficulties. Thermoregulation: Skin is thin with blood vessels near the surface and little sub-Q white fat is present to serve as insulation. Heat loss is rapid. Fluid & Electrolyte balance: Because their skin has little protective sub-Q white fat and a greater water content it is more permeable than the skin of term infants. The large surface area in proportion to body weight and last of flexion further increase transepidermal water loss. Radiant warmers heighten insensible water losses enough to result in a 40-50% increase in fluid needs. Also fluid is lost through respiratory and Gl tracts....rapid resp. and use of oxygen can increase fluid loss from the lungs....runny loose stools will lead to rapid dehydration. Development of the kidneys is not complete and the ability of the kidneys to concentrate or dilute urine is poor causing a fragile balance between dehydration and overhydration, Fluid Needs ofpreterm infants: range from 80-120ml/kg on the first day to 90-140ml/kg/day on the second and third days of life and may reach to 100-175ml/kg/day by the end of the first week. Skin: Fragile, permeable and easily damaged skin. Alcohol, iodine, and other preparations used to disinfect the skin before invasive procedures can be damaging to fragile skin and may be absorbed. Infection: 3-10 times greater than that in full term newborns. Several risk factors for infection are: Maternal infection caused by labor to begin prematurely and expose the infant to the same infection May not have received adequate passive immunity of IgG from mother during the 3rd trimester Preterm immune response to infection is less mature than full term infants. Fragile skin easily damages causing opportunity infections. Prolonged stay in the hospital can expose them to nosocomial infections Pain: NICU infants undergo many painful procedures and treatments (intubation, heel sticks, chest tubes, venipuncture every day). Pain may be greater and last longer.

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Common Complications of preterm birth: RDS (respiratory distress syndrome): caused by insuffiecient surfactant production in the lungs Results in atelectasis, hypoxemia, hypercapnia

BPD (bronchopulmonary dysplasia): Chronic pulmonary condition in which damage to the infant's lungs requires prolonged dependence on supplemental oxygen. ROP (retinopathy of prematurity): Condition in which damage to blood vessels often associated with oxygen use may cause decreased vision or blindness. NEC (necrotizing enterocolitis): Serious inflammatory condition of the intestines.

Problems associated with Postterm birth: Hvpoglvcemia: Due to rapid use of glycogen stores. Asphyxia: Due to loss of amniotic fluid causing cord compression and decreased oxygen and nutrients Thermoregulation: Poor temperature regulation due to fat store were used for nourishment in utero. Hyperbiliruinemia: Resulting from polycythemia secondary to hypoxia. c) Discuss newborn complications related to small for gestational age, large for gestational age, cold stress, respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, hyperbilirubinemia, infants of a diabetic mother, trauma, drug addiction, and neonatal sepsis. Complications from: SGA (small-for-gestational age): intrauterine growth retardation. Complications and severity depend on the cause and degree of growth restriction. Infants are more prone to meconium aspiration, polycythemia, and hypoglycemia, and inadequate thermoregulation. LGA (large-for-gestational age): due to the large size of the fetus, they are more likely to be injured during birth. Shoulder dislocations, fractures to the clavicle or skull, damage to the brachial plexus or facial and phrenic nerves can be damaged. Cephalhematomas and bruising occur more often in these infants. Congenital heart defects and higher mortality rate is more common. Cold stress: hypoglycemia and respiratory problems. This limits the glucose and oxygen available to increase metabolism as a method of heat production. Vasocontriction which occurs when body temp drops, may lead to metabolic acidosis, pulmonary vasoconstriction, and interfere with production of surfactant and more respiratory difficulties. Respiratory distress syndrome: Insufficient production of surfactant in the lungs results in atelectasis, hypoxemia and hypercapnia. Transient tachypnea: Rapid respiration caused by inadequate absorption of fetal lung fluid. Resolves within a few days. Mild immaturity of surfactant production may also be the cause. Meconium aspiration syndrome: Most often occurs in preterm infants who have decreased amniotic fluid and are prone to cord compression. It can lead to persistent pulmonary hypertension of the newborn. Hyperbilirubinemia: Pathologic jaundice; can lead to kernicterus which is a condition where bilirubin deposits cause yellowish staining of the brain especially the basal ganglia, cerebellum and hippocampus. Can result in acutre bilirubin encephalopathy, which may be reversible in early stages but can progress to bilirubin induced neurologic dysfunction and cause permanent damage to the brain.

Infants of diabetic mother: Depending on the type of diabetes and how well it is controlled in the mother. Cardiac, urinary tract, and Gl anomiaies, neural tube defects, and caudal regression syndrome are most frequent. Incidence of anomalies is less if glucose levels remain within normal limits, especially before conception an in the early weeks of gestation. Infants may be SGA because of decrease in placental blood flow causing intrauterine growth retardation. IDM may have a greater risk of asphyxia and RDS dues to increased levels of insulin interfering with surfactant production. Other risks are hypocalcemia, Low mag levels, and polychythemia. IDM are more likely to be born premature and admitted to the NICU. Trauma: Usually occurring in LGA due to abnormal size of fetus. Shoulder dislocations, fractures to the clavicle or skull, damage to the brachiai plexus or facial and phrenic nerves can be damaged. Cephalhematomas and bruising occur more often in these infants. Drug addiction: abuse during the first 2 months of pregnancy may cause congenital anomalies. Later abuse interfere with development of functioning of organs already formed. Effects depend on the substance abused: Tobacco: carbon monoxide inactivates fetal and maternal Hgb. Reduce the amounts of oxygen delivered to the fetus. IUGR, and Low birth weight and premature infants. Alcohol: Results in FAS (fetal alcohol syndrome) which is the leading cause of preventable mental retardation. Low birth weight and developmental delay and hyperactivity may not be obvious until 1-2 years Marijuana: Infant may exhibit hyperirritability, tremors, sleep disruption, and unusual sensitivity to light. Long term effects are unclear.

Cocaine: low birth weight, tremors, tachycardia, marked irritability, muscular rigidity, hypertension and exaggerated startle reflex. They are often poor feeders and have frequent diarrhea. Increased risk for SIDS. Methamphetamines: decreased weight and length at birth, Abnormal sleep patterns, agitation, diaphoresis, and vomiting associated with withdrawal. Opiods: Intermittent episodes of hypoxia in utero which increases the risk of prematurity and growth restriction, spontaneous abortion and stillbirth. May have meconium aspiration. They exhibit withdrawal syndrome which affects all body systems. Mostly visible signs are neurologic and Gl. Neonatal sepsis: Systemic infection from bacteria in the bloodstream. Preterm infants have fewer antibodies and are unable to localize infection as well as older children. Most common causes are Strep and E Coli. Candida albicans are the most common causes of nosocomial infection in low birth weight infants in the hospital. d) Discuss the impact on the family of having a newborn with complications Infants are often hurried to the NICU shortly after birth and parents cannot see them initially. Later when the parents see the infant attached to an array of machines, they have difficulty developing feeling of attachment to a tiny baby who looks so different from what they expected.

When the infant's appearance and behavior are different from the parents expectations, attachment may be Mdelayed. Interference in the attachment process increases vulnerability for parents inestablishing a nurturing *' relationship with the infant.

Extended hospitaiization produces emotional trauma, and disrupts family life. Loss of the parental role is a major stressor for the parents. In addition, parents worry about the infant's condition and outcome.

e) Develop nursing care for the newborn with various types of complications Nursing care plans for the preterm infant on pg 780-781 of the text. Nursing care plan for the infant with jaundice on pg 809-810 of the text Nursing care plan for the drug exposed infant pg 819-820 of the text

Objective 22 The student will analyze women's health promotion a) Indentify common health promotion teaching needs Prevention is better than a cure and early diagnosis allows early treatment Breast self-exams and clinical exams Vulvar self exam Regular pap test Recognizing CAD Managing PMS S/S of Menopause Osteoporosis Sexually transmitted diseases. b) Discuss health promotion practices to include breast exam, mammography, pap smears, vulvar examination, pelvic examination. Breast exam: CBE (clinical breast exam) should be routinely preformed every 3 years for women ages 20-39 and yearly for those 40 years and older. Self exams supplement rather than replace CBE, but most women detect breast cancer themselves so self exam is the only realistic means of early cancer detection. Mammography: Used either to screen for cancer or to assist in the diagnosis of a palpable mass in the breast. Can detect breast lumps well before they are large enough to be palpated. Pap smears: Changes occur in the cells of the cervix before cervical cancer develops. Cervical cytology or the pap test is the most useful procedure for detecting precancerous and cancerous cells that may be shed by the cervix. Regular pap tests can increase survival for women who develop cervical cancer by identifying it when it is most treatable. Because HPV has been shown to contribute to cervical cancer, testing for this virus is often done during a pelvic exam. Vulvar exam: Vulvar self exam should be performed monthly by all women 18 and older and by those younger than 18 who are sexually active. It is a visual inspection and palpation of the female external genitalia to detect signs of precancerous conditions or infections. Pelvic Exam: complete gynecologic assessment. External organs are inspected for the degree of development or atrophy of the labia, distribution of hair, and character of the hymen. Internal inspection via a speculum is done to inspect the vagina and cervix. Bimanual exam provides information about the uterus, fallopian tubes and ovaries. c) Discuss the processes involved in the onset of menopause The entire process often called "change of life' is correctly termed climacteric. Premenopause refers to the early part of the climacteric, before menstruation ceases but after the woman experiences some of the climacteric symptoms such as irregular menses. Perimenopause includes premenopause, menopause and at least 1 yr after menopause. Post menopause refers to the phase after menopause when menstrual periods have ceased. The average age for natural menopause is 51.5 yrs. Climacteric takes place over 3-5 years. d) Develop nursing care for the woman who is experiencing peri-menopause/menopause Send them on a long vacation....ALONE!!!

Objective 23 The student will analyze common disorders affecting women a) b) c) d) e) Identify risk factors for each disorder Identify genetic risk factors for each disorder Describe pathophysiology of each disorder Describe multidisciplinary management of each disorder Discuss medication used in the treatment of various disorders

Rish Factors: Menstrual cycle disorders: 4 major disorders Amenorrheaabsence of menses. May be genetic (ovarian failure). May occur is girls with Turners syndrome, lower body weight for height, abnormalities of the uterus, vagina, or hymen and congenital enzyme abnormalities. Abnormal uterine bleedingprevious spontaneous abortion, anatomic lesions, either benign or malignant of the uterus, cervix or vagina, systemic disorders such as diabetes, uterine myomas (fibroids), and hypothyroidism, failure to ovulate. Cyclic pelvic painwomen who have pain midway between menstrual periods at the time of ovulation, edometriosis in women in their 30's and nuliparous and may have had fertility problems. PMSwomen who have had medical or psychiatric disorders are more at risk, but pms can affect 10% of all menstruating women. Genetic Risk Factors: Mothers with ovarian failure or congenital enzyme abnormalities. Systemic disorders (fibroid, diabetes, hyperthyroidism) can lead to genetic risk associated with the dysfunction. Pathophysiology: Menstrual cycle disorders are symptoms not a diagnosis. Dysfunctional uterine bleeding is bleeding that occurs with abnormal frequency and lasts an abnormal amount of time, occurs irregularly and is excessive in amount. Usually secondary to underlying systemic disorders. Cyclic pelvic pain is spasmodic and colicky in nature because of the increased prostaglandins secreted at this time. Can be symptoms associated with endometriosis. PMS causes physical and emotional changed during menstrual cycle and although the cause is unknown, several theories of PMS is that normal fluctuation in gonadal hormones during a cycle, mainly estrogen, progesterone and serotonin levels fall during the luteal phase. Management and Medications used: PMSrelaxation therapy, exercise, reduce salty foods, caffeine, chocolate, red meat, dairy products, and alcohol. Small and frequent meals may reduce mood swings. Supplemental calcium has some effect with magnesium. Garbs rich food and beverage may improve the mood and reduce food cravings. Women with emotional, cognitive and physical symptoms may be prescribed antidepressant meds, oral contraceptives to suppress ovulation or both. To help with PMS associated migraines, estrogen therapy may be given. Antianxiety, SSRI, TCA have all been shown to have benefits for PMS. For dysfunctional uterine bleeding, hormone treatment progesterone and estrogen oral contraceptives that suppress ovulation allow more stable endometrial lining to form. Surgical therapy may include dilation and curettage (D&C) to remove fibroid polyps and treated with progesterone to suppress excess uterine lining. For cyclic pelvic pain associated with endometriosis, treatment may be either medical or surgical. Continuous oral contraceptives suppress endometrial tissue proliferation. Progestins such as Depo-Provera or Micronor are given to directly inhibit growth of excessive endometrial tissue. Surgical treatment is performed as iaparoscopy for lysis of adhesions and lasor vaporization of lesions of endometriosis. For women with severe

pain who no longer want to have children, a hysterectomy and/or bilateral salpingo-oophorectomy to remove both fallopian tubes and ovaries, and excision of all lesions offer relief. Risk Factors: Benign disorders of the breast: Fibrocystic Breast Changes (Fibroadenoma, Ductal Ectasia, Intraductal Papilloma)Hyperplastic lesions with atypical cellular changes have an increase risk to become malingnant, but most women with fibrocystic breast changes do not have a greater risk for breast cancer. Genetic Risk Factors: In atypical hyperplasia in the lesion, these patients also have a history of breast cancer and their risk for developing cancer is greater. Pathophysiology: Changes are thought to be heightened responsiveness of breast parachyma and stroma to circulating estrogen and progesterone. Pain is produced by nerve irritation from connective tissue edema and fibrosis from nerve pinching. Management and Medications used: Avoiding caffeine, and other stimulants reduces methylxanthines that may increase discomfort during the last half of the menstrual cycle. Limiting salt intake in diet can decrease edema. In treating Intraductal Papilloma, the mass and ductal area is excised. In Fibroadenoma, the mass may be excised and a sample analyze to R/O malignancy. Risk Factors: Cardiovascular disease: (M = modifiable) (U= unmodifiable) Cigarette smoking (M) Hypertension (including isolated systolic hypertension) (U) Serum lipids: Elevated total cholesterol >=240 mg/dl (M) HDL <35 mg/dl Cholesterol ratio: ratio should be <5 and optimum of 3.5:1. Triglyceride level >150 mg/dl (M) Diabetes Mellitus (U) Overweight and obesity (M) Sedentary lifestyle (modifiable) (M) Poor nutrition (high in saturated fats and cholesterol and low in fiber and fruit) (M) Age >60 (U) Postmenopausal status (U) Family history of CAD (U)

Genetic Risk Factors: Diabetes Mellitus, CAD, family history of high cholesterol, hypertension, and obesity. Pathophysiology: Atherosclerosis is the major cause of CAD. Characterized by a focal deposit of cholesterol and lipids primarily within the arterial intimal wall. Plaque formation is the result of compex interactions between components of the blood and the elements forming the vascular wall. Inflammation and endothelial injury play a central role in the development of atherosclerosis Management and Medications used: Prevention is the key to reducing death and illness from all cardiovascular diseases in women. Lowering hypertension through medication and diet (DASH diet plan). The medications used to treat hypertension are diuretics, Adrenergic inhibitors (SNS), direct vasodilators, angiotensin inhibitors, and calcium channel blockers. Periodic monitoring of BP, smoking cessation, diet and glucose control, exercise and low dose aspirin therapy (81 mg/day) is used to treat and manage CAD.

Risk Factors: Pelvic floor dysfunction: (Vaginal wall prolapsed, Uterine prolapsed) /" Traumatic vaginal deliveries, many vaginal deliveries, and large infants delivered at birth contribute to the risk N^-- of Uterine prolapsed. Vaginal wall prolapsed is a risk for women with weakened upper anterior wall of the vagina and is unable to support the weight of urine in the bladder. Genetic Risk Factors: None found Management and Medications used: Treaments of disorders related to pelvic floor dysfunction depends on the womans age, physical condition, sexual activity and degree of prolapsed. Surgical procedure provide the most satisfactory therapy for women with significant discomfort. Most common is the anterior and posterior colporrhaphy. Involves suturing the pubocervical fascia to support the bladder and urethra when a cystocele exists. If a retrocele exists, then a posterior colporrhaphy is done which is suturing the fascia and perineal muscles that support the rectum and perineum. A vaginal hysterectomy is the most common surgery to correct vaginal wall prolapse. If surgery is contraindicated a pessary (device to support the pelvic structure) is inserted into the vagina. Pelvic exercise (Keegels) can be used to strengthen the pubococcygeal muscle. Some drugs used for overactive bladders and used to enhance bladder control are: Vaginal estrogen cream, tablet, vaginal ring to reduce atrophy of the urinary and vaginal areas, Anticholenergic drugs such as oxybutynin or tolterodine. Risk Factors: Disorders of the reproductive tract: (Cervical polyps, Uterine leiomyomas, Ovarian cysts) Estrogen dependent so they grow rapidly during childbearing years and shrink during menopause. Genetic Risk Factors: None found Pathophysiology: Cervical polyps are caused by the proliferation of cervical mucosa. Uterine leiomyomas develop from smooth muscle cells that are completely dependent are estrogen and grow rapidly when estrogen is abundant. Ovarian cysts (follicular or luteal) develop when the corpus luteum becomes cystic and fails to regress. Mangement and Medication used: Treatment for uterine leiomyomas include progesterone only or combination progesterone-estrogen oral contraceptives to reduce excess menstrual flow. Short course of GnRH agonists (gonadotropin releasing hormone) may be effective in reducing the size of myomas and less the need for surgical removal. Cervical polyps are surgically removed outpatient. Ovarian cysts are removed laproscopically from the ovary and examined by a pathologist. Risk Factors: Infectious disorders of the reproductive tract: (Candidiasis, Sexually transmitted diseases) Sexually active women (teens, young adults) Multiple partners Pregnancy (candidiasis) Diabetes mellitus (candidiasis) Oral contraceptive use Prolonged systemic antibiotic therapy (candidasis) Use of diaphragms, cervical caps, and spermicidal foams and jellies for contraception Inadequate knowledge and education regarding transmission and prevention of STD. ^Genetic Risk Factors: 'None found

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Pathophysiology: Changes in Vaginal pH and flora that favor accelerated growth of C. Albicans (Candidasis), a yeastlike fungus commonly found in the Gl tract and on the skin. Trichomoniasis is an anaerobic protozoon that thrives in an alkaline environment such as the vagina. Bacterial vaginosis (vaginitis) causes bacterial proliferation in the vagina by replacing normal lactobacilli with Gardnerella vaginalis. Chlamydial infection is caused by the gram negative bacterium C. trachomatis. Gonorrhea is an infection of the genitourinary tract by the gonococcus Neisseria Gonorrhoeae. Syphillis, caused by the spirochete Treponema pallidum is divided into primary, secondary and tertiary stages. First sign is a painless chancre that develops on the genitalia, anus, lips or oral cavity. Although the chancre disappears the spirochete lives and is carried by the blood to all parts of the body. After about 2 months infected people exhibit symptoms of secondary syphilis; enlargement of the spleen, liver, headache, anorexia and maculopapuiar skin rash. Skin eruptions may develop on the vulva during this time. If untreated the disease enters the latent stage that may last several years. Tertiary syphilis which follows mayinvolve the heart, blood vessels and CNS. General paralysis and psychosis results. Condylomata acuminata (aka: veneral or genital warts) are caused by the HPV and closely associated with cervical cancer. HPV can not be eradicated and may cause frequent reoccurrences. AIDS (HIV) is a ribonucleic acid (RNA) virus that replicates in a backward manner going from RNA to DNA. HIV infects human cells that have CD4 receptors on their surfaces (lymphocytes, monocytes/macrophages, astrocytes and oligodenrocytes). Caused by predominant destruction of CD4 Tcells (T-helper or CD4 lymphocytes) Leads to opportunistic diseases. Management and Medications used: CandidiasisMeds available W/O prescription include butoconazole, miconazole, clotrimazole, nystatin, terconazole, tioconazole by vaginal application. Patients with severe candidaisis can be given oral meds including Fluconazole. TrichomoniasisMeds given are Flagl, Protostat in oral dose for 7days. Women should be advised to avoid using alcohol during treatment with metronidazole until therapy is complete. Sexual partners should refrain from intercourse until a cure is established. Condoms should be used with new partners. Metronidazole is the durg of choice. Clindamycin is an alternative treatment. The woman should refrain from sexual activity until cured or her partner should use a condom.

C Bacterial vaginosistreatment geared toward reestablishing the balance of flora in the vagina.

Chlamydial InfectionTreatment is usually directed to eradicate both Chlamydia and gonorrhea because the two often coexist. Meds given include Zithromax, doxycyline, clindamycin, ofloxacin, levofloxacin, and erythromycin. Treatment of all sexual partners is necessary to prevent recurrence. Use of condoms until cured. Gonorrheatwo considerations influence the treatment of gonorrhea: 1) the high number of organisms that have become resistant to previously used antibiotics and 2) the high frequency of Chlamydial infections in persons with gonorrhea. Suprax, Recephin and Cipro in combination with one of the antibiotics used for Chlamydia appear to be affective for gonorrhea treatment. All sexual partners should be treated simultaneously and intercourse avoided and the man should use a condom until a cure is confirmed. SyphlisBest treatment in all stages of syphilis is with penicillin. Ceftriaxone and doxycycline can also be used. Tetrcycline is an alternative if the woman is not pregnant. Women allergic to penicillin can be admitted to the hospital for desensitization to PCN followed by administration of the drug. Herpes genitalisNo cure exists but antiviral drugs reduce or suppress symptoms, shedding, and recurrent episodes. Zovirax, Famir, and Valtrex are all used. Women should be advised to abstain from sexual contact while the lesions are present to avoid transmission to their partner. Condylomata acuminataTreatment does not eradicate the virus. The goal of treatment is to remove the warts which transmit the virus back and forth between sexual partners. Topical treatment options include podophyllin, trichloroacetic acit (TCA), bichloroacetic acid (BCA), and imiquimod cream. Extensive warts that

do not respond to topical treatment are removed by cryotherapy, eletrodessication, electrocautery, or laser. Interferon (antineoplastic drug) is sometimes used to treat condylomata acuminatat in woman >18yo who have f" not responded to conventional therapy. Sexual contact should be avoided until all lesions are healed and the v use of condoms is recommended to reduce transmission. AIDSNo medications have been shown to cure AIDS. Treatment is centered around symptoms and combined drug therapy often benefits the HIV-infected woman and may have acceptable safety if she is pregnant. Drugs that my interrupt production of the virus are: Zidovudine (reverse transcriptase inhibitor). Protease inhibitors, such as indinavir and saquinavir, block the enzyme crucial to one step in the reproductive cycle of HIV. HIV is highly infectious through intimate contact with blood, blood products, infected bodily secretions and prenatal transmission from mother to infant f) Develop nursing care for the woman with: Osteoporosis, pelvic floor disorders, menstrual cycle disorders, benign and malignant breasts and reproductive tract disorders, PMS, cardiovascular disease, and infectious disorders of the reproductive tract.

Nursing care for women with: Osteoporosis:--teach about lifestyle factors that contribute to bone loss, such as cigarette smoking, excessive alcohol use or caffeine intake. Daily calcium supplements are recommended. Exercise with weight bearing and resistance is beneficial. Pelvic floor disorders: Have patient practice doing Keegel exercises holding for 10 sec with 24-45 repetitions a day. Lying down with legs elevated for a few minutes several times a day. Teach measures to prevent constipation. Menstrual cycle disorders: Benign & Maliqnanct breasts: Reproductive tract disorders: PMS: Cardiovascular disease: Infectious disorders of the reproductive tract:

Objective 24 The student will discuss induced abortion a) Describe methods used for pregnancy termination Medical termination of pregnancy is a voluntary method of ending a pregnancy by the use of drugs or surgical methods: Drugs: (Medical) Mifepristone (Mifeprex or RU-486)antiprogesterone drug, followed by misoprostol (Cytotec) a Prostaglandin drug commonly used to reduce gastric acid secretion, Methotrexate (Folex, Mexate)an antimetabolite also used to treat certain types of cancer. Misoprostol may be prescribed to enhance expulsion of the uterine contents. Misoprostol (Cytotec)a prostaglandin drug normally given to reduce acid secretion Medical methods (drugs) exist for abortion in the second trimester but these involve labor. Retention of the placenta often occurs, requiring a D&C to fully clean out the uterus. Prostaglandin E2 which stimulates uterine contractions may be given via vaginal suppository or intraamniotic infusion. Surgical: Through 12 weeks gestation, vacuum aspiration with curettage is the method of choice. The cervix is dilated after locally injecting anesthetic in the area, and a plastic cannula is inserted into the uterine cavity. The contents are aspirated with negative pressure and the uterine cavity may be scraped with a curet to ensure that the uterus is empty. Second trimester a dilation with removal of the fetus and placenta is generally performed. Similar to vacuum curettage, but requires greater cervical dilation and a larger spirator because the products of conception have grown in size and must be removed gradually. b) Explain physical and psychological needs of the patient prior to and after induced abortion Prior to and after abortion, provide physical and emotional support and information about the methods used. Rh-negative women should receive Rh (D) immune globulin (RhoGAM) Self care information, follow up visits and contraception. c) Explain post abortion teaching needs After termination provide information about self care and guidelines Normal activities may be resumed but strenuous work or exercise should be avoided for a few days Bleeding or cramping may occur for a week or two. If either becomes severe, seek medical advice Light spotting may occur for about one month Sanitary pads should be used instead of tampons for the first week after the abortion to avoid infection Intercourse should be curtailed until 1 week after abortion due to possible infection Birth control measures should be used if sex is resumed before menstruation begins. Temperature should be taken twice a day to detect possible infection; Above 100.F should be reported. Importance of keeping follow up appointment in 2 weeks or as recommended. d) Develop nursing care of the woman who seeks to terminate pregnancy physical and information. Counseling and lending emotional C (Provide responsibilitiesemotional support and counselors are also responsible to perform thesesupport are nursing although designated services.

Objective 25 The student will discuss contraception methods a) Describe various contraceptive methods b) Describe how each method prevents pregnancy c) Analyze advantages, disadvantages, side effects, effectiveness, contraindications and cost of each method Sterilization (vasectomy & tubal liqationused for couples who have completed their families. Both methods should be considered permanent to end fertility. In the female, the fallopian tubes are occluded and a section remove and tying the ends. In males the vas deferens which carries sperm from the testes to the penis is removed, severed or cauterized. Pregnancy rate is 0.15% for tubal ligation and .5% for vasectomy Advantages: Ends concern about contraception, low long term cost (usually covered by insurance), vasectomy can be perform in a physicians office with local anesthesia. Disadvantages: No protection against STD's, reversal is difficult, Side effects: potential complications as with any surgery, mild to moderate pain at site of incision Progestin injections & (Depo-Prevera)prevents ovulation for 12 weeks. Pregnancy rate is 0.8% Advantages: unrelated to coitus, avoids the need for daily use, may cause eventual amenorrhea Disadvantages: No protection against STD's, must remember to repeat every 12 weeks, may decrease bone density. Side effects: effects similar to other progestin contraceptive (birth control pills), headaches, nervousness, decreased libido, breast discomfort and depression Oral contraceptives (& transdermal patch) Estrogen and progestin in combination cause thickening of the cervical mucosa which prevents sperm from entering the upper genital tract. Also blocks the luteinizing hormone surge from pituitary, which inhibits maturation of the follicle and ovulation. Pregnancy rate is 8%. Advantages: unrelated to coitus, requires application only weekly(patch), regulates menstrual cycle. Diadvantages: No protection against STD's, requires a prescription, must apply on the right day, less effection for women over 90kg (198lbs), may cause skin irritation Side effects: Headache, weight gain or loss, fluid retention, amenorrhea, and melasma. Contraindicated for smokers, history of DVT, obesity, diabetes, hypertension. Impaired liver function. Vaginal contraceptive ringthe ring which measures 5cm in diameter and 0.3cm thick, releases small amounts of progestin and estrogen continuously to prevent ovulation. The woman removes the ring at the end of 3 weeks and bleeding occurs. A new ring is then inserted. Pregnancy rate is 8%. Advantages: unrelated to coitus, in place for 3 weeks at a time, no fitting required. Diadvantages: No protection against STD's, requires prescription, must remember when to remove and when to insert

C Side effects: expulsion, vaginitis, vaginal discomfort, others similar to those with oral contraceptives. ^

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IUDinserted into the uterus to provide continuous pregnancy prevention. It causes a sterile inflammatory response resulting in a spermicidal intrauterine environment. Very few sperm reach the fallopian tubes. Pregnancy rate is 0.8%. Advantages: unrelated to coitus, in place at all times, low long-term cost Diadvantages: No protection against STDs, high initial cost, can be expelled without the woman knowing (must check for strings) Side effects: cramping, bleeding with insertion, increased bleeding during menstruation, complications can result in uterine perforations, infection, ectopic pregnancy and abortion Chemical spermacides(a.k.a. chemical barriers) Chemicals that kill spermicides and come in many forms. Creams and gels are the most widely used. Foams, suppositories and vaginal film may be used alone or with another contraceptive measure. They are effective for about 1 hour and should be reapplied if intercourse is repeated. Pregnancy rate is 29% if used alone. Advantages: quick and easy, no prescription required, inexpensive per single dose Diadvantages: no protection from STDs, coitus related, may interfere with sensation, contraindicated for allergies to components of spermicides. Films and suppostitories must melt before they become effective, effective for only 1 hour and must be reapplied for repeated intercourse, may be messy Side effects: frequent use can cause genital irritation which can increased susceptibility to infection and HIV

Condoms(a.k.a mechanical barriers) placed over the penis or cervix to prevent passage of sperm into the _, uterus. They include: condom, sponge, diaphragm and cervical cap. Pregnancy rate is 15% for male condoms ( and 21 % for female condoms.
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Advantages: quick and easy, no prescription needed, best protection against STDs (except the sponge), low cost per single dose, can be carried discreetly, vaginal condoms increase a womans control over contraceptive use and protection against STDs Diadvantages: must be checked for expiration date, can only be used once, can break or slip off, vaginal condom may seem unattractive. Sponge doesnot protect against STDs Side effects: contraindicated for allergies to latex, can be affected by vaginal medications and should not be used together. The sponge should not be left in the vagina for more than 30 hours, can result in toxic shock, Diaphragmlatex dome surrounded by a spring coil. Placement of spermicidal cream or gel into the dome and around the rim, then inserts over the cervix. Prevents passage of sperm into the uterus. Pregnancy rate is 16%. Sponge is 32% in parous women and 16% in nulliparous women. Advantages: can be inserted several hours before coitus Disadvantages: initially expensive, requires fitting by health care provider, requires education on how to use it, difficult to insert and remove for some women, added spermicide is needed for repeat coitus, needs to be checked annually for proper fit and following birth, abortion, or weight change of 10lb or more. Side effects: prolonged placement can result in toxic shock or bladder infections.

pervical capinserts a cone cap over the cervix after placing spermicide on both sides. Keeps sperm from entering the uterus.

Advantages: smaller than a diaphragm and may fit a woman who cannot wear a diaphragm. No pressure on the bladder, less noticeable than a diaphragm, can remain in place 48 hrs. ^ Diadvantages: initially expensive, requires fitting by health care provider, requires education on proper use and insertion, added spermicide necessary for repeated coitus. Side effects: possibility of toxic shock. Natural family planninguses physiological cues to predict ovulation and avoid coitus when conditions are favorable for fertilization. Calendar method is based on timing of ovulation approximately 14 days before the onset of menses. Standard method uses a string of beads that is color coded to help keep track of the days of each cycle. Days 18-19 are considered fertile days. Basal body temperature method uses oral temperatures based on temperature drop just before ovulation, with ovulation, the temperature rises. The woman is no longer fertile after the temperature rises. Pregnancy rate is 25% Advantages: inexpensive, no drugs or hormones, helps women learn about their bodies, can be combined with barrier methods in increase effectiveness, acceptable in most religions, may be used to help achieve pregnancy Diadvantages: No protection from STDs, requires high motivation and education, abstinence necessary for large part of each cycle, high risk of pregnancy from error, many factors may change ovulation time Side effects: none d) Develop nursing care for the individual seeking contraception

The role of the nurse in family planning is that of a counselor and educator. Use current and correct information about contraceptive methods. Reinforce teaching and provide an opportunity to ask questions after initial use can help ensure the woman is using the method correctly. Nurses must be sensitive to the woman's concerns and feelings when discussing contraceptive use. In discussing family planning, the nurse must be careful not to introduce their own biases toward or against specific methods. Provide individualized family planning information to women in every situation in which it would be appropriate.