Mastitis
Inflammation and infection of the breast tissue.
Patho: Inadequate drainage of milk allows for bacterial contamination, resulting in infection.
RF: Infrequent feeding, clogged milk duct, nipple damage r/t improper breastfeeding technique, poor hand hygiene.
S/S: Firm, red, swollen area on one breast, fever, chills, malaise.
Dx: History and clinical presentation.
Tx: Antibiotics, analgesics (e.g., NSAIDs).
PT: Practice good hand hygiene. Apply heat prior to breastfeeding (to facilitate emptying). Ensure proper infant latching (mouth should cover nipple AND part of areola) and removal (break seal w/finger). FULLY empty the breasts via breastfeeding, hand/manual expression, or pumping.
Card 3
Endometritis
Risk Factors
Signs/Symptoms
Labs
Diagnostics
Treatment
Nursing Care
Answer
Endometritis
Inflammation and infection of the uterus. Most common postpartum infection.
RF: C-section, chorioamnionitis, retained placental fragments, PROM, prolonged labor, internal fetal monitoring, multiple cervical examinations.
S/S: Fever, suprapubic pain and tenderness, excessive/malodorous lochia, tachycardia, hypotension.
Labs: ↑ WBC.
Dx: Clinical presentation, cervical and blood cultures.
Tx: IV/oral antibiotics, analgesics.
NC: Monitor for complications (e.g., sepsis, necrotizing fasciitis).
Card 4
Postpartum Hemorrhage
Methylergonovine & Carboprost:
- Indications, Mode of Action, Contraindications,
- Side Effects
Answer
Methylergonovine & Carboprost
Indications: Prevention and treatment of postpartum hemorrhage.
MOA: Uterine stimulant.
Contraindications:
- Methylergonovine: Hypertension.
- Carboprost: Asthma.
Side Effects: Hypertension (methylergonovine only), abdominal pain, nausea, vomiting.
Card 5
Postpartum Hemorrhage
Risk Factors
Signs/Symptoms
Labs
Treatment
Nursing Care
Answer
Postpartum Hemorrhage
Blood loss of > 500 mL after vaginal birth, or > 1,000 mL after cesarean birth.
RF: Uterine atony, magnesium administration, birth canal trauma (e.g., lacerations, hematoma), precipitous delivery, retained placental fragments, uterus inversion or subinvolution, coagulopathies (e.g., DIC, ITP - immune thrombocytopenic purpura), multiparity, fetal macrosomia.
S/S: Saturating pad ≤ 15 min, soft/boggy uterus, large blood clots, constant blood flow from vagina, S/S of hypovolemic shock (tachycardia, hypotension, cool/clammy skin).
Labs: ↓ Hemoglobin and hematocrit.
Tx: Uterine stimulants (oxytocin, methylergonovine, misoprostol, carboprost), bimanual compression, uterine packing, surgical intervention (e.g., artery ligation, hematoma evacuation, hysterectomy).
NC: Firmly massage fundus. Administer O2, IV fluids, blood products as ordered. Elevate patient's legs.
Card 6
Pulmonary Embolism (PE)
Signs/Symptoms
Diagnostics
Treatment
Nursing Care
Answer
Pulmonary Embolism (PE)
Life-threatening emergency when an embolus moves into the pulmonary vasculature, occluding the vessel and obstructing blood flow to the lungs.
S/S: Chest pain, dyspnea, hypotension, hypoxia, peripheral edema, tachypnea, bloody sputum.
Dx: Ventilation Perfusion scan (V/Q scan), CT Pulmonary Angiography (CTPA), MRI.
Tx: Thrombolytics (e.g., alteplase, streptokinase).
NC: Place the patient in semi-fowler's position and administer oxygen. Implement bleeding precautions.
Card 7
Deep Vein Thrombosis (DVT)
Prevention
Patient Teaching
Answer
Deep Vein Thrombosis (DVT)
Prevention:
- Ambulate early and often, avoid prolonged immobility.
- Wear antiembolic stockings.
- Elevate legs when sitting, avoid crossing legs.
- Drink 2 - 3 L of fluid per day.
- Do not smoke.
PT:
- Do NOT massage legs (may dislodge thrombus into bloodstream, causing an embolus).
- Bed rest may be ordered.
Card 8
Deep Vein Thrombosis (DVT)
Risk Factors
Signs/Symptoms
Diagnostics
Treatment
Nursing Care
Answer
Deep Vein Thrombosis (DVT)
Blood clot (thrombosis) in the deep veins (e.g., femoral, saphenous, popliteal).
RF: Immobility, obesity, diabetes, pregnancy, c-section (doubles risk), multiparity, smoking, varicose veins, history of thromboembolism.
S/S: Unilateral leg pain, swelling, warmth, redness, hardness.
Dx: Doppler ultrasound, CT scan, MRI.
Tx: Anticoagulants, analgesics.
NC: Elevate the extremity; do not put pillows/knee gatch under the knees! Apply warm moist compresses. Implement bleeding precautions.
Card 9
Cardiovascular Changes
Blood Loss with Delivery
Cardiac Output
Blood Volume
Lab Values
Nursing Care
Patient Teaching
Answer
Cardiovascular Changes
Blood Loss: 500 mL vaginally or 1,000 mL c-section.
Cardiac Output: Remains elevated for first 48 hours, then ↓ gradually and returns to baseline within ~ 12 weeks.
Blood Volume: Drops rapidly after birth, returns to baseline ~ 4 weeks postpartum.
Labs:
- ↑ Coagulation factors for ~ 3 weeks. Provides protection from hemorrhage during childbirth, but ↑ risk for thrombus formation.
- ↑ WBC for ~ 1 - 2 weeks, up to 25,000/mm³.
NC: Assess patient's legs for signs of DVT (erythema, edema, warmth).
PT: Encourage early ambulation to prevent DVTs.
Card 10
Sexual Intercourse
Patient Teaching
Answer
Sexual Intercourse
Do not have sex until cleared by provider (usually ~2 - 4 weeks after delivery). Episiotomy needs to be healed, and lochia should be white.
Lubricant can help prevent discomfort, as the body's reaction to sex may be diminished.
Discuss contraception options with provider as ovulation can begin 1 month after delivery.
Contrary to many old wives' tales… pregnancy can occur while breastfeeding, even if menses has not returned!
Card 11
Sibling Adaptation
Family Teaching
Answer
Sibling Adaptation
Let sibling be one of the first people to see the baby.
Provide a gift from the infant to the sibling.
Give younger siblings a doll to care for, allow older siblings to help provide care for the baby.
Plan individual time with each child.
Regression in toileting/sleeping habits or behavior issues (intended to gain attention) may occur.
Monitor behavior of older children, divert aggressive behavior.
Card 12
Parental-Infant Bonding
Signs of Bonding
Signs of Impaired Bonding
Family Teaching
Answer
Parental-Infant Bonding
Signs of Bonding: Holding the infant, talking or singing to the infant, gazing and smiling at the infant, recognition of the infant's distinct features.
Signs of Impaired Bonding: Ignoring infant, apathy when infant cries, disgust with diapers or spit-up, expressing disappointment in infant.
FT:
- Encourage hands-on approach (cuddling, diapering, bathing) and skin-to-skin contact.
- Provide education on infant hunger cues (card 108), and encourage early breastfeeding.
- Provide community resources and support organization information.
Card 13
Maternal Role Attainment
Three Phases:
- Dependent (Taking-In)
- Dependent-Independent (Taking-Hold)
- Interdependent (Letting-Go)
Answer
Maternal Role Attainment
Dependent (Taking-In): 24 - 48 hours after birth. Mother is often passive and dependent (i.e., relies on others for help). She is eager to talk about her birth experience.
Dependent-independent (Taking-Hold): Begins on day 2 or 3, lasts for several weeks. Mother begins the transition from dependent to independent. She begins to care for herself and learns how to care for her baby.
Interdependent (Letting-Go): Mother reestablishes her relationships with others, including her partner. She adjusts to a lifestyle that includes the infant and may return to work.
Card 14
Postpartum Immunizations
Vaccines Provided to Patient Before Discharge
Answer
Postpartum Immunizations
Rubella: Vaccine given to patients without immunity (titer
Tdap: Vaccine that protects against tetanus, diphtheria, pertussis. Administer to patients who did not receive in the third trimester.
Varicella: Vaccine given to patients without immunity. First dose given prior to discharge from hospital, second dose at follow-up appointment (6 - 8 weeks after delivery). Advise patient to avoid pregnancy for at least 28 days after immunization.
Rhogam: Given within 72 hours of birth to Rh- moms who gave birth to Rh+ babies to prevent antibody formation that would affect subsequent pregnancies.
Card 15
Breast Care
Patient Teaching
Answer
Breast Care
Wash hands prior to breastfeeding.
Ensure baby is latched on correctly (takes in part of areola with the nipple).
Apply breastmilk to sore nipples and allow to air dry.
Report signs of mastitis to provider (cracked/sore nipples, erythema, flu-like symptoms).
Stay hydrated by drinking plenty of water.
Breastfeeding produces oxytocin which helps the uterus contract and prevents hemorrhaging. Uterine cramps may occur during breastfeeding.
Card 16
Breast Care
Colostrum and Milk
Breast Engorgement
Suppression of Lactation
Answer
Breast Care
Colostrum and Milk:
- Colostrum is rich in antibodies, protein, and fat-soluble vitamins. Secreted during pregnancy and 2 - 3 days after delivery.
- Milk is produced 3 - 5 days after delivery.
Breast Engorgement:
- Empty breasts completely with each feeding.
- Apply warm compresses prior to feeding (or take a warm shower), and apply cool compresses after feeding.
Suppression of Lactation:
- Wear a supportive bra for 72 hours after delivery.
- Avoid breast stimulation and warm water on breasts.
Apply fresh cold cabbage leaves to breasts to help with breast engorgement and/or suppression of lactation.
Card 17
Perineum Care
Patient Teaching
Answer
Perineum Care
Apply ice packs to the perineum to reduce pain/edema and prevent hematoma formation.
After voiding, use a squeeze bottle filled with warm water to clean the perineal area, pat dry.
Use sitz baths several times daily for 15 - 20 minutes.
Topical anesthetic agents (e.g., benzocaine) can be used for perineal pain.
Witch hazel pads can reduce pain and swelling associated with hemorrhoids.
↑ Fluid and fiber intake to prevent constipation.
Card 18
Lochia Assessment
Amount of Lochia
Answer
Lochia Assessment
2.5 cm is the size of 25 cents (a quarter).
Amount of Lochia
Size of Stain
Scant
Light
Moderate
Large/Heavy
> 15 cm (6 inch) stain or one pad saturated within two hours
Excessive
Saturation of perineal pad within 15 min
Be sure to check for pooling of blood under the buttocks!
Card 19
Lochia Assessment
Lochia Types
Abnormal Findings
Answer
Lochia Assessment
Lochia is uterine discharge after delivery that contains blood, mucus, and uterine tissue.
Type
Timing
Description
Lochia Rubra
1 - 4 days after delivery
Dark red
Lochia Serosa
4 - 9 days after delivery
Pinkish brown
Lochia Alba
10 - 14 days after delivery (up to a few months)
Creamy white
Abnormal Findings: Malodorous lochia (indicates infection), lochia rubra beyond one week.
Fundal Assessment
Twelve hours after delivery the fundus should be firm, midline, and approximately at the level of the umbilicus.
The fundus descends ~1 cm each day.
At day 6 the fundus is halfway between the umbilicus and symphysis pubis.
The uterus should not be palpable two weeks postpartum.
Card 21
Fundal Assessment
Nursing Care
Patient Teaching
Answer
Fundal Assessment
Assessment of fundal height, uterine placement, and uterine consistency.
NC:
- Assess fundal height (card 117).
- If the fundus is displaced laterally, have the patient empty their bladder.
- For difficulty voiding, try non-invasive techniques first (e.g., gently pour water over the vulva). If this is unsuccessful, catheter insertion may be needed to drain bladder.
- If the fundus is boggy (soft), gently massage until it is firm (this expels any clots).
- Administer oxytocin as ordered, which contracts the uterus and reduces bleeding.
PT: Encourage breastfeeding (↑ oxytocin).
Card 22
Car Seat Safety
Family Teaching
Answer
Car Seat Safety
Place car seat in back seat, preferably in the middle seat.
Use rear-facing seat with 5-point harness.
Install car seat at a 45° angle.
Position straps at or below the child's shoulders.
Chest clip needs to rest at nipple or armpit level (not on abdomen).
Keep infant in rear-facing seat until a minimum of age 2.
Card 23
Crib Safety & Sleeping
Family Teaching
Answer
Crib Safety & Sleeping
Crib Safety:
- Use a firm, tight-fitting mattress, covered ONLY by a fitted sheet.
- Crib slats should be ≤ 2 ⅜" (6 cm) apart.
- Do not place anything in crib (e.g., pillows, blankets, toys).
- Put crib away from windows and cords/blinds.
Sleeping:
- Place infant on back to sleep (even naps) to prevent SIDS.
- Prevent overheating during sleep.
- Newborns sleep ~14 - 17 hours/day.
- Room share, but do not bed share with babies.
Remember the ABCs of safe sleep: Alone, Back, Crib.
Card 24
Bathing & Cord Care
Family Teaching
Answer
Bathing & Cord Care
Bathing:
- Set water heater at ≤ 120°F.
- Wash from cleanest to dirtiest (face first, genital area last).
- Be sure to clean between skin folds.
- Provide a complete bath 2 - 3 times/week with mild soap.
- Keep baby warm during bath, dry thoroughly after bath.
- Do NOT immerse baby until umbilical cord has fallen off.
Cord Care:
- Keep cord dry (sponge baths until cord falls off ~10 - 14 days after birth). Fold diaper under cord.
- Monitor for infection (malodor, purulent drainage, moist/red cord).
Card 25
Circumcision
Benefits
Contraindications
Nursing Care
Family Teaching
Answer
Circumcision
Removal of foreskin from the penis. Performed via Gomco clamp, Mogen clamp, or Plastibell Technique.
Benefits: ↓ Risk of UTIs and STIs.
Contraindications: Hypospadias or epispadias (foreskin needed for surgical repair of defects).
NC: Implement pain relief measures during and after procedure (e.g., acetaminophen, pacifier, sucrose).
FT:
- Notify provider if infant has not urinated within 6 - 8 hours after the procedure.
- Clean penis with warm water at every diaper change.
- With clamp procedure, apply petroleum jelly with each diaper change for the first few days.
- Do NOT remove yellowish crust over the circumcision site.
- Do NOT give tub bath until circumcision is healed (a couple of weeks).
- Monitor for excess bleeding, fever, malodorous drainage, swelling.
Card 26
Formula Feeding
Do's and Don'ts
Answer
Formula Feeding
Do:
- For powdered formulas, use the exact water amount listed on the label. Use water from a safe source.
- Use room temperature formula within 2 hrs of preparation.
- Refrigerate prepared formula for up to 24 hrs.
- Feed baby in semi-upright position.
- Hold bottle at an angle, keep the nipple filled with formula.
- Burp baby at natural breaks during feeding.
- Discard unused formula remaining in bottle.
Don't:
- Prop up a bottle when feeding.
- Freeze formula or warm it in the microwave.
- Add water to "ready to feed" liquid formula.
Card 27
Breastmilk Storage
Do's and Don'ts
Answer
Breastmilk Storage
Do:
- Room temperature up to 4 hours.
- Refrigerated up to 4 days.
- Frozen up to 6 months.
- Deep freezer up to 12 months.
- Thaw in the refrigerator or in lukewarm water.
- Discard unused portions of breastmilk.
Don't:
- Microwave breastmilk.
- Refreeze thawed milk.
Card 28
Breastfeeding
Advantages
Patient Teaching
Answer
Breastfeeding
Advantages: Prevents infections, enhances brain growth, reduces risk of SIDS, convenient, inexpensive.
Patient Teaching:
- Initiate breastfeeding within 30 minutes of delivery.
- Spread colostrum on nipple and stroke baby's lips to promote sucking.
- Correct latch is when baby's nose, cheeks, and chin touch the breast, with a portion of the areola in the infant's mouth.
- Prior to removing baby from breast, insert finger into side of baby's mouth to break suction.
- Infants will have loose, yellow stool.
- Adequate feeding will produce 6 - 8 wet diapers/day.
Card 29
Infant Nutrition
Weight Loss
Hunger Cues
Family Teaching
Answer
Infant Nutrition
Weight Loss: Infants are expected to lose 5 - 10% of their weight in the days following birth. It is normally regained within 2 weeks.
Hunger Cues: Hand to mouth motions. Sucking, rooting, or mouthing.
FT:
- Newborns do not need to be given water.
- Breastfed: Give 400 IU of vitamin D daily. After 6 months, infants need iron-fortified cereal/foods.
- Formula-fed: Require iron-fortified formula for first year of life.
- Solid foods introduced around 4 - 6 months.
- Introduce foods one at a time to rule out allergies.
Card 30
Meconium Aspiration Syndrome
Pathophysiology
Risk Factors
Signs/Symptoms
Complications
Nursing Care
Answer
Meconium Aspiration Syndrome
Inhalation of amniotic fluid with meconium in utero or at birth.
Patho: Fetus passes meconium (i.e., early newborn stool) due to intrauterine distress. Inhalation of amniotic fluid mixed with meconium leads to respiratory distress.
RF: Late and postmature infants, fetal hypoxia, oligohydramnios, placental insufficiency.
S/S: Green-stained amniotic fluid, dyspnea at birth.
Complications: Airway obstruction, surfactant inactivation, pneumonia.
NC: Prepare equipment and resources for neonatal resuscitation. Only suction infant if airway is obstructed. Administer oxygen, nitric oxide, and surfactant as ordered.
Card 31
Postmature Infant
Risk Factors
Signs/Symptoms
Complications
Nursing Care
Answer
Postmature Infant
Birth after 42 weeks gestation.
RF: Maternal obesity, prior prolonged pregnancy.
S/S: Meconium staining, long hair/nails, hypoglycemia, polycythemia, loose/wrinkled leathery skin, loss of subcutaneous fat, little or no vernix caseosa.
Complications: Fetal hypoxia, meconium aspiration, LGA, birth trauma (e.g., clavicle fracture).
NC: Provide early and frequent feedings, closely monitor blood glucose. Prevent heat loss (as post-term infants are at ↑ risk for hypothermia).
Card 32
Preterm Infant
Nursing Care
Answer
Preterm Infant - Nursing Care
Use radiant heat warmer or incubator to maintain infant's body temperature. Monitor temperature continuously.
Place infant in side-lying or prone position to improve oxygenation.
Administer oxygen and ventilatory support. Suction only as needed. Monitor oxygen saturation levels.
Provide synthetic surfactants as ordered.
Cluster care and minimize stimulation.
Provide enteral feeding or TPN as ordered. Carefully monitor I&Os.
Phototherapy
Baby is placed under UV lights or in a special light-producing blanket.
Place baby under lights wearing just a diaper.
Protect baby's eyes with mask if placed under bili-lights.
Turn baby frequently (every 2 hrs).
Monitor baby's temperature during therapy.
Monitor for dehydration: monitor baby's weight and urine output (weigh diapers).
Do NOT apply lotion on baby.
Check bilirubin levels every 6 - 12 hrs.
Possible side effects: Rash, "bronze-baby syndrome".
Encourage parents to hold infant if bili-blanket is used.
Card 35
Hyperbilirubinemia
Labs/Diagnostics
Treatment
Complications
Nursing Care
Family Teaching
Answer
Hyperbilirubinemia
Labs/Dx: Bilirubin > 5 mg/dL.
Tx: Phototherapy, ↑ frequency of breastfeeding, blood exchange transfusion.
Complications: Kernicterus - unconjugated bilirubin crosses the blood-brain barrier, causing permanent neurologic dysfunction (cerebral palsy, seizures, hearing loss, cognitive impairment).
NC: Note time of onset of jaundice. Provide care during phototherapy (card 103).
FT: Feed baby often to promote bilirubin excretion in stool. Loose, frequent, green bowel movements are expected.
Card 36
Hyperbilirubinemia
Pathophysiology
Signs/Symptoms
Answer
Hyperbilirubinemia
Increased bilirubin in the blood resulting in jaundice.
Patho: When RBCs are broken down, bilirubin is formed. ↑ Bilirubin levels are caused by:
- Physiologic Jaundice: Common, mild, transient. Due to infant's immature liver function. Usually begins on day 2 - 4, peaks between 4 - 5 days, and resolves in 2 weeks. It NEVER occurs in the first 24 hrs!
- Pathologic Jaundice: Caused by hemolysis due to maternal-fetal blood type mismatch, resulting in ABO incompatibility. Occurs within the first 24 hours, with a rapid ↑ in bilirubin levels (> 5 mg/dL per day).
S/S: Jaundice (yellow discoloration of the skin, eyes, and mucosa).
Necrotizing Enterocolitis
Life-threatening inflammation of the intestines, leading to necrosis.
RF: Prematurity, low birth weight, hypoxia (r/t congenital heart defect).
S/S: Poor feeding, lethargy, vomiting, abdominal distension.
Tx: NPO, NG tube, TPN, broad spectrum IV antibiotics, bowel resection surgery for worsening condition and/or perforation.
Complications: Perforation, peritonitis, sepsis, death.
Card 38
Sepsis Neonatorum
Risk Factors
Signs/Symptoms
Labs
Treatment
Nursing Care
Answer
Sepsis Neonatorum
Infection involving the bloodstream of an infant
RF: Prematurity, low birth weight, chorioamnionitis, prolonged rupture of membranes.
S/S: Poor feeding, irritability, lethargy, respiratory distress, fever, hypothermia, hypotension.
Labs: Positive blood cultures, hyperglycemia or hypoglycemia, acidosis, ↑ CRP.
Tx: IV antibiotics.
NC: Alert provider to early S/S of sepsis. Obtain specimens for culture (e.g., blood, urine) as ordered.
Card 39
Macrosomic Infant
Risk Factors
Complications
Nursing Care
Answer
Macrosomic Infant
Large for Gestational Age (LGA) infant, above 90th percentile or 4,000 g (≥ 8 lbs., 13 oz.).
RF: Maternal diabetes, postmature newborns, maternal obesity, genetics.
Complications: Birth injuries (asphyxia, shoulder dystocia), respiratory distress, hypoglycemia, polycythemia, hypocalcemia, hypomagnesemia, hyperbilirubinemia.
NC: Perform early and frequent blood glucose testing.
Card 40
Hypoglycemia
Risk Factors
Signs/Symptoms
Treatment
Nursing Care
Answer
Hypoglycemia
Serum glucose
RF: Preterm/postmature infants, maternal diabetes, perinatal stress.
S/S: Poor feeding, jitteriness, weak cry, fatigue, flaccid muscle tone, seizures, diaphoresis, cyanosis, apnea.
Tx: Early initiation of breastfeeding, formula supplementation, dextrose gel, IV glucose.
NC: Provide frequent feedings and monitor blood glucose levels closely with heel sticks.
Card 41
Neonatal Abstinence Syndrome (NAS)
Signs/Symptoms
Treatment
Nursing Care
Answer
Neonatal Abstinence Syndrome (NAS)
Multisystem infant disorder due to maternal use of drugs (especially opioids) during pregnancy.
S/S: High-pitched/shrill cry, tremors, convulsions, fever, tachypnea, diaphoresis, irritability, poor feeding, diarrhea, constant sucking, ↑ muscle tone.
Tx: Morphine sulfate, buprenorphine, methadone, anticonvulsants (phenobarbital).
NC:
- Seizure precautions (↓ environmental stimuli).
- Frequent, small, ↑ calorie feedings.
- Refer mom to drug/alcohol treatment center as needed.
- Initiate Child Protective Services (CPS) consult for illicit drug use.
- Perform Finnegan NAS screening every 3 hours.
Card 42
Medications After Delivery
Prophylactic Medications Provided to Newborn
Answer
Medications After Delivery
Erythromycin Ophthalmic Ointment: Prophylaxis to prevent ophthalmia neonatorum (caused by gonorrhea/chlamydia exposure in birth canal).
Vitamin K: Prevents hemorrhage. Vitamin K is needed for clotting and is not produced until around day 8. Administer IM in vastus lateralis.
Hepatitis B Vaccine: Given at birth, 1 - 2 months, and 6 - 18 months. Need signed informed consent. Do NOT administer in same thigh as vitamin K.
Administer hepatitis B immune globulin (HBIG) and Hep B vaccine for infants born to infected mothers within 12 hours of birth.
Medications after delivery go in the eyes and both thighs!
Card 43
Heel Stick
Illustration
Answer
Heel Stick
Card 44
Laboratory Studies
Heel Stick Procedure
Lab Tests at Birth
Answer
Laboratory Studies
Heel Stick Procedure:
- Warm newborn's heel to ↑ blood circulation.
- Cleanse with alcohol swab and allow to dry.
- Use spring-activated lancet on the medial or lateral portion of the plantar surface of the heel.
- Apply pressure with dry gauze and bandage.
Lab Tests at Birth:
- Newborn genetic screening within 24 - 48 hours of birth.
- Screening tests are state-mandated, typically include: phenylketonuria (PKU), congenital hypothyroidism, galactosemia, and sickle cell disease.
- PKU is a defect in protein metabolism that can result in intellectual disabilities. If positive (> 20 mg/dL), child will require a special formula and low protein diet for life.
With PKU, Protein can Kill U.
Primitive Reflexes
Reflex
Reflex Disappears
Description
Palmar Grasp
5 - 6 months
When an object is placed in baby's palm, infant closes hand and grips object.
Tonic Neck Reflex
5 - 7 months
When head is turned, infant extends arm/leg on same side, while the opposite arm/leg flexes inward.
Fencing position!
Plantar Grasp
9 - 12 months
Infant flexes/curls toes when the sole of the foot is touched near the base of the toes.
Babinski
12 month
When lateral plantar aspect of the foot is stroked, infant's toes dorsiflex/fan outward.
Note: All primitive reflexes normally present at BIRTH.
Primitive Relfexes
Reflex
Reflex Disappears
Description
Moro/Startle
2 months
Baby extends arms then bends and pulls them in toward the body with a brief cry in response to a sensation of falling, loud noise or sudden movement.
Walking/Stepping
2 months
Takes steps when both feet are placed on a surface with body supported.
Rooting
4 months
When cheek or mouth are stroked, infant turns head and opens mouth in search of nipple.
Sucking
4 months
Infants begin to suck when lips are touched.
Premature babies may have a weak sucking reflex.
Note: All primitive reflexes normally present at BIRTH.
Physical Assessment: Expected Findings
Face:
- Eyes: Intact blink reflex. Initial blue/gray color, may change by 6 mos.
- Ears: Aligned with the outer canthi of the eyes.
Low-set ears are a sign of Down syndrome.
- Mouth: Lips and mucous membranes are pink and moist. Epstein's pearls (small white cysts on gums/palate) are a normal variation.
Neck/Clavicles: Full ROM. No crepitus, swelling, tenderness.
↑ Risk of clavicle fractures during birth with macrosomic infants.
Umbilical Cord: Should contain 2 arteries and 1 vein, no green/brown discoloration (indication of meconium staining in utero).
Baby AVA (Artery, Vein, Artery).
Hips: Equal leg length, symmetrical gluteal/thigh creases, no developmental dysplasia of the hip (tested with Barlow and Ortolani maneuvers).
Card 48
Head Assessment
Expected Findings
Normal Variations
Answer
Head Assessment
Expected Findings: Symmetric, round head shape. Soft, flat, open fontanelles.
- Anterior Fontanel: Diamond shape, larger.
- I like my diamonds large, front and center!
- Posterior Fontanel: Triangular shape, smaller.
Normal Variations:
- Molding: Elongated fetal head shape (to accommodate passage through birth canal). Usually resolves within a week.
- Caput Succedaneum: Soft tissue swelling that crosses the suture line, due to pressure during birth. Typically resolves in 3 days.
It succeeds in crossing the suture line and resolves sooner.
Cephalohematoma: Collection of blood between skull and periosteum that does NOT cross suture line. Common with prolonged labor or vacuum/forceps assisted birth. May last several months.
Card 49
Skin Assessment
Normal Variations
Answer
Skin Assessment - Normal Variations
Telangiectatic Nevi ("stork bite"): Pink discoloration from dilated capillaries, often found on the eyelids, between the eyes, or neck. Usually fades within 18 months.
Milia: Small white cysts, often on the face. Disappear within a few weeks.
Congenital Dermal Melanocytosis: Blue/purple pigmented skin on back/buttocks that resemble bruises (more common in dark-skinned newborns). Usually fade in a couple of years.
Previously known as Mongolian spots, but this term should be avoided.
Nevus Flammeus ("port-wine stain"): Purple/red discoloration caused by capillary malformation. Permanent.
Erythema Toxicum: Transient rash with papules. Disappears within first week.
Skin Assessment
Expected Findings:
- Color: Pink or acrocyanotic. Acrocyanosis is the bluish discoloration of fingers/hands or toes/feet in response to cold exposure.
- Vernix: Thick white substance, protects fetal skin in utero.
- Lanugo: Fine/downy hair, small amount often found on shoulders, sides of the face, and upper back of the newborn.
Abnormal Findings: Jaundice within the first day of life, persistent central cyanosis, green/brown discoloration of skin/nails (indicating meconium passed before/during birth, sign of possible fetal distress).
Card 51
Anthropometric Measurements
Weight
Length
Head Circumference
Chest Circumference
Answer
Anthropometric Measurements
Measurement
Expected Range
Weight
2,500 - 4,000 g (5 lbs., 8 oz. - 8 lbs., 13 oz.)
Length
48 - 53 cm (19 - 21 in.)
Head Circumference
32 - 38 cm (13 - 15 in.)
Chest Circumference
30 - 36 cm (12 - 14 in.)
At birth, head circumference is 2 - 3 cm larger than chest circumference. Head and chest circumference are approximately equal at 1 year of age.
Card 52
Thermoregulation
Newborn Risk Factors
Types of Heat Loss
Nursing Care
Answer
Thermoregulation
Balance between heat loss and heat production.
RF: Large surface area to body mass ratio, less subcutaneous fat, lack of shivering ability.
Types of Heat Loss:
- Conduction: Heat loss from direct contact with a cooler surface (e.g., metal scale).
- Convection: Heat loss from cooler air (e.g., air conditioning, fan).
- Evaporation: Heat loss when surface liquid is converted to vapor (e.g., after birth, bathing).
- Radiation: Heat loss from close proximity to cooler surface (e.g., windows).
Minimizing heat loss in the infant is critical!
NC: Dry newborn immediately after birth and after bathing. Swaddle and place a hat on the infant. Encourage skin-to-skin contact with mother. Use protective cover over scale. Keep cribs away from air conditioners, windows, drafty areas.
Card 53
New Ballard Scale
Physical Maturity Assessment
Answer
Physical Maturity Assessment
Assessment
Premature
Mature
Skin
Sticky/transparent
Leathery/wrinkled (postmature)
Lanugo
None (very premature), Present (premature)
Mostly bald
Plantar Surface Creases
Absent
Creases over entire sole
Breast
Imperceptible
Full areola with 5 - 10 mm bud
Eye/Ear
Lids fused/no recoil of pinna
Eyes open/pinna recoils when folded
Genitals
Flat smooth scrotum OR prominent clitoris w/flat labia
Pendulous testes w/rugae OR labia majora covering labia minora and clitoris
Card 54
New Ballard Scale
Neuromuscular Assessment
Answer
Neuromuscular Assessment
Assessment
Premature
Mature
Posture
Fully extended
Fully flexed
Square Window
(wrist flexibility)
≥ 90° angle
0° angle
Arm Recoil
No recoil
Full recoil
Popliteal Angle
(extend baby's knee)
180° (big angle)
>90° (smaller angle)
Scarf Sign
(cross baby's arm over chest)
Little to no resistance
Resistance
Heel to Ear
(reach baby's heel to their ear)
Little to no resistance
Resistance
Card 55
Newborn Vital Signs
Temperature
Pulse
Respirations
Blood Pressure
Answer
Newborn Vital Signs
Vital Sign
Expected Range
Temperature
97.4 - 99.6 °F
(36.3 - 37.6 °C)
Pulse
100 - 160 bpm
Respirations
30 - 60 breaths/min
Blood Pressure
SBP: 65 to 90
DBP: 45 to 65
Short periods of apnea (
Card 56
APGAR Scoring
Components
Scoring
Answer
APGAR Scoring
Method used to assess newborn, 1 minute and 5 minutes after birth.
Indicator:
0 Points
1 Point
2 Points
A
Activity
(Muscle Tone)
Flaccid
Some flexion
Well-flexed/active motion
P
Pulse
Absent
> 100 bpm
G
Grimace
(Reflex Irritability)
None
Grimace
Cry
A
Appearance (Color)
Blue/pale
Acrocyanosis
Pink
R
Respirations
Absent
Slow/weak cry
Good cry
Overall Score:
0 - 3 = Severe distress
4 - 6 = Moderate distress
7 - 10 = Minimal difficulty adjusting to extrauterine life.
Card 57
Precipitous Labor
Risk Factors
Signs/Symptoms
Complications
Nursing Care
Answer
Precipitous Labor
Labor lasting less than three hours from onset of contractions to time of delivery.
RF: Hypertensive disorders, oxytocin, younger maternal age, preterm delivery, lower infant birth weight, placental abruption.
S/S: Abrupt onset of intense contractions.
Complications: Maternal lacerations, tissue trauma, uterine rupture, postpartum hemorrhage, fetal hypoxia, fetal intracranial hemorrhage.
NC: Encourage patient to remain in a side-lying position. Administer oxygen, IV fluids as ordered. D/C oxytocin if being used. Assist with emergency delivery.
Card 58
Amniotic Fluid Embolism
Risk Factors
Signs/Symptoms
Complications
Nursing Care
Answer
Amniotic Fluid Embolism
Amniotic fluid infiltrates maternal circulation and obstructs pulmonary vessels.
RF: Advanced maternal age, diabetes, eclampsia, multiparity, uterine rupture, meconium-stained amniotic fluid.
S/S: Sudden chest pain, dyspnea, tachycardia, bleeding, hypotension.
Complications: Respiratory distress, circulatory collapse, Disseminated Intravascular Coagulation (amniotic fluid has ↑ thromboplastin, which causes ↑ clotting).
NC: Administer oxygen, IV fluids, and blood products as ordered. Assist with CPR, intubation, and mechanical ventilation if needed.
Card 59
Uterine Rupture
Risk Factors
Signs/Symptoms
Complications
Nursing Care
Answer
Uterine Rupture
Incomplete or complete rupture of the uterine wall, peritoneal cavity, and/or broad ligament.
RF: Hyperstimulation from oxytocin, overdistention of uterus, multigravida, uterine trauma, previous uterine surgery (e.g., fibroid removal, c-section).
S/S: Sharp abdominal pain ("tearing" feeling), nonreassuring FHR, hypovolemic shock (tachycardia, hypotension, pallor).
Complications: Maternal hemorrhage, fetal hypoxia, maternal/fetal death.
NC: Administer IV fluids and blood as ordered. Prepare patient for immediate c-section with possible hysterectomy. Monitor for signs of shock r/t hemorrhage.
Card 60
Cesarean Section (C-Section) Birth
Indications
Risk Factors
Complications
Nursing Care
Answer
Cesarean Section (C-Section) Birth
Delivery of the infant through an incision in the abdomen and uterine wall. Spinal, epidural, or general anesthesia used for the procedure.
Indications: Maternal, fetal, and/or placental factors that make a vaginal birth contraindicated.
RF: Labor dystocia, fetal malpresentation (e.g., breech), fetal distress, previous c-section.
Complications: Hemorrhage, infection.
NC: Prepare surgical site, start IV fluids, insert Foley catheter, administer preoperative medications. Post-op, provide analgesics for incisional pain, inspect abdominal dressing for drainage.
Card 61
Prolapsed Umbilical Cord
Risk Factors
Signs/Symptoms
Nursing Care
Answer
Prolapsed Umbilical Cord
Umbilical cord protrudes through the cervix before the baby, leading to cord compression and compromised fetal circulation.
RF: Rupture of amniotic membranes, abnormal fetal presentation, unengaged presenting part.
S/S: Palpation or visualization of the umbilical cord with vaginal examination, variable or prolonged decelerations in FHR.
NC:
- Call for assistance - a medical emergency!
- Apply sterile gloves, insert two fingers into the vagina (one on each side of the cord) and elevate the fetal presenting part off the cord.
- Position mom knee-chest or in Trendelenburg.
- Apply warm, sterile, saline-soaked towel over cord.
- Administer oxygen to patient.
- Prepare for birth of infant.
Card 62
Labor Dystocia
Risk Factors
Signs/Symptoms
Nursing Care
Answer
Labor Dystocia
Prolonged, difficult labor.
RF: Fetal macrosomia, maternal fatigue, uterine abnormalities, cephalopelvic disproportion, fetal malpresentation (e.g., shoulder dystocia), anesthetic/analgesic use.
S/S: Insufficient progress in dilation, effacement, or fetal descent during labor.
NC:
- Encourage ambulation and position changes. Position patient on hands and knees to help rotate fetus from posterior to anterior position.
- For shoulder dystocia, apply suprapubic pressure (to push baby's shoulder off symphysis pubis) or perform McRobert's maneuver.
- Assist with amniotomy (to augment labor).
- Provide oxytocin as ordered.
- Prepare for assisted birth or cesarean as indicated.
Card 63
Preterm Labor
Terbutaline:
- Indications, Mode of Action, Side Effects, Nursing Care
Answer
Terbutaline
Indications: Preterm labor (delays but does not prevent labor).
When flying, turbulence delays arrival time (just like terbutaline delays arrival of the baby).
MOA: Relaxation of the uterus.
Side Effects: Tachycardia, angina, hypokalemia, dysrhythmias, restlessness, tremor.
Maternal and fetal distress if used > 48 - 72 hours.
NC: Used for pregnancies
Other tocolytics include magnesium sulfate and nifedipine.
Preterm Labor
Uterine contractions AND cervical changes between 20 - 37 weeks gestation.
RF: Infection, diabetes, hydramnios, multifetal pregnancy, previous preterm birth, smoking, substance abuse, HTN, PROM, placenta previa.
S/S: Cervical dilation, vaginal discharge, uterine contractions.
Labs: Fetal fibronectin (amniotic enzyme) in vaginal secretions early in pregnancy may indicate an ↑ risk of preterm labor.
Tx: Nifedipine (suppresses contractions), magnesium sulfate (relaxes the uterus), terbutaline, indomethacin (suppresses labor), betamethasone (given 24 - 48 hours before delivery).
NC: Monitor for magnesium toxicity (calcium gluconate is antidote). Ensure hydration of mother.
PT: Avoid intercourse, modified bed rest.
Card 65
Premature Rupture of Membranes (PROM)
Risk Factors
Signs/Symptoms
Diagnostics
Treatment
Complications
Nursing Care
Patient Teaching
Answer
Premature Rupture of Membranes (PROM)
Rupture of amniotic membranes prior to the onset of true labor.
Preterm PROM (PPROM) - Rupture before 37 weeks gestation.
RF: Maternal infection, incompetent cervix, previous preterm birth.
S/S: Leakage of fluid from the vagina.
Dx: pH test of vaginal fluid (nitrazine paper turns BLUE with amniotic fluid), positive ferning test.
Tx: Ampicillin (to prevent/treat intrauterine infection), betamethasone (to promote fetal lung maturity).
- Preterm gestation: Hospital observation, home management.
- Gestation near term: Labor induction.
Complications: ↑ Risk of infection (e.g., chorioamnionitis), especially when membranes are ruptured > 24 hrs prior to delivery. ↑ Risk of prolapsed umbilical cord.
NC: Assess FHR. Avoid vaginal exams.
PT (for home management): Modified bed rest, no intercourse, take temp every 4 hrs, report fever or foul-smelling discharge.
Card 66
Vacuum-Assisted Delivery & Forceps-Assisted Delivery
Indications
Complications
Nursing Care
Answer
Vacuum- and Forceps-Assisted Delivery
VAD: Cup-like suction device attached to the fetal head to provide traction and assist with fetal descent.
FAD: Curved spoon-like blades used to guide the fetal head out of the birth canal.
Indications: Prolonged second-stage of labor, abnormal fetal presentation, fetal distress, maternal exhaustion, or ineffective pushing.
Complications: ↑ Risk of maternal/fetal lacerations, infant subdural hematoma, neonate facial bruising, cephalohematoma, and caput succedaneum (usually resolves in 3 - 5 days).
NC: Assist patient into lithotomy position. Empty bladder w/catheter before procedure. Ensure rupture of membranes and fetal engagement have occurred prior to use.
Card 67
Labor Induction/Augmentation
Oxytocin & Dinoprostone:
- Indications, Mode of Action, Side Effects, Nursing Care
Answer
Oxytocin & Dinoprostone
Indications: Used to increase the strength, frequency, and length of uterine contractions during labor.
Oxytocin is also used for postpartum hemorrhage.
MOA: Uterine stimulant.
Side Effects: Painful contractions, uterine rupture.
NC: Monitor FHR and contractions. Administer a tocolytic agent (e.g., terbutaline, magnesium, nifedipine) to decrease uterine activity if needed.
Discontinue if contractions occur more than every 2 min, last longer than 90 sec, intensity >90 mmHg with IUPC, or resting tone >20 mmHg between contractions.
Card 68
Labor Induction/Augmentation
Cervical Ripening:
- Nursing Care
Amniotomy:
- Nursing Care
Answer
Labor Induction/Augmentation
Cervical Ripening: Promotes cervical softening, dilation, and effacement. Includes chemical agents (prostaglandins such as misoprostol) and mechanical methods (balloon catheter, dilators, membrane stripping).
- NC: Major adverse effect of prostaglandins is tachysystole (uterine hyperstimulation). Monitor FHR and contractions.
Amniotomy: Use of a sharp instrument to rupture amniotic membranes. ↑ Risk for cord prolapse and infection (e.g., chorioamnionitis).
- NC: Ensure presenting part of fetus is engaged prior to amniotomy. Monitor FHR before and immediately after amniotomy for bradycardia and variable decelerations. Monitor temp every 2 hrs (or per facility policy).
Card 69
Bishop Score
Components
Scoring
Answer
Bishop Score
Used to determine maternal readiness for labor induction based on cervical readiness.
Components: Cervical consistency, cervical dilation, cervical effacement, cervical position, station of presenting part.
Scoring:
- Each component is given a score of 0 to 3 (except position and station, which are given a score of 0 to 2).
- > 8 in a multiparous patient and > 10 in a nulliparous patient indicates readiness for labor induction.
I WISH my BISHop score would be high enough to induce labor!
Card 70
External Cephalic Version
Procedure
Complications
Nursing Care
Answer
External Cephalic Version
Ultrasound guided procedure to externally turn a baby to the normal vertex presentation.
Procedure: Pressure is applied externally to rotate the fetus at 37 weeks gestation. Performed in a hospital due to risk of complications.
Complications: HIGH risk of umbilical cord compression and placental abruption.
NC:
- Administer IV fluids and tocolytics to relax the uterus as ordered.
- Continually monitor FHR and maternal vital signs.
- Rhogam is administered to Rh- mothers after the procedure (to prevent sensitization to fetal blood).
Card 71
Fetal Heart Rate Patterns
VEAL CHOP
Answer
FHR Patterns: VEAL CHOP
FHR Pattern
Significance
V = Variable Decelerations
→
C = Cord Compression
E = Early Decelerations
→
H = Head Compression
A = Acceleration
→
O = Okay
L = Late Decelerations
→
P = Placental Insufficiency
Abnormal FHR Findings
Late Decelerations: Gradual decrease in FHR after contraction has started, prolonged return to baseline.
- Cause: Uteroplacental insufficiency (↓ blood flow → fetal hypoxia).
- Tx: Place pt side-lying, administer IV fluids, administer oxygen, d/c oxytocin, notify provider.
LION (Left-lying, IV fluids, Oxygen (and d/c Oxytocin), Notify provider).
Variable Decelerations: Abrupt decrease of FHR, no association with contractions.
- Cause: Umbilical cord compression (leads to ↑ fetal BP and ↓ FHR).
- Tx: Place pt knee-chest or reposition from side to side, d/c oxytocin, administer oxygen, notify provider. Amnioinfusion may be indicated.
Abnormal FHR Findings
Fetal Bradycardia: FHR
Causes: Prolonged cord compression, umbilical cord prolapse, anesthetic medications, fetal heart abnormalities.
- Prolonged bradycardia → fetal hypoxia.
Tx: Notify provider, d/c oxytocin, place pt side-lying, oxygen, ↑ IV fluids.
Fetal Tachycardia: FHR > 160 bpm for ≥ 10 minutes.
Causes: Maternal fever, fetal hypoxia, maternal hyperthyroidism, maternal/fetal anemia, cocaine use, dehydration.
- Fetal tachycardia accompanied by ↓ variability is indicative of severe fetal distress.
Tx: Antipyretics for maternal fever, IV fluids, oxygen.
Card 74
Normal FHR Findings
Baseline FHR
Accelerations
Decelerations
Variability
Answer
Normal FHR Findings
Baseline FHR: 110 - 160 bpm.
Accelerations: Present or absent.
- Accelerations: Transient increases in FHR above baseline (≥ 15 bpm, ≥ 15 sec), indicative of fetal well-being. Caused by fetal movement, vaginal examination. Reassuring, no intervention required!
Decelerations: Present or absent EARLY decelerations.
- Early decelerations: Gradual decrease in FHR with contractions (onset, peak, recovery of deceleration "mirror" the contraction). Caused by fetal head compression with contraction. Benign, no intervention required!
Variability: Moderate variability.
- Moderate variability: Fluctuations of the FHR by 6 - 25 bpm around the baseline. Indicative of a healthy fetal nervous system.
Card 75
Fetal Assessment
PMI Based on Fetal Position:
- Illustration
FHR Monitoring
External: Ultrasound transducer is placed over the point of maximal impulse (PMI), the location on the mother's abdomen where fetal heart tones can be heard best. Water-soluble gel is applied to the abdomen or ultrasound device to promote sound transmission, and the transducer is held in place with an elastic belt. Non-invasive.
Internal: Electrode placed on the presenting part of the fetus. May be used with intrauterine pressure catheter (IUPC). Membranes must be ruptured, cervix dilated ≥ 2cm. ↑ Risk of infection and injury to mother/fetus.
Card 77
Fetal Assessment
Leopold Maneuvers:
- Illustration
Answer
Leopold Maneuvers
Card 78
Fetal Assessment
Leopold Maneuvers:
- Steps
Answer
Leopold Maneuvers
External palpation of the uterus through the abdomen to determine the presenting part, fetal lie, fetal attitude, and point of maximal impulse (PMI). Determines placement of external transducer for fetal monitoring.
Palpate uterine fundus (top) to distinguish cephalic/breech position.
Feel along both sides of the uterus to identify the location of the fetal back.
Palpate above pubic bone and "pinch" presenting part - if part is pushed upward, not engaged; if difficult to move, engaged in maternal pelvis.
For cephalic presentation, face mom's feet and use fingers to feel if fetal head is flexed (vertex position, normal) or extended (face).
Pain Management
Epidural Block:
- Administered in epidural space, typically between L3 - L4.
- Reduces or eliminates pain/sensation below the umbilicus.
- Can cause maternal hypotension and fetal bradycardia.
Spinal Block:
- Administered into the CSF in the subarachnoid space.
- Performed just prior to birth (often c-section).
- Eliminates pain/sensation between the nipples (T6) and feet.
- Can cause maternal hypotension, fetal bradycardia, headache.
- Risk of maternal bladder and uterine atony.
Nursing Care: Administer IV fluids and position mom on her side (to prevent hypotension), monitor FHR and maternal vitals continuously.
Pain Management
Systemic: Opioids (e.g., meperidine), antiemetics (e.g., promethazine), benzodiazepines (e.g., diazepam).
Opioids can lead to maternal and fetal respiratory depression and ↓ FHR variability. Naloxone is antidote.
Inhaled: Nitrous oxide gas, self-administered.
Regional Analgesia/Anesthesia:
- Epidural/Spinal block (card 58).
- Local Infiltration: Lidocaine injection, numbs area for episiotomy or suturing.
- Pudendal Nerve Block: Provides pain relief in lower vagina, vulva, and perineum for episiotomy or vacuum/forceps-assisted birth.
Pain Management
Effleurage: Light stroking of abdomen in rhythm with breathing during contractions.
Sacral Counterpressure: Heel of hand or fist pushed against maternal sacrum to relieve pain in lower back.
Breathing Techniques: Patterned-paced breathing, beginning and ending with a cleansing breath.
Others: Hydrotherapy (shower, bath), TENS, acupressure or acupuncture, ambulation and position changes, imagery, music, heat/cold.
Card 82
Effacement vs. Dilation
Illustration
Answer
Effacement vs. Dilation
Card 83
Stages of Labor
Key Characteristics at Each Stage
Answer
Stages of Labor
First Stage: Onset of labor until complete dilation of cervix (10 cm).
- Latent Phase*: Cervix 0 - 6 cm, mild to moderate contractions ≥ 5 min. apart. Mom may be talkative and excited or calm and focused.
- Active Phase*: Cervix 6 - 10 cm, moderate to strong contractions 2 - 5 min. apart. Mom becomes more apprehensive and inwardly focused. As this phase progresses, mom may feel out of control ("I can't do this") and a sensation of needing to defecate.
Second Stage: Complete dilation of cervix until delivery of baby. Mom feels an overwhelming urge to push.
Third Stage: Delivery of baby until delivery of placenta.
Fourth Stage: Delivery of placenta until stabilization of mother.
*Some nursing textbooks/sources may include 3 phases (vs. 2 phases) in the first stage of labor. Please defer to your instructor, textbook, or facility.
Card 84
Fetal Station
Illustration
Answer
Fetal Station
Card 85
Fetal Position
Illustration
Answer
Fetal Position
Card 86
Factors Affecting Labor
3Ps
Answer
Factors Affecting Labor
3Ps in a Pod: Passageway, Powers, Passenger!
Passageway: The birth canal (cervix, vagina, pelvis).
Powers: Contractions (resulting in effacement and dilation).
Passenger: Fetus and the placenta.
- Fetal Head: Head size, molding.
- Fetal Lie: Longitudinal, transverse, or oblique.
- Fetal Presentation: First part of the fetus to enter the pelvic inlet (head, chin, shoulder, or breech).
- Fetal Attitude: Flexion or extension.
- Fetal Position: Labeled with three letters (LOA is optimal).
Use direction of child's back to determine position.
-
- First Letter: Right (R) or Left (L)
- Second Letter: Occiput (O), Sacrum (S), Mentum (M), or Scapula (Sc)
- Third Letter: Anterior (A), Posterior (P), or Transverse (T)
- Fetal Station: How far the fetus has descended into the pelvis (station 0 is at ischial spines; fetus said to be "engaged").
Card 87
True vs. False Labor (Braxton Hicks Contractions)
Key Differences
Answer
True vs. False Labor
True Labor
False Labor
Regular contractions, become stronger and closer together.
Weak, irregular contractions.
Walking ↑ contraction intensity.
Walking or position change ↓ intensity of contractions.
Contractions continue despite comfort measures.
Contractions often stopped by comfort measures.
Cervical changes are present (dilation/effacement).
No significant cervical changes.
Presenting part of fetus is engaged in pelvis.
Presenting part of fetus not engaged in pelvis.
Card 88
Physiologic Changes Before Labor
Expected Findings
Answer
Physiologic Changes Before Labor
Backache (caused by pelvic muscle relaxation)
Bloody show (brown/bloody vaginal discharge)
Burst of energy ("nesting")
Contractions (become stronger and more regular)
GI upset (n/v, heartburn)
Lightening (baby dropped lower into the pelvis)
Rupture of membranes (clear/watery)
Weight loss (~ 1 - 3 pounds)
Amniotic Abnormalities
Polyhydramnios: Excess amniotic fluid volume.
- RF: Gestational diabetes, fetal congenital abnormalities.
- Tx: Amniocentesis for severe polyhydramnios.
Oligohydramnios: Decreased amniotic fluid volume.
- RF: PROM, uteroplacental insufficiency, fetal genitourinary abnormalities.
- Tx: Amnioinfusion (infusion of NS or LR into the amniotic cavity) for umbilical cord compression.
Chorioamnionitis: Inflammation/infection of the amniotic sac.
- RF: Lower genitourinary tract infection (S/S: maternal fever, ↑ WBCs, uterine pain, malodorous discharge).
- Tx: Antibiotics.
Card 90
Group B Streptococcus Beta-Hemolytic (GBS)
Diagnostics
Treatment
Complications
Answer
Group B Streptococcus Beta-Hemolytic (GBS)
Bacterial infection that can be passed to a child during the birthing process and can cause life-threatening newborn infections.
Dx: GBS screening (rectovaginal culture) for all patients between 35 - 37 weeks gestation.
Tx: Intrapartum antibiotics (e.g., ampicillin or penicillin G) for:
- Positive GBS screening during this pregnancy.
- Previous delivery of an infant with GBS.
- Unknown GBS status.
- Fever of ≥ 38°C (100.4°F).
- Prolonged rupture of membranes (> 18 hours).
- Preterm labor (
Complications:
- Maternal: Sepsis, chorioamnionitis.
- Neonate: Meningitis, pneumonia, sepsis.
Card 91
Hypertensive Disorders
Treatment
Nursing Care
Patient Teaching
Answer
Hypertensive Disorders
Tx: Anti-hypertensives (hydralazine, labetalol, methyldopa, nifedipine), anticonvulsants (magnesium sulfate).
ACE inhibitors and ARBs are contraindicated during pregnancy!
NC: Monitor for S/S of magnesium toxicity (↓ deep tendon reflexes, urine output
PT: Avoid high sodium foods, limit caffeine. Maintain a quiet environment to prevent seizures. Bed rest may be required.
Hypertensive Disorders
Disorder that causes systemic vasoconstriction and vasospasm, leading to impaired circulation to organs (including the placenta) during pregnancy.
Gestational HTN (GH): After 20 weeks gestation, BP ≥ 140/90 mmHg recorded at least twice (≥ 4 hours apart). No proteinuria.
Mild Preeclampsia: BP ≥ 140/90 mmHg, proteinuria ≥ 1+.
Severe Preeclampsia: BP ≥ 160/100 mmHg, proteinuria ≥ 3+, headache, blurred vision, epigastric pain, thrombocytopenia (↓ platelets), impaired liver function (↑ AST, ALT), impaired kidney function (↑ creatinine), edema, hyperreflexia.
Eclampsia: Onset of seizures.
HELLP Syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets. High risk of maternal death.
Card 93
Abruptio Placentae
Risk Factors
Signs/Symptoms
Diagnostics
Treatment
Nursing Care
Answer
Abruptio Placentae
Premature separation of the implanted placenta from the uterus after 20 weeks gestation. High risk of maternal and fetal morbidity/mortality.
RF: Maternal HTN (e.g., preeclampsia), trauma, multiparity, use of cocaine, smoking.
S/S: Dark red bleeding and severe abdominal pain (sudden/abrupt onset, i.e., "abruptio"), rigid "board-like" abdomen, fetal distress, S/S of hypovolemic shock (hypotension, tachycardia, pallor).
Dx: Clinical assessment, ultrasound to rule out placenta previa.
Tx: Emergency c-section for fetal distress.
NC: Administer IV fluids, blood products, oxygen as ordered. Continuous maternal/fetal monitoring. Do not perform vaginal exam.
Card 94
Placenta Previa
Types
Signs/Symptoms
Diagnostics
Treatment
Nursing Care
Answer
Placenta Previa
Placental implantation near or over the cervical os which results in bleeding during the third trimester.
Types:
- Complete (total): Placenta completely covers the cervical os.
- Partial: Placenta partially covers the cervical os.
- Marginal: Placental edge is within 2 cm of the cervical os.
- Low-lying: Placenta is implanted on the lower uterus near the cervical os (within 2 - 3.5 cm).
S/S: Painless bright red bleeding during the second half of pregnancy.
Placenta Previa is Painless.
Dx: Ultrasound.
Tx: Bed rest at home for stable mother/fetus. C-section delivery at 36 - 37 weeks, or immediate delivery for excessive bleeding.
NC: Do not perform a vaginal exam. Administer IV fluids and blood products as ordered. Corticosteroids may be given to promote fetal lung maturation if delivery is expected.
Cervical Insufficiency
Premature dilation of the cervix. Also called "cervical incompetence".
S/S: Pelvic pressure, vaginal bleeding or pink-tinged discharge, gush of fluids from vagina, cervical dilation.
Dx: Transvaginal ultrasound to assess cervical length.
Tx: Cervical cerclage ("purse-string" suture used to close the cervix) placed at 12 - 14 weeks gestation and removed at 36 - 38 weeks gestation.
PT: Bed rest may be needed. Drink enough fluids each day and avoid sexual intercourse.
Gestational Diabetes Mellitus (GDM)
Hypoglycemia:
- S/S: Diaphoresis, cold/clammy skin, headache, shakiness, blurry vision, hunger.
If their skin is cold and clammy, then your patient may need candy!
- Tx: 15 g of a quickly absorbed carbohydrate (e.g., 4 - 6 oz juice, 8 oz milk), followed by protein intake.
Hyperglycemia:
- S/S: 3Ps (Polydipsia, Polyphagia, Polyuria), warm/dry skin, fruity breath odor, rapid breathing, fatigue.
If their skin is warm and dry, their blood sugar might be high!
- Tx: Insulin, notify provider immediately.
Gestational Diabetes Mellitus (GDM)
Impaired glucose tolerance during pregnancy.
RF: Obesity, HTN, family history of DM, GDM in previous pregnancies.
S/S: Usually asymptomatic. Polyuria, polydipsia.
Labs/Dx: 1 hour/3 hour glucose tolerance tests (card 18).
Tx: Diet modification, exercise, blood glucose monitoring. Insulin (most oral diabetic medications are contraindicated during pregnancy).
Complications: Fetal macrosomia, neonatal hypoglycemia. ↑ Risk of: preeclampsia, birth trauma, c-section, and diabetes following pregnancy.
Patient Teaching: Take blood glucose readings first thing in the morning (fasting) and 2 hours after each meal. Recognize S/S and treatment for hypoglycemia and hyperglycemia (card 41).
Urinary Tract Infection (UTI)
Bacterial infection in any part of the urinary tract.
RF: Pregnancy (due to urinary tract changes), urinary catheterization, frequent pelvic exams, c-section, hypotonic bladder.
S/S: May be asymptomatic - screening necessary! Dysuria, urinary urgency and frequency, cloudy/malodorous urine, fever, chills, fatigue, suprapubic pain.
Labs/Dx: Urinalysis postive for bacteria, WBC, RBC, nitrites, leukocyte esterase.
Tx: Antibiotics.
PT: Wipe front to back, take showers instead of baths, stay hydrated (drink 6 - 8 glasses of water a day), drink unsweetened cranberry juice, empty bladder regularly, urinate before and after intercourse, wear cotton underwear.
Card 99
Iron-Deficiency Anemia
Signs/Symptoms
Labs
Treatment
Nursing Care
Answer
Iron-Deficiency Anemia
Anemia due to inadequate iron stores and/or insufficient intake of iron-rich foods.
S/S: Fatigue, shortness of breath, pallor, pica (consumption of non-food substances such as clay, dirt, ice).
Labs: ↓ Hgb, Hct, iron, and ferritin.
Tx: Ferrous sulfate. Take with vitamin C (to ↑ absorption). ↑ Fluid and fiber intake (to prevent constipation).
NC: Increase intake of iron-rich foods (e.g., meat, fish, chicken, liver, green leafy vegetables).
Candidiasis
Fungal infection caused by Candida albicans ("yeast infection"). Common during pregnancy due to changes in vaginal pH and flora.
S/S: Thick white vaginal discharge ("cottage cheese" appearance), pruritus, vaginal inflammation, burning with urination.
Tx: Topical antifungal agents (e.g., clotrimazole, miconazole).
PT: Avoid tight clothing, damp clothing or bathing suits, douching, scented feminine products. Wear cotton underwear.
Card 101
Hyperemesis Gravidarum
Signs/Symptoms
Treatment
Nursing Care
Answer
Hyperemesis Gravidarum
Severe nausea and vomiting that extends beyond the first trimester of pregnancy.
S/S: Nausea/vomiting, electrolyte imbalances, dehydration, weight loss, ketonuria.
Tx: Antiemetics (e.g., ondansetron, metoclopramide, promethazine), pyridoxine (vitamin B6). Corticosteroids for refractory hyperemesis.
NC: Administer IV fluids and electrolytes as ordered. Monitor I&Os and weight. Encourage small/frequent meals, dry/bland foods.
Card 102
HIV/AIDS
Nursing Care
Patient Teaching
Contraindications
Answer
HIV/AIDS
Retrovirus that destroys T lymphocytes leading to immunosuppression. Transmitted from mother to infant via placenta or breastfeeding.
Nursing Care: Use standard precautions. Administer antiretrovirals to mother throughout pregnancy and labor as ordered. Administer to infant at delivery. Bathe newborn immediately after birth (before remaining with mother).
PT: Plan for C-section at 38 weeks if maternal viral load > 1,000 copies/mL. Mother should NOT breastfeed.
Contraindications: If HIV+ avoid amniocentesis, CVS, episiotomy, forceps/vacuum extraction, and internal fetal monitors.
Card 103
Sexually Transmitted Infections (STIs)
Chlamydia and Gonorrhea
Syphillis
Trichomoniasis
Answer
Sexually Transmitted Infections
Chlamydia and Gonorrhea: Bacterial infections that can cause PROM, preterm labor.
- S/S: Dysuria, vaginal discharge, may be asymptomatic.
- Tx: Antibiotics (e.g., azithromycin for chlamydia, cephalosporins for gonorrhea). After delivery, erythromycin ophthalmic ointment is administered to ALL infants to prevent ophthalmia neonatorum.
Syphilis: Bacterial infection that can cause preterm labor and infant infection.
- S/S: Genital chancre (ulcer), rash on hands/feet, flu-like symptoms.
- Tx: Antibiotics (e.g., penicillin G).
Trichomoniasis: Protozoan infection that can cause PROM and preterm labor.
- S/S: Yellow/green malodorous vaginal discharge, itching, dysuria.
- Tx: Antibiotics (e.g., metronidazole).
Card 104
TORCH
Infections Included
Patient Teaching
Answer
TORCH
Acronym for infections that are teratogenic (i.e., may cause birth defects).
Toxoplasmosis: Parasitic infection acquired by consumption of raw/undercooked meat or handling cat feces.
- PT: Do not clean cat litter box or garden (soil may contain contaminants/animal feces). Cook foods thoroughly.
Other: Varicella, syphilis, parvovirus.
Rubella:German measles.
- PT: Vaccine contraindicated when pregnant. Women without immunity should be vaccinated during the immediate postpartum period.
Cytomegalovirus: Member of the herpes virus family.
Herpes Simplex Virus: STI that can cause genital lesions.
- PT: Can be transmitted to baby during vaginal birth if mother has active lesions. C-section is often recommended.
Ectopic Pregnancy
Implantation of a fertilized ovum outside of the uterus (commonly in the fallopian tube).
RF: Hx of STI (e.g., chlamydia), hx of previous ectopic pregnancy, use of IUD, previous tubal surgery, multiple pregnancy losses.
S/S: Unilateral stabbing pain in the lower abdomen, vaginal bleeding (i.e., "spotting"), S/S of hemorrhage (hypotension, tachycardia, pallor).
Tx: Methotrexate to dissolve the pregnancy and save the fallopian tube. Salpingostomy (tubal incision to remove ectopic pregnancy) or salpingectomy (removal of fallopian tube).
Hydatidiform Mole (Molar Pregnancy)
Abnormal growth of trophoblastic villi in the placenta prevents normal embryo maturity. 2 types: Partial (embryonic tissue present), and Complete (embryonic tissue absent). Can lead to gestational trophoblastic disease, e.g., choriocarcinoma (a type of uterine cancer).
S/S: Dark brown vaginal bleeding ("prune juice" appearance), larger uterus/higher fundal height than expected for gestational age, high hCG levels, cramping, n/v, passage of tissue described as "grape-like clusters".
Dx: Ultrasound.
Tx: Surgical uterine evacuation (D&C), hCG monitoring.
PT: hCG serum levels monitored for 6 mos. after D&C. Avoid pregnancy for 1 year, as pregnancy ↑ hCG and would make it difficult to monitor for choriocarcinoma (which also causes ↑ hCG).
Spontaneous Abortion (Miscarriage)
Loss of pregnancy prior to 20 weeks gestation due to natural causes.
Indications: High risk pregnancies, non-reactive nonstress test.
Type
Signs/Symptom
Threatened
Slight bleeding, no cervical changes, mild cramping, no passage of fetal tissue.
Inevitable
Moderate bleeding, cervical dilation, rupture of membranes, strong cramping, no passage of fetal tissue.
Incomplete
Heavy bleeding, cervical dilation, severe cramping, passage of some fetal tissue.
Complete
Decrease in pain and bleeding after passage of all fetal tissue.
Missed
Spotting, no cervical dilation, no cramping, non-viable embryo retained in uterus.
Treatment: Dilation and curettage (D&C), prostaglandins (e.g., misoprostol), Rhogam for Rh- women within 72 hrs of miscarriage.
Card 108
Contraction Stress Test (CST)
Indications
Patient Teaching
Results
Complications
Answer
Contraction Stress Test (CST)
Invasive test to measure FHR response to contractions.
Indications: High-risk pregnancies, non-reactive stress test.
PT: To induce contractions, nipple stimulation or oxytocin may be used.
Results:
- Negative: Normal. 3 contractions in 10 minutes with no late decelerations of FHR.
- Positive: Abnormal. Late decelerations in ≥ 50% of contractions (indicating uteroplacental insufficiency).
Complications: Contractions can lead to preterm labor, so this test should be performed in a hospital setting.
Biophysical Profile (BPP)
Non-invasive assessment of fetal well-being using ultrasound and NST.
Indications: High risk pregnancies, non-reactive nonstress test.
Component
Score = 2
Score = 0
Fetal Heart Rate
(FHR)/NST
Reactive
Non-reactive
Fetal Breathing Movements
≥ 1 episode of 30 sec.
Absent or
Gross Body Movements
≥ 3 body/limb movements
Fetal Tone
≥ 1 extension/flexion
None or slow movement
Amniotic Fluid Volume
≥ 1 pocket of fluid ≥ 2 cm
Overall Score: 8 - 10 is normal,
Card 110
Nonstress Test (NST)
Indications
Patient Teaching
Results
Answer
Nonstress Test (NST)
Non-invasive test done in the third trimester to measure FHR response to fetal movement.
Indications: Decreased fetal movement, advanced maternal age, diabetes, gestational HTN, postmaturity.
PT:
- Mom pushes a button when she feels fetal movement.
- If the fetus is sleeping, a vibroacoustic device may be used to awaken them.
Results:
- Reactive: Normal. FHR has normal rate, moderate variability, accelerates (by ≥ 15 bpm for ≥ 15 secs) ≥ 2x in 20 mins.
- Non-reactive: Abnormal. FHR does not accelerate sufficiently with fetal movement. Further testing recommended (e.g., biophysical profile or contraction stress test).
Card 111
Amniocentesis
Indications
Procedure
Complications
Answer
Amniocentesis
Procedure used to identify chromosomal abnormalities, neural tube defects, Rh incompatibility, and fetal lung maturity.
Indications: Family history of chromosomal abnormalities, abnormal MSAFP. Therapeutic amniocentesis for polyhydramnios (card 48).
Procedure:
- Performed between 15 - 18 weeks gestation.
- Empty bladder beforehand!
- A sample of amniotic fluid is removed from the uterus via a long, thin needle inserted through the abdomen under ultrasound guidance.
- Rhogam is administered to Rh- mothers after the procedure.
Complications: Maternal or fetal hemorrhage/infection, PROM, amniotic fluid leakage, preterm labor, miscarriage.
Chorionic Villus Sampling (CVS)
Invasive procedure that provides early diagnosis of chromosomal, metabolic, or genetic abnormalities.
Indications: Family history of genetic disease, previous birth of a child with chromosomal defects.
Procedure:
- Performed between 10 - 13 weeks gestation.
- A portion of the placenta is removed via the cervix or abdominal wall under ultrasound guidance.
- Rhogam is administered to Rh- mothers after the procedure (to prevent sensitization to fetal blood).
Complications: Post-procedure bleeding, spontaneous abortion, chorioamnionitis, PROM.
Card 113
Ultrasound
Indications
Patient Teaching
Answer
Ultrasound
Non-invasive procedure that uses high frequency sound waves to visualize the developing fetus.
Indications: Standard part of prenatal care to confirm pregnancy, site of implantation, assess fetal growth and development, and need for additional testing.
PT:
- Transvaginal ultrasound: Used early in pregnancy, does not require a full bladder.
- Abdominal ultrasound: Used during the second or third trimester in pregnancy. Procedure requires a full bladder to better reflect sound waves.
Card 114
Maternal Teaching
Unpleasant Side Effects (2 of 2)
Answer
Unpleasant Side Effects
Hemorrhoids: Use warm sitz baths and witch hazel pads. Avoid straining during bowel movements.
Nausea/Vomiting: Eat crackers before getting out of bed in the morning, eat small/frequent meals and bland foods.
Urinary Frequency: Empty bladder often. Kegel exercises help decrease stress incontinence.
Varicose Veins: Elevate legs, wear compression socks/stockings, walk often, and avoid prolonged standing.
Others: Backaches, breast tenderness, cramps, edema.
Card 115
Maternal Teaching
Unpleasant Side Effects (1 of 2)
Answer
Unpleasant Side Effects
Congestion: Use normal saline spray. Certain antihistamines appropriate for pregnancy (e.g., Zyrtec).
Constipation: ↑ Fluid and fiber intake.
Epistaxis: Use a humidifier.
Fatigue: Take frequent rest periods and/or naps.
Gingivitis: Practice good dental hygiene. Brush with soft toothbrush, floss daily.
Heartburn: Eat small/frequent meals, avoid laying down after meals, avoid spicy and greasy foods.
Card 116
Maternal Teaching
Things to Avoid During Pregnancy
Warning Signs of Complications
Answer
Maternal Teaching
Avoid During Pregnancy:
- Medications and supplements (unless provider is aware and confirms safety during pregnancy).
- Too much caffeine (limit to
- Fish high in mercury (limit albacore tuna to
- Alcohol, drugs, smoking.
- Hot tubs/saunas.
Warning Signs (notify provider):
- Diarrhea, fever, chills
- Severe abdominal cramping/pain
- Severe vomiting
- Vaginal bleeding
- Decreased fetal activity
Card 117
Maternal Teaching
Weight Gain
Calorie Intake
Answer
Maternal Teaching
Weight Gain (total during pregnancy): For underweight women, 28 - 40 pounds. For women of average weight, 25 - 35 pounds. For overweight women, 15 - 25 pounds.
- First Trimester: Gain of 2.2 - 4.4 pounds.
- Second Trimester: Gain of 1 pound per week.
- Third Trimester: Gain of 1 pound per week.
Calorie Intake:
- First Trimester: Do not increase calorie intake.
- Second Trimester: ↑ Calorie intake by 340 per day.
- Third Trimester: ↑ Calorie intake by 450 per day.
- Breastfeeding: ↑ Calorie intake by 450 - 500 per day.
Card 118
Maternal Teaching
Nutrition
Answer
Maternal Teaching - Nutrition
Folic Acid: ↑ Intake to 600 mcg/day (prevents neural tube defects).
Protein: ↑ Intake to 60 g/day (supports maternal and fetal tissue growth).
Iron: ↑ Intake to 27 mg/day (for production of RBCs to supply oxygen to the fetus). Take iron supplement (ferrous sulfate) with vitamin C to ↑ absorption.
Calcium: 1,000 mg/day (helps formation of fetal bones and teeth).
Vitamin D: 600 IU/day (allows for absorption of calcium).
Fluids: 2 - 3 L/day.
Mothers with Phenylketonuria (PKU) need to follow a strict low-phenylalanine diet (LOW in protein) and have phenylalanine levels monitored throughout pregnancy.
Labs/Diagnostics
MSAFP: Tests for genetic abnormalities, performed at 15 - 20 weeks gestation.
- ↑ MSAFP indicative of neural tube defects.
- ↓ MSAFP indicative of Down syndrome.
MSAFP will be Down for Down syndrome.
OGTT: Screens for Gestational Diabetes.
- 1-Hour OGTT: Done at 24 - 28 weeks (no fasting required). Drink 50 g glucose solution, if glucose is > 140 mg/dL 1 hr later, pt must follow up with 3-hour OGTT.
- 3-Hour OGTT: Fasting blood glucose is tested before drinking 100 g glucose solution, then every hour after for 3 hours. If 2 or more results exceed threshold, patient is diagnosed with gestational diabetes mellitus.
Card 120
Labs/Diagnostics
Human Chorionic Gonadotropin (hCG)
Rh Factor
Answer
Labs/Diagnostics
hCG: "Pregnancy hormone", detected with OTC pregnancy tests.
- ↓ Due to ectopic pregnancy, miscarriage.
- ↑ Due to molar pregnancy, multifetal pregnancy.
- Rh Factor: Tests for maternal-fetal blood incompatibility.
- Blood typing is done at the first prenatal visit to determine if mother has Rh antigen on RBCs (+) or lacks Rh antigen (-).
- If Rh-, administer Rh immune globulin (Rhogam) at 28 weeks and within 72 hrs of delivery (to prevent formation of Rh antibodies). Rhogam is also administered after any pelvic/abdominal trauma or vaginal bleeding.
Card 121
Prenatal Care
Estimated Delivery Date:
- Naegele's Rule
- Alternative Method
Answer
Estimated Delivery Date
Determine the first day of the patient's last period.
Naegele's Rule: Subtract 3 months, then add 1 week and 1 year.
- Example: First day of last menses is Apr 1, 2020 - 3 mos = Jan 1, 2020 + 1 week = Jan 8, 2020 + 1 year = Jan 8, 2021.
OR
Alternative Method: Add 9 months and 1 week.
- Example: First day of last menses is Apr 1, 2020 + 9 mo = Jan 1, 2021 + 1 week = Jan 8, 2021.
Card 122
Prenatal Care
GTPAL
Gravida Terms
Answer
Prenatal Care
GTPAL:
- Gravidity: The total # of pregnancies (including current pregnancy).
- Term: The # of full term births (≥ 38 weeks).
- Preterm: The # of births from viability (~ 20 weeks) to 37 weeks.
- Abortion: The # of miscarriages or induced abortions prior to viability.
- Living: The # of children currently alive.
Gravida Terms:
- Nulligravida: Never been pregnant.
- Primigravida: First pregnancy.
- Multigravida: Multiple (≥ 2) pregnancies.
Card 123
Prenatal Care
Third Trimester Visits
Answer
Third Trimester Visits
28 Weeks:
- Rhogam administered to Rh- patients.
- Beginning at this time, visits will be every 2 weeks.
30 - 32 Weeks:
- Education: Perform daily kick counts until delivery.
- Administer TDaP at or after this point.
- Non-stress tests (NSTs) 1 - 2 x/week may begin for high-risk patients.
35 - 37 Weeks:
- Obtain vaginal/rectal Group B Strep swab.
- After ~ 36 weeks, visits will be weekly until delivery.
Card 124
Prenatal Care
Second Trimester Visits
Answer
Second Trimester Visits
14 - 18 Weeks:
- MSAFP testing (card 18).
- Amniocentesis may be done for investigation of abnormal MSAFP.
- Gestational diabetes screening for high risk patients.
18 - 22 Weeks:
- Ultrasound to assess for any fetal abnormalities.
- Fundal height will be measured beginning at this point. Between 18 - 32 weeks gestation, the fundal height (in cm) ≈ gestational age (+/- 2 weeks).
- 22 - 28 Weeks:
- Cervical length may be measured via ultrasound for first pregnancies and those at high risk for preterm labor.
- 24 - 28 Weeks:
- 1 hour glucose tolerance test, with follow-up 3 hour test if needed (card 18).
-
Card 125
Prenatal Care
First Trimester Visit
Answer
First Trimester Visit
First prenatal visit should be within the first 12 weeks of pregnancy.
Obtain obstetric history, GTPAL (card 15).
Calculate Estimated Date of Delivery (card 16).
Labs: CBC, urinalysis, STI testing, pap test, blood typing (including Rh factor), rubella titer, Hep B, HIV. For high-risk patients, hCG levels.
Transvaginal ultrasound to confirm pregnancy, site of implantation, and gestational age.
Maternal teaching (cards 19 - 23).
After this point, fetal heart rate will be assessed via doppler and vital signs/weight will be obtained at each visit.
Until ~ 28 wks, visits will be monthly.
Card 126
Physiologic Changes During Pregnancy
Gastrointestinal
Renal
Reproductive
Integumentary
Answer
Physiologic Changes During Pregnancy
Gastrointestinal: ↓ Peristalsis and gastric emptying (contributing to nausea/vomiting, constipation, heartburn).
Renal: ↑ Blood flow to kidneys, urinary frequency.
Reproductive: Uterus and breasts ↑ in size. Cervix softens and becomes blue/purple (i.e., Chadwick's sign). Areolas darken.
- Heavier uterus can compress the inferior vena cava in the supine position, causing a drop in BP ("supine hypotensive syndrome"). Advise patient to rest in side-lying position or with a pillow under one hip.
Integumentary: Chloasma (brown patches on face), striae gravidarum (stretch marks), linea nigra (line from navel to pubic bone).
Card 127
Physiologic Changes During Pregnancy
Respiratory
Cardiovascular
Musculoskeletal
Endocrine
Answer
Physiologic Changes During Pregnancy
Respiratory: ↑ O2 requirements and respiratory rate, ↓ lung capacity.
Cardiovascular: ↑ Cardiac output, heart rate, blood volume, RBCs, coagulation factors.
- ↓ Hgb/Hct due to dilution of RBCs in increased plasma ("physiologic anemia"). True anemia if Hgb
- ↑ Coagulation factors = ↑ risk of blood clots.
Musculoskeletal: Pelvic joint relaxation, lordosis (↑ inward curvature of the lumbar spine).
Endocrine: Production/secretion of hormones from the placenta (e.g., hCG, progesterone, estrogen).
Card 128
Signs of Pregnancy
Presumptive Signs
Probable Signs
Positive Signs
Answer
Signs of Pregnancy
Presumptive: Fatigue, nausea, vomiting, urinary frequency, amenorrhea, breast changes, quickening (sensation of fetal movement - may be peristalsis/gas).
- These signs can be explained by conditions OTHER than pregnancy.
Probable: Chadwick's sign, Goodell's sign, Hegar's sign, ballottement, positive pregnancy test.
- These signs are PROBABLY related to pregnancy.
The "signs" are all the probable signs.
Positive: Fetal heart sounds, fetal movement felt by a healthcare provider, ultrasound visualization of the fetus.
- These signs are DEFINITIVE for pregnancy.
When baby is heard, felt, or seen, I am positive you are pregnant!
Card 129
Infertility
Risk Factors
Diagnostics
Treatment
Answer
Infertility
The inability to conceive for at least one year.
RF: Older female, endometriosis, ovulation disorders, tubal occlusions, hormonal disorders, ↓ sperm count, male with history of mumps.
Dx:
- Semen Analysis: Often the first test performed (non-invasive and less expensive).
- Hysterosalpingography: Contrast dye is used to assess the patency of the fallopian tubes. Assess for allergies to contrast dye, iodine, and shellfish* prior to procedure.
- Hysteroscopy: Visual exam via camera to assess the uterus.
Tx: Intrauterine Insemination (IUI), In Vitro Fertilization (IVF), Embryo Transfer (ET), donor eggs/embryo/sperm, gestational carrier (surrogate).
*Recent evidence suggests that allergies to shellfish do not increase the risk of reaction to IV contrast more than any other allergies, however, for testing purposes defer to your instructor, textbook, and/or facility.
Card 130
Contraception - Permanent Sterilization
Female Sterilization
Male Sterilization
Answer
Contraception- Permanent Sterilization
Female Sterilization (Tubal Ligation): Surgery that severs the fallopian tubes. Provides permanent sterilization, cannot be reversed.
Male Sterilization (Vasectomy): Surgery that severs the vas deferens.
- Requires follow-up testing of sperm count!
- Utilize an alternate form of birth control until semen is free of sperm (~ 2 - 4 months).
- Reversal may be possible.
Intrauterine Device (IUD)
T-shaped device inserted into the uterus via the cervix. Releases hormones or copper ions that harm sperm and prevent fertilization.
Side Effects:
- ↑ Risk of ectopic pregnancy, pelvic inflammatory disease (PID), and uterine perforation.
- Irregular periods, cramping.
PT:
- Check string length monthly.
- Report to the provider: change in string length, abdominal pain, foul smelling discharge.
- Does not protect against STIs.
Card 132
Contraception - Hormonal Methods
Transdermal Patch
Vaginal Ring
Subdermal Implant
Answer
Contraception- Hormonal Methods
Transdermal Patch: Estrogen and progestin patch applied on the lower abdomen, buttocks, or upper body (excluding the breasts).
- Apply new patch to a different site each week for 3 weeks, no patch for 1 week to allow for menstruation.
Vaginal Ring: Small, flexible ring that releases estrogen and progestin.
- Left in place for 3 weeks, taken out for the 4th week to allow for menstruation.
Subdermal Implant: Progestin-only rod implanted under the skin in the upper arm (using local anesthetic).
- Provides 3 years of contraception.
These methods do not protect against STIs. Side effects similar to those with oral contraceptives (card 3).
Medroxyprogestrone (Depo-Provera)
Progestin-only IM or subcutaneous injection that suppresses ovulation, prevents implantation, and ↑ viscosity of cervical mucus.
Side Effects: Menstrual irregularities (e.g., spotting), weight gain, ↓ libido, decreased bone density, headache, nervousness.
PT: Get injections every 12 weeks. ↑ Calcium and vitamin D intake, engage in weight-bearing exercises. No STI protection.
Oral Contraceptives
Hormone-based oral medications that suppress ovulation and prevent implantation. Includes combined oral contraceptives (estrogen and progestin) or progestin-only "mini-pills".
Side Effects: Breast tenderness, breakthrough bleeding, fluid retention, nausea, HTN, headache.
Contraindications: Smoking (↑ clot risk), pregnancy, history of blood clots, stroke, CAD, uncontrolled HTN. Combined oral contraceptives during breastfeeding.
PT: Take pills near the same time each day. Monitor for S/S of thromboembolic events (DVT, PE, stroke, or MI). Carefully follow instructions for missed doses. No STI protection.
- Progestin-only pills are safe during breastfeeding, but are less effective than combination oral contraceptives.
Oral Contraceptives Cause Clotting (CCC).
Card 135
Contraception - Barrier Methods
Diaphragm
Condoms
Answer
Contraception- Barrier Methods
Diaphragm: A flexible dome placed over the cervix, usually used with spermicide.
- Can be inserted up to 6 hours prior to sex.
- Keep the diaphragm in place for at least 6 hours after sex, but no more than 24 hours total.
- Reapply spermicide around the rim prior to each act of intercourse.
- Get refitted every two years, with a weight change of > 10 pounds, after pregnancy or abdominopelvic surgery.
Condoms: Male or female, made out of polyurethane or latex. ONLY method that offers protection against STIs.
- Male condoms: Pinch tip of the condom during application to create a reservoir for ejaculate.
Card 136
Contraception - Behavioral Methods
Abstinence
Withdrawal
Natural Family Planning
Answer
Contraception- Behavioral Methods
Abstinence: Not partaking in sexual intercourse.
Withdrawal: Removal of the penis from the vagina before ejaculation occurs.
Natural Family Planning: Avoiding intercourse (or using an alternative method of birth control) during "fertile periods". Uses calendar method and/or daily assessment of basal body temperature or cervical mucus consistency.
No STI protection with withdrawal and natural family planning methods.