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How often is APGAR scoring done?
- 1 minute
- 5 minutes
- 10 mins if low score @ 5 minutes
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APGAR Scoring
- Heart rate: (0) absent (1) below 100 (2) 100 or higher
- Respiratory: (0) no spontaneous effort (1) slow or weak (2) strong lusty cry
- Muscle tone: (0) limp (1) minimal flexion (2) flexed posture
- Reflex: (0) no response (1) minimal response (2) responds promptly
- Color: (0) pallor or cyanosis (1) bluish hands and feet (2) pink
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Protective actions for newborn:
- Eye drops for gonorrhea & chlamydia
- Vitamin K for blood clotting
- Hep B if mother is positive
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S/S of hypoglycemia
- jittery & tremors
- hypothermia
- difficulty feeding
- limpness
- apneic spells
- weak or high pitched cry
- sudden pallor
- eye rolling
- cyanosis
- convulsions
- cardiac arrest or failure
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Valves that close after birth:
- Ductus venosus: in liver
- Foramen ovale: between rt & left atria
- Ductus arteriosus: in aortic arch
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Newborn temperature
97-99 F axillary
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Newborn male genitalia
- hypospadias: urethral opening on bottom of penis
- epispadias: urethral opening on top of penis
- cryptorchidism: undescended testicles
- phimosis: end of penis is closed; needs surgery
- hydrocele: water in scrotum
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How often do newborns feed?
- Breastfed: every 1 1/2 - 3 hours
- Bottlefed: every 2-4 hours
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Calorie needs for newborn
- need 55cal/pound
- formula & breast mile have 20 cal/ounce
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Polycythemia:
hematocrit
signs/symptoms
- hematocrit over 65-70%
- tachycardia
- resp distress
- poor color (will be bright red)
- congestive heart failure
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Fontanelles
- anterior - closes at 12-18 weeks
- posterior - closes at 8 wks
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Caput Succedaneum
- collection of fluid/swollen edematous area, between skull & skin
- does not cause pressure on the brain: is on outside of skull
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Cephalhematoma
- blood under skin covering bone
- caused by vessel broken
- doesn't go into skull
- look forjaundice from breakdown of RBC's
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Newborn Behavioral States
- deep sleep
- active sleep
- drowsy but eyes open
- quite alert - content, looking around, resting: Best stage for breastfeeding
- active alert - awake & moving
- crying
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Newborn weight
- Low birth weight: 5.5 pounds
- Very low birth weight: 3.3 pounds
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Ideal pregnancy weight gain
27-35 pounds
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Terms for weeks of gestation
- Full term: 38-42 weeks
- Abortion: before 20 weeks
- Preterm: 20-37 weeks
- Postterm: >42 weeks
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Gravida & Para
- Gravida: number of pregnancies
- Para: number of births
- - nulli - never carroed a baby over 20 weeks
- - Primi - 1st pregnancy
- - Multip - Many births
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Nagele's Rule
1st day of last cycle, minus 3 months, plus 7 days, plus 1 year
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McDonald's Method
measure fundal height in cm from top of pubis to top of fundus. number = weeks gestation
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Presumptive Signs of Pregnancy:
- amenorrhea
- nausea
- urinary frequency
- breast tenderness
- quickening (at 20 weeks)
- fatigue
- weight gain
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Probable Signs of Pregnancy
- Chadwick's sign: bluish color vagina & cervix
- Goodell's sign: cervical softening
- Hegar's sign: softening between cervix & uterus
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Positive Signs of Pregnancy
- fetal heart heard
- seen during ultrasound
- movement felt
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Respiratory changes during pregnancy
- increased O2 demands
- ligaments of rib cage relax
- increased vascularity of respiratory
- thoracic breathing
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Renal changes during pregnancy
- relaces muscle tone can lead to UTI
- increased bladder tone leads to urgency/frequency
- increased glomerular filtration rate & renal blood flow
- increase sodium retention may lead to clucosuria or proteinuria
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Skin changes during pregnancy
- hyperpigmentation
- - chloasma
- - linea nigra
- - striae gravidarum
- increased hair growth
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Muscular skeletal changes during pregnancy
- posture changes with center of gravity shift
- increased lumbosacraql curve
- waddling gait
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Dietary needs of pregnant woman
- 300 more cal/day
- 60 gms protein daily
- 1200 mg/day calcium & phosphorus
- folic acid
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Where does O2/CO2 exchange take place?
- intervillar spaces
- more villa = better exchange
- decrease in mothers BP -> decreased blood flow
- diabetes = decreased blood flow
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Fetal Landmarks
- Occiput - preferred-smallest part
- Mentum - chin
- Sacrum - breech
- Scapula - shoulder (c-section needed)
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External Version/Possible Complications
- turning the baby with hands on mothers belly
- cord becomes tied or pinched
- rupture of membranes
- rip cord off
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Ballotable vs Engagement
- ballotable - not engaged - in pelvic inlet but if the baby's head is touched it will float up
- engagement - 0 station or more - mother can breathe easier but pressure on bladder causes frequent urination
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Presentation & Position
Best Position for delivery
- Presentation - part of the baby's body that enters the birth canal first
- Position - where the baby is located relative to the maternal pelvis
- Best position: LOA - facing left, occiput presenting, anterior position
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Types of Presentation
- vertex: baby is head down and in full flexion
- breech: complete - feet and buttocks present together
- : footling - one or both feet come first
- : frankling - buttocks present and feet/legs are up
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Leopold's Maneuvers
- push on upper stomach to determine head or butt
- feel sides for back
- feel for head at pubic pone
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True vs False Labor
- True:
- regular contractions
- increase in duration
- discomfort begins in back, radiates to abdomin
- intensity increases with walking
- False:
- irregular contractions
- no change in duration
- discomfort in abdomin
- walking has no effect
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Effacement and Dilation
- effacement - thinning of uterus
- dilation - size of opening
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Purpose of amniotic fluid
- cushions baby
- protects baby
- regulates babys temp
- protection from infection
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First assessment when water breaks?
fetal heart rate to determine is cord is around neck or pinched
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Stages of Labor
- 1st: cervic effaces and dilates
- 2nd: complete dilation to birth of baby
- 3rd: delivery of placenta
- 4th: immediate 4 hours after delivery (recovery period)
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Phases of first stage of labor
- latent or early - 0-3 cm dilated
- active - 4-7 cm dilated
- transition - 8-10 cm dleated
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Cardinal Movements
- 1. descent
- 2. flexion
- 3. internal rotation
- 4. extension
- 5. restitution
- 6. external restitution
- 7. expulsion
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Degrees of tearing
- 1st degree - just skin
- 2nd degree - skin & tissue
- 3rd degree - tear to anus
- 4th degree - tears thru anus
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Ferguson's Reflex
stretch receptors in the pelvis floor which may determine the mother's urge to push
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Fundal Pressure vs Suprapubic Pushing
- Fundal pressure-pushing on fundus - dangerous
- Suprapubic pushing - when shoulders are caught - pushing straight down on suprapubic area
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Supine Hypotensive Syndrome
- occurs when the mother is lying supone and the weight of the uterus and the fetus compresses the vena cava and aorta
- placing a wedge under one hip or turning mother onto her side reduces this
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Pre-eclampsia
- progressive form of PIH
- symptoms: high blood pressure, edema and proteinuria
- presence of grand mal seizures with any of the symptoms is called eclampsia
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Pregnancy blood gas values
- pO2 - 101 to 108
- pCO2 - 27 to 32
- pH - 7.40 - 7.45
- HCO3 - 18 to 21
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Obstretic Emergencies
- abruptio placenta - premature separation of the placenta
- placenta previa - placenta is over all or part of the cervical opening
- prolapsed cord - umbilical cord presents before the baby
- fetal distress - demonstrated through non-reassuring fetal heart rate
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Monitoring fetal heart rate
- active labor: low risk every 30 min / high risk every 15 min
- stage two - low risk every 15 min / high risk every 5 minutes
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Continuous fetal monitoring
- external uses ultrasound
- intenal uses an electrode that is attached to the presenting part
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Baseline heart rate
- where the fetal HR spends most of the time between contractions for 2 minutes
- normal range is 110 - 160
- measured in increments of 5
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Baseline Variability
- fluctuations in the baseline
- line looks jagged on the monitor
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Absent Variability
- indicates there are no detectable fluctuations
- flat line on the monitor strip
- anything below 2 beats from baseline
- minimal: 2-5 beats from baseline
- average: 5-25 beats from baseline (preferred)
- marked: more than 25 beats from baseline
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Causes of decreased variability
- baby sleeping
- meds to treat pre-eclampsia and preterm labor
- narcotics
- gestational age
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Accelerations
- visible increases above the baseline
- must be at least 15 beats above baseline for 15 seconds
- considered a reassuring sign and may be associated with fetal movement
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Decelerations
visible decreases from baseline
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Early decelerations
- gradual decrease that starts with a contraction and returns to baseline at the end
- mirrors contraction - start and end together
- caused by head compression
- not treated
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Variable decelerations
- visible abrupt drop in heart rate
- decreased rate is at least 15 bpm below baseline
- may or may not be associated with contractions
- ** most commonly associated with cord compression
- looks like V or U on monitor strip
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Late decelerations
- decrease that starts after teh peak of the contraction and returns well after the contraction is over
- results in minimal blood flow thru placenta
- ** placental reserve is inadequate for the fetus and the heart rate drops before contraction is over
- ** indicates inadequate placental support during a contraction
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Reassuring/Non-Reassuring Heart Rate
- reassuring: when fetal heart rate is in the normal baseline rate with variability and accelarations present
- non-reassuring: persistent late or variable decelarations or prolonged baseline bradycardia and absence of variability. Fetus is at risk
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1st hour after delivery critical assessments
- fundus
- lochia
- vitals
- perineum
- bladder
- skin
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Diastasis Recti
- lateral separation of the two halves of the rectus abdominis muscle
- usually heals on its own
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Lochia: Names & Colors
- rubra - dark red
- serosa - pinkish to brownish
- alba - creamy or yellowish discharge
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Rubin's Psychological Adjustment Phases
- Taking-In: recognize reality of labor and birth
- Taking-Hold: teachable reachable phase focuses on infant
- Letting-Go: relinquishment of fantasies and accept reality
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Hyperemesis Gravidarum
persistent uncontrolled vomitting
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Incompetent cervix
weak - can't hold the weight of the fetus
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Molar Pregnancy
- cells that would become the fetus grow too rapidly
- grapelike cysts grow really fast
- S/S: n/v, dark red bleeding, edema
- high risk to develop cancer
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Rh sensitization
Rh negative mothers get Rhogam at 28 weeks and w/in 72 hours of birth and anytime there's a mixing of blood
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Alphafetalprotein testing
- Elevated results: open neural tube, anencephaly, gastroschesis, fetal demise
- Decreased results: down's syndrome, trisomy 18
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Non Stress Test (NST)
- mom pushes a button when baby moves & compare to fetal monitor
- looking for accelerations
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Contraction Stress Test
- looking for late decels and watching baby's reactions
- looking for 3 contractions/10 minutes
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Biophysical Profile
- done under ultrasound
- looking for: resp movements, body movement, fetal position, amniotic fluid volume
- Scoring: 0-2 deliver baby
- 4: >36 deliver <36 repeat w/in 24 hours
- 6: repeat in 4-6 hours
- 8-10: good
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Chorionic Villus Sampling
- done at 10 wks
- identifies chromosomal abnormalities
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Amniocentisis
- done in 2nd trimester
- detects open neural tube defects by high AFP level
- identify Rh factor
- identify intrauterine infections
- fetal lung maturity
- detect bilirubin present
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L/S Ratio
- lecithin to spingomyelin
- detects lung maturity
- done at 30 weeks
- want to be 2:1 or 3:1
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Gestational Diabetes Risks
- overweight before pregnancy
- previous gestational diabetes
- previous newborn over 8.5 pounds
- family history of diabetes
- >25 years old
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Glucose Challenge Test
- <140 negative
- >140 positive
- if positive then GTT is done
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Glucose Tolerance Test levels
- fasting >95
- 1 hr >180
- 2 hrs >155
- 3 hrs >140
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