Exam 1 Maternal Newborn Nursing, Study notes of Obstetrics

Download Exam 1 Maternal Newborn Nursing and more Study notes Obstetrics in PDF only on Docsity! Exam 1 Study Guide NUR 346 MATERNAL NEWBORN NURSING 1. Goal of maternal newborn nursing: a. A safe and satisfying experience for the mother, her family, and her baby. 2. Nursing Roles in Women’s Health: a. RNs work as labor nurses, mother-baby nurses, lactation consultants (help teach breastfeeding), clinic nurses, newborn nursery nurses, home health nurses, NICU nurses and gynecology nurses b. RNCs are RNs who have demonstrated clinical expertise in a field and are certified by a national organization c. Nurse Practitioners are usually Master’s prepared nurses who function as advanced practice nurses. NPs usually focus on ambulatory nursing. Women’s Health NPs or Family NPs are examples. Neonatal NPs work in newborn nurseries and NICUs. NPs perform H&Ps, order diagnostic tests and procedures. d. Certified Nurse Midwives function similarly to NPs but also perform deliveries and care for newborns e. Clinical Nurse Specialists have Master’s degrees and specialized knowledge and competence in a specific clinical area 3. Family Centered Childbirth a. Provision of safe, quality nursing care that recognizes, focuses on and adapts to the physical and psychosocial needs of the pregnant woman, her family and her newborn. b. Fosters family unity and promotes and protects the physiologic well-being of the mother and newborn. c. Fathers, siblings, grandparents, friends encouraged to participate in the birth process d. Families make choices based on their desires. These may include having a physician or midwife attend their births or whether to deliver in a hospital, birth center or at home e. Hospitals now have both Labor & Delivery (L&D) rooms but also Labor, Delivery, Postpartum (LDRP) suites f. The mom dictates who is in the room and who is considered family 4. Philosophy of Family-centered maternal/Newborn Nursing a. Pregnancy and childbirth are usually normal healthy events within the family. b. Childbirth affects the whole family and marks the beginning of a new set of important relationships. c. Families are able to make decisions about care if given the proper information. d. A maternal/newborn nurse serves as an advocate for the rights of all family members, including the fetus. e. Personal, cultural, and religious attitudes influence the meaning of pregnancy and birth within the family. f. Promoting health through role modeling, teaching, and counseling is important to the future health of the community in which the family lives g. Advocate for pt desires and preferences: cultural etc 5. Important Features of Family Centered MNN a. Prenatal and parent education classes. b. Family participation in all aspects of pregnancy & birth. c. Presence of support person for complicated births or cesarean sections d. Use of homelike birth settings. e. Flexible policies regarding routine procedures. f. Flexible rooming in policies. g. Early extended parent-newborn contact. h. Family involvement in care of the mother and newborn. i. Early post birth discharge with close follow up. j. Nontraditional labor and birth settings k. Single room maternity systems which may be called LDR or LDRP. 6. Culturally Competent Care a. Religion/social beliefs b. Presence of extended family c. Communication patterns d. Beliefs and understanding about concepts of health and illness e. Beliefs about propriety of physical contact with strangers f. Education 7. Legal Considerations a. Scope of practice defined as limits of nursing practice as set forth in state statutes b. Health maintenance and disease prevention c. Expanded practice roles include planning care, diagnosis, prescription privileges 8. Standards of Nursing Care a. Establish minimum criteria for competent, proficient delivery of nursing care b. Designed to protect the public and used to judge quality of care provided c. Legal interpretation of actions within standard of care is based on what a reasonably prudent nurse with similar education and experience would do in similar circumstances d. ANA, AWHONN help define e. Nurse who fails to meet appropriate standards of care may be subject to allegations of negligence or malpractice 9. AWHONN Standards of Care a. Comprehensive nursing care of women and their infants focuses on assisting individuals and families to achieve their optimal health. b. Health education is an integral aspect of comprehensive nursing care, Health teaching focuses on health promotion, maintenance, and restoration. c. The qualifications of personnel authorized to provide care are delineated. The scope of practice is clarified in written policies, procedures, and protocols. d. The nurse must be clinically competent to provide comprehensive care for the mother and newborn. The nurse is legally accountable and responsible for the care given. e. Practice settings must have sufficient numbers of qualified nursing personnel to meet patient care needs. f. Ethical principles guide the clinical judgment of nurses caring for mothers and infants. g. Research and research findings are used to improve client outcomes. h. Systematic evaluation using specific clinical indicators is done to ensure quality of care 10. Informed Consent= Shared Decision Making a. Protects patient right to autonomy and self-determination b. No action may be taken without that person’s consent c. Usually consent obtained by physician or midwife; RNs may witness client’s signature giving consent d. If nurse determines that patient doesn’t understand procedure or risk, RN must notify MD e. In most states, pregnant teenagers are considered emancipated and may give consent for herself f. Refusal of treatment, medication, procedure requires signed form releasing provider and hospital from liability. Jehovah’s Witness patient may refuse blood transfusions or Rhogam 11. Pelvic Exam Consent a. July 1, 2020 Florida statute to require written consent for any pelvic exam. 12. Right to Privacy a. Right of person to keep person and property free from public scrutiny b. Avoid unnecessary exposure of women’s body c. Avoid discussing her care with people not involved in her care 13. Special Ethical Issues in Maternity Care a. Maternal-Fetal conflict b. Abortion c. Intrauterine fetal surgery d. Reproductive Assistance e. Embryonic Stem Cell Research f. Surrogate Childbearing g. Genetically designed babies h. Cord Blood Banking i. Micropreemies j. Drug addiction 14. History of Childbirth a. The process of labor and birth unchanged over thousands of years b. Traditionally births have been domain of women c. Family members, birth attendants, midwives d. During Middle Ages and Renaissance, physicians claimed responsibility for childbirth and moved births to asylums and hospitals; forceps developed e. Poor sanitation and poor hand washing led to increase in childbed fever f. During 1800s many women in US and Europe still preferred home births g. Use of Chloroform and Twilight sleep (narcotics, amnesiacs) brought women into hospitals h. Birth became hospital based again but poor sucking, feeding of infants from drugs, sleepy, drugged mothers made breastfeeding difficult i. 1970s saw routine use of fetal monitoring but also a trend toward father participation, natural methods of pain relief, family centered care and home environments in the labor room 15. Statistics in Maternal-Newborn Nursing a. Birth Rate- number of live births per 1000 people b. Infant mortality rate-number of deaths of infants under 1 year of age per 1000 live births c. Neonatal mortality rate- number of deaths of infants less than 28 days of age per 1000 live births d. Fetal death is death in utero at 20 weeks or more gestation e. Perinatal mortality rate- includes both neonatal deaths and fetal deaths per 1000 live births f. US statistics 2020 Reproductive Anatomy and Physiology and Conception Chapter 3 1. External Genitalia a. Mons pubis-mound of subcutaneous fatty tissue b. Labia Majora-outer folds of pigmented skin covered by hair follicles- protection of other structures c. Labia Minora-inner folds of skin that converge near the anus- form forchette d. Clitoris-covered by clitoral hood or prepuce- rich blood and nerve supply- primary erongenous organ e. Urethral meatus i. Skene’s glands- lubricate vaginal opening f. Vaginal vestibule-enclosed by labia minora i. contains vaginal opening or introitus ii. Hymen-thin layer of tissue that surrounds introitus iii. Bartholin’s glands-secrete alkaline mucus that enhance viability and motility of sperm g. Perineal body-fibromuscular tissue between vagina and anus i. Perineum- superficial area 2. Internal Reproductive Organs a. Vagina-muscular and membranous tube that connects the external genitalia to the uterus i. Passage for sperm and fetus ii. Passage of menstrual products iii. Protection b. Uterus- hollow, muscular organ c. Fallopian Tubes-arise from each side of the uterus and turn toward ovaries i. Transport for the ovum from the ovary to the uterus (3-4 days) ii. Site for fertilization iii. Nourishing environment for ovum or zygote d. Ovaries-almond-shaped structure on each side of the pelvic cavity i. Primary source of estrogen and progesterone 3. Uterus a. 2 parts i. Corpus-uterine body 1. Fundus 2. Cornua-fallopian tubes enter 3. Isthmus-area between internal os and endometrial cavity 4. 3 layers a. Perimetrium b. Myometrium c. Endometrium b. Cervix-narrow neck of the uterus i. Chief characteristic-elasticity c. Uterine ligaments i. Broad-uterus centrally placed ii. Round-help broad ligament located near fallopian tubes iii. Ovarian-anchor ovary to the cornua of uterus iv. Uterosacral-supports uterus and cervix at the ischial spines 4. Female Reproductive Cycle a. 2 Cycles that occur simultaneous i. Ovarian-ovulation occurs ii. Follicular-immature follicle matures-FSH-anterior pituitary iii. Luteal-ovum leaves the follicle iv. Follicle maturation b. Uterine-menstruation occurs i. Menstrual ii. Proliferative iii. Secretory iv. Ischemic 5. Menstrual Cycle a. Menstruation is normal cyclic bleeding in response to hormonal change b. Usually 28 day cycle but can vary from 21 to 42 days c. Duration 3-8 days d. 4 phases of menstrual cycle i. Menstrual phase: shedding of endometrial lining ii. Proliferative: endometrial development in response of estrogen iii. Secretory: occurs after ovulation-vascularity increases iv. Ischemic: occurs once CL begins disintegration-estrogen and progesterone diminish e. Time frame from ovulation to beginning of next cycle is consistent 14 days-luteal phase 6. Menstrual cycle Hormones a. Estrogen: i. contributes to development of breasts, body hair, fat deposits; ii. leads to maturation of ovarian follicles and maturation of endometrium; iii. highest amount of estrogen during proliferative phase of menstrual cycle; increases uterine contractility iv. inhibits FSH and LH production b. Progesterone: i. secreted by corpus luteum; ii. higher amounts in secretory phase of cycle iii. decreases uterine contractility and motility caused by estrogen iv. contributes to endometrium stimulation v. causes rise in temperature at ovulation vi. increases breast tissue, cervical mucous with conception vii. Hormone of pregnancy c. Hypothalamus triggers release of Gonadotropin-releasing hormone (GnRH) d. GnRH stimulates anterior pituitary to release follicle stimulating hormone (FSH), luteinizing hormone (LH) e. FSH causes maturation of ovarian follicle; maturing follicle secretes estrogen f. LH production peaks at follicle maturity, triggering ovulation g. Ruptured follicle becomes corpus luteum which secretes large amount of progesterone and smaller amounts of estrogen h. If no fertilization, CL begins to disintegrate, E&P production decreases, endometrium sheds, anterior pituitary releases FSH, LH again Chapter 4 Conception and Fetal Development 1. Cellular Division a. Gametogenesis- process by which germ cells or gametes (sperm & ovum) are produced i. Oogeneis-female ii. Spermatogenesis -male b. Meiosis- a type of cell division in which diploid cells in testes and ovaries give rise to gametes (sperm and ova) c. Each has haploid number of chromosomes (23) d. Mitosis-cell division that produces diploid cells (46) e. Sex chromosome is chromosome number 23 i. XX female XY male ii. Ovum have only X chromosomes iii. Sperm may have X or Y f. Sex is determined at moment of fertilization 2. Fertilization a. Process by which a sperm fuses with an ovum to form a diploid cell, zygote b. Ovum viable for 12-24 hours after ovulation c. Sperm viable for 24-72 hours d. Fertilization occurs in ampulla (outer third) of fallopian tube e. Only one sperm (out of 200-300 million) able to penetrate ovum due to reaction of outer layer of ovum 3. Preembryotic Development a. First 14 days fertilized ovum called a zygote b. Cells rapidly multiply and differentiate c. Multiplication i. Moves through fallopian tube by weak fluid current and beating action of ciliated epithelium that lines tube ii. Tubal peristalsis occurs in response to estrogen iii. Journey to uterine cavity can take 3 or more days iv. Once zygote has divided into 16 cells it is called a morula which is divided into blastocyst and trophoblast v. Blastocyst develops into embryo; trophoblast into chorion d. Nidation- (Implantation) Endometrium prepares for implantation i. Once implantation has occurred, now called an embryo ii. Implantation occurs 3-5 days after fertilization usually in upper part of posterior uterine wall iii. Cells of trophoblast grow into thickened endometrium and form chorionic villi 4. Cellular Differentiation a. Between 10-14 days blastocyst differentiates into primary germ layers from which all tissues, organs develop b. Primary germ layer divided into endoderm, mesoderm and ectoderm c. Embryonic membranes develop and form the amnion and chorion 5. Primary Germ cell layers Physical and Psychological Changes of Pregnancy 1. Uterus a. capacity grows from 10 ml to 5000ml b. Same number of cells in myometrium but they enlarge c. Braxton Hicks contractions-irregular contractions that may be felt beginning in the 4th month 2. Signs of pregnancy a. Subjective (Presumptive) Changes i. Symptoms woman experiences and reports but may be due to other causes b. Objective (Probable) Changes i. Perceived by examiner but may be due to other causes c. Diagnostic (Positive) Changes i. Perceived by examiner but can be due only by pregnancy 3. Presumptive signs a. Amenorrhea- absence of menses (period) b. Nausea & vomiting c. Excessive fatigue d. Urinary frequency e. Breast changes f. Quickening- mother’s perception of fetal movement usually occurs between 16-20 weeks (usually closer to 20 weeks with first pregnancy) 4. Probable signs a. Changes in pelvic organs- i. Enlargement and softening of uterus ii. Goodell’s-softening of the cervix iii. Chadwick’s-bluish iv. Hegar’s-softening of the isthmus v. McDonald’s-ease in flexing the uterus against the cervix b. Enlargement of abdomen c. Braxton-Hicks contractions d. Uterine souffle-soft blowing sound-same rate maternal pulse e. Skin pigmentation changes f. Pregnancy tests i. OTC home tests detect hCG. Usually positive 7-10 days after conception 5. Cervix a. Cervix- endocervical cells produce a thick mucous plug i. Goodell’s sign is softening of cervix due to increased vascularity ii. Chadwick’s sign is bluish discoloration due also to vascularity iii. Hegar’s sign is softening of uterine isthmus (area between cervix and body of uterus) 6. Vagina- Estrogen causes increased vaginal discharge 7. Positive signs a. Fetal Heartbeat b. Fetal Movement noted by examiner c. Visualization of fetus by ultrasound 8. What might a woman experience in pregnancy a. Harder time breathing b. Urgency to pee because baby compresses bladder c. Back problems from compression of spinal cord and organs 9. Common discomforts a. Result from physiologic and anatomic changes of pregnancy b. Can be generalized by trimester 10. First trimester a. Mostly due to hormonal influences b. Usually resolve by 12-14 weeks i. Nausea & Vomiting ii. Urinary Frequency iii. Fatigue iv. Breast Tenderness v. Increased Vaginal Discharge vi. Nasal Stuffiness & Epistaxis vii. Ptyalism: excessive saliva 11. Nausea and Vomiting a. AKA “morning sickness”: usually first sign of pregnancy b. Occurs in 70-85% pregnancies; can be toward specific foods, occur during a specific time of day or throughout the day; Usually resolves by 12-14 weeks c. Thought to be due to elevated hCG levels but changes in carbohydrate metabolism, fatigue and emotional factors may play a part d. Small, frequent meals, eat before rising out of bed, avoid rich, spicy, greasy foods, drink carbonated beverages e. CAM: Ginger, Vitamin B6 & Unisom, Peppermint tea f. Acupressure: Sea bands/Relief bands g. RX: Phenergan, Zofran, Compazine, Diclegis (Vit B6 + antihistamine doxylamine) h. Evaluate skin turgor, mucous membranes etonuria, weight loss i. Encourage 6 small meals instead of 3 large ones, carbonated beverages help, eat a carbohydrate before getting up 12. Breast tenderness a. Related to hormonal changes particularly estrogen b. Appropriately fitted bra; wider strips c. Evaluation by bra specialist d. Enlarge and become more glandular e. Areola darken, nipples become more erect f. Striae develop g. Colostrum produced/excreted in last trimester 13. Nasal Stuffiness and Epistaxis a. Estrogen may produce edema of nasal mucosa leading to stuffiness, discharge b. Vaporizers may help but many resort to OTC nasal sprays that eventually increase symptoms over time c. Tylenol Sinus, Sudafed, Zyrtec can be used in pregnancy for severe cases 14. Increased Vaginal Discharge a. Leukorrhea b. Caused by hyperplasia of vaginal mucosa and increased mucus production c. Increase acidity encourages growth of candida albicans d. Bathe daily, avoid douching (washing of the vagina), cotton underpants e. Note complaints of vaginal pruritis (itching of the vulva), odor 15. Ptyalism a. Excessive, bitter salivation b. Unknown cause c. Chew gum, suck hard candies 16. Second and Third trimesters a. Second trimester is time when woman feels the best b. Most of the following complaints occur in third trimester but may occur earlier i. Heartburn ii. Edema iii. Varicosities iv. Flatulence v. Hemorrhoids vi. Constipation vii. Backache viii. Leg cramps ix. Faintness x. Dyspnea xi. Difficulty sleeping xii. Round ligament pain xiii. Carpal tunnel syndrome 17. Cardiovascular System a. Blood volume increases i. This includes both plasma and erythrocytes ii. Erythrocytes necessary to transport O2 iii. Because plasma volume greater than erythrocyte volume, anemia occurs iv. Physiological anemia of pregnancy v. Increased Fe needs to make hemoglobin vi. Leukocyte production increased up to 12,000 (20-30,000 in labor) vii. Clotting factors increase slightly making pregnancy a hypercoagulable state b. Increased cardiac output c. Increased pulse rate d. Functional murmurs may be normal e. BP decreases slightly in 2nd trimester, then returns to prepregnant levels in 3rd trimester f. Enlarging uterus puts pressure on pelvic and femoral vessels g. Dependent edema, varicosities, hemorrhoids h. Postural hypotension-Supine hypotensive syndrome-compression of the vena cava (lie on L side) 18. Headaches a. Due to hormones, fatigue, fluid changes, caffeine withdrawal b. Evaluate timing, duration of headaches; what provides relief c. Treat with Tylenol products only, increase fluid consumption, rest, avoid stimuli d. Migraine Headaches difficult to treat in pregnancy e. Concern if associated with visual disturbances, scotomata, elevated BP 19. Faintness a. Due to changes in blood volume, postural hypotension caused by pooling of blood in dependent veins; May also be due to anemia, low blood glucose levels b. May occur with sudden change of position, prolonged standing especially in warm, crowded areas c. Sit or lie down with head lowered, fresh air, hard candy, orange juice d. Avoid long periods without eating, prolonged standing e. Evaluate CBC 20. Edema a. Due to poor venous return b. More common in hot months or with prolonged standing or sitting c. Elevate legs, frequent dorsiflexion of feet, if sedentary move around frequently, avoid restriction around legs d. Limit sodium consumption, avoid high heels e. Prescription support hose 21. Varicosities a. Weakening of walls of veins or faulty functioning of valves b. Due to poor circulation, prolonged standing, pressure of gravid uterus on pelvic vessels inhibiting venous return c. Vulvar varicosities cause aching and sense of heaviness d. Treat by elevating legs, support hose, avoid crossing legs, prolonged standing, perineal slings 22. Respiratory System a. As uterus enlarged, more pressure on diaphragm b. Chest circumference expands c. Nasal stuffiness and epistaxis common-due to estrogen induced edema 23. Shortness of Breath (dyspnea) a. Due to rise of uterus into abdomen and pressure on diaphragm b. Proper posture, sleep propped up on pillows at night 24. Gastrointestinal System a. Nausea & vomiting common first trimester due to HCG levels b. Gums bleed easily; ptyalism(excessive saliva) c. Progesterone-Delayed gastric emptying, decreased peristalsis result in bloating, constipation 25. Heartburn (pyrosis) a. Regurgitation of acidic gastric contents into esophagus, creating burning sensation b. Due to displacement of stomach by growing uterus, effects of progesterone, decreased gastric motility and relaxation of cardiac sphincter c. Eat small, frequent meals, avoid greasy, fried, spicy foods, avoid lying down or sitting after eating d. OTC antacids: Maalox e. H2 prohibitors: Zantac, Tagamet 26. Constipation and Flatulence a. Due to increased bowel sluggishness from progesterone, intestinal displacement, oral iron supplements b. High fiber diet, adequate fluids, exercise c. May use stool softeners, suppositories d. Avoid laxatives for concerns re uterine contractions e. Flatulence often associated with constipation and due to decreased GI motility f. OTC Mylicon, Gas X 27. Hemorrhoids a. Varicosities of veins in lower rectum and anus b. Due to gravid uterus causes pressure on veins and impeding circulation as well as straining that accompanies constipation c. Itching, burning, pain, bleeding, may be thrombosed d. May reduce hemorrhoid manually, use OTC products (witch hazel, preparation H), Sitz bath e. Avoid constipation and straining with BM 28. Urinary Tract i. Husband acts ill 43. Common guidelines a. Exercise: May continue pre-pregnant regime; avoid horseback riding, skiing, bike rides after 1st trimester; if starting exercise stick with walking, swimming b. Sexual activity: not contraindicated unless pregnancy complication c. Dental care: may go for routine cleanings, treatments; lead apron for X-Rays d. Work: usually may work until labor; should be aware of fetotoxic hazards related to occupation e. Travel: usually no restrictions but prolonged trips after 26 weeks not advised i. Automobile: stop q 2 hours to ambulate, always wear seat belt and harness ii. Plane, train best for longer distances but hydrate, ambulate frequently to avoid phlebitis iii. Patient should be aware that if she develops complications and delivers far from home, infant will not travel home with her 44. Medications a. USDA classes no longer used b. as FDA labeling as of 2014 c. Class A: safe d. Class B: probably safe (PCN, Tylenol) e. Class C: benefit>risk (drugs to treat medical problems) f. Class D: risk>benefit (epilepsy drugs) g. Class X: teratogen h. Isotretinoin is a teratogen and is highly likely to cause birth defects if taken by women during pregnancy or even a short time before conception. A few of the more common birth defects this drug can cause are hearing and visual impairment, missing or malformed earlobes, facial dysmorphism, and mental retardation. Isotretinoin is classified as FDA Pregnancy Category X and ADEC Category X, and use is contraindicated in pregnancy 45. Caffeine a. Moderate intake shows no teratogenic effect nor linkage to LBW, preterm birth b. 600mg daily associated with decreased birth weight i. one cup coffee = 100mg ii. 12oz can soda= 50mg; iii. cup of tea =50mg c. Advised to limit to 300mg daily 46. Alcohol a. Safe threshold unknown b. Fetal alcohol syndrome (growth retardation, facial anomalies, CNS dysfunction) c. Low birth weight d. Preterm delivery e. Birth defects (including facial deformities) f. Developmental delays and long-term cognitive disabilities 47. Tobacco a. Associated with SIDS, preterm labor & delivery, low birth weight infants, stillbirth b. Carbon monoxide, nicotine are toxic to fetus and decrease availability of oxygen to tissue, cause premature aging of placenta c. Most women aware of harm but addiction too great d. Encourage to smoke < ½ pack daily if she cannot stop 48. Danger signs in pregnancy a. Sudden gush of fluid from vagina b. Vaginal bleeding, with or without pain c. Persistent or severe abdominal pain d. Chills or temperature above 101 e. Dizziness, blurring of vision, double vision, spots before eyes (scotomata) f. Persistent vomiting g. Edema of hands, face, legs and feet. h. Continuous, pounding headache i. Muscular irritability j. Persistent or severe abdominal Pain k. Painful urination l. Change in frequency or strength of fetal movement 49. Premonitory signs of labor a. Lightening: baby drops lower into mother’s pelvis b. Braxton Hicks Contractions c. Cervical Changes d. Bloody Show e. Rupture of Membranes f. Sudden Burst of Energy g. Weight Loss h. Increased backache and sacroiliac pressure i. Diarrhea, indigestion, or nausea and vomiting 50. False Labor vs True labor a. Contractions i. False: inconsistent in frequency, duration and intensity 1. Exercise does not alter ctxs ii. True: consistent increase in frequency, duration, and intensity 1. Exercise increases ctxs b. Discomfort i. False: felt in abdomen and groin. May be more annoying that painful ii. True: begins in lower back, sweeps around to lower abdomen. Early labor feels like cramps c. Cervix i. False: no change in effacement or dilation ii. True: progressive effacement and dilation Maternal Nutrition CH 12 1. Maternal weight gain a. Underweight women: 28-40 lbs b. Normal weight women: 25-35 lbs c. Overweight women: 15-25 lbs d. Obese women: 15 lbs e. Approximately 300 calorie daily increase 2. Weight Gain Distribution a. Fetus, placenta, amniotic fluid: 11 lbs b. Uterus: 2 lbs c. Increased blood volume: 4 lbs d. Breast tissue: 3 lbs e. Maternal stores: 5-10 lbs anticipating extra stores for breast feeding after pregnancy) f. Ideal weight gain i. 1st trimester: 3.5-5 lbs ii. 2nd trimester: 12-15 lbs iii. 3rd trimester: 12-15 lbs 3. WIC Program a. Women, Infants & Children i. Federally funded program providing nutritional support to pregnant and nursing women and children under age 5 b. Being underweight could get you on the WIC program: like a debt card that you can use in the grocery store- only certain foods that fit healthy women c. Counseling with nutritionist, breastfeeding support and education, exercise classes- yoga 4. Nutritional Requirements a. Balanced diet of carbohydrates, protein and fat b. Vitamin/mineral supplementation i. Fe (iron) supplementation for Hgb < 10 grams 1. Consume with OJ, not milk, caffeine: best opportunity for absorption ii. Vitamin A not included as most consume adequate levels: can be toxic to the fetus iii. Folic acid deficiency associated with Neural Tube Defects; reproductive aged women should take 400 mcg daily c. Fluids, especially water (8-10 glasses daily) 5. Nutritional History a. Subjective information i. Journals, daily diaries, questionnaires ii. 24 hour recall b. Objective information i. Weights: taken every appointment to ensure healthy weight gain ii. Lab values 6. Foods to Avoid a. Deep sea fish d/t concerns re mercury b. Swordfish, shark, mackerel c. No more than 12 oz weekly of fish, shellfish d. Avoid albacore tuna e. Mercury exposure can cause CNS abnormalities, cognition, (language, attention, memory) f. Salmonella may be found in raw eggs, cake batter, homemade ice cream g. Listeria bacteria found in unpasteurized dairy, meat, poultry i. Avoid hot dogs, deli meats, luncheon meats ii. Avoid soft cheeses (feta, brie, camembert) 7. Cravings a. Very real in pregnancy but some don’t have them b. Pickles, ice, chips, or ice-cream are common examples c. Encourage healthy snacks instead of cravings d. Not twice the calories but pay attention to what you are consuming 8. PICA: eating non-food sources a. Craving and consumption of nonnutritive substances b. Soil, clay, starch, laundry detergent, ice c. Must ask patient; very few will freely admit d. Suspicion of pica if Fe(iron) deficient e. Thorough history – ask about pica directly i. Education surrounding this Assessment of Fetal Well-being 1. Why do we assess the fetus? a. To evaluate the fetus: fetal monitoring system is “babies call light system” b. To confirm fetal well being c. To identify fetal compromise 2. Indications for fetal assessment a. Decreased fetal movements b. Elevated MSAFP, Quad Screen, cfDNA c. History of preterm labor, genetic problems d. Maternal medical history e. Multiple gestations f. Post-term gestations g. PROM h. IUGR fetus i. Vaginal bleeding j. Maternal Age: Advanced Maternal Age (AMA) k. History of stillbirth 3. Fetal heart rate (FHR) a. Assessed during each prenatal visit from 12 wks (Doppler) or 20 wks with Fetoscope b. 120 –160 bpm is normal (110-160 at term) c. Failure to hear FHR may result from i. User error ii. Obesity iii. Polyhydramios: lot of fluid- need internal monitoring iv. IUGR / SGA fetus v. Fetal Death d. If patient is heavier or has polyhydramios then we need to use an internal fetal heart monitor 4. Fetal Doppler a. At 8 weeks you can hear fetal heart rate 5. Ultrasonography a. Indications: helps to determine fetal growth, we can also confirm gestational age and EDD if woman doesn’t know last menstrual cycle or has irregular one b. First Trimester i. Gestational Age/viability ii. Congenital anomalies iii. Vaginal bleeding iv. Fetal growth c. Second Trimester i. Congenital anomalies ii. Guidance for procedures iii. Placental location/grading b. 14. Biophysical Profile a. Indications: i. Non-reactive NST: this is the follow up test ii. Suspected oglio or polyhydramnios iii. Suspected fetal hypoxia iv. PROM v. Maternal infection b. Look for these 5 things: i. Reactive Fetal Heart Rate (pos NST):NST via ultrasound ii. Fetal Breathing Movements iii. Gross Body Movements: large body movements iv. Fetal Tone: how contracted the baby is v. Amniotic Fluid Volume: pocket of fluid on monitor c. Fetus receives either 0 or 2 points for each category. Top score 10/10 15. Amniocentesis a. Indications: i. 16-18 wks - chromosomal, biochemical measurement ii. 30-35 wks- lung maturity, infection iii. 24-36 wks- Fetal hemolytic disease management iv. Elevated fetal fibronectin levels b. Procedure: i. Empty bladder, lateral tilt, fetal evaluation done prior to and after start of procedure ii. Use ultrasound to identify fetal parts, pocket of amniotic fluid iii. Administer Rhogam if Rh negative mother c. Complications: i. Fetal, umbilical, placenta injury, hemorrhage, infection, preterm labor ii. Complication rate <1% 16. Fetal Lung Maturity a. Lecithin/Sphingomyelin Ratio (L/S Ratio) b. Surfactant required for sustained respirations: helps to keep lungs open and avoid sticking together c. L & S are two components of Surfactant d. Ratio of 2:1 or 2.0 indicates RDS unlikely e. Phosphatidylglycerol (PG) f. Appears when fetal lung maturity obtained around 35 weeks g. Reported as present or absent 17. Other diagnostic tests a. Nuchal Translucency i. US done between 11-14 weeks gestation. NT may be done in correlation with serial blood tests ii. Could show for trisomy 21 b. Fetoscopy i. Direct observation and obtainment of sample of skin or blood ii. Fetal hemoglobinopathies, immunodeficient disease, Chromosomal defects c. Doppler Flow Studies i. studies maternal fetal blood flow ii. measures velocity RBCs travel through uterine and fetal vessels iii. Assists with management of IUGR, poor placental perfusion, at risk pregnancies d. Percutaneous Umbilical Blood Sampling i. Cordocentesis UV blood sample and transfusion ii. Kleihauer-Betke test determines if blood from fetal or maternal source e. MRI i. Fetal CNS ii. Maternal mass Antenatal Nursing Assessment 1. Obstetrical Terms a. Gestation: number of weeks since first day of LMP (last menstrual period): use ultrasound if unknown b. Term: Normal duration of pregnancy (38-42 weeks) c. Antepartum: Time between conception and onset of labor (AKA prenatal) d. Intrapartum: Time between onset of labor and birth of baby and placenta e. Postpartum: Time between birth and when women’s body returns to prepregnancy conditions (usually 6 weeks or 42 days) f. Abortion: birth that occurs before end of 20 weeks or birth of fetus weighing less than 500 grams, could be natural or via medical devices : no intervention usually done before 20 weeks of life (at 20 weeks the fetus is viable and can survive on its own) g. Preterm or premature labor: labor that occurs after 20 weeks but before 37 completed weeks h. Term: Normal duration of pregnancy (37-42 weeks) i. Postterm labor: labor that occurs after 42 weeks, can have complications because of placental breakdown j. Gravida: any pregnancy regardless of duration, including current pregnancy k. Nulligravida: woman who has never been pregnant l. Primigravida: woman pregnant for the first time m. Multigravida: woman experiencing second or more pregnancy n. Para/Parity: pregnancies reaching 20 weeks and beyond regardless number of fetuses or outcomes o. Stillbirth: infant born dead after 20 weeks: beyond viability p. Gravida: number of pregnancies Parity: number of births after 20 weeks i. refer to number of pregnancies not number of fetuses ii. Twins, triplets and so forth count as one pregnancy and one birth. q. TPAL: Count each birth i. T: number of term births (born >37 completed weeks) ii. P: number of preterm births (born >20 weeks but <37 weeks) iii. A: number of abortions either spontaneous or elective (<20 weeks) iv. L: number of living children the woman has given birth to (note: twins/triplets count individually) 2. Prenatal Assessment a. Current pregnancy b. Past pregnancies c. Gynecological problems d. Current medical history e. Past medical history f. Family medical history g. Religious/cultural history h. Occupational history i. Partner’s history j. Social history 3. Determination of due date a. Last menstrual period (LMP) b. Evaluation of Uterine Size (fundal height) c. Determination of when Quickening (little flutters of baby) occurs (first perceived movement) d. Ultrasound 4. Nagele’s Rule a. EDC = From first day of LMP, subtract 3 months and add 7 days b. Meghan’s LMP was 12-26-21 What is her due date? 10-2-22 i. Also be able to reverse it c. What normal conditions can make Nagele’s rule incorrect? Abnormal menstrual cycle d. Wheels 5. Determination of Due date terms a. Estimated date of confinement (EDC) b. Estimated date of delivery (EDD) c. Estimated date of birth (EDB) 6. Pregnancy dating a. First trimester: 0-14 weeks b. Second trimester: 14-28 weeks c. Third trimester: 29-42 weeks 7. Uterine Assessment a. First trimester: Uterus is still pelvic organ i. 12 weeks uterus is at symphysis pubis ii. FHTs can be heard by doppler b. Second trimester i. 16 weeks fundus of uterus is between umbilicus and symphysis pubis ii. 20 weeks fundus of uterus at umbilicus c. After 20 weeks fundal height measurement (from top of fundus to symphysis) measured in centimeters. i. Equals weeks gestation +/- 2 centimeters d. Assessments done each visit to evaluate growth of fetus e. Measuring Fundal Height : distance in centimeters from fundus to pelvic bone 8. Assessment of Fetal Development a. Fetal heartbeat: first heard with doppler between 10-12 weeks b. Quickening: first perception of fetal movement by mother c. Ultrasound: can be done anytime but earlier done in pregnancy more accurate for evaluating gestational age 9. Screening Tests: initial Blood work a. ABO & Rh b. Antibody screen c. Rubella titer (antibody titer >1:8 indicates immunity) d. HepatitisBsAg e. Hepatitis C f. RPR (syphilis) g. CBC h. HIV i. Varicella titer j. Tuberculosis (if high risk) k. Sickle screen (as indicated) l. Cystic Fibrosis (carrier screen) m. Urinalysis with Culture and sensitivity ( C&S) urine dip at every appt n. Pap smear o. STI screening (gonorrhea and chlamydia} p. Genetic screening (cfDNA, CVS, CF, Quad screen) q. One hour glucose screen @ 24-26 weeks: look for gestational diabetes r. Group B streptococcus @ 35-37 weeks 10. Prenatal visits a. Initial visit in first trimester b. Follow up visits q 4 weeks until 28 weeks c. 28-36 weeks q 2 weeks d. Weekly after 36 weeks e. May vary depending upon the patient’s medical, obstetrical, social history f. Screen for complications at each visit g. BP, Weight gain h. Urine dipstick for glucose, protein i. Teach! 11. Childbirth Education a. Provide information regarding self care, discomforts, birthing process b. Early pregnancy classes focus on pregnancy changes, teratogenic avoidance, common discomforts, nutrition, lifestyle issues c. Late pregnancy classes discuss labor, delivery, pain management, newborn care, postpartal care, sibling issues 12. Cultural Awareness a. Caucasian i. Freely express themselves, fathers take active role b. Native American i. More private, avoid direct eye contact. Women encouraged to be stoic. Fathers may not be present but other female family members are c. African American i. More hesitant to provide information; more animated in communication; Express pain more readily; fathers actively participate d. Latinos i. More direct, attentive; fathers may not participate actively; vocal and active in labor although physically prefer privacy c. Early: gradual decrease in FHR mirror moms contractions d. Late: gradual decrease of FHR after nadir of contraction e. Variable: abrupt decrease in FHR that quickly returns to baseline 13. Early Decelerations a. Onset occurs with onset of contraction and is uniform in shape b. Caused by central vagal stimulation when fetal head is compressed c. Benign and requires no intervention: check cervix still 14. Late Decelerations a. Uteroplacental insufficiency resulting from decrease blood flow and oxygen transfer to fetus b. Onset of deceleration occurs after onset of contraction, uniform shape c. Non reassuring d. 15. Variable Decelerations a. Umbilical cord compression reducing blood flow b. Varies in timing with onset of contractions c. Varies in shape of deceleration d. Severe variable decelerations FHR drops below 70 bpm for longer than 30-45 seconds e. 16. Prolonged deceleration a. Deceleration lasting > 60-90 seconds b. May occur with rapid cervical dilation and fetal descent c. Slow return to baseline d. Turn off the Pitocin to decrease contractions 17. Uterine Contraction Pattern a. Uterine resting tone-should be 10-15 mm Hg pressure b. Frequency of contraction c. Duration of contraction d. Intensity of contraction (can only be evaluated using IUPC) i. Intrauterine pressure catheter is ony way to evaluate or you ask mom about the intensity 18. How to read a fetal monitoring strip a. Evaluate uterine contractions i. Resting tone, frequency, duration, intensity b. Baseline FHR- is there evidence of bradycardia or tachycardia? c. FHR variability: Is it present or absent? d. Are there periodic changes present? i. Are there accelerations and if so, do they meet the criteria for Reactive NST? ii. Are there decelerations? If so, are they uniform in shape? If so, are they early or late? 19. Nursing Interventions a. IV hydration b. Vital signs c. Left lateral side lying d. Discontinue pitocin e. Vaginal exam to r/o cord prolapse f. Oxygen at 8-10 liters/minute g. SQ Terbutaline (Brethine) if hyper stimulated h. Close monitoring 20. Nursing Documentation a. Vaginal exams b. Amniotomy or SROM and color of fluid c. Maternal V/S d. Maternal position changes e. Application of internal monitoring f. Medications given g. Oxygen administration h. Maternal behaviors (emesis, coughing) i. Fetal scalp stimulation j. Vomiting k. Pushing l. Administration of anesthesia blocks 21. Fetal Scalp Stimulation a. Tickle fetal head during vaginal exam b. Healthy fetus will respond with acceleration 22. Cord blood gases a. Umbilical cord blood gases assessed at birth b. Recommend sampling if 5 minute Apgar <7 c. Cord clamped before first infant cry d. Sample taken from umbilical artery e. pH >7.25 Processes and stages of labor and birth ch 17 1. Labor and birth a. 5 critical factors during intrapartum period i. Passage (Pelvis) ii. Passenger (Fetus)(and placenta) iii. Position (Relationship between the passage and the fetus) iv. Powers (Physiologic forces of labor) (strength to push) v. Psyche (Psychosocial considerations) (mental aspects that affect birth) b. Abnormality in any factor can affect outcome 2. Birth passage- the pelvis a. 3 components to true pelvis i. Inlet ii. Midpelvis iii. Outlet b. Think where is baby in relation to ischial spine (little nodules) 3. Pelvic types a. 4 types of pelvises i. Gynecoid, android, anthropoid and playtpelloid 1. Gynecoid most favorable for vaginal birth 4. Passenger-the fetus a. Important considerations to outcome of labor i. Size, macrocosmic baby: big baby ii. Attitude: how baby is lying OA or OP, transverse or vertex iii. Lie iv. Presentation v. Orientation vi. Position 5. The fetal skull a. Fetal skull (cranium) consists of face, base of skull and vault of cranium (roof) i. Bones of face and base are fixed. However, bones of vault are not fused. ii. Allows head to mold to adjust to narrow portions of pelvis. Molding is overlapping of bones due to the forces of labor and unyielding pelvis b. Spaces between bones called sutures. c. Intersection of sutures called fontanelles d. 4 sutures i. Frontal ii. Saggital iii. Coronal iv. Lambdoidal e. 2 fontanelles i. Anterior is diamond shaped: doesn’t close till 18 months ii. Posterior is triangle shaped: closes in 6-8 weeks 6. Fetal landmarks a. Mentum-fetal chin (face presentation, extended) b. Sinciput- fetal brow c. Bregma- anterior fontanelle d. Vertex- area between fontanelles (ideal presentation occiput anterior) e. Occiput- area of skull beneath the posterior fontanelle 7. Fetal attitude a. Relationship of fetal parts to one another b. Fetus usually with moderately flexed head, arms flexed on chest and legs flexed on abdomen i. A--Complete flexion.(ideal) B-- Moderate flexion. C--Poor flexion. D--Hyperextension 8. Fetal Lie a. Relationship of the cephalocaudal (spinal) axis of fetus to the cephalocaudal axis of mother i. Longitudinal ii. Transverse: cesarian section required iii. b. c. Cephalic: vertex Occipital anterior d. Breech: butt down 9. Fetal Presentation a. The part of the fetus that enters the maternal pelvis first b. Referred to as presenting part c. May be either cephalic, breech or shoulder d. Cephalic occurs 97% of time 10. Cephalic presentation a. Vertex- most common and presents smallest diameter of fetal head. Occiput is landmark b. Military- head neither flexed nor extended. c. Brow- head is partially extended and is largest presenting diameter. d. Face- head is hyperextended Small diameter presents. Mentum is landmark 11. Breech presentation a. Complete breech- fetal knees and hips both flexed. Buttocks and feet present b. Frank Breech- fetal hips flexed, knees extended, legs straight up. Buttocks presents- hip dysplasia, legs always pop after birth c. Footling breech- fetal hips and knees extended. Feet present (one or two) d. Sacrum is landmark noted on all breech presentations 12. Shoulder presentation 4. 70-90 mm Hg transition 5. 70-100 mm Hg while pushing iii. Peak of flow is where least oxygenated and is best time to push 20. Physiology of labor a. Usually begins between 38-42 weeks b. Many hypotheses: i. Progesterone withdrawal: no longer available to relax uterine muscles; estrogen better able to simulate uterine muscles ii. Prostaglandin: causes increased level of estrogen iii. Hormones released by the fetus iv. Telomeres in Fetus and Placenta (DNA response to aging) become present in amniotic fluid – message to mother? v. Oxytocin, Prolactin, Endorphin blood levels and their receptors increase as pregnancy progresses, sharply at term. vi. Oxytocin reduces the oxygen requirement in the fetal brain having a neuroprotective effect during labor – synthetic oxytocin does not – link to cerebral palsy or autism? 21. Myometrial activity a. Contractions stimulated by hormone oxytocin produced by hypothalamus b. Leads to dilation and effacement of cervical canal, inner os c. Presenting part and fetal membranes act as wedge to dilate cervix 22. Dilation and effacement a. Dilation: opening of cervix which allows fetal head to pass; Measured in centimeters (cm) 0-10 b. Effacement: thinning of cervical canal as part of labor process; measured in percentage 0-100% c. Check cervix with pointer and middle finger 23. Psychosocial considerations a. Fear, anxiety, excitement, joy, anticipation b. Many have high expectations for themselves c. Nesting behavior- cleaning up d. Support system very important e. May be anxious about pushing because of trauma in past, first time 24. Premonitory signs of labor a. Lightening—engagement; fetus descends into pelvic inlet: baby lower in pelvis, feels like you can breathe b. Braxton Hicks contractions—may increase in frequency and discomfort c. Cervical changes—ripening, effacement, possibly some dilation d. Bloody show—expulsion of mucous plug e. Rupture of membranes—leak in amniotic sac f. Sudden burst of energy: nesting—from 24 to 48 hours prior to labor onset g. Weight loss—1 to 3 lbs h. Flu-like symptoms—diarrhea, nausea, indigestion 25. Stages and phases of labor: 4 stages a. First stage: onset of regular uterine contractions to complete dilation of cervix 0-10 cm change, DES i. Latent phase: 0-3 cm ii. Active phase: 4-7 cm iii. Transition phase: 8-10 cm b. Second stage: period between complete dilation of cervix until delivery of fetus c. Third stage: period between delivery of fetus and delivery of placenta: shortest stage d. Fourth stage: Immediate 1-4 hours after birth: forgotten stage, highest risk for postpartum hemorrhage e. Babies come faster when you have had more 26. First stage a. Latent phase: beginning of regular contractions; contractions q 3-5 minutes, 45-60 seconds (0-4 cm) b. Active phase: fetal head descent progresses, dilation becomes regular; contractions q 2-3 minutes, lasting 60 seconds (one cm an hour change, regular contractions that get stronger) c. Transition phase: may lose control, very intense, may note rectal pressure due to pressure of descending fetal head; contractions q 1-2 minutes, 60-90 second duration (mom needs epidural) 27. Rupture of Membranes a. SROM Spontaneous rupture of membranes happens at height of contraction caused by pressure of membranes bulging through cervix b. AROM Artificial rupture of membranes done by provider using an amnihook 28. Second stage a. Cervix is 100% effaced and 10 cm dilated, want station at 0, +1, +2 b. Woman usually feels urge to push as fetal head descends onto pelvic nerves c. “Laboring down” means patient in 2nd stage but without urge to push. Allows contractions to continue passive descent of fetal head d. Crowning occurs when fetal head at introitus e. Ends with birth of the baby 29. Cardinal Movements of labor a. Descent: head enters inlet transverse (inlet is widest side to side) b. Flexion: chin flexes presenting vertex (small diameter) c. Internal rotation: pelvic cavity widest here AP. Fetal head rotates so saggital suture aligns with AP diameter d. Extension: fetal head extends as it passes under symphysis pubis e. Restitution: shoulders remain oblique as head rotates to AP diameter. Once head is born, realigns with shoulders f. External Rotation: Shoulders rotate to AP, head turns farther to one side g. Expulsion: Anterior shoulder slips under SP 30. Third Stage a. After birth of infant, uterus continues to contract, decreasing surface area of placental attachment b. Placenta begins to separate from uterus, gush of blood c. Signs of placenta separation: i. Globular shape uterus ii. Rise of fundus in abdomen iii. Sudden gush or trickle of blood iv. Lengthening of umbilical cord d. If placenta separates from inside to out, fetal side presents (shiny Schultze); If separates from outside in, it will present sideways and delivery maternal side first (dirty Duncan) 31. Fourth Stage a. Blood loss ranges from 250-500 ml b. Moderate drop in systolic and diastolic BP, moderate tachycardia c. Uterus midline between SP and umbilicus; constricts vessels at placental site d. Shaking chill common e. Bladder may be hypotonic due to trauma 32. Causes of labor pain a. First Stage i. Cervical dilation ii. Stretching of lower uterine segment iii. Pressure on adjacent structures iv. Hypoxia of uterine muscle cells during contraction v. Pain usually over lower abdominal wall, lower lumbar region, upper sacrum b. Second Stage i. Hypoxia of contracting uterine muscle cells ii. Distention of vagina and perineum: stretching ring of fire iii. Pressure on adjacent structures 33. Pain response a. Influences i. Culture ii. Preparation for childbirth/knowledge: education iii. Fatigue/sleep deprivation iv. Previous experiences v. Unfamiliar surroundings/lack of family support Intrapartum Nursing Assessment CH 18 1. Evaluating labor progress a. Cervical progress: obtained by vaginal exam b. Once ruptured only check every 2 hrs 2. Evaluating labor progress a. Contraction assessment i. Palpation ii. Electronic monitoring 1. External: toco device placed on uterine fundus. Disk responds to pressure created by contraction; noninvasive; can evaluate frequency but not intensity 2. Internal: Uses intrauterine pressure catheter; inserted into uterine cavity after ROM; measures pressure in mm Hg. Must note contraction strength but also resting tone 3. Evaluating labor progress a. Fetal Assessment b. Fetal position evaluated by inspection, palpation, vaginal exam, auscultation of FHR c. Leopold’s maneuver: evaluation of fetal position by palpation Nursing Care of the Laboring Patent CH 19 1. Nursing Care in First Stage a. Maternal temperature q 4 hours: once ruptured check more frequently because of infection b. If ROM, q 1-2 hours c. BP, P, RR, pain response q 1 hour d. Palpate uterine contractions q 30 minutes e. Evaluate FHR q 30 minutes (low risk patient); q 15 minutes (high risk patient) f. Frequency of vaginal exam varies (can lead to infection if performed too frequently especially with ROM) g. Evaluate for ROM- note amount, color, odor, consistency and time of rupture h. NPO or clear liquids, ice chips, popsicles i. IV antibiotics for positive GBS status: bacteria can affect the baby j. Provide comfort with clean linens, perineal pads k. Frequent voiding l. Back rubs, ambulation, aromatherapy (no candles!), music, rocking chair, showers, cool cloths m. Breathing patterns n. Relaxation 2. Nursing care in second stage a. BP q 30 minutes b. FHR q 5 (high risk)-15 (low risk) minutes c. More guttural noises from patient d. Support legs for pushing/birth e. May use stirrups, squat, birthing bar f. Note birth and placenta times, baby APGARS 3. Nursing care in third/ fourth stage a. After delivery of placenta b. Pitocin 10-20 units IV or Pitocin 10 mg IM c. Manually massage uterus d. If ordered: Methergine 0.2 mg IM, Hemabate 250 mcg/ml IM for excessive bleeding due to uterine atony e. Vital signs q 15 minutes f. Assist with repair of episiotomy/lacerations g. Continue evaluating for uterine firmness/vaginal bleeding h. Continue evaluating for perineal integrity (hematoma) i. Provide ice pads to perineum j. Keep bladder empty: may have to use a straight cath, need full mobility in legs to get up k. May eat if stable 4. Placenta and Cord variations a. Velamentous cord insertion b. Battledore placenta- umbilical cord inserted at or near placental margin c. Succenturiate placenta- extra lobe 5. Initial care of newborn a. Infant placed on maternal abdomen or under radiant warmer b. Dry, suction secretions if excessive with bulb syringe, wrap in clean, warm blankets c. Evaluate heart rate and respiratory rate 6. Apgar Scoring System a. Score of 0,1,2 b. Done at 1 minute and 5 minutes