Maternal Death: death of a women during pregnancy or within 42 days of termination of pregnancy

Direct: resulting from complications during pregnancy, labor/birth, postpartum, and from interventions,

omission of interventions, or incorrect treatment

Indirect: due to a preexisting disease or a disease that develops during pregnancy that doesn't have a direct

OB cause, but its likelihood is aggravated by the changes in pregnancy

Late: death occurs more than 42 days after termination of pregnancy from either direct or indirect causes

Pregnancy Related: maternal death during pregnancy or within 42 hours of termination of pregnancy

regardless of COD

Highest infant mortality for:

1. Mothers 16 years and younger related to

socioeconomic status and being biologically immature

2. Mothers older than 44 years of age related to an

increased risk of complications due to age, such as

gestational diabetes and hypertensive disorders

Check respiratory patterns, nasal

flaring, color and temperature at birth -
environmental temperature needs to be
that of intrauterine environment
For first breath to be taken, low PVR
and high SVR is needed

Maternal BP < 120/80 compromises fetal oxygenation and

circulation

Maternal VS taken every 2 minutes after epidural is given

Internal Monitor External Monitor



Pre-embryonic Stage (weeks 1-2) - least

susceptible to teratogens effects

Embryonic/Fetal Stage - increased

susceptibility to teratogens effects with

weeks 3-12 being the most susceptible to

structural abnormalities at the cellular level,

depending on the substance type and degree

of exposure

Leopold Maneuvers help to identify fetal position and

fetal lie whereas fetal attitude is best identified by USS
fetal attitude: relationship of fetal parts to one another
fetal lie: fetal spine in relation to maternal spine


0-3: sodium bicarbonate, intubation, and GI lavage



HR: 120-160 Color: pink Cry: lusty RR: 30-60 Muscle Tone: flexion

Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy
Homan's Sign
Emotional
State
Bonding

Immediate Postpartum Period Uterus Assessment

q 15 minutes for the first hour
q 30 minutes for the second hour
q 4 hours for the next 22 hours
q shift after the first 24 hours
Assess the uterus prn if the fundus is boggy or if the mother has excessive, heavy
bleeding or clots

Vital Signs Assessment

q15 minutes for the first hour postpartum
q30 minutes for the second hour postpartum
q4 hours for the next 22 hours
every shift after the first 24 hours postpartum
Check labs - CBC, HCT, HGB: If maternal HGB < 10, they should not be sent home without further evaluation

Assessment of Respirations
q15 minutes for the first hour postpartum

q30 minutes for the second hour

q4 hours for the next 22 hours

q shift after the first 24 hours

Vaccinations Rh Isoimmunization
Trap, Hep B, Varicella, Influenza when an Rh negative mother develops antibodies to Rh positive blood

Women who contract Rubella during the 1st trimester have a exposure through blood transfusions or exposure to an Rh positive fetus
90% chance of transmitting the virus to the fetus mother produces IgG anti-D antibodies which crosses the placenta

fetus has birth defects - deaf, blind, cardiac/mental and causes hemolysis in the fetus
retardation Rho immune globulin/RhoGam is given to Rh negative mothers at 28

Nonimmunized mother should be immunized prior to hospital weeks - prevents the production of the anti-Rh antibodies
discharge Coomb's Test: Rh negative mothers who give birth to Rh positive newborns

Women who receive the Rubella immunization should avoid are screened for anti-Rh antibodies
pregnancy for at least 4 weeks if the test is negative, a 2nd dose of RhoGam is given
a 300 mag dose of RhoGam = 1500U Rophylac, which must be
given IM within 72 hours post delivery

Assess bladder for distention - voiding less than 150 mL/occurrence will place the mother at risk for uterine atony & displacement of uterus
to a dextroverted position (shifted to the right)
Encourage frequent voiding and increased fluid intake - insert straight/foley catheter as per MD order
Check temperature q4 hours and signs and symptoms of infection


Mothers are hunger after a

NSVD - encourage them to

eat an adequate, regular

diet and adequate fluid

intake

Assess bowel sounds q

shift

For an early delivery

administer 12mg

betamethasone to the mother

to help strengthen fetal lungs

As fetal hypoxia worsens, FM decreases as a means to reduce fetal oxygen

consumption


All would be C/S. A primigravida breech position is an indication for C/S. A multigravida breech position is also
an indication for C/S unless the mother is rapidly dilating or of the physician thinks the baby is small enough.

Girls can present with an edematous labia. Boys can present with 1 scrotum and a large amount of edema

1st letter: side of the maternal pelvis (right or left)

2nd letter: fetal presenting part

3rd letter: anterior or posterior side of the maternal pelvis

Rugae need to be flattened to allow for the descent of the

baby. Primipara mothers' rugae will return to their original
condition but multipara mothers' will not - their is loss of
tone which allows for faster subsequent deliveries. For
postpartum management to prevent uterine/vaginal
Station refers to the relationship of the fetal presenting part to the maternal iscial spines
prolapse, kegal exercises are recommended to help
(station 0) - engaged, unballotable fetal presenting part. A vaginal exam allows the examiner
strengthen the vagina.
to determine station using the maternal ischial spines as the landmark.

Middle Phase: 4-7 cm dilation, 40-80% effacement, Transition Phase: 8-10 cm dilation, 80-100%
Latent Phase: 0-3 cm dilation, 0-40% effacement,
more intense UCs q2-5 minutes lasting 45-60 seconds effacement, more intense UCs q1-2 minutes lasting
irregular to q10-15 minutes UC
Ongoing Labor Support: ice chips for dry mouth otherwise 60-90 seconds
Admit to LDR: introduce and establish rapport
NPO Ongoing Labor Support: ice chips for dry mouth
have patient undress, place in semi-fowlers
SVE & ROM if indicated otherwise NPO
position on bed and obtain UA specimen
Pain Management: medication or epidural as indicated patient is often irritable, diaphoretic, and may
obtain history - PMH, PSH, prenatal
Continuous evaluation of labor progress have the urge to bear down
CBC, possible drug screen, rapid ELISA HIV as
Patient/Family/Labor Coach support and education as SVE & ROM as indicated
needed; SVE exam
necessary Epidural Anesthesia: hyperbolus IV fluids as indicated
Maternal Vital Signs
low risk patients: q1 hour maternal vital Signs q1-2 minutes post
Pushing Phase: complete dilation to birth of baby
temperature q4 hours if membranes epidural/foley insertion
Ongoing Labor Support: ice chips for dry mouth
are intact and q2 hours if ROM Continuous evaluation of labor progress
otherwise NPO
high risk patients: q15-30 minutes Patient/Family/Labor Coach support and education
patient if often irritable and diaphoretic
temperature q2-4 hours based on as necessary
usually has the urge to bear down so assist into
membrane status proper pushing position - mother may be Stage 3: Placenta Delivery
ROM, SROM, AROM - also assess fluid amount, color exhausted or have a burst of energy & guttural Usually within 3-5 minutes but may take up to 30
and odor sounds may be exhibited minutes
EFM: Leopold's Maneuver for fetal back location; FVS for SVE as indicated Cord lengthens
baseline FHR, variability, accelerations and decelerations Continuous evaluation of labor progress and support of Trickle of Blood: active, bright red bleeding
Venous Access: start IV or saline lock mother Observe cord blood aspiration for blood sampling
Labor Support Patient/Family/Labor Coach support and education as Examination of placenta for intactness
necessary

Stage 4: Immediate Postpartum/ NB Assessment

Begins after the delivery of the placenta and ends within 4 hours after delivery

NB assessment, NB medications are given, mother may breastfeed for the first time, maternal/infant bonding is encouraged, NB receives a first bath

NB Assessment
NB is dried, stabilized, and placed under a radiant warmer for thermoregulation and APGAR scoring

oxygen and suctioning as needed

infant is ID'd and alarmed

NB VS: HR, RR, T q15 minutes for the 1st hour

NB medications: 1mg/0.5kg vitamin K, ophthalmic ointment erythromycin in both eyes, 10mcg/0.5mL Hep B vaccine with maternal consent
NB head to Toe Assessment and Ballard Scale

first feeding: breast vs. bottle

glucose monitoring and other labs prn

pediatrician examination

Latent, Middle, Transition Phase Pushing Phase

Vital Signs and Head to Toe Assessment with primary RN and faculty approval Help support mother's legs during pushing
EFM: FVS for FHR, variability, accelerations, decelerations, and UC monitoring with primary RN and faculty support Continuous evaluation of labor progress and support of
Ongoing Labor Support: ice chips for dry mouth otherwise NPO mother with the primary RN and faculty person
Continuous evaluation of labor progress and support mother Patient/Family/Labor Coach support and education as
assist primary RN during SVE & ROM procedures necessary with the primary RN and faculty person

Patient/Family/Labor support and education Evaluate NB upon delivery with primary RN and faculty
Evaluate & Care for mother post delivery with primary RN
and faculty

Methods of Fetal Monitoring

Indications for EFM
1. Intermittent Auscultation: fetoscope or Doppler
1. Pre-existing maternal/fetal medical/prenatal conditions
2. Continuous External Monitoring - most common
2. Previous history of stillbirth
A. Tocodynometer is placed over the uterine fungus to monitor UCs
3. Pregnancy Complications: fibroids, placental abnormalities
B. USS device is placed over the fetal back to record FHR
4. Induction/Augmentation of labor
C. Information from both the tocodynometer and USS device is transmitted to the
5. Preterm labor
electronic fetal monitor
6. Non-reassuring fetal status: fetal movement
a. FHR is audio and digital - recorded on the EFM graph paper
7. Meconium staining of amniotic fluid
b. UCs are also displayed on the EFM graph paper
8. Multiple fetuses
3. Continuous Internal Monitoring

Baseline FHR of 120-160 bpm with moderate (+2) variability. Acceleration of 15x15.

Proper Pushing Position

Generational age is based on maternal history, USS, and NB maturation evaluation (Ballard Scale)
The NB should exhibit flexion of the extremities - lack of flexion is related to prematurity or a depressed NB
Measurements
head circumference: 33-33.5 cm/ 13-14 in.
chest circumference: 30.5-33 cm/ 12-13 in
length: 45-53 cm/ 19-21 in
weight: 2500-4000 g; 5lbs 8oz - 8lbs 13oz
axillary temperature: 36.5-37.2 C/ 97.9-99 F
Vital Signs
RR: 30-60 breaths per minute with diaphragmatic and abdominal breathing (slightly irregular pattern)
apical pulse/HR/pre-clamped umbilical cord rare: 120-160 bpm
BP: 50-75/30-45 mm Hg

Head: note the size and shape of head, palmate fontanels and suture lines
fontanels are open, soft, flat and slightly depressed that may bulge with crying - anterior fontanel is diamond shaped that closes by 18 months, posterior fontanel is triangular
and closes in 2-4 months
suture lines should be approximated - they are sometimes overriding just after delivery and should not be separated
check for capital succedaneum (fluid can cross suture lines) and cephalohematoma (blood doesn't cross suture lines)
Eyes/Ears: note position and discharge
check eyes for sclera, pupil size and blink reflex. Pediatrician will check for + red reflex
check ears for vernix and drainage - a hearing screen is state mandated that NBs can either PASS or DEFER
NB may be referred to an audiologist if fails to pass screen in one or both ears.
Nose: observe shape and check nares for patency
Neck: neck is short with skin folds
Mouth: inspect lips, gums, palate, and tongue - test for rooting, sucking, swallowing, and gag reflexes


Chest/Lungs: barrel shaped and symmetrical, auscultation all lung fields (AF in lungs may cause crackles), RR, observe chest for retractions
Cardiac: listen to all cardiac landmarks, assess S1 and S2, point of maximal impulse at 3rd-4th intercostal space, HR, peripheral pulses
bilaterally
murmurs in 30% of NBs disappear within 2 days
landmarks on the NB chest are much more compact related to the small surface area of the chest
the NB heart is tipped higher in the chest - as a result, the mitral valve is located approximately at the 3rd-4th intercostal space

Check size and shape

Palmate for tone, hernias and diastasis recti
Listen to bowel sounds in all quadrants
Inspect umbilical cord - check for intactness of the cord clamp, are sure the NB alarm is activated and intact if located in the cord stump
depending on hospital protocol, alarm may be located on the leg

Inspect anus prior to inserting a rectal thermometer - rectal is usually the mode for assessing the initial temperature in a NB
Observe for meconium - the NB should have the first stool within 24 hours

Females Males
inspect labia majora and minora which may be edematous inspect penis and note the position of the urethral opening, looking
pseudo-menstruation may be present as slight vaginal bleeding for hypospadias or epispadias
directly related to the excretion of maternal hormones and is normal inspect the scrotum for rugae/septum - palmate scrotum for the
inspect perineum for urethra, clitoris and vaginal opening (introitus) presence of testes
inspect tested for hydrocele
NB should urinate within 24 hours

NIPS Pain Scale

Initial Period of Reactivity: in the first 15-30 minutes after birth, the NB is alert, active and crying or is in a quiet alert state, just looking
around
NB vigorously responds to environmental stimuli - cold, heat, touch, sounds, light
HR may be as high as 180 bpm and RR can be as high as 90 breaths per minute, rapid and irregular with brief periods of cyanosis
Sleep State: begins about 30 minutes after birth where the NB is unresponsive to external stimuli - respirations decrease sometimes below
normal range and HR decreases within normal limits
Second Period of Reactivity: follows the sleep state, varies between alert and quiet alters state and lasts 2-8 hours
increased bowel activity and may have first meconium stool; NB may void

Erythromycin Opthalmic Ointment (0.5%): STATE MANDATED prophylaxis treatment for gonorrheal/chlamydial eye infections
Vitamin K IM Injection (0.5-1mg/0.5mL): into the left vastus lateralis for NB clotting factors
Hepatitis B Vaccine: the 1st of 3 doses is generally given in the hospital after signed consent is obtained into the rig vastus lateralis
1st dose - HBIg (hepatitis immune globulin) is given within 12 hours of birth
2nd dose - given at 1-2 months of age
3rd dose - given at 6-18 months of age

Elective surgery to remove the foreskin of the penis - decision is made by the NBs parents and requires a consent
Contraindications: urogenital defect, preterm status, NBs with bleeding problems, RDS or other unstable conditions of the NB
Risks: hemorrhage, infection, adhesions, pain, too much foreskin removed
Pre-Operative: NB vital Signs and verification that the NB has voided
NPO 2-3 hours prior to the procedure
pain management as per MD order
Emla Cream (lidocaine 2.5% & prilocaine 2.5%) applied to the penis prior procedure
Lidocaine injected into the surgical site by MD
Acetaminophen orally 1 hour prior to the procedure
non-nutritive glucose sucking prior/during the procedure
Procedure: Gomco clamp or Plastibell
Post-Operative: check penis q15 minutes for bleeding, check for any postop pain med orders, usually acetaminophen q4-6 hours; penis will be covered by petroleum gauze

vital signs and postoperative voiding; swaddle infant for comfort and feed prn